Rare Lesions of the Shoulder

Chapter XV

The use of the adjective "rare," in the title of this chapter, merely signifies that the author believes that the lesions to be considered are relatively uncommon when compared to those which have already been discussed. Yet some of the basic principles of science are implied when this word is used. In common parlance, an insect, a bird or a disease may either have an identity or be unidentified and yet be called rare, but in science it must be described, named, classified, and the members of its class shown to be in a numerical minority in relation to those of similar classes, before being thus designated. A flower, common in Borneo, may be rare in London, but from a scientific point of view it cannot be so classified. Thus the word should not be used as relative to the extent of knowledge of the observer or in relation to a locality, but to scientific knowledge the world over. It implies that science recognizes the identity of the unit, its class and the relative numerical occurrence of the individuals of that class, compared to that of individuals of similar classes. An unidentified bird is not considered rare until its species has been described with sufficient accuracy to show that it is essentially different from other known species. There is a large group of obscure shoulder lesions, which probably contains many, as yet, undescribed entities. I have attempted by description and naming to subtract from this group, what I believe to be certain new but common species, but there are, I am sure, several still left to be described by other explorers. My descriptions and names will persist only until some other investigator takes the trouble to write a .better book. I hope there may never be a new specialist (the omologist ? ), but that in the near future, there may be some surgeon in each hospital who is interested in shoulders and could write a better book, if he could spare the time. As yet there has not been even an attempt to classify shoulder lesions, although in the index of this book a tentative nomenclature will be offered.

One might contend that the degree of advance in any branch of science may be estimated by the accuracy with which it is possible to apply the word "rare," to any of the individual units with which the science deals. By this criterion there is a woeful lack of scientific knowledge concerning the lesions which affect the human shoulder, not so much as to the available descriptions of the individual units, as in their nomenclature and classification, and in the recorded facts about their numerical incidence of occurrence. We need the names of all the clinical entities, a list of these names and a knowledge of their relative frequency, in order to teach future medical students how to recognize and to treat at least the more common ones. Moreover, there is evidently a considerable ratio of unidentified cases, which are not yet accurately described and named, and which can only be classified under a general term as "sprains" or "strains." The difficulties presented in any attempt to classify the diseases of a given part of the body are, however, far greater than those with which the ornithologist has to deal, but in spite of these we should at least make an effort to succeed although we may be pardoned for lack of success, or of clarity, in our attempt. The difficulties are many. For instance, species seldom mix, but several lesions of the shoulder are often combined in the same individual; lesions may arise from many different causes as congenital, inflammatory, traumatic, etc.; symptoms are often given names as if they were clinical entities, e.g., arthritis might be due to tuberculosis or to syphilis; we deal with a variety of anatomic structures, several of which may be damaged by a single accident; some local conditions are due to generalized disease and others are secondary effects of lesions at distant anatomic locations.

I do not know where to find a nomenclature for lesions of the shoulder. If a thousand patients with such lesions consulted in turn two different hospitals, the diagnoses, under which they would be classified, would be hopelessly at variance. Unanimity could be obtained on only a minority of the cases when classified under very general headings such as those used by the Massachusetts Industrial Accident Board in the table on p. 160, and even then would be subject to the fallibilities discussed in the adjoining text.

At present my own records of most of the shoulder cases, which I have studied over and over again as a basis for this book, are filed for my convenience as follows:

 

No other surgeon or hospital would classify these cases as I have done. Were I to attempt to rearrange them today, I should very likely shift them about to some extent as I have done many times in the past. If I considered "bursitis" an entity, it would cover half these cases. The scheme on p. 124 represents cases picked from this same file to illustrate the four most common groups and even these would be to some extent interchangeable. Many of them were seen in consultation and had already puzzled other doctors, so that they are in a way picked cases. The list, therefore, does not represent the routine shoulder lesions which would be seen by the average practitioner or general clinic. Prom my (perhaps prejudiced) point of view, it seems that lesions of the supraspinatus are far the most common, not always isolated, but occurring as important complications of the common sprains, dislocations, fractures and paralyses of this part of the body. The "rare" cases, with which this chapter deals, were only forty-two in number, but there must be more among the 118 which were not diagnosed.

So little interest has been taken in sore shoulders that as far as I know, no one has even attempted to list the lesions of this joint, much less to place them in their order of frequency. It is possible, however, to find such a list in a roundabout way. Since X-ray films are demanded for nearly all cases of pain in the shoulder, it would seem that a fair idea of the relative frequency of the conventional diagnoses might be obtained by the study of a consecutive series of shoulder cases in the Rontgenologic Department of some large hospital of high standing. Fortunately such a list exists in an article by King and Holmes. Their study was made to determine the reasons why the X-ray is of so little help in shoulder conditions, but the table they compiled of the cases reviewed gives some idea of the relative frequency of the different diagnoses. This table probably illustrates very well the customary diagnoses used for shoulder lesions in the United States in 1927. It is significant chiefly in showing that in two-thirds of the shoulder cases referred to a large Rontgenologic clinic (The Massachusetts General Hospital), during a year and a half, not much help in diagnosis was obtained by the use of the X-ray. Definite diagnoses were made in only 150, or one-third of all the cases. Let us consider in a general way, some of the items on this list, which we may use as a guiding thread to follow through the mazes of this somewhat irregularly arranged chapter, although we must also introduce some other descriptive names. Little space can be given to each heading, but an effort will be made to refer the reader to a few out-standing articles on the different subjects.

Under the first main heading of Arthritis there were twenty cases, but only six of these were cases to which we ordinarily apply this term. This tends to confirm what I have said in Chapter IV to the effect that a true monarticular arthritis of the shoulder is rare, and that even when the disease is generalized, the shoulder tends to escape, or if affected, to return to normal function. These authors, in alluding to the six cases, say, "They were all cases of at least fifteen years' duration, and the shoulder involvement was part of a generalized ankylosing process involving most of the major joints. We believe that the Rontgen ray has missed, and will continue to miss, most of the cases of shoulder arthritis." In my opinion, the reason that they found so few cases is that arthritis in this joint is rare.

Tuberculous arthritis. This is surely a rare diseasein the shoulder, and yet there were five cases in a large hospital in a year and a half.There are only five cases in my own series, but they compromise the largest single group among my forty-two rare lesions. This condition gives a very definite Rontgen picture, so that every case would be picked up by the X-ray. In no other disease of the shoulder is the sulcus deepened and widened at the expense of the articular head. That it is rare may be judged by the following statistics: Townsend reported twenty-one cases out of 3,24-4 patients with bone and j oint tuberculosis. Whitman had thirty-eight cases out of 1,833 tuberculous joints, exclusive of spines. Young, of Philadelphia, seven cases out of 5,680 tuberculous joints at the University of Pittsburgh. Of 1,900 cases of joint disease at Billroth's Clinics, the shoulder was involved in fourteen, or less than one per cent. At the Children's Hospital, Boston, Sever reports seventeen cases out of 7,474 patients with joint disease.

There is a wide age incidence of the twenty-one cases reported by Townsend, but most of the cases occurred in youth. The youngest patient was three and one-half years, while the oldest was thirty-five ; ten were less than ten; seven were between ten and twenty, while four were more than twenty. In five cases the disease was secondary. The average duration of symptoms was one and three-fourths years. The longest duration was ten years; the shortest, three months. One patient, age sixty, has been reported.

Pathology.

Usually two types of the disease as it affects the shoulder are described. My own experience indicates that such a distinction is artificial and is made by the clinical course rather than by the X-ray or the pathology.

(1) Caries sicca is a chronic, slowly acting form which may destroy the head of the humerus and the shoulder joint without acute inflammation. There is very little tenderness and the symptoms are not marked. With the gradual destruction of bone and constriction of the capsule, the joint is diminished in size. There is loss of motion, atrophy is extreme and ankylosis eventually results. Destruction of the head of the bone proceeds from the anatomic neck, which it deepens and widens, so that the articular area becomes smaller and smaller.

(2) Caries carnosa is a more acute fulminating type. It may complicate the first type with abscess formation. There may be communication between the joint cavity and medulla of the bone, and the latter may be filled with granulation tissue studded with tubercles. In advanced cases the axilla may be indurated and perforated by sinuses.

The common findings are dull, aching pain, sensitiveness, spasm with restriction of motion, atrophy, change in contour, loss of function, glandular enlargement, shortening of arm, abscesses, ankylosis. Pain is usually the first symptom noted. This is frequently misdiagnosed as chronic rheumatism. It may be mild or severe in character. It is sometimes referred to the deltoid tubercle or to the elbow. The discomfort is usually increased by attempted motion, especially rotation, and motions going beyond the limit of mobility of the scapula are very painful. There is frequently associated tenderness over the anterior portion of the joint. The pain is a serious symptom and is usually worse at night. The patient is unable to lie on the affected side, but this symptom is common in most diseases of the shoulder.

Reflex spasm is the most important sign. The fixation of the scapulo-humeral joint is almost absolute. Clinically, the early stages of the dry type (caries sicca) are much like the cases described under tendinitis, but the fixation is more pronounced and the deltoid is more apt to be atrophied and therefore the whole shoulder seems small. The X-ray usually shows the characteristic deepened sulcus by the time the patient seeks medical advice. The onset must be insidious usually, for I have never seen a case so early that a diagnosis could not be made by an X-ray.

If abscess forms, local heat, infiltration and swelling will be present. The humerus is apt to be shorter than on the normal side, for the disease usually begins in adolescence. There may be some glandular enlargement in the axilla. If abscess forms, it may point near the coracoid or make its way down the shaft of the bone and appear on the surface anywhere in its upper third or half. The subacromial bursa may fill with pus. Sometimes perforation occurs posteriorly beneath the acromion. Abscess about the shoulder is more apt to be due to this than to any other cause. Mondan and Audry reported abscesses in twenty-seven out of thirty-three patients. Townsend reports abscesses in all his cases. Sinuses remain and drain for long periods. Loss of function is due to muscular spasm in early cases and to ankylosis later. Ankylosis, partial or complete, is the usual termination, and thus the range of motion which may be attained depends entirely on that of the scapula.

Prognosis

has to be considered constitutionally and locally, for there is frequently an associated pulmonary involvement. The patient may die of miliary tuberculosis or pulmonary complications. In children the outcome is usually more favorable than in adults. In adults, as far as the joint is concerned, there is little hope of recovery without ankylosis unless operation is done. The duration of the active stage is from two to five years.

Treatment.

This is general and local. The former is of great importance, as in all forms of tuberculous disease. It is usual to immobilize the joint by the use of a plaster cast. The arm should be abducted and brought forward slightly and somewhat externally rotated. Since the joint tends to become ankylosed in internal rotation and adduction, and as the scapula is very evasive in a plaster cast, over-correction of the desired position should be aimed at. When abscesses form they may have to be drained. Necrotic bone may require removal, but even such a minor operation is accompanied with the danger of causing miliary tuberculosis. If a localized area is found by X-ray, it may be removed, but, in my opinion, if any operation is done in adult cases, radical excision of the articular head with preservation of the short rotators is indicated. When excision is done and the tissues are well carbolized the disease tends to heal, even if it is not all removed. Other surgeons advocate ankylosis. We greatly need a large collection of postoperative statistics to determine the relative values of these two operations. At present ankylosis is more popular than excision. In children, interference with the humeral epiphysis may mean cessation of growth of the arm, and conservative treatment should be given a long and fair trial. In the acute stage traction sometimes has to be applied to relieve pain.

Syphilis

in the shoulder joint must be very rare. The following remarks are made entirely from, a perusal of the literature, for I have never recognized a case of this condition in the shoulder. The statements apply to the joints in general rather than to the shoulder in particular. That the j oints are affected in this disease was recognized by Peter Martyr as early as 1498, but it was first accurately described by Ricket in 1853. The manifestations have been classified into arthralgia, acute synovitis, chronic synovitis, and gummatous affections. There may also be periostitis, osteitis, osteomyelitis and bursitis. The most outstanding symptom is pain, which is usually nocturnal. It may be dull, aching or sharp. It is often relieved by exercise.

Arthralgia

often occurs in the primary stage. The onset may occur as early as six days after appearance of the primary sore, but usually comes much later than this. There is no demonstrable pathology. Acute synovitis occurs within the first or second year. The joint is swollen and hot, but limited motion may be painless. The condition lasts one to two weeks or may become chronic. In chronic synovitis there is marked swelling with effusion and fluctuation, but there is little pain. Ankylosis may result. Late in the disease gummatous affections are found. In periostitis there is thickening of the periosteum as shown by X-ray. There may be a localized tender area. In syphilitic osteitis there is rarefaction of the bone. In osteomyelitis the symptoms depend upon the severity of the involvement. The X-ray appearances are fairly characteristic. The last two conditions are usually seen between the second and third years of the disease. Bursitis may be primary or secondary. This condition has been discussed by Churchman. He does not mention the subacromial bursa. I have never recognized a case of syphilitic bursitis in the shoulder, but I have seen on the superior surface of the acromion two cases of syphilitic ulcer, which presumably involved the subcutaneous bursa. It is very unusual to find any manifestation of this disease in the shoulder joint or in the structures near it. In a series of sixty-three cases of syphilitic arthritis reported by Baetz, and in eighty-three cases reported by Whitney and Baldwin, the shoulder is not mentioned. My assistant could find only four cases of osteitis mentioned in the literature. One was reported by Brickner in a man of thirty-two, who had pain and disability of his left shoulder. The X-ray showed fine lines indicating periostitis about the surgical neck and also beginning rarefaction, indicating necrosis of the greater tubercle. Another was reported by Wile and Senear, who state that the shoulders were definitely swollen. Meriel saw a juxta-epiphyseal fracture of the upper end of the humerus with gumma formation. Fred H. Albee reported a case of gumma of the shoulder which showed an area of increased radiability with disintegration at its center and bone sclerosis below this area. There was a periostitis about the surgical neck. A good illustration is given in the article.

Diagnosis

is made on the basis of history, Wassermann, other signs of syphilis, and by X-ray. Luetic lesions occur in the epiphyseal end of the diaphysis and this distinguishes them from tuberculosis which arises in the epiphysis. Swelling of the soft parts is more common in tuberculosis, while in lues there is thickening of the bone. In tuberculosis there is a tendency to sinus formation. The outlines of the bone entering into the articulation are distinct in lues in contrast to the deep sulcus in tuberculosis.

Treatment

is antiluetic and prognosis is good with proper treatment.

In my opinion, the chief danger of error in diagnosis in such cases is in crediting a pain in the shoulder to the disease, when in reality the fact may be that a syphilitic patient has a sore shoulder from some other cause. The lesions connected with the supraspi-natus tendon described in this book are so common that patients with all sorts of general diseases may suffer from them. Since lues and its treatment tend to weaken the collagenous parts of the body, we might expect weak tendons in such patients.

Closely allied to syphilitic lesions of the joints are the neuropathic conditions, and while the majority of these are secondarily due to lues in cases of tabes dorsalis, there are other spinal lesions which produce similar arthritic changes. Although no neuropathic lesions are mentioned in King and Holmes' list, we may give them brief consideration. There were only two in my series, one due to tabes and the other to syringomyelia.

Charcot's Joint

In his original article in 1868, Charcot writes: "The disorder generally shows itself at a determinate epoch of the ataxia, its appearance coincides in many cases with the setting in of the motor incoordination without any appreciable cause. We may see, between one day and the next, the development of a general and often enormous tumefaction of the member, most commonly without any pain whatever or any febrile reaction; ... a more or less considerable swelling of the joint remains owing to the formation of hydrarthus; and sometimes to the accumulation of liquid in the periarticular serous bursae also. . . . One or two weeks after invasion, sometimes much sooner, the existence of more or less creaking sounds may be noted betraying the alteration of the articular surfaces, which at this period is already profound. . . . Besides the wearing down of the articular surfaces you notice here the presence of foreign bodies, of bony stalactites. . . . The articular affection in question is itself, also, the expression of trophic disorders directly dependent on the lesion of the spinal nerve center."

Little more can be said now, but contrary to this early description by Charcot, onset is often gradual. Since the joint is insensitive the first symptom is usually merely swelling, without the concomitant signs of inflammation. This is followed by an abnormal range of motion, so that deformity and instability result. There is practically no local pain or sensitiveness, but pain may result from distention. Subluxation is common. As the weakness and instability progress nature makes feeble attempts at repair with irregular for-mation of fibrous tissue, cartilage, and even bone in the capsule. Thus the joint as a whole becomes enlarged and yet there is marked laxity of the ligaments and painless, abnormal mobility.

Involvement of joints is seen in or as a precursor of two to ten per cent of cases of tabes dorsalis. It may take the form of a simple chronic synovitis or a destructive osteoarthritis. The latter form, or Charcot's joint, is seen more often in the lower extremity and may be multiple. It rarely affects the shoulder joint. In 155 cases reported by Flatlow, quoted by Whitman, twenty-seven involved the shoulder. In 217 cases of Chipault this joint was not involved. In eighty-eight cases Wile and Butler found four in the shoulder. In 167 cases reported by Sutherland from the Mayo Clinic the shoulder was involved twice.

This type of joint is not limited to tabes, for it or a similar condition is seen in syringomyelia, and very rarely in psoriasis, leprosy, spina bifida, and in cases of direct injury to or after cutting of dorsal roots. The spinal lesion is probably the basic cause, while trauma may precipitate the appearance of the local lesion.

Carman states that in most cases the X-ray alone is sufficient for diagnosis. He makes the following points: (1) Atrophy of articular cartilages. (2) Irregular destruction of bone, often associated with (3) irregular hyperplasia in the same joint, (4) detached bone masses and detritus, (5) translucent areas.

The presence of painless lateral mobility in any joint should suggest this diagnosis. Reliance should not be placed on the Wasser-mann reaction, which is usually negative both in the blood and cerebrospinal fluid.

Prognosis.

This is not good, but if the tabetic processes can be halted, the change in the joint may also stop. The bone may regenerate somewhat and there may be some shrinking of the capsule. Fluid may be absorbed.

Treatment.

The treatment is general and local. An effort is made to control the tabes. A support to prevent progressive distortion should be used. An airplane splint or elastic shoulder cap may be employed. Tapping of the joint for fluid may be done.

Syringomyelia

is usually considered a separate disease entity characterized by formation of cavities in the spinal cord, but a similar condition may result from degeneration of a central glioma. It was first described by Charles Estienne Stephanas in 1546. Schlesinger collected 260 cases for his book, Die Syringomelie, published in 1902.

The disease is progressive. The characteristic symptoms depend upon the extent and area of the cord involved. Dissociated anaesthesia, loss of pain and temperature sense and retention of tactile sense are most important. Trophic disturbances, with involvement of skin and joints, are common. Joint affections are a very common complication. Schlesinger collected 105 cases with joint involvement. He estimates that this occurs in ten per cent of the cases. Unlike Charcot's disease, in which the knee is most often involved, in syringomyelia the shoulder is most commonly affected. In a series of ninety-seven, the order given by Schlesinger was: Shoulder twenty-nine, elbow twenty-four, wrist eighteen, hip four, knee seven, foot seven, other joints eight. The lesion resulting in the joint is very similar to that in Charcot's. Progressive muscular atrophy with paralysis is usually present. Deep X-ray treatment of the spinal lesion is often successful in checking the progress of this disease.
Hygroma of the Subacromial Bursa. The surgical literature of the last century occasionally mentions the term Hygroma, meaning a collection of fluid in an enlarged bursa or joint. This condition was more often described in connection with other regions, but occasionally hygromas of the shoulder were mentioned. The subject can best be discussed in connection with the following case:

Mrs. H. Massachusetts General Hospital No. 3 50673 E. S., Dec. 15, 1906. The patient was a stout woman of 5 J, who gave the history of having always been well. She was referred from the Dispensary with a diagnosis of a fracture of the head of the humerus, but the X-ray showed that there was no fracture. She stated that six years before she had strained her arm in lifting, and that since then it had been somewhat stiff and sore and painful on use. Eighteen months before entrance after carrying a heavy bag she noticed that the arm had become much swollen. After a time the swelling disappeared. Ten days before entrance she fell forward down two steps, striking on her head and shoulders. The arm again became swollen and painful, particularly around the shoulder joint. Since that time the swelling had increased and at the time of entrance it was very conspicuous, suggesting a tumor of the head of the humerus, but it was fluctuant. The record states: "Movements of the arm free and not painful; soft crepitus near head of bone; clavicle palpable over top of swelling and apparently loose at its outer end." The operation was performed by me and the notes were by the house officer. An incision was made over the subacromial bursa and it was found to be "enormously dilated to the size of a large grapefruit. Inside were numerous cartilaginous bodies in size from (word illegible) to a pea, attached loosely to the walls. The sac contained yellowish mucous fluid, semi-viscid. The head of the bone was much roughened and covered with bits of cartilaginous bodies similar to those found on the walls of the sac. The normal topography of the bones about the joint was destroyed by the pressure of the fluid in the sac. The clavicle was lifted two inches from the acromial-clavicular attachment. The glenoid cavity was obliterated." I excised the head of the humerus and the redundant bursal sac. There was a mild staphylococcus infection. The patient was discharged from the hospital in six weeks with a small sinus. Her pain was relieved and she was intensely grateful, but I doubt if she ever had a very satisfactory arm. Unfortunately I was unable to follow up the case. Pathologic report No. 612-54. "The head of the humerus almost devoid of cartilage, to which several irregular pieces of capsule were adherent; also two pieces from the joint 1.5 cm. in length.   Diagnosis, chronic synovitis."

This was undoubtedly a case which the older writers would have called a hygroma; even now I cannot state positively what the condition was, although I fully believe it was the late result of such a case as that described on page 389. The short rotators had been torn from the head of the humerus at the time of the accident six years before, leaving the head of the bone free under the deltoid; chronic synovitis, effusion and slow distention of the bursa and joint followed. The woman had continued to do her housework for six years in spite of the disability. The case mentioned on p. 389 very likely will eventually have a similar condition. In both cases movement of the joint was not painful because the short rotators had retracted to a fixed position on the glenoid.
Since I operated on the above case I have seen several others of a similar character in which there was a smaller quantity of fluid. Any patient with ruptured supraspinatus, who is able to continue to use his arm, may develop a large amount of fluid. It is my personal belief that most of the cases formerly diagnosed as hygroma were these extreme cases of accumulation of fluid due to the use of a shoulder joint in which the bursal floor was in communication with the true joint.  Others may have been Charcot's joints.
My interpretation of this case may be incorrect. The trouble may have been a Charcot's joint. The record gives no reference whatever to the question of syphilis, but there was nothing in the physical examination to indicate it. The case was at the time diagnosed a Charcot's joint, and this shows that the question of syphilis was entered into, but that there was no positive finding in the history or physical examination. In those days we did not use the Wasser-mann test.
I feel very confident that most similar cases are primarily due to ruptures of the tendon. The case described in the chapter on Arthritis showed similar changes in both shoulders, but of less extent. Several of the cases Dr. Akerson has found at autopsy showed similar lesions.
 
Treatment. In the past, incision of the bursas and evacuation of the fluid and necrotic villi was recommended. Withdrawal of the fluid, followed by the injection of irritants as in hydrops of the joints, was also done. The treatment which would be recommended now would be ankylosis of the joint.
In 1922, Aldo Avoni was able to find only thirty cases of hygroma in the literature. Churchman ably discusses the subject in relation to syphilis. H. T. Jones reviews the literature on Cystic Bursal Hygromas.

Progressive muscular atrophy, as the name implies, is characterized by progressive wasting of the muscles. It rarely begins before the twentieth year. Its onset is very slow and months or years may elapse before symptoms are present. It is dependent upon a chronic degeneration of the cells of the anterior horns of the spinal cord. The small muscles of the hands are usually involved first, although the disease may begin in the muscles of the shoulder girdle. It is usually bilateral.
The objective signs are: atrophy, fibrillary twitching, paralysis, reaction of degeneration, decreased or absent reflexes, deformity and changed attitude. Subjective symptoms are weakness, impaired function and clumsiness. There is no pain, and it is never accompanied by loss of sensation.  In diagnosis we must consider:
(1) In syringomyelia there is sensory dissociation, trophic changes and unilateral distribution.
(2) In anterior poliomyelitis there is rapid onset, loss of power before atrophy.
(3) Amyotrophic lateral sclerosis shows spasticity with exaggerated reflexes.
(4) In lead palsy the lead line, colic and extensor paralysis occur.
(5) In caries of the vertebras there are sensory symptoms, pain, positive X-ray findings.
It almost seems superfluous to consider this condition in a book on the shoulder, but practically I have several times seen cases in which the atrophy of the shoulder muscles from this cause has led to the conclusion that ther-e was a local lesion in the shoulder joint. It is not uncommon to find some fibrillary twitching in the muscles about a sore shoulder, but this sign should always suggest the diagnosis of progressive muscular atrophy. We may make this diagnosis if the twitching and atrophy are not accompanied by pain or restriction of motion, or loss of sensation, especially if both shoulders are affected.
 
We may return now to the table of King and Holmes. We have considered the different forms of arthritis there listed as well as the forms of arthritis due to changes in the cord, and have already discussed in other parts of the book acromio-clavicular arthritis. It can be seen from the list, that King and Holmes found that the X-ray was chiefly useful in fractures and dislocations, for nearly two-thirds of the 150 cases in which the X-ray was useful were of this nature. This portion of the subj ect has been referred to in Chapters IX and X. Attention is particularly called to their figures on uncomplicated fractures of the tuberosity and on uncomplicated dislocation, which seem so contradictory to my remarks on the frequency with which these lesions are found in combination. The rontgenologist sees these cases after the reduction has taken place either spontaneously or as a first aid measure. We have also considered the diagnoses of subacromial bursitis and periarthritis. Of the last ten diagnoses on their list there are three which it seems worth while to discuss.

Osteomyelitis may be disposed of very briefly. While it may occur about the shoulder, its occurrence must be very rare, for in spite of my interest in the shoulder for many years, I have never seen a case of osteomyelitis of the upper end of the humerus in an adult. I have seen the condition in children who had osteomyelitis also in other bones. I do not refer, of course, in this connection to bone infection following surgical operations. I refer to inflammation of bone caused by blood-borne germs which produce suppuration. My experience with bone sarcoma has been, of course, unusual, so that it is perhaps not fair for me to draw comparisons between this disease and osteomyelitis, but I cannot help saying that when a surgeon sees a bony lesion of the upper end of the humerus I believe he should think of bone sarcoma first and osteomyelitis second, for while sarcoma is rare, I do not believe it is as rare as osteomyelitis in this region of the body.

Myositis Ossificans is to be thought of in the diagnosis of shoulder conditions, although it is very unusual for it to involve the shoulder muscles. In the traumatic variety the shoulder is rarely involved. The writer has never seen a case. In 127 cases reported by Strauss the shoulder is not mentioned. The most common sites are, in order of frequency: (1) Brachialis, (2) quadriceps femoris, (3) adductor longus, and (4) biceps brachii.
In 233 cases from the German military service, the brachialis and quadriceps were the only muscles involved in all except three cases. In eighty-six cases analyzed by Binnie, the "shoulder" was mentioned once, deltoid once and pectoralis major twice.The progressive type (the ossified man of the circus) has been studied thoroughly by Rosenstirn. He reviews the literature and presents 115 cases extending back to 1692. Ossification of the supra-spinatus was mentioned four times.

Relaxed Capsule. The term relaxed capsule is perhaps inappropriate as a diagnosis, because the causes of the condition may be of several different kinds. The term simply means a condition in which the head of the humerus can be pulled downward from the glenoid to an abnormal degree. Since the capsule of the joint is essentially made up by the short rotators, paralysis of these muscles permits a sagging of the humerus. We may expect, therefore, that the X-ray will show a large gap between the humerus and the glenoid if traction is exerted on the arm when these muscles are paralyzed or stretched. If the X-ray is taken while traction is being made, the gap may be one or two inches in extent. A similar condition occurs when the supraspinatus, together with other short rotators, has been torn and fluid has accumulated in the joint and bursa. Perhaps the condition may also appear in old cases of habitual dislocation. As a rule, however, the X-ray appearance of relaxed capsule means paralysis of the short rotators or deltoid. Investigation of this sign is much needed. It is a troublesome thing to take films of a shoulder joint and then repeat the same films with traction on the arm. In a normal person the j oint surfaces may be separated to a certain extent by traction, and the degree of separation must vary with the amount of fluid present which may fill the gap as suction is made. We must remember too that the joint cartilages do not show in the picture. To obtain a correct estimate the direction of the rays must be parallel with the glenoid surface.
Cotton and Hammond have drawn attention to this condition. Cotton believes that the persistent dragging of the swollen arm, or the arm plus heavy splinting, gradually stretches the deltoid and brings the head of the humerus lower and lower in relation to the glenoid. Hammond shares the same views. Cotton makes an observation which is quite at variance with my views and those of Stevens, described in Chapter XI. He says, "Deltoid paralysis assumed to be from circumflex damage I do not see; all the cases seem to be either brachial plexus lesions or the sort of thing here described." I cannot agree with this statement, for I believe that circumflex damage is very common as a complication of dislocation. However, I am sure Cotton and I would agree that in all cases of fracture of the humerus ith paralysis of the deltoid, it is wise to support the arm so that the weight will not sag on the deltoid or on the short rotators. I should interpret Case & in Hammond's paper, and also one of Cotton's cases (Fig. 6) to be clearly cases of comminuted fracture of the upper end of the humerus. In all fractures of this kind, and in many of the minor ones, there is swelling and edema of all the tissues in the neighborhood, and this edema or joint fluid tends to permit the glenoid and head of the humerus to separate.
In some of the cases of circumflex paralysis described previously, after the arm has been put up in elevation, it may take twenty-four hours or more before the edema is forced out of the subacromial space to make room for the head of the humerus. The relief which so constantly occurs in these cases under this treatment is partly due to the displacement of this edema as well as to relieving the stretched condition of the deltoid.
In making the diagnosis of a relaxed capsule, one must always bear in mind that in order to determine the size of a gap between the head of the humerus and the acromion, we must be sure that the path of the X-ray is parallel with the plane of the acromion, so that the latter will be shown in profile. If the path of the X-ray is not in this line, the shadow of the acromion appears to fill up the gap. Films taken of the shoulder when the plate is anterior are much more likely to show the acromion in profile than are antero-posterior views. There is quite a large gap in normal cases. "Dropping shoulder" is a better term than "relaxed capsule," for the relaxation is in the muscles.

Referred Pain. Among their three hundred cases which were negative, King and Holmes suggest that perhaps there were many in which referred pain caused the symptoms. They list as possible causes the following:
1. Cardiovascular lesions, angina, aortitis, aneurysm, coronary sclerosis.
2. Pleural, pulmonary and mediastinal.   Pleurisy, pneumonia, intrathoracic new growth, pneumothorax.
3. Abdominal lesions, gastritis, gastric ulcer or carcinoma, gall-bladder
disease, hepatic or subphrenic abscess, pneumoperitoneum, ascites, rupture of ectopic pregnancy.
4. Neurological lesions, hemiplegia, new growth, cervical Pott's disease,
cervical arthritis, cervical ribs, herpes.
They comment:
"Let it be remembered that these lesions can not only cause pain referred to the shoulder, but when severe will cause limitation in motion and localized tenderness, followed by atrophy of the muscles about the shoulder, moderate capsular relaxation and continued or increasing disability."
 
I am unable to agree with these authors as to the statements in the last paragraph. I have never observed cases of referred pain in their first three groups, which showed limitation of motion or true localized tenderness in the scapulo-humeral joint. Hyperalgesia to pressure on the trapezius or to pinching of the skin over the shoulder there may be, but not deep, local tenderness over the joint. Atrophy of the muscles and bones may perhaps be present after long-continued pain and disuse on account of pain, but only in a few of the above lesions, especially those associated with lesions in paragraph 4, such as cervical rib and cervical arthritis, which cause pressure on the nerve roots.
Shoulder pain, as has long been known, may appear in some cases of gallstones and of other lesions of the liver, and students for generations have been taught that this pain is a typical example of "Referred Pain." Cope lists the following conditions in which he has found shoulder pain to be of diagnostic value. (1) Liver abscess, (2) perforated gastric or duodenal ulcer, (3) subphrenic abscess, (4) cholecystitis with adjacent peritonitis, (5) perforation of the gall bladder, (6) splenic infarct, (7) spontaneous rupture of spleen, (8) acute pancreatitis, (9) appendicitis, (10) ruptured ectopic gestation, (11) dilated stomach, (12) actinomycosis of thoraco-dia-phragmatic junction, (13) diaphragmatic pleurisy, (14) basal pulmonary infarct, (15) pericarditis.
It has been well established by surgeons since the use of local anaesthesia was introduced, that the viscera are as a whole incapable of sending sensory impulses to the brain in response to such injuries as cutting and bruising, although distention of their cavities may register on the brain local distress and even agony. Injuries to the parietal layer of the peritoneum or pleura, on the other hand, can usually be localized almost as accurately by the patient as if they were on the skin. On evolutionary grounds it seems probable that all the external parts of the body developed accurate protective sensitivity, while the vital organs did not, because injury to them from the claws of other animals meant death. If a beaten animal, even without a whole skin or abdominal wall, escaped, he might live to breed another day, but if his heart, intestines, lungs or liver were injured, he could leave no protective reflexes to his posterity. Therefore, nature has not developed useless sensory nerves in these organs to give us needless pain from local injuries. Yet these very organs are provided with the mechanism to give us pain when they are functionally abused.   Distention from gluttony or from poisonous foods may give us protective abdominal warnings. So may over-exertion cause a warning distress in the heart or lungs. Yet the heart and lungs, when torn or scratched, give us no distress. It is almost a rule that the better protected a vital organ is, the less will be its sensitiveness to touch stimuli. Capps has shown that the heart cannot convey to the brain any painful or localizing sensation when touched with a wire, nor can the inside of the pericardium which surrounds it, but the parietal pleura is sensitive and the patient can localize the point at which it has been touched.
Capps' work has extended over many years and has only recently (1932) been summarized in a little volume which will stand for a long time as a first-rate example of scientific clinical observation, experiment, logic and presentation. He has been able, by using the opportunities which have occurred in his practice in cases where it was necessary to tap the peritoneum, pericardium and pleurae for therapeutic purposes, to ascertain quite definitely the sensitivity of most of the visceral organs, and not only to map out those areas capable of localizing painful stimuli, but also to determine certain areas, which, when touched, refer the sensation to other distant areas. His work has made the rather vague subject of referred pain, and particularly that of referred shoulder pain, far more succinct and intelligible than it was formerly, although many other investigators had prepared the way.
His essential contribution was made by the cooperation of his patients, who told him their sensations as he touched various spots on the heart or on the diaphragm with his probe when he was obliged to tap the peritoneum, pericardium or pleurae to withdraw fluid. In this way it was found that when he touched from above or below the central area of the diaphragm or the outer lateral portions of the pericardium, shoulder pain was always experienced by the patient. He proved, as the anatomists already had suspected, that these areas were supplied by the phrenic nerve which arises in the fourth and fifth cervical segments, which also gives origin to the nerves which furnish the sensitivity to the skin of the upper posterior part of the shoulder (the trapezius ridge), to which area the pain sensation in these patients was invariably referred.
His experiments, therefore, confirmed the ideas previously worked out by others, which may be expressed in a general way thus: The afferent nerves from the viscera often terminate in the cord in close association with the afferent nerves from certain skin areas. When a powerful sensory stimulus is received from the viscera as a result of disease, it may be projected to the peripheral distribution of those nerve fibers which terminate in the same segment of the spinal cord. Head suggests that this is an example of a general law; i.e., when a painful stimulus is applied to a part of low sensibility in close connection in the cord with a part of much greater sensibility, the pain produced is felt in the part of higher sensibility.
Hypersensitivity, or hyperalgesia of the skin area, probably arises because repeated abnormal impulses from the diseased viscus irritate its particular region of the spinal cord, and this point becomes an "irritable focus." The intensity of impulses entering this area of the cord from areas not diseased becomes increased, and stimuli applied to the sensitive areas of the body surface which would normally arouse only slight discomfort, now become endowed with distinctly painful properties, i.e., hyperalgesia is present in the corresponding segment of the body wall. Pain may or may not be felt over the organ involved.
Capps defines referred pain as follows:
1. It is often remote from the site of irritation. (This is especially well
demonstrated in phrenic shoulder pain.)
2. It follows lines on the skin of spinal segmentation rather than the
course of peripheral nerves.
3. It is usually associated with cutaneous hyperesthesia and tenderness
to pressure (over the referred area).
4. Often the pain fails to involve a whole segmental area of skin, but
finds expression in one or more points of maximal tenderness and spontaneous pain.

The phrenic shoulder pain varies in intensity and quality. It may shoot down over the outer aspect of the shoulder along the distribution of the 5th cervical nerve. Cope says, " Usually it has the quality of an ache and is regarded by the patient and often by the doctor as a rheumatic pain. Sometimes it is very sharp and stabbing or it may feel as if a nail were being driven into the spot. Some patients may say that they have no pain, but that there is a sensation of stiffness in the affected part." The pain is in the skin or superficial tissue and is always associated with hyperalgesia. It is said that there may be muscle spasm. I have never observed a case where this was present. In Capps' experiments the area affected was often small and very definite.   He does not speak of spasm.
Practically it is very seldom that confusion arises in the diagnosis between actual lesions of the shoulder tissue and lesions causing shoulder pain by way of the phrenic.  Usually much more pronounced symptoms indicate the serious lesions which cause it. However, the possibility should be borne in mind in all cases of aching pain in or near the trapezius ridge accompanied by hyperalgesia. Such shoulder pain is apt to be enhanced if the patient takes a deep breath. It is also possible that a mistake might occur in the reverse way and a true shoulder lesion be ignored in a patient suspected of or found to have a visceral lesion, for shoulder lesions are very common and may affect a patient with gallstones as well as one without them.

Referred Pain from Pressure on the Roots of Cervical Nerves. Confusion in diagnosis is much more likely to arise in the fourth division of the causes listed by King and Holmes, than it is in the first three divisions. The reader who wishes details on the first three divisions is referred to Capps's book, for the cause of the pain in all the lesions mentioned is the phrenic pain we have just considered. The kinds of pain listed in the fourth division are quite different in character. The explanation usually accepted in such cases is that pressure on the nerve roots of the brachial plexus may give pain associated with the sensory areas supplied by the plexus. Any lesion which causes a swelling of the tissues in the spinal canal or in the bony gutters or in the part of the first rib which the nerves cross, may cause this kind of pain. The diagnosis, therefore, becomes complicated, for we must consider all the lesions which may affect the nerves themselves or the vertebra between which they find their points of exit. For instance, in my opinion a very common cause of shoulder pain is hypertrophic arthritis of the cervical spine. I frequently make this diagnosis.
Bassoe says, "I have become more and more convinced that a great many cases of painful shoulders and arms in middle-aged people are caused by osteoarthritis of the neck and 'funiculitis' rather than by arthritis of the shoulder or toxic neuritis or neuralgia. I have repeatedly found rontgenologic evidence of such arthritis and seen relief from it by stretching the neck, which automatically relieves the pressure on the funiculi."
Cervical ribs and enlarged transverse processes on the 7th cervical vertebra are also, I am convinced, common causes of shoulder pain. Other rarer conditions, such as new growths or tuberculosis of the cervical vertebrae, produce the pain after the same manner, i.e., by local pressure of the nerve roots. It seems to me that this is to be considered "referred pain" rather than pain from direct pressure. Certainly the sensory disturbance felt in the toe of an amputated leg, but caused by a neuroma in the stump, must be of a some-what similar character, so far as the mechanism of cord and brain is concerned. In the same way a cervical rib or an hypertrophic arthritis may produce pain felt in the hand. I am very confident that most of these lesions which press on the nerve roots cause a vague pain of segmental type rather than pain of a type associated with peripheral nerve distribution. It therefore seems very unlikely that restriction or atrophy could accompany this type of pain, except secondarily from disuse on account of the pain.
We may speculate a little more in regard to the mechanism of shoulder pain caused by direct pressure on the nerve roots. Each of these roots contains efferent fibers (motor), afferent fibers (sensory) and sympathetic fibers. Besides these we may assume local nerve endings, because local pressure on a nerve trunk causes distinct local pain which the brain can accurately locate. I know of no positive evidence for or against such an assumption.
Granted that pressure on the afferent fibers would only give a false sense of pain in the shoulder, which could cause no changes such as spasm or atrophy or restriction, could pressure on the efferent motor fibers produce such changes ? Two ways in which this might happen are obvious. First, the local pressure on the motor fibers might persistently stimulate the muscles to contract. Spasm would occur which would be followed by exhaustion and atrophy, and thus by restriction. Spasm itself is painful. Second, local inflammation within the fibrous nerve sheath of the trunk might be first caused by the pressure. A local lesion would be produced and the edema caused within the trunk gradually destroy or weaken the true motor nerve fibers, so that impulses could not travel normally to the muscles, which in consequence would atrophy. We know that when we cut the nerves which give the motor supply to a muscle, the muscle first becomes flaccid and then atrophic and later contracted. Perhaps tension confined within the fibrous nerve trunk may have the same effect.
Another way for pressure on the nerve roots to cause actual physical changes in the muscles and joints supplied by those nerves, would be by interference with the sympathetic fibers which lie in the nerve roots and are in control of expansion and contraction of, not only the main artery of the limb, but of each of its branches. Obviously, if pressure on these sympathetic fibers could cause undue interference either with the contraction or expansion of the arteries of the limb, physical changes might be produced. We know, for instance, that ischaemia and even gangrene occur sometimes in cases of cervical rib, but perhaps this is only when the artery is also involved.We know also that removal of the sympathetic fibers about an artery causes hyperaemia below.
A fourth hypothesis might be to suppose that the pressure first stimulates the local afferent protective nerve endings in the root itself, and this centripetal impulse causes a command to return from the brain to produce a constant local contraction of the muscles thus leading to spasm, atrophy and restriction. In this case all the muscles supplied by that trunk would be affected.
We know from sad experience that pressure produced by tight bandages may lead to ischaemia in the muscles of the forearm (Volk-mann's contracture), although we do not know whether this occurs through interference with the sympathetic or motor fibers. Could the much slighter and much slower pressure from cervical ribs act in the same way?
On the other hand, we know that bony tumors may grow to large size, obviously pressing large nerve trunks from their normal paths, without producing pain or paralysis in the muscles which these nerves supply. Sometimes such changes take place; sometimes they do not. I have read the detailed histories of many cases of bone sarcoma and do not recall such symptoms, except in a few cases of giant cell tumor of the upper end of the fibula, where mild symptoms of toe drop and tingling in the peroneal nerve area occurred. The pressure in these cases must have been excessive. I have seen chondromatous tumors, which have developed to enormous size, with no nerve symptoms, although nerve trunks were pushed far from their normal places and held in canals in the tumors.
It therefore seems to me that the nerve symptoms caused by pressure in the cases of cervical rib and hypertrophic cervical arthritis must have some additional explanation besides mere irritative pressure. Perhaps there is some strangulation of the nerve root as well. As a matter of fact, we do not understand the exact reasons for the shoulder and arm symptoms in these cases, although we call them "pressure neuritis." Many physicians are satisfied to treat for "neuritis" any painful arm without even taking the trouble to use the X-ray. Brachial neuritis is for them a satisfactory diagnosis, as if there were such a pathologic entity.

Cervical ribs, according to Keen, were mentioned by Galen, but our real knowledge of the subject dates back to Hunauld in 1742. The presence of a cervical rib is no longer considered a rarity. It may occur in one to two per cent of all subjects, but in probably ninety per cent of these it causes no symptoms.  Eighty per cent or more of cervical ribs are bilateral, but ninety-five per cent of the cases where pain results give unilateral symptoms. About seventy per cent of the clinical cases occur in females.
Cervical ribs can be divided into four classes: (1) a node that does not extend beyond the transverse process; (2) a blunt projection of bone four to five centimeters long; (3) ribs long enough to articulate with the first rib or be attached to the sternum with a ligament; (4) complete rib with vertebral origin and costosternal cartilage.
Symptoms may be divided into local, vascular, neurologic and muscular. A bony tumor can be felt in the supraclavicular region. Pressure on it causes pain. Bruit may be present where the artery crosses it. There may be disturbance of blood supply to the hand, usually causing only pallor, but sometimes gangrene of the fingers. It is disputed as to whether this is due to pressure on the brachial plexus or to pressure on the axillary artery. The neurologic symptoms depend somewhat upon the part of the plexus affected, but the pain is apt to be of segmental type. Pain is often severe and aggravated by certain movements, or it may be dull, continuous, or only a heavy feeling. The patient may have numbness, tingling, neuralgic pains, and weakness. A sensation of fatigue in the arm is very common. Muscular- atrophy, loss of power or restriction are seen only in very severe prolonged cases. Sir Harold Stiles has pointed out that pressure of the normal first rib may also cause similar symptoms which may be relieved by removal of the rib. Sometimes a short cervical rib may have cartilaginous or tendinous prolongations that provoke symptoms. These may be attached to the first rib or to the dome of the pleura.
In my personal experience I cannot recall seeing any cases of shoulder pain caused by cervical ribs which were associated with a decided atrophy of the shoulder muscles or stiffness in the joint. I have seen a few very severe cases in which there was atrophy of the hand muscles. The pain was so severe as to demand excision of the rib. The type of case in which I personally make the diagnosis, and I have done this a number of times before receiving confirmation from the X-ray, is characterized by the vagueness and yet persistency of intermittent pain without definite disturbance along any particular peripheral nerve; without restriction or atrophy, and usually relieved by hunching the shoulder or holding the arm up so that the arch formed by the clavicle and scapula is raised. At the same time there will be found a slight enlargement in the region of the cervical rib, and a slight amount of localized tenderness as compared with the other side. These signs are exactly similar to the signs which one finds in the next condition to be considered, cervical arthritis. I cannot differentiate between the two without the help of the X-ray, and even then sometimes am inclined to compromise.

Cervical Hypertrophic Arthritis. While one must rely on the X-ray for demonstration of this condition in most cases, we must always remember that the swelling of the soft parts adjacent to the hypertrophic ridges may be of considerable extent without showing in the film. Rigidity in the muscles of the neck must be present to some extent if this diagnosis is to be made. Lateral motion of the head and neck will not be symmetrical, and will cause local pain or increase the pain in the shoulders. As pointed out by Bassoe, there may be relief of the pain when the neck is passively stretched. The pain may be relieved by a Thomas collar, but is usually so mild and irregular in character that the patient soon wishes to abandon the collar!
I do not make a diagnosis of this condition or of cervical rib or of any other condition causing nerve root pressure, if I find any restriction of the scapulo-humeral joint. Even atrophy of the spi-nati without restriction would incline me to rule out this diagnosis, because this combination is the rule in cases of rupture of the supra-spinatus. Pressure on the nerve roots makes a false pain, just as the pressure of a neuroma gives pain in the amputated limb. There is no more reason to expect physical changes in the scapulo-humeral joint from such pressure than there is to expect physical changes in the amputated toe. As in the case of the phrenic nerve pain above described, this pain is referred by the cord and brain and is not caused by a physical disease of the part where the pain is felt.
X-ray evidences of hypertrophic changes in the cervical spine are so common that we must be on our guard not to have them mislead us in cases where the real pathologic condition is in the tendons of the short rotators. The symptoms characteristic of a "frozen shoulder" cannot be explained by pressure on the nerve roots, but pain about the shoulder without limitation of motion may be due to this cause.

Brachial Neuritis is a very indefinite term meaning literally, inflammation of a nerve in the arm, but clinically, applied to pain in the arm from various causes. In my own opinion such cases are usually due to traumatic or inflammatory changes in the musculotendinous cuff or in the subacromial bursa, and are in no way connected with true inflammation of the nerves themselves, although "brachial neuritis" symptoms are present. The proof is that most cases can be at once relieved by appropriate treatment for the bursitis ; miraculously in a few days in the cases of calcified deposit, and surely, though less rapidly, in a few weeks in cases of tendinitis.

I have come to believe there is no such thing as a brachial neuritis per se. The nearest approach to such a condition is in the cases of pressure on the nerve roots we have just been considering. Possibly in these there is a "neuritis" at the point of local pressure, but it seems to me more likely that there is no inflammation even at that point, and that the symptoms arc due to mechanical irritation of the nerves, either of the afferent or more probably of the sympathetic fibers. Perhaps the nearest thing to a real neuritis is what we know as Herpes Zoster.

Herpes Zoster sometimes causes pain in the shoulder, and if the characteristic lesions of the skin are not present might be confused with other pathology in this region. Mchlis, in 1818, was the first to suggest that the eruption follows the distribution of the nerves, but von Biirensprung was the first to prove the hypothesis. This condition has been presented thoroughly by Head. Very little light has been shed upon the subject since. Head collected twenty-one cases which had been examined at autopsy. The 3rd cervical nerve was involved twice and the 4>th once. In 416 clinical cases he found the 3rd cervical involved fifteen times, the 4th cervical twenty-one times and the-5th cervical twice. The skin over the shoulder is supplied by these nerves, and by the posterior branches of the next four or five lower nerves. It is unnecessary to review here the whole subject of herpes, but it is perhaps well to remind the reader that long after the skin lesions have disappeared there may be subjective pain of neuralgic character associated with anaesthesia. This is due to destruction of the nerve endings by the herpetic lesion. In this condition there is some pathologic evidence of actual lesions in the nerve and in the spinal ganglia.
In the diagnosis of cases of painful shoulder this condition must be borne in mind. We are so accustomed to think that "shingles" occur on the sides of the chest that we are apt to forget that the peripheral nerves supplying the skin over the backs and tops of the shoulders are subject to the same painful malady. I recently saw a working woman who for several weeks was quite incapacitated by such a lesion. The characteristic rash extended over the dorsum of the shoulder just above and just below the spine of the scapula. At first sight I was deceived, because acne over the shoulders is so common and so apt to follow the use of any plasters, hot applications, and other remedies. Once having thought of herpes the diagnosis became clear, for the rash was unilateral and characteristic in appearance and in distribution. There was no atrophy of the muscles or restriction of motion. The patient was obliged to continue her work and the atrophy of disuse did not set in. If this patient had been a woman of the leisure class and could have coddled the arm, she would perhaps have had atrophy from disuse, a frozen shoulder, and have been many months in recovering from these secondary symptoms. As it was, the patient suffered for three months and still some hypersensitivity of the skin remained.
Whether or not there is a neuritis per se which is not secondary to the common shoulder lesions or to pressure on the nerve roots, and which is not accompanied by an herpetic rash, there certainly are forms of toxic neuritis capable of giving shoulder pain. That caused by lead poisoning may be taken as a type. However, the symptoms in this condition and in alcoholic and other forms of toxic neuritis are quite different from the condition which doctors treat as "brachial neuritis," for the element of muscle paralysis is dominant instead of scapulo-humeral spasm. The symptoms are usually bilateral. To my mind the presence of scapulo-humeral spasm is not consistent with a true neuritis. In shoulder lesions the spasm itself produces the neuritic symptoms. The pain is from the nerve endings in the spasmodic muscles, not from disease in the nerve trunks, although the nerve trunks themselves become sensitive to the touch, even to the very roots of the plexus. If the nerves themselves were really inflamed, removal of a small calcified deposit or the breaking up of adhesions would not produce immediate relief. Their sensitiveness may be due to hyperemia, but I know of no real explanation nor of experiments to determine whether a normal nerve trunk is capable of transmitting to the brain the exact location of touch stimuli.

Tumors of Spinal Cord and Nerves may cause shoulder pain, but they are rare. Among 35,000 autopsies Schlesinger found only 104 cases in which the spinal cord was involved. The cervical region is involved in about twenty-five per cent of the cases. In 264 cases he found it involved in seventy. In sixty-four cases reported by Ayer, twenty-six showed cervical lesions. In eight hundred cases referred to by Elsberg, twenty-four per cent were cervical. In his personal series of one hundred, Cl-4 was involved six times; C5-8, twenty-six times.
The first symptom is usually root pain which is sharp, sudden and severe. It is aggravated by motion and patient holds his neck stiff. Tumors in the region of C4 or C5 give pain on the top of the shoulder which is distributed along the roots. Numbness, paresthesia, spasm and paralysis soon follow. Wasting of the muscles about the shoulder is often marked. There may be a dull "spinal pain." Lumbar puncture (Froin's syndrome) combined with cistern puncture and lipiodal injection help in diagnosis.
Tumors of peripheral nerves sometimes occur in the shoulder region and give rise to constant pain. Symmers has reported a case. Gatch and Ritchey reported two cases in which the brachial plexus was involved. Cushing reported a case in 1904 in which the pain radiated from the shoulders into the arm. He also reviewed the operated cases. If I have ever seen a case where shoulder pain due to this cause was the first or only symptom, I have failed to recognize it.

Cervical Potts Disease or tuberculosis of the cervical vertebras may cause shoulder pain but is very rare in adults. Whitman says that in a series of 1,355 cases of tuberculosis of the bones, the fourth cervical vertebra was involved twenty times and the fifth thirteen times. Pain is sometimes referred to the distribution of the cervical nerves. A report based on eighty-seven cases has been given by Volkmann.

Lead Palsy may take a number of forms. Its onset may be gradual or sudden. Frequently there are prodromal symptoms such as general lassitude, muscle cramps or tremor, numbness, dull ache or formication in the affected area. The palsy may manifest itself as muscular weakness or motion may be lost. The common type is the antibrachial with wrist drop. This may gradually increase until all the muscles supplied by the radial nerve are involved, except the brachio-radialis, anconeus and usually the abductor of the thumb. This is an important point in a difficult diagnosis. There is marked atrophy. A second or brachial type involves the deltoid, biceps, brachialis anticus and brachio-radialis, thus simulating an Erb-Duchenne palsy. The pectorals may be involved and sometimes a scapulo-humeral palsy results. "It is very rare for this to occur without wrist drop; but even when associated with palsy of forearm and hand, this type of paralysis is not a common manifestation of lead poisoning."   (Aub.)
A third form is characterized by progressive atrophy of the thenar and hypothenar eminences and small muscles of the hand. 
In diagnosis poliomyelitis, progressive muscular atrophy, amyotrophic lateral sclerosis, cervical rib, arsenic or alcoholic neuritis have to be ruled out. Colic, lead line, stippling and lead in the urine are very important.  Prognosis is good.

Diabetic Neuritis. While neuritis in diabetes usually manifests itself by aching or gnawing pains in the legs and feet, with hyperesthesia and burning sensation, it is said that it may also involve the brachial plexus in rare cases and give rise to similar symptoms in the arm and shoulder.
A good review of the subject with bibliography is given by Woltman and Wilder (Arch. Int. Med., 1929, 44: 576). Joslin says, "Neuritis is most uncommon among my patients. . . . Indeed, primary 'neuritis' in diabetes is usually a misnomer. It is secondary to some form of circulatory obstruction or some form of arthritis."
Tendinitis and consequent subacromial bursitis are not uncommon in diabetic patients, and it is probable that most cases considered as "neuritis" in diabetics, just as in non-diabetics, are due to this cause. The similarity of degenerative changes in the arterial walls and in the tendons has been alluded to under Pathology, and it is noteworthy that these conditions both appear with unusual frequency in diabetics.

King and Holmes also give a list of what they call "The more common shoulder lesions causing pain and disability," which are not demonstrable by Rontgen rays. We may briefly consider these diagnoses.

Postural                          Attrition—slight to moderate
Subcoracoid bursitis        Relaxed capsule—slight to
Tenosynovitis biceps                   moderate
Myositis—traumatic and   Tight axillary capsule
infectious

Postural. There can be little doubt that a poor posture may cause shoulder symptoms just as certainly as that poor posture tends to cramp all the viscera and lead to a general condition of lowered vitality. Goldthwait, who has always been interested in this matter, is insistent on its effect on shoulder conditions. The type of patient in whom we might expect shoulder pain from poor posture, would be an adult past middle life with head held somewhat forward, exaggerated dorso-lumbar curves, protuberant abdomen and sloping shoulders. Such cases not infrequently have in addition hypertrophic changes in the cervical spine.  I recently saw such a patient with vague shoulder pain, without restriction of motion or atrophy of the muscles. I was uncertain whether to attribute the pain to the hypertrophic arthritis or to the posture. The two conditions are bad companions, and it is not improbable that they interact on one another. The forward position of the shoulders tends to drag the nerve roots down across the first rib, and to exaggerate any irritation which the hypertrophic changes about the intervertebral foramina are already producing. Such patients often have sedentary occupations which compel them to sit for hours in a slumping position. In my experience, shoulder pain from this cause is never unendurable or of a very severe nature. Obviously the treatment should be general, and no time and energy should be wasted on local physiotherapy, for the patient will need all his courage to change his habits. The subject of posture as related to the education of children is undoubtedly of more importance than has been realized, and improvement in the condition of shoulders will be but one of the minor results of its general appreciation.

Subcoracoid Bursitis. In my early papers I alluded to this condition and sometimes made the diagnosis as if it were a distinctly separate condition from subacromial bursitis. As I have explained on page 27, I now feel that it should be considered one and the same thing, although doubtless the subcoracoid portion of the bursa might be inflamed without involving the subacromial bursa. Certainly there are some cases in which a calcified deposit forms in the subscapularis tendon and therefore may involve the subcoracoid portion of the bursa. Goldthwait, in 1908, wrote two articles on the shoulder in which he made more of the subcoracoid bursa than I had in my original article. He insisted on its cause being related to poor posture. I believe that his articles are misleading, particularly as to his idea that the lesser tuberosity impinges on the coracoid process. As a matter of fact, the lesser tuberosity is almost wholly covered by the muscle and tendon of the subscapularis, so that such impingement is next to impossible. In the normal working of the joint not only the lesser tuberosity but the bicipital groove may pass beneath the coracoid process in internal rotation.

Tenosynovitis of the Biceps. When I was in the Medical School, I used to hear this diagnosis made. At that time there was a general impression that if you moved the forearm up and down you moved the tendon of the biceps in its groove. This, as explained previously, is erroneous. There may be such a lesion as tenosynovitis of the long head of the biceps, but I have never demonstrated it either clinically,at operation or at autopsy, except in conjunction with rupture of the supraspinatus. I cannot say that it does not occur, but practically I do not make this diagnosis, and have no temptation to do so. I think that tenderness over the bicipital groove is more apt to be due to inflammation at the insertion of the pectoralis tendon or that of the teres major or of the bursas which accompany them, than it is to inflammation in the groove itself. It is not uncommon for persons after unusual muscular effort to have tenderness and lameness for a few days in this region.
Tuberculosis in the shoulder joint may involve the groove and the tendon, and, if it is accompanied by suppuration, the pus may run down the course of the sheath and make an abscess in the upper anterior part of the arm. Fracture of the tuberosity very commonly causes hemorrhage to run down parallel with but not in the groove, but I am quite confident that inflammation of the tendon is rare. I have occasionally thought that I recognized a mild tenosynovitis in young people who have used their arms to excess in playing games, particularly such games as Ring Toss and Quoits, which require antero-posterior motion of the humerus.

Myositis. Muscular rheumatism used to be a diagnosis for the cause of pain of an unexplained nature in the region of the muscles. It was a diagnosis commonly applied to what we now call subacromial bursitis. Doubtless it does occur as a complication of other lesions, such as fractures, but as a matter of fact all surgeons would agree with me that inflammation of a muscle, except as a secondary complication from infection of neighboring structures, is very uncommon. During the war I saw some instances of streptococcus infection of the muscles, but I have rarely seen such cases in civilian life. In my opinion "myositis" as a diagnosis, which explains any ordinary shoulder pain, has no pathologic or even intellectual foundation. We might as well be satisfied with having "caught cold" in the shoulder. The transient soreness in muscles after unusual or prolonged effort is the only evidence of even a temporary inflammation of which I know.
Attrition. Dr. A. W. Meyer, Professor of Anatomy at Leland Stanford University, has been the great exponent of this condition. His researches have been almost wholly from a purely anatomic standpoint, and they have not yet been accepted by clinicians. His articles are well worth reading, and there is some reason to believe that his contention, that the tendons and other portions of the joints may actually wear from continued use, has much to support it.

Dislocation of the Long Head of the Biceps.
According to Dr. Meyer, dislocation of the biceps tendon is a lesion which has not been sufficiently recognized clinically, for he found four instances in 286 cadavers. He was able to find only two cases in the literature. One of these was proved at operation. He believes the condition results from destruction of the superior part of the capsule from attrition. He also believes that actual wear plays a part in rupture of the biceps tendon.
I have seen one case in which dislocation of the tendon was probably the cause of symptoms which were much like those of a complete rupture of the supraspinatus. There was a loud, painful "snapping" as the arm was elevated. I opened the bursa, but not the joint, and as no rupture was found I closed the wound. The snapping continued. Later I found that I could prevent the snapping by making the patient rotate the humerus internally with the elbow flexed; then put the humerus in dorsal flexion; then extend the forearm and rotate externally. When this was done he could elevate the arm in the coronal plane without pain and without the snapping. This maneuver would have placed the biceps tendon in the groove in internal rotation; held it snug in the groove by extension of the forearm; permitted external rotation while the tendon was taut and therefore could not slip out of the groove. Once in external rotation the arm could be elevated in the coronal plane without releasing the tendon.
From Meyer's findings in the dissecting room, the reason why the tendon may slip out, is denudation of the capsule at the inner edge of the intertubercular notch, so that in external rotation the tendon slips over the upper part of the lesser tuberosity. The symptoms in my case and their relief by the maneuver described are compatible with Meyer's findings. However, in the case in question, the X-ray showed a small fragment or "mouse" in the neighborhood of the tuberosity which may have caused the symptoms, so that I do not feel sure of the diagnosis. The patient refused further exploration. In a few other cases I have been inclined to make this diagnosis for similar reasons, but the symptoms were not severe enough to justify operation.
Meyer's careful observations deserve more attention than they have received from clinical surgeons. My own opinion is that the cases he describes are usually the result of ruptures of that portion of the musculo-tendinous cuff which is inserted into the inner side of the intertubercular notch. This portion is made up by the joined edges of the supraspinatus and of the subscapularis.  I do not believe that bare tuberosities are the results of attrition; I think they are due to evulsion of the tendon fibers. This is shown by the fact that in most cases the evulsion of fibers begins on the cartilage side of the tendon.
Whatever the cause, it is undoubtedly true that in the cadaver one occasionally finds that the long head of the biceps can slip out of the upper end of the groove on to the lesser tuberosity. It may be that the maneuver I have described may some day help to make this diagnosis clinically. In such a case it should not be difficult to promote adhesions over the point where the tendon slips and thus hold it in place. There are several ways in which the surgeon could accomplish this.
The remaining two items on King and Holmes' list, relating to the condition of the capsule, have already been considered. It is my belief that most of the three hundred cases in which they state that the X-ray films had been negative were cases of lesions of the tendons of the short rotators, such as those described in Chapters III to V. These lesions do not give pronounced X-ray findings and need special technique for their demonstration. Each facet should be taken in profile separately, and even then the lesions which I have described as excrescences, caverns, and bursal osteitis, are small and inconspicuous. When the attention of the profession has been aroused to the fact that these small but painful lesions exist, Rontgenologists will certainly find the technique to demonstrate them. The average surgeon is not interested in them, but they are of great importance to the patient and to industrial insurance companies. In all such cases the Rontgenologist should take comparative plates of both shoulders to determine the relative amount of bone atrophy. Most of the conditions to which this book is chiefly devoted show bone atrophy at least as early as the fourth week.
It does not seem worth while to enter into the diagnosis of still rarer lesions than those mentioned in this chapter. My list of forty-two consists mainly of one or two instances of each of these unusual conditions, and others could be collected from the literature. We might, for instance, find the report of a case of echinococcus cyst, of a monstrosity or of involvement of the shoulder bones in certain rare general diseases which affect all the bones, such as leprosy, lymphoma, osteomalacia, etc. Our real troubles in diagnosis come, not from the rare diseases, but from the common conditions. A list of such rare cases might be interesting but would not be of great importance. However, there are a few more subjects, if not diseases, which should be mentioned in this connection. These subjects are: bone atrophy, ruptures of muscular insertions, congenital anomalies, the normal epiphyses and variations in their time of union; lastly, zero cases.

Bone Atrophy. Acute bone atrophy was established as a clinical entity by Sudeck. He attributed the condition to low-grade inflammation, but later modified his view and asserted that it was essentially a trophoneurosis. Atrophy occurs more rapidly than it does in the chronic form resulting from disuse and may occur when there is no disability.
The condition is most often studied in the bones of the hands because it is easily recognized in small bones. There is usually a history of trauma with or without fracture, although the condition may arise spontaneously. Onset of symptoms may occur almost as soon as the initial shock has worn off or may be delayed several days. Pain is usually a prominent feature. The overlying tissue may become swollen and glazed. Motion is limited. The pain is more marked with motion.  There may be hyperesthesia over the part.
The X-ray shows rarefied areas in the spongiosa. The Rontgenologists speak of it as "spot-atrophy." The trabecular fade into one another and produce a poorly defined shadow. The rarefied areas disappear and the individual longitudinal striations are thicker and stronger. The bones are represented by mere outlines in extreme cases.
Acute bone atrophy in the shoulder, particularly in the humerus, has not received any attention. In fact, acute bone atrophy, as a distinct lesion apart from the atrophy of disuse, is still sub judice. In my dispensary work, years ago, I thought that I had many occasions to verify the entity described by Sudeck. I had read his original article in 1900, and many times thought that I had made the diagnosis, particularly in the bones of the hand, in cases of low-grade inflammation not accompanied by suppuration or perhaps by a focus distinct from the atrophied bones, for instance, in cases of felons of the finger. Sometimes in a few weeks following such a lesion the bones of the hand would show extreme atrophy in the X-ray. I soon came to recognize that atrophy occurred very early, and to a great extent, in some of the cases of frozen shoulder. I now know that within about three weeks, if not before, after the onset of restriction of motion, the humerus, and sometimes also the scapula, show marked signs of atrophy. This atrophy is much more marked in some cases than in others. Of late years I have come to think of atrophy of the bone in all cases as being pretty well proportionate to the atrophy of the short rotators. It appears in all these cases to some degree, and involves the whole humerus and especially the spongy bone in the upper end. Very often it is closely associated with the bursa, so that the X-ray shows atrophy which corresponds quite exactly with the part of the bone which is covered by the base of the bursa. Normally, there is less density in the spongy bone in this region, but where atrophy sets in, not only is the density less, but the peripheral outline of the area of absorption is irregular. It seems to me that it is best explained by supposing that an active or passive congestion of the medullary spaces in the spongy bone produces absorption of the intervening trabeculae.
Since the interesting experiments of Allison and Brooks conducted on dogs to study the atrophy of disuse, my convictions have been more or less shaken. Their experiments seemed clearly to indicate that fixation only was responsible. They could detect X-ray changes in the lower extremities as early as seven days after fixation. They concluded that the changes observed were the same whether non-use resulted from nerve paralysis, injury to joints or simple fixation. The degree of atrophy was proportioned to the degree of non-use. My own theory that the trabecular absorption is from congestion seems also to be confuted by the experiments of Grey and Carr, from which they concluded that alterations of the blood supply had no effect. A good review of the literature has been given by Noble and Hauser in Arch, of Surg., Vol. 12, p. 75, 1926.
I still cling to the feeling that there is an atrophy of bone which is produced independently of fixation, and is, as claimed by Sudeck, a trophoneurosis. It is hard for me to believe that a few weeks of fixation could produce the extreme atrophy of the humerus which we find in some cases of tendinitis. I do not find bone atrophy in the shoulders of malingerers or of hysterical cases. When I am in doubt of the preponderance of the mental element in a given case, atrophy demonstrated by the X-ray- strongly influences me to believe that there is a physical lesion as a basis for the symptoms.
At any rate, I feel confident that many cases of atrophy would have been demonstrated in the three hundred negative cases listed by King and Holmes if an effort had been made to find it, by taking comparative films of both shoulders.

Rupture of Muscles and, Tendons. While I may be prejudiced enough to think that rupture of the supraspinatus tendon is more common than that of any other muscular insertion in the shoulder, or even in the whole body, my mind has not become so distorted in writing this book that I ignore other tendons and muscles either about the shoulder or elsewhere. In fact, the reverse is the case, for now I am inclined to the opinion that minor ruptures of tendons about various other joints may initiate the phenomena which we call arthritis. The same degeneration of collagen which I find in the shoulder probably occurs in other tendons and ligaments; slight, unusual efforts tear a few fibers and the same vicious circle which arises in the shoulder conditions, spasm, adhesion, non-use from pain, further degeneration, more ruptured fibers, etc., produces the picture of arthritis.
In the shoulder we have already seen that the long head of the biceps and the tendons of the short rotators may individually, or to a greater or less extent together, become evulsed. I have seen two cases where almost the whole of the great pectoral insertion tore out. Several times I have seen partial rupture of this tendon. No doubt the insertions of the rhomboids, of the latissimus and of other tendons at times tear out and produce soreness and pain and muscular spasm. Yet the literature concerning these lesions is scanty. I am apt to make provisional diagnoses of these lesions when I find sharply localized tenderness at the insertion and spasm in the belly of a muscle, especially if there is also spasm in the antagonistic muscles.
According to Loos, Petit was the first to report a case of ruptured muscle, in 1722. The muscles most commonly injured, according to Gottlieb, in a review of five hundred cases, are: (1) back, (2) calf, (3) quadriceps, (4) adductors, and (5) biceps.
The muscles about the shoulder, other than the biceps and supra-spinatus, are seldom injured, if we may judge by statistics. In the library of the Surgeon General, one case of rupture of trapezius, three cases of deltoid, two cases of pectoralis major, and four of triceps are listed. Rupture usually results from indirect violence. Sudden sharp pain is experienced. There may be a loud snap. A break in continuity can be made out and loss of function results. Contraction of the muscle may cause a swelling, but atrophy results later. Suture of the muscle or tendon, if it can be done soon, will hasten recovery.

Since writing the above I was consulted by a colleague (age about 60), who had a fluctuant tumor, the size of a hen's egg, situated in the anterior lower portion of the right deltoid. He stated that on the evening before he had noticed some pain in the region, and when undressing at night had found the tumor. It was far too large and conspicuous to have escaped his notice if it had been there previously. He recollected that in the morning he had been stooping over and had made quite a violent effort to open a drawer, but did not recall any special pain in doing this. The tumor is firm when the muscle is contracted, and soft when it is relaxed. The X-ray shows an oval cyst-like shadow in the muscle beneath the fascia. There has been no ecchymosis. The tumor caused slight pain for a few days, but since then it has neither caused pain nor interfered with the use of the arm. Two months have elapsed without any apparent change in the size or in other characteristics of the tumor. No operation has been done. My diagnosis of this case is that some of the deltoid fibers in one of the compartments of the muscle were ruptured, and the hematoma being confined between the intermuscular septa has dilated the space, which would normally be shaped somewhat like a section of a melon, until it has assumed the contour of an egg. The case is unique in my experience, and in that of the rontgenologists who have seen the films.

Congenital Anomalies are rare about the shoulder. Absence of the whole or of a portion of the clavicle occasionally occurs. Congenital elevation of the scapula ("Spengel's Deformity") is well known, though rare. The scapula is small and broad. In addition to elevation, internal rotation is also present. A fibrous band may attach the scapula to the vertebral column, and this interferes with motions of the shoulder. I have had no personal experience in treating these cases. Horwitz reviewed 136 cases in Am. Jour. Orth. Surg., 1909, Vol. VI, No. 2.
The only anomaly which the writer has frequently noticed is a protuberance on the clavicle adjacent to the coracoid. In one case which I observed, this protuberance touched the coracoid and there formed, according to the X-ray, a small joint. I do not know whether this protuberance is to be explained by any hypothesis founded on embryology. I do not know whether it has any practical significance. In the case I observed there had been a trauma, the patient complained of pain in the region, the X-ray showed an abnormality and compensation was awarded. I have not seen this condition described elsewhere.
"Snapping Shoulder" is a term used to describe certain cases where there is a definite audible snap in the shoulder when the arm is abducted and externally rotated. The condition may or may not cause pain. I do not understand it, but it may be due to the lesser tuberosity catching as it passes under the short head of the biceps.
As is obvious to every one, there is a wide variation in the shapes of the shoulders of different individuals, and when one studies a large series of macerated specimens, many details in each of the three bones which compose the shoulder are found to vary, as do their mutual relations, and their positions as a group in regard to the rest of the skeleton.  The variations of the humerus and of the clavicle have not received as much attention as have those of the scapula, which have been intensively studied by Dr. W. W. Graves (Director, Department of Neuro-Psychiatry, St. Louis University School of Medicine), not as a contribution to anatomy or to explain local clinical manifestations, but for the broader object "of laying the foundation for investigations on the vital and enduring problems of individual, family and racial fitness." After a series of careful studies, he has concluded that the outline of the greater portion of the vertebral border of the scapula below the base of the spinous process is the most practical, convenient and reliable, single, skeletal landmark yet known to science, for use as a criterion to determine the fitness of individuals, of groups or even of peoples. The valuable anatomic data that he has accumulated are merely by-products of his examinations of large series of scapulae, including anatomic and anthropologic museum specimens from monkeys, apes, primitive man, racial types, and even from collections of foetuses. Data have been derived from healthy and sick groups for comparative study. In a book of this kind I can only afford space for a brief abstract of his evidence, argument, and conclusions.

1. All scapulas may be classified into several distinct types and each type has a characteristic contour of the vertebral border.
2. The general contour of the vertebral border remains the same from the latter part of foetal life until death.
3. Omitting subordinate or incomplete specimens there are two main types of scapulae, and these are found in both ancient and modern men, the scaphoid and the convex.
4. The outline, once formed, is not changed by age, nutrition, occupation, disease, or by any other factor.
5. He has found no1 inherited characters, common to human beings, to be more constantly transmitted from parents to progeny, than scapular types: the scaphoid types showing Mendelian dominance.
6. Statistics of age incidence show that decade by decade the proportion of the convex type increases, so that the incidence of occurrence from birth to the age of sixty-five is almost reversed; i.e., two scaphoid instances to one convex become one scaphoid to two convex.
7. Hence, many individuals possessing the scaphoid type cannot be as resistant to the exigencies of life as are the possessors of the convex types of scapula.
8. Statistics from hospitals, insane asylums, pauper institutions, etc., show that the scaphoid type is represented in greater than normal proportion; therefore, this type indicates a tendency to lack of adaptability as well as to diminished longevity.

Dr. Graves does not assert that the type of scapula is of major importance in a person's psycho-physical make-up; he simply argues that the vertebral border furnishes a conditional index to determine probable longevity, health, and adaptation in general. As a practical example one might say that if one had to pick a baseball team, an army or a board of trustees from groups of otherwise unknown applicants, one would be wise to select those whose scapulas were of the convex type, for the psycho-physical mechanisms of these individuals would probably be of a higher order than those of the remainders of the groups.
Among the by-products of these years of research, Dr. Graves has called attention to an anatomic finding which he calls "the acromial plaque," a condition to which I have alluded in Chapter III, p. 68, as "hypertrophic changes at the acromial edge." Dr. Graves in his paper of 1922 has described these plaques very carefully and has noted their incidence of occurrence. I am inclined to interpret them as results of irritation of the region in response to friction in the bursa, due to irregularity in its base from ruptures of the tendons or from hypertrophic changes in the tuberosities. Their age incidence and percentage of occurrence are confirmatory of this supposition.  Dr. Graves states:
"(4) that neither in man nor in other primates has it thus far been found in young and relatively young, but invariably in old and relatively old bones; and (5) that it is indicated as early as the thirtieth year in human scapulae, increasing in size and frequency of occurrence in succeeding age periods, although it may be either rudimentary or absent even in senile bones. The precise structure or structures involved in the genesis of the plaque; what relation, if any, its presence may bear to pathological processes in general, aside from those incident to age, are problems for further investigation."
Dr. Graves' intensive studies of the age changes in this one bone would make his opinion on anomalous conditions of great value. It is always difficult to say whether such hypertrophic changes and "lip-pings " on the edges of other bones where ligaments, tendons or muscles have their origins and insertions, are due to anomalies, age changes, excessive use of the structures or to toxic conditions in the blood. In these instances at the acromial edge it may be that continued irritation of the tuberosity by the acromial plaque produces the changes in the insertion of the tendon, but my present view is that the reverse is the case.
A very important result of Dr. Graves' studies is, that he has found and used a principle applicable to the evaluation of other criteria on which life expectation may be estimated; i.e., the age incidence of any given inherited morphologic criterion which, after type differentiation, remains throughout life, may be thus used. He merely claims that the shape of the vertebral border of the scapula is a most practical unit. He definitely shows that many of those who possess what is called scaphoid types are less fitted to meet the world, not on account of their scapula, but because the shapes of the vertebral borders are indicative of other mental and physical characteristics. Dr. Graves' work is a fine example of how the scientific method carefully applied year after year, on some apparently trivial circumstance, may lead to conclusions of great importance to future generations.

Epiphyses in the Shoulder Bones. Since the centers of ossification may be mistaken for fractures, the following table (Cunningham) may be of use in the diagnoses of shoulder lesions occurring in youth.

Occasionally the epiphyses of the acromion fail to fuse with the rest of the bone, and the greater part of the acromion is throughout life a separate bone, united to the rest of the process by periosteum and a strip of cartilage, or by a joint which appears like a line of fracture in the X-ray. J have known one such case to be mistaken for a fracture. It is possible that the coracoid epiphyses might cause a similar error, but I have never observed such a case. The coracoid would appear to be broken off at its base.   (See Fig. 56.) In preparation for this book I took my records of shoulder cases and endeavored to file them under definite headings, as in the table on page 469. The task was a difficult one, so far as about one-fifth of the cases were concerned, because for one reason or another the diagnosis was complicated by other considerations than mere s3rmptoms and signs. In some cases I suspected exaggeration, if not actual malingering; others were complicated by coincident injuries; some had trivial or mild symptoms; some had no organic signs to confirm the existence of alleged pain; others had unusual symptoms. Finally, I concluded to classify under the main headings only cases in which the diagnosis was reasonably sure. I marked 0 on the records of the doubtful or trivial cases; thus I have come to think of this group as zero cases.

Zero Cases. It is easy enough to detect typical cases of extreme degrees of rupture of the tendons or of calcification in them, but the cases which are really troublesome in diagnosis are those where the symptoms are mild and transient, where varying degrees of pain and restriction exist or are complicated by the mental attitude of the patient. This is particularly true in industrial cases where the element of compensation enters the problem.
Many of these mild cases, without clear-cut signs, can only be classed as strains; the shoulder remains sore for a few days or weeks, and recovers under palliative remedies. We can no more absolutely define strain in the shoulder than we can strains and sprains in the other joints or muscle insertions. My belief is that most of these cases are due to what I call "rim rents," i.e., the evulsion of a few of the fibers of the short rotators on the joint side. In such cases, with almost negligible physical signs and a mere complaint of pain, I cannot be positive as to the exact nature of the lesion. The more my experience has increased, however, the more sure I am able to feel of this conviction. Oftentimes I can palpate very distinctly the tender spot on the tuberosity which is, I believe, the location of the actual lesion, although the patient refers the pain to the spasmodic muscles. Patient, repeated examinations, which show consistent accuracy in the location of tenderness, may strengthen one's conviction that there is a real injury, even though it is pretty obvious that the employee is making the most of his symptoms in order to get compensation. "Strain" is the word which, by long custom, we apply to indefinite lesions of the muscles and tendons, and we do not yet know of any technique by which these lesions can be actually demonstrated. However, the cases of complete rupture of the supraspinatus described in this book must be promptly diagnosed and not passed off as strains. At present the only way to be sure in a suspicious case is to make a small exploratory incision in the bursa. Improved Rdnt-gen technique aided by injection of air or of opaque fluids will make this Zero Class smaller.
Of course, many of these cases I saw only once, and any doubtful case needs repeated study. However, even with more study there would have been a large class in which I was in doubt of the real nature of the lesion, which caused the patient to claim disability. Usually this doubt was more of a mental than of a physical nature. How much more satisfactory the world would be if we gave up lying! How inefficient it is, particularly in regard to medical science and its results! What with patients lying to doctors, and doctors lying to patients and our lying to each other at scientific meetings, "we tend to become confused," as the patient, polite, dignified man of science would put it.
Of course, this group of zero cases interests me just because I do not understand them. I think I see some promising leads which will throw light on their nature, but I must admit that I do not know enough about one-fifth of the shoulder cases I see to be confident of the detailed diagnoses. I could write a most uninstructive book about this group, for each case is a puzzling and unsolved complex of phases of human nature, vague physical signs and inaccurate statements of the clinical history. I alternately wonder at the good will in human society which has produced the workmen's compensation ideals, and at the viciousness in human nature which constantly interferes with their practical application.

REFERENCES

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