A Manual of the Operations of Surgery. Joseph Bell

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

      Another, but not so good method of making an external flap, is the following:—(a.) For the right arm.—The patient lying well over on his left side, the surgeon stands to the inside of the arm to be removed. Seizing the deltoid in the left, with the right he passes an amputating knife, seven or eight inches in length, from a point a little nearer the clavicle than the middle space between the acromion and coracoid processes; then, transfixing the base of the deltoid, and just grazing the posterior surface of the humerus, thrusts the knife downwards and backwards till it protrudes at the posterior margin of the axilla. When doing this, it is important that the arm be held outwards and backwards, and even upwards, as far as possible to relax the deltoid; without this it will be impossible to make the flap of the full size. The flap must then be cut of as full length as can be obtained, four or five inches at least. An assistant then holds it upwards, while the surgeon, or (if the arm is very muscular) another assistant, brings the arm forwards well across the patient's chest, thus exposing the posterior aspect of the joint. This may have very possibly been already opened during the transfixion; the attachments of muscles must now be divided, the knife passed behind the head of the bone, which is dislocated forwards, and a suitable flap of the tissues in front cut from within outwards. The assistant is to follow the knife with his finger and compress the vessels.

      (b.) If the left shoulder is to be amputated, the patient lying on his right side, the surgeon stands behind him, and raising the elbow of the limb to be removed from the side, and pulling it slightly backwards, enters the knife at the posterior fold of the axilla (Plate II. fig. 2), and passing the posterior aspect of the head of the humerus, endeavours to protrude it as near the acromion as possible; the flaps must be cut and the rest of the operation performed in the manner we have just described for the other arm.

      3. Where the destruction of tissue has been chiefly below the joint, a very good flap may be obtained from above, composed chiefly of the deltoid muscle, and the skin over it. This may be made by transfixion at its base, but is better obtained by dissection from without.

      The surgeon cuts (Plate II. figs. 3, 3) in a semilunar direction (with the convexity downwards) from one side of the deltoid to the other, viz., from the root of the acromion to near the coracoid process; he then raises the large flap upwards and throws it back, opens the joint, disarticulates, passes the knife behind the head of the bone, and cuts out without attempting to save any flaps below, in a transverse direction. By this means the artery is still almost the last structure to be divided, and can be secured by a ready assistant. In cases where much injury has been done to the floor of the axilla and wall of chest, the deltoid flap must be made large in proportion, and triangular rather than semilunar in shape.

      N.B.—The statistics of amputation at the shoulder-joint bring out some interesting facts: 1. That the primary amputations here are far more successful than secondary ones. Guthrie records nineteen cases of the former out of which only one died, while out of a similar number in which the amputation was secondary, fifteen died. In the Crimea, British surgeons had thirty-nine cases, with thirteen deaths; of thirty-three primary, nine died; and of six secondary, four were fatal.

      S.W. Gross's35 statistics confirm this: of one hundred and seventy-eight primary, forty-six died—25.8 per cent.; ninety-five secondary, sixty-one died—64.2 per cent.

      Amputations above the Shoulder-Joint.—Under this head we may group the comparatively rare cases in which, from accident or disease, the removal of portions of the scapula and clavicle, or even the entire bones, is rendered necessary. That it is quite possible to survive such injuries has been frequently shown in cases of accident when the scapula along with the arm has been torn off, and yet the patient recovered.

      Encouraged by such cases, Gaetani Bey of Cairo removed the whole of scapula and part of the clavicle in a case where he had amputated at the shoulder for smash. The patient recovered. Heron Watson has had a similar case. Dr. George M'Lellan amputated arm and scapula in a youth of seventeen for an enormous encephaloid tumour. Fifty-one such cases are now on record.