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

The arm being placed with the thumb uppermost, an assistant should retract the integuments as much as possible, while the operator makes a circular incision through them. They are then to be drawn up for nearly an inch. The muscles on the inside of the arm should be divided by one slanting cut to the bones; then those on the outside. The bones are to be cleared by cutting through any muscular fibers attached to them, when the interosseal ligament should be divided, and the linen retractor passed between the bones, which may be sawn through at the same time without difficulty. The stump is to be dressed in the usual manner. The operation may be done by cutting through the integuments and muscles at once in an oblique manner, until the flaps thus formed shall be sufficiently large to make a thick cushion over the ends of the bones.

126. Amputation at the wrist, or the joint of the radius and ulna with the first row of the bones of the carpus, has been recommended by some surgeons as preferable to amputation above the ends of the radius and ulna. The hand being placed midway between pronation and supination, the soft parts are to be divided by a circular incision beginning from half an inch to an inch below the ends of the radius and ulna. The integuments being turned up without the tendons, they are to be divided, and the joint is to be opened into before the spinous process of the radius; and, while the hand is pressed down, the knife should divide all the soft parts, and separate the carpus from the radius and ulna. The wound is to be closed by sutures in the usual manner. When a circular incision cannot be made, in consequence of the nature of the injury, and this operation is still preferred, a covering for the bones must be obtained wherever it can be procured, by one or more flaps.

127. In all injuries of the hand, the value of a thumb and a finger, or of two fingers, or even of one, should be borne in mind, and no part should be removed that can be saved, and appears likely to be of use. When cannon-shot, large splinters of shells, or grape-shot have struck the hand, amputation will often be necessary; but the foregoing precept should never be forgotten.

A musket-ball fairly passing through the hand generally fractures two metacarpal bones, although a small ball may pass between them without breaking either. The wounds should be enlarged, and the broken ends of the bone sawn off, or the splinters removed, and the points of bone smoothed off, the tendons to be carefully preserved, and vigorous antiphlogistic measures adopted. The tendency to tetanus or trismus will be best obviated by such measures, the incisions, when necessary, being made in the direction of the bones and tendons. Any hemorrhage which can ensue will be readily commanded by ligature, by torsion of the vessel, or by a small graduated compress and bandage, when those are inapplicable. Injuries by musket-balls to the metacarpal bones rarely take place without implicating one or more flexor or extensor tendons, and the consequence is that the fingers to which they belong are often bent inward toward the palm, constituting a defect less inconvenient, however, than if the finger remained straight and immovable.

128. When one or more fingers are destroyed, and the metacarpal bones injured, they are to be sawn or cut off, but not removed at the carpus, although an opening into the joint of the carpus will generally do well, if skin can be saved to cover it. In all cases of amputation of one or more fingers, the metacarpal bones, if injured, should be left as long as possible, and particularly that of the index finger, when the thumb remains. In all cases it is better, if possible, to leave the heads of the metacarpal bones in their places, rather than open into the joint of the carpus, if it can be avoided. If the articulating heads must come out, a strong, thin scalpel is to be pushed in between the bones, the ligaments cut through above, below, and at the sides, and care should be taken, in removing one or two of these bones, not to dislocate the others, and the joint should be covered by a flap or flaps made for the purpose, the sides of the remaining fingers being covered in a similar manner. This succeeds admirably, when the two outer bones and fingers only are taken away.

129. The phalanges of the fingers may be removed by making a flap from the upper or under part, or from both, or from the sides. The square flap from the upper part of the finger is preferable, when the joint with the metacarpal bone is to be operated upon, the commencing points of the flap being united by a transverse incision on the under part of the joint. It should be recollected, that in all these excisions the larger end of bone belongs to that which is not removed, as may be shown by bending the finger; and that the ligamentous attachment between the metacarpal bones, connecting a middle one to its fellows on each side, should be cut through, when the joint will be easily dislocated. Attention should be paid to the division of the lateral ligaments, in the removal of any of the bones of the fingers.

Professor B. Langenbeck has operated in some instances, and he says successfully, without the loss of the finger, by sawing off, in his first case, the articulating ends of the first phalanx and of the metacarpal bone of the forefinger, in consequence of an injury from a rotating piece of machinery; in another, the ends of the first and second phalanges of the middle finger after a severe laceration; and in a third case, by sawing off the end of the second phalanx, and removing the whole of the bone of the third of the forefinger from the soft parts, leaving the nail; the man recovering with a shortened but useful finger. In all these cases the flexor and extensor tendons were from the first uninjured.

M. Langenbeck has also removed the metacarpal bone of the thumb in the following manner: “An incision is to be made along the whole length of the bone toward the palmar aspect, thus avoiding the tendons. Then free both articulating extremities, separate the soft parts from the body of the bone, which is to be drawn outward by a strong pair of forceps, with two bent points or teeth at each extremity. To prevent the shortening or drawing inward of the thumb, it is to be kept straight and duly extended by a splint and other apparatus.” He recommends, with Flourens, the preservation of as much as possible of the periosteum, and uses for its detachment a small curved knife with a square end. Separating the periosteum from the bone is more easily directed than done. Professor Quekett, at my request, made some trials on the humerus to ascertain the point, and found that the periosteum could not be separated from the cartilaginous covering of the head of the bone, in the manner proposed, although it could be done by scraping half an inch below the insertion of the capsular ligament, and a sufficient portion saved to cover the sawn end of the bone, in the manner recommended by M. Baudens.

LECTURE VII.

SECONDARY AMPUTATIONS, ETC.