two at the clavicular-acromial joint, the two latter, having been treated as "sprains."

Modern surgery has opened the way, to the successful reduction of those cases, otherwise rebellious to manipulation, by free dissection. But, infection almost invariably follows arthrotomies, and, in any event, so many tendinous structures must be divided, and adhesions of the vessels and nerve cords are so common, that after the large wound has cicatrized, the functional result may be no better, if they are as good, as a pseudarthrosis.

Fractures through the omoplate or shoulder blade, whether they involve the spine of the scapula or not, result from direct violence, and usually do well, when there are no internal complications, as anything more, than a slight displacement is not possible.

In the lower extremity, in those railroad accidents, which cause a crunching off of the limb, the conformation of the external surface of the hip, often causes a sliding away of the joint, so that a disorganization, through the shaft above the trochanters is never seen, except, when the pelvis itself has been implicated. Through a somewhat similar arrangement of the shoulder, the claviculo-scapular slope, force is deflected away from the body, and the point of mutilation, is below the insertion of the latissimus-dorsi muscle. Thus, the humero-scapular articulation is spared destruction, though generally, the object which crushes through the limb, destroys so much of the integument above, that, in order to provide a covering for the stump, the remaining root of the humerus must be sacrificed.

MORBID ANATOMY.

Having, in a very brief and superficial manner, considered some of the grosser anatomical structures of the shoulder, their relations and functions, it now remains, to deal with some of the lesions of tissues, resulting in this situation, from the application of violent force.

A correct understanding of this division of the subject, at once elucidates diagnostic difficulties, and suggests a rational treatment. But, to deal with it, in detail, or on any systematic plan, would be to enter on a large undertaking, far beyond the scope of this contribution; therefore, nothing more, than a rudimentary and fragmentary presentation of the subject, embracing in a measure, only the principal features of shoulder lesions, which strike. strike

me, as of the greatest practical interest, will be considered, without dwelling on details with that fullness and minutiæ, which properly belong, to special works on the subject.

SPRAINS, ENTASIS, ETC.

In the most common varieties of severe shoulder injuries, the articular structures, the main blood trunks and large nerve cords, passing through the armpit, escape serious damage. The structures which suffer most serious harm are the peripheral nerves; these are overstretched or contused. The circumflex or musculo-spiral nerves, in super-rotation, or violent extension of the arm, are unduly strained, resulting in hyperæsthesia, and diminution in power in the muscles, supplied by them. In violent blows over the deltoid, the shoulder movement for a time, may be as effectively crippled, as by a fracture or dislocation. It is so well known, that, if caution be not exercised in examinations, a possible dislocation may be overlooked, it being hastily assumed, that only a sprain exists. In aggravated cases of this description, traumatic inflammation follows, in all the soft parts overlapping the head of the humerus. The shoulder becomes fixed, swollen and painful. At the tip of the acromion, the firm attachment of the deep fascia, securely holds the skin in close contact with the bone, but, beyond this point, as this becomes more loosely applied over the deltoid, cellular inflammation produces so much swelling, as to obscure or obliterate many well-recognized anatomical landmarks. Under these circumstances, without a test examination, a conclusion may be hastily made, that a complete luxation or a fracture exists. Many of these shoulder injuries of this class, may pursue a very tedious course, when the contusive force has been so great, as to lacerate muscular tissue, and induce consecutive myotrophic changes, atrophy, contraction or adhesions between the overlying and intervening fascia and muscle sheaths; a low grade of bursitis synovitis, with or without effusion, arthritis or peri-arthritis. The tendency of those parts, after trauma to pathological changes, is greatly accentuated by various constitutional conditions and hygienic surroundings. With those of a syphilitic taint, a tubercular diathesis, or a tendency to rheumatism, a severe wrench of the shoulder, may give rise to such organic changes, as require a long time in recovering

from, if not lead to a permanent impairment, in the strength or function of the articulation.

In those of a nemotic habit, with hysterical tendencies, in the female sex, psychical impressions profoundly influence the course of cure, in the traumatic artherosis. In malarious districts paludal influence should not be overlooked, as a complicating factor, as local repair is quite impossible, while this lethal element operates in the system.

DISLOCATIONS.

Treves claims, that in cases of full dislodgment, or dislocation, the capsule is always torn, the head of the humerus passing out through it, producing the so-called "buttonhole" rupture. No opportunity has yet permitted me to verify this, on the subject. In only one case of humero-scapula dislocation, coming under my care, did death soon follow injury. In this, the young man had simultaneously suffered an extensive rent in the liver, followed by mortal internal hemorrhage. But, in spite of appeal to the coroner and relatives, an autopsy was denied.

The tension of the muscles with atmospheric pressure, so firmly retains the humeral head in position, that it is probable it is only when these are off guard, and the parts are relaxed, luxation is possible. My own impression is, that in the greater number, the capsule is not torn but stretched, while in aggravated cases, not only the synovial investment is lacerated in its long axis, but even torn through, or disconnected, with its attachment around the epiphyseal line or anatomical neck. It is highly probable, too, that the insertion of the scapular muscles may give, or the long head of the biceps be torn off, from its root, in the fibro-cartilaginous margin of the glenoid cavity. Therefore, generally speaking, it may be stated, that in one variety, by far the most common in young, growing subjects, the head of the bone leaves its socket, through relaxation or extreme tension, on the capsule and muscles. In this type, reduction is usually simple, and restoration of function, prompt and complete.

In the second, the extent of disorganization has been considerable. Not only has there been extensive rupture of the capsular ligament, tendon and muscle, but the whole nerve structure of the joint has sustained violent shock. This class is often unsatisfactory to treat, and may force the attending surgeon into

a defensive litigation. Conditions resulting from the innate character of the primary lesion, may be charged against him, on the score of incompetence or neglect. Relocation or reduction in this class, may be attended with great difficulties, and while attempting it, further damage may be inflicted on contiguous structures, as great or greater, than those borne by the primary trauma. And, what is equally unfortunate, in quite a few, the tendency of the head of the bone, to fall out of the glenoid cavity, after reduction, is very great; not, for a few days only, but sometimes this predisposition to relapse, may remain for weeks. When, however, this does not occur, yet such pathologic changes may occur, as tend to diminish. shoulder power, or reduce power of action.

Dislocations at the acromio-clavicular joint, at the movable part of the shoulder, though not so common as those just considered, are nevertheless more common than is generally supposed. This joint, lying immediately under the integument, when the head of the clavicle is dislodged, it can be generally easily detected on inspection; or, by manipulation. But, if this lesion is simple of recognition, it is not so, with treatment, for, in all cases of complete luxation, the capsule and synovial membrane are disorganized beyond repair; the coracoid and coroco acromion ligaments are sundered, and permanent reduction, with restitution of integrity, seldom occurs. It is through this joint, it will be remembered, that uniform relations are preserved, with the movement of the scapulahumeral joint, forward and backward, over the latteral arc of the thorax. And, through it, to the "leg" of the shoulder-the clavicle, transmits in a certain degree, the impact of force, from the shoulder to the sternum.

This dislocation is often overlooked. We will find, on close inspection, not a few of those "lame shoulders" following sprains, are really dislocations of this type. The arm preserves its strength, but through laxity at the joint and a swaying motion, the patient is conscious of a sense of insecurity, at this point of the shoulder.

FRACTURES OR FRACTURE-DISLOCATIONS AT THE SHOULDER JOINT.

The bones which constitute the framework of the shoulder are often fractured, after the application of direct or indirect force; more often the latter. Sometimes dislocation is

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. A 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 orthopadic 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-DISLOCATION.

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.

TRAUMATIC BURSITIS.

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. 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 exutendon date into the adjacent muscle or 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 niuscles, 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.

CASES ILLUSTRATING VARIOUS PHASES OF SHOULDER INJURY.

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 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. 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 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,