disease has lasted for some time. Hence excision, which secures a useful movable joint after a short convalescence, eradication of the disease, and diminished danger of deposit of tubercle elsewhere, is distinctly preferable to expectant methods, which demand a long time, leave the patient subject to risks of infection elsewhere, and at the best give a stiff joint which is of comparatively little use.

Excision of the Shoulder-joint.-We recommend the following method. The patient should lie upon his back with a firm pillow or sand-bag beneath the affected shoulder, which is drawn well to the

FIG. 96.-WEIGHT EXTENSION APPLIED FOR TUBERCULOUS SHOULDER-JOINT DISEASE. The extension is made with the arm in the abducted position. In the figure above, however, the arm is rotated too much inwards. The forearm should be raised almost into the vertical position by using a thick wedge cushion, with its base beneath the hand; it will then correspond to the position of the limb seen in the preceding figure.

side of the table. The arm should be slightly abducted and rotated outwards. The surgeon stands on the outer side of the joint and makes an incision about four inches in length, commencing just external to the tip of the coracoid process, and extending downwards and outwards parallel to the anterior border of the deltoid (see Fig. 97). It is well to curve the incision outwards at the lower end and to detach a portion of the insertion of the deltoid. In this way the region of the joint can be exposed much more freely than is possible by simply retracting a straight incision. The divided fibres of the deltoid can be stitched together afterwards (see Vol. II. p. 63).

The dissection is carried down to the thickened capsule at the upper part of the incision, and the tendon of the long head of the biceps must be looked for; it is brought into view if the arm is rotated slightly outwards. The biceps tendon should be freed from its sheath, and pulled inwards if it is healthy; if, however, the disease extends down the bicipital groove it must be dissected out. The finger is then passed beneath the deltoid muscle, which is pulled forcibly outwards. Should the deltoid bursa be affected, it must be removed, the arm being fully abducted and the deltoid muscle everted. The front part of the capsule is defined and isolated from the structures lying over it, and the

The arm is now

portion thus separated clipped away with scissors. carried backwards so as to hang over the table, and the muscles attached to the tuberosities are divided sufficiently to enable the head of the bone to be protruded (see Fig. 98). In most cases enough bone can be removed without complete division of the rotators, as a bone section about the level of the anatomical neck or just below it usually suffices. If, however, there is a deposit in the greater tuberosity, that structure must either be removed or the deposit must be gouged out.

After the head of the bone has been removed, the glenoid cavity is sawn off, the amount of bone removed depending on the extent of the disease present. The remains of the capsule must now be clipped away with scissors, and a careful examination of the whole area is made to see that all tuberculous material has been removed. It is important to leave the attachment of the rotators intact if this can be done safely; this permits rotation of the arm, whereas after the old operation, in which the rotators were completely cut across and the bone was sawn on a level with the surgical neck, the resulting limb was often very useless, rotation being always imperfect, and indeed sometimes absent altogether.

FIG. 97. INCISION FOR EXCISION OF THE SHOULDER

JOINT.

To prevent the stiffness which is so liable to follow excision, a layer of fascia taken from the upper arm should be placed over the divided surface of the humerus, and sutured to the periosteum (see p. 153).

A drainage tube should be inserted at the lower angle of the wound, as a considerable cavity is left which may become distended with blood and serum; this tube may be taken out as a rule in three days. A large wedge-shaped pad should be placed in the axilla so as to prevent displacement inwards of the upper end of the bone. It is well also to place a firm pad over the front of the joint, because the upper end of the bone is apt to be drawn forwards. The wedge-shaped pad should be carried down as far as the elbow, and the forearm should be supported in a wrist-sling. The hand should not be bound to the side, but the limb

should be put up with the forearm looking forward in the position already recommended on p. 236. Middeldorpf's splint (see Vol. II. p. 324) is very suitable.

When there is already actual anchylosis of the joint, the head of the bone must be removed in situ at the level of the anatomical neck with a chisel of suitable breadth, the soft parts on the inner and posterior aspects

FIG. 98.-REMOVAL OF THE HEAD OF THE HUMERUS IN EXCISION OF THE SHOULDER. The assistant holds the humerus almost vertical and at the same time pushes the head upwards and outwards. The soft parts are protected by a flexible copper spatula suitably bent, and the saw is applied as shown above.

of the joint being protected from damage by a flexible copper spatula which is pushed in around the head of the bone. A second bone section is then made through the glenoid cavity, and the portion of bone thus detached is removed with lion forceps. In these cases it is simpler to use a Gigli's wire saw for the division of the neck of the bone; it can be passed round the bone by means of a special introducer (see p. 33.)

After-treatment.-As soon as the wound has healed, the arm may be

fixed in position by a starch or water-glass bandage for about two or three weeks, and then passive and active movements should be begun. The time at which these movements should be commenced depends largely upon the amount of bone removed; if the whole of the upper end of the bone has been taken away and the rotators divided, as was done in the old operation, the elbow should be supported and the arm fixed for four or five weeks, otherwise a very lax joint is likely to result; if, on the other hand, the operation we have described above is sufficient, movements should be begun after a fortnight. Special attention must be paid to preserving rotation, which is the movement most likely to be lost; abduction should also be carefully attended to.. The axillary pad and the wrist-sling should be continued for six or eight weeks.

Results. The results of the operation are satisfactory on the whole; all the arm movements, with the exception of a certain amount of rotation, may be preserved, but it is seldom that abduction can be carried as far as, and certainly not beyond, a right angle. If, however, the patient can abduct the limb nearly to a right angle he is generally very well satisfied.

OSTEO-ARTHRITIS.

The shoulder-joint is frequently affected by this disease, and here the affection is often monarticular, or at the most only affects two or three joints. The affection in the shoulder is often spoken of as malum senile, just as in the case of the hip-joint. In the shoulder-joint the disease is often accompanied by severe pain, beginning in the early stages, and also by marked limitation of movement in all directions. Associated with this is rapid atrophy of the deltoid, so that the head of the humerus and the osteophytes, which are common in this situation, can be felt easily.

TREATMENT.-The treatment must be carried out on the same lines as for the disease elsewhere (see p. 143); the only point that we need deal with here is the question of excision. As a means of relieving the pain there is no doubt that excision has great advantages, and therefore, if the patient's general condition is good, and the pain intolerable, it may be justifiable for that reason. The functional result, however, is seldom good in these cases. The movements of the limb are apt to be very imperfect, mainly on account of the atrophy of the deltoid and the other muscles around the joint.

In excising the joint for the relief of the excessive pain, it is advisable to remove the head alone, leaving the greater part of the tuberosities untouched. This can usually be done by means of a chisel and without completely dividing the rotator muscles of the shoulder. The surface of the glenoid cavity should also be removed; and, to prevent anchylosis, a layer of fascia should be inserted between the raw bony surfaces.

After the operation the arm should be kept at rest, with the elbow well away from the side and fixed by a wedge-shaped pad in the axilla, or Middeldorpf's splint (see Vol. II. p. 324). Should fibrous or bony anchylosis occur, this position will give the patient a useful limb, the movements of the shoulder-joint being replaced by the increased mobility of the scapula.

CHARCOT'S DISEASE.

The shoulder is not infrequently the seat of this affection, especially in connection with syringo-myelia. The treatment offers no points of special importance, and has already been described in connection with the disease in general (see p. 134).