ABNORMAL CONDITION OF THE ELBOW-JOINT. 



79 



swelling that had presented the usual charac- 

 ters of this disease in its advanced form, we 

 usually notice the surface of the skin studded 

 over here and there with the orifices of fistulous 

 canals ; these are found generally to have pro- 

 ceeded by a winding course, either from the 

 cavity of the elbow-joint or from the cancellous 

 structure of the bones, or from both these 

 sources. \V hen a section is made of the bones 

 in this advanced period of the disease, they 

 will generally be found to be softened in the 

 interior, and to contain a fatty or yellowish 

 cheese-like matter in their cells ; when exam- 

 ined in an earlier stage of this scrophulous 

 caries, these organs are generally found to be pre- 

 ternaturally red and vascular, and with much 

 less proportion of earthy matter than natural, 

 so that they admit not only of being cut with a 

 knife without turning its edge, but yield and 

 are crushed under very slight pressure. 



We have also occasionally opportunities of 

 examining the joint when the process of caries 

 would appear to have been arrested and to 

 have given place to a new growth of bony vege- 

 tations around the joint; under such circum- 

 stances, conical granulations, several lines in 

 length, shoot out like stalactites around the 

 trochlea of the humerus and from the olecranon 

 and coronoid processes of the ulna ; the bones 

 are, however, in these specimens remarkably 

 light, porous, and friable. In some cases, 

 however, the caries of the bone has altogether 

 ceased, and a process of anchylosis has been es- 

 tablished, and the fore-arm is flexed on the arm : 

 a section through the elbow-joint longitudinally 

 will in such cases frequently exhibit a com- 

 plete continuation of the cancelli through the 

 joint from the cells of the humerus to those of 

 the radius and ulna. 



Rheumatism. The elbow-joint, like all the 

 other articulations, is liable to attacks of acute 

 rheumatic inflammation, the external signs of 

 which differ but little from those which we 

 observe to attend an ordinary case of acute 

 synovitis. The disease, however, seldom fixes 

 itself for any time upon this or any one joint 

 in particular and usually terminates favourably, 

 so that opportunities seldom occur of ascer- 

 taining by anatomical examination the effects 

 of this species of inflammation in the different 

 structures of the elbow-joint. But this articu- 

 lation is, in the adult and in those advanced in 

 life, affected by a disease which, for want of a 

 better name, is termed chronic rheumatism, 

 the anatomical characters of which are very 

 remarkable, yet they never have received 

 from pathologists that attention they appear 

 to us to deserve. In these cases the elbow- 

 joint becomes enlarged and deformed; its or- 

 dinary movements, whether of flexion, exten- 

 sion, or rotation, become restricted within very 

 narrow limits ; and when we communicate 

 to the joint any of these motions, the patient 

 complains of much pain, and a very remarkable 

 crepitation of rough rubbing surfaces is per- 

 ceived : a careful external examination of the 

 joint will in such circumstances enable us to 

 detect foreign bodies in the articulation. Some 

 of them are small, but others occasionally are 



met with of a very large size, and can easily be 

 felt through the integuments. Sometimes the 

 synovial membrane of the joint itself is much 

 distended with fluid, and the bursa of the ole- 

 cranon is likewise affected, in which small fo- 

 reign bodies are also to be detected : sometimes, 

 however, there would appear to exist in the in- 

 terior of the joint even less synovia than natural. 

 The muscles of the arm and fore-arm for want of 

 use are more or less wasted and atrophied. As 

 the external appearances vary, so also do we find 

 the anatomical characters of the disease to pre- 

 sent varieties, some of which deserve notice. 

 We have found the most general abnormal ap- 

 pearance to be that the cartilages are removed 

 from the heads of the bones which are greatly 

 enlarged, and that these articular surfaces are 

 covered by a smooth porcelain-like deposit, 

 and after a time attain the polish and smooth- 

 ness of ivory : the trochlea of the humerus, 

 also, and corresponding surface of the great 

 sigmoid cavity of the ulna are also marked 

 with narrow parallel sulci or grooves in the di- 

 rection of flexion and extension. In these cases 

 the radio-humeral joint is likewise affected, the 

 head of the radius becomes greatly enlarged, 

 and it assumes quite a globular form, while the 

 anterior and outer part of the lower extremity 

 of the humerus will have its capitulum or con- 

 vex head not only removed, but here the 

 humerus will be found to be even excavated to 

 receive the head of the radius, and to accom- 

 modate itself to the new form it has acquired 

 from disease. In many cases where the radius 

 had become thus enlarged and of a globular 

 form, the writer has found the cartilage removed 

 altogether and its place occupied by an ivory- 

 like enamel. In two examples he has seen a 

 depression or dimple in this rounded head of 

 the radius, similar to what naturally exists in 

 the head of the femur, and in these two cases, 

 strange to relate, a distinct bundle of ligament- 

 ous fibres analogous to a round ligament passed 

 from the dimple or depression alluded to, con- 

 necting this head of the radius to the back 

 part of the sigmoid cavity of the ulna. In 

 some few cases, when the external signs of this 

 chronic disease in the elbow-joint were present, 

 we have found the bones of this articulation 

 enlarged, hard, and presenting a rough porous 

 appearance, while the cartilage was entirely 

 removed ; but in these specimens no ivory 

 deposit was formed. These were cases in 

 which the same disease existed locally, and the 

 same disposition prevailed in the constitution ; 

 but from the bones having been kept in a state 

 of quietude, the rough surfaces of the articular 

 extremities had not been smoothed by the 

 effects of friction, nor an ivory-like enamel 

 formed. We believe that in such cases, were 

 life prolonged, anchyloses would be established : 

 in other instances the head of the radius has 

 not been found enlarged as above described, 

 but otherwise altered from its natural form. 

 The superior articular extremity of this bone 

 has been found excavated from before back- 

 wards, its outline not being circular nor exactly 

 oval but ovoidal, accurately representing on a 

 small scale the glenoid cavity of the scapula. 



