Case. —John Smith, wt. 50, was thrown down by a runaway horse one morning during the summer of 1833; in about ten minutes after this occurred, he was brought to Jervis Street Hospital, when the writer, at that time one of the surgeons of the institution, was prescribing for the extern patients. The man was in a cold perspiration, pallid, and apparently on the verge of syncope. The writer imme diately observed that the patient had a dislo cation of his left humerus, into the axilla, and, proceeding to point out, as was his cus tom, to the clinical class the diagnostic marks of the luxation, he noticed that the cavity of the axilla was filled up to a remarkable de gree. This sudden filling up of the axilla he immediately concluded could be attributed to no other source than to the laceration of a large artery. He quickly sought for the pulse in the radial and brachial artery of the dislo cated limb ; but no pulsation could be felt in any artery below the site of the left subcla vian, while the pulse, though feeble, could be readily felt at the heart, and in every external artery of the system, except in those of the dislocated arm.* The writer then observed to the clinical class, that in this case there were two lesions to be noticed, namely, a disloca tion into the axilla, the features of which were very well marked, coinplicated with a rupture of the axillary artery ; in a word, be sides the dislocation there was a diffused aneurism ; the latter was unattended by any pulsat;on, so that he conjectured the artery was completely torn across. He did not long &liberate as to what course was the best to pursue under existing circumstances, because he felt sure that, so far as the torn artery was concerned, if the head of the humerus was once restored to its place, this vessel would be in at least as favourable a condition as it then was, and secondly that the state of prostration and debility the patient was in, at that moment, offered an opportunity which, if once lost, might not again be afforded, of reducing easily the dislocation. Taking the
patient, therefore, unawares, the writer placed his knee in the axilla of the dislocated arm, and then slight extension having been made over this fulcrum, the bone at the first trial returned into the glenoid cavity. The patient was placed in bed in the hospital, under the care of the late Mr. Wallace, whose day it was for admitting accidents. There was much more superficial ecchymosis about the axillary, and subclavian region, and along the inside of the left arm, than is usually observed after a simple dislocation of the head of the humerus. The deep axillary swelling re mained stationary for some days; but no pul sation could be discovered either in it, or in the arteries of the limb. A feeble and fre quent pulse could be felt in the left subcla vian, and in all the other arteries, as well as in the heart. After the space of ten days, Mr. Wallace's month of attendance having expired, the case came under the care of Mr. O'Reilly, who having been satisfied that a diffused aneurism existed, and was on the increase, performed the operation, at which the writer was present, of tying the subclavian artery in the third stage of its course. The patient recovered, and was discharged from the hospital about two months afterwards ; he lost the last two fingers by gangrene ; but whether from an attack of erysipelas, which succeeded the operation, or from the effects of the ligature of the main artery of the limb, is not clearly known. The man lived for many years afterwards, in the immediate vici nity of the Richmond Hospital.