1619HOSPITAL MEDICINE AND SURGERY.

healthy, and there was no evidence of iritis or keratitis eitherpresent or remote. The glandule conoatenatse on both sidesof the neck were slightly enlarged. The right knee wasaffected with synovitis ; it measured twelve and a half inchesover the centre of the patella, whilst the left only measuredten and a quarter inches in circumference at the same place.There was a little synovitis of the left knee. The synovialmembrane in both joints appeared to be thickened, and thiswas especially marked at the sides. The patient occasionallyhad a little throbbing pain at nights, but unless the kneewas moved he did not complain of pain. He never hadstarting pains at night. The boy was ordered one-graindoses of grey powder, and in ten days’ time his complexionhad cleared, many of the ulcers had healed, and his voicewas less husky. There was less synovial effusion in theright knee, whilst the left appeared to be healthy. This

improvement continued until March 7th, when the patientwas allowed to go home with his right knee in a plaster-of-Paris case. He returned on March 26th complaining ofmuch pain in both knees, with increased swelling. A

plaster-of-Paris splint was put upon each leg. He returnedon April 2nd with increased swelling of both knees and somesynovitis of both elbows, and he then confessed that hehad not taken any powders for a, fortnight. He was againordered single grain doses of grey powder three times a day.On April 9Lh his elbows were less swollen, though his kneeswere still troublesome. He was ordered to take half-drachmdoses of perchloride of mercury with five grains of potassiumiodide thrice a day, and a week later the boy reappearedsaying that his elbows were well, his knees were better, andhe had not suffered any pain since he had taken the newmedicine. He had increased in weight to five stone one anda half pounds. He was sent to the seaside to completehis convalescence.

-Re?itarks by Mr. D’ARCY POwER.-Hereditary syphilis inyoung adults is often difficult to diagnose, since it may bemistaken for some tuberculous manifestation, and this is

especially the case when, as in the present instance, thejoints become involved. The boy whose case forms the sub-ject of the present report would in all probability havebeen treated for tuberculous synovitis had he not had thegood fortune to be brought by his mother, who presentedobvious signs of tertiary syphilis. Her appearance at onceput us on the alert as to the true nature of the affectionfrom which he was suffering. The facility with which the- boy walked in spite of the advanced disease in hisknee ; the comparative freedom from pain which he

- experienced; the slight symptoms of laryngitis ; and, aboveall, the remarkable benefit which he derived from greypowder-all pointed to the accuracy of our diagnosis-anaccuracy which was confirmed by the fact that when thegrey powder was omitted for a fortnight both elbows becameaffected with synovitis, the inflammation of the kneesbecame as bad as at first, and the boy became really ill-symptoms which all passed away after the administration oismall doses of potassium iodide and perchloride of mercury.It is of interest, too, to notice that the stress of the diseasEfell upon the skin and synovial membranes, for the teeth anceyes were entirely unaffected.

MANCHESTER ROYAL INFIRMARY.A CASE OF SARCOMATOUS DEGENERATION OF THE

SYNOVIAL MEMBRANE OF THE KNEE-JOINT.

(Under the care of Mr. HARDIE.)IT is a well-known fact in surgery that sarcoma of the

lower end of the femur frequently simulates disease of theknee-joint, and it is sometimes very difficult to diagnosebetween the two conditions. There are cases on record wherethe growth has even invaded the joint secondarily, havingperhaps passed along the crucial ligaments ; but this exten-sion of the disease is rare, the synovial membrane beinggenerally pushed away by the advancing growth. A primary,growth of a sarcomatous nature in the synovial membrane ispractically unknown, and, as Mr. Salter remarks, is notalluded to in our text-books, nor is it apparently noticed inworks of reference. This case is, therefore, one of unusualinterest, and we shall be pleased to receive details of anysimilar case known to our readers. For the notes of the casewe are indebted to Mr. S. Colley Salter, late house surgeon.

The patient, a man twenty-five years of age, was admitted) the Manchester Royal Infirmary under the care of Mr.fardie on Nov. 29th, 1893, suffering from "disease of theft knee-joint." He appeared to be a fairly healthy but notery robust man, and according to his own statement he hadlways been in the enjoyment of good health until the com-lencement of the present trouble. His family history con-ained nothing bearing on his present condition, except theact that his father had once suffered from "rheumatic;out." The patient’s history of the joint affection was asollows. About five years ago he had considerable painn the joint, for which he underwent a prolonged course)f hydropathic treatment, the pain being thereby consider-ably relieved. For the next two or three years he was,vith occasional exceptions, free from pain. About twoears ago he first noticed a small " lump " about the size oft marble on the outer side of the knee, near the head of theibula. It was quite free from pain or tenderness and appa-rently remained of the same size until about twelve monthsgo, when the patient, while carrying a load, fell with hisLeg doubled under him. This caused him great pain in thejoint, which became very much swollen and tender andnecessitated his being confined to bed for five weeks, duringwhich time the "lump " also increased considerably in size.While in bed the swelling of the joint diminished, and at theend of five weeks the patient was again able to wa,lk about,although the joint was very stiff. During the next fewmonths this stiffness increased very much, until the joint wasalmost fixed. At the same time the swelling reappeared, andthe patient began to have pain of a burning, aching characteron walking. The external application of iodine was tried forsome time, but with no effect, and eventually the patient’smedical adviser punctured the swelling with a hypodermicneedle, and, obtaining nothing but pure blood, he advised thepatient to seek admission to the Manchester Royal Infirmary.The notes taken at the time of admission say : " The

patient lies with his left knee flexed and abducted. The joint isperfectly fixed and very much swollen. The swelling is general,with obliteration of all the depressions round the joint, butis especially marked on the outer side of the joint, where itforms a distinct prominence about three inches in diameter,extending about equal distances over the head of the fibulaand the condyle of the femur. This prominence is soft anddoughy in consistence, with equivocal fluctuation. In frontof it, over the joint line, is a hard, movable body about thesize of a peach-stone and closely resembling a loose cartilage.The whole of the joint has the same doughy feel, exceptabove and to the inner side of the patella, where fluctuationis more distinct. Patient complains of no pain, except anaching on attempted movement." The diagnosis beingrather obscure, it was decided to keep the patient underobservation for a short time, giving him in the meantimeiodide of potassium in doses of five grains three times a day.An exploratory puncture was subsequently made at the mostfluctuant spot, and, as the fluid withdrawn consisted entirelyof blood, evidently old, it was decided to make a free incisionand explore the joint thoroughly, and then to adopt suchmeasures as should be deemed advisable.

Operation.-The patient having given his consent to ampu-tation if necessary, an incision was made on the inner side ofthe joint over the site of the exploratory puncture. Thisseemed to open up a large cyst containing fluid, blood, andclot, and extending well forwards in front of the joint andbackwards into the popliteal space. The contents wereturned out, and as the cyst appeared to be separated fromthe joint cavity merely by a very thin layer of fibrous tissueit was decided to lay open the joint in such a manner thatexcision might be performed if necessary. On being laidopen the joint was found to be full of a granular roe-likematerial, readily turned out with the fingers and leaving the

synovial membrane only slightly thickened and reddened.This granular material was submitted to microscopic exa-mination by Mr. Pomfret, surgical registrar, who at oncepronounced it to consist of sarcomatous tissue of the spindle-celled variety, and this opinion was confirmed by Dr.Dreschfeld, who examined the specimen at the time. On

hearing this report all hope of saving the joint was aban-doned, and the limb was amputated in the lower third of thethigh by the oblique circular method, the only departurebeing the substitution for the ordinary rubber drainage-tubeof a new " spring drainage hook " introduced by Mr. Hardie.

Subseq1tent rvress.-The drainage hook was removed atthe end of forty-eight houra, and there was found to beabsolutely no retention of discharge within the flaps, the

1620 REVIEWS AND NOTICES OF BOOKS.

whole having escaped into the dressing. The stump was notagain disturbed for ten daya, when the wound was found tohave healed by primary union and the sutures were con-

sequently removed. subsequently to operation the patientwas perfectly comfortable and free from pain. The tempera-ture remained at or about normal throughout, except on oneocca,sion, when he complained of sore-throat and the eveningtemperature reached 100’2° l’B Three weeks after the opera-tion the patient was sent to the Convalescent Hospital atCheadle, where he remained ten days and was then senthome. He has recently written that he has remained in goodhealth.The following is the description of the specimen by

Mr. H. W. Pomfret :-Naked-eye appearalwes,-Upon cutting into the swelling

on the inner side of the knee-joint a dark grumous fluid

gushed out from the midst of a venous-coloured, very soft, andfriable tissue. This tissue presented a granular structure

approaching that of a fi5h’s roe and was apparently confinedwithin a thin membranous wall. This swelling was in factcircumscribed and formed a large cyst. Intervening betweenthis cyst and the articular line was a cluster of white, pulta-ceous, but individually distinct bodies bearing the exactappearance of boiled haricot beans. Attached to thetendons of the inner hamstrings and extending up theham at distances of about an inch apart were foundthree venous-coloured cysts about the size of walnuts.These cysts were definitely encapsuled and connectedwith the tendons like ganglia, The capsule of each ofthese smaller cysts was lined with the same friable tissue asthat found in the larger cyst at the inner side of the knee,the central contents being also similar grumous fluid.The articular cartilages were for the most part perfectlynormal, but at points round the head of the tibia the edgeof the cartilage was slightly ercded by the altered synovialtissue. This same condition prevailed round the margins ofthe posterior ends of the femoral condyles, whilst at one

point on the internal condyle was a larger erosion, caused bytissue spreading from the inter-condyloid fossa. This largererosion presented much the appearance of tuberculous ulcera-tion ; the synovial membrane, however, presented littleresemblance to tuberculous disease. The thickening of themembrane was, in most parts, not more than in simplechronic synovitis. Its surface glistened, was of a brightclaret red, and appeared flocculent. Round the margins ofthe articular cartilages, especially posteriorly about thecrucial ligaments, the membrane became much thicker,studded with small, round, bright red elevations, and mergedin the inter-condyloid notch into a soft tissue resembling thatof the cysts. Lower down, behind the crucial ligaments andlargely replacing the ligamentum posticum, was another col-lection of the white bean-like bodies. The patellar cartilage,the superior tibio-fibular articulation, and the bones were allperfectly normal.

Miorosoopioal appearances.-The friable roe-like tissue ofthe cysts and the tissue from the inter-condyloid notch hadthe microscopical appearances of spindle-celled sarcoma

undergoing mucoid degeneration--that is to say, looselyarranged spindle cells with here and there branched cellsand clear spaces between them. Closely packed spindlecells without degeneration were the only elements to befound composing the structure of the white bean-like bodies.Remarks by Mr. SAL’rER.-The foregoing is a fairly com-

plete history of the case, which is undoubtedly one of primarysarcoma of the synovial membrane, the rarity of which con-dition is such that I have been able to find no record of anyprevious case in the English journals, and Mr. Hardie informsme that he has only once previously met with a case of thekind. This occurred in a middle-aged woman in private prac-tice. Amputation through the thigh was performed, and thepatient succumbed to the effects of secondary growths in thebones of the face and skull about eighteen months afterwards.

FOREIGN UNIVERSITY INTELLIGENCE.-St. Petersburg (Mtlitary Medíoal Academy) A new Professorship ofInfectious Diseases and Bacteriology is about to be estab-lished, and in connexion with it a special clinic for infectiousdiseases, with about fifty beds, is to be built.-Berlin : Dr.Langaard, for many years Professor Liebreich’s assistant,and one of the editors of the 2’Jrerapeutische Monatskefte, hasbeen raised to the rank of Professor.-Leipsic: ProfessorSoltmann of Breslau has been appointed to the ExtraordinaryProfessorship of Children’s Diseases vacated by the migrationof Professor Heubner to Berlin.

Reviews and Notices of Books.1’7te P7t!lsiolog?l f!/ the Carbohydrates, their Applieation as:

1’ood and Relation to Diabetes. By 1’. W. PAVY, M.D.London : J. & A. Churchill. 1894. Pp. 280.No more able exponent of the physiology of the carbo-

hydrates than Dr. Pavy could be found. A large part of his,life has been spent in studying their properties, in examiningtheir composition, and in endeavouring to trace their historyin the animal body from the moment of their ingestion in the-solid state to that of their elimination in the form of waterand carbonic acid gas ; whilst in his practice he has been,largely occupied in the endeavour to divine the causes and toprevent the consequences of that excessive discharge from thebody in diabetes and allied affections. It is therefore withmuch interest that we have read the results of his mature

judgment in the pages of this work. That starch, one of the-most typical examples of the carbohydrates, is formed by thechlorophyll of plants, under the influence of the sun’s rays,from the carbonic acid gas and water of the atmosphere is.

undoubted, but the exact steps of the process by whichCO2 and H2O yield this substance has not been clearly demon-strated, and Dr. Pavy points out that two hypotheses maybe advanced: in one, the formic aldehyde hypothesis,formic aldehyde, CH2O, may first be produced, and then,by polymerisation (or the union of several molecules toform one larger molecule), six such molecules may uniteto form a carbohydrate of the composition CüH1206; or

"instead of the carbohydrate being directly or by inter-mediate steps synthesised from its elements, it may happenthat these become appropriated by the living protaplasm and’worked up into the proteid matter of which protoplasm isconstituted, and from which the carbohydrate by a furtheraction is afterwards split off." A considerable section ofDr. Pavy’s work is devoted to argument in support of thishypothesis.The general formula for the carbohydrate group is repre-

sented as [C6(HO)n]n’. They are therefore six carbon-

atom compounds. A fermentable sugar named a-acrose,.

resembling dextrose and having the same composition(CÙH120()), but optically inactive, has been syntheticallyformed by Emil Fischer, and has become the starting-pointof the synthesis of several fermentable sugars of the glucosegroup, and other sugars have been formed possessing seven,eight, and nine carbon atoms in the molecule.

Dr. Pavy divides the carbohydrates which fall under hisconsideration into the amyloses with the formula (06H1005) n,including cellulose, starch, glycogen, and dextrin ; the

saccharoses, C12H22Ol1’ including maltose, lactose, and canesugar; and the glucoses, CüH1206’ including dextrose, loavulose,and galactose, and each of these he describes in detail. Thebehaviour of sugars with phenyl-hydrazine is briefly given,and it is shown that combinations of this substance with the

sugars exist, the product being formed in two stages, onemolecule of the sugar becoming united in the first instancewith one molecule of phenyl-hydrazine giving rise to hydra-zone, which then takes up oxygen and combines with anothermolecule of phenyl-hydrazine to produce osazone, and thedifferent osazones can be recognised by well-marked chemicaland physical characteristics. A long chapter is devoted to,the "glucoside constitution of proteid matter, " in which theauthor inserts some part of the paper he read last year beforethe Royal Society. Dr. Pavy next proceeds to consider thedestiny of starch after its ingestion into the alimentary tract.The action of ptyalin is shown to be that of converting starchinto maltose by augmenting its hydration, and correspond-ingly increasing its reducing power on cupric oxide. In the

stomach, as is well known, starch undergoes little change,though the action of the saliva may be continued in it. The