Sometimes in advanced cases the fibrous capsule has been found much contracted as well as thickened, and having numerous per forations in it, which had been the internal orifices of several fistulous canals, which having opened externally had acted as ex cretory ducts, as it were conducting purulent matter from the different points of the carious surfaces of the bones of the joint, and even from the centre of the diseased head of the humerus. In all of the advanced cases that we have examined, the tendon of the bieeps, so far as its intra-articular portion is concerned, has been removed. The articular surfaces have been always divested of their cartila ginous incrustations, and the reticular struc ture of the head of the humerus, and of the scapula where it forms the glenoid cavity, usually exposed and bare sonletimes coated with a lay er of puriform lymph. Part of the head of the humerus has been removed, and in what remains of it deep digital depressions have been observed,and foramina, which pene trate even into the centre of the head of the bone.
M. Bonnet, of Lyons, states, " that on making the post-mortem exarnination of one of his patients, who died of articular caries of the shoulder joint, he discovered, when a vertical section was made of the humerus, that in the centre of the head of this bone there was contained a cavity or cell, the size of a hazel nut, filled with tubercular matter, in the middle of which were found fragments of necrosed particles of bone. In this case also, he adds, tubercular matter was found in the axillary glands." Bony nodules and stalactiform osseous productions are observed to be produced from different parts of the scapula and head 'of the humerus, in the vici nity of the shoulder joint. The coracoid process and acromial end of the clavicle we have found in these cases carious ; the alter ations of the osseous structure do not seem confined to the bones in the immediate vici nity of the joint itself. The whole scapula and humerus seem specifically lighter than they should be normally. We have tried the experiment of placing the diseased bones in water, and have seen them float, while the normal bones of the same region sink. The ribs, too, have been found sometimes carious simultaneously with the bones which con stitute the scapulo-humeral joint.
These observations refer merely to the local condition of the articular structures them. selves. The state of the constitution of many of these cases affected with chronic arthritis of the shoulder deserves the attentive con sideration of the physician and surgeon.
The prognosis to be formed as to any ad vanced case of articular caries of the shoulder joint should be a guarded one, as the follow ing facts may convince us. In the first case which we shall now adduce, fatal disease of the lungs seemed coincident with the articu lar caries of the shoulder ; and at last it was doubtful which of the two diseases was the im mediate cause of the death of the patient. In the second case disease of the brain, with paralysis, came on, and was the immediate cause of the death of' the individual, who had been previously mueh reduced by articular caries of the shoulder.
Case 3. Chronic arthritis or articular caries ty the shoulder joint, lasting thirteen months.
—Matthew M`Cabe, a labourer, 38, was admitted into the Richmond Hospital, Sept. 2. 1846, under Dr. Hutton's care.f He stated that about nine months previously he was seized with a pain in his left shoulder, which soon extended to his elbow ; he was able to work for two months after the first attack of pain, hut after this period the arm became stiff; and remained powerless by his side ; the muscles around the shoulder and of the whole extremity were wasted ; fistulons open ings existed beneath the coracoid process, and through the deltoid muscle ; the limb was of its normal length. When the joint was pressed
the patient complained of pain ; the motion of the head of the humerus on the glenoid ca vity of the scapula appeared much limited ; he had cough and hectic fever, of which the prominent symptoms, beside the cough, were a quick pulse and diarrhcea. He died Jan. 25. 1842.
Post-mortem examination.— The body was emaciated. Before making the examination, a plaster of Paris cast was taken of the left shoulder joint, which is preserved in the hos pital museum : this shows especially the wasted condition of all the muscles around the shoulder joint, and the consequent prominence of the spine and acromial process of the scapula, usual in cases of articular caries of the shoulder. For the space of two inches along the anterior wall of the axilla and line of the humerus an oblong depressed scrofulous ulcer existed, in which were seen the orifices of three or four fistulous canals, which led from the interior of thejoint. The elbow was placed somewhat backward, and the long axis of the humerus was consequently directed. front below up wards and forwards ; the convexity of the head of the humerus, without being dislocated,. was placed somewhat more forwards and in wards than natural. TJpon removing the deltoid muscle, which was wasted and per forated by fistulous openings, it was found that the capsular ligament was contracted and thickened, and had several openings in it,, and that purulent matter was effused both into the joint and under the deltoid muscle, which thus formed the sac of an abscess. The car tilages had been entirely removed from the ar ticular surfaces, The intra-capsular portion of the tendon of the biceps had disappeared ; the highest part of thistendon which remained vs as attached to the inside of the capsular ligament. The bones had been injected with size and vermilion, and presented in their interior as well as on their carious surfaces a reddish colour; but they did not appear softened ; when after maceration they had been, dried, they seemed to be preternaturally light. The. superior hemispherical portion of the head of the humerus had been removed very nearly to the level of the anatomical neck, or situation for the attachment of the capsules ; and the surface was red, porous, and much rough ened. from. caries. Towards the highest part of the humerus, just within the line which separates the great tuberosity from the head of the hurnerus, there existed two very deep digital or alveolar depres.sions, whieh pene trated into the cellular structure of the head of the humerus : the anterior part of the upper extremity of this bone, where the bicipital groove exists, W8s rough and porous ; the groove was much deepened, particularly in, the situation of the lesser tuberosity, which was elevated into a bony nodule, and enlarged about one inch below the lesser tuberosity, On the front of the surgical neck there existed another bony nodule, but smaller.