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 diarrhma 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, and 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 fimbrim (as they are called) which encircle the neck of the radius, and occupy the different fosses 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 fimbrim 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, hut 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.)