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

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:—

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.”