Part 13
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:--
“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.