But, equally, neither is it possible to ignore the effect of posture. Dr. Joel E. Goldthwait has expended endless trouble in his attempt to prove to his professional brethren the value of insisting on the restoration of the proper carriage of the body in the erect position. Unfortunately there are many who have failed to listen. No treatment can relieve a brachial neuritis, which is due to pressure owing to incorrect posture, except the correction of the defect.1 Indeed, nothing in my whole visit impressed me more than the careful attention he has paid to postural treatment. The testimony of his countless patients is evidence of its value. The variety of lesions he has relieved in this way is very great; and, though I had thought previously that I had attributed sufficient importance to the study of posture, he has taught me that I have failed to do so up to the present. Of this I am convinced: no manipulation and no support will ever do more than give temporary and partial relief unless postural treatment receives the attention it deserves.

I cannot pass over one observation that has filled me with amazement for several years. Perhaps it is an example of folklore which, in the light of recent experiences, has gained an importance which I had not formerly attributed to it. There is a custom, among many different classes of manual workers, to fasten up their nether garments with a leather strap-belt, while the trousers are suspended in the usual way by braces. Care is often taken to thread the braces through the loops attached to the top of the drawers. The belt is always of a pattern which gives a strength and stability out of all proportion to the work done if its object is merely to support clothing. Equally it is applied with a firmness and vigour which is quite unnecessary if this is the sole function of the belt. So far as I know, the custom is confined to men whose work is very laborious. Is it not possible that this custom has, in reality, some hidden meaning? It seems such a senseless procedure otherwise, and would not be confined to such a narrow circle of the community. It would seem not improbable that the custom arose in the past owing to an instinctive desire for support to the sacro-iliac region during the periods of severe strain.

More doubt and indecision is left in my mind when I reconsider my investigations into the condition known as sub-deltoid bursitis even than when considering sacro-iliac "strain." One surgeon recognised the lesion I intended to describe by this name, but informed me that the chief difficulty was that it was not "sub-deltoid" and was not a "bursitis." He was not alone in expressing this view. In fact, I am of opinion that the diagnosis covers a variety of definite lesions, which, in this country, we group together under the generic term of "arthritis" of the shoulder.

1 See "Some Points of Contact between Neurology and Orthopaedic Surgery" (Journal of American Medical Association, September 11th, 1909).

In one school I received assurance that "sub-deltoid bursitis" was due to tearing of the periosteum at the insertion of the supraspinatus. I was shown radiographs in support of this contention, in which could plainly be seen an unusual bony prominence at the spot indicated.

In the second school I was shown photos in which shadows had been thrown by what were apparently calcareous nodules in the sub-deltoid bursa, and the claim was made that a true sub-deltoid bursitis was the cause of the symptoms. In a third school it was held that, at operation, it had been demonstrated that so-called "sub-deltoid bursitis" was due to a tearing away of the subscapularis from the capsule of the shoulder-joint. Another school tends to ignore the very existence of the lesion, and classes all conditions which might be known by this name as manifestations of monarticular osteo-arthritis.

Those who hold the first three views are, however, unanimous in considering the various conditions as very disabling and very difficult to treat. They were all equally pessimistic as regards prognosis, and all expressed doubt as to the possibility of ultimate restoration. One patient particularly interested me. He is now a well-known surgeon in New York, and the son of a medical man. When at college he was a first-class pitcher at baseball. He pitched in three important matches in close succession. During the third match he "felt something snap in his shoulder," was completely disabled for a considerable time, and, in spite of frequent attempts, has never been able to pitch over-hand again, though he succeeded in "making some sort of show round-arm."

The boy, wearying of his tedious convalescence, was taken by his father to see a large number of experts, amongst them a surgeon of wide international fame. All failed to hasten his recovery. In despair, he succeeded in persuading his father to allow him to visit a famous bone-setter in Ohio. This irregular practitioner owned at once that this was a type of case for which he could do nothing and - this was many years ago - gave most interesting advice: - To go home, to lie flat on the bed several times a day, to move the hand out across the bed away from the side as far as it would go without pain and then to return it to the side. He promised, as a result of perseverance, that the range of movement would gradually increase until full movement was restored. He also cautioned the patient that, if he tried to force progress to an extent that caused pain, he would never recover; and that, at best, he would never be able to pitch again, even though movement might be perfect. This prophecy was fulfilled in all detail.

The usual prescription is hot-air baths, complete rest for varying periods, and thereafter the patient is left to work out his own salvation - advice usually unsatisfactory to the patient and barren in result. When the value of graduated faradic contraction in the treatment of muscles is duly appreciated in America, I cannot help thinking that cases of "sub-deltoid bursitis" will be offered a more favourable prognosis.