May, 1945 PRACTICALITIES 167

ductus in all patients treated by ligation hasnot yet been achieved, and division betweenclamps may supersede simple ligation.

5. The effects and results of operation arereviewed.

6. Illustrative cases are recorded.

REFERENCES

ABBOT, MAUDE E. (I936), Atlas of Congenital Heart Disease, New York:American Heart Association.

BARCLAY, A. E., BARCROFT, J., BARRON, D. H., and FRANKLIN,K. J. (1942), Am. J. Roetgenol. 47, 678.

BOURNE, G., KEELE, K. D., and TUBBS, 0. S. (I94I), Tancet 2,444.BULLOCK, L. T., JONES, J. C., and DOLLEY, F. S. (1939), J. Pediat.

15, 786.EPPINGER, E. C., and BURWELL, C. S. (I940), J. Amer. Med. Ass. 115,

I262.GRABIEL, A., STRIEDER, J. W., and BOYER, N. H. (I938), Amer.

Heart J. 15, 62I.GROSS, R. E., and HUBBARD, J. P. (I939), J. Amer. Med. Ass. 112,

729.GROSS, R. E. (I944), Surg. Gynec. and Obst. 78, 36.HARRINGTON, S. W. (1943), Proc. Staff Meet. Mayo Clinic. 18, 217.KENNEDY, J. A., and CLARK, S. L. (I941), Anat. Record 79, 349.MUNRO, J. C. (I907), Ann. Surg. 46 335.SHAPIRO, M. J., and KEYS, A. (s94i), New Internat. Clin. 4, 48.SHAPIRO, M. J., and KEYS, A. (1943), Am. T. M. Sc. 206, 7;4.TOUROFF, A. S. W., and VESSELL, H. (1940), J. Thoracic Surg. 10, 59.TOUROFF, A. S. W. (I942), Am. Heart J. 23, 847.TUBBS, 0. S. (1944),Brit. J. Surg. 32, I.WILSON, M. G. and LUBSCHEZ, R. (I942), J. Pediat. 21, 23.

FRACTURES II

THE UPPER LIMB-DIAGNOSISAND TREATMENT

By E. H. HAMBLY, F.R.C.S.(Surgeon E.M.S., Royal National Orthopaedic

Hospital, W.i)It is rarely emphasised in writing that the

treatment of fractures generally is very difficult.Nowhere does this apply more than to the commonfractures occurring in the upper limb. For exam-ple, it is extremely difficult to obtain absoluteanatomical and functional correction in manyfractures of the elbow and the wrist in adults.Writers only too frequently suggest that suchfractures can be easily reduced and full correctionobtained. Such statements only depress thereader, who may be having considerable difficultiesin his treatment of these fractures. It is only fairto indicate which fractures are difficult to treatand to indicate methods by which the treatmentof these difficulties can be rendered more effective.

Nevertheless, the general standard of resultsstill obtained from such fractures as those of theelbow, forearm, and wrist in adults is far too low.This standard can be raised by. greater care intreatment, more attention to detail, a desire toobtain better anatomical and functional results

than heretofore, and better after-treatment to thesoft tissues and to the joints not immobilised.

Radigraphic DiagnosisMore and more the finer points of the diagnosis

of fractures rest upon the methods of radiographicprocedures. It is still true that clinical examina-tion is pre-eminent, but only too frequently theonly clinical sign is tenderness at the site of thefracture.

In injuries to the limbs the whole of a long boneshould be X-rayed. Also the joints above orbelow the fracture must be included in the film.X-rays of both limbs should be taken for com-parison. Especially is this necessary in the caseof joint injuries. Furthermore, X-rays must betaken in at least two planes at right angles, andpreferably in a third oblique plane.

Fractures of the ClavicleFractures of the clavicle occur most commonly

in the middle and towards the outer extremity.The chief points concerning treatment are theavoidance of stiff fingers and a stiff shoulder.The usual method of treatment by three handker-chiefs or figure of eight bandage is very painfulif applied properly, or ineffective if applied com-fortably. The reader has only to permit himselfto be tied tightly for one night with three handker-chiefs to appreciate this point.The most efficient and most comfortable method

is to place a four-inch square of adhesive felt onthe fracture site and a similar square of adhesivefelt on the under-surface of the olecranon. Elasto-plast is then applied from the axilla on the innerside of the arm, round the under surface of theelbow, up the outer aspect of the arm over theclavicular felt pad, and across the trapezius tothe back. Two pieces of elastoplast are so fixedwith one circular piece loosely around the arm.This enables the patient to move the shoulder,elbow, and hand from the beginning.

Sayre's method is absolutely contra-indicatedas it prevents active movements of all the joints.

Fractures of the ScapulaThe scapula may be fractured in the body, neck,

coracoid process, or acromium. Although fre-quently badly splintered by multiple fissurefractures the correct treatment for all thesefractures is radiant heat and active exercisesfrom the first day of injury.

Passive exercises should never be given in injuriesof the limbs, in fact the writer is convinced that ithas no place in bone and joint surgery. The onlyindication for passive exercises is paralysis associa-ted with a nerve lesion.

copyright. on M

arch 17, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.21.235.167 on 1 M

ay 1945. Dow

nloaded from

copyright. on M

arch 17, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.21.235.167 on 1 M

ay 1945. Dow

nloaded from

copyright. on M

arch 17, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.21.235.167 on 1 M

ay 1945. Dow

nloaded from

168 POST-GRADUATE MEDICAL JOURNAL May, 1945Only rarely do severe fractures of the neck of

the scapula require traction in abduction forabout four weeks.

Fractures of the HumerusFractures of the Neck.

Over 95 per cent of fractures of the neck of thehumerus are very easy to treat. The remainderhowever, are the reverse. Such a one is seen inX-ray No. i.

Fractures of the humeral neck are sub-dividedinto three groups, namely, crack fractures due tocontusion, adduction fractures, which are- im-pacted, and abduction fractures, which may ormay not be impacted.The only treatment necessary for contusion

fractures is radiant heat and active exercisesdaily from the first day. The sling is abandonedafter a week.Adduction fractures are always impacted. The

best treatment again is radiant heat and activeexercises daily from the day of the injury. Onlywhen the shaft is very adducted on the head istraction in -abduction of a frame necessary forfour weeks. Even then the deformity frequentlyfails to correct itself. Nevertheless, functionalresults are excellent. See X-ray No. 2.The treatment of abduction fractures depends

on whether the shaft is impacted or not. Ifimpacted, treatment consists of radiant heat andactive exercises and a sling for one week.

Occasionally, an impacted abduction fractureoccurs where the head is dislocated. Again, inthe writer's opinion, conservative treatment ispreferable after manipulation- has been per-formed.Open reduction of such a fracture-dislocation

only tends to cause aseptic necrosis of the head.If late osteo-arthritis is severe an arthrodesis isindicated. It is incredible what good functionalresults can be obtained in these cases if radiantheat and active exercises are commenced immedi-ately after the injury, even in the presence ofshocking X-rays.

If abduction fractures are un-impacted aserious dislocation results. In these cases anabduction frame clearly makes the deformityworse, unless continuous screw -traction isapplied. If such traction is applied it must befixed to strapping on the arm and not to a pinthrough the olecranon. This causes effusion andstiffness of the elbow joint. The best treatmentfor such un-impacted fracture-dislocations inabduction is manipulation of the humerus acrossthe chest, at the same time applying pressure out-wards. The limb is then placed in a collar andcuff sling for three weeks. Radiant heat and such

active exercises as the sling permits are com-menced at once.

Dislocation of the ShoulderAll dislocations of the shoulder, as indeed all

suspected injuries to bones and joints, should beX-rayed before reduction to exclude an associatedfracture of the humeral head.

Dislocations of the humeral head are usuallysub-coracoid. Other positions include sub-glenoid,luxatio erecta, sub-spinous, and between theclavicle and the first rib. The last two are rare.A deep anaesthetic is essential, e.g. Pentothal

FIG.3.-Fracture of lower one-third of shaft ofhumerus which cannot be immobilised with-out an onlay graft.

or Ether. Gas should never be used for reducingfractures and dislocations. Complete relaxationis essential. Reduction is carried out by externalrotation of the arm with the elbow by the side.Reduction frequently occurs during this firstmovement of manipulation. The second move-ment consists of bringing the elbow across thechest. Finally, the third movement internallyrotates the arm.

Five per cent of all dislocations of the shouldercause injury to the circumflex nerve, with deltoidparalysis. The arm should be held in abductionin a frame until the paralysis recovers. If theparalysis is only partial active exercises aresufficient.

copyright. on M

arch 17, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.21.235.167 on 1 M

ay 1945. Dow

nloaded from

May, I945 PRACTICALITIES 169Fracture-Dislocation of the Shoulder

In these cases the head of the humerus may belying free. It may even be upside down. SeeX-Ray No. i. These are very difficult cases.Manipulation should be undertaken with the armin traction and in abduction or hyper-abduction.Open reduction is contra-indicated on account ofaseptic necrosis of the humeral head. The besttreatment if the humeral head is still upside downafter careful manipulations is to ignore the X-raysand to commence radiant heat and active exercisesat once. If osteo-arthritis becomes severe anarthrodesis can be performed.

Fractures of Shaft of HumerusFortunately, all fractures of the shaft of the

humerus unite well and rapidly with one exception.The latter occur at the junction of the thirdquarter and the lowest quarter of the humerus(Fig. 3). Here immobilisation without fixation isimpossible.Treatment of fractures of the humeral shaft

consists in manipulation and application of aposterior plaster slab from the shoulder to theknuckles. Gravity maintains the shaft in correctalignment provided the wrist is held with a collarand cuff or ordinary sling. Active exercises at theshoulder joint are undertaken from the beginning.

For fractures of the lowest quarter of the shaftsee X-ray No. 4, the only treatment, as thewriter has found from bitter experience, is anonlay tibial bone graft, which is fixed with fourvitallium screws. It is important in this connec-tion to have screws of sufficient length to lodgefirmly in the compact bone on the other side ofthe shaft to the graft. The humerus is thenimmobilised in a shoulder spica for at least fourmonths. The bone graft is most brittle betweenthe seventh and eleventh weeks.

Fractures of Lower End of HumerusThe two main principles of treatment of injuries

to the elbow joint are avoidance of all forcing,stretching, or manipulation, and to avoid theinsertion of all metallic foreign bodies.

Supra-Condylar Fractures.Supra-condylar fractures are extremely common.

They are of two very distinct types. The first andcommoner consists of backward displacement ofthe lower fragment. See X-ray No 5. This typeshould be treated by manipulation and fixationin flexion. This is done by the application of aposterior plaster slab and a wet cotton bandage.A complete round and round plaster is extremelydangerous. Care should be taken to observe if theradial pulse is still present. Absence of the pulse

after manipulation does not mean Volkmann'sischaemic contracture. It only means that theelbow is too flexed. The writer recently has seenthree such cases in one month. The correcttreatment when the pulse is absent at the end ofmanipulation is to extend the elbow to 20 degreesbeyond the right angle, and to apply anotherplaster back slab in that position with an ordinarysling. The clinical sign of true Volkmann's Con-tracture is complete inability to extend the fingerswithout severe pain. Treatment for Volkmann'sContracture is to extend the elbow to 2o degreesbeyond the right angle. If finger movements donot return after six hours the brachial arteryshould be explored in the ante-cubital fossa. Ifthe artery is actually damaged, an inch of it shouldbe excised. The writer believes that this operationis never necessary if the elbow is extended to20 degrees beyond the right angle as soon as theradial pulse is absent, or as soon as extension ofthe fingers is absent. Clearly, all supra-condylarfractures should be admitted after reduction forobservation.The second type of supra-condylar fracture is

that in which there is an anterior displacement ofthe lower fragment. These should be treated bymanipulation and fixation with a posterior slab infull extension. See X-ray No. 6.

Fracture-Dislocation of Capitellum andHalf Trochlea

In adults this is not uncommon. Nearly thewhol-e of the articular surface of the humerus iscompletely displaced upwards in front of thehumerus. See X-ray No. 7. This is a very diffi-cult fracture to treat successfully. The writerhas tried open reduction with repair with catgut,attempted closed reduction by extension, andexcision of the fragment. All these methods haveleft a relatively stiff elbow. The best treatmentis manipulation and application of a plaster-backslab in full extension. This is left for three weeks.The elbow is then flexed under anaesthesia and aplaster-back slab applied with the elbow at rightangles.

Inter-Condylar and Y-shaped Fracturesof Humerus

These types of fracture are also very difficuitto treat satisfactorily when displacement is marked.Although many forms of treatment have beenrecommended, the writer favours manipulationand plaster with the arm in full extension for threeweeks, after which time it is fixed at right anglesunder anaesthesia in a back slab. Immediatearthroplasty has been advised, but this givesmobility at the expense of strength.

copyright. on M

arch 17, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.21.235.167 on 1 M

ay 1945. Dow

nloaded from

170 POST-GRADUATE MEDICAL JOURNAL May, I945

Anterior Displacement of Whole Epiphysisin Children

This type of fracture should be treated similarlyto an anterior type of supra-condylar fracture.The elbow is manipulated and immobilised witha plaster-back slab in full extension.

Displacement of External CondylarEpiphysis

The external condylar epiphysis may be dis-placed and rotated go degrees in both vertical andhorizontal axes. This results in cubitus valgusand ulnar paralysis. Treatment consists inmanipulation or fixation by open reduction.See X-ray No. 8.

Displacement of Internal EpicondyleThis injury is not rare. The ulnar nerve may

be carried with the displaced fragment into theelbow joint. If the detached fragment lies withinthe joint space open reduction is necessary. Theulnar nerve should always be transplanted at thesame time. See X-ray No. 9.

Fractures of the Radius and UlnaFracture of Head of the Radius.

Fissure fractures of the radial head only requirea sling for four weeks. Active movements areundertaken at once. If fracture of the radial headis suspected clinically it should be treated accord-ingly, even if the standard three X-ray views, i.e.antero-posterio, lateral, and oblique, are negative.

If there is displacement of the articular surfaceof a portion of the radial head, the latter should beexcised as soon as the arm can be suitably pre-pared. Delayed excision does not give goodresults. The radial head should not be excised inchildren and adolescents on account of Madelung'smanus valgus of the wrist developing. Thewriter's method of excising the head of the radiusis by means of the Gigli's saw, after turning backthe periosteum This causes less crushing and late"myositis ossificans" than other methods.

Displacement of Radial Head in ChildrenIn children the whole head of the radius may be

displaced laterally. This should be reduced bymanipulation and direct pressure on the head.Excision of the head of the radius in children is adisaster. The whole radius shifts upwards, andMadelung's deformity results.

Dislocation of the ElbowThe elbow may dislocate backwards with a

fracture of the coronoid process, or forwards witha fracture of the olecranon. Backward disloca-

tions are reduced under deep anaesthesia, and aposterior slab applied with the elbow at rightangles. This is removed after four weeks, andactive exercises only commenced. Anterior dislo-cations are treated by manipulation and fixationin full extension for six weeks, or, alternatively; theolecranon can be repaired by operation. SeeX-ray Nos. io and ii.

Fracture of the OlecranonThis is a common injury. If the patient is less

than forty years of age, the elbow should beplastered in full extension for six weeks. Whenthe limb is taken out of plaster it will be found tobe quite stiff. It should be then flexed io degreeseach week by the use of successive plaster slabs,until the position of right angles is achieved. Theplaster slab is then abandoned and active move-ments only commenced.

Alternatively, and in all patients over forty, theolecranon should be repaired by operation. If thefractured fragment is small, it should be excisedand the triceps repaired. In the elderly the frag-ment should be excised or ignored and activemovements commenced.

Monteggia Fracture of Shaft of Ulna withDislocation of Head of Radius

This type of injury is not uncommon. It isvery difficult to treat satisfactorily. See X-rayNo. I2. There are two types of Monteggia injuries.In the first type the ulna is angulated forwards,and the head of the radius is dislocated anteriorlyat the elbow. In the second type the ulnar shaftis angulated backwards, and the head of the radiusis dislocated posteriorly. This is the commonertype.Treatment of the first type in which the ulnar

shaft is angulated forwards is to reduce the fractureof the ulna by open operation and fixation by avitallium plate with four screws. The head of theradius can be replaced by manipulation at thesame time.

In the second type of Monteggia injury treat-ment, where the ulna is angulated backwards, thebest treatment is plaster in full extension for fourto six weeks depending upon the age of the patient.In many Monteggia injuries, the radial head isalso fractured. In these cases the head of theradius should be excised early. However, whenthe head of the radius is not fractured, but onlydislocated, excision of the head should be leftuntil late. Otherwise the shaft of the radius ridesupwards with manus valgus deformity.

"Myositis Ossificans" of ElbowThis condition is merely calcification of a haema-

copyright. on M

arch 17, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.21.235.167 on 1 M

ay 1945. Dow

nloaded from

May, I945 PRACTICALITIES 171

toma. It is made worse by passive movements andmanipulation. Treatment of this very difficultcondition is immobilisation in plaster at rightangles for four weeks only. The plaster is thenremoved, and active movements are undertaken.See X-ray No. 13.

Fractures of Shafts of Radius and UlnaWhen both bones are fractured in mid-shafts

they should be reduced by manipulation or openoperation. The plaster should extend from theknuckles to the axilla. This should be kept onuntil strong union occurs. Reduction of theplaster to below the elbow is contra-indicated as itfails to immobilise the fracture.

If the mid-shaft of the radius alone is fracturedand angulated with dislocation of the lower endof the ulna, the fracture should be reduced by openoperation and fixed by one vitallium screw.

"Irreducible" Pronator Quadratus Fracturein Children

This type of injury is shown in X-ray No. I4.It is commonly irreducible by ordinary manipula-tion. Open reduction is easy, and gives excellentresults.

Colles' Fracture-Dislocation of WristColles' fracture-dislocation of the lower end of

the radius and ulnar styloid presents three dis-placements at once. They are radial deviation,dorsal displacement, and dorsal rotation of thedistal fragment. See X-Rays I5 and i6. Thehand is thus carried towards the thumb anddorsally. A deep anaesthetic is required. Thefracture is reduced by disimpacting the fragmentsby dorsi-flexion. All three displacements arecorrected at the one time. A three-quarter roundplaster slab is applied on the radial side of theforearm, from the knuckles to the elbow. Theplaster is trimmed to allow free movement of theelbow and fingers. The hand should be in theposition of full ulnar deviation and in the sameplane as the forearm, i.e. neither dorsi- nor palmar-flexed. Re-X-ray should show the lower articularsurface of the radius to be facing slightly towardsthe palm. The position of this articular surfaceat right angles to the shaft of the radius is notsufficient.The plaster should be changed under deep

anaesthesia after ten days as all cases tend torelapse at this time. The plaster stays on for fiveweeks altogether. A sling is worn for twenty-fourhours only. Active movements of fingers andelbow must be performed at once. The patientmust do his normal work. If the fingers becomeswollen it is a sign that he is not using the hand

FIG. i6.-Colles fracture-dislocation. Anterio-pos-tenor view shows radial displacement of distalfragment.

and fingers enough, provided that the plaster isnot too tight in which case it should be changed.

Smith's Fracture-Dislocation of theWrist

This is the reverse deformity to a Colles. It isassociated with an anterior marginal fracture ofthe lower end of the radius with subluxation ofthe wrist. The hand is carried palmar-wards.Treatment consists of manipulation under deepanaesthesia, and plastered in full dorsi-flexion.It is a difficult injury to hold in the correct position.

Injuries to the HandFracture of the Scaphoid.A suspected fracture of the scaphoid must be

X-rayed in three planes, i.e. antero-posterior,lateral, and oblique. If there is clinical evidenceof fracture without X-ray signs the wrist shouldbe plastered as for a scaphoid for three weeks andthen re-X-rayed. Treatment consists of plasterwith the thumb at right angles to the plane of thepalm until the bone is united, i.e. twelve to twentyweeks or more. In late cases, where the diagnosishas been missed, drilling or bone-grafting is verysuccessful.

It may be recalled that simple sprains of thewrist are rarer than fractures of the radius andscaphoid.

Dislocations of the LunateThis should be reduced under deep anaesthesia

by dorsi-flexion and traction, and application ofdirect pressure to the lunate. If operation has to

copyright. on M

arch 17, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.21.235.167 on 1 M

ay 1945. Dow

nloaded from

172 -POST-GRADUATE MEDICAL JOURNAL May, I945be undertaken it is better to excise the lunatethan to replace it, as the latter treatment alwayscauses aseptic necrosis of the lunate. The writerhas met a surgeon who was able to amputate aleg through the thigh seventeen days after removalof the lunate upon his own wrist, following severalattempts at rmanipulative reduction. Twentyyears later he appears to-have a normal wrist.

Bennett's Fracture-Dislocation of theThumb

This is a fracture-dislocation of the base of thefirst metacarpal. Treatment should consist oftraction with a pin through the pulp fixed tocramer wire, which is incorporated in a forearmand wrist plaster. The thumb should be in a planeat right angles to the palm, and extension should lastfor four weeks.

Fractures of the MetacarpalsFractures of the shafts of the metacarpals other

than that of the thumb should be treated bymanipulation followed by active exercises only.The fingers should never be splinfed nor immo-bilised in these fractures. Stiff fingers are theresult.

Fractures of the neck of the metacarpals withforward angulation of the distal fragment shouldbe corrected by right-angled flexion and backwardpressure, and not by hyper-extension.

Fractures of the PlalangesThese fractures usually show forward angulation

and should be treated by extension by strappingon either side of the fingers in flexion on a malle-able wire splint on the palmar surface for tendays. Each finger should point to the tubercleof the scaphoid. No finger must ever be splintedin extension. Strapping should never be appliedround a finaer or toe. It should be appliedlongitudinally on either side.

All compound fractures of the fingers must beoperated upon immediately. They can give moreserious after-results than a fracture of the femurin a working man. In operating upon a compoundfracture of the finger, the fracture should bereduced. Cut tendons should never be suturedat the original operation. Tendons should besutured two weeks after healing in the case of aclean wound, and two months after healing in thecase of an infected one. The skin should not besutured at the original operation. Catgut shouldnot be buried. The finger should be splinted ina palmar malleable wire or plaster in flexion'. Iftraction is required, it should be done by means oftwo lateral strips of strapping.

- All compound fractures of the fingers should beadmitted as emergencies, and should be under thedirect supervision of an experienced surgeon.The aiter-results of these injuries are. still verydepressing, and only too frequently result in thepatient losing his occupation or being down-graded.

THE ART OF ORTHOPAEDICSPART IV

INJURIES AND DISEASES OF THESHOULDER AND ELBOW JOINTS

By G. 0. TIPPETT, F.R.C.S.(Hon. Asst. Orth. Surgeon to Queen's Hospital for

Children and Croydon Hospital; Med. Off. Physio-therapy Dept. Bermondsey Health Centre)

Shoulder JointOwing to the varied uses to which the arms are

subjected injuries of the shoulder joint are ex-tremely common, ranging from injuries to the softparts to dislocations and fractures. As in previousarticles, fractures are not being discussed. Thetraumatic injuries which the examiner must bearin mind are the following:

SprainsA sprain may damage by tearing either some of

the muscles surrounding a joint or may partiallyor completely tear the ligaments or capsule of ajoint. In injuries to the muscles around the jointthe patient usually can tell the examiner whatparticular movement brought on his trouble andthe examiner, by making that group of musclesperform a particular movement, can reproduce thepatient's pain. Similarly, if the examiner puts thejoint through the opposite range of movement,that is passive movement, pain again will bereproduced. Sometimes, however, all musclesaround a joint have been over-stretched, in whichcase all joint movements will be rather painful.At this stage it is well to bear in mind that whatare commonly called the movements of the shoulderjoint by the patient are not only the movementsbetween the humerus and the scapula, but alsothe movements between the scapula and the chestwall, sometimes called the compensatory shouldermovement. The differentiation of these twogroups of movement is extremely important in the

copyright. on M

arch 17, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.21.235.167 on 1 M

ay 1945. Dow

nloaded from

210 POST-GRADUATE MEDICAL JOURNAL June, 1945

SELECTION FROM THE SUBJECTS ALREADY DEALT WITH

Carcinoma of the Lung February -1943

Childlessness August -1944

Diseases of Pregnancy June -1944

Disorders of Micturition December-1944

Gall-Bladder Diseases - February -1944

Intestinal Obstruction March -1945

Mass Radiography May -1944

Meningoencephalitis March -1944April -1944

Oesophageal Diseases October -1944

Renal Tuberculosis December-1943

CORRIGENDA

In the May issue of the POST-GRADUATE MEDICAL JOURNAL an incorrect caption appearedbeneath Fig.. 2 in E. H. Hambly's article "Fractures of the Upper Limb," this caption shouldread "Adduction Fracture of Neck of Humerus."

Owing to an error the April issue of the JOURNAL was.numbered incorrectly 234 insteadof 233.

H. K. LEWIS & Co. Ltd. Medical Lending LibraryMedical Publishers ANNUAL SUBSCRIPTION from ONE GUINEAand Booksellers FOR THE CONVENIENCE OF POST-GRADUATE

STUDENTS SHORT PERIOD SUBSCRIITIONS136 GOWER STRE ET ARE ARRANGED-FOR THREE OR SIX MONTHS

LONDON, W.C. I Detailed Prospectus on applicationThe Library Catalogue revised to December, 1943, containing classi-

(Adjoining University College and Hospital) fled index of authors and subjects. To subscribers, 12s. 6d. net;to fnon-subscribers, 25s. net, postage 8d..

Telephone: EUSton 4282 (5 lines).Telegrams: Publicavit, Westcent. London. NEW BOOKS ADDED IMMEDIATELY UPON PUBLICATION