FIVE CASES OF DISLOCATION AND FRACTURE OF THE SHOULDER.*

BY HOWARD J. WILLIAMS, A. M., M. D., MACON, GA.

These five cases, two of simple fracture of the humerus near the shoulder-joint, two of

dislocation and one of fracture and dislocation, have come under my observation during the past seven months. They are reported simply to call attention to the necessity of early diagnosis, prompt reduction and careful after

treatment:

Case I: J. S., male, 25 years old, white, machinist, had his left shoulder dislocated in a wreck on August 30, 1895. The dislocation was of the sub-coracoid variety and was promptly reduced without the aid of an anæsthetic at the scene of the wreck. Upon reaching his home he placed himself under the care of his own physician, who kept the arm bound to his chest for a month, without passive motion. Three months later he was sent to Dr. McHatton and myself because of limitation of motion in the shoulder-joint. He could not raise his arm to a right angle from the body and could not place his hand upon his head. Ether was administered and the adhesions about the joint broken up. Anodyne lotions and daily passive motion were ordered, with recovery of a large part of the use of the joint.

Case II: W. M., male, 22 years of age, negro, porter on a Pullman car, had his right shoulder dislocated (sub-coracoid) in a wreck, February 29, 1896. I reduced the dislocation under the influence of chloroform at the scene of the wreck and placed temporary dressings on the arm and body.

The patient was sent to the hospital and placed under the charge of Dr. McHatton, March 1, 1896, and early passive motion instituted. Recovery followed with no loss of motion in the joint.

Case III: E. F., male, aged 48, white, engineer, had his left shoulder dislocated and the humerus fractured near the joint, in a wreck in December, 1895. Under chloroform, the dislocation was reduced and the fracture adjusted by Dr. McHatton and myself at the wreck. He was admitted to the hospital and kept under close observation for two weeks,

*Read before the Central of Georgia Railway Surgeons' Association, Augusta, Ga., April 14, 1896.

early passive motion being instituted. He was then transferred to his home at Rome, Ga., and was under the charge of his family physician. The dressings put on him before he left the hospital were undisturbed for three weeks. When they were finally taken off he had only slight motion and could not carry the arm six inches from the side of his body and could not move the arm forward or backward at all.

March 16, 1896, he was returned to us for treatment. He was chloroformed and by violent manipulation the strong fibrous adhesions about the joint were broken up. Daily passive motion, massage and electricity were used. The deltoid and other muscles about the joint were wasted by non-use. He remained under treatment in the hospital for seven weeks. Once every ten days chloroform was administered and vigorous passive motion used. He then could carry his arm outward by his own effort to an angle of 45 degrees, and had recovered nearly the entire forward and backward motion. Under the anaesthetic his hand could be placed upon the top of his head and the arm carried nearly vertically above the joint. He will never recover the complete use of the joint, but will in time regain much of the voluntary use of the limb. Case IV: D. C., female, 75 years old, negro, laundress, fell on the pavement on March 1, 1896. March 6 she sent for me, and finding the arm and shoulder swollen, painful and deformed, I suspected either fracture or dislocation. I had her sent to the hospital at once. Her general health was good, but she had a very marked arcus senilis. The urine was examined with the following result: sp. gr. 1020, no albumen, no sugar.

On March 7 chloroform was administered and a fracture of the humerus just above the surgical neck was discovered. Splints were applied. At the end of the second week gentle passive motion was used. The forearm and hand were badly swollen and painful, and there was pain in the scapular region.

Again, at the end of the next week, passive motion was used. Owing to her extreme age we cannot say what will be the final outcome of the case, but hope to recover considerable motion.*

*May 23, since reporting the above before the association, I regret to say that while she has some motion in the joint, it is painful, the swelling of the forearm is still present and there is some deformity left about the shoulder.

Case V: A. W., male, 51 years old, a negro laborer, fell out of the door of his house, September 19, 1895, producing some injury to the left shoulder. On September 22, 1895, he was admitted to the hospital and, in addition to his injury, it was found that he was suffering with advanced Bright's disease, feet and legs oedematous, insomnia, hiccough, obstinate diarrhoea, urine largely increased in quantity, sp. gr. 1014, slight trace of albumen and tube casts. The shoulder was swollen and painful. Chloroform was carefully administered and a fracture very high up was found, which we thought to be in the anatomical neck. Dressings were applied.

His diarrhoea could not be controlled, the hiccough persisted and at the end of the second week coma developed. He died three days later.

The shoulder-joint was opened after death and the head of the humerus, with two inches of the shaft, removed (specimen exhibited). It will be seen that the fracture is just half an inch below the anatomical neck and transverse in direction, and it will further be seen that there is a split running into the anatomical neck. There is a natural groove on the upper and outer part of the anatomical neck in all bones, but in this case the split is deeper, and by a little manipulation is can be made to open. This case came very near being comminuted or impacted. The cancellous tissue of this bone is very thin and friable. This is the highest fracture I have seen post-mortem. It was not intracapsular. Fracture of the anatomical neck is doubted by some authorities, but Gross and others record cases.

As the shoulder-joint is the most important joint, particularly to the laboring man, we should be extremely careful to make an early diagnosis of all injuries, using an anæsthetic if in doubt. If swelling has occurred an anæsthetic should always be employed. As soon as discovered, measures to reduce the deformity should be instituted; no delay should be allowed. When there is a combination of the two injuries, fracture and dislocation, without

an external wound, if there is great difficulty or impossibility of reducing the dislocation and adjusting the fractured ends of the bone, an incision, under antisepticism, should be made and the deformity corrected by mechanical means rather than allow the functions of

the shoulder to be lost. After-treatment to prevent inflammation should be used. Rest is the first indication, followed by cooling lotions to the injured parts, but rest should not be carried too far. It will be seen that in two of my cases this occurred. The joint was allowed to remain bandaged for three weeks in one case and for one month in the other. Early passive motion should be instituted in all injuries of this joint to prevent faulty adhesions and restore the usefulness of the joint. In the case of the old colored woman, I think the bone was comminuted and her age was against successful repair of fractured bones. We used passive motion but failed to recover much use of the joint.

SHOULD WE HAVE PUS IN RAILWAY SURGERY?*

BY LESTER KELLER, M. D., IRONTON, OHIO.

One to whom the above question is put would most likely answer-yes, if we have it anywhere. We formerly had it in almost all kinds of cases, we sometimes have it now, but it surely should be a rare thing where we have control of our patient from the start.

We look with awe upon a man who speaks with authority, but when we get in a meditative mood we sometimes wonder whether even he might not be mistaken. Our Railway Surgeon, that contains so many good things and is supposed to be the beacon light for the way-station railway surgeon, sometimes contains things that make us sit down and think: "How different from the results we have been trying to obtain!" And we wonder whether the editor really means it-whether it is really

SO.

From an editorial in the issue of November 5, 1895, we take the following: "While the presence of pus may be lacking in a great majority of operative cases, yet in accidental surgery its presence is the rule, and its entire absence is a marked exception. Again, it will be noticed that it is almost as universal an attendant as it was prior to the introduction of

antiseptics. Even in amputations, necessitated in consequence of the crushing of limbs by ponderous wheels, particularly when the inferior extremity is involved, under the strictest

Read by title at the ninth annual convention of the National Association of Railway Surgeons, at St. Louis, Mo., May 1, 1896.

antiseptic or aseptic precautions, healing by first intention is not obtained in one case out of ten-yes, we can almost say not one in twenty cases." Can this be so? Hardly. Particularly must we object to the assertion in regard to the amputation of lower extremities. Our experience has not been such and others with whom we have talked confirm us in our opinion. We should have as good results here as in any case where traumatism is the cause of amputation. Were I to have pus in a wound of that kind I would think I was to blame. When I speak of having pus in railway surgery I mean in all cases, large and small. I fear that we, as a body, devote too much time to the consideration of the severer cases and not enough to the more trivial ones. Our reports of an operation after fracture of the spine are very complete. Being very careful of our asepsis, we would have been much chagrined to have had pus; in fact, it would have been disastrous to our case. We are prone to dismiss a brakeman with a mashed finger with much less ceremony. I once heard a most eminent surgeon deliver a very fine lecture on the use of antiseptics in surgery, and within a month saw him apply a dressing to a mashed finger which I should have been ashamed to have seen coming from my office. Our crying evil, as surgeons, and particularly as railway surgeons, has been the lack of attention to little things. A mashed finger may be a small thing in the surgeon's estimation, but it is a large one to the man who owns it. We must not depend on asepsis alone; we must use antiseptics if we would succeed. There are many of them, and good ones, too, and it matters not so much which one we use as how we use it. We must not undo the good work of our antiseptic by using a suture not properly prepared. We might get our operating field in good condition by using soap and water. Surely, these are important, but how much more certain of good results are we when they are supplemented with some efficient antiseptic. The half-read and illy understood writings of the great Tait have caused more suffering than he has ever saved by his wonderful skill. I do not know of a general practitioner who attemps to do surgery and makes failures, because he is not careful of his asepsis and ignores his antiseptics (and notice, I associate the two conditions), but quotes Lawson

Tait and excuses his failures because he has followed "the very best." I have no idea that Tait ever intended to be so interpreted. He, no doubt, would use antiseptics if he were doing railway surgery away from his hospital and under the conditions with which most of us have to contend. The avenues for the infection of a wound are so many that it keeps us constantly on the lookout to keep from spoiling the work well begun and almost perfect. I have seen a surgeon, very elaborate in all his details in preparing for an operation, careful of his hands and all, and then, after the operation was carefully done, make one last wipe across the stump with the cleaning-up towel.

I have seen a man, who thought he was careful, put his silk ligatures in a carbolic solution. for fifteen minutes and think they were sterile. This same man often complained that he had a little "stitch hole" suppuration.

Often the meddlesomeness of a patient or his friends spoils our good work. It is next to impossible to make a man believe you are not neglecting him if you put up a small injury and tell him to report at your office in a week. The chances are, if he has had no experience with an antiseptic surgeon, that he or his friends will find some excuse for opening it, if only for a peep. To sum up, if we have a correct idea of the principles underlying antiseptic surgery, will follow them out in the minutest detail and will control the curiosity of the patient and his friends, we will have no occasion to think pus is any more necessary in railway surgery than anywhere else-and that is very seldom.

You need not doubt; you are no doctor.

Science is knowledge and art is skill; or, more fully, science is organized knowledge, while art is educated skill. The same ideas are expressed by the terms theory" and "practice." This is the fundamental distinction. Here art is actual skill, practice or doing, but art has a second meaning; it signifies, also, a body of rules, or precepts, that guide skili, practice or doing. This is the sense of art in the statement that science teaches us to know and art to do, or in the statement that the two differ, as the indicative mode differs from the imperative, the first making declarations, the second issuing commands. Hinsdale.

Apropos of the statement that aseptic surgery can be done anywhere where hot water can be obtained, we have a little story to tell. Not very long ago, during one of our outing trips, we visited an old friend and classmate whose lot has been cast in the country, or almost in the country, at a little railroad town, a center from which the farmers ship their produce, and in the company of this genial country doctor we spent some very pleasant hours. Born and bred among the people whom he serves, he began the study of medicine about fifteen years ago with a common school education and the robust health of a farmer's son as his capital. College life in the metropolis failed to spoil him or to make him discontented with the home which he had left, and he determined to return to his people and to do better work, if it was possible, for those whom he knew and who had always been his friends. That he has succeeded was abundantly demonstrated during our short stay with him by his large following of trusting friends, the good work which we saw him do and by glancing over the carefully selected books in his library.

While we sat chatting early one morning in

the doctor's snug little office, there was a knock at the door and the swarthy section boss entered, closely followed by a man with his left hand bound with a bandanna, from the dependent corner of which drops of blood were falling. We smiled inwardly and said to ourselves: "Now is our opportunity to see some cross roads surgery." After a few words of cordial and sympathetic greeting, the patient was asked to be seated and the doctor went quietly and quickly about his preparations for the care of the wound, first uncovering the hand to learn the extent of the injury. The hand had been caught in the hasty handling of a hand-car and there was an ugly, lacerated and contused wound of the palm, involving tendons, vessels and nerves of the ring and little fingers. A rubber sheet was produced and spread out upon the table, which served as operating table and gynecological chair in this simple office; a clean hand basin was placed upon the table, some crystals of washing soda thrown into it, and the basin filled with boiling water. As soon as the solution had sufficiently cooled, the injured hand was immersed and allowed to soak until other preparations were completed. A scalpel, a pair of scissors, two or three needles of different size, some tissue forceps and two pairs of snap-forceps were placed in a pan upon the oil stove, covered with hot water containing more of the sodium carbonate and boiled for several minutes. We had noticed that the doctor's hands were clean, that the finger nails were closely trimmed, and that the subungual spaces gave evidence of frequent attention; also that the hands were soft and not as brown as the doctor's face and neck, eloquent testimony that he knew the value of gloves. When everything else was in apparent readiness, he took from a jar of 5 per cent., a stiff brush, carefully scrubbed his hands and covered them with alcohol, and the work began.

The patient's hand was carefully scrubbed, not with soap, but with the soda solution in which the instruments had been boiled. These were now placed upon a clean towel and spread upon the table. After the hand had been soaked a few minutes in a solution of lysol the edges of the wound were carefully trimmed, partially detached masses of tissue were dissected out, bleeding was stopped by pressure and the occasional use of snaps, and the deep

proportions of the wound more carefully examined. It was found that two tendons had been drawn from their sheaths and one partially, another completely torn across. These were carefully adjusted, the torn ends approximated with fine catgut sutures, the catgut having been sterilized by the doctor himself, as he afterward told us, by boiling in alcohol. The wound was then adjusted with greatest nicety with silkworm gut sutures, the hand dressed with borated absorbent gauze, and placed upon a Palmer splint.

The next day we drove together into the country in answer to an ordinary call, the messenger simply saying that Farmer Hicks was ill. Upon arriving we found a case of welldeveloped appendicitis, which evidently called for an early operation. When our friend had so pronounced and explained in simple terms the nature of the trouble, the patient simply replied: "All right, Doc, you know best and we know you'll do what's right."

Immediately the same simple preparations were made that we had witnessed in the office, save that a number of towels and soft clothes were sterilized by boiling, to be used about the field of operation and for sponges.

When the patient had received a bath, all other preparations had been made and a clean bed prepared for his reception after the operation. The doctor proceeded with the chloroform himself, using an Esmarch inhaler and the drop method, and while the patient was gently yielding to the influence, he quietly instructed one of the good angels of the neighborhood who had been sent for in the hour of need, how to continue its use when he was otherwise engaged. When the patient was asleep the good doctor again sterilized his hands and the field of operation, by first scrubbing with soap and hot water, then with pure hot water, and finally with alcohol. The incision was quickly made, the bleeding vessels twisted, the peritoneum opened, the inflamed and swollen, almost necrotic, appendix brought to the surface, cut off, the stump invaginated and sutured, and the abdominal wound closed with a small gauze drain.

These two operations were performed with as true a regard for asepsis, as if they had been done in the tiled operating room of the most modern hospital and with as perfect results, as subsequent events proved, yet how simple the

I desire to announce to you that the date of the meeting of the Mississippi Valley Medical Association has been changed to September 15-16-17-18, in order to permit the members and their families to take the opportunity accorded by this change to make a pleasant tour through the Yellowstone Park, so justly celebrated as the Wonderland of America.

Prominent resident members of our association in St. Paul and Minneapolis are formulating plans for the special Yellowstone Park excursion trip, to leave on the evening of September 18, arriving in Mammoth Hot Springs in the Yellowstone Park about noon on the following Sunday, and devoting the following five days to the wonders of this remarkable region, returning to St. Paul, Sunday, September 27.

The cost of the trip, including all expenses west of St. Paul, will be announced in due season, but we are authorized to say that the figure will be a very favorable one, and we simply wish at this time to make the preliminary announcement of this most enjoyable feature of the St. Paul meeting, so as to give members the opportunity of making their plans in advance to join the party. It is desirable that there be a party of 100 or more, in order to obtain the benefit of the special train service in both directions.

It is urged that all members who desire to join the party should send their names to Dr. C. A. Wheaton, chairman of the committee on arrangements, St. Paul, at as early a date as possible. If you desire to read a paper before the meeting, please send to me the title Very truly yours, HANAU W. LOEB, (L.) Secretary.

at once.

3559 Olive St.

Guy Patin recommends to a patient, "to have no doctor but a horse, and no apothecary but an ass."-Chesterfield.

"How do you find yourself, Mrs. Judy?" said a St. Bartholomew's surgeon, after taking off the arm of an Irish basket-woman. "How do I find myself? Why without an arm; how the d-1 else should I find myself?"