hygiene and sanitation is largely to be solved by the medical profession, and as the most promising solution is in the education of the child, this book is heartily recommended for the careful consideration of medical men and educators.

CONSTIPATION AND INTESTINAL OBSTRUCTION. By Samuel G. Gant, M.D., LL.D., Professor of Diseases of the Rectum and Anus in the New York PostGraduate Medical School and Hospital. Octavo of 559 pages, with 250 original illustrations. W. B. Saunders Company, Philadelphia and London, 1909. Cloth, $6.00 net; half morocco, $7.50 net.

In the whole domain of medicine there is probably no one ailment that calls for correction so frequently and yet whose treatment receives such scant attention as does constipation. How prone we all are to pass the subject by with the mere giving of a prescription calling for some favorite drug or combination of medicines, with little or no inquiry into the patient's habits of life other than what may be given under "occupation" in a routine anamnesis. And yet so well recognized is the fact that continued medicinal treatment for chronic constipation is an absolute failure, that every conscientious physician must surely feel a certain sense of guilt when he asks his patient to rely upon such remedial measures alone, to the neglect of such valuable therapeutic adjuncts as diet, exercise, educational and psychic training, hydrotherapy, electricity, etc.

So that when so eminently practical a work on the subjects of chronic constipation and intestinal obstruction is presented to the profession, and by one whose success in his specialty is the result of large experience and close application, it can but receive the heartiest welcome. And when Dr. Gant tells us that his results in overcoming the most troublesome case of constipation by non-medicinal measures far surpasses any that he has been able to obtain by drugs, we should be grateful for a detailed summary of his methods.

In this work, case histories are omitted that more time and space may be given to etiology, diagnosis and treatment. When more expedient, drugs are made use of temporarily in addition to other measures; hence space is given for a couple of chapters on the favorite medicinal remedies recognized by the best authorities.

Exception might be taken to the rather narrow conception of Glenard's disease held by the author, and to one or two of his therapeutic agents, such as his attempt at overcoming an atonic condition of the bowel musculature by colonic inflation with oxygen.

On the whole, however, the author's reasoning is sane and logical, the work is well written, profusely illustrated and, above all, decidedly practical and timely.

TUBERCULOSIS. A Treatise by American Authors on its Etiology, Pathology, Frequency, Semeiology, Diagnosis, Prognosis, Prevention and Treatment. Edited by Arnold C. Klebs, M.D. With 3 colored plates and 243 illustrations in text. Pp. 939. Cloth, $6.00. D. Appleton & Co., New York and London, 1909.

With a list of collaborators comprising such men as Baldwin, Barlow, Biggs, Brown, Coleman, Freeman, Hektoen, Hutchings, Klebs. Knopf, McArthur, Minor,

Osler, von Pirquet, Ravenel, Sewall, Trudeau and Webb, each and every one an authority on one or more phases of the great subject of tuberculosis, this truly American work is a masterpiece indeed. Each chapter, written as it is by a clinician of the widest experience in his particular branch of the subject, and such text supplemented by a more or less complete bibliography, together with a résumé, in the form of an appendix, of the data offered at the recent International Tuberculosis Congress held last year at Washington, would seem to stamp this publication at the time of its issue, the final word on the subject.

The volume opens with a most interesting historical sketch by Osler, the chapter closing by a short review of American work on tuberculosis, the greatest of those who have passed away being named as Austin Flint. It is probable that there are to-day living in America men who are doing more for the cause of tuberculosis than any named in this chapter; for instance, Trudeau.

Ravenel's chapter on etiology and Hektoen's morbid anatomy are, as might be expected, all that could be desired on their respective subjects. Baldwin's rich experience at Saranac has enabled him to make most interesting his treatment of the subjects of resistance, predisposition, immunity and personal prophylaxis. Klebs, in his short article on the frequency of the disease, emphasizes the paradox that while tuberculosis at some time attacks practically every one of a civilized community, yet the disease in a dangerous form is relatively rare. He deprecates the lack of facilities in this country for a large series of post-mortems.

Symptomatology and diagnosis are treated in a most thorough and satisfactory manner, many illustrative cuts being employed. Relative to the much disputed question of dosage in the subcutaneous tuberculin test for diagnosis, Minor puts the minimum at 1/5 mgm. and the maximum at 10.mgm. The important chapter on public measures in prophylaxis is concisely written by Knopf. Under the heading of specific treatment Brown sums up the present status of tuberculin therapy as follows: "Tuberculin when properly given does no harm, may produce no apparent result, and may markedly benefit an individual patient, who can follow at the same time the hygienic-dietetic treatment while in a health resort, at home and at rest, or at work. Small doses and careful increase are most important, and by following them very closely some patients, even in advanced stages, reap great benefit. The immediate and ultimate results are, improved, fewer relapses occur, and more patients lose the tubercle bacilli in their sputum."

The chapters on home treatment by sanatorium methods by Coleman, and on climatic treatment by Sewall are eminently practical.

McArthur's and Freeman's contributions on surgical tuberculosis, though rather short for so important a subject, are nevertheless excellent.

All told the work is probably the best of its kind in the English language and should prove an exceedingly valuable addition to the working library of every general practitioner.

ALBERT E. BULSON, Jr., B.S., M.D.. Editor and Manager

VOLUME III

NUMBER 3

ORIGINAL ARTICLES

THE SHOULDER-JOINT.*

PAUL F. MARTIN, M.D.

Associate Surgeon, Indiana University School of Medicine; Attending Surgeon, Indianapolis City Hospital, etc.

INDIANAPOLIS, IND.

Although the subject embraces a variety of different injuries that might prove interesting to discuss, the paper is limited to the consideration of only two classes, of which two cases have come under my observation recently, namely: 1. Complete supracromial dislocation of the clavicle. 2. Fracture-dislocation of the upper end of the

humerus.

Until the advent of the systematic employment of the x-rays as an aid to diagnosis, such injuries were believed extremely rare, exceptionally serious, of difficult diagnostication, complicated treatment and unfavorable prognosis. Even from our present viewpoint, they are by no means to be considered of common occurrence, though with the advance in diagnostic and surgical technic, the difficulties may be said to have been largely overcome. Indeed, I feel it my extraordinary good fortune to have them fall to my lot, and believe them to be sufficiently uncommon to justify their publication.

CASE 1.-Complete supra-acromial dislocation of clavicle. Open reduction and suture. James H., aged 35 years, was admitted to the City Hospital July 2, 1908. He had been riding home from work on a 22-inch frame bicycle, and the front wheel striking a pile of dirt he was suddenly hurled head foremost over the handle-bars,

* Read before the Indiana State Medical Association, at Terre Haute, Oct. 8, 1909.

deformity in the left shoulder-joint, which simulated the ordinary angular deformity expected to be seen in a downward dislocation of the humeral head. However, the condition allowed a greater range of active motion and was associated with the ability to place the hand on the opposite shoulder, though an inability to reach the top of the head, and an entire restriction to all movements of the arm posterior to the body. The wing of the scapula was prominent and tilted on its axis outward and downward, displacing the acromion process slightly downward. The outer extremity of the clavicle was found situated 11/2 inches posterior to and above the acromion process. It was ascertained that the humeral head was securely resting in the glenoid cavity, and the absence of crepitus was definitely determined. The forcible contraction of the sterno-cleido-mastoid muscle caused its undue prominence, and the partly unopposed action of the trapezius inclined the head toward the affected side, and pulled the outer end of the clavicle upward and backward. The diagnosis offered some practical difficulties, and was made only provisionally until the x-ray plate demonstrated the exact condition. Physical signs excluded humeral dislocation, but the possibility of an accompanying fracture of the clavicle accounting for the extreme displacement of the acromial end, could not be definitely excluded without the aid of the more exact method of skiagraphy.

The initial line of treatment pursued was according to the generally approved methods in vogue, by the application of adhesive straps about the body, under the flexed arm and over the padded displaced end of the clavicle, and the whole re-enforced by a Velpeau bandage. Apparently, this method succeeded in the reduction, but failed utterly in securing its retention. Pain continuing, interference with functional and passive movements increasing, former displacement and

deformity recurring, in fact, the general unsatisfactory results ensuing upon this course of treatment for a week, determined me to perform the reduction by open arthrotomy and to secure firm retention by suture.

Operation performed July 8 by an anterior curved incision over the outer third of the clavicle, convexity backward, and splitting part of the trapezius muscle. The posterior dislocation with absence of fracture was substantiated, the coracoclavicular as well as the acromio-clavicular ligaments were found torn, their fringed ends enveloped in a mass of old blood-clot, and recent inflammatory exudate, and interposed between the articular surfaces. Only after freeing the jointcavity of blood-clots, tissue fragments, etc., and extending the incision transversely through the trapezius fibers, was it possible to secure complete replacement of the luxated bone. It was necessary to drill holes through the end of the clavicle and the acromion process, approximating them with chromic gut, in order to maintain firm reduction, as the torn ligaments and the edema tous periarticular tissues were too fragile to hold

and chest was encased in a plaster-of-Paris Velpeau bandage, and he complained of constant pain in the shoulder region, radiating down the arm to the hand. The history chart gave the following record:

John J.; nationality Macedonian. Admission March 23, 1908. Diagnosis: Fracture of head of humerus. On the night of March 23 the patient walked into the hospital, evidently in considerable pain. He had jumped from a train at 9 a. m., and had fallen upon his left shoulder. No pain elsewhere. Left shoulder was much swollen and contused, several blebs on posterior aspect of left shoulder. Forearm and hand edematous. On March 24 (following day), under ether anesthesia, as full reduction as possible was accomplished by traction; a firm triangular pad was placed in the axilla, a plaster-of-Paris cap and splint placed over the shoulder and the arm and forearm bandaged securely to the body.

Upon removal of the bandage on May 2, examination revealed the helpless arm swung in a typical attitude of downward dislocation of the

securely the sutures placed through them. Having coapted the frayed ends of the ligaments and sutured the severed muscle fibers, a small cigarette drain was inserted and the wound closed. The immobilizing adhesive straps as previously described, supported by a firm Velpeau bandage, were reapplied. Uneventful recovery followed, the patient leaving the hospital July 26, with good functional use of the joint.

CASE 2.-Old subglenoid dislocation of the humeral head with concomitant fractures of the anatomical neck, through the smaller and greater tuberosities, and of the surgical neck. Difficult resection. I saw the patient for the first time at the City Hospital, May 1, 1908, five and one-half weeks after the receipt of his injury. His shoulder

once

humerus, abducted from the body, and supported at the wrist in front by the well hand.. It was swollen, especially at the elbow, and excruciatingly painful upon the slightest motion. The normal, rounded contour of the affected shoulder was flattened, the acromion process unduly prominent, the muscular deltoid seemed atrophied. Measurement from the acromion to the external condyle showed no difference in comparison with the unaffected side. Any effort to find the location of the humeral head, or any attempt to elicit further evidence, proved futile, as the patient could not endure the pain caused by the necessary manipulation. After repeated efforts to secure a satisfactory skiagram, one was finally obtained, which showed fractures delineated along the anatomical and surgical necks,

at the base of the greater tuberosity, through the smaller tuberosity, and also a subglenoid dislocation of the head of the humerus, which latter fragment had been separated and displaced downward into the surgical neck. It was explained to the patient that the best possible result could be obtained only by resection of the head of the humerus, to which he consented readily, bitterly complaining of the constantly paining and useless arm in its present state.

Operation May 13, 1908. The usual anterior incision and blunt separation of the deltoid fibers were done. Adventitious tissues, cicatrices and extensive adhesions had effected great changes from the normal anatomy of the parts. By carefully isolating the long biceps tendon, and pulling it aside intact, the much-altered joint-capsule was penetrated with comparative little difficulty. The glenoid socket, largely filled with inflammatory products, was devoid of its humeral head, which was imprisoned by dense adhesions and newly organized tissue in a false socket in the axilla, and bound down firmly by the shortened and contracted subscapularis tendon. The greater tuberosity seemed pulled upward toward the

the insertion of a small cigarette drain, the wound was closed. The drain was removed at the end of forty-eight hours, and passive motion inaugurated at the end of a week. At the end of the fifth week the patient grew anxious for work, and requested his release from the hospital, being free from pain and satisfied of a useful arm in his own capacity for earning a livelihood.

Injuries, such as are represented by Case 1, constitute a field apparently wholly neglected by authors of surgical-text-book literature. The subject is superficially treated, totally inadequate for instruction, or is dismissed with misleading statements of the true anatomical lesions produced, and of the logical methods of surgical procedure. By way of illustration, I deem it not amiss to mention certain instances, to-wit: "Retention of the bone in place, after reduction, has presented so many difficulties, that some have thought it not A

Fig. 3.-Case 1.-Skiagram of supra-acromial dislocation of clavicle; (1) clavicle; (2) acromion process.

acromion, possibly by the action of the supraspinati and infraspinati muscles. The capitellum, displaced downward and rotated backward and inward on its own axis, was firmly imbedded by abnormal bony union into the upper end of the shaft. The new joint permitted only a very limited range of motion. By tedious dissection, separation of dense adhesions and severance of the subscapularis from its attachment into the lesser tuberosity, the head was finally liberated and forced out without doing damage to any of the surrounding important structures. Subperiosteal resection of the bone was done at the surgical neck. After irrigation and thorough cleansing of the wound, the capsular ligaments were partially restored by suture, the deltoid loosely coapted, and with the exception of the gape necessary for

Fig. 4. Case 2.-Fracture dislocation of shoulder joint. Indistinct skiagram taken at time of injury, seven weeks before operation, leading to faulty diagnosis and improper treatment, true nature of injury being undetected. B, Fracture at surgical neck; A, fracture dislocation of head, not recognizable.

worth while to attempt it, especially since the persistence of the dislocation ordinarily causes no loss of function." According to another author: "After reduction the old method of treatment was to apply a Desault bandage, which was left on for three weeks, and decided deformity, enduring pain and disability were looked for as inevitable." Following this expression of opinion no further advice is given. Another view treating of the

pathology of this important condition, is accordingly expressed: "The exact pathological anatomy is difficult to ascertain, since only a very few have come to the autopsy table and the extent of the injury varied."

Upon perusal of the current surgical literature, a few notable exceptions to the common textbook presentation of this subject were found. Recognizing the true importance of these injuinjuries, and that without a thorough knowledge of the condition, a rational treatment can impossibly be defined, Krecke, Pourier, Roeffel and Sheldon formulated certain deductions based on the pathological anatomy of the injury, which were derived as a result of separate and individual observation, respectively, on the

living at operation, and not at the autopsy table. According to the extent of the rupture of the clavicular ligaments, the dislocation is classified into incomplete and complete varieties. The first division includes those cases accompanied by a separation of the acromio-clavicular articulation of less than the vertical diameter of the articular surface. In these the superior acromio-clavicular ligament is always torn, and sometimes the inferior acromio-clavicular ligament, and the conoid ligament of the coraco-clavicular articulation, and successful results may be obtained without operative interference. Complete disloca

tion includes all in which the displacement is greater, and accompanied by rupture of both coraco-clavicular as well as acromio-clavicular lig aments. There is inability to reduce the deformity and retain the reduction, .and in these open operative reduction is invariably indicated. According to Sheldon, when the separation approaches one inch, this indicates torn coracoclavicular ligaments, and means operation and suture. suture. My personal experience certainly corroborates these views, for in this particular case it might be said with definite assurance that a successful result was impossible without operative intervention. The interposition of torn ligaments, blood-clots and tissue fragments primarily prevented reduction; the inflammatory exudation ultimately forming pathological organization, and producing adhesions would undoubtedly have resulted in the "decided deformity, enduring pain and disability, so inevitable," as recorded and invariably observed by our forefathers.

Scudder, in his article on this subject, read before the American Medical Association, and published in Jour. A. M. A., July 7, 1907, remarks: "From the evidence afforded, by some fifteen operations on the living recorded in literature, it seems to me that the conclusions of Pourier and Sheldon are amply justified."

Neither the uncommon occurrence of the injury nor the particular surgical technic followed in Case 2 is worthy of any especial note, but the early diagnosis of the condition, the recognition of its severity, and the prompt surgical operative intervention are of prime importance.

Fractures of the upper end of the humerus were formerly believed extremely rare, W. W. Keen1 stating that in the statistics of Gurlt, covering 100 years, he records but 46 examples of fractures of the greater tuberosity. Skiagraphy has disproved this notion, for, according to Keen, the combined observation of six radiographers in Philadelphia has resulted in the compilation of 970 cases of fractures of the upper end of the humerus covering a period of about five years; 39 of these were of the greater tuberosity, 21 uncomplicated and 18 associated with other lesions. According to Dr. Pancoast of the Hospital of the University of Pennsylvania, of the skiagraphs made at the hospital, of fractures of the upper end of the humerus, there were 13 of the greater tuberosity. In six of them also a fracture of the surgical neck, in three also a fracture of the anatomical neck, the other four being uncomplicated. I have been unable to find in the litera

1. Am. Surg., June, 1907.