ABNORMAL CONDITIONS OF THE SHOULDER JOINT. 



585 



be observed to be somewhat elevated, ad- 

 vanced, and very generally approximated 

 towards the middle line. When we view the 

 articulation in profile (as it were), the amount 

 of the advancement of the head of the hume- 

 rus is more readily appreciated. And when we 

 look at the shoulder joint from behind, a very 

 remarkable abnormal depression may be seen, 

 which corresponds to the space or interval 

 which exists between the posterior part of 

 the glenoid cavity arid the head of the hume- 

 rus. After a time, the voluntary motions of 

 the joint become restricted within very nar- 

 row limits. The patient cannot well abduct 

 the elbow from his side, nor elevate it nearly 

 to an horizontal level. The motions he is 

 himself capable of communicating to his arm 

 are chiefly confined to under movements, yet 

 the head of the humerus is in some of these 

 cases susceptible of an abnormal degree of 

 mobility. Although in the ordinary form of 

 this disease the head of the humerus will be 

 found to be placed above its normal level, and 

 is observed to be several lines higher than the 

 coracoid process, still if the arm be grasped by 

 the surgeon it can be drawn down, and the 

 head of the bone will place itself beneath the 

 coracoid process ; the joint will then as- 

 sume all the appearances usually assigned as 

 the marks of the case styled by Sir A. Cooper 

 " Partial luxation of the head of the humerus 

 forwards and inwards." In cases of long 

 standing, the capsular ligament becomes wider 

 than natural, and the articular surfaces are so 

 altered that partial dislocation of the head of 

 the humerus occurs in other directions besides 

 those above alluded to; but any observations 

 we have to offer upon this part of our subject 

 it will be more convenient to defer until we 

 come to speak of the anatomical characters of 

 this disease. 



Although the patient may complain of pain 

 in the middle of the arm, and of spasms of 

 the muscles, of the whole extremity of the 

 affected side, even to the fingers, yet if the 

 surgeon elevate the arm at the elbow, and 

 press the humerus even rudely against the 

 glenoid cavity of the affected articulation, the 

 patient experiences no uneasiness. 



It is very remarkable that this peculiar 

 affection of the shoulder joint has never, as 

 far as we have known, terminated in anchy- 

 losis, nor proceeded to suppuration ; nor has 

 its presence excited any sympathetic disturb- 

 ance in the constitution of the patient ; yet 

 from year to year the disease slowly but gra- 

 dually increases, until the patient is carried 

 off by some other complaint, or dies from the 

 mere effect of age alone. 



Diagnosis. This peculiar affection of the 

 shoulder joint, particularly when the history 

 of the case is known, cannot well be con- 

 founded with any other disease of the articu* 

 lation with which we are acquainted. Scro- 

 fulous caries of the bones of the shoulder 

 joint may have some symptoms in common 

 with the chronic disease we are describing, 

 but there is more pain and more wasting of 

 the muscles of the arm and fore-arm, and 



more sympathetic disturbance of the constitu- 

 tion in the case of articular caries of the 

 shoulder than in that of chronic rheumatic 

 arthritis of this articulation ; and while the 

 former case usually proceeds to suppuration, 

 or to anchylosis of the joint, these processes 

 never take place in the latter. 



In the chronic rheumatic disease, the op- 

 posite shoulder joint will, in general, be found 

 symmetrically affected; a circumstance we 

 have never yet known to have been the case 

 in a chronic arthritis, or articular caries, of 

 the shoulder. 



The history of the case of chronic rheuma- 

 tic arthritis usually betrays its nature by the 

 general rheumatic pains the patient reports 

 himself to have suffered from ; by the disease 

 not being confined to the one articulation ; 

 by the enlargement of the bony prominences 

 about the joint, although the muscles are 

 wasted. In both cases there may be crepi- 

 tus felt on moving the joint and on making 

 pressure ; but the efforts to elicit crepitus, 

 and the pressing together of the articular sur- 

 faces cause, in the case of chronic arthritis, 

 or articular caries, so much pain, that the 

 patient shrinks back from our attempts at 

 making these trials ; while in the ordinary 

 case of chronic rheumatic arthritis of the 

 shoulder, when even it appears as a local 

 disease confined to one or two articulations, 

 we find we can even rudely press the head of 

 the humerus against the surface of the glenoid 

 cavity without causing the patient pain, just 

 as we can, in the case of the same disease 

 when it affects the hip joint, press the head of 

 the femur against the acetabulum without 

 causing the least uneasiness to the patient 

 (see Vol. II. p. 799.). 



No doubt some few cases of chronic rheu- 

 matic arthritis of the shoulder joint in the 

 living and in the dead have been mistaken for 

 partial dislocation of the head of the humerus, 

 the result of accident ; but we are of opinion 

 that, as the chronic rheumatic affection is 

 daily becoming better known to the profes- 

 sion than formerly, such errors will no longer 

 be committed, particularly when the anato- 

 mical characters of this disease have been more 

 fully studied by the profession. 



Anatomical characters. When we ana- 

 tomically examine the shoulder joint of a 

 patient who has long laboured under this 

 chronic disease in the articulation, we notice 

 on removing the integuments that the deltoid 

 muscle is unusually pale, and that the inter- 

 stices between its fibres are occupied by an 

 unhealthy-looking fat. This and the sub- 

 jacent capsular muscles are in a state of 

 atrophy. The capsular ligament is generally 

 altered in form and structure, and it will 

 be sometimes found to have abnormal attach- 

 ments above to the acromion or coracoid 

 process ; and, below, its attachment to the 

 anatomical neck of the humerus is some- 

 times partially interrupted, allowing of an 

 interval which in some forms of the disease 

 permits the head of the humerus to pass 

 through it. 



