80 



ABNORMAL CONDITION OF THE ELBOW-JOINT. 



It may be remarked that one of our patients, 

 a man, aged sixty, in the surgical wards of 

 the House of Industry, who had for many 

 years suffered from the severest forms of chronic 

 rheumatism in all the articulations, got diarrhoea 

 and died. The writer had previously noted 

 in particular the condition of the right elbow- 

 joint; the motions of flexion and extension 

 were very limited, attended with much crepi- 

 tation, and caused to the patient very great 

 pain. The exact condition of the bones 

 described in the preceding paragraph existed, 

 and the loss of the circular outline of the 

 radius fully accounted for what we had in this 

 case previously noted, viz. that to remove the 

 hand from the state of pronation in which it 

 habitually remained, or to communicate any 

 movement of rotation to the radius was nearly 

 impracticable; the glenoid-shaped surface for 

 the head of the radius allowed of flexion and 

 extension in the radio-humeral articulation, but 

 any except the perfect circular form was ill- 

 suited to permit any rotatory movement of the 

 radius on the ulna. This then is a peculiar 

 disease which causes a complete removal of 

 the articular cartilage from the head of the 

 bones of the elbow-joint, so that the porous sub- 

 stance of the bones becomes exposed : they do 

 not become carious, but on the contrary they 

 are enlarged, hard, aud their surfaces seem to 

 expand. If the joint be much used, the effects 

 of friction become evident; if kept at rest, they 

 are rough, and anchylosis may take place. 



From the phenomena we observe in the 

 variety of cases that present themselves, we 

 may infer that, when this disease affects the 

 elbow-joint, in whichever bone most vitality 

 exists and most active nutrition is going on, 

 enlargement would appear to take place, while 

 in the bone which is softer and in which the 

 process of nutrition is least, the effects of fric- 

 tion become of course most manifest. Thus, 

 in some cases, as already mentioned, we have 

 found the head of the radius greatly enlarged 

 and of a globular form, and the outer condyle of 

 the humerus excavated to adapt itself to this 

 convexity, while on the contrary, in other cases 

 the outer condyle of the humerus seemed to 

 have been the seat of active nutrition, and the 

 head of the radius to have been rendered soft and 

 to have yielded to the effects of friction. In all 

 these cases, there seems to be a very active cir- 

 culation of blood in the capillary vessels of the 

 bones and other structures of the joint. Much 

 of the synovial membrane may be removed 

 with the cartilages ; but the synovial folds and 

 fimbrise (as they are called) which encircle the 

 neck of the radius, and occupy the different 

 fossae in front and behind the trochlea of the 

 humerus, become unusually vascular and en- 

 larged. 



In most of the cases we have examined, we 

 have discovered what are called foreign bodies 

 in the cavity of the joint. These we have found 

 of all sizes, from that of a pea to that of a 

 walnut. Some were seen hanging into the 

 cavity of the articulation, being suspended by 

 white slender membranous threads which 

 seemed to be productions from the synovial 



sac; and some were loose in the joint: while, as 

 to their structure, some were cartilaginous and 

 bony. The number of these foreign bodies 

 we have seen in the cavity of the elbow-joint 

 we confess has astonished us, amounting in 

 one case to twenty, in another to forty-five. 

 In all these cases the vessels of the synovial 

 fimbrise of the joint were in a highly congested 

 state. The co-existence, therefore, of foreign 

 bodies with such a condition of the membranes 

 and their capillary vessels as these dissections 

 elicited, cannot be too fully impressed on the 

 mind of the practical surgeon, who is some- 

 times solicited to undertake an apparently 

 simple operation for their removal. Lastly, 

 instead of the few scattered fibres external to 

 the synovial sac, which, in this joint, when in a 

 normal state, can scarcely be said to resemble 

 even the rudiment of a capsule, we have found 

 in these morbid specimens the thickness and 

 number of ligamentous fibres so considerable, 

 that the joint seemed to possess almost a com- 

 plete capsular ligament. 



In Cruveilhier's Pathological Anatomy, Li- 

 vraison No. 9, Plate 6, Figure 1, there is a gra- 

 phic delineation of an elbow, illustrating many 

 of the points here alluded to : he denominates 

 the disease usure des cartilages, but it is quite 

 sufficient to look at one of these cases, either 

 in the living or the dead, to be satisfied 

 that the disease does not confine itself to 

 the cartilages of the joint, but that the arti- 

 cular heads of the bones are also engaged; 

 indeed, in many of our specimens, the bones 

 of the elbow-joint are so much enlarged as to 

 resemble at first sight the knee-joint; the shafts 

 also of the ulna and radius are heavier and 

 harder than natural,and their cancellated struc- 

 ture no longer exists, the cells being so densely 

 penetrated with phosphate of lime that the 

 sections of these bones in several parts present 

 the appearance of ivory. This account of the 

 state of the elbow-joint produced by that slow 

 disease called chronic rheumatism, is the result 

 of many observations and dissections made 

 specially by ourselves. We may also add that 

 Mr. Smith, the able curator of the Museum of 

 the Richmond Hospital, who has given equal 

 attention to such investigations, has examined 

 and preserved several specimens which verify 

 the account here given of the anatomical cha- 

 racters of this disease ; while, under the writer's 

 own immediate charge in the House of Industry, 

 are numerous living examples of, and sufferers 

 from, this chronic disease, affecting the elbow- 

 joint. In most of these cases, however, some 

 of the other articulations are equally engaged.* 

 (R.Adams.) 



* [Since the preceding article was put to press, 

 the Editor has been favoured with the following 

 communication from the Author, which is too inte- 

 resting to be omitted : " Within these three days I 

 met with a very singular case of congenital 

 deformity of both elbows in a girl about eleven 

 years of age. The radius could be felt to press 

 forwards and backwards for the extent of an inch 

 when it was rotated either in pronation or su- 

 pination. These movements did not consist in 

 a simple rotation of the radius on its longitu- 



