582 



ABNORMAL CONDITIONS OF THE SHOULDER JOINT. 



narrowed transversely. The axillary margin 

 of the scapula, where the long head of the 

 triceps arises, was furnished with the friable 

 stalactiform osseous productions, which we 

 have already noticed to have existed around 

 the articular surfaces of all the other articu- 

 lations, when they had been for a long time 

 the seat of strumous arthritis, or scrofulous 

 .caries of the joint.* The rest of the scapula 

 had a rough scabrous aspect ; the coracoid pro- 

 cess presented the appearance also of having 

 been in a commencing state of caries. The 

 external lamina of the bone had been absorbed; 

 the exposed reticular structures of it were so 

 friable, they would crumble under the slightest 

 pressure.f 



The lungs presented the ordinary appear- 

 ances of phthisis in its last stage ; there were 

 tubercles and tubercular excavations in both 

 lungs. 



In this case the disease of the shoulder 

 joint seemed to have arrived at its last stage, 

 and to have been in itself sufficient to have 

 induced a fatal hectic fever. However, co- 

 incident with the articular caries appeared the 

 .disease of the lung, which caused, or at all 

 events hastened, the death of the patient. 



Case 4. Articular caries of the shoulder in the 

 fourth stage. , Edward Brady, seL 36, a baker, 

 was admitted into the Richmond Hospital, 

 6th of May, 1828, labouring under disease of 

 the right shoulder joint. It appeared that he 

 Jhad had for some time previously a chronic 

 inflammatory affection of this articulation, for 

 the origin of which he knew no cause ; that an 

 abscess had formed, and that matter had made 

 its way through the skin just beneath the 

 point of insertion of the pectoralis major into 

 the humerus, where a fistulous aperture ex- 

 isted, wra'ch daily gave exit to a considerable 

 discharge of purulent matter. On admis- 

 sion into the hospital, the right shoulder 

 joint was swollen, the man was emaciated 

 and in a state of debility, his pulse quick and 

 weak ; he complained of pain when the 

 slightest pressure was made on the joint, or 

 motion communicated to it. From the short 

 notes of the patient's symptoms during the 

 two last months of his life when in hospital, 

 we learn, that after five weeks' treatment, 

 such as local bleeding and counter-irritations, 

 as blisters, &c., he was not really better. On 

 the contrary, " the patient was much debili- 

 tated, the hectic symptoms had increased, the 

 shoulder was flattened, the motions of the 

 joint were circumscribed within very narrow 

 limits, the acromion was prominent as in 

 axillary dislocation." In another month, viz. 

 July 12, we find entered the following re- 

 port: " No improvement either locally or 

 constitutionally; the shoulder is more ema- 

 ciated, and a crepitating, grating sound is el> 

 cited on rotating the humerus ; the hand is 



* Vide HIP JOINT, ABNORMAL CONDITION or, 

 Vol. II. p. 794. fig. 311. 



t Museum, Richmond Hospital. 



j This case has been extracted from the case book 

 of the late Dr. Macdowell, whose accuracy of obser- 

 vation and fidelity were well known to the editor of 

 ibis work as weH"as to the writer. 



slightly csdematous, yet the discharge is less 

 profuse, and considered of a more healthy ap- 

 pearance." Eight days subsequently to this 

 report the patient became comatose, and died 

 in the course of a few hours. 



Post-mortem examination. The subcuta- 

 neous cellular structure which covered the 

 deltoid muscle of the affected side was desti- 

 tute of all adipose tissue ; the deltoid was pale 

 and thin ; the sub-deltoid bursa contained a 

 sanious fluid, which being removed it was 

 seen that the bursa had been lined with lymph ; 

 the fibrous capsule, ulcerated at one point, 

 was thickened, as was the synovial membrane, 

 which was pulpy; the articular cartilage was 

 entirely removed from the head of the hume- 

 rus and surface of the glenoid cavity of the 

 scapula. The superior extremity of the 

 former was almost totally destroyed, the bone 

 having been crumbled down into many small 

 portions. The surfaces were covered with 

 unhealthy looking pus and lymph. The long 

 tendon of the biceps had disappeared ; the 

 surface of the glenoid cavity was carious ; the 

 small muscles about the joint resembled the 

 deltoid as to the state of thinness and atrophy 

 they had been reduced to. The sinus leading 

 to the point in the axilla already mentioned 

 was lined with lymph. 



The disease of the shoulder joint in this 

 case, it appears, had, as in the preceding, ar- 

 rived nearly at its last period, and we might 

 have supposed that the morbid state here 

 described of so important an articulation was 

 of itself sufficient to cause a fatal result, when 

 the affection of the brain suddenly supervened, 

 and became the immediate cause of the death 

 of the patient. 



It were very desirable that we could assign 

 to the four periods of this disease of the 

 shoulder joint, when affected by chronic ar- 

 thritis, the anatomical characters which belong 

 to each stage respectively ; but we repeat, we 

 are as yet only truly acquainted with those 

 appearances which the post-mortem exami- 

 nations exhibit of the ultimate result of the 

 disease as it has affected the articular tex- 

 tures, when it has been the cause of the death 

 of the patient. 



The pathological condition, therefore, of 

 the different tissues which enter into the com- 

 position of the shoulder joint, as they are af- 

 fected in the early stages of this chronic dis- 

 ease, is as yet, we believe, but little known. 

 The most remarkable features of the second 

 stage of chronic arthritis of the shoulder joint 

 we notice, is the descent of the head of the 

 humerus from the glenoid cavity, and conse- 

 quent elongation of the upper extremity of 

 the affected side. This, we conjecture, may 

 be accounted for by recollecting that the del- 

 toid and articular muscles, which in their normal 

 state maintain the head of the humerus close 

 up against the glenoid cavity, are now in a state 

 of atrophy. They have from want of use, and 

 perhaps, also, from sympathy with the dis- 

 eased state of the articular structures, lost all 

 tonic force. Although these muscles are not 

 really paralysed, still they seem not to have 



