As to the anatomical examination of the joint, it will be recollected that the disease had been only six months established, and there'bre that the more striking results of chronic rheumatic disease should be found was not to be expected. Those which w ere noticed, however, were such as might be sup-. posed to represent the anatomical characters of chronic rheumatic arthritis of the shoulder in an early stage.
As to whether Mr. Soden's interpretation of his own case be the correct one, or the doubt we have ventured to express should be considered to have a just foundation, we must leave to the judgment of others, to time, and to the result of future investigations to determine ; but the subject must be con fessed to be one of a truly practical nature, and therefore worthy of further inquiry.
We had written thus mach on the subject of partial dislocation of the head of the hu merus upwards, with displacement inwards of the long tendon of the biceps, when (on the 12th of August,1848) an opportunity' occurred to us of examining anatomically both shoulder joints of a patient who had died in the North Union Poor House the day before, who had been for eight years one of the severest sufferers the writer had ever known from chronic rheumatic arthritis in almost all his joints. The disease existed in an aggravated form in his hips and knees, wrists and elbows, and of late years began also to affect equally both shoulder joints. It was very remark able that, on examining anatomically the shoulder joints in this case, e discovered the same displacement of the head of the humerus upwards, with dislocation of the tendon of the biceps inwards, as in Mr. So den's case, in both shoulder joints, and with the dislocation of the long tendon in both shoulder joints in this case, which we shall now relate, were found associated the ordinary anatomical characters of chronic rheumatic arthritis in rather an early stage of the disease; while in the other articulations of this same individual the chronic rheumatic disease was in a very advanced state.
Case. Charles Mailly, wtat. 48, had been a farming servant in the country,and was remark able for his strength and activity. He was addicted to drinking ardent spirits to excess, and it was stated of him that he frequently lay whole nights in the open air in a state of insensibility froin drunkenness. To these circumstances he attributed the origin of his disease, which disabled him from earning his bread ; he was therefore admitted into the poor house, in 1840. For the last five 3:ears he has been altogether confined to his bed, as he could not stand upright, much less walk, when the writer visited him in August, 1847. His hips, knees, and elbow joints were semiflexed and rigid, his wrist extended, his fingers and toes presented the ordinary characteristic distortion belonging to rheumatic gout, or chronic rheumatic arthritis.* Although the shoulder joints in this case had lost much of their muscular covering, the deltoid and cap sular muscles being in a state of atrophy, yet the bones of the articulation seemed much enlarged, and the heads of both humeri were evidently situated much above the level of the coracoid process. He did not complain of much pain in the shoulders ; the constant torture he endured in the right hip and both his knees quite distracted his attention from all minor suffering. He stated that he had a " crackling " sensation in all his joints when ever they were moved ; that his sufferings were influenced by the weather, and that he endured more pain during the frost of winter than at any other time. The patient died worn out by pain and irritative fever, attended with severe diarrhcea.
Posl-morlenz examination. —Dr. R. Smith assisted the writer in this examination. As the body lay on its back on the table, the hips, the elbows, and knee joints were semi flexe I, and could not be. extended, but they
permitted of flexing to a very trivial degree. When any of the affected joints were moved, the characteristic crepitus, or crackling, so often alluded to, was elicited now as during life. The head of the os humeri of each side was drawn up much above the level of the coracoid process, and was preter naturally advanced. Upon rotating the hu merus, a marked crepitus was evident in these as well as all the other joints. On re moving the integument over the right shoul der joint, the deltoid muscle was found pale, and forming a thin attenuated layer of muscular fibres covering the articulation. When this was removed, the sub-deltoid bursa was seen to be of a yellowish colour, and it had a fibrous appearance externally, like to a capsular ligament. When this bursa was freely cut into by an incision parallel to the margin of the acromion, its cavity was observed to be more capacious than usual. The posterior or inferior wall of the bursa was found to have identified itself with the external and superior part of the fibrous capsule of this articulation, and both seemed here to have become degenerated into thin cellular structure, which adhered to and formed a periosteal covering for the summit of the htnnerus near to the upper part of the great tuberosity. The capsular ligament was elsewhere somewhat thicker than natural, particularly at the upper and anterior part, where it seemed to have identified itself at its origin with the coraco humeral ligament, which was much thickened. As to its attachment to the humerus, the capsular ligament, superiorly and posteriorly, was very short, having become adherent to the head of the bone before this capsule had reached its usual point of insertion into the anatomical neck of the humerus. Ante riorly and inferiorly the capsule descended on the neck of the humerus below its normal level (fig. 430.). When this ligament was cut into and exainined posteriorly, several broad patches of adhesion were found to exist (as in Mr. Soden's case) between its internal surface and the head of the bone pos teriorly, so that in these parts the syno vial cavity was completely obliterated by the adhesion of the opposed surfaces of the membrane which lined the capsular liga ment, and invested the posterior part of the head of the humerus, just as we find occa sionally the pericardium partially adherent to the surface of the heart. When the capsular ligainent was fully opened anteriorly, where it is covered by the tendon of the subscapu laris, it was seen, more evidently than it could have been previously, that the head of the humerus had been placed habitually above the level of the coracoid process and the highest point of the glenoid cavity from which the long tendon of the biceps springs (fig. 430.). The tendon of the biceps lay entirely to the inside of the head of the humerus ; indeed, such- was its position, that it might rather be said that the humerus was displaced out wards, and elevated above the level of the course of the tendon of the biceps, than that the latter was dislocated inwards. A semi circular groove marked the course of the tendon of this muscle as it arched across from the highest point of the glenoid cavity to the summit of the bicipital groove. The portion of the head of the humerus which was situated above the course of the tendon of the biceps was divested of all cartilaginous covering, was of a yellowish colour, and remarkably hard, and presented an appearance as if the summit of the humerus had been prepared for the polish of eburnisation, but as yet no ivory-like enamel had formed, because as yet bone had not come in contact with bone.