AMPUTATION OF
THE ARM.
Civil War
Amputation Kit
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.
