A 
NEW OPERATION 
.f or Artificial Miip Saint 
IN 
BONY ANCHYLOSIS. 
ILLUSTRATED BY TWO CASES. 
By LEWIS A. SAYRE, M. D., 
OF NEW YOHK. 
ALBANY: 
STEAM PRESS OF C. VAN BENTHUYSEN. 
18G3. Reprint from Transactions of Medical Society of the State of New York; 1863. A NEW OPERATION FOR ARTIFICIAL HIP JOINT IN 
BONY ANCHYLOSIS- 
Case I. Anchylosis oe both hip joints-Tenotomy and brisement forc6 in 
ONE, AND IN THE OTHER EXSECTION OF SEMICIRCULAR SEGMENT OF BONE ABOVE 
TROCHANTER MINOR. RECOVERY WITH ARTIFICIAL JOINT. 
Robert Anderson, native of Lexington, Ky., age 26, was admitted 
into Bellevue Hospital in May, 1862, and gave the following history 
of himself: During the summer of 1849, when 14 years of age, 
he was accustomed to go in the river every evening to swim, and 
on one occasion remained in the water some hours, having previ- 
ously taken very severe exercise in running and jumping. 
About the middle of September he was taken with a dull pain 
in the right hip, which continued about one week, so gradually 
and imperceptibly developed, that the exact date of commencement 
is not known. During this time he continued in attendance at 
school, and enjoyed the usual sports and games of his schoolmates. 
One day, after having exercised more freely than usual, he was 
attacked with fever, and the following day stupor set in, which 
lasted nearly three weeks, with the exception of intervals; when 
aroused by the family, was totally indifferent to anything that 
transpired around him, except when thus diverted by his friends. 
All this time he suffered intense pain in the right hip, which was 
sharp and lancinating. The hip was red, hot, and greatly swollen, 
which extended half way to the knee. 
At the end of a month the swelling had much subsided, and the 
pain very greatly diminished, though when moved* it was still very 
intense-of the same character felt in the hip, and never at the 
knee. 
About this time began to have pain in hip joint of left side, and 
also in the knee, which was dull, and never of that sharp, lanci- 
nating nature which he suffered in the other joint. This continued 
two months. 
Ten days after the commencement of the disease, pillows were 
placed under his knees to relieve the pain. These were increased in 
thickness and continued all the time he remained in bed, which was 
six months; also during the next six months, whenever he was in 
bed: but during this latter period he sat up occasionally in a chair. 
From the position assumed during this prolonged confinement, tha 4 
legs were flexed upon the thighs, and the thighs upon the pelvis, 
and have been immovably fixed in that position ever since. Had 
occasional pains all this time in both hips, but most severe in the 
right. 
At the end of two years from date of attack, an abscess formed 
in left groin, which remained and discharged pus for two years. 
Abscesses also formed about the right hip ; one beneath the gluteal 
muscle, and another near the anus. These discharged very freely 
and continued open for nearly a year and a half. 
At the end of the first year, began to use crutches-compelled 
to use them ever since. 
For the last six or eight years, general health has been perfectly 
good. 
On admission he had anchylosis of both hips in the position seen 
in the annexed photographs. 
The left thigh was immovably fixed at nearly a right angle with 
the pelvis, by bony cementation of true anchylosis. The right was 
very firmly attached at an angle not quite so acute, and by a very 
careful examination I thought some slight motion could be detect- 
ed which indicated that the attachments were fibrous in character, 
or at most were osteophytes only, and external to the joint, and 
that there was no agglutination between the femoral head and the 
acetabulum, whereas the opposite side seemed perfectly cemented 
together. He could not walk, except by whirling himself in semi- 
circles, first on one leg as a pivot, and then the other-or else by 
swinging himself on his crutches from the axilla. In order to get 
both feet upon the ground at.the same time, his back was curved 
inward very much at the sacro-lumbar junction, the left knee flexed 
Fig. 1. 
Fig. 2. 5 
at an angle of about 45 degrees with the thigh, and the right side 
of the pelvis was some inches higher than the left. He could only- 
sit, by assuming a most awkward posture, half reclining on his side 
upon a couch or sofa ; and in laying down, was curled up either on 
one side or the other, or if upon his back, he had to be supported by 
pillows under his knees, and under the lumbar vertebrae. In fact, 
he was the most pitiable object I ever saw, and one that would ex- 
cite the sympathy of any surgeon. 
On the 4th of May I divided subcutaneously the adductor 
muscles, the rectus, tensor vagina femoris, and femoral facia of 
the right hip, and breaking up the adhesions by some considerable 
force, obtained a very good motion of the joint. Extension was 
made to the limb by a weight and pulley, and the hip enveloped in 
cloths wet in cold water; no serious trouble followed the operation, 
and in six weeks he could flex and extend, ab, and adduct his right 
limb with considerable freedom. 
On the 11th of June, 1862, I removed a semicircular segment of 
bone above the trochanter minor of the left femur, for the purpose 
of establishing a new joint. Drs. I. P. Batchelder, Woodhull and 
Osborne of this city, Drs. Hooker of New Haven, Ct., Hichborne, of 
Mass., and Dr. James S. Green, of Elizabeth, N. J., were present at 
the operation. 
As this is the first section of this kind ever made in this bone 
at the place indicated that I am aware of, I will give a brief descrip- 
tion of the operation, and my reasons for performing it in the /nan- 
ner I did. 
It is well known that Dr. Rhea Barton of Philadelphia, first ope- 
rated for a deformity of this kind by making a V section in the 
shaft of the bone and thus bringing the leg from that point down 
parallel with the other and obtaining anchylosis in an improved po- 
sition. And the late Dr. J. Kearney Rodgers of this city repeated 
the operation in another case, only higher up in the shaft of the 
bone with equally good results. But my object was to go above 
the trochanter minor, so as to retain the insertion of the psoas 
magnus, and illiacus-internus muscles attached to the lower frag- 
ment, for the purpose of flexion, and by cutting out a semicircular 
piece thus X with its concavity downward, and then rounding 
off the upper end of the lower section I would more nearly imitate 
the natural joint, and give him a fair chance for motion at that point, 
with less danger of the parts slipping by each other when he walked, 
than there would be if I cut out a parallelogram, or a V shaped 
piece. 
The plan of the operation will be seen in the annexed figure No. 3. 6 
The description of the operation, and notes 
of the case, are taken from the hospital records, 
which were kept by Dr. Shaw, house surgeon at 
that time, and at present in the U. S. Navy. 
"An incision of about six inches was made 
over the trochanter major, in the axis of the limb. 
The cut was slightly lunate, with the concavity 
looking downwards. The lips were then separated, 
and the deeper structures, including the peri- 
osteum, were detached from the bone. 
A curved instrument, armed with the chain 
saw, was passed around the bone between the 
trochanters, and the femur first sawn transversely 
across. A roof-shaped piece was then sawn out 
of the upper fragment.* The limb was then put 
upon moderate traction, longitudinal and lateral; 
the margins of the wound approximated by adhesive straps, and cold 
dressings applied. 
June loth. Wound begins to suppurate, and looks very well ; 
no constitutional excitement. 
16th. He has considerable pain in the limb, and has been unable 
to sleep. Relieved by increase of extension. 
20th. Patient finds that pain is relieved sometimes by less 
extension. 
July 4th. He has less pain; purulent discharge free. 
Sept. 1st. Since last report patient has experienced no untoward 
symptoms; discharge from wound is now very slight. All exten- 
sion is removed, and he begins, to sit up. General condition very 
good, and has improved very much in flesh since admission. 
Oct. 12th Since last report patient has been walking around the 
hospital on crutches, which had to be lengthened seven inches, as 
he is that much taller than he was before the operation, and is now 
quite straight, except the lateral curvature of the lower lumbar 
vertebras, which raises one side of his pelvis more than the other 
and makes the right leg apparently shorter than the one from which 
the segment of bone was removed; but this is easily rectified by a 
higher heel on that side. He can sit down in a chair, and get up 
without assistance, except such as he obtains from his crutches. 
To-day he walked into the ampitheatre by the aid of his crutches, 
and exhibited himself to the class, and left the institution well, and 
with very good motion at both hip joints." 
Fig. 3. 
1, head of femur ; 2, tro- 
chanter major; 3, trochant- 
er minor; 4, line of in- 
sertion of capsular liga- 
ment (variable); 5, ten- 
don of psoas mag and illiac- 
us interns muselc ; 5, line of 
curved section; 7, line of 
transverse section; 8,8, dot- 
ted lines indicatingrounding 
off of lower fragment after 
removal of the segment. 
* In my second operation, see page 116, I sawed the curved section first, and should 
advise the operation to be performed in that way, for reasons which are there given. 7 
About three weeks after he left the hospital, he was attacked 
with acute pain in the region of the wound, which became inflamed, 
and soon suppurated. In a few days a small semicircular piece of 
bone came away, and four days after, another similar piece; the 
two together making almost a ring, and seemed to be exfoliations 
from the lower fragment. All the pain immediately left him, and 
the wound healed in a very short time. 
Mr. Anderson remained in the city until late in December, when 
he left, very unexpectedly, for Kentucky. 
The night before he left he walked to my office, and could go up 
and down the steps without any difficulty; could stand on either 
leg without either crutch or cane; could take a step with either 
foot 27 inches, and when he supported his body on his crutches, 
could abduct his legs so that his heels were 36 inches apart. He 
could cross either leg over the other below the knee, without assist- 
ance, but could not cross them upon the thigh. 
The following extract is from a letter of his dated the 20th Jan- 
uary, 1863 : 
"My leg is getting on famously, since I came to Kentucky. The 
first day after leaving New York I grew very tired, but continued 
night and day until we arrived at Cincinnati. I believe that when 
I got to Cincinnati I was fresher than when I started. We were 
in the city about half a day, and then came on to Lexington, stayed 
all night, and again resumed our journey. So far from being ex- 
hausted at the end of the trip, I started next morn- 
ing in a buggy and drove some twenty miles. I 
think if I had been compelled to travel a thousand 
miles before stopping, I could almost have danced 
a jig at the termination of the trip. But to speak 
seriously, I think I am doing very well indeed, and 
my leg gains strength continually." 
Fig. 4 is engraved from a carte visite, which 
was received after the paper was sent to press, in 
a letter dated Spring Station, Woodford Co., Ky., 
April 11, 1863, in which letter he states : " lean 
now ' rough it ' a little without apprehension of 
having to suffer for it afterwards. I can bear my 
whole weight on my left leg without inconvenience, 
and can walk very well without other assistance 
than a walking stick, and the improvement is as 
great in a month now, as at any previous time." 
Note.-With the exception of figures 1, 2, 5, 9, all the drawings were made by Gregory 
Doyle, medical student in my office, to whom I must express my obligations. 
Figure 4. 8 
Case II. Anchylosis of Left Hip, Section of Elliptical Segment of Femur 
above Trochanter Minor. Recovery, with False Joint and good motion. 
Miss Susan M. Losee, of Buffalo, N. Y., aged 24, of healthy 
parents and of a robust and vigorous constitution, was attacked 
with pneumonia in March, 1856; attended by Dr. F. H. Hamilton, 
After three weeks went down stairs, contrary to the advice of her 
physician, and the following day was attacked with intense pain in 
the left hip and thigh, which was constant, persistent and most 
severe for several months. She did not fall or receive any injury 
that she was aware of, but it was supposed that she must have 
wrenched her hip in some way going down stairs, as she was very 
weak and went down without any assistance. During the first few 
weeks her leg was straight and could not be flexed, abducted or 
adducted without intense suffering. Bed sores by this time had 
become so extensive as to make it imperative to change her posi- 
tion, and in doing this, her limb was forcibly flexed at the knee and 
hip, but with the most intense pain; and when flexed in this posi- 
tion it could not be extended again without the greatest suffering, 
and was therefore permitted to remain in the flexed posture. 
New sloughs appearing over the right trochanter, she was placed 
in a large chair and was not removed for two months, when slough- 
ing occurred over the tuber ischii, and at the extremity of the 
coccyx, and she was again compelled to assume the horizontal posi- 
tion, and being forced to lie upon the right side, the left thigh was 
thrown over the right, in a flexed position, and thus became perma- 
nently and perfectly anchylosed, at the expiration of about seven 
months from the commencement of the disease. 
No local application was made to the hip, but the pain and con- 
stitutional difficulty was combated principally by morphine, and 
no extension was applied to prevent the muscular contraction and 
deformity. When she recovered, her left 
thigh was permanently flexed, at about 
forty degrees with the pelvis, and strongly 
adducted across the lower third of the 
right thigh, as seen in the accompanying 
drawings which were taken from life. 
Fig. 5 represents her standing. Fig. 6, 
in the act of walking. 
In the erect posture, the heel of the 
left foot was ten and a half inches from 
the floor, and on the right side of the 
right leg. In attempting to walk, it was brought to 
Fig. 6. 
Jig. 5. 9 
the floor, still on the right side of the opposite limb, or cross 
legged; and was made to reach the floor by a remarkable cur- 
vature forward of the lumbar portion of the spinal column; 
but walking was attended with great fatigue, and a peculiar 
dull pain in the lumbar region. Urination produced constant 
excoriation of the limbs, requiring great care and trouble in 
drawing a handkerchief or soft rag between the closely com- 
pressed thighs, to keep them clean or comfortable. Several efforts 
were made to insert a catheter, in order that the urine might be 
led off without irritating her limbs; but it was impossible to insert 
the finger so as to reach the orifice of the urethra, either from the 
anterior or posterior position, although every effort was made, and 
with great perseverance. 
She remained in this condition until the 6th of November, 1862, 
seven years. She came to New York and placed herself under the 
care of Dr. C. F. Taylor, in the fall of 1861, who thought the 
anchylosis was simply fibrous, and capable of being relieved by 
passive movements. Dr. Van Buren saw her at this time, and 
diagnosticated the case as one of true bony anchylosis. I saw her 
in April, 1862, in consultation with Drs. Taylor, Peaslee and E. Lee 
Jones, and confirmed the diagnosis of Dr. Van Buren; but it was 
thought by all present that I might possibly break up the adhesions 
if I preceded the attempt by section of the tendons of the contracted 
muscles. 
Accordingly, on the 10th of April, assisted by Drs. Peaslee, Tay- 
lor and Jones, I divided, subcutaneously, the adductors longus and 
magnus, the gracillis and pectineus, the rectus, sartorius and tensor 
vaginae femoris, and immediately closed the wounds with adhesive 
plaster, and applied a firm roller. No hemorrhage followed the 
operation. The pelvis was then firmly secured and every effort was 
made to give motion to the joint, that was consistent with safety or 
prudence, but without the slightest benefit whatever, and we were 
all satisfied that an entire section of the bone by the saw, was the 
only way that the limb could be moved from its flexed and fixed 
position. The patient was under the full influence of chloroform, 
administered by Dr. Jones, and was entirely insensible during the 
whole operation. The wounds healed kindly in a few days, without 
suppuration, and she was then in exactly the same condition as she 
was previous to the operation. As the weather was getting warm, 
I determined to leave her until fall and then make a section of the 
bone above the trochanter minor, and give her a chance to form an 
artificial joint, similar to Anderson's case. 
On the 6th Nov., 1862, assisted by Profs. Peaslee and Raphael, 
and in the presence of Dr. J. P. Batchelder and Mr. Donne, medical 10 
student, I performed the following operation : The patient having 
been put under the full influence of chloroform, a longitudinal inci- 
sion six inches in length was made over the trochanter major, com- 
mencing just above its crest, and as near as possible to its centre, 
and carried directly down to the bone. About the centre of the 
incision I made another at right angles to it, in the posterior flap, 
but only carried it through the tegumentary and adipose tissue and 
the femoral fascia. The blade of the knife was then laid aside and 
with its handle and an elevator something like an ordinary oyster 
knife, I carefully peeled off the attachments from the bone, on its 
anterior surface, until my forefinger could reach the trochanter 
minor in front. The same thing was then done on the posterior 
surface of the bone, and the two fingers could then surround the 
bone, with the exception of a thin, firm fascia, between them on 
the front. This was readily pierced by a steel sound, curved to fit 
the femur, at this part, and a chain saw was then drawn through 
above the trochanter minor, which could be distinctly felt and was 
my guide. 
About half an inch above it I commenced to saw, and carrying 
it first upward and outward, then outward, and then downward and 
outward, I made a curved section with its concavity downward, 
thus X" .* The saw was again passed around the bone, as at 
first, and inserted about an eighth of an inch below the first section 
and the bone sawed square off, at right angles with the long diame- 
ter of the bone. The segment thus removed was one-eighth of an 
inch in front or internal margin, three-fourths at its middle, and 
nearly half an inch at its external margin, as seen in Fig. 7. 
The bone was very dense in tex- 
ture, almost eburnated, as seen in 
Fig. 8, which represents the lowei 
section. 
There was not more than two oz. of blood lost in the operation, 
and no ligature was necessary. y 
-- ------ -- 
Fig. 7. 
Fig. 8. View of lower surface. 
* It will be seen that in this case I reversed the order of the section of the bone from 
what I did in Anderson's case, and made the curved section first, and I should advise 
the operation to be performed in this way, as it is much easier and you are more cer- 
tain to make your saw enter at the part desired when the shaft is complete, besides 
having the limb to keep the parts steady while the section is made. And as it requires 
some little delicacy of manipulation to carry a chain saw in this position in the curve 
required, it is well not to add to the complication by having a movable bone. 
It may be asked, why not make both sections curved ? Because it is so difficult to do 
it with accuracy, when one end of the bone is movable, and as the rounding off of the 
lower section is more simple and equally satisfactory, I prefer it. 11 
The wound was brought together by two sutures and adhesive 
plaster, except the posterior incision, which was kept open by a 
tent of oakum. Adhesive plaster was applied below the knee, for 
the purpose of making extension, and a roller applied tolerably 
firm, from the toes up, over the entire limb, and around the pelvis. 
She was then put in bed, the foot of which was raised some 
twelve inches higher than the head, and a pulley applied, over 
which a weight was attached by a cord to the adhesive plaster, for 
extension, the same as in a case of fracture of the thigh. Lateral 
extension was also applied to the upper portion of the thigh, to 
keep the upper end of the femur from crowding against the femoral 
vessels, by means of a broad band passed around the thigh and a 
cord attached to its outer aspect, which played through a pulley 
fixed in an upright by the side of the bed, just below the pelvis, 
and a weight attached. By this means the limb was brought in its 
natural position, parallel with the other and apparently of the same 
length. Ten drops of morphine were given, with instructions to 
repeat if necessary. 
The following record of the case is an abstract from my note book : 
17th Nov. Has had a very comfortable night; urinated without 
scalding her limbs, for the first time in seven years. No hemor- 
rhage, or much heat of limb; pulse 94 ; complains of pain in the 
back, otherwise perfectly well. 
IIP. M. Pain in the back very severe, just at the lower lumbar 
vertebrm, which is carried very much forward, and can only be 
relieved by being well bolstered up, and by raising the head and 
shoulders almost to the sitting posture. 
18th. Slept well all night, with only 60 drops of Majendie's solu- 
tion ; pulse 94, and only complains of her back, which requires to 
be pressed frequently and quite firmly to make her comfortable; as 
it was difficult to use a bed-pan, and without it the urine soiled the 
bed and excoriated her person, I drew it by the catheter, which 
can now be inserted without the least difficulty. 
19th. Wound commencing to suppurate, at the tent, the rest of 
the wound united by first intention ; removed the sutures without dis- 
turbing the adhesive plaster; pulse 94 ; bowels moved naturally, and 
with the exception of pain in the lower part of the back, feels well. 
Dec. 1st. No particular change since last report; suppuration 
healthy and not profuse. The only complaint she makes is from 
her back, and the difficulty she has in using the bed-pan. I put her 
to-day upon Dr. Nelson's fracture bed, which is a triple inclined 
plane, with an opening for defecation, and it has made her very 
comfortable indeed-and the extension was accomplished by simply 
flexing the legs at the knee, over the inclined plane, as seen in Fig. 9. 12 
Figure 9. 
Tins fracture bed was first constructed by Dr. Robert Nelson, of 
this city, formerly of Canada, and for convenience and comfort, as 
well as fulfilling all the indications required, is the most perfect con- 
trivance I have ever used, and I cannot speak too highly in its favor.* 
From the time the patient was placed upon it until she entirely 
recovered, a period of nearly four months, she was perfectly comfort- 
able-could be raised or depressed to any desired angle, as often as 
required, without inconvenience, which greatly added to her com- 
fort, by the change of position. The wound healed entirely within 
four weeks, except a very small opening in the posterior cut, which 
was at the most dependent position, and from which a small dis- 
charge of pus escaped ; this discharge gradually diminished and 
finally ceased about the 1st of March, four months after the ope- 
ration. Two small pieces of bone escaped during this time the size of 
a pin's head. For some weeks before its stoppage the discharge 
consisted of only a few drops in a day, of a very peculiarly whitish- 
yellow semi-fluid, of the consistency of thick starch water, and upon 
examination proved to be nearly pure albumen. 
*In Hesselbach's Handbuch der Chirurgischen, printed in Jenna, 1845, will be found 
an almost exact duplicate of Nelson's bed on plate xxxix, with a description on page 
1036, as having been constructed by Weckcrt; but as Dr. Nelson made his bed in 
1820 we must give him the preference of priority 
Figure 10. Dr. Nelson's fracture bed. 13 
After the first ten days from the operation I made slight move 
ments of the limb very frequently, in order to prevent anchy- 
losis, and this was also accomplished by the extension, which kept 
the severed bones from coming in contact with each other, and thus 
prevented osseous adhesion. 
I gradually increased the extent of these motions, until, about the 
first of February, I could flex and extend, rotate, ad and abduct 
the limb with almost the freedom of a natural joint, and could also 
press the bones together with considerable force without pain. 
On the 8th of February, 1863, she got out of bed for the first 
time-the limbs are perfectly symmetrical and parallel-the left 
nearly three-quarters of an inch shorter than the right, when her 
weight is put upon it; but when she stands erect upon the other 
limb, it falls down, and is nearly if not quite as long as its fellow. 
By pressing it up you can shorten it a full half inch, and by concus- 
sion it gives a smooth, cushioned feel to the hands, without any crep- 
itus or pain to the patient. 
July 20th. She begins to have some control over the movements 
of her limb by voluntary muscular contraction, and can bear nearly 
her whole weight upon it as seen in figure 11. 
The motions are nearly as perfect as those of the natural 
limb. From the perfect success attending the operation 
in these two cases of true anchylosis, and the freedom 
from all danger, as well as ease of its peformance, I feel 
justified in recommending it to the profession as safe, and 
am satisfied that it will become established as one of the 
proper operations in surgery. 
Sequel. 
The patient progressed rapidly and favorably dur- 
ing several weeks, being able to bear her entire weight 
on the affected limb, with perfect freedom to passive 
motion, and gradual increase of control over the volun- 
tary movements. 
isne was acquiring sufficient command over the limb to enable 
her, as the result of practice, to walk around her room, the exercise 
conducing to the improvement of her general health, as well as to 
the education and development of muscles which had long remained 
dormant; when, about the 1st of February, in opposition to my 
advice, she removed her flannels. She remained with them off for 
several days, and, on the 4th and 5th of February, being exposed 
for some hours to the intense cold then prevailing, she had a severe 
Fig. 11. 14 
chill, followed by great difficulty in breathing, pain in the chest, 
cough, &c., arising from congestion of the lungs. 
She neglected to send for me at once, and when she did_I was 
out of town, and she refused other medical attendance. She grew 
worse rapidly, and when I saw her upon my return, I at once 
recognized her condition as one of extreme danger, and requested 
the presence of Dr. Flint in consultation. 
We found the left lung had become almost hepatized, and for 
some days no respiration could be detected on that side. Under 
treatment resolution gradually took place, with the exception of 
an abscess in the upper lobe of the left lung, which Dr. Flint 
thought was the result of an apoplectic effusion. Dr. Flint did not 
at this time diagnosticate tubercles, but did at a later period. 
To the pneumonia was superadded, in a short time, pleurisy of 
the left side. The urgent symptoms of the pneumonia were sub- 
dued, but the cough, which was very distressing, continued. There 
was no expectoration at any time. 
Under a sustaining plan of treatment, with spirits of turpentine 
locally over the hepatized lung, she improved, and I was encouraged 
in the hope that the abscess might become sacculated, and remain 
circumscribed. 
The weather, up to about the middle of April, had been too 
inclement to allow her the advantages of passive out-door exercise, 
which, together with nourishment, was now considered the principal 
treatment required. 
During all this time the cough had remained of. the same rack- 
ing, distressing character, and without expectoration. 
On the 20th of April, she complained of some pain in the vicinity 
of the cicatrix of the wound left by the operation, and the lower 
part of the wound became inflamed and puffed out, although it had 
been closed several weeks. 
On the 22d, an abscess having formed, the wound opened, and a 
small curved piece of bone escaped, about one-eighth of an inch 
long, and of the thickness of an ordinary probe, quite rough and 
jagged. 
The wound discharged a little bloody pus for a few days, after 
which it gradually merged into the same kind of oily fluid as had 
exuded during some months subsequent to the operation. 
This, in a few more days, began to diminish, and gradually the 
wound again closed, leaving no tenderness upon pressure, or from 
motion of the new joint. 
She could again bear her whole weight upon the limb without 15 
inconvenience, and her command of its movements materially 
improved. 
About the 1st of May she changed her residence, and for a number 
of days improved rapidly in strength and flesh, the principal 
annoyance being the cough. 
On the 10th of May, having business out of town, I left the case 
in charge of Dr. Flint, who prescribed, for the cough, codeia, four 
grains, to simple syrup, four ounces, with directions to the nurse 
to give the patient a teaspoonful once in three hours while the 
patient remained awake, but to discontinue it while she slept. 
During the night, as the result of larger and more frequently 
repeated doses of this mixture than had been ordered--which 
appeared from the admission of the nurse, and the small quantity 
left in the bottle-the patient had become thoroughly narcotized, 
and subsequently suffered for more than forty-eight hours, with 
most alarming symptoms of narcotic poisoning. 
The utmost exertions on the part of Drs. Flint, Peaselee, and 
Wells, were required to sustain life, in consequence of the stomach 
rejecting stimulants, coffee, &c. 
The cough had now entirely ceased, and never returned. 
Great distress in the lungs was complained of, and partially 
relieved by counter-irritants. The stomach continued so weak as 
not to retain even a teaspoonful of iced water. 
On the 12th she had recovered from the severe symptoms, when 
a relapse occurred from the administration of another dose of the 
cordeia, in direct violation of orders that no more should be given, 
which it seems were misunderstood by the nurse. During the night 
the patient was violently delirious, her screams arousing and dis- 
turbing the household until morning, when Dr. Wells administered, 
by inhalation, a small quantity of chloroform, which at once calmed 
the patient, and she slept for several hours. 
I returned on the 13th, and found her still in a wild and dis- 
stracted state of mind, and excessively prostrated, the stomach not 
having retained anything for several days. 
The process of nutrition was necessarily suspended, and the 
patient was dying in consequence. 
The stomach had lost all tone as the result of protracted nar- 
cotizing, induced carelessly, but with humane intent, and she was 
now sustained by enema. 
On the 14th she had rallied, and become quite cheerful, but had 
no recollection of the terrible ordeal through which she had passed. 
Later in the day, while I was sitting by her bed, she suddenly had 
two severe convulsions, during which her lower limbs were flexed 16 
at a right angle, and strongly adducted, the left one requiring 
almost as much force to straighten as the right. 
The nurse stated that the patient had had a similar fit during 
the preceding night, the limbs being fixed in the same manner for 
a long time, and that when the spasm passed off she voluntarily 
straightened her limbs. 
On the 16th she sat up about an hour, and after getting back in 
bed, discovered that the wound had again opened and discharged 
a few drops of bloody serum. 
She passed a remarkably good night, and on the following day 
felt so much better that she begged me to allow her to take a ride 
the next day. 
I tried to persuade her that she was too weak, but she was quite 
importunate, and after I had left, in order to test her strength in 
view of the anticipated ride, she got out of bed, and sat up in a 
chair for two hours. 
The exertion was too much, and she fainted. 
I was hurriedly summoned, and found her cold and pulseless, 
except at the carotids. Pupils much dilated ; jaws relaxed; respi- 
ration very feeble and slow; unable to swallow. Brandy was given 
in enema, but not retained. 
She gradually recovered consciousness and ability to talk, which 
she did rationally, but grew weaker and weaker until about six, 
p. m., on the 17th, when she died from exhaustion. 
Post Mortem. 
An examination of the body was made about thirty-six hours 
after death, in the presence of Profs. Bush, of Lexington, Ky. ; 
Parker and Raphael, of New York; and Drs. Spencer, of Water- 
town; Batchelder, Dewees, Stone, Bernachi, Elsburg, Wells, Swift, 
Doyle, and Peck, of New York. 
The body was extremely emaciated; the left leg being parallel 
with the right, the foot lying in the natural position, and was 
found to be half an inch shorter, and admitted of free, passive 
motion in all directions without crepitation. Upon opening the 
thorax, adhesions were noticed of various portions of the pleura 
and lungs, and a large abscess in the anterior portion of the upper 
lobe of the left lung. Two quite small abscesses were found in the 
lower lobe of the right lung, but neither of them communicated 
with the bronchi. 
There was infiltration of deposit throughout the substance of the 
upper lobe of the left lung, which, under the microscope, was deter- 
mined by Dr. Dewees to be tuberculous. 17 
Upon examination of the artificial joint, it was found to be pro- 
vided with a complete capsular ligament, and the articulating 
surfaces were tipped with cartilage, and furnished with synovial 
membrane. (See Fig. 12.) 
There was a very small spicula of bone, which had exfoliated 
from the lower section in the orifice of the external wound, and 
which would have escaped in a few days. Four other small 
fibrillm of bone, about one-half inch in length, and the thickness of 
the lead of an ordinary pencil, were found attached at one of their 
extremities, by periosteum, to the margin of the new head of tho 
femur; their three extremities were thrust into the tissue around 
the joint. They were easily pulled 
off, having nearly exfoliated, and 
doubtless would have come away 
as the other pieces had done, had 
the patient lived. 
All the other parts of the head 
and the new acetabulum were 
smooth, and covered with cartilage. 
The conjunction of the articu- 
lating surfaces was perfected by 
the formation of two round liga- 
ments springing from the surface 
of the new acetabulum, and by their 
convergence at the same point of 
attachment to the new caput femoris 
formed a new ligamentum teres. 
These converging portions of the 
Ligament were fan-shaped, and 
united at the sulcus of the new 
head of the femur. 
A portion of the ilium, together 
with the cotyloid cavity, contain- 
ing the anchylosed head of the 
femur, was removed, and upon 
section through the original aceta- 
bulum and caput femoris, only a slight line of demarcation was 
discoverable, the whole joint being fused into one solid, bony mass. 
(See Fig. 13.) 
As I have recently exsected a perfect artificial joint, in a case of 
ununited fracture, and which was examined by Prof. Austin Flint, 
jr., and found to possess all the characteristics of the natural joint, 
and as I have not been able to find an examination of this kind 
Fig. 12.-a, a, a, a, capsular ligament 
opened and reflected, b, b, round ligament 
in imitation of ligamentum teres, c, articu- 
lating head of lower section, covered with 
cartilage, d, d, new acetabulum, covered 
with cartilage; both lined with synovial 
membrane. 18 
recorded, I publish it in connection with this paper, as it illus- 
trates the manner in which nature effects a cure in these cases. 
Figure 13. 
Exsection of Ununited Ulna-True False Joint with Capsule 
and Cartilage. 
Mrs. G., aged 34, was admitted into the medical wards of 
Bellevue Hospital, in August, 1861, suffering from paralysis. la 
September she fell whilst attempting to get out of bed and frac- 
tured both bones of the forearm. She partially recovered from 
her paralysis, but the bones never reunited, and she was sent 
to the Island Hospital, and came under my charge in February, 
1863, seventeen months after the accident. 
She had so far recovered from the paralysis as to be able to walk 
tolerably well, and the upper extremities were as muscular and 
powerful as ever, but the right arm was entirely useless on account 
of the ununited fracture about the junction of the middle and 
upper third of the forearm. 
On the 19th of February, 1863, I cut down upon the bones at 
this point, intending to saw off the ends of the ununited portions 
and obtain reunion by a readjustment of the bones, but when I came 
down to the point of fracture, I found it had been very oblique, and 
separated about a quarter of an inch, thus, 
and had become attached by a very firm 
ligamentous band, which admitted of quite a 
free gliding motion, without any crepitus 
whatever, and I decided to remove the en- 
tire portion, without severing the attach- 
ments of the artificial joint. 
I therefore sawed out a portion half of an inch in length, which 
embraced the artificial joint and brought the bones fairly together 
and dressed with splints in the natural position, with the exception 
of the necessary shortening. 
Fig. 14. 19 
One of the sections passed through the new joint at A, thus 
giving an opportunity of examining its internal character and 
structure. B, shows the lines of the saw. The ligamentous attach- 
ment was more than one- 
eighth of an inch in length, 
very firm-tense and of a 
silvery shining whiteness. On 
looking at the open section, it 
had the smooth and oily ap- 
pearance of a natural joint, 
and the motions of the bones 
upon each other were perfectly 
gliding without any friction 
or roughness. 
Dr. Austin Flint, jr., ex- 
amined the specimen by the 
microscope and reports that 
the lining is true cartilage, and it is therefore as perfect in all its 
physiological characters as any natural joint. 
The annexed diagram shows the cartilage, cavities and cells, a 
taken by Dr. Flint under the microscope. 
Fig. 15.-Cartilage, Cavities and Cells. : 
A, cart, cavities without cells; B, cartilage, cavities and, 
cells. J