ABNORMAL CONDITIONS OF THE SHOULDER JOINT. 



579 



ever she moves her arm in the slightest de- 

 gree the scapula follows the luimurus, so 



Fig. 427. 



Case of M. Moore : Articular caries of the right 

 shoulder joint ; second stage of the disease, 



that in the voluntary movements of the upper 

 extremity really no motion takes place in the 

 shoulder joint ; but if we grasp the scapula, 

 and thus firmly fix it, and at the same time 

 move the humerus, a distinct crepitus is oc- 

 casionally elicited, of which the patient her- 

 self also is conscious. When the arm is per- 

 mitted for a moment to hang down by her 

 side unsupported, she has great pain, ant! she 

 feels the advantage of keeping it constantly 

 in a sling, with her hand as high as her oppo- 

 site collar bone. The muscles surrounding 

 the right shoulder joint were observed to be 

 in a wasted condition ; this shoulder seemed 

 higher up than the other, and the clavicle of 

 this side to have a corresponding obliquity. 

 The history she gives of the origin and 

 progress of this disease is, that she has had 

 a certain degree of pain and uneasiness in 

 the articulation for the last four years, but 

 that it never swelled much nor became in- 

 flamed, nor did it prevent her from follow- 

 ing her occupation as housemaid, until three 

 months ago, when she felt compelled to give 

 up her situation. She referred the aggrava- 

 tion of her distress latterly to an injury the 

 joint received from a severe fall she got 

 down an entire flight of stairs. The latter 

 circumstance in the history of her case made 

 us more particular in our inquiries as to 

 whether any fracture or dislocation could 

 have occurred at the moment of this accident, 

 and have been left unreduced. We were 

 readily satisfied that there had been no frac- 

 ture, as the affected arm was longer than the 

 other. 



The deltoid muscle was flattened and the 

 acromion was seen presenting an angular 

 projection as in an old luxation ; yet the head 

 of the humerus could be felt below the acro- 

 mion; the anterior fold of" the axilla was 

 deeper than natural, but the elbow in this 



woman was placed habitually close to her 

 side, ant! the long axis of the humerus could 

 be traced by the eye to run nearly perpendi- 

 cularly upwards towards the site of the gle- 

 noid cavity, and not more inwards towards 

 the axilla, as in the case of luxation. 



The atrophy we observed to affect the 

 muscles in the vicinity of the diseased shoul- 

 der joint in this case, was not confined to the 

 deltoid and capsular muscles ; but the great 

 pectoral was so much wasted that the ribs 

 and intercostal interstices were seen con- 

 spicuously on the right side, while the cor- 

 responding spaces on the left side of the front 

 of the thorax were sufficiently covered by 

 muscle, &c. The right arm and forearm were 

 more wasted than the left or unaffected limb, 

 while the former extremity, measured from the 

 acromion to the outer coudyle of the humerus, 

 shows an addition of length, or rather a descent 

 of the humerus from the glenoid cavity, for the 

 space of one inch. This woman has been 

 subjected to the ordinary treatment for such 

 cases ; she feels the necessity of supporting 

 her arm, and not allowing it out of the sling 

 during the day, while she walks in the open 

 air.. 



The foregoing case presents us, as we have 

 said, with a good specimen of the simple 

 chronic arthritis, or articular caries of the 

 shoulder in the second stage of the disease. 

 It is probable that a slow process of bony an- 

 chylosis will be ultimately established ; and the 

 woman after a time may lose all pain, regain her 

 general health, and ultimately recover, but with 

 the impediment which must ever attend an an- 

 chylosed shoulder joint. The course of the 

 disease is not always so favourable ; on the 

 contrary, when the disease has arrived, as in 

 the case of Moore just related, at the second 

 stage, the pain is in some instances increased, 

 the head of the humerus becomes wasted by 

 caries as well as the surface of the glenoid 

 cavity, when it will be found that the affected 

 extremity, which was really longer than the 

 other, shall have become shorter. This 

 shortening,, which marks the third stage of 

 the disease, is frequently thought to be the 

 result of complete dislocation ; but this occur- 

 rence, the possibility of which we do not 

 deny, we believe, however, to be exceedingly 

 rare. The shortening may be the consequence 

 of caries and absorption of the head of the 

 humerus, as well as of the surface of the gle- 

 noid cavity. Under such circumstances the 

 head of the bone may lean towards the 

 axilla and subscapular fossa, or backwards to- 

 wards the dorsum of the scapula ; or it may 

 be elevated, so as to reach the concavity of 

 the coraco-acromial vault, and be maintained 

 there by the tonic force of the elevator 

 muscles ; but we have not found it com- 

 pletely dislocated as a result of caries. 



Case 2. Articular caries at llic shoulder joint 

 in the fourth stage of the disease. Mary 

 Ann Malloy, aet. 21, servant, admitted 

 into the Richmond Hospital 25th July, 

 1847, under the care of Dr. Hutton. She 

 has been now (June, 184-8) eleven months 



p p 2 



