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Calcified deposits in subscapularis tendon
CALCIFIED
DEPOSITS IN SUBSCAPULARIS REPORT
C.
OF A CASE
EDWARD THOMPSON, M.D. AND CHARLES W. OMAHA,
D
URING
the past twenty-five years much has been Iearned concerning the pathoIogy of painful lesions of the shoulder joint. As a result of the work of Codman, Carnett, Brickner and others, it is now we11 recognized that caI&ed deposits in the severa tendons inserting about the shouIder joint are a frequent cause of pain in this region. The tendon of the supraspinatus muscIe is much the most frequentIy invoIved and it is such a Iesion that is erroneousIy caIIed subdeItoid or subacromia1 bursitis. CaIcified deposits in the tendons of the infraspinatus and the teres minor muscIes are not infrequent, but the presence of such deposits in the tendon of the subscapuIaris muscIe appear to be distinctIy rare. CASE
TENDON
REPORT
T. B., maIe, aged fifty years, was first seen on May 20, 1935, compIaining of pain and tenderness about the right shoulder. His past history was essentiaIIy negative except for a minor injury to the same shoulder received twenty years before whiIe playing soccer. The patient was a dry cIeaner by trade and activeIy engaged in this work unti1 the onset of the present iIIness. Twenty-four hours before reporting for examination, the patient was thrown into a puIIey, striking his right shoulder. He immediateIy noticed pain in the right shouIder with associated tenderness over the anterior portion of the joint, but he continued to work during the remainder of the day. The pain however became progressiveIy more severe during the next twenty-four hours and any motion of the shouIder caused distress. On examination the patient was a we11 developed, we11 nourished, stocky individual suffering marked pain in the right shoulder. The temperature was IOI’F., the puIse 90 and the respirations 22. The right forearm was supported by the Ieft hand and every effort
MCLAUGHLIN, JR., M.D.
NEBRASKA
was made to limit a11 motion in the right shouIder joint. Positive physical findings were Iimited to this region. There was no asymmetry, atrophy or deformity in the region of the joint. On gentIe paIpation exquisite tenderness was eIicited over the Iesser tuberosity of the humerus, extending down the inner edge of the bicipita1 groove for a short distance. There was no tenderness over the greater tuberosity and no increased heat or discoIoration of the skin noted. FIexion and extension of the forearm caused no discomfort but rotation of the humerus was extremeIy painfu1. Abduction of the arm aIso caused marked pain and was Iimited to approximateIy 45’. A tentative diagnosis of fracture of the Iesser tuberosity of the humerus was made, but the usua1 anteroposterior and IateraI x-ray pIates taken were negative for fracture. The patient’s forearm was pIaced in a sling and he was sent home with instructions to rest and appIy heat IocaIIy for a period of twenty-four hours. At the end of this time the patient’s temperature was norma but the pain had increased in intensity. Tenderness was even more marked and any rotation of the shouIder was resented. He was admitted to the ImmanueI HospitaI for further x-ray studies and treatment. On the assumption that this might be a bursitis or a caIcified tendonitis in the region of the Iesser tuberosity, x-ray studies were made with the arm sIightIy rotated and abducted 90’ to obtain better visuaIization of the Iesser tuberosity. The fiIms taken in this position are shown in Figure I and the report submitted by Dr. TyIer is as foIIows: “X-ray examination of the patient’s right shouIder taken with the arm in the abducted position shows a caIcium deposit in the region of the Iesser tuberosity, interpreted as being a caIcified bursa.” A cIinica1 diagnosis of caIcified tendonitis invoIving the tendon of the subscapularis muscIe was made and the patient was treated conservatively for a period of five days. There was no improvement during this time and operation was decided upon in an effort to
524
NEW SERVES VOL. XxX11,
No. 3
Thompson
& McLaughlin-Tendon
reheve the patient’s pain and permit him to return to his work at an earIy date. Operation, May 30, 1935. Under open drop ether anesthesia, using a modified Lane technique an incision 6 ems. in Iength was made over the anteroIatera1 aspect of the patient’s extending down from the right shouIder, acromial process. The deItoid muscIe was spIit and the greater tuberosity exposed. The tendons of the supraspinatus, infraspinatus and teres minor muscIes were each carefuIIy examined and seen to be normaI. Rotating the arm outward, the Iesser tuberosity was exposed. A definite yeIIowish-gray deposit, I cm. in diameter, was seen in the substance of the subscapuIaris tendon. This area was incised and a quantity of thick granuIar materia1 simuIating toothpaste escaped. This pocket was then thoroughIy curetted, no effort being made to close the rent in the tendon. Further expIoration discIosed an extension of the process downward aIong the inner edge of the bicipita1 groove, beneath the short head of the biceps. In this area about I cm. of simiIar white pasty materia1 was found and removed. A smaI1 fragment of the tendon of the subscapuIaris adjacent to the calcified deposit was removed for section and a cuIture was taken. The wound was closed in Iayers and the arm Ioosely bound to the side for a period of twenty-four hours. The materia1 removed Pathological Report. for cuIture was steriIe. Microscopic examination of the tissue removed for section showed edematous connective tissue, in which there were Iarge numbers of mononucIear ceIIs and diffuseiy distributed poIymorphonucIear ceIIs. Diagnosis. Acute and subacute inAammation. Twenty-four hours after the operation the patient’s pain was entireIy reIieved and he made a rapid and uneventful recovery. One week after operation he couId abduct his arm 90~ without pain and rotation was accomplished without the Ieast discomfort. He returned to his work one month following operation and has continued without pain, weakness or limitation of motion in the six
months that have eIapsed since that time. DISCUSSION
The tendon of the subscapuIaris muscIe appears to be a very unusua1 site for the deposition of caI&ed deposits causing
A m&can
~~~~~~~d
surgr;y 525
acute shouIder pain. In a careful review of the Iiterature covering the past twenty years only 2 such cases have been found.
FIG. 1. Film of the upper right humerus with the arm in the abducted position. Note caIcified deposit overIying the Iesser tuberosity.
Both of these were reported by Codman in a persona1 series of 970 lesions of the shouIder joint, of which 135 patients suffered with caIcified tendonitis. That the tendon of the subscapuIaris shouId be invoIved much Iess frequentIy than the supraspinatus, infraspinatus and the teres minor is readiIy understood from an anatomica standpoint. However an adequate explanation for the deveIopment of the pathoIogica1 process in our patient is as diffIcuIt to suggest as in the more frequent case in which the tendon of the supraspinatus is affected. Acute and chronic trauma to the shouIder, occupation, working with the arms in the abducted position, foca1 infection and abnorma1 caIcium metaboIism have a11been suggested as factors predisposing to the deveIopment of painfu1 caIcified tendonitis. Typists, fiIe clerks, chauffeurs and physicians constitute more than a normal percentage of patients suffering from this condition. It seems quite IogicaI to suspect that proIonged hours of work with the arms abducted, may place undue stress
526
A m&can
JournaI
of Surgery
Thompson
JUNE,1936
& McLaughIin-Tendon
upon the tendons about the shouIder joint and predispose to pathoIogica1 changes. This patient has for years operated a pressing machine which necessitates working for hours with the arms abducted 90’ from the body. There can be IittIe doubt that the caIcified deposits were present in the invoIved tendon prior to the acute trauma which caused the patient to seek medica advise. The frequency with which painIess caIcium deposits about the shoulder joint are seen by the roentgenoIogist in the course of examinations for other causes, is good evidence that many of these Iesions may go for years without causing any troubIe. That varying degrees of trauma to such deposits may promptIy resuIt in acute symptoms is aIso we11 appreciated. This patient undoubtedIy is an exampIe of such a sequence of events. LittIe di&uIty is encountered in demonstrating on the x-ray pIate caIcihed deposits present in the tendons inserting into the greater tuberosity of the humerus. However, when such coIIections occur in the SubscapuIaris tendon, as in this case, they may be very easiIy overIooked in the usua1 anteroposterior and TateraI views taken. If the deposit is recent, it may cast onIy a faint shadow on the fiIm, and overIying the head of the humerus, be readiIy missed. PIacing the fiIm in such a position that the Iesser tuberosity is seen in profiIe readiIy obviates the possibiIity of missing such a deposit, shouId it be present. One wonders if cases of pain about the shotrIder joint due to caIcification in the tendon of the subscapmaris muscIes are not infrequentIy undiagnosed when studied in the usua1 manner by x-ray. Bed rest, morphine for pain, graduaIIy carrying the arm into the abducted position by traction, heat or coId IocaIIy, injections of quinine and urea and diathermy have a11 been suggested in the conservative treatment of these Iesions. Codman is the authority for the statement that, in his experience, a11 cases of caI&ed tendonitis, whether treated or not, eventuaIIy recover
without any permanent compIications of any kind. “Recovery is onIy a matter of time.” One may in a11 honesty assure the patient that the caIcified deposit wiI1 in a11 probabiIity disappear spontaneousIy in a period of severa months. ShouId the deposit chance to rupture into an adjacent bursa, permanent reIief wiI1 probabIy foIIow in a few weeks time. In most instances, however, the economic factor must be considered and many patients suffering from the acute pain incident to a caIcified tendonitis are either unabIe or unwiIIing to devote the time necessary to treatment by conservative measures. To this group of individuaIs surgery may be offered as a prompt and safe way of reIieving their pain and permitting their earIy return to work with Iittle chance of recurrence. SUMMARY
A case of acute shouIder pain incident to the presence of caIcihed deposits in the tendon of the subscapularis muscIes is reported. OnIy 2 simiIar cases have been found in the Iiterature covering the past removal of the twenty years. Surgical deposit resuIted in the prompt reIief of pain and compIete return of function. REFERENCES
E. A. On stiff and painful shoulders. Boston Surg. and Med. Jour., 154: 613, rgo6. 2. CODMAN, E. A. The Shoulder, Thomas Todd Co. Boston, 1934. 3. CARNE~, J. B. Calcareous deposits of so-caIIed caIcif+ng subacromia1 bursitis. Surg. G.ynec. I. CODMAN,
Obst.,-r/I~404,
1925.
A. CARNETT. J. B. A clinica and oathoIo&aI discussion of so-caIIed subacromia1 bursi:is. Swg. Clin. No. America, g: I 107, rgzg. 5. CARREL, J. B. So-caIIed subacromial Bursitis. Surgical Clinics c~fNo. America, IO: 1309, 1930. 6. CARNE~, J. B. So-caIIed subacromia1 bursitis. Radiology, 17: 505, rg3r. 7. BRICKNER, WM. PrevaIent faIIacies concerning subacromia1 bursitis. Amer. Jour. Med. Sci., 149: 351. 1915. 8. BRICKNER, WM. The location and cause of Iime deposits associated with subacromia1 bursitis. Amer. Jour. Surg., 30: 108, 1916. g. BRICKNER, WM. Pain in the arm-subdeItoid bursitis. J.A. M. A., 69: 1237, 1917. [For Remainder of References see p. ~37.1
New
SERIES VOL.XXXII,
No. 2
Dittrich-Vascular
covering the dura was not seen to be in any direct contact with the nerve roots, nor was it possible to ascribe to it any pressure produced on the cord. The postoperative improvement in the condition of the upper extremities, though not as prompt as it was in the lower extremities, was such that it may be safely considered the result of removing a disturbing factor by the operation. The same factor was undoubtedly also responsible for the trophic disturbance of the face. The sympathetic nerves from the upper dorsal level of the cord constitute the only structure which has common connections with both of these regions. Therefore it seems likely that an irritation of the sympathetic nerves was responsible for the vasomotor dysfunction of the upper extremities and the face. In conclusion it is obvious, from observations in this case, that the vasomotor disturbance can be ascribed to clear cut
REFERENCES
OF DRS.
Disease
I I.
21.
14. 15. 16. 17.
18. 19.
537
The condition described in this case is evidently a vasospastic disturbance of the peripheral circulation. The treatment employed consisted of Iaminectomies in the lumbosacral and the cervicodorsal regions and the remova at both IeveIs, of masses of fat and fibrous tissue, situated in the spinal canal. The immediate result of the operations was an improvement in the circulatory condition of the extremities, with a rapid healing of the gangrenous areas. With the exception of a brief recurrence of the vascular dysfunction, the result at the end of one year is very satisfactory.
20.
I 3.
of Surgery
SUMMARY
IO. DUNLOP,
12.
.lournal
pathological structures, which can be removed by operation. The result was sufficiently satisfactory to justify further application of the therapeutic principles which were employed.
THOMPSON
J. Deposit in the supra-spinatis muscIe. Am. Jour. Ortbop. Surg., 14: 102, 1916. MONTGOMERY,A. H. SubdeItoid bursitis associated with deposition of lime saIts. J. A. M. A., 66: 264, 1916. SMITH, M. K. SubdeItoid bursitis with lime salt deposit. Medical Record, 91: 406, 1917. DAY, J. F. Observations on disabIed shouIders with reference to subacromia1 bursitis. Boston Med. and Surg. Jour., 178: 389, 1918. WOLF, H. F. Acute subacromial and subdeItoid bursitis. Am. Jour. Surg., 37: 59, 1923. HODGES, F. M. Subdeltoid bursitis. Virginia Med. Montbly, 52: 155, 1925. GRANGER, F. B. CaIcified subdeItoid bursitis. International Clinics, 4: 265 (Dec.) 1926. SIMON, S. Concerning the mucous pocket formation in the shoulder joint of man. Ztscbrjt. j. Anat., 81: 389, 1926. HAUSSLING, F. R. PainfuI shouIders. Surg. Clin. No. America, 6: 1503, 1926. MORRIS, J. N. Disabilities of the shouIder region. Med. Jour. of Australia, I : 432, 1926.
Amencan
22.
23.
24. 25.
26.
AND
MCLAUGHLIN”
FISHER, C. F. SubdeItoid bursitis. West Virginia Med. Jour., 23: 250, 1927. KING, J. M. JR. and HOMES, G. W. The diagnosis and treatment of 450 painful shouIders. J. A. M. A., 89: 1956, 1927. BOCKOVEN. S. Inffammatorv invoIvement of the bursae about the shouIder joint. U. S. Vet. Bureau. Med. Bull., 6: 549, 1930. GILLIES, A. ShouIder pain-a consideration of some easiIy overIooked causes. Canadian Med. Ass. Jour., 23: 402, rg3o. CLEVELAND, M. Shoulder pain. Am. Jour. Surg., 8: 783, 1930. MUMFORD, E. B. and MARTIN, F. J. Calcified Deposits in Subdeltoid Bursitis. J. A. M. A., 97: 690, 1931. RICHARDS, T. K. A New Treatment of Acute Bursitis. New England Jour. of Med., 205: 812,
1931. 27. HITZROTE, I. M. SurgicaI diseases of the shoulder bursae. Ann. .Surg.,-98: 273, 1933. 28. RODGERS. M. H. Studv of IOO Cases of Subdeltoid Bursitis. Jour. Bonk and Joint Surg., 16: 145, 1934.
* Continued from p. 526.
DEPOSITS IN SUBSCAPULARIS REPORT
C.
OF A CASE
EDWARD THOMPSON, M.D. AND CHARLES W. OMAHA,
D
URING
the past twenty-five years much has been Iearned concerning the pathoIogy of painful lesions of the shoulder joint. As a result of the work of Codman, Carnett, Brickner and others, it is now we11 recognized that caI&ed deposits in the severa tendons inserting about the shouIder joint are a frequent cause of pain in this region. The tendon of the supraspinatus muscIe is much the most frequentIy invoIved and it is such a Iesion that is erroneousIy caIIed subdeItoid or subacromia1 bursitis. CaIcified deposits in the tendons of the infraspinatus and the teres minor muscIes are not infrequent, but the presence of such deposits in the tendon of the subscapuIaris muscIe appear to be distinctIy rare. CASE
TENDON
REPORT
T. B., maIe, aged fifty years, was first seen on May 20, 1935, compIaining of pain and tenderness about the right shoulder. His past history was essentiaIIy negative except for a minor injury to the same shoulder received twenty years before whiIe playing soccer. The patient was a dry cIeaner by trade and activeIy engaged in this work unti1 the onset of the present iIIness. Twenty-four hours before reporting for examination, the patient was thrown into a puIIey, striking his right shoulder. He immediateIy noticed pain in the right shouIder with associated tenderness over the anterior portion of the joint, but he continued to work during the remainder of the day. The pain however became progressiveIy more severe during the next twenty-four hours and any motion of the shouIder caused distress. On examination the patient was a we11 developed, we11 nourished, stocky individual suffering marked pain in the right shoulder. The temperature was IOI’F., the puIse 90 and the respirations 22. The right forearm was supported by the Ieft hand and every effort
MCLAUGHLIN, JR., M.D.
NEBRASKA
was made to limit a11 motion in the right shouIder joint. Positive physical findings were Iimited to this region. There was no asymmetry, atrophy or deformity in the region of the joint. On gentIe paIpation exquisite tenderness was eIicited over the Iesser tuberosity of the humerus, extending down the inner edge of the bicipita1 groove for a short distance. There was no tenderness over the greater tuberosity and no increased heat or discoIoration of the skin noted. FIexion and extension of the forearm caused no discomfort but rotation of the humerus was extremeIy painfu1. Abduction of the arm aIso caused marked pain and was Iimited to approximateIy 45’. A tentative diagnosis of fracture of the Iesser tuberosity of the humerus was made, but the usua1 anteroposterior and IateraI x-ray pIates taken were negative for fracture. The patient’s forearm was pIaced in a sling and he was sent home with instructions to rest and appIy heat IocaIIy for a period of twenty-four hours. At the end of this time the patient’s temperature was norma but the pain had increased in intensity. Tenderness was even more marked and any rotation of the shouIder was resented. He was admitted to the ImmanueI HospitaI for further x-ray studies and treatment. On the assumption that this might be a bursitis or a caIcified tendonitis in the region of the Iesser tuberosity, x-ray studies were made with the arm sIightIy rotated and abducted 90’ to obtain better visuaIization of the Iesser tuberosity. The fiIms taken in this position are shown in Figure I and the report submitted by Dr. TyIer is as foIIows: “X-ray examination of the patient’s right shouIder taken with the arm in the abducted position shows a caIcium deposit in the region of the Iesser tuberosity, interpreted as being a caIcified bursa.” A cIinica1 diagnosis of caIcified tendonitis invoIving the tendon of the subscapularis muscIe was made and the patient was treated conservatively for a period of five days. There was no improvement during this time and operation was decided upon in an effort to
524
NEW SERVES VOL. XxX11,
No. 3
Thompson
& McLaughlin-Tendon
reheve the patient’s pain and permit him to return to his work at an earIy date. Operation, May 30, 1935. Under open drop ether anesthesia, using a modified Lane technique an incision 6 ems. in Iength was made over the anteroIatera1 aspect of the patient’s extending down from the right shouIder, acromial process. The deItoid muscIe was spIit and the greater tuberosity exposed. The tendons of the supraspinatus, infraspinatus and teres minor muscIes were each carefuIIy examined and seen to be normaI. Rotating the arm outward, the Iesser tuberosity was exposed. A definite yeIIowish-gray deposit, I cm. in diameter, was seen in the substance of the subscapuIaris tendon. This area was incised and a quantity of thick granuIar materia1 simuIating toothpaste escaped. This pocket was then thoroughIy curetted, no effort being made to close the rent in the tendon. Further expIoration discIosed an extension of the process downward aIong the inner edge of the bicipita1 groove, beneath the short head of the biceps. In this area about I cm. of simiIar white pasty materia1 was found and removed. A smaI1 fragment of the tendon of the subscapuIaris adjacent to the calcified deposit was removed for section and a cuIture was taken. The wound was closed in Iayers and the arm Ioosely bound to the side for a period of twenty-four hours. The materia1 removed Pathological Report. for cuIture was steriIe. Microscopic examination of the tissue removed for section showed edematous connective tissue, in which there were Iarge numbers of mononucIear ceIIs and diffuseiy distributed poIymorphonucIear ceIIs. Diagnosis. Acute and subacute inAammation. Twenty-four hours after the operation the patient’s pain was entireIy reIieved and he made a rapid and uneventful recovery. One week after operation he couId abduct his arm 90~ without pain and rotation was accomplished without the Ieast discomfort. He returned to his work one month following operation and has continued without pain, weakness or limitation of motion in the six
months that have eIapsed since that time. DISCUSSION
The tendon of the subscapuIaris muscIe appears to be a very unusua1 site for the deposition of caI&ed deposits causing
A m&can
~~~~~~~d
surgr;y 525
acute shouIder pain. In a careful review of the Iiterature covering the past twenty years only 2 such cases have been found.
FIG. 1. Film of the upper right humerus with the arm in the abducted position. Note caIcified deposit overIying the Iesser tuberosity.
Both of these were reported by Codman in a persona1 series of 970 lesions of the shouIder joint, of which 135 patients suffered with caIcified tendonitis. That the tendon of the subscapuIaris shouId be invoIved much Iess frequentIy than the supraspinatus, infraspinatus and the teres minor is readiIy understood from an anatomica standpoint. However an adequate explanation for the deveIopment of the pathoIogica1 process in our patient is as diffIcuIt to suggest as in the more frequent case in which the tendon of the supraspinatus is affected. Acute and chronic trauma to the shouIder, occupation, working with the arms in the abducted position, foca1 infection and abnorma1 caIcium metaboIism have a11been suggested as factors predisposing to the deveIopment of painfu1 caIcified tendonitis. Typists, fiIe clerks, chauffeurs and physicians constitute more than a normal percentage of patients suffering from this condition. It seems quite IogicaI to suspect that proIonged hours of work with the arms abducted, may place undue stress
526
A m&can
JournaI
of Surgery
Thompson
JUNE,1936
& McLaughIin-Tendon
upon the tendons about the shouIder joint and predispose to pathoIogica1 changes. This patient has for years operated a pressing machine which necessitates working for hours with the arms abducted 90’ from the body. There can be IittIe doubt that the caIcified deposits were present in the invoIved tendon prior to the acute trauma which caused the patient to seek medica advise. The frequency with which painIess caIcium deposits about the shoulder joint are seen by the roentgenoIogist in the course of examinations for other causes, is good evidence that many of these Iesions may go for years without causing any troubIe. That varying degrees of trauma to such deposits may promptIy resuIt in acute symptoms is aIso we11 appreciated. This patient undoubtedIy is an exampIe of such a sequence of events. LittIe di&uIty is encountered in demonstrating on the x-ray pIate caIcihed deposits present in the tendons inserting into the greater tuberosity of the humerus. However, when such coIIections occur in the SubscapuIaris tendon, as in this case, they may be very easiIy overIooked in the usua1 anteroposterior and TateraI views taken. If the deposit is recent, it may cast onIy a faint shadow on the fiIm, and overIying the head of the humerus, be readiIy missed. PIacing the fiIm in such a position that the Iesser tuberosity is seen in profiIe readiIy obviates the possibiIity of missing such a deposit, shouId it be present. One wonders if cases of pain about the shotrIder joint due to caIcification in the tendon of the subscapmaris muscIes are not infrequentIy undiagnosed when studied in the usua1 manner by x-ray. Bed rest, morphine for pain, graduaIIy carrying the arm into the abducted position by traction, heat or coId IocaIIy, injections of quinine and urea and diathermy have a11 been suggested in the conservative treatment of these Iesions. Codman is the authority for the statement that, in his experience, a11 cases of caI&ed tendonitis, whether treated or not, eventuaIIy recover
without any permanent compIications of any kind. “Recovery is onIy a matter of time.” One may in a11 honesty assure the patient that the caIcified deposit wiI1 in a11 probabiIity disappear spontaneousIy in a period of severa months. ShouId the deposit chance to rupture into an adjacent bursa, permanent reIief wiI1 probabIy foIIow in a few weeks time. In most instances, however, the economic factor must be considered and many patients suffering from the acute pain incident to a caIcified tendonitis are either unabIe or unwiIIing to devote the time necessary to treatment by conservative measures. To this group of individuaIs surgery may be offered as a prompt and safe way of reIieving their pain and permitting their earIy return to work with Iittle chance of recurrence. SUMMARY
A case of acute shouIder pain incident to the presence of caIcihed deposits in the tendon of the subscapularis muscIes is reported. OnIy 2 simiIar cases have been found in the Iiterature covering the past removal of the twenty years. Surgical deposit resuIted in the prompt reIief of pain and compIete return of function. REFERENCES
E. A. On stiff and painful shoulders. Boston Surg. and Med. Jour., 154: 613, rgo6. 2. CODMAN, E. A. The Shoulder, Thomas Todd Co. Boston, 1934. 3. CARNE~, J. B. Calcareous deposits of so-caIIed caIcif+ng subacromia1 bursitis. Surg. G.ynec. I. CODMAN,
Obst.,-r/I~404,
1925.
A. CARNETT. J. B. A clinica and oathoIo&aI discussion of so-caIIed subacromia1 bursi:is. Swg. Clin. No. America, g: I 107, rgzg. 5. CARREL, J. B. So-caIIed subacromial Bursitis. Surgical Clinics c~fNo. America, IO: 1309, 1930. 6. CARNE~, J. B. So-caIIed subacromia1 bursitis. Radiology, 17: 505, rg3r. 7. BRICKNER, WM. PrevaIent faIIacies concerning subacromia1 bursitis. Amer. Jour. Med. Sci., 149: 351. 1915. 8. BRICKNER, WM. The location and cause of Iime deposits associated with subacromia1 bursitis. Amer. Jour. Surg., 30: 108, 1916. g. BRICKNER, WM. Pain in the arm-subdeItoid bursitis. J.A. M. A., 69: 1237, 1917. [For Remainder of References see p. ~37.1
New
SERIES VOL.XXXII,
No. 2
Dittrich-Vascular
covering the dura was not seen to be in any direct contact with the nerve roots, nor was it possible to ascribe to it any pressure produced on the cord. The postoperative improvement in the condition of the upper extremities, though not as prompt as it was in the lower extremities, was such that it may be safely considered the result of removing a disturbing factor by the operation. The same factor was undoubtedly also responsible for the trophic disturbance of the face. The sympathetic nerves from the upper dorsal level of the cord constitute the only structure which has common connections with both of these regions. Therefore it seems likely that an irritation of the sympathetic nerves was responsible for the vasomotor dysfunction of the upper extremities and the face. In conclusion it is obvious, from observations in this case, that the vasomotor disturbance can be ascribed to clear cut
REFERENCES
OF DRS.
Disease
I I.
21.
14. 15. 16. 17.
18. 19.
537
The condition described in this case is evidently a vasospastic disturbance of the peripheral circulation. The treatment employed consisted of Iaminectomies in the lumbosacral and the cervicodorsal regions and the remova at both IeveIs, of masses of fat and fibrous tissue, situated in the spinal canal. The immediate result of the operations was an improvement in the circulatory condition of the extremities, with a rapid healing of the gangrenous areas. With the exception of a brief recurrence of the vascular dysfunction, the result at the end of one year is very satisfactory.
20.
I 3.
of Surgery
SUMMARY
IO. DUNLOP,
12.
.lournal
pathological structures, which can be removed by operation. The result was sufficiently satisfactory to justify further application of the therapeutic principles which were employed.
THOMPSON
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* Continued from p. 526.