OSTEOSARCOMA. AMPUTATION AT THE HIP-JOINT 
FOR 
A LARGE OSTEO-SARCOMATOUS TUMOR OF THE FEMUR. 
J. MASON WARREN, M.D. 
Re-published from The Boston Medical and Surgical Journal. 
March, 1859.—J. Lougee, 16 years of age, of very light com- 
plexion, and reddish hair, was born in Lowden, Me., of healthy 
parents, and, so far as he knows, with no scrofula in the family. 
His employment for the past year has been that of shoemaking. 
About seven months since, at the upper and front part of the 
thigh a deep-seated tumor began to make its appearance, immova- 
ble, and slightly painful. It increased slowly in every direction, 
until he was brought to the Hospital in the last week of March, 
by his brother, who is a medical man. At this period, the 
left femur, which was the seat of the disease, was slightly flexed 
on the pelvis, and the upper half of it was occupied by a large, 
firm tumor, making a very distinct projection in front, but more 
indefinite behind, where it mounted up, and was lost in the nates. 
The front part of it was somewhat nodulated, and was in immedi- 
ate contact with, and partially pressed up, Poupart’s ligament. 
The skin was everywhere movable on the surface of the tumor, 
except on the outer side, where a slight redness existed, caused 
by the application of a blister. There was a moderate degree of 
mobility of the joint, sufficient to show that the articulation had 
not been invaded by the disease. The patient could use the limb 
a little, and was able to walk out with support, though very lame. 
The glands in the groin were healthy, as well as those of the ab- 
domen, so far as could be distinguished; in short, the glandular 2 
system generally was intact. The appetite was poor. He had 
no fever. The pain in the tumor required the use of an opiate at 
night. The circumference of the limb over the tumor was twenty- 
two inches; the measurement of the corresponding part of the 
opposite thigh, fifteen inches. 
Having made an examination of his case, I at once told the 
brother of the patient, who from his profession was able to ap- 
preciate its importance, that all applications were useless, and the 
only remedy left was amputation at the hip-joint. The case being 
a very important one, on the following day I called a consultation 
of the Surgeons of the Hospital, which resulted in the following 
conclusions. That the disease was probably an osteo-sarcomatous 
affection of the femur, which, if left to itself, would very shortly 
terminate the patient’s life in a most painful manner, and the only 
thing to be thought of was the removal of the femur at its articu- 
lation with the hip-bone. On the other hand, from the size and 
situation of the tumor, the operation was an exceedingly hazard- 
ous one, more so than in the ordinary cases of its performance; 
that there was a possibility of his dying during the operation, or 
within the subsequent ten days; and even if he recovered from 
the immediate shock, that there might be a re-appearance of the 
disease; that these conditions being properly placed before the 
patient and his friends, if they concluded to take the risk, the 
operation ought to be done. This question having been fully 
weighed by the patient and his brother, they decided to have the 
limb removed, rather than run the risk of submitting to the linger- 
ing course of the disease. 
The operation was performed in the following manner, on Mon- 
day, March 28th, the fifth day after his entrance into the Hospital. 
The ordinary method by transfixion being impracticable, and in 
view of the possibility of a dissection of the tumor from its at- 
tachments, a large flap of skin was raised from its front part; the 
incision commencing at the root of the scrotum, and terminating 
just above, and in front of the great trochanter. The flap was 
now dissected up quite to Poupart’s ligament, the fascia over the 
artery opened, the vessel exposed, a ligature passed around it and 
tied. An incision was now made on the back part of the thigh, 
corresponding with that in front, and the flap partially raised. 
With a short, strong knife the muscles running from the pubis to 
the inside of the tumor were cut through, and those on the out- 3 
side treated in a similar manner. These incisions loosened the 
thigh, which had before been confined, and allowed it to be de- 
pressed and rotated outward. It was necessary to do this to a 
great extent, on account of a lobe of the tumor projecting over 
and obscuring the articulation. The knife was next applied to 
the capsule, which was divided, the round ligament snapping off 
at the same time from the powerful force applied to it. The bone 
was then disarticulated, the great muscles of the thigh cut through 
behind, and the limb removed. A very large sponge was thrust 
into the wound, to prevent bleeding, while the smaller vessels in 
the flap and trunk were secured. By the skilful compression of 
the aorta by Dr. Gay, the immediate seizure and compression of 
the flaps by Dr. Cabot, together with the previous ligature of the 
femoral, scarcely any blood was lost. The vessels in the flaps 
were successively tied as they were uncovered by the removal of 
the sponge; it was also found necessary to secure the great femo- 
ral vein. 
The lips of the wound were brought together by a number of 
sutures, a compress was applied, and a very large sponge, to make 
gentle compression, and fill up the deep cavity in the side of the 
pelvis; over this a towel, and the whole firmly secured by a band- 
age. The operation was necessarily protracted much beyond the 
usual time of an ordinary disarticulation, yet after its termination, 
and just before the removal of the patient from the table, his pulse 
was as good as before the operation was commenced. 
A section made through the tumor and the femur, which was 
sawn longitudinally through its middle, presented the following 
appearances. The tumor was beautifully variegated, and present- 
ed the ordinary aspect of osteo-sarcoma. It had its origin be- 
tween the periosteum and the bone, and extended from the middle 
of the femur quite to its neck. The periosteum covering the 
greater trochanter had been peeled up, and the sac of it filled 
with that yellow oleaginous fluid which is so frequently seen in 
tumors connected with the bone. The parietes of the bone were 
somewhat thickened in the centre, thinned toward either extre- 
mity, and the medullary cavity was not entirely obliterated. The 
substance of the tumor itself was quite firm, having the ordinary 
appearances of carcinoma interspersed with spiculae of bone. A 
microscopic examination of it was made by Dr. Ellis, and verified 
the diagnosis. The head and neck of the bone seemed to have 4 
completely escaped invasion. The muscles covering the tumor 
were partially adherent to it, but none of them so completely in- 
corporated with it as at first had been feared. The tumor seemed 
to have been entirely enucleated, and, so far as could be ascer- 
tained, not the slightest trace of it was left behind. 
In the afternoon of the day of the operation the patient seemed 
to be in a good condition, and complained only of the tightness of 
the bandage around his body. This was loosened by cutting it 
away partially, and completely removed on the following morning. 
He passed a pretty good night, under the effect of a drachm of the 
solution of the sulphate of morphia, complaining principally of an 
excessive thirst, which no amount of drink seemed to satisfy, and 
which was apparently caused by the operation, but I attributed it 
partly to the ether. On March 30th, the thirst was somewhat 
alleviated, but he was still without appetite, and complained of a 
little soreness in the groin; pressure gave pain in the lower part 
of the abdomen. The pulse was 100. 
The following day he took an enema,, which emptied his bowels, 
and seemed to improve his appetite, so that he chewed a little 
beef; also took brandy and water, and milk punch, to which he was 
much averse, never having taken spirit in his life. 
On Saturday, April 2d, the wound began to be rather offensive, 
and at the suggestion of the venerable and distinguished Profes- 
sor Mussey, who was present, the dressings were removed, and a 
yeast poultice applied; the pulse was rather over 100; the appe- 
tite was still doubtful. On Monday, the 4th, his pulse was 120, 
there was profuse sweating while sleeping; he began to take his 
food more regularly, and his pulse to have considerable firmness. 
He was allowed bread, tea and baked apple for breakfast; bread, 
meat, and baked apple, of which he was very fond, vegetables, 
with brandy and water, for dinner; for supper, the same as at 
breakfast; and at bedtime, to drink through the night, from half a 
pint to a pint of milk punch. On the 8th of April he is reported 
as doing well, '‘lie makes no complaint, the pulse is about 100, and 
he may be said to be in a convalescent condition; the bowels are 
emptied every other day by enemata, and he has taken no purga- 
tive medicine since the day of the operation.” 
The patient went on improving till the third week after the ope- 
ration. The wound healed well, leaving an aperture at either 
end for the escape of ligatures. About the twenty-fourth day, on 5 
"Waking in the morning, he felt a pressure at the inner part of the 
stump, and shortly after a stream of blood slowly trickled down. 
Dr. Dyer, the resident surgical pupil of the Hospital, was immedi- 
ately summoned, and by means of a sponge applied over the aper- 
tures from which the ligatures issued, and a strong compressing 
bandage, succeeded in arresting the bleeding. The bleeding re-’ 
eurred again in about two hours, and was arrested in the same 
way. When I saw the patient, about 9, A.M., he was rather pale, 
his pulse rapid, and his system had evidently received a severe 
shock. He wras not much alarmed, but on this and the following 
day made great complaint of excessive thirst, as he did after the 
operation, showing that it was the loss of blood, and not the ether, 
which caused this symptom. From the free escape of blood at 
the time, and its arterial color, it was thought probable to have 
escaped from the great vessel, in consequence of the ligature having 
partially detached itself; and for this reason it was deemed pru- 
dent not to interfere with the wound for the next two or three 
days. No new bleeding having occurred, I then had all the dressings 
removed. The two ligatures at the outer part of the stump 
were seized by the fingers, and withdrawn with very slight force. 
The four ligatures at the internal part of the stump were then 
separated, and dragged upon singly, and all of them were removed 
without difficulty. The two large ones, which had belonged to 
the artery and vein, had probably been for some time detached, 
and lay coiled up in the wound, causing irritation and suppuration, 
and probably the haemorrhage which had given the alarm. 
From that time the wound rapidly healed. The patient left his 
bed in about a week, and in ten days was able to go out of doors. 
He has now, May 10th, returned home in the full enjoyment of 
health. 
Remarks.-*—This case is worthy of notice from having been the 
first of amputation at the hip-joint that has succeeded in Boston. 
The following statistics, from Mr. Erichsen, in his valuable work 
on Surgery, may be interesting, as showing its mortality, and are 
partly taken from data furnished by Dr. Smith, of New York: Of 
126 cases, 76 died; of 47 cases in which it was done for injuries, 
35 died; of 10 cases operated on in the Crimea, all died. 
The flaps in this case being principally composed of skin, made 
the wound much less appalling, and more manageable than where 6 
large muscular flaps are left, as in the ordinary operation. This may 
be considered worthy of imitation, even when not required by ne- 
cessity, as in the present case. The previous tying of the artery, 
together with the compression of the aorta, allowed the operation 
to be performed in a perfectly comfortable manner, without the 
slightest hurry, and with almost a dry wound, if the expression 
may be used. 
It may not be inappropriate to append to the history of this 
case, an operation of similar character performed at the Hospital 
last year, and printed in this Journal among the Records of the 
Boston Society for Medical Improvement. 
“ Amputation at the Hip-Joint.—Dr. Warren mentioned the case as 
an interesting one, from the fact of its being the first ever done 
at the Hospital, and, so far as he knew, in Boston. The patient 
was a child, 6 years old, and was first seen by him on the 19th of 
June, at three o’clock, having been injured about two hours before, 
lie was sitting on the curb stone of the sidewalk, when a truck 
wheeled round against him, crushing his limb against the stones. 
His injury at first was not detected ; being lifted up by some passer- 
by, and placed upon his feet, not being able to support himself, he 
fell, and received, in addition to his other injuries, a violent blow 
upon the forehead. When brought to the Hospital his state was 
as follows. He was quite faint, countenance livid, pulse small. The 
integuments of the thigh, near the hip, were nearly cut through by a 
semicircular wound, and on the outside a deep wound in the muscles 
communicated with the bone, which was fractured obliquely, and 
denuded nearly up to the joint. As the blood was flowing from 
this extensive wound, the case admitted of no delay, and amputa- 
tion was at once proceeded to. The boy was first stimulated with 
as much spirit as he would bear, and ether was administered, which 
quickly brought up the circulation. The limb was now separated at 
the fractured part, Dr. Shaw compressing the artery. Dissection 
was next made at the side of the bone, which was disarticulated 
with difficulty, both from the anatomical relation of the parts, these 
being obscured by ragged muscles, and, more especially, from the 
remaining portion of the femur being too short to be easily con- 
trolled in effecting the disarticulation. The capsule was, however, 
opened, and the bone dissected out with but little delay. The boy at 
this moment became deadly faint, and was only restored by using fric- 
tions of brandy and ammonia, the latter being applied also to the 
nostrils. He was likewise suspended by the remaining leg, so as to 
throw the blood to the brain, and under this treatment soon revived, 7 
although at one moment he seemed to be dead. The vessels were 
now tied, and the wound temporarily dressed. Just as this was fin- 
ished, he a second time came in peril of his life. As is often the case 
with patients recovering from ether, he seemed disposed to vomit, and 
in fact a basin was held, and he threw up a large quantity of liquid 
substance. Immediately after this, he fell back as if exhausted, a 
cold sweat came over him, and the respiration and pulse ceased. The 
frictions, and other means for restoring suspended animation, were at 
once again resorted to, and Dr. W. proceeded to pass the finger into 
the mouth for the purpose of raising the epiglottis and making a pas- 
sage for the air into the windpipe, when it encountered a mass of 
solid potato-like substance, with which, on further investigation, the 
whole mouth and fauces were found completely blocked, so as entirely 
to exclude the air, and almost suffocate the patient. The teeth had 
allowed the liquid contents of the stomach to pass between them, but 
had acted as a strainer to retain the solid matters in the mouth. The 
mouth being now cleared, and artificial respiration set up, the child 
gradually commenced to breathe, and in the course of half an hour 
was in a safe state. At nine, P.M., the limb was dressed, and he 
was taken to his bed in the ward of the Hospital. The patient lived 
thirteen days, and received during this time the most unremitting care 
from the nurse in charge of him, and from Mr. Dyer, the House-sur- 
geon of 4he Hospital. The stump during this time became quite 
sloughy, and one or two abscesses formed in the groin. The whole 
wound, however, finally assumed a healthy appearance, and when 
there seemed to be every prospect of his having gone safely through 
the most dangerous part of the trial, he suddenly fell off, and died, 
nearly a fortnight after the reception of the injury.”