ABNORMAL CONDITIONS OF THE SHOULDER JOINT. 



617 



as it then was, and secondly that the state of 

 prostration and debility (he patient was in, 

 at that moment, offered an opportunity which, 

 if once lost, might not again be afforded, of 

 reducing easily the dislocation. Taking the 

 patient, therefore, unawares, the writer placed 

 his knee in the axilla of the dislocated arm, 

 and then slight extension having been made 

 over this fulcrum, the bone at the first trial 

 returned into the glenoid cavity. The pat'ent 

 was placed in bed in the hospital, under the 

 care of the late Mr. Wallace, whose day it 

 was for admitting accidents. There was 

 much more superficial ecchymosis about the 

 axillary, and subclavian region, and aiong the 

 inside of the left arm, than is usually observed 

 after a simple dislocation of the head of the 

 burner us. The deep axillary swelling re- 

 mained stationary for some days ; but no pul- 

 sation could be discovered either in it, or in 

 the arteries of the limb. A feeble and fre- 

 quent pulse could be felt in the left subcla- 

 vian, and in all the other arteries, as well as 

 in the heart. After the space of ten days, 

 Mr. Wallace's month of attendance having 

 expired, the case came under the care of 

 Mr. O'Reilly, who having been satisfied that 

 a diffused aneurism existed, and was on the 

 increase, performed the operation, at which 

 the writer was present, of tying the subclavian 

 artery in the third stage of its course. The 

 patient recovered, and was discharged from 

 the hospital about two months afterwards ; 

 he lost the last two fingers by gangrene ; but 

 whether from an attack of erysipelas, which 

 succeeded the operation, or from the effects 

 of the ligature of the main artery of the limb, 

 is not clearly known. The man lived for 

 many years afterwards, in the immediate vici- 

 nity of the Richmond Hospital. 



SECTION 3. Congenital malformation of the 

 shoulder joint. Although little can be done 

 by medicine or surgery to alleviate, much less 

 to remedy, the evils attending on congenital 

 malformation of the shoulder joint, still it 

 appears to us to be not the less necessary 

 that the abnormal conditions of this articula- 

 tion resulting from congenital defects should be 

 studied. These, like some other congenital 

 malformations of the joints, attract but little 

 notice during the first months of infancy, but 

 as the child grows the defect becomes more 

 manifest. It very commonly happens in these 

 cases, that after some time the ordinary sur- 

 gical opinions taken on the case, and the mea- 

 sures recommended failing, as -they naturally 

 do, to produce satisfactory results, the ill- 

 fated patient, born with malformation of the 

 shoulder joint, is subjected to ignorant and 

 empirical treatment, the inutility of which 

 too often proves to be the least cf" the evils 

 attending it.* 



* About ten years ago the writer met in consulta- 

 tion surgeon W. Wilde on the case of an only child, 

 a girl of thirteen years of age, who had a congenital 

 malformation of the shoulder joint,presenting exactly 

 the appearance of the joint (Jig. 441.). The young 

 lady is now twenty-three years of age, and the 

 writer has been informed by one of her relatives, 



The most common form of congenital mal- 

 formation of the parts composing the region 

 of the shoulder joint that we have noticed, 

 has been apparently the result of an arrest of 

 development, and of atrophy affecting the 

 muscles, the bones, and probably also the 

 nerves of this region. Sometimes we find 

 both shoulder joints are malformed in the 

 same individual ; generally one only is thus 

 affected. In this last case the atrophied con- 

 dition of the malformed joint is well seen on 

 comparing the normal and abnormal shoulder: 

 the latter is smaller than the former ; the 

 muscles around the joint are so imperfectly 

 developed, that the coracoid and the acro- 

 mion processes and the head of the humerus 

 become unusually conspicuous. The deltoid 

 and articular muscles are so weak, and the 

 capsule so loose, that the limb seems usually 

 to be drawn down, as it were, by its own 

 weight, and then becomes displaced forwards 

 and inwards beneath the coracoid process, 

 where it habitually remains, the head of 

 the humerus forming a protuberance in 

 front, which yields to the slightest force 

 pressing it backwards towards the usual 

 site of the glenoid cavity of the scapula. 

 When the arm is taken hold of at its lowest 

 extremity, as at the elbow, and drawn back- 

 wards, the head of the humerus advances 

 forwards and passes beneath the coracoid 

 process, and a depression, corresponding to 

 the posterior half of the glenoid cavity, is 

 perceptible. On the contrary, when the elbow 

 is drawn forwards, the head of the humerus 

 recedes towards the normal site of the gle- 

 noid cavity ; when the humerus is raised up 

 perpendicularly towards the acromion, and 

 the influence of the weight of the limb is thus 

 counteracted, the shoulder appears of its 

 natural form, but diminished about half the 

 normal size. The muscles around the joint 

 are so badly developed, that the bony process 

 which surrounds it becomes very conspicuous. 



The accompanying drawing is designed to 

 pourtray the general aspect of one of these 

 cases of congenital malformation of the shoul- 

 der joint in the displacement inwards of the 

 head of the humerus (fig. 441.). 



Case. The following is the history of the 

 case from which the drawing has been taken. 

 M. H., aet. 28, is in every respect healthy 

 and well formed, except as to his left shoul- 

 der, which, since his birth, has always been 

 noticed to have been smaller than the other. 

 This defect gives a peculiar appearance to his 

 whole figure as he stands or walks. As his 

 arm hangs by his side, the longitudinal axis 

 of it is directed downwards and a little back- 

 wards. The head of the humerus is a liitle 

 advanced as well as depressed beneath the 

 outer margin of the coracoid process ; it is 



that she is in no respect better as to the condition of 

 her shoulder joint ; but that her general health has 

 suffered materially in r<>iiMM|urnce of the various 

 treatment she had been subjected to in vain. Her 

 parents, ignorant of the nature of the case, and too 

 sanguine in their hopes, had been the easy dupes of 

 charlatanism. 



