Joseph Bell - A Manual of the Operations of Surgery

Modifications and Varieties. —Teale's method may of course be used here as elsewhere. The internal line of incision ( Plate IV.fig. 8) should be made just in front of the brachial vessels. This method requires the amputation to be performed higher up than would otherwise be necessary (from the length of the anterior flap), and this disadvantage is not counterbalanced by any special advantage in the posterior retraction of the cicatrix.

In feeble flabby arms, the true circular operation is very easily performed, and with good results. A circular sweep of the knife is made through the skin alone, which is drawn up by an assistant, while the surgeon separates it from the fascia; another circular cut through fascia and muscles exposes the bone, which must then be cleared and cut through at a still higher level.

Amputation at the Shoulder-Joint.—This operation, like that at the hip joint, can, from the nature of the joint to be covered, and the abundant soft parts in the normal state of the tissues, be performed on the dead in very various ways, by single, double, or triple flaps, by transfixion or dissection, rapidly or slowly. Hence manuals of operative surgery might collect at least twenty different methods, most of which have some recommendation, and all of which are practicable enough.

When, however, we reflect that in the living body, in cases where amputation at the shoulder-joint is required at all, the severity of the accident, or the urgency of the disease, will, in general, leave no room for selection, we shall see how utterly valueless is any knowledge of mere methods of operating, and of how much greater importance it is that we should be simply thoroughly familiar with the anatomy of the joint.

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.

Operation. —With a moderate-sized amputating knife an incision of about two inches in length, extending through all the tissues down to the bone, should be made from the edge of the acromion process to a point about one inch below the top of the humerus; from this latter point a curved incision, enclosing a semilunar flap, should be made on each side of the limb to the anterior and posterior folds of the axilla respectively ( Plate IV.fig. 9, and Plate III.fig. 3). These flaps should then be dissected back, including the muscles and exposing the joint. When thoroughly exposed, the joint must then be opened from above, and the bone separated. One small portion of skin lying above the artery, vein, and nerves still remains to be divided ( Plate I.fig. 13). This may be done by an oblique cut from within outwards, in such a direction as to form part of the anterior or internal incision, and with the precaution of having an assistant to command the vessels before they are divided. The resulting wound is almost perfectly ovoid, the flaps come together with great ease in a straight vertical line, which admits of easy and thorough drainage. Union is generally rapid. Larrey's success by this method was very remarkable: ninety out of a hundred cases in military practice were saved, notwithstanding the well-known risks of such operations.

2.As good as the former, and nearly as universally applicable, is the method devised by Professor Spence, and practised by him in nearly every case:—"With a broad strong bistoury I cut down upon the inner aspect of the head of the humerus, immediately external to the coracoid process, and carry the incision down through the clavicular fibres of the deltoid and pectoralis major muscles till I reach the humeral attachment of the latter muscle, which I divide. I then with a gentle curve carry my incision across and fairly through the lower fibres of the deltoid towards, but not through, the posterior border of the axilla. Unless the textures be much torn, I next mark out the line of the lower part of the inner section by carrying an incision through the skin and fat only , from the point where my straight incision terminated, across the inside of the arm to meet the incision at the outer part. This insures accuracy in the line of union, but is not essential. If the fibres of the deltoid have been thoroughly divided in the line of incision, the flap so marked out, along with the posterior circumflex trunk, which enters its deep surface, can be easily separated from the bone and joint, and drawn upwards and backwards so as to expose the head and tuberosities, by the point of the finger without further use of the knife. The tendinous insertions of the capsular muscles, the long head of the biceps, and the capsule, are next divided by cutting directly upon the tuberosities and head of the bone; and the broad subscapular tendon especially, being very fully exposed by the incision, can be much more easily and completely divided than in the double-flap method. By keeping the large posterior flap out of the way by a broad copper spatula or the fingers of an assistant, and taking care to keep the edge of the knife close to the bone, the trunk of the posterior circumflex is protected. In regard to the axillary vessels, they can either be compressed by an assistant before completing the division of the soft parts on the axillary aspect, or to avoid all risk, the axillary artery may be exposed, tied, and divided between two ligatures so as to allow it to retract before dividing the other textures." 34