ON AMPUTATION 401 



cases of injury demanding removal of the limb, in wliich also the parts necessary 

 for the large external flap are often encroached on ; and in tumour of the bone, 

 which is the other affection that most frequently calls for amputation in this 

 situation, transfixion becomes inadmissible. 



On the other hand, Larrey's mode of operating, by lateral flaps of equal 

 size, proved almost always applicable in his cases of gunshot-wound, while it 

 was as secure against haemorrhage as that of Lisfranc. Thrusting the point 

 of a knife of moderate length down to the bone immediately below the acromion 

 process, Larrey first made a longitudinal incision about two inches in length, 

 from the extremity of which he cut in a curved line at each side of the limb to the 

 fold of the axilla ; then dissected up the muscular flaps so as to expose the articu- 

 lation completely, a finger of an assistant being placed upon the divided circumflex 

 artery ; and, having severed the connexions of the head of the humerus, passed 

 the knife round it, and kept the instrument close to the inner side of the bone, 

 till, turning the edge towards the surface, he last of all divided transversely the 

 tissues intervening between the axillary folds, containing the artery, previously 

 commanded by the hand of the assistant following the knife. ^ 



This operation is improved by dividing the structures between the folds of 

 the axilla obliquely, as part of the internal flap, the lower portion of which is 

 reserved to be cut from within outwards, at the conclusion of the operation : 

 the result being two precisely similar semilunar flaps, meeting above at the 

 acromion and below at the posterior fold of the axilla, adapted for immediate 

 union throughout their length, and presenting as small a wound as is consistent 

 with an efficient covering. 



When the bone is broken near the joint, it will be found useful to adopt 

 Mr. Syme's expedient of introducing the finger into a longitudinal wound in the 

 capsule, for the purpose of drawing down the head of the bone so as to gain 

 access to its attachments. In some cases of tumour it may be necessary to raise 

 all the soft parts, including the axillary vessels, from without inwards ; when 

 haemorrhage must be restrained by compression of the subclavian artery o\er 

 the first rib, by the thumb of an assistant pressed down behind the collar- 

 bone. 



Sometimes it may be best to make a large superior flap, cut from without 

 inwards, containing the whole width and chief length of the deltoid muscle ; 

 but circumstances will often arise in which no regular rule can be followed, and 

 the parts that happen to be sound must be turned to the best advantage, accord- 



* Durinf,' one period of his piacUce, he loiincd the lower parts of the llaps by transftxing from the 

 end of the longitudinal incision to the borders of the axilla, and cutting from within outwards ; but 

 the method given in the text is that to which he uliiinately gave the preference. Sec Larrey's Cliuique 

 chirurgicale, 1829, p. 563. 



