578 



ABNORMAL CONDITIONS OF THE SHOULDER JOINT. 



simple chronic arthritis of the shoulder ; se- 

 condly, we shall describe those which belong 

 to chronic rheumatic arthritis of the same arti- 

 culation. 



While the two chronic diseases of the 

 hip, namely, the scrofulous affection and the 

 chronic rheumatic arthritis of this joint, have 

 of late years attracted much attention from 

 the profession, it appears to the writer of this 

 article that the corresponding diseases of the 

 shoulder joint have been much overlooked. 

 He hopes, therefore, he shall be excused if he 

 deems it necessary to enter into more than 

 ordinary details relative to the two chronic 

 affections of the shoulder joint, which he will 

 now endeavour faithfully to delineate. 



Simple chronic arthritis of the shoulder may 

 be the result of a sprain or contusion : the 

 synovial and fibro-synovial structures are in 

 this case principally affected. If, however, 

 the inflammatory action be not arrested, the 

 bones, as well as their cartilaginous incrusta- 

 tions, become ultimately engaged, and true 

 articular caries is established. The disease 

 sometimes begins in the shoulder joint, with- 

 out the patient being able to assign any cause 

 for it ; and in this case it may have a consti- 

 tutional origin, and be the result of struma, 

 or acute rheumatism, which last having sub- 

 sided in the other joints, has concentrated 

 itself on this one articulation, assuming the 

 form of an articular caries. We have known 

 it also appear in a young female during the 

 convalescence from a long-continued gastric 

 fever. 



Symptoms. The first symptoms the patient 

 suffers from, who is affected with simple 

 chronic arthritis, or articular caries of the 

 bones which enter into the formation of the 

 shoulder joint, is a sensation of weight, weari- 

 ness, and aching in the affected arm. These 

 signs of the disease are at first not constantly 

 present ; they appear and then disappear, to 

 return again in some days. Some stiffness in 

 moving the affected arm is next complained of, 

 to which is soon added pain, which the patient 

 says is deeply seated in the joint, and which is 

 augmented by using the articulation, or when 

 the articular surfaces are pressed against each 

 other. These symptoms are seldom so severe 

 as to prevent the patient from following his 

 ordinary occupations. 



So far the disease may be said to be merely 

 in its commencement ; but very soon we ob- 

 serve it to pass into the second stage, when it 

 may be discovered, on minute inquiry, that 

 there is some sympathetic disturbance' of the 

 system some heat of skin and slight acce- 

 leration of the pulse. 



On examining the affected joint, we observe 

 that the patient habitually carries it higher 

 than the opposite shoulder, and the clavicle at 

 the affected side is observed to pass, as it 

 were, obliquely upwards and outwards, the 

 adipose and cellular tissue, as well as all the 

 muscles around the shoulder joint waste. 

 The deltoid muscle, in a state of atrophy, 

 appears stretched longitudinally, and the 

 affected shoulder to have lost much of its 



normal roundness. The acromion process 

 projects (see fig. 427.), and the arm of the 

 affected side appears, and is usually found, 

 on comparative measurement, to be really 

 lengthened ; the anterior fold of the axilla 

 is deepened by the descent of the humerus 

 from the glenoid cavity. The pain increases, 

 and extends downwards from the shoulder 

 to the inside of the elbow and wrist. 



In the third period of the disease, the wasted 

 condition of the muscles around the shoulder 

 joint, as well as those of the whole upper 

 extremity, becomes still more obvious, and 

 now the arm, which was really longer than 

 natural, becomes gradually shorter. It is 

 quite possible that, after the limb has become 

 shortened, any pain or uneasiness felt in 

 the joint may subside, and a process of true 

 anchylosis be established before suppuration 

 takes place ; but it much more frequently 

 occurs, that about the time of the shortening 

 of the limb, or subsequently, a chronic symp- 

 tomatic abscess will make its appearance, and 

 perhaps open spontaneously, in the axilla, or 

 on some point along the outline of the deltoid, 

 or inferior margin of the pectoral muscle ; 

 and then the disease may be said to be in the 

 fourth stage. 



This very serious chronic disease of the 

 shoulder may be sometimes arrested in its 

 early stage, and the patient recover the use of 

 the joint; but, on the other hand, the disease 

 frequently ends unfavourably by hectic fever, 

 with its fatal consequences supervening. The 

 more usual course for the disease to run will 

 be found in general to be, that suppuration 

 will take place, abscess after abscess will form, 

 their purulent contents escaping and con- 

 tinuing to flow, greatly exhausting the strength 

 and spirits of the patient ; but under the in- 

 fluence of good air and judicious management, 

 the discharge from the abscesses may cease, 

 the constitution improve, and true bony an- 

 chylosis of the shoulder joint be established. 



The history of the two following cases of 

 simple chronic arthritis of the shoulder, at 

 this moment (June, 1848) under treatment at 

 the Richmond Hospital, will serve to illus- 

 trate some of the preceding observations as to 

 the symptoms which patients usually labour 

 under when affected by this chronic disease. 



Case 1. Chronic arthritis of the right shoulder 

 joint of four years' duration. The disease in 

 the second stage. Margaret Moore, aet. 27, 

 servant, admitted March 8th, 1848, under 

 the writer's care. She complained of stiff- 

 ness and weakness of her right shoulder 

 (Jig- 427.), and of pain, which was much 

 worse at night than during the day ; she 

 had also a constant uneasiness at the inner 

 side of the right elbow, and her nights 

 were restless, her sleep interrupted by spas- 

 modic starting of the whole limb, and pain 

 extending down to the wrist and back of the 

 hand ; she states that she has really more 

 pain in the elbow and wrist than in her 

 shoulder, and that these pains are increased 

 when the arm is moved, or the articular sur- 

 faces are pressed against each other. When- 



