Shoulder:Basics - Revision history

Alexandre.laedermann at 12:26, 18 May 2021

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Alexandre.laedermann at 11:58, 18 May 2021

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Alexandre.laedermann at 11:47, 18 May 2021

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2020-12-26T06:23:41Z

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Alexandre.laedermann: /* Honoring Dr. Ernest Amory Codman */

2020-07-12T16:53:51Z

Honoring Dr. Ernest Amory Codman

Alexandre.laedermann: /* Honoring Dr. Ernest Amory Codman */

2020-07-12T16:53:07Z

Honoring Dr. Ernest Amory Codman

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Alexandre.laedermann: /* Honoring Dr. Ernest Amory Codman */

2020-07-12T16:51:02Z

Honoring Dr. Ernest Amory Codman

Alexandre.laedermann at 16:49, 12 July 2020

2020-07-12T16:49:25Z

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Alexandre.laedermann at 16:26, 12 July 2020

2020-07-12T16:26:11Z

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-Sisson in "Comparative Anatomy of the Domestic Animals" (1921 edition) gives the following definitions: "Motion which diminishes the angle included by the segments forming the joint is termed flexion, while that which tends to bring the segments into line with each other is called extension. Circumduction. This designates movements in which the distal end of the limb describes a circle or a segment of one. In man such movement is easily performed, but in quadrupeds it is possible to a limited degree only, and is to be regarded usually as an indication of disease. Adduction and abduction designate respectively movement of a limb toward and away from the median plane." The horse clearly flexes his scapulo-humeral joint as he takes a jump and extends it as he lands on the other side. From a quadruped point of view we might say that the anatomic position of man is one of flexion of the shoulder; complete elevation of the arm (the Statue of Liberty or the diving position) is extension
+Sisson in "Comparative Anatomy of the Domestic Animals" (1921 edition) gives the following definitions: "Motion which diminishes the angle included by the segments forming the joint is termed flexion, while that which tends to bring the segments into line with each other is called extension. Circumduction. This designates movements in which the distal end of the limb describes a circle or a segment of one. In man such movement is easily performed, but in quadrupeds it is possible to a limited degree only, and is to be regarded usually as an indication of disease. Adduction and abduction designate respectively movement of a limb toward and away from the median plane." The horse clearly flexes his scapulo-humeral joint as he takes a jump and extends it as he lands on the other side. From a quadruped point of view we might say that the anatomic position of man is one of flexion of the shoulder; complete elevation of the arm (the Statue of Liberty or the diving position) is extension.
 [[File:Codman image025.jpg|thumb|Elevation of the arm. The term "elevation" clearly applies to the Statue of Liberty, but the arms seem to be "depressed" in the case of the diver, and it would seem absurd to use it to describe the position of these joints in the case of the horse, yet the relations in his shoulder bones are the same as in those of his human companions. A comparative anatomist would hold that all these figures represent "extension" of the scapulo-humeral joint. In this book the term "elevation" will be used for this relation of the humerus and scapula whatever the position of the body, but occasionally, to make the meaning clear, the term "extension," usually qualified by "quadruped," will be used.]]
-From general usage in medical works, on the other hand, we think of the anatomic position as the starting point. Abduction to most surgeons probably means raising the arm to the completely elevated position pointing to the sky, and they would not specify whether this should be done in internal or external rotation, nor in what plane. Extension would probably mean to them the position assumed in enthusiastic greeting with both arms thrust forward (i.e., the anatomic position for the quadruped). When one falls in this position one is said to fall on the extended hands or arms. If you ask a surgeon to put his shoulder joint in extreme flexion he will usually flex his elbow and bring his arm forward and upward. On the principles of comparative anatomy, he should bring his elbow behind his back, or shrug his shoulder. I have several times asked audiences of doctors to rise and place their arms in flexion, extension, adduction or abduction; the results were amusing enough to convince all of us that these terms have very vague meanings, so far as the shoulder is concerned.
+From general usage in medical works, on the other hand, we think of the anatomic position as the starting point. Abduction to most surgeons probably means raising the arm to the completely elevated position pointing to the sky, and they would not specify whether this should be done in internal or external rotation, nor in what plane. Extension would probably mean to them the position assumed in enthusiastic greeting with both arms thrust forward (i.e., the anatomic position for the quadruped). When one falls in this position one is said to fall on the extended hands or arms. If you ask a surgeon to put his/her shoulder joint in extreme flexion he/she will usually flex his elbow and bring his/her arm forward and upward. On the principles of comparative anatomy, he/she should bring his/her elbow behind his back, or shrug his shoulder. I have several times asked audiences of doctors to rise and place their arms in flexion, extension, adduction or abduction; the results were amusing enough to convince all of us that these terms have very vague meanings, so far as the shoulder is concerned.
-The fact is that the members of the medical profession have taken very little interest in this wonderful joint and do not think of its mechanism as precisely as they do of that of their favorite automobile. For the very reason that there are no standard definitions I must be somewhat arbitrary in defining the terms I shall use in this book.
+The fact is that the members of the medical profession have taken very little interest in this wonderful joint and do not think of its mechanism as precisely as they do that of their favorite automobile. For the very reason that there are no standard definitions I must be somewhat arbitrary in defining the terms I shall use in this book.
-When in doubt it is well to follow Gray in anatomic matters, but in this instance he avoids the issue with great skill. Gray says: " The shoulder joint is capable of movement in every direction, forward, backward, abduction, adduction, circumduction, and rotation. The humerus is drawn forward by the pectoralis major, anterior fibers of the deltoid, coracobrachialis, and by the biceps when the elbow is fixed; backward, by the latissimus dorsi, teres major, posterior fibers of the deltoid, and by the triceps when the elbow is fixed; it is abducted (elevated) by the deltoid and supraspinatus; it is adducted (depressed) by the subscapularis, pectoralis major, latissimus dorsi, and teres major; it is rotated outward by the infraspinatus and teres minor; and it is rotated inward by the subscapularis, latissimus dorsi, and teres major." Observe that he has not used flexion or extension and thus avoids controversy. He qualifies "abducted" by a bracketed (elevated) and "adducted" by (depressed). Are the arms in diving depressed, elevated, abducted or extended? Piersol does not help us, for according to him the diver's arms are flexed.  "A motion bringing the distal end of a limb bone nearer the head is called flexion; the opposite movement, extension." If we accept this definition for the scapulo-humeral joint, flexion would occur as we raise the arm from the anatomic position to bring the elbow up beside the head, a motion which in the horse would be extension.
+When in doubt it is well to follow Gray in anatomic matters, but in this instance he avoids the issue with great skill. Gray says: " The shoulder joint is capable of movement in every direction, forward, backward, abduction, adduction, circumduction, and rotation. The humerus is drawn forward by the pectoralis major, anterior fibers of the deltoid, coracobrachialis, and by the biceps when the elbow is fixed; backward, by the latissimus dorsi, teres major, posterior fibers of the deltoid, and by the triceps when the elbow is fixed; it is abducted (elevated) by the deltoid and supraspinatus; it is adducted (depressed) by the subscapularis, pectoralis major, latissimus dorsi, and teres major; it is rotated outward by the infraspinatus and teres minor; and it is rotated inward by the subscapularis, latissimus dorsi, and teres major." Observe that he has not used flexion or extension and thus avoids controversy. He qualifies "abducted" by a bracketed (elevated) and "adducted" by (depressed). Are the arms in diving depressed, elevated, abducted or extended? Piersol does not help us, according to him the diver's arms are flexed.  "A motion bringing the distal end of a limb bone nearer the head is called flexion; the opposite movement, extension." If we accept this definition for the scapulo-humeral joint, flexion would occur as we raise the arm from the anatomic position to bring the elbow up beside the head, a motion which in the horse would be extension.
 [[File:Codman image026small.jpg|thumb|Abduction. The comparative anatomist would admit that the scarecrow holds its arms abducted, but he would differ with the anatomist as to the degree of abduction, and as to the plane in which the humerus had arrived at this position. The polo pony, he would contend, is in the same position as is the scarecrow; i.e., the forelimbs are carried outward from the median line as far as nature permits. The anatomist would say that the scarecrow had performed abduction for about 90° from the anatomic position through the vertical coronal plane; the comparative anatomist would insist that the motion had occurred in the horizontal transverse plane. Abduction for the comparative anatomist has reached its limit, but the ordinary surgeon would say that the arms could be still further abducted until they pointed vertically -upward at the side of the head; yet the anatomist might call this portion of the motion, flexion. Both would agree that the scarecrow's arms are abducted, and I shall call this position abduction irrespective of the degree of rotation of the humerus, or of the plane through which it is attained. A horse or a dog may appear to abduct one leg somewhat as in the lower cut (c), but careful observation will show that most of this abduction is obtained by flexion of the elbow joint plus a little rotation of the scapula; little or no outward motion has occurred in the scapulo-humeral joint itself.]]
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 [[File:Codman image035.jpg|thumb|The terms to be used in this book]]
-Should this man bring the right arm in its lower phase, which is "dorsal flexion," directly forward in the sagittal plane, he could not arrive in the pivotal position without rotating his humerus inward for about 90°. I prefer to call the motion in which he would endeavor, without rotating the humerus, to raise his arm forward in the sagittal plane "elevation in the sagittal plane," but it may be called forward flexion. In the extreme of this position, the axis drawn through the condyles of the lower end of the humerus would be the same as in the anatomic position, i.e., transverse or coronal; in the pivotal position this axis changes 90° {i.e., becomes sagittal), and the inner condyle points forward. When I say that a patient "elevates his arm" I do not especially indicate whether he rotates it externally and carries it up in the coronal plane, or whether he rotates it internally and carries it up in the sagittal plane. Usually he elevates it in some intermediate plane, and the rotation of the clavicle and of the humerus on their long axes occurs without his knowledge or observation. The only justification for using "forward flexion" is that it is the opposite of dorsal flexion, which is true extreme flexion as in the jumping horse. Forward flexion is really only extension.
+Should this man bring the right arm in its lower phase, which is "dorsal flexion," directly forward in the sagittal plane, he could not arrive in the pivotal position without rotating his humerus inward for about 90°. I prefer to call the motion in which he would endeavor, without rotating the humerus, to raise his arm forward in the sagittal plane "elevation in the sagittal plane," but it may be called forward flexion. In the extreme of this position, the axis drawn through the condyles of the lower end of the humerus would be the same as in the anatomic position, i.e., transverse or coronal; in the pivotal position this axis changes 90° {i.e., becomes sagittal), and the inner condyle points forward. When I say that a patient "elevates his/her arm" I do not especially indicate whether he rotates it externally and carries it up in the coronal plane, or whether he/she rotates it internally and carries it up in the sagittal plane. Usually he/she elevates it in some intermediate plane, and the rotation of the clavicle and of the humerus on their long axes occurs without his knowledge or observation. The only justification for using "forward flexion" is that it is the opposite of dorsal flexion, which is true extreme flexion as in the jumping horse. Forward flexion is really only extension.
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 ====Rotation on the long axis of the humerus====
-When the patient is standing in the anatomic position, with his arm at the side and the palm forward, the humerus is in almost a mid-position between internal and external rotation. By turning the palm as far as one can outward, the humerus has moved to extreme external rotation. By turning the palm inward until it has faced backward and again outward, the plane of the palm has traversed nearly a complete circle (360 degrees), owing to rotation of the humerus and scapula (180 degrees), plus rotation of the radius (nearly 180 degrees). When one reaches up as high as possible, the humerus arrives at a fixed position where it can no longer be rotated, although the palm will turn nearly 180 degrees. Now in all of these motions, the turning of the palm is deceptive, because the palm turns almost a half circle by the motion of the radius over the ulna—the rotation of the humerus on its long axis being only a part of the motion. In order to get rid of this deception in testing the scapulo-humeral motion, one should flex the forearm to a right angle, and retain it in this position throughout our tests. Since the elbow joint does not move laterally, one can discount the motion of the palm and judge the rotation of the humerus (and scapula) by the angle through which the flexed forearm (i.e., the ulna) moves inward and outward. No matter what position the palm assumes, the motion of the humerus is not affected so long as the forearm is flexed at a right angle, but when the elbow is extended the humerus may rotate synchronously with the radius without our perception.
+When the patient is standing in the anatomic position, with his/her arm at the side and the palm forward, the humerus is in almost a mid-position between internal and external rotation. By turning the palm as far as one can outward, the humerus has moved to extreme external rotation. By turning the palm inward until it has faced backward and again outward, the plane of the palm has traversed nearly a complete circle (360 degrees), owing to rotation of the humerus and scapula (180 degrees), plus rotation of the radius (nearly 180 degrees). When one reaches up as high as possible, the humerus arrives at a fixed position where it can no longer be rotated, although the palm will turn nearly 180 degrees. Now in all of these motions, the turning of the palm is deceptive, because the palm turns almost a half circle by the motion of the radius over the ulna—the rotation of the humerus on its long axis being only a part of the motion. In order to get rid of this deception in testing the scapulo-humeral motion, one should flex the forearm to a right angle, and retain it in this position throughout our tests. Since the elbow joint does not move laterally, one can discount the motion of the palm and judge the rotation of the humerus (and scapula) by the angle through which the flexed forearm (i.e., the ulna) moves inward and outward. No matter what position the palm assumes, the motion of the humerus is not affected so long as the forearm is flexed at a right angle, but when the elbow is extended the humerus may rotate synchronously with the radius without our perception.
-Keeping the forearm flexed at a right angle and keeping the elbow at the side, one can rotate the humerus from the anatomic position outward about 90 degrees. Keeping the elbow at the side and placing the flexed forearm behind the back, one can rotate the humerus inward about 90 degrees.  The total arc of rotation, therefore, is at least 180 degrees in a normal person of medium age, provided that the arm is at the side in the anatomic position, for the degree of rotation diminishes as the arm is elevated. This estimate is not perfectly exact because the whole scapula rotates a little also. It is slightly in excess of 180 degrees in young people, particularly in girls, and is slightly beneath this in elderly persons —although occasionally, elderly persons, particularly women, retain a large range of motion.
+Keeping the forearm flexed at a right angle and keeping the elbow at the side, one can rotate the humerus from the anatomic position outward about 90 degrees. Keeping the elbow at the side and placing the flexed forearm behind the back, one can rotate the humerus inward about 90 degrees. The total arc of rotation, therefore, is at least 180 degrees in a normal person of medium age, provided that the arm is at the side in the anatomic position, for the degree of rotation diminishes as the arm is elevated. This estimate is not perfectly exact because the whole scapula rotates a little also. It is slightly in excess of 180 degrees in young people, particularly in girls, and is slightly beneath this in elderly persons —although occasionally, elderly persons, particularly women, retain a large range of motion.
 I wish to warn the reader not to get the idea that rotation of the humerus is a motion which occurs in the true shoulder joint only. The subacromial bursa, particularly its subcoracoid portion, is as essential in rotation as in upward motions of the arm.

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 ==What would Codman have thought about this?==
 ===Normal motions of the shoulder joint===
-There are certain anatomic terms customarily applied to the motions of the joints in general which are well understood except when applied to the shoulder. For instance, will the reader kindly flex his shoulder, i.e., his scapulo-humeral joint, to its utmost. Please pose in turn in extreme abduction, extreme adduction, and in extreme extension. I plead with you to try these positions before you read any further, for it probably will be necessary for you to reeducate yourself so far as the meanings of these terms are concerned. Having determined what you think they mean, answer the following questions': What motion occurs in the scapulo-humeral joint when you raise your finger tips as high as you possibly can toward the ceiling? In what position is the joint when your body is in the "anatomic" position ? Picture to yourself a horse taking a jump. Does he flex his scapulo-humeral joint before he takes the jump or after?
+There are certain anatomic terms customarily applied to the motions of the joints in general which are well understood except when applied to the shoulder. For instance, will the reader kindly flex his/her shoulder, i.e., his/her scapulo-humeral joint, to its utmost. Please pose in turn in extreme abduction, extreme adduction, and in extreme extension. I plead with you to try these positions before you read any further, for it probably will be necessary for you to reeducate yourself so far as the meanings of these terms are concerned. Having determined what you think they mean, answer the following questions: What motion occurs in the scapulo-humeral joint when you raise your finger tips as high as you possibly can toward the ceiling? In what position is the joint when your body is in the "anatomic" position? Picture a horse taking a jump. Does he flex his scapulo-humeral joint before he takes the jump or after?
-[[File:Codman_image024.jpg|alt=|frame]]
+[[File:Codman_image024.jpg|alt=|thumb|HORSE TAKING A JUMP Before reading further please name to yourself the position in which this figure shows the scapulo-humeral joint. In the man? In the horse?]]
-There is some room for a difference of opinion on these questions, because we may be guided by the point of view of comparative anatomy or accept the terms which have become customary for the biped human. In man, the conventional anatomic position adopted for teaching purposes is a standing one with the arms at the side and the palms forward. The anatomic position for a horse is the position in which we usually see him standing, with his forelegs at a right angle with his spine. Man would have to raise his arms to a right angle in front of his body to approach the horse's position.
+There is some room for a difference of opinion on these questions, because we may be guided by the point of view of comparative anatomy or accept the terms which have become customary for the biped human. In humans, the conventional anatomic position adopted for teaching purposes is a standing one with the arms at the side and the palms forward. The anatomic position for a horse is the position in which we usually see him standing, with his forelegs at a right angle with his spine. A human would have to raise his arms to a right angle in front of his body to approach the horse's position.

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 ===Normal motions of the shoulder joint===
 There are certain anatomic terms customarily applied to the motions of the joints in general which are well understood except when applied to the shoulder. For instance, will the reader kindly flex his shoulder, i.e., his scapulo-humeral joint, to its utmost. Please pose in turn in extreme abduction, extreme adduction, and in extreme extension. I plead with you to try these positions before you read any further, for it probably will be necessary for you to reeducate yourself so far as the meanings of these terms are concerned. Having determined what you think they mean, answer the following questions': What motion occurs in the scapulo-humeral joint when you raise your finger tips as high as you possibly can toward the ceiling? In what position is the joint when your body is in the "anatomic" position ? Picture to yourself a horse taking a jump. Does he flex his scapulo-humeral joint before he takes the jump or after?
+[[File:Codman_image024.jpg|alt=|frame]]
 There is some room for a difference of opinion on these questions, because we may be guided by the point of view of comparative anatomy or accept the terms which have become customary for the biped human. In man, the conventional anatomic position adopted for teaching purposes is a standing one with the arms at the side and the palms forward. The anatomic position for a horse is the position in which we usually see him standing, with his forelegs at a right angle with his spine. Man would have to raise his arms to a right angle in front of his body to approach the horse's position.

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 In studying the motions of the shoulder one must always bear in mind the serratus, the action of which is concealed. It is of great importance and is necessary to complete elevation of the arm. Remember that the majority of the animal world walk, run and leap on their serrati, for they have no clavicles to make skeletal contact.
-I do not intend to attempt to review in detail the action of the other individual muscles about the shoulder. At best I could not equal the wonderful descriptions of their actions written by Duchenne in his "Physiologie des Movements," published in Paris in 1867 and remaining unsurpassed today.
+I do not intend to attempt to review in detail the action of the other individual muscles about the shoulder. At best I could not equal the wonderful descriptions of their actions written by Duchenne in his "Physiologie des Mouvements," published in Paris in 1867 and remaining unsurpassed today. Physiologie des mouvements: Démontrer à l'aide de l'experimentation électrique et de l'observation clinique et applicable à l'étude des paralysies et des déformations.<ref>Duchenne de Boulogne GB. [Physiologie des Mouvements] Ed Bailliere J.-B. et Fils. Libraires De L'Academie Imperiale De Medecine, Loudres, France, 1867</ref> He was greatly interested in the study of the paralyses of these various muscles, and his analysis is much influenced by this point of view. More recently Mollier has published his lectures addressed to art students.<ref>Mollier S, Plastische Anatomie, Verlag von J. F. Bergmann, Munchen, 1924</ref> I have been able to find no contribution of importance in the literature during the 60 years that intervened.
 Curiously enough, neither of these writers shows any interest in the subacromial bursa, which I regard as an indispensable part of the human joint. They do not mention it. I have frankly given all the space I can spare on anatomy to my own point of view to bring out what I feel is the relative importance of the bursa, compared to the joint itself. I have tried to show that the destruction of either joint or bursa takes away not only the motions which quadrupeds possess, but most of those remarkable additional features of the mechanics of the joint which have come to us and to the monkeys to fulfill the need for abduction and adduction. I have described in these two chapters some aspects of shoulder motion which I have not seen mentioned elsewhere, but Duchenne and Mollier have between them covered about everything else now known about this joint, including a great deal that I have not alluded to above. We simply must close this chapter, for there is no end to the beautiful complexities of motion which this joint performs, but if the reader has not understood and agreed (or rationally disagreed) with what I have said here, he had better not finish the book.

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-The End Result Idea was never mentioned. He was the best of us. And perhaps in a new century, new millennium, the respect he so deserves will finally be accorded him.
+The End Result Idea was never mentioned. He was the best of us. And perhaps in a new century, new millennium, the respect he so deserves will finally be accorded him.<ref>Berwick DM. “E. A. Codman and the rhetoric of battle: a commentary.” Milbank Quarterly. 1989;67(2):262-267</ref><ref>Codman EA. Committee for Standardization of Hospitals of the American College of Surgeons. Minimum standard for hospitals. Bull Am Coll Surg. 1924;8:4</ref><ref>Codman EA. A Study in Hospital Efficiency. As Demonstrated by the Case Report of the First Five Years of a Private Hospital. Boston: Thomas Todd Co., 1918-1920</ref><ref>Codman EA. Bone Sarcoma: An Interpretation of the Nomenclature Used by the Committee on the Registry of Bone Sarcoma of the American College of Surgeons. New York: Paul B. Hoeber, Inc., 1925</ref><ref>Codman EA. The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions In or About the Subacromial Bursa. Boston: Thomas Todd Co., 1934</ref><ref>Donabedian A. The end results of health care: Ernest Codman’s contribution to quality assessment and beyond. Milbank Quarterly.1989;67(2):233-256</ref><ref>Mallon B. Ernest Amory Codman: The End Result of a Life in Medicine. Philadelphia: W. B. Saunders (Elsevier), 1999</ref><ref>Neuhauser D. Ernest Amory Codman, M.D., and end results of medical care. Int J Tech Assessment Health Care. 1990;6:307-325</ref><ref>Reverby S. Stealing the golden eggs: Ernest Amory Codman and the science and management of medicine. Bull History Med. 1981;55:156-171</ref>
 ==References==
 <references />

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 ==Honoring Dr. Ernest Amory Codman==
-From Amory Codman: The End Result of a Dream to Revolutionize Medicine<ref>Mallon B. Amory Codman: The End Result of a Dream to Revolutionize Medicine. https://www.codmansociety.org/honoring-dr-codman-1</ref>, with permission.<ref>Berwick DM. “E. A. Codman and the rhetoric of battle: a commentary.” Milbank Quarterly. 1989;67(2):262-267</ref><ref>Codman EA. Committee for Standardization of Hospitals of the American College of Surgeons. Minimum standard for hospitals. Bull Am Coll Surg. 1924;8:4</ref><ref>Codman EA. A Study in Hospital Efficiency. As Demonstrated by the Case Report of the First Five Years of a Private Hospital. Boston: Thomas Todd Co., 1918-1920</ref><ref>Codman EA. Bone Sarcoma: An Interpretation of the Nomenclature Used by the Committee on the Registry of Bone Sarcoma of the American College of Surgeons. New York: Paul B. Hoeber, Inc., 1925</ref><ref>Codman EA. The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions In or About the Subacromial Bursa. Boston: Thomas Todd Co., 1934</ref><ref>Donabedian A. The end results of health care: Ernest Codman’s contribution to quality assessment and beyond. Milbank Quarterly.1989;67(2):233-256</ref><ref>Mallon B. Ernest Amory Codman: The End Result of a Life in Medicine. Philadelphia: W. B. Saunders (Elsevier), 1999</ref><ref>Neuhauser D. Ernest Amory Codman, M.D., and end results of medical care. Int J Tech Assessment Health Care. 1990;6:307-325</ref><ref>Reverby S. Stealing the golden eggs: Ernest Amory Codman and the science and management of medicine. Bull History Med. 1981;55:156-171</ref>
+From Amory Codman: The End Result of a Dream to Revolutionize Medicine<ref>Mallon B. Amory Codman: The End Result of a Dream to Revolutionize Medicine. https://www.codmansociety.org/honoring-dr-codman-1</ref>, with permission.
 Ernest Amory Codman was born in Boston just after Christmas in 1869. He died in Ponkapoag, a neighborhood just south of Boston, around Thanksgiving 1940. In those 71 years, he attempted to revolutionize the way medicine is practiced in the United States. You could say he did it quietly, as it is not well known today, but Codman rarely did anything quietly, and perhaps that was part of the problem. His efforts failed in his own lifetime, and he predicted that, saying that perhaps they would be appreciated by a future generation. Yet for all those failures, he may have been the most important American physician of the 20th century.
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 The End Result Idea was never mentioned. He was the best of us. And perhaps in a new century, new millennium, the respect he so deserves will finally be accorded him.
 ==References==
 <references />

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 The combined action of the two muscles is so habitual that one cannot voluntarily disassociate them in abduction, although one frequently uses the power of the deltoid alone to raise or square the shoulder, and vice versa, in lowering the shoulder to the position of round or sloping shoulder, one abducts the scapula on the humerus by using the supraspinatus. Even in the latter motion one cannot disassociate contraction of the deltoid.
-As the years have passed I have seen no reason to withdraw any of the above statements, and I have seen many individual cases which confirm and illustrate the importance of these observations. I have seen a number of cases which confirm the observation of Duchenne, that the supraspinatus alone can perform abduction. This is referred to in Chapter XII, p. 393. On the other hand, every case of rupture of the supraspinatus confirms the remarks in regard to the function of the supraspinatus in furnishing a fulcrum for the deltoid. All cases of rupture of the supraspinatus illustrate the tendency of the deltoid to lift the arm on its vertical axis.
+As the years have passed I have seen no reason to withdraw any of the above statements, and I have seen many individual cases which confirm and illustrate the importance of these observations. I have seen a number of cases which confirm the observation of Duchenne, that the supraspinatus alone can perform abduction. On the other hand, every case of rupture of the supraspinatus confirms the remarks in regard to the function of the supraspinatus in furnishing a fulcrum for the deltoid. All cases of rupture of the supraspinatus illustrate the tendency of the deltoid to lift the arm on its vertical axis.
 Stevens in the above article quotes me as holding that the supraspinatus initiates the motion of abduction. If I have expressed myself thus, I have changed my mind now, and as stated on page 52, I at present believe that the scapulo-humeral rhythm in elevation of the arm and shoulder together is uniform from first to last, all the muscles cooperating to some degree. It is probable that the reason that the motions of the shoulder have been misinterpreted so long, i.e., that it is almost universally accepted that the humerus moves before the scapula, is a simple little point. When the model stands erect preliminary to the order to raise his arm so that the motions of the bones can be observed, his muscles are relatively relaxed. As soon as his mind obeys the order, all the muscles related to the scapula have to work in some degree in cooperation. The very first observable motion in the scapula is a slight movement of the inferior angle toward the vertebral column. Shortly after this, the inferior angle proceeds slowly and steadily in a curved line toward the axilla. I interpret the little preliminary motion toward the median line as an effort of the secondary shoulder muscles to fix the scapula so that the short rotators and muscles of the arm can begin to work. The phenomenon may be just as well interpreted in the reverse way; that is, that the sudden assumption of scapulo-humeral action throws weight on the scapula and therefore tips the inferior angle toward the back bone. It does not seem important to decide which of these sets of muscles first begins to operate, but it is important to know that there is this little hesitation at the beginning of the motion, for I think that it is this brief period of preliminary stabilization of the whole shoulder which has led to the deception that the humerus begins to move on the scapula before the scapula begins to move on the body. At any rate, I feel quite certain that the supraspinatus must exert its power before the deltoid can act as an abductor, and that in a normal person abduction of the scapulo-humeral joint is due to a combined effort of the two muscles. As reiterated in other places in this book, I am also sure that elevation can be freely and haltingly performed, even when the supraspinatus has been evulsed, for the other short rotators can to a certain extent hold the head of the humerus on its fulcrum, the glenoid.
 A few principles should be briefly emphasized before leaving the subject of the action of the muscles about the shoulder. In the first place many of the muscles in this region are fan-shaped, and therefore their fibers pull in greatly different directions. The trapezius, for instance, is really a compound muscle. Each bundle of fibers is almost a separate muscle and in fact the extreme ones are almost antagonistic. The lowest fibers pull the shoulder down and the uppermost pull the shoulder up. The deltoid itself is fan-shaped, with the edge of the fan curved. The subscapularis, infraspinatus, latissimus dorsi and pectoralis major and minor are also fan-shaped. All the handles of the fans point toward the head of the humerus. How extremely sensitive must be the cooperation between these varied muscles, all the parts of which must act together in almost any motion which we perform with our hands, for not only are the various nerves which we know as branches of the brachial plexus concerned, but the subdivisions of these nerves after they have proceeded to the individual bundles of muscular fibers. In raising the arm, for instance, a ripple of impulses must run through the bundles composing the trapezius, and similar ripples must take place through the fan-shaped origins of the latissimus dorsi, serratus, pectorals, etc. Relaxation of some fibers at appropriate moments is quite as important as stimulation of others. In fact, as one makes the simplest motion to raise the arm to touch a point on the wall with the finger, there must be a perfect symphony of cooperating relaxing nerve impulses harmonizing witli contractions from various other groups of muscle fibers, which, if analyzed in detail, would be more complex than the music written for a whole burst of harmony from an orchestra.
 In studying the motions of the shoulder one must always bear in mind the serratus, the action of which is concealed. It is of great importance and is necessary to complete elevation of the arm. Remember that the majority of the animal world walk, run and leap on their serrati, for they have no clavicles to make skeletal contact.
-I do not intend to attempt to review in detail the action of the other individual muscles about the shoulder. At best I could not equal the wonderful descriptions of their actions written by Duchenne in his "Physiologie des Movements," published in Paris in 1867 and remaining unsurpassed today. He was greatly interested in the study of the paralyses of these various muscles, and his analysis is much influenced by this point of view. More recently Mollier has published his lectures addressed to art students (S. Mollier, Plastische Anato-mie, Verlag von J. F. Bergmann, Miinchen, 1924). I have been able to find no contribution of importance in the literature during the 60 years that intervened.
+I do not intend to attempt to review in detail the action of the other individual muscles about the shoulder. At best I could not equal the wonderful descriptions of their actions written by Duchenne in his "Physiologie des Movements," published in Paris in 1867 and remaining unsurpassed today. He was greatly interested in the study of the paralyses of these various muscles, and his analysis is much influenced by this point of view. More recently Mollier has published his lectures addressed to art students.<ref>Mollier S, Plastische Anatomie, Verlag von J. F. Bergmann, Munchen, 1924</ref> I have been able to find no contribution of importance in the literature during the 60 years that intervened.
 Curiously enough, neither of these writers shows any interest in the subacromial bursa, which I regard as an indispensable part of the human joint. They do not mention it. I have frankly given all the space I can spare on anatomy to my own point of view to bring out what I feel is the relative importance of the bursa, compared to the joint itself. I have tried to show that the destruction of either joint or bursa takes away not only the motions which quadrupeds possess, but most of those remarkable additional features of the mechanics of the joint which have come to us and to the monkeys to fulfill the need for abduction and adduction.
-I have described in these two chapters some aspects of shoulder motion which I have not seen mentioned elsewhere, but Duchenne and Mollier have between them covered about everything else now known about this joint, including a great deal that I have not alluded to above.
+Curiously enough, neither of these writers shows any interest in the subacromial bursa, which I regard as an indispensable part of the human joint. They do not mention it. I have frankly given all the space I can spare on anatomy to my own point of view to bring out what I feel is the relative importance of the bursa, compared to the joint itself. I have tried to show that the destruction of either joint or bursa takes away not only the motions which quadrupeds possess, but most of those remarkable additional features of the mechanics of the joint which have come to us and to the monkeys to fulfill the need for abduction and adduction. I have described in these two chapters some aspects of shoulder motion which I have not seen mentioned elsewhere, but Duchenne and Mollier have between them covered about everything else now known about this joint, including a great deal that I have not alluded to above. We simply must close this chapter, for there is no end to the beautiful complexities of motion which this joint performs, but if the reader has not understood and agreed (or rationally disagreed) with what I have said here, he had better not finish the book.
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 It was not well-received. Several doctors got up and left in a huff. Others accosted him verbally and tempers had to be calmed. Codman was asked to resign as chairman of the Surgical Society and his practice suffered. External events would later add to the damage. On 5 December 1917, two munition ships, the Imo and the Mont Blanc, refueled in Halifax Harbour in Nova Scotia, anchoring there overnite. The next morning, at 9 AM, they collided in the harbour, with the result being the largest man-made explosion in the history of the world, until the advent of World War II and the atomic bomb. Over 3,000 people were killed in a city of 60,000 people, and many more were blinded by the remnants of the explosion and flying glass. Codman had many friends in Nova Scotia, a place he had visited many times for hunting and fishing trips. The day after the explosion he took a train from Boston, along with some of the nurses from the Codman Hospital, and set up a mobile hospital in Halifax, staying there for over two weeks to treat the survivors of the explosion. To this day, because of the aid given by Codman and other Boston physicians, the citizens of Halifax send a Christmas tree to Boston, which is lighted on Boston Common.
 World War I was soon upon the United States, and when Codman returned from Halifax, he enlisted in the Army. He was stationed mostly at Camp Taylor, Kentucky. While he did not see overseas duty, his work in the Army was harrowing because of the 1918 influenza pandemic, considered the greatest pandemic in the history of mankind. Possibly as many as 50 million people died world-wide from influenza, and its precise cause is still being studied. It is postulated that it began among the American military and was spread world-wide when the US Army was mobilized to Europe. Codman’s wards were filled with flu-stricken troops, who were under his care. Codman soldiered on, working almost inhuman hours while caring for the dying.