treatment during convalescence. When an important tendinous synovial
(carpal, tarsal, great sesamoid) has been the seat of suppurative inflam-
mation, it is rare if the region recovers the entire freedom of its motion.
In such cases, to overcome the remaining induration, cauterization must
â– be resorted to.
CLOSED ACUTE SYNOVITIS.
Due to various causes (overwork, contusions, luxations, sprains, juxta-
epiphysar fractures, perisynovial abscesses), simple acute synovitis offers,
in its mode of development, various characters which have justified the
â– division into a dry form (crepitant or plastic synovitis) and another with
effusion (serous or purulent synovitis). On account of its superficial
situation and the important part it plays during locomotion, the great ses-
amoid synovial is the most frequently affected.
In crepitant synovitis, there is no marked exudation ; the congested
serous, partly deprived of its endothelium, remains dry and the friction of
its wall gives rise to a sort of crepitation. This variety, which sometimes
is but the initial condition of the serous synovitis, has not been well
studied in our animals.
Plastic synovitis begins also dry ; the synovial becomes covered by a
layer first embryonic, then fibrous, which creates tendinous adhesions. It
occurs specially after sprains, luxations or traumatic synovitis. The ten-
don, more or less ankylosed in its sheath, retracts; and functional impo-
tence or deformity of the joint are the results. When they exist in the
tendons of the flexors of the phalanges, these " vagino-tendinous sym-
physis " promote the production of knuckling.
Serous sytiovitis is characterized by the exudation, on the surface of the
synovial, of a reddish liquid, gathering in the cavity and distending its
â€¢cul de sac.
The clinical characters of acute synovitis and anatomical data permit
an easy diagnosis. The region is painful, tumefied, and little by little the
serous is distended, pushed out by the fluid accumulated in it.
At the beginning, the inflammatory phenomena are treated by rest and
â– continued irrigation or by cold compresses and repeated astringent lotions.
To control the intra and perisynovial exudation, it is advantageous to apply
on the compresses a band of flannel or of linen ; rubber bands can also be
328 VETERINARY SURGICAL THERAPEUTICS.
employed. The bandage of Delorme answers the same purpose. (Se&
Sedative applications are indicated if pain is great. Sedative fomenta-
tions will be advantageously employed. Generally the phlegmatic phen-
omena subside ; but ordinarily there remains a dropsical condition of the
serous with thickening of the perisynovial tissues. Hot, moist compresses,
massage, elastic roller, slight exercise relieve small exudations and tendin-
ous stiffness. When their action is insufficient, blistering and firing are re-
sorted to. Acupuncture is preferable to the last even completed by iodu-
xated application and pressure. If there is excessive tension of the
synovial walls, aseptic ptmcture with the trocar is indicated, with or with-
out the washing of the serous sac.
When suppuration occurs, one may, from the start, resort to phenic
washing of the synovial, but if the symptoms become aggravated, it is
better to freely open the sac, drain it and make antiseptic irrigations-
Then the prognosis is very serious ; often, if the treatment is continued,,
it lasts several months and recovery is incomplete.
In the course of some general or infectious diseases, there sometimes
appear closed, acute synovitis, serous or purulent. Rheumatism, glanders,
distemper, typhoid fever, purulent infection, tuberculosis, pleuro-pneumonia,
dourie, variola may occur with them. In horses, they are commoa
during or after pneumonia.
Infectious synovitis are due either to the pullulation, on the surface oÂ£
the serous, of the specific micro-organisms, or to the irritating action of the
toxins eliminated by the serous system. Their symptoms and march arer
identical to those of the closed acute synovitis, but the presence of the
producing diseases guides the diagnosis. The treatment includes anti-
phlogistics at the start, later warm water, massage, blistering and firing. If
the severity of the inflammatory symptoms makes one fear suppuration,,
puncture with phenicated or sublimated washing is indicated. General
treatment may be useful ; in presence of a rheumatismal synovitis, salicylate,
of soda will be prescribed.
Para or metapneinno7iic synovitis are peculiarly common in horses, where
they have already been described as rheumatoid synovitis. Out of sixty-
eight cases of " diseases of the chest," Palat has seen this complication
live times. Bouley Jr. thought it was also common after pleurisy ; to-day-
it is recognized that it occurs habitually with pneumonia. It is observed,
also in man. Chomel, GrisoUe, Andral, Gintrac have seen it.
INFECTIOUS SYNOVITIS. 329
During convalescence or when the animal has recovered, lame-
itess, at times very severe, appears from one day to the other ; several
members may be affected at once. According to Bouley Jr., it shows itself
most commonly from fifteen to twenty days after the appearance of the
thoracic trouble, and according to Trasbot from the twentieth to the twenty-
fifth day. Sometimes it occurs later. Palat has observed it three months
after pneumonia. It may affect tendinous or articular synovial sacs ; but
has a predilection for the great sesamoid â€” that of the fetlock.
The exploration of the lame leg allows the recognition of the diseased
synovial. There is oedematous swelling, heat and pain of the region ;
these with the previous history render the nature of the trouble sus-
picious. What characterizes it essentially, is its ambulatory character, its
moving from one serous to another. Trasbot has seen it affecting suc-
cessively the two great anterior sesamoid sheaths, then the two posteriors
and afterwards the two carpals.
Starting with the idea that the disease resulted from the accumulation
in the blood of the products of disassimilation â€” urea, uric or hippuric
acid, coloring matters, bilious salts â€” and of the irritating action that
they would produce upon tendinous synovials, Trasbot believes that
they can generally be prevented by the use of diuretics at the period of
resolution of pneumonia. Evidently, the blood undergoes serious changes
during the inflammation of large parenchymas, but it is hard to explain
the long retention of these products and their slow action. And again it
is impossible to reproduce experimentally the affection in injecting in the
veins, even in larger quantity, these products of disassimilation.
Bacteriology has inquired into the nature of metapneumonic synovitis.
For man, it is known to-day that it is an inflammation produced by the
infectious element which gives rise to pneumonia. This pseudo-rheuma-
tism penumonia, promoted by the single pneumococcus, is not serious ;
at times there is no pure pneumococcic infection ; the pyogenus strep-
tococcus is sometimes associated with the pneumococcus. (Jaccoud and
The preservative action of diuretics (bicarbonate of soda, nitrate of
potass) is uncertain. Many practitioners have seen synovitis appear in
pneumonic patients treated by diuretics, antiseptics, or by both. A good
pieventive treatment is yet to be found. The curative treatment includes
local means and an internal medication. We have little faith in setons
tinder the chest, as recommended by Palat. The application upon the
synovial of a blistering preparation, the daily administration internally of
salicylate and bicarbonate of soda, is the therapeutics which has given us
the best results, salicylate specially. We give it in doses of 20 to 30
grammes a day; it may be carried to 100 and 150 grammes (Fried-
330 VETERINARY SURGICAL THERAPEUTICS.
berger and Frohner). By the combination of these means, a rapid im-
provement is habitually obtained ; sometimes in less than 1 5 days
the lameness disappears. If dropsy of the serous remains, firing generally
removes it. That which renders the prognosis serious is the peculiar
moving about character of the disease, which involves other serous.
"When one first lameness is relieved, and the animal is ready to resume
work, another synovial may be affected and the disease reappears in it
with all its acute characters. However, cases similar to that of Trasbot,
where the lameness lasted eleven months, are absolutely exceptional.
If the severity of the inflammatory phenomena indicates the possibility
of suppuration, aspiration followed by phenicated washing may prevent
the ulceration of the synovial.
CHRONIC SYNOVITISâ€” DROPSIES.
Common in horses, they are due to the same causes as hydarthrosis
are. They sometimes follow acute inflammation of serous, or again and
most frequently under the influence of excessive work. Most of the
animals used for a long time to heavy work have on their legswindgalls or
thoroughpins. If the accumulation of synovia in tendinous sheaths does
not at first disturb the regularity of the movements, there is a moment
when continually increasing it gives rise to lameness.
In the places where it is less protected, the synovial sac protrudes.
The dilatations, whose seat is known for each serous, always insure
the diagnosis. According to the length of time of the affection,
they are soft, fluctuating, or again indurated, calcified. The ordinary
clinical characters of these dropsies may be modified by the partitioning
of the cavity ; the dropsy is unevenly marked in the various culs de sac,
sometimes even scarcely in one of them. The aspect of their fluid
varies very much : often clear and serous at first, it is generally thick and
dark in old dropsies. Sometimes riziform granula are found in them.
By regular training, a moderate work proportionate to the organic
resistance, by douches, massage, compression, one may, in numerous
instances, prevent the dropsies of tendinous synovials. When they are
recent, it is again the same means that are to be used, adding to them
rest in a box-stall or in the field. Purgatives and diuretics are useless.
Later, when the tumors have already reached a certain size, when the
perisynovial tissues are indurated, more active treatment must be resorted
to : blistering, strong liniments, cantharided collodion, sublimated collo-
dion and a mass of more or less complicated preparations can be used ;
but their action is less powerful and less certain than firing under any of
CHRONIC SYNOVITIS â€” DROPSIES. 33 1
its various forms. If one is not familiar with the technic of the needles
cauterization, he may use the method of Leblanc. The following mixed
method has given excellent results : With fine points irons the skin
is fired through by two or three applications, and then with a red needle,
and with one stroke, the synovial sac is perforated in the half or the third
of the number of points made.
For centuries, it was considered a good treatment to relieve the drop-
sies of tendinous synovials by allowing the escape of the excess of synovia.
From time immemorial, Arabs have opened the thoroughpins of their horses
with the red iron. Notwithstanding the success obtained by Bosco, this
process is dangerous, when the puncture is not made with a very small
point. Some authors have advised the use of the bistouri. With it
specially, one must take great aseptic precautions, if he wishes to
avoid the infection of the synovial; it is after all a " synoviotomy " that
must be made. Capillary puncture, made asepiically, is without danger ;
one must be careful not to make it in the few days following cauterization,
when the points suppurate and the skin is infiltrated ; a careful dis-
infection does not render the skin aseptic and the trocar may carry in-
fectious elements in the synovial. After the puncture, the fluid often
returns, but not with all the characters that it had first : the thick synovia
is replaced by a clear fluid, more resorbable. Anyhow, the puncture can
be repeated and completed by elastic pressure, blistering or firing.
As soon as injections of iodine were recommended in human surgery,
Leblanc and Thierry tried them in animals. If they have been put aside
for hydarthrosis, they are yet used in the treatment of tendinous dropsies,
where they have given numerous successes. Leblanc and Thierry, who
studied comparatively injections of iodine, vinous injections, and firing in
penetrating points, have published the results of their observations in
1845. The solution of iodine (one part of the tincture in two of water)
was injected in articular and tendinous synovials of the knee, hock, fetlock
and in several mucous bursas. The results were excellent. " We are
authorized, from those facts, in saying that the injections of iodine in
mucous bursas and synovial sheaths of horses, can advantageously take
the place of cauterization with the red iron, and that in the plurality of
cases this medication must be used first."
Those experiments were repeated by Bouley, Rey, Lafosse, Pressecq,
Verrier, Barry, Festal, Abadie, Poret, Dupont and many others. The
new method gave occasion for much discussion, and notwithstanding the
influence of Leblanc, it is but little used by veterinarians, who have yet
great respect for synovial sacs. The rules of the use of iodine are well
described by Rey. For each synovial, the place of election is the most
prominent part of the tumor ; it is there that it is easier to penetrate
VETERINARY SURGICAL THERAPEUTICS.
into the cavity. A trocar, 2 or 3 millimeters in diameter, will be used, its
three-faced point will penetrate through the tissues and leave an imper-
ceptible opening which closes at once. Leblanc operated with the animal
standing, but it is better ta
cast him. The leg to be
operated on is carried in
extension. After all aseptic
precautions have been taken
(see Antisepsy), the operator
takes hold of the trocar with
the right hand, limiting his
entrance through the tissues
with his fingers, and he pushes
it perpendicularly to the skin,
or in a slight oblique direc-
tion, by a gradual pressure
with some rotatory motion.
The rod removed, a jet of
synovia escapes more or less
abundant, according to the
tense condition of the sac ;
sometimes, however, it is nec-
essary to squeeze the tumor
to accelerate the flow. At
the clinic of Alfort we use
generally the aspirator of
Dieulafoy or that of Potaia
(figs. 79 and 80). Must the
synovial be entirely emptied?
Barry recommended to ex-
tract only a small quantity ;
he wished to reduce the effects of the iodine by mixing with the synovia ;.
there is, however, cases where this is grumelous and escapes with difficulty ;
and only a portion of it is removed ; but when it flows freely, as much as
possible must be extracted. It is not necessary to inject a large quantity-
of the iodine; according to the size of the sac, from 20 to 100 grammes
are sufficient. An ordinary syringe can be used, though special instruments
are better. The fluid is left in the pouch for a few minutes only ; gentle
pressure insures the intimate contact of the irritating fluid with every
point of the diseased membrane ; then a second evacuation is to be made.
This is sometimes difficult, even with the aspirator ; clots filling up the
canula of the trocar. Sometimes the greater quantity of the fluid has to-
Fig. 79. â€” Dieulafoy's Aspirator.
CHRONIC SYNOVITIS â€” DROPSIES.
be left in the cavity ; notwithstanding, the subsequent phenomena have
nothing alarming. In a horse affected with a large tarsal thoroughpin^
we have injected lOo cubic centimeters of a solution of iodine to the third,
without being able to draw out a noticeable quantity ; no accident resulted
from it ; three months later, the tumor was considerably reduced. The
operation ended, the canula is withdrawn, avoiding to pull on the skin,
and the wound is closed with collodion.
The solution of iodine has been used in various degrees of concentra-
tion. In man, Bonnet has used it pure first, afterwards he employed a
solution made of i6 grammes of water, 2 of iodine, 4 of iodide of potas-
sium. Like Velpeau, Leblanc and Thierry mixed, as we said before, i
Fig. 80. â€” Potain's Aspirator.
part of the tincture with 2 of water. Barrier added to the tincture equal
part of camphorated alcohol. We use the tincture of the Pharmacopoeia,
to which we add 2, 3 or 4 parts of boiled water and a small quantity of
iodide of potassium to dissolve the iodine which precipitates by the mix-
ture of the two fluids.
Though the animal shows no pain after the operation, absolute rest is
indispensable. The days following, the region becomes painful and swol-
len ; in some horses there is a high fever and great lan.eness; others
exhibit but slight reaction. When the operation has been made asepti-
cally, the inflammatory phenomena soon diminish. After the fourth
week the animal can resume his work. The therapeutic results cannot be
appreciated for several months.
How do iodined injections act? For Perosino, they produce adhesions
of the synovial walls. Bouley long ago showed this to be an error : " the
serous in the parts where it is far from the center of the motion, in its
diverticulums, is very vascular ; there, deposits of plastic matter take place
334 VETERINARY SURGICAL THERAPEUTICS.
â– which glue and unite the walls together by their free face, in such a way,
that in the center itself, on the articular surface, on the parts of tendons
which rub and slide over smooth grooves, no false membranes are formed ;
the freedom of motion is preserved by that of the rubbing surfaces.
Irritating frictions give rise by adhesion, far from the center, to the dim-
inution in the size of the sheaths. Besides this, they modify the general
vascularity of the membrane, and hence act upon its secretion."
A high fever and severe local phenomena may demand pulverized
douches or cold lotions on the region ; but if the operation has been well
done, no serious accident is to be feared.
The entrance of air in the synovial is without influence upon the subse-
quent manifestations. Complications attributed to it are the results of
other causes. Many injections are made without washing of the skin, or
clipping the hair; is it surprising that suppuration should occur? It has
also happened that a fraction of the iodined solution has been injected in
the subcutaneous tissue.
Leblanc and Thierry have made a series of thirty-five injections (15 ia
joints, 7 in mucous bursse, 10 in tendinous sheaths and 2 in the pleura)
without having had a single accident. Less skilful and less clean operators
have had afterwards suppurative inflammation of the dropsical synovia
â€” a complication which, in a number of cases, has ended fatally.
Tincture of iodine is not the only fluid to use ; phenic acid at 3-5 p.
100; thymic acid at 5 p. 1000; sublimate i p. 1000 and most of the
almost concentrated antiseptic solutions have been used. Chlorhydrate
of morphine and ergotine have given to Lafifltte excellent results. Biot
has related successes obtained by the injection of blood. Stottmeister has
recommended the injection of 5 to 10 centigrammes of eserine dissolved
in 5 to 10 grammes of water.
When the serous is much thickened or lined with a fibrinous deposit
ordinarily all those means fail. It is in those severe cases that it is
advised to open the synovial.
The incision of a tendinous synovial may be done, in all species, with-
out accidents â€” providing the rules of asepsy are minutely carried out. In
the horse, if one has a convenient local, and is assisted by one or two
assistants familiar with the work, most rigorous asepsy can be made. But,
in ordinary practice, it is difficult to realize all the necessary requirements
and on that account veterinarians will do well to leave the incision of
synovials alone. It is, however, well known that the opening of the
sheaths of the extensor tendons is far less dangerous than that of the
flexors â€” as claimed rightly by Glinther and Moller.
If we wish to make the incision, here is the manner to proceed :
twenty-four to forty-eight hours before the operation, the region is dis-
CHRONIC SYNOVITISâ€” DROPSIES. 335
infected, the hair cut short, the skin is shaved over a wide surface, its
greasy secretion wiped off with etljer, and then washed with Van
Swieten solution, and a compress moist with the same solution kept over
the region. The animal cast and the leg properly secured, the compress
is removed and a new disinfection of the skin made ; with an incision
parallel to the long axis of the synovial, open it where it is most super-
ficial, remove the fluid, the riziform granulations it may contain, with the
finger or the curette, take off the fibrinous clots deposited on the surface
of the serous, wash off the cavity with an antiseptic solution (sublimate
I p. 1000 or phenic acid 3 p. 100), make a partial synovectomy in excis-
ing a piece of the walls, close it with silk stitches and apply a wadded
dressing completed with a plastered bandage. Be careful that the horse
does not bite or kick the dressing off. The progress of the trauma is in-
dicated by the general condition. After three or four days, generally the
wound is closed, but the cicatrix is not strong. It is better not to re-
move the dressing for a week.
With this operation, Ries has cured a chronic synovitis of the great
sesamoid and one dropsy of the precarpal sheaths of the anterior extensor
of the phalanges, which had both resisted other means.
Let us also mention the drainage of the synovia, studied in horses by
Trinchera. It consists in making a small incision on the upper part of
the synovial or one of its cul de sacs, in evacuating the fluid, making a
counter opening on the most dependent part of the tumor, introducing a
drainage tube through and irrigating the synovial with a sublimate solution
I p. 1000. Serious inflammatory symptoms follow, which last for three or
four weeks and gradually diminish as suppuration disappears. The free
surface of the synovial becomes covered with granulations, but in favor-
able cases the walls will not unite but become covered with an endothelial
layer and the freedom of the movements remains. This treatment, usedf
until to-day only for dropsy of the synovial of the extensors of the front o
the knee, hock and fetlock, might be applied to carpal and tarsal sheaths.
Specml Chronic Synovitis and Dropsies.
/. â€” Sheath of the Biceps (^Coraco-Radialis).
Sometimes the sheath alone is affected, sometimes also the tendon. In
fact, most ordinarily, it is not only a simple synovial dropsy, but a dry
synovitis or teno-sy?wvitis. If the contusions of the shoulder and upper
part of the arm are its ordinary causes, at times the affection is brought
about by heavy trotting work, violent efforts in pulling upon uneven
ground ; it is quite frequent in omnibus and tramway horses (Williams).
VETERINARY SURGICAL THERAPEUTICS.
It has been observed sometimes as accident of an infectious morbid con-
dition, specially of rheumatism. Â«
It is seen under two forms â€” an acute and a chronic state. In this last
form, it may last a long time, and be accompanied with secondary lesions
of the tendons and bone. In a horse treated by Villate, there was syno-
vitis, osteitis, destruction of the bicipital groove and recent lesions of the
articulation. In Goubaux's case, there were well-marked alterations of
the groove and of the synovial, but the joint was free. MoUer has
found exostosis and partial necrosis of the humerus. Williams met with an
almost complete ossification of the tendon of the biceps.
Fig. 8i.â€” Horse affected with bicipital sj-novitis (MoUer).
Inflammation of the sheath of the humeral biceps is indicated by
very significant manifestations ; at rest, the leg is held in semi-flexion, back
of the plumb line ; in walking, it is carried forward with difificulty, the
forearm cannot flex on the arm, the foot drags more or less on the floor,
the step is very short. In the observation of Villate, there were almost
CHRONIC SYNOVITIS â€” DROPSIES. 33/
310 movements on the upper part of the leg, " flexion of the forearm was
possible only when it was raised, and then the pain was so great that the
animal pulled back and reared up." When the affection is bilateral
both legs are as if they were hobbled together, locomotion is extremely-
painful, the steps are short, the foot drags on the ground. Locally, more