increased, and this somewhat rapidly toward the end of the first week. There was also some purple discoloration about the inner and posterior parts of the shoulder. Still there were no appearances which might not attend an ordinary bruise or laceration about the part. But, in the course of the following week, enormous swelling had come on, extending from the elbow up the arm, and over the chest to the level of the outer third of the clavicle, and over the scapula." The swelling was soft and fluctuating; the skin in places dark purple and thin; the radial pulse was natural. Fever, with slight shivering and one distinct chill. "About the third or fourth week an incision was made in the arm, and the hand passed up into the cavity, which contained an enormous amount of blood, chiefly coagulated, extending under the pectoral muscles, down the side of the chest, and behind over a great part of the scapula, and communicating with the shoulder-joint. The subclavian and axillary arteries could be felt." The man died with symptoms of septicemia. In Körte's second case (loc. cit., p. 635) the patient was fifty-two years old, the dislocation forward and inward. Several unsuccessful attempts to reduce were made during the sixth month, and the last was followed by the gradual appearance of a non-pulsating swelling under the pectoral muscle, oedema of the arm, and sharp neuralgic pain. Radial pulse. The patient became feverish, the tumor softer, the skin thin, and at the end of six weeks it ruptured spontaneously. The hemorrhage was arrested with a tampon, and the patient died shortly afterward. The autopsy showed a large cavity occupying all the space under the pectoralis major, and filled with large blood-clots. On the outer and front side of the artery, 4 centimetres below the clavicle, was a transverse opening measuring 0.4 by 0.3 centimetre (one-sixth by one-eighth inch), thought (loc. rit., p. 650) to have been produced by the tearing off of an arterial branch. In Desprès's case there was the same swelling, slowly increasing and becoming fluctuating, oedema of the arm, and persistence of the radial pulse. In addition, a bruit was audible after the tenth day, and the swelling subsequently pulsated at times. An operation for ligature of the subclavian was done on the fifty-fifth day, and was followed by arrest of the pulsation, but, after the patient died, on the fifty-fourth day, it was found that the ligature had been placed upon a nerve immediately overlying the artery. The common trunk of the circumflex arteries was found to have been torn off at its origin. On the other hand, in Körte's first case, in which the lesion proved, post-mortem, to be a similar opening upon the side of the axillary artery, and of almost exactly the same size, pulsation in the brachial and radial arteries was barely perceptible two months after the accident, when the patient first came under observation with an enormous pulsating swelling of the shoulder filling the axilla and extending up to the clavicle. These histories show, and many of the others might be quoted in confirmation, that, although the diagnosis, so far as the general nature of the accident, rupture of a bloodvessel, is concerned, does not long remain. obscure, the identity of the injured vessel cannot always be determined. If the tumor pulsates, the diagnosis of rupture of an artery may be made; and if, in addition, the radial pulse is present, it is extremely probable that the injured vessel is not the main artery, but that one of its branches, probably the subscapular or circumflex, has been ruptured or torn off at its origin. Beyond this it does not seem at present possible to go with much certainty, although the great preponderance of arterial lesions in the known cases-26 out of 28, or, adding Hailey's and de Morgan's, out of 30, or, again, adding Platner's and Braun's, in which both artery and vein were torn, out of 32-makes it highly probable in any given case that an artery and not the axillary vein has been torn. Of the remaining 15 cases, 6 recovered without operation (Desault, Malgaigne, Nélaton's second case,' Anger, Agnew, and Sands) and have been already discussed. Nélaton, Anger, and Sands made the diagnosis of rupture of an artery. In 8 (Warren, O'Reilly, Green, Volkmann, Létiévant, Cras, Archangelski, and Parker) the subclavian was tied; in 7 of them with success; in 1, Green's, the result is not known. In 1, Dickson, pulsation was arrested by digital pressure on the subclavian continued for eight hours; a year later the tumor was again pulsating, and digital pressure was again made, apparently for a week; three years later there was no trace of the tumor. In the last 7, and in 3 of the first 6, it seems reasonably certain that an artery was injured, for pulsation of the swelling is noted in every account that is given in detail, and such was the opinion of the surgeons who treated them. The record, then, may be made as follows: Of 47 cases, an artery (the axillary or a large branch) was ruptured in 38, the artery and vein in 2, the vein alone in 2, in 2 dissection failed to reveal the source of the hemorrhage, and in 3, in which the patients recovered without operation, the symptoms do not justify a positive diagnosis. The terminations were as follows: 15 recoveries, 31 deaths, and in 1 (Green's) the result is unknown; 20 received no operative treatment; of these 6 recovered and 14 died.2 In 16 the subclavian was tied, with 6 recoveries, 8 deaths, and 1 unknown result. In 1 a cure was effected by digital pressure on the subclavian. In 6 an incision was made in the axilla, and the artery tied above and below the point of rupture; all died. In 4 the limb was articulated; 1 recovery, 3 deaths. The treatment in the cases that recovered without operation was simply compression of the swelling and immobilization of the arm, with the application of ice in Malgaigne's, and compression of the subclavian artery in Agnew's. In drawing inferences from these results, it must be borne in mind that in many of the cases in which operations were undertaken nonoperative treatment had previously been employed, and had resulted in a condition that made an operation necessary. Thus, using only those cases in which the record is sufficiently detailed, of the 17 cases of ligature or compression of the subclavian, in 10 the operation was done after the lapse of several weeks or even months, in 1 on the third day, in 1 on the tenth day, and in 5 the length of the interval is not known. Of the 4 disarticulations, in 1 the operation was at a late date, in 1 five days 1 After rupture of the tumor without hemorrhage, and suppuration of the sac and shoulder-joint. See Körte, loc. cit., p. 655. 2 Possibly Körte's second case should be included among the recoveries. after the accident, and in 2 unknown. Of the 6 treated by incision and double ligature of the axillary artery, the operation was done promptly in 2, and after a long interval in 4. Consequently the results of non-operative treatment may be tabulated as follows: Of 35 patients, 6 recovered, 14 died, and 15 (with 10 deaths) subsequently underwent operation, either because death by hemorrhage threatened, or because of the existence of a growing aneurism.1 A fair inference is that conservative treatment may properly be tried at first, but should not be prolonged if the symptoms do not promptly yield; and, secondly, that, in case of resort to operation, ligature of the subclavian artery or disarticulation at the shoulder is to be preferred to incision of the sac and double ligature of the artery. Experience with arteries wounded under other conditions has shown that they will sometimes quite readily heal, or the opening made into them will close, under pressure accurately made at the point of injury, and it would therefore be proper to attempt to treat this injury by direct, limited pressure. Whether or not it would be possible to recognize the wounded point and make efficient pressure directly upon it cannot be said, since the attempt does not appear to have been made. In default of such limited pressure, general compression of the swelling in the axilla seems to be the only resource short of operation. The common treatment of ruptured artery, incision and double ligature of the vessel, was immediately resorted to in only two of these cases, Lister's and the one at the Sheffield Infirmary. Both were promptly fatal. An important question arises from these facts in connection with the treatment of dislocation of the shoulder: How far does the possibility of the occurrence of this accident affect the choice of a method of reduction? and also concerning the propriety of attempting reduction in cases that are not recent. In the reduction of recent dislocations, these accidents show that abduction of the arm especially should be avoided, as also circumduction, violent traction, and rough pressure in the axilla. Kocher's method by manipulation appears well adapted to avoid the danger. It is also to be remembered that the injury to the vessel may be caused by the dislocation itself, and its symptoms may be masked by the swelling commonly present during the first few days. In old dislocations the probability of the occurrence of the accident is increased by the more forcible measures usually necessary to break up the adhesions that bind the bones in their new relations; and, while it may be proper in many cases to make the attempt to restore the limb to usefulness, the possibility creates another reason for abstention when the patient is old, the duration of the dislocation long, and the adhesions firm. Even a dislocated arm may be very useful, and the fatality of this accident, more than seventy per cent. of deaths, may well cause the surgeon to hesitate to incur the risk merely for the sake of ameliorating a condition which does not endanger life and is quite compatible with activity and usefulness. Kōrte's second case is an exception; an error in diagnosis led to an operation after the aneurism had apparently undergone spontaneous cure. LIST OF CASES. A. Fatal without Operation. 1. Verduc (Malgaigne, Des luxations, p. 149); artery wounded; no treatment; death by hemorrhage. 2. Petit (Malgaigne, Des luxations, p. 149); artery wounded; no treatment; death by hemorrhage. 3. Pelletan (Malgaigne, Des luxations, p. 149); artery wounded; puncture; death by hemorrhage. 4. Platner (Malgaigne, Des luxations, p. 151); artery and vein; death by hemorrhage. 5. Leudet (Malgaigne Des luxations, p. 149); artery; 57 years. 11 days. Dislocation 6. Froriep (Malgaigne, Des luxations, p. 151); vein; 26 years. Dislocation 3 weeks. 7. Gibson, I., Surgery, i. p. 325; 50 years. Disloc. 2 months. Death in a few hours. 8. Price, quoted by Callender, p. 107; vein. Death on following day. 9. Körte, I., Arch. für klin. Chir., vol. xxvii. p. 631; artery; 25 years. Disloc. recent. Puncture. 10. Körte, III., Ibid.; artery; 52 years. Disloc. 54 months. Rupture. 11. Mash (Carruthers), Brit. Med. Journ., 1872, i. p. 526; artery; 38 years. Disloc. recent. 12. Haily, Ibid., 1863, ii. p. 634; 59 years. Disloc. recent. 13. De Morgan, Ibid., 1872, i. p. 54; 54 years. Disloc. recent. Incision. B. Ligature of Subclavian. 14. Green, Lancet, 1825, vol. viii. pp. 189 and 283; 33 years. Result unknown. 15. Warren, Med.-Chir. Trans., vol. xxix. p. 25; 30 years. Recovery. Disloc. recent. Disloc. recent. 16. Gibson, II., loc. cit., p. 334; 35 years. Disloc. 9 weeks. Death. 17. O'Reilly (Adams), Cyclop. of Anat. and Phys., vol. iv. p. 616; 50 years. Disloc. recent. Recovery. 18. Nélaton, I., Path. chir., ii. p. 368. Disloc. old. Death. 19. Rigaud, Dict. encyclop., art. Épaule; artery; 23 years; death. 20. Von Pitha (Körte, loc. cit., p. 649); artery; death. 21. Volkmann (Körte, loc. cit., p. 656). Recovery. 22. Panas (Marchand, p. 52); artery. Dislocation recent; death. 23. Desprès, Bull. de la Soc. de chirurgie, 1878, p. 116; artery; 40 years. Recent; death. 24. Gärtner, Schmidt's Jahrb., 1871, vol. cli. p. 304; artery; 20 years. Recent; death. 25. Létiévant, Bull. de la Soc. de chir., 1884, p. 748. Recent; recovery. 28. Archangelski, Centralblatt für chirurgie, 1885, p. 383. Dislocation habitual; aneurism appeared after unsuccessful attempt on 4th day, and increased after a second attempt in 4th week. Subclavian tied below the clavicle; recovery. 29. Parker, Lancet, 1885, i. p. 704. F. 36 years. Disloc. 7th week. The ruptured artery was apparently the subscapular. C. Double Ligature—all Fatal. 30. Callender, St. Barthol. Hosp. Rep., vol. ii. p. 96; artery; 61 years. Disloc. old. 31. Wutzer, Arch. für klin. Chir., vol. x. p. 308. 32. Körte, II., loc. cit.; artery; 29 years. Disloc. recent. 33. Lister, Edinb. Med. Journ., 1873, p. 829; artery; 58 years. Disloc. 8 weeks. 34. Rivington, Brit. Med. Journ., 1872, i. p. 420; artery; 71 years. Disloc. recent. 35. Sheffield Inf., Ibid., 1883, i. p. 207; artery; 62 years. Disloc. 6 weeks. 36. Baum, Deutsche Klinik, 1867, p. 431; artery and vein. Lig. of axillary (possibly double). D. Digital Pressure. 37. Dickson, Keney, Philad. Med. and Surg. Reporter, 1882, vol. xlvii. p. 256. M. 24. Recent; recovery. E. Disarticulation at Shoulder. 38. Jünken, Arch. für klin. Chir., vol. x. p. 313; artery. Unsuccessful attempt to apply double ligature; recovery. 39. Bell (Malgaigne and Callender). Death. 40. Ledentu, Bull. de la Soc. de chir., 1877, p. 187; artery. Disloc. recent; death. 41. Bellamy, Lancet, 1880, ii. p. 260; artery; 55 years. Disloc. 7 weeks; death. F. Recovery without Operation. 42. Desault, Œuvres chirurgicales, vol. i. p. 380; 60 years. Disloc. 14 month. 43. Malgaigne, loc. cit., p. 150; 44 years. Disloc. 2 months. 44. Anger, Bull. de la Soc. de chir., 1878, p. 122; 54 years 45. Nélaton, II., Ibid. 46. Agnew, Willard in Phila. Med. Times, 1873, p. 721; 60 years. Disloc. 6 weeks. 47. Sands, N. Y. Med. Record, 1880, p. 45; 84 years. Disloc. 7. weeks. Autopsy in the proceedings of the New York Surgical Society, May 26, 1885, in N. Y. Med. Journal and in The Medical News, June 13, 1885. Injuries to Nerves.-These also have been far more frequently observed at the shoulder than elsewhere, and there is the same difficulty in many of the recorded cases in determining whether the injury was caused by the dislocation or by the manoeuvres employed to effect a reduction. The injury may consist in direct compression of the nerve against the bone, as in the attempted reduction by the method of the door or ladder or by the heel in the axilla, or in forcible elongation or complete rupture of the nerve by traction upon the limb, or such change in its position that the nerve is stretched around the head of the bone, or in avulsion of the nerve from the spinal cord. As the autopsies are few in number our knowledge of the lesions is mainly clinical. In a case quoted in the preceding section, one of rupture of the brachial artery near the elbow, the median nerve was also ruptured; and this double injury has been several times encountered in compound dislocation of the elbow. In a case reported by Flaubert,' and mentioned above in the section on Emphysema, a dislocation of the left shoulder five weeks old in a very stout woman aged seventy years, reduction was accomplished with difficulty after prolonged traction upon the arm by eight assistants. Besides the emphysema extending over the neck and back, there were syncope lasting an hour, cloudiness of vision, paralysis of the right arm, and left hemiplegia with loss of sensibility in the left arm but with pain referred to it. Thirty-six hours later there was sharp pain in the back of the head and neck and in the ears; pain also in the left thigh, in which sensation was better than in the right; the left arm was insensitive, with Marchand: Loc. cit., pp. 25 and 67. |