course of half an hour, when the man manifested marked anemia, and appeared as though he had sustained a severe loss of blood, and yet physical examination of the chest showed that it was apparently normal. There was some fluid in the pleural cavity, but not more than there had been during the whole course of his illness after he was admitted to the hospital. The bowels were somewhat distended, and it was stated that after three or four o'clock he had been vomiting a good deal more, shortly after which it subsided and he began to fail. A diagnosis was made of probable rupture of the liver. I profited by the case of the lady who was returning from her wedding trip; was in a Northwestern train going out of Chicago when a boiler exploded in a building adjacent to the track, and she was injured in the side. She was treated in Chicago, and at the end of two or three weeks was supposed to be well. She was about to return to her home when along in the night the attending surgeon was called suddenly to attend her, and before he arrived she was dead. A post-mortem examination showed an extensive laceration of the liver, which was the cause of the sudden death. Having in mind this case, which had occurred a few months before, I was impressed that my case might be a similar one. The man was prepared for an operation, and when we opened his abdomen we found a large quantity of blood. The vomiting which this man had, raised the question whether or not the bowel was ruptured, although there was no evidence of peritonitis. I ran rapidly over the presenting intestinal loops, but found none collapsed. Further investigation disclosed a rupture of the posterior part of the liver, into which one could pass the whole hand; the rupture was very irregular. Clotted blood was also found in this locality, so that we were positive our previous probable diagnosis of rupture of the liver was correct, and that this was another case of traumatism over a solid glandular organ, which resulted in laceration from the shock incident to the traumatism. I should say in this case that one interesting feature which accounts for the extensive laceration of the liver was the fact that he had recovered from typhoid fever two months before, which accounted for the unusual friability of the liver in his case. I have cited this case somewhat in detail, because it brings out the importance of examining our cases of injury to the right side very carefully, and we should not be too sanguine as to the outcome of any case of traumatism over the liver. These two cases occurred in Chicago within a few months, and how many more may have occurred no one can tell, but undoubtedly these injuries are quite common.

What should be the treatment, had the diagnosis been made at the time, is apparent to you. Free incision laterally and packing is the proper treatment in a case of laceration of the liver. We have in packing an absolute means of controlling hemorrhage in most instances. Occasionally it may be necessary to resort to suturing, but ordinarily packing is sufficient, and it can be done so quickly, requiring only a few moments, that undoubtedly many lives can be saved and have been saved by this

means.

Hemorrhage from the kidney is just as important as hemorrhage from the liver, although located, as it is, ex

traperitoneally, the danger of fatal hemorrhage is not so great from this organ as it is from the liver. Primary hemorrhage from the kidney is rarely fatal, because the organ is extraperitoneal. The condition develops slowly, as a rule; it is recognized early, and proper surgical measures for the control of hemorrhage are employed; therefore, the mortality rate from hemorrhage from this organ is not so great. Hemorrhage from the spleen is likewise a serious matter. It is serious to the extent that it may prove fatal on account of the organ being very vascular. If we can make a diagnosis early, it is an organ we can treat with satisfaction. If deemed necessary, we can extirpate the entire organ without any serious damage to the individual.

There are constitutional means of treating hemorrhage. The use of adrenalin is now being advocated. Personally, I have had but little experience with this agent, except the local application of it. The injection beneath the skin of 1 to 2 per cent solution of gelatin, also by favoring coagulation, would be of value in controlling oozing.

When the hemorrhage has been controlled position of the body and elevation of the extremities, or alternating bandaging of the extremities, are of distinct value, particularly so in the absence of the means for administering normal saline solution. These are measures for the maintenance of life and function until reaction and recuperation are established. As previously stated, the surgeon's first duty is to stop the hemorrhage, which, having been. accomplished, the restoration of the circulatory volume and its normal constituency is to be aimed at.

Dr. P. Daugherty of Junction City, Kan.: I was pleased with Dr. Bouffleur's remarks. There were two points I expected he would touch on that occurred to me in the control of hemorrhage, and one is position. In a case of hemorrhage from an extremity, elevate the extremity, it makes no difference if it be a leg or an arm, you can control a severe hemorrhage by position alone. Of course, internal hemorrhage cannot be controlled in that way, but in external hemorrhage, as from a crushed arm or a severed vessel in the arm or leg, there is one thing that you should not do, and that is to give anything to increase the force of the heart until the hemorrhage is arrested. A weak heart often stops a hemorrhage. Let a man lose blood until he faints, and hemorrhage will nearly always cease, but if you give anything to increase the force of the heart until you control the hemorrhage you will simply make the man that much worse. Let the heart alone until you have the hemorrhage under control.

Dr. T. B. Greenley of Meadow Lawn, Ky.: I wish to say a word or two in regard to the value of normai salt solution. About two years ago I believe I was able to save the lives of two women by the timely use of this remedy, both of whom were bleeding to death from the effects of abortion. One was pulseless when I got to her. In the other case the pulse could be felt at the wrist, but it was very feeble. I injected about half a gallon of normal salt solution into the bowel, which was held by pressure, and in less than half an hour the pulse began to beat more forcibly. I gave the normal salt solution every two or three hours until relief was afforded. I treated the other

woman in the same way, and the results were gratifying in both instances. I think a good deal about normal salt solution, and believe it is of great value.

Dr. D. S. Fairchild of Clinton, Ia.: There are one or two points worthy of consideration in reference to this matter of surgical hemorrhage that have not been touched on. It is undoubtedly true, as the doctor has stated, that only a small percentage of railroad accidents results in fatal hemorrhage, yet those few cases which result fatally are entitled to careful consideration. It is true, in a certain number of cases of hemorrhage from crushing injuries, as a car passing over a limb, the shock of the accident results in such a degree of prostration and interference with the action of the heart that hemorrhage does not occur at once, but it takes place later on, when reaction appears, which may occur in a comparatively short time. Furthermore, an individual may have a limb crushed who is in vigorous health at the time of the accident, and the hemorrhage then will be severe. The difference between the two lies in the fact that in the first case the shock affects the heart and its pulsation is weak, while in the other case the pulsation of the heart is not very much, if at all, affected, and the hemorrhage may be abundant from the beginning.

Another question comes up in regard to these cases of hemorrhage which, I am sorry to say, is true. Often a patient undergoes an amputation of a leg er an arm at the railroad station under the most unfavorable circumstances, with the aid of a smoky lamp. There are physicians, I know, who feel that the way to check hemorrhage in a case of injury of a limb is to amputate it. Then comes the unfavorable circumstances. The amputation results in a considerable loss of blood. The efforts of the surgeon in seeking the bleeding vessel or vessels, or the source of the hemorrhage from which the patient suffers, added to the hemorrhage at the time of the accident, may result fatally. As Dr. Bouffleur has stated, the Esmarch bandage can be applied for three or four hours, or even six hours, without resulting in gangrene of the leg. I speak of this more particularly on account of the fact that it not infrequently happens an effort is made to check hemorrhage when it can be controlled by some other means temporarily. The arteries may be ligated, if deemed necessary. You know it is extremely difficult sometimes to find the bleeding vessel. A bandage may be applied with the result of checking hemorrhage until the patient can be taken to a hospital where electric light is available or wait until the morning to have the aid of sunlight. This may seem trivial to some of you, but it is a very important factor. Within a month I have seen a patient die as the result of hemorrhage, an attempt being made by the physician to amputate the leg by the aid of a smoky lamp. After he had amputated it, he was unable to find the arteries, and the elastic bandage was retained on the limb until the patient was in proper position and the arteries sought for.

Dr. S. S. Thorn of Toledo, Ohio: I was once charged with a man's death from hemorrhage. It was not my fault that the man died. His death was due very largely to the first aid which was rendered by uneducated men, railroad men. Here the elastic bandage or pressure was kept up too long. I am convinced that ten or twenty

not

minutes, at most, is quite sufficient for the elastic bandage, and not four, six or ten hours. Twenty minutes is the time for such physiologic action to take place as will arrest hemorrhage. I believe the older surgeons taught this, and I fear this point has been forgotten. At any rate, if it has not been forgotten, physicians do not take advantage of it in their surgical work to-day. I believe the lives of patients are very much endangered if elastic constriction is kept up for more than twenty minutes. After the first twenty minutes the bandage is applied and we have time enough to put the patient in such a position as to aid very materially in the arrest of hemorrhage.

I made a Schede operation soon after it was announced by him; I applied a bandage above the knee, and left it on for about twenty minutes. I then closed the wound, took off the bandage, and a slight accident occurred. I did not get the full physiologic effect that I spoke of, but I had time to put the patient in a position so that the hemorrhage was not troublesome. The wound was dressed before I took off the Esmarch bandage. If it had not been for my position, I believe I would have had trouble.

Part of the instruction which should be given in medical colleges should be as to how to control hemorrhage. Position, as has been said by Dr. Daugherty, is a valuable factor. It does not endanger the life of the patient, but I do believe that bandaging longer than twenty minutes to arrest hemorrhage endangers the limb. The average man, who is not properly instructed, will apply a bandage in the wrong place to control hemorrhage, that is, those who attempt to render first aid. They will put a bandage above when it should be applied below, and vice versa.

Dr. C. B. Stemen of Fort Wayne, Ind.: I do not believe I have much to say on this subject. There has been so much said, and it has been so well said, in regard to the control of surgical hemorrhage that there is very little left for me. I want to say, however, that the Esmarch bandage has been very satisfactory to my hands, and I have never yet witnessed any serious results following its use. I have no doubt that results have not been so favorable in the hands of others who have used it. I have never applied it for any great length of time, but I seldom make an amputation without using the Esmarch bandage, and the only objection I have to it is that there is more capillary oozing after one has used it than there is when he does not. Of course, I do not allude to the application of rubber bandages that are applied by the laity, and which so powerfully constrict the limb as to do injury to the soft parts. In cases where the bandage has been too loosely applied, there has been venous hemorrhage.

As has been said by others in the discussion, crushing, injuries, as a rule, do not bleed very much. In fact, I might say, with Dr. Fulton, I have not seen any case. where a patient has bled to death. But I have had cases where there has been great loss of blood and the patients have been very much prostrated in consequence of it.

One method of controlling hemorrhage, and which has been very satisfactory in my hands, is with hemostatic forceps and clamps. I have frequently made use of hemostatic forceps in making amputations, grasping the blood vessels as soon as I cut them, and I have found this method eminently satisfactory. I had the pleasure of witnessing Sir Joseph Lister excise a mammary gland, and

really I could not see hardly how he could use so many hemostatic forceps, he used over thirty during that operation. He had very little hemorrhage, he applied a forceps whenever there was the least bit of hemorrhage, and did this himself. He ligated some of the vessels afterwards and resorted to torsion with others.

Speaking of torsion of arteries, we have had from this. platform a valuable paper on torsion of arteries in amputations and in surgical procedures by the lamented Murdoch. I shall never forget the remarks of those two gentlemen, who were so much thought of by this association, who are now gone to their reward-Dr. Murphy of St. Paul and Dr. Murdoch of Pittsburg. Dr. Murdoch read his paper from this platform at the second meeting, in which he said that in the West Penn Hospital they had never used a ligature, not even for the femoral artery, but resorted to torsion altogether, and I believe this is the practice in that hospital to-day. They do not use ligatures for the control of hemorrhage, but torsion, and I shall never forget Dr. Murphy, who got up and said that he was determined, after he went home, and had his first case of amputation, to use torsion, and then ligate the vessel (laughter) to control the hemorrhage.

As has been well said, but few surgeons to-day become alarmed in regard to hemorrhage as much as they used to. I can very well remember when we used to be very much alarmed over hemorrhage, but now we are prepared for its control with hemostatic forceps and clamps, so that we need not be much alarmed about it. When we have hemorrhage from any of the internal organs, we are confronted with a more serious proposition. I presume some of the gentlemen present have had occasion to remove the spleen for disease, and if you have ever done it, you must have encountered more or less hemorrhage, and some difficulty in controlling it. In my own experience I have applied clamps and have allowed them to remain for forty-eight hours before removing them in a case of that kind.

There is another class of cases that some of us older surgeons have had the utmost difficulty with, and I refer now to bleeders. I have had a few cases of that kind, in whom I have had difficulty in controlling the hemorrhage, and I have been alarmed for a number of days. One of the speakers said that we should never give anything to stimulate the heart's action when we are confronted with hemorrhage. I want to say, that where you have a bleeder, where you have a case of purpura hemorrhagica, or where a patient bleeds considerably from a small wound, the best remedy you can give is one-twentieth of a grain of strychnia hypodermically. It will control the hemorrhage better than anything else that I know of. It produces an effect that is most satisfactory to me, and I have had a few cases of that kind where this remedy has proven very satisfactory. I am not positive, but I think it was Dr. McCandless, or someone in this city, who spoke of this remedy, and I have had occasion to use it and have found it to be what it was recommended to be. In cases where there is constant oozing of blood, if you will give strychnia in this way you will find it a very efficient agent.

In regard to alarming hemorrhage, only a short time. ago I was sent for to go to the freight house to see a man,

a switchman, whose arm had been run over by an engine. He was a strong man. When I arrived I found him sitting in a chair and the blood had run at least two feet from him on the floor. He was becoming very weak. I had an Esmarch bandage and applied it to control the hemorrhage. I had him taken to the hospital and amputated the arm at the shoulder-joint. I would advise anyone to use an Esmarch bandage under such circumstances, or else the patient is likely to bleed to death before he can be removed to the hospital. Pressure with gauze and bandages might have controlled the hemorrhage, but I have my doubts in regard to it.

There are other cases that have given me greater annoyance, such as traumatic ectopic pregnancy, with uptured tube, and internal hemorrhage. I recall the case of a woman who was suddenly seized with pain in the abdomen; she became pale and cold, and was suffering great pain. There was coldness of the extremities, and she presented a peculiar appearance, indicative of internal hemorrhage. I am always more or less alarmed when I have to deal with one of these cases, and the thing to do is to open the abdomen at once, ligate and arrest the hemorrhage.

OPERATIVE INTERFERENCE IN IRREDUCIBLE DISLOCATIONS OF THE SHOULDER.*

BY R. HARVEY REED, M. D. (UNIV. OF PA.), DIVISION SURGEON U. P. R. R., ROCK SPRINGS, WYOMING.

My limited experience, combined with the experience of others, has led me to believe that this is one of the many important subjects which the emergency surgeon has to deal with, and is particularly interesting to the railway surgeon. It is a subject which, compared with other emergency injuries of less magnitude, has not received the attention its importance demands. Very few cases of operative interference in irreducible dislocations. of the shoulder have been reported, for the reason that comparatively speaking, very few of these cases of irreducible dislocations have been operated upon.

It is true that as early as 1819, long before the day of aseptic and antiseptic surgery, Weinhold and Swanzig, and in 1820 Wattmann, performed arthrotomy for the relief of irreducible dislocation of the shoulder. It was

a score of years after that before we find any record of further operative interference for this difficulty, when Dieffenbach resorted to it, after which there was another intermission of thirteen years, when Simon, in 1852, revived the operation. In 1874 operative measures for the relief of irreducible dislocations of the shoulder were reinforced by Thiersch, Annandale, Langenbeck and Burns. From this on numerous operators have reported a few cases each, among which were Post, and later, Knapp, McBurney, Warren and others.

The introduction of aseptic surgery removed many of the dangers that confronted the surgeon prior to this time, and made operative interference in this difficulty comparatively safe, and the prognosis much more favorable, although even to this day the success of opera

A paper read before the eighth annual meeting of the American Academy of Railway Surgeons, held at the Auditorium Hotel, Chicago, Ill., Thursday and Friday, September 12 and 13, 1901.

tive interference in these cases is not so encouraging as might be desired.

One of the most frequent factors underlying operative interference in these irreducible dislocations is that the surgeon oftentimes believes that he has successfully reduced a dislocation, when in reality he has not. Quite a number of these cases are on record, where the joint has been allowed to remain in a luxated condition for a week or more, and when the dressings were taken off the joint was found to be out of place. Usually adhesions have formed, which, combined with cicatricial contractions, make a simple reduction impossible. In cases of this kind operative interference is clearly indicated, for as a rule these irreducible dislocations are not only painful on account of pressure on the sensory nerves, but are complicated with paralysis, the result of pressure on the motor nerves, saying nothing of the interference with the circulation, which may assume one of the two extremes of either oedema on the one hand or atrophy on the other, owing to whether the arterial or venus circulation is being interfered with. Any one or all of these complications are not only distressing to the patient, but sooner or later impair the usefulness of the arm to such an extent as to make it practically useless.

The intricate and complex anatomy of the shoulderjoint and its surrounding parts makes operative interference something to be shunned rather than sought for by the surgeon. The best and most experienced operators have met with accidents in these oprations, which are paralyzing to those of average experience, saying nothing of tyros.

When we remember that the brachial plexus is usually involved, causing more or less paralysis, saying nothing of the brachial artery, which, if torn or injured, may lose the patient his arm, and make a shoulder amputation imperative and immediate, saying nothing of the great cluster of muscles and tendons that are involved in this operation, we are not surprised that the literature on this subject, as compared with appendicitis and ovariotomy, is a mere speck in the firmament of surgical literature.

Another cause for the paucity of reports of this class of cases is no doubt from the fact that the results of these operations have not been as successful in many of the cases operated upon as might be desired. It is always It is always more or less embarrassing to a surgeon to report a case on which he has operated that has been a failure, notwithstanding such cases are often much more instructive than those which have been successful.

I remember witnessing an operation of an irreducible dislocation of the shoulder performed by the iste Dr. John B. Hamilton of Chicago, at the Presbyterian Hospital in that city, in which he attempted to reduce an old dislocation, and after several very desperate efforts he found it impossible to do so. During the course of the operation he unintentionally cut the brachial artery and was obliged to amputate the arm. Imagine yourself in his position under such conditions, with a patient who went under an anesthetic in anticipation of having a useless arm restored to usefulness, to waken and find that it had been amputated at the shoulder joint. It is a condition of affairs which would certainly cause you to think well and to think long before you attempted a similar operation.

On the other hand, these accidents may occur to any operator. I remember that in this particular case the doctor was very much exercised and was very much surprised when he found that he had cut the artery and that nothing but an amputation was left to save the patient's life.

From a study of the literature of the subject, it appears that no very definite method of operating has been decided upon. Each operator seems to have followed his own ideas and operated accordingly, whilst few have operated sufficiently often to have established any very definite method of procedure.

There are three incisions which have been used in this operation-the anterior, the posterior and the axillary. The anterior incision, however, seems to be the more desirable method, as it presents less danger and is more easy of access. The head of the humerus is more easily manipulated through this incision than through either of the others. The axillary incision is much more liable to involve complications with the arteries, nerves and veins, and in addition to all these, it is more difficult to push the head of the humerus back into the glenoid cavity. after it is dissected out.

The history of surgical interference for irreducible disiocations of the shoulder has resulted in more resections of the head of the humerus than any other or perhaps all other methods combined.

This method of relief was practiced as early as 1795 by Percy with remarkable success for that day and age. Whilst a resection gives relief to the sufferer and often is the only course to be pursued, it should only be advised when other methods that look toward the preservation of the joint are compelled to be abandoned. Lister reports a case of double dislocation of the shoulder joint, where the shoulder had been out of place for some length of time. He first operated on one side, and two weeks later on the other. The operation in both cases was successful. The operation consisted of an anterior incision through which the soft tissues were loosened from around the bone, after which it was easily put back in place. The patient recovered and had very good use of both

arms.

Lister advises cutting down on the bone from the coracoid process and with a curved periosteum detacher to separate the soft parts from the inner side of the upper end of the humerus, and if this fails, detaching the rotator muscles.

Gerster, in 1884, resected a portion of the capsule, which was followed by a superative erysipelas, but finally the patient made a fairly good recovery.

Wolfe, in 1886, dissected out a portion of the capsule and sutured the remaining parts together with catgut.

Samosch, in 1889, split the capsule, and after overlapping its edges, held them in place by buried sutures, thus reducing its size, which held the head of the humerus more firmly in the glenoid cavity.

Ricard, in 1892, "reefed" the capsule so as to reduce its size without opening it.

A number of successful cases were reported in 1892 by Reichert, in which he "reefed" the capsule. This method, however, can only be resorted to where the capsule is not lacerated.

In irreducible dislocations of the shoulder you may have the capsule lacerated and the head of the humerus protruding through and caught as if in a "buttonhole." On the other hand, there is a variety in which the capsule is simply stretched sufficiently to allow the head of the humerus to escape from the glenoid cavity. There is still another variety in which either of these conditions may exist and be complicated by the head of the humerus being caught behind some one of the numerous tendons that cluster around the shoulder joint. Subcoracoid dislocations are the most frequent, but I find only one case reported of subcoracoid dislocation in which the head of the humerus was caught behind the pectoralis minor. The case was operated on by Cottell in 1893, the tendon of the muscle divided and the dislocation reduced without much difficulty.

It is clearly evident that whilst an anterior incision in the majority of the cases may be preferable, yet the method of completing the operation must be so modified as to suit the particular conditions of the case, and cannot always be decided on prior to the operation.

Personally I have had but three cases in which it was necessary to resort to operative measures for the reduction of the head of the humerus.

The first one was a "buttonhole" tear of the capsule. I operated through an anterior incision and enlarged the tear in the capsule sufficiently to permit the head of the humerus to return to its normal position, sutured the tear in the capsule and closed the wound antiseptically and applied a fixation dressing to the entire arm. The case was a recent one and recovered without any untoward symptoms or bad results.

The second case consisted in the dislocation of the head of the humerus, which was caught under the coracobrachialis muscle. In this case the capsule was severely stretched but not lacerated. I divided the fibers of the muscle sufficiently to release the head of the humerus, after which I reduced the luxation, sutured the dividend muscle fibers with catgut and dressed the entire arm with an immobilizing dressing. Fortunately the results were fair, although there was considerable paralysis for a time which gradually disappeared.

The third and last case was sent to me some fifty-three days after the accident which caused the disiocation, by Dr. G. G. Verbryck, chief surgeon for Kilpatrick Bros. & Collins, railway contractors, then at Aspen, Wyo.

The patient was a young, muscular fellow of thirty years of age, who was not only suffering from an irreducible dislocation of the right shoulder, but also a dislocation of the right hip, both of which were caused by falling rock.

This was one of those cases which was supposed to have been reduced when it was not, or if it had been it did not remain so. By this remark I do not intend to even insinuate that either diligence, experience or skill was neglected in this case, so far as the dislocation of the shoulder was concerned, by not less than two of Dr. Verbryck's assistant surgeons as well as himself and one or more competent physicians in the vicinity of where the accident occurred. He was admitted to the hospital June 21, 1901. On June 25 I attempted reduction under complete anesthesia, without success. An operation was de

ing the wound by buried catgut sutures, reinforced by silkworm gut sutures in the skin.

I then discovered 21⁄2 inches of shortening of the right leg, which on careful examination was found to be a backward and upward dislocation of the hip, which was reduced and dressed in the usual manner, and the patient kept quiet on his back for three weeks, at which time a careful examination was made, which revealed both in place.

Two days after I examined the case again, and, much to my surprise, I found the shoulder luxated again. Reduction under anesthesia was resorted to without success, and as the patient refused to have another operation I was more or less handicapped. I finally succeeded in getting him transferred to Omaha and placed under Chief Surgeon Jonas' care, when he subsequently submitted to a second operation, when the doctor resected the head of the humerus, which was followed by as good results as could be expected from an excision of the head in such

cases.

REMARKS.

This case demonstrates the importance of either "reefing" the capsule or excising a portion of it, with a view of preventing a redislocation of the joint. Had I done this at the first operation, I am inclined to believe now the second dislocation would not have occurred, and a second operation would undoubtedly have been averted. At the same time, had the patient consented to a second operation sooner, a resection of the head of the humerus might have been obviated.