Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands / from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

by G. J. Guthrie

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.