Volume 1

A dictionary of practical surgery / [Samuel Cooper].

  • Samuel Cooper
Date:
1825
Catalogue details

Licence: Public Domain Mark

Credit: A dictionary of practical surgery / [Samuel Cooper]. Source: Wellcome Collection.

    112/1282 (page 100)
    phical Transactions. White made only one in- cision, from the vicinity of the acromion down to the middle of the arm. Bent, not being able to get at the head of the bone through the wound which he had made, from the clavicle to the at- tachment of the pectoral muscle, detached a por- tion of the deltoid, where it is connected with the clavicle, and another part, where it is adherent to the humerus. A_ third successful case is also reported in the 69th vol. of the same work, p. 6. Afterwards, Bromfield published some directions for the guidance of the surgeon in such operations. (Chir. Obs. and Cases.) Sabatier proposed making two cuts at the upper part of the arm, which meet below like the letter V, extirpating the flap, dividing the inner head of the biceps, and capsular ligament; dislocating the head of the bone, and sawing it off. (Médecine Opera- toire, t. 3.) I think the cases, recorded by White and Bent, are truly important, inasmuch as they are the earliest models of a practice, which may some- times supersede all occasion for one of the most formidable and mutilating operations ef surgery. To military and naval surgeons, these cases can- not fail to be highly interesting, as they must have frequent opportunities of availing themselves of the instruction which they afford. Larrey, who was surgeon-general to the French army in Egypt, employed the practice, with the greatest success, in cases of gunshot wounds. He thereby saved limbs, which, according to ordinary precepts and opinions, would have been a just ground for am- putating at the shoulder; and, when it is con- sidered, not only that amost dangerous operation is avoided, but that an upper extremity is saved, for which no substitute can be applied, we must allow that the plan, first suggested and practised by Mr. White, cannot be too highly appreciated. When the arm was fractured near its upper ex- tremity by a musket-ball, most surgeons formerly deemed it necessary to amputate the limb. Here, says Larrey, it would be useless to dilate the en- trance and exit of the ball, because a sufficient opening could not be prudently made in this way ' for the extraction of the head of the bone. Yet this body is now an extraneous substance, having ‘lost its connexion with the body of the humerus, | and its presence exciting irritation and inflamma- tion of the joint, abscesses, necrosis, &c. Here Larrey, seems to imply, that the detached head of the bone cannot unite again; an assertion which, I have no doubt, is quite incorrect, as I have attended several cases in which the humerus was broken very high up, yet united without dif- ficulty. The bad symptoms, which he so empha- tically attributes to the detachment of the head from the body of the bone, are in reality the effects of the gunshot violence itself. If, therefore, the and the neighbouring part of the bone not splin- tered, nor the flesh not more extensively injured than would arise from the passage of a musket- ball, and the joint itself not involved, I should question the propriety of having recourse, at once, either to the extraction of the head of the bone, or amputation at the shoulder. When the bone is shattered, the case is often very different, and Larrey’s practice is then commendable. In con- firmation of these sentiments, [may mention Mr. Guthrie’s opinion, who, in reference to the ex~ traction ofthe head of the bone, says, he does’ not cogsider a perfect fracture of the humerus, ‘an inch below its head (although there be evident separation), as demanding even this operation, as he has known such cases do well, when treated as. other compound fractures, except that the motion’ of the joint was nearly lost. (On Gunshot Wounds, p. 329.) However, it is fair to men-. tion, that Mr. Guthrie inclines to amputation at theshoulder when the body of the bone is splintered, or has long fissures in it, in which sentiment he is probably right. The other operation seems prin- cipally calculated for cases, in which the damage is restricted to the head and uppermost portion of the bone. . According to Mr. Guthrie, when the’ ball passes out with little injury to the bone, and the openings already made are not sufficient to admit of a moderate examination with the point of the finger, the wound should be enlarged. However, others might argue, that such dilatation should be made only when the bone is felt to be seriously broken, and the fragments will probably require immediate removal. But whatever course be adopted, the most rigorous antiphlogistic treat- ment will be proper; ard, if abscesses form depending openings should be made for the dis- charge. Larrey says, “ I have had the good fortune, on ten different occasions, to supersede the ne- cessity for amputation at the shoulder, by the complete and immediate extraction of the head of the humerus, or its splinters, without delay- I perform the operation in the following manner : I make an incision in the centre of the deltoid muscle, and parallel to its fibres, carrying the incision as low down as possible. I get the edges of the wound drawn asunder, in order to lay bare the articulation, of which the capsule is generally opened by the first incision, and by means of a probe-pointed bistoury, I detach with the greatest ease from their insertions the tendons of the supra » and infra spinati, of the teres minor, of the sub- scapularis, and of the long head of the biceps; then I disengage the head of the humerus, and remove it through the wound in the deltoid by means of my fingers, or of an elevator. I bring the hu- merus up to the shoulder, and fix it in a proper position with the aid of a sling and a bandage. — Such is the operation, which I performed on ten patients, in extirpating the head of the humerus; one of these died of the hospital fever, two of the scurvy, at Alexandria, and the fourth, after he was cured, died of the plague on our return to Syria. The rest returned to France in good health. In some, the arm became anchylosed to the shoulder, and in others, an artificial joint, allowing of motion, was formed.” (See Mém. de Chir. Militaire, t. 2, p.175.) Another successful case, of the same kind, has been more recently published by Mr. Morel. (See Medico-Chirurg. Trans. vol. 7, p. 161.) . Mr. Guthrie thinks it not sufficient to makea simple incision through the deltoid muscle into the capsular ligament, and take away the fragments of bone, but urges the removal at the same time of a considerable part of the capsular ligament, lest disease still go on in the joint. Also, as it is im- possible to know, beforehand, in what state the | bone may be below the fracture (that is, with | respect to fissures running more or less down it),