CONSULTING-SURGEON TO THE WESTMINSTER HOSPITAL, SURGEON TO THE ROYAL WESTMINSTER OPHTHALMIC HOSPITAL, ETC. LECTURE VII. 99. AN upper extremity should not be amputated for almost any accident which can happen to it from musket-shot; and there is scarcely an injury of the soft parts likely to occur which authorizes amputation as a primary operation. 100. If the head or articulating extremity of the bone entering into the composition of the shoulder-joint be merely or slightly injured by

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... t, the arm ought to be saved with some defect of motion in the joint. The wound should be enlarged in the first instance, to allow of a sufficient examination with the point of the finger, and any loose pieces of bone should be removed. Inflammation is to be restrained within due bounds until suppuration has been established, when, if a clear depending opening should not exist for the discharge of the matter poured out, it should be made, and any loose portions of bone removed. The principal points to attend to are, the prevention of sinuses around the joint, by the formation of dependent openings, position, perfect quietude, due support, the methodical application of bandages, and occasional mild stimulating inject.ions into the wound. A simple incised wound penetrating the joint, and even injuring the bone, does not call for any immediate operation. An attempt should be made to effect a cure by the first intention, which can only be effected by means of a proper position and support. 101. If the head of the bone be much splintered, or if a ball have gone through it, that portion should be sawn off; for a part thus injured has often been a source of great inconvenience and suffering for many years afterwards-during, in fact, the remainder of the life of the sufferer; which misery would have been avoided by the excision of the bone in the first instance-an operation which ought in fact to be done even at a later period, if it has not been performed at the time when the injury was received. 102. When the splinters extend far into the shaft of the humerus, it may be proper to amputate the whole extremity, especially if the great artery be also wounded; but the shaft is seldom broken in such accidents to any great extent, and amputation should be confined almost to injuries from cannonshot or shells, or heavy machinery, destructive of the soft parts as well as of the bone. 103. When the injury done to the upper arm is so extensive that it cannot be saved, although the head of the humerus is not injured, the amputation should take place immediately below the tuberosities, and not at the joint, which latter operation always renders the shoulder flatter, and the appearance of the person more unseemly, than when the head of the bone is left in its place. 104. It will frequently happen that the arm may be irrecoverably shattered, and the thorax partake in a less degree of the injury, there being apparent only some slight contusion or grazing of the skin; if low down, the elasticity of the false ribs may have prevented the integuments being much injured in appearance, although the blow has been violent; yet the force of the large shot may have ruptured the liver or spleen. If higher up, it may perhaps fracture the ribs, in addition to a more severe contusion of the integuments. When these accidents occur, the symptoms arising from the wound or contusion of the trunk of the body are to be first considered. If they do not indicate a speedy dissolution of the patient, or the prospect of such an event in two or three days, the operation ought to be performed, and a chance of recovery given to the suiferer, which he would not have, the arm being retained, and the injury of the chest remaining the same. The danger to be apprehended in the more favourable cases is from inflammation, and this will be rather diminished than increased by the operation; the danger of deferring which is manifest and certain, whilst the injury committed in the thorax or abdomen is not ascertained, and its effects may be obviated. If the termination should be unfavourable, it can only be a matter of regret for the sake of the individual, and not for the non-performance of a duty. If the cavity of the chest be laid open, or several ribs beaten in, or a stuffing of the lungs take place from a large ruptured blood-vessel, all of which circumstances are obvious, and cannot be mistaken, the operation would, in all probability, be useless. A haemorrhage of short duration, or the expectoration of blood in moderate quantities, although a dangerous symptom, is not to be considered as depriving the patient of a reasonable chance for life, for it frequently follows blows from more common causes, and from which many people recover. If the operation be delayed to ascertain what injury may have been done to the chest, from the symptoms that will follow, the danger resulting from both will be increased; and even when it is ascertained that there is but little mischief existing in the thorax, the operation can no longer be performed with the same propriety, in consequence of the inflammation which has supervened; and the patient will probably die, when he would have recovered under a more decided mode of treatment. 105. A round shot or flat piece of shell may strike the arm, after rebounding from the ground, or when nearly exhausted in force, without breaking the skin, or only slightly doing it, yet all the parts within may be so much injured as not to be able to recover themselves: the bone may be considerably broken or splintered, the muscles and nerves greatly contused. The injury may not, perhaps, be quite so extensive. The bone may be merely fractured, and yet the soft parts will often be so much destroyed as not to be able to carry on their usual actions. A ruptured bloodvessel may, with an apparently slight external wound of this nature, pour out its blood between the muscles, and inject the arm to nearly double its size, all of which are causes that render an operation necessary, and require decision, for inflammation will, and mortification may, ensue in a short time, when the most favourable moment for operation will have been lost. 106. Amputation at the sh,oulder joint is an operation of little surgical importance. The fear formerly entertained of loss of blood has passed away, and every surgeon now knows that if he should happen to cut the axillary artery unintentionally, it can be held between the forefinger and thumb, without difficulty or danger, until a ligature can be placed upon it. No accomplished surgeon of the present day should give himself the least concern about compressing the subclavian artery. It is, on the contrary, better, when the arm is raised from the side preparatory to entering or using the knife, that the surgeon should then feel the pulsation of the artery in the axilla, that he may the more easily avoid, and subsequently command it. The axillary artery does not throw out much blood at each pulsation, and a little pressure with the end of the fore-finger will always prevent bleeding until the surgeon is prepared to take hold of the vessel with the tenaculum or forceps. The operator should, in fact, divest himself of all fear of hoomorrhage. When gentlemen are, however, afraid, and cannot help it, (for Henry IV., of France, ce 7-oy si vaillant, always felt an inconvenient intestinal motion when a fight began,) compression may be made upon the subclavian artery, by the thumb of an assistant, the round handle of a key, or the padded end of the handle of a tourniquet; the latter forms the best pad, and is usually at hand. 107. The great point to be attended to in performing the operation is, to save skin to cover the stump. The directions, therefore, which are usually given for doing it after any particular method can only be occasionally useful, for the surgeon may not always be able to select the parts to be divided or retained. In cases of malignant disease of the bone and periosteum of the middle of the arm, the operation should be for the removal of the whole of the bone at the joint, and not the amputation of it below the head, although the appearance of the integuments, and of the bone itself, would seem to encourage the attempt to preserve the roundness of the shoulder. In such cases the removal of the extremity at the joint may be done by any one of the many ways which have been recommended for its performance. In none should the acromion or coracoid processes be exposed, unless previously injured. Neither is it necessary to lose time, or to give pain, by depriving the glenoid cavity of its cartilage; but it should always be borne in mind, that if the nerves are not shortened ' after the removal of the arm, they may be included in or adhere to the cicatrix, and cause, during a long life, much distressing pain to the sufferer. . 10S. Amputation at the shoulder-joint, performed imme-' diately after the receipt of an injury, is now a very simple operation ; for which simplicity English surgery is indebted to the Peninsular war. As a secondary operation, or done at a later , period, when the parts are all impacted together, it is somewhat less so. In both stages it is absolutely necessary to