Dislocation of the shoulder-joint is the t commonest of dislocations and one of the most liable to i remain unreduced. This liability may be explained in the 13 following way. The joint is thickly covered with both t muscle and fat in the middle-aged males who are most liable 1 3 ( to this injury, so that when swelling supervenes a wrong or { doubtful diagnosis is apt to be made. The patients are not t infrequently alcoholic and therefore careless of their persons ( and dilatory in reporting

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... mselves to their medical attendant or in presenting themselves at hospital. The injury is not always a very painful one. Possibly one reason why it is sometimes confounded with fracture is that it usually is i complicated with some minor fracture, especially with fracture I of the greater tuberosity of the humerus. We have learnt 1 this from the practice of operating on unreduced dislocations 4 and also from the use of the x rays. The great majority of ] these dislocations are subcoracoid and it will be remembered that their reduction is usually attempted either by extension combined with leverage obtained by using the surgeon's foot or fist as a fulcrum or else by manipulation, using the attachment of the coraco-humeral ligament to the edge of the glenoid cavity as a fulcrum and often also combining with the manipulation extension applied to the upper end of the arm and at right angles to its long axis so as to prize the head of the humerus from beneath the coracoid or the clavicle. And it is not uncommon to combine with any method direct pressure with the fingers over the head of the humerus with a view to pushing it into the glenoid cavity. The most justly popular of the manipulation methods is Kocher's and there is no better extension method than that known'as Astley Cooper's-namely, with the heel in the axilla. Kocher's method, as is well known, is based mainly on the consideration that the upper and outer part of the capsule, including especially the strong bands which extend from the coracoid process to the humerus on each side of the bicipital groove, remains untorn. In order to relax this the upper arm is rotated strongly outwards. Previously, in order to bring the head of the humerus firmly against the edge of the glenoid, the elbow is pressed against the flank and, in resistant cases, backwards and towards the spine as well. Then the arm is raised in an antero-posterior plane up towards the front of the shoulder. The head of the humerus ought then to have been by these manipulations levered into position on the edge of the glenoid opposite the rent in the capsule and ready to slip into place as soon as the humerus is rotated inwards. Measures like these frequently succeed in old dislocations as well as in new, especially if they are used with skill, patience, and perseverance. (Great force should not be employed on account of its dangers') Thus Kocher reduced 12 out of 13 dislocations by manipulation. Their age was as follows : one of three weeks, two of five weeks, three of seven weeks, four of three months, and two of four months. Other surgeons do not seem to have been quite so successful, though Kocher's pupil, Ceppi, says that one can reduce an old as easily as a recent dislocation. It is difficult to avoid a slight feeling of scepticism, especially when one has inspected the interior of an old unreduced shoulder-joint. The usually accepted limit for even attempting reduction of dislocated shoulders has long been three months. It is well known that success has occasionally followed attempts on much older cases, but only rarely. And many dangerous accidents have resulted from the employment of even moderate force. No reasonable person can suppose that a very old unreduced dislocation can be freed from its adhesions and from its new capsule, and a place remade for it in the glenoid now firmly adherent to overlying soft tissues and often to fragments of bone without the exeicise of force. SYMPTOMS. Those of an old unreduced dislocation differ in some points from those of a fresh one. Instead of swelling and effusion of blood there is wasting of the deltoid and of other muscles. The absence of the head of the humerus from the glenoid and its presence elsewhere thus become very obvious. On the other hand, in some old cases the original projection of the elbow from the side becomes lessened, but not in all, at least until a very considerable time has elapsed. In some cases time and exercises increase the range of movement of the displaced shoulder-joint, but in others time diminishes it. The freedom of movement of the scapula on the trunk tends to increase. As a rule there is no difficulty in recognising an old dislocation of the shoulder, because the absence of the head of the humerus from the glenoid can be felt so easily as well as seen. Whether or not there is also a fracture is less easy to determine, but the x rays can be of great assistance. Neither in a skiagram nor even in the course of an open operation is it always possible to be sure whether abnormally placed bone has been chipped off, torn off, or altogether newly formed. PROGNOSIS. The longest series of cases of old dislocation of the shoulder treated at one hospital under one surgeon with which I am acquainted is that given by J. Finckh in his admirable account of the experience of Professor Bruns in the Tubingen Clinic. It includes exactly 100 cases. In 27 of these reduction was not attempted and in 73 it was. In nearly two-thirds of these 73 it was successfully effected.