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Damaged or displaced semi-lunar cartilages are perhaps the most frequent condition confused with the free or loose bodies. This condition was first described by Hey of Leeds, England, in 1803, and was called "Hey's Internal Derangement of the Knee," and was treated by splints, supports, and appliances. In 1885 Mr. Ammandale" of Edinburgh, followed closely by A. W. Mayo Robson" of Leeds, operated for the relief of this condition.

With the adoption of the radical cure, abnormal semi-lunar cartilages have been assuming a position of more importance. As showing the relative frequency with which these two conditions are encountered, Allingham" found 12 cases of loose body and 35 cases of pathological condition of the semi-lunar cartilages in 59 cases operated upon for internal derangement. In 33 operations of this character performed by Robson," 21

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for

deranged semi-lunars and 12 for free bodies in the joint. In 106 cases of internal derangement which came to operation Bennett removed the semi-lunar cartilages 80 times and loose bodies 16 times. In 505 cases of recurrent effusion of the knee joint the same author found obvious symptoms of loose body in 21 cases. That the differential diagnosis between these conditions is at times most difficult will be shown by the following case reported by Hubbard," which had been examined by many men and was frequently diagnosed as a slipping cartilage. The patient was seen by no less a man than Dr. R. F. Weir of New York, who, after a careful examination and a knowledge of the history of the case, was of the opinion that the inner semi-lunar cartilage was the seat of the trouble, and advised operation, at which the cartilage was found to be thickened, but this was not deemed sufficient to account for the symptoms. Manipulation of the limb allowed the escape of three unsuspected

floating cartilages. Allingham" cites a case in which his diagnosis of damaged semi-lunar proved at operation to be a loose body.

He gives as characteristics of damaged semi-lunar cartilages:

(a) Distinct history of traumatic. origin,

(b) Well defined site of pain, either internal or external according to the cartilage damaged,

(c) No foreign body palpable, and
(d) No creaking in the joint.

Cotterill" makes the point that in damaged semi-lunars full extension is painful, while full flexion is painless. The X-ray may be of value, in that loose bodies will practically always contain bone, and therefore cause a shadow, while the separated semi-lunar, being of cartilage exclusively, will not show in the skiagram.

Under the title "Treatment of Puzzling Knee Affections" Hoffa" mentions the cases that were hitherto called "Neuralgia of the knee," and states that many such cases are due to certain definite pathological changes within the joint, among which he includes free bodies.

In reporting four cases of "Contusion and Laceration of the Mucous and Alar Ligaments and Synovial Fringes of the Knee-joint," Flint" mentions a very instructive instance, case IV, in which at examination there was a sensation of something slipping beneath the finger, in the swollen region. At operation, the mucous ligament was found free in joint with a thickened, jagged margin. On manipulating the joint, this reddened area comes to be between the outer margin of the patella and the condyle of the femur, and corresponds to the mass felt to slip beneath the finger before the operation.

Indications for Operation-After the diagnosis is fully established there is no question but that the joint will continue to cause trouble until the offending body is removed.

There is always a possibility that the free body may become attached in some cul-de-sac in an out-of-the-way location, and give rise to no farther trouble, but such a fortunate contingency rarely occurs in actual practice.

If the body is in such a location and giving rise to no disturbance it should not be disturbed. They should not be removed merely because they are present, but because they are causing symptoms and disturbing the function of the joint. In case of doubtful diagnosis, rest, splints, massage, etc., should be judiciously tried before advising operation. Exploratory incision of the joint is allowable in certain cases. Allingham" in 59 cases operated upon found nothing abnormal in three instances. Bennett made an exploratory incision 12 times in 106 operations and in five of these nothing was found to account for the symptoms, but in two of these five the exploration was followed by relief of the symptoms. Goldthwait" advocates incision and exploration, not only for the various causes of internal derangement, but also in doubtful cases for diagnosis.

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The cases of Flint" were operated upon for exploratory purposes. Absolute diagnosis was not possible, but it was highly probable that some lesion would be found.

Treatment-The treatment should be the removal of the offending body. The old classification into treatment by (a) direct incision, and (b) indirect incision is no longer of any practical value, and the second subdivision only of historic ininterest. Under perfect aseptic environs the operation is practically devoid of danger.. The fact that there is danger in the opening of a large joint like the knee is established beyond cavil, but that the danger has been practically removed when operating under favorable circumstances is also well recognized. The joint must be approached with as much care and solicitation as when we invade the peri

toneal cavity. These two serous sacs, the peritoneal and the synovial, are similarly susceptible to infection, with the peritoneum being more tolerant. The power of the peritoneum to take care of a certain amount of infection is well known. The serous lining of the joint cavities is not so resistant. The absence of a structure analogous to the omentum, "the policeman of the peritoneal cavity," may account in part for this difference. This well known lack of resistance of the joint makes it necessary to exercise more than usual caution in the operation.

As showing how much disturbance may be caused by invading a large joint even though no sepsis is present, J. H. Barbat" reports a case in which, 48 hours after the removal of a large body, there was great pain, pulse 120, temperature IOI F., with the knee swollen and tender. He removed a skin suture and allowed about two ounces of bloody serus to escape, which on culture media proved to be sterile. More serum was removed two days later, and on the twelfth day the condition was normal.

General anesthesia is not always necessary, and the employment of infiltration anesthesia should be considered, if not used in every case. In case I the body was removed in a manner perfectly satisfactory to both patient and operator after infiltration with a solution of eucaine lactate, gr. I to the ounce of normal salt solution, to which was added gtt. 4 of adrenalin chloride 1-1000.

Houghton" removed a floating cartilage from an extremely neurotic individual after a similar analgesia, and even tapped the articular surfaces with a knife, without any objection being made by the patient.

The incision of the skin and that in the capsule of the joint should be on different planes, as a safeguard against the extension of a possible superficial infection from without inward. The incision should

be located so as to expose the body to be removed, and at the same time permit of an examination of the corresponding condyle of the femur. The incision generally employed is longitudinal at either side of the patella, but this is not always sufficient to secure all of the bodies, especially if they happen to be numerous, situated behind the condyles, or attached. In some cases a more extensive operation, with transverse division of the patella and complete exposure of the joint, may be necessary, as in the case of Lord in which he removed ten bodies.

Sir William Banks" removed forty after incising the tendon of the quadriceps and turning down a lower flap which contained the patella. These more serious opThese more serious operations are fortunately but rarely indicated.

The gloved finger may be used to palpate the articular cartilage. In this manner partially detached fragments have been discovered and removed, saving the patient from the necessity of a future operation. In dealing with the knee joint the "fingerless" operation has been insisted upon by many authorities, such as Konig and Hoffa, but since the introduction and use of rubber gloves, which are essential, it would seem that the objection to digital palpation of the articular surfaces has been overcome.

These floating bodies of the joints are aptly called "Gelenkmaus" by the Germans, because of their liability to disappear during the anesthesia or the operation, unless such a contingency has been considered and measures taken to prevent it. The suggestion that a needle be passed through the skin and the body in the joint is not always practicable. Elastic conElastic constriction of the limb above and below the floating cartilage will usually prevent it from slipping into the joint and out of sight at an inopportune moment.

The results following the removal of these bodies show a marked improvement,

due without question to the introduction and practice of aseptic surgery.

In 1558 Pare was the first to remove a loose cartilage from the knee-joint, after which removal by direct and indirect incision was performed with increasing frequency.

In 1860 Larry collected all of the cases up to that time, 170, of which 117 were successful, 33 died, and 20 were failures. Nine years later Benndorff" collected 269 cases, 209 with success, 46 deaths and 14 failures. Barwell found 88 cases between 1860 and 1875, 73 successful, 5 deaths and IO failures. The failures were ineffectual attempts to operate by the indirect, or subcutaneous incision of the capsule, which method has been obsolete for many years.

of operation for the relief of this condiMuller in 1886 gathered 190 instances tion, with 96 per cent. recoveries and 4 per cent. deaths.

Woodward up to 1889 found 104 cases, with 6 bad results, 2 amputations, and I death.

Marsh mentions 72 instances of operative removal of these bodies between the years 1885 and 1895, with no deaths and 10 failures.

During these same years Bolton"

states that no fatal result has been recorded.

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Cloudot states that no death from an operation for this condition has been reported since 1877.

Tenny in 1904 found 297 cases, since 1895, with no amputation and no deaths.

These late statistics are certainly interesting and encouraging when compared with the words of Benj. Bell," who, in 1787, while speaking of those bodies in the knee-joint that are not freely movable, said: "In this case I would advise amputation of the limb. The remedy is no doubt severe, but it is less painful as well as less hazardous than the excision of

any of these concretions that have been attached to the capsular ligament.”

REPORT OF CASES.

plication usually relieved the pain and reduced the swelling.

Six months ago, after one of these attacks of locking of the joint, he noticed a

miner. Irish.

Previous History-Fracture of right leg, above the ankle, about eight years ago; recovery perfect. During life he has received more or less severe sprains, bruises and falls, and in his occupation he has frequently injured his knees, but has no recollection of severely injuring either joint.

Present illness began about eight months ago, with an injury to his left knee. While timbering, in a crouched position, his right knee on the ground with the left limb abducted and semi-flexed, the foot on the ground and the knee about six inches above the ground, the force of his blows upon the timbers dislodged some particles of rock and a piece weighing about four or five pounds fell a distance of about ten or twelve feet and struck his left knee, bringing it forcibly against the ground. He experienced severe pain in the knee and the entire limb, but in about an hour he was able to ride (horseback) to his home. After nursing the joint for a few days he was able to walk about, but with a decided limp, due to the stiffness and soreness which remained for some weeks. About a week after the accident he consulted a physician who treated him for rheumatism. He became no better, and since the injury the knee has been weak and unreliable, allowing him to work only a few days at a time.

The joint is always sore and painful, but at irregular intervals there is a sharp shooting pain with a locking of the joint. First attack about six weeks after injury, lasting a variable time from an instant to half an hour. After these attacks of acute pain the knee is swollen, tender to touch and painful upon motion. Hot ap

the knee, at about the lower edge of the patella. Two months ago, after a like attack, a similar swelling appeared about an inch above the head of the fibula. These swellings were about the size of an ordinary bean-hard, immovable, and very tender. They remained visible for about three or four hours in each instance and finally disappeared without the knowledge of the patient. Hot cloths were applied each time, and caused relief from the pain.

On February 6, 1904, while splitting wood, he slipped, twisted his knee, and had another attack of acute pain, but much more severe than the preceding ones. He dragged himself from the yard into the house, and on examining the knee found a swelling a trifle larger than the previous ones, in the same location that it had assumed at the last attack, i. e., above the head of the fibula.

The writer was called and examined the joint about one hour after the onset of the attack. The joint was not swollen; mensuration showed both joints to be of the same dimensions. There was no fluid in the joint, the limb was flexed at almost a right angle, and motion was very limited and painful. The entire left knee was very tender, though the pain at this time was greatly lessened to what it had been. Hot applications had been continually applied. The greatest tenderness was in the neighborhood of the small swelling, pressure upon which caused exquisite pain. This mass was a trifle larger than an ordinary bean, was immovable, very hard, and the skin, which was not reddened, moved freely over it.

A diagnosis of floating cartilage was made, and its immediate removal advised, but the patient would only consent to

operation on the following day, if the symptoms did not disappear in the meantime. Consequently a hot moist dressing with a posterior splint was applied.

On the following day, as the conditions were practically the same, the patient was removed to St. Vincent's Hospital.

Operation-February 7, 1904, assisted by Dr. J. A. Jeannotte. After the usual preparation and before the incision an elastic band was applied around the knee, above and below the body to be removed, to prevent it from slipping into the joint during the maneuvers that might be necessary in its removal.

Anesthesia by infiltration-with Eucaine lactate, gr. 1; normal salt solution, os. I; adrenalin chloride 1-1000 gtt. 4was perfectly satisfactory.

An incision one inch long was made parallel to the long axis of the limb over the tumor, which was situated an inch above the head of the fibula. Skin fascia and capsule of the joint were all divided and the mass of cartilage was grasped with a sequestrum forcep and easily delivered. It was then found to be attached by a membranous pedicle. This was ligated, divided, and the cartilage taken away.

The capsule was sutured with plain catgut, and the skin with silkwormgut; a collodion dressing applied, and the limb put in plaster paris.

On the seventh day the plaster bandage was taken off and the stitches removed. On the tenth day the patient was discharged from the hospital with the normal function of the joint.

The body that was removed measured 1.5 cm. in length, .5 cm. in thickness, and .5 cm. in width. Its external surface is convex, bony and rough, with many indentations; the inferior surface concave, bony, and .5 cm. broad. The superior surface is convex, bony and narrow, terminating in a distinct ridge. The internal surface is flat and covered

with a layer of cartilage about 1 mm. in

thickness.

At one extremity of this body, the one to which the pedicle was attached, there is found a distinct particle of bone about I by 3 mm. in size, and this is held to the larger fragment by the cartilage in which it is embedded.

Two months after his discharge Mr. S. informed me that he had been entirely well up to a few days previous, when he had an attack very similar to those with which he suffered before operation, with the exception that the pain was not so severe. A small swelling, about half the size of the body removed, presented itself at the inner and lower aspect of the patella, the location in which he first noticed such a swelling, about six months previous. This swelling was noticeable for about half an hour, and the soreness of the joint was practically all gone the next day.

He was told that there was certainly one, and perhaps more such bodies as had been removed, still in the joint, and that the next time one presented itself he should come to the hospital at once and

have it removed.

Four months later the patient again presented himself and reported that the knee was bothering him considerably. He said that he could feel a swelling down deep in the muscles of the upper portion. of the calf of the leg. A few days before his visit it had returned to its old location, at the inner and outer border of the patella, and had remained there all day, but the following morning it had disappeared and he felt much better. Examination of the knee at this time was absolutely negative; the joint was apparently normal. The cicatrix of the operation. was barely visible and caused no inconvenience.

Case 2. J. G., male, 42 years, switchman. American.

On March 4, 1904, a locomotive ran