588 



ABNORMAL CONDITIONS OF THE SHOULDER JOINT. 



affected with chronic rheumatic arthritis was, 

 that the long intra-articular portion of the 

 tendon of the biceps was absent from the joint, 

 although adherent outside to the highest point 

 of the bicipital groove (/g.428.). Thisremoval 

 of a large portion of the tendon of the biceps 

 strikes the observer who is unacquainted with 

 this disease as a direct proof that the tendon 

 had been ruptured by accidental violence, and 

 that a partial luxation of the head of the hu- 

 inerus has been the consequence. 



Another character of this disease is, that 

 the humerus has a very general tendency to 

 pass upwards towards the coraco-acromial 

 vault ; and besides the removal of the tendon 

 of the biceps, the superior part of the capsular 

 ligament is observed to be deficient. Those 

 who do not know that this perforation is a 

 consequence of slow disease, immediately take 

 it for granted that the same accident which 

 ruptured the tendon of the biceps had also 

 caused the head of the humerus to be partially 

 dislocated upwards, perforating as it passed 

 the superior part of the capsular ligament. 



If, in addition to these abnormal appear- 

 ances, small portions of bone, as if fragments 

 broken off from the margins of the glenoid 

 cavity, are found to be present, as they fre- 

 quently arc, this also is an appearance cal- 

 culated to confirm an erroneous impression, 

 that some external violence has been the 

 source of it ; and if in addition the acromion 

 process be found divided into two portions, 

 as we have frequently noticed it, the preju- 

 dice in the observer's mind may at first be 

 strongly in favour of the idea, that accidental 

 violence has been the source of these many 

 and combined phenomena. 



But notwithstanding all these lesions, 

 namely, the total disappearance of the articular 

 part of the tendon of the biceps ; the perfora- 

 tion of the superior part of the capsular liga- 

 ment by the head of the humerus, and the 

 separation into two portions of the acromion 

 process, we feel convinced that all these phe- 

 nomena combined should by no means be 

 considered as proof of any accident having 

 occurred to produce them ; but, on the con- 

 trary, should be looked upon as the usual 

 result of chronic rheumatic arthritis of the 

 shoulder. 



The tendon of the biceps in all those cases 

 of presumed accidents is said to be ruptured; 

 yet the chronic disease of the shoulder joint is 

 frequently found to affect both shoulder joints 

 in the same individual, and the long tendon of 

 the biceps, in these cases, to be removed on 

 loth sides. It is easy to conceive that this 

 double lesion may be the effect of disease, but 

 difficult to imagine how any accidents could 

 occur to "rupture" the tendons of the biceps 

 in both shoulder joints. Nor is it easy to ad- 

 mit that the long tendon of the biceps can 

 be readily ruptured in partial dislocations of 

 the humerus from accident, when we know 

 that this tendon is rarely if ever ruptured, 

 even in complete luxation of this bone. The 

 statement made in the report of various cases 



in surgical works, and in the catalogues of 

 museums, in which we find it briefly noted, 

 " that the tendon of the biceps was found 

 ruptured," has been made by the writers con- 

 fessedly without any knowledge of the pre- 

 vious history of the case, the anatomical cha- 

 racters of which they are describing. On this 

 account we feel the less delicacy, after long 

 and patient consideration of the subject, in 

 expressing our conviction that the tendon of 

 the biceps, in the numerous cases published, 

 was not (as supposed to be) ruptured by acci- 

 dent, but absorbed as the result of disease. 



We have stated that the bones entering 

 into the formation of the shoulder joints are 

 very generally enlarged as a consequence of 

 this chronic disease having for a considerable 

 time existed in the articulation. It is right, 

 however, here to observe, that very exten- 

 sive inquiry into the pathological anatomy of 

 this peculiar affection as it presents itself in 

 the shoulder joint, will prove that some few 

 exceptions to this rule may be occasionally 

 met with ; and that, instead of the bones enter- 

 ing into the formation of the shoulder joint 

 being found hypertrophied, they may be dis- 

 covered, on the contrary, to be in a state of 

 atrophy ; or portions of these bones may be 

 removed altogether, as the apparent result of 

 this chronic rheumatic disease. 



That the writer may not appear to have 

 been singular in having observed the changes 

 which the acromion process and neighbour- 

 ing bones have undergone as the result of 

 this chronic rheumatic disease, he may refer 

 to the dissection of a case mentioned by 

 Cruveilhier, in which the affection we have 

 called chronic rheumatic arthritis was so ge- 

 neral that there was scarcely anv articulation 

 in the body exempted from its effects. When 

 adverting to the anatomical changes observ- 

 able in the region of the shoulder in this ex- 

 ample, he says, the external extremity of the 

 clavicle and the neighbouring part of the 

 acromion were in a great part destroyed, &c.* 



In the museum of the College of Surgeons 

 in Dublin will be found a preparation of a 

 shoulder joint, which is styled by the late 

 Dr. Houston in his catalogue, a specimen of 

 chronic rheumatic arthritis of the shoulder ; 

 and that it was justly so styled may also be 

 inferred from the " bunches of synovial fim- 

 brire," which hung into the synovial cavity 

 of the joint ; the existence of hydrops ar- 

 tieuli, or over-distension of the synovial sac 

 by an albuminous fluid ; and from the de- 

 ficiency of the intra-articular portion of the 

 tendon of the biceps, mentioned in the ac- 

 count given of this case:- all these show the 

 disease to have been correctly designated. 

 The writer finds upon examining this prepa- 

 ration with the intelligent curator, Mr. Carte, 

 that the acromial end of the clavicle is un- 

 supported, and that the acromion process has 

 been removed for the amount of an inch in. 

 extent ; that which remains for this process 



* Cruveilhier, livraison ix. p. 12. 



