ABNORMAL CONDITIONS OF THE SHOULDER JOINT. 



681 



of his patients, who died of articular caries of 

 the shoulder joint, he discovered, when a 

 vertical section was made of the huinerus, 

 that in the centre of the head of this bone 

 there was contained a cavity or cell, the size 

 of a hazel nut, filled with tubercular matter, 

 in the middle of which were found fragments 

 of necrosed particles of bone. In this case 

 also, he adds, tubercular matter was found in 

 the axillary glands."* Bony nodules and 

 stalactiform osseous productions are observed 

 to be produced from different parts of the 

 scapula and head of the humerus, in the vici- 

 nity of the shoulder joint. The coracoid 

 process and acromial end of the clavicle we 

 have found in these cases carious ; the alter- 

 ations of the osseous structure do not seem 

 confined to the bones in the immediate vici- 

 nity of the joint itself. The whole scapula 

 and humerus seem specifically lighter than 

 they should be normally. We have tried the 

 experiment of placing the diseased bones in 

 water, and have seen them float, while the 

 normal bones of the same region sink. The 

 ribs, too, have been found sometimes carious 

 simultaneously with the bones which con- 

 stitute the scapulo-humeral joint. 



These observations refer merely to the local 

 condition of the articular structures them- 

 selves. The state of the constitution of many 

 of these cases affected with chronic arthritis 

 of the shoulder deserves the attentive con- 

 sideration of the physician and surgeon. 



The prognosis to be formed as to any ad- 

 vanced case of articular caries of the shoulder 

 joint should be a guarded one, as the follow- 

 ing facts may convince us. In the first case 

 which we shall now adduce, fatal disease of 

 the lungs seemed coincident with the articu- 

 lar caries of the shoulder ; and at last it was 

 doubtful which of the two diseases was the im- 

 mediate cause of the death of the patient. In 

 the second case disease of the brain, with 

 paralysis, came on, and was the immediate 

 cause of the death of the individual, who had 

 been previously much reduced by articular 

 caries of the shoulder. 



Case 3. Chronic arthritis or articular caries 

 of the shoulder joint, lasting thirteen months. 

 Matthew M'Cahe, a labourer, aet. 38, was 

 admitted into the Richmond Hospital, Sept. 2. 

 1846, under Dr. Button's care.f He stated that 

 about nine months previously he was seized 

 with a pain in his left shoulder, which soon 

 extended to his elbow ; he was able to work 

 for two months after the first attack of pain, 

 but after this period the arm became stiff, 

 and remained powerless by his side ; the 

 muscles around the shoulder and of the 

 whole extremity were wasted ; fistulous open- 

 ings existed beneath the coracoid process, and 

 through the deltoid muscle ; the limb was of 

 its normal length. When the joint was pressed 

 the patient complained of pain ; the motion 

 of the head of the humerus on the glenoid ca- 

 vity of the scapula appeared much limited ; 



* Trait< ; do ^Maladies des Articulations, 

 t The writer is indebted to Dr. IIutt"ii lor the 

 notes of this case. 



he had cough and hectic fever, of which the 

 prominent symptoms, beside the cough, were 

 a quick pulse and diarrhoea. He died Jan. 25. 

 1842. 



Post-mortem examination, The body was 

 emaciated. Before making the examination, 

 a plaster of Paris cast was taken of the left 

 shoulder joint, which is preserved in the hos- 

 pital museum : this shows especially the wasted 

 condition of all the muscles around the shoulder 

 joint, and the consequent prominence of the 

 spine and acromial process of the scapula, usual 

 in cases of articular caries of the shoulder. For 

 the space of two inches along the anterior 

 wall of the axilla and line of the humerus an 

 oblong depressed scrofulous ulcer existed, in 

 which were seen the orifices of three or four 

 fistulous canals, which led from the interior 

 of the joint. The elbow was placed somewhat 

 backward, and the long axis of the humerus 

 was consequently directed from below up- 

 wards and forwards ; the convexity of the 

 head of the humerus, without being dislocated, 

 was placed somewhat more forwards and in- 

 wards than natural. Upon removing the 

 deltoid muscle, which was wasted ami per- 

 forated by fistulous openings, it was found 

 that the capsular ligament was contracted 

 and thickened, and had several openings in it, 

 and that purulent matter was effused both into 

 the joint and under the deltoid muscle, which 

 thus formed the sac of an abscess. The car- 

 tilages had been entirely removed from the ar- 

 ticular surfaces. The intra-capsnlar portion of 

 the tendon of the biceps had disappeared ; the 

 highest part of this tendon which remained was 

 attached to the inside of the capsular ligament. 

 The bones had been injected with size and 

 vermilion, and presented in their interior as 

 well as on their carious surfaces a reddish 

 colour; but they did not appear softened; 

 when after maceration they had been dried, 

 they seemed to be preternaturally light. The 

 superior hemispherical portion of the head of 

 the humerus had been removed very nearly to 

 the level of the anatomical neck, or situation 

 for the attachment of the capsules ; and the 

 surface was red, porous, and much rough- 

 ened from caries. Towards the highest part 

 of the humerus, just within the line which 

 separates the great tuberosity from the head 

 of the humerus, there existed two very deep 

 digital or alveolar depressions, which pene- 

 trated into the cellular structure of the head of 

 the humerus : the anterior part of the upper 

 extremity of this bone, where the bicipital 

 groove exists, was rough and porous ; the 

 groove was much deepened, particularly in 

 the situation of the lesser tuberosity, which 

 was elevated into a bony nodule, and enlarged 

 about one inch below the lesser tuberosity. 

 On the front of the surgical neck there existed 

 another bony nodule, but smaller. 



The surface of the glenoid cavity seemed to 

 have been somewhat worn away and rendered 

 more than naturally concave ; the anterior or 

 inner margin of it was rounded off by caries. 

 The oval outline of the glenoid cavity was elon~ 

 gated from above downwards, and somewhat 



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