over his right leg. He was immediately removed to St. Vincent's Hospital, where an examination revealed a crushing injury to the bones and soft parts of the right leg, which necessitated amputation above the knee joint.

Upon opening the knee joint a large floating cartilage popped out. This body resembles a pumpkin seed in size and shape. It is 2.5 cm. long, 1.5 cm. wide and 5 cm. in thickness. One surface is hard, bony, and very rough and corrugated, with many large and small eminences and depressions. The opposite surface is slightly convex, its edges are raised and fluted, and the area within these raised edges is smooth and covered with a thin layer of cartilage. One pole of this body is broad, and the other comes to a point, and at this point there is attached, by a fibrous band, a very small spherical solid mass, in structure apparently similar to the bony part of the larger body. This small body is about 2 mm. in diameter, and resembles a mustard seed.

The joint was very carefully examined, but beyond a thickening of the synovial membrane there was nothing abnormal. The articular surfaces gave no clue as to the origin of the body.

Upon inquiry, after the patient was convalescent, it was learned that he had for many years suffered with "rheumatism" of the right knee. He frequently had sudden attacks of sharp, shooting pain in the joint that would almost cause him to faint. With this intense pain he could not move the joint, nor even rest his foot upon the ground, but would have to lean against some stationary object until the pain had passed away. On more than one occasion he failed to catch a switching engine or car because of this sudden pain which would make it impossible for him to move. In duration these attacks were always short. He never noticed any marked swelling of the joint,

and after these attacks had passed away he could go about his work as before, except that there would be some lameness and that the joint might be sore and tender for some hours or days. He never had any trouble with the other knee, or any other joints. There was no history of any distinct traumatism.

A striking feature common to these two specimens is the smaller bony mass in connection with each. In a review of the literature obtainable reference to such small adherent particles is not found. Their significance is obscure. It would seem that they might be the origin of an additional body, and in the first case reported, where there was more than one body, this explanation might seem tenable, but in the second case it would seem that there had been ample time for a more advanced development of this second body.

The presence of these smaller bodies in these two instances may be merely a coincidence, but if they are met with more frequently they may be found to have a bearing upon the question of the formation of these floating bodies in the joints. Case 3. Seen in consultation with Dr. T. N. Moxon, of Salida.

T. T., male, aged 41 years, policeman, American.

Previous History-Had most of the diseases of childhood, and "chills and fevers" when a youth in Missouri. When 32 years of age had a severe attack of inflammatory rheumatism—all of the large joints were involved, the knee no more than others-with which he was confined to bed for six weeks. In his thirty-third and in his thirty-fifth years he had similar attacks of rheumatism, each of which lasted about six weeks. Since then he has not been troubled with rheumatism or any other form of sickness.

Present Illness-When 15 years of age he was riding horseback, dismounted to open a gate, and in again mounting

slipped and fell, but grasped a tug of the harness and was dragged along the ground, head foremost, for a distance of about twenty feet. He did not seem seriously injured, but there was a small triangular cut over the center of the right patella. As he remembers it, this cut extended to the bone. The knee was somewhat swollen and slightly painful for a few days, during which time he remained. in bed and local applications were applied. In a week or ten days he had entirely recovered from the accident and was using the joint as usual.

About six months after this accident he had his first attack of locking of the knee joint. While walking, feeling perfectly well, he experienced a severe, sharp, shooting pain. in the right knee knee which caused him to sink to the gronud. He could not move the joint, but this pain and inability to move the joint soon passed away, and he was able to resume his walk, but there was considerable soreness remaining in the joint for a few days. Since then attacks similar to this one occurred at irregular intervals, four to six in a year, for a number of years. They never necessitated his being confined to bed. About five years after the injury to his knee, there being no injury during the interval, he noticed the presence of loose, movable bodies in the right knee. It seemed to him that there were many bodies in the joint, behind and on each side of the patella. They were about the size of a pea and some of them as large as a bean. He could feel them grate against one another or against the bones of the knee joint, and at times they would "pop" quite loudly, and would then cause moderate pain.

Since first noting these movable bodies he has always had trouble with the joint, has had "rheumatism," and the joint is a perfect barometer, always increasing in pain before the coming of a storm.

The longest time that this knee has caused him to remain in bed has been about four or five days, only a few times. He admits, however, that he has many times hobbled around when it would have been much better for him had he rested. The use of strong liniment and the application of hot flannel cloths generally relieved the acute pain, and he was able to put up with the soreness.

About four years ago the joint became ankylosed for about five days. This is the only time that such an occurrence has taken place. At present there is an almost constant pain when the joint is in action, but when at rest there is no pain. The limb remains a trifle flexed at the knee and there is a slight eversion of the leg. The gait is very good considering the pathology within the joint. It may be plainly seen, in walking, that one joint does not move as freely as the other.

The patient states that the pain in the joint is much worse now, since these bodies have become larger, than it was when the bodies were small, but he has not had the actute attacks of pain, with locking, for many years. The duties of a policeman are performed without any great apparent effort.

Examination-Well

developed and nourished man, head, thorax and abdomen negative. Both limbs of the same length, patellar reflex normal on both sides. Left knee normal. Right knee three-fourths of an inch larger than the left. Extension perfect, but extreme flexion is resisted and causes some pain. There is slight abduction of the leg. Passive and active motions of the knee are accompanied by crepitus. There is an effusion into the joint, the patella floats, but the normal depressions above and on each side of the patella are not obliterated.

Palpation reveals a hard, resisting, movable mass about one-half the size of the patella, situated below the tendon of

the quadriceps extensor muscle. This mass can be moved laterally and also up and down, but only a small distance in either direction. It is not sensitive.

A smaller body, about one and one-half by one-half inches, can also be felt. This body is freely movable and can be made to pass from the median line above the patella to the center of the right lateral aspect of the patella. This body is quite sensitive, and with its movements crepitus can be distinctly felt and heard. Sometimes this movable mass becomes lodged behind some muscular or tendinous structures and cannot be palpated, but some few maneuvers on the part of the patient can usually bring it within reach. of the palpating fingers again.

These are the only movable bodies that can be palpated, but the patient states that occasionally a swelling can be felt in the popliteal space.

The internal portion of the head of the tibia seems to be uniformly enlarged, and the tibial tubercle, the attachment of the patellar tendon, seems to be enlarged and extended laterally and superiorly on each side of the patella.

Case 4. J. V., male, 28 years, laborer, Italian. Previous history negative.

Present Illness-Entered D. & R. G. R. R. Hospital on October 26, 1904, because of a simple fracture of both bones of the right leg at about the middle. In addition to the above at examination there was found a swollen, tender and painful right knee-joint.

With the rest and immobility necessary in the treatment of the fracture the knee rapidly improved. After union of the bones and removal of the cast the patient complained of some pain, soreness, stiffness, tenderness, and creaking in the joint upon motion.

Examination of the knee revealed the presence of some fluid in the joint, a slight abduction with marked lateral motion of

the leg. Complete extension caused no pain, but flexion to a right angle caused pain, with crepitus that could be distinctly heard and felt. It was impossible to locate the seat of this crepitus. There was no actual pain with it, but when the leg was flexed the patient complained of pain, which he located in the center of the popliteal space.

On the external surface of the knee, between the condyle of the femur and the articular surface of the tibia, there could be felt a mass about one-half inch wide and one-quarter inch thick. This was movable. When pushed toward the center of the joint it seemed elastic and would spring back to its former position. The up and down and the anterior posterior motions were limited. The mass was not tender, nor was there any pain complained of when it was moved. Operative removal of the body was advised, but refused. refused. Under rest, counter-irritation with pressure, the fluid was absorbed, the motion became much better, the abduction less marked, and the crepitus almost absent. But the mass could be palpated in the same position.

In the absence of operation and a presentation of the specimen the propriety of including this case with the others may be questioned.

The mass in this case was certainly a movable body, outside of the joint, but its origin must have been within the joint, either from the articular surfaces or from the semi-lunar cartilages. After a careful study of the case I am constrained to class this with the three cases of Bennett, in which a piece of the semi-lunar cartilage is torn from its connections anteriorly and then pushed forward, in this manner producing a tumor readily felt under the soft parts.

Usually when the semi-lunars are damaged they are forced into the joint or retain their normal position. In these cases

a part of the cartilage is forced outward, a part of the cartilage is forced outward.

'Hoffa, Journal American Medical Association, Sept. 17, 1904.

"Mueller, Gaz. de Strasburg, Feb., 1886. 3Hunter, "The Blood, Inflammation and Gunshot Wounds," Philadelphia, 1841.

"Rainey & Solly, Proc. Path. Soc., London, Vol. 11, 1848-50.

"Barth, Archiv. f. Klin. Chir., Vol. 56, 1898. "Vollbrecht, Beit. z. Klin. Chir., Vol. 21,

1898.

"Humphry, Brit. Med. Jour., Vol. 1, 1888. Kraglund, Zentralblatt f. Chir., 1887. "Codman, Boston Med. & Surg. Jour., Oct. 15, 1903.

1oBurghard, Brit. Med. Jour., Vol. 1, 1892. "Cornil & Coudray, Rev. de Chir., April, 1905.

Bul. de L'Acad. de Med., March 14, 1905. 12Rimann, Virchow's Archiv., Vol. 90, No. 3. 13 Konig, Lehrbuch der Spec. Chir., Vol. 111 Verhand. der Deut. Ges. f. Chir., 1899. Deut. Zeit. f. Klin. Chir., Vol. 27, 1887. "Paget, Clinical Lectures and Essays, 1875. St. Barthol. Hosp. Report, Vol. 6, 1870. 15Tale, Medico-Chir. Trans., Vol. 39.

18 Klein, Virchow's Archiv., Vol. 29, 1864. "Poulet & Vaillard, Archiv. de Physiol., April, 1885.

"Harris, Trans. West. Surg. & Gyn. Assn.,

1901.

19Gruder, Deut. Zeit. f. Chir., Vol. 72, 1904. 20 Martens, Deut. Zeit. f. Chir., Vol. 53. Konig, Zentralblatt f. Chir., No. 31, 1905. "Bowlby, Lancet, Vol. 39, 1888. 23Clutton, Lancet, Vol. 39, 1888.

24 Weichselbaum, Virchow's Archiv., Vol. 57, 1873.

23 Bennett, "Recurrent Effusions Into the Knee Joint," 1905.

26 Halstead, Annals of Surgery, Sept., 1895. "Schuller, Arezt. Sachverst. Zeit., February, 1896.

2 Lane, Brit. Med. Jour., Vol. 2, 1893. MacCormac, The Clinical Journal, 1896. 30 Wilson, Annals of Surgery, July, 1903. 31 Fairchild, Omaha Clinic, January, 1894. 2Barwell, "Diseases of Joints," New York,

1881.

Shaw, Path. Trans., London, Vol. 6, 1854. Sutton, "Tumors Innocent and Malignant,"

1903.

Berry, Brit. Med. Jour., Vol. 1, 1894. "Berry, Brit. Med. Jour., Vol. 2, 1890.

Reichel, System of Surgery, Bergmann, Bruns & Mikulicz, Vol. 111.

3Tenny, Annals of Surgery, July, 1904. Hey, "Practical Observations in Surgery," 1803.

"Ammandalė, Brit. Med. Jour., Vol. 1, 1885. Brit. Med. Jour., Vol. 1, 1887.

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43Hubbard, Trans. Am. Orth. Assn., Vol. 11,

1898.

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1900.

Barbat, Jour. Am. Med. Assn., April 27, 1901. "Houghton, Jour. of Royal Army Corp., April 19, 1905.

N. Y. & Phil. Med. Jour., June 10, 1905.

50 Lord, Jour. Am. Med. Assn., May 7, 1904. 51Banks, Brit. Med. Jour., Vol. 1, 1902.

Larry, Int. Enc. Surgery, Vol. 3, 1889.

53 Woodward, Boston Med. & Surg. Jour., April 25, 1889.

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1889.

"Bell, System of Surgery, Vol. 5, Sect. 3, 1787.

DISCUSSION.

Dr. Powers: I am heartily in accord with all that Dr. Connell has said. I would add that when these little bodies are pedunculated, as they sometimes are, very careful ligation of the pedicle should be made or a serious haemarthoris may result.

Dr. Grant: We are wanting in some knowledge of the pathology of these bodies, which it seems to me is the most interesting feature concerning it, and I can add probably nothing to that. But the fact that in two of these cases they followed an injury to the knee joint and an examination of the specimens, which I have had the pleasure of examining with Dr. Connell, indicate to me that they were chipped off during or at the time of these accidents. Some occur, of course, in old, rheumatic, gouty subjects, such as in chronic osteoarthritis, but in these cases the indications were that these little small bodies were chipped off at the time and subsequently became attached to the larger body. That seems to me probable, though we are unable to prove it.

Discussion Closed.

Dr. Connell: As to the etiology of these bodies, the question is a very large one and very much unsettled. In my complete paper I have gone into it rather extensively. As I consider it of more theoretical than practical value I confined my fifteen minutes to the more practical side of the subject. The etiological factors are considered in the complete paper.

REPORT OF CASES OF MORPHINISM.

By J. E. COURTNEY, M. D., Denver.

I have selected histories of five cases which very well illustrate the phenomenal pertaining in cases of morphinism and the group of symptoms appearing in various stages in the treatment of these cases known as "withdrawal" symptoms. I will present photographs of two of these cases showing extensive mutilation of the person in the needle habit.

Case 1. Male, 59 years, real estate dealer, no history of insanity in the family, no neurotic inheritance in other di

rections.

When he came under my care he had been using morphine hypodermically, administered by himself, for eighteen years. The cause ascribed was injections given by a physician for hepatic colic. For some years the amount taken had varied from eight to ten grains daily in four to six injections. It was possible to count about a hundred small abscesses and the surface was quite covered with cicatrices. The photograph will show this. He was under treatment for seven weeks, the drug being withdrawn in two weeks. During reduction of his dose and for two weeks after it was stopped, he suffered from withdrawal symptoms. These strongly resemble shock from any other cause; small, feeble pulse, pallor, prostration, sighing, retching, yawning, considerable mental confusion, tossing in bed and, in a confused way, begging for relief and the assurance that death was not impending.

erative employment was resumed after an idleness of several years. The psychical disturbance in this case was not great. The patient did not approach a condition of delusion of persecution, ill treatment. mismanagement, the determination to. stop all attempts at cure or to change physician and location, which is the usual picture confronting one just as he begins to think that withdrawal of morphine from an habitue is not a difficult matter.

The photograph of the chest of this patient and syringe used by him for years is exhibited.

Case 2. Female, 28, single, no heredity traceable; attributed habit to grief at deception in love affair; duration of habit eight years; claimed to have reached a maximum of fifteen grains per day, hypodermically; cicatrices in the skin are shown in the photograph.

The menses had been suppressed for five years and returned in two weeks after withdrawal of the drug. This case was