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 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. \\ lien 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 Out with a knife without turning its edge, but yield and are crushed under very slight pressure.
\Ve 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 trot:Idea 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-arin 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.
lacumatism.—The elbow-joint, like all the other articulations, is liable to attacks of acute rheumatic inflammation, the external signs of which differ hut 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 crepitatiou 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 n 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. \Ve believe that in such cases, were life prolonged, anehyloses 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.