580 



ABNORMAL CONDITIONS OF THE SHOULDER JOINT. 



in hospital, and her left shoulder joint has in 

 this period pone through all the stages of 

 chronic arthritis ; and a process of anchylosis, 

 with shortening of the left upper extremity, 

 appears to have been nearly completed. Her 

 general health seems at this time but little 

 affected: several depressions along the mar- 

 gins of the deltoid muscle, anteriorly and pos- 

 teriorly, mark the situation of the numerous 

 openings, most of which are now closed, 

 through which purulent matter had escaped 

 from the joint. The history which we collected 

 of her case was, that about two months pre- 

 viously to her coming to the hospital she fell 

 backwards on her left elbow, to which acci- 

 dent she ascribes her disease ; that subse- 

 quently to this fall she felt pain in her left 

 shoulder, but she cannot recollect that the 

 joint swelled or became hot ; on the contrary, 

 the shoulder always seemed to her, from the 

 first, to waste, and to be colder (as it is at 

 this moment) than the other ; except when 

 the period of the formation of the abscesses 

 arrived. She states that the movements of 

 the joint, during the progress of the disease, 

 were most painful, and that she had a sensa- 

 tion of something grating in the joint when- 

 ever the surgeon, in examining it, moved the 

 arm. The arm is half an inch shorter than the 

 other, and is closely approximated to the 

 side : whenever abduction, flexion, or exten- 

 sion of it is attempted by the patient, the 

 scapula invariably moves also. The patient 

 has no power of rotation of the head of the 

 humerus on the scapula, nor can any move- 

 ment of the kind be communicated. The 

 head of the humerus in this case has not 

 been dislocated, but its tendency is certainly 

 backwards towards the infraspinatus fossa, 

 where some fulness is perceived. The par- 

 tial absorption of the head of the humerus, as 

 well as the removal of a portion of the sur- 

 face of the glenoid cavity by caries, which we 

 believe has occurred here, will sufficiently 

 account for the shortened condition of the 

 arm, 



The most favourable prognosis we can form 

 as to this case is, that a bony anchylosis of 

 the shoulder joint will be .established. 



In the first of these cases (M. Moore) it 

 was very manifest that the limb was elongated; 

 and in this second ease {Malloy), when the 

 disease of the shoulder joint had arrived at a 

 much more advanced stage, it was equally 

 evident that the length of the affected ex- 

 tremity was diminished. We have adduced 

 these cases as examples of what may be 

 frequently expected to be seen by those who 

 watch the course of articular caries of the 

 shoulder joint ; but we must be prepared to 

 meet with examples in which it may be ob- 

 served, that during the whole progress of the 

 disease the length of the limb will be neither 

 increased nor diminished. Varieties analogous 

 to this we notice in the symptoms and pro- 

 gress of articular caries when it affects other 

 joints (see HIP JOINT); and therefore we need 

 not be surprised, when the shoulder joint is 

 the seat of chronic arthritis, that sometimes 



the extremity of the affected side is shorter, 

 sometimes longer, and that sometimes during 

 the whole course of the disease but little al- 

 teration as to increase or diminution of length 

 is appreciable. 



Anatomical characters of chronic arthritis of the 

 shoulder. The specimens we have an opportu- 

 nity of examining anatomically, which show the 

 ultimate effects of chronic arthritis on the se- 

 veral structures composing the shoulder joint, 

 cannot be considered very rare ; but it must be 

 confessed that we seldom can ascertain the 

 condition of the different structures of the 

 shoulder joint which have been affected by 

 chronic arthritis, excepting in cases in which 

 the disease has arrived at its last stage, and 

 has been the cause of the death of the patient. 

 On making the post-mortem examination of 

 the affected shoulder in cases where the dis- 

 ease has arrived at its last stage, we usually 

 notice that the skin has been perforated by 

 numerous fistulous openings ; these are some- 

 times to be seen in the axilla, or ranged along 

 the line of the margin of the deltoid muscle, 

 perhaps at points more distant from the joint, 

 as on the lower margin of the pectoral muscle 

 near the mamma (case of Malloy). The subcu- 

 taneous cellular structure we have not found 

 infiltrated, as it is in cases of white swelling 

 of the knee, or of the other joints, with a ge- 

 latinous glairy matter; on the contrary, the 

 cellular structure itself has always seemed 

 to us to be in a wasted condition, containing 

 no adeps ; the deltoid as well as the arti- 

 cular muscles have been found in a state of 

 atrophy. The bursa underneath the deltoid 

 muscle has been observed to have been the 

 seat of an effusion of fluid, quite distinct 

 from that contained within the capsule of the 

 joint; the internal surface of the bursa as well 

 as the synovial lining of the fibrous capsule 

 have been also found coated with lymph. 



Sometimes in advanced cases the fibrous 

 capsule has been found much contracted as 

 well as thickened, and having numerous per- 

 forations in it, which had been the internal 

 orifices of several fistulous canals, which 

 having opened externally had acted as ex- 

 cretory ducts, as it were conducting purulent 

 matter from the different points of the carious 

 surfaces of the bones of the joint, and even 

 from the centre of the diseased head of the 

 humerus. In all of the advanced cases that 

 we have examined, the tendon of the biceps, so 

 far as its intra-articular portion is concerned, 

 has been removed. The articular surfaces 

 have been always divested of their cartila- 

 ginous incrustations, and the reticular struc- 

 ture of the head of the humerus, and of the 

 scapula where it forms the glenoid cavity, 

 usually exposed and bare sometimes coated 

 with a layer of puriform lymph. Part of the 

 head of the humerus has been removed, and 

 in what remains of it deep digital depressions 

 have been observed, and foramina, which pene- 

 trate even into the centre of the head of the 

 bone. 



M. Bonnet, of Lyons, states, " that on 

 making the post-mortem examination of one 



