after a diagnosis has been made, and no operation is more essential to life, but a delay of two to four days is usually made in order to get the patient into the best physical shape possible. He should be thoroughly nourished with casily digestible food, stimulated freely, and the site of the operation most thoroughly disinfected. Recurrent malignant growths should be removed within a few days after discovery. In so far as it is possible to do so, the profession should allay the popular idea that operation in malignant disease is a last resort. It should be the first resort, and people should be taught that all malignant growths or tumors that are removed within a month after their first discovery get well and stay well, and that the chances for relief grow less with each day's delay after that time.

Among elective operations may be classed radical cures for hernia, most rectal operations, tubercular disease amenable to surgical treatment, bone, orthopedic and plastic surgery, the removal of benign tumors, and exploratory laparotomies and most gynecological operations. In this class of operations the surgeon is justified in postponing the operation until he can bring his patient into the best possible physical condition.

It is of especial importance that the surgeon be candid and honest prior to deciding upon an operation. He should tell his patient as exactly as possible what is to be done, and to what discomfort or disturbances he will be subject as a result of the disease or injury as modified by the operation. This is especially important in the treatment of fractures and in all other cases in which litigation might ensue.-American Prac. and News.

SOME INTERNAL INJURIES OF THE KNEEJOINT.

BY M. L. HARRIS, M. D., CHICAGO, ILL.

The knee-joint is the largest joint in the body. It contains the largest amount of articular surface and synovial membrane, and as it is subcutaneous and lies in an unprotected location, it is particularly liable to injury.

It is the intention of the author in this article to briefly call attention only to two varieties of injuries to the inner structures of this joint, which, the author believes, are more common than the attention heretofore given them would seem to indicate. Recalling the anatomy of this joint, it will be remembered that the convex surfaces of the condyles of the femur rest upon the slightly concave surface of the upper end of the tibia, while anteriorly the patella articulates with the intercondylar articular surface of the femur. As the convexity of the articular surfaces of the condyles of the femur is greater than the concavity of the articular surface of the tibia, a somewhat triangular space remains surrounding the point of contact of these two bones, which is partially filled or obliterated by the intra-articular semilunar fibro cartilages. There remains anteriorly, however, between the lower end of the patella and the patella ligament in front and the femur and tibia respectively above and below, a somewhat triangular space of considerable size, which normally is occupied by a mass of fat and connective tissue, lined on its inner or articular aspect with synovial membrane. It is the function of the mass of fat with its synovial lin

ing to mold itself constantly during motion of the joint to the varying outline of the space which it fills. Atmospheric pressure keeps the apex of the mass constantly crowded into the receding angle between the femur and tibia. The apex of this mass, made up of a fold of synovial membrane, is what is known as the ligamentum mucosum. It is injury to this triangular mass of fat and the ligamentum mucosum to which attention is first directed. An injury here may be produced in one of two ways: First, by the direct application of force, as may occur in a fall upon the knee, or by the forcible impingement of a more or less pointed object against this portion of the joint; and, second, by pinching or crushing the apex of the mass in the angle between the femur and tibia, as may occur when these bones are slightly separated during hyperflexion or sudden wrenching. In this case the apex or synovial fold of the mass is forced by atmospheric pressure into the slight gap between the bones, where it is suddenly nipped or pinched. A small hemorrhage may take place in the fold, which may become organized, thus forming a mass of new connective tissue, which will persist indefinitely as an irregularity on the edge of the fold. This new-formed mass or irregularity is subject to unequal pressure during motion of the joint, and as it is well supplied with nerves it is sensitive and pressure upon it produces pain.

The clinical history of a case of this kind may be described as follows: Upon the receipt of an injury, as for instance, a fall upon the flexed leg, thus producing hyperflexion, the patient experiences an acute pain in the kneejoint and the joint becomes swollen. After treatment with fixation, rest, etc., for the usual length of time, it is found on attempting to get around again that the knee remains more or less painful and tender. Pain is particularly apparent on standing or going up and down. stairs. Occasionally during certain motions of the joint acute pain of considerable severity will be experienced, which the patient will often locate just below or to one or the other side of the patella. Pressure carefully applied to this region by the tip of the finger may detect a spot which is very sensitive, and pain may be produced thereby which the patient will state is similar to the acute pain experienced at times during motion of the joint. If the joint be fixed and no weight placed upon it, the pain disappears, only to return again, however, when an attempt is made to use the joint. As illustrating this variety of injury the following case may be mentioned:

Miss E., aged 33 years. About two and a half years ago she was thrown from her bicycle. She fell with her left knee flexed under her. Upon attempting to extend the leg the pain produced was so acute that she fainted. The knee was treated by rest and ice bags for twentyeight days, when she was able to walk about and use it some, although it was still painful. As the pain seemed to increase rather than to diminish, the joint was fixed in a plaster-of-Paris cast. This treatment was continued for about five months, the cast being renewed from time to time. No material improvement apparently followed this immobilization, for although there would be no pain while in the cast, when this was removed and an attempt was made to use the leg, or to bear weight on it, the old pain would return. Massage, local applications, liniments, etc.,

were now diligently tried, but at the end of two and a half years her knee was in much the same condition as in the beginning. At this time she came under my care. She described the pain as a more or less continued soreness, with an occasional sharp, severe pain during certain motions. She would locate the pain as extending across the joint just below the patella. There was no swelling present. On palpating carefully a small spot was found just to the outer side of the ligamentum patellæ and opposite the line of articulation between the femur and the tibia, which was quite sensitive, and pressure upon this spot produced the same kind of acute pain which she complained of. Suspecting a localized injury of some kind to the inner structures of the joint at this point, an operation was advised and the joint opened by a slightly curved external incision, January 18, 1901. On the free edge of the ligamentum mucosum, a little to the outer side of the center, was found a whitish fibro-connective tissue mass about 1 cm. in width and projecting about 5 mm. beyond the free border of the ligament. It was 2 to 4 mm. in thickness, and its surface showed evidences of compression. Its free edge was irregular and ragged looking. The mass was removed with the scissors and the synovial membrane stitched with fine catgut. The joint was closed and immobilized. Primary union. The recovery was perfect and all the former pain disappeared. The presence of this little mass may be explained by supposing the ligamentum mucosum to have become nipped or crushed at this point between the tibia and femur during hyperflexion of the joint, which undoubtedly took place when the patient fell. A small hemorrhage occurred in the tissue with organization of the clot. The hyperplasia of connective tissue formed the little mass which was constantly pressed upon during motions of the joint.

The second variety of injury to the knee-joint to which attention will be directed is the forcible detachment of a piece of articular cartilage from the articular surface of one of the condyles of the femur. It will be seen that the articular surfaces of the condyles become more and more exposed on either side of the patella and its ligament a the joint is flexed. In the flexed state of the joint this articular surface may therefore be injured by the direct application of force, as may occur in a fall upon the knee, or by a hard body striking against this region. The application of force in that manner may cause the detachment of a small piece of the articular cartilage, which may remain completely severed from its base, or if near the edge of the articular surface may remain attached by a small pedicle of synovial membrane and connective tissue. Koenig is of the opinion that a pathologic condition of the articular surface, which he terms osteochondritis desiccans, precedes the detachment of the piece of cartilage in these cases. It has been abundantly demonstrated, however, that traumatic detachment of the articular cartilage may take place in perfectly normal points. The clinical history of these cases is that of a loose body in the joint, or so-called "gelenkmaus." After the immediate effects of the injury have passed away, the patient may experience no pain or trouble in the joint for some time, even weeks or months, when while walking or making some movement of the joint a sudden acute pain is experienced in the knee, the joint is rigidly fixed by mus

cular spasm, and cannot be moved without the most excruciating pain. After a moment's rest, or some slight manipulation of the joint, the spasm relaxes, the pain disappears and the joint becomes freely movable again. Some swelling and soreness may be present for a few days, when the parts return to their normal condition, and no further trouble is experienced until the next attack, which may occur at any time from a few days to several weeks or months. In other cases general symptoms, such as soreness with a small amount of effusion, persist in the joint during the interval between the acute attacks. The following case, which illustrates this variety of injury, is of particular interest, owing to the great length of time32 years-during which the symptoms persisted:

Mrs. B., aged 44. When 12 years of age, or 32 years ago, the patient fell, striking on her left knee. The knee became swollen and painful, but under rest and local applications these symptoms disappeared. Ever since that time, however, the knee has been sensitive and subject. to periodic attacks of acute pain and tenderness, accompanied with redness, heat and swelling. During these attacks she would be compelled to remain in bed and rest the knee. After the subsidence of the acute symptoms the knee would apparently be all right for some time, when suddenly during some peculiar motion or twist of the knee she would have an acute pain with fixation of the joint, followed by swelling, etc., which would lay her up for a few days again. Such attacks have recurred at intervals of a few weeks for thirty-two years. last attack, about five weeks ago, was more severe and persistent than the others, and she was compelled to keep to the bed a longer time than usual. When she got up walking remained painful. Becoming thoroughly discouraged with her condition she was sent to me October 6, 1901, ready to submit to any operation, even to the loss of the knee-joint, in order to be rid of her trouble. On examination a small mass could be detected by palpation of the outer condyle of the femur at the edge of the articular surface. articular surface. The mass was sensitive and tender,

The

somewhat movable, but could not be made to disappear. It was thought to be a detached portion of cartilage, and an operation was advised. The joint was opened by an external incision October 9, 1901. The mass was found to be a piece of the articular cartilage, which had been detached from the articular surface of the external condyle of the femur. It was about 2 cm. in length by I cm. in width, and remained attached by one end to the bone just beyond the articular surface by a small pedicle of synovial membrane and connective tissue. The defect in the articular cartilage corresponded in size and shape to the detached piece of cartilage. During the thirty-two years there had not been the slightest attempt to repair the defect in the cartilage, and the bone exposed looked as fresh as though the accident had occurred but recently. The piece of cartilage was removed and the joint closed. Primary union.

These cases illustrate the serious and persistent disablement that may occasionally result from comparatively slight pathologic changes affecting the inner structures of the knee-joint, and show the necessity of operative treatment in those cases following an injury, in which the characteristic symptoms above described persist after

the usual treatment of the joint by rest and immobiliza

tion.

DISCUSSION.

Dr. A. C. Bernays of St. Louis, Mo.: The author of this paper has directed our attention to a part of surgery which has been treated in the past in a somewhat stepmotherly manner. Our text-books do not say anything about injuries to the ligamentum mucosum and very little about loose cartilages, which are the result of cracking or breaking loose of small parts of the articular ends of the bones. The pathology and explanation which the doctor gave of injury to the ligamentum mucosum in the case which he reported are new to me. I do not believe that I have met with a similar condition in the literature, and therefore we ought to be congratulated upon having this subject brought before us for the first time. Of course, not having seen a case of this kind I am unable to say much about it. But I am reminded that in my own practice I have seen a number of obscure troubles of the knee-joint, in which I believe now, looking back over what I can remember of some of them, that the injury was probably such a one as the doctor demonstrated by cutting open the knee-joint. I know that some of these obscure, painful lesions are liable to be thrown into the great waste-basket which we all make use of occasionally, which we call neuropathic troubles, which no one can define, and which I believe largely originate in the minds of physicians. Every time, when one of those things is thrown into the waste-basket and is rescued by one of our number and brought to light and explained in a rational way, it signifies progress in our science and

art.

Dr. A. E. Halstead, of Chicago, Ill. In connection with the excellent paper of Dr. Harris, I wish to say that a frequent cause of pedunculated bodies in the knee-joint is injury to the ligamentum mucosum. It is a wellknown fact that the synovial capsule of the joint contains and has carried throughout its inner surface cartilage cells, and, as the result of injury or chronic inflammation, cartilage cells may develop and form a circumscribed cartilaginous growth in the capsule. At the time the growths become drawn into the knee-joint, they assume the form of pedunculated bodies. Ultimately they may become loosened. The same thing holds true with reference to hemorrhages into the capsule of the joint, and the proliferation of connective tissue above these hemorrhages. I disagree with Dr. Bernays that Dr. Harris has given us a new pathology. I do not think Dr. Harris himself claims it is new. This was mentioned years ago in the treatment of movable bodies in the kneejoint.

Another frequent cause of floating bodies in the kneejoint is the development of cartilage in the joint villi, a fringe being found on the ligamentum mucosum. The mechanism by which the cartilage becomes displaced is rather peculiar. It is not due to hyperflexion or hyperextension, as was formerly supposed, but to rotation of the tibia when the joint was in position halfway between extension and flexion.

Another point that it might be well to mention is that these dislocations occur sometimes after chronic inflammation has been in progress; that is, the inflammatory

condition is primary, the inflammation causes a relaxation of the ligaments of the joint and permits hyperrotation, which terminates in dislocation of the cartilage.

I disagree with Dr. Harris as to the frequency of movable cartilages in the joints being due to trauma, or the immediate effect of trauma. Very few such cases are on record. A few cases have been published where the joint has been opened immediately or a skiagraph has been taken and a portion of the cartilage has been found to be fractured. The explanation of Koenig is probably the correct one to apply in most cases, namely, that the separation of the cartilage takes place some time after the injury, and this may be several months or years. The fact that we find a defect in the articular surface of the bone corresponding to the size and shape of the loose cartilage does not argue that it has been broken off. Such cartilage may develop without injury from detached cartilage cells of the capsule of the joint, or from detached villi and pressure atrophy causes a depression in the articular surface of the bone which closely corresponds to the size and shape of the cartilage.

Dr. John B. Murphy of Chicago: I am very much pleased with the paper of Dr. Harris. He brought out an important point in this matter, and I desire to cite a case in connection with this subject. I operated on a patient some ten days ago, and some of the gentlemen present saw me do the operation. The diagnosis was made with the assistance of the X-ray, a picture of the cartilage having been made at this point (indicating). But there was no cartilage there, there was merely an elongation of the ligamentum mucosum which had flattened out. There was a ligament three-eighths of an inch in length that passed down through the joint and out to the opposite side. It looked like a free crucial ligament, but not the entire length of its attachment. In looking for the cartilage, after making the incision, the attachment to the ligament from that point to this (indicating) was perfectly free throughout its entire extent. The boy had a history of repeated paroxysms in walking. After each attack he would have inflammation of the ends of the joint, effusion and swelling, which would last two or three weeks, until finally he became practically incapacitated. Locomotion was greatly impaired as the result of impingement of this dense fibrous mass between the bone. This is the only case of this kind I ever saw.

Dr. Grant: Was there a posterior attachment? Dr. Murphy: Yes. Whether this was a congenital or an acquired condition, I do not know.

Dr. A. C. Bernays: I was evidently misunderstood by the first speaker (Dr. Halstead). I did not mean to convey the idea that Dr. Harris had given us a new pathology of foreign bodies in the knee-joint, and what Dr. Murphy has described is not a foreign body in the kneejoint. I do not think he meant to say it is a foreign body. The origin of these things is not the same, pathologically speaking, as the origin of free cartilages. Furthermore, I want to say that Dr. Hall, of Kansas City, saw me operate on a case in which a piece of the femur had cracked off, entirely separated from its bed, which, when I opened the knee-joint, fell out of place. It seems to me that the only rational explanation for a foreign body which lies in a bed, accurately fitting each elevation and de

pression on its surface, cannot be of any other origin than traumatic. Therefore I consider traumatism to be one of the common causes for free bodies in the kneejoint.

Dr. Halstead: I would like to ask Dr. Bernays how long he operated after the injury.

Dr. Bernays: There was no history of a definite injury. The patient had numerous slight injuries, according to his story, and he had had more or less trouble with the joint for ten years. Still I cannot doubt for a moment that this piece of the femur was lifted out from its bed easily, without any trouble. It fell out, and left, after its removal, a deep cavity of the size and shape I show you here (illustrating). Its surface was shaped like this (indicating), perfectly smooth, and had cartilage on it, while the posterior surface was cancellated bone. But the outer lower surface, this irregular line which I show you here, was somewhat cartilaginous. In the interior there was cancellated bone, showing that there must have been broken off a piece of the femur. As I have previously remarked, I believe trauma is the most common origin of foreign bodies in the knee-joint. Cartilage cells in synovia are rarely a cause of foreign bodies in the knee-joint. Of course, we are discussing a subject which neither one of us can prove. You cannot prove that they originate from sells in the synovia, nor can I prove that they originate from traumatism.

Dr. Halstead: The case mentioned by Dr. Bernays illustrates what one author has described as osteochondritis desiccans. There is no doubt at all the piece of femur was broken off, or it came off as the result of fatty necrosis. It is primarily the result of trauma interfering with the nutrition of the bone, and this sequestrum is thrown off in the course of time. While we cannot say positively that this is the case, it appears to me to be a more rational explanation than direct traumatism.

Dr. Lewis Schooler of Des Moines, It.: The author of the paper very clearly traces these cases to a distinct injury of great severity, but there are a number of cases in which there is no history of injury. There are also cases in which villous growths occur along the fringe of the synovial membrane and sometimes undergo degeneration and form cartilage. They may not always be loose in the joint, but they may be formed along the edge of the ligament. They never form true bony growths, and the ligaments, as a rule, are not involved. But I have seen one case in which there was the formation of cartilage as broad as two fingers and two inches long following a line on the inner and outer surfaces of the knee-joint; yet there were these villous pear-shaped growths that were vascular. I think later pathology shows they have been traced to the effects of a bacillus or a germ; but in the case of loose bodies either with or without a history of injury there is no such pathology. It is not uncommon to find cases described of bodies, either loose or partially so, clinging to the fringes of the synovial membrane, in which we have no history of injury at all. We have been led to believe that there were injuries, perhaps repeated slight traumatisms, but they pass out of the mind of the patient, and these patients come to us complaining of a category of symptoms which everyone recognizes as being either tubercular or some affection of the liga

no doubt a large number of cases are sometimes classified as tuberculous, and many others are simply cases of repeated traumatisms of the ligamentum mucosum.

Dr. Harris (closing the discussion): The discussion has wandered a little from the subject of my paper, as I feared it would. In the first place, the cause of movable bodies in the knee-joint was not touched upon at all. As far as bringing forth anything new is concerned, I am always a little slow in making any such claims; but I must say that the mechanism of pinching the triangular mass by hyperflexion of the joint and by atmospheric pressure, so far as my reading goes, is new. There is no reference to the subject in any literature that has been accessible to me, that is, in so far as an explanation of this particular injury goes. I made no statement to the effect that the most frequent way of producing movable bodies was by detachment of the articular cartilage. I did not touch on the subject or method of production of loose bodies in joints.

Koenig's paper on osteochondritis desiccans was written fifteen years ago, based on three cases, which he had observed indefinitely himself, because he had indefinite knowledge, so that upon these cases he based the theory that the disease always preceded detachment of the articular cartilages, and this disease which preceded it was not the result of trauma, but the diseased condition was the cause of the cartilage becoming detached subsequently by the injury. That was his idea. He said he did not think it possible that detachment of the articular cartilage could be brought about by trauma in a perfectly normal joint. I will say further, that in my subsequent study of these cases there is almost no one who reports a case who does not reach the conclusion that Koenig was wrong. One of the most recent writers, who has collected the largest number of cases in the literature of detachment of the cartilage, cases which were actually observed from the day of the injury to the subsequent operations, and cases that occurred in the army where the patients were under supervision, came to the conclusion that these cartilages are detached directly by trauma, and that diseased cartilage preceded by trauma is extremely rare. So much for Koenig's theory.

With reference to the remarks concerning synovial fringes, I did not consider that phase of the subject at all, and consequently it needs no discussion.-West Med. Review.

THE METHODS OF ANESTHESIA AND THEIR

LIMITATIONS.

BY J. V. MIKULICZ.

In this article the writer presents a generai resumé of the subject of anesthesia, both local and generaí, as practiced in his clinic during the past five years. For purposes of comparative study, he also presents the statistics of 783 physicians and dentists of Silesia who have had more or less occasion to employ anesthetics and who report 98,539 anesthesias.

He refers to the statistics of Gurlt of 330,429 anesthesias with a mortality of 1 to 2,429. In the great majority of cases chloroform was employed with a mortality of

I to 2,075, while in the cases in which ether was employed the mortality was I to 5,112.

Considerable attention is devoted to the subject of local anesthesia and the dangers associated with it. In over 100,000 cases there were only three deaths attributable to the local anesthetic, which in each instance was cocaine. A strong point in favor of local anesthesia is the absence of severe after-results, although the occurrence of pneumonia after Schleich's local anesthesia is a well-recognized complication. Furthermore, the artificial edema of the tissues produced by the use of Schleich's solution is in some instances a distinct disadvantage, especially when careful dissection must be done. The relative proportion of local anesthesia with Schleich's solution to general anesthesia as used in the general operating room of von Mikulicz's clinic during the past five years is 1 to 8.6. Bier's cocainization of the spinal cord has also been practiced in a number of cases with valuable results. In some instances the anesthesia was satisfactory, while in others it was not.

In choosing the form of anesthesia to be employed as well as the character of the anesthetic one must bear in mind three factors: First, the immediate danger of the anesthesia; second, the untoward after-effects, and, third, the ability of the patient to endure pain.

Before the introduction of Schleich's anesthesia it was the opinion that a great majority of the post-operative pneumonias were due to the general anesthesia, but careful statistics seem to indicate the post-operative pneumonia occurs about as frequently after local as it does after general anesthesia. Von Mikulicz advises strongly against the use of local anesthesia for extensive operations upon individuals very sensitive to pain or nervous. In regard to the question as to which is the safer anesthetic, chloroform or ether, he does not feel that the matter is as yet definitely settled. In his statistics there was one death in 1,699 cases of chloroform anesthesia.

The writer carefully analyzes the fifty-five cases of death ascribed to chloroform in the statistics collected by himself, and in only four of these cases does death appear to have been directly and solely due to chloroform. He urges the very great need of a careful examination of every patient to be anesthetized and the careful consideration of all contraindications, and believes that if sufficient attention is paid to those contraindications deaths from anesthesia will be far less frequent. He also urges the necessity for the exercise of great care and skill in the administration of an anesthetic and deplores the fact that it is usually administered by the least experienced assistant, while, as a matter of fact, it should be administered by the most skilled. He also gives the rules governing the administration of anesthetics in his clinic. In conclusion, the writer indicates certain general rules for the safe conduct of anesthesia :

(1) The most important factor in the limitation of the danger of anesthesia is the restriction of its administration.

(2) In every case contraindications to anesthesia should be carefully sought after, and if found the anesthesia should be omitted or given with the greatest care.

(3) The technique of the administration of an anesthetic is of the greatest importance.

(4) The proper choice as to the anesthetic to be used in each individual case is of the greatest importance in restricting the danger.

(5) It is advisable in certain cases to combine local with general anesthetics, in order that the quantity of the latter administered should be limited.

(6) It is unnecessary and a bad practice to push the anesthesia in every case to the point where not only consciousness but also the reflexes are lost.

(7) There should be exercise of great care in the selection of the anesthetist.-Albany Med. Annals.

It very frequently happens that patients under the care of a physician for pulmonary or cardiac trouble are also under the care of a dentist and require operative work upon the inferior denture or extraction of the teeth from the inferior denture. Such cases are just the ones that do not endure pain well as a rule and require a general or local anesthetic; and in the cases where there is a considerable cardiac lesion the local anesthetics generally used are unsafe. Hence, it falls to the lot of the physician to devise ways and means for reducing the pain or controlling it while the dentist performs his task.

The author has devised the following method for obtaining the desired result by the injection of morphine or a very weak cocaine and nitroglycerine solution over the course of the inferior dental nerve.

If the mouth is held wide open the finger can be passed inside the mouth and the anterior border of the coronoid process and of ramus of the inferior maxillary can be outlined. Just internal to this, toward the median line and extending obliquely upward, backward and inward from its attachment to the angle of the inferior maxillary the internal pterygoid muscle will be felt. Between the two is a very narrow space which offers no resistance to pressure, the mucous membrane of the buccal cavity being stretched over that surface. Directly back of and a little below the center of this space the inferior dental nerve enters the inferior dental foramen. Now, if an imaginary line be drawn from the last upper molar to the last lower molar, just to the inner side of the anterior border of the coronoid process, so that its center will pass over the center of the slight depression between the bone and the internal pterygoid muscle before described, the physician will have his landmark for the introduction of the hypodermic needle. Let the point of the needle be placed on the center of this perpendicular line, which has been drawn so as to mark the depression formerly mentioned, and the barrel of the hypodermic syringe be held so that it will exactly bisect the angle formed by the superior and inferior maxillaries with its apex beyond the point of your needle, the needle may be pressed directly back about one-half inch between the pterygoid muscle and the coronoid process, when its point. will lie very nearly, if not absolutely, over the point where the inferior dental nerve enters the inferior dental foramen. From one-eighth to a quarter of a grain of morphine injected at this point is sufficient to produce enough