596 



ABNORMAL CONDITIONS OF THE SHOULDER JOINT. 



has been altogether confined to his bed, as he 

 could not stand upright, much less walk, when 

 the writer visited him in August, 1847. His 

 hips, knees, and elbow joints were semiflexed 

 and rigid, his wrist extended, his fingers and 

 toes presented the ordinary characteristic 

 distortion belonging to rheumatic gout, or 

 chronic rheumatic arthritis.* Although the 

 shoulder joints in this case had lost much of 

 their muscular covering, the deltoid and cap- 

 sular muscles being in a state of atrophy, yet 

 the bones of the articulation seemed much 

 enlarged, and the heads of both humeri were 

 evidently situated much above the level of 

 the coracoid process. He did not complain of 

 much pain in the shoulders ; the constant 

 torture he endured in the right hip and both 

 his knees quite distracted his attention from 

 all minor suffering. He stated that he had a 

 " crackling " sensation in all his joints when- 

 ever they were moved ; that his sufferings 

 were influenced by the weather, and that he 

 endured more pain during the frost of winter 

 than at any other time. The patient died worn 

 out by pain and irritative fever, attended with 

 severe diarrhoea. 



Post'inortem examination. Dr. R. Smith 

 assisted the writer in this examination. As 

 the body lay on its back on the table, the 

 hips, the elbows, and knee joints were semi- 

 flexe 1, and could not be extended, but they 

 permitted of flexing to a very trivial degree. 

 When any of the affected joints were moved, 

 the characteristic crepitus, or crackling, so 

 often alluded to, was elicited now as during 

 life. The head of the os humeri of each 

 side was drawn up much above the level 

 of the coracoid process, and was preter- 

 naturally advanced. Upon rotating the hu- 

 merus, a marked crepitus was evident in 

 these as well as all the other joints. On re- 

 moving the integument over the right shoul- 

 der joint, the deltoid muscle was found 

 pale, and forming a thin attenuated layer of 

 muscular fibres covering the articulation. 

 When this was removed, the sub-deltoid 

 bursa was seen to be of a yellowish colour, 

 and it had a fibrous appearance externally, 

 like to a capsular ligament. When this bursa 

 was freely cut into by an incision parallel 

 to the margin of the acromion, its cavity 

 was observed to be more capacious than 

 usual. The posterior or inferior wall of 

 the bursa was found to have identified itself 

 with the external and superior part of the 

 fibrous capsule of this articulation, and both 

 seemed here to have become degenerated 

 into thin cellular structure, which adhered 

 to and formed a periosteal covering for 

 the summit of the humerus near to the 

 upper part of the great tuberosity. The 

 capsular ligament was elsewhere somewhat 

 thicker than natural, particular!}' at the upper 

 and anterior part, where it seemed to have 

 identified itself at its origin with the coraco- 

 luuneral ligament, which was much thickened. 

 As to its attachment to the humerus, the 



* See HAND, Vol. II. p. 518. fig. 233. 



capsular ligament, superiorly and posteriorly, 

 was very short, having become adherent to 

 the head of the bone before this capsule 

 had reached its usual point of insertion into 

 the anatomical neck of the humerus. Ante- 

 riorly and inferiorly the capsule descended on 

 the neck of the humerus below its normal 

 level (fig. 430.). When this ligament was 

 cut into and examined posteriorly, several 

 broad patches of adhesion were found to 

 exist (as in Mr. Soden's case) between its 

 internal surface and the head of the bone pos- 

 teriorly, so that in these parts the syno- 

 vial cavity was completely obliterated by 

 the adhesion of the opposed surfaces of 

 the membrane which lined the capsular liga- 

 ment, and invested the posterior part of the 

 head of the humerus, just as we find occa- 

 sionally the pericardium partially adherent to 

 the surface of the heart. When the capsular 

 ligament was fully opened anteriorly, where 

 it is covered by the tendon of the subscapu- 

 laris, it was seen, more evidently than it could 

 have been previously, that the head of the 

 humerus had been placed habitually above the 

 level of the coracoid process and the highest 

 point of the glenoid cavity from which the 

 long tendon of the biceps springs (Jig, 430.). 

 The tendon of the biceps lay entirely to the 



Fig. 430. 



Case of Charles 3/i7///. Chronic rheumatic arthritis. 

 The lonij tendon of the biceps dislocated inwards, 

 the head of the humerus partially displaced up- 

 wards, as in Mr. Soden's case. '. 



inside of the head of the humerus ; indeed, 

 such was its position, that it might rather be 

 said that the humerus was displaced out- 

 wards, and elevated above the level of the 

 course of the tendon of the biceps, than that 

 the latter was dislocated inwards. A semi- 

 circular groove marked the course of the 

 tendon of this muscle as it arched across from 

 the highest point of the glenoid cavity to the 

 summit of the bicipital groove. The portion 

 of the head of the humerus which was situated 



