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

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.