102. An upper extremity should not be amputated for almost any accident
which can happen to it from musket-shot; and there is scarcely an
injury of the soft parts likely to occur which would authorize
amputation as a primary operation.
103. If the head or articulating extremity of the bone entering into
the composition of the shoulder-joint be merely or slightly injured
by musket-shot, the arm ought to be saved with some defect of motion
in the joint. The wound should be enlarged in the first instance, to
allow of a sufficient examination with the point of the finger, and
any loose pieces of bone should be removed. Inflammation is to be
restrained within due bounds until suppuration has been established,
when, if a clear depending opening should not exist for the discharge
of the matter poured out, it should be made, and any loose portions of
bone removed. The principal points to attend to are, the prevention
of sinuses around the joint, by the formation of dependent openings,
position, perfect quietude, due support, the methodical application of
bandages, and occasional mild stimulating injections into the wound. A
simple incised wound penetrating the joint, and even injuring the bone,
does not call for any immediate operation. An attempt should be made
to effect a cure by the first intention, which can only be managed by
means of proper position and support.
104. If the head of the bone be much splintered, or if a ball have gone
through it, that portion should be sawn off; for a part thus injured
has often been a source of great inconvenience and suffering for many
years afterward--during, in fact, the remainder of the life of the
sufferer; which misery would have been avoided by the excision of the
head of the bone in the first instance--an operation which ought in
fact to be done even at a later period, if it had not been performed
at the time when the injury was received. Secondary operations of this
kind are never so successful as primary ones, and great discrimination
should be exercised in attempting to save the head of the bone, or, in
other words, to avoid the operation for its removal.
105. When the splinters extend far into the shaft of the humerus,
it may be proper to amputate the whole extremity, especially if the
great artery be also wounded; but the shaft is seldom broken in such
accidents to any great extent, and amputation should be confined almost
to injuries from cannon-shot or shells, or heavy machinery, destructive
of the soft parts as well as of the bone.
106. When the injury done to the upper arm is so extensive that it
cannot be saved, although the head of the humerus be not injured, the
amputation should take place immediately below the tuberosities, and
not at the joint, which latter operation always renders the shoulder
flatter, and the appearance of the person more unseemly, than when the
head of the bone is left in its place.
107. It will frequently happen that the arm may be irrecoverably
shattered, and the thorax partake in a less degree of the injury, there
being apparent only some slight contusion or grazing of the skin; if
low down, the elasticity of the false ribs may have prevented the
integuments being much injured in appearance, although the blow has
been violent; yet the force of the large shot may have ruptured the
liver or spleen. If higher up, it may perhaps fracture the ribs, in
addition to a more severe contusion of the integuments. When these
accidents occur, the symptoms arising from the wound or contusion
of the trunk of the body are to be first considered. If they do not
indicate a speedy dissolution of the patient, or the prospect of such
an event in two or three days, the operation ought to be performed,
and a chance of recovery given to the sufferer, which he would not
have, the arm being retained, and the injury of the chest remaining
the same. The danger to be apprehended in the more favorable cases is
from inflammation, and this will be rather diminished than increased
by the operation; the danger of deferring which is manifest and
certain, while the injury committed in the thorax or abdomen is not
ascertained, and its effects may be obviated. If the termination should
be unfavorable, it can only be a matter of regret for the sake of the
individual, and not for the non-performance of a duty. If the cavity
of the chest be laid open, or several ribs beaten in, or a stuffing
of the lungs take place from a large ruptured blood-vessel--all of
which circumstances are obvious, and cannot be mistaken--the operation
would, in all probability, be useless. A hemorrhage of short duration,
or the expectoration of blood in moderate quantities, although a
dangerous symptom, is not to be considered as depriving the patient
of a reasonable chance for life, for it frequently follows blows from
more common causes, from which many people recover. If the operation
be delayed to ascertain what injury may have been done to the chest,
from the symptoms that will follow, the danger resulting from both will
be increased; and even when it has been ascertained that there is but
little mischief existing in the thorax, the operation can no longer be
performed with the same propriety, in consequence of the inflammation
which has supervened; and the patient will probably die, when he would
have recovered under a more decided mode of treatment.
108. A round shot or flat piece of shell may strike the arm, after
rebounding from the ground, or when nearly exhausted in force, without
breaking the skin, or only slightly doing it, yet all the parts within
may be so much injured as not to be able to recover themselves: the
bone may be considerably broken or splintered, the muscles and nerves
greatly contused. The injury may not, perhaps, be quite so extensive.
The bone may be merely fractured, and yet the soft parts will often be
so much destroyed as not to be able to carry on their usual actions.
A ruptured blood-vessel may, with an apparently slight external wound
of this nature, pour out its blood between the muscles, and inject the
arm to nearly double its size, all of which are causes rendering an
operation necessary, and requiring decision, for inflammation will,
and mortification may, ensue in a short time, when the most favorable
moment for operation will have been lost.
109. _Amputation at the shoulder-joint_ is an operation of little
surgical importance. The fear formerly entertained of loss of blood
has passed away, and every surgeon now knows that if he should happen
to cut the axillary artery unintentionally, it can be held between the
forefinger and thumb, without difficulty or danger, until a ligature
can be placed upon it. No accomplished surgeon of the present day
should give himself the least concern about compressing the subclavian
artery. It is, on the contrary, better, when the arm is raised from
the side preparatory to entering or using the knife, that the surgeon
should then feel the pulsation of the artery in the axilla, that he
may the more easily avoid, and subsequently command it. The axillary
artery does not throw out much blood at each pulsation, and a little
pressure with the end of the forefinger will always prevent bleeding,
until the surgeon is prepared to take hold of the vessel with the
tenaculum or forceps. The operator should, in fact, divest himself of
all fear of hemorrhage. When gentlemen are afraid, however, and cannot
help it, (for Henry IV. of France, _ce roy si vaillant_, always felt an
inconvenient intestinal motion when a fight began,) compression may be
made upon the subclavian artery by the thumb of an assistant, the round
handle of a key, or the padded end of the handle of a tourniquet; the
latter forms the best pad, and is usually at hand.
110. The great point to be attended to in performing the operation is
to save skin to cover the stump. The directions, therefore, which are
usually given for doing it after any particular method can only be
occasionally useful; for the surgeon may not always be able to select
the parts to be divided or retained. In cases of malignant disease
of the bone and periosteum of the middle of the arm, my experience
directs the removal of the whole of the bone at the joint, and not the
amputation below the head; although the appearance of the integuments,
and of the bone itself, would seem to encourage the attempt to preserve
the roundness of the shoulder. In such cases, the removal of the
extremity at the joint may be done by any one of the many ways which
have been recommended for its performance. In none should the acromion
or coracoid process be exposed, unless previously injured. Neither is
it necessary to lose time, or to give pain, by depriving the glenoid
cavity of its cartilage; but it should always be borne in mind that if
the nerves be not shortened after the removal of the arm, they may be
included in or adhere to the cicatrix, and cause, during a long life,
much distressing pain to the sufferer.
111. Amputation at the shoulder-joint, performed immediately after
the receipt of an injury, is now a very simple operation, for which
simplicity English surgery is also indebted to the Peninsular war. As
a _secondary_ operation, or done at a later period, when the parts are
all impacted together, it is less so. In both stages it is absolutely
necessary to remember--1st. That, except in cases of disease, and not
of injury, the shaft of the bone must be broken; and that _all_ the
directions usually given for rotation of the arm inward and outward
during the operation are _unnecessary cruelties_ not to be attempted,
and rarely to be effected if attempted, with a broken bone. 2d. That
the arm should always be raised from the side and supported by the
hand of an assistant, who can feel, if he please, at any time of the
operation, the pulsation of the axillary artery; and all operative
methods are hereby condemned in which this precautionary measure is not
the first step.
112. _Operation by two flaps, external and internal._--The
outer--beginning nearly an inch below the acromion process, the hair in
the axilla having been previously removed--is to be carried down with
a gentle curve so deeply as to divide the deltoid muscle, and to show
the long head of the triceps at its under and outer edge. The second
incision is to be carried in a similar direction on the inside, through
the deltoid muscle, but need not divide the insertion of the pectoralis
major, which should be exposed. These flaps being held back, the joint
will be seen and readily opened into at its upper part, by cutting upon
the head of the bone, in doing which the long tendon of the biceps will
be divided, allowing the head of the humerus to drop from the glenoid
cavity sufficiently to admit the forefinger of the left hand, on which
the supra-spinatus, infra-spinatus, and teres minor may be cut through
externally, as they go to be inserted into the great tuberosity,
and the thick tendon of the sub-scapularis muscle internally, where
it is attached to the smaller tuberosity. The head of the bone is
then readily drawn out from the glenoid cavity, when the inner flap,
including the axillary artery, vein, and nerves, may be taken hold
of between the two forefingers and thumb of an assistant, while the
surgeon, with one sweep of the knife, divides all the remaining parts
below. The axillary and the posterior circumflex arteries will have to
be secured; the anterior circumflex, when arising from the posterior,
is frequently cut off with it; the nerves are to be shortened; the
flaps brought together by sutures; and an especial pad placed upon the
pectoralis major, to prevent unnecessary retraction, if possible.
113. _The operation by one_, or nearly one upper flap, is to be
performed when the under soft parts of the arm have been destroyed,
and the bone broken. It may be done by thrusting a small, two-edged
knife through the integuments and under the deltoid muscle, from side
to side, to form a flap; or it may be made by commencing an incision
an inch above the posterior fold of the armpit, and carrying it over
the arm in a curved form, the convexity being downward, to the same
height on the anterior fold; the lowest part of the incision being five
fingers’ breadth from the point of the acromion, the posterior end or
point of it being somewhat higher than the anterior one. The flap being
turned up, and the tendon of the pectoralis major divided, the head of
the bone is to be exposed and separated as before stated, as much as
possible of the integuments being preserved on the under part of the
arm. This will often be best done by dissecting out the head and broken
pieces of bone, and then preserving in succession every piece of sound
integument, before the artery, vein, and nerves are divided.
114. Lisfranc and many French and continental surgeons recommend
the operation to be done with a pointed, double-edged knife, in the
following manner: The arm being approximated to the trunk, in a state
of half pronation, the point of the knife is to be entered at a
small triangular space, which may be perceived on the inside of the
fullness of the shoulder, bounded above by the scapular extremity of
the clavicle and a small part of the acromion; on the inside, by the
coracoid process; and on the outside, by the head of the humerus. The
knife thus entered obliquely is to be passed across to the outside,
opening in its passage into the joint, when, by sliding the knife
forward over the head of the bone, while the deltoid is raised up by
the operator or an assistant, a flap is to be formed, during which
proceeding the arm is to be raised from the side, to facilitate
its performance. If this flap be well made, the upper part of the
capsular ligament, the tendons of the long head of the biceps, and the
supra-spinatus are divided, and the tendons of the infra-spinatus,
teres minor, and sub-scapularis are also cut through in part, if not
entirely. The upper and posterior flap is thus completed.
In the second step of the operation, the surgeon passes the knife
behind the head of the humerus, and makes the under and anterior or
inner flap, by cutting downward and inward, including in it a very
small portion of the deltoid, the pectoralis major, latissimus dorsi,
teres major, the triceps, coraco-brachialis, the short head of the
biceps, and the vessels and nerves, when the limb is separated from
the body. The flaps are nearly of the same size, and are to be brought
together by sutures.
In the secondary operation, or that done several weeks after the
receipt of the injury, in consequence of the attempt to save the arm
having failed, it should be borne in mind that the soft parts will
often be found so altered and impacted together that they will not
yield or separate; and nothing is gained but by each cut of the knife,
causing thereby some little delay, inconvenience, and loss of time.
115. _Amputation of the arm immediately below the tuberosities of the
humerus_ ought to be done in the following manner: The arm being raised
from the side, and an assistant having compressed, or being ready to
compress, the subclavian artery, the surgeon commences his incision
one or two fingers’ breadth beneath the acromion process, and carries
it to the inside of the arm, below the edge of the pectoral muscle,
then under the arm to the outside, where it is to be met by another
incision, begun at the same spot as the first, below the acromion
process. The integuments, thus divided, are to be retracted, and the
muscular parts cut through, until the bone is cleared as high as the
tuberosities. The artery will be seen at the under part, and should be
pulled out by a tenaculum or spring forceps, and secured as soon as
divided. The bone is best sawn, the surgeon standing on the outside;
the nerves should be cut short, and the flaps brought together by two
or three silk or leaden sutures. There are few or no other vessels to
tie, and the cure is completed in the usual time, while the rotundity
of the shoulder is preserved. This operation is similar to that already
recommended for the amputation at the joint, which in many cases it is
intended to supersede.
116. _Excision of the head of the humerus._--The point governing the
modus operandi of this operation is, and ought to be, the fact that,
under the most favorable state of recovery which can take place, the
shoulder-joint usually becomes so stiff that its ordinary motions may
be considered to be lost. Operative processes which have for their
principal object the sparing of the deltoid muscle are unnecessary,
for, if spared, it is as useless as if it had been cut; and it seems to
have been forgotten that, when cut, it reunites, and becomes nearly as
strong as before it was injured. It is the joint that cannot be moved,
not the muscle which has lost its power. I prefer, therefore, in doing
this operation, in cases of some standing, to make a _short_ crescentic
flap by an incision across the anterior part of the shoulder, as in the
operation of amputation, which, on being turned up, leaves the joint
exposed. The edge of the knife being applied to the head of the bone
in a line below, but immediately under the acromion process, divides
the capsular ligament, and with it the long tendon of the biceps, on
which the arm drops from the socket, or glenoid cavity, and allows the
finger to be introduced, when the three muscles inserted into the great
tuberosity may be cut through, and the sub-scapularis inserted into the
small tuberosity will also be divided. The head of the bone is then
readily brought out, and may be easily detached from any surrounding
connections, and sawn off with little or almost no loss of blood. The
elbow is to be supported, so as to bring the end of the sawn bone in
apposition with the glenoid cavity. The flap may be allowed to unite
with the parts below as soon as it will, the shot-holes, if any, being
in general sufficient to allow of such discharge as may be necessary.
In cases of _recent_ injury, considerable aid will be obtained in
keeping the sawn end of the humerus in apposition with the glenoid
cavity, by not dividing the long tendon of the biceps. This must be
done by dissecting it out of its groove in the humerus, between the
tuberosities, and by cutting through the capsular ligament vertically,
so as to follow it up to its attachment to the upper edge of the
glenoid cavity, when it may be easily drawn aside with a blunt hook,
until the operation has been completed--a proceeding difficult of
accomplishment in old cases of disease or injury, and in them not
necessary nor advisable.
The accompanying sketch shows the head of the humerus of the right
arm or side, with a ball lodged in it, a relic from Inkerman, sent to
me as an especial mark of attention by one of the medical officers
at Scutari, but without the name of the man, the regiment he belonged
to, or the surgeon who performed the operation for its removal. The
following account was wrapped round the bone. It commences a day or two
after the operation was done at Scutari, and shows that the man died
from an affection of the lungs, not uncommon, as was first shown during
the late war, after operations following extensive suppurations:--
[Illustration:
_a._ The head of the humerus sawn off below the tuberosities.
_b._ The ball.
_c c._ Fractures of the head of the bone.]
“Pulse soft, 120. He passed a rather restless night, although he had
another opiate at one A.M., and partially removed the dressings. In
the morning he was better; he took some tea and a little wine with
arrow-root, but was very much depressed in spirits. The wound looked
well, there being less discharge, and of a more healthy character;
no increased inflammation around the wound, but no tendency to union
by the first intention on removal of the stitches. He was put upon
farinaceous diet, with four ounces of wine and beef-tea. He continued
to do well till the evening of the 16th, when he complained of
tightness of the chest and slight cough. Harshness of respiratory
murmur and increased vocal resonance, but no crepitation, could be
detected on the right side on auscultation; he complained also of
pain in the hypogastrium and slight diarrhœa. At bedtime he had a
sedative antimonial draught, after which he rested well, but perspired
profusely. On being particularly questioned, he admitted that he had
had diarrhœa several times since landing at Varna, and had had bloody
stools after the battle of Alma, for which, however, he had never been
off duty; he had also frequently been troubled with cough, and two
of his family, he understood, died of consumption. For two days he
continued to improve in spirits, to take his food better, and the wound
assumed a healthy granulating appearance, but a very small portion
of the end of the humerus appeared white, as if going to necrose. On
the evening of the 18th his breathing was more oppressed, and his
countenance flushed and anxious. On examination of the chest, the
lower two-thirds of the right lung were dull on percussion; bronchial
breathing in the lower half, with crepitation above; in the left lung
loud sub-crepitus; diarrhœa had also supervened during the day, but was
checked for the time by an opiate enema. From this date his strength
gradually sank; the diarrhœa returned again and again, in spite of
repeated opiate enemata and small doses of Dover’s powder with hyd. c.
cretâ. The surface of the wound assumed a less healthy appearance; the
respiration became more labored, and he gradually sank till Saturday,
November the 25th, when he died at half-past ten A.M.
“On examination of the head of the bone, after its removal, there was
found an irregular, rugged cavity in the cancellated tissue, about
an inch long, by half an inch broad, extending nearly transversely
from the smaller to the greater tuberosity, and above the latter a
musket-ball was found deeply imbedded, its external convex surface
being on a level with the articular cartilage. From this several small
fissures radiated over the globular head, and from each end of the
cavity a much deeper one extended round the anatomical neck, separating
the articular portion of the bone, in two-thirds of its circumference,
from the shaft.
“At the post-mortem examination, the surface of the wound looked
black and sloughy near the seat of injury, but more healthy in the
direction of the incisions. A small portion of the end of the humerus
was of a pearly white, in progress of necrosing; but around the shaft,
immediately below this, and in the glenoid cavity, the process of
repair had commenced. Both lungs were found engorged with frothy
serum; the lower two-thirds of the right lung hepatized; traces of
old tubercle in apices of both lungs, with miliary tubercle scattered
throughout the whole substance of the left and upper part of the right.
The whole tract of the colon, from the cæcum to the rectum, presented
traces of ulceration, the ulcers being seldom larger than a split pea,
with hardened, elevated edges; the bases in some instances were formed
by the peritoneum only; generally they were scattered irregularly,
but occasionally they were found in rows corresponding to the long
diameter of the gut. In the rectum the ulceration was more extensive,
in some parts the size of a farthing, the edges very irregular, and the
direction more transverse.” These appearances precisely resemble those
observed during the autopsy in cases of death from consumption, and are
not therefore peculiar to the dysentery under which he had suffered.”
117. Professor B. Langenbeck, in order to save the deltoid muscle,
proposed and practiced the operation in the following manner, during
the Danish war in Sleswick-Holstein, with success in several instances:
Begin the incision through the integuments and deltoid muscle
immediately below the anterior border of the acromion, and continue
it directly downward, over the minor tuberosity of the humerus, to
the extent of four inches. Separate the parts, open the sheath of the
long tendon of the biceps muscle, and draw out and hold it on one side
with a blunt hook. Rotate the arm outward, (_if it will rotate_,) to
facilitate the division of the tendon of the sub-scapularis; then
rotate the arm inward, to aid in the division of the tendons of the
supra-spinatus, infra-spinatus, and teres minor muscles, inserted into
the great tuberosity. Complete the division of the capsular ligament,
push the bone through from below, using the arm as a lever if you can,
and saw it off. No arteries of consequence are wounded.
This operation would not be so easy of execution as is supposed, in
cases in which the head and neck of the humerus are broken from the
shaft; it would be very difficult of execution in old cases in which
the soft parts are so hardened and impacted as to admit of little or no
motion.
The extent to which the shaft of the humerus may be removed with the
head cannot be distinctly defined. The greater the distance, the less
will be the chance of the bone uniting to the glenoid cavity, in such
a manner as to render it a useful limb, whether by the formation of
a ginglymoid joint, or by anchylosis. In the present state of our
knowledge the bone should not be sawn lower than the insertion of the
deltoid muscle. If the arm were preserved by an operation below that
part, it is probable that the bone, however supported, would not become
attached to the glenoid cavity. It might however become useful, by some
artificial help, as has occurred in cases of false joint in the middle
arm, after ununited fractures.
118. Excision of the head of the humerus is not to be done in every
instance of compound fracture of that bone, as the following cases will
show:--
Lieutenant Madden, 52d Regiment, was wounded at the assault of Badajos
in 1812, by a musket-ball, which fractured the head of the humerus,
and lodged in it. The broken pieces were from time to time removed
by incisions, together with the ball, and he ultimately preserved a
very serviceable arm. He is now a very zealous member of the Church of
England.
Robert Masters, 40th Regiment, was wounded at the battle of Toulouse,
on the 12th of April, 1814, by a musket-ball in the right shoulder,
which lodged in the head of the bone. Shown to me a few days afterward
as a case for amputation at the shoulder-joint, I directed the excision
of the head of the bone as soon as the parts became more quiescent.
Under venesection, purgatives, leeches, the constant application of
cold, and low diet, the high inflammatory symptoms which had supervened
subsided, and, six weeks after the accident, the ball, and part of
the head of the humerus, were removed, after an incision had been
made through the external parts for the purpose. Three mouths after
the receipt of the injury, the man was sent to England, with no other
inconvenience than that resulting from the loss of motion in the
shoulder, which was stiff. The use of the forearm was preserved, and a
limited one of the upper arm, by moving the shoulder-bone on the trunk.
Private Oxley, 23d Regiment, was wounded at the battle of Toulouse, in
April, 1814, by a musket-ball, which entered at the anterior edge of
the deltoid muscle, passed across the head of the humerus, injuring
it in its course, and went out near the posterior edge of the muscle,
through which, at its middle part, the deficiency in the rotundity of
the head of the humerus could be distinctly felt. Shown to me a few
days afterward as a slight but peculiar wound, it was marked as a case
for excision, if circumstances should render it necessary. No bad
symptoms, however, supervened; the man only complained of the restraint
put upon him, and the lowness of his diet. Some pieces of bone came
away, or were removed, and in July he was sent to England, the wound
being healed and free from pain; the shoulder stiff. The lower arm he
used as before the accident.
General Lord Seaton suffered from a nearly similar wound, at the taking
of Ciudad Rodrigo, and recovered with a good use of his arm.
These cases were fortunate in their results, but such do not always
follow. Major C. was wounded in one of the battles in the Pyrenees,
in 1813, by a musket-ball, which injured the head of the left humerus
from side to side. Thirty years afterward the wounds still discharged,
and gave him great uneasiness. A probe discovered much diseased bone.
I advised the excision of the head of the bone, to which he would not
assent. His courage had been broken by continued suffering.
Ensign Moore, of the Bengal army, was wounded at Sobraon, on the 10th
February, 1846, by a musket-ball, which passed through the anterior
and inner part of the deltoid muscle, one inch and a half below the
inner part of the acromion process, struck and went through the head of
the bone, which it splintered, and made its exit behind, in front of,
but near the inferior angle of the scapula. He remained in camp three
days, and was sent to hospital at Ferozapore, where he suffered much
from inflammation, pain, etc., and after a month was sent to Subaltro
in the Hills, where some pieces of bone came away, during which time
he suffered severely, and was much weakened by it and the discharge.
On the 20th October, 1846, he was removed to Bunda, in Bundeleund;
here more bone came away, accompanied by much discharge. Thence
he proceeded in April, 1847, to Juanpore, where he suffered three
attacks of inflammation, two of them very severe; the constitutional
disturbance was great. The posterior wound was reopened, and a large
quantity of offensive matter discharged. On the 7th of August, 1847,
the suppuration is stated to have been still great, and the strength
very much reduced, on which account he was recommended to proceed to
Europe. On the 9th June, 1848, the wounds were healed, the last piece
of bone having come away about ten days before. The pieces of bone
are from the head and from the part adjoining. The head of the bone
is greatly diminished in size, so much so as to appear to have been
almost entirely removed; the joint is stiff, if not anchylosed, the
shoulder flat, the under use of the arm perfect, that of the upper
part dependent on the motion of the shoulder-blade. The removal of the
head of the bone, immediately after the receipt of the injury, would
have been the best course to have pursued, for the arm when the cure
took place was not in a better state than it would have been in if the
operation had been performed at first, and the patient would have been
spared two years of great suffering, not unattended with considerable
danger.
M. Baudens, in a very able paper, an extract of which, made by himself,
is published in the “Comptes Rendus” of the French Academy of Sciences,
for February, 1855, on the Resection of the Head of the Humerus, seems
to have overlooked, or not to have seen, the foregoing observations,
as he assumes, as a consequence of his own observations on fourteen
primary cases of which one only died, that the resection of the head of
the humerus ought to be the rule in surgery when a ball has broken this
part, and that amputation of the limb should be the exception--a point
long since settled in my surgical works.
He considers that surgical writers in general have supposed that the
bone remains suspended in the middle of the muscles, which does not
accord with his practice, nor with the remarks made by me on this
subject.
He recommends the following mode of operating: The arm being slightly
turned outward and backward, the point of a small, straight amputating
knife is to be entered on the outside of the coracoid process,
immediately over the head of the humerus; lower the hand and carry the
point of the knife in a straight line for ten or twelve centimeters
downward, always applied to the bone, which serves as a guide.
If the incision thus made should not be large enough to expose the head
of the humerus, a transverse subcutaneous one should be made through
the muscular fibers toward the superior angle. If it be sufficiently
large and open, this is not necessary. The long tendon of the biceps
will be seen at the bottom of the incision, and is to be cut across.
Bring opposite the incision, by rotating the arm, first the great
tuberosity, then the smaller one, in order to divide the four
muscles attached to them. The division of these parts will largely
open the joint, when the elbow being carried backward and upward,
the head of the bone will protrude. Detach gently the periosteum,
slip the chain saw behind and below the head of the bone, so as to
leave the periosteum as much uninjured as possible, doing in fact a
sub-periosteal extirpation.
Tie the vessels, cover the upper end of the humerus with the periosteum
thus saved like a hood, and keep it in contact with the glenoid cavity.
He maintains that when a ball has broken the head of the humerus, if
the removal of the head be not effected, one of three things follows:
the operation is performed subsequently, or the patient dies of
purulent deposits, or recovers with a stiff joint, accompanied by
fistulous openings of a disagreeable nature.
He contends that a ginglymoid joint is always formed by his method,
which enables the sufferer to make much greater use of it than if
the operation were performed in any other way; but it will be very
difficult of performance if the bone should be so much injured as to
prevent the tuberosity following the motion to be given to the elbow,
and is not therefore recommended.
119. If, from some complication of injury, the axillary or other artery
should give way during the treatment, the extremity is not to be
amputated. The artery is to be secured by one ligature applied above
the opening in it and by another below it, the surgeon always bearing
in mind the fact that the proper way to get at the axillary artery is
by cutting _across_ the fibers of the pectoral muscle, and not in their
direction, and that it will be better to amputate the arm than to tie
the subclavian artery above the clavicle.
120. _Amputation of the arm_ by the common circular incision should
only be practiced in the space between the lower edge of the insertion
of the pectoralis major and the elbow-joint; and rarely in cases of
injury from musket-balls. No common flesh-wound, made either by cannon
or musket-shot, even including a division of the artery, absolutely
demands this operation, the bone being uninjured. If, in addition to a
destructive flesh-wound, the bone be broken, or if it be mashed with
the muscles by an oblique stroke of a round shot, or the forearm be
carried away or destroyed, it is admissible. It is to be done in the
following manner: An assistant draws up the integuments with both
hands; another does the same downward, if the parts admit of it; the
forearm is to be moderately bent. The integuments are to be divided
by a circular incision, and retracted. The muscles and vessels are
then to be cut through by one sweep of the knife, if it can be done.
The muscles adhering to the bone are next to be separated from it to
the extent of two inches. The retractor is to be applied, and the
periosteum divided by one circle of the knife around the bone, and
in the circle thus cut the saw is to work until the bone is divided;
attention being paid to the directions already given to saw in a
perpendicular, not slanting direction. The artery or arteries are to be
tied, the surface of the stump cleansed with warm and then with cold
water, and dried. Leaden sutures are useful.
121. Mr. Luke performs the operation by two flaps on the same principle
as in the thigh. There is a close resemblance in the manner of
amputating the arm by the double-flap operation to that adopted for
the amputation of the thigh. The first flap is made posteriorly to the
bone, by transfixing the limb, for which purpose the knife is entered
at the mid-point between the anterior and posterior surfaces, carried
transversely across the limb, and made to cut toward the posterior
surface, in an oblique direction, until all the soft structures are
divided. It is necessary, in entering the knife, to bear in mind that
the bone lies opposite to the mid-point, and that, in carrying the
knife across the limb, it would strike against the surface of the
bone, unless means were adopted for its prevention. This is easily
done by grasping the structures which are to form the posterior flap
between the fingers and thumb of the left hand, and by drawing them
backward during the time the knife is entering at the mid-point and
being carried across the limb. Having formed the posterior flap, the
anterior one is formed as in amputation of the thigh, by cutting inward
from the surface toward the bone with a sweep, which will make this
flap equal in length to the posterior. The operation is completed by
dividing the remaining soft parts by means of a cut carried circularly
around the bone, and by sawing the bone in the line of division. The
after-treatment is the same as in the thigh.
122. _Excision of the elbow-joint._--An incised wound of moderate
extent into the elbow-joint, cutting off with it a part of the condyle
of the humerus, or the head of the radius, or a part of the ulna,
demands the removal of the injured piece of bone only. The forearm
should be bent, and the antiphlogistic treatment fully carried out.
A ball fracturing the olecranon, or other portion of a single bone,
although opening into the joint, does not immediately require any
operation.
If a ball should lodge in the lower part of the humerus, or in either
of its condyles, it should be removed as quickly as possible by the
trephine, or other appropriate instrument.
When the articulating ends of the humerus, radius, and ulna are wholly
or in part injured by a musket-ball, it was formerly the custom to
amputate the arm in such instances of great mischief--an operation
which should be superseded by that of excision of the joint, by which
the forearm will be saved, and considerable use of it retained.
To perform this operation, a straight, strong-pointed knife is to
be pushed into the joint behind, immediately above but close to the
olecranon process, and exactly at its inner edge, to avoid the ulnar
nerve, which lies between it and the inner condyle, to which it may
be considered to be affixed. The incision thus begun is to be carried
outwardly to the external part of the humerus, dividing the insertion
of the triceps. At each end of this transverse cut an incision is to
be made upward and downward for about two inches each way, the three
resembling the letter =H=. The flaps thus made being turned up and
down, the olecranon should be sawn across, together with the great
sigmoid cavity and the coronoid process of the ulna, the insertion
of the brachialis internus having been previously separated from the
coronoid process. Before this is done, the ulnar nerve should be
separated with its attachments from the inner condyle, and turned
aside to avoid injury. The joint being now fully exposed, the head
of the radius may be sawn off or cut through with the strong spring
scissors if possible, above the tubercle into which the biceps tendon
is inserted. The extremity of the humerus should next be pushed through
the wound, and the broken end sawn off, a spatula or other thin
solid substance being placed underneath it, to prevent the brachial
artery or median nerve being injured. Any hemorrhage which there may
be having ceased, the forearm is to be bent, the bones are to be
placed in apposition, and the incisions approximated by sutures and
sticking-plaster, duly supported by compress and bandage, so that
union may take place if possible, particularly of the transverse wound
first made. The arm should be supported by a sling, and dressed early,
as the shot-hole or holes must remain open and discharging. Some motion
of the new joint to be formed may be expected under gentle passive
movements; but as a stiff joint cannot always be avoided, the arm
should be kept bent.
123. _Amputation of the elbow-joint_ has been recommended, but not
frequently performed. It may be done in any way by which good covering
can be obtained, and it has been supposed that the long stump thus
made is more useful if the olecranon process be sawn across, and left
with the triceps attached to it, than if it be removed. When the parts
are sound, a flap may be made in front by introducing a straight,
double-edged knife over the outer condyle, and carrying it across and
through the soft parts over the opposite or inner condyle, when by
cutting downward and outward a flap is to be formed of from three to
four fingers’ breadth in length. A shorter flap is to be made behind,
when both are to be raised, and the bleeding vessels previously
secured, the external lateral ligament being divided. The radius is to
be separated from the humerus, when the olecranon may be sawn across,
or, if the arm be bent, separated from the humerus without difficulty.
The flaps are to be brought together and retained in the usual manner.
124. _Amputation of the forearm_ is seldom required after wounds from
musket-balls. The bones can be readily got at, and large pieces removed
with ease. The arteries can be cut down upon and secured without
difficulty, except at the upper part, and even there with some little
sacrifice of muscular parts, which are not to be spared. The fascia
may be divided freely in every direction, and as mortification from
defect of nourishment rarely takes place in the fingers, as it does in
the toes, when the great arteries of the limb have been injured, every
effort should be made to save a forearm, however badly it may at first
appear to be injured.
The flap operation is to be preferred to the circular, particularly
when done a little above the wrist; to which operation Baron Larrey
and the surgeons of France particularly objected during the late war.
Having done it most successfully since 1806, however, it is recommended
as preferable to any other, even when the injury admits of its being
done neat the carpus. When the nature of the injury does not admit of
two equal flaps being formed, it must be done by two unequal ones, or
even by one, it being important for the fixing of an artificial hand or
other help to have a long stump.
The arm being placed and held firmly in the intermediate position
between pronation and supination, with the thumb uppermost, so that the
radius and ulna are in one line, a sharp-pointed straight knife is to
be entered close to the inner edge of the radius, and brought out below
at the inner edge of the ulna. It is then to be carried forward for
half an inch, and made to cut its way out with a gentle inclination, so
as to form a semicircular flap. Re-entered at the same point as before,
a similar flap is to be made on the outside, the position of the bones
being a little altered to admit of its easy execution. The two flaps
are to be turned back; the tendon of the supinator radii longus, and
all other tendinous, muscular, or interosseous fibers, not cut through,
are then to be divided, and the linen retractor run between the bones,
which are to be sawn across at the same time. All pressure being taken
off, the tendons and the vessels, if long, are to be cut short, and the
arteries to be tied, after which the flaps are to be brought together
by sutures, and retained by sticking-plaster, compress, and bandage.
125. When the operation is to be performed above the middle of the arm,
it may be done by the _circular_ incision.
The arm being placed with the thumb uppermost, an assistant should
retract the integuments as much as possible, while the operator makes
a circular incision through them. They are then to be drawn up for
nearly an inch. The muscles on the inside of the arm should be divided
by one slanting cut to the bones; then those on the outside. The bones
are to be cleared by cutting through any muscular fibers attached to
them, when the interosseal ligament should be divided, and the linen
retractor passed between the bones, which may be sawn through at the
same time without difficulty. The stump is to be dressed in the usual
manner. The operation may be done by cutting through the integuments
and muscles at once in an oblique manner, until the flaps thus formed
shall be sufficiently large to make a thick cushion over the ends of
the bones.
126. _Amputation at the wrist_, or the joint of the radius and ulna
with the first row of the bones of the carpus, has been recommended
by some surgeons as preferable to amputation above the ends of the
radius and ulna. The hand being placed midway between pronation and
supination, the soft parts are to be divided by a circular incision
beginning from half an inch to an inch below the ends of the radius and
ulna. The integuments being turned up without the tendons, they are
to be divided, and the joint is to be opened into before the spinous
process of the radius; and, while the hand is pressed down, the knife
should divide all the soft parts, and separate the carpus from the
radius and ulna. The wound is to be closed by sutures in the usual
manner. When a circular incision cannot be made, in consequence of the
nature of the injury, and this operation is still preferred, a covering
for the bones must be obtained wherever it can be procured, by one or
more flaps.
127. _In all injuries of the hand_, the value of a thumb and a finger,
or of two fingers, or even of one, should be borne in mind, and no part
should be removed that can be saved, and appears likely to be of use.
When cannon-shot, large splinters of shells, or grape-shot have struck
the hand, amputation will often be necessary; but the foregoing precept
should never be forgotten.
A musket-ball fairly passing through the hand generally fractures two
metacarpal bones, although a small ball may pass between them without
breaking either. The wounds should be enlarged, and the broken ends of
the bone sawn off, or the splinters removed, and the points of bone
smoothed off, the tendons to be carefully preserved, and vigorous
antiphlogistic measures adopted. The tendency to tetanus or trismus
will be best obviated by such measures, the incisions, when necessary,
being made in the direction of the bones and tendons. Any hemorrhage
which can ensue will be readily commanded by ligature, by torsion of
the vessel, or by a small graduated compress and bandage, when those
are inapplicable. Injuries by musket-balls to the metacarpal bones
rarely take place without implicating one or more flexor or extensor
tendons, and the consequence is that the fingers to which they belong
are often bent inward toward the palm, constituting a defect less
inconvenient, however, than if the finger remained straight and
immovable.
128. When one or more fingers are destroyed, and the metacarpal bones
injured, they are to be sawn or cut off, but not removed at the carpus,
although an opening into the joint of the carpus will generally do
well, if skin can be saved to cover it. In all cases of amputation of
one or more fingers, the metacarpal bones, if injured, should be left
as long as possible, and particularly that of the index finger, when
the thumb remains. In all cases it is better, if possible, to leave
the heads of the metacarpal bones in their places, rather than open
into the joint of the carpus, if it can be avoided. If the articulating
heads must come out, a strong, thin scalpel is to be pushed in between
the bones, the ligaments cut through above, below, and at the sides,
and care should be taken, in removing one or two of these bones, not
to dislocate the others, and the joint should be covered by a flap or
flaps made for the purpose, the sides of the remaining fingers being
covered in a similar manner. This succeeds admirably, when the two
outer bones and fingers only are taken away.
129. _The phalanges_ of the fingers may be removed by making a flap
from the upper or under part, or from both, or from the sides. The
square flap from the upper part of the finger is preferable, when the
joint with the metacarpal bone is to be operated upon, the commencing
points of the flap being united by a transverse incision on the
under part of the joint. It should be recollected, that in all these
excisions the larger end of bone belongs to that which is not removed,
as may be shown by bending the finger; and that the ligamentous
attachment between the metacarpal bones, connecting a middle one to
its fellows on each side, should be cut through, when the joint will
be easily dislocated. Attention should be paid to the division of the
lateral ligaments, in the removal of any of the bones of the fingers.
Professor B. Langenbeck has operated in some instances, and he says
successfully, without the loss of the finger, by sawing off, in his
first case, the articulating ends of the first phalanx and of the
metacarpal bone of the forefinger, in consequence of an injury from
a rotating piece of machinery; in another, the ends of the first and
second phalanges of the middle finger after a severe laceration; and in
a third case, by sawing off the end of the second phalanx, and removing
the whole of the bone of the third of the forefinger from the soft
parts, leaving the nail; the man recovering with a shortened but useful
finger. In all these cases the flexor and extensor tendons were from
the first uninjured.
M. Langenbeck has also removed the metacarpal bone of the thumb in the
following manner: “An incision is to be made along the whole length of
the bone toward the palmar aspect, thus avoiding the tendons. Then free
both articulating extremities, separate the soft parts from the body
of the bone, which is to be drawn outward by a strong pair of forceps,
with two bent points or teeth at each extremity. To prevent the
shortening or drawing inward of the thumb, it is to be kept straight
and duly extended by a splint and other apparatus.” He recommends, with
Flourens, the preservation of as much as possible of the periosteum,
and uses for its detachment a small curved knife with a square end.
Separating the periosteum from the bone is more easily directed than
done. Professor Quekett, at my request, made some trials on the humerus
to ascertain the point, and found that the periosteum could not be
separated from the cartilaginous covering of the head of the bone, in
the manner proposed, although it could be done by scraping half an inch
below the insertion of the capsular ligament, and a sufficient portion
saved to cover the sawn end of the bone, in the manner recommended by
M. Baudens.