NOTES ON SURGICAL CASES 
BY 
L' 
J. JR.* M. D., 
Professor of the Principles and Practice of Surgery, 
Omaha Medical College. 
OMAHA: 
Reprint from The Omaha Clinic for December 
188 A Jt XI *NOTES ON SURGICAL CASES. 
By J. E. Summers, Jr., M. D., 
Professor of the Principles and Practice of Surgery, Omaha Medical 
College. 
I. 
Tuberculosis of the Ankle-Joint—Am- 
putation.—The patient, a young lady, twenty 
years of age, was first seen by me September 
6th, 1888. She gave briefly this history: 
Following a fall one and one-half years pre- 
viously, she commenced to suffer pain and 
difficulty on locomotion, in the ankle-joint. 
This was treated by extension, cold, heat, 
poultices, etc., until eight months prior to 
my seeing her, when she went to Chicago and 
entered a hospital under the care of a well- 
known surgeon, who incised the joint and 
evacuated some pus. Counter openings were 
made from time to time, and an attempt by 
drainage and irrigation with dilute muriatic 
acid made, to dissolve the carious bone. After 
six months of such treatment, the joint was 
resected. This was a complete failure. On 
October 7th, 1888, the patient being in a bad 
condition constitutionally and locally, I am- 
putated the leg through the middle third. 
She made a good recovery. 
Remarks.—Had proper fixation with a 
Thomas or Sayre ankle brace been adopted, 
no operation would have likely been required; 
or if, after the formation of pus, instead of 
simple incision and drainage, a thorough 
search for and removal of its cause had been 
♦Read before the Medical Society of the Missouri Valley, Sept. 20, 1889 2 
made, the limb would probably have been 
saved. Specimens are to be seen. 
II. 
Tuberculosis of the Knee-Joint-Amputa- 
tion.—The patient, a man fifty-nine years old, 
had suffered, off and on, for years with inflam- 
matory symptoms in the knee-joint and upper 
third of the tibia. Four years ago pus had 
discharged from a point about the middle of 
the upper third of tibia. Last fall, after an 
attack of acute inflammation in the knee, the 
leg was markedly flexed on the thigh, and re- 
mained so until six weeks prior to my seeing 
him, when it was forcibly straightened, after 
division of the ham-string tendons, and put 
in a plaster cast. 
When the man came under my care, the 
joint was swollen and painful, and the 
patient’s general condition approaching a 
critical form, two days later I amputated 
the thigh through the lower third. Primary 
union followed, and the man left the hospital 
in three weeks, and has continued to im- 
prove in general health. 
Remarks.—My diagnosis, prior to amputa- 
tion, was chronic tuberculosis, but on examina- 
tion of the joint after operation I could not tell 
what the lesion was except an osteo-arthritis. 
Dr. Gifford solved the problem by the inocula- 
tion of the anterior chamber of a rabbit’s eye 
with fluid from the joint, a typical tubercu- 
losis of the iris resulting. Resection in this 
case was out of the question; the age of the 
patient contra-indicated it. The general con- 
dition demanded the removal of the limb. 
III. 
Sarcoma of Lower End of Femur Com- 
mencing in the Periosteum—Amputation.— 
I wish simply to call your attention to 
these gross and microscopical specimens of 3 
this lesion occurring in a boy nineteen years 
old, whom I saw with Dr. Coffman, of this 
city, and whose thigh I assisted Dr. Coffman 
in amputating, August 11 of this year. The 
boy is well and going about, but a recurrence, 
with death, is certain. There is only one 
case on record (Butlin) of cure in this lesion, 
whether the operation was made through the 
thigh or hip-joint. The gross examination 
of the specimen shows the disease to have 
begun in the periosteum, and the microscopi- 
cal sections classify the lesion as a small 
round-celled sarcoma. As you remember, the 
typically small round-celled sarcomas are 
most malignant, approaching nearest in 
form to embryonic tissue — the spindle- 
celled are next in degree of malignancy, while 
the giant-celled are the least malignant. 
Clinical experience has shown that when a 
sarcoma commences in the bone itself, the 
degree of malignancy is much less than when 
it commences in the periosteum, and many 
cures after operation have been recorded. The 
rule to follow in these cases is amputation 
through or above the joint on the proximal 
side of the bone involved. Most, if not all, 
primary malignant growths of bone are sar- 
comas, Carcinoma of bone is secondary. 
Schwartz found out of 200 cases that the 
lower extremity was attacked 155 times. 
(Jones). 
IV. 
While on the subject of bone and joint les- 
ions, I wish you would notice these two 
pieces of bone. They are the upper and lower 
ends of the fragments of a case of non-union 
of a simple fracture of the lower third of the 
femur. Eight months after the injury the case 
came under my care and I resected the femur 
with great difficulty, wired the ends and got 4 
union. This is the man, who is now walking 
on the limb, the operation having been done 
in February of this year. 
Y. 
From my hip-joint resections I select one 
done last May. A boy, twelve years of age, 
was well advanced in what is known as the 
third stage of hip-joint disease. The upper 
end of the femur was removed on a line with 
the lesser trochanter, and because of perfora. 
tion and disease, all of the acetabulum. Six 
weeks after the operation the boy was out, 
and has been going around on his crutches, 
wearing a long Sayre’s splint. Recently the 
symptoms of tuberculosis of the kidney have 
set in. This case had passed the period of 
disease when operation could be of more than 
temporary benefit, and is an example of the 
result of too long delay in explorative meas- 
ures in this disease. 
VI. 
Tuberculous Tumor of the Bladder.— 
July 18, 1889, a young man, aged twenty- 
three years, gave the following history: When 
two years of age he received an injury of the 
left hip, which was followed, judging from 
the cicatrices and the marked flexion of the 
atrophied limb onto the trunk, by a neglected 
hip-joint disease, which nature had cured in 
the deformed position. Two years ago the 
patient began to suffer with frequency of 
urination, and this increased so much that he 
was obliged to give up going to school. From 
time to time the urine was bloody and for 
two or three months has been more or less 
continuously so. 
Two months ago the patient was examined 
by a surgeon, who divided a stricture two 
inches from the meatus. For the past two 
weeks the patient has been troubled with a 5 
bad cough and raises a muco-purulent secre- 
tion. The urine is passed every hour in a 
small stream which frequently stops suddenly 
and then begins again. Family history elicits 
that a brother of the young man’s father died 
of tuberculosis of the lungs. Physical signs 
show a little dullness over the lower portions 
of both lungs behind, with fine bubbling rales. 
Temperature 100Y20 F. Under chloroform, 
after injecting three ounces of warm car bolized 
water, a sound was introduced into the blad- 
der—the beak of the instrument could be easily 
moved to the left and towards the base of the 
bladder in this direction, but encountered 
resistance on being turned in the opposite 
direction, the sensation being that of a very 
much thickened, irregular bladder wall, or of 
a new growth occupying the base and front 
of the bladder to the right of the median line. 
The finger introduced into the rectum, the 
sound still in the bladder, confirmed the loca- 
tion of this abnormal state of affairs. After 
the examination considerable blood and detri- 
tus was washed out of the bladder. 
Microscopical examination of sputum— 
Tubercle bacillus. Microscopical examination 
of urine—Tubercle bacillus. 
Remarks.—Without the aid of the micro- 
scope in this case the diagnosis could not 
have been made, as the general condition of 
the patient was excellent, and the examina- 
tion of the bladder proved only the presence 
of a new growth. My suspicions were aroused 
by the deformity of the hip, and the family 
history. The patient was sent back to his 
home. 
VII. 
Stone in the Female Bladder—Lith- 
olopaxy—The patient, about thirty-five years 
of age, had suffered with symptoms of stone 6 
n the bladder for about two years. Some 
months previous to my seeing her, she had 
been relieved by her physician of a stone 
which had, unaided, nearly completed its 
course through the urethra. The bladder 
was in fair condition; urine had to be passed 
every one to two hours. The stone was in 
my opinion too large to be delivered through 
the urethra with safety to the subsequent 
integrity of control over the urine. [A stone 
more than 8 to 10 lines in diameter should 
not, as a rule, be removed through the female 
urethra, experience having demonstrated the 
great risk of incontinence following such 
practice.] A lithotrite was introduced in 
this case, the stone crushed and the frag- 
ments washed out, the patient returning to 
her home ten days after the operation; pass- 
ing her urine not oftener than every five or 
six hours. The operation was done in July, 
1889. 
VIII. 
Stone in the Bladder—Lateral Lithot- 
omy—A gentleman, sixty-seven years of age, 
with a history of stone in the bladder dating 
back more than two years, was first seen by 
me five weeks ago. Urine was bloody and 
mixed with muco-pus, and the bladder con- 
tracted, its walls thickened. The urine was 
passed every hour. The searcher disclosed a 
stone. Three weeks ago to-day I did a lateral 
lithotomy, removing a calculus about one inch 
in diameter. There was considerable phos- 
phatic incrustation of the mucous membrane, 
and two large pediculated masses of the same 
material, which were removed with the 
scoop. The wound is closed and the urine 
passes through the natural channel, being 
voided every three hours. 
Remarks—I believe there are few cases in 7 
which a stone in the female bladder cannot 
be crushed and removed through the urethra, 
and only in the rarest cases will a cutting 
operation be called for. I cannot agree with 
the recent writings of a well known teacher 
and author who says {Med. Red., Aug. 17, 
1889): “ For stone in the female it (the high 
operation) should be invariably selected, 
when the calculus is too large or too firm to 
be crushed and removed per urethram.” The 
vaginal operation, by using Simon’s incision 
(a Y) will give ample room for the removal of 
most any sized stone, and only in the most 
exceptional cases, chiefly in young children, 
should the high operation be done in the fe- 
male sex. The immediate or later closure of 
the incision is under the control of the sur- 
geon in the vaginal operation. My reasons 
for doing a perineal operation in the case of 
the old gentleman are obvious—a median in- 
cision would have, perhaps, done as well as 
the lateral, because of the size of the stone, 
yet on the whole, I prefer the lateral in most 
all cases. 
IX. 
Gun-Shot Wound of the Intestine.— 
Laparotomy.—Death.—I heard Dr. McGraw, 
of Detroit, read a paper before the A. M. Assn, 
some two or three years ago, advocating 
strongly that the incision in laparotomy for 
gun-shot wounds, where the point of entrance 
of the bullet was at some distance from the 
median line, should as a rule, be made through 
this point and in a direction giving the nearest 
approach to that part of the intestine proba- 
bly the seat of injury—this I have reason to 
believe sound practice. In a case operated 
upon by myself a few weeks ago, where the 
point of entrance of a 38-calibre bullet was 
about two inches to the left of the left rectus 8 
muscle, and above the umbilicus, the missile 
having been fired by an individual on horse- 
back, the victim being afoot, I made my incis- 
ion, a long one, in the median line, and it was 
with the utmost difficulty that, after the 
removal of all of the small intestine, I was 
able to close four perforations of the sigmoid 
flexure, the lowest being just above the com- 
mencement of the rectum. The meso-colon 
was so short that it was impossible to bring 
the wounded gut into the incision, and all of 
my sutures had to be made with hands and 
instruments deep within the abdominal cavity. 
The necessary manipulation of the small in- 
testine and the length of time required to 
complete the operation, so added to the shock 
of the injury, that my patient died some six 
hours later, never rallying. The operation 
was done ten hours after the receipt of 
the injury. There was extravasation of 
fecal matter with a commencing periton- 
itis. 
Remarks.—Had a lateral incision been 
done the shock would have been much less, as 
the points of injury could have been more 
readily and rapidly repaired, and the patient 
given some chance for a recovery. When I 
state, that out of fifteen laparotomies done 
by me within a little over two years, for 
varied lesions, not one, and there have been 
some difficult ones, has given me more 
physical and mental strain, you will appre- 
ciate how I feel in regard to this suggestionof 
Dr. McGraw’s. 
These cases are chosen from among a 
goodly number occurring in my practice dur- 
ing the past year, and illustrate, I believe, 
practical points in surgery.