594 



ABNORMAL CONDITIONS OF THE SHOULDER JOINT. 



relaxed : " The shoulder joint presented a 

 remarkable degree of mobility in this case ; 

 and the head of the humerus of the affected 

 side could be pushed half an inch higher than 

 its fellow." The great peculiarity in this case 

 Dr. R. Smith thought consisted in the cir- 

 cumstance that the tendon of the biceps was 

 not, as it usually is in cases of this chronic 

 disease, absorbed, but was in a perfect state of 

 integrity as to structure. 



This tendon having been thrown off the 

 head of the humerus, and displaced inwardly, 

 its normal function to restrain the ascent of 

 the humerus, through the medium of its mus- 

 cular connection, was as much annulled as if 

 it had been removed altogether, as it usually 

 is, under the influences of this chronic dis- 

 ease. 



Questions here naturally arise : Can the 

 tendon of the biceps be dislocated from its 

 groove by accidental violence ? and if so, Shall 

 the consequent dislocation of the head of the 

 humerus be in the direction upwards, exactly 

 as it was in the preceding case, which was 

 evidently an example of the displacement of 

 the tendon from disease. 



Mr. John Soden, junior, of Bath, has pub- 

 lished a case, accompanied by some interesting 

 remarks, the objects of which are to prove that 

 the tendon of the biceps may be dislocated by 

 accident, and that a partial displacement of 

 the head of the humerus upwards must im- 

 mediately follow. 



Mr. John Soden's case. Partial disloca- 

 tion upwards. " Joseph Cooper, aged 59, 

 was admitted into the Bath United Hos- 

 pital, November 9, 1839, on account of a 

 compound fracture of the skull. His death 

 afforded an opportunity of examining an old 

 injury of the right shoulder, the symptoms of 

 which had been always involved in great ob- 

 scurity, and which occurred in the following 

 manner : 



" In the month of May, 1839, the deceased 

 (six months before his death) was engaged in 

 nailing down a carpet, when, on rising sud- 

 denly from his occupation, his foot slipped, 

 and he fell backwards on the floor. In order 

 to break the force of the fall, he involuntarily 

 placed his arm behind him, and by so doing 

 received the whole weight of the body upon 

 his right elbow ; that joint, the only one 

 struck, received no injury, for the shock was 

 instantly transmitted to the shoulder, and 

 there the whole effects of the accident were 

 sustained. Acute pain was immediately ex- 

 perienced, and the man supposed he had 

 either suffered a fracture or a dislocation, but 

 finding that he could raise the arm over his 

 head y he felt reassured, and endeavoured to 

 resume his work. The pain, however, com- 

 pelled him to desist, and he went home." 

 " When I saw him," says Mr. Soden, " on the 

 following morning, the joint was greatly 

 swollen, tender to the touch, and painful on 

 very slight motion. There was then no pos- 

 sibility of his placing his arm over his head, 

 as he had done immediately after the acci- 

 dent. I satisfied myself that there was nei- 



ther fracture nor dislocation of the bones, 

 and not suspecting the existence of a more 

 specific injury than a severe sprain, I set 

 down the case as such, and avoided the un- 

 necessary pain of further examination. Un- 

 usually active means were necessary to sub- 

 due the inflammation, and at the end of 

 three weeks, though the swelling was much 

 reduced, the tenderness in the front of the 

 joint, and pain on certain motions of the limb, 

 were scarcely less than on the day after the 

 occurrence of the accident. 



" On comparing the joint with its fellow, 

 now that the swelling had subsided, a marked 

 difference was observable between their re- 

 spective outlines. The injured shoulder was 

 evidently out of drawing, but without pre- 

 senting any glaring deformity : when the man 

 stood erect with his arms dependent, the dis- 

 tinction was very manifest, but difficult to 

 define. There was a slight flattening on the 

 outer and posterior part of the joint, and the 

 head of the bone looked as it were drawn up 

 higher in the glenoid cavity than it should be. 

 Examination verified the appearance in two 

 ways : first, on moving the limb, with one hand 

 placed on the shoulder, a crepitating sensation 

 was experienced under the fingers, simulating 

 a fracture, but in reality caused by the fric- 

 tion of the head of the humerus against the 

 under surface of the acromion : secondly, on 

 attempting abduction, it was found that the 

 arm could not be raised beyond a very acute 

 angle with the body, from the upper edge of 

 the greater tubercle coming in contact with 

 that of the acromion, and thus forming an 

 obstacle to all further progress. The head of 

 the bone was also unduly prominent in front, 

 almost to the amount of a partial dislocation. 

 For all useful purposes the arm was power- 

 less. The pain caused by the action of the 

 biceps was acute, extending through the whole 

 course of the muscle, but felt chiefly at its 

 extremities. When the joint was at rest the 

 pain was referred to the space in front, be- 

 tween the coracoid process and head of the 

 humerus ; which spot was marked by extreme 

 tenderness and some puffy swelling. 



" The patient being of a rheumatic habit, in- 

 flammatory action of that character was soon 

 established in the joint, so that the peculiar 

 symptoms of the injury were marked by those 

 of general articular inflammation, which added 

 greatly to the man's suffering, and to the dif- 

 ficulty of diagnosis. On examining the joint 

 the accident was found to have been a dislo- 

 cation of the long head of the biceps from its 

 groove, unaccompanied by any other injury. 

 The tendon was entire, and lay enclosed in 

 its sheath, on the lesser tubercle of the hu- 

 merus ; the capsule was but slightly ruptured ; 

 the joint exhibited extensive traces of inflam- 

 mation ; the synovial membrane was vascular 

 and coated with lymph ; recent adhesions 

 were stretched between different parts of its 

 surface, and ulceration had commenced on 

 the cartilage covering the humerus, where it 

 came in contact with the under surface of the 

 acromion ; the capsule was thickened and ad- 



