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

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.