SURGICAL GASES 
IN 1867. 
DAVID W. GHEEVER, M.D. 
SURGEON TO THE BOSTON CITY HOSPITAL. Reprinted from the Boston Medical and Surgical Journal. SURGICAL CASES. 
Case I.—Naso-pharyngeal Polypus, attached to the Basilar Process 
of the Occipital, and Body of the Sphenoid Bones, successfully removed 
hy a Section, Displacement, and subsequent lie-placement and Re-union 
of the Superior Maxillary Bone.—(Service of Dr, Cheever.) The 
patient, a student, eighteen years old, entered the Hospital, July 20th, 
with the following history:— 
About two and a half years ago he had profuse epistaxis, which 
continued twenty-four hours. During the six months next following 
this, he had only occasional slight attacks. At the end of that period 
he found that his right nostril was wholly obstructed, and he has never 
since been able to blow through it. He soon became aware of a 
growth behind that nostril, which gradually but steadily increased, 
until within a few weeks of the time of entrance, when it grew ra- 
pidly. There was some discharge, but it was not offensive until quite 
recently. 
At the time of admission to the Hospital, the soft palate was 
found to be depressed and pushed forward until it hung at a right 
angle with the hard palate, and both it and the tonsil were inflamed. 
At the right side of the fauces a small ulcerated patch could be seen. 
By the finger, a tumor could be felt behind the soft palate, firm, full 
and lobulated, and extending farther up than the finger could be car- 
ried. Its lower lobes hung down into the throat. The whole of the 
upper part of the pharynx was occupied, except a small space on the 
left side. Nothing could be passed into the pharynx through the 
right nostril, but the left was clear. Hearing was imperfect in 
the right ear; and the respiration was mostly through the mouth. 
The microscopical examination of the debris of the tumor, removed 
by a digital examination, revealed only blood corpuscles, pus cells 
and fibrous tissue. There was no evidence of malignancy. 
The patient was able to take liquid or soft food only. The gen- 
eral health was good, with no hereditary predisposition. He was 
very desirous of an operation for the removal of the tumor. 4 
SURGICAL CASES. 
There was no question that the tumor must be removed, or, before 
long, cause the death of the patient. The problem to be solved was 
as to the best method of operating. Three modes offered themselves 
for consideration. 
Ist. By ligature, or the icraseur, through the nares. This was 
impracticable, because nothing could be passed through the right nos- 
tril opposite to which the bulk of the tumor lay; also because it 
was not a pedunculated growth. Were it practicable, it could only 
cut off the growth, without eradicating it; and it would, probably, 
speedily recur. 
2d. By section of the soft palate, of the hard palate, and re- 
moval through the mouth, with a subsequent operation for staphy- 
loraphy. This mode, advocated and revived by Nelaton, but really 
as old as Hippocrates, was abandoned on account of the size and 
high attachments of the tumor, and the fear that room enough to ma- 
nipulate could not be got through the section of the hard palate. 
3d. By removing the superior maxilla—a plain and easy way, 
but accompanied by deformity and serious mutilation. Here was a 
young man with a.healthy jaw and perfect teeth, and the disease whol- 
ly behind it. Could a portion of the jaw be saved ? or even the 
whole replaced ? I decided to make a horizontal section of the jaw ; 
depress it, saving all attachments of the soft parts possible; see if 
the tumor could thus be reached; and, if practicable, to replace the 
jaw, and try to save it. 
July 23d.—Operation. The patient was etherized during the 
first part of the operation, and partial etherization was renewed at 
intervals; he was seated in a chair, with the head on a pillow. 
An incision was made from just' below the inner canthus of the 
right eye, downwards by the side of the nose, following the naso- 
labial fissure, to the corner of the mouth. The inner flap was dis- 
sected up until the symphysis was exposed; and the outer, until near- 
ly the whole of the superior maxilla was free. With a narrow- 
bladed saw, about three inches long, the superior maxilla was now 
divided transversely, about half an inch below the floor of the orbit. 
The blade of the saw was plunged into the zygomatic fossa, and the 
front and back walls of the antrum were sawn through horizontally, 
starting just below the articulation with the malar bone, and termi- 
nating in the anterior nares, at the lower end of the nasal bone. 
The ala of the nose having been lifted up, the right central incisor 
was next extracted. Strong bone forceps were now used to divide 
the alveolar process, through the socket of the right central incisor. 
The cut included the alveolus only. The hard and soft palate were 
not touched. The bone was now held by the palate process, palate 
bone, and its co-ossification with the pterygoid processes. Seizing 
the alveolar process with strong tooth-forceps, the whole section of 
the superior maxilla was bent down and displaced into the mouth. 
The antrum was found to be filled by one lobe of the tumor without NASO-PHARYNGEAL POLYPUS. 
5 
attachment, while the body of the tumor was attached to the upper, 
back part and right side of the pharynx and to the base of the 
sphenoid bone. The body was very firm, and the attachments were 
broad, covering a space two inches square. These, with consid- 
erable difficulty, were severed by scissors, introduced through the open- 
ing above the depressed section of the superior maxilla, and the base 
was cauterized repeatedly with strong nitric acid. The haemorr- 
hage, which was not excessive, was thereby effectually checked. Four 
ligatures were applied to bleeding vessels in the course of the first 
incisions. With the forefinger of the right hand in the throat, and 
the left in the cavity above the section of the maxilla, they could be 
made to meet freely, and explore thoroughly the pharynx, which was 
now found entirely clear of obstruction. 
The superior maxillary bone was now hanging with its antrum 
exposed; and attached by the bent, or broken hard palate, the un- 
broken soft palate, and the broken osseous, and unbroken muscular 
and vascular attachments of the pterygoid process of the sphenoid 
bone. On these attachments we were to rely for the restoration of 
the bone. The maxilla was easily pushed up into its place, and 
held by a silver wire passed round the left central, and right inci- 
sor teeth; and by the closing of the lower jaw. The flaps of skin 
were accurately approximated, and united in place by six interrupted 
sutures. 
At the close of the operation, the pulse was 120 and of fair 
strength. Wine, iced milk, beef tea and opium were ordered, 
pro re natd. 7 P.M. Pulse 132. Reaction good. Takes nourish- 
ment freely. No vomiting or pain. Urine free. R. Pulv. Dovcri, 
grs. x. 10 P.M. Sleeping quietly. Pulse 88. Respiration free. 
July 24th, A.M.—Pulse 120, good. Patient in good spirits. 
Face drawn a trifle to left side. ' There is a little swelling of the 
face, and some offensive odor from the clotted blood. The parts 
syringed with R. Tr. myrrh., § i.; aqua, g iv. M. P.M. Pulse 130. 
No pain. Takes beef-tea, milk, eggs,j &c., freely. Sleeps consider- 
ably. Functions regular. 
July 25th.—Pulse 96. Except some drowsiness, feels very well. 
Appetite good. Sutures removed, and good union found. Eye near- 
ly closed by adjacent swelling. The nares and pharynx to be 
syringed twice a day. 
July 26th.—Pulse 112. Looks brighter. Eye very much better. 
Union of flaps quite firm. 
July 28th.—Improving. Discharges more moderate and less offen- 
sive. Upper jaw in good position, having fallen only a very little. • 
Appetite good; bowels regular; sleeps well; no pain. 
July 29th.—A small swelling of palate just behind incisor teeth 
lanced. Discharge of pure blood. General condition of patient as 
good as usual. 
July 30th.—Ligatures all away. External wound entirely healed. 6 
SURGICAL CASES. 
Ang. Ist.—Quite comfortable. Discharge diminishing. A small 
piece of gutta-percha was moulded between upper and lower jaws 
of right side, and a bandage around the head and chin to keep the 
bone up in place. 
Aug. 3d.—Steadily improving. Jaw in good position. 
Aug. sth.—Discharge from right nostril about normal. Patient 
walks about Hospital grounds, without suffering any inconvenience 
or pain. 
Aug. 12 th.—Still doing admirably. No purulent discharge. Some 
pain on pressure where the jaw was sawed across. Plug between 
jaws continued. No appreciable motion of parts of bone. 
Aug. 22d.—Progressing very favorably. Bandage and gutta per- 
cha removed. Union of maxilla firm. Pour weeks since operation. 
Aug. 2 Bth.—Discharged at his own request, well. Still wearing the 
wire about the teeth. 
Sept. 2d.—Deported himself at the Hospital, in excellent condition. 
The wire removed. Union perfect; able to chew; now six weeks 
since the operation. Respiration clear. Examined with the rhi- 
noscope by Dr. Langmaid, and the pharynx found healthy. A slight 
catarrh from the right nostril; nothing more. 
Case ll.—Popliteal Aneurism treated hy Flexion. Recovery.—(Ser- 
vice of Dr. Buckingham.) E. 8., set. 40, a laborer, entered the 
City Hospital March 13th. His health had always been good. 
Ten weeks ago, he first noticed a swelling in the right ham, which 
has slowly increased in size since. He can assign no cause for its 
appearance. It has begun to be somewhat painful of late; darting 
pains shooting through the calf. 
Now, has a pulsating tumor, three inches long and one and a half 
broad, in the right popliteal space. No redness; no oedema either 
there, or below in the foot. No tenderness on pressure. The swell- 
ing is even, fusiform and smooth; and seems like a dilatation of the 
popliteal artery, gradual, uniform and not diffused. 
Compression over the femoral artery checks all pulsation in the 
tumor. Flexion of the leg on the thigh stops the pulsation in the 
tumor, as well as in the anterior and posterior tibial arteries. 
After consultation, a trial of the treatment by flexion was deci- 
ded on. 
Flexion was begun March 20th, and morphia subcutaneously or- 
dered, when needed. Flexion was borne by the patient only about 
sixteen hours, and even then with some minutes of occasional exten- 
sion. At no time was the current wholly stopped in the tumor, but 
only retarded. At the end of this period of about sixteen hours, the 
tumor had changed in appearance. It was somewhat shorter and 
very considerably wider than before. The patient was unwilling to 
have the leg flexed again, on account of the pain, and it was deter- 
mined to wait and see the result. POPLITEAL ANEURISM. 
7 
March 22d, the following day, the tumor had diminished in size; 
there was only a feeble pulsation, and very little pain. 
2-3d.—Tumor hard to the touch. No pulsation in it, or the tihials 
below. Two days only since flexion was discontinued. 
31st.—Tumor has been quite tender to touch. Now, less so. No 
return of pulsation. 
April sth.—Tumor diminishing in size. No pulsation below tu- 
mor yet. 
13th.—About this time pulsation was detected feebly in the dor- 
salis pedis artery; between three and four weeks since the operation. 
30th.—The circulation of the foot is perfectly restored; now about 
six weeks since flexion. The aneurismal sac has shrunk up, and re- 
mains without pulsation, hard, and not sensitive. 
May 10th.—He was discharged, well. 
Case Hl.—Popliteal Aneurism treated by Acupressure. Recovery.— 
(Service of Dr. Cheever.) The patient is 30 years old, by occupa- 
tion a bootmaker. He entered the City Hospital July 30th, 1867, 
having noticed, seven months previously, a small tumor in the left 
popliteal space, which was quite painful. The pain had continued, 
at intervals, up to the time of admission, and was aggravated by 
fatigue, especially after unusual exercise in walking. The tumor 
grew slowly, and it was noticed that the leg was at times considera- 
bly swollen. 
The aneurismal tumor, at entrance, was situated in the left popliteal 
space. The difference in the circumference of the two legs at the 
knee was about two inches. The patient’s condition was otherwise 
good; appetite, pulse, and functions generally, all normal. 
On the day after entrance to hospital, treatment by flexion was com- 
menced. The leg was flexed on the thigh, and retained in position 
by proper straps. Complete flexion almost entirely controlled the 
pulsation of the aneurism, but this at first was not persisted in. One 
fourth of a grain of sulphate of morphia was ordered pro re natd. 
Flexion was commenced at 2, P.M., July 31st. 
Aug. Ist, 6, A.M.—Severe pain until 11 o’clock last night; reliev- 
ed by morphia. Not much sleep during night. Is now quite com- 
fortable. 9.30, A.M.—Severe pain in knee. Morph, sulph. gr. i. 
10.30, A.M.—Pulse 96. Leg and foot somewhat swollen, and tempera- 
ture increased. Pain less. 2.15, P.M.—Pulse 92. Sole of foot 
feels as if 11 needles were sticking in it.” 8, P.M.—Pain in knee 
continues. Morh. sulph. gr. J. 
2d, 6.30, A.M.—Slept well last night. Quite comfortable now. 
Tea and toast for breakfast. Pulsation to be felt distinctly. 10, 
A.M.—Morph, sulph. gr. subcutaneously. 4.15, P.M.—Flexion 
discontinued and leg extended. Pulsation seemed weaker, 6.30, 
P.M.—Flexion renewed (45°). 7.15, P.M.—jft. Morph, sulph. gr. I, 
subcutaneously. 8 
SURGICAL CASES. 
3d, 8, A,M.—Slept well until 2, A.M. Leg extended. Pulsation 
about the same. 10.30, A.M.—Flexion renewed as before. 3.15, 
P.M.—Morph, sulph. gr. I, subcutaneously. 8, P.M.—Leg extended 
for the night. 
4th, 7, A.M.—Comfortable night. Pulsation same. Leg flexed 
at an angle of 45°. Foot and leg swollen and oedematous. 11, 
A.M.—Flexion increased by one half by tightening straps. 12, M.— 
Pain severe through the knee and foot. Morph, sulph. gr. 4, subcu- 
taneously. 8, P.M.—Pain continues. Morph, sulph. gr. subcu- 
taneously. 
sth, 7, A.M.—Flexion remitted. The dimensions of the tumor 
are now as follows:—Transversely, four and a half inchesj longi- 
tudinally, three and a half inches. Pulsation as strong as before 
treatment. 
The following synopsis will exhibit more succinctly the times of 
flexion and extension. Treatment by flexion lasted 118 hours; or 
five days and nights, lacking two hours. 
The first period of flexion at 45° was 52 hours. 
“ second “ “ “ “ “ 
“ third « « « « 9£ « 
“ fourth “ “ drawn up tight, 24 “ 
Flexion, 99 “ 
Relaxation 2 hours. 
“ 24 “ 
“ 11 « 
“ 34 “ 
99 hours of flexion out of 118 hours of treatment, 
19 “ 
It seemed idle to pursue this method farther. The patient was 
getting depressed by it, and no sign of consolidation appeared in the 
tumor. On the contrary, the latter looked as though it might become 
diffused before long. 
Treatment by any form of pressure was therefore abandoned. 
And it remained to resort to the ligature or to acupressure. The 
latter was.decided on. 
Aug. 6th, 11, A.M,— Operation. The patient was fully etherized. 
The leg and thigh were flexed and rotated outward. An incision 
about two inches in length was made in the apex of Scarpa’s trian- 
gle, parallel with the inner margin of the sartorius muscle. The 
femoral artery was readily reached, and a curved director was passed 
beneath it. The long saphenous nerve was drawn outwards. An 
ordinary shawl pin, with a large glass head, was passed from with- 
out, inwards obliquely through the skin and subjacent muscle (sarto- 
rius). It entered at a point one inch external to the incision, and 
was directed obliquely downward and inward, so as to cross the POPLITEAL ANEURISM 
9 
artery above, and to pass between it and the vein. The point was 
then directed downward to pierce the adductor muscles beneath the 
vein. It was hoped thus to compress the artery, without pressing 
on the vein. This manoeuvre failed to control the pulsation, and was 
abandoned. The artery being lifted on a director, the acupressure 
needle, piercing the sartorius and crossing over the artery as before, 
was now passed between the artery and vein, and the point turned 
outwards along the director, and beneath the artery, until it pierced 
the rectus muscle and rested on the femur. Thus the artery was 
lifted away from the vein, and compressed between the pin and the 
sartorius and skin. 
All pulsation immediately ceased in the aneurism and below. The 
wound was closed externally by three wire sutures, the pin being left 
in place, with the head alone protruding. 12, M.—Patient was placed 
in bed, with leg slightly flexed. Special watch. 
Having observed the great rise in temperature following lesions of 
the sympathetic nerve in the lower animals, through some impression, 
probably, conveyed to the vasa vasorum; and having also noticed a simi- 
lar increase of heat after the ligature of large vessels, I directed that 
the limb should not be packed in wool, as is ordinarily done after 
ligature, but be left uncovered, and the temperature carefully watched. 
External warmth was to be applied if the heat of the limb or foot fell 
below that of the other, 12.52, P.M.—Temperature in axilla, 98.5°; 
in groin, 97.25°. Left leg (the leg alfected), four inches below the 
knee, 95.5°; right leg, four inches below the knee, 93,5°. 2, P.M,— 
Recovered from effects of ether. Complains of darting and sting- 
ing pains in sole of foot, calf of leg and seat of aneurism. 5.15, 
P.M.—Temperature the same. Pain continues, with slight twitching 
of muscles of calf. Milk ad libitum, and sulphate of morphia to be 
given pro re natd. 6, P.M.—Pain undiminished. Morph, sulph. gr. 
subcutaneously. 8, P.M.—Pain continues. Morph, sulph. gr. 
subcutaneously. 10.15, P.M.—Slight spasmodic contractions about 
seat of aneurism. No pulsation. Pulse 88, 11.45, P.M.—Yery 
restless. Morph, sulph. gr. *, subcutaneously. Yery slight oozing 
from the wound. 
7th, 6.30, A.M.—Rested well the latter part of the night. One 
dejection at 4, A.M., and another now. Darting pain in leg and 
popliteal space. Aneurismal tumor smaller, hard and tender. Leg 
and foot somewhat swollen and oedematous. Twenty drops of tincture 
of opium to control tendency to diarrhoea. Milk and cracker for 
breakfast. Pulse 96. 8, A.M.—Vomited soon after taking lauda- 
num. One loose dejection. Morph, sulph. gr. subcutaneously. 
Tongue dry and coated. Much thirst. Broken ice by mouth. 10.30, 
A.M.—Drowsy. No very severe pain. Diet of milk porridge and 
boiled milk ad libitum. 12.35, P.M.—Two discharges since last 
record. Pil. opii gr. £, after each dejection. 2.30, P.M.—Feels 
quite comfortable. Pulse 104. One dejection. Continue opium 10 
SURGICAL CASES. 
pill. 4.25, P.M.—Pain in popliteal space. Morph, sulph. gr. J, 
subcutaneously. 8, P.M.—Diarrhoea continues. Opium pill. Some 
swelling noticed about incision. 
Bth, 2.30, A.M.—Restless and retching. Pulse 100. Morph, 
sulph. gr. subcutaneously. 10.45, A.M.—Slight blush about wound. 
Sutures removed. No pus, and only a drop of serum. Warm fo- 
mentations to wound. Apparent temperature of left foot lower than 
that of right; foot covered with cotton. Pace flushed. Pulse 120. Ice 
to tongue. 2, P.M.—Quiet and comfortable. Pulse 112. 6.15, P.M.— 
Quite comfortable. Wound surrounded by swelling and' redness, 
which tend to increase. Aneurism less tender. Leg and foot less 
swollen. Pain of sole and toes of left foot, with pricking and dart- 
ing. Patient in good spirits. 
9th.—Had a good night. Reports himself u feeling splendid ” at 
7, A.M. Blush about the same. Twitching of muscles all gone. 
Swelling of foot and leg less, and tenderness of the tumor much di- 
minished. Fomentations still continued. Sensation in left foot less 
acute than in right. 12, M.—The pin removed, exactly seventy-two 
hours after its insertion. No pus or serum followed. Pin perfectly 
dry. No pulsation in popliteal tumor or in foot. Tumor diminish- 
ing in size. The incision above had apparently closed by first in- 
tention, yet it was thought that fluid could be detected beneath. The 
blush was a little increased; fomentations continued. Diet—tea and 
toast. Br. Tr. ferri mur. gtt. xx. ter die. 7.30, P.M.—Doing nicely. 
Morph, sulph. gr. 4, subcutaneously. 
10th, 7, A.M.—About two drachms of pus pressed out from be- 
neath incision. Pulse 90, strong. Blush about the wound much 
less. Appetite improving. 
11th.—Small discharge of pus. Swelling less. The blush nearly 
all gone. Pulse 76. 
12th.—Comfortable night, with opiate. Incision granulating. 
P.M.—Sat up in chair an hour. Sensation returning in sole of foot. 
13th.—Continues to improve. Discharge from wound slight. 
Fomentations to thigh and wool to foot continued. 
14th.—Doing well. Apparent temperature of left leg higher than 
that of right, as determined by the hand. 
15th.—Progressing favorably. Temperature—left leg (the one 
operated on) at calf, 96.5°; right leg do., 92.5; left foot between 
toes, 94°; right foot do., 92°. 
16th.—Very slight discharge. Incision one half closed. Tem- 
perature unaltered. To-day, for the first time since operation, tick- 
ling of the sole gives reflex motion. 
17th.—Sits up more or less every day. Discharge from wound 
very slight, and does not increase on pressure of adjacent parts. Pa- 
tient can move leg and foot without discomfort. Temperature—left 
leg at calf, 96.5°; right leg do., 93°; left foot between toes, 97°; 
right foot do., 92.5°. Has taken every night at bed-time, since Aug. 
12th, morph, sulph. gr. TV-ib subcutaneously. POPLITEAL ANEURISM. 
11 
18th.—Improving. Fomentation omitted. Simple cerate dress- 
ing. Temperature—left leg at calf, 97.5°; right leg, 95.5°; left 
foot, 98; right foot, 92.5°. Opiates omitted. R. Potassii bromid. 
grs. xxx. at 7, P.M, 
19th.—At 2, A.M., a slight oozing haemorrhage occurred from 
wound, apparently of venous blood. Yesterday, without permission, 
patient walked about ward on crutches, dragging his left foot, and 
during last night he moved his leg and foot considerably in bed. 
Hemorrhage easily controlled by pressure. 9.30, A.M.—Slight he- 
morrhage renewed; controlled readily by ice to part. 7,P.M.—R. 
Morph, sulph. gr. subcutaneously. 
20th.—Rested well last night without recurrence of hemorrhage. 
Quite free discharge of bloody pus from incision. Warm fomenta- 
tions applied to part. Slight darting pain in foot. Temperature— 
left calf, 96.5°; left foot, 98°; right calf, 94°. 
21st.—Comfortable and doing well. Discharge nearly ceased. 
Fomentations omitted. Temperature—left calf, 95.5°; left foot, 
96.5°; right calf, 93.5°. 
2 2d.—Doing well. No pain in leg or foot. Temperature—left 
calf, 93.5°; left toes, 93.5°; right calf, 92.5°. 
23d,—Improving daily. Incision nearly healed. No pus. Takes 
potass, bromid. grs. xl.-lx., in divided doses after 3, P.M. Sleeps 
well. Temperature—left calf, 95°; left toes, 95.5°; right calf, 94.5°; 
right toes, 96.5°. 
24th.—Leg and foot appear of natural color, but the foot still 
feels slightly numb. Temperature—left calf, 95.5°; left toes, 96.5°; 
right calf, 94°; right toes, 96.5°. 
25th,—Discharge just enough to slightly soil dressings. Patient 
walks about ward with crutches, and can bear some weight on left 
foot. Temperature—left calf, 96°; left toes, 95°; right calf, 93.5°; 
right toes, 95.5°. 
26th.—Incision almost well; small granulating spot. Leg and 
foot are in every respect normal in appearance and condition, except 
in temperature; and the left foot is slightly more sensitive than the 
right. There is no tenderness in popliteal space. Aneurismal tu- 
mor small and very hard. Discharged, well—twenty days after 
operation. 
It will thus be observed that throughout the period of acupressure, 
and even until his discharge, the temperature of the left (operated) 
limb was uniformly higher than that of the other. Unfortunately, 
in the midst of the case, the thermometer constructed to take the 
temperature was broken, and several days were lost before another 
could be obtained. It was during this interval that the apparent 
temperature of the toes to the hand seemed slightly lower than that 
of the other foot, and I therefore applied cotton to the foot, but no 
higher up the limb. 
May it not be that external warmth applied after ligature pro- 12 
SURGICAL CASES. 
motes gangrene, by favoring and increasing the passive congestion 
which exists already ? Such we know to be the action of warm 
poultices in the congestive stage which precedes senile gangrene. 
I am inclined to think that the suppuration which followed the 
acupressure was due to long and rough manipulation in securing the 
vessel. Could the last manoeuvre adopted have been foreseen and 
used first, I think laceration and stretching of the sheath and cellu- 
lar tissue might have been avoided. 
The peril of secondary haemorrhage from the vessel divided by 
the ligature iyas avoided by acupressure. 
It may be noticed in the first case reported, that flexion, for a few 
hours only, altered the sac so that consolidation took place promptly. 
In the second case, flexion was pursued over four days and nights 
constantly, but without effect. The difference in result, I think, is 
due to the fact that the first tumor was very small, fusiform, and 
easily compressed; the second was very large, flattened, and tending 
to become diffused. 
Flexion so long in the second case may have enlarged the collate- 
ral vessels, and put them into a better state to sustain the circulation 
after acupressure of the femoral artery. 
One month after leaving the hospital, the patient continued per- 
fectly well. 
Case IY.—Excision of the Hip. Recovery.—(Service of Dr. Buck- 
ingham.) Feb. 12lh, 1867. F. T., aet. 14, of scrofulous parentage, 
was healthy until last September, when he began to have pain and 
stiffness in left hip. Soon after, had an attack of fever lasting three 
weeks; was confined to his bed thirteen weeks, being much reduced, 
with night sweats and emaciation. During this time an abscess was 
opened below the trochanter major, and it has ever since discharged 
pus freely, .with, occasionally, small fragments of bone. He has 
grown feeble, pale and thin. Appetite good. No cough. The 
thigh is held persistently flexed. The nates are flattened, and there 
is a good deal of swelling. Great pain on moving the limb. 
He was put to bed; extension by weight applied, and the syrup 
of iodide of iron given. 
Feb. 15th.—Unable to bear weight. 
20th.—Discharge more profuse; patient more feverish and feeble. 
24th.—A painful diarrhoea; treated by astringents and opiates. 
March Ist.—Diarrhoea better. Less pain, but cannot bear exten- 
sion. Lies with leg drawn up constantly. 
sth.—More sallow and emaciated daily. 
10th.—Is very weak. 
13th,—Return of diarrhoea. 
14th.—Extremely pale, thin and exhausted, with diarrhoea, hectic 
and suppuration. Appetite, however, good. 
The patient was now so excessively reduced that it seemed an EXCISION OP THE HIP. 
13 
open question whether he would survive more than a few days. It 
appeared very doubtful whether it was expedient to interfere with 
the apparent course of this disease to a fatal result. Nothing 
could be done, unless by operation. Without interference, he was 
slowly sinking. After weighing well the probabilities of the course to 
be pursued, Dr. Buckingham determined to give him the benefit of the 
only doubt which presented itself, and, with his consent, to cut open 
the joint and remove the diseased bone, or so much of it as may be 
practicable. 
Operation.—March 15th. After etherization, an incision, Y-shaped, 
point downwards, was made over the joint. The muscles were dis- 
sected away from the great trochanter; the chain saw was passed 
beneath, and the femur sawn through just below the trochanter. The 
head of the bone was now seized with heavy clawed forceps, the 
muscles dissected back from the acetabulum, the capsule opened, 
and the head and neck of the femur removed. The ligamentum 
teres had disappeared, but the head was not dislocated. The head 
of the femur was extensively eroded. The acetabulum was carious, 
and a few loose pieces were removed. The haemorrhage was slight ; 
some small vessels were tied, and the wound filled with a sponge. 
"Stimulants and morphine were given. After the operation, the pulse 
was 140, and very compressible. One hour later, pulse 150, and 
weaker. Ten drops of tincture of opium were given in milk. 
In the afternoon, a Smith’s anterior splint was applied, from the 
toes to the abdomen, keeping the leg quiet. At 6, P.M., pulse 150; 
sleeping. Milk punch was ordered, during night. 
March 16th.—Pulse 140. Much irritative fever. 
17th.—Pulse 140. One egg for breakfast. Sponge removed from 
wound. 
19th.—Pulse same, but he looks better. Granulations appearing. 
20th.—Odor less offensive. Pulse 140. 
24th.—Wound measures four by five inches. It is filled with 
healthy granulations. General condition improving. 
28th.—Wound contracting. 
31st.—Appetite better. But little pain. Wound discharges healthy 
pus. Appearance of countenance better. 
It was now, a fortnight since the operation, evident that he had 
rallied from the shock, and was going on favorably. Improvement 
was, necessarily, slow, and could be measured only by 
months. 
April.—The wound continued to close. 
May.—He improved, taut suffered much from bed-sores, being 
very emaciated. 
June.—He was put into a basket, and taken out of doors daily— 
and from this time a very marked improvement began. 
July.—He was encouraged to use a little passive motion of the 14 
SURGICAL CASES. 
legs, daily. The wound was closing; a fragment of carious bone 
was discharged. 
August.—He steadily gained, until the 27th, when he was dis- 
charged ; five months since the operation, and one year since the 
beginning of the disease. 
At this time his condition was as follows:—Face round, fat and 
sun-burned. Appetite excellent. No hectic, nor sweats. Very 
slight discharge from wound of excision, which has nearly closed. 
Bed-sores healing. Has gained flesh. Both knees crippled by false 
anchylosis, owing to long flexion. Passive motion of them, however, 
is improving daily. Moving the hip gives no pain. 
His ultimate recovery seems no matter of doubt. Ho was so 
near death at the time of the operation, that great fears were ex- 
pressed whether he would survive it. 
Case Y.—Excision of the Hip. Recovery.—(Service of Dr. 
Cheever.) Martha S., set, 6 years, entered the hospital Peb. 23d, 
1867, with the following history:— 
Nearly a year before entrance, she complained of pain in the knee, 
followed after a time by pain in the hip, which increased to such ex- 
tent that, in November, 1866, six or seven months after the first at- 
tack, she was no longer able to stand upon the affected limb, and 
was confined to bed most of the time. She had always had a feeble 
constitution, and at the time of admission was very delicate. Her 
mother had died of phthisis. 
On entering the hospital, the right limb was continually adducted, 
the toes being inverted, and the slightest efforts at abduction 
giving pain. There was no appreciable shortening. Bowels consti- 
pated, and appetite variable. 
Until March Ist, the patient remained in bed, with extension by a 
five-pound weight applied. R. Olei morrhuse, | ss. t. d. 
March Ist.—Sayre’s splint adjusted. Sat up three hours. 
3d.—Extension in bed resumed, as it is more comfortable than 
the splint. 
10th.—Continues comfortable. R. Elix. bark and iron, 5 ij. t. d. 
15th to May 7th.—Extension continued, without decided benefi- 
cial effects. Sayre's splint adjusted again May 7th. 
20th.—Hip was so excessively tender that the splint was kept on 
only about a week. The joint seems more tender, and the deformity 
is increasing. The head of the femur is out of its socket, and the 
two contiguous surfaces are rough and denuded. 
The question of performing the operation of excision of the head 
of the femur was now seriously considered. Three months of rest 
and extension had been productive of no benefit. Were it possible 
to have the patient treated by a long-continued expectant method, 
and under the best hygienic influences, the case might be fairly left 
to nature, and recover ultimately with anchylosis. On the other EXCISION OP THE HIP. 
15 
hand, the circumstances of the child’s friends rendered it impossible 
for them to take care of her, and carry out treatment. Abscess, si- 
nuses, and perhaps death, must be an early result of letting her walk 
round, and of neglect. 
Under the circumstances, it was not deemed precipitate to operate, 
even though no evident abscess existed. 
The operation was performed in the presence of many members of 
the Massachusetts Medical Society, June 4, 1867. 
A Y-shaped incision was made over the trochanter major, the apex 
pointing downwards. The head of the femur was found to be de- 
nuded over almost its entire surface, and the disease extended to 
the brim of the acetabulum. The head of the femur rested on the 
upper and outer lip of the acetabulum; and about two drachms of 
pus were found around the joint. The cup of the acetabulum was 
filled with fungous granulations, and not carious. The diseased por- 
tion of the ilium was left to exfoliate. The femur was sawed by 
means of a chain saw, below the trochanter major, and a piece re- 
moved an inch and a half long. The cancellous structure was found 
to be very soft. Some of the adjacent softened and degenerated tis- 
sues were removed, two ligatures were applied, and the wound left 
open. There was very little haemorrhage. Patient was placed in 
bed, on her left side, without apparatus. Evening.—Pulse 140, 
regular. Very little pain. 
June sth.—Patient feels bright and playful. She takes milk free- 
ly. There is no vomiting, and no pain in wound. Patient altoge- 
ther as comfortable as before operation. 
6th.—Sleeps well at night. Cheerful during day. Pulse 140. 
Strength fair. Tongue furred and moist. Wound has commenced 
to suppurate. 
9th.—Patient has had so little pain that only one or two opiates 
have been required since the operation. The wound is clean. 
10th to 30th.—Continually improving. 
30th.—Leg can be moved considerably without discomfort. 
July sth.—Sits up in a chair, and stands on sound limb. Is able 
to move about the bed. Wound 3 inches by f inch. 
10th.—Doing well. No soreness. Discharge very slight. Wound 
nearly closed. 
20th.—Steadily improving. Creeps about the ward. Ulcerated 
surface 2 inches by | inch. 
30th.—Patient has some power of motion in the affected limb. Is 
beginning to walk on crutches. 
Aug. 2d.—Yery comfortable. Walks about the ward a little with 
crutches, and can bear considerable weight on the foot. 
10th.—Improving. Wound nearly closed; very little discharge 
and no pain. Appetite good, functions regular, and spirits excellent. 
15th.—Walks with crutches very smartly, bearing some weight on 
the right limb. Can stand without support. No pain on motion of 
leg. Wound nearly closed, and no dressings required. 16 
SURGICAL CASES. 
25th.—Hops about ward without crutches. No pain. 
Sept. 3d.—Patient can walk without crutches, but with a limp. 
Can nearly bear weight of body on affected limb. Health and 
strength improving. Wound almost closed. No pain or tenderness 
about hip. Shortening of right limb, one and a half inches. She 
was discharged; three months after operation. 
These two cases were in striking contrast with each other. In 
the first, the disease had advanced to the limits of endurance, and 
the patient was hanging between life and death. In the second, the 
joint was excised before an abscess, of any magnitude, had formed. 
Both cases resulted favorably. 
Case Vl.—lmpermeable Stricture of the Urethra ; Per meal Section 
by one stroke of the Knife, without Dissection. (Service of Dr. 
Chbeyee.) The patient, 44 years old, has had stricture for seven 
years. Entered the hospital June sth, at one o’clock in the morn- 
ing, with retention for thirty-six hours. The catheter could be passed 
only to the root of the penis, when it brought up suddenly and com- 
pletely, without entering the bulb. There was swelling and oedema, 
with redness and induration of the scrotum, but no appearance of 
extravasation in the perinseum or over the abdomen. The bladder 
was tapped through the rectum, and a quart of urine drawn. The 
catheter was fastened in. 
The next day an abscess was opened in front of the scrotum, and 
a good deal of pus and infiltrated urine evacuated. The patient’s 
condition improved much after these measures; but the urethra 
remained impermeable, and it was evident that a radical operation 
would be required to ensure permanent relief. 
June 7th.—He was etherized and placed in the position for litho- 
tomy. No staff could be introduced. Instead of dissecting down 
for the membranous urethra in the usual way, perineal section was 
done, as follows. 
The forefinger of the left hand, with the palmar surface upper- 
most, was introduced into the rectum, and the tip of the finger placed 
at the apex of the prostate gland. A long, narrow, single-edged 
amputating knife, with a blade of four inches in length, was held, 
with the cutting surface uppermost, in the right hand. The point 
was entered in the median rapid, half way between the perineal cen- 
tre and the anus, and pushed straight in until the point could be felt 
impinging on the tip of the left forefinger. Guided on this, as on a 
director, the back of the knife sliding over the finger, with a thin, but 
perceptible septum of the wall of the rectum between them, the point 
of the knife was pushed straight on into the bladder. A pint of 
urine followed the knife, and a very little venous blood. The blad- 
der was thus opened by a single incision, without withdrawing the 
knife; and the incision being exactly in the median line, but few 
vessels were cut. A catheter was fastened in. STRICTURE OF THE URETHRA. 
n 
The patient made a more prompt recovery than is usual after peri- 
neal section. In four weeks, he took a No. 8 catheter by the ure- 
thra. In five weeks he was discharged, passing a bougie himself. 
In seven weeks, the perinaeum was closed. 
In all those cases in which we have seen perineal section perform- 
ed by dissection, without a guide in the urethra, and in several cases 
in which we have so performed the operation ourselves, fully an hour 
has been consumed in finding the membranous urethra. The peri- 
meum has been very much cut up by repeated, though minute inci- 
sions ; a wound has been left, lacerated rather than incised, and 
hence slow to heal and prone to slough j and the patient has been 
left in a state of very considerable exhaustion from prolonged etheri- 
zation and haemorrhage. In all such cases recovery has been slow, 
and the peTinaeum reluctant to close. Perineal section of the mem- 
branous urethra, done without a bougie or a staff, in a case of im- 
permeable stricture, has been notorious among all surgical writers 
as a long and difficult operation. 
By the method above described, advocated by Mr. Cox, we sub- 
stitute a minute or two for an hour; and a single, clean median incision 
for a prolonged hacking of the parts. Duo care being taken to start 
in the median raphe, to use a single, deliberate and unswerving 
thrust with a long, narrow and single-edged knife, it does not seem 
to me that this mode of operating is as difficult as, or more danger- 
ous than, the ordinary way. 
Sir Henry Thompson, in his admirable work on Lithotomy, insists 
again and again that far more danger results from laceration in the 
vicinity of the neck of the bladder, than from the most free incisions. 
In speaking of the dangers of urinary extravasation after lithotomy, 
he says (pp, 87-88);—“There is good reason to believe that, in 
most cases, urinary extravasation is not the primary cause of the in- 
flammation, but vice versa. Cellulitis, produced by violence, has first 
destroyed the connections of the tissues, and then the urine infiltrates 
into the disintegrated parts Infiltration by no means 
necessarily occurs when urine passes over free incisions of cellular 
spaces, so called. In fact, cellular interspaces between muscles dp 
not exist, except when made by the dissector, &c.” 
“It appears that, in the majority of cases, death is due to unne- 
cessary violence inflicted on the neck of the bladder, and the parts 
adjacent, occasioning destructive inflammation of the connective tis- 
sue, and of the network of minute vessels that pervade it.” 
Neither does he consider that urinary infiltration will necessarily 
follow an incision carried beyond the fibrous capsule of the prostate. 
Such an incision is always made in the operation for lithotomy in 
children, in whom the prostate is only rudimentary, and yet urinary 
infiltration in them is very rare. 
Now it is precisely an analogous series of lacerations and vio- 18 
SURGICAL CASES. 
lence which is inflicted on the cellular tissue of the deep perinaeum 
in the ordinary search for the membranous urethra sans guide ; hence 
its indisposition to close. Neither does it appear that any serious 
peril will necessarily follow a clean incision, prolonged even through 
the prostate itself. 
Case VII.—A Foreign Body, unsuspected for three years, removed 
from the Side; Recovery.—(Service of Dr. Chester.) Mrs, , 
aged 27, was first troubled three years ago with a pain in her left 
side. Three months later, she noticed a projection of the lower ribs, 
just over the stomach. This state of affairs continued until a year 
ago, since which the pain and swelling have increased. The pain is 
throbbing, and requires the daily use of opiates. Since four months 
past, it has begun to wear upon her health. The ribs are much 
more prominent than on the other side. The skin is neither adhe- 
rent nor inflamed, though discolored by many applications. There 
is great tenderness on pressure. A lateral curvature of the spine, 
towards the left, exists in the dorsal region. There is a general ful- 
ness over the left side. Just outside the swelling is a scar, where 
she had caries of a rib when a child. There are no signs of any 
organic disease to be discovered. The lung is resonant, and respi- 
ration good down to the very line of the swelling. The form is 
distorted from the spinal curvature. Position and sounds of heart 
normal. Tongue furred. Pulse 80, Bowels a little confined. 
The patient has consulted numerous surgeons and physicians of 
eminence, both in Boston and elsewhere. No satisfactory diagnosis 
has been given. She has suffered from polypharmacy. Our own 
suspicions point to one of two diseases—caries of a rib, or an old 
and limited empyema. 
Worn out by pain, and tired of spending her time and means in 
fruitless medical advice, she enters the hospital, desiring some form of 
operation for relief. An exploratory incision having been proposed 
to her, she readily assented, and preferred to bear it without ether. 
June 2d.—A crucial incision was made over the most tender spot. 
The knife came directly down on a cambric needle, much corroded, 
which lay across and between the ribs. No other disease was found. 
There were several indurated and tender spots near by, where the 
needle had probably laid from time to time. These were all laid 
open, and the external wound enlarged. 
It is needless to follow the subsequent history of the case. The 
neuralgia gradually subsided; and she was discharged, at the end of 
three weeks, with every prospect of entire recovery. 
Case Vlll.—Peri-nephritic Abscess.—(Service of Dr. Chester.) 
C. S., aged 17, a delicate and amende girl, in wdiom the catamenia 
have never appeared, entered the hospital April 9th, 1867. Has PERI-NEPHRITIC ABSCESS. 
19 
been somewhat troubled with incontinence of urine for three years; 
otherwise in fair health. Two weeks ago, first noticed a slight sore- 
ness over right kidney, and a small tumor growing slowly. Now, a 
fluctuating swelling in right lumbar region, three inches in diameter, 
without redness; but little tender, and having a boundary wall of 
lymph. No sensitiveness or deformity of spine. No weakness or 
paralysis of legs. No lameness or evidence of any trouble in the 
hip-joint, nor has there ever been. No chills, but profuse sweats 
within the fortnight. 
She was etherized and the tumor opened, giving exit to a conside- 
rable quantity of laudable pus, free from odor. A probe could be 
passed in three inches, perpendicularly. No denuded bone to be 
found. Probe impinges on an elastic wall. The urine was examin- 
ed, but nothing abnormal found. 
The abscess continued discharging less and less for one month. 
No other symptoms presented themselves. She improved under 
tonic treatment, and was discharged, nearly well, May 10th. 
The freedom from acute symptoms must class this collection with 
cold abscesses. The absence of all spinal or pelvic disease, and 
the depth and location of the matter, indicate the cellular tissue near 
the kidney as its probable source. 
Case IX.—Peri-nephritic Abscess.—(Service of Dr. Cheeyer.) 
Lizzie 8., Irish domestic, aged 17, born in Boston, of healthy pa- 
rentage, entered the hospital Feb. 11th, 1867. Four weeks ago, 
after wetting her feet, the menstrual flow ceased, and a difficulty in 
retaining urine occurred. This symptom at first compelled frequent 
micturition only; at present, however, there is complete inconti- 
nence. There is no pain, nor has there been at any time a chill. 
No dribbling of urine while lying down. During night, obliged to 
pass water five or six times, owing to pain at meatus. Pulse 90. 
Temperature 100°, Bowels costive. Tenderness in right lumbar 
region. No tenderness nor dulness at hypogastrium. 
An examination of the urine resulted as follows ;—“ Color, orange; 
sediment, white, and pours like white of egg; specific gravity, 1017; 
acid; albumen By microscope, large amount of pus corpuscles ; 
no blood nor casts.” Treatment—lron, oil and uva ursi. 
Four days after entrance, had a slight chill during the night, fol- 
lowed by pyrexia. Another chill soon occurred. 
March 22d.—An increased amount of pus in urine; another chill; 
tenderness over left kidney. 
April Ist.—Chills again. Same condition of urine; no casts 
found. Some complaint of fixed pain in right renal region; hereto- 
fore pressure was needed to obtain evidence of its existence. 
During the month of May, a troublesome cough (bronchitic) existed. 
June 12th.—Urine examined; specific gravity 1015; sediment 20 
SURGICAL CASES. 
less than at previous examinations, somewhat agglutinated; no albu- 
men. Pus, under microscope. 
July 7th.—Dr. Cheever examined the patient, in consultation. He 
confirmed diagnosis of fluctuation in right lumbar region. Fluctua- 
tion was very difficult to verify. By placing the left hand flat over 
the right lumbar region, closing the eyes, and having some one else tap 
repeatedly on the other border of the swelling, a wave could be felt. 
The indications of pus, from the swelling, deformity and rational 
signs, were more marked. 
10th.—Patient having been fully etherized, Dr. Cheever introduced 
an exploratory trocar between the 12th rib and the crest of the ilium. 
Pus appeared. The large trocar was then introduced, and at least 
two ounces of a thick, purulent fluid, quite foetid, were discharged. 
The portion last appearing was thick and curd-like. A probe could 
be passed in, perpendicular to the surface, at least three inches. It 
reached a soft, elastic wall. No bone could anywhere be felt; nor 
was there any other evidence of disease of the spine or hip. 
13th.—Increased amount of pus in urine; less pain in renal 
region. 
24th.—Urine examined. For the first time, an abundant amount 
of mucous cloud is seen, containing a white deposit. The merest 
trace of albumen. Pus corpuscles still found under the microscope. 
The amount of purulent sediment, however, has excessively diminished. 
29th,—Urine diminishing in quantity. Bight leg cedematous, 
somewhat painful. 
31st.—No albumen nor pus found in a specimen of urine passed 
this morning. Skin of leg tense and shining. 
Aug. 4th.—Bowels becoming loose. Pulse has been almost uni- 
versally above 100. Cough now became troublesome, together with 
soreness of chest. 
Sept. 9th, she died. No autopsy. 
These two cases are thought to be peri-nephritic abscesses. Both 
patients were feeble, anaemic, half-developed girls. Both had incon- 
tinence of urine. The first recovered; the second had pus in the 
urine, other organic disease, and death. 
Case X.—Traumatic Hernia of the Omentum.—(Service of Dr. 
Cheever.) The patient, a robust young man, received a prick in 
the abdominal wall, near the umbilicus, with a pocket knife. I saw 
him two hours after the accident. As much of the greater omentum 
as would fill a tablespoon was protruding through the small opening 
made by the knife. There were no constitutional symptoms. A 
physician called had applied warm fomentations to the hernia. The 
omentum not cold, nor livid. It was washed; the wound of the pa- 
rietes enlarged, and the omentum returned. The patient recovered 
promptly. STRANGULATED HERNIA. 
21 
Case XL—(Service of Dr. Cheeyer.) The patient was picked 
up in a state of intoxication, and put in the Tombs. It was found, 
in the morning, that lie had a wound of the abdomen, and something 
protruding. The wound must have been inflicted by himself, or 
others, over night. He was sent to the hospital. A portion of the 
omentum, as large as an egg, was protruding through a small hole 
of the abdominal parietes, near the umbilicus. It was cold, dirty, 
livid, and looked as if it had been out for some hours. Patient still 
under the effects of liquor. No constitutional symptoms. It was 
judged imprudent to return the omentum, and it was strangulated 
with silver wire. No symptoms followed, beyond an attack of deli- 
rium tremens. The omentum sloughed off in sis days, and he was 
discharged, well. 
Case Xll.—Femoral Hernia strangulated for four Days ; Opera- 
tion ; Recovery.—(Service of Dr. Cheeyer.) Mrs. M., 40 years old, 
had had femoral hernia for many years. Her truss, having become 
worn, did not control the rupture. After working all day with the 
rupture down, she was awakened in the night by colicky pains near 
the umbilicus, followed by one stool. Next morning, the pain re- 
curred, with nausea. No further motion of the bowels until after 
the operation. Yomiting of a distressing character set in the second 
night, with pain and constipation. The matter vomited was, first, 
the contents of the stomach; next, bile; next, mucus from the duo- 
denum ; then, chyle from the small intestine, coupled with a foul- 
smelling mass from below. The vomiting was never fecal, nor even 
stercoraceous, nor have I ever seen it so. It appeared intestinal; 
thick, conglomerated, homogeneous, and offensive. It recurred, at 
intervals, for three days, with constipation, a cool, moist and shrunk- 
en skin, and feeble pulse. These symptoms, at no time very violent, 
were controlled by opium; so that, in the intervals, a great apparent 
amelioration appeared. 
After four days’ delay, she consented to have an operation done. 
Tfie sac was opened, the stricture cut, and the bowel, which was 
deeply congested, but not gangrenous, returned within the abdomen. 
She recovered perfectly—a spontaneous evacuation of the bowels 
occurring within a few hours after the operation. 
The interesting points of this case were: the mildness of the 
symptoms for four days, and the deceptive amelioration produced 
by opium. We can easily conceive that a continued use of this 
drug might load to a fatal delay. 
The cool, moist skin, indescribable shrunken aspect, and the na- 
ture of the vomit, were the symptoms most indicative of the mischief 
going on unseen. 
It will be understood that an operation was urged on the patient 
from the beginning of the case. 22 
SURGICAL CASES. 
Case Xlll.—Strangulated Hernia relieved hy Operation ; The Canal 
closed hy wire Sutures, left in permanently.—(Service of Dr. Chester.) 
J. D., set. 17, was born with double inguinal hernia, and wore a truss 
until he was 6 years old. From that time he had no trouble until 
two days since, when, on making a sudden exertion, the rupture re- 
appeared on the right side, and soon showed signs of incarceration. 
Patient had severe pain all night, and vomited three times. The 
following afternoon, he was seen by his family physician, who applied 
taxis, under ether, without success. 
On being called to him, I advised his removal to the hospital, and 
as it was then late at night, and the symptoms not urgent, he was 
put to bed, with hop fomentations and a full opiate. The hernial 
sac lay in the inguinal canal, and the constriction was at the inner 
ring. 
April 30th.—He was etherized, and, taxis having failed, hernioto- 
my was performed. An incision having been made over the tumor, 
a hydrocele of the cord was found below the outer ring. The sac 
having been reached and laid open, a half ounce of serum escaped. 
The constriction was found very high up at the inner ring, and divi- 
ded. The bowel was congested, and infiltrated with serum, but there 
were no signs of gangrene. The bowel having been returned, the 
two pillars of the canal were drawn together by a single, stout wire 
suture. The ends were cut short off and left in the wound, and the 
skin closed by one stitch. 
With the exception-of a mild attack of rheumatism, the case went 
on perfectly well. The wires kept up suppuration for six weeks be- 
fore the sinus had so far closed that he could be let up with safety. 
Meanwhile, a large amount of lymph was effused. There was no suf- 
fering, and no orchitis. At the end of six weeks he was let up, with a 
spica bandage. There was no relapse of the bowel. The ulcera- 
tion remaining was one inch long by one half broad. The sinus 
discharged thin serum. 
On July Ist, he was discharged from the hospital, with the wound 
nearly closed, and allowed to go about without a truss. « 
Aug. Ist.—Three months since the operation, he reports himself 
well. Wound closed; no soreness; still a large effusion of lymph 
around the wire; no truss: no bulging of the abdominal wall, or bu- 
bonocele. Time must prove the event. 
The question to be solved, as to the use of wires after hernioto- 
my and their permanent retention, is: on the one side, a protracted 
convalescence; on the other, immunity from return of the hernia 
and freedom from a truss—provided the wires become encysted and 
the occlusion of the rings lasts. 
Note.—Nov. 17th, six months since the operation. The wound 
has re-opened, portions of the wire have been discharged, and the 
hernia has returned. DOUBLE RADICAL OPERATION. 
23 
Case XFV,—Double Oblique Inguinal Hernia ; Operation for a 
radical Cure.—(Service of Dr, Chester.) The patient, a young 
man 20 years of age, has a congenital inguinal hernia on the left 
side, and on the right, one of two years’ duration. Both are reduci- 
ble, and have not troubled him much until recently. Now desires 
an operation. 
June 14th.—The patient having been etherized and the hernia 
reduced, an incision, an inch and a half long, was made through the 
skin of the scrotum, on the left side. The skin and cellular tissue 
were thoroughly freed from the spermatic fascia for an inch all round 
the incision. The spermatic fascia and sac having been invaginated 
on the forefinger, the hernia-needle was passed up through the inner 
pillar and conjoined tendon, high up near the inner ring. The nee- 
dle emerging through the skin of the abdomen was threaded with 
large size (No. 20) copper wire, electro-plated, and withdrawn. 
Next the needle, unthreaded, was passed through the outer pillar 
and Poupart’s ligament, and up through the same opening in the skin, 
the other end of the wire hooked on and withdrawn, leaving the loop 
over the abdomen, and two free ends below, emerging from the scro- 
tal incision. These two ends were now crossed through the sper- 
matic fascia and sac, by passing the needle across from within out- 
ward, and threading one end and drawing it across, and vice versa. 
Pinally, the needle was passed through the conjoined tendon close to 
its insertion, and the outer end of the wire hooked on and drawn 
through; then the needle was passed through the insertion of Pou- 
part’s ligament, close to the spine of the pubes, and the inner end 
of the wire hitched on and drawn through. We now had the loop 
above, the two free ends below, and, between them, a complete figure 
of eight, formed by two stitches through each pillar and by the 
crossing through the sac. The lower ends were twisted together, 
and drawn up into the canal by pulling on the loop above, which was 
then twisted*down into the skin. The ends were then secured over 
a roller. The other side was operated on in precisely the same man- 
ner, and a double spica bandage applied over all. The patient was 
put to bed, with the knees flexed over a pillow. One fourth of a 
grain of morphia wa's given subcutaneously. 
Moderate swelling of the scrotum supervening on the second day, 
the bandage was removed, and the scrotum slung. Moderate suppu- 
ration came on, but no constitutional disturbance. The wires were 
removed on the tenth day. The discharge had nearly ceased, and 
he was allowed to sit up, with a spica bandage, at the end of the 
three weeks. At the end of four weeks he was discharged, with a 
light, double Wood’s truss. There was a firm elfusion of lymph, and 
no signs of weakness on coughing. 
The experience of the past year has led ns to modify somewhat 
our opinion of Wood’s operation for the radical cure of hernia, as 24 
SURGICAL CASES. 
expressed in a clinical lecture delivered and published in 1866.* 
Of the twenty cases there published, we may fairly eliminate seven, 
as operations either abandoned (1), lost sight of (2), or performed 
on improper subjects, viz., very obese or too old men, and largo direct 
hernim (4). This leaves a total of thirteen fair cases. Of these, three 
only were then put down as successful. Two were classed as recent 
operations. Both these latter cases—young men—at the end of a 
year, are well. They are now without trusses, and with" no evidence 
of relapse. This would give five entirely successful cases out of thir- 
teen, or per cent, of success. It will be remembered that Mr. 
Wood claims a percentage of seventy. Should the case just narra- 
ted prove favorable, we should have 50 per cent, of success. 
It is fair to conclude that the later cases of our own were opera- 
ted on more thoroughly than the earlier ones. In the last case, in- 
deed, as we have said, a much more perfect occlusion of the canal 
and rings was effected by additional stitches. It is fair, too, to say 
that the operation is as safe as any one in surgery. In twenty-one 
cases we have had no bad result. 
As we said in the article referred to above, we repeat now—“ The 
operation palliates, if it fails to cure. It may render an uncontrol- 
lable hernia controllable by a truss. It tends always to reduce the 
size of the rupture; and it gives nature a chance to restore the parts 
by retention and adhesion. It will cure some adult cases, if they be 
selected with care and judgment. 
“It will fail to cure some adult cases. It affords the best chance 
of a perfect cure in children from 6 to 12 years of age—after in- 
fancy and the first dentition are over, and during the formative pe- 
riod before puberty. Nature then tends to close up the rings, and 
the adhesive inflammation set up by the operation, even if but tem- 
porary, is of great assistance in furthering this desirable result. 
“ It is true, that the same end may be sometimes attained by truss- 
es—but they must be very faithfully applied for a long while, and 
an operation shortens this period essentially.” 
We cannot do better than to quote the following summing up of 
Mr. John Wood, of London, in a letter addressed to us in answer 
to some inquiries : 
“ In children before puberty, and in young men, the success of the 
operation is so decidedly superior to the great uncertainty, and, when 
probable, the slowness of cure by truss pressure, and the symptoms 
are so slight after the operation, that I should not hesitate in sub- 
mitting myself, or a child of mine, to it, rather than to endure the 
inconvenience and risk which a hernia, supported by a truss only, 
entails. After all, it is an operation of expediency. No man is jus- 
tified in pressing it on his patient. He should lay the facts before 
him fairly, and leave it to him to decide.” 
* Boston Medical and Surgical Journal, July 5,1866. CASES OP FRACTURE. 
25 
Synopsis of five hundred Fractures treated a t the Boston City Hospital, 
in three years—from June, 1864, to June, 1867. 
The relative order of frequency was as follows : 
Fractures of the femur, 75 Fracture of the toes, 3 
clavicle, 68 “ “ body of scapula, 3 
“ tibia and fibula, 58 “ “ coracoid, 5 
“ humerus, 49 “ u patella, 3 
“ radius, 46 “ “ nasal bone, 3 
“ radius and ulna, 35 “ “ many bones, 3 
“ fibula, 27 “ “ spine, 2 
“ “ ribs, 23 “ “ both femurs, 3 
“ tibia, 22 “ “ both legs & femur, 4 
“ “ skull, 20 “ “ both legs, 2 
“ lower jaw, 14 “ “ upper jaw, 1 
“ fingers, 11 “ “ sternum, 1 
“ pelvis, 9 
“ metacarpus, 5 Total, 500 
“ “ tarsus, 6 
Ligamentum patella;, 2. Dislocat. clavicle, acromial end, 2; sternal end, I—s. 
Of 20 fractures of the skull there were—4 of the frontal bone, of 
whom all recovered; 10 of the vault, of whom 5 recovered and 5 
died; 6of the base, of whom all died.* Total, 20 fractures—9 re- 
covered; 11 died. Two fractures of vault trephined—both recover- 
ed. Three fractures of base trephined—all died. One, for com- 
pression, trephined—died. Trephining, 6—of whom 2 recovered 
and 4 died. Three fractures of the vault recovered without trephin- 
ing; 2 were fissures; in the third there was no compression. In no 
case of fracture of the base was there a distinct discharge of serum 
from the ear. In some, there was haemorrhage. 
The following cases comprise the chief points of interest. 
Two cases of compound, punctured and depressed fracture of the 
vault were trephined, and both recovered.! In neither were there 
any cerebral symptoms on entrance. 
Case XY.—(Service of Dr. Cheeyer.) The first had a small, 
sharp cut depression, and on trephining, extensive splintering of the 
inner table was found, with loose fragments lying on the dura mater, 
which must have given rise to necrosis and meningitis, unless they 
had been removed. 
Case XYl.—(Service of Dr. Thaxter.) In the second case there 
were no cerebral symptoms until the third day, when one pupil be- 
came sluggish, and the pulse slow and intermittent. The operation 
found the skull very vascular from commencing inflammation, and 
the periosteum very loosely adherent. Splintering of the inner 
table; and a slower recovery than in the first case. 
* Cases trephined for fractures of the vault, not knowrn to extend to the base, 
f See Boston Medical and Surgical Journal, October 4, 1866. 26 
SURGICAL CASES. 
Case XYll.—(Service of Dr. Cheeyer.) There was one case 
without fracture, with unequal pupils and rapid pulse, with great 
restlessness, which terminated fatally, and in which a diffused contu- 
sion of the brain wras found. Minute, miliary clots were scattered 
through the brain in the base and near the lateral ventricles. In some 
of these extravasations, yellow softening had taken place. 
Injuries of the skull were causes of pyaemia in two cases—of 
whom one died and one recovered. 
Case XVlll.—Large Compound Depressed Fracture of Skull, ter- 
minating in Fycemia ; Purulent Deposits in the Lungs, and Death.— 
(Service of Dr. Thaxter.) The patient was struck by a locomotive 
engine, and knocked down backwards. One hour after the accident 
he was conscious; skin normal; respiration 15; pulse 56, and soft; 
pupils contracted. 
Dr. Thaxter enlarged the external wound, and found a large, de- 
pressed fracture, two inches by one, driven in and wedged. There 
were also three fissures. The depressed fragment was removed with 
a Key’s saw, and the dura mater found wounded, with brain pro- 
truding. The patient survived one week. He remained torpid, with 
rather a slow pulse, until the sixth day, when he had convulsions and 
obstructed respiration. The trouble in breathing increased until his 
death. 
At the autopsy, it was found that the fracture had laid open the 
frontal sinus and extended through the cribriform plate of the eth- 
moid. The brain was here softened, discolored and offensive. The 
lower lobes of both lungs contained numerous soft, circumscribed 
puriform deposits, without induration, and quite offensive. The other 
organs were healthy. 
Case XlX.—Fissure of the Skull, with Depression ; Fycemia; Re- 
covery.—(Service of Dr. Homans.) 
Oct. 22d.—A healthy laborer, aged 28, was struck on the head by 
the handle of a crank, by which a ton weight was being raised. 
He did not become unconscious. The integuments were lacerated 
over the right vertex. The pericranium is torn off for a space half 
an inch square. One inch and a half above the eyebrow is a linear 
fracture of the skull, three-fourths of an inch long, and probably ex- 
tending farther beneath the soft parts. The upper border is de- 
pressed the thickness of a case knife.* Severe headache. Pulse 62. 
No vomiting. Converses rationally. 
Oct. 25th.—Pulse 52. Discharge from wound; a slight rigor, 
followed by fever and headache. 
Oct. 26th.—Sweats freely; sensation of weight at stomach, and 
difficulty in passing water. 
. Oct. 29th.—One week since accident. Complains of pain in left CASES OF FRACTURE. 
27 
shoulder and in left popliteal space. Pulse 99; skin hot; pupils 
alike. Profuse sweats. Wound healthy. 
Oct. 31st.—Nine days since accident. In left popliteal space is 
a reddened tumor, without fluctuation. No injury there at time of 
accident. No chills since the first, but paroxysmal fever, 
# Nov. Ist.—Right pupil more contracted than left, but equally mo- 
bile. Pulse 66. No cerebral symptoms. Quinine and good diet 
ordered. 
Nov. 10th.—Nineteenth day. Abscess in ham opened. Discharged 
several ounces of thin greenish pus, tinged with blood. Patient un- 
able to extend right arm. Continues to sweat. 
Nov. 13th.—Probe reveals a small necrosis of skull. 
Nov. 21st.—Right elbow much swollen; pain in left shoulder; 
pain in epigastrium. 
Nov. 29th.—Fluctuation over right tibia; pus evacuated; night 
sweats copious. 
Dec. Ist.—lnduration of arm less. 
Dec, sth.—Swelling of elbow subsiding. Ordered large doses 
of quinine for a brief period. Appetite good. Is sitting up. 
Dec. 12th.—Necrosis exposed by incisions. 
Jan. 10th.—He was discharged well, except a slight necrosis. 
Now ten weeks since the receipt of the injury. 
There can be little doubt that purulent absorption took place 
from the veins of the diploe beneath the linear fracture. Rigor 
began in three days, and the tumor in the ham in nine days. The 
question of interfering with the trephine was seriously entertained 
at first, but the symptoms did not seem to warrant it. 
In the first case of pymmia, the depots were formed in the vital 
organs, and death followed. In this case the pus determined to the 
surface, and lie recovered. 
In another case of fissure of the skull, recovery took place 
promptly, and without symptoms. 
Cases XX., XXL and XXll.—Three fractures of the frontal bone 
were depressed into the frontal sinus, but did not penetrate farther. 
The injury was inflicted with a flat-iron in two instances, and with a 
brick in the third one. The frontal sinus in one case was extremely 
deep, and the anterior lobes of the cerebrum set back, like the Simian 
race. This saved the patient, who was unusually stupid, from injury 
of the brain. In every case the sinus granulated, and the patient 
recovered without bad symptoms. 
The following case, also, deserves to be recorded. 
Case XXlll.—(Service of Dr. Buckingham.) A little boy, play- 
ing in a stable, was kicked in the face by a horse. There were nei- 
ther shock nor cerebral symptoms. The upper edge of the orbit 28 
SURGICAL CASES. 
was denuded of periosteum, and the orbital process of the malar 
bone fractured and comminuted; there was also a deep, ragged 
wound in the temporal fossa. The eye escaped, and so did the 
skull, both of which seem quite remarkable, when we consider the 
violence of the blow. He recovered promptly, and without necrosis. 
Case XXlV.—Fracture of Skull opening the Longitudinal Sinus; 
Death.—A boy of 9 years of age was struck on the head by a piece 
of joist, falling four stories. He was felled senseless, and never 
regained consciousness. Pulse 54, feeble; respiration 30 ; left pupil 
contracted; right, dilated. The blow was across the vertex. A 
large fluctuating tumor was formed. Symptoms of compression 
being evident after some hours, a slight opening was made, when 
large quantities of venous blood gushed forth. Haemorrhage was 
restrained by pressure and bandaging. The pulse failed; and death 
occurred in three hours. No autopsy. 
Three cases were complicated with hernia cerebri—of whom two 
died and one recovered. 
Case XXV.—Compound, depressed Fracture; Hemiplegia and 
Death.—A lad of eight years was struck on the head with a small 
hammer, producing a compound, depressed fracture of the right ver- 
tex, one inch and a half in diameter. Cerebral substance exudes. 
Perfectly conscious. Portions of jagged and depressed bone were 
elevated and removed. The dura mater was found lacerated. Her- 
nia cerebri followed. Pulse 160; conscious; cheeks flushed; both 
pupils much dilated, and both eyes obstinately directed to the right 
side. They could not be diverted. The left arm and leg were para- 
lyzed, but reflex movements could be excited. Urine voluntary. 
He survived five days. 
Case XXVI.—In the second case, hernia cerebri followed the 
use of the trephine; complete hemiplegia of the opposite side suc- 
ceeded, and eventually coma and death. 
Case XXVII.—The third case recovered. A strong, healthy man, 
aged 29, was struck from behind with an axe, held in both hands, 
and with great force. He was unconscious for two hours; then had 
severe pain and restlessness; no paralysis; pupils alike and normal; 
pulse 60, full, intermitting every fourth beat. A depressed portion 
of the occiput, two inches square, communicating with a large lace- 
rated wound of the scalp, was raised and removed. Dura mater 
scratched, but not perforated. The pulse became regular. Next 
day, he was delirious. On the following day, intermittent pulse, 
with fever. Four days after injury, pulse down to 54. No paraly- 
sis. Wound of integuments opened. Suppuration has begun. 
Wound black and sloughy. Dura mater bulging. CASES OP FRACTURE. 
29 
Dr. Homans, fearing compression from blood or pus, laid open 
the dura mater. The membrane was congested, but nothing else 
found. Hernia cerebri slowly extruded, until it attained the size of 
an English walnut. For the following week lie was violent and de- 
lirious. The hernia pulsated strongly. At the end of a week he 
became quiet and rational. Hernia covered with granulations. 
Pulse 76, regular. The following week it alternated from 48 to 60, 
A little incoherent at times. Wound healthy. The following fort- 
night, pulse from 50 to 60. Dizziness only on turning in bed. 
Wound contracting. At the end of another fortnight he was walk- 
ing about, with a pulse of 70, and regular. Improving in appetite, 
strength and flesh. Ten weeks after the receipt of the injury he 
was well, and discharged. The hernia cerebri had subsided, and 
was covered with sound integument. The only symptom complained 
of was dizziness on moving the head suddenly, and a feeling as if 
the brain were shaken on the injured side, at those times. 
Of fractures of bones of the face there were only three of the nasal 
bones; probably because the injury is too trivial to seek hospi- 
tal treatment. 
Case XXYlll.—Fracture of the Superior Maxilla, recognized as 
very rare, existed once in five hundred other fractures. The malar 
process and the antrum were broken by great direct violence. Re- 
covery was early, and without necrosis. Malgaigne makes a special 
exception, in the case of this bone, to the rule about removing com- 
minuted fragments in compound fractures. All such particles usu- 
ally become reunited, if suffered to do so. The great reparative 
power of the upper jaw is well shown in the case of its section and 
displacement for polypus, in the first paper of this series. 
Of the fourteen fractures of the lower jaw, several were double, and 
one triple. Only one was a simple fracture. They were usually 
compound into the mouth. Where double, one was near the sym- 
physis and the other near the angle. These double fractures were 
very hard to keep in place. lam inclined to think that the second 
fracture is often overlooked. One of the double compound fractures 
was followed by abscess, an opening through the skin of the chin, 
and necrosis with non-union. In this case the bones were drilled 
and wired from the outside. The wires were removed in six weeks, 
and union was firm. There was less inconvenience and suffering 
than when internal wiring and splints were used. 
There were three dislocations of the clavicle, which are alluded to 
here on account of their rarity. The one of the sternal end project- 
ed upwards, and the patient refused to submit to treatment. One of 
the dislocations of the acromial end, well known to be of very diffi- 
cult maintenance in place after reduction, resulted in some tilting up 
and deformity. 30 
SURGICAL CASES. 
The other one had a perfect result, and was treated by my House 
Surgeon, Mr. Gay, with the following apparatus of his own contriv- 
ing. A pad was put in the axilla, and a sling and Fox’s apparatus 
applied. By these means the acromion was drawn outward to re- 
ceive the uplifted end of the clavicle. Next, the clavicle was held 
down against the pulling up of the trapezius by a strap and buckle 
passing under the fore-arm, and thence up over the shoulder. From 
this a shorter one connected it with the ring of the Fox’s apparatus. 
A pad was placed over the sound part of the clavicle towards the 
acromial end, and by drawing the buckle tight, the clavicle was held 
firmly down in place. This was kept on about four weeks, when it 
was found that the bone was perfectly restored to place. 
Fractures of the Clavicle were very numerous; sixty-eight in all. 
Some were comminuted, none were compound. In all, good union 
resulted; in many, with almost entire freedom from deformity; in 
many, with some projection at the seat of fracture; and in a few 
restless patients, or old cases, with marked deformity—thus verify- 
ing the common surgical axiom, that when broken in the middle, be- 
tween the costo-clavicular and coraco-clavicular ligaments, this 
fracture is one of the most difficult to treat with perfect success; 
fracture of the lower end of the radius ranking next to it in the 
chances of ultimate deformity. Unlike the latter, fracture of the 
clavicle leaves no disability, as it sometimes does malposition. 
As to treatment, three methods were used. In children, the band- 
age of Velpeau was found sufficient. A moderate pad was put in 
the axilla, and the arm drawn back and bandaged to the side, with 
the hand carried up toward the sound shoulder. Starch or glue 
was often applied to this bandage. 
In adults, treated as out-door patients, Fox’s apparatus was used, 
and frequently re-adjusted. 
Adult in-patients were kept in bed on the back, where practicable, 
for two or three weeks. No apparatus was used, except a sling con- 
fining the arm, and a narrow pillow between the shoulders. In this 
position the fragments sink perfectly into place, and in these patients 
by far the best results were obtained. In girls and adult females 
such a mode of treatment should be insisted on, if they desire a per- 
fect outline. 
There were three undoubted fractures of the body of the scapula ; 
none of the neck of the scapula, that could be verified. 
The fracture of the body of the scapula is extremely rare. Ham- 
ilton has seen only two cases. Four cases occurred in 2358 frac- 
tures at the Hotel-Dieu, and eight among 1901 fractures in the Mid- 
dlesex Hospital. 
It must be the result of direct violence, and it was so in all our 
three cases cited. Heavy derricks or timber fell, striking the shoul- 
der from behind. The infra-spinous portion was usually broken; CASES OF FRACTURE 
31 
sometimes the spine. This corresponds with the statements of 
authors. 
In fracture below the spine, the anterior fragment is pulled to- 
wards the axilla by the teres muscles and scapular head of the 
triceps, while the posterior fragment is drawn upwards and back- 
wards by the rhomboid muscles. 
It is difficult to keep the fragments from tilting. Nelaton and 
Malgaigne confess that they have never kept them perfectly in place. 
Our cases were treated by adhesive strips over the injury, and band- 
aging the arm and hand to the body. They all resulted in good 
prospective use of the arm. 
Case XXIX.—To cite briefly one case. The fracture ran ob- 
liquely across the infra-spinous fossa, beginning at the axillary bor- 
der of the bone, just below the glenoid cavity, and passing down- 
wards and backwards to the posterior border and lower angle. 
There were mobility and crepitus, and a little displacement. 
Great inability to move the shoulder and arm. Treatment was by 
broad adhesive straps, fixing the scapula and fastening the arm to 
the side—the patient being kept on his back. In ten days an effu- 
sion of callus could be felt, forming an oblique ridge across the infra- 
spinous fossa, as evident as the spine itself. In three weeks union 
was good. 
In the treatment of fractures of the arm, fore-arm and hand, one 
hundred and forty-eight in number, splints were more frequently im- 
provised for the occasion than reliance placed upon those ready 
made. To this statement the exception should be made of the use 
of shoulder-cap splints for the fractures around the shoulder-joint, 
and of the internal angular splint for the elbow. Of the former, the 
sized felt, cap-splints of Aid were employed; and for the latter, the 
adjustable angular splints of Goodwin. 
Experience and common sense seem to us to fully endorse the 
statement of Hamilton, that ready-made splints, carved with fenes- 
tra}, and ridges and hollows all prepared for uniform processes of 
bones, more often misfit than fit the broken arm; and that they are 
the rude appliances of the mechanic rather than the surgeon. So 
many circumstances of individual peculiarities, of the nature of the 
injury, or the amount of contusion and swelling, are to be taken 
into account in every case of fracture, that we can no more expect 
ready-made splints to fit every broken limb, than we can expect 
ready-made shoes to fit every foot. And we believe more harm 
to have resulted from the rigid application of harsh apparatus, than 
from leaving fractures more to time, rest and soothing applications. 
The material we have found most useful is bass-wood, or white- 
wood, sawed into convenient lengths and widths, and planed to a 
thickness of from three-sixteenths to one-fourth of an inch. 32 
SURGICAL CASES. 
Sheet tin, or tinned iron, as heavy as can be bought, was also 
largely used for splints, and proved most serviceable in compound 
fractures and excisions. Applied to the bare skin, without padding 
of any kind, it was the least irritating, the coolest and the cleanest 
splint employed. It has the advantage also of being easily mould- 
ed or cut into any shape desired. 
In the fractures of children, heavy binders’ board was largely 
used. And in fractures around the elbow joint in young persons, 
angular splints were moulded from gutta-percha. The only objec- 
tion to its hospital use is its cost. 
The splints called Crimean were very comfortable for splints of 
coaptation, to be applied to restrain muscular action in fracture of 
the thigh, for instance. Made of separate narrow wooden splints, 
quilted into cotton cloth, they fit well, and can be easily washed. 
It has been very much the practice in this hospital to treat frac- 
tures of the upper extremity with very little bandaging, but to leave 
them exposed as far as possible. The splints were held in place 
by three or four strips of plaster, and no roller applied. Thus the 
amount of swelling, the lines of the limb, &c., could be always seen, 
and any defects remedied early. For this use, also, the strap and 
buckle, made of woolen, or elastic webbing, two inches broad, has 
been extremely popular. It holds on more uniformly than plaster 
or bandage, and can be quickly loosened or tightened. 
Of course it is essential, in patients treated outside the Hospital, 
that due caution should be insisted on lest they loosen their appara- 
tus too frequently themselves; and in out-patients it is more prudent 
to sometimes put on the roller, and even to fasten it with starch or 
glue. 
Colles’s fracture of the radius, of which there were forty-six cases, 
was treated rarely by Nekton’s pistol-splint, frequently by the 
straight splint; but the majority, by Bond’s splint. The pistol-splint 
has been the least satisfactory with us. The straight double splint 
has given many good results. Bond’s splint seems to be the most 
comfortable; and to be reliable, if the patient can be seen often. 
This splint was always made extempore, for the case in hand. The 
shape of the fore-arm and hand, the latter abducted, is marked out 
on a strip of bass-wood, and then cut accordingly—sides about half 
an inch high, of tin, are tacked on. A piece of turned wood, or a cotton 
roller, is fastened at the distal end, for the metacarpus to rest over. 
The splint is then padded to suit the case. The fractured limb is laid 
in it, and confined by straps, or bandage. The thumb and fingers are 
left free, and the fore-arm placed in a sling. When well applied 
this was an extremely comfortable apparatus. 
It is, of course, well understood that the result in this fracture de- 
pends very considerably on the nature and amount of injury. Some 
cases turn out well, and some badly, in any apparatus. The fracture CASES OF FRACTURE. 
33 
may be impacted, and permanently deformed; the amount of subse- 
quent effusion among the flexor tendons may be large and permanent; 
or rheumatism may set in, in elderly patients, all of which influences 
may give a bad result. 
Passive motion should be gently used, pretty early in the case ac- 
cording to our experience. 
Case XXX.—Before leaving the upper extremity it is proper to 
mention that one fracture was thought to be the very rare one of the 
coronoid process of the ulna. The patient, a boy of 9 years, came in 
with a dislocation of both bones of the fore-arm backwardsi The 
joint fell out of place as often as it was put in. No fracture of the 
lower end of the humerus, condyles or olecranon could be made out. 
And as a proof that something more than ordinary dislocation back- 
wards had occurred, the arm, placed on an angular splint, became 
anchylosed (false anchylosis); did not regain its power of motion 
when it was moved (and it was moved early), and required the usual 
treatment of several weeks of passive motion to restore its functions. 
We mention this case with diffidence, well knowing that the existence 
of this fracture is disputed ; and having suspected it in another case, 
where early mobility of the joint proved that we were mistaken. 
Case XXXl.—There was one case of Fracture of the Sternum. 
The patient, while fresco painting a church ceiling, fell to the floor, 
a distance of 40 feet, striking on the backs of the pews, and being 
also bruised by having the planks of the staging fall on him. He 
sustained a fracture of the sth and 6th ribs, at their middle. He 
also had a fracture of the sternum, displacing the manubrium from 
the body of the bone. The upper end of the lower fragment pro- 
jected upwards. - He had great pain in deglutition as well as in inspira- 
tion. There was a good deal of constitutional shock the first twelve 
hours. He rallied, under the use of stimulants and opiates. A 
broad, tight bandage was applied around the chest, which gave much 
relief. 
In three days he was able to sit up. In one week he was dis- 
charged, at his own request, relieved. There was neither pleurisy 
nor pericarditis. 
Cases XXXII-lll.—Two Fractures of the Spine have been fully 
reported before :* we will only allude to them now. Both occurred 
near the junction of the cervical and dorsal vertebrse. Both occurred 
from considerable falls on the back and occiput. In each there was 
complete paralysis below the nipples. The respiration was purely 
diaphragmatic. There was priapism and retention. The mind 
* Boston Medical and Surgical Journal, January 31,1867. 34 
SURGICAL CASES. 
clear. The pulse, in the first case, sank to 44, full and soft. The 
respiration was obstructed by meteorism of the bowels. The breath- 
ing became more and more shallow, until he died, 50 hours after the 
accident. 
The second case was trephined over the injury. Segments of the 
arches of four vertebrae were removed. The respiration became 
thoracic. The intercostals in good action. He survived until the 
following day, when he had emphysema and obscure respiration, with 
a tympanitic percussion, a pulse of 160, short, catching breathing, and 
death. We think the latter immediately due to fracture of ribs and 
pneumothorax. There was no autopsy. 
There were nine Fractures of the Pelvis. Of these, five were frac- 
tures of the crest of the ilium, or of the anterior superior spine. In 
three cases the patients fell from a height, striking on the side of the 
pelvis. In two, they were caught between cars, or timbers. All of 
these cases recovered perfectly in from two to four weeks. In none 
was there any injury of the viscera. Treatment consisted of rest in 
bed, and sometimes a broad bandage, but not always. 
One patient was thrown backwards from a horse, and sustained a 
fracture, or partial dislocation of the sacro-iliac synchondrosis. There 
was deformity, and inability to stand. No paralysis. He was treat- 
ed with the pelvic bandage. He recovered so as to move about in 
three weeks, but with a little shortening of the leg of the injured side. 
One case, fully narrated in the Boston Medical and Surgical Jour- 
nal for May 3, 1866, was a fracture through the os innominatum, 
caused by falling four stories. The fracture started from the crest 
of the ilium and ran downwards, and was met, at the acetabulum, by 
a fracture of the ramus of the ischium and pubes, running upwards. 
The whole fractured piece of the os innominatum was movable on 
the rest of the pelvis. There was no complication with the viscera. 
Recovery took place in five months, with shortening of the affected 
limb, and sciatica. 
The remaining two cases were both complicated with rupture of 
the urethra, or bladder, and terminated fatally. They are worthy of 
brief recital. 
Case XXXIV.—A boy of 11 years got caught between the hunt- 
ers of two railroad cars, and his pelvis crushed. He was not 
brought to the hospital until twenty-four hours afterwards. He was 
quite conscious, and seemed to be suffering mainly from retention of 
urine. There were contusions on each hip. The lower part of the 
abdomen was tense and dull on percussion. No urine passed since 
accident. Pulse 140. Ineffectual attempts were made to pass a 
catheter. Under ether, the catheter could be passed as far as the 
prostatic portion, where a false cavity seemed to exist. With the 
finger in the rectum, the catheter could be felt with such a thin sep- CASES OP FRACTURE. 
35 
turn intervening, and moved about so freely, that great laceration of 
the urethra was evident. No prostate could be felt. A fracture of 
the pubes was made out, to the left of the symphysis. A dissection 
was made down into the perinaeum, by Dr. Cheever, until urine flowed 
freely. The bladder being thus collapsed, and the membranous and 
prostatic parts so torn, no catheter could be got into the bladder. He 
was left to drain through the perinaeum. 
The following day it was found that urine had ceased to flow by 
the perinaeum, and the bladder was again distended. Constant vom- 
iting and great prostration. The bladder was now opened over the 
pubes, with a curved trocar. Urine flowed freely, and an elastic 
catheter was introduced to act as a syphon. The patient sank and 
died the same afternoon. 
The autopsy revealed a separation of the symphysis pubis; a frac- 
ture a little to the left of the symphysis; and two symmetrical frac- 
tures of the rami of the ischium just in front of the tuberosities. 
The bladder was empty. The neck of the bladder and prostate 
entirely torn across. 
Case XXXY.—A strong man had the pelvis caught between a 
schooner and a tug boat. The pulse was rapid, quick and feeble; 
the skin cool and moist; aspect collapsed. Severe pain across the 
pelvis, increased by any motion of the body, or of either leg. Some 
relief was given by strapping the knees together. Brandy and mor- 
phia were given. 
He was etherized, and a separation of the symphysis pubis, with 
mobility and fracture of the left os innominatum was clearly made 
out. A catheter could be passed down to the membranous urethra 
without difficulty; then it seemed to push into a free cavity, but no 
urine could be obtained. Warm water was injected, and returned 
bloody. The patient was in such a collapse that further attempts 
were desisted from. Complains of intense, burning pain in abdomen, 
which is tense and tympanitic. Respiration entirely costal. He 
gradually became pulseless; the body cold, but the abdomen hot, 
and died seven hours after the injury. No autopsy could be obtain- 
ed. Whether death was due to rupture of the bladder and extrava- 
sation into the peritonaeum and shock, only, or whether there was 
rupture of any other viscus, or a bloodvessel, also, we cannot now 
decide. We may fairly consider the question, whether in another so 
desperate case it would not be proper to cut over the pubes and 
search for the bladder there, if wo failed to give relief through the 
perinaeum.* 
Of the series of nine pelvic fractures, only one third were serious, 
and but two died. 
* See case by Dr. Win. J. Walker, in his treatise on compound and complicated fractures; 
also several reported in Eye’s Surgical Cases. 36 
SURGICAL CASES. 
Seventy-five Fractures of the Femur are enough to furnish some 
basis for a comparison of results. 
To speak, first, of simple and uncomplicated fractures, they occur- 
red at all ages and in all parts of the femur. Treatment, with very 
few exceptions, soon settled down into the following uniform course. 
The apparatus to be described is a modified combination of the 
methods of Buck and Liston. 
First—Extension was made by strips of adhesive plaster carried 
above the knee, up to the seat of fracture, and down below the foot, 
on each side. They were retained by spiral turns of plaster and by 
bandaging. The lower ends were attached to a cord, passing over 
a pulley, and suspending a weight of from five to fifteen pounds, ac- 
cording to the age of the patient, or his muscular power. 
Second—Counter-extension was made solely by raising the foot of 
the bed four inches. 
Third—Rotation was prevented by a long, outside splint, extend- 
ing from above the pelvis, below the foot. This was lightly bandaged 
on from the ankle to the groin, and ended in a few turns of the single 
spica, around the trunk. Sand bags were sometimes added. 
Fourth—Splints of Coaptation were applied around the muscles 
of the thigh, next the skin, and secured by broad straps and buckles. 
The advantages of this method are steady, persistent extension, and 
freedom of the perinmum from any counter-extension; comfort and 
ease to the patient; no sloughs, and good average results. 
Shortening rarely exceeded three-fourths of an inch; often it was 
much less. No adult escaped without some shortening; many of 
the children had, however, no perceptible difference between the two 
legs. In none of the simple fractures were there any sores, or 
sloughs from the apparatus. 
Non-union, originating in the hospital, occurred only once in the 
five hundred fractures. The double-inclined plane was used for some 
fractures near the hip. The double-inclined plane, combined with 
extension by weight in the axis of the femur, the pulley being at a 
height of five or six feet from the floor, according to the plan of 
Prof. Nathan Smith, was used in one case. The anterior splint of 
Dr. Nathan R. Smith was used in a few instances. 
It was not perceived that either of these modes, in simple fractures 
of the femur, was more beneficial than that first described. 
Intra-capsular fracture in old perons was treated by the fracture- 
bed, and, in some cases, by the long splint and weight, temporarily, 
to relieve pain. No apparatus was applied for a long time, and the 
patient was got up on crutches as soon as practicable. One case, in a 
person younger than middle age, was thought to be wholly intra- 
capsular and not impacted, and recovered with firm, bony union. 
The majority of the cases of compound fracture of the femur 
were the result of such great violence, and accompanied with so CASES OP FRACTURE. 
37 
much laceration of the soft parts, that amputation was the only 
resort. 
Cases suitable for conservative efforts did well on the fracture-bed 
of Dr. Crosby; and on some heavy, iron substitutes for it, contrived 
and modified by Mr. Cutler, the Superintendent. The great 
advantage of these last was, their complete immobility and their 
durability. 
There were three cases of simple fracture of both femurs. One, 
adult, was treated in Gibson’s apparatus, which consists of two 
crutches from the axilla to beyond the heels, and a foot-piece, by 
which extension can be applied to both legs. Two, in children, 
were treated by double, plaster extension of the two legs, terminat- 
ing in one pulley, and heavy weight; and sand-bags to check 
rotation. # 
All three cases did well. 
There were three fractures of the patella. All were treat- 
ed in the straight position, with the heel raised eight to ten inches. 
All did well; one, transverse, had bony union. 
There were one hundred and seven fractures of the tibia and fibula. 
The majority were simple, though many threatened to become com- 
pound. Pott’s fracture, with dislocation of the ankle, was pretty 
common. 
The fracture-box was used more than any other apparatus, especially 
in the earlier treatment; simple fractures were soon got into an im- 
movable bandage. Certain fractures of the tibia, threatening to be- 
come compound, were successfully treated by flexing the leg, and lay- 
ing it on its side, in Mr. Pott’s position, with a carved splint to steady 
it. After several weeks the straight, starched bandage was applied. 
Certain others were suspended in Dr. N. R, Smith’s apparatus, with 
good results ; and where there was simply an oblique fracture of the 
tibia pressing against the skin, it was remedied by raising the heel. 
The compound fracture of the leg depended for good or bad results 
on the habits and the age of the patient. 
During the last six months the glue bandage of Mr. De Morgan 
has been largely substituted for starch. It is made of ordinary 
boiled glue, to which one-fifth part of alcohol is added. Its advan- 
tages are facility of application Avith a brush; quicker drying, greater 
solidity, and firmer union of the folds of bandage after being slit 
open, than the starched bandage of Seutin. 
Reprinted from the Boston Medical and Surgical Journal, vol. Ixvii., 1867-