Extracted from the 
TRANSACTIONS OF THE COLLEGE OF PHYSICIANS OF 
PHILADELPHIA. 
THIRD SERIES, VOLUME III. CASE 
OF 
PERIPHERAL NECROSIS OF THE HUMERUS, 
INVOLVING THE HEAD AND ENTIRE SHAFT ; PRE-EXISTING 
OSSEOUS ANCHYLOSIS OF THE SHOULDER', AND FIBROUS 
ANCHYLOSIS OF THE ELBOW ; AMPUTATION AT 
THE SHOULDER-JOINT. 
By 
J. EWING MEARS, M.D., 
SURGEON TO ST. MARY'S HOSPITAL, ETC. 
[Read October 4, 187G.J 
The patient, whom I bring before the College to- 
night, gives the following history :- 
P. B., set. 37, a native of Ireland, and by occupation an 
accountant; so far as could be ascertained, hereditary disease 
did not exist in bis family. When twelve years of age, after 
the receipt of an injury and exposure to cold, he was attacked 
with fever and very painful swellings of the right shoulder- 
joint and left knee-joint. A month after he was taken sick, 
matter formed in both joints, and pieces of bone were dis- 
charged. From the knee-joint, the pieces were small and 
not very numerous; but from the shoulder-joint a large piece 
was discharged, which, according to the description given, 
resembled the head of the bone. 
In six months, the wounds healed, with partial stiffness of 
the left knee-joint and right elbow-joint, and complete im- 
mobility of the right shoulder-joint. From that period until 
the month of April of this year, he enjoyed very good health, 18 
MEARS, 
being able to engage in his duties as accountant and school- 
teacher. The stiffness of the knee-joint made him slightly 
lame, while the movements of the arm were restricted by the 
immobility of the shoulder-joint. 
At this time, he strained his arm in an effort which he 
made to lift a heavy box. Two days after receipt of the 
injury, the arm began to swell, and he was attacked with 
fever, somewhat in the same manner as when he had the 
first attack twenty-five years before. The swelling continued, 
and in three or four weeks matter escaped from the arm by 
a number of openings ; small pieces of bone were discharged, 
and the number of openings increased until there were thir- 
teen in all. During his illness he sustained fracture of the 
bone, in an effort made to raise his body in bed, the sound 
produced by the fracture being quite audible. 
He entered the hospital on June 15, and was under the 
care of my colleague, Dr. Grove, who delayed operative 
interference on account of the patient's condition, transfer- 
ring him to me on July 1, when I came on duty. The tonic 
treatment instituted by Dr. Grove was continued until 
August 1, at which time the patient's condition was thought 
to be such as to warrant an operation. 
With a view to perform excision, if the condition of the 
bone and tissues were found to be such as to admit of it, an 
incision was made on the outer side, beginning about mid- 
way between the shoulder-joint and the insertion of the 
deltoid muscle, and extending below the middle of the arm. 
This incision permitted an inspection of the tissues, which 
were found to be so changed by inflammatory action as to 
forbid any attempt to save the limb. Amputation at the 
shoulder-joint was then determined upon, and performed by 
Dupuytren's method. On exposing the joint, firm, bony 
anchylosis was found to exist. Section of the bone, as near 
to the joint as possible, was made with the saw, the remain- 
ing portion being removed by the forceps and chisel. 
The recovery of the patient was as rapid as could be 
expected for one in his condition; it was somewhat retarded NECROSIS OF HUMERUS. 
19 
by the formation of an abscess in the lumbar region, from 
which two pints of gelatinous pus were removed by the 
aspirator. The union of the flaps occurred with but slight 
suppuration. 
A dissection of the limb was made after removal, and the 
soft structures were found much changed by the extensive 
suppuration which had occurred ; they were perforated by 
numerous sinuses lined with unhealthy granulations. The 
periosteum was at some points destroyed; at others, indurated 
and much thickened ; in a few places, there were slight evi- 
dences that its osteogenetic function still existed. At the 
time of the operation it was ascertained that bony anchylosis 
existed at the joint, and that, as stated by the patient, the 
head of the bone had been separated and discharged during 
the first attack of illness; the upper portion of the bone, 
corresponding to that embraced between the tuberosities and 
the insertion of the pectoralis major muscle, was but slightly 
affected, although there were evidences that it had been 
attacked in the previous disease; the compact tissue was 
removed, leaving the central cancellated portion, which was 
somewhat softened, and, when compressed by the pliers, 
exuded a frothy fluid. Below the surgical neck, the shaft 
of the bone was found to be in a condition of extensive 
peripheral necrosis, giving it a worm-eaten appearance; this 
condition extended to the articulating surface of the bone, 
but did not involve it. At about the junction of the upper 
with the middle third of the bone, there wTas a fracture, in 
w7hich fibrous union had occurred. There was no evidence 
of an attempt on the part of nature to obtain any osseous 
union ; the ends of the bone were in apposition, and the 
surfaces were smooth. The appearance of the bone is shown 
in the accompanying illustration (page 20). 
It would appear from the history given by the 
patient that, in all probability, the attack of illness 
which occurred at twelve years of age, was arthritis, 
following contusion of the joints and exposure to 20 
MEARS, NECROSIS OF HUMERUS. 
21 
cold, the former being produced by a fall from a 
horse. In the shoulder-joint, the disease was very 
extensive, producing complete destruction of the 
articulation, and obliterating its structures. The 
epiphysis, being separate at that time, was easily 
detached, and removed by the suppurative action. 
The knee-joint was not involved to any great extent, 
and the fibrous anchylosis of the elbow-joint was, 
without doubt, the result of disuse, assisted by the 
contraction and adhesion of the adjacent muscles and 
tendons. 
The second attack of illness, that occurring in 
April of this year, was evidently one of diffuse peri- 
ostitis, following the injury sustained in lifting a heavy 
weight. A condition of the periosteum may have 
existed, as the result of the previous disease, which 
rendered it susceptible to an attack of this nature. 
With regard to the treatment of these cases, the 
most energetic means must be employed in the first 
stage of the inflammatory action-free incisions to 
relieve the tension of the periosteum, and to deplete 
it, and also to permit free escape of the pus should 
this form; at the same time constitutional remedies 
for the purpose of maintaining the strength of the 
patient should be resorted to. When extensive 
destruction of the bone ensues, amputation must be 
performed, providing the condition of the patient will 
admit of it.