—This includes removal not only of the arm, but of the scapula and clavicle as well, or at least its outer portion. It is not often required, and inasmuch as the circumstances which justify it are seldom duplicated, a suitable method for each individual case should be planned, rather than try to make one set of directions cover them all. Much will depend upon whether sufficient skin can be saved in order to cover the large defect thus made. In general, however, an incision should first be made along the clavicle, exposing it and dividing it near its middle. It is convenient to take out the middle portion at this time, and in this way to afford ample room through which a proximal ligation of the subclavian vessels may be made, they being here carefully dissected out, secured by double ligation, and divided. From the outer part of the above incision another is carried downward and outward toward the deltoid groove and then beneath the axilla to its posterior margin. The posterior flap is then furnished by an incision continuous with the last one, which terminates below about opposite the lower angle of the scapula, and is then continued upward along the inner scapular border and over the shoulder until it reaches the outer end of the incision first made. In this manner will be furnished a sufficient covering. The balance of the operation consists in the gradual separation of the entire mass from the outer wall of the thorax. With a preliminary ligation of the subclavian vessels there will be no hemorrhage which cannot be easily checked by pressure and forceps.
The above, however, is only a general description, which may need to be modified in most cases. If the amputation be done for injury all the skin which is still viable should be utilized, no matter how shaped, while if done for disease the incisions may have to be modified materially, taking more skin from one side and less from the other, in order to avoid that involved in the disease process.
In the majority of cases the result is satisfactory, in spite of the mutilation thus afforded.
Fig. 691
Esmarch’s elastic constrictor applied and held in place by a bandage or a strap (Wyeth’s pins may also be used to hold the constrictor in place) in high amputation of the arm. (S. Smith.)
AMPUTATIONS OF THE LOWER EXTREMITY.
The most important physiological purposes of the foot are those of support and locomotion, not mere tactile sensibility nor prehension. Its purposes being different from those of the upper extremity, the tenets previously held regarding the advantage of conservatism may be changed to some degree, for a tender foot or leg-stump is sometimes extremely annoying, even disabling, and it is in the end far better to so plan an amputation of this extremity as to make the stump most serviceable, without primary reference to its exact length. As in the hand, foot-stumps should be covered with dense plantar (instead of palmar) tissues, and the long flap should, therefore, be made from the sole. When this is impossible it would be wiser to shorten the stump. Moreover, as there will be constant friction upon the resulting cicatrix, this should be placed in the most protected location, on the dorsum of the foot.
The most important indication, then, in all foot amputations is to furnish a complete plantar flap and to place the scar on top of the foot.