For example, an accident which necessitates amputation so high up has, in all probability, opened into the joint and destroyed the soft parts on at least one aspect; in such a case the flaps must be cut from the uninjured soft parts only. If an aneurism has rendered amputation through it and through the joint a last resource, the flap must be gained chiefly at least from the outside; a malignant tumour of the humerus will almost certainly prevent any transfixion, and require flaps to be made by dissection, wherever the skin is least likely to be involved. Again, some of the most vaunted and most rapid operations almost require for their success the integrity of the humerus, which has to make itself useful as a lever in disarticulation, while in most cases of accident we are amputating for compound injury of the humerus, almost certainly implying fracture with comminution.
From its proximity to the trunk, hæmorrhage is one of the chief dangers to be apprehended during this operation, especially from the axillary artery. As far as possible to obviate this danger, most plans of operating are based on the principle that the vessels and nerves should be the last tissues to be cut; in some they are not divided till after disarticulation.
While a good assistant, to make pressure on the subclavian above the clavicle, is a most advisable precaution, too much must not be trusted to this pressure above, as the struggles of the patient and the spasmodic movements of the limb, which are so apt to occur under the stimulus of the knife, are apt to render futile the best efforts at compression.
The operator should trust rather to making the incisions in such a manner that the great vessel be not divided till the hand of an assistant, or in default of a suitable one, his own left hand, is able to follow the knife and grasp the flap.
The bleeding from the circumflex, subscapular, and posterior scapular arteries can easily be arrested by a dossil of lint till the great vessel is tied, and they can be secured.
In cases where proper assistants cannot be had, temporary closure of the axillary vessel could easily be made by carrying a strong silver wire or silk ligature completely round the vessel by a curved needle before the incisions are commenced, and by tying this firmly over a pad of lint.
Pressure on the artery above the clavicle is best made by the thumb of a strong assistant, who endeavours to compress it against the first rib; where the parts are deep and muscular, the padded handle of the tourniquet, or of a large door-key, will do as the agent of pressure.
A brief notice of three of the best methods of operating will be quite sufficient to show what should be aimed at in shoulder-joint amputations:—
1. In cases where the surgeon can choose his flaps, the following method will be found the most satisfactory, as resulting in the smallest possible wound, in having less risk of hæmorrhage during the operation than any other method, and in providing excellent flaps.
It is Larrey's method slightly modified.