In the third period of the disease, the wasted condition of the muscles around the shoulder joint, as well as those of the whole upper extremity, becomes still more obvious, and now the arm, which was really longer than natural, becomes gradually shorter. It is quite possible that, after the limb has become shortened, any pain or uneasiness felt in the joint may subside, and a process of true anchylosis be established before suppuration takes place ; but it much more frequently occurs, that about the time of the shortening of the limb, or subsequently, a chronic symp tomatic abscess will make its appearance, and perhaps open spontaneously, in the axilla, or on some point along the outline of the deltoid, or inferior margin of the pectoral muscle ; and then the disease may be said to be in the fourth stage, This very serious chronic disease of the shoulder rnay be sometimes arrested in its early stage, and the patient recover the use of the joint ; but, on the other hand, the disease frequently ends unfavourably by hectic fever, with its fatal consequences supervening. The more usual course for the disease to run will be found in general to be, that suppuration will take place, abscess after abscess will form, their purulent contents escaping and con tinuing to flow, greatly exhausting the strength and spirits of the patient ; but under the in fluence of good air and judicious management, the discharge front the abscesses may cease, the constitution improve, and true bony an chylosis of the shoulder joint be established.
The history of the two following cases of simple chronic arthritis of the shoulder, at this moment (June, 1848) under treatment at the Richmond Hospital, will serve to illus trate some of the preceding observations as to the symptoms which patients usually labour under when affected by this chronic disease.
Case 1. Chronic arthritis of the right shoulder joint of four years' duration. The disease in the second Rlargaret Moore, mt. 27, servant, admitted March 8th, 1848, under the writer's care. She complained of stiff ness and weakness of her right shoulder (fig. 427.), and of pain, which was much worse at night than during the day ; she had also a constant uneasiness at the inner side of the right elbow, and her nights were restless, her sleep interrupted by spas modic starting of the whole limb, and pain extending down to the wrist and back of the hand ; she states that she has really more pain in the elbow arid wrist than in her shoulder, and that these pains are increased when the arm is moved, or the articular sur faces are pressed against each other. When ever she moves her arm in the slightest gree the scapula follows the humerus, so that in the voluntary movements of the upper extremity really no motion takes place in the shoulder joint; but if we grasp the scapula, and thus firmly fix it„ and at the same time move the humerus, a distinct crepitus is oc casionally elicited, of which the patient her self also is conscious. When the arm is per mitted for a moment to hang down by her side unsupported, she has great pain, and she feels the advantage of keeping it constantly in a sling, with her hand as high as her oppo, site collar bone. The muscles surrounding the right shoulder joint were observed to be in a wasted condition ; this shoulder seemed higher up than the other, and the clavicle of this side to have a corresponding obliquity. The history she gives of the origin and progress of this disease is, that she has had a certain degree of pain and uneasiness in the articulation for the last four years, but that it never swelled much nor hecame in flamed, nor did it prevent her from follow ing her occupation as housemaid, until three months ago, when she felt compelled to give up her situation, She referred the aggrava tion of her distress latterly to an injury the joint received from a severe fall she got down ari entire flight of stairs. The latter
circumstance in the history of her case made us more particular in our inquiries as to uhether any fracture or dislocation could have occurred at the moment of this accident, and have been left unreduced. We were readily satisfiefi that there had been no frac ture, as the affected arm was longer than the other.
The deltoid muscle was flattened and the acromion %vas seen presenting an angular projection as in an old luxation; yet the head of the humerus could be felt below the acro mion; the anterior fold of the axilla was deeper than natural, but the elbow in this noman was placed habitually close to her side, and the long axis of the humerus could be traced by the eye to run nearly perpendi cularly upwards towards the site of the gle . . • .
nom cavity, anct not more inwaras towards the axilla, as in the case of Iuxation, The atrophy we observed to affect the muscles in the vicinity of the diseased shoul der joint in this case, was not confined to the deltoid and capsular muscles ; but the great pectoral was so much wasted that the ribs and intercostal interstices were seen con spicuously on the right side, while the cor responding spaces on the left side of the front of the thorax were sufficiently covered by muscle, &c, The right arm and forearm were more wasted than the kft or unaffected limb, while the former extretnity,.measured from the acromion to the outer condyle of the humerus, shows an addition of length, or rather a descent of the humerus from the glenoid cavity, for the space of one inch. This woman has been subjected to the ordinary treatment for such cases ;, she feels the necessity of supporting' ner arm, ana not allowing it out ot tne siing during the day, while she walks in the open air, The foregoing case, presents us, as we have said, with a good specimen of the simple chronia arthritis, or- articular caries. of the shoulder in the second stage of the disease. It is probable that a slow process of bony an-. chylosis will be ultimately established; and the woman after a thne may, lose all pain, regain her general health, a.nd ultimately recover, but with the impediment which must ev.er attend an an chylosed shoulder joirtt. The•eourse of the disease is not always so favourable ; on the contrary, when the disease has arrived, as in the case of Moore just related, at the second stage, the pain is in some instances increased,, the head of the humerus becomes wasted by caries as well as the surface of the glenoid cavity, when it will be found that the affected extremity, which was really longer than the other, shall have become shorter. This shortening, which marks the third stage of the disease, is frequently thought to be the result of complete dislocation; but this occur, rence„ the possibility of which we do not deny, we believ,e, however, to be exceedingly rare, The shortening may be the consequence of caries and absorption of the head of the humerus, as well as of. the surface of the gle, noid cavity. T.Juder such circumstances the head of the bone may lean towards the axilla and subscapular fossa, or backwards to. wards the dorsurn of the scapula ; or it may be elevated, so as to reach the concavity of the coraco-acromial vault, and be maintained there by the tonic force of the elevator muscles ; but we have not found it com-. pletely dislocated as a result of caries.