A 19 year old student had to leave the rugger field due to a injury to his right shoulder. When the doctor saw him he was supporting his right forearm with his left hand. On observation the shoulder was in a position of slight abduction and internal rotation. The right shoulder was compared with the left shoulder. The lateral aspect of the shoulder is normally rounded, but in this patient it was flattened. On the right side the arm appeared to arise from the junction of the middle and the outer thirds of the clavicle. The right axillary folds appeared to lie at a lower level.

On palpating below the acromian the head of the humerus was not felt with the finger tips the upper third of the deltoid was palpated. Normally the head of the humerus gives a bony resistance. In this patient the fingers appeared to sink in. When the lateral third of the pectoralis major was palpated, a bony resistance was felt due to the displaced head of the humerus.

The presence of the head of the humerus is due to the anterior subcoracoid dislocation. The dislocation is due to forced extension and external rotation of the abducted arm. Following dislocation there are no active or passive movements. The humerus is locked in position by muscle spasm. Rarely posterior dislocation could occur. The dislocation is confirmed by a X-ray. Together with the dislocation other injuries may occur. These are :

The dislocation is reduced with or without general anaesthesia. A sling is placed with the arm in full adduction and internal rotation for 3 weeks. On anatomical basis, explain :

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A three month old infant was brought to the paediatric clinic because of a red mass at the umbilicus. There was no discharge from the umbilicus. On examination, the skin around the umbilicus was not red or swollen. The mass was rounded, red and pedunculated. The surface was shiny and not ulcerated. It was not tender. The axillary and inguinal lymph nodes were not enlarged. An umbilical adenoma was diagnosed. Surgical removal of the adenoma was decided on. The peduncle was tied and the adenoma excised. The parents were requested to bring the child to the clinic if the condition recurred.

DISCUSSION
The umblicus is a scar on the anterior abdominal wall situated in the aponeurosis of the linea alba at or below its center. It is a fibrous ring at the attatchment of the umbilical cord. Several stuctures pass through this opening during fetal life. These include,

(1) The allantosis which extends from the cloaca. It is continuous with the devoloping urinary bladder

(2) The vitelline duct or yolk stalk that connects the degenerating yolk sac to the mid gut. The umblical veins of which the left vein persists as the umbilical vein. The right disappears.

(3)The umblical arteries arising from the internal iliac arteries. The umblicus is a scar on the anterior abdominal wall situated in the aponeurosis of the linea alba at or below its center. It is a fibrous ring.

Some of the structures disappear. Others persist as fibrous cords extending from the umbilicus. They lie in the extraperitoneal tissue and produce peritoneal folds. The falciform ligament is such a peritoneal fold and enclose in its free margin ligamentum teres, which is the obliterated left umbilical vein. In the fetus this vein opens into the left branch of the portal vein. This oxygenated blood passes through the ductus venoses, bypassing the liver tissue to the inferior vena cava and then to the right atrium.

There are no anomalies associated with the left umbilical vein. Extending from the umbilicus to the apex of the urinary bladder is the urachus this is a derivative of the allantois. After birth it forms a fibrous cord referred to as the median umbilical ligament which raises a fold of peritoneum in the midline. Even if patent urine does not pass through to appear at the umbilicus as its opening closes when the bladder contracts. Passing downwards and laterally to the internal iliac arteries are the obliterated umbilical arteries. The persistence of the vitelline duct or yolk sack can lead to several anomalies;

1. The duct may be patent along the whole extent forming an umbilical fistula that would discharge mucus. Though it communicates with the -small intestine, it rarely discharges faeces.

2. The duct may persist near the umbilicus to form a sinus that discharge mucus. Its epithelial lining is everted to form a pink mass called an adenoma as was seen in this infant. It is also referred to as a raspberry tumour the everted mucosa giving a raspberry like appearance. It is moist because of mucus and tends to bleed. It consists of a columnar epithelium rich in goblet cells.

In the treatment if pedunculated the stalk is tied, it may reappear and then a umbilectomy is recommended. The disadvantage of this operation is that the child would not have an umbilicus and is likely to be made fun of by other children.

3. An intra abdominal part of the vitelline duct may persist as an intra abdominal cyst.

4. the vitelline duct may undergo fibrosis and persist as an intrabdominal band. A loop of intestines may get twisted around it and cause an intestinal obstruction.

5. The proximal part of the vitelline duct, that is , the part adjacent to the small intestines, may persist as a diverticulum of the ileum. This is the Meckel's diverticulum. This anomaly occurs in about 2% of individuals.
It is usually found about 2 feet from the ileocaecal junction and is about 2 inches long. It is seen on the antimesenteric border of the ileum. It has all the layers of the ileum and has its own blood supply. Frequently this diverticulum contains heterotropic gastric, colonic or pancreatic mucosa. If inflamed the condition clinically resembles acute appendicitis at appendicectomy if the appendix appears normal, a search has to be made for a Meckel's diverticulum.

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A fifty year old lawyer was a smoker from his early twenties. At present he smokes about twenty cigarettes a day. For quite some time he has had a cough, worse in the morning (smokers cough ). Recently he had a sore throat and a sever cough. His doctor prescribed antibiotics which he took for two weeks but with little improvement. A course of another antibiotic was given for further two weeks, but there was no improvement.

At the next visit WBC-DC, ESR and a X-ray of the chest was done. The X-ray showed evidence of mild bronchitis and an opacity of about one inch in diameter close to the right hilum. The patient was referred to a cardiothoracic surgeon. Apart from the cough the patient had no other complaint. On examination there were no palpable cervical or axillary lymph nodes. The liver was not palpable and there was no ascites.

At bronchoscopy a tumour protruding into a large bronchus was seen. A biopsy was taken. The pathologists report confirmed the diagnosis of carcinoma of bronchus. There was no clinical or radiological evidence of metastases. at operation a lobectomy was done. Subsequently irradiation and chemotherapy were done at the cancer hospital.

DISCUSSION
Carcinoma of the lung could be primary or secondary. In this patient it was a primary carcinoma of the bronchus. Smoking is considered to be a predisposing factor. The symptoms are due to,

INVESTIGATIONS

The large bronchi are usually the site of carcinoma. A opaque mass is seen in the hilar area. If in the periphery a rounded area (coin lesion) is seen without calcification.
A primary carcinoma has to be differentiated from secondary deposits in the lung. Secondary deposits are usually multiple and the patient would have signs and symptoms related to the primary. The primary is commonly in the kidney, thyroid, breast, testis or intestines. A solitary area in the lungs in an asymptomatic patient is usually a primary. Bronchoscopy is usually done by a cardiothoracic surgeon. The tumour which usually occurs in the lager bronchi could be seen and a biopsy obtained. The smaller bronchi can be reached by a fibro optic bronchoscope.

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