ABNORMAL CONDITION OF THE ELBOW-JOINT. 



77 



the sigmoid cavity of the ulna was the result of 

 a natural effort to compensate for the loss of 

 strength the joint suffered from the dislocation 

 of the radius. Still, supposing it possible that 

 the surface of the capitulum of the htimerus 

 could be so completely removed, under such 

 circumstances, as we find it was in the cases of 

 vfhichjigs. 44 and 45 are delineations, we may 

 ask, is it likely, from accident or disease, 

 that both elbow-joints should be similarly 

 arfected, as they were in Dupuytren's cases. 

 Another circumstance in our mind cannot be 

 accounted for, unless by supposing these cases 

 congenital, . namely, the alteration and great 

 elongation of the neck of the radius. " L'ex- 

 tremite superieure de chaque radius avail 

 abandonne sa situation naturelle, se trouvait 

 place derriere 1'extremite inferieure de 1'hu- 

 merus, et depassait cette extremite d'un 

 pouce ciu moins. Cette disposition etait ab- 

 solument la meme de chaque cote du corps." 

 We know of no process which could take 

 place in the head and neck of the radius after 

 it had been dislocated, which could satis- 

 factorily account for the elongation of the 

 radius, which has been remarked in these 

 cases. While looking on them as congenital, 

 we need not be surprised at it ; for we have 

 known the neck of the femur elongated and 

 atrophied, in the case of congenital luxation 

 of the femur, and have very frequently seen 

 the lower extremity of the ulna exceed in length 

 by half an inch the corresponding extremity 

 of the radius ; and these were cases in which 

 no doubt could be entertained that they were 

 congenital. 



Disease. Acute and chronic inflammation 

 produces effects on the membranes, cartilages, 

 and bones entering into the composition of the 

 elbow-joint, which w r ill be found nearly analo- 

 gous to those which the same morbid action pro- 

 duces on similar structures in other articulations. 

 A few local peculiarities, if we may so call them, 

 when the elbow is the seat of the acute or 

 chronic disease, should alone occupy our atten- 

 tion here. 



Synovitis of the elbow-joint, uncombined 

 with any affection of the other structures, is 

 rare ; it may, however, present itself either in 

 the acute or subacute form. Increased effusion 

 of fluid into the joint, accompanied with the 

 usual local and sympathetic phenomena of in- 

 flammation, is the result. Two well-marked 

 oblong swellings at each side of the olecranon 

 process in these cases first present themselves, 

 which after a time, if the disease proceeds, 

 join and form one swelling, which extends up 

 the back of the arm, occupying the cellular in- 

 terval existing between the back part of the 

 humerus and the front of the triceps muscle, 

 opposite to the outer condyle of the humerus 

 and head of the radius; the supinators arising 

 here are, in severe cases, occasionally elevated 

 and thrown out from the bones by a soft tumour, 

 which, upon examination, conveys to the fingers 

 a distinct feeling of a fluid contained beneath. 

 The nature of the accumulated fluid will, when 

 the joint is cut into, be found to vary. When 

 the effusion has followed an acute attack of in- 



flammation of the membrane, it will be gene- 

 rally found to be purulent, though sometimes 

 we have observed the quality of the synovia 

 but little altered, except that it was more or 

 less turbid. When the contents of the synovial 

 sac have been washed away, the membrane will 

 be seen to be highly vascular, and the ves- 

 sels of the subsynovial tissue congested 

 with blood, and its cells infiltrated with se- 

 rum; while, if fine injection, coloured with 

 vermillion, is thrown into the vascular system 

 of these parts, the unusual redness the mem- 

 branes assume can only be compared in height 

 of colouring to the membrane of the eye in 

 acute conjunctivitis. With this intense red- 

 ness of the surrounding membranes is strongly 

 contrasted the appearance of the cartilages of 

 the joint; these, but little altered from their 

 natural colour, are seldom in this articulation 

 found covered with vascular membranes, and 

 even when the surrounding structures are mi- 

 nutely injected, the fluid cannot be made to 

 penetrate the synovial investment of the carti- 

 lages. 



Cartilage. When acute inflammation has 

 existed in the synovial membrane or bones of 

 the elbow-joint, the articular cartilages covering 

 these will very frequently be found to have 

 assumed, in patches, a dull yellow colour ; in 

 the latter discoloured points the cartilage is soft- 

 ened, and a blunt probe slightly pressed will 

 sink into its structure, and its subjacent surface 

 will be found to be detached. A new vascular 

 membrane having been interposed between the 

 cartilage and the cancellous structure of the 

 bone, this elevation and partial detachment of 

 the articular cartilages from the heads of the 

 bone, and interposition of a new organized mem- 

 brane, are probably the usual preludes to those 

 other changes we notice. Tims sometimes a 

 leaf or flap of the articular cartilage, adherent 

 only by an edge, hangs into the cavity of the 

 joint, and again fragments of this structure 

 completely detached are found loose in the in- 

 terior of the articulation. In these instances 

 there is reason to conjecture that the diseased 

 action which detached the cartilage began on 

 the surface of this structure contiguous to the 

 bone. We have occasionally, however, evidence 

 of ulcerative absorption having commenced on 

 the free surface of the cartilage. The peculiar 

 worm-eaten appearance which the surfaces of 

 cartilages next the cavity of the joint occa- 

 sionally present, and which, wherever it exists, 

 is considered by many pathologists to be the 

 result of a process of ulceration which had be- 

 gun on the free surfaces of the articular carti- 

 lages, has been occasionally though rarely seen 

 in the elbow-joint ; much more frequently in 

 examining elbow-joints which have been the 

 seat of disease, the articular surfaces of the bones 

 have been found extensively divested of their 

 cartilages ; a few patches of them alone here 

 and there remain ; and these, though apparently 

 thinner than natural, are of their ordinary tex- 

 ture, and are firmly adherent to bone. 



Such extensive removal of cartilage, which 

 has exposed the cancelli of the heads of the 

 bones, has generally been the result of some 



