Operation.—Though perhaps not the easiest, the following method is the one followed by the best results. It is suited especially for cases of caries or other disease of the joint, where the head of the humerus is either alone or chiefly affected:—
A single straight incision ([Plate I.] fig. a.) is made from a point just external to the coracoid process downwards along the humerus for at least three inches. It corresponds almost exactly to the bicipital groove, and has the advantage of avoiding the great vessels and nerves. The long head of the biceps may then be raised from its groove, and drawn to a side so as to be preserved. This is deemed of importance by Langenbeck and others. Mr. Syme, however, did not attach much value to its preservation, as it is often diseased. The capsule, which is often much altered, perhaps in part destroyed, is then opened, and the tendons of the muscles which rotate the head of the humerus divided in succession, while the elbow is rotated first inwards and then outwards by an assistant so as to put them on the stretch. The arm being then forced backwards, the head of the bone can be protruded through the wound, and sawn off at the necessary distance down the shaft. The glenoid must then be carefully examined, and any diseased bone removed by the cutting pliers. One or two small branches supplying the anterior fold of the axilla are the only vessels divided, and may not even require ligature, unless, indeed, from necrosis, or to remove a tumour, a larger portion of the humerus than usual has been removed. If the limit of capsule has been infringed on below, the circumflex vessels may probably be cut, in which case the bleeding may be considerable.
N.B.—In cases of fracture of neck of humerus, or of compound gunshot injury, or where the head has been separated by necrosis from the shaft, or where, as has happened to Stanley and others, the bone broke in the endeavour to tilt the head out, the surgeon will require to seize the detached head with strong forceps, and dissect it out with care.
Other methods of Resection.—When from great thickening and induration of the soft parts, enlargement of the head of the bone, or other reason, the straight incision may be deemed insufficient for the purpose (and we may remark that there are comparatively few cases in which it is insufficient), access may be obtained to the joint by raising a flap from the deltoid ([Plate III.] fig. a). Its shape—V-shaped, semilunar, or ovoid—is not of much consequence, for there are no great nerves or vessels to wound on the outside of the joint, and the surgeon should be guided, as in all other operations on the joint, very much by the position of any pre-existing sinuses. This flap being raised upwards towards its base, very free access is gained to the joint.
In these cases, fortunately comparatively rare, in which there is reason to believe that the glenoid is chiefly involved in disease, and yet that the disease can be removed without amputation, access will be gained most easily by an incision ([Plate III.] fig. b.) on the posterior surface of the joint, corresponding in size and direction to the linear incision in front. This gives a much easier mode of access to the glenoid. I have seen this practised in one very remarkable case by Mr. Syme, in which the glenoid cavity and neck of the scapula were extensively diseased, while the head of the bone was quite sound.
After-treatment is exceedingly simple; for the first day or two the shoulder is to be supported on a pillow with a simple pad in the axilla, if there is any tendency for the arm to drag inwards; after this the patient should be encouraged to sit up and move about with his arm in a sling, the elbow hanging freely down.
Results.—Hodge records ninety-six cases in which this excision was performed for gunshot injury, of which twenty-five proved fatal, and fifty for disease, of which only eight died,—results which are more encouraging than those of amputation at the shoulder-joint for disease; though for injury the mortality is much greater than Larrey's famous Statistics of Amputation, q.v. p. 65.
Spence had thirty-three cases, with three deaths. He generally made a counter-opening behind to get rid of discharges, and inserted a drainage-tube.
Gurlt's statistics of excision for gunshot injury give of 1661 cases 1067 recoveries, 27 doubtful results, and 567 deaths, the mortality being 34.70 per cent.
Excision of the Elbow-Joint—In what cases should it be performed?—1. For disease of the elbow-joint which has resisted ordinary remedies, and is wearing down the patient's strength, including caries, ulceration of cartilages, and gelatinous synovial degeneration.