ABNORMAL CONDITION OF THE ELBOW-JOINT. 



78 



very violent attack of inflammation, which, no 

 matter in what situation it had originated, ulti- 

 mately we tind had not spared any of the tis- 

 sues entering into the formation of the articu- 

 lation. 



Hone. The elastic white swelling (which is 

 one of the usual external signs of this articular 

 caries when the bones of the elbow-joint are the 

 seat of the affection) is always situated poste- 

 riorly, and gives a characteristic appearance 

 and a rounded form to the back part of the 

 elbow-joint, which cannot be mistaken nor 

 misunderstood. The wasted appearance of the 

 arm above and of the fore-arm below makes 

 this swelling more conspicuous, and the whole 

 limb remains habitually in the semirlexed posi- 

 tion, with the fore-arm somewhat prone ; every 

 movement of the articulation causes the patient 

 much pain. The disease, thus arrived at its 

 second or third stage, may remain stationary 

 for a time or terminate in an anchylosis of the 

 bones; commonly, however, the morbid pro- 

 cess goes on. Luxation of one or both bones 

 of the fore-arm occurs, symptomatic abscesses 

 present themselves, and these after a time make 

 their way to the surface, and discharge their 

 contents through openings, sometimes near, 

 and frequently at a distance from the joint; and 

 thus, at length, we see formed direct outlets as 

 well as sinuses and fistulous canals, which give 

 exit to exhausting discharges. The pain and 

 irritation attendant on the disease itself, added 

 to all these, give rise to hectic fever, which too 

 frequently nothing but the desperate measure 

 of amputation will arrest. The disease, which 

 produces such serious consequences, often be- 

 gins very insidiously, either in the head of the 

 radius and external condyle of the humerus, or 

 in the trochlea of this bone and the great sig- 

 moid cavity of the ulna. When the disease 

 begins at the radial side, the pain runs along 

 the course of the musculo-spiral nerve, and 

 there is a manifest swelling externally in the 

 situation of the radio-humeral articulation : 

 although there is even now a marked tendency 

 in the fore-arm to remain in a semiflexed posi- 

 tion, still gentle flexion and limited extension 

 are admissible ; but when the radius is pressed 

 against the humerus, and a movement of rota- 

 tion at the same time is given to the fore-arm, 

 much pain is complained of. The disease may 

 go on, confining itself chiefly to the radial side 

 of the elbow-joint through its first stage of 

 pain and swelling; through its second of effu- 

 sion of fluids and relaxation of the coronary and 

 external lateral ligament; and, thirdly, to dislo- 

 cation backwards of the head of the radius, 

 and even to suppuration and discharge of mat- 

 ter through an ulceration or slough of the inte- 

 guments. 



When the caries has commenced in one of 

 the opposed surfaces of the trochlea of the 

 humerus or great sigmoid cavity of the ulna, 

 the swelling and effusion are first noticed in- 

 ternally at the side of the olecranon and inter- 

 nal condyle. The pain extends to the wrist 

 along the course of the ulnar nerve ; the fore- 

 arm is in this case also in a state of semi- 

 flexion, and any attempt to extend or increase 



the degree of flexion causes very severe pain, 

 while, on the contrary, a movement of rotation 

 of the fore-arm is permitted. If the disease pro- 

 ceeds, the great sigmoid cavity of the ulna be- 

 comes wider and deeper, and the humerus ad- 

 vances on the coronoid process; the internal 

 lateral ligaments are relaxed, and the triceps 

 drags back the fore-arm, so that the olecranon 

 process projects somewhat posteriorly, and there 

 is a tendency to a displacement backwards. 



Whether the disease has originated on the 

 radial or ulnar side of the joint, it very generally 

 spreads so as to involve the articular surfaces 

 of the three bones, and now the disease, termed 

 scrophulous white swelling, becomes fully esta- 

 blished, and is easily recognized by the usual 

 signs. Besides dislocation backwards, either of 

 the radius or of the ulna singly, or of both 

 these bones together, lateral displacements of 

 the bones of the fore-arm at the elbow have 

 been noticed as a consequence of caries ; nor 

 need we be surprised at such variety of posi- 

 tion being assumed by the bones, when inflam- 

 mation has softened the strong lateral ligaments 

 and caused their ulceration. While the patient 

 is confined to bed or to the horizontal posture, 

 the mere position which is given to the fore-arm 

 on the pillow will influence the direction of 

 the displacement that will occur. We have 

 seen, under such circumstances, complete late- 

 ral displacement of both bones of the fore-arm 

 outwards. The internal condyle of the hume- 

 rus pressing against the integuments covering 

 it had caused a round slough, through which 

 the internal condyle of this bone protruded, 

 while the rounded head of the radius had on 

 the outer side caused a similar slough and 

 ulceration of the integuments, through which 

 the upper cup-like extremity of this bone had 

 protruded. 



This lateral displacement of both bones of 

 the fore-arm outwards, whether occurring sud- 

 denly from accident, or slowly from the 

 effects of articular caries, if it be complete, 

 must always (we imagine) be followed by a 

 consecutive dislocation upwards. In this case 

 of caries above alluded to, we found the whole 

 extremity somewhat shortened, that the hand 

 remained habitually prone, and that the fore- 

 arm (in a state of semiflexion as to the arm) 

 was directed with considerable obliquity in- 

 wards. It was plain that the causes of all 

 these external signs were, that both bones of 

 the fore-arm having their normal relation to 

 each other, were first carried completely out- 

 side the inferior extremity of the humerus, and 

 were then drawn upwards above the level of 

 the outer condyle of this bone. The olecranon 

 process was not thrown at all backwards, but 

 was situated immediately above and outside 

 the external condyle of the humerus ; the coro- 

 noid process was in front of this bone; the 

 inner semilunar edge of the great sigmoid ca- 

 vity therefore corresponded to the convexity of 

 the outer side of the humerus, and seemed, as 

 it were, to embrace this bone here so as to for- 

 bid any further retraction of the fore-arm. 

 When we proceed to examine an elbow-joint 

 which has been the seat of a scrophulous white 



