ABNORMAL CONDITIONS OF THE SHOULDER JOINT. 



589 



than natural, and in a state of wasted appearance; the acromion process 



is thinner 

 atrophy.* 



The coracoid process is not usually found so 

 much altered by the existence of this peculiar 

 disease in the shoulder joint as the acromion; 

 but we have found its under concave surface 

 in some cases to have entered into the forma- 

 tion of the shoulder joint, and to have pre- 

 sented a broad glenoid-shaped surface, which 

 had been smoothed oft' from frequent contact 

 with the head of the humerus, while the 

 breadth of the process had been at the same 

 time much increased. 



We have thought it necessary to enter into 

 this subject thus minutely, because we are 

 convinced that, up to the present hour, these 

 remarkable appearances, when met with, have 

 been misunderstood even by some of the 

 most intelligent anatomists and physicians. 

 This circumstance may appear perhaps ca- 

 pable of explanation, by recollecting that the 

 disease generally runs a long course, is not in 

 itself fatal ; and' hence, although the practical 

 medical man may have had numerous oppor- 

 tunities of witnessing the symptoms of this 

 disease in the living, he may never have had 

 any opportunity in any case of informing 

 himself of the true relation subsisting between 

 the symptoms of this disease of the shoulder 

 joint as observed in the living patient, and the 

 phenomena which the post-mortem examina- 

 tion of the same shoulder joint might have 

 presented. On the other hand, when anato- 

 mists have heretofore discovered in dissection 

 appearances which are stated to be truly those 

 of chronic rheumatic arthritis of the shoulder, 

 they have not at that time been able to learn 

 the previous history of the case. 



The following case may contribute some- 

 what to supply this deficiency : 



Case. Chronic rheumatic arthritis of the 

 shoulder. J. Byrne, a servant, 33t. 55, was 

 admitted into the Whitworth Hospital House 

 of Industry in 1831. Dr. Mayne, at that time 

 resident clinical clerk in the hospital, informed 

 the writer that, besides the disease of the 

 lungs, for which the man was admitted, he 

 also had an affection of the right shoulder 

 joint, which presented all the characters at- 

 tributed to the case of partial luxation of the 

 humerus, and was kind enough to invite the 

 writer to examine him. 



The man complained of an inability to use 

 his right arm well, in consequence of his 

 having for some years an affection of his right 

 shoulder joint, in which he felt almost con- 

 tinually a dull boring pain. He could how- 

 ever perform, without much inconvenience, 

 all those motions of the arm which did not 

 require it to be raised near to the horizontal 

 line. The joint felt to his own sensation 

 somewhat stiff; and he was conscious, under 

 certain movements of the arm, of a sense of 

 something crepitating or crackling in the joint. 

 Upon viewing the shoulder in front, it had a 



* See a preparation in the Museum of the College 

 of Surgeons, Dublin, Catalogue, vol. ii. p. o'J7. E. 

 6. 901. 



was more prominent, rendering the bony 

 eminences around very conspicuous ; the 

 head of the humerus seemed to be a little 

 higher than usual, and to have advanced 

 somewhat forwards. The amount of advance 

 was best seen by viewing the joint in profile or 

 laterally. In this aspect a slight elevation and 

 the increase of the antero-posterior measure- 

 ment of the joint became very obvious. When 

 the arm was pressed by the surgeon, and 

 very slight force used, the humerus could be 

 easily made to descend somewhat, and at the 

 same time to pass a little beneath the outer 

 margin of the coracoid process ; and the finger 

 could be readily pressed into the outer half 

 of theglenoid cavity, into the space which the 

 head of the humerus was found to have aban- 

 doned. When again the shaft of the humerus 

 was elevated vertically, its superior extremity 

 could be felt to strike against the under sur- 

 face of the acromion. In a word, the symp- 

 toms strongly resembled those usually as- 

 signed to the partial luxation forwards and 

 inwards. 



This patient remained in the Whitworth 

 Hospital until the pulmonary affection proved 

 fatal. Dr. Mayne and the writer carefully 

 examined the joint, which is still preserved 

 in the museum of the Richmond School 

 O%. 429.). 



We found the deltoid and other muscles 

 around the joint in a wasted condition, and 

 much paler than those of the opposite shoul- 

 der. When the capsular ligament was ex- 

 posed, it was found to have superiorly a much 

 wider and more extensive adhesion than 

 natural. Instead of this fibro-synovial sac 

 having its ordinary attachment all round 

 to the limited circumference of the glenoid 

 cavity of the scapula, its adhesion to the 

 upper margin of this cavity did not exist, but 

 the superior and outer portions of the capsu- 

 lar ligaments seemed to have acquired new 

 attachments, and to be connected superiorly 

 and externally with the anterior margin of 

 the coraco-acromial arch ; and thus the space 

 in which the head of the humerus had been 

 permitted to move, had been rendered much 

 more extensive than natural. 



The capsular ligament was much thick- 

 ened, and when opened more synovia than 

 usual flowed out. This membrane was lined 

 with cellular flocculi, and several small carti- 

 laginous bodies, rounded, and of the size of 

 ordinary peas, were seen to float in the inte- 

 rior of the synovial sac, appended by means 

 of fine membranous threads. All those parts 

 which, in the normal condition, intervene be- 

 tween the superior part of the head of the 

 humerus and under surface of the coraco- 

 acromiid arch, were completely removed. 

 No remnant or trace of the supra-spinatus 

 tendon, nor any portion of the capsular liga- 

 ment to which this tendon is attached, was to 

 be found. The entire of the articular portion 

 of the tendon of the biceps was absent, and 

 the highest point of the remaining portion of 

 the tendon was attached to the summit of the 



