584 



ABNORMAL CONDITIONS OF THE SHOULDER JOINT. 



freely communicating with each other, just as 

 we have already noticed as exemplified in 

 complete bony anchylosis of the hip joint 

 (see Vol. II, of this work, p. 796.). It may 

 not be uninteresting to transfer our attention 

 from the appearances disclosed by the post- 

 mortem examination of an anchylosis of the 

 shoulder joint to the signs by which we re- 

 cognise this state of the articulation in the 

 living. 



A labourer, Thomas Rooney, set. 24, ap- 

 peared among the extern patients at the 

 Richmond Hospital on Thursday, 8th June, 

 1848, seeking relief for some internal ailment; 

 we noticed the wasted condition of the 

 right shoulder joint. We learned that about 

 three years previously he had fallen on 

 the right shoulder and injured it ; he applied 

 for relief to an ignorant person called a bone 

 setter, in whose hands he suffered severely, 

 having been subjected to violent dragging, with 

 the view, as he was told/of reducing a sup- 

 posed dislocation of his shoulder ; violent in- 

 flammation of the joint succeeded, for the treat- 

 ment of which he was admitted into Steeven's 

 Hospital. While in the house suppuration of 

 the joint occurred, and purulent matter made 

 an exit beneath the anterior fold of the 

 axilla, where the tendon of the pectoralis 

 major is inserted into the humerus. The 

 pain and swelling then became less, and he 

 returned to the country, the abcess and sinus 

 leading from it closed up, and his general 

 health became gradually as good as it had 

 been before he met with the accident, and 

 remained so until he became affected with the 

 trivial ailment he now sought advice for as 

 an extern patient at the Richmond Hospital. 

 The shoulder joint, on a superficial ex- 

 amination, might be said to resemble some- 

 what the appearance presented in a case of 

 an old unreduced axillary dislocation, but the 

 resemblance was but slight. It is true that 

 the acromion process stood out laterally, that 

 the deltoid was flattened, that the anterior 

 fold of the axilla was deeper than natural, and 

 that the angular appearance the right shoulder 

 presented was strongly contrasted with the 

 natural rounded contour of the left shoulder 

 joint ; but the head of the humerus could be 

 felt underneath the acromion process ; the 

 elbow, instead of being separated from the 

 .side as in disolcation, seemed habitually ap- 

 proximated to it. The biceps muscle, in 

 consequence of the atrophied condition of 

 the elevators of the extremities, had double 

 duty to perform, and hence had been greatly 

 hypertrophied at its lower part. The man 

 can hold the plough, and can perform all the 

 under movements of the arm very well, but 

 cannot elevate k, nor place his forearm be- 

 hind his loins. 



In this case the arm is habitually approxi- 

 mated to the side, directed somewhat for- 

 wards, and strongly rotated inwards. The 

 most striking features in the case are the 

 wasted condition of the shoulder joint from 

 the atrophy of the deltoid and articular 

 muscles, and the extraordinary development 



of the lower part of the belly of the biceps 

 the cause of which hypertrophy is easily un- 

 derstood. 



We have seen cases in the living subject of 

 perfect anchylosis of the shoulder joint, in 

 which it seemed doubtful whether any short- 

 ening of the extremity existed. In these cases 

 we must suppose that the head of the hu- 

 merus became directly consolidated with the 

 surface of the glenoid cavity, and without the 

 more usual union having been established 

 between the upper extremity of the bone and 

 the superincumbent processes. 



One of the most important points which 

 engages the attention of the practical surgeon, 

 in the treatment of cases of diseased joints at 

 the period when it is expected that a process 

 of anchylosis is going on, is to preserve the 

 affected limb in that position which will be 

 found most convenient to the patient, when 

 true bony anchylosis of the joint shall have 

 been established; for example, under such 

 circumstances we take care to preserve the 

 knee and hip joints extended, the ankle and 

 elbow joint bent to a right angle ; but the 

 shoulder joint, when anchylosis is taking 

 place, may be left to nature, so far as the 

 position of the limb is concerned, because the 

 humerus in these cases habitually remains 

 nearly parallel to the long axis of the body, 

 somewhat rotated inwards ; and, in a word, 

 ia a position which will be found most favour- 

 able to the performance of those functions it 

 shall be called upon to execute when the 

 scapulo-humeral joint is in an anchylosed 

 state. 



CHRONIC RHEUMATIC ARTHRITIS OF THE 

 SHOULDER JOINT. The shoulder joint is some- 

 times the seat of this peculiar disease, though 

 by no means so frequently as many of the other 

 articulations. The origin of it we hav.e known 

 to be attributed to accident, such as a fall 

 on the shoulder, or to a sprain of the joint. 

 On some occasions the sudden exposure of 

 the person, when overheated, to currents of 

 cold air, has been referred to as its cause $ 

 and in others the chronic disease of the 

 shoulder joint has been supposed to have 

 originated in the lingering remains of a rheu- 

 matic fever. These are, indeed, the ordinary 

 exciting causes of this disease in general, no 

 matter in what particular joint it may show 

 itself. 



Symptoms. The patient complains of 

 feeling pains in the shoulder joint, which, like 

 those of rheumatism, are variable, and seem 

 to be under the influence of changes in the 

 atmosphere. He states that he feels a stiffness 

 in the joint, and is conscious of a " crackling" 

 sensation in it, particularly when he first moves 

 it in the morning. The muscles around the 

 articulation fall into a state of atrophy, while 

 the bony prominences around the joint ge- 

 nerally become conspicuous from their en* 

 largement, 



If only one shoulder joint be affected with 

 the ordinary form of the disease, and we com- 

 pare it with that of the opposite side, the 

 head of the humerus of the affected side will 



