Injuries of the Main Blood- 
Vessels in the Axilla caused 
by Efforts to reduce 
Dislocations of the 
Shoulder. 
BY 
LEWIS A. STIMSON, M.D., 
PROFESSOR OF CLINICAL 8UROKRY IN 1IIE UNIVERSITY 
OF THE CITY OF NEW YORK, ETC. 
KEI'HINTJSD FltOM 
2TI)e Xrto Yorfc Jttclrical Journal 
for June 13, 1885. Reprinted from the New York Medical Journal 
for June 13, 1885. 
INJURIES OF THE 
MAIN BLOOD-VESSELS IN THE AXILLA 
CAUSED BY EFFORTS TO REDUCE 
DISLOCATIONS OF THE SHOULDER* 
By LEWIS A. STIMSON, M. I)., 
PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF THE CITY OF NEW 
YORK, ETC. 
Dislocation of the shoulder, an injury, both relatively 
%to the other dislocations aud actually, common, is, at least 
when recent, deemed one of minor gravity, the cure of which 
can be effected readily and without risk to the patient. 
But, from time to time, cases are reported in which the 
gravest consequences have followed reduction or the attempt 
to reduce, and such accidents have happened and continue 
to happen in the practice of even the most experienced sur- 
geons, aided by anaesthetics and employing methods of 
manipulation rather than those of force. The importance 
of the general recognition of this possibility, the interest 
attaching to certain questions of diagnosis and treatment, 
and the discovery of certain errors current in the statistics 
of the subject, have led me to bring before you a question 
which, within the last few years, has been the theme of sev- 
eral writers, and with which all are reasonably familiar. 
* Read before the New York Surgical Society, May 26, 1885. 2 
INJURIES OF THE MAIN 
Among these accidents, the most frequent and most im- 
portant are those of injury to the main blood-vessels in the 
axilla. 
Although the earliest recorded cases of this accident 
occurred at about the beginning of the eighteenth century, 
the subject did not receive the attention of systematic writ- 
ers on surgery until after the publication, in 1827, of an arti- 
cle 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,f 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,J Willard, # and 
Marchand.|| In 1882 Korte A reported three personal cases, 
and wrote a very full and valuable paper on the subject con- 
taining 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 disloca- 
tion or of reduction ; and in 1884 Cras () reported a personal 
case of injury of the axillary artery, and added a few others 
to Korte’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 reduc- 
tion, and in many others it remains uncertain whether the 
same objection might not be made to them. They are re- 
* “ Mem. sur plusieurs cas de luxations dans lesquels les efforts pour 
la reduction ont 6t6 suivis d’accidents graves,” “ Repertoire d’anat. et 
de phys.,” 1827. 
f “St. Bartholomew’s Hosp. Reports,” vol. ii, 1866, p. 96. 
\ “ Diet. encyclop6dique des sci. med.” Article Axillaires. 
* “ Phila. Med. Times,” 1873, vol. iii, p. 721. 
|| “ Des accidents qui peuvent compliquer la reduction des luxations 
traumaliques,” “These de concours,” Paris, 1876. 
A “Arch, fur klinische Chirurgie,” vol. xxvii, p. 631. 
() “Bull, de la soci6te de chirurgie,” 1884, p. 739. BLOOD-VESSELS IN TIIE AXILLA. 
3 
tained because they serve equally well with the others to 
further the study of most features of the subject. * 
* 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-men- 
tioned 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 dis- 
location, but a fracture of the humerus. As it has been widely quoted 
and is, indeed, given in detail as a dislocation by Dr. Hamilton (“Fract. 
and Disloc.”), an explanation of the manner in which the error arose 
may be of service. Blackman reported it as a dislocation in the “ West- 
ern Lancet,” August, 1856, p. 469, and an abstract of this report was 
given in the “Am. Journal of the Med. Sciences,” 1856, vol. xxxii, p. 
671, 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 doubt- 
ful even if the limb was dislocated. 
In Delpech’s case it is recorded only that at the moment of reduc- 
tion 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 hospital, the 
former operated upon it. 
A case which Callender quotes, a man treated by a “ bone-setter,” 
does not deserve to be grouped with those treated by professional sur- 
geons, although the force employed—traction by twelve or eighteen 
assistants—was not much in excess of that recorded in some of the other 
cases, or of what I have myself seen employed. Not only the artery, 
but also the muscles were torn and the humerus was broken. 
Green’s case (“Lancet,” vol. viii, 1825, pp. 189 and 283) is quoted 
as one of recovery after ligature of the subclavian, but the reports end 4 
INJURIES OF TIIE MAIN 
The trustworthy recorded cases of injury to the larger 
vessels of the axilla in dislocation or reduction of disloca- 
tion of the shoulder are forty-four in number. Of these, 
the axillary vein alone was ruptured in three (Froriep, * 
Price,f Hailey J), although I think the last one doubtful, 
and the artery and vein together in two (Platner,* Baum ||). 
In most of the others the axillary artery or one of its 
branches was injured, but in some the source of the haemor- 
rhage remains uncertain. In thirty-two cases death or am- 
putation of the arm furnished the opportunity to examine 
the region and determine the character of the lesion ; this, 
in some cases, was a complete or partial rupture of all the 
coats of the artery, or of the inner and middle coats alone, 
with subsequent formation of a circumscribed aneurysm.A 
In other cases the vitality of the wall appears to have been 
diminished or destroyed by direct pressure, and this to 
have been followed, after the lapse of a few days, by rupture 
(Warren Q), or, still later, by the formation of an aneurysm. 
Iu Gibson’s second case J an aneurysm appears to have 
formed in consequence of the earlier attempts to reduce, 
and then itself to have been ruptured when Gibson effected 
reduction. Rupture appears always to have taken place 
quite high up, and usually at the point pressed upon by the 
on the eighteenth day with the ligature still in place, and after a free 
haemorrhage on the thirteenth day. 
* Malgaigne, ‘‘Luxations,” p. 151. 
f Callender, loc. cit., p. 107. 
\ “British Medical Journal,” 1863, ii, p. 634. 
# Malgaigne, loc. cit., p. 151. 
|| “Deutsche Klinik,” 1867, p. 431. 
A It is possible that this rupture may be followed by obliteration of 
the artery at the wounded part. Scarpa held this opinion (Hodgson, 
“ I)is. of Arteries,” p. 488). 
() “ Med.-Chirurg. Trans.,” vol. xxix, p. 25. 
$ “ Surgery,” vol. i, p. 334. BLOOD-VESSELS IN THE AXILLA. 
5 
head of the humerus. Callender found it necessary to 
divide the pectoralis minor to reach it. In the fatal cases of 
injury of the vein alone the vessel was torn completely, or 
almost completely, across. In Baum’s case both artery and 
vein were partly torn by a broken piece of the new bony 
socket that had formed about the head of the humerus. 
The artery was tied above the origin of the long thoracic, 
and a second ligature was subsequently placed on it at the 
level of the lower border of the pectoralis major. 
In five cases (Callender, Despres,* and Korte’s three) 
only a small (one sixth of an inch) oval opening was found 
on the anterior wall of the artery, and was thought to have 
been produced by the tearing off of a branch, the subscapu- 
lar or circumflex. 
In Gartner’s f case the opening in the artery is described 
as funnel-shaped, but the tumor was small, formed slowly, 
and presented the common signs of aneurysm, so that it 
seems probable that what he describes as the opening in- 
cluded also the neck of an aneurysmal sac. In other cases 
the subscapular (LefeuvreJ) or the circumflex artery (von 
Pitha #) was torn across at or near its origin. These last- 
named eight cases form a considerable proportion of the 
whole number, and are of great importance because they 
explain the persistence of the radial pulse noted in several 
of the histories. 
Of twenty-nine cases in which the age of the patients 
is given, in twenty they were more than forty years old. 
The youngest was twenty (Gartner), the oldest eighty-six 
(Sands ||). In very few of the cases is it noted that the 
arteries were atheromatous, although the advanced age of 
* “Bull, de la soc. de chirurgie,” 1878, p. 116. 
f “Schmidt’s Jahrbiich.,” 1871, vol. cli, p. 304. 
| Cras, loc. cit., p. 750. * Korte, lor. cit., p. 649. 
| N. Y. “Medical Record,” 1880, p. 45. 6 
INJURIES OF THE MAIN 
many of the patients makes it probable that the elasticity 
of the vessels was diminished. 
In more than half the cases the dislocation was recent— 
less than three weeks. In not more than one third of them 
is it reasonably certain that the lesion was caused during 
reduction ; in three cases it was certainly caused by the dis- 
location ; in the remainder the cause is obscure. To these 
latter belong those cases in which the reduction was prompt- 
ly effected, and without the use of much force or of exag- 
gerated positions of the arm. 
In many of the others the attempt to make reduction 
was greatly prolonged or several times repeated, and the 
force used was very great or improperly applied. This last 
criticism is probably applicable to the earliest four cases 
(Yerduc, Petit, Platner, Bell), about which nothing is 
known except that death was caused by hfemorrhage. In 
one of them (Bell *) the use of the ambi is mentioned, and 
it is probable that it or the method of the door or ladder 
was employed in all. 
In some the injury was evidently caused by excessive 
traction (Gibson, traction by five or six assistants in one 
case, by pulleys for nearly two hours in the other; Lcudet, 
eight assistants) ; in others by faulty manoeuvres, such as 
extreme abduction or elevation of the arm, rotation, and 
circumduction ; in others again apparently by direct com- 
pression of the vessel against the underlying bone, as by 
the booted heel in the axilla (Warren, Rivington f), or pos- 
sibly by the thumbs (Panas J). 
Leaving aside the earlier cases in which faulty methods 
no longer in use were employed, and those old dislocations 
in which the relations and connections had been perma- 
* Callender, loc. cit., p. 101. 
f “British Medical Journal,” 1872, i, p. 420, 
\ Marchand. loc. cit., p. 52, BLOOD-VESSELS IN THE AXILLA. 
7 
nently changed by fibrous or bony tissue of new formation, 
it becomes evident that in dislocation of the shoulder the 
accident is most to be apprehended when the elbow is 
raised in abduction to the height of the shoulder, or is car- 
ried, as in Callender’s case, across the chest and face in a 
wide movement of circumduction ; and for this reason, that 
in these movements the dislocated head of the bone is 
turned downward into the axilla, and the vessels which lie 
upon its inner side are pressed down before it and forcibly 
put upon the stretch, while those branches which run al- 
most directly outward, the subscapular and circumflex, and 
are fixed to the tissues amid which they branch, are directly 
and forcibly elongated. Even when the head of the hu- 
merus is in its socket the axillary vessels are put upon the 
stretch when the arm is widely abducted, as can be readily 
verified during an operation for the removal of the axillary 
glands, or, still more simply, by observing the arrest of the 
radial pulse when the arm is raised and carried backward; 
and there are several cases on record in which this move- 
ment alone has resulted in the formation of an axillary 
aneurysm or in rupture of the axillary artery.* Although 
in dislocation inward the limb is shortened by being ab- 
ducted, yet the artery is not thereby relaxed, but, on the 
contrary, it is still further stretched around the head of the 
bone. Jbssel,f in a recent case in which death was caused 
by associated injuries, found the “nerves of the brachial 
plexus, especially the circumflex nerve and the subscapu- 
lar artery, greatly stretched by the head of the humerus,” 
and, according to.Kbrte (loc. cit., p. 640), he found in 
another case of recent dislocation the subscapular artery 
torn. 
* Cases of Pelletan and Paget, and specimen in museum of St, 
George’s Hospital; Callender, loe. cit., pp. 103 and 107, 
f “Deutsche Zeitaehrjft,” vol, xiji, 1880, p, 177. 8 
INJURIES OF THE MAIN 
In liis remarks on the case at the Sheffield Infirmary * 
in which the artery was torn across during an unsuccessful 
attempt to reduce a dislocation of six weeks’ standing, and 
an incision was made through which each end of the torn 
artery was tied, Mr. Jackson says: “ One thing was noticed 
on cutting into the axilla: the extreme tension caused by the 
pressure of the head of the humerus on the vessels and 
nerves when the arm was raised above the shoulder.” This 
patient died two days after the operation. 
In some of the cases in which it is certain or probable 
that the injury to the vessel was inflicted at the moment of 
dislocation, it is noted that the latter was produced while 
the arm was widely abducted—that is, under circumstances 
in which the head of the humerus would be driven down- 
ward and inward. 
If the dislocation is an old one, and especially if there 
has been much inflammatory reaction and the vessels have 
become firmly adherent to the bone or imbedded in un- 
yielding cicatricial tissue, the liability to rupture is increased 
because of the loss of elasticity occasioned by the latter 
condition, and because of the limitation of the strain to a 
shorter segment of the vessel in the former. If, in addi- 
tion, the distensibility of the vessel has been further reduced 
by atheroma, the danger is still greater; and this last pre- 
disposing cause may properly be deemed sufficient to lead 
to the rupture even when the traction is slight and the 
manoeuvres confined are within a narrow range. 
In Anger’s f case, fracture of the head (?) of the humerus 
co-existed; in Mash’s J two pieces had been chipped off the 
head of the humerus, and were lying in tlie glenoid cavity. 
* “British Med. Journal,” Feb. 3, 1883, p. 207. 
f “Bull, de la soc. de chirurgie,” 1878, p. 122. 
\ “ British Medical Journal,” 1872, i, p. 526. Reported by Car- 
ruthers, the house surgeon, BLOOD-VESSELS IN THE AXILLA. 
9 
In several others fracture of the greater tuberosity of the 
humerus or of the riin of the glenoid cavity is noted ; the 
former of these two complications is common in inward dis- 
location of the humerus, and could have had no direct in- 
fluence in causing the injury of the vessels; the latter, also, 
was probably without influence, since the vessels are pushed 
away from the scapula, and the fragment remains attached 
to it. 
The symptoms at the beginning present two widely dif- 
ferent forms; in one, the less common, a tumor presenting 
many of the signs of an encysted aneurysm appears in the 
axilla a few days or weeks after the reduction, and increases 
in size rather rapidly; if not successfully treated, it soon 
involves the skin and ruptures externally. In the other 
form, the more common, a diffused fluctuating swelling, 
without bruit or pulsation, appears immediately, or within 
a few hours, in the axilla, raising the pectoral and deltoid 
muscles, or is, perhaps, most prominent posteriorly, and in 
most cases promptly reaches a large size, even that of the 
adult head (Lister*); the radial pulse sometimes persists. 
The only exception to rapid growth among the recorded 
fatal cases is Korte’s third case (he. cit., p. 636), in which 
the extravasated blood disappeared slowly, leaving a firm, 
non-pulsating lump, as large as a walnut, in the course of 
the axillary artery, which a surgeon supposed to be a lym- 
phatic gland, and undertook to extirpate nearly five months 
after the accident. It proved to be an aneurysm containing 
much stratified clot; the axillary artery was tied above and 
below, and the patient died. 
In several cases the patients died promptly after the 
accident, sometimes after profound syncope, sometimes 
(Gibson’s first case f) after a short period of apparent well- 
* “Edinb. Med. Jour.,” 1873, p. 829. 
f “ Surgery,” vol. i, p. 325. 10 
INJURIES OF THE MAIN 
being, with symptoms of shock or acute anaemia. In two, 
which finally ended in recovery (Sands, Agnew *), the 
patients were at first greatly prostrated, and death by 
syncope threatened. In another (Mash’s) emphysema de- 
veloped in the arm, and the patient died forty hours after 
the reduction. In this case the inner and middle coats of 
the artery were torn across “just beyond the point of origin 
of the dorsal scapular branch.” The radial pulse was at 
first perceptible, but had ceased the next morning. 
In most of the others the swelling increased, and, in a 
longer or shorter time, ruptured spontaneously, or was threat- 
ening to rupture when operative interference (puncture, in- 
cision, or ligature of the subclavian) was resorted to. The 
longest period was in Bellamy’s f case, six months after re- 
duction, and even in this case the first haemorrhage occurred 
five weeks after reduction. 
In the cases that recovered without operation (Agnew, 
Sands, Desault, # Anger, Nelaton’s second case ||) 
the swelling subsided, and the ecchymosis was slowly ab- 
sorbed. Agnew’s patient was discharged in ten days, An- 
ger’s and Desault’s in a fortnight, Malgaigne’s wTas well on the 
twenty-second day, and Sands’s, a woman eighty-six years 
old, made a slow recovery. In three of them (Nelaton’s, 
Anger’s, Sands’s A) the diagnosis of rupture of the axillary 
artery was made. Desault’s diagnosis was “ emphysema 
* Willard, in “Phila. Med. Times,” vol. iii, 1873, p. 721. 
f “ Lancet,” 1880, ii, p. 260. \ Loc. cit., p. 150. 
* “ (Euvres chirurgicales,” i, p. 380. 
| Referred to by Anger and Le Fort, loc. cit. 
A Dr. Sand’s patient died in May, 1885. The injury proved to have 
been of the axillary artery, which was .occluded at a point a quarter of 
an inch above the origin of the posterior circumflex. The specimen 
was presented at the meeting of the New York Surgical Society, at 
which this paper was read, and a description of it will be found in the 
report of the proceedings, BLOOD-VESSELS IN THE AXILLA. 
11 
of the cellular tissue ”; he had reduced by violent and pro- 
longed traction a dislocation 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 tilled 
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 at first 
discolored, and percussion gave a sort of sound (espece de 
bruit). On these symptoms rupture of the artery was ex- 
cluded, and the diagnosis of emphysema made. Malgaigne 
and Agnew made the diagnosis of rupture of the axillary 
vein. 
I think there is reason to doubt the correctness of the 
diagnosis in the last three cases, certainly in Desault’s and 
Malgaigne’s, for it was avowedly based on the persistence 
of the radial pulse, and, although it is not so stated in the 
report of Dr. Agnew’s case, it seems fair to assume that the 
same persistence of the pulse which is noted in the report 
was also the basis of his diagnosis. As has been already 
mentioned, rupture of the subscapular or circumflex artery 
has several times presented similar symptoms, and, as in 
Mash’s case just quoted, the radial pulse may even persist 
after rupture of the inner and middle coats of the axillary 
artery itself. Pelletan * had a case similar to Desault’s, 
made the same diagnosis, and incised the tumor; the pa- 
tient died of haemorrhage, and the artery was found to 
have been ruptured. 
In the two cases in which rupture of the vein alone 
was demonstrated post mortem (Froricp, Price), the patients 
died promptly, in an hour and a half and on the follow- 
ing day, respectively. In the third case, Hailey’s, in which 
this lesion is said to have been proved by the autopsy, the 
* “ Clinique chjrurgicale,” vol, ii? p. 95. Quoted by Malgaigne, 12 
INJURIES OF TIIE MAIN 
account of the examination is very unsatisfactory, and leaves 
it, I think, quite uncertain what the actual injury was. The 
patient was a man tifty-nine years old; the dislocation was 
caused by a fall from a wagon and was very easily reduced. 
The symptoms were, first, pain in the wrist, then, after a 
few days, swelling of the shoulder and oedema of the arm; 
at the end of two months a tumor appeared between the 
acromion and coracoid (sic), and death by exhaustion a few 
days later. The tumor was blood-clot, more than two 
pounds being removed from the axilla. 
In De Morgan’s case * “ it was impossible to detect the 
source of the haemorrhage ” at the autopsy, and it was attrib- 
uted to the rupture of many small veins. This explanation 
also, I think, may well be questioned, for in this case too the 
radial pulse persisted, and at that time no cases had yet 
been reported in which similar symptoms had been shown 
to be caused by rupture or avulsion of a branch of the main 
artery. If, as seems probable from the account and in view 
of the ignorance of this fact, the examination was mainly 
directed to the condition of the veins, it is not unlikely 
that rupture of an arterial branch may have been over- 
looked, especially since the symptoms were not unlike those 
of some of the other cases in which this rupture was dem- 
onstrated (Despres, Korte’s second case). The symptoms 
and course of this case were, in brief, as follows: 
The patient was a man fifty-four years old, the disloca- 
tion subcoracoid, the reduction immediate, under chloroform, 
with the heel in the axilla. During the first week “ there 
was nothing to be noticed but the ordinary swelling attend- 
ing such a dislocation. This swelling, instead of subsiding, 
increased, and this somewhat rapidly toward the end of the 
first week. There was also some purple discoloration about 
* “British Med. Journal,” 1872, i, p. 5. BLOOD-VESSELS IN THE AXILLA. 
13 
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, extend- 
ing from the elbow up the arm and over the chest to the 
level of the outer third of the clavicle, and over the scapu- 
la.” 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 arte- 
ries could be felt.” The man died with symptoms of septi- 
caemia. 
In Korte’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. Ra- 
dial pulse. The patient became feverish, the tumor softer, 
the skin thin, and at the end of six weeks it ruptured spon- 
taneously. The haemorrhage 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 oval opening measuring 0‘4 by 0’3 
centimetre (one sixth by one eighth inch), thought {loc. 
cit., p. 650) to have been produced by the tearing off of an 
arterial branch. 14 
INJURIES OF THE MAIN 
Iii Despres’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 subse- 
quently pulsated at times. An operation for ligature of the 
subclavian was done on the forty-fifth day, and was fol- 
lowed 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 Ivorte’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 pul- 
sating swelling of the shoulder filling the axilla and extend- 
ing 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 blood- 
vessel, is concerned, does not long remain obscure ; the iden- 
tity of the injured vessel can not 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 sub- 
scapular 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 prepon- 
derance 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 BLOOD-VESSELS IN THE AXILLA. 
15 
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 12 cases, 6 recovered without opera- 
tion (Desault, Malgaigne, Nelaton’s second case,* Anger, 
Agnew, Sands) and have been already discussed. Nelaton, 
Anger, and Sands made the diagnosis of rupture of an 
artery. In the other 6—Warren, O’Reilly,f Green, Volk- 
mann,J Letievant,* Cras—the subclavian was tied; in 5 of 
them with success ; ini, Green’s, the result is not known. 
In the last 6, and in 3 of the first 6, it seems reasonably 
certain that an artery was injured, for pulsation of the swell- 
ing 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 44 cases, an 
artery (the axillary or a large branch) was ruptured in 35, 
the artery and vein in 2, the vein alone in 2, in 2 dissection 
failed to reveal the source of the haemorrhage, and in 3, in 
which the patients recovered without operation, the symp- 
toms do not justify a positive diagnosis. 
The terminations were as follows: 12 recoveries, 31 
deaths, and in 1 (Green’s) the result is unknown; 20 re- 
deceiv no operative treatment; of these, 6 recovered and 14 
died. || In 14 the subclavian was tied, with 5 recoveries, 8 
deaths, and 1 unknown result. 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 disarticulated ; 1 
* After rupture of the tumor without haemorrhage, and suppuration 
of the sac and shoulder joint. See Kiirte, loc. cit., p. 655. 
f “Cyclopaedia of Anat. and Phys.,” vol. iv, part 1, p. 616, art. 
“ Shoulder Joint.” 
f Kiirte, loc. cit., p. 656. * Cras, loc. cit., p. 748. 
H Possibly Kbrte’s second case should be included among the recov- 
eries. 16 
INJURIES OF THE MAIN 
recovery, 3 deaths. The treatment in the cases that recov- 
ered without operation was simply compression of the swell- 
ing 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 opera- 
tions were undertaken non-operative treatment had pre- 
viously 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 
14 cases of ligature of the subclavian, in 7 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 disarticula- 
tions, in 1 the operation was at a late date, in 1 five days 
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 32 patients, 6 recovered, 
14 died, and 12 (with 10 deaths) subsequently underwent 
operation, either because death by hajmorrhage threatened, 
or because of the existence of a growing aneurysm.* 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 disarticula- 
tion at (he shoulder is to be preferred to incision of the sac 
and double ligature of the artery. 
Experience with arteries wounded under other condi- 
* Korte’s second case is an exception; an error in diagnosis led to 
an operation after the aneurysm had apparently undergone spontaneous 
cure. BLOOD-VESSELS INT TIIE AXILLA. 
17 
tions lias shown that they will sometimes quite readily 
heal, or the opening made into them will close, under press- 
ure accurately made at the point of injury, and it would 
therefore he 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 can not 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 other 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 con- 
nection with the treatment of dislocation of the shoulder: 
How far does the possibility of the occurrence of this acci- 
dent 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 avoid- 
ed, as also circumduction, violent traction, and rough press- 
ure in the axilla. Kocher’s method by manipulation appears 
well adapted to avoid the danger. It is also to be remem- 
bered 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 usu- 
ally necessary to break up the adhesions that bind the bones 
in their new relations; and, while it may be proper in many 
* “British Mod. Jour.,” February 3, 1883, p. 207. 18 
INJURIES OF THE MAIN 
cases to make the attempt to restore the limb to usefulness, 
this 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 70 per 
cent, of deaths, may well cause the surgeon to hesitate to 
incur the risk merely for the sake of ameliorating a condi- 
tion which does not endanger life and is quite compatible 
with activity and usefulness. 
List of Cases. 
A. Fatal without Operation. 
1. Verduc (Malgaigne, “Des luxations,” p. 149); artery 
wounded; no treatment; death by haemorrhage. 
2. Petit (Malgaigne, “ Des luxations,” p. 149) ; artery wound- 
ed; no treatment; death by haemorrhage. 
3. Pelletan (Malgaigne, “ Des luxations,” p. 149); artery 
wounded; puncture; death by haemorrhage. 
4. Platner (Malgaigne, “ Des luxations,” p. 149 ; artery and 
vein ; death by haemorrhage. 
5. Leudet (Malgaigne, “ Des luxations,” p. 149); artery; 57 
years. Dislocation 11 days. 
6. Froriep (Malgaigne, “Des luxations,” p. 149); 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; vein. Death on following 
day. 
9. Korte, T, “ Arch, fur klin. Chir.,” vol. xxvii, p. 631; ar- 
tery ; 25 years. Disloc. recent. Puncture. 
10. Korte, III, Ibid.; artery ; 52 years. Disloc. 5£ months. 
Rupture. 
11. Mash (Carruthers), “Brit. Med. Jour.,” 1872, i, p. 526; 
artery ; 38 years. Disloc. recent. 
12. Ilailey, Ibid., 1863, p. 634; 59 years. Disloc. recent. 
13. De Morgan, Ibid., 1872, i, p. 54; 54 years. Disloc. re- 
cent, Incision, BLOOD-VESSELS IN THE AXILLA. 
19 
B. Ligature of the Subclavian. 
14. Green, “Lancet,” 1825, vol. viii, pp. 189 and 283; 33 
years. Disloc. recent. Result unknown. 
15. Warren, “ Med.-Chir. Trans.,” vol. xxix, p. 25 ; 30 years. 
Disloc. recent. Recovery. 
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. N61aton, I, “Path, chir.,” ii, p. 368. Disloc. old. Death. 
19. Iiigaud, “Diet, encyclop.,” art. fipaule; artery; 31 
years; death. 
20. Von Pitha (Korte), loc. cit.; artery; death. 
21. Volkmann, loc. cit. Recovery. 
22. Panas (Marchand, p. 52); artery. Dislocation recent; 
death. 
23. Despres, “Bull, de la soc. de chirurgie,” 1878, p. 116; 
artery; 40 years. Recent; death. 
24. Gartner, “Schmidt’s Jahrb.,” 1871, vol. cli, p. 304; ar- 
tery; 20 years. Recent; death. 
25. L6ti6vant, “Bull, de la soc. de chir., 1884, p. 748. Re- 
cent; recovery. 
26. Lefeuvre, Ibid., p. 750; artery; 52 years. Recent; death. 
27. Cras, Ibid., p. 739; 45 years. Recent; recovery. 
C. Double Ligature—all fatal. 
28. Callender, “St. Barthol. IIosp. Rep.,” vol. ii, p. 96; ar- 
tery; 61 years. Disloc. old. 
29. Wutzer, “Arch, fur klin. Chir.,” vol. x, p. 308. 
30. Korte, II, loc. cit.; artery; 29 years. Disloc. recent. 
31. Lister, “Edinb. Med. Jour.,” 1873, p. 829; artery; 58 
years. Disloc. 8 weeks. 
32. Rivington, “Brit. Med. Jour.,” 1872, i, p. 420; artery; 
71 years. Disloc. recent. 
33. Sheffield Inf., Ilid., 1883, i, p. 207; artery; 62 years. 
Disloc. 6 weeks. 
34. Baum, “Deutsche Zeitschrift,” 1880, vol. xiii, p. 177; ar- 
tery and vein. Lig. of axillary (possibly double). 20 
INJURIES OF MAIN BLOOD-VESSELS IN THE AXILLA. 
D. Disarticulation at Shoulder. 
35. Jungken, “Arch, fur klin. Chir.,” vol. x, p. 313; artery. 
Unsuccessful attempt to apply double ligature; recovery. 
36. Bell (Malgaigne and Callender). Death. 
37. Ledentu, “Bull, de la soc. de chir.,” 1877, p. 187; ar- 
tery. Disloc. recent; death. 
38. Bellamy, “Lancet,” 1880, ii, p. 260; artery; 55 years. 
Disloc. 7 weeks; death. 
39. Desault, “ (Euvres cliirurgicales,” vol. i, p. 380; 00 years. 
Disloc. H month. 
40. Malgaigne, loc. cit.; 44 years. Disloc. 2 months. 
41. Auger, “Bull, de la soc. de chir.,” 1878, p. 122; 54 
years. 
42. N61aton, II, Ibid. 
43. Agnew, “Phila. Med. Times,” 1873, p. 721; 60 years. 
Disloc. 6 weeks. 
44. Sands, N. Y. “Med. Record,” 1880, p. 45; 84 years. 
Disloc. 7 weeks. Autopsy in the proceedings of the Newr York 
Surgical Society, May 26, 1885, in this number of the Journal. 
E. Recovery without Operation. The lew York Medical Journal, 
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