In the second step of the operation, the surgeon passes the knife behind the head of the humerus, and makes the under and anterior or inner flap, by cutting downward and inward, including in it a very small portion of the deltoid, the pectoralis major, latissimus dorsi, teres major, the triceps, coraco-brachialis, the short head of the biceps, and the vessels and nerves, when the limb is separated from the body. The flaps are nearly of the same size, and are to be brought together by sutures.
In the secondary operation, or that done several weeks after the receipt of the injury, in consequence of the attempt to save the arm having failed, it should be borne in mind that the soft parts will often be found so altered and impacted together that they will not yield or separate; and nothing is gained but by each cut of the knife, causing thereby some little delay, inconvenience, and loss of time.
115. _Amputation of the arm immediately below the tuberosities of the humerus_ ought to be done in the following manner: The arm being raised from the side, and an assistant having compressed, or being ready to compress, the subclavian artery, the surgeon commences his incision one or two fingers’ breadth beneath the acromion process, and carries it to the inside of the arm, below the edge of the pectoral muscle, then under the arm to the outside, where it is to be met by another incision, begun at the same spot as the first, below the acromion process. The integuments, thus divided, are to be retracted, and the muscular parts cut through, until the bone is cleared as high as the tuberosities. The artery will be seen at the under part, and should be pulled out by a tenaculum or spring forceps, and secured as soon as divided. The bone is best sawn, the surgeon standing on the outside; the nerves should be cut short, and the flaps brought together by two or three silk or leaden sutures. There are few or no other vessels to tie, and the cure is completed in the usual time, while the rotundity of the shoulder is preserved. This operation is similar to that already recommended for the amputation at the joint, which in many cases it is intended to supersede.
116. _Excision of the head of the humerus._--The point governing the modus operandi of this operation is, and ought to be, the fact that, under the most favorable state of recovery which can take place, the shoulder-joint usually becomes so stiff that its ordinary motions may be considered to be lost. Operative processes which have for their principal object the sparing of the deltoid muscle are unnecessary, for, if spared, it is as useless as if it had been cut; and it seems to have been forgotten that, when cut, it reunites, and becomes nearly as strong as before it was injured. It is the joint that cannot be moved, not the muscle which has lost its power. I prefer, therefore, in doing this operation, in cases of some standing, to make a _short_ crescentic flap by an incision across the anterior part of the shoulder, as in the operation of amputation, which, on being turned up, leaves the joint exposed. The edge of the knife being applied to the head of the bone in a line below, but immediately under the acromion process, divides the capsular ligament, and with it the long tendon of the biceps, on which the arm drops from the socket, or glenoid cavity, and allows the finger to be introduced, when the three muscles inserted into the great tuberosity may be cut through, and the sub-scapularis inserted into the small tuberosity will also be divided. The head of the bone is then readily brought out, and may be easily detached from any surrounding connections, and sawn off with little or almost no loss of blood. The elbow is to be supported, so as to bring the end of the sawn bone in apposition with the glenoid cavity. The flap may be allowed to unite with the parts below as soon as it will, the shot-holes, if any, being in general sufficient to allow of such discharge as may be necessary.