Part 14

Every fluid differing from the blood, can be separated from it to be afterwards transmitted to an organ, but in one of the three following ways; 1st, by secretion, a function characterized by the existence of a gland intermediate to the blood vessels that bring the materials to it, and the excretories which carry off the result; 2d, by exhalation, a function distinguished from the first, by the absence of this intermediate gland, and by the immediate continuity of the blood vessel and the exhaling duct; 3d, by transudation, a phenomenon purely physical, almost always happening after death, rarely observed during life, a simple transmission of a fluid by the pores of an organ, towards which it is mechanically determined. Let us examine which of these three modes is that chosen by nature to deposit the synovia upon the articular surfaces.

_Is the synovia transmitted by secretion to the articular surfaces?_

We are indebted to Clopton Havers for the system which places in the glands the sources of the synovia. Many authors had designated obscurely before him these organs in the articulations; but he made them the particular object of his researches, described them in the different articulations, divided them into two classes, the one principal, the other accessory, and assigned them characters so evident, that according to him, they could not be forgotten. Reddish bunches, spongy, formed by membranes folded upon themselves, situated sometimes without, and sometimes within the articulations, always arranged so as to be protected from too strong a compression, and pouring out through ducts in the form of fringe the fluid they secrete; such are the characters drawn by Havers, which all anatomists since him admire, and the correctness of which the most modern and distinguished authors have acknowledged in their works.

Some anatomists of this age have however thrown doubts upon these glandular bodies. Lieutaud confounds them with the fatty cellular texture. Desault did not distinguish them from it. Every thing confirms me in the same opinion, which many considerations appear to establish in an undoubted manner. The following are these considerations; 1st, these reddish bunches are met with only in certain articulations. There are many of them in which their existence cannot be established but by supposition. 2d. The greatest number of the synovial membranes of the tendons certainly do not exhibit any of them, though Havers, Albinus, Juncke and Fourcroy admit them in all, founded no doubt upon analogy and not upon inspection. Yet the synovia is separated equally in both cases, and lubricates the surfaces of the articulations and of the tendinous sheaths; this separation is then independent of glandular action. 3d. If the best marked synovial glands are examined, such as that of the cotyloid cavity, no trace can be discovered there of this parenchyma of an unknown nature, but remarkable for its structure, which composes in general the glands, and which distinguishes them from every other part and forms their true organic character. 4th. No excretory duct can be demonstrated in these organs. Those in the form of fringes, admitted by Havers, are imaginary. Bertin himself has acknowledged this truth, though he attributed to these bodies a glandular structure. The transudation of the fluids injected by the arteries in the neighbourhood of the articulation, proves the existence of these ducts no better than it establishes them in the cavities of the serous membranes in which it also takes place, and yet in which it is well proved that no gland pours out the albuminous fluid that constantly lubricates these cavities. 5th. Inflation resolves completely these fatty bunches into cellular texture. Maceration produces the same effect. When gradual and long continued ebullition has removed all the fat from them, there remains only a mass of cells pressed together, and similar to those of the common cellular texture. 6th. The glandular character is manifested in certain morbid cases, by a peculiar swelling and hardening, of which the other organs except the glands, such as the muscles, the tendons, &c. never offer an example. The liver, the kidneys, the salivary organs, all the considerable glands are remarkable for this. So true is this character, that it serves to indicate glands, the delicacy of which conceals them in the natural state. For example, the existence of the cryptæ of the stomach, the urethra, and several other mucous membranes, is founded first upon the analogy of the other membranes of this class, but principally upon the preternatural development which these cryptæ acquire in certain diseases. Never, on the contrary, do the pretended synovial glands present to the observer a similar development. Always in the diseases of the articulations, a common swelling seems to identify them with the neighbouring cellular texture. They have not like the other glands, affections distinct from those of this texture, no doubt because they have not a peculiar vitality, because being mere elongations of the neighbouring cellular texture, they partake of its nature and properties, and ought consequently to partake of all its conditions, as it in its turn ought immediately to receive the influence of their affections.

The considerations which I have just offered successively form, I think, sufficient data to resolve the problem proposed above, by establishing as an incontestable proposition, that the synovia is not transmitted by secretion to the articular surfaces.

Let us examine the second mode of transmission stated by authors.

_Is the synovia transmitted by transudation to the articular surfaces?_

It was an opinion anciently received, that the marrow of the long bones oozes through the pores of their extremities and through those of the cartilages which terminate them, to lubricate the articular surfaces. Havers renewed this idea forgotten at the time he wrote, united this source of the synovia to that which had placed it in the glands, and thus formed of this fluid a mixture composed of two fluids differently transmitted to the articulation. The most of those who succeeded him partook of his opinion upon this point. Those even, such as Desault, who rejected the existence of the articular glands and the secretion of synovia, admitted the transudation of it founded upon the following observations. 1st. A long bone, stripped of its soft parts and exposed to the air, allows a fatty oozing to pass through the pores of its cartilages which does not cease till the medullary juice is completely exhausted. 2d. The mechanical compression of the cartilaginous extremity of a long bone produces for a moment the same effect. Are these facts, which are evident in the dead bone, also real in the living one? Different considerations, which I will now state, induce one to believe the contrary.

1st. The vital forces, the effect of which is to impart to all the organs which they animate a degree of tone sufficient to resist the entrance of the fluids, leave, when they are extinct, the fibres of these same organs in a state of laxity that renders them everywhere permeable. Thus transudation is now considered as hardly any thing else than a phenomenon that takes place only after death, which, if transformed into a vital one, would offer an evident exception to the laws of nature that are especially characterized by simplicity and uniformity. 2d. The fatty oozing takes place in the experiment noticed above, not only through the pores of the cartilages, but also through those of the whole surface of the bone; so that by reasoning from what has been here observed upon the dead body, it is evident that during life the whole bone would be, if you may so say, immersed in an atmosphere of synovia, a consequence, which being proved false by the most simple inspection, demonstrates the falsity of the principle deduced from it. 3d. The articulations of the cartilages of the larynx are lubricated like those of the bones, by the synovial fluid; and yet here all transudation of marrow is impossible, as it does not exist in the substances of the cartilages. 4th. The marrow is almost always sound in diseases which, affecting the articulations alter the fluid that lubricates them. And reciprocally the synovia does not take a different character in the affections of the interior of the bones, which have an influence especially upon the medullary organ. 5th. Finally, the experiment that I have made, and which has been stated in the article upon the marrow, evidently proves the non-transudation of this fluid.

Desault, in order to explain the manner in which the synovia is separated from the blood, added to this pretended transudation of the marrow, an oozing furnished by all the parts contained in the articulation, such as the capsular and inter-articular ligaments, the internal fat, the cartilages, &c. A comparison will suffice to show the value of this hypothesis. What should we say of a system in which to explain the production of the serous fluid of the abdomen, the source of it should be placed in the liver, the spleen, the intestines, and in general in all the organs of this cavity? No doubt we should answer, that a fluid of the same nature, could not be furnished by parts of such different structure, that it is much more simple to search for a single source in the single membrane that covers all the gastric viscera. The application is exact and the analogy perfect between it and the articular cavity.

We can, I believe, without fear of error, conclude from all that has been said above, that the synovia is not transmitted by transudation to the articular surfaces.

I will now examine the last mode pointed out for the separation of the synovia.

_Is the synovia transmitted by exhalation to the articular surfaces?_

The solution of the two preceding problems seem naturally to lead to that of the question which we here propose. The certainty of the two following data may, I think, be relied on; 1st. Secretion, exhalation and transudation are the only means by which a fluid different from the blood can be transmitted to an organ. 2d. Secretion and transudation are foreign to the transmission of the synovia. Now from these two certain data, can we not draw this conclusion as certain, that exhalation is the mode by which the synovia is carried to the articulations? But let us add to these negative proofs some considerations which establish this proposition positively.

The most striking relations are observed between the synovia and the fluid that lubricates the parietes of the serous membranes. 1st. The relation of composition. These two fluids are essentially albuminous. Albumen predominates in both, though a little different in each, as Marguerron has demonstrated. Havers had previously pointed out this analogy; he knew that these two fluids are coagulable by alkohol, the acids, and caloric, without knowing the principle to which this property is owing. 2d. The relation of functions. Both are destined to lubricate surfaces on which much motion takes place, to diminish the friction which is the inevitable consequence of it and to prevent fatal adhesions. Both are in the same state on their respective surfaces; it is merely a dew spread upon these surfaces, and soon taken up from them. 3d. The relation of affections. Inflammation dries up the source of both, and produces adhesions, more common in the serous membranes and more rare in the articulations in which they produce anchylosis. Both are subject to preternatural enlargement, which is designated by a common word, viz. dropsy. 4th. The relation of absorption. The lymphatic system is for both the way by which they re-enter the circulation, after having remained sufficiently long upon their respective surfaces.

Do not these various resemblances, which with some slight differences of composition only, so evidently connect the synovia with the fluid of the serous membranes, lead us to this very simple consequence, viz. that these two fluids being analogous in all other respects must be so also as to the manner in which they are separated from the mass of blood? Now it is a point in physiology at the present day generally acknowledged, that the fluid of the serous membranes is brought to them by exhalation; then we are evidently lead by induction to this which answers the question proposed above; The synovia is transmitted by exhalation to the articular surfaces.

This rigorous and accurate conclusion drawn from obvious and uniform facts will become, I think, a demonstrated truth, when to the analogies already established we shall add that of the membranous organ, the essential seat of the exhalation of the synovia.

II. _Remarks upon the Synovia._

Thus separated from the mass of blood, the synovia has the appearance of a white, viscid and transparent fluid. It ropes, like some syrups, when it flows from the articulations. This unctuous property renders it peculiarly fit to lubricate the articular surfaces which rub together, and to protect them from violent shocks.

Its quantity varies; there are articulations which contain much of it; that of the ankle has always appeared to me to have the most of it. Then come the ilio-femoral, the scapulo-humeral, the humero-cubital, &c. There are others in which there is scarcely any; such are the sterno-clavicular, the sterno-costals, the costo-vertebrals, &c. It is not the smallness of the synovial surfaces that occasions in these articulations the constant dryness that is observed in them; for the synovial sacs of the larynx, which are much smaller, are much more moist.

Besides, the synovia does not vary in quantity in each articulation, like the serum in the serous membranes. Those who have opened peritoneums, pleuras, pericardiums, &c. must have seen that hardly two are similar; sometimes there is only a mere dew, at others there is a real collection of fluid. Here on the contrary there is always nearly the same quantity; which is owing to this, that the synovial surface does not feel as easily as the serous surfaces, the sympathetic influences of the other organs when diseased.

The synovia is not subject to the different alterations which the serous fluids exhibit. I have never seen upon the articular surfaces what are called false membranes from inflammation. The preternatural collections of synovia never contain those white flakes, so common in the serous collections. I do not know of an example of milky serum effused in an articulation. One of the most frequent alterations of the synovia is that, I think, in which it takes the consistence of a jelly and is of a reddish colour, analogous, if I may be allowed the comparison, to currant jelly. Now this alteration is wholly foreign to the serous fluids.

These essential differences which the synovia and the serum exhibit in their alterations, evidently suppose a diversity of nature in the principles which compose them in the natural state. The viscidity of one and the greater fluidity of the other, also declare it, as Fourcroy has observed. This diversity of nature appears to depend especially upon a peculiar substance which enters into the composition of the synovia, which few animal fluids possess, which Marguerron who has observed it designates by the name of albumen of a peculiar nature, and which should be the object of new researches.

I shall not give here the details of the analysis of the synovia; they belong to animal chemistry.

III. _Of the Synovial Membranes._

We have seen all the great cavities lined by the serous membranes, which form by their folds species of sacs without an opening, and which embrace both the organs and the parietes of these cavities. There exists in all the moveable articulations membranes precisely analogous, the uses of which are the same, the nature of which is not different and which I call synovial, because their parietes constantly exhale and absorb synovia.

_Forms._

Every synovial membrane then, should be considered as a sac without an opening, spread upon the organs of articulation, upon the diarthrodial cartilages, upon the internal face of the lateral and capsular ligaments, upon the whole of the inter-articular ligaments when they exist, upon the prominent fatty bunches in some articular cavities, &c. It is from it that these different organs borrow the smooth, polished and shining appearance which characterizes them in these cavities, and which they have not elsewhere. Just as by dissecting carefully the gastric organs, the peritoneum can be removed, its sac remaining whole, so we can conceive of the possibility of separating this membrane, notwithstanding the intimate adhesions it forms in some places. All the parts that it embraces are out of the articular cavity, though projecting into this cavity, as the lungs are found on the exterior of the sac formed by the pleura, the liver on the exterior of the peritoneal sac, &c. &c.

The synovial membrane is found in all the moveable articulations, the greatest number of which has only it and the lateral ligaments. What is commonly called the fibrous capsule is only met with around some of the articular surfaces. The connexions of the humerus, the femur, and one or two other bones, the extremities of which are joined by enarthrosis, present the only examples of it. There are seen in these articulations two very distinct coverings. One which is fibrous is external, and is found arranged in the form of a sac open above and below, embracing by its two great openings the surfaces of the two bones, and being intermixed around them with the periosteum, the fibres of both interlace with each other. The other cellular, which is the synovial membrane, lines the first on the interior, separates afterwards from it when it arrives towards the two diarthrodial cartilages, and is reflected upon them, instead of being united to the periosteum. Boyer has pointed out this arrangement in regard to the femur.

In all the ginglymoid articulations, as in those of the elbow, the knee, the phalanges, the hand, the foot, &c. &c. the fibrous capsule is wholly wanting. The fibres, instead of extending and interlacing in the form of a membrane, are collected into fasciculi more or less thick, which form the lateral ligaments. There is only found in them the internal layer of the enarthrodial articulations, that is to say the synovial membrane, which does not contract here any adhesion with the periosteum, but is reflected upon the cartilages. By taking it at the place of this reflection, it can be detached far enough to prove that it has an external organization wholly different from that which the idea of a capsular ligament at first presents to the mind. This arrangement is very easily perceived by the least dissection, at the knee behind the tendon of the cruræus and the inferior ligament of the patella, at the elbow under the tendon of the triceps, at the phalanges under that of the extensor, &c. All the arthrodial articulations have also an analogous organization, as will be seen in the Descriptive Anatomy; so that it is ascertained that the fibrous capsules exist but in a very small number of articulations, that almost all have only synovial sacs which are spread out and reflected upon the osseous surfaces, without being attached around them, as all authors have said.

I have proved this remarkable difference of the articulations by many dissections. Some anatomists were in the way to discover it, when they observed that the different capsules appeared to be wholly formed of cellular texture. It is in fact the texture of the synovial membrane, which differs essentially in this from the fibrous capsules. The mode of capsule for all articulations may be preserved, if it is wished, but different ideas must then necessarily be attributed to it. Compare, for example, the fibrous capsule of the femur with the synovial capsule of the knee; you will find on the one hand, 1st, a cylindrical sac with two great openings for the osseous extremities, and with many small ones for the vessels; 2d, a fibrous interlacing, similar to that of the tendons, the aponeuroses, &c.; 3d, a mode of sensibility analogous to that of these organs; 4th, the use of retaining strongly in place the articulated bones, which have only this bond to strengthen their union. On the other hand you will observe, 1st, a sac without an opening; 2d, a cellular structure, the same as that of the serous membranes; 3d, a sensibility of the same nature as theirs; 4th, the simple function of containing the synovia and separating it, the bones being tied by strong ligaments. Besides, the different reagents have upon the fibrous capsules an influence wholly different from that which they exert upon the synovial. Ebullition yellows them, renders them semi-transparent, softens them like tendons and gradually melts them like gelatine. The synovial ones boiled remain whitish, and furnish but little of this substance. I would observe that the yellowish tinge and semi-transparency of the boiled fibrous capsules are a certain means of distinguishing the articulations in which they exist and those which are destitute of them.

The existence of the synovial capsule in the greatest number of articulations in which it is found alone, is placed beyond a doubt by the slightest inspection. In those in which it is united to a fibrous capsule, it is very clearly distinguished in several places. Thus in the thigh, it is found upon the interarticular ligament, upon the fatty bunch in the cotyloid cavity, and upon the neck of the bone at the places where it leaves the fibrous capsule, to be reflected upon the cartilages, &c.; but its adhesion to these cartilages and to the internal face of the capsule, may excite some doubts as to its arrangement in the form of a sac everywhere closed, which we have attributed to it; it is then essential to offer some considerations that may dissipate these doubts.