501

blood in the right aide of the heart, which Iam disposed to believe, from the appearanceof the coagula, and the circamstaacea inwhich it occurred, took place previous to,and might have been the immediate cause of,death.

Before concluding, I may advert to thehæmoptysis which this patient experiencedat an early period of his life, and which re-carred on two or three occasions, at ratherremote periods. The first and most severeattack followed violent muscular efforts incarrying heavy pieces of timber, and I am

disposed to believe depended on bronchial,not pulmonary, haemorrhage, or pulmonaryapoplexy, as it is called. It is, also, equallyprobable that its occurrence was favoured,or that the predisposition existed, in conse-quence of previous disease of the heart. Forhypertrophy of this organ is a frequentcause of haemoptysis, particularly under theinfluence of the exciting cauaes which werein operation in this patient when it first oc-curred. Its subsequent occurrence obvi-

ously supervened on congestive bronchitis,of which he had several attacks, brought onby exposure to cold, and still more by theintemperate habits of the patient. Thatthese, also, were complicated, on one occa-sion, with plenritis, was shown by the oldand dense cellular adhesions which existedso extensively on the left side of the chest. Lastly, I may remark that, in the history ofthe case of this patient, it is stated he lostseveral of his relations on his father’s side,and his sister, from consumption. We didnot find in the lungs any trace of tubercu-lous matter, or other alterations, dependentl1pon it, to afford us any evidence that hehad had tubercular phthisis at an early pe-riod of life, at the age of 19, the period atwhich the hæmoptysis first took place, andto the presence of which the occurrence ofthe haemorrhage might have been ascribed.We found, however, evidence of tuberculardisease having been present at a remote pe-riod in the bronchial glands. Several of

these, situated along the course of the left

bronchus, were completely tilled with a

hard, cretaceous-looking matter, such as is

frequently met with in those who die of

scrofulous disease of these and other organsof the body, and of tubercular phthisis. If

the morbid condition which I have noticedwas the consequence of scrofula, it is an

example, among many which I have met

with, of the curability of the disease, whenconfined to the lymphatic glands, establishedby the most unequivocal of all evidence,-that afforded by an examination of the affec t.ed parts aiter death.

CASES OF

CONGENITAL LUXATIONSOF THE

UPPER EXTREMITY OF THE HUMERUS.

By ROBERT WILLIAM SMITH, Lecturer ONSurgery at the Richmond Hospital Schoolof Medicine.

TnR following cases, which we extract froma late number of the " Dublin Journal," areexamples of a condition of the shoulder’

joint, which, so far as we know, has nothitherto been described by authors. Con-

genital luxation of the head of the humeruspresents two varieties, which Mr. Smith dis-tinguishes into the subcoracoid and bubacro-mial ; of the former species he has seen threeexamples, of the latter but one.

CONGENITAL stJDCORACOID LUXATION.

CASE 1.—The first case of original luxa-tion of the head of the humerus was that ofAlexander Steele, about twenty years ofage; he has been an inmate of the House ofIndustry, Dublin, for the last four years.He presents an example of congenital dis-placement of the left shoulder-joint, andupon the same side a specimen of that varietyof club-foot termed pes equinus : he doesnot remember having ever met with any in-jury of the shoulder ; the present conditionof the joint has existed from the earliestperiod of his recollection. The muscles ofthe shoulder and arm are wasted to a re-

markable degree, the circumference of thecentre of the arm being three inches and ahalf less than that of the opposite side; theatrophy has likewise extended to the mus-cles which pass from the side of the chest tothe humerns aud scapula, so much so, thatthe left side of the thorax, measured fromthe centre of the sternum to a correspondingpoint posteriorly, is one inch and a half lessin circumference than the opposite side ofthe chest; the trapezius muscle, though notso fully developed as its fellow, still is notwasted to such a degree as the other musclesof the timh ; it is the principal muscle ivhiclimoves the scapula ; indeed, it appears to bealmost the only one capable of acting upon

that bone; the left humerns is nearly half aninch shorter than the right.The motions of the arm are extremely

limited ; as it hangs by his side he can

merely swin it backwards and forwards,and even in this motion the scaputa largelyt participates; he cmnot abduct it in theleast, or raise it in any direction: neither

can it he abducted by another so far as to

bring it to the horizontal line; in the sca-pula, however, there is a compensatory

motion that is very striking ; it moves withevery motion of the anti; or, perba-9, it

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would be more correct to say, that the armfollows every motion of the scapula, as themuscles of the former appear to be quitepassive, while the trapezius acts stronglyupon the latter; indeed so great is the mo-bility of the scapula, and so relaxed are itsmuscles, that when both elbows are pressedupwards simultaneously, and with equalforce, the left shoulder can be made to risebetween three and four inches above theright. Although the muscles of the forearmare not wasted to such a degree as those ofthe arm, still great difficulty (owing appa-rently to the atrophied condition of the

biceps), is experienced in flexing the elbow-joint, so as to bring the forearm even to aright angle with the arm; and the means bywhich the patient does effect it are remark-able : the elevation is not performed gra-dually, but with a sudden jerk, in which thescapula is also raised considerably, and thearm applied to the side ; and sometimes thebody is also inclined to the opposite side,and the elbow supported upon the crest ofthe ileum. The head of the humerus caneasily be pressed inwards, so as to allow ofthe finger being placed in the outer part ofthe glenoid cavity, and when the bone ispressed outwards towards the acromion, theremainder of the socket can be felt, situatedapparently upon a plane posterior to theouter portion; the head of the humerus pre.sents nearly its natural form, as far as canbe ascertained by an external examination ;the left acronio-clavicular articulation ap-pears to enjoy an unusual degree of motion.The shoulder has not the rounded form

which is natural to it, yet still does not pre-sent the flattened appearance which marksthe accidental luxation of this joint. Theacromion process is prominent, and whenthe arm hangs by the side, the head of thehumerus, distinct and prominent, is so farremoved from the under surface of the acro-miou, that the thumb can easily be placedbetween them ; by raising the elbow thisappearance is altogether removed, aud thejoint assumes more of its natural form, still,however, wanting the rotundity and plump-ness derived from a proper development ofits muscles.

CONGENITAL SUBCORACOID LUXATION.

CASE 2.-Upon the morning of the 3rd ofApril, 1839, I visited Mr. H-, aa.20,whose left shoulder-joint presents an exam-ple of congenital dislocation under the co:a-coid process ; the appearances are so pre-cisely similar to those detailed in the pre-ceding case, that a full description of themwould be useless repetition ; it will be suf-ficient to enumerate a few of the lead-

ing characters of the deformity. As thearm hangs by the side, the head of thehumerus lies under the coracoid process,and the outer part of the glenoid cavity canbe felt beneath the prominent acromion;

when the elbow is drawn forwards across the chest, the head of the humerus passesbackwards beneath the acromion, vacatingcompletely the abnormal portion of thesocket, which can then be plainly felt; themuscles of the shoulder and arm are muchwasted, but, as in the case of Steele, thetrapezius appears to be as well developedas its fellow of the opposite side; the mo.tions of the arm are very limited ; he cannotraise or abduct it, and the motions back-wards and forwards are almost the only onesenjoyed; even these are not performed with.out corresponding movements of the scapula ;the deformity has existed since his birth, but became more obvious and striking as heincreased in age and stature. For the oppor.tunity of examining this case I am indebtedto Mr. Adams.

SYMMETRICAL SUBACROMIAL LUXATIONS.—CONGENITAL.

CASE III.-A woman named Judith TracyDoyle, aetat. 42, a lunatic, died on the Sthof last February, in the House of Industry;she had been a patient in the lunatic depart.ment of the institution for fifteen years ;she was subject to severe epileptic convul.sions, in one of which she died. Upon theday following her death I made an examina-tion of the body ; the brain presented theappearances so frequently observed inidiots, and so accurately delineated byCruveilheir; the convolutions of the cere-brum were small and wasted, and the an-terior lobes were separated from the frontalbone by an interval of at least three quar.ters of an inch. When the clothes were re-moved from the body 1 noticed (as did alsoMr. Brabazon, who assisted in making the! examination) a very singular, and to me, atleast, a most unusual appearance of the leftshoulder-joint, which, as the body wasplaced, first caught my eye; the head of thehumerus seemed to have been dislocatedupon the dorsum of the scapula ; but findingthat the opposite joint presented a preciselysimilar appearance, and reflecting upon thevery rare occurrence of such an accident, Iabandoned this idea, and expressed myopinion at the time, that we had got anexample of double congenital luxation of thehead of the humerus upon the dorsum of thescapula; so perfectly alike were the shoul-ders, that the description of one will be suf-ficient.The coracoid process formed a very re-

markable projection, and the acromion wasunusually prominent, but still the glenoidcavity could not be felt beneath it; thehead of the humerus formed a distinct tu-mour towards the dorsal surface of the sca-pula, beneath and hehind the summit of theacromion, and closely applied to its inferiorsurface : the arm was not removed from theside, and the forearm was rotated inwards.Upon examining the interior of the joint, I

503

found that there was no trace of a glenoid occupy the time of the reader in attempt-cavity in the usual situation, but there was ing to prove that these jointa presenteda wen-formed socket, surrounded by a gle- examples of congenital luxations of the headnoid ligament, upon the outer surface of the neck of the scapula; broader above

af the humerus upon the dorsum of the sca-than below, and reaching upwards close to pula : the total want of a glenoid cavity iathe under surface of the acromion ; the ten- the natural situation, the perfect resemblancedon of the biceps, perfect throughout, ad- between the two abnormal sockets, in form,hered to the upper and inner part of its cir- size, and position ; the integrity of the ten-cumference: the aspect of this abnormal dons and ligaments, the singular form of

. cavity was directed forwards and odiw ards. ’ -

The head of the humerus presented the same the head of the humerus, all confirm thisoval form, with this difference, however, that idea. I migbt also add the very rare oc-

in the latter case, as already described, the currence of such an accident as dislocationoval form was due to the deficiency of the upon the dorsum of the scapula ; few, com-posterior part of the head, while, in the case paratively speaking, have seen it, and whoof Doyle, it was the anterior portion which was wanting ; the lesser tubercle formed a has witnessed its occurrence in both shonl-

very remarkable projection,-it was elon- ders of the same person ? Sir A. Coopergated and curved, so as to bear considerable mentions that he had met with only tworesemblance to the coracoid process of the examples of luxation backwards of the hu-scapula. merus in the course of eight and thirty

REMARKS. years; and of such rare occurrence did the

On the foregoing cases Mr. Smith re- Baron Boyer think the injury, that to admitmarks:—It will be asked, why I consider of its taking place he supposed there mustthese cases to present examples of congenital exist some malformation of the articular

malformation, rather than the consequence of surface.

disease or accident ? 2 Many circumstances, This, as far as I have been able to ascer-

and much reflection, have induced me to tain, is the only allusion made by anyform this opinion. With respect to the writer to the deficiency of a portion of thefirst case, that of Steele, it is easy to prove glenoid cavity, as a cause of luxation of thethat in his shoulder-joint we have an nn- head of the humerus.doubted specimen of congenital luxation ; Whether the dislocation upon the dorsumthe boy who is the subject of it never met of the scapula be the result of accident, orwith any accident, never received any injury the consequence of an original malformationof the joint, and it is well known that the of the glenoid cavity, the external characterscondition of the joint which I have described of the affection are, as we migbt expect,has existed from his infancy, and that the similar in both cases ; this will be apparentarticulation has never been the seat of pain, from the following brief examination of theinflammatory action, or disease of any de- appearances which I observed in the casescriptiou: moreover the coexistence of a pes of Judith Dovle. The transverse diameterequinus would seem, in some measure, to of the shoulder, measured from the centreconfirm my opinion as to the nature of the of the clavicle to the head of the humerus,affection of the shoulder. was obviously greater than natural ; theThe symptoms and appearances which exact amount of increase, of course, could

have been described by more than one not in this case be ascertained, as bothwriter, as belonging to an accident termed shoulders were similarly altered. Stm,partial luxation of the head of the os humeri, however, the distance between the tworesemble very much those which present points that I have mentioned struck me atthemselves in cases of congenital dislocation once as being greater than natural ; indeed,of the same bone, and I feel convinced that it is a necessary consequence of the alteredexamples of the latter have been published position of the head of the humerus. Theunder the titte of partial luxation ; and were acromion process did not project so much asit not foreign to the subject of my commu- it does in the other luxations of the shoal.nication, I could easily show, that the same der, neither was the rounded form of theappellation has been given to a condition latter as much altered; the Battening wasof the joint which is obviously the conse- connned altogether to the anterior part ofquence of rheumatic disease. the joint; and what was lost in this direc.

I sbootd think it scarcely necessary to tion was gained externally and posteriorly,

504

where a round, firm tumour indicated plainlythe situation of the head of the bone. Inthe other luxations of the shoulder there isno remarkable projection of the coracoidprocess; it is in a measure obscured by thehead of the humerus; but in the case we are

considering, nothing could be more strikingthan the prominence formed by that process,owing, no doubt, to the removal of the headof the humerus from its vicinity. This is a

symptom belonging to dislocation upon thedorsum of the scapula, that appears to haveescaped the notice of British surgeons,although more than one of the continentalwriters have enumerated it; it was, I be-lieve, first mentioned by Manne, of Toulon,afterwards by Sedillot, and very lately ithas been much dwelt upon by Lepelletier,The arm was directed obliquely downwardsand inwards, the elbow approximated to theside, and the hand and forearm in a state ofpronation.

Such is a brief but accurate statement ofthe facts which I have observed relating tocongenital luxations of the articulation ofthe shoulder. Our knowledge of these re-markable affections must, of course, be con-sidered as still incomplete; we want a moreextended series of observations ; a largernumber of cases must be grouped togetherto enable us to give a full and completehistory of congenital dislocations of the

shoulder.—Abridged from the Dublin Jour-nal, May, 1839.

CASES OF HERNIA CEREBRI,WITH REMARKS.

By G. MALLETT, Esq., Surgeon, Bolton.

JOHN ISHERWOOD, set. 36, received, whilestanding at the bottom of a coal-pit, a

wound upon the forehead, from the falling ofa piece of coal from the mouth of the pit.The scalp was much lacerated and contused,and the os frontis shattered near its mostcentral point, but rather inclining to the leftside. Many fragments of bone and coal hadpenetrated the brain, and about three or

four teaspoonfuls of its substance were foundlying upon the hair and face; there was noetupor or paralysis, neither did there appearto be that nervous shock or disturbance tothe constitution which might have been ex-pected to have occurred from such an in-jury. The wound was cleaned, and severalsmall pieces of coal and twelve fragmentsof the frontal bone were removed fromthe brain, having penetrated its substancemore or - less deeply. One of the por-

tions of coal, measuring an inch in lengthand half as much in breadth, was foundresting upon the floor of the left orbitaryplate. The pulse being about the naturalstandard, no bleeding seemed requisite;quiet, abstinence, and aperients, when ne-cessary, were directed. Nothing particularoccurred till the tenth day, when a smallhernia cerebri began to make its appear-ance, which increased till it had attained thesize of a large walnut ; it then remained fita-tionary until various small portions of theinner table of the cranium had exfoliated,and then, assisted by slight pressure, it gra-dually disappeared, and the man completelyrecovered. He resumed his occupation,that of a collier, as well as the practisinga variety of Merry-Andrew tricks, such asstanding upon his head, tumbling, &c. Hedied five or six years afterwards from apo-plexy.Abraham Johnson, act. 6, received a kick

from a donkey, producing a compound frac.ture of the occipital bone ; a considerableportion of it was depressed into the brain,and a small fragruent disconnected from tharest of the bone; the former was elevated,the latter removed. The case did wellwithout any untoward symptom.

J. Bates, set. 18, when in a coal-pit, wasstruck upon the head by a lump of coal fall-ing from the roof of the mine. It produceda compound fracture about the centre of thesagittal suture. Some small pieces of bonewhich had been driven into the substance ofthe brain were removed. In eight days alittle elevation or growth from the brain ap.peared, which continued about a week, whena small piece of coal was discharged, aboutthe size of a pea. The rising then graduallydisappeared by the sole application of lint,wetted with very diluted nitric acid. No

unpleasant effects remained as the result ofthe accident.

J. D., ast. 4, was playing in the middle ofa public road, and not hearing the approachof a cart and horse, was knocked down bythe latter, and then trod upon by its fore feet.The upper and central part of the frontalbone was driven into the brain, and two orthree spoonfuls of it were spattered uponthe face and hair. One side, the left, wascompletely paralysed, and the thigh-bone ofthe same side broken about the iunction ofits upper third. The broken and loose por-tions of the frontal bone were removed, andthe wound dressed lightly. In about a weekhernia cerebri made its appearance, which,in spite of pressure and various local &ppli-cations, gradually increased till it hadgained the size of a large duck’s egg; itthen remained stationary for a fortnight,when I determined to remove it by means ofthe knife. The operation was performed ina few seconds, and apparently without thelittle patient being sensible of any pain.The wound was then accurately examined,