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present, as, a complication. As to the frequency of clavicular or humeral fractures, they rank a good third; those of the lower extremity being most common, the arm and forearm second. The outer third of the clavicle, the neck of the scapula, the acromian and coracoid apophyses and humeral epiphysis are all essential, parts of the mechanism of the shoulder. They are all highly vascular, and with exception of the humeral head, are so bound down by ligaments or muscles, that movement or separation of their fractured surfaces is slight, in most cases; hence, the degree of tangible deformity accompanying them, is trifling. fracture through the scapular neck, or an epiphyseal separation in the youth, almost invariably provokes a high degree of inflammation, with a free sanguinous extravasate. In the process, from a local pseudarthritis, inflammation is quickly propagated into neighboring parts, inducing general muscular spasm, cessation of function and great tumefaction. In fractures, through the anatomical neck, or separation of the epiphyseal-isthmus, distension of the capsule, from synovial inflammation, with extensive swelling over the free end of the distal fragments, may render its detection. a matter of great difficulty. Through this pathological change, it is often not an easy task, not only to determine, whether a fracture is present, but whether or not the lesion may not be a dislocation. And in a fracture dislocation, it is obvious that the difficulty is greater yet.

When in the presence of such a case, there are many doubtful features. The tissues perchance, bruised, lacerated and extensively disorganized, the questions arise; is it compatible with the best interests of a patient suffering pain, if not bordering on shock, is it good surgery at this juncture, to force our patient immediately after injury, to submit to fresh violence, in an endeavor to make a definite diagnosis? Or, is it not better to wait, until the vital powers have revived, till muscular spasm has passed away and inflammation has subsided?

My own opinion, founded on the treatment of many thousand fractures, incline me most positively to the latter.

In this class of shoulder injuries, the way that the examination of them should be made,

with the greatest ease and certainty, is with the patient resting on his back, the head and shoulders somewhat raised, the entire muscular system relaxed.

Having in due time, recognized the true character of a fracture, over the shoulder girdle, our attention is next directed to treatment. Bearing in mind, the nearness of this region, to the center of circulation, its high vascularity, the nondisplacement of exceptional marked displacement of the fragments, or visible deformity, is at once apparent, that the underlying principle of therapy must be simple, unrestrained rest in bed, without the application, or adjustment of any description of orthopædic apparatus. As compared with a comfortable bed, in this class of injuries, the most perfectly constructed splint or brace sinks into insignificance.

Two cases of very serious shoulder injury, with other complications, which came under my care within the past two years, illustrated this. In one, a woman had fallen through a fire escape, a distance of thirty feet, to the ground, her right shoulder and side, first striking over the broad rail-plate of a fence, before she struck the flagged yard, six feet lower down.

She was seen by me, within an hour after the injury, at which time she was in great shock. On examination, it was found, that she had fracture of the convexity of the shafts of the third, fourth, fifth and sixth ribs, and of the acromial end of the clavicle. There had been a large hemorrhage into the pleural cavity. Exhaustion by loss of blood, and great distress in respiration, were very marked. She was simply bolstered up in bed, no description of dressing applied. Her recovery was remarkably rapid, and never before, have I witnessed such rapid and perfect union, of the costal braces and the clavicle.

A little more than a year ago, a man came under my care, with fracture of the surgical neck of the humerus; and one through the middle third of the clavicle, with upward dislocation of its sternal end, besides fracture of the third, fourth and fifth ribs. He had been injured, by a collision on the street, in which he was crushed, between a loaded brewer's wagon and a pillar of the elevated railroad structure. Shock was so great and respiration so em

barrassed, that beyond semiflexing the arm on the thorax, and supporting the shoulder and head with pillows, nothing was done. In this case, as in the preceding, it was surprising how rapidly and regularly, ossification of the fragments advanced, the only drawback being, the difficulty of retaining the sternal end of the clavicle in place.


Fracture and dislocation at the shoulder, as a coincident lesion, are very rare. When the arthritic structures, permit the heads of the bone to leave their socket, the continuity of the shaft is spared, as a general rule; though cases do, at rare intervals, occur at the humeroscapular junction, in which, simultaneously, or successively, the head of the humerus is driven from its socket, and the shaft fractured external to the capsule. This unfortunate complication, often results, from fruitless or unsuccessful efforts at reduction, of dislocation.


Between the broad, flat surfaces of the tendons and muscular structures, which act on the humerus, in situations exposed to great lesion and pressure, are lodged several pockets, composed of fibrous envelopes, and lined by flat endothelia. Their number varies, although as a rule, from seven to eight are quite constant, at the shoulder. Their outline is somewhat flat and oblong, and they are capable of great expansion.

The largest is the subdeltoid, extending under the coraco-acromial vault, and outward, under the deltoid muscle. When this undergoes sudden distention from inflammation after injury, it may advance forward under the muscle, producing an apparent flattening above, very much like, a sub-glenoid dislocation of the humerus. This distention of the pouch has not been inaptly described, by Morel Lavellée, as a "traumatic hydrocele of the subcutaneous cellular tissues." (Follin, Pathologie-Exterm. p. 756, vol. 7.) Trenillon and Boisompiere (Arch de Med., 1877), have also described a most distressing affection, following shoulder injury, in the broad sub-scapular bursa, which sometimes extends far down, between the muscle and the costal walls. It produces a fullness forward, into the axillary space, which imparts, on motion of the shoulder, a crackling sensation to the finger. In the minor

varieties of the sub-acute type, bursitis induces severe neuralgic pains, which extend with greatest severity, over the muscular expansion of the particular muscle, or group of muscles involved. involved. Protracted bursitis always induces marked muscular wasting. According to Malgaigne, forcible rupture of a bursa, is one of the most prolific sources of peri-arthritis. (Magaigne-Path. Des. Artic., Vol. II, p. 312.) Bearing in mind, the anatomical situation of these hygromatous enlargements, often their relations to the joints, and the tendency of an inflamed bursal envelope, to provoke an exudate into the adjacent muscle or tendon sheaths, thereby inducing a rigid adhesion, it is easy to understand, how joint action may be distrained, or a pseudo-anchylosis induced.

A bursitis, in a healthy individual, of itself, is of little consequence, as it tends to early spontaneous resolution; its effects, however, are baneful about fleshy joints, like the shoulders and hip, chiefly because, of the adhesions which they may give rise to; and which, if not early liberated, may lead to organic changes, wasting or contraction of the nauscles, with ultimate impairment of joint action; something not altogether unlike the multiple tendo-vaginitis, quite frequently seen after violent sprains of the wrist or ankle.


One year ago, I was able to publish four cases of acromio-clavicular dislocation (International Medical Magazine, May, 1896). They constituted an interesting group, for various reasons. I had seen them all within six months. Two had been overlooked. All were produced by direct force. None of them could be retained after reduction, and in all, fair, practical results have followed. Dr. J. O'Connor lately reports a case of this description, which he treated by operation. He exposed the dislocated end of the clavicle, and cut away half an inch, then gouged an opening in the upper surface of the acromion, and forced the nude end of the clavicle into it. Union, he tells us, was complete, but he lost sight of the patient, a sailor, after thirty days, and hence cannot say, how permanent the results have been. (New York Medical Journal, April 25, 1896. Report of case of displacement Backward of Scapula From the Clavicle.)

Although no untoward results appear to have followed this operation, there is nothing to warrant, the repetition of such a procedure.

A pseudo-arthritis at this joint, is much preferable to no joint, or an anchylosis. A condensation of the plastic element, around the end of the displaced bone, provides ample fibrous material, to hold the articular end in place, and allow, at the same time, an ample degree of motion In all severe shoulder injuries, a most thorough examination should be made, for this description of luxation. It is much more difficult, to detect there, a humero-scapula dislocation; besides, it is seldom looked for.

Complete displacement of the humeral head is not difficult, as a rule, for an experienced surgeon to detect, when it occurs in an adult. But, several cases have come under my care, which experienced practitioners were unable to decide on.

Their reduction is generally easy, by most any method. Kocher's method is the most scientific and simple, in some types. But a tremendous leverage may be employed by it, and there is great danger, of fracturing the shaft of the humerus, if the head be at all locked. In stubborn cases, it may be well to comfortably support the shoulder, and allow the patient a few hours' rest. Then, if moderate manipulation will not succeed, a considerable degree of properly directed force must be employed. Pulmonary anæsthetics have never, seemed of any value in my hands, as an aid in effecting reduction, at the shoulder.

When more force is employed, than a patient can endure, there is danger of damage to the nerves or vessels. Quite a few cases have come under my notice in which manipulation was futile, but, after a few hours' rest of the bruised and lacerated muscles, reduction was easily effected. The axilla had been violently crushed, under the heel, and the unfortunate patient dragged about, in vain, repeated efforts at reduction. Arthrotomy for irreducible humerus, I have never performed, nor, have I ever seen an arm that survived it, any better, from a functional standpoint, if as good, as those which were left unreduced.

The surgeon is scarcely warranted in expecting much from this operation, if he is justified in performing it at all, unless, for the relief of pain, when probably the resection of

the head of the humerus, will promise better results. It will certainly entail much less mutilation.

The clavicle is as much an integral part of the shoulder, as a rib is of the thorax. When fractures of this bone go badly, the shoulder suffers somewhat in mobility and strength. They are generally easily detected, where they are anterior, to the insertion of the deltoid; but posterior to this point, as there is little or no displacement, their presence may be overlooked without a searching examination, in the recumbent posture. This attitude retaxes the thoracic and cervical muscles, pushes the shoulder forward, and removes all strain, on the sectional end. More than once I have been enabled to detect fractures, of the acromial end, impossible of discovery, in the standing or sitting attitude. Many of this type of clavicular fractures, are undoubtedly overlooked, as are the acromio-clavicular luxation above; fortunately, with no serious disadvantage to the patient. Its importance of recognition, only becomes manifest, in medico-legal cases. Complete clavicular fracture occurs most commonly, at the junction of the two curves of the shaft. It is usually attended, with overriding of the fragments, which in a limited degree so unites, as to leave a noticeable deformity. No description of apparatus, will entirely obviate the tendency of the shoulder, to advance inward, when the patient occupies, an erect attitude of the body. Hyperostosis provides, for the defective strength in the limb, resulting from this malposition, and, fairly, full functional strength in the shoulder is restored, after osseous consolidation.

One instance has come under my notice, after clavicular fracture, followed by so much. displacement downward, of the proximal fragment, and excess of callus, that the brachial plexus was so compressed against the first rib, as to produce complete, remote paralysis of the upper extremity. The patient was a powerfully built coal heaver, who was injured while intoxicated. The morning following the injury, he tore off all the dressing, and returned to work. In spite of this, the fracture united with marked overriding of the fragments, and a massive callus.

Six weeks after injury, he came under my care, when the clavicle was again re-fractured, the excess of ossific material was hewn away,

and the fragments were brought into position. No wiring was employed, but he was confined to bed, in the dorsal decubitus. Union of the integument and bone were prompt, without any shortening. The palsy promptly disappeared, after pressure was removed. Rare fractures of the scapula, as these of the coracoid and acromion processes, the neck of the scapula, the spine or the omoplate, are chiefly of interest, from the side of diagnosis. It sometimes requires skill and experience, to detect them. No special apparatus is required for their treatment. Rest in bed, muscular relaxation, topical applications with time, in nearly all, accomplish all the necessary therapeutic ends.

Fractures in the humeral shaft, through the surgical neck, are not common. But few of them, have come under my own notice. They generally result from direct violence, and may be productive, of troublesome shoulder or arm complications, because, at the time of fracture, the circumflex or musculo-spiral nerves, which lie in close contact with the bone, may be lacerated, or torn in two, by the sharp fragments, and besides, owing to the difficulty in permanent co-operation, hyperostosis, in callus formation may gather in these nerve trunks, or unduly compress them.

In all severe fractures, consecutive inflammation is propagated to the nearest arthritic structures, with a consequent limited anchylosis or muscular atrophy, in all the neighboring muscle groups.


This subject has already been touched on, but its importance justifies a repetition, inasmuch as, it points to the necessity of sometimes addressing remedies, to the general system simultaneously with local treatment. Rheumatism, of all constitutional maladies, aggravates joint injuries. This points to the necessity, of instituting an inquiry into our patient's former health, and his general condition, at time of injury. At the time of writing a man. is under my care, for treatment of a spinal traumatism. He undoubtedly had a hemorrhage into the medullary substance of the cord, with resulting syringomyelia, for along with most pronounced muscular atrophy, he

has pronounced arthritic changes, in the articulations of the upper limbs. Although muscular power has partly returned, both shoulder joints permit of only limited motion.


By W. B. O.

Dr. Galen Puchu came from a family of doctors; his own father was a doctor, as was Galen's grandfather, besides Galen's mother was the daughter of a prominent doctor of a neighboring state. He was an only child in this family of Puchu's; born in the oldest town, not only in Southeast Missouri, but Missouri itself. Galen's earliest thoughts were connected with medicine; his growth was by the aid and through the judicious administration of preventive medicine, for from his very youthful days, he had been almost a daily partaken of assafoetida and a strong decoction of chincona bark. The philosophy of giving these two medicines as explained by Galen's father was as follows:

"From previous experience I found that the administration of assafoetida upon going to bed, relieved nerve tension and kept many people in these malarial regions from having malarial troubles, besides a strong decoction of cinchona bark, given every day, was an excellent tonic and prevented, not only malarial troubles, but other troubles as well."

According to this theory, Galen then took his assafoetida at night in order to keep off the chills, and the bark decoction he took three times a day to make him strong and prevent other sickness. When Galen was old enough his father utilized him to pound and powder divers roots and herbs and help him compound various medicines, which thus enabled his father to make them economically. Hence, as Galen grew up he was as familiar with mortar, pestle, graduates and pill tiles, as he was with his bread and butter. He knew the appearance of roots, gums and herbs without number, and could call their true and efficient dose with as perfect a memory as could a physician or an apothecary. He began the study of medicine long before he did that of geography, and he learned most of his

geography by reading the habitat, the action, and the doses of the drugs in the United States Dispensatory in which was detailed from what country came this or that drug; hence, he knew of Arabia, China, India, Japan, the countries of South America, etc. He knew the apothecary's table of weights and measures before he knew his multiplication table.


Gradually Galen grew up to manhood. He was chiefly remarkable at school for always having well-learned lessons; he never cared for recreation or play. He seemed to hold all the sports of youth as being utterly useless. He was also noted for the additional fac he would only talk about sickness and drugs; nothing else seemed to have any interest for him. Galen had no associates among his schoolmates, never sought for the society of girls, and his fellow-students never met him. except at school; all of his time was seemingly spent at his father's surgery. When he arrived at the age of twenty-one he was sent to a medical college at St. Louis, and he would proudly state, that "I want you to understand, sir, that I went to the old St. Louis Medical College." After two years' attendance at this school he graduated, along with others, not only with words of commendation, but with a certain degree of distinction. Upon the day of his graduation he had been presented by his father with an undoubted black silk stove-pipe hat, of which he seemed to be almost as proud as he was of his degree of Doctor of Medicine. When he came back to his home, after graduation, he was more medicated than ever. He became so thoroughly impregnated with medicine that his conversation literally reeked with it. To him everything had symptoms, diagnosis and prognosis. He used techincal terms to express his wants, aims and hopes. Watson, Wilson, Draper, Fownes and other authorities were constantly in his mouth. He had a diagnosis for every thought, a prognosis for every sentiment, and a remedy for every condition. At this period of his life, he was twenty-three years of age, slim, and about six feet, two inches tall, with an oblong, not unshapely head. His forehead, while receding, still a massive, yet agreeable was of mold; his brow looked as though he was phrenologically a master of form, number, memory and location. His ears were somewhat large and pointed at the helix or upper

rim, and seemed as though they were pasted close to the side of his head. His nose was of the Roman type, presenting a strong and unflexed disposition. It was the nose of either talent or mania. His eyes were small, deep and sunken, but brilliantly black, intense and penetrating. These eyes never had a mild look, they seemed either to not look at all, or else they were unduly and forcibly penetrating. His cheek bones were high and prominent, and he had a rather firm looking combative lower jaw; a medium sized, rather agreeable looking, yet sad mouth. His father, when commenting upon Galen to Professor L., had said: "Yes, he is morally very good, good enough for anybody, and seemingly smart enough for all practical purposes, but he has never been either a man or a boy; as a boy he seemed not to possess any of the characteristics of a boy, as he never played, but always stayed in and studied; as a man he has given evidence of almost childish characteristics. His likes and dislikes are entirely different from those of the average human being. He is cranky in sentiment, iconoclastic in thought, and a monomaniac in his study. He never was wrong in his life, he is always right, and apparently never thinks of anything but himself, unless reminded; then he is all right, but you have to remind him every moment of the day. He plainly does not lack brain and conversationally always indicates his knowledge of medicine. He will make one of the mose brilliant suggestions, almost astounding in its character, regarding medicine, to be shortly afterward followed by the most purile and nonsensical assertion competent to be uttered by a thinking mind. If you notice," he would say: "Galen's face and head are a little one-sided, that is, right-sided; this was caused by the great trouble which we had when we brought him into this world with instruments."

If Lombroso had examined Galen, he doubtless would have said, that this one-sided condition of Galen's head was plainly and undoubtedly the asymmetry of degeneration. Galen always went clean-shaven, his clothes invariably dark in color and well kept. From the day of his graduation he never failed, when an opportunity offered, to wear his black stove-pipe hat. The general shape of this much appreciated hat very


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