90

tic with the history of the caseby the celebrated Professor whoperformed the experiment. Butour readers will now see thatthe Physicians were not evenpresent during- the experiment; ’;and that the statement on whichDr. JAMES JOHNSON endeavoursto build an argument, for reconciling- his readers to the ’ chaffand bran’ of the Medico Chirur-gical Review, is absolutely andgratuitously false. The positionin which Dr. JAMES JOHNSONstands, as -,the Editor of the

Medico-Chirurgical Review, isat once ludicrous and humilia-tinm. The more he has endea-voured to extricate himself fromit, the deeper has he plungedinto the mire of subterfngeand misrepresentation. By hisimpotent attempts to shake, the

reputation of THE LANCET hehas succeeded only in callingforth such an exposition of thecharacter of his own Journal asmust’ infallibly consign it to

public contempt and oblivion-—Nec lex est æquior ulla

Quam necis artifices arte perire su.

FOREIGN DEPARTMENT.

Cllse of Rupture of the Axillary Ar-tery, in a successful attempt to re-duce an old luxation at the shoulder

joint by W. GIBSON, M. D. Pro-fessor of.Sargery in the Universityof Pennsylvania.JAMES SCOFIELD, fiftv years of age,

of intemp.erate habits, and foreman tothe Penns Grove Cotton Factory, inChester creek, applied to me on the10th of Mav last, on account of a dis-location of’ the left arm, at the shoul.der joint, produced two months before,by the weight of a heavy chest, whichfell upon him, from a cart, while hewas driving it along the road. A physi-

cian was immediately sent for, who sta;,ted that the arm was fractured just abovethe elbow, and must be secured bysplints and bandages. These were ac-

cordingly applied and continued, abouttwo weeks, when the bone was de-clared so far united as to render thedressings unnecessary. No notice, ac-cording to the patient’s account, was

taken of the shoulder, although, fromthe first, the swelling had been con-

siderable, and the pain very severe.

A short time afterwards the patientconsulted Dr. Dutton, of Village-Green, Delaware county, who, dis-covering that the os humeri had beenluxated at the shoulder, and still re-mained displaced, determined to makean effort to restore it to its naturalsituation. With this view the patient’sbody was securely bound and renderedimmoveable ; three pints of b’ood weredrawn from the right arm, whilst., a

strong sheet was twisted around the

injured arm, above the elbow, and itsends given to five strong men, whowere directed to keep up a constantand s!eady extension, which was con-tinued for some time, and frequentlyrepeated, but without any benefit.The patient suffered, as he remarked,a good deal, from this attempt to res-tore the bone to its place, and wasdebilitated by the loss of blood ; stillhe was willing to undergo any torture,provided there was the slightest pro-bability of his arm being again ren-dered useful. For this purpose hecame to i’hiladelphia, and consultedDr. Humphreys, by whom he was re-ferred to me. It was evident, uponexamination, that the head of the os

humeri had been separated for a con-

siderable time, from the glenoid cavity;for I found it so firmly lodged in theaxilla, that the arm would scarcelyadmit of any motion, and the slightestmovement occasioned pain. Afterexplaining to the patient the un-

certainty of any benefit result-ing from a further attempt to re-

duce the bone, and pointing out tohim the suffering that must necessa-

rily follow the efforts to restore it, Idetermined to make the trial, and forthis purpuse requested him to meet meon Monday the t8th of May, at theAlms House. Having arranged thenecessary apparatus, I desired Mr.Gregg, one of the house pupils, tobleed the patient in the right arm.While the blood was flowing, a buck-

91

skin band, with an iron plate and ringsecured to it, was fastened around thewrist. A large rolier was then fixedin the arm-pit. and over this a sheet,folded diagonally.’ the ends of whichwere carried before and behind thechest, towards the opposite shoulder,and fastened io a hook. This she,tserved for the counter extending band.Pumes were next attached to the ringat the wrist, and every thing beingprepared, I commenced the operation.(in presence of Dr,,. Humphreys.Horner, Jackson, the resident phy-sicians, and students of the house, an:lseveral other spectators), by settingthe’pullies in motion and keeping up,for several minutes, a continued butsteady extension and-counter exten-sion. This fatigued the muscles of thearm considerably, and the patient wassensiblv afiecaed by the loss of nearlytwo pound of bloocl, but did not faint.I then relaxed the pullies, and takinghold of the arm, near the elbow, usedit as a lever, and communicated a ra.

tatory motion, in hopes of breaking upthe adhesions and adventitious liga-ments. connecting the head of the buneto its new socket. Additional at-

tempts were made with the pullies,apparently without the -slightest effect.Dr. Herller now proposed to changethe direction of the force of the counterextending bnnd, by fastening a hook inthe floor, seating the patient on a

chair, and passing the middle of a strapover the point of the acromion process,in order to secure the scapula. Thiswas, also, tried, but with no bettersuccess. I next disengaged the ex-

tending and counter extending bands.and laying the patient out upon thetable, placed one of my heels in theaxilla, while I produced extension, bypulling at the patient’s wrist. Thesame was done by a house pupil Strudwick. Finding these efforts unavail-

ing, another attempt was made bymeans of sheets, fastened above theelbow and under the arm-pit. Five orsix assistants took hold of the ends ofeach, and pulling steadily for sometime, the head of the bone was per-ceiyed gradually to yield. It quicklyreturned, however, nearly to its for-mer position, as soon as the effortswere discontinued. By this time thepatient was greatly exhausted, and themuscles very much relaxed, when Dr.Horner requested him to lay on thefloor, and at the same time stretched

himself down opposite to him, andtaking hold of the wrist, made a con-tinued but forcible extension, whilecounter extension was ejected by hisheel in the axilla. During these effortsthe head of the bone gradually ap-proached the glenoid cavity, and atla3t entered it. The slightest move-ment, however, was sufficient to throwit out again, which led me to supposethat a portion of the capsule might be

interposed between it and the socket.and would require further lacerationbefore the reduction could be entirelyaccomplished. But the patient wastoo much overcome to make anv fur-ther attempt at that moment, and wastherefore put. to bed. On visiting himhalf an hour afterwards, with Dr.Humphreys, I found the head of thebone resting on the lower edge-of theglenoid cavity, and a hollow under theacromion. I took hold of the arm, andmade two or three slight rotatory mo-tions, when it slipped suddenly intoits place, and was completely reduced.There was a general swelling aboutthe deltoid and pectoral muscles, whichwas noticed both by Dr. Humphreysand myself, but supposing it to be anapproach to inflammation, a conse-

quence to be expected after the effortsmatle to restore the head of the bone,nothing was apprehended from it. The

swelling increased, however, veryslowly, for several hours, and althoughreniarked by the house pupils and at-

tendants, did not excite any alarm,inasmuch as the patient complained of

ry

little pain. and conversed cheerfullywith ’ome of his friends during thegreater part of the afternoon. Aboutsix o’clock in the evening Dr. Brinton,one of the house pupils, visited him,and hearing that he had a short timebefore turned over in bed, in order tosleep, and struck with the unusuallypallid appearance of his face, was in-duced to suspect that some unfavour-abta change had taken place. These s

suspicions were confirmed, fbr upon

examination the pulse was foundscarcely perceptible, and the wholesystem so much sunk, as to render

iecovei-y, impossible. Leaving, Dr.Hopkinson in charge of the patient,Dr. Brinton immediately repaired tomy house, and informed me of hiscondition. Before 1 could reach him...however, he expired. The appear-ance of the shoulder and adjacentparts soon explained, it seemed to me,

92

the nature of the case; for the pectoralmuscle was considerably elevated, andthe skin for some distance about thechest and shoulder discoloured andecchymosed showing in all proba-bility that some large artery qr veinhad been torn across during the ef-forts to reduce the luxation. To de-termine this point with accuracy, Iobtained this consent of the patient’sfriends to examine the body and atten o’oclock next morning the dissectionwas made by Drs. Horner and Law-

rence, in presence of Drs. HumphreysJackson the house pupils, several stu-dents, and myself.’ Dissection.Three incisions were made—one

from the acromion process, along thecourse of the clavicle, as far as thesterum—another perpendicular to thesterum, and about ten inches long—athird nearly at right angles with thelower extremity of the perpendicularone and running across the chest to-wards the arm-pit. The integumentsand pectoral muscles being elevatedalong the edge of the sternum, andthrown back ward towards the shoulder,a considerable quantity of coagulatedblood was found filling the cellularmembrane a44 laving in masses be-tween the interstices of the muscles-In order to ascertain the condition ofthe large vessels beneath the clavicle,this bone was separa e4 at its juncturewith the sternum and raised. Thecourse of the subclavian artery andvein was then distinctly seen. A smallopening was made in the vein, intowhich a. bougie was introduced for several inches towards the axilla, as aguide during the dissection; but t6evessel was found perfectly soundthroughout. Under the vein, as dtpasses near the glenoid cavi-ty, a largemass of coagulated blood was obser-ved, and upon clearing this, away, theaxillary artery was aeen protruding,with its mouth open, having been torndirectly across and separated from itsconnexions. Upon further examina-tion it was discovered that the headof the bone at the time of the luxa.tion had been carried downwards intothe axilla about an inch and a halfbelow the glenoid cavity, where itformed a white ligamentous Guft-iikesocket, in the subscapulary muscle, andpressing upon the axillary artery,produced such a degree of inflamma-tion as gave rise to a copious effusion

of coagulable lymph, which united theartery completely for some distancetaj the capsule of the joint, where itsurrounded the neck of the bone. Thelower part of the capsule was torn andseparated from the neck of the hume- ::

rus; the upper part remained entire,and was very much thickened. Thehead of,the-- bone filled completely theold socket or glenoid cavity. Beneaththe’deltoid muscle there was a largehollow fllled with blood, and the wholearm, as far as the elbow, had been ex-, tensively injected with the same fluid.The os humeri was carefp igy dissected

from the condyles to its head, and theperiosteum entirely scraped off with-out showing the slightest vestige of afracture.. The long. tendon of -’the,’-,biceps was found considerably elonga-.gateat but not ruptured.*Remarks.

The, foregoihg case must be consi-dered in every point of view, ex-- tremely interesting; it was mistaken,it appears, by the physician who firstsaw it, for a fracture near the elbow,and treated accordingly; a few weeksafterwards the true nature of the dis-ease was discovered by another prac-’titioner,’ and an attempt very properly:mad6; but without effect, to restore thehead of the bone to its natural situa-tion, The patient finding his arm

useless, and unable to follow his occu-patiori, determined, not withstandinghis previous suffering from one op-era- --

tion, to submit to another. The trialwas made, under every disadvantage,the head of the bone restored to’ its

socket, the axiitarv artery torn across,owing to an accidental adhesian be-tween it and the capsule of the joint,which could not be foreseen, and the

patient died. Persons. acquainted withthe difficulties often encountered’, eveirwin the most simple cases of luxation,will readily understand, without com-ment the peculiar nature and the me-vitabie result of’ the case 1 have de-

tailed. For those who possess littlepractical information on the sub,ject; ,and who may, perhaps; be led to con-demn the -efforts, to relieve the unfor-tunate patient, as rash ’and unwarrant-

The diseased part being removed,was carefully prepared by Dr. Law-rence, and deposited in the surgicalcabinet at the University, where it

may at any time be inspected.

93

able, the following obervations arechiefly intended.’ The head of the humerus may be- forced from the glenoid cavity of the°sca.pula and lodged in different-situa-tions. In nine out of ten cases,- how-ever, it rests in the hollow of the arm-’pit. having previously ruptured tho in-- ferior portion of :the capsuiar ligament.- The tumour, formed by the -head of-the bone., in the axilla, and, the unna-tural hollow under the acromion pro-cess, are, signs so decisive of the natureof the accident as not to be overlooked,except by.--the, most careless or igno-rant ’practitioners.. To restore the-bone to its original position, the sur-geon makes extemion and counter-ex-tension, either by the hands of strongassistants, some of w,hoQ1, take hold ofthe .dislocated arm, and pull steadily,but forcibly, while other resist, ’by se,.curing the body or shoulder,, or bytowels, or sheets, straps, or pullies, asthe case may require.: If the force bewell directed, and continued suffi--cientiv long to fatigue the muscles,’and thereby overcome their resistance,the.- head of the bone generally slipsinto its place, without:much difficulty.But the alit or, rupture in the capsuleremains open for a considerabler time,and in many instances never- closes..Under these circumstances, the pa-;tiBnt is continually liable to a recur-rence of the accident, and the slightesteffort will, sometimes be sufficient to,induce it. It not unfrequently hap-ens that the surgeon finds it impossi-.ble, by the most powerful extension.and counter-extension to restore thehead of the bone, even in the most re-cent cases. This is owing generally,as is-now well understood, to the rentin the capsule being too small to ad-mit the head of the os humeri to pass through. and enter the glenoid cavity.When such dimculties ’exist, the sur-

geon discontinues the extending andcounter-extending forces, and takinghold of:the arm, uses it as a lever, andcommunicates a,r-otatory motion to. it,the chief object of which is to tear upand enlarge the opening in the capsule.This being done, a very slight eifort,in the way of extension, will proba-bly be sufficient to reduce the bone.When the head of the bone. insteadof being restqred immediately-to itsproper cavity, is suffered to remain inthe arm-pit, for weeks o’r’ ’months, it

will be lound in a very different condi-

tion from that last described ;. inflam-xnation takes place, adhesions form be-tween, the bohe.and surrounding parts,adventitious ligaments oare ,ereated, anew socket is produced, the ial-4 onepartially or entirely filled up, and- thebone after a short time almost as firmlyfixed as it, was in its original position.Previous to the - time of ..the. enlight-ened and adventurous Dessault, such acase was deemed hopeless and irreme-diable. This great surgeon conceivedthe possibility of restoring the use ofthe arm, :-under these almost desperatecircumstances, and succeeded in. seve-ral cases of one, two. three and fourmonths ’standing, ’by the..followingmeans:-’ Previously to making ex-tension, it is necessary to move.thethe bone very forcibly in every direc-

tion, in order first t6 break the adhe-sions, to tear the condensed cellularmembrane, which serves- as an acci-dental capsule, and to produce, sp to

speak, a second luxation, with a viewto make way for a perfect reduction ofthe first.. The straps being then ap-plied, as in ordinary cases, serve thepurpose of extension, for the accom-plishment of which, the number of as-sistants must be increased, Often-- times the ;first efforts are fruitless, andthe luxated head remains stationary.amidst -the most violent efforts. Letthe-extension then be discontinued:renew the forcible motions of the limb:carry the humerus upwards, down.wards. forward and .backward ; forcethe resistances to give way ; make thearm describe a large arch of a circleround the place which it occupies ; letthe rotatory motions on, its. own axisbe impressed on it anew; and then re-commence the extensions, and jet thembe made in every direction. By these,the head, already, disengaged,by meansof the preceding-vioLent motions, willbe brought to a level with-the glenoidcavity, and ultimately replaced. *"From these extracts it will, be, seen,that Dessault strongly inculcates theemployment of forcible and even vio-lent exertions in the reduction of allold luxations-of the os humeri; -thesuccess, indeed, which he met with,almost invariably, and that too inrmanyinstances, after other practitioners whoemployed milder * means had failed,was such as to justify the practice cum-

*Dessault’s works, by Cadwell,p. 144.

94

pletely, and’ induce other surgeons,both in Europe and in this country, tqfollow his example. The practice, Itherefore, has long since become gene- :ral and established, so much so, thatthe surgeon who should refuse to at.tempt to relieve his patient, because ithe head of the bone had remained outof the socket several months, woullbe considered culpable by all intelli-gent members of the profession.-Dr. Physick has, "in a variety ofof instances, succeeded after two ofthree months."* The late Dr. Dorsey,one of the best informed and most ac- I

plished surgeons of this country, en-tirely approved of Dessault’s practice,and followed it successfully in severalcases. " Dr. M’Kenzie. of Baltimore,replaced a dislocated os humeri nearlysix months after its luxation."t Thesame has subsequently been accutn-

plished by Mr. Kirbv,4, ol’ Dublin.For the last twelve or thirteen years,I have repeatedly reduced luxations at-the shoulder, and some other joints,from two to four months standing, andalthough in several instances the ad-hesions, surrounding the head of thebone and the new socket were so con-

siderable as to require great force andextensive laceration, not the slightestaccident has ever occurred. The re-cords of surgery, indeed, furnish veryfew examples, so far as I am acquaint-ed, of injury, much less of death, re-

sulting from attempts to restore thehead of the bone even after it had beendisplaced for a very long period. Des-sault details the history of one case inwhich either a large emphysematousor bloody tumour formed under thepectoral muscle immediately after thehead of the os humeri had been re-stored to its glenoid cavity . ·° Scarcelywas the reduction accomplished, whena tumour rose suddenly under the pec-toraiis major, propagated itself towardsthe armpit and occupied immediatelyits whole extent. All the assistants,astonished at the phenomenon, knewnot to what circumstance to attributeit. Dessault.himself, a little embar-rassect, thought first of an aneurism

* Dorsey’s Elements of Surgery.-Vol. 1. p. 237.. t Ibid.

t Kirby’s Cases; with observationson Wryneck, the reduction of luxa-tions of the shoulder, &c. p. 53.

suddenly produced by th6 violence ’ofthe extension. The pulse of the pa-tient, being scarcely perceptible in .theside affected, and a syncope which,; su-

pervened, appeared at first to favourthis suspicion; but immediately theabsence of a fluctuation, of a pulsationand of a change in the colour of theskin, the return of the pulse, the cir-

cumscription of the tumour, its resis-tance and the sound caused by strik-ing on it, produced a belief that it wasowing, not-to an effusion of blood butto a disengagement of air that adbeen confined in the now lacerated cellsof the c’llular membrane. On thethirteenth dav, the tumour was en-tirely gone. In the place which it had ’o.

occupied a large ecchymosis’appeared,produced, no doubt, by the rupture ofthe small vessels at the time of reduc-tion."’" This patient recovered per-

I fectlv in less than a month after thereduction, and no other similar case ismentioned, that 1 know of, either byDessault or any other writer.Although most writers on discola-

tions seem to think a rupture of theaxillary artery, from attempts to restorethe bone, after it has been displaced a.’

few weeks, a possible occurrence, yet Ihave not been able to find, after verydiligent research, a single instance ofthis description except one, which is

merely glanced at by Mr. CharlesBell. I, In this violent operation,"says he.

" one can imagine that if theaxillary artery were at all diseased itmight be torn ; but I have not knownof such an accident, though I have.known such an ecchymosis succeed theoperation of reduction, as would implythe rupture of some considerable vein,In employing the zanbe in the New-castle Infirmarv, both the axillarv ar-tery and the muscles have been torn,so that they were obliged to amputateon the instant."t Mr. Bell is silent asrespects the event of the case; thereis every reason to conclude, however,

that it could not have been otherwisethan fatal. A very remarkable in-stance has been recorded by Loder ofhigh inflammation, mortification anddeath, from Rn attempt to reduce a

luxation of several months duration.

* Dessault’s works, p. 149. ’

* Bell’s Operative Surgery. Vbt.II, p. 247.

95

" When Loder was studying at theHotel Dieu at Rouen, a man came tothe hospital, on account of some tri-

fling-complaint. The celebrated M.David, then the principal surgeon ofthat establishment, perceived that thepatient had also a dislocation of theleft arm. The displacement had al-

ready existed several months, and thelimb had acquired some degree of mobi-lity. M. David recommended makinga fresh trial to reduce the bone, andthe patient’s consent being obtained,the attempt was made with immenseforce, and the arm restored to its pro-per place again; but the event wasmost disastrous; for the whole limbwas attacked with such violent painand inflammation, that notwi,hstand-ing every means which surgery couldsuggest was immediately put in prac-tice, mortification ensued, and the pa-tient lost his life."’

The foregoing observations are cal-culated to exhibit the treatment ofluxations of the os humeri as sanc-

tioned and pursued by the best surgi.cal authorities, and to show that thepractice thus established, if not uns-

formlv successful, has, with the ex-ception of two or three cases, been un-

attended with danger. A question,however, may possibly arise—whethersurgeons should be influenced by theevent of the case I have detailed, andby those I have quoted, and deterrecl

altogether from attempting reductionin dislocations of long standing, or

whether the established practice shouldstill be continued, unatyected by for-tuitous circumstances or contingenciesneither to be forseen nor controlled ?To the latter proposition I have nohesitation to give unqualified assent,and to declare, that should a case simi-lar in exterial appearance to that ofJames Scofield again occur, I shallfeel jusfified in adopting a similarcourse.

We will give a few remarkson the above case in our nextnumber.

* First lines of the Practice of Sur-gery, by S. Cooper. Vol. II. p. 466.

REMARKS ON SUICIDE,BY PROFESSOR GROHMANN,

OF HAMBURGH.

A calculation has been,madein England, founded upon ob-servations made during ten

years, from which it appearsthat suicides are more frequentin England in the month of

July than in any other part ofthe year; that they decrease inthe following progression ;June, March, January, Febru-ary, November, December,

April. August, September, May,and that the month of Octoberis that in which the fewest

suicides are committed. Pursu-

ing the same course of observa-tion, Professor GROHMANN,

after having’ discussed the cau-

ses of suicide in Hufeland’s Me-dical Journal, gives the follow-ing table of suicides, which took

place at Hamburgh from theyear 1816, to the year 1822,inclusive:

Table of the Suicides observed at Ham-burgh from the year 1816 to 1822. a

. Years.

ISM OJ 001 1 0 0 0 0 0 0 0 2-

1816 0 1 0 0 1 0 0 0 0 0 0 0 2 w1818 2 6 0 0 1 0 2 2 1 3 3 3 171S19 1 1 1 0 1 1 1 2 2 0 1 0 2 121820 0 1 0 0 0 1 0 0 2 0 4 2 101821 2 4

1 8. 4 0 7 3 2 3 1 2 31p Total 6 4 8 8 4 4 4 11 5 1 7 4 59permonth