A CASE OF 
OF ELBOW-JOINT, 
By Y. R. LeMonnier, M. D., 
Visiting Surgeon Charity Hospital; Professor of Histology and Pathological 
Anatomy, Charity Hospital Medical College of New Orleans; Member 
and Secretary of Board of Health, State of Lo aisiana. 
Labor improbus omnia vincit. 
Compound comminuted fracture of left humerus, extending into and 
laying open the elbow-joint. Suppuration at seat of injury. Re 
section. Second operation for necrosis of inferior end of humerus. 
Third operation for caries of shaft of humerus, 2.J inches above 
seat of last operation. Guerin's wadding dressing (Pansement a 
la ouate. Pansement par occlusion). Anti-scrofulous Treatment. 
Fourth and last operation—removal of invaginated sequestrum of 
humerus and resection of (new) elbow-joint for second time. Re- 
covery with use of joint. 
[From the New Orleans IMedical and. Surgical Journal.] 
November, 1876. A CASE OF 
RESECTION Of ELBOW-JOINT, 
By Y. R. LeMonnier, M. D., 
Visiting Surgeon Charity Hospital; Professor of Histology and Pathological 
Anatomy, Charity Hospital Medical College of New Orleans; Member 
and Secretary of Board of Health, State of Louisiana. 
Labor improbus omnia vincit. 
Compound comminuted fracture of left humerus, Utrm 
laying open the elboiv-joint. Suppuration at seat of injury. Re- 
section. Second operation for necrosis of inferior end of humerus. 
Third operation for caries of shaft of humerus, 21 inches above 
seat of last operation. Guerin’s wadding dressing (Pansement a 
la ouate. Pansement par occlusion). Anti-scrofulous Treatment. 
Fourth and last operation—removal of invaginated sequestrum of 
humerus and resection of (new) elbow-joint for second time. Re- 
covery with use of joint. 
William Egan, set. 13 years, entered my ward, 3, Charity Hos- 
pital, bed 34, on the 3d of April, 1875; left January 26th, 1876; 
re-entered April 17th, 1876. Left, almost cured, June 28th, 
187 6, and on the 15th July he was cured. This patient is a somnambulist. On the 3lst of March, 1875, 
while walking in his sleep, he fell from the gallery into the yard, 
and, striking upon the external condyle of the left humerus, 
fractured this bone transversely, at one inch above the condyles. 
Another fracture extended from this one, vertically downwards, 
between the two condyles, thereby fracturing the bone in three 
pieces and laying open the articulation ot the elbow. He was 
brought to the hospital on the 3d of April. When I took charge 
of the ward on the 6th—three days after—suppuration at the 
seat of injury existed, with two fistulous openings on the postero- 
external surface of the arm. Badio ulnar articulation sound; 
movements normal and almost painless. I diagnosed a necrosis 
at seat of injury, and decided upon a resection of elbow-joint. 
On April 10th, surgical ischemia being obtained, by Esmarch’s 
method, a longitudinal incision was carried, on the postero- 
external surface of the arm, entending above and below the 
elbow-joint, about four inches in length. The radio-ulnar articu- 
lation was found uninjured. As much of the inferior extremity 
of the humerus (three inches) was removed as was found necrosed 
or denuded of its periosteum, preserving the latter wherever it 
existed. During the operation all arteries and nerves were 
respected. The operation over, the wound was plugged with 
lint (charpie), dressed and washed every day with hydrate of 
chloral wash (2.J grains to the ounce), and the best nourishment 
given. Things progressed with satisfaction. An immense quan- 
tity, in fact too much, of new bone formed; so much so, that on 
the 15th of August the hollow left by the removal of three inches 
of the inferior extremity of the humerus was filled by bone of 
new formation, and the arm ankylosed at right angle. On the 
26th of April, accumulation of pus at the inferior extremity of the 
humerus, concomitant with an (edematous condition of the arm, 
forced me to make an incision here, and pass a drainage tube 
through the cloacum. On the 17th of May the arm was quite 
swollen, and an abscess forming on the postero-internal surface 
of arm. R—Poultices to the parts. On the 21st I lanced the 
abscess, which gave issue to eight ounces of pus. The arm was 
quite swollen and cedematous. I diagnosed a necrosis, passed 
two drainage tubes through the parts, and instituted an expect- 
ant treatment, nourishment ad libitum, and exercise in the yards 
of the hospital. June 23d, chloroformed patient and removed 
one and a half inches of the inferior extremity of the humerus,, 3 
which was necrosed and invaginated in the newly-formed bony 
tissue. Things improved for some time, the patient’s arm being 
dressed every day or two with charpie soaked with the solution 
of hydrate of chloral. During this time he was submitted to 
the following anti scrofulous treatment: comp, tinct. cinch. 5 vi., 
sulphate iron grs. vi., sulph. quinine gss., sulph. acid q, s. M. S. 
A. S. Tablespoonful three times a day. The arm suppurated 
more or less when, during the latter part of July, an cedematous 
condition again called my attention to the probability of an 
affection of the bone, though I could detect nothing with my 
probe. About the 10th of August, not only my probe detected 
denuded bone, but easily penetrated into the shaft of the hume- 
rus—caries—at about its centre, on its postero-internal side. 
On the 12th, the patient being chloroformed, surgical ischemia 
obtained, an incision three inches long was carried down 011 the 
internal surface of the arm, where the caries existed, at the 
junction of its upper and middle third. The periosteum was 
carefully and gently pushed aside, aud the carious portion of the 
bone very easily scraped off. The caries was in the shaft of the 
humerus, extending 2J inches in length by £ inch in width at its 
largest place. As I ascended the shaft it extended deeper and 
deeper, finally invading the whole thickness of the bone, leaving 
the marrow, inflamed, exposed and of a deep claret hue. At the 
bend of the elbow was another carious spot, which I also scraped 
off. The shaft of the humerus bled freely, when the circulation 
of the arm was reestablished, completely saturating the dressing 
with blood. I now had two wounds, one at the elbow and one 
in the shaft of the humerus. In order to obviate an excess of 
suppuration, and to compare the two modes of dressing, in the 
same case, I plugged the wounds with wadding soaked in carbo- 
lized oil (1 part to 6), and applied the dressing by occlusion 
(pansement a la ouate d’Alph. Guerin), thereby protecting the 
wounds from the contact of the atmosphere and rendering the dress- 
ings less frequent. 
This dressing consists in surrounding a limb with sheets of 
carded cotton, fifteen to thirty or more, and binding them down 
very tightly with rolls of bandages. If the dressing be well 
applied, the contact of the atmosphere with the wound will be 
prevented, and suppuration thereby lessened. This renders the 
renewal of the dressings less frequent. Besides it has many 
other advantages, which it is not my province here to mention. 4 
Vide Bulletin de F Academic do Medeeine de Paris, pages 1029, 
et. seq., 1875. 
Ou the morning of the 13th, the day after the operation, the 
boy was without fever and going about the hospital. 
On the 15th the dressing was removed for the first time since 
the operation, i. e., on the commencement of the fourth day. It 
was removed that early on account of the commencing offensive 
smell of the blood that had permeated through the dressing at 
the time of the operation. There was not over an ounce of sup- 
puration, which was from the elbow. The wound of the hume- 
rus was doing so very well that I did not remove the plugging. 
I reapplied the dressing and continued the ferrated cinchona 
and quinine treatment and best nourishment. 
On the 21st, bandage removed. Wounds doing very well. 
Bones and soft parts granulating kindly. Very little suppura- 
tion from wound of humerus, but that of the elbow had suppu- 
rated freely. The wounds were washed with alcoholized water 
(spirits of camphor and water), and the dressing reapplied. 
On the 30th the bandage was again removed. The suppura- 
tion was scanty. The wounds were healing kindly, and the bony 
surfaces seemed covered over with healthy granulations. Same 
treatment and dressing. 
On September 4th the wounds were doing well, but a carious 
spot of the shaft of the humerus was detected. The internal 
treatment was altered to cod-liver oil and comp, tinct. cinch, 
aa Siij., sulph. iron grs. vj. M. Tablespoonful every 3 hours. 
Same dressing. 
On September 10th the dressing was removed, and substituted 
by a simple dressing of dry charpie, and the necrosis of the 
humerus was daily watched. The wounds had improved; they 
were washed, every day or two, with alcoholized water. General 
treatment continued. 
On October 15th he had improved steadily but slowly, and left 
the hospital to come to my office consultations. From this time 
out, I again instituted the expectant treatment, and continued 
the internal one, with the hope that nature would eliminate the 
necrosis. On the 25th of January, 1876, I saw him for the last 
time that winter. He was then very fat and used his arm freely. 
Two fistules existed, leading to necrosed bones. 
Act Second. On tlie 17 th of April, 1876, lie again presented himself at my clinic, at the Charity Hospital. His general health 
was much improved under the anti-scrofulous treatment, which 
he had followed with more or less regularity. On the internal 
surface of the arm, where the shaft of the humerus had been 
scraped, three fistules existed, leading to a loose bone. Satisfied 
that this sequestrum was invaginated in the shaft of the humerus, 
and could not be eliminated by the sole efforts of nature, I decided 
upon an operation for its removal. The patient chloroformed, 
and surgical ischemia obtained, I made an incision 3J inches in 
length, on the tract of the fistules. The healthy, newly-formed 
bone was easily removed, as is generally the case in young pro- 
liferated bony tissue, and in the canal of the humerus a loose 
sequestrum, 2| inches long by § inch wide, was picked up with 
the forceps. I then concluded to reestablish if possible the move- 
ments of the elboiv-joint, which the patient had allowed to become 
almost completely ankylosed, at au angle of 65 (?) degrees. For 
this I made a crucial incision at the posterior and exterior sur- 
face of the elbow-joint, in the cicatrix of the former incision. 
With difficulty I removed all the bony and ligamentous tissue 
around the heads of the ulna and radius, which had caused the 
ankylosis. This was new bone, a year old, and hard, which 
had proliferated from the periosteum of the humerus, which 
(periosteum) I had carefully preserved last year while removing 
the condyles of the humerus. Au examination of this newT osse- 
ous growth showed that, in its proliferation, it had adapted itself 
to the eminences at the head of the ulna, so as to form a joint 
somewhat similar to the normal one. The radio ulnar articula- 
tion I did not open, but satisfied myself of its integrity and 
physiological functions. After the removal of this newly pro- 
liferated bone, the arm could be extended almost to its full ex- 
tent, to an angle of 80 degrees, and bent ut supra. The perios- 
teum throughout was preserved. The operation over, the angles 
of the wound were sewed up, to obtain if possible union by first 
intention. The cavity, which was a bony one, was plugged with 
dry charpie. No disinfection of any kind nor any styptics were 
used. I am opposed to the use of styptics, as the salts of iron, 
which only dirties wounds, and retards somewhat the appearance 
of granulations, by the eschar which it forms. The best hemos- 
tatic, in my opinion, is the natural coagulation of the blood by 
the action of the air, and the contracting effect it (the air) has 
on the small blood-vessels. As to disinfections, as a general rule 6 
they are useless in this, the climate of our beautiful Louisiana. 
The operation was bloodless. The gutta-percha ligature was 
then removed, and the blood allowed to flow back into its 
emptied vessels, and in order to diminish‘the shock of the 
heart’s systole, I compressed with the hand the brachial artery, 
allowing the blood to flow by degrees. With the other hand I 
held tightly the charpie in the wounds. The patieut then lost 
about five ounces of blood. After treatment: the arm and elbow 
were next encircled with a sufficient amount of bandages to keep 
the lint in the wound. The effects of chloroform over, the 
patieut complaining, a third of a grain of sulphate of morphia 
was injected under the skin of the right arm, which gave instant 
relief. He was put to bed, and syrup of sulphate of morphia 
(gr. j. to 3j.) ordered, p. r. n., to relieve pain. On the 18tli he 
had a little fever, and had passed a good night. The bandage 
was bloody and dry. Five grains, three times a day, of sulph. 
quinine were ordered and best nourishment ad libitum. 18th— 
Bandage removed and wounds washed. Some tumefaction of 
arm and elbow; no fever; wounds doiug well. B—Cod-liver oil, 
comp, tinct. cinchona, aa 3iv.; sulph. iron, grs. viij. Tip. By table- 
spoonfuls four times a day. Nourishment ad libitum. Under 
this treatment he improved steadily and slowly, the wounds 
being dressed p. r. n. with charpie and simple cerate, and washed 
with alcoholized water. The patient was watched and made to 
keep up the movements of the joint during the healing process, 
in order to prevent ankylosis. On the 5th of June a piece of 
bone, the size of a pea, was removed, and on the 20th the wounds 
were almost healed. Another necrosis existed, which would 
either be eliminated or have to be removed. The general and 
local treatment were continued. There seemed to be then but 
little movement in the joint. On the 28th of June he left the 
hospital, though not yet cured, promising to continue his anti- 
scrofulous treatment and report to me from time to time. The 
arm seemed to be ankylosing at an angle of about 70°. I again 
reminded him of the importance of a free use of the joint, if he 
did not wish to have a stiff arm, after which we parted. I saw 
him no more until a fortnight ago, when he called on me to show 
me his arm, which was cured since the 15th of July, the day on 
which the wound was completely healed. To-day—October 
6th, 1876, by a free and proper use of the joint, he has improved 
wonderfully. On the 20th of June there seemed to be but little movement in the joint; so much so, that I entertained fears of 
an ankylosis. To-day he can extend the arm to its full length 
and bends it to an angle of 60°. In strength it is almost, if not 
altogether, equal to’the sound one. He easily picks up a bucket 
(3 gallons! of water, and uses indifferently the one or the other 
arm. The operated arm is about three inches shorter than the 
sound one. At the elbow-joint, so great has been the prolifera- 
tion of new osseous tissue, that this elbow is larger than the 
sound one. His general health is excellent. 
28 Conti Street, New Orleans, La., October 6th, 1876.