330 Disloeatiou of the ltamerus.

medical doctor. IIe visited me on his return to this country, when he seemod in all respects in robust health.

This is the only case of plastic bronchitis which has occurred in my practice. The pathology of this coudition is still undetermined. It appears to have no affinities with diphtheria. I t has been conjectured that it may be due to a micro-organism, but of this there is at present no proof.

ART. XIu of tt~e Humerus complicated with Fracture of the Neck of the Bonc.a By WILLI~,~ TA~mon, F.R.C.S.I. ; Surgeon ~o the Meath Hospital and Co. Du~l~,lin Infirmary; Surgeon to Cork-street Hospital, &o.

To-gAY I purpose dealing with a somewhat rare injury which was exemplified., in the ca,se of the patient sitting before you. The history is, that during the great storm before Christmas last, this man, whose age is over sixty years, was going home after his day's work when a gust o~ wind suddenly caught him up, as he was going round the corner of the street, and threw him with great force to the ground. As well as he remembers he fell on the outer and back par~ of his right shouMer, his arm being thrown our to t ry and break the fall. After this he got home as best he could, but though his shoulder pained him considerably he dreaded the storm too much to venture out that night, or the next day, to come to hospital; so that it was not until two days after the accident that he sought admission here. The nature of the injury was easily recognised from the features that were present, and which I shall subsequently detail to you.

Tha~ the lesion is comparatively rare, as I have already mentioned, you will at once recognise when I tell you that, so far as the records of surgery go, only 122 cases have been reported up to the present time. The lesion is inter- esting to us all, not 'only on account of its rarity, but on account of the great impairment ~f fuactio~ that m~tst necessarily ensue if imperfectly treated.

* k b s l r a e t of a Cl in ical :Lecture de l ivered in the M e a l h Hosp i t a l on :Febrt~ury 4, 1901.

By MR. WILLIA~ TAYLO~ 331

The variety of dislocation usually met with in these c a m , as we would naturally expect% is subcoracoid, that being the r form of uncomplicated dislocation. When oomplicated by fraet.m'e it is said the head of the bone, is often rotated on its axis, thus separating the fractured surfaces still more. This, again, is only what we should expect if we consider the ]manner it. wl~ich the fracture is produced. The history of the production of the lesion is somewhat obscure. ~ome autho,rities state that the dislo- cation is produced in the usual way--viz., by a fall upon the extended and abducted arm, and that the fracture is subsequently caused by continued abduction, as well as possibly some rotatory movement, the edge of the glenoid cavity or tho acromlon process acting as a fulcrum, agains~ which the bone is broken. Others state it is produced by violence applied direct to the shoulder itself, and that wcmld seem, from the imperfect history the patient gave us, to be the way in which the injury was produced in this case. I t scarcely seems conceivable, though, that the frac- ture is the primary lesion, and that the luxation takes place subsequently. I have seen it, stated that the fracture was possibly due, in some cases, to the violence used by the medical attendant to reduce the luxation. That I canno~ believe, unless there was some diseased conditicm of the bone predisposing to fracture present, and then we should expect the fracture to take place at once without disloca- tion. At any rate, I feel sure no one here will ever attempt to reduce a dislocation by such unscientific methods as would lead to the production of fracture in a healthy bone. l{emember that in most eases the dislocation is the primary lesion, and that the fracture takes place subsequently.

The site of the fracture in the majority of the recorded cases (59 per cent.) is stated to have been through the surgical neck, while ia abot~g 25 per cent. it is saSd to have been through the anatomical neck ; and in the remain- ing 16 per cent. of the cases the site o~ fracture was vaguely stated to have been t hrottgh the, neck. In this case the line of fracture ran obliquely immediately be,low the anatomical ~eck in front, bat emerged posteriorly one and a quarter inches belo~ the head, thus running obliquely from in front and without,

332 l)i.,loeation of the Humerus.

downwards, inwards, and backwards. Portion of the great tuberosity was torn off by the muscles attached thereto, while two other small portions of bone were broken off in the neighbourhood of the lesser tuberosity, and a small indentation or impaction of the compact tissue of the promi- nent inner part of the great tuberosity can easily be noticed in the specimen as well. It will thus be seen that the injury here was a severe oue, and could have been produced only by considerable violence. The head of the bone was displaced dowr~wards and inwards, while it was so rotated that. its articular surface looked directly downwards. The upper end of the shaft here, ~s i,n all other cases, was dr~wn upwards an,! outwards. ~Vith regard to the diagno.sis of the do~tble lesion, I think you should not have much difficulty. Most of the ordinary evidences of dislocation of the shoulder are present--such as angularity and promi- nence of the acromion process, increased perimeter of the shoulder, inability to use the arm in any way, swc,lling, ecchymosis and paln ; while the head of the bone can easily be palpa.tod in its abnormal situation. These ought to be sufficient to indicate dislocation. On the other hand, there is incleased l:assive mobility of the arm, the elbow can easily be placed agairLst the side while the hand is placed upon the opposite shoulder; on rotating the arm the head of the bone w.i]l not move, and crepitus is readily obtained.

Measurenaents will show a fair amount of shortening. The points, then, on which you will rely irL making your diagnosis of tke double lesion are : - -

I. Angulari ty of the shoulder and prominence of the acromion process.

II . Absence of the head of the bone from the glenoid cavity and its presence in some abnormal situation.

I I I . Increased perimeter o.f the shoulder. IV. Increased passive mobility of the arm, which can

easily be approxianated r the side while the hand rests upon the opposite shoulder.

V. F~ilure of the head of the bone to rotate on rotation of the arm--one of the most important signs of solution in the continuity of the bone.

-VI. Crepitus and shortening on measurement. I"inally, I would recommend in all cases that an X-ray

By Ma. WILLIAM TAYLOR. 333

photograph be taken. This will not only clear up the diagnosis, but will be an excellent record of the case. :For the radiograph ill this ease I am indebted to my colleague, Mr. Lane ffoynt.

H-~ving made the diagnosis, what then will your progmosis be? You wi]~! remember I have already partly indicated that when I said if imperfectly treated the resul~ must necessarily be great impairment of Iunc- tion. The, prognosis, then, must be bad unless operative treatment be undertaken, which, from looking over the cases reported, seeans to me the only rational treatment one could adopt, provided, of course, there be no constitutional condition militating against that procedure. I t is only within recent years that operation has been recommended, for I well remember, when I first came here, as a student, being told that in case of a fracture and a dislocation, if there was leverage, reduce the dislocation first and then set the fracture, while if there was no leverage set the fracture, and when it has united then try and reduce the l u x a t i o n ~ thing easier said than done. In very few cases will you ever find it possible to reduce the head of the bone and restore it to its normal position, unless by open incision. Let nothing ever induce, you to, attempt reduc- tion by extension or ~oy placing the heel in the axilla. The sharp, broken ends of the bone in this way may be made to do irreparable damage to the great vessels and nerves in the axilla. In no case, so far as I am aware,, ]ms the, dislo- cation been reduced after union of the ~racture; and, indeed, in this case union could never have taken place, as the fractured surfaces could not have been got into. ~ppo- sition, while the head of the bone would have had no blood- supply, for it was merely attached by about half an inch of capsule. Necrosis would doubtless have resulted. Some surgeons endeavoured to. guard against u~ion of any sort, with the object o.f establishir~ a false joint at the site of fracture, but with indifferent results.

t taving thus indicated the prognosis you must give if you adopt any of these nlethods of treatment I have just montio,ned, let us now consider whst I look upon as the correct procedure Ih~I you should adopt Jn case you are

334 Dislocatio~ of the Ilumerus.

fortunate enol~gh to meet with such a lesion. Two lines of operative procedure mawr be adopted : - -

I. To cut down upon (he seat. of fracture and reduce the dislocated head by enlarging, if necessary, the rent in the capsule, by grasping the head with a "lion" forceps, or by adopting M'Burney's method of drilling the, bone and placing a beck (or a sterilised piano wire would do as well) into the drill-hole, and pulling upon it at right angles to the trunk. t tavln~ reduced the. head of the bone, the broken fragments should then be screwed or pegged together, or, if preterred, sutured with silver wire. The rent in the capsule is then to be carefully sutured up, the joint being previously thoroughly washed out, and all blood-clots removed ; finally the wound is closed with or without drainage, according to your own judgment and practice. Undot~btedly this operative procedure will give the best results where it can be carried out. The method of fixing the fractured ends firmly together permits of early passive movements being undertaken, thus preventing stiffness from adhesions form- ing inside the joint as well as in the injured tissues around.

II . Removal of the head of the bone-- in fact performing excision, the only difference being that the head of the bone is already separated for you. Then round off any sharp spieula of bone you may find o~ the upper end of ihe humerus, wash out your wound and suture it up. This, I think, should be your line of procedure where your patient is old, such as this patient is. I t would also seem to me the proper treatment where the head of ~he bone was torn co.mpletely, or almost completely, from its attachment to the capsu]c in other words, where the fracture runs through the anatomica.1 neck. In such a case, it the head of the bone were left and fastened to, the shaft, I should be very apprehensive of necrosis resulting.

The objection to excision is that the result will not be so perfect, and that, as the fracture, generally runs through the surgical neck, a flail-like arm is likely to be the resuR of the removal of such a large piece of bone. These ob- jections I quite recognise, but ~hink that in such a case as we had to deal with here no other line of treatment, save that of excision, which was done, cou]d have been enter-

Notes on Some Stomach Cases. 335

rained. I f the l~tient is comparatively young and healthy, and if the line o~ fracture is below the tuberosities--in which ease the head of the bone wi]~l have a sufficiently good blood-supply to obviate risk of necrosis--then by all means reduce the he~d of the bone and firmly fasten the fragments together by screws or pegs, which, in such a case, are better than silver wire, as they keep the broken surfaces more firmly together during passive movements, while silver wire will permit of some movement between the fractured surfaces. With regard to drainage, a good deal will depend upo,n whether the so~t parts around are much injured ; and as this is extremely likely to be the case in ~hese rare acci- dents, I would recommend you to employ drainage, at any rate for a few days. A clean tube cannot do any harJn. You will seldom regret inserting one; but may often regret leaving it out. Begin your passive movements a~ s.oon as possible, if you wish to obtain a good result. In this case, though the wound is perfectly healed up, and though all the lower motions of t~he arm are perfect, still there is a limitation in the upward motions, which may, and I have no doubt will, improve in time with practice. In any case~ the man is now (it to return to his, work, which is that of a scavenger in the employ of the Corporation.

A ~ . X V . - - N o t e s o~ Some Stomach Cases. ~ By WILLIA~I CALWELL, ~{.A., ~V~.D., M.Ch. R.U.I., L.M.R.C.P.I. , Consulting Physiclan to the Ulster Hospital for Women and Childre,, Belfast; Physician to the Royal Victoria Hospital, Belfast, and Throne Consmnption Hospital.

A FEW years ago I attended Nurse B. for anorexia and dyspepsia. The symptoms were such as led me to suspect the existence of a case of anorexia nervosa. She improved, however, somewhat, and was sent abroad as companion to an invalid. In 1897 she had one of the most sudden and severe attacks of h~ematemesis I have ever seen; however, she again rallied, and finally was able to perform some of the less laborious duties of a nurse, and perhaps, if not actually

Read before ~he Section of Medicine of ~he Royal Academy of Me.dici~ao in Ireland, on Friday, April 19, 1901.