" On comparing the joint with its fellow, now that the swelling had subsided, a marked difference was observable between their re spective outlines. The injured shoulder was evidently out of drawing, but without pre senting any glaring deformity : when the man stood erect with his arms dependent, the dis tinction was very manifest, but difficult to define. There was a slight flattening on the outer and posterior part of the joint, and the head of the bone looked as it IA ere drawn up higher in the glenoid cavity than it should be. Examination verified the appearance in two ways : first, on moving the limb, with one hand placed on the shoulder, a crepitating sensation was experienced under the fingers, simulating a fracture, but in reality caused by the fric tion of the head of the humerus against the under surface of the acromion : secondly, Oil attempting abduction, it was found that the arm could not be raised beyond a very acute angle with the body, from the upper edge of the greater tubercle coming in contact with that of the acromion, and thus forming an obstacle to all further progress. The head of the bone was also unduly prominent in front, almost to the amount or a partial dislocation. For all useful purposes the arm was power less. The pain caused by the action of the biceps was acute, extending through the whole course of the muscle, but felt chiefly at its extremities. When the joint was at rest the pain was referred to the space in front, be tvveen the coracoid process and head of the humerus ; which spot was marked by extreme tenderness and some puffy swelling.
" The patient being of a rheumatic habit, in flammatory action of that character was soon established in the joint, so that the peculiar symptoms of the injury were marked by those of general articular inflammation, which added greatly to the man's suffering, and to the dif ficulty of diagnosis. On examining the joint the accident was found to have been a dislo cation of the long head of the biceps from its groove, unaccompanied by any other injury., The tendon was entire, and lay enclosed in its sheath, on the lesser tubercle of the hu merus ; the capsule was but slightly ruptured ; the joint exhibited extensive traces of inflam mation ; the synovial membrane was vascular and coated with ly mph ; recent adhesions were stretched between different parts of its surface, and ulceration had commenced on the cartilage covering the humerus, where it came in contact with the under surface of the acrornion ; the capsule was thickened and ad herent, and in time, probably, anchylosis might have taken place." Observations on this case. — In this interest ing case, recorded by Mr. Soden, it is true that the tendon of the biceps was dislocated; but, we may ask, are the appearances noticed during life, as well as the condition of the shoulder joint found on examination after death, capable of any other explanation than that given to them by' Mr. Soden ? Upon such a matter we feel we ought to speak with the greatest diffidence, because this case is so far unlike almost every case of partial luxa tion yet published in this circumstance, that its history was known before the examination of the joint was instituted.
However, we must confess that we do not as yet feel convinced that the case of partial displacement upwards of the head of the hu merus, as the immediate and direct result of accident, has been fully proved by Mr. Soden. If we analyse the symptoms the patient him self reports to have observed immediately after the accident, we find that he at first supposed he had either suffered a fracture or a dislocation, but finding that " he could raise the arm over his head," be felt and endeavoured to resume his work. It would appear to us, that if the tendon of the bi ceps were accidentally dislocated the patient would not be able, immediately after the acci dent, to raise his arm over his head ; while the circumstance here noticed seems quite reconcilable with Mr. Soden's own impres sion, that there was in this instance no other injury than a severe sprain of the joint. The symptoms under which the patient subse quently laboured were those of an inflamnia tory character, such as might have been expected where so severe a sprain had oc curred, as we may suppose the shoulder joint in this instance to have suffered. The ap pearance the joint presented externally wben the disease became subacute, or chronic, namely the flattening of the outer and poste rior part of' the joint, and the appearance of the head of the bone, which had been drawn up higher in the glenoid cavity, the crepitating sensation caused by the friction of the head of the humerus against the under surface of the acromion, the pain felt in the whole course of the biceps muscle, the difficulty experienced in abduction of the elbow from the side, the prominency of the head of the bone in front, almost to " the amount of a partial disloca tion,"—all these symptoms we have repeatedly noticed to belong to the affection of the shoul der joint which we have called chronic rheu matic arthritis, and all these have been present in patients who have had this disease in both shoulder joints at the same time, and in whom they could not by any means be referred to accident. Finally, before we leave our analy sis of the symptoms of this case, we must not omit to allude to the author's own observa tion—" The patient being of a rheumatic habit, inflammatory action of that character was soon established in the joint, so that the peculiar symptoms of the injury were masked by those of general articular inflammation, which added greatly to the man's suffering, and to the difficulty of diagnosis." The patient being, as we are told, of a rheumatic habit, or predisposed to this ar ticular disease, it may' be readily conceived that any injury this man, aged fifty-nine, might receive in the shoulder joint would be well calculated to give rise to the disease which we have called chronic rheumatic arthritis.