This major operation developed in the 18th century, promoted by detailed anatomical knowledge, including initial compression of the subcla-vian artery against the first rib, and acceptance of ligatures for major arterial bleeding, achieving great popularity during the Napoleonic wars. According to Ledran, his father performed the first disarticulation before 1731, for a patient with caries involving the humeral neck, achieving a successful outcome.93 French surgeons promoted many methods of performing this operation, confirming a need to vary approaches, dictated by individual pathology and in particular the state of skin flaps after gunshot injury. Indeed, scrutiny of Velpeau's 1840 survey reveals an astonishing list of 33 reported procedures employing circular, flap and elliptical incisions, including his own three variations of the latter.94 Larrey is famous for claiming 90 cures of 100 disarticulations using a racquet incision, although Malgaigne was sceptical in view of personal statistics and experience in the Crimean War when mortality in the French army was 52.7% and in the British 33.3%; in the American Civil War, the mortality was 39.2%.95 Farabeuf apologised for a "historical atlas" of diverse shoulder disarticulation techniques occupying 24 pages, to which he added 28 illustrations of variant incisions!96 This extraordinary ingenuity reflects an obsessive interest in a major procedure which demanded precise anatomical knowledge, providing satisfaction to many surgeons. Gross observed:
"Amputation at the shoulder joint is one of the most easy operations in surgery. Richerand long ago remarked that it might be performed with the same celerity with which an adroit carver separates the wing of a partridge, and nothing is more true, although I have occasionally seen a case in which the surgeon consumed time enough not only to cut up the whole bird, but also to devour it."97
In 1900, Bryant confined himself to four methods including Larrey's racquet approach and reported a mortality of 25% to 38% for gunshot wounds.98 Removal of the humeral head left an unsightly and often uncomfortable prominence of the acromion, and after World War I experience Elmslie advised saving the humeral head if not damaged; this was also the message from World War II. Vitali et al. confirmed the problems of fitting prostheses and recommended part-excision of a prominent acromion.99
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