Case 2. Articular caries at the shoulder joint in the fourth stage of the disease. — Mary Ann Malloy, mt. 21, servant, admitted into the Richmond Hospital 25th July, 1847, under the care of Dr. Hutton. She has been now (June, 1848) eleven months.
in hospital, and her left shoulder joint has in this period gone through all the stans of chronic arthritis ; and a process of anch}losis, with shortening of the left upper extremity, appears to have been nearly completed. Her general health seems at this time but little affected: several depressions along the mar gins of the deltoid muscle, anteriorly and pos teriorly, mark the situation of the numerous openings, most of which are now closed, through which purulent rnatter had escaped from the joint. The history which we collected of her case vvas, that about two months pre viously to her coming to the hospital she fell backwards on her left elbow, to which acci dent she ascribes her disease ; that subse quently to this fall she felt pain in her left shoulder, but she cannot recollect that the joint swelled or became hot ; on the contrary, the shoulder always seemed to her, from the first, to waste, and to be colder (as it is at this moment) than the other ; except when the period of the formation of th,e abscesses arrived. Site states that the movements of the joint, during the progress of the disease, were most painful, and that she had a sensa tion of something grating in the joint when ever the surgeon, in examining it, moved the arm. The arm is half an inch shorter than the other, and is closely approximated to the side : whenever abduction flexion, or exten sion of it is attempted Cy the patient, the scapula invariably moves also. The patient has no power of rotation of the head of the humerus on the scapula, nor can any move ment of the kind be communicated. The bead of the humerus in this case has not been dislocated, but its tendency is certainly backwards towards the infraspmatus fossa, where some fulness is perceived. The par tial absorption of the head of the humerus, as well as the removal of a portion of the sur face of the glenoid cavity by caries, which we believe has occurred here, will sufficiently account for the shortened condition of the arm.
The most favourable prognosis we can form as to this case is, that a bony anchylosis of the shoulder joint will be established.
In the first of these cases (M. Moore) it was very manifest that the limb was elongated; and in this second case (Malloy), when the disease of the shoulder joint had arrived at a much more advanced sta67, it was equally evident that the length of the affected ex tremity was diminished. We have adduced
these cases as examples of what may be frequently expected to be seen by those who Watch the course of articular caries of the shoulder joint; but we must be prepared to meet with exampins in which it may be ob served, that during the whole progress of the disease the length of the limb will be neither increased nor diminished. Varieties analogous to this we notice in the symptoms and pro gress of articular caries when it affects other joints (see HIP Jowl); and therefore we need not be surprised, when the shoulder joint is the seat of chronic arthritis, that sometimes the extremity of the affected side is shorter, sometimes longer, and that sometimes during the whole course of the disease but little al teration as to increase or diminution of length is appreciable.
Anatomical characters of chronic arthritis of the shoulder.—The specimens we have an opportu nity of examining anatomically, which show the ultimate effects of chronic arthritis on the se veral structures composing the shoulder joint, cannot be considered very rare ; but it must be confessed that we seldom can ascertain the condition of the different structures of the shoulder joint which have been affected by chronic arthritis, excepting in cases in which the disease has arrived at its last stage, and has been the cause of the death of the patient. On making the post-mortetn examination of the affected shoulder in cases where the dis ease has arrived at its last stage, we usually notice that the skin has been perforated by numerous fistulous openings; these are some times to be seen in the axilla, or ranged along the line of the margin of the deltoid muscle, perhaps at points more distant from the joint, as,on the lower margin of the pectoral muscle near the mamma (case of Malloy). The subcu taneous cellular structure we have not found infiltrated, as it is in cases of white swelling, of the knee, or of the other joints, with a ge latinous glairy matter; on the contrary', the cellular structure itself has always seemed to us to be in .a wasted condition, containing no adeps ; the deltoid as well as the arti cular muscles have been found in a state of atrophy. The bursa underneath the deltoid muscle has been observed to have been the seat of an effusion of fluid, quite distinct from that contained within the capsule of the joint; the internal surface of the bursa as well as the synovial lining of tbe fibrous capsule have been also found coated with lymph.