This patient remained in the Whitworth Hospital until the pultnonary affection proved fatal. Dr. Mayne and the writer carefully examined the joint, which is still preserved in the museum of the Richmond School (fig. 429.).
We found the deltoid and other muscles around the joint in a wasted condition, and much paler than those of the opposite shoul der. When the capsular ligament was ex posed, it was found to have superiorly a much wider and more extensive adhesion than natural. Instead of this fibro-synovial sac having its ordinary attachment all round to the limited circumference of the glenoid cavity of the scapula, its adhesion to the upper margin of this cavity did not exist, but the superior and outer portions of the capsu lar ligaments seemed to have acquired new attachments, and to be connected superiorly and externally with the anterior margin of the coraco-acromial arch ; and thus the space in which the head of the humerus had been permitted to move, had been rendered much more extensive than natural.
The capsular ligament was much thick ened, and when opened more synovia than usual flowed out. This membrane was lined with cellular flocculi, and several small carti laginous bodies, rounded, and of the size of ordinary peas, were seen to float in the inte rior of the synovial sac, appended by means of fine membranous threads. All those parts which, in the normal condition, intervene be tween the superior part of the head of the humerus and under surface of the coraco acromial arch, were completely removed. No remnant or trace of the supra-spinatus tendon, nor any portion of the capsular liga ment to which this tendon is attached, was to be found. The entire of the articular portion of the tendon of the biceps was absent, and the highest point of the remaining portion of the tendon was attached to the summit of the bicipital groove. It was remarkable that the acronlion process and other portions of bone, viz. the outer extremity of the clavicle and coracoid process, had acquired size and density, although their under surfaces were much worn and excavated where they formed an arch which overhung the humerus. These appear ances showed the great degree of friction and pressure from below upwards which these bones had been subjected to, from the head of the humerus being constantly drawn up wards by rnuscular action. We also noticed
that the acromion process was traversed front within outwards by a perfect solution of con tinuity, completely dividing it into two nearly equal portions. This might be supposed by some to have been a fracture which never had been united by bone — an opinion which, however, we did not entertain ; the two pieces of the acrornion were on a perfect and uniform level, and the edges of the separated portions of bone exhibited no evidence of any' ossffic de posit, nor any such appearances as would lead us to infer that a fracture had existed.
The glenoid cavity of the scapula was larger and deeper, and more of a cup-like form than usual. The cartilage of encrustation and glenoid ligament were removed, the sur face of the cavity presented a porous appear ance. Along its inner margin were arranged several round and firm cartilaginous granules.
The head of the humerus was somewhat enlarged. The articular surface had become extended over the superior margin of the greater and lesser tuberosity. Much of the cartilaginous investment of the head of the bone had been removed, and its place supplied by means of a porcelain-like deposit. The line which marks the junction of the head of the bone to the shaft, was studded all round with granular elevations of bone Cflg. 429.).
Our knowledge of the anatomical cha racters of this disease has now arrived at a degree of precision quite sufficient, we might suppose, to save us henceforth from falling into the error of confounding tlie morbid re sults of chronic rheumatic arthritis of the shoulder with the consequences of chronic or acute osteitis, or with the ultimate ef fects of accidents sustained during the pa tient's lifetime. Nevertheless we feel called upon now to allude to some cases of partial taxation of the shoulder joint which have been published as the result of accident, but which we consider to be specimens of the chronic rheumatic disease of the shoulder joint which we are endeavouring to describe.