ORIGINAL COMMUNICATIONS— ..... Charge to Graduating Class, delivered by W. H. Witt, M. D., SELECTED ARTICLES Early Diagnosis and Treatment of Puerperal Septic Diseases by ...... EXTRACTS FROM HOME AND FOREIGN JOURNALS 193 205 205 208 Surgical. Knee-Joint Injuries and How to Manage Them.... Imperforate Hymen. A Case of Multiple Fractures in an Infant. Removal of Gall Bladder..... Appendectomy; Modified Method. 217 218 219 219 220 221 222 A Death Under Ethyl Chloride.. Medical. A New Method to Aid the Diagnosis and Treatment of Gonorrhoea 223 Pyrenal a Chemical Compound of Salicylic Acid, Benzoic Acid and Thymol 223 Glycosuria and Albuminuria, Significance of Slight. 225 Obstetrical. A New Operation for Complete Prolapse after the Menopause.. 226 BY J. W. BRANDAU, M. D., CLARKSVILLE, TENN. No. 6 The synovial membrane is one of the constituents of the body very prone to respond rapidly to irritants or infection by intense reaction, or inflammation; and that inflammation is usually strongly marked because it produces, whether serum, blood, or pus, concentrated within the cavity of a joint, again affect the synovial membrane itself with painful and often injurious tension. Inflammation has been well described as "the phagocytic method by which an organism attempts to render inert noxious elements introduced from without or arising from within." In order to meet this demand we have a large and rapid increase in the number of phagocytes, or white blood cells, in the part, due primarily to increased blood supply, and in suppurative cases to an increased proportion of phagocytes in the blood. Increased blood supply also means an increased supply of red cells, resulting in the more severe forms of inflammation, in mi gration of the red cells (Diapedesis). Hence we have the effused serum tinged more or less with them; and the surrounding tissues in a more or less intense state of inflammation. Now, it is not the migrated cells that chiefly produce new tissue which forms in and about an inflamed joint, but the increased functional activity of the fixed tissue cells due to the presence of this exuded element. Contusions, sprains, or any form of traumatism, direct or indirect, may produce a hyperæmia followed by the ordinary phenomena of an inflammatory process, with loss of function and increased exudate or normal joint fluid; or, in furtheir continuence of the process, by fibrinous exudation. If, now, an infection by pyogenic cocci should occur, either from without or from within, suppuration will result, with probable destruction of cartilage; or, the process may advance to the destruction of bone. The diagnosis of acute synovitis is usually not difficult. The cardinal symptoms of inflammation excepting redness, are usually present. There is an increase of the surface temperature of the joint, from one and a half to two and four-tenths degrees, in severe synovitis. The temperature may be taken best with an ordinary thermometer, under a thick covering or gauze, or a towel covered with rubber tissue or a piece of oiled silk. Except in the uncommon form of dry synovitis, the swelling is always present, and varies in proportion to the amount of effusion within, and the degree of infiltration of tissue around the joint. In the shoulder there is a broadening of the part, as may be seen best by looking down upon the shoulders, the patient sitting. The groove separating the shoulder from the chest is partly or completely obliterated. The depression-in thin persons at the back of the shoulder below the acromion is also more or less obliterated. The apex of the axilla, in severe cases with a large amount of effusion, is more or less filled in by a swelling at its outer side. In the elbow the points at which the swelling is most pronounced are at the back of the joint, filling out the depression on each side of the tendon of the triceps. There is also a fluctuating swelling at the junction of the humerus and radius. A wave of fluctuation may be made to run from one to the other of the points mentioned. At the wrist the swelling occurs behind, on each side of the extensor tendons of the fingers and between those of the thumb; the swelling giving a bracelet like enlargement across the back of the wrist; whereas, effusion in the tendinous sheaths gives rise to a longitudinal fusiform enlargement, that is, its long axis is parallel to the arm and hand, bifurcating at its lower end, and encroaching upon the back of the hand. Synovitis of the hip is uncommon. A slight effusion does not cause external swelling, but may produce such changes in the position and relation of the parts as may lead one erroneously to infer that shortening or lengthening exists. In making measurements it is necessary to place the parts in their normal relation: the pelvis exactly transverse. When a large amount of effusion exists, swelling will be noticed behind the great trochanter and in the groin below Poupart's ligament. In thin patients fluctuation may be felt between these points. Some swelling may also be felt in the angle between the thigh and perineum, behind the tendon of the adductor longus muscle. Two adjacent bursæ may, when inflamed and distended with an effusion, simulate synovitis of the hip. One of these is located between the tendons of the psoas and iliacus muscles and the head and neck of the femur as low as the lesser trochanter. It sometimes communicates with the cavity of the joint. When it is a separate case and becomes distended it causes a swelling in the groin, but no swelling exists posteriorly. The other bursæ, a very large one, lies behind the joint under the gluteus maximus. When distended it produces a broad, rounded swelling, occupying a larger surface than the swelling of synovitis of the hip; increasing in mass the soft parts over the great trochanter, more completely concealing it. No swelling exists in the groin. The knee being a large and superficial joint, is more frequently affected with the various forms of synovitis; and owing to these peculiarities, the disease is the more easily detected. The swelling even in moderate effusions may obliterate the depression on either side of the tendon of the rectus, the patella and its tendon; but, when the effusion is large in quantity the swelling becomes so great that the parts naturally projecting form the floor of a hollow depression; the patella, however, being pushed away from its contact with the condyles, as may be proven by depressing it by a quick movement of the fingers, when it can be felt to strike the femur, but immediately to rebound and resume its floating position. Pressure upon the patella also produces still greater prominence of the lateral swelling, the wave of fluctuation being both seen and felt. In large effusions of the knee joint there is also a protrusion into the popliteal space, which becomes shallowed or even obliterated. Inflammation of the bursa patella causes a conical swelling in front of that bone. The swelling from inflamed bursa of the ligment of the patella is local, and resembles an enlargement of the tubercle of the tibia; from which it can be differentiated by the presence of fluctuation in bursitis with effusion. This bursa occasionally communicates with the joint. The ankle is not infrequently the seat of synovitis, but rarely severe in character. The disease either quickly subsides or becomes chronic. The swelling is most prominent in front of the malleoli, especially the outer malleolus. A lesser degree of swelling is noticeable behind; the entire tumefaction forming an enlargement around the joint like an anklet, which is readily distinguishable from an effusion into the tendinous sheaths, the swelling of the latter running lengthwise on the leg, encroaching somewhat upon the instep. The pain of synovitis, in the more and acute stage, that is, in the first two or three days, in quite severe. It consists of a continuous duller or sharper aching along with a sense of distension, |