Amputation at Shoulder 259 



Excision of the shoulder- joint, or, rather, resection of the upper 

 end of the humerus, is performed by thrusting the point of a short, 

 strong scalpel through the deltoid in the space between the coracoid 

 and acromion, the ligament between these processes being also 

 traversed by it. The incision is continued three or four inches down 

 the limb. 



The arm is then rotated outwards, so that the subscapularis may 

 be detached from the lesser tuberosity ; the capsule is opened up 

 in the bicipital groove, and the tendon of the biceps is raised from its 

 bed and hitched inwards over the lesser tuberosity, and well to the 

 inner side of the head. After this the arm is rotated inwards, and 

 the insertions of the supra-spinatus, infra-spinatus, and teres minor 

 are detached from the greater tuberosity. Some of the capsule has 

 then to be divided before the end of the bone can be thrust through 

 the wound and sawn off. 



Amputation at the shoulder-joint is best performed by prolong- 

 ing the incision, which was made in the last operation, a little further 

 down the shaft of the bone. And, in those cases in which the surgeon 

 does not know whether the disease will demand resection or amputation, 

 he can begin by adopting the former method (short of sawing across the 

 humerus), and then, if necessary, go on to amputate, clearing the humerus 

 of the insertion of the muscles into the bicipital groove. The humerus 

 having been brought out through the wound, an assistant thrusts his 

 thumbs into the hollow whilst with his fingers on the outer side he com- 

 presses the blood-vessels ; the soft parts are then cut. Compression of 

 the subclavian artery in amputation at the joint is by no means satisfac- 

 tory, though it is often advised ; it is far better to grasp the vessel in 

 the shell of the soft parts as just described. (Compare this operation 

 with Furneaux Jordan's amputation at the hip-joint, p. 469.) 



The tissues divided in the r :-:;\lcal cut are the skin, superficial and 

 deep fasciae ; the deltoid, and part of the coraco-acromial ligament, 

 and the capsule of the joint. Then, insertions of the subscapularis, 

 supra-spinatus, infra-spinatus, and teres minor ; the anterior circumflex ; 

 the pectoralis major ; latissimus dorsi and teres major. The trans- 

 verse incision sweeps through the skin, superficial fascia, cephalic vein, 

 filaments of the internal and lesser internal cutaneous, intercosto- 

 humeral, musculo-cutaneous, and circumflex nerves ; the deep fascia'; 

 the coraco-brachialis and short head of biceps, the long head of biceps ; 

 the ending of the axillary vessels or the beginning of the brachial artery, 

 venae comites, and basilic vein ; the ulnar, internal cutaneous, median, 

 musculo-cutaneous and musculo-spiral nerves ; also some part of the 

 insertions of the pectoralis major, latissimus dorsi, and teres major, and 

 the lower end of the deltoid. Branches of the posterior circumflex 

 artery and of the circumflex nerve are cut in disarticulating, but the 

 main trunks of the circumflex nerve and the posterior circumflex artery 

 escape section. 



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