“It has been the experience of all who treat tuberculous joints that bony ankyloses [joint fusion] is the most satisfactory result which can be obtained. No other result assures equal permanency of cure and freedom from late recurrences. The truth is that our means of treating tuberculosis are limited and only feebly effective. In the last analysis, it is the patient himself who masters the infection. We have no specific drug, serum, or therapeutic agent, the use of which will quickly kill the organisms. [Only two things] are of any material value: rest and sunshine.”
—R. I. Harris, Toronto, Ontario, 19351
“Dr. Neer became disenchanted with the end results of patients with fractures of the proximal humerus treated with resection of the humeral head. He mentioned this to Dr. Darrach who said, ‘Smiley, why don’t you do something about it?’”
—Charles Rockwood, MD
My heart sinks when I hear that Miranda has dislocated her shoulder again. I first met her a year ago, when she estimated that she had dislocated both shoulders dozens of times each. As a seizure patient, Miranda is susceptible to a particularly diabolical type of dislocation where the humeral head is forced backward (posterior) and out of joint, instead of the usual anterior dislocation, in which the humeral head is displaced forward and toward the chest wall. Most full-blown dislocations require manipulation (reduction) by a clinician, preferably under deep sedation in the Emergency Room, with the sobering realization that vast numbers of patients over the millennia simply lived with a chronically dislocated and crippled shoulder.
Miranda’s latest dislocation was particularly discouraging for her, because as a twenty-five-year-old, she and her doctor had finally found a medication regimen that had eradicated her seizures. Finding the right anti-seizure medicine can be extremely tricky, balancing side effects against the burden, embarrassment, and inconvenience of a seizure. She had lived seizure-free for months, daring to hope that they were finally gone. But here she was in our ER, painfully frozen to her gurney, her arm protected against her abdomen, downcast and dispirited. She knew the drill: we’d start an IV, “knock her out” with powerful sedatives, and I’d maneuver the arm around while pulling powerfully on her forearm. It seemed plain that she was more disconsolate about her seizure than her dislocation, but then again, my primary job was to relocate the shoulder. Meeting people at their lowest and later helping them to be at their best is among the greatest honors of being a surgeon. A major part of facilitating that transition is providing hope, and I told her that we’d promptly get her shoulder reduced, but more importantly, I gently suggested that we should surgically address her shoulder in the future and make her dislocations a thing of the past. It was as though she hadn’t realized that there was a cure for her problem; I saw a spark of hope, asking, “Is it really possible to keep my shoulder from dislocating?” “Yes,” I assured her, “we are much better at solving people’s shoulder instability problems today through a combination of techniques. Once we’re done here today, let’s set up an appointment in my clinic to fully talk about your shoulders.”
Miranda eventually saw me in clinic, where we discussed surgery. After a detailed conversation she opted for surgery, and soon we addressed her stretched-out shoulder capsule, torn labrum (the gristly connective tissue around the shoulder socket that keeps the humeral head in place), and damaged bony surfaces, and were able to give new life to her left shoulder. In the months that followed, she progressed well, not dislocating either side, and more significantly, not experiencing another seizure.
Now, half a year after her left shoulder operation, Miranda has returned to my clinic, where I learn that she dislocated her shoulder again. “Her left or right?” I ask. “The right side—not the one she had fixed,” my assistant Kristy replies.
Relieved that her operatively repaired left shoulder is still doing well, I knock on her exam room door and enter, finding Miranda sitting on an exam table, and I’m struck by how nervous she is. We know each other pretty well, but she’s anxious, even fidgety.
“Miranda, how are you doing?”
“I had another seizure … I’m sorry,” she blurts out.
I have seen this kind of apologetic reaction in patients who are subject to migraines, seizures, inflammatory bowel disease, and other episodic illnesses where the sufferer has little-to-no control over the disease. The self-reflection on causality, I think, makes them explore whether or not they are to blame for their infirmities.
“This last seizure was a really bad one. Normally I have a pretty strong sense it’s coming on, but I had almost no warning this time. My boyfriend had never seen me have a seizure, and it was really tough for him to see my face so screwed up during the convulsions. You know, my friend videoed me once during a seizure and I couldn’t believe how scary I looked. Now, he saw me look that way …” and she trails away with her eyes welling up with tears.
My hand on her shoulder, I console her, “You know it’s not your fault, right, Miranda?”
“I just feel so bad about it. I also wet my pants and had to leave the restaurant with pee all over my jeans. I just don’t know why I have to have all these damn seizures.”
“Miranda, I cannot imagine how frustrating that must be. I feel so sorry that you suffer from these seizures. It simply isn’t fair. I’m hoping that you and your neurologist can tweak your meds and get your seizures under control, and this I swear to you: I will do everything in my power to make both of your shoulders stable and pain free, so that even if you have another seizure your shoulders will be okay.”
When treating a chronic dislocator who suffers from seizures, I often think about patients in antiquity, who were castigated for their epileptic fits, abused for their “demon possession,” or suspected of witchcraft. The writhing and grimacing of a paroxysm, and the apoplexy that followed a seizure, lead the ancients to conclude that some supernatural power was governing the bodily temple of the victim. And just when the patient’s existence couldn’t be more precarious (with the inference of a hellish collusion), their earthly subsistence increasingly deteriorated with headaches, bodily injuries, tongue bites, confusion, and psychosis.
The rare early philosopher had insight that seizures were not underworldly, but instead were physical disease states. Only in the last century have seizure disorders become treatable, roughly in the same time frame that shoulder instability has become manageable. All medical pioneers shared a certain exasperation, an odium, for the way things were. Even today, when speaking with patients who are burdened with unjust conditions, I have a bitter sadness and vexation for their “dis-ease” that I know my medical forbears had in great measure, as well as a disgust for their poor understanding of what causes disease and how to treat it.
Dr. Charles Neer glanced at the X-rays of Mrs. Harrison’s shoulder, recognizing in a moment that the elderly New Yorker’s arm would be useless for the rest of her life. Frustration growing, Dr. Neer reckoned that this was the third severe shoulder fracture of the month, and he had nothing to offer the patient—at least nothing that would help—and his sense of impotence roiled beneath his tranquil exterior. He had been summoned to the emergency room to evaluate the seventy-year-old Manhattanite who had fallen in her apartment earlier in the day and had been conveyed to the Columbia Presbyterian Medical Center. Although his hospital was one of the first in the world to have a “fracture service,” Dr. Neer knew that in 1951, he was powerless to help Mrs. Harrison, not with surgery, not with a plaster cast, not with a prayer.
With the discovery of X-rays in 1895, Wilhelm Röntgen had revolutionized fracture care—instead of doctors blindly treating crooked and shattered limbs, X-rays divulged detailed information about the location and “personality” of the broken bones. Soon, fracture taxonomy reports appeared in medical journals, and these would eventually guide treatment. Each bone in the body, in time, would have its own classification scheme, usually referred to by its primary author. In the first half of the 20th century, little appreciable progress in patient care had been achieved, but physicians had started to notice the predictable patterns by which bones break.
The “father of shoulder surgery” is Ernest Amory Codman, a firebrand who published The Shoulder in 1934, the first textbook solely dedicated to the treatment of shoulder injuries.2 Codman instigated many crucial changes in medicine, including outcomes research, hospital accreditation, tumor registries, and the advancement of shoulder surgery. Despite his pioneering role in medicine, and particularly in shoulder surgery, Dr. Codman never published a journal article on shoulder fractures, arthritis, rotator cuff tears, or shoulder instability. After a tumultuous career, Dr. Codman died in 1940 at the age of seventy, and in the war-torn decade that followed, a few scattered reports on the treatment of comminuted, or “shattered,” fracture dislocations of the shoulder were published. These articles (written in English, Italian, and German), published just half a century ago, are shockingly simplistic to the modern reader and would stand zero chance of publication today. In general, the authors concluded that surgery of smashed and fragmented shoulder bones was successful (enough) if the fragments were simply removed, leaving a blank shoulder socket that was intended to heal with a blob of scar tissue, with the hope that the resultant “flail arm” provided at least a modicum of function with the arm at the side. The journal publications in the 1940s included no measurements of angular motion of the shoulder joint, no pain scores, and minimal commentary about functional abilities.
A more scientific (less anecdotal) evaluation of the flail arm patients was needed, and the young Charlie Neer was the man to do it.
Born and raised in Vinita, Oklahoma, Charles Sumner Neer II was the namesake of a general physician and surgeon, who was born in New York, trained in St. Louis, and practiced frontier medicine in the Indian Territory that would become the forty-sixth state of the Union. The elder Dr. Neer was himself the son of a physician, and Charlie once wrote that his father “never once thought of me being anything other than a doctor.”3
Vinita, Oklahoma, was the epitome of a frontier town when Charlie was born on November 10, 1917. Oklahoma achieved statehood in 1907, formed from the many independent Indian lands of the (western) Oklahoma Territory and (eastern) Indian Territory. Vinita, located in northeast Oklahoma (near the Kansas and Missouri borders), was in the center of Cherokee lands when the elder C. S. Neer moved there from Missouri to start his new practice.
C. S. Neer, senior, established his clinical practice on the major intersection of town (Wilson Street and Illinois Avenue), on what is now US Route 66. Utilizing literature search techniques, one can trace Dr. Neer’s path from St. Louis to Springfield, Missouri, and then to Vinita; he had publications in the Journal of the American Medical Association in 1907 while a resident, then in 1908 while employed in Springfield, and then in 1909 after setting up shop in Vinita. Charlie was born in 1917 when his physician father was thirty-eight years old, and grew up an accomplished horseman and natural-born Oklahoma lad. Expecting his son to become a physician, Dr. Neer and his wife made the decision to place young Charlie on a train and enrolled him at the Shattuck Military Academy in Faribault, Minnesota (today known as a major incubator of National Hockey League talent), where he would spend his prep school days as a tennis and football standout. The superior education at Shattuck prepared him for Dartmouth College, from which he matriculated in 1939, and then medical school at the University of Pennsylvania, graduating in 1942.
After an internship in 1943 in Philadelphia, Charlie’s surgical training was interrupted by World War II. Like so many physicians during the second great war, life was placed on hold, and Dr. Neer served in both major theaters of war, in field hospitals in Europe (under General George S. Patton) and the Philippines (under General Douglas MacArthur), and at a general hospital in Japan.
Dr. Neer returned to the United States, and for the first time in his life moved to New York City in 1945. For the next half century, the country-born Dr. Neer lived in the busiest city in the world, establishing himself as one of the most influential surgeons who has ever lived. His arrival in New York coincided with waning European medical leadership, and he is one of the pioneers who planted the flag on American soil. His papers are the most quoted in all of orthopedic surgery, and his shoulder surgery trainees became the most influential thought leaders around the world. The manner in which shoulder arthritis, rotator cuff tears, shoulder instability, stiff shoulders, and painful shoulders are treated are all deeply influenced by his original works. And it all started with his truth-telling about our incompetence in dealing with severe shoulder fractures.
In the late 1940s, Dr. Neer completed his orthopedic residency at the New York Orthopedic Hospital (which would join Columbia Presbyterian on the Upper West Side of Manhattan in the early 1950s), and his mentors were the physicians who led the fracture service: William Darrach, Clay Ray Murray, and Harrison McLaughlin. In today’s orthopedic departments, there are many divisions: foot and ankle, sports medicine, total joints, spine, tumor, hand, shoulder and elbow, and pediatric orthopedics; but in the 1940s, fracture care was just starting to be the first specialty of orthopedics, undergoing a major metamorphosis due to a combination of historic advances in metallurgy and antibiotics. As Dr. Neer entered internship in 1942, penicillin was in its first year of use in the United States, reversing a trend where any open fracture (bone poking through the skin) was potentially lethal.
The act of operating in the era before antibiotics made any elective operation risky. There was, therefore, almost no enthusiasm prior to the immediate postwar epoch for insertion of any type of foreign material into the human body. The track record of implanted ivory, bone, glass, metals, plastics, and rubber was abysmal: almost every occasion of implantation resulted in infection, necessitating removal. Today, we hear of fracture and trauma patients undergoing fixation of broken bones on a regular basis; this simply did not exist just a few generations ago. Like an invalid stroke patient, fracture patients were placed in bed, with weeks or months passing before getting in a wheelchair or standing bedside. With no possibility of surgically reassembling the bone fragments, pioneering surgeons were little better than ancient “bone-setters.” Instead of “fixing fractures,” doctors would treat their supine patients with heavy plaster bandages and a dizzying array of ropes, pulleys, splints, and overhead trapeze frames.
Dr. William Darrach was seventy years old, and newly retired from full-time academic surgical practice when Dr. Neer returned from the Pacific Theater. Dr. Darrach had been one of the world’s first great fracture surgeons, and in the few years that their professional lives overlapped in New York, the elder surgeon left an indelible mark on Neer’s career. Decades later, Charlie Neer would still refer to Dr. Darrach as “my Chief.” When Dr. Neer was a resident, he prepared his first publication, “Intracapsular Fractures of the Neck of the Femur,” which was published in the American Journal of Surgery in November 1948. This was copublished with Harrison McLaughlin, MD, then the chief of the fracture service at Columbia. Unusual for its time, the five-page article describes a retrospective chart and X-ray review of 130 fracture patients over a thirteen-year span (1932–44). All 130 patients suffered a hip fracture of the femoral neck, and all of them were treated with the Smith-Petersen nail, the metal plate and screws that were developed by the pioneering orthopedic surgeon from Harvard Marius Nygaard Smith-Petersen. Thoughtful data presentation of patient profiles, disease states, and rudimentary patient satisfaction was conveyed in fourteen tables. Noticeably absent are the outcome measures, hip range of motion numbers, and pain scores that modern orthopedic papers must exhibit. However, the brilliance of reasoning, arrangement, and conclusion reveal a prodigy in the making.
There are six conclusions in the hip fracture paper, the truths of which today are set in stone:
•The best time for reduction and fixation of a hip fracture is immediately. (There is no benefit in waiting for surgery.)
•Good treatment for impacted valgus fractures of the femoral neck is internal fixation and avoidance of bed stay. (Neer makes the assertion that patients do better when bones are stabilized and the patient is moved out of bed.)
•Open reduction, properly done, is surer, shorter, and no more dangerous than closed reduction and blind nailing.
•Open reduction does not increase the incidence of subsequent aseptic necrosis. (Surgery, by itself, does not cause bone death—it’s the fracture that causes necrosis.)
•Results are known only after objective evaluation. (Neer echoes the great scientists and surgeons of the 17th and 18th centuries: Take no man’s word for it.)
•Almost all of the bad results of hip nailing are still the results of bad hip nailing. (In this, Neer’s final sentence of his first paper, he makes plain that technique matters.)
Charlie Neer completed his residency in 1949, shortly after the publication of his hip fracture paper. He immediately became an assistant professor in the Department of Orthopedic Surgery in Columbia University’s College of Physicians and Surgeons on the Upper West Side of Manhattan, and served on the Fracture Service, treating fractures from the neck to the toes. Manhattanites could choose from several world-class hospitals that proudly boasted of new fracture services. The newly constructed Columbia-Presbyterian Medical Center in Morningside Heights (completed in 1928) served the upper portion of Manhattan, the Bronx, and even New Jersey, with the recently opened George Washington Bridge (1931) offering access to the bedroom communities across the Hudson.
Charlie Neer had arrived at Columbia at the perfect time. The mergers of a medical school and university, the building of a campus and a bridge, and the postwar boom provided an expanding patient population for his observations. Reflecting fifty years later, Dr. Neer said, “When I was a resident in orthopedic surgery [1946–9] at the New York Orthopedic, Columbia-Presbyterian Medical Center, the only procedures used to treat problems of the glenohumeral joint were fusions or resections to manage tuberculosis, infections, and old injuries. I became interested in severely displaced fracture-dislocations of the proximal humerus and made a study of lesions of this type that had been treated … with open reduction and internal fixation, closed reduction, and removal of the humeral head.”4
The few resources available to guide orthopedic resident Charlie Neer in the treatment of shoulder fracture-dislocations provided no practically useful information. Ernest Codman’s five-hundred-page-long magnum opus, The Shoulder, focuses on the supraspinatus tendon and bursa, while offering no effective treatment of shoulder arthritis and fractures. One can hardly blame the Boston surgeon for his anemic ministrations; he would die in 1940 without knowing about penicillin, screw fixation of broken bones, or joint replacement. Regarding surgical treatment of fractures, Codman only said, “… early operation is far more promising than if it is delayed for even a few weeks. Surgical skill in handling fractures of the head of the humerus will be displayed more in attaining rapid and comfortable recovery than in ultimately securing good results, for nature alone would produce them in most cases. Injudicious fixation is responsible for most delays and failures in the recovery of normal function.”5 And that’s all—no technique recommendations, and certainly no comment on implants: there were none in 1934.
The other main textbook available to Charlie Neer during his residency was Arthur Steindler’s The Traumatic Deformities and Disabilities of the Upper Extremity, published in 1946. Steindler, the chair of Orthopedic Surgery at the University of Iowa, had published a book that was the most comprehensive technique guide for shoulder, elbow, and hand surgery that had ever been written; by today’s standards, it has almost nothing to say. For treatment of shoulder fractures in which the humeral head had broken and was dislocated, Steindler advised, “Incise along the axillary fold. Proceed bluntly through the subcutaneous tissues. Expose the head by blunt dissection and remove it.”6 Unimaginably terse, removal of the humeral head was the only option considered.
Shortly after Charlie Neer graduated, a breakthrough book by A. F. DePalma, professor and head of Orthopedics at Jefferson Medical College, was published in 1950. His book, Surgery of the Shoulder, was much more descriptive, richly illustrated, and practically useful than anything that had preceded it. Interestingly, there is no mention of penicillin or other antibiotics in the text, and no discussion of infections. A few pages in this lengthy tome dwell on fracture-dislocations of the shoulder, but as with other orthopedic textbooks of the day, the treatment of humeral head fractures is surprisingly crude. DePalma stated, “… removal of the head is unavoidable, despite the realization that the procedure causes great functional disability.”7 Later in the book, he softens, asserting, “with careful management, considerable control of the extremity and a surprisingly good range of painless motion may be obtained.”8
The most authoritative works of Charlie Neer’s early career all concluded the same thing: when faced with a severe fracture-dislocation of the shoulder, the only treatment available was extraction of the humeral head, and the only proper emotional response was a resigned, flimsy hope that a flail arm was better than an amputated arm.
Dr. Neer made his way up to the twelfth floor of the Columbia-Presbyterian Medical Center to visit Mrs. Harrison. She had been admitted to the Orthopedic Unit, awaiting surgery to have her humeral fracture fragments surgically removed in a day or two. Charlie Neer, bald from early adulthood but still athletically built, was accompanied by a few residents who were in their late twenties, boasting of no war experience. The small medical contingent shuffled into the elderly woman’s hospital room, and Dr. Neer sat on the edge of her bed. Mrs. Harrison’s X-rays divulged the severe nature of her injury: the upper portion of her humerus was in multiple pieces, and the humeral head, like part of a Granny Smith apple, was ripped in two. The fracture doctor needed to convey to the patient how serious her injury was and what the treatment plan was.
“Mrs. Harrison, you have a terrible fracture of your arm. The humerus bone is in many pieces.”
With her arm swathed against her body with a linen sheet, and with broken eyeglasses and a fresh black eye from her fall, she was the very picture of a broken and vexed woman.
“There is no way we can save the ball of your shoulder, Mrs. Harrison. But I can’t leave it where it is. We’ll need to take you to the operating room, make an incision, and remove all the broken parts. The only way to treat your shoulder is to take out all the shattered pieces and sew together the tendons in your shoulder and close you up.”
Dr. Neer was a man of few words and quiet contemplation. He paused, waiting for Mrs. Harrison to contemplate what he had proposed.
“Well,” she haltingly started, “am I going to be okay? Will my arm be usable?”
“It’s a little hard to say. This is a fairly rare injury, and we don’t have much guidance in the medical literature, but I don’t think you’ll ever raise your arm above your head, and it will be difficult dressing and working around the house. I’m sorry to tell you this, but you’ll mostly have to use your arm just by moving your elbow and wrist.”
After a brief silence in which Mrs. Harrison pursed her lips, fighting tears, Dr. Neer resumed. “I’ve been interested in this very problem for several years. We don’t do a very good job treating fractures like yours, and I have been spending a great deal of time trying to figure out how we can do better. My fracture colleagues around the world can’t even agree how to describe these kinds of fractures, how common they are, and how to make a difference. But it all starts with seeing how our patients have done here in this hospital, and it’s a project that I’m doggedly working on.” With that, the retinue of residents accompanied Dr. Neer out the door, making their way to the orthopedic clinic.
The residents knew about Dr. Neer’s new project, digging into old charts and X-ray jackets and reviewing the results of patients who had been treated for shoulder fractures at the New York Orthopedic-Columbia Presbyterian Medical Center since 1929, namely, since the hospital had opened its doors in the Morningside Heights neighborhood of Manhattan. This was no small task for the ambitious young attending surgeon, who knew well the dogged determination required in the bowels of the hospital’s chart rooms, with their musty gray patient folders and hand-scribed surgical logs crammed into crenelated shelves, the new fluorescent bulbs purring overhead and the smell of mimeograph ink permeating the medical records department.
Similar to the hip fracture paper he had published a few years before, this chart review project required herculean effort, poring through logbooks from the Fracture Service and the operating room. Charlie Neer wanted to evaluate every shoulder fracture and dislocation (or both) that had darkened the doors of the New York Orthopedic Hospital over a twenty-three-year period (from 1929 to 1951), and determine how many of those injuries involved a fracture, and subsequent dislocation, of the humeral head. A young physician performing this project today would contact her medical records department, submit the ICD-10 code (the national standard diagnosis code, e.g., S42.241A for a severe fracture of the right proximal humerus), and the information technology department would, in a matter of minutes, churn out a list of every patient in that category, replete with their demographic information and hospital number. Armed with these particulars, a skilled data-miner could generate a treasure trove of information from any computer, opening the hospital’s electronic medical records and imaging software. Dr. Neer, instead, needed to summon the skillset of an archeologist, scratching through opaque, coffee table–size logbooks with single-line handwritten entries of patients, with the briefest of descriptions of their names, dates of birth, and fractures.
Every available moment away from patient care was spent delving into the medical histories of shoulder fracture and dislocation patients over the life of the Columbia-Presbyterian Medical Center. Those patients who had suffered simple shoulder fractures were carefully tabulated but not investigated. He knew that most of those patients recovered reasonably well, without the need for surgery. Additionally, those who had experienced dislocations of the shoulder joint were chronicled, but again, not intensively evaluated. Dr. Neer was searching for the patients who had suffered the diabolical combination of a shattered proximal humerus and a dislocation of the humeral head. Slowly, the tedious work of searching through the medical records started to yield the occasional patient who had fallen victim to the terrible amalgamation. After months of chart review, Dr. Neer (and his helpers) had identified 1,796 total patients who had been afflicted with shoulder trauma at the hospital over twenty-three years. More than half of those patients (51.2 percent, or 921 patients) had suffered a fracture of the neck of the humerus. A total of 784 patients had dislocated their shoulders (44 percent of all patients seen at the hospital), and 71 patients had endured a fracture of the tuberosity (the large bump at the top of the humerus where the rotator cuff tendons attach). Of all the patients treated at Columbia-Presbyterian, only 20 had fractured and dislocated the proximal humerus, representing only 1.1 percent of all shoulder trauma patients. Less than one patient per year had fallen victim to the condition that would be the focus of Charlie Neer’s first shoulder publication, but the most significant impact of his inaugural shoulder paper was to illuminate how poorly those twenty patients had responded to the treatment of the day.
“Fracture of the neck of the humerus with dislocation of the head fragment” was published in the March 1953 issue of the American Journal of Surgery, authored by Charles Neer, Thomas Brown, and Harrison McLaughlin.9 After identifying the twenty patients of interest, an analysis was performed. The average age was fifty-six (what the authors described as being “midway between young and old”), and the typical mechanism was a fall from a standing height. Regarding treatment, in only two instances was closed treatment (no surgery) the final remedy. In three instances an attempt was made to surgically save the humeral head and reassemble the fragments together, and in a lone patient the surgeons had effected a fusion of the humerus to the shoulder socket.
Of the original twenty patients, sixteen underwent excision of the humeral head. In some of these patients, parts of the muscles and tendons were sewn to the broken top of the humeral shaft, not too different than someone duct-taping a car’s side mirror back to its base after a vehicular accident. In the results section of the paper, the authors outlined average follow-up time and the level of patient satisfaction. In what is perhaps the most profound sentence of the publication, the surgeons concluded: “There was usually from 5 to 25 degrees glenohumeral motion following head removal regardless of whether or not a [reconstructive] procedure had accompanied the [humeral head] resection.”
If a regular patient lifts his hand straight up in the air, evaluators would describe that as 160 degrees forward flexion; in the 1953 article, the typical patient barely had enough power to lift her hand imperceptibly away from the body. In other words, the wounded had essentially ended up with ankylosed, or fused shoulders.
Just a couple generations ago, chronic tuberculosis and trauma savaged many denizens of cities like New York, and a useless limb was all too common. Somehow, fourteen of the nineteen patients whose humeral heads were resected were “satisfied with their result and were carrying out their usual work without appreciable disability.” Neer and his colleagues dared to disagree, saying, “Nevertheless, the limited motion and fatigue pain following resection has suggested the value of a replacement prosthesis to serve as a fulcrum for motion.”
In the final column of the text, on page 257, is pictured a shiny, metallic object, which is described as, “a recently devised articular replacement currently being investigated.” The concluding sentences of the publication assert, “Replacement prosthesis presents logical possibilities and may prove of value in dealing with major injuries of humeral head. Its true worth remains to be determined.”
Like holding Edison’s light bulb in your hands, unplugged, you couldn’t be sure of what you were seeing. But, in time, surgeons would realize that the most important shoulder surgeon who ever lived, in his first article on the shoulder, had given a sneak preview of the future, not just for surgery of the shoulder, but for every joint. The ability to implant foreign materials in the body would awaken the imagination of engineers, biologists, and surgeons, and would usher in one of the most significant upheavals in human history—the implant revolution.