SURGICAL CLINIC 
St. Louis college of Physicians and surgeons 
SERVICE' OF 
PROF. A. C. BERNAYS. 
Cases Operated on During the First Month of the 
Winter Session, 1887-88. 
Reported by Dr. W. V. Kingsbury, Assistant to the Chair op Anatomy. 
The following cases comprise the important operations performed 
from Sept. 22 to Oct. 22, which appeared of sufficient interest to be 
worthy of publication ; 
CASE I. 
Carious Rib—Resection. —L. S., age 15, female. The patient 
gave history of tuberculosis in some members of the family. Two 
years ago a cold abscess developed upon the back, which, after reach- 
ing the size of a baby’s head, was opened and left several sinuses, 
which discharged freely and led to a carious rib. On Sept. 22 an in- 
cision seven inches long, parallel with, and down to the ninth rib, was 
made. The periosteum was found much thickened, and was easily 
raised from the diseased and roughened bone by means of elevators. 
The vertebral end of the rib was cut off at its angle by means of a 
chain saw, and four inches of the rib was excised. The wound was 
carefully washed with a solution of bi-chloride (1-4000), and a drainage 
tube was inserted, after which the wound was closed with silk sutures. 2 
Dk. W. V. Kingsbury 
[Oct. 
The end of the drainage tube led out of the vertebral incision. The 
old sinuses were carefully scraped with a curett, all the pyogenic 
membrane and cheesy deposits being carefully removed. 
The wound healed by first intention in its entire extent. The sutures 
were removed on the fifth day and the drainage tube on the eighteenth 
day. There was no elevation of temperature during the healing pro- 
cess, and the patient was discharged, cured, on Oct. 16. 
CASE 11. 
Laceration of the Cervix Operation. Mrs. D. F., 22 years 
old, from St. Joseph, Mo., received bilateral laceration of the cer- 
vix during her first confinement. This was followed by chronic met- 
ritis, sometimes falsely called sub-involution of the uterus, which 
caused severe menstrual molimina. Emmett’s operation of trachelor- 
raphy was performed on Sept. 22d, at the Pius Hospital. Four silk 
sutures were used on each side. The patient was kept in the recum- 
bent position six days, and a vaginal douche with a solution of per- 
manganate of potassium used twice daily. The stitches were removed 
on the seventh day, complete union having been achieved. 
CASE 111. 
Cancer of the Tongue Total Extirpation.-—L. E., male, 
age 66, had cancerous tumor at the root of the tongue. It had begun 
to ulcerate on the right margin and back of the tongue in the region 
of the circumvallate papillae. The tumor was as large as a lemon and 
caused great pain as well as impairment of speech, and also of the 
act of deglutition. The operation, total excision of the tongue, was 
performed on Sept. 22d. The first step was performing pro- 
phylactic tracheotomy and the introduction of Trendelenburg’s tam- 
pon-canula. Next two silk ligatures were passed through each side of 
the tongue in its middle third by means of which traction could be 
made in any desired direction. Then Kocher’s incision corresponding 
to the course of the digastric muscle was made and the flap contain- 
ing the skin and platysma myoides was turned up over the face. 
After this the fibres of the hvo-glossus muscle were cut through and 
o O 
the lingual artery was ligated. Then the floor of the month was cut 
through parallel to the jaw-bone, and the right half of the tongue 
was drawn down through the opening, and detached from its origin 
at the hyoid bone. This maneuvre immediately made plenty of room 
for the removal of the left half of the tongue, the only difference 
being that the lingual artery was ligated after it was cut through. 
The incision was closed by silk sutures after a large drainage tube 
had been introduced near the angle of the jaw. At the conclusion of 1887] 
Surgical Clinic. 
3 
the operation, Prof. Bernays called attention to the vast difference 
between total and partial resections of the tongue. The total resec- 
tion is a capital operation of the first magnitude, whereas, partial 
resection can be performed through the mouth with scissors, and is a 
minor operation. The tracheotomy tube was allowed to remain in 
situ for forty-eight hours. The patient was fed through an oeso- 
phageal tube for two weeks. His recovery was uninterrupted. He 
was discharged from treatment after three weeks and expressed him- 
self as being greatly relieved. 
CASE IV. 
Cancer of the Inferior Maxillary Operation. W. 8., 38, 
from Burlington, lowa, had epithelial cancer of the floor of the 
mouth and the mental portion of the inferior maxillary bone. Was 
operated upon Sept. 30 at Pius Hospital. The operation con- 
sisted in the resection of a little more than the middle third of the 
jaw-bone. A median incision, splitting the lip and extending down to 
the hyoid bone was made, the two flaps were turned back and the 
iaw-bone was divided on the right side by means of a circular saw 
and the dental engine, and on the left side just behind the first bicus- 
pid tooth by means of a Jeffries saw. The patient made a rapid 
recovery. The remaining portion of the jaw-bone on the right side 
was displaced outward and upward by muscular traction. Myotomy 
of the temporal and masseter muscles was performed in order to 
facilitate the reduction. The patient was discharged cured on Oct. 
20. 
CASE V. 
Cancer of the Uterus Operation. —C. G., female, aged 32, 
cancer of the neck of the uterus, not suitable for total extirpation on 
account of the immobility of the organ. Was operated upon Oct. 
4. The operation consisted in evidement with Simon’s curettes, 
followed by the supra-vaginal amputation with scissors. The Paque- 
lin cautery was freely used to stop hemorrhage and to destroy sus- 
picious looking tissue in the para-metria. The wound in the laquear 
of the vagina was partially closed by silk sutures. Dr. K,. T. Stoffel, 
who conducted the after-treatment, reports the patient doing well. 
CASE VI. 
Laceration of the Perinaeum Operation. Mrs. M., age 38, 
from Joplin, Mo., almost total laceration of perineeum and a large 
labial abscess of the right side. The os uteri was almost destroyed 
by numerous ovula-Nabothii. Operation at the Pius Hospital, 
Oct. 7. The first step consisted in enucleation, or incision of the 4 
Dr. W. V. Kingsbury. 
» 
[Oct. 
ovula-Nabothii. The labial abscess was laid open by an incision be- 
ginning at the duct of Bartolini’s gland and extending half an inch 
backwards into the vagina. The ruptured perinseum was pared and 
sutured by Goodeli’s method. The patient made an uninterrupted 
recovery. One of the principal complaints of the patient was pain 
during coition. Dr. Bernays called attention to the fact that in his 
experience this symptom was due to the chronic dilatation, or as it 
were, a cystic purrulent degeneration of Bartholini’s gland, and could 
be promptly relieved, in most cases, by incising the sac of the diseased 
gland. 
CASE VII. 
Genu-Yalgum Pes Planum—Operation. —E. J., from Flora, 
111., age 13 years, male, was a sufferer from a congenital contraction 
of the muscles supplied by the sciatic nerves. This condition had 
given rise to an extreme Genu Valgum and Pes Planum. The rec- 
tification of deformity consisted in tenotomy of the hamstrings and 
Achilles tendons. Eight tenotomies were made at one session and 
the lower extremities and pelvis fixed in their normal positions and 
held by a plaster of Paris casement. After one week the upper part 
of the plaster of Paris pants was removed and the patient allowed to 
walk by the aid of crutches. The patient made a painless and 
a febrile recovery and is doing well. 
CASE YIII. 
Rupture of the Perinasum—Operation.—Mrs. K., age 32. 
Complete rupture of the perinseura, of four years’ standing, extend- 
ing about three-fourths of an inch into the vagina. Operation at 
Pius Hospital, Oct. 11. The operation was a modification of 
Simon’s. The paring and the vaginal sutures were made after 
Simon’s method, and the body of the perineenm restored according 
to Goodell’s method, the same as in Case YI. No rectal sutures were 
employed. The silk sutures were used in this case. The patient 
made a complete recovery. 
CASE IX. 
Laparotomy. —Mrs. H., 44 years old, ovarian tumor. The tumor 
was known to be adherent and of rapid growth. It was suspected to 
be malignant. Dr. Schwartz, who had seen the patient some months 
previously, stated that he was then able to make out distinct adhe- 
sions of the tumor to the right iliac fossa. The bladder was crowded 
backward and downward by the growth. Under these conditions, 
Prof, Bernays thought it advisable to make the explorative incision 
on the right side, parallel to Ponpart’s ligament. The abdomen was 1887] 
Surgical Clinic. 
5 
opened in the transverse direction from the conjoined tendon to the 
anterior superior spine of the ilium, one inch above Poupart’s liga- 
ment. The introduction of the hand proved the tumor to be a soft, 
lobulated carcinoma of the right ovary, firmly adherent to the iliac 
fossa, to the sacrum, to the bladder and to the uterus, and its radical 
extirpation impossible. The peritoneal cavity was closed by a con- 
tinuous cat-gut suture, over which the abdominal incision was closed 
by eight deep and numerous superficial sutures. Fifteen days after 
the operation the patient’s pulse and temperature are normal, and she 
may be considered reconvalescent from the operation. The operation 
could have no influence on the fatal disease, either for better or for 
worse. 
CASE X. 
Pokro’s Operation,—M. T., female, age about 35, colored, from 
Lewisburg, Mo. Fibroid tumors of uterus, complicating a pregnancy. 
Porro’s operation. Patient was sent to St. Louis by her physician for 
operation, with the diagnosis of abdominal tumor. An examination 
proved the presence of numerous hard, slightly moveable tumors, one 
of which had grown into the umbilicus, distending the umbil- 
ical ring, and much resembling a hernia. With the exception of the 
large nodules, the tumor was well rounded and free from adhesions. 
Digital exploration of the vagina showed a virginal os uteri, and a 
large tumor in the uterus, filling out the vesico-uterine excavation to 
within an inch of the poitio. Although the patient absolutely denied 
the possibility of a pregnancy, Prof. Bernays was of the opinion that 
there was a pregnancy existing of about 7 or 7j months’ duration. 
Dr. Bernays, Sr., and Dr. Cross white made an examination of the 
patient, in order to either verify or contradict the diagnosis of preg- 
nancy, but were unable to positively assert either one way or the 
other. Some of the most trustworthy signs of pregnancy were ab- 
sent, for instance, the cessation of menses, development of breasts, 
nor could the sounds of the foetal heart be heard. Palpation of the 
abdomen was also unsatisfactory on account of the fibroid tumors. 
The vaginal examination, in addition, was not conclusive on account 
of a large fibroid in the lower segment of the uterus. On Oct. 15, at 
the Pius Hospital, laparotomy was performed. After the incision in 
the linia alba was made, Prof. Bernays introduced his hand into the 
abdomen, and feeling numerous fibroid tumors in the distended walls of 
the pregnant uterus, one of which, just behind the neck of bladder, 
would form an impediment to the delivery ofthe child pervias naturales, 
and all the others being most liable to produce a rupture of the uterus 
during labor, determined to perform Porro’s operation. A medium- 6 
Dr, W. V. Kingsbury. 
[Oct- 
sized trocar was introduced and a part of the fluid contents of the uterus 
evacuated. Then the uterus was lifted out of the abdominal cavity and 
turned forward over the pubes, so that none of its contents could fall 
into the abdomen after the organ was incised. The uterus was cut in 
the median line on its anterior surface and the foetus extracted and 
taken charge of by an assistant. The uterus was constricted by Tait’s 
wire clamp and the ligatures applied to the uterine vessels near the 
cervical portion on either side. The organ was then cut off, and the 
stump united by deep muscular sutures, over which was placed a row 
of Lembert sutures. The toilet of the peritoneum was carefully 
performed, a drainage tube inserted into Douglas’ cavity, and the ab- 
dominal incision closed in the usual manner. 
The child was a girl of about seven months, and is prospering. 
The mother rallied from the operation. Her temperature never rose 
above 99.5 F. until her death occurred on the fifth day of collapse. 
The autopsy revealed nothing abnormal in the abdominal cavity, ex- 
cepting the adhesive inflammation surrounding the stump of the 
uterus. No sepsis. 
At the conclusion of the operation, Prof. Bernays stated that the 
operation was neither new nor original. Hofmeier, of Berlin, the 
first assistant of Schroeder, has stated among the indications for 
Porro’s operation (Deutsche Med. Wochenschrift, 1886, No. 30), 
“ cases in which the body of the uterus is so altered that its removal 
appears desirable, especially on account of fibromatous neoplasmata.” 
He reports a successful case, mother and child both being saved. 
CASE XI. 
Laceration of the Cervix Operation.—Mrs. M. W., age 
28, from Calhoun County, 111., sent for operation on account of 
a laceration of the cervix and a rupture of the perinseum. This is a 
rare case of laceration of the cervix, the rent running up the posterior 
lip into Douglas’ cul de sac. The two halves of the posterior lips of 
the os uteri stood apart like the folded ends of a standing collar. 
They were freshened and united by five deep silk sutures. First 
intention, and the patient is now ready for the operation upon the 
perineeum. Prof. Bernays will perform Tait’s operation in this case 
before the class at the next clinic. 
CASE XII. 
Fracture of the Fore-arms and Dislocation of the Shoulder,— 
F. 8., age 45, was brought from Grafton, 111., on Oct. 16th. Ten 
days previously he had been thrown from a wagon and dragged by 
the horses for a long distance. He received a fracture of both bones^ 1887] 
Surgical Clinic. 
7 
of the left fore-arm and a dislocation of the same shoulder. This 
latter accident was overlooked or misjudged by the attending physi- 
cian, probably on account of the enormous swelling of the limb. 
The patient was seen at the Pius Hospital by Prof. Bernays and, 
after an examination, it was found that the head of the humerus was 
completely dislocated into the axilla. The patient was suffering in- 
tensely. Administered 1-2 gr. morphine hypodermically, but failing 
to secure relief, the patient was chloroformed and the reduction per- 
formed. The ordinary methods of extension and manipulation, and 
Schinzino’er’s method of rotation failed to reduce the head of the hu- 
merus, it being firmly fixed in its false position by adhesions and exuda- 
tions. Simon’s pendulum method was next employed, and succeeded in 
bringing the humerus back to its place with a snap, at the first attempt. 
This method was practiced in the following manner: An assistant 
stood up on a chair and took hold of the wrist of the dislocated arm, 
lifting the body of the patient off the floor and holding it there while 
Prof. Bernays gave the body a swinging motion, when the head of the 
humerus soon slipped back into its place. After the reduction the 
pain immediately left and the swelling gradually subsided. 
CASE XIII. 
Gastrostomy.—Mrs. T., age 58, of this city, has been suffering 
with a difficulty of swallowing for about one year. Was treated 
for the last two or three months by different physicians of this 
city, the last one of which diagnosed cancer of the oesophagus and 
recommended gastrostomy. The patient called on Prof. Bernays, 
on Oct. 16th, and an examination demonstrated the impossibility of 
introducing the smallest oesophageal sound; even liquids, such as 
milk, could not pass the stricture and the patient had lost over fifty 
pounds in weight during the past summer. On Oct 18th, the oper- 
ation of gastrostomy was performed, according to the method of 
Prof. Bernays, an accurate description of which will appear in the 
near future. The patient now, ten days after the operation, is regu- 
larly fed through the gastric fistula. Twenty-four years ago the 
patient had a piece of bone lodged in her oesophagus and the attend- 
ing physician, after failing to extract it, pushed it further down in 
the oesophagus hoping to make it enter the stomach. Prof. Bernays 
believes that this piece of bone is the cause of the stricture, and that 
it is lodged one and one-half inches above the cardia. As soon as the 
borders of the gastric fistula will permit it, an attempt will be made 
to extract the bone through the stomach. 8 
Dr. W. V. Kingsbury. 
[Oct. 
CASE XIY. 
Cancer of the Kidney—Operation.—J. W., female, age 61 
diagnosis of cancer of the kidney was made and on Oct;. 19th the oper- 
ation of extirpation of the kidney was performed. The incision was 
made in an oblique direction directly over the a modification 
of Konig’s lumbo-abdominal incision. The organ was enucleated. 
The operation was a very bloody one. The tissues around the renal 
vessels were so degenerated that three ligatures, one behind the other,, 
had to be applied before the hemorrhage could stopped. The 
upper third of the kidney was normal; but the lowej> two-thirds had 
degenerated into a large cancerous tumor, weighing alfrout five pounds, 
which, to the naked eye, appeared to be of the medullary variety. 
The patient never rallied, but died of shock about eighteen hours- 
after the operation. 
Cancer of the Uterus Operation. —Supra-vaginal amputation 
of the cervix uteri for cancerous growths. J. S., age 43, was suffer- 
ing from cancer of the cervix. The stench was one of the most offen- 
sive the operator ever encountered. The case seemed unsuitable for 
Kolpo-hysterectomy on account of glandular involvement". The oper- 
ation was similar to that performed in Case Y., with the exception 
that much more tissue was removed with the knife and the scissors. 
Eight sutures were applied to close the vaginal vault. The patient 
made an a-febrile recovery. 
All of the above operations were performed under the strictest an- 
tiseptic precautions. The chloroform-morphine narcosis was used in 
each case. 
CASE XY. 
Note. Physicians who are residents or visitors in the city are invited to make 
their desire known to witness surgical operations, when they will be promptly notified 
to assist at interesting cases that are always at the command of Dr. Bernays. The 
four Laparotomies, cases 9, 10, 13 and 14, together with two ordinary ovariotomies 
from private practice, will be reported in detail by Dr. A. C. Bernays as soon as the 
final results are known. 
903 Olive Street,