Selected writings of A. Jackson Howe.
The following abstract is from Dr. Howe's surgery, showing the manner in which he treated even small surgical items, and the freedom from technical involvement in his directions for treatment. The whole work is equally clear; he never obscured his meaning by a display of technicalities not necessary to the purpose. This made his book extremely popular with both physicians and surgeons, and readily comprehended by the medical student.—Ed. Gleaner.
"LOOSE CARTILAGES" IN JOINTS.—The knee-joint, more frequently than other articulations, is liable to have developed in it one or more movable bodies of cartilaginous consistence, which, although quite free in the articulation, are attached to the walls of the joint by narrow pedicles; and when they get between the articular surfaces, may act like a nail in a hinge, abruptly arresting motion, and causing the most excruciating pain. These bodies pop about so quickly from one part of a joint to another that they have received the vulgar name of "joint mouse." They do very little mischief unless caught between the articular surfaces, as just described.
"Loose cartilages" vary in size, from that of a barley corn to the magnitude of a small patella. Those the size and shape of an almond kernel are the most troublesome. In rare instances these bodies lose their connection with any tissue in the joint, yet by absorption are able to maintain an independent existence, darting about from one pocket to another in the articulation. From the fact that these loose bodies are sometimes osseous it has been supposed that they were originally pieces of bone broken from the ends of the bones entering the articulation. It has also been presumed that these strange products were nothing more than solidified precipitates from the synovia.
The treatment alone which can be relied upon is radical; and consists in removing these bodies from the joint through an incision made for that purpose. It may be of service, as a palliative measure, to wear an elastic knee cap, but this will not prevent occasional trouble; and when the loose body slips between the articular surfaces of the bones constituting the joint the patient falls, and is unable to rise or move until the agonizing pain subsides, and then the accident may recur again at any instant. Therefore, to escape the impending evil, removal of the cause is the only hope. But, before cutting for the body the patient must be able with his fingers to fix it in some accessible part of the joint. The outer and lower part of the joint is the best place to arrest the loose cartilage, as there the coverings are thinnest. It is well to grasp the moving body with vulsellum forceps, the long teeth going through the soft structures, or doubling them in behind the loose cartilage so it can not escape the grip while being cut upon. When once reached it is to be seized with toothed forceps and removed, the fingers of the operator closing the wound and pressing upon the parts to prevent blood from entering the joint. The knee is then to be bandaged, and the patient put under the influence of chloral. The danger is from shock and tetanus. No risks in the way of exercise are to be taken for several days; and local irritation is to be kept down by the topical use of anodynes and evaporating lotions.
Another method for extracting a loose cartilage from the joint is to make an incision in the synovial bag with a tenotome, and then force or drag the loose body through the opening and into the soft tissues between the synovial membrane and the integument. It is to rest in that place until the synovial capsule has healed, and then it may be safely removed through an incision made in the skin.
According to M. Larry, who refers to 167 published cases of removal of loose cartilages by operation, out of 121 cases in which the old or direct method was employed, 98 were successful, 5 doubtful, and 28 died; whilst of 39 indirect operations, 19 were successful, 15 failed, and 5 died. From this it would appear, as M. Larry states, that extraction by either method is attended with decided danger. I have removed false or moving cartilages from the knee joint, and always by the direct method (fixing the body, then cutting upon and removing it at once), and never had worse symptoms to deal with than a severe "chill" and threatened tetanus. I think the danger of the operation come chiefly from the presence of blood in the synovial cavity. In the event of tetanus the life of the patient would not be safe without amputation.—HOWE, Art and Science of Surgery.
The Biographies of King, Howe, and Scudder, 1912, was written by Harvey Wickes Felter, M. D.