The surface of the glenoid cavity seemed to have been somewhat worn away and rendered more than naturally concave; the anterior or inner margin of it was rounded off by caries, The oval outline of the glenoid cavity was elon gated from above clownm ards, and_somewhat narrowed transversely. The axillary margin of the scapula, where the long head of the triceps arises, was furnished with the friable stalactiform osseous productions, which we have already noticed to have existed around the articular surfaces of all the other articu lations, when they had been for a long time the seat of strumous arthritis, or scrofulous caries of the joint.* The rest of the scapula had a rough scabrous aspect ; the coracoid pro cess presented the appearance also of having been in a commencing state of caries. The -external lamina of the bone had been absorbed; the exposed reticular structures of it were so friable, they would crunible under the slightest pressure.f The lungs presented the ordinary appear ances of phthisis in its last stage; there were tubercles and tubercular excavations in both lungs.
In this case the disease of the shoulder joint seemed to have arrived at its last stage, and to have been in itself sufficient to have induced a fatal hectic fever. However, co incident with the articular caries appeared the disease of the lung, which caused, or at all events hastened, the death of the patient.
Case 4. Articular caries of the shoulder in the jinirth stage.t —Edward Brady, mt. 36, a bak er, was admitted into the Richmond Hospital, 6th of May, 1828, labouring under disease of the right shoulder joint. It appeared that he had had for some time previously a chronic inflammatory affection of this articulation, for the origin of which he knew no cause ; that an ,abscess had formed, and that matter had made its way through the skin just beneath the point of insertion of the pectoralis major into the humerus, where a fistulous aperture ex isted, which daily gave exit to a considerable discharge of purulent matter. On adtnis sion into the hospital, the right shoulder joint was swollen, the man was emaciated and in a state of debility, his pulse quick and weak ; he comtilained of pain when the slightest pressure ,was made on the joint, or motion communicated to it. From the short notes of the patienes symptoms during the two last months of his life when in hospital, We learn, that after five weeks' treatment, such as local bleeding and counter-irritations, as blisters, &c., he was not really better. On the contrary, " the patient was much debili tated, the hectic sytnptoms had increased, the shoulder was flattened, the motions of the joint were circumscribed within very narrow limits, the acromion was prominent as in axillary dislocation." In another month, viz.
July 12, we find entered the following re port : —" No improvement either locally or constitutionally ; the shoulder is more ema ciated, and a crepitating, grating sound is elL cited on rotating the humerus ; the hand is slightly irdenzatous, yet the discharge is less profuse, and considered of a more healthy ap pearance.." Eight days subsequently to this report the patient became comatose, and died in the course of a few hours.
Post-mortem examination. — The subcuta neous cellular structure which covered the deltoid muscle of the affected side was desti tate of all adipose tissue; the deltoid was pale and thin ; the sub-deltoid bursa contained a sanious fluid, which being removed it was seen that the bursa had been lined with lymph ; the fibrous capsule, ulcerated at one point, was thickened, as was the synovial membrane, which was pulpy ; the articular cartilage was entirely removed from the head of the hume rus and surface of the glenoid cavity of the scapula. The superior extremity of the former was almost totally destroyed, the bone having been crumbled down into many small portions. The surfaces were covered with unhealthy looking pus and lymph. The long tendon of the biceps had disappeared; the surface of the glenoid cavity was carious ; the small muscles about the joint resembled the deltoid as to the state of thinness and atrophy they had been reduced to. The sinus leading to the point in the axilla already mentioned was lined with lymph.
The disease of the shoulder joint in this case, it appears, had, as in the preceding, ar rived nearly at its last period, and we rnig,ht have supposed that the morbid state here -described of so iniportant an articulation was of itself sufficient to cause a fatal result, when the affection of the brain suddenly supervened, and became the immediate cause of the death of the patient.
It were very desirable that we could assign to the four periods of this disease of the shoulder joint, when affected by chronic ar thritis, the anatomical characters which belong to each stage respectively ; but we repeat, we are as yet only truly acquainted with those appearances which the post-mortem exami nations exhibit of the ultimate result of the disease as it has affected the articular tex tures, when it has been the cause of the death of the patient.