Guthrie thought the insertion of the deltoid the lowest point at which the bone could be divided with any prospect of success; but Esmarch has shown that as much as four and a half inches may be removed from the humerus, and yet a most useful arm remain. The ligamentous matter necessary to produce such a favourable result, requires a " " of constitution which our patients did not possess. The fact, so clearly brought out by Stromeyer, should be always borne in mind in determining on operations at the shoulder joint, that in comminution of the shaft of a long bone, the fissures never extend into the epiphysis; HOT WOUNDS OF JOINTO. in tlic same manner, injuries of the epiphysis only in extremely r nd into the shaft, unless the bullet strikes the adjoinin- borders of both parts, in which case both usually more or less seriously comminuted.
As t<> the best method of proceeding for resecting the head.f the huiiierus, some little difference exists, as is the case with regard to the excision of some of the other 'itliose methods adapted for military and civil praetic,-. This arises, in a great measure, from the acter of the injuries necessitating the operation in either case. The soft parts suffer little, and the bone is not although broken, in cases operated on in the field, nor are tin* parts bound together, as they so often isions performed in civil hospital-it follows that we can often remove all that is oecei through a much more limited incision of the soft p than we could if disease was the cause of the operation, of th- accidents which occur in civil life, in which, although the joint may be but slightly implicated, the soft parts arc yet so often greatly destroyed.
In tin- case of gun-shot wounds too, the periosteum, as well as the ligamentous and muscular ti08Hfl8, of the articu11 be retained, and thus a very great advantage is secured, accordim: to the views of this operation set forth l.y Stionieycr and Baudens. A single straight incision will D very often sutlice in resecting either the shoulder or elbow joint, and even in similar operations;iid hip. so that the maxim of I >csanlt, that u the simplicity of an operation is the measure of its permplitied in military than in ci\ il practice. ->lmt wounds two. illde them if possible in the incision, we have a further illustration of the saying that the surgeon should be bound to no particular form of operation, but should adapt his proceedings to his case.
One of the chief dangers following resection of the shoulder is the formation of sinuses and abscesses in the neighbourhood. The best mode of avoiding this, is to arrange the line of incision so as to give free exit to the pus. Stromeyer's semicircular incision over the posterior surface of the articulation fulfils this end better perhaps than any other. The joint is there very easily got at. Langenbec's one straight incision on the anterior aspect of the articulation, with or without the transverse cut suggested by Franke,gave much satisfaction in Schleswic, where it was largely put in practice; and I have myself seen most admirable results got by the straight incision of White through the deltoid: but Stromeyer's allows of the more rapid discharge of all secretions than any of the others.
Baudens, as is well known, prefers a straight incision on the inside of the joint in front, and from his large practice of it in x\frica was highly pleased with its efficiency, believing that it best allows of that ginglymoid joint being formed, which, he says, takes the place of the former articulation. Whichever of these methods of operation we adopt and they represent those which have received the preference from military surgeons during late wars it seems conceded by them all, that we do not require in field practice such extensive incisions as we do in civil life, and that by such limited incision the muscular and tendinous parts can be more respected, and thus the hope of restored action be much increased.
The report of Esmarch on the practice of Stromeyer and N-6HOT worxns <>F JOINTS. Franke shows us. that to cut across the fibres of the deltoid does not much interfere with its after usefulness, its uppc: 'plied itself to, and united with the articular surtace,.f the seapula, and was thus fully attaeht-d and alile to raise the arm. The healing was also <jni' he filled by granulation was iniich diminished in size by the application of the muscle to id fossa.'* When the neck of the bone is broken here, as in the hip. so that it is difficult to seize the round head of tinbone, the powerful forceps used by Mr. Ferguson in excision of the jaw will be found to do good service.