or that have been complicated by much inflammatory reaction. The reasons for the greater liability to rupture of the arteries under these conditions are not obscure; the loss of elasticity because of atheromatous change in the vessels in the old, and the adhesion of the vessels to adjoining parts as a sequence of inflammation are a sufficient explanation, and the mechanical difficulties created by the contraction and readjustment of the torn tissues in old dislocations explain the others by the force that is required to overcome them. Integument. The skin may be bruised or lacerated at a distance from the joint by the pressure of the cords through which traction is made, or near the joint by the pressure of the hands or instruments acting upon the dislocated end of the bone, or it may be torn across if the traction is exerted upon it rather than upon the bone. These lesions are seldom serious, and the former may usually be avoided by protecting the surface with thick layers of cotton or flannel. Transverse rupture of the skin between the points of extension and counter-extension is due to a faulty application of the force, by which it is exerted upon the skin alone and not upon the underlying bone. The skin is elastic and tough, and when unaltered by disease will support a very considerable strain, one far in excess of that commonly needed to overcome the contraction of a muscle, but the traction may be so applied that it will act only upon the skin. Thus, if a broad band is strapped snugly about the middle of the arm and traction is made by a cord attached to it, it will draw the skin downward toward the elbow; and if at the same time the skin of the axilla and chest-wall is prevented by counter-extension from sharing in the movement, the intermediate portion is put upon the stretch and may tear, as in the following case reported by Mr. Hutchinson :1 "In a case not long ago, of a six weeks' dislocation, we were compelled to desist because the skin had torn across the axilla. This curious accident occurred whilst we were trying the heel in the axilla method, and without the application of any unusual force, nor was the operator's boot on. Suddenly the skin gave way from side to side, and a great transverse rent presented itself. The patient was a woman of fifty, of lax, flabby tissues. The wound healed quickly." 2 Similar cases have been reported in dislocations of the shoulder (Malgaigne, Smith3), elbow (Marchand'), and of the terminal phalanx of the great toe." In connection with this, as representing a less degree of the same injury, may be mentioned an experience of Malgaigne's (loc. cit., p. 528) which he considered unique. He was attempting to reduce an intracoracoid dislocation in a very fat woman, and had increased the traction to 230 kilograms (about 500 pounds). The traction was made in the arm, the elbow being held at a right angle by an assistant. Just as Malgaigne changed the position of the limb in an effort to throw the bone into place the assistant loosed the forearm, and the bracelet slipped nearly to the wrist, dragging the skin along. The skin was not broken, Hutchinson: Lond. Med. Times and Gazette, 1866, i. p. 304. Smith: Lancet, July 6, 1878. but the underlying cellular tissue was extensively torn, and gangrene, fortunately limited in extent, followed. To guard against the occurrence of this accident the limb should be firmly grasped, if traction by the hands is used, at the enlarged distal end of the bone, so that the skin should not be drawn downward by the slipping of the hands, and the additional precaution may be taken to press the skin of the forearm (in the case of a shoulder dislocation) upward before the limb is grasped, and similar precautions suitable to the region should be taken at the point of counter-extension. If traction is made by a cord or band, it should be attached to the limb just above a bony prominence or enlargement which will prevent its slipping; it should not be made fast simply by enclosing its loop in circular turns of a bandage which maintain their hold upon the skin by friction. For the same reason, if the attachment is made by means of strips of adhesive plaster, the strips should not extend far up the limb, and the gliding of the skin should be guarded against by snug circular turns of the bandage above bony enlargements. As the maximum of distention will be suffered by the portion of skin which covers and immediately adjoins the dislocated joint, and as this distention will increase as the bone yields to the traction and moves toward its cavity, the effect upon the skin of the counter-extending measures should be carefully scrutinized, and the bearing changed from time to time, if possible, so as to take advantage of the elasticity and mobility of the adjoining portions of integument. Sloughing of the skin, due to its compression against an underlying bone by direct pressure exerted to force the latter back into place, has been occasionally observed, in a dislocation of the astragalus,' and over the olecranon in an attempt made by a bonesetter to reduce a backward dislocation of the elbow. Emphysema of the Cellular Tissue.-On the basis of two cases, in which the condition of the parts was not shown by direct examination, it has been asserted that a gaseous tumor may form in the cellular tissue under the skin as a result of efforts to reduce a dislocation. In each of these cases the dislocation was of the shoulder, and the explanation offered in one was that the emphysema was due to air that had escaped from the lung after its rupture during and by the struggles and cries of the patient. The first case was reported by Desault; he reduced by violent and prolonged traction a dislocation of the shoulder of six weeks' standing, in a man sixty years old. At the moment of reduction a tumor formed suddenly under the pectoral muscle, and soon filled the axilla; the patient fainted, and the pulse was barely perceptible on the affected side. The tumor was well defined, elastic, not fluctuating; the overlying skin was not discolored, and percussion gave a "sort of sound" (espèce de bruit). On these symptoms rupture of the artery was excluded, and diagnosis of emphysema made. In two weeks the tumor had entirely disappeared, leaving in its place a large ecchymosis. Pelletan3 had a similar case, made the same diagnosis, incised the tumor, 1 Dauvé: Rec. de Mém. de Méd. et Chir. Milit., 1867, vol. xix. p. 143. 2 Desault: Œuvres Chirurgicales, vol. i. p. 380. 3 Pelletan: Clinique Chirurg., vol. ii. p. 95, quoted by Malgaigne. and lost his patient by hemorrhage; the artery was found to have been ruptured. The only symptom in Desault's case which gives support to his diagnosis is an alleged resonance in percussion, and that, in which an error of observation might so easily be made, cannot be allowed to outweigh all the others which point so plainly to rupture of a vessel. The third case cannot be so seriously criticised. Flaubert' reduced a dislocation of the shoulder of five weeks' standing in a woman seventy years old; the first attempt was unsuccessful; in the second traction was made by eight students, and the patient, who at first uttered vehement eries, seemed afterward to be upon the point of suffocating, and her face became purple and injected. An emphysema immediately appeared above the clavicle and spread over the shoulder to the middle of the back. She died on the eighteenth day, apparently in consequence of the tearing away of the lower four trunks of the brachial plexus at their attachment to the spinal cord. Rupture of the Muscles.-Under this head only those lacerations of the muscles will be mentioned which are occasioned, especially in old dislocations, by violent traction or by forcible, exaggerated, and longcontinued manipulation of the limb. The cases in which the injury has been confirmed by autopsy are few, only those in which death has promptly followed in consequence of associated lesions or of the inflammation to which the violence has given rise. Yet, in another of Flaubert's cases, quoted by Marchand, there seems to be no doubt that not only the muscles but also the ligaments and other soft parts were extensively torn. The case was one of dislocation of the elbow backward, twenty-seven days old, in which traction was made upon the forearm by seven assistants; suddenly the parts seemed to yield and change their positions with a sound of tearing, and at the same moment a zone of narrowing or depression appeared at the level of the joint with a bony prominence above and below. It seemed to all present that the muscles and soft parts covering the joint had been ruptured, leaving a gap two inches long. An enormous fluctuating swelling promptly appeared, the radial pulse returned the next day, and the patient recovered. In the cases confirmed by autopsy the dislocation has always been of the shoulder, and the muscles most frequently torn have been the pectoralis major and the subscapularis. In a case reported by Petit the long portion of the biceps was torn from its tendon, and in one examined by Sir Astley Cooper,3 a woman, fifty years old, who had died apparently from the violence used in reduction, "the pectoralis major was found to have been slightly lacerated, and blood was effused among its fibres; the supraspinatus was lacerated in several places; the infraspinatus and teres minor were torn, but not to the same extent as the former muscle. Some of the fibres of the deltoid muscle and a few of those of the coraco-brachialis had been torn, but none of the muscles had suffered so much injury as the supraspinatus." In a case briefly mentioned by Callender "a bonesetter employed 1 Flaubert: Répertoire d'Anat. et de Phys., 1827, quoted by Malgaigne. 2 Marchand: Loc. cit., p. 20, and Malgaigne, loc. cit., p. 149. 3 Cooper: Disloc. and Fract., Am. ed., p. 320. Callender: St. Bartholomew's Hosp. Rep., 1866, vol. ii. p. 101. twelve or sixteen men to pull at the arm of a man sixty years old, who was said to have dislocated his shoulder some time previously, and the following were the fatal results: the pectoral muscle was torn through, the plexus of nerves ruptured just below the clavicle, where also the artery was torn across. The bones of the forearm were dislocated at the elbow, and the bones of the arm and forearm fractured." Avulsion of a portion of a limb is fortunately a very rare accident. Except for one or two cases of avulsion of the thumb, known only by tradition, the only instance of complete avulsion is that in which Alphonse Guérin tore away the forearm at the elbow in an attempt to reduce a subcoracoid dislocation of the shoulder, The following is an abstract of a full report of the case published in the Bulletins de la Société de Chirurgie, 2d Series, vol. 5, 1864, pp. 121 and 131. The patient was a woman of good health and constitution. The dislocation was not recognized until six, weeks after its occurrence, when unsuccessful attempts were made to reduce it. All power of voluntary motion of the limb had been lost since shortly after the accident. At the time of admission to the hospital there was found a complete subcoracoid dislocation of the left humerus; the limb hung motionless beside the body, and only the fingers could be slightly moved; its cutaneous sensibility was dulled, temperature unchanged; there was oedema of the lower part of the forearm and especially of the hand; skin faintly purplish; sharp pains throughout the limb. Chloroform was given to complete resolution; a broad bandage was passed under the axilla for counter-extension, and another made fast to the wrist and confided to four assistants. During the first attempt the second bandage slipped; it was tightened, and traction again made, steadily and without much force. Suddenly, without warning, the limb separated at the elbow. The artery was tied, the lower two and a half inches of the humerus sawn off, and the stump trimmed. The rupture had taken place mainly through the joint, a small portion of each condyle remaining attached to the muscles of the forearm, and a portion of the olecranon to the triceps, and through the substance of the biceps and brachialis anticus; the nerves had given way at distances above the elbow varying from five to seventeen inches, the latter being the musculo-cutaneous very much drawn out, and the brachial artery at three and a half inches. The muscles were softened and brown, especially the pronator quadratus which was pulpy; the nerves were injected, with nodes at intervals; the veins were dilated. The ends of the long bones were profoundly disorganized, with thinning of the compact shell and rarefaction of the spongy part; they broke under slight pressure and could be easily perforated with the scalpel. The radius and ulna had been broken about half an inch above their lower articular surfaces. Microscopical examination showed degeneration of the nerves, muscles, and bones. The patient died on the thirteenth day, and the autopsy showed no change in the tissues of the other limbs; the muscles of the left shoulder were normal, except the deltoid, the fibres of which were pale and degenerated. The nerves were matted together in the axilla and firmly pressed against the head of the humerus; above the point of compression they were normal, contrasting strongly with the parts below. It is evident that the accident was favored by great trophic changes in the limb due to pressure upon the nerves in the axilla. 3 Injuries of the Main Bloodvessels.-Although the earliest recorded cases of accidents of this class occurred at about the beginning of the eighteenth century, the subject did not receive the attention of systematic writers on surgery until after the publication, in 1827, of an article by Flaubert. Malgaigne, in 1855, discussed the subject at length in his work on dislocations, mentioning sixteen cases of all kinds, certain and uncertain. Callender,2 taking as a text his own fatal case, again collected and collated the known cases; and similar use was made of the material, and other cases added to the list by Le Fort, Willard,* and Marchand.5 In 1882, Körte reported three personal cases, and wrote a very full and valuable paper on the subject, containing forty-four supposed (actually thirty-eight; see note below) cases of dislocation of the shoulder, in which the vessels had been seriously injured during the act of dislocation or of reduction; and in 1884 Cras reported a personal case of injury of the axillary artery, and added a few others to Körte's list. Strictly speaking, several of these cases should not be here considered, since in them the vessel was injured at the moment of dislocation and not during reduction, and in many others it remains uncertain whether the same objection might not be made to them. They are retained because they serve equally well with the others to further the study of most features of the subject. Flaubert: Mém. sur plusieus cas de luxations dans lesquels les efforts pour la réduction ont été suivis d'accidents graves, Répertoire d'anat. et de phys., 1827. Callender: loc. cit., p. 96. Le Fort: Dict encyclopédique des sci. méd., article Axillaires. ♦ Willard: Phila. Med. Times, 1873, vol. iii. p. 721. 5 Marchand: Des accidents qui peuvent compliquer la réduction des luxations traumatiques, Thèse de concours, Paris, 1875. Körte: Arch. für klinische Chirurgie, vol. xxvii. p. 631. Cras: Bull. de la société de Chirurgie, 1884, p. 789. Reference to the original accounts, so far as I have been able to obtain them, shows several errors in the lists given by the above-mentioned writers. Sir Astley Cooper's case must be excluded because it is the same as Gibson's first case, having been simply quoted by Cooper without acknowledgment. Blackman's case must be excluded because it proved to be not a dislocation, but a fracture of the humerus. As it has been widely quoted, and is, indeed, given in detail as a dislocation by Dr. Hamilton (Fractures and Dislocations), an explanation of the manner in which the error arose may be of service. Blackman reported it as a dislocation in the Western Lancet, August, 1856, p. 469, and an abstract of this report was given in the Amer. Journal of the Med. Sciences, 1856, vol. xxxii. p. 571, and is quoted by most writers. But on page 508 of the same (August) number of the Western Lancet is a note by Blackman, which apparently had been overlooked by the maker of the abstract, giving the results of the autopsy, and showing the error in the diagnosis. The fracture was at the surgical neck, and the end of the shaft had been displaced upward, and lay in contact with the coracoid process; the head was still in the glenoid cavity, and had partly united with the shaft about, an inch below its upper end.. In Segond's case not only does the artery appear to have been wounded by a piece of the dish the patient was carrying, but it is doubtful even if the limb was dislocated. In Delpech's case it is recorded only that at the moment of reduction the patient grew pale, became unconscious, and died immediately, and there is nothing to show the cause of death. In Fano's the artery may have been simply compressed. O'Reilly's is the same as Adams's. The latter admitted the case into the hospital, the former operated upon it. A case which Callender quotes, a man treated by a "bone-setter," does not deserve |