ABNORMAL CONDITIONS OF THE SHOULDER JOINT. 



597 



above the course of the tendon of the biceps 

 was divested of all cartilaginous covering, 

 was of a yellowish colour, and remarkably 

 hard, and presented an appearance as if the 

 summit of the humerus had been prepared for 

 the polish of eburnisation, but as yet no 

 ivory-like enamel had formed, because as yet 

 bone had not come in contact with bone. 



The head of the humerus was much en- 

 larged and altered from its normal figure, par- 

 ticularly above, in the neighbourhood of the 

 great tuberosity, which bulged out much ex- 

 ternally ; the usual deep groove above, sepa- 

 rating the tuberosity from the head, and here 

 marking the anatomical neck of the humerus, 

 was effaced. 



The under surface of the neck of the hu- 

 merus was furnished with a vast number of 

 the synovial fimbriae before noticed by us 

 when describing the anatomical characters of 

 chronic rheumatic arthritis of the shoulder 

 and other articulations. * These were in 

 the recent state of a very red colour. The 

 humerus seemed habitually to have remained 

 in contact with the glenoid cavity, rotated 

 inwards, and in this position these synovial 

 fimbriae lay in contact with the inferior and 

 broadest part of the glenoid cavity ; and it was 

 very remarkable that wherever these red sy- 

 novial fimbriae had been in exact apposition 

 with the cartilage of incrustation of the gle- 

 noid cavity, exactly in the extent of the con- 

 tact the cartilage had been removed, satisfac- 

 torily proving that these vascular fimbriae had 

 been absorbing villous surfaces. 



The glenoid articular surface presented but 

 little worthy of notice, except a porous ap- 

 pearance where its cartilaginous investment 

 had been removed by the absorbing villi, and 

 the commencing state of disintegration of the 

 glenoid ligament. The cartilage which re- 

 mained on a portion of the head of the hu- 

 merus, as well as that which still adhered to 

 the surface of the glenoid cavity of the sca- 

 pula, was rough, and altered from its natu- 

 ral state. The acromio-clavicular articula- 

 tion of this side seemed enlarged externally, 

 the periosteum about.it thickened. When the 

 articular surfaces were exposed, it was found 

 that the cartilaginous covering had been re- 

 moved, and that the articular surfaces were 

 nearly double their normal size. 



It is quite plain that the movements of the 

 head of the humerus in the glenoid cavity in 

 this case had been confined to those of a 

 species of semi-rotation only ; the adhesions 

 which were found to exist between the head 

 of the humerus and the inner surface of the 

 synovial membrane of the joint sufficiently 

 suggest this, as well as the new form which 

 the head of the humerus had assumed. 



The left shoulder joint in almost every re- 

 spect was symmetrically affected with the 

 right, but particularly as regarded the dis- 

 location of the tendon of the biceps, the ex- 

 istence of fimbriae, &c. &c. } and therefore it 

 does not require a separate description. 



* See Dublin Journal, vol. xv. p. 159. 



It does not appear to us necessary to enter 

 into any details here, relative to the condition 

 the other articulations were found in. The 

 lungs and other viscera were sound. Whether 

 the patient ever had rheumatic fever or not we 

 are not now able to learn ; but we may mention 

 that upon looking to the state of the heart and 

 its membranous coverings we found the peri- 

 cardium adherent to the heart on all its sur- 

 faces except where it lay on the diaphragm. 

 It seems to us plain that hereafter, when the 

 tendon of the biceps shall be found displaced 

 internally, we are not at once to refer the 

 dislocation to accident, but that inquiry must 

 be made as to whether chronic rheumatic 

 arthritis may not have been its cause. That 

 the tendon of the biceps should, under the 

 influence of changes which the structures of 

 the joint may have undergone from disease, 

 be thus thrown off' the head of the humerus 

 over which it arches, does not appear to us 

 extraordinary, because we have known similar 

 displacement of tendons under analogous 

 circumstances ; indeed, we have generally 

 found the extensor tendons of the fingers 

 displaced, and the ligament of the patella and 

 patella itself are sometimes thrown on the 

 outer side of the external condyle of the 

 femur when the knee joint has been the 

 seat of chronic rheumatic arthritis. 



In Mr. Soden's case accident may have had 

 just so much to do with the displacement of 

 the tendon, that the injury was the immediate 

 exciting cause of the development of a local 

 disease, a predisposition to which had pre- 

 viously existed in the constitution of the 

 patient. 



The writer regrets much that he has not 

 as yet had any opportunity of examining the 

 preparation of the shoulder joint presented 

 by Mr. Soden to the museum of King's Col- 

 lege, London ; but he requested his friend Dr. 

 Macdowell, at the time in London, and who 

 was familiar with the many preparations of 

 chronic rheumatic arthritis contained in the 

 Richmond Hospital Museum, to report to 

 him his opinion on the appearances the pre- 

 paration presented, and he writes to say, 

 " that from the partial examination he could 

 make of the preparation he had only to re- 

 mark, that the head of the humerus is con- 

 siderably enlarged, and that the long tendon 

 of the biceps, which has been dislocated in- 

 ternally, is in a state of atrophy." In these 

 two additional circumstances, as well as those 

 already mentioned, the preparation resembles 

 those of the shoulder joints in the case of 

 Mailly. 



Although we have as yet said but little 

 of any displacement of the head of the 

 humerus occurring as a consequence of this 

 chronic rheumatic disease, except in the di- 

 rection upwards, and upwards and inwards, 

 yet we would now call attention to facts 

 to prove that the head of the humerus, un- 

 der the influence of the changes induced by 

 this disease in the structures of the shoulder 

 joint, may suffer a partial displacement di- 

 rectly inwards under the coracoid process ; 



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