roads, the future is bound to bring a heavy reduction in the number of accidents, and make the work of operating railroads safer than many other kinds of employment in which thousands of men are daily employed.

After all, considering the magnitude of the business of transportation in this country, the number of employes killed on railroads in any one year in doing this work is relatively small. In 1899, on the railroads reporting to the Interstate Commerce Commission, 2,210 employes of all kinds were killed. In that year 959,763,583 tons of freight were carried on those lines, representing 123,667,257,153 tons carried one mile, or a carriage of 55.912,786 tons one mile for every man killed in doing the work-certainly a singularly small number of fatalities, all things considered.

The following observations are made by Mr. II. G. Prout, editor of the Railroad Gazette, concerning passenger accidents in 1897:

"But let us take all the passengers killed, namely 222, and divide the number into the total miles traveled. We discover than fifty-five million miles were traveled for each passenger killed. Or let us put it in another way: The best limited trains from New York to Chicago make an average speed of forty miles an hour from terminus to terminus. If one should travel at that rate night and day, year after year, with no stops, he would travel 157 years before he got killed on a railroad, and he would travel more than twice as long as that before he got killed in a train accident." These figures show that accident. insurance, so far as railroads are concerned, is not a very hazardous business after all.

What I would impress upon you most of all, at the conclusion of this paper, is that a large majority of accidents are due solely to the negligence of employes themselves. There is ample ground for controversy in the forum of reason whether a railroad company should pay one employe for an injury caused by his fellow employe's negligence, in direct violation of the company's orders. Unfortunately for the companies such is the state of the law that the companies are compelled to pay many hundred thousands of dollars under precisely these circumstances. In view of that fact alone, it is simple justice that the employe himself shall he held to a high degree of care, and that we emphasize once in a while his very serious obligation to his employer.-Proceedings Rocky Mountain Railway Club.

EXPERT TESTIMONY.

Expert testimony furnishes the theme for many articles in medical journals, and there is a feeling among medical men that their work includes about all that is important in opinion testimony. The remedies that are brought forward in such profusion by the profession in the hope of improving expert testimony relate almost exclusively to medical expert testimony, the writers not seeming to recognize that opinion testimony upon medical subjects is only a part of expert testimony in general. In patent cases, real estate valuations, which includes the whole range of condemnation suits, the application of the technical arts, all may be the subject of opinion testimony, which may be the subject of adverse comment from the bench. Of late the lay papers have discussed the extent

to which expert testimony was employed in the trial of Molineux in New York. The expense of the first trial was said to have amounted to nearly $300,000, of which about $200,000 was spent on expert testimony.

A recent case calling for comment is that of the will of one Robert E. Hopkins, who died in 1901, and a copy of his will was produced which was made ten years before. When it was found it was noted that fourteen nearly perpendicular marks had been drawn through the signature, thus canceling it. The question raised in the court was whether the testator had drawn the lines for the purpose of canceling the will, or whether they had been drawn by some other person. A handwriting expert by the name of Carvalho, who has figured in a number of important cases, gave it as his opinion that the lines were not made by the same hand that wrote the signature.

The court, in discussing the case, made some pointed references to expert testimony in general, but conceded the value of testimony as to handwriting by experts, stating that such investigations should be encouraged within reasonable limits. The court thought that valuable proof might be furnished by comparing different writings in order to determine the characteristics of that which was in dispute, by the study of the known handwriting of an individual. When it comes to asserting that an expert can pronounce definitely whether straight lines contain the characteristics of a certain person's writing, the court is of the opinion that "the time has come when a limitation should be placed upon this class of evidence."

It is said that misery loves company, and it may be 'some satisfaction to the medical man to know that there are other classes of experts besides those dealing with medical topics that occasionally bring themselves within the criticism of the courts. We are not expert in handwriting; if we were, doubtless we should not agree with the court. We presume that there are no limits to the possibility of drawing conclusions from the handwriting, but we had always supposed that it was the written characters, and that the fact that they had certain characteristics when used by the same individual, that govern in such cases. If marks such as these can be identified as having individual characteristics, then it will be useless in the future when an illiterate person places his mark to a document to have it witnessed, as is now necessary. As we have said before, not being an expert in chirography, we are inclined to side with the court in the statement that the expert went too far in this particular case. Medicine.

EXPERT TESTIMONY.

In the course of trials at law it will often be necessary for the court and jury to receive instruction upon some professional or technical subject which enters into the case. As physicians it is naturally the matter of medicalexpert testimony in which we are specially interested. Members of the profession are called in where there has been suspicion of foul play and where damage suits are brought on account of injuries. In the former class of cases a heavy responsibility rests upon the witness. His opinions and expressions will have a serious influence in

determining questions of life and death. In damage suits his reputation as a sagacious and accurate diagnostician is liable to be conspicously heightened or marred by the manner in which he testifies. All who have occupied the stand as medical-expert witnesses will concur upon these points. Probably all will likewise agree that, as the system at present remains, a very unsatisfactory state of affairs exists. The system in vogue pleases neither the lawyers nor the doctors. The former often speak slightingly of the value of the expert witness. The latter complain of the long and circumstantial hypothetical questions put to him and which he is expected to answer categorically in a few words. The greatest objection to the arrangements which now exist is the liability of the medical witness to become almost unconsciously and almost inevitably a partisan of the side for which he is called. It is in accordance with human nature that if a man expresses an opinion in public and such opinion is challenged by an opponent he will feel himself bound. to justify his belief to the best of his ability. He must remember, however, that he is not before the court to render any judicial expressions, even within the domain of his own profession, but to advise the court and jury concerning matters with which their position and pursuits have not made them familiar, but which are directly within the line of his life's work. His duty is to study the subject impartially and without prejudiced or preconceived ideas. It would be well if courts all over the land could adopt a course suggested by Judge Abraham Beitler, of Philadelphia, in a recent trial over which he presided. A woman had brought suit against the street company on account of injuries received in a collision between the car on which she was a passenger and another car. A number of witnesses testified to conflicting views, and it seemed difficult to arrive at a just decision. At this point the judge interposed. Calling the two lawyers before him he said that both were there in the interests of justice. If the claimant had been severely and irreparably injured through no fault of her own and while. under the care of the company's representatives, and if the facts were consonant with the law for such cases, sh would have a legal right to compensation. The object of the trial was to establish justice as between the company and the claimant. In order to have doubtful points explained, the learned judge suggested that the opposing counsel should select a physician in whom they could all place confidence and bring him into court for the purpose of making a thorough examination from the medical point of view. The judge was willing that the physician should have the right and power to ask such questions as he saw fit, to examine the patient, and take the stand as an expert representing both sides. The lawyers at first agreed to the proposition, and a physician was selected; but a disagreement then arose among the lawyers and the plan was abandoned. A scheme of this kind would be far better than that now in operation, in which doctors are pitted against each other, give, perhaps, divergent opinions, and sometimes bring the medical profession into something like contempt. The physician, as a man of science, is the last in the world who should allow himself to be turned into an advocate. The lawyer is in court for the purpose of establishing the contention

of his client or of defending him against a charge. The physician is there with a distinctly different object. He is to testify to the facts of the case irrespective of their bearings or effects. It is for the lawyers, the judge, and jury-the apparatus of the court of law-to adjudicate upon the evidence. In so far as it comes within his sphere it is the physician's duty to inlighten the members of the court upon matters brought up for discussion. Some such agreement, some such modification of existing customs, would seem to be demanded at the present time. It is a not infrequent, but unseemly, spectacle to see physicians disputing with each other in court, "darkening counsel" rather than enlightening the mind. In every trial which involves medical question, more particularly in criminal cases, the necessity for change and improvement is made manifest.

The present system does not work well in practice, is unsatisfactory to all parties concerned, and calls loudly for amendment in such a manner that the ends of justice may be attained in a more speedy, sure, effectual, and dignified manner than is possible under existing regulations. Medical Bulletin.

SEMILUNAR CARTILAGES; THEIR ANATOMY AND SURGERY.

rest.

BY H. A. SIFTON, MILWAUKEE, WIS.

Anatomy. The semilunar interarticular fibro-cartilages are two in number, an inner and outer, placed horizontally between the articular surfaces of the femur and tibia. In general outline they correspond to the circumferential portions of the tibial facets upon which they Each has a thick, convex, fixed border in relation to the periphery of the joint and a thin, concave, free border directed towards the interior of the joint. Neither of them is sufficiently large to cover the whole of the articular surface upon which it rests. The upper and lower surface of each semilunar is smooth and free and each cartilage terminates in an anterior and posterior fibrous horn. The internal semilunar fibro-cartilage forms very nearly a semi-circle. very nearly a semi-circle. It is attached by its anterior horn to the non-articular surface on the head of the tibia in front of the tibial attachment of the posterior crucial ligament, and by its posterior horn to the non-articular surface immediately in front of the tibial attachment of the posterior crucial ligament. The external semilunar fibro-cartilage is attached by its anterior horn to the nonarticular surface of the tibia in front of the tibial spine, where it is placed to the outer side and partly under cover of the tibial end of the anterior crucial ligament. By its posterior horn it is attached to the interval between the two tubercles which surmount the tibial spine. This fibro-cartilage with its two horns therefore forms almost a complete circle. The two horns of the external semilunar are embraced by the two horns of the internal one, and while the anterior crucial ligament has its tibial attachment almost between the anterior horns of the two semilunars, the tibial attachment of the posterior crucial ligament is situated behind the posterior horns of the two cartilages. Both cartilages possess other attachments. The external semilunar sends a large bundle of

fibers to the posterior crucial ligament. Both semilunar cartilages are attached to the deep surface of the capsule and by some short fibrous bands to the circumference of the tibial head, these fibers being known as the coronary ligaments. The two cartilages are bound together in front by a transverse ligament, which stretches between their anterior margins.

In studying the semilunar cartilages nearly 100 joints were examined. Great variation was noticed in the size and thickness of the cartilages in different knees. Considerable difference is often found in the two knees of the same subject. The cartilages are always loose and can be moved backward and forward and laterally through a range of probably a quarter of an inch, although the amount of mobility is very difficult to determine owing to the hardening of the bodies that were preserved, and to the changes that take place in the tissues soon after death in the subjects that were examined fresh. The thickness of the cartilages varied greatly. In some subjects they were thick and narrow, leaving a considerable portion of the head of the tibia exposed, while in others they were broad and thin, covering a large portion of the head of the tibia. The external cartilage was always broader and covered a greater portion of the head of the tibia than the internal. In two instances the internal semilunar was found rudimentary, being represented only by a narrow band on the inner surface of the capsular ligament.

The attachment of the circumference of the cartilages to the head of the tibia by the so-called coronary ligaments is often deficient, the coronary ligaments being represented in most cases by but a few fibrous strands. The so-called transverse ligament was found present in but half of the subjects examined.

In studying the relations of the cartilages to the blood supply of the knee a goodly sized artery was usually seen. to follow the circumference of the cartilage immediately beneath its lower edge. These arteries come from the inferior articular and are more constant in relation to the external cartilage than to the internal. These arteries are often sufficiently large to bleed freely if wounded, and if divided while operating may be difficult to reach owing to their position inside the capsule and the limited space available for manipulation.

The cartilages are said to act as wedges, helping to maintain the bones and other structures about the joint in proper position. This is probably correct, but if the cartilages by any means become loosened from their attachments so that it is possible for them to be caught between the opposing surfaces of the joint as it is brought into full extension, they will act as a foreign body, locking the joint and causing injury to its surface or to the cartilage.

Injuries. Various diseases, like tuberculosis, which affect the knee-joint destroy the semilunar cartilages along with the other structures. However, it is not our purpose, in this paper, to consider anything but injuries. The cartilage is usually injured or displaced by a fall with the knee partly flexed and rotated. In this position the force of the fall is brought to bear directly on the cartilage. Occasionally they are displaced by direct vio

lence.

In severe injuries one or both ends of the car

tilage may be torn loose. It is, however, much more frequent that the circumference of the cartilage is torn loose from the capsular ligament or that the cartilage is split in its long direction by being caught between the ends of the bone. Sometimes what would appear to be a very slight injury will tear the cartilage loose. It has been stated that a cartilage that has been displaced may be injured by an unusual movement of the joint causing inflammation and thickening of its inner edge, thus simulating a displaced cartilage. It is also possible that a loose fold of synovial membrane may get caught between the bone ends and produce all the symptoms of a loose cartilage. This has been found on several occasions when the joint was opened.

Symptoms. The symptoms that are produced depend upon the nature and severity of the injury. If the carti lage is simply displaced, destroying only a few of its attachments, the difficulty will often be mistaken for a sprain. The distinctive feature, however, will be tenderness confined to the line of the attachment of the cartilage. If the displacement is outwards, the cartilages will be found more prominent than normal. If the displacement is inwards toward the cavity of the joint, there will be a depression corresponding to the postion of the cartilage. The knee will usually be locked in a position somewhat short of complete extension. This locking of the joint and inability to quite extend it is almost always present in injured or displaced cartilages. We do not, as a rule, find this condition in any other injury to the joint except in case of a floating body, which is practically the same as a loose cartilage. Often the most careful examination will reveal no evidence of injury, the joint being apparently normal, but yet, owing to the fact that a part of the cartilage is torn loose and gets between the articular surfaces, the patient finds it impossible to put any weight upon the leg. The joint is usually slightly swollen, and if the limb is used the swelling increases.

Treatment. The treatment of injuries or displacement to the semilunar cartilages may be divided into that which is appropriate for cases seen immediately after the first occurrence of the injury and those in which the displacement constantly recurs. Under the first condition, the cartilage should be reduced if possible. Of course if the cartilage is divided or torn loose from its end attachments it will be impossible to replace it by any form of manipulation, but if it is only dislocated it can readily be replaced by fully flexing the knee, rotating it outwards or inwards, and then quickly extending it. If the cartiage is prominent, pressure should be made on the prominent point, while manipulations are being carried on. An anesthetic is seldom necessary. Any form of splint which will give the knee absolute rest should then be applied. After a week this splint should be removed daily for careful massage and passive movements. The attachments of the cartilage unite very slowly and failure in the treatment is usually due to insufficient time al lowed for complete union to take place. It requires from eight to twelve weeks for the cartilage to become fixed after the first injury. A certain proportion of the cases, under any form of treatment other than the removal of the cartilage, will not completely recover. This will be the case in injuries which tear loose the ends of the

cartilage or split it longitudinally or transversely, as the cartilage will constantly get out of place on the slightest provocation, thereby locking the joint and producing all the symptoms of the original injury, although usually in a milder degree as the joint acquires tolerance to the traumatism. Under these conditions no palliative treatment, in my opinion, is worth considering. Elastic knee bandages and braces of various kinds have been recommended. They are all worthless. Permanent relief can be obtained only by operative measures, completely removing all detached or loose portions of the cartilage. It is useless to attempt to fix the cartilage or any part of it by sutures, and it is wholly unnecessary for the reason that complete removal of the cartilage in no way damages the joint, providing it is properly done.

In opening the knee-joint for this, or any other purpose, the greatest possible care should be taken to prevent infection. Only under perfect aseptic conditions is it allowable. The knee-joint will not bear the amount of traumatism, or take care of the number of germs, that the peritoneum or other large serous cavities of the body will. This lack of immunity to infection is probably due to its scant vascularity in comparison with the other serous cavities.

After the knee-joint has been opened the amount of pain suffered varies very much in different patients, some having but little pain, others suffering greatly. I am inclined to think the amount of pain will be directly in proportion to the amount of injury to the synovial membrane that is produced by the necessary manipulation.

The best form of incision for the removal of a semilunar cartilage is U-shaped, with the convex border towards the patella. Turning the flap down to the required extent, the joint is opened by a transverse incision above the upper surface of the cartilage. This incision should be made as far above the cartilage as possible, for the reason that there is a considerable artery immediately beneath the lower border, which might be wounded if the incision was made close to the cartilage. I believe that the U-shaped incision of the skin and overlying tissues is much preferable to a straight incision, for the reason that it divides the resulting scar into three parts, and is consequently more flexible than if all the tissues had been divided in the same line. If the incision is carried well forward it will not be necessary to interfere with the lateral ligaments, ample room being obtain able by running the cut well forward. By retracting the patella and manipulating the joint a good view of one-half of the knee is easily obtained. As above stated, I would not recommend, under any circumstance, an attempt to suture the cartilage, but would remove all the detached portion. This can best be done by a strong, narrow-bladed scissors. I think no fluid should be introduced into the joint unless considerable hemorrhage has been encountered and it becomes necessary to wash out blood or clots which have accidentally obtained access to the cavity. The rule which should always be followed is to produce as little traumatism as possible and attain the object necessary.

The joint should be closed by a continuous, fine catgut suture and the skin incision then closed. The limb should be put at rest by means of a plaster dressing for two

weeks, at the end of which time, the wound being entirely united, gentle manipulation of the joint is commenced, the patient being also allowed to bear some weight upon the leg.

I have been able to find but very scant literature on the subject of injuries to the semilunar cartilages, nor could I find a report of a case where both cartilages of the same joint had been removed. My study of the nature and structure of the cartilages lead me to believe that they can be removed without damaging the function of the joint.

To make more clear what has been set forth here I report two cases which have recently come under my

care.

C. E., 21 years of age, while wrestling, fell, with his leg twisted under him, injuring his knee. He walked home with but little difficulty. The next morning he was unable to walk. The knee was but slightly swollen and could be flexed and extended with but little difficulty. There was some tenderness over the inside of the knee, but not severe. Rest in bed with the use of liniments, etc., was tried for a few days without effect. He went about on crutches for four weeks with his knee bandaged. It was then placed in a plaster dressing and kept immobilized for two months before he was able to use it. At the end of two months more he was able to walk without support. About two years after the first injury he again hurt the knee while playing baseball. He was immediately unable to walk a step, although the swelling and tenderness about the knee were slight. It was placed in a plaster dressing at once and in about two months he was able to walk without support. Within a year he again injured it while putting on his pants. It was again immobilized and it was all of four months before he was able to use it. From this time on there was always a feeling of uncertainty about the knee. About six months after the last injury, while walking across the road, his knee suddenly became locked and he was unable to step. Examination next day showed it to be slightly swollen. Flexion was practically normal, but the joint could not be fully extended. The joint was not tender, with the exception of a spot over the middle of the internal semilunar cartilage, where there was slight tenderness. The knee-joint was opened and the semilunar cartilage was found torn from its attachment to the capsular ligament throughout the greater part of its length, leaving it attached by its two ends only. It was rolled into a very hard, cordlike band, that caught between the articular surfaces when the knee was fully extended. The loose cartilage was cut away from its attachment and removed. The joint was at once closed and the leg dressed in plaster for two weeks, when the wound had completely healed. Within three months the function of the articulation was perfect, and as soon as the atrophy of the muscles, which resulted from the long periods of confinement, had been overcome, he was able to play baseball on the university team.

Mrs. C., age 45, while lifting a tub of water, accidentally fell, the tub tumbling upon her in such way as to twist her knee under her. She says she felt something give way in the joint. The joint was very much swollen and she was unable to use it for two months, after which

time she gradually began to walk. About six months after the first injury she slightly wrenched her knee, when it became locked and exceedingly painful; so much so that she fell, injuring the arm on the opposite side. After this she was always in dread of the knee becoming suddenly locked. I saw her about a year after the first injury. The joint was slightly swollen and tender over the inside. It could be put through all normal movements. In fact, outside of the slight swelling and tenderness it appeared to be perfectly normal. The knee-joint was opened and the internal semilunar cartilage was found to be torn from its anteriar attachment. The end curled up and floated around in the cavity of the joint. The detached The detached portion and about two-thirds of the circumference of the cartilage was cut away and the joint closed in the usual manner. A perfect result was obtained.-Clinical Review.

TURPENTINE IN SURGERY.

BY W. K. GATEWOOD, M.D., WEST POINT, VA. Having on two occasions recently to resort to an old remedy that has always given good results, I wish to call the attention of the young doctors to its great value. I speak of oleum terebinthina.

I was called to see a negro boy 18 years old, who had gotten all five of his toes cut off by a saw just at the junction of the foot. I found the foot dreadfully torn and lacerated and very filthy. They were very poor, and I could get no water boiled, as the old stove was so worn out it would take more time than I could spare, as night was coming on, so I washed off what I could with the water on hand, put him on a filthy old table in front of a door, as the house had no windows, and got my friend, Dr. Nunn, to administer the chloroform. Having a bottle of turpentine in my satchel, I used it to cleanse the foot-using gauze saturated with it to scrub with, and succeeded in getting it in very nice order. After I had amputated the foot, I poured turpentine all over the stump, then wiped it off with gauze. I then dusted it with bismuth formic-iodid powder and bandaged it up. I dressed the foot five times, and to-day discharged him well, as nice a stump as you ever saw, and not one drop of pus have I seen during the healing, which was by first intention. I only write this to show the great value of turpentine as an antiseptic and healing remedy. I have in a practice of forty-six years had dozens of like results from this great remedy, which has never disappointed me.-Virg. Med. Semi-Monthly.

LARGE SALINE INJECTION FOLLOWED BY DEATH.

Achard and Paisseau report having made an autopsy upon a woman in whom, in order to combat an internal hemorrhage in consequence of a hysterectomy, there had been injected beneath the skin within twenty-four hours 2 gallons of an artificial serum containing 5 parts of sodium chlorid and 10 parts of sodium sulphat to 1,000 parts of water. Death was due to pulmonary Death was due to pulmonary edema, of which the patient had presented the symptoms and of which they had found the lesions. There were

also renal lesions consisting of considerable edema in the pyramids, together with epithelial alterations in the tubuli.

It is not established that these lesions were due exclusively to the sodium chlorid in excess, for that salt was much diluted in the solution injected; the fluid itself was hypotonic and congealed at 0.44. It is precisely by reason of this hypotony that the muscles of the patient had given a less proportion of the chlorid than those of a subject dead of rapid suffocation, taken as a term of comparison.

Nor does it seem that the quantity of sodium sulphat injected could explain the lesions. It was therefore necessary, in the opinion of the reporters, to refer the effects to the enormous quantity of water.

Experiment shows, moreover, that by the comparative injection of strong and weak solutions of sodium sulphat into the veins, rabbits are destroyed by a small amount of the sulphat and much water as well as by much of the sulphat and a little water.

Finally, by injecting beneath the skin of a rabbit nearly a quart of the saline solution which had been used in the patient's case, death had been produced in a few hours in consequence of dilatation of the heart. The authors had likewise detected some alterations of the renal epithelium, comparable to those obtained by MM. Castaigne and Rathery in vitro by submitting that epithelium to the action of hypotonic liquids.-Med. Bull.

THE TREATMENT OF SHOCK.

At the meeting of the Harvard Medical Society, of New York, on March 28, 1903, there was a discussion upon the subject of "Shock." In closing Dr. Geo. E. Brewer said that most of the drugs recommended for shock are utterly ineffectual. It seems unwise to prescribe nitroglycerin, since the modern idea of shock is a vasomotor dilatation owing to paralysis of the vasomotor nervous mechanism, and the special physiological action of the nitrites is to cause vasomotor dilatation.

Adrenalin is the substance on which all eyes are fixed now in the matter of the drug treatment of shock. Experimentally the outlook seems to be very promising. Dr. Cushing recently saw a dog stop breathing during an experiment. A solution of adrenalin was injecte into the veins, but without effect. The heart was then exposed and irritated by direct compression, but without result. Artificial respiration was kept up and adrenalin was injected directly into the heart cavity. The heart began to beat again, and though it was over twenty minutes since the animal had stopped breathing, recovery was complete.-Med. News.

RELATION BETWEEN TRAUMA AND TABES.-In the strictest sense according to Schittenhelm there is no such condition as traumatic tabes, but rather in all those cases in which tabes follows a trauma, the latter is to be regarded as an accessory or exciting cause, leading to a predisposition, or in the presence of an actual predispo sition to tabes, tending to kindle it or serving to unmask a latent tabes and to accelerate its progress.—Med. News.