Amputation of the Arm

 

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[See Also: Civil War Medicine, Amputation Overview, Amputation of the Leg, Amputation Below the Knee, Amputation of the Arm, Amputation of Fingers and Toes]

Amputation: Amputation of the Arm

(From "The Practice of Surgery", by Samuel Cooper, and notes by Dr. Alexander H. Stevens. This book served as the "How To" guide for Civil War surgeons)

 

AMPUTATION OF THE ARM.

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The structure of the arm bears a great analogy to that of the thigh. There is only one bone, round which the muscles are arranged, the deep ones being adherent to the os brachii, while the outer ones extend along the limb, without being attached to this bone. The first are the brachialis internus, and the two short heads of the triceps; the others are, the long portion of the latter muscle, and the biceps. Hence amputation, in this situation, is performed in a very similar manner to the same operation on the thigh, unless it be necessary to remove the limb above the insertion of the deltoid muscle.

The patient may either sit on a chair, or lie near the edge of a bed, and an assistant is to hold the arm in a horizontal position, if the state of the limb will allow it. The pad of the tourniquet is to be applied to the brachial artery, as high as convenient. The assistant is then to draw up the integuments, while the surgeon makes the first circular incision. In this operation, the skin need only be detached from the muscles to a very trivial extent, as there is no risk of not having sufficient flesh and integuments to cover the bone. When the muscles, in front of the arm, are to be divided, the elbow should, if possible, he bent by the assistant who holds the arm, and if the joint were quite movable, the limb might be placed in a straight posture, when the division of the tricepts is to he effected. It is best to divide the biceps first, and after the retraction of this loose muscle, to cut the brachialis internus, which is fixed to the bone, by an incision sloping obliquely upward.

The triceps may be cut through at once, by one sweep of the knife, with its edge turned obliquely upward. The other proceedings do not require description, after the account already given, of what is necessary in amputating the thigh.

When it becomes indispensable to amputate the arm very high up, there is no room for the application of the tourniquet. In this instance, the subclavian artery is to be firmly compressed, as it passes over the first rib, by an assistant, who can most effectually accomplish this important object, by pressing the vessel from above the clavicle with the handle of a key, or any other suitable instrument. The danger of a sudden profuse hemorrhage having been thus guarded against, the operation is to be done variously according to circumstances. When the bone can be sawn through below the insertion of the pectoralis major, there is no peculiarity in the method of operating. But, if it be necessary to take off the limb still higher up, the circular incision is not adopted. Here some surgeons make a flap of the deltoid muscle, and commence with making an incision corresponding to its margin in shape and situation. Then the muscle is to be detached from the bone beneath, so as to form the flap, which is to be turned up. The operation is now finished by cutting through the other soft parts, from one side of the base of the flap to the other.

Instead of making a short stump, when the arm must be taken off very high up, Larrey thinks it more advisable to amputate at the shoulder joint. He says, that if the humerus is sawn through higher than the insertion of the deltoid muscle, the stump becomes retracted towards the arm-pit by the pectoralis major and latissimus dorsi; the ligatures on the vessels irritate the brachial plexus of nerves; great pain and nervous twitchings are apt to be excited; tetanus is frequently brought on; the stump is affected with considerable swelling; and at length, an anchylosis of the shoulder follows.

According to the experience of Mr. Guthrie, when amputation is attempted at the insertion of the pectoralis major, the bone will mostly protrude after a few dressings; and, frequently, a disagreeable and painful stump be the consequence. The artery is also liable to retract into the axilla, where it cannot readily be taken up. In cases of this description, instead of amputation at the shoulder joint, Mr. Guthrie advises the following operation:Two incisions of a similar shape are to be commenced, one or two finger's breadth below the acromion, as the case may require: the point of the inner one, instead of ceasing, as in the operation of the shoulder, a little below the pectoral muscle, is to be carried directly across the under part to meet the point of the outer incision; so that the under part of the arm is cut by a circular incision, the upper in the same manner as in the operation at the shoulder. These incisions are only through the skin and cellular membrane, which have liberty to retract, but are not to be turned up. The deltoid and pectoralis major are then divided close to the inner incision, and the opposite portion of the deltoid, with the long head of the biceps on the outside, to the extent of the outer incision. A half-circular cut on the under part, in the line of the skin down to the bone, clears it underneath, and shows the artery retracting with its open mouth, which is at this moment advantageously pulled out by a tenaculum, and secured." The flaps are then held asunder, and the bones sawn, etc.

I should conceive that either this method of operating, or that previously mentioned, which appears to me more simple, ought to be preferred to taking the humerus out of the glenoid cavity, when the nature of the disease or injury does not render it absolutely indispensable.

AMPUTATION OF THE FOREARM.

The forearm is to be amputated as low as the case will allow. The tourniquet is to be applied a little above the condyles of the humerus, with its pad on the brachial artery, at the inner edge of the biceps muscle. While one assistant holds the hand, another is to take hold of the forearm, above the place where the first circular wound is to be made. Thus, in conjunction with the former, the latter will be able to fix the limb in a proper manner, and, at the same time, draw up the integuments. After the amputating knife has been carried round the limb, the skin is to be detached from the fascia, a little way upward. The muscles are then to be divided obliquely upwards with the common knife, as long as this will do what is to be done with convenience, and the catling is afterwards to be employed for completing the division of the soft parts, between the radius and ulna. The retractor is to be applied, and the bones sawn, with the hand in the state of pronation.

In general, only four vessels require ligatures, viz. the radial, ulnar, and two interosseous arteries.

Larrey thinks it advantageous to take off the forearm in its fleshy part, notwithstanding the nature of the disease, or injury, would admit of the, operation being done towards the wrist. However, as I have amputated several forearms near to the wrist, and the stumps healed in the best way, I see every reason for still adhering to the old good maxim of saving as much of the limb as possible. The cause of the had success, which many of the French surgeons have had after amputating in the tendinous part of the forearm, has been correctly referred by Mr. Guthrie to their prejudices against the attempt to heal the stump by the first intention.

In the lower part of the forearm, Mr. Guthrie prefers making two flaps; a method, which another surgeon particularly recommends, in amputating the more fleshy part of the member below the elbow. I see no reason for deviating in either situation from the ordinary method.

AMPUTATION AT THE SHOULDER JOINT.

The loss of blood is to be prevented, by compressing the subclavian artery, in the way mentioned in the account of high amputations of the arm. With a large common bistoury, a semicircular incision is to be made, with its convexity downward, across the integuments covering the deltoid muscle, about four inches below the acromion. The skin is not to be detached: but the surgeon is to proceed immediately to raise the muscle from the bone, quite up to the joint. If the circumflex arteries bleed considerably, they are now to be tied, before the operator proceeds further. Then the surgeon should cut the tendons passing over the joint, and, also, the capsular ligament, so as to be enabled to dislocate the head of the bone. With one stroke of the amputating knife, he is then to divide the skin, muscles, and other parts underneath the joint, and thus complete the separation of the limb. The axillary artery should be instantly taken hold of with the fingers, or forceps, and tied.

The flap of the deltoid muscle is next to be laid down, and its edge will then meet the lower margin of the wound.

The preceding method of operating was first practised by De la Faye, and is one of remarkable simplicity, as I can truly affirm, not only because I have tried it myself, but seen it done on several occasions by other surgeons. The last case, in which I was requested to give my assistance, was a patient of Dr. Blickes, of Walthamstowe: the operation was done as a last resource for a spreading mortification of the arm, from external violence; and though the man survived only about a fortnight, nothing could be more easy than the operation itself, and it was impossible to have had a better stump.

In order to make a flap of the deltoid muscle, some operators prefer first pushing a catling, or long straight double-edged knife, through the muscle, near the joint, and, next cutting downwards, they detach as much of the flesh from the bone, as they consider necessary; the flap is then turned up; the tendon of the long head of the biceps divided; and the operation finished, as already described. It was in this manner, that Loder chose to perform the operation.

Nothing, however, exhibits more strikingly the absurdity of generalizing too much even upon the subject of amputation, than the fact, that excellent as the preceding flap-operation is for the shoulder, the exclusive preference to this method, as declared by some writers, has been made without reflecting, that, in many of the examples in which amputation at the shoulder is indicated, the middle and upper portion of the deltoid muscle is very much lacerated, or more or less of it is actually torn away. Under such circumstances, a sufficiency of soft parts for making the flaps must be saved at the anterior and posterior sides of the shoulder; which plan, modified and executed in various ways, is approved off by a considerable number of excellent surgeons, even where circumstances leave a choice of this, or the foregoing method. On the other hand, in certain other cases, there is no possibility of making the flap on each side of the joint. Favorably as I have spoken of the mode of making a single flap of the deltoid, I do not consider it a matter of great importance, whether that operation, or the other above spoken of, be selected, where circumstances offer a choice; for both methods have now been rendered extremely simple and perfect.

As I have explained in the chapter on gun-shot wounds, the necessity for amputation at the shoulder joint may often be removed, and the limb be preserved, by the performance of a less severe and mutilating operation, which consists in merely making an incision for the extraction of the diseased, or splintered head of the humerus, and, if necessary, of the adjoining part of the scalpula. The arm is afterwards to be properly supported in a sling, so as to keep the upper end of the humerus as high as possible. It was in an example, where the head of the humerus was diseased, that this judicious practice was first adopted by Mr. White; and Larrey, in the Egyptian campaign, superseded, in not less than ten instances, the necessity of amputating at the shoulder, by the complete and immediate extraction of the head of the humerus, and its splinters.

 

 

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