A CASE 
OK 
SUPPOSED DISLOCATION OF THE TENDON OF THE LONG 
HEAD OF THE BICEPS MUSCLE. 
BY 
J. WILLIAM WHITE, M.D., 
SURGEON TO THE PHILADELPHIA HOSPITAL, ASSISTANT SURGEON TO THE 
PNIVERSITY hospital; 
DEMONSTRATOR OF SURGERY AND LECTURER ON OPERATIVE SURGERY AND VENEREAL 
DISEASES IN THE UNIVERSITY OF PENNSYLVANIA; 
FELLOW OF THE AMERICAN SURGICAL ASSOCIATION AND OF THE 
PHILADELPHIA AC A DEALX-dF-AU-lUiER Y, ETC. 
Reprinted from the 
American Journal of the Medical Sciences for January, 1884. 
PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1884. 
r A CASE 
OF 
SUPPOSED DISLOCATION OF THE TENDON OF THE LONG 
HEAD OF THE BICEPS MUSCLE. 
BY 
J. WILLIAM WHITE, M.D., 
SURGEON TO THE PHILADELPHIA HOSPITAL, ASSISTANT SURGEON TO THE 
UNIVERSITY HOSPITAL ; 
DEMONSTRATOR OF SURGERY AND LECTURER ON OPERATIVE SURGERY AND VENEREAL 
DISEASES IN THE UNIVERSITY OF PENNSYLVANIA ; 
FELLOW OF THE AMERICAN SURGICAL ASSOCIATION AND OF THE 
PHILADELPHIA ACADEMY OF SURGERY, ETC. 
Reprinted from the 
American Journal of the Medical Sciences for January, 1884. 
PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1884. A CASE 
OF 
SUPPOSED DISLOCATION OF THE TENDON OF THE 
LONG HEAD OF THE BICEPS MUSCLE.1 
Before proceeding to a description of the case which, by reason of its 
apparent rarity, it has seemed worth while to bring to the attention of the 
profession, it may be profitable, possibly not uninteresting, to review the 
history of the few other cases in which this same accident, luxation of the 
tendon of the long head of the biceps muscle, was supposed to have occurred. 
The earliest mention of it in surgical literature seems to have been 
made in the first quarter of the last century, or thereabouts. 
Tn the edition of the Myotomia Reformata of William Cowper, published 
thirteen years after his death by Richard Mead, at London, in 1724, ap- 
pears the follow'ing description :—1 
“ An extraordinary Case, relating to this Muscle, has more than once happened 
in our Practice. Particularly a Woman, three days before she consulted us, had 
(as she suspected) dislocated her Shoulder-Bone, by wringing of Linen Clothes 
after washing (which is commonly done, to express the Water), adding that, in 
straining her arms in that Action, she sensibly felt something (as she thought) 
slip out of its place on her Shoulder. After examining the Part, we were well 
satisfied that there was no Dislocation ; but observing a Depressure on the exter- 
nal part of the Deltoid Muscle, and finding the two inferior Tendons of this 
Bicipital Muscle rigid, and the Cubit thereby denied its due Extension, we sus- 
pected that the external tendinous Beginning (before taken notice of) was slipped 
out of its Chanel on the head of the Os Humeri; but finding the part at that time 
1 Read before the Philadelphia Academy of Surgery, Dec. 3, 1883. 
2 An Anatomical Treatise on the Muscles of the Human Body. Illustrated with 
Figures after the Life. By the late Mr. William Cowper (p. 75). 2 
somewhat inflamed, we advised her to an emollient Application, and to give her 
Arm rest till the next day, at which time we found our Conjecture true ; for by 
turning the whole arm to and fro, the Tendon readily slipped into its place, she 
recovering the use of the Part immediately.” 
Monteggia2 (Institutione Chirurgiche, t. v. 179) describes the case 
Of an aged woman, who fell, receiving a severe shock to the shoulder, followed by an 
acute pain which only ceased after she had felt “ something” which was displaced 
return to its proper position. Afterwards she had a recurrence of this symptom 
from very trivial causes. Each time that she felt anew the localized pain, she 
would rest the hand of that side upon the shoulder of another person, and with 
the arm in that position, she felt the tendon of the long head of the biceps return 
to its position, and the pain disappeared. 
Mr. William Bromfeild, Surgeon to her Majesty’s Household, and to 
St. George’s Hospital, in his Chirurgical Observations and Cases (Lon- 
don, 1773), says (p. 7G) :— 
“I dare say many surgeons have seen a lameness in the shoulder from almost 
a similar cause, that is, the tendon of the biceps muscle, which runs in the exca- 
vated groove in the head of the os brachii, having by some turn of the limb, slip- 
ped out of the sulcus, and resting on one of the little exuberances of the upper 
part of the channel, till it returned, has occasioned, not only an immobility of the 
joint, but most violent pains. When the case is known, the reduction is very 
easy, for the cubit being bent the muscle is relaxed, and while an assistant hold- 
ing the lower extremity of the os brachii, moves the head thereof, sometimes in- 
ward, sometimes outward in the acetabulum scapulae; the operator with his 
lingers will easily replace it, and the patient presently becomes perfectly easy.” 
Tn the one hundred years which have elapsed since worthy Mr. Brom- 
feild thus confidently expressed his views upon this subject, but very few 
if any cases have been reported, which on examination seem to belong 
beyond question to the class of injuries which he here describes. 
The case of Mr. John Soden, of Bath, communicated to the Royal 
Medical and Chirurgical Society of London, July 6, 1841, by Richard 
Partridge, Esq., is the one which has excited most comment, as the symp- 
1 Mangetus, who died in 1742, at the advanced age of ninety, in his Theatrum Ana- 
tomicum, published at Geneva in 1717 (subsequent to the first edition of Mr. Cowper’s 
treatise on the muscles), quotes the above case (pp. 39 and 40), together witli some 
remarks on the “ two inferior tendons” of the biceps, and on their relation to the 
operation of phlebotomy, all of which he translates, without the alteration of a word, 
into the scholarly Latin in which his work is written. He gives Mr. Cowper full credit, 
as is apparent from his opening sentence (see foot-note to page 53), in which he speaks 
of him as “ Accuratissimus Anatomicus,” etc. 
Mr. Henry Hancock (Provincial Medical and Surgical Journal, 1844, vol. viii. 
p. 507), quoting the case of Mangetus (whom he calls Magnetus) from the Encyclo- 
pcedie Mtthodique, and that of Cowper from an edition published in 1737 by Albinus, at 
Leyden, very unjustly observes that these “ two cases,” as he calls them, so closely re- 
semble each other that there can be little if any doubt that the one is an unacknow- 
ledged and pirated version of the other; and as Cowper is known to have appropriated 
Bidloo’s anatomical plates, he suggests that he would not hesitate long in appro- 
priating another man’s case. An excellent illustration of the danger of quoting at 
second-hand! 
2 Quoted by Jarjavav, Gazette Jlebdomadaire, May 24, 1867, p. 325. 3 
toms daring life were in this instance supposed to be explained by the re- 
sult of the autopsy :— 
A man aged 59, while falling backwards, placed his arm behind him and 
received the whole weight of his body on the right elbow. Acute pain in the 
shoulder was immediately experienced, and the man supposed that he had suf- 
fered either a fracture or dislocation, but, finding that he could raise the arm 
over his head, he felt reassured. 
The next morning the joint was greatly swollen, tender to the touch, and pain- 
ful on very slight motion. A severe sprain was diagnosed and antiphlogistic 
measures adopted, but at the end of three weeks the tenderness in front of the 
joint and pain on certain movements of the limb were scarcely less than on the day 
after the occurrence of the accident. Another careful examination was then made. 
On comparing the joint with its fellow, now that the swelling had subsided, a 
marked difference was observable between their respective outlines. The injured 
joint was manifestly out of drawing, without presenting any glaring deformity. 
When the man stood erect, with his arms dependent, the distinction 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 though it were 
drawn up higher in the glenoid cavity than it should be. Examination verified 
this appearance in two ways: 1st. On moving the limb, with one hand placed 
on the shoulder, a crepitating sensation was experienced under the fingers, simu- 
lating a fracture, but in reality, caused by the friction of the head of the humerus 
against the acromion. 2d. On attempting abduction, you found that the arm 
could not be raised beyond a very acute angle with the body, from the upper 
edge of the great tubercle coming in contact with the tip of the acromion. The 
head of the bone was unduly prominent in front, almost to the amount of a partial 
dislocation. 
For all useful purposes the arm was powerless. The smallest weights could 
not be raised on account of the severe pain induced by any exercise of the 
biceps, which was described as very acute and extending through the whole 
course of the muscle, but felt chiefly at its extremities, the lower with the upper. 
When not excited by muscular action it was referred to the front of the joint 
and confined to the space between the coracoid process and the head of the hu- 
merus, which was marked by some puffy swelling. 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 found most relief from the elbow being well supported and placed 
close to the side, with pressure by a soft 
pad firmly applied against the deltoid 
muscle. 
All this occurred in the month of May, 
1839. In November of the same year 
the patient died of compound fracture of 
the skull, and an opportunity for an 
autopsy was afforded. 
On examining the joint the accident 
was found to be a dislocation of the long 
head of the biceps from its groove, unac- 
companied by any other injury (Fig. 1). 
The tendon was entire and lying inclosed 
in its sheath on the lesser tubercle of the 
humerus; the capsule was but slightly 
ruptured; the joint exhibited extensive 
traces of inflammation; the synovial 
membrane was vascular and coated with 
lymph; recent adhesions were stretched 
between different parts of its surface, and 
ulceration had commenced on the carti- 
Fig. 1. 4 
lage covering the humerus where it came in contact with the under surface of 
the acromion; the capsule was thickened and adherent, and in time probably 
anchylosis of the joint would have taken place. 
In his remarks on this interesting case, Mr. Soden endeavours to explain 
the phenomena by attributing to the long head of the biceps the function 
of a capsular muscle. He remarks that the altered position of the bone 
must have been dependent on the displacement of the tendon, as the 
injury was uncomplicated ; and continues : The head of the humerus is 
said to owe the security of its position rather to the combined action of 
the capsular muscles than to the ligamentous attachments of the humerus 
to the scapula; and the tendon is vaguely described as strengthening the 
joint, and in that respect having an analogy to the ligamentum teres of 
the femur. The capsular muscles may be considered as having their 
origin from the upper three-fourths of the circumference of a circle ; they 
then converge towards its centre, represented by the head of the humerus, 
into the upper, anterior, and posterior parts of which they are inserted. 
In the lower segment of this circle there is a gap (the axilla) not occupied 
by muscles. As the head of the bone rolls on an almost flat surface, its 
position is entirely under the control of the capsular muscles; it follows, 
therefore, that to enable the bone to maintain its equilibrium these muscles 
should exactly antagonize each other or the head of the humerus would 
be drawn to the side of the preponderating muscle. The necessity of a 
muscle from the ribs to the humerus, to counteract the upper capsular 
muscles, is probably superseded by the singular course of the long head 
of the biceps. We can thus understand why, when the tendon is rup- 
tured or displaced, the head of the bone should rise upwards and forwards 
—a precisely opposite direction to that in which the tendon would, when 
in situ, tend to direct it. 
This case and Mr. Soden’s remarks have been quoted by almost every 
writer on the subject since their publication. Bransby Cooper, in his 
edition of Sir Astley Cooper’s Treatise on Fractures and Dislocations of 
the Joints (London, 1842), quotes it almost in full with seeming approval 
under the head of “ Partial Dislocation upwards of the Shoulder-joint.”1 
Mr. Pirrie under the same caption gives in his treatise on surgery an 
abstract of the case. He adds that in the museum of the Medico-Chi- 
rurgical Society of Aberdeen there is a preparation of an unreduced dis- 
location upwards which in all respects very closely agrees with the de- 
scription and figure of Mr. Soden’s case. The criticisms of other writers 
in this case will be given presently.2 
1 See Agnew, vol. ii. pp. 55-56, on those cases of so-called partial dislocation for- 
wards and upwards, which lie believes to be impossible, without fracture of the coracoid 
process. 
2 The second case of Mr. Soden was one of forward dislocation of the humerus at- 
tended with great difficulty in reduction. The patient died in a few days from internal 
injuries received at the time of the accident, and the autopsy disclosed the fact that 5 
Dr. James S. Green reports a case ( Virginia Medical Monthly, vol. iv. 
p. 10G) of supposed luxation of the tendon occurring during muscular 
action. It was thought that in this case the tendon was preternaturally 
mobile (see supra, case of Monteggia), at least after the first of a series 
of accidents which took place as follows :— 
In November, the patient, a large corpulent woman, aged 52 years, fell on a 
slippery step, injuring her shoulder She was taken home in a carriage, on get- 
ting out of which she fell again and felt something—“the bone”— return to its 
place, upon which she was relieved. Ten weeks later, while attempting to drive 
a bird into its cage, striking at it over head with a newspaper, she was seized 
with violent pain in the same shoulder, and the arm fell to her side. The next 
day she had the following symptoms: Exquisite tenderness on the anterior and 
inner surface of the shoulder, over a space about a finger’s widtli and finger’s 
length in extent; abduction of the arm gave great pain; movement of the arm 
backward, either passively or by means of the latissimus dorsi, gave rise to the 
same pain which extended along the tract of the musculo-cutaneous nerve. This 
pain was constantly present as far as the external condyle of the humerus. 
Active flexion of the forearm upon the arm, to less than a right angle, gave most 
acute pain at the shoulder. 
There were no symptoms of fracture or of scapulo-humeral displacement. 
Partial relief from pain was obtained by keeping the arm close to the body and 
elevating it by a sling and bandage. 
Ten days later, in an effort to save herself from another fall, she suddenly 
threw the injured arm upward and backward, when she “felt something return 
to its place with a snap,” accompanied by agonizing pain. After this the symp- 
toms all gradually disappeared. 
From the study of the mode bv which this spontaneous reduction took place, 
and of the symptoms of the case, T)r. Green recommends in the treatment of such 
cases, flexion of forearm, rotation of the hand outward, and the use of a sling. 
Mr. G. W. Callender, in an article on Dislocations of Muscles and their 
Treatment (I'he British Medical Journal, July 13, 1878), wrote:— 
“Perhaps of all tendons, those which have been most under notice are the 
biceps of the arm, and the conjoined tendon, which, through the patella, comes 
occasionally to be dislocated from the front surface of the femur. There is Dr. 
Hamilton’s case of supposed dislocation of the biceps tendon; and in our London 
museums there are specimens showing displacement of the tendon of this muscle. 
It is not long since a woman was under our notice in Sitwell ward, who suffered 
from a hurt of this nature. I am very sorry we could do but little for her; but 
we did not see her until long after the first occurrence of her trouble. This 
woman had great pain with her hurt. The shoulder seemed to droop forward, 
and she shrank from using the biceps, and, indeed, from moving the joint. The 
tendon lav on the inner side of its groove, and by pressing against it so as to push 
it outwards, and by rotating the arm inwards, it would slip back into the groove, 
but only to slip out again, when the pain, which had been for the time relieved, 
was again felt. Of course continued rest was tried in the hope that the tendon 
would be resheathed in its groove, but it was not so ; and the conclusion we came 
to was that the groove had become in part filled up, probably, by fibrous tissue; 
the tendon had escaped and had slipped completely over the head of the bone, lying 
at the Inner and posterior part of the joint. 
No symptoms are mentioned except that the dislocation was “ very high up.” The 
difficulty in reduction was attributed to the complication of the injury to the biceps. 
“ The inferences from the former case would lead us to expect that, had the tendon 
been in nitu, it would have aided in the return of the bone; but its influence being 
removed the influence of the upper capsular muscles became doubled, and twice the 
amount of force was consequently required to overcome it.” 6 
or that the tendon could not lie and act in it without some binding down by a 
sheath ; and as such ensheathing did not follow the reduction, the leader worked 
out so soon as any strain was brought to bear on it.” 
Laugier, Chirurgien de l’Hopital Necker, has recorded (Archives Gene- 
rales de Medecine, 2d series, vol. v. pp. 65, 66, 67) a case of “ incomplete 
luxation of the head of the humerus upwards and forwards behind the 
coracoid apophysis, 
In which, some days after an accident which was at first taken for a sprain of the 
shoulder, he found a slight depression beneath the acromion, a prominence of the 
head of the bone anteriorly, a shortening of the arm to the extent of five or six 
lines, and a difficulty in abduction of the humerus, the movement being accom- 
panied by an equal movement of the scapula. There had been at no time the 
signs of a fracture or dislocation. Attempts at reduction were made, but were 
unsuccessful.” 
Mr. Alfred Mercer (Buffalo Med. and Surg. Journal, vol. xiv. p. 611) 
relates the following case :— 
“Mrs. B,., a well-developed woman, of full habit, aged fifty-six, seven years 
since was thrown from a carriage, dislocating her right shoulder, which was 
reduced a short time after the accident, but the shoulder was painful, and tender 
to the touch, and almost useless for months after. She could carry the arm 
forwards and backwards, but could not raise it from the side, or carry the hand 
behind her, or raise it to her head for fourteen months. She has gradually 
gained better use of her arm, but now, July, 1858, she cannot raise her elbow 
from the side more than half-way to a horizontal position without assistance ; but 
with assistance the arm may be carried into any position without pain or resist- 
ance. Measurement shows no appreciable difference in the size or length of the 
arm or size of the shoulder; but the point of the shoulder is still tender to the 
touch, is prominent in f ront, and correspondingly flattened behind. The head of 
the humerus appears to rest against the outside of the coracoid process, but the 
fulness of habit obscures the diagnosis compared with the other cases. Several 
doctors at different times have examined the shoulder; some have said it was 
not properly reduced, and advised a suit for malpractice. 
“ I examined the shoulder again in November last; it presented the same general 
appearance, although the patient was much thinner in flesh, from recent sickness. 
Some six weeks previous to this examination, in a sudden and thoughtless effort 
to raise the arm above the head, the muscles unexpectedly obeyed the will; since 
which time she has had perfect use of it, though the deformity still remains. She 
thinks she felt or heard a snap when the arm went up, but it was followed by no 
pain, soreness, or swelling.” 
There can be no doubt, we think, adds Dr. F. II. Hamilton, that in this 
case, at least, the deformity and maiming were due, in a great measure, 
to a displacement of the long head of the biceps. 
Mr. Henry Hancock, Surgeon to Charing Cross Hospital, wrote as fol- 
lows (loc. cit.) in reference to this dislocation, but describes no particular 
case:— 
“The principal signs of this accident are pain and tenderness in front of the 
joint, corresponding to the bicipital groove; acute pain in the course of the 
biceps, when it is thrown into action, the pain being referred more particularly to 
its two extremities; the patient is unable to raise his hand to his head, or his arm 
beyond an acute angle from his body; the appearance of the shoulder is some- 
what altered, the head of the humerus being drawn upwards, and more forward 
than natural, lying close beneath the acromion process, while the posterior and 
external part of the joint is somewhat flattened. When we consider how much 7 
in appearance these accidents resemble partial dislocations of the humerus upward 
and forward, we can entertain but little doubt that they have frequently been 
mistaken for them.” “ I am not aware of any particular symptom by which we 
can be guided with any certainty as to when the tendon is dislocated inward, or 
when outward ; but, as a result of my experiments, I should imagine that it is 
more frequently dislocated inward than outward, the inclination of the head of 
the humerus, and the greater projection of the large tubercle being unfavourable 
to the latter displacement.” 
These clinical cases were long ago supplemented, and were supposed to 
be confirmed by the reports of dissections in which dislocation of the ten- 
don of the hiceps was found associated with other pathological conditions 
of the shoulder-joint. For example, in the Medical Gazette for May 24, 
1835, Mr. John Gregory Smith reported seven cases of injury of the 
shoulder-joint as observed in the dissecting-room. The pathological 
changes which have any bearing on the present paper, may be enume- 
rated as follows, it being understood, of course, that no clinical histories 
were obtainable :— 
Cask. I. The bursa beneath the deltoid was much enlarged and thickened, and 
communicated with the general cavity of the joint by a large, irregular opening. 
The tendons of the scapular muscles were completely detached from the greater 
and lesser tuberosities. The tendon of the longhead of the biceps had been torn 
away from the upper part of the glenoid cavity, and entirely withdrawn from the 
joint; it was found to be firmly attached to the anterior margin of the bicipital 
groove. The head of the humerus moved freely in all directions on the glenoid 
surface of the. scapula. 
Cask II. Sub-deltoid bursa as above; tendon of subseapularis detached; ten- 
don of long head of biceps ruptured ; attached to margin of bicipital groove. 
Cask III. Tendons completely torn from greater tuberosity ; that of subscapu- 
laris partially detached; tendon of long head of biceps torn ; attached to bicipi- 
tal groove. 
Cask IV. Bursa beneath deltoid as above; tendons of subseapularis and supra- 
spinatus detached : tendon of long head of biceps torn from the upper part of 
the glenoid cavity ; attached to bicipital groove ; the portion of the belly of the 
biceps pertaining to the long head was remarkably short, the short head being 
unusually developed. 
Cask Y. Sub-deltoid bursa as above; partial separation and detachment of 
the supra-spinatus and subseapularis muscles from the larger and lesser tubercles ; 
tendon of the biceps torn. 
Cask VI. Bursa as above; tendon of subseapularis and supra-spinatus de- 
tached; fibres of infra-spinatus and teres minor appear to have suffered severe 
tension ; tendon of the long head of the biceps displaced from its groove, but 
not separated from its origin ; it lay loose in the inner part of the cavity of the 
joint; the capsular ligament had been much stretched and readily allowed the 
head of the humerus to be displaced so as to rest upon the inner margin of the 
glenoid cavity. 
Cask VII. Bursa very large, parietes thickened, separated from cavity of joint 
by a thick layer of lymph. Head of bone freely movable, and easily drawn to 
inferior margin of glenoid cavity ; tendon of subseapularis detached ; tendons of 
supra- and infra-spinatus attached, but the fibres of these muscles had evidently 
been much stretched ; tendon of the long head of the biceps permanently dis- 
placed from the bicipital groove, and lying at the inner and lower part of the joint, 
playing over a smooth part of the lesser tubercle.1 
1 Cases VI. and VII. represent the two shoulder-joints of one individual, as did also 
Cases IV. aud V. 8 
Mr. Edward Stanley, in the London Medical Gazette for 1829 (vol. iii. 
p. 12), wrote :— 
“ In two instances I have found, upon dissection, the tendon of the biceps sepa- 
rated from the edge of the glenoid cavity, and firmly adherent to the margin of 
the bicipital groove; but. there was no other unusual appearance of the parts, 
either in or about the joint. In a third instance, I found the tendon of the 
biceps dislocated from its groove, and resting upon the great tuberosity of the 
humerus. A membranous sheath attached to the humerus, and extending around 
the tendon, confined it in its new situation. This sheath was polished on its inter- 
nal surface, it seemed for the purpose of facilitating the play of the tendon, and 
its formation may be presumed to have been analogous to that of the capsule 
inclosing the ends of a fractured bone.” 
These cases will suffice as examples of this sort of evidence, that obtained 
at autopsies and unassociated with clinical histories. They, as well as 
their predecessors, have met with scant mercy at the hand of their critics. 
Pouteau, who believed that lie had established the occasional dislocation 
of muscles from their aponeurotic sheaths, asks himself (Melanges de 
Chiruryie, p. 433) if it is possible for tendons to become thus displaced, 
and, after some expression of doubt, declares that he is forced to the con- 
clusion that, during the energetic contraction of muscles, the tendons 
themselves would break rather than their sheaths. 
Mons. J. F. Jarjavay, Professeur a la Faculty de Mfidecine, chirurgien 
de l’hopital Beaujon, etc., published in 18G7 ( Gazette Hebdomadaire, Nos. 
21 and 23) a paper on this subject. After alluding to the cases of Broin- 
feild, Cowper, Monteggia, Stanley, Smith, and Soden, he sums up, not 
altogether correctly, the symptoms observed by the first three of them as 
follows:— 
An acute pain in the point of the shoulder during a violent twist of the arm; 
a sensation of displacement in that region, giving rise to the belief on the part 
of the patient that a luxation of the humerus has occurred; a greater or less 
difficulty in the movements of the seapulo-lmmeral articulation ; a variable degree 
of inflammation ; a well-pronounced bruit heard on moving the arm ; rigidity of 
the biceps with flexion of the elbow ; a sensation of reduction following move- 
ments of rotation imparted to the head of the humerus. This group of symp- 
toms, he says, has led the authors in question to diagnose a luxation of the biceps 
tendon, but he considers the proof of such a lesion to be entirely wanting. He adds 
that there is no doubt, however, that patients present themselves after violent 
strains of the shoulder, with acute pain and immobility of the joint, with a sen- 
sation of fatigue about the lower portion of the biceps, with a feeling of some- 
thing displaced, and with a marked bruit produced by rotating the arm, but that 
these phenomena are due to a lesion altogether different from luxation of the 
tendon. In proof of this he reports five cases of injury of the shoulder which 
may be summarized as follows:— 
Case I. A man, aged 25 years, in order to carry a heavy bag of sand on his 
left shoulder, steadied it with his right hand passed behind and above his head. 
While he was raising it into this position he felt a sudden pain at the point of 
the shoulder, and the arm became powerless and fell suddenly by the side of the 
trunk. Three days later he presented the following symptoms : Slight swelling 
of the right shoulder; forearm flexed on arm ; immobility produced by the pain 
of movement; pain over lower portion of the biceps on which the skin above 
the elbow is tense; pain in extending the forearm. He could carry the arm 
feebly forward, backward, and inward, but abduction to a slight extent caused 
severe pain. Rotation of the humerus with the arm at the side was noiseless, 
with the arm abducted until it was horizontal was associated with a species of 
claquement, which could be plainly heard by the surgeon and his assistants. If 9 
the arm were then abandoned it would fall to the side with a sudden pain and 
noise resembling the reduction of a luxation. The same phenomena could be 
reproduced repeatedly. If, during the rotation of the humerus held horizontally, 
an assistant pressed downwards its upper extremity, the noise ceased. 
All these symptoms greatly diminished in a few days under the use of cold 
lotion and a sling. Nine days after the accident the sling was discarded and 
movements of the arm were good. 
Cask II. A man, 56 years of age, while drawing powerfully on a corkscrew, 
had an acute pain in the shoulder. Eight days afterwards, when he was first 
seen, he had painful abduction, creaking on rotation, etc. (as in Case I.), flexion 
of the forearm, etc. No swelling or tenderness. Nearly well in three days. 
Cask III. A woman, 47 years of age, fell and twisted her right arm, pro- 
ducing a sharp pain in the shoulder. The symptoms were the same as the above. 
No pain except during abduction, when it was acute and associated with the 
creaking noise. She returned to her work quite well in three days. 
Cask IY. A man, 28 years of age, fell on his right hand, wrenching his 
shoulder. The same symptoms followed-—moderate swelling of the shoulder, 
but no deformity and no ecchymosis. Four days later all the swelling had dis- 
appeared and much of the pain. In three weeks he was entirely cured. 
Cask Y. A man, 27 years of age, and entirely without any history of trau- 
matism, presented himself with a swollen reddened shoulder, with painful rotation 
of humerus, a slight creaking, etc. A puncture beneath the tip of the acromion 
was followed by the escape of about two teaspoonfuls of clear serum. This was 
repeated two or three times—other treatment was applied, and the patient was 
almost well in six weeks. 
These cases have the following characteristics which distinguish them, 
according to M. Jarjavay, from other injuries about the shoulder, and 
which establish the fact that they were not due to a luxation of the 
bicipital tendon. 1. They were all produced—except Case Y by a twist 
of the arm. 2. The seat of the pain (as in the cases of Cowper, Bromfeild, 
and Monteggia) was at the external aspect of the point of the shoulder, 
on a line with the tip of the acromion. 3. The long tendon of the biceps is 
at least two and a half centimetres within this point. 4. The pain and 
the noise are synchronous, and are manifested only at the moment when 
the arm is carried into abduction, and is sufficiently elevated for the great 
tuberosity to glide under the tip of the acromion, or is rotated, while in 
that position. 5. Case V. shows that an acute hygroma of the sub-acro- 
mial bursa may produce all these symptoms. G. If we examine this bursa 
we find that movements of tension distend or crumple up its walls ; if the 
deltoid muscle is detached from its insertion and turned upwards over the 
acromion and clavicle, and the humerus is abducted, it will be seen that 
the walls of this bursa are folded upon themselves, and form a pad or cushion 
beneath the tip of the acromion, and that at the moment the humerus 
reaches the horizontal, the tuberosity glides under the acromion, pushing 
these folds of the bursa before it. 
Bearing these clinical and anatomical facts in mind, M. Jarjavay comes 
to the following conclusions, which refer to his own cases and to those of 
Cowper, Bromfeild, and Monteggia.1 
1 Those of Stanley and Gregory Smith observed post mortem only, he attributes to 
previous luxation. As to that of Sodeu he agrees entirely with Malgaigne, whom he 
quotes. 10 
1. Simple luxation of the long tendon of the biceps muscle does not exist, or 
at least has never been demonstrated. 
2. The lesion which has been considered to be a luxation of this tendon, has 
its seat in the sub-acromial serous sac. 
3. This lesion is an inflammatory enlargement, caused by contusion or 
tion of this sac, or by hypertrophy, with induration of its walls and fibrous trans- 
formation of its cellular partitions, consecutive to inflammation. 
4. Its symptoms are the following: Sensation of displacement at the time of 
the accident; swelling of the shoulder; pain preventing movements of the arm, 
principally those of abduction; forearm flexed upon the arm, and consequent 
rigidity of the biceps muscle and a feeling of uneasiness in the front of the elbow ; 
increase of pain, and bruit below the acromion when the arm is raised and ab- 
ducted, and the greater tuberosity is made to glide under this apophysis (the 
bruit is a crackling sound, and gives the sensation of a reduction of something 
displaced ; it is reproduced whenever the bone maintained in a horizontal posi- 
tion is rotated) ; relief of pain, and restoration of the movements of the arm after 
rest; habitual persistence of the crackling bruit, even when the pain is no longer 
felt, and the movements are free. 
Malgaigne (Traite des Fractures et des Luxations, Paris, 1855, t. ii. 
pp. 565-66-G7) makes the following criticism upon Mr. Soden’s cases, 
prefacing it with a few remarks upon the so-called upward luxation, 
which are so pertinent to the case I am about to describe, that I translate 
them also:— 
It is not rare to observe in scapulalgies, which have become chronic, a sub- 
luxation upward and forward, which has acquired a certain importance on ac- 
count of the mistakes to which it has given rise. I have shown many examples 
of it at my clinics. The humeral head is elevated until it is almost in contact with 
the acromion, and is carried forward against the external border of the coracoid pro- 
cess ; there is found, in consequence, a slight depression under the acromion, 
shortening of the arm and limitation of its movements. It is really this condition, 
unless I am mistaken, which M. Laugier has described as an incomplete upwards 
and forwards luxation, produced by traumatism. (See p. 22.) His patient, 
after a twist of the shoulder, had pain and swelling. M. Laugier, after a careful 
examination, diagnosed at first only a sprain. At the end of twelve days, how- 
ever, the swelling had largely disappeared, and he then perceived that the head 
of the bone was prominent at the front and inner side of the joint near the coracoid 
process, and was somewhat elevated, the arm being shortened five or six lines.1 
M. Avrard has observed a displacement of the same character, dating back 
thirty-one years, and following a fall upon the shoulder. The head occupied 
the space included between the coracoid, the acromion, and the glenoid cavity, 
into which it could not be brought again. The arm was shortened from eight to 
ten millimetres; abduction was arrested at 30° by the impinging of the great 
tuberosity upon the point of the acromion, and all the movements of the joint were 
greatly restricted.2 
That which deceived these two observers was the traumatic cause of the 
affection ; I have myself for a long time sought to explain their observations 
by a traumatic lesion. J. Soden, in England, having been able to study an 
analogous case with the scalpel, came to the conclusion that it was a luxation of 
the long tendon of the biceps. Ilis patient, after a fall on the elbow, felt a sharp 
pain in the shoulder, and fearing a fracture or a luxation, was only reassured by 
finding that he could raise the arm above his head. The next day the shoulder 
was swollen, and elevation of the arm had become impossible. Soden was called 
in, found no displacement, and treated the case as a sprain. Finally, at the end 
of three weeks, the swelling having subsided, it was found that the head of the 
humerus was unnaturally prominent in front and above. There was still pain in 
the joint, and elevation of the arm appeared to be prevented by contact between 
1 Arch. G<$n. de Mdd., 1834, t. v. p. 65. 
2 Revue Med.-Chir., 1878, t. iv. p. 282. 11 
the great tuberosity and the acromion. Five months later the patient died of a 
head injury. 'J'he joint showed numerous traces of injtanimation, the synovial 
membrane was unduly vascular and covered with lymph ; there were recent ad- 
hesions between dif'erent points of its surface; the cartilage of the humeral head, 
where it was in contact with the lower surface of the acromion, was ulcerated; 
the capsule was thickened and adherent.1 Finally, the tendon of the biceps was 
displaced from its groove without other lesion. 
A figure accompanying this description (see Fig. 1) seems to complete it. 
The head is actually elevated in the glenoid cavity ; at the inferior portion of 
which a little space is left empty. The tendon occupying the greater part of its 
sheath, has simply dilated it above, in such a manner as to deviate a little in the 
direction of the lesser tuberosity. A deviation to that extent is not necessarily 
traumatic; and besides it would not explain the ascension of the humerus, which 
can readily be accounted for by the pathological retraction of the ligaments. On 
the other hand, this ascension might well have been the determining cause of the 
deviation of the tendon, forced to slip forwards in order to reach its glenoidal in- 
sertion by the shortest path. I have seen and shown at my clinic, many cases 
of the same character, and have come to a definite conclusion in reference to 
them. There has never been a traumatic luxation of the tendon of the biceps, 
otherwise than as a complication of a fracture or luxation ; there cannot be a 
traumatic luxation which holds the head at the external side of the coracoid pro- 
cess; but there is a pathological sub-luxation of the humerus, due to articular in- 
fiammation and to retraction of ligaments, favoured, perhaps, by mal-position, or 
improperly applied dressings. 
The criticisms of Mr. Robert Adams on the case of Mr. Soden, in 
his article on Abnormal Conditions of the Shoulder-Joint (Cyclopcedia of 
Anatomy and Physiology, vol. iv. p. 59o), seem to me worthy of great 
consideration. lie had previously shown : 1. That one of the commonest 
conditions in chronic rheumatic arthritis of the shoulder-joint was atrophy 
or degeneration of the bicipital tendon which was often absent from the 
joint. 2. That in these cases the humerus has a very general tendency 
to pass upward towards the coraco-acromial vault, and that besides the 
removal of the biceps tendon the superior part of the capsular ligament is 
also observed to be deficient. 3. That these changes, as demonstrated in 
autopsies, frequently affect both shoulder-joints (see Cases VI. and VII. of 
Mr. Smith) ; but are described by writers, who (with the one exception of 
Mr. Soden), knew nothing of the clinical histories of their cases, as “ rupture 
of the tendon of the biceps,” an accident in the highest degree unlikely to 
occur symmetrically. 4. That so long as the long tendon of the biceps 
remains in its state of integrity, arching over the head of the bone, and 
then passing in a perpendicular line down along the humerus, the head of 
this bone cannot be partially elevated above its normal situation, nor even 
drawn inwards or backwards by either of the great muscles which form 
the anterior or posterior walls of the axilla; but that when the long tendon 
of the biceps is destroyed or dislocated, then the head of the humerus may 
be moved in whatever direction the inclination of the new plane formed 
by the altered surface of the glenoid cavity may give, or the muscles may 
draw it in. 5. He had given also the results of a post-mortem examina- 
tion in a case of chronic rheumatic disease in a patient of Mr. Robert 
1 The Italics are Malgaigne’s 12 
Smith, in which there was no history of accident. The head of the 
humerus was displaced upwards; the capsular ligament was deficient supe- 
riorly ; the tendon of the biceps was perfect, but was thrown off the head of 
the bone inwards ;l and, 6. Had given in addition the details of an autopsy 
in which almost the same displacement of the head of the humerus and 
tendon of the biceps, as in Mr. Soden’s case, were found in both shoulder- 
joints, associated with the ordinary anatomical characters of chronic rheu- 
matic arthritis. 
Examining Mr. Soden’s case in the light of these facts, it is important 
to observe : 1. That the patient was a man 59 years of age, “of a rheu- 
matic habit,” and that “ inflammatory action of that character was soon 
established in the joint,” etc. 2. That he at first supposed he had either 
a fracture or dislocation, but, finding that “ he could raise the. arm over 
his head,” he felt reassured, and tried to resume his work. It would ap- 
pear to us, says Mr. Adams, that if the tendon of the biceps were acci- 
dentally dislocated, the patient would not be able, immediately after the 
accident, to raise his arm over his head. 3. That the first symptoms were 
simply those of an inflammatory character, or, as Mr. Soden then supposed, 
of a severe sprain. 4. That the later symptoms; the flattening of the 
outer and posterior part of the joint; the elevation of the head of the 
bone ; the crepitation, the pain along the biceps, the difficulty in abduc- 
tion, the prominence of the head of the bone in front, all belong to an 
early stage of chronic rheumatic arthritis of the shoulder. 5. Dr. Mac- 
dowell (who examined the specimen for Mr. Adams) reported to him that 
“ the head of the humerus is considerably enlarged, and that the long ten- 
don of the biceps, which has been dislocated internally, is in a state of 
atrophy.” 
The criticism directed against the clinical aspects of these cases has 
been strongly reinforced by observations on disease of the shoulder-joint, 
particularly chronic rheumatic arthritis, which showed that many cases 
of dislocated tendon, discovered post mortem, and supposed to be the result 
of injury, were really due to disease. 
Dr. Knox, of Edinburgh (quoted by Callaway), seems to have been the 
first person to notice a morbid condition of the tendon of the biceps. He 
found in the dissecting-room four cases in which the tendon had more or 
less disappeared, in one case altogether. In the others it was reduced to 
a few cellular and fibrous-looking threads, which could be traced with 
difficulty. 
1 “ The great peculiarity in this case, Dr. Smith thought, consisted in the circum- 
stance that the tendon of the biceps was not, as it usually is in cases of this chronic 
disease, absorbed, but was in a perfect state of integrity, as to structure. This tendon 
having been thrown off' the head of the humerus and displaced inwardly, its normal 
function to restrain the ascent of the humerus through the medium of its muscular 
connection was as much annulled as if it had been removed altogether, as it usually is 
under the influence of this chronic disease.” 13 
Mr. Hargraves reported (Edinburgh Journal, 1837), a case of “ partial 
dislocation” of the humerus in which the biceps tendon was ruptured. 
Sir Astley Cooper’s case has already been referred to. In this the tendon 
wfas thought to have been ruptured, but to have again united. Mr. Cal- 
laway thinks (op. cit., p. 151), that he must have meant “united to the 
capsule of the joint.” 
Mr. Stanley (Medical Gazette, vol. iii. p. 12), says that in one instance 
he found the tendon of the biceps dislocated from its groove and resting 
on the great tuberosity of the humerus. A specimen (No. 55) in the 
museum of St. Bartholomew’s Hospital is an example of dislocation (Cal- 
laway, op. cit., p. 145).1 
Mr. Canton (London Med. Gazette, 1879, vol. viii., 3d series, p. 958) 
reports a case of chronic rheumatic arthritis of the right shoulder, in 
which the long tendon of the biceps was flattened and expanded, “ permit- 
ting the head of the humerus to shift upward and thereby to articulate 
with the under surface of the acromion process.” 
Among the most important papers bearing upon this subject with 
which I am familiar, are those published by Dr. Robert W. Smith, Pro- 
fessor of Surgery in the University of Dublin (fVhe Dublin Quarterly 
Journal of Medical Sciences, 1853, vol. xv. pp. 1, 343), under the 
title “Observations upon Chronic Rheumatic Arthritis of the Shoulder.” 
Having detailed the pathological appearances of this disease, and illus- 
trated them by a case of his own, he proceeds to review the various cases 
which have from time to time been recorded in surgical literature as in- 
stances of rupture or dislocation of the biceps tendon, partial luxation of 
the humerus upwards, etc., beginning with Mr. John Gregory Smith’s 
series of cases (see p. 23). He says :— 
“ It would be difficult to lay before the reader any more striking examples of 
the anatomical characters of chronic rheumatic arthritis of the shoulder than those 
furnished by the preceding group of cases, gratuitously described by the author 
(for their history was unknown) as instances of the effects of accidental violence. 
The absorption of a portion of the capsule ; the detachment of the tendons of the 
capsular muscles from the tubercle of the humerus ; the separation of the acro- 
mion into two portions; the ivory-like deposit upon the surface of the bones ; the 
loss of the tendon of the biceps; its adhesions to the bicipital groove ; its dis- 
placement inwards from the summit of the humerus ; the osseous nodules about 
the tubercles; the conversion of these processes into articular surfaces ; the en- 
largement of the capsule ; the symmetrical development of the disease,2 etc. etc., 
are elucidated in the clearest manner by this series of specimens.” 
1 Mr. Stanley found that in a case which he supposed to be rupture of the biceps ten- 
don, the slightest movement of the elbow backwards was followed by acute pain, pre- 
cisely in the situation where the tendon of the biceps turns over the head of the hume- 
rus. There was also effusion of blood into the subcutaneous cellular tissue, butconfined 
to the tract of the biceps tendon. In a similar case occurring- in the practice of Mr. Nor- 
mald it was observed that “ the effort of bending the forearm was attended with a 
peculiar spasmodic and vibrating movement of that part of the biceps from which the 
long head is continued, and which was distinctly felt by the hand placed against the 
arm.” 
2 Cases 4 and 5 occurred in the same person, as did also Cases 6 and 7. 14 
Professor Fergusson’s statement that partial luxation of the head of the 
humerus upward occurs pretty frequently, his opinion being grounded 
upon phenomena observed in the dissecting-room (see p. 34), he believes 
to be erroneous, and attributes it to the same cause: “ In the remarks 
which he has made upon the subject, he has unknowingly described 
many of the leading features of chronic rheumatic arthritis of the shoul- 
der, although he looks upon them as resulting from accident.” Mr. 
Hilton’s case1 ( Guy's Hospital Reports, vol. v.) and Mr. Alfred Smee’s2 
( The Lancet, 1845, vol. i. p. 323) are interpreted by him in the same 
manner. He disposes similarly of the cases of Mr. Barron3 {London Med. 
Gazette, vol. xx. p. 554), of Dr. Knox {Ibid., vol. i.), of Mr. Stanley {Ibid., 
vol. iii.), of Sandefort {Museum Anatomicum, vol. iv., tab. cli.), of 
Mr. Callaway (see p. 35), and of Sir Astley Cooper (see p. 20), all of 
which were reported as partial dislocation of the shoulder upwards, or 
as instances of rupture or dislocation of the bicipital tendon, and all of 
which, as he clearly shows, presented marked evidence of chronic arthritis. 
In none of them was there any satisfactory clinical history, the diagnosis 
having been founded, chiefly if not entirely, on post-mortem appearances. 
Of Soden’s case he says :— 
liIt has been clearly demonstrated that the fall alluded to in the history of the 
case had only this much to do with the partial displacement upwards of the head 
of the humerus which succeeded to it, that this accident became the starting- 
point of an inflammatory action of a rheumatic character, under the influence of 
which the head of the bone became elevated to the acromion process and the 
tendon of the biceps displaced.” 
He then describes the case of an elderly female, who had for many 
years suffered from chroic rheumatic arthritis of the right shoulder-joint, 
which, after death, was examined by him. The head of the humerus 
was displaced upwards, and the tendon of the biceps, perfect as to struc- 
ture, crossed the inner instead of the upper surface of the head, the carti- 
lage of which was abraded. The case of Charles Mailly, recorded by 
1 Dislocation downwards of the humerus into the axilla, associated with rupture of 
the tendon of the biceps. 
2 Dissection of a partial dislocation of theshoulder upwards. There was detachment 
of the biceps tendon from the edge of the glenoid cavity. Mr. Smee says : “ Regarding 
the total alteration in the joint, arising from the injury, as a whole, we find that the 
shoulder-joint was converted into a double joiut, one joint existing between the head 
of the bone and the glenoid cavity, the other between the great tuberosity and the 
under surface of the acromion.” After study of the case he comes to the following 
conclusions: “ First, that the tendon of the biceps is sufficient alone to keep the head 
of the bone from rising from its situation, or, at any rate, contributes principally to 
that object. Secondly, that the supra- and infra-spinati have no influence in drawing 
the head of the humerus under the acromion, as it was drawn into that situation when 
these muscles were divided.” 
3 Detachment of the biceps tendon from the glenoid cavity. Mr. Barron and Mr. 
Pilcher met with this condition frequently in dissecting-rooms, especially in aged 
females. 15 
Mr. Adams (see page 27), illustrates the same displacements of the head 
of the humerus and of the tendon, occurring in both shoulder-joints (as in 
Cases VI. and VII. of Mr. J. G. Smith’s series). 
lie continues:— 
“ The remarkable elevation of the head of the humerus to which the name of 
‘ partial luxation upwards ’ has been given has invariably been ascribed to the 
destruction or displacement of the tendon of the biceps, not only by those who 
look upon it as the result of external injury, but also by those who, in my opinion, 
correctly refer it to the effects of chronic rheumatic arthritis. Mr. Adams, for 
instance, observes that ‘the effects of the loss of the tendon of the biceps are 
such that the head of the humerus is at once elevated by the deltoid and kept 
habitually pressed up against the under surface of the acromion.’1 The correct- 
ness of this opinion certainly admits of being questioned, and I am inclined to 
believe that in the cases under consideration the cause has been mistaken for the 
effect. I do not mean to say that the accidental rupture or displacement of the 
biceps in a healthy shoulder-joint would nut be followed by the elevation of the 
head of the humerus, but I suspect that in cases of partial luxation upwards re- 
sulting from the rheumatic disease in question the sequence of events is different 
from that observed by authors. I believe that in these cases the elevation of the 
head of the humerus occurs at a comparatively early period of the disease, and 
is a gradual process, and that the displacement is not in any instance sudden, as 
might be expected to happen were it consequent upon the rupture or dislocation 
of the tendon.” 
lie believes the sequence of phenomena is as follows : Spastic contrac- 
tion of the muscles under rheumatic irritation of the joint ; elevation of 
the head of the bone; pressure against the tendon of the biceps; dis- 
placement inwards of the tendon which slips over the smooth globular 
head of the humerus until the tension is somewhat relieved ; later should 
the tendon not atrophy under pressure the extra-capsular portion may 
become implicated, and will be found crossing the lesser tubercle. 
Dr. Smith concludes his elaborate paper as follows:— 
“ A long and careful consideration of the subject discussed in the preceding 
pages leads me to believe that the occurrence of partial dislocation of the head 
of the humerus upwards, as an immediate result of rupture or displacement of 
the tendon of the biceps muscle from accidental violence, has not been anatomi- 
cally demonstrated ; that all the cases accompanied by dissections that have 
hitherto been published, as examples of the luxation in question, resulting from 
injuries to the tendon, have, in reality, been instances of the effects of chronic 
rheumatic arthritis; and that the morbid conditions which in them have been 
regarded as affording the clearest evidence of the joint having at some former 
period suffered from external violence, are among the most constant effects of 
this disease.” 
I)r. A. G. Gerster, of New York, in an article on Subcutaneous Injuries 
of the Biceps Bracliii (Arew York Medical Journal, 1878, vol. xxvii. p. 
487), refers to injuries and dislocations of the tendon of the muscle, as 
follows:— 
1 Mr. Canton also, in his description of a case of this disease, brought under the 
notice of the Westminster Medical Society, and in which the tendon was divided into 
four or live slips, remarks that this condition of the tendon had permitted the head 
of the humerus to shift upwards, and thereby to articulate with the under part of the 
acromjon process.” 16 
“ There are cases where the tendon of the long head is but partially lacerated, 
or in which it is intact, its sheath only being injured. These changes have been for 
a long time the diagnostic stumbling-blocks of many surgeons. The changes in the 
outward shape of the shoulder are very slight indeed in these cases; you find, 
perhaps, a scarcely noticeable synovial effusion in the joint, sometimes an ecchy- 
motic streak in the front of the shoulder; but the functional disturbance is very 
marked, in fact it seems to be out of proportion with the visible anatomical 
changes. The patient is unable to use his arm, and endeavours with earnest 
care to keep it in the same well-flexed condition as if the humerus were broken. 
“Passive extension, as well as flexion, of the pronated forearm, causes some 
pain, active extension and flexion in the same position possible, but a good deal 
more painful; active flexion of the forearm in supination quite impossible. By 
pressing the finger tips against various points of the humerus, palpation along 
the bicipital sulcus, especially between the two tubercles, elicits marked signs of 
distress.” 
Dr. Gerster then quotes the case of a carpenter, mt. thirty- ve, who fell 
down a staircase and “ struck the ground heavily” (how, it is not said) ; 
he instantly felt something snap, followed by a stinging pain in his left 
shoulder ; swelling rapidly ensued, and ecchymosis along the course of the 
bicipital tendon. A week after the accident active and passive extension 
were possible, but somewhat painful; passive flexion the same ; active 
flexion in pronation difficult, but possible; active flexion in supination 
absolutely impossible; even the attempt producing intense pain at the upper 
bicipital region. Ecchymosis, which before was marked, almost gone. 
Since even most careful palpation could not prove breach of continuity of 
the tendon, or signs of dislocation in the shoulder-joint, the diagnosis was: 
laceration of the tendon, and the corresponding part of the sheath of the 
long head of the biceps. The arm was restored to usefulness by the use 
of a simple sling. 
After narrating the views of the older surgeons, and mentioning 
Mr. Soden’s case, and Malgaigne’s opinion thereof (see p. 26), he con- 
tinues :— 
“ So much is true, that no surgeon ever saw the said tendon in statu luxationis, 
and that those who made a diagnosis of dislocation concluded a posteriori from 
conditions consequent upon, or found after, a supposed dislocation.” 
He then directs his argument against the probability of inward or out- 
ward rotation of the arm forcing the tendon from its sheath without either 
disrupting or causing a luxation of the joint, but says nothing as to the 
possible effect of direct force. His conclusions are :— 
“First, that the luxation of the longhead of the biceps never was observed 
on the living subject in its uncomplicated form, and that its existence is very 
doubtful, although conventionally accepted by and reprinted in older manuals of 
different surgeons. Second, in cases presenting compound injuries of the joint 
and its osseous components, accompanied by rupture of the articular capsule, the 
inevitable displacement of the tendon is not of much consequence as to the whole 
injury, and therefore cannot be ranked as a pathological phenomenon of indepen- 
dent standing.” 
Yon Pitha writes as follows (Handbuch der Chirurgie, Bd. 4, Abth. 2, 
p. 46 : Luxation der Bicepssehne und Ruptur desselben) :— 17 
“Besides the previously mentioned luxation of the biceps tendon upon the tu- 
berosity (as a complication of luxation of the humerus) an uncomplicated disloca- 
tion of this tendon has been described by Monteggia, Bromfield (sic), and Stanley, 
occurring during violent exertion, or through sudden inward rotation of the 
humerus. It is not apparent how in such a manner the biceps tendon is to be 
lifted out of its sulcus upon the great tuberosity, a dislocation in the way 
of which stand the insertion of the capsular ligament and of the tendon of the 
supra-spinatus. The diagnosis has often been made erroneously on the basis of the 
subjective symptoms, referred to the neighbourhood of the bicipital groove and 
on the associated disturbance of function. A crackling noise produced by raising 
the arm has been given as an important symptom. This is, however, poorly 
adapted to show a luxation of the tendon, as in that case the noise could only be 
produced by a rapid drawing back (spontaneous reposition) of the tendon from 
the great tuberosity with the sulcus, which would be accompanied by an instant 
relief to the patient; while, on the contrary, in the supposed injury the pain is 
increased during the production of the noise.” 
lie then states that Jarjavay has elucidated this matter, and refers to 
his paper (see p. 24), adding that, moreover, no one has ever felt a lux- 
ated tendon on the great tuberosity1 or been able to replace it. The trou- 
ble requires no manoeuvres for the purpose of reposition, but disappears 
of itself under rest, and cold fomentation of the shoulder, with the arm 
in a sling. 
lie believes that although this “ mystereriose luxation der bicepssehne 
als selbstandige dislocation auf das tubere. majus,” thus appears in its 
true light that other injuries of the tendon of the long head of the biceps 
are well grounded, instancing its rupture and its separation from its scapu- 
lar insertion. 
Yolkmann (Handbuch der Chirurgie, Bd. 2, Abd. 2, p. 874. Luxationen 
der muskeln und Sehnen), after detailing the symptoms described by 
Cowper, Bromfeild, and Monteggia, says that it is well known that 
similar symptoms present themselves in relation to other joints, and de- 
pend upon conditions entirely different from injuries or luxations of ten- 
dons. He alludes to Jarjavay’s cases, and their implicit acceptance by 
Von Pitha, and to the fact that Chassaignac also denies the occurrence of 
this luxation, adding, that it seems to him, that these authors go too far. 
He mentions a case recorded by Cloquet, in which a man was able at will 
to dislocate the biceps tendon either inwards or outwards. 
“Autopsies have not thus far shown the existence of an uncomplicated luxa- 
tion of the tendon, t. e., one not associated with luxation of the shoulder. The 
oft-quoted case of Soden is inconclusive. In future cases of this supposed injury 
in the living, there will be necessary a much more precise local examination with 
especial reference to the function of the biceps.” 
The views in regard to this accident of the other writers whom I have 
been able to consult, may be readily summarized. 
Agnew ( The Principles and Practice of Surgery, vol. iii. p. 394), says :— 
“ Though I have seen a number of supposed luxations of the long tendon of the 
flexor biceps cubiti muscle, yet in only one case, that of a patient of Dr. J. Wil- 
liam White, were the evidences of the displacement unequivocal.” 
1 Why he insists upon it being on the great tuberosity is not apparent. 
2 18 
Gross (A System of Surgery, vol. i. p. 1161), says:— 
“The nature of the lesion is always obscure, and, therefore, very apt to be 
overlooked, or to be mistaken for fracture, sprain, or dislocation of the shoulder. 
The most reliable symptoms are, inability to flex the arm from loss'of power in 
the biceps, and pain at the seat of the injury, either alone, or in conjunction with 
more or less prominence of the head of the humerus.” 
Mr. Flower (Holmes’s System of Surgery, vol. i. p. 841), says :— 
“In the opinion of the last-named surgeon (Dr. R. Adams, of Dublin), the 
reported cases of dislocation of the long tendon of the biceps with partial displace- 
ment of the head of the humerus upwards, are also to be classed as the effects of 
disease, and not of injury ; but the proof of this appears to me not quite so satis- 
factory as in the former cases.” 1 
Prof. Andrews, of Chicago (International Encyclopcedia of Surgery, 
vol. iii. p. 670), dismisses the subject thus:— 
“Dislocation of the long head of the biceps from the bicipital groove some- 
times causes a puzzling deformity after a successful reduction, or even when there 
has been no luxation. Without being ruptured, this tendon is not certainly 
known ever to have been dislocated, although commonly so stated by old au- 
thors.” 
Ashhurst (Principles and Practice of Surgery, p. 287), says:— 
“Under this head (.partial dislocation) has been described an injury which ap- 
pears to consist in a rupture or displacement of the long head of the biceps muscle, 
allowing the head of the humerus to project anteriorly.” He adds in a foot-note: 
“ This inward displacement of the biceps tendon, which Soden and others have 
considered traumatic, is believed by Canton to be due to the existence of chronic 
rheumatic arthritis, which may or may not have been the result of injury.” 
Hamilton (Fractures and Dislocations, p. 614), speaking of partial dis- 
location of the humerus, says :— 
“ It is quite probable that a majority of these accidents were examples of rup- 
ture or displacement of the tendon of the long head of the biceps muscle.” “ I 
have seen one example, in which the tendon of the biceps suddenly resumed its 
position after the lapse of several days, and the prominence of the head of the 
humerus at once disappeared.” “ If a displacement of the tendon necessarily 
causes a displacement of the head of the humerus, it might seem proper to infer 
that a rupture of the tendon would do the same. The only example of rupture 
of the tendon which has come under my observation does not confirm this view. ” 
Sir William Fergusson (A System of Practical Surgery, Philadelphia, 
1853, p. 201), says:— 
“That this tendon is displaced in the luxations forwards or backwards (or, 
perhaps, to speak more correctly, that the head of the bone in such instances is 
displaced from the tendon), there can be little doubt; I have seen the change more 
than once in the dissecting-room.” 
Nancrede (Article on Injuries and Diseases of the Burste, Internat. 
Encyc. of Surg., vol. ii. p. 709), says :— 
“ It is quite probable that the so-called luxation of the long head of the biceps 
is really due to chronic bursitis of this sac,2 for all the symptoms attributed to that 
1 The cases referred to are those in which, like those of J. G. Smith, Stanley, Cooper, 
and Fergusson, without history of injury, the tendon was found on dissection to be 
torn or absent. He attributes the majority of these to “ chronic rheumatic arthritis,” 
resulting in disorganization and destruction of the intra-capsular portion of the tendon. 
2 The sub-deltoid bursa. 19 
lesion are present in such an inflammation with others which are irreconcilable 
with the existence of any displacement of the tendon.” 
Mr. Thomas Callaway (A Dissertation on Dislocation and Fracture of 
the Clavicle and Shoulder-Joint, London, 1849, p. 143) thinks that the 
accident which is usually described as a partial dislocation of the humerus 
forwards results from either dislocation or rupture of the long head of the 
biceps muscle. He describes the cases of Knox, Stanley, and Soden, and 
then discusses the possibility of distinguishing between a dislocation and 
rupture of the tendon, premising that he fears that there are but 
“few distinctive signs which would materially help us in our diagnosis. Rup- 
ture, of the tendon usually takes place in old persons in whom the powers of 
nutrition have begun to fail, it is a milder accident than dislocation. It usually 
takes place midway between the glenoid cavity and the anatomical neck of the 
humerus. The capsule of the joint is not ruptured, hence there is but little 
effusion, and the subsequent inflammation is not severe.” 
A writer in the Real Fncyclopcedia, vol. xii. p. 451, says:— 
“Luxations of tendons, since the confident observations of W. Cowper and 
Monteggia, have been met with frequently only in the case of a few tendons. 
Indeed, that of the tendon of the long head of the biceps is contradicted, and 
has been characterized once (Jarjavay) as a supposed contusion of the sub- 
acromial bursa; in another case, as the result of a chronic rheumatic arthritis. 
(Adams.)” 
Mr. W1 uirton Hood (On Bone-Setting, p. 37), says :— 
“Displacement of a tendon is certainly of more frequent occurrence than is 
usually supposed : and, excluding several cases where the symptoms were unmis- 
takable, I have seen numerous others operated upon in which the alteration in 
the appearance of the joint immediately afterwards, could only be accounted for 
by this explanation of the injury.” 
The author of the article on Tendons, in the Nouv. Diet, de Med. et 
Ch., vol. xxxv. p. 185, merely alludes to the subject as follows:— 
“ The luxation of tendons was absolutely denied by Cl. Routeau, but its possi- 
bility was demonstrated by Monteggia, in 1803. Before him, however, William 
Cowper had recorded the case of a woman who had dislocated the long portion 
of the biceps in wringing linen.” 
C. Hueter says (Grundriss der Chirurgie, vol. ii. p. 735) :— 
“It may lie remarked that, following the lead of Cowper, Monteggia, and 
others, a traumatic luxation of the long tendon of the biceps has been accepted 
by some. 1’. Vogt is very properly of the opinion that these luxations are only 
a portion of the injury in case of fracture of the tubercles, or of dislocations of 
the shoulder, and cannot well arise independently.” 
Mr. Frederick Treves says (Surgical Applied Anatomy, p. 191) :— 
“ In certain violent wrenches of the limb the tendon may slip from its groove 
and be displaced to one or other side, usually to the inner side. In these cases, 
also, the head is drawn up under the acromion, and is prominent in front, while 
abduction is rendered less free than normal, owing to the great tuberosity being 
sooner brought in contact with the acromion.” 
Mr. George Murray Humphrey says (A Treatise on the Human Skele- 
ton, p. 415) :— 
“ I quite agree with the writer in the Cyclopaedia of Anatomy, that many of 
the specimens in which the biceps tendon stops short in the bicipital groove, or 20 
becomes lost in the capsule of the joint, are to be attributed, not to rupture of 
the tendon, but to the continued effects of chronic rheumatism originating in an 
accident or commencing spontaneously.” 
We find thus, in studying the literature of the subject, and I believe 
that the foregoing represents about all of importance which relates directly 
to it, that the recorded evidence of the occurrence of dislocation of the ten- 
don of the long head of the biceps muscle may be divided into two general 
classes: 1. The reports of clinical cases in which certain symptoms were 
referred by the writers to this displacement, but in which its existence 
was not otherwise confirmed. 
2. The reports of cases in which the tendon of the biceps was found lux- 
ated at an autopsy, or during a dissection, but in many of which no clinical 
history was obtainable. 
Mr. Soden’s case seems to be the only one which belongs to both classes, 
and must be considered separately. 
Under the first class may be placed the cases of Cow per, Monteggia, 
Bromfeild, Green, Callender, Mercer, and Hancock. The first three 
of these, as we have seen, have been assigned by Jarjavay to the cate- 
gory of contusions of the sub-acromial bursa, and with some show of 
reason. Without entering into a discussion which, on account of the 
meagreness of the clinical premises, would probably be fruitless, I may 
call attention to the fact that he does not explain satisfactorily certain 
symptoms which are stated positively by these writers to have existed and 
are entitled to as much credence as any other portion of their very careless 
reports. In tine case of Cowper there was said to be “ a depressure of 
the deltoid muscle,” and “ the two inferior tendons of the biceps”1 were on 
the stretch. The difficulty was immediately removed by forcible rotation of 
the arm. Bromfeild describes the same method of reduction by rotation 
and the same result of speedy relief, while in Monteggia’s case the tendon 
was said to return to its place and the pain to disappear, while the hand 
of the injured side was “ upon the shoulder of another person,” or in the 
very position which, according to Jarjavay, by making pressure on the 
inflamed bursa, should excite the most acute pain. The bursitis, which 
no doubt existed in his own cases, does not account for the depression of 
the deltoid, the stretching of the “ lower tendons” of the biceps, or 
the sudden relief afforded during rotation. The true character of these 
cases will doubtless always remain undetermined for lack of sufficient evi- 
dence ; but, whatever they may have been, it seems evident to me that 
they are not satisfactorily explained by Jarjavay. 
Dr. Green’s case can hardly be considered as conclusive, but the mode 
of disappearance of the trouble was certainly suggestive of a spontane- 
ously reduced luxation of the tendon. Every other symptom can be 
explained on the theory of lesion of the subacromial bursa, the attachment 
1 The tendon of insertion into the radius, and the bicipital fascia. 21 
of which over the bicipital groove to the sheath of the tendon would 
account for the pain felt in the shoulder on flexion of the forearm. 
Mr. Callender states positively that in his case the tendon could he felt 
in its unnatural position, and could be replaced, but not retained in its 
groove. This would be evidence of a very high order if the tendon of 
the long head of the biceps were a structure easily recognized by palpa- 
tion through the overlying tissues, but as any one can verify in his own 
person it is not. If Mr. Callender had stated that he recognized the 
bicipital groove—a distinct depression, with well-marked, prominent bony 
walls, having sharp edges—his assertion would have carried much greater 
weight. 
Mercer’s case I have only included out of deference to the high au- 
thority of Prof. Hamilton, who, as it seems to me, on very insufficient 
grounds classes it as an instance of luxation of the tendon. It was at 
any rate not an uncomplicated case, as the original injury was a disloca- 
tion of the shoulder, and it may therefore be dismissed without further 
consideration. 
Hancock describes the symptoms of displacement of the tendon in much 
detail; but as far as I can learn does not seem, himself, ever to have seen 
a case. 
Among those authors, who in a general way admit the existence of the 
luxation and describe certain symptoms as associated with it, but who do 
not state that they have ever met with it, may be mentioned Callaway, 
Gross, Ashhurst, Flower, Hood, and others, whose opinions therefore, 
though always worthy of respectful consideration, have not in this instance 
the weight which would attach to them if founded on personal observation. 
The second group of cases in which the luxation was found at autopsies 
includes those of Gregory Smith, Knox, Stanley, Hargraves, Astley 
Cooper, and Fergusson, which have been so clearly shown to be in all 
probability examples of changes in the joint produced by rheumatoid 
arthritis, and not by traumatism, that no further consideration of them is 
necessary. 
In discussing the case of Soden, which I have reserved to the last, as 
being by far the most important, I wish to admit to the fullest possible 
extent the weight of the arguments advanced by Malgaigne, Adams, 
and Smith in favour of the pathological causation of the displacement 
of the tendon. It seems to me, however, that certain important facts 
remain unexplained in the light of this theory. Three wreeks after 
the accident the head of the bone was found drawn up under the 
acromion and unnaturally prominent in front; abduction was impos- 
sible ; flexion of the forearm intensely painful, etc. Although the patient 
is stated to have been “ of rheumatic habit,” there is no mention made of 
any previous trouble with the shoulder, and it seems hardly probable that 
these marked changes occurred solely as a result of a rheumatic inflamma- 22 
tion of the joint of three weeks’ duration. They may partly have been due 
to a bursitis such as is described by Jarjavay, which would account for the 
crepitation, painful abduction, puffy swelling over the front of the joint, 
etc. etc., and which, it would be necessary to suppose was prevented from 
subsiding, as in Jarjavay’s cases, in two, three, or four days, by the super- 
vention of the rheumatic inflammation. But even admitting the plausi- 
bility of this theory, it hardly seems to me that it is in perfect accord with 
the result of the autopsy. I refer here especially to the degree of displace- 
ment of the tendon as compared with the duration of the supposed chronic 
rheumatic arthritis and with the slight and certainly doubtful concomitant 
changes in the joint. The rheumatoid inflammation was believed to date 
its origin from the fall which the patient had in May, 1839. He died in 
November, 1839, six months later, and the tendon was found, not only dis- 
placed as to its intra-articular portion, but out of the bicipital groove. Now, 
it is evident that viewing the progress of the case in the light of the theory 
of Messrs. Smith and Adams, that while displacement of the upper part of 
the tendon over the smooth rounded head of the humerus might be expected 
to occur early in the disease, on the other hand, detachment of the tendon 
from the firm fibrous prolongation of the capsule and the synovial mem- 
brane which holds it in its groove must necessarily be a much later phe- 
nomenon. The amount of pressure required for this purpose either must 
be very great when it is done suddenly, 
or must be distributed over a long period 
of time before it can produce the neces- 
sary weakening and disintegration of 
structure. 
The accompanying cut, which repre- 
sents the right shoulder-joint in the case 
of Clias. Mailly, reported by Mr. Adams, 
as parallel with that of Mr. Soden, illus- 
trates the point to which I refer (Fig. 2). 
It will be seen that while the intra- 
capsular portion of the tendon is dis- 
located inwards, the displacement does 
not extend beyond the summit of the 
bicipital groove, in which the rest of the 
tendon lies. 
And yet this patient had been ill for 
seven years or more, and bedridden for 
five years; and the joint was extensively 
diseased. The left shoulder-joint was symmetrically affected, particularly 
as regarded the tendon of the biceps. 
Mr. Adams himself says, in regard to the condition of the joint in 
Soden’s case:— 
Fig. 2, 23 
“As to the anatomical examination of the joint, it will be recollected that the 
disease had been only six months established, and, therefore, that the more 
striking results of chronic rheumatic disease should be found was not to be ex- 
pected. Those which were noticed, however, were such as might be supposed 
to represent the anatomical character of chronic rheumatic arthritis of the shoulder 
at an early stage.” 
It would appear, therefore, that, although the case cannot be considered 
as it originally was, as demonstrating beyond a doubt the possibility of 
the accident, on the other hand, it cannot be summarily dismissed as one 
of the many instances of post hoc ergo propter hoc reasoning, which have 
led to the mistaking of lesions due to chronic arthritis for those caused by 
traumatism. 
In addition to the positive opinions of Malgaigne, Adams, Smith, and 
Jarjavay, the no less strongly expressed views of Pouteau, Von Pitha, 
Volkmann, Ilueter, Vogt, Gerster, and others, as well as those contained 
in the Nouveau Dictionnaire, the Real Encyclopadie, and the various 
treatises on surgery, must be given their due weight in discussing the 
historical aspect of the subject, which I have reviewed thus at length, 
in order to supply to every one the data for an independent conclusion. 
A careful study of the foregoing evidence has convinced me of the impro- 
priety of basing upon it either a dogmatic assertion or denial of the exist- 
ence of this lesion, the Scotch verdict of “ not proven,” representing the 
opinion at which I have arrived, and which may be more formally ex- 
pressed as follows :— 
Although for more than a hundred years cases of supposed luxation of 
the tendon of the long head of the biceps muscle have been reported or 
alluded to by surgical writers, yet they have been so poorly observed or so 
carelessly described, that they fail altogether to carry conviction, the one 
case which possesses any strong element of probability being itself open to 
reasonable doubt. 
As introductory to the case which I am now about to describe, I may 
perhaps be pardoned for mentioning a few elementary points, in the 
anatomy of the shoulder-joint, which bear directly upon the subject, and 
which may tend to make it more readily comprehensible: The large 
rounded head of the humerus rests upon the shallow surface of the com- 
paratively small glenoid cavity, which is not more than one-third the size 
of the former. The depth of the cavity is, however, somewhat increased 
by a narrow fibro-eartilaginous rim, the glenoid ligament. Overhanging 
this cavity is a vaulted arch formed by the coraco-acromial ligament, 
uniting the two processes from which it takes its name. Arising from 
the margin of the glenoid cavity, embracing loosely the head and anato- 
mical neck of the humerus, and extending down to be attached below the 
tuberosities, is the capsular ligament, which has been described as “a sac 
having two apertures, of which the lower is by far the larger.” This sac 
is so loose and capacious that it could contain a body nearly twice as large 24 
as the head of the humerus ; it gives no aid in maintaining the latter in 
contact with the glenoid cavity, and does not appreciably limit its move- 
ments. With its fibres are intermingled those of the tendons of insertion 
of the supra- and infra-spinatus and subscapularis muscles, which mate- 
rially add to its strength. It is also reinforced in front and within by the 
tendon of the long head of the biceps which arises from the summit of the 
glenoid cavity, where its fibres are intimately blended with the glenoid 
ligament, and passes directly over the top of the head of the humerus 
within the capsule (Fig. 3), and then down exactly in front of the joint 
Fig. 3. 
in the sulcus—the bicipital groove—between the greater and lesser tuber- 
osities. A prolongation of the capsular ligament, and within that another 
of the synovial membrane, cover the tendon at this point, and convert 
the groove into a canal. This is strengthened externally by the insertion 
of the tendon of the pectoralis major into its outer lip. 
The bicipital tendon, however, at least when the forearm is fixed, would 
manifestly have a tendency to draw downwards the head of the humerus, 
and certainly cannot be considered as holding it in its articular cavity. 
This is effected chiefly by atmospheric pressure, aided greatly, however, by 25 
the action of the deltoid, the clavicular fibres of the great pectoral, and the 
•upra-spinatus, all of which muscles act to great mechanical advantage as 
direct elevators. The arm is turned outward by the action of the muscles 
inserted into the greater tuberosity, the supra- and infra-spinatus and teres 
minor; it is rotated inwards by the subscapularis assisted by the sternal 
fibres of the pectoralis major; it is abducted, or drawn directly out from 
the side by the deltoid, assisted by the supra-spinatus. It is then lowered 
by the latissimus dorsi and teres major muscles. 
Between the outer and anterior portion of the capsular ligament and 
the under surface of the deltoid muscle is situated a large bursa (Fig. 4), 
Fig. 4. 
which, by reducing friction, facilitates the movements of abduction and 
rotation. The lower wall of this bursa is attached by some strong con- 
nective tissue fibres to the underlying parts; including the fibrous sheath 26 
of the bicipital tendon. Its upper wall is attached to the under surface of 
the deltoid muscle. Another bursa lies beneath the subscapularis muscle, 
and almost invariably communicates with the general synovial cavity of 
the joint. 
Between the lower surface of the acromion and the upper surface of the 
head of the humerus there exists normally a considerable interval (Fig. 5), 
Fig. 5. 
which is occupied when the arm hangs by the side by the upper portion 
of the capsular ligament, and by some fibrous tissue j1 when the arm is 
brought into the horizontal position this space is diminished, and the sub- 
deltoid bursa glides into it, or, in other words, becomes sub-acromial, by 
which name it is often described. 
Case. In September, 1881, I saw, in consultation with Dr. Thos. K. 
Reed, of Atlantic City, New Jersey, the following case:— 
1 A case of paralysis of the deltoid is recorded by Nannoni, in which four fingers 
could be lodged between the humeral head and the acromial vault. Paulet, Traite 
cl’ Anatomie Topographique, p. 677 27 
T. W., a carpenter, aged 37, previously healthy in every respect, while 
ascending a ladder, with his arms full of tools, lost his balance, and fell 
backward from a height of six or eight feet. While falling he made an 
effort to save himself, and so far succeeded as to effect a semi-rotation of 
the head and trunk, whicli brought the right anterior surface of the body 
into the most dependent position. His fall was arrested by a porch about 
fifteen inches in height, upon which the front of his right shoulder struck, 
his right ear just grazing the edge of it, but his head escaping all other 
injury. There was immediately acute pain and swelling over the right 
shoulder, with helplessness of the arm on that side. He was seen in a 
few minutes by Dr. Reed, and then presented the following phenomena: 
He was sitting, holding the hand of the injured side in the left band, palm 
upward, and turning its ulnar border strongly in the same direction, or, 
in other words, was holding it in a position of external rotation, or forced 
supination. The forearm was flexed on the arm at an obtuse angle, and 
the elbow was held close to the side of the trunk. On releasing the hand 
and allowing the arm to hang by the side there was instant and irresistible 
rotation of the humerus inward, which occurred to such an extent as to 
turn the palmar surface of the forearm and the palm of the hand back- 
ward, and even slightly outward. Any attempt to remove the elbow from 
contact with the side was followed by a seeming displacement of the head 
of the humerus, which slipped forward and inward, increasing the projec- 
tion on the front of the joint, although at no time could the head of the 
bone be felt in the axilla, and it was always possible to place the hand of 
the injured side on the sound shoulder, keeping the elbow in contact with 
the front of the chest. There was great swelling of the shoulder, most 
marked over its anterior and outer aspects. This swelling was soft, almost 
fluctuating, and not ecchymotic. On the front of the joint, about one and 
a half to two inches below the level of the acromion, was an oval depres- 
sion, about an inch in length, and a half inch in depth, its long axis 
parallel with that of the humerus. A finger inserted into this depression 
seemed to come almost directly in contact with the bone, nothing but skin 
and subcutaneous tissue appearing to intervene ; and these seemed to be 
bound down tightly at this particular point. The patient described the 
condition as the skin having “ grown fast” to the bone. There was sharp 
lancinating pain in the shoulder on the slightest movement of the arm, 
which was preternaturally mobile. On removing the elbow from the side 
a creak or “ squeak” could be plainly heard by the bystanders, resembling, 
but moister than, the sound of true crepitus. There was a slight but 
undoubted depression beneath the acromion externally. An axillary pad 
and a handkerchief so applied as to carry the elbow inward gave great 
relief to the patient, although he still suffered considerable pain, which 
persisted in varying, but gradually decreasing, intensity for some weeks. 
At the time of my visit, about two weeks after the accident, the above 
symptoms were noted, and, in addition, the following : The vertical cir- 
cumference of the shoulder, although there was still some swelling, was 
half an inch to one inch less than that of the sound side (Fig. 6). A line 
of ecchymosis, beginning about on the level of the axillary border, ex- 
tended down the arm, following closely the line of the biceps. This had 
made its appearance three or four days after the injury. It persisted for 
some weeks, gradually finding its way down the radial side of the fore- 
arm almost to the wrist. 
When the forearm was extended upon the arm, a painful degree of 28 
tension was produced along the line of the biceps, the border of which 
muscle became plainly evident beneath the skin ; this pain extended to 
the point of insertion in the radius and was described by the patient as 
even running down to the wrist. Flexion of the forearm was pos- 
sible with difficulty, the movement being tremulous and void of force; 
Fig. 6. 
it was associated with a sharp pain over the head of the humerus. 
Flexion of the supinated forearm was much more painful than flexion 
during pronation. In the former case the sensation described by the 
patient was one of “ dragging” over the head of the humerus. The 
oblong or oval depression over the head of the bone (Fig. G) had, with 
the subsidence of the swelling, become more rounded in appearance, but 
was still very distinctly marked. At this point, and for a little distance 
above and below it, a longitudinal furrow could be plainly felt in the bone 
which seemed to correspond accurately with the situation of the bicipital 
groove. This furrow was empty. To its inner side could be felt indis- 
tinctly a round movable body, rolling slightly beneath the fingers, and 
thought at the time to be the bicipital tendon. Neither this nor the groove 
could be felt on the sound shoulder. All attempts at replacement were 
futile. 
On elevating the arm, it was seen that the scapula moved largely 
with the humerus, the acromion became prominent on the summit of 
the shoulder (Fig. 7), and the axilla of the injured side as compared 
with that of the sound side was greatly lengthened (Fig. 8). The 
angle of the scapula on the injured side, when the arm was raised above 
the head, was carried out quite to or a little beyond the side of the chest. 29 
The slight depression immediately below the tip of the acromion still 
existed, with considerable fulness over the upper, front, and inner aspects 
Fig. 7. 
of the joint, apparently due to an abnormal projection of the head of the 
humerus in that region. There was slight shortening on measurement from 
Fig. 8. 
the acromion to the external condyle, but not more than half an inch, pos- 
sibly u little less. The tendency to spontaneous rotation of the arm was 30 
still felt, but was much less noticeable. The arm was very mobile, and the 
head of the bone could be rotated freely in every direction. There was 
no history of rheumatism in the patient himself or in his family. 
In October, 1883, the patient was again seen and examined. He had 
regained almost entire use of his arm, although the disability had been 
almost complete for a year and quite marked for eighteen months. 
Flexion of the forearm on the arm was complete and painless. 
Elevation of the arm above the head was still accompanied by undue 
movement of the right scapula, the acromion becoming unnaturally promi- 
nent and the angle going somewhat nearer the side of the chest than on the 
left side (see Fig. 9). The bicipital groove could still be felt, and possibly 
Fig. 9. 
the tendon to its inner side. On raising the arms equally the depression 
which normally appears at the tip of the acromion was apparent on the left 
or sound side, but could not be seen on the right (see Fig. 9). With the 
arms pendent there was a noticeable difference between the shoulders, 
the deltoid on the right side being shorter and its curve rounder and 
fuller, while at the same time the acromion projected more than normal 
(see Fig. 10). 
It will be seen, I think, on carefully analyzing these symptoms, that 
taken together they lead almost irresistibly to the conviction that, in this 
case at least, there had been true traumatic luxation of the bicipital tendon, 
and that each one of them is susceptible of rational explanation on this 
theory. 
They may be enumerated as follows :— 
1. The recognition of the bicipital groove, empty. This, which was 
the symptom on which the original diagnosis was founded, is perhaps the 31 
most important of the group, as, if its existence be admitted, it is abso- 
lutely pathognomonic. In very thin persons the groove may be felt through 
the anterior fibres of the deltoid which overlies it; in muscular persons not 
Fig. 10 
so readily. Empty of its tendon its sharp edges, its deep sulcus, its situation 
precisely in front and a little to the inner side of the head of the bone, its 
movement with the latter, might be expected on a priori grounds to ren- 
der it much more easily recognizable than in its normal condition. 
It certainly seemed to me, when I first saw the patient, that it could be 
readily aud unmistakably felt, but I am glad in this respect, as well as 
in others, to have the corroborative opinion of so distinguished a surgical 
anatomist as Professor Agnew, to whom the case was submitted for criti- 
cism, and who was equally convinced of the facts above stated. 
2. Recognition of the tendon itself. Of this I was by no means positive. 
It seemed that the tendon could with difficulty be felt a slight distance to 
the inside of the joint, but it was so uncertain that I do not attach any 
weight to this symptom, which was of but doubtful value. 
3. Inward rotation of the arm. This was very peculiar, and could only 
be simulated, as far as I know, by that which is said to occur after frac- 32 
ture of the great tuberosity in which the external rotators, the supra- and 
infra-spinatus and teres minor being rendered powerless the arm is turned 
inwards by the subscapularis assisted by the sternal fibres of the pectoralis 
major. Something analogous to this took place, I believe, in this case. 
Although, as I have said, there was no conclusive evidence as to the posi- 
tion of the tendon, there are good reasons for supposing that in any case in 
which it was displaced by direct violence it would probably go inwards. 
The tendon of the great pectoral arching above the groove and inserted 
into its outer edge (Fig. 4), and at a higher level the tendon of the supra- 
spinatus inserted into the great tuberosity would probably prevent it in the 
majority of cases from passing outwards.1 If then it went in the opposite 
direction it would lie directly on the tendon of the subscapularis, which 
would thus be stimulated to spasmodic action, and would tend strongly to 
rotate the bone inwards,2 acting in the new position of the bone, as will 
presently be seen, to much greater advantage than its antagonists. Then 
too the tendon itself, in its new position, would strongly aid in the move- 
ment of internal x'otation.3 
4. A slight depression under the tip of the acromion; a prominence of 
the shoulder in front; and a flattening behind. It will be observed that 
in cases of rheumatoid arthritis in which the bicipital tendon is atrophied 
or displaced, the head of the bone is invariably found to be elevated and 
to lie just beneath the acromion. Mr. Soden gives excellent reasons for 
supposing that the course of the tendon permits it to act in the place of 
a capsular muscle running from the ribs to the humerus, and opposing the 
upper capsular muscles. This opinion as to the function of the intra- 
capsular portion of the tendon appears to be that of the large majority ot 
surgeons. I have found none who dispute it.1 If now, this tendon is dis- 
placed by violence, there can be no reason why, just as when it is dislo- 
1 “ In its course between the tubercles it plays upon the inner rather than the outer 
one.” Humphry, op. cit., p. 414. 
2 Duchenne (Pliysiologie des Mouvements, p. 84) describes the subscapularis as the 
great anterior—or internal—rotator of the humerus. 
3 See Humphry, op. cit., p. 414. “ By its pressure upon the inner tubercle the 
tendon prevents undue rotation of the head of the humerus outward,” et seq. 
* “It strengthens the upper part of the articular cavity, and prevents the head of 
the humerus from being pressed up against the acromion process when the deltoid 
contracts.” Gray, p. 310. “ The biceps tendon strengthens the upper part of the joint 
. . . and prevents the head of the bone from being pulled too closely upwards 
under the acromion.” Treves, op. cit., p. 191. “Several purposes are served by the 
peculiar course and disposition of this tendon. It strengthens the capsule at the 
upper part, and assists to prevent the head of the humerus being pressed against the 
acromion by the contraction of the deltoid and other muscles.” Humphry on the 
Skeleton, p. 414. “ The biceps tendon tends to prevent the head of the humerus 
being pulled too closely upward against the under surface of the acromion.” Henry 
Morris, Anatomy of the Joints, p. 218. “ Its evident function is to apply the humeral 
head to the glenoid cavity and to prevent its displacement in shocks directed from 
below upward.” Paulet, op. cit., p. 678. 33 
cated from disease, the powerful deltoid, aided by the supra-spinatus1 and 
the clavicular fibres of the pectoralis major, should not draw it up into 
close proximity to the acromion, and this seems to be what occurred in the 
present case, the bone at the same time being drawn inward by the sternal 
fibres of the pectoralis major, and by the latissimus dorsi and teres major, all 
of which are placed somewhat on the stretch by this elevation of the hume- 
rus. This drawing inwards permits, in spite of the elevation of the head 
of the humerus, of the little depression beneath the tip of the acromion. 
While on the one hand, also, the origin and insertion of the supra-spina- 
tus, an active external rotator, are approximated, the origin and insertion 
of the subscapularis are removed from each other, favouring strongly the 
internal rotation above described. 
5. Diminution in the vertical circumference of the shoulder. That this 
existed even during the period of swelling was very significant. It is just 
the reverse of the sign of dislocation, originally pointed out by Mr. Calla- 
way, and was evidently due to the elevation of the head of the humerus. 
G. Shortening of the arm as measured from the tip of the acromion to 
the external condyle. This should, of course, in the absence of symptoms 
of fracture, be referred to the same cause. 
7. Elevation of shoulder, tilting up of acromion, and elongation and 
narrowing of axilla when the arm was carried upwards. This was also 
due to tlie elevation of the humerus. The muscles which constitute the 
axillary borders, the great pectoral and latissimus, already on the stretch, 
as has been said, were made more so by the abduction of the arm, became 
tense and elongated, and gave rise to the peculiar appearance of the 
axilla which contrasted strongly with the easy natural curves of that on 
the sound side. (Fig. 8.) 
The tilting up of the acromion was due to the presence of the head of the 
humerus just beneath its tip, the two bones impinging on the injured side 
when they-formed a large obtuse angle, while on the other side they 
hardly touched until the arm was lifted a little above the head, or had 
at least attained a horizontal position. 
This symptom (as will be seen by reference to Figs. 9 and 10) persisted, 
though to a less degree, two years after the accident. To the same cause 
—elevation of the humerus—are due the shortened deltoid, the unnaturally 
rounded outline of the shoulder, the lessened vertical circumference, the 
absence during elevation of the arm of the normal dimple found at the 
tip of the acromion superiorly, and the slight tilting of the scapula, all of 
which appearances are admirably shown in the same cuts. 
8. The peculiar depression situated over the bicipital groove. Unless the 
“ depressure in the deltoid muscle” described by Cowper, referred to a 
1 Duchenne (op. cit., p. 75) say6 that this elevating action of the supra-spinatus 
is much more energetic and important than is generally supposed. 34 
similar appearance, I can find no mention of any sucli exact phenomenon in 
surgical writings, either in connection with this or any other injury of 
the shoulder-joint. I believe it to have been probably caused in one of 
the following ways, the last of which I am inclined to favour, though it 
does not appear that anatomical considerations alone enable us exactly to 
determine the point:— 
1. The tendon in its displacement from the groove may have dragged 
with it a portion of the inner edge of the subdeltoid bursa attached to 
its sheath, and through its medium, put on the stretch and tied down 
some of the fibres of the deltoid muscle itself. The injury being fol- 
lowed, just as in a bad sprain, by rapid and extensive synovial effusion, 
involving not only the bursas but the general cavity of the joint, this 
swelling manifested itself wherever the capsule and the bursas permitted 
of distension. Over the region of the groove, however, they were drawn 
so tightly and were so tense by reason of their connection with the 
sheath of the tendon that swelling could not occur. (The succeeding 
symptom, No. 9, will explain my reason for thinking that this sheath 
was put greatly on the stretch, but not lacerated.) The drawing of the 
muscular fibre with them would account for the ease with which at the 
bottom of this dimple the bicipital groove could be felt, covered apparently 
with little else than skin. The chief objection to this view lies in the fact 
that the subdeltoid connective tissue, though exceptionally very dense and 
firm, is, as a rule, loose and yielding, and would probably stretch con- 
siderably without materially displacing the muscle itself. 2. There may 
have been rupture with retraction of some of the fibres of the deltoid 
muscle directly over the seat of injury. 3. The bursal and synovial swell- 
ing pushed before it, and slightly separated the adjacent edges of the 
deltoid and pectoralis major muscles, leaving the interspace over the line 
of the groove, without superjacent muscular tissue. The larger size of 
the bursa external to the groove,1 and the greater freedom from tension of 
the capsule and synovial membrane at that point—the tendon having 
been presumably displaced inward—would account for a greater propor- 
tionate displacement outward of the anterior edge of the deltoid, giving 
the depression the appearance of being somewhat external to the normal 
situation of the groove between that muscle and the pectoralis major. 
Examination of the dissected shoulder shows that a line drawn from a 
little within the tip of the acromion directly down over the front of the 
joint, will at a point below the head of the bone intersect the bicipital 
groove and the intermuscular fissure in question, or will at the furthest be 
a few lines outside of that fissure. Now it must be remembered that in 
this case the deltoid was markedly shortened, and its anterior edge conse- 
quently displaced upward, so that the peculiar depression and the part of 
1 See Morris, op. cit., p. 221. 35 
the interspace overlying the bicipital groove were in the same general 
locality. 
It is well known that the synovial swelling which sometimes makes 
its appearance in the groove between the pectoralis major and the deltoid 
muscles during the course of a synovitis may be distinctly bilobed from 
pressure of the unyielding biceps tendon, then in situ, and this resembles 
more closely the symptom under consideration than any other develop- 
ment associated with disease or injury of this joint.1 
While, therefore, I do not deny the possibility of the depression having 
been caused in one of the two preceding ways, I think on anatomical 
grounds that the latter explanation is the most probable, though I do not 
pretend to consider it as indubitable. 
9. The line of ecchymosis following and strictly limited to the course 
of the biceps muscle. This was most marked and characteristic, appear- 
ing only some days after the injury, and slowly gravitating down the arm 
in the line of the sheath of the muscle. It might occur, of course, in a 
fracture between the tuberosities extending into the bicipital groove, or it 
might follow a rupture of the tendon. If the sheath of the tendon were 
torn the ecchymosis would possibly be less strictly limited to the area of 
the muscle. 
10. A creak or “ squeak,” heard distinctly on carrying the elbow away 
from the side. This was thought at the time to be due to the play of the 
tendon in its new position, but it is more probable that it was caused by 
the accompanying bursitis. To elicit it it was not necessary to take the 
arm more than a few inches from the side of the chest, but then it must 
be remembered that the head of the bone was already high up beneath the 
acromion, and that the bursa was largely distended, so that compression of 
the latter between the humerus and the acromion would begin very early 
in the movement of abduction. This noise was not heard on flexion of 
the elbow, another fact which renders it probable that its origin was bur- 
sal and not tendineal. It was not to be confounded with true crepitus, 
which could at no time be elicited. 
11. Flexion of the forearm on the arm teas painful, the pain being 
sharp, lancinating, and felt at the front of the shoulder ; flexion during 
supination was much more painful than flexion during pronation. The 
existence of pain during flexion of the forearm can readily be understood. 
The reason for the difference between pronation and supination may 
best be explained by the following article by C. Ilueter,2 which I trans- 
1 Lorsqu’une collection liquide s’amasse dans la synoviale, le gonflement qui en 
risulte arrondit le inoignon de l'epaule et en fait disparaitre les saillies exterieures ; 
inais le tendon du biceps se trouvant de plus en plus distendu, coupe, pour ainsi dire, 
la tumeur en deux, de sorte que celle-ci 6emble 6tre II est elair que si la 
collection liquide est situ<5e en dehors de l’articulation, on n’y observera rieu de sem- 
blable.” Paulet, op. cit., p. 078. 
2 Zur Diagnose der verletzungen des M. Biceps Brachii. Archiv fur Klinische Chirur- 
gie, 1804, Bd. 5, s. 321. 36 
cribe somewhat fully on account of the important bearing of the symp- 
tom to which it relates. 
A student suddenly felt, while fencing, a severe pain in the upper third 
of the forearm exactly corresponding to the long head of the biceps; 
thenceforth he had on account of this severe pain, which manifested itself 
at every attempt at motion, lost the ability to bend the forearm actively 
while it was supinated. But on the contrary, when the forearm was in 
pronation, active flexion was easy and painless. This particular symptom 
in an injury which certainly must have been associated with a lesion in 
the course of the long head of the biceps or with a rupture of the muscu- 
lar fibres, or with an injury of the sheath of the tendon, was to me espe- 
cially striking, because theoretically I had believed, on the contrary, that 
we should expect a marked pain on flexing the pronated forearm. It is 
well known that w'hen the forearm is pronated, the points of origin and 
insertion of the biceps are further apart than in supination, its muscular 
fibres being also stretched to a greater degree.1 A contraction of these 
must on that account, in this position, so much the more draw7 apart 
from each other the already separated fibres or much more strongly drag 
the tendon against the wrounded sheath. 
Nevertheless, the elucidation of the symptoms becomes very easy if wre 
sufficiently consider the physiological action of the biceps. In the pro- 
nated forearm, the radius crosses the course of the ulna in such a manner 
that it can be supported in the movement of flexion of the latter ; the 
moving forces which have their points d’appui in the ulna can, by the 
motion of the pronated forearm under these favourable circumstances, 
move the radius in the direction of flexion with very slight exertion. 
In supination both bones lie next to each other, and on that account 
the mechanical relations become so unfavourable for their common 
flexion that the contraction of the brachialus internus2 is no longer suffi- 
cient for the completion of this motion. At least one feels on flexion of 
the supinated forearm, even although there is nothing to overcome but 
gravity, that the biceps swells. But in the pronated forearm, flexion 
is not only possible through the unaided action of the brachialis internus, 
but this flexion is well known to be, as a rule, exclusively completed 
through this muscle. If one then, with moderate force, completely flexes 
the pronated forearm, it may easily be felt that the belly of the biceps 
muscle remains soft and flabby. In a similar complete flexion of the 
supinated forearm, there may be plainly felt, on the contrary, a contraction 
of the biceps, and by measuring the circumference of the arm at its mid- 
dle, there is found in the latter instance an increased circumference of 
several lines. In very energetic movements the biceps muscle also con- 
tracts in flexion of the pronated forearm, but there always remains notice- 
able, in a similarly strong complete flexion of the supinated forearm, a 
striking difference in the tension of the muscle. Clearly a contraction of 
1 Gerster translates this : “ The tendon of the biceps is stretched to its full length in 
supination, in pronation it is wound around the radius.” (Op. cit., p. 498.) “The 
sentence in the original is as follows : Bekanntlich 6ind bei pronirtem Vorderarm die 
Insertionspunkte des M biceps weiter von einander entfernt, als bei Supination, seine 
Muskelfasern, also in hbherem Grade gespannt; eine Contraction derselben muss 
desshalb in dieser Stellung die getrennten Fasern um so mehr auseinander-zerren, 
oder die Sehne gegen die verletzte Scheide um so kraftiger andrangen.” 
2 Brachialis anticus. 37 
the biceps in the pronated forearm must always next occasion a movement 
of supination ; i. e., the tendon rolled around the neck of the radius must 
be unrolled before its flexing action can take place, and therefore we are 
accustomed in movements of moderate force not to set that muscle in action. 
In powerful movements, however, its contraction is not superfluous; its 
supinating action must then become equalized through the contraction of 
the pronators. In supination the action of the biceps is indispensable, 
both on account of the above-mentioned unfavourable position of the two 
bones of the forearm and also because the muscles which can largely aid 
in flexion of the forearm, especially the pronator teres and the flexor carpi 
radialis, have at the same time a pronating action, and therefore cannot 
contract. 
The above described symptom, which led me to a consideration of the 
facts detailed, makes it clear that in flexion of the pronated forearm, the 
biceps muscle is not usually brought into action, and on that account a 
separation of its injured fibres does not occur during this movement. We 
have also in this symptom a means of diagnosticating injuries of the 
biceps in doubtful cases. 
12. When extension o f the forearm was attempted, a tense line along the 
edge of the biceps could be both felt and seen. The cause of this is 
obvious.1 
13. The pain felt over the joint was also felt along the line of the biceps 
as far as its insertion, and the patient still has a “ drawing” sensation 
over that region. The explanation of this is to be found in the fact that 
Mr. Hilton long ago called attention to :— 
“ That the same trunks of nerves, the branches of which supply the groups of 
muscles moving any joint, furnish also a distribution of nerves to the skin over 
the same muscles and their insertions, and that the interior of the joint receives 
its nerves from the same source.”1 
14. The arm was preternaturally mobile for some time after the acci- 
dent. The support of the tendon being withdrawn, this was to be expected.3 
It is important, however, to note that at no time was there any approach 
to anchylosis, which might have been suspected from the tilting of the 
1 The stretching of the “two inferior tendons” of the biceps, described by Cowper 
and Mangetus, will be remembered. This expression, which does not occur in modern 
anatomical or surgical writings, is explained by the following passage from the 
Theatrum Anatomicum of Mangetus (Geneva, 1717, p. 39), and clearly refers to the 
bicipital fascia and to the radial tendon of insertion: “Aeeuratissimus Anatomicus, 
Guilelmus (6ic) Cowper super Musculo Bicipite, seu potius ejus tendine, haec observat. 
Tendo hie duplex est, ejusque pars exterior, quae tenuis est, transit oblique super 
Muitculum Pronatorem Jtadii Teretem & instar membranae se se expandens, jungitur 
Mernbrame Musculorum Comrnnni, que omnes externos Carpi ae Digitorum Musculos 
complectitur. Altera vero robustior multo ac rotunda in superiori Radii capite iuser- 
itur. Duplex autem, addit, tendinosa hujus museuli terminatio (quamvis & nullo 
antore, quod sciam, observato fuerit) est admodum evidens, & st nobis prim&m con- 
specta ante aliquot annos,” etc. For the original, see Cowper, op. cit., pp. 74, 75. 
2 “ By its passage along the bicipital groove it assists to render the head of the hume- 
rus steady in the various movements of the arm and forearm.” Humphry, op. eit., 
p. 413. See also Cloquet, Anatomie Descriptive, p. 199. 38 
shoulder and the appearance of the axilla. The head of the bone was 
always freely movable with no trace of adhesion. 
15. The position of the patient after the accident. This was markedly 
different from that seen after fracture of the clavicle, dislocation of the 
humerus, etc. No attempt was made to support the humerus, as in those 
cases, by the hand placed under the elbow. The effort was obviously 
directed to overcome: (1) the internal rotation of the humerus; and (2) 
the drawing inwards of the head of the bone; and for these objects the 
hand was held strongly with its ulnar border upward, and the elbow was 
brought in front of the chest. 
16. The character of the force producing the difficulty. This was 
peculiar in the fact that the front part of the shoulder struck first, the 
height of the piazza protecting the head from injury. It was, as will be 
evident on careful thought, just such a blow as might be expected to pro- 
duce the injury in question, the force coming evidently from above and 
outside, and striking just in the region of the tendon ; the biceps at the 
time was probably relaxed, though this is a matter of conjecture. 
These symptoms, as I have said, seem to me collectively to constitute 
very strong evidence in favour of the existence in this case of a luxa- 
tion of the tendon, but a few words may be added in regard to diagnosis. 
From chronic rheumatic arthritis, the entire absence of rheumatic his- 
tory, the cause and the progress of the case sufficiently separate it, all the 
diagnostic symptoms coming on in a healthy joint within a few moments of 
the accident. Those which remained after the subsidence of the swelling 
and traumatic inflammation were evidently due to the new position of 
the head of the bone and not to any arthritic process. 
From uncomplicated subdeltoid bursitis, it might be diagnosed by the 
elevation of the head of the bone, the accompanying changes in the 
shape and size of the shoulder, and all the symptoms referable to the 
biceps muscle itself; i. e., the ecchymotic line, the difference in flexion 
between pronation and supination, etc. The much greater severity of the 
accident also constitutes a marked point of distinction. It will be noticed 
that two of Jarjavay’s patients were nearly or quite well in three days, 
one in nine days, one in three weeks, and the other in six weeks, in the 
latter instance in spite of very meddlesome treatment. 
These symptoms also differentiate it from fractures near the joint, 
the only one of which that at all resembles it being fracture of the greater 
tuberosity. In a supposed case of this injury, Gurlt1 noted the symptoms 
as extreme passive mobility at the shoulder, complete loss of voluntary out- 
ward rotation, and partial loss of voluntary elevation of the arm ; crepita- 
tion could be elicited by vigorous rotation. There is to this extent a 
superficial resemblance between the cases, but it goes no further, all the 
1 Quoted by Stimson—Treatise on Fractures—p. 363. 39 
other symptoms noted in my case being absent or at least undescribed. 
In the cases of’ Mayo (quoted by Bransby Cooper) there was flattening of 
the deltoid, and abduction, instead of increasing the deformity, which 
resembled a luxation, caused its disappearance. In the cases of R. W. 
Smith1 there was probably a concomitant luxation; the transverse 
diameter of the shoulder was apparently much increased. 
In Stimson’s case,2 voluntary abduction was possible; there was demon- 
strable separation between the two tuberosities, the lesser one moving with 
the shaft of the humerus ; there was crepitus, and the shoulder presented 
no deformity, except general swelling. In my case the entire head of the 
humerus could always be felt to move with the shaft, there was no crepitus, 
the transverse diameter of the shoulder, if changed at all, was lessened, 
certaiidy not increased ; the groove felt in front of the head of the bone 
wras perfectly fixed. If it had been a line of fracture or separation between 
the two tuberosities, the outer lip should have been more or less mobile. 
The symptoms directly referable to the biceps muscle complete the diag- 
nosis. 
From dislocation of the humerus it could readily be distinguished by 
the preternatural mobility, the presence of the head of the bone in or 
above the glenoid cavity, the ability to place the hand on the opposite 
shoulder, the diminished circumference of the injured shoulder, etc. 
In all of these cases there are to be mentioned, in addition, the pecu- 
liar symptoms of the case, the recognition of the groove, the depression 
in front of the shoulder, the line of ecchymosis, the early movement of the 
scapula during abduction, the inward rotation of the arm, the difference 
between flexion in pronation and that in supination, etc. etc. 
The condition with which it is most likely to be confounded is rupture 
of the biceps tendon, apparently a more frequent accident. 
As might be expected, several of the symptoms coincide. The painful 
flexion, the difference between pronation and supination, the sharp pain at 
the shoulder-joint, the approximation between the head of the humerus 
and the acromion,3 etc. etc., are all present. There is, in addition, how- 
ever, in the large majority of the reported cases of rupture, a larger ecchy- 
motic swelling coming on almost immediately ; no mention has been made 
of the peculiar depression; or of the internal rotation of the arm ; or of 
the line of tension along the edge of the biceps ; the accident has invariably 
been caused by violent muscular action, not by direct force ; and there 
is also in most of the cases of rupture4 a history of the sudden appearance 
on the front of the arm of a more or less firm tumour, consisting of the con- 
1 Fractures in the Vicinity of Joints, p. 170. 
2 Op. cit., p. 3(54. See also, Hamilton, p. 240; Agnew, vol. i. p. 881. 
op. cit., p. 500. 
4 Gerster, op. cit., p. 40(5; Hamilton, op. cit., p. (516; Hancock, op. cit., p. 530; 
Stokes, Lancet, 1842-51, vol. ii. pp. 621, Humphry, op. cit., p. 415, etc. etc. 40 
tracted belly of the muscle. In other cases, the whole muscle is flabby 
and relaxed. As I have said, these cases are comparatively numerous; 
they may as a class be illustrated by the accompanying cut (Fig. 11), 
Fig. 11 
taken from a case reported by Dr. Hopkins {Med. Times, March 24, 1883), 
in which, during violent muscular exertion in a man 55 years of age, who 
had had for several months a chronic rheumatic trouble of the shoulder, 
something was suddenly felt to snap, and there was pain with partial loss of 
power in the arm. He was disabled for but a short time. The deformity, 
five weeks later, is figured in the cut, and was thus described: “ The mass 
of muscle stood out prominently. Its upper border, irregular in outline and 
somewhat nodular, terminated abruptly in the depression which exists just 
below the inferior margin of the deltoid. The hard nodulated condition, at 
this point was evidently caused by the contraction of unresisted muscular 
fibres on themselves, and on their tendinous coverings. The position of the 
muscle was changed, being below the middle of the arm rather than slightly 
above, as in health. The tendon of the short head could be clearly traced 
almost up to its origin at the coracoid process of the scapula, while that 
of the long head could not be felt to react at all beneath the fingers during 
forcible flexion and extension of the forearm, as it ordinarily can be.” 
It is possible that the case which I have thus related may be susceptible 
of some other interpretation ; it is not one about which it would be judi- 
cious to dogmatize ; surgical experience is amply convincing of the inevi- 
table uncertainty which hangs about changes occurring beneath the skin, 
and especially in the neighbourhood of joints; surgical literature shows, 
and very aptly in this particular instance, that phenomena which at one 
time or to one mind seem susceptible of but one interpretation, at another 41 
period or to other observers assume a widely different aspect. Yet the 
symptoms in this case, taken as a group, and viewed from the theory 
that an uncomplicated luxation of the tendon of the long head of the 
biceps took place, certainly seem sufficiently consistent with one another 
and with the facts anatomy and physiology, to justify me in placing 
them in this shape before the profession. 
222 S. 10th St., Philadelphia.