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Surgeon General's  Office     1
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No.
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SURGICAL   CASES
BY
   DAVID W.  CHEEVEK, M.D.,
ADJITNCT PROFESSOR OF CLINICAL SURGERT IN HARVARD UNIVERSITY.
        SURGEON TO THE BOSTON CITY HOSPITAL.
? AT?

             BOSTON:
PRINTED  FOR  THE  AUTHOR
    David Clapp & Son, 334 "Washington St.
               1869. 
Wo



i'869 
  The  following cases, embracing either rare forms of disease,
novelty in mode of operation, or variation  in results from pre-
vious statistics, were thought to be not  unworthy the  notice of
Profession, to whom they are respectfully presented.
D. W. C.
126? Washington Street,
  Boston, April,  1869. 
 
SURGICAL   CASES.
Encefhaloid Tumor of Tonsil ;  Eemoval  by External Dissection.

   The following case presents two points of great interest.  First,
cancerous disease is excessively rare in the tonsil; second, the mode
of operating for its  removal, by external incision, is believed to be
without precedent.
   Gr. M.,  a well-formed, robust sailor, aged 34 years, without any
hereditary predisposition to disease, and in the enjoyment of per-
fect health previous to .his present disability, presented himself at
the  hospital with the following history.   Six months before, with-
out any known cause, his left tonsil became enlarged and painful.
It was treated by- his physician as a case of tonsillitis, and, in due
time, a portion of it was excised from within.  No relief followed,
but, instead,  the tonsil continued to increase in size, and the re-
gion of the section became an obstinate ulceration.   His articula-
tion and deglutition were impaired to a  considerable degree,  and
dyspnoea was  quite marked, especially at night.
   On his entrance to the hospital the affected tonsil appeared much
enlarged.   The mass protruded into  the fauces,  and at its apex
presented an indolent ulcerated surface, one inch and  a half in
diameter, with raised and everted edges.  Externally, correspond-
ing with the internal  growth, and moving  with it as if it were a
part, was  a nodule lying in the left sub-maxillary triangle,  of the
size of an English walnut. Manipulation of this mass gave pain.
The condition of the man otherwise was  excellent.  There was
neither the history, nor any appearance of syphilis.
   He was able to take only liquid diet, and was ordered a gargle
of diluted  liquor sodse  chlorinatse, the  discharge from  the ulcer
being offensive.
   During an interval of  three weeks, it  was observed  that  the
tumor doubled in size, internally and externally.  The consequent
symptoms became much more grave, and called for some operative
interference.  The situation and large size of the tumor, as well as
        1 
2      .            SURGICAL  CASES.
its projection outside  the  throat, contra-indicated any operation
from inside the mouth, and it was therefore decided to attempt re-
moving it from the outside by external incision.
   Operation.—Etherization was slow and difficult, on  account of
the obstruction to respiration by the tumor in the fauces.  As soon
as it was accomplished, an  incision was made, extending from just
within the angle of the jaw, downward, over the most  prominent
part of the tumor, a distance of three inches and  a  half, and  in
direction parallel with the sterno-mastoid muscle ; this incision was
met by another, one inch and  a  half long,  extending along the
lower  border of  the jaw.   The  parts were dissected away  on
either side until the  diseased growth  was reached.  On  enuclea-
tion this was found to be an  enlarged and diseased  lymphatic
gland, of the size of an English walnut.  It  had no distinct con-
nection with the tonsil within, but the disease was encephaloid
in character.  It lay outside all important structures, and was
entirely removed  without difficulty. The dissection was now ex-
tended until the tonsil was reached.  In its course, the digastric,
the stylo-hyoid and the stylo-glossus  muscles were divided, the
stylo-pharyngeus  being left intact, on account of its proximity to
the glosso-pharyngeal nerve.   The fibres of the superior constric-
tor of the pharynx were picked  apart with a director,  and the
pharynx thus opened between them.  The finger of the operator
was now enabled  to sweep entirely around the diseased tonsil, the
pillars of the soft palate being left intact;  the mass was removed,
and presented all the appearances of encephaloid disease, its size
being that of a pullet's  egg.
 _ The haemorrhage during the operation was free but  not exces-
sive ; the largest vessel divided being the facial artery,  which was
cut close to the carotid.  Twelve ligatures were applied.  A few
of the smaller branches of the facial nerve were divided, and para-
lysis of the lower lip, on the same side, was  the consequence.   It
was also observed that, on account of the section of the stylo-glos-
sus muscle, the tongue, when  protruded, took a direction toward
the opposite side.  A single suture closed  the horizontal incision ;
the wound otherwise was left freely open, air passing  through it
with each expiration.  Recovery from ether was speedy, and there
was no marked depression from the operation.
  Not a single complication  occurred to  hinder the progress  of
recovery.   Suppuration of  a satisfactory character commenced on
the second  day.  During the  first week after the operation the
patient took  liquid  nourishment, administered by means of the
stomach-pump.  From the outset  there was no pain, and respira-
tion was easy.  The  granulating process was rapid, and at the end
of eight days no fluid passed through the wound  in deglutition
After eleven days a small patch was observed at the lower part of
the posterior pillar of the palate, which had the appearance of the
original malignant growth; it was freely cauterized with  nitric acid 
SURGICAL  CASES.
3
and there was no subsequent reappearance.  After seventeen days,
solid food was swallowed without difficulty.   In thirty-one  days
the wound had entirely closed.   The pharynx was entirely clear ;
and except that the pillars of the palate on the side affected were
somewhat  separated, it  appeared in perfectly normal condition.
The tongue was protruded in a straight line, and no paralysis  of
the lip remained.  From the operation until recovery, there was no
constitutional disturbance requiring special notice.
  As has been already stated, the gross appearance of both tonsil
and gland were alike, and unmistakably encephaloid.   The follow-
ing is a record of the microscopic appearance :
  " The tumor was of a soft and friable nature, slightly lobulated,
and of a grayish-red color.  On section it yielded an abundance of
juice of a milky  color, and of considerable consistency.  Under
the microscope both the  tonsil  and  the enlarged lymphatic gland
appeared the same.  They were composed of cells of moderate and
uniform size and ovoid form, containing nuclei, and many,  also,
nucleoli.  There was no  fibrous tissue between them, but a  great
number of small dark granules, appearing to be freed nucleoli.  On
the addition of acetic acid the nuclei became  more distinct, and
cells were visible containing three or four of them.
   "To base the diagnosis  of the character of a tumor upon its
microscopic appearance alone, is a mistake not to be committed.
   " No single element of which a  structure  is composed can  be
looked  upon  as 'characteristic of the cancerous form of growth
only.  Neither the character of the cells,  nor the nature of the
matrix, nor the arrangement of the elementary constituents, can
separately determine the point; and it is only by carefully compar-
ing the collective appearances observed upon microscopical exam-
ination, that we can decide.
   " If we examine the cellular pathology of cancer, we shall find
that in the whole range of pathological growths there  cannot be
found  any structure of an absolutely new form, or one which, in
one way or another,  cannot  be regarded as a reproduction of physi-
ological tissues.
   " The mere form of cells which  compose a structure  is  of no
decisive value ;  and although it is thought by many that any cell
of a spindle or caudate shape with  large  nuclei  is a cancer-cell,
yet the fact that on  the surfaces of the urinary passages in their
whole extent, the same curious bodies, provided with large nuclei
and nucleoli, are found, tends  to upset the whole theory  of there
being anything peculiar in a cancer-cell."

                            Rarity.
   " Cancer of the tonsils is a very rare disease, whether  scirrhus
or encephaloid.  Its existence is even doubted by some authorities,
and it is not mentioned by  the majority.   It  has been  observed
by Lobstein, J. 0. Warren,  Velpeau (five cases), Vidal de Cassis, 
4
SURGICAL  CASES.
Roux and Fano, Lebert and Demarquay.  It is  observed, for the
most part, from the age of forty up to advanced  life ; and presents
itself offcenest in the form of a tumor developed in these glandular
bodies, and, at an advanced stage, with the appearance of an open
ulcer, showing all the characteristics of cancerous disease.
  " Cancer of the tonsils is primary  or secondary; sometimes limi-
ted to that gland or even to one of its parts (Fano); in other cases
sending out irradiations  more or less extended towards the neigh-
boring parts, particularly at the side of the velum palati, or re-ap-
pearing in other organs.
  " The  submaxillary ganglia  frequently  submit to  the law of
secondary invasion, which influences the lymphatic glands whose
vessels proceed from parts affected with cancer.
  " The degeneration is in general encephaloid, rarely scirrhus.
  " Diagnosis:  cancer  of the  tonsils can  be  confounded with
hypertrophy or with syphilitic changes.
  " If at the outset the cancer appears with the aspect of a benign
hypertrophy, or if on the other hand the jagged  appearance of the
tonsil, the ulceration of the orifices of the lacunaa, can in a simple
hypertrophy make  one  think of a cancerous degeneration, there
comes a time when the  presence of stony hardness,  of sanious
offensive ulcerations,  of signs of cancerous cachexy, or the pro-
gress of the malady allow its nature to be appreciated.
  " The syphilitic  changes of the tonsil most  often confounded
with cancer, are the gummous tumors at different periods of devel-
opment, and above all at the time of their ulceration.  And indeed
it is an  error with difficulty avoided in the absence of knowledge
of the antecedents of the patient,  or at least  of the  proof of a
specific treatment.
  " Another kind of syphilitic lesion can moreover be  a source of
error.   It  is the  hypertrophy and the vegetation of  plaques
muqueuses of the tonsils/'—Nouveau Dictionnaire de Medecine  et
de Chirurgie pratiques.   Tome  deuxieme.   (Amygdales—Lesions
organiques.)
  In our own case  there seemed to  be no doubt as to its  being
cancer.   The growth of the tumor, as distinguished from the ulcer-
ation and waste of syphilis, was one marked point.  The tumor of
the tonsil doubled in three weeks.   The gross and the microscopic
appearances were submitted to several observers, who were of one
opinion as to its being cancer.  The enlargement of the lymphatic
gland and the identity of its structure, under the microscope, with
that of the tonsil, were other  strong points indicating cancer.
The whole aspect of the  man was singularly free from syphilitic
taint.
  Operative Interference.—Dr. John C. Warren,  in his  work  on
Tumors, mentions two cases of " scirrhus of the tonsil."   The first
was  ligatured by a wire.  At the end of five days, after atrocious 
SURGICAL  CASES.
5
suffering, symptoms of tetanus appeared, and the ligature was re-
moved.  The tumor sloughed away.
  The second was seized with  hooked forceps,  drawn forward and
removed with the knife, and the mass iu the pharynx was removed
with a curved, probe-pointed bistoury.  Finally, the actual cautery
was applied.  The patient recovered.
  " Amygdalotomy has  been practised frequently  in  cases of
cancer of the  tonsil.   Velpeau performed this operation upon  a
man sixty-three years old, who had had a cancer of the tonsil for
two years.   The cancerous mass covered the velum palati in front,
nearly filling up the pharynx ; suffocation was imminent.   Having
laid bare the primitive carotid and passed under it a controlling
ligature, Velpeau grasped the  tumor with a  double hook, drew it
forcibly forward,  then with a  bistoury, the  handle of which  was
fixed  and the blade curved, he slit up the  left side of the velum
palati, and succeeded in extirpating the tumor.   At the same time
he removed a lymphatic gland affected with cancer, resting upon
the pharynx at the lower portion of the parotid region.   The
patient succumbed seventeen days after the operation from pyaemia.
The autopsy  showed  that all  the cancerous element had  been
removed, and that the large vessels had received no injury.   The
same operation,  but this time without a controlling ligature,  was
performed by  Mason  Warren.  In a similar case,  Demarquay, by
means of an incision extending from  the anterior border of the
sterno-mastoid and terminating at the top of the larynx, laid bare
the vessels and nerves which came in contact  with the  diseased
tonsil, and  was able to hold them aside, while an assistant  man-
aged the ecraseur, and thus performed the extirpation of the can-
cerous mass."—L. A. de Saint Germain.
  There can be little doubt that in this last case the ecraseur was
applied from within the mouth, although the description is obscure.
  Removal by external incision is a dangerous operation, on account
of  the  depth  of the  wound,  and the proximity  of the  internal
carotid artery.   Numerous and important nerves  cross our path,
also,  as  the hypoglossal,  the gustatory and  glossopharyngeal.
Operating from within  the  mouth we  have the danger of swelling
and sloughing, and of haemorrhage beyond control.  By attacking
the tonsil from without, we have no  inconvenience to fear after
the primary dangers  of  the operation, except the risk of a pha-
ryngeal fistula.
  Our cases of cesophagotomy, however, have demonstrated that
openings into  the gullet close readily.  The case above reported
closed earlier than the wounds of  the oesophagus, partly because
the opening was higher up, and partly because the pillars of the
palate closed the fistula by a valve-like action of their own.
  The facility with which"the tonsil can be  enucleated with the
finger is surprising.  The following anatomical peculiarity,  how-
ever, explains  the reason pretty well : 
6
SURGICAL  CASES.
  "Perhaps the  most important point of the  anatomy  of the
tonsils,  next to  their proximity to the internal carotid artery, is
the fibrous  semi-capsule described by Chassaignac, as follows:
' When one has enucleated a well developed tonsil, and examined
with attention its external  and internal surface, he does not hesi-
tate to declare that the external, or adherent face, is covered with
a fibrous semi-capsule,  well circumscribed,  independent  of the
neighboring aponeurosis, and resting  on the cellular tissue."
  The  arteries of the tonsil are large compared with the size of
the gland ;  they come from the ascending pharyngeal and  the in-
ferior and superior palatine arteries.
  We desire, in the report of this interesting  case, to express our
appreciation of the aid we  have  received, in the history of the
disease and other points, from  Mr. F. W. Draper, House-surgeon,
and Mr. C. B. Brigham.
     Depression and Re-placement op the Superior Maxilla
                  (Langenbeck's Operation).

  Case I.—Naso-pharyngeal Polypus.  The patient was a student,
aged 19 years.   Thirteen months previously  to his entrance to the
Hospital  for his present disability, he had undergone an operation
for  the relief of the disease of which this  was  the  recurrence ;
and the history of the  growth dated two years and a half before
that time.  Its development had given rise to the following symp-
toms :  profuse epistaxis, complete obstruction  of the nostril, and
the discharge  of  a thin  and offensive fluid.   Examination  dis-
covered the presence  of a firm, lobulated  tumor pressing down
on  the soft palate and filling  the  upper and  back part of the
pharynx.  The general condition of the patient was good, and the
growth was not painful.
  Operation.—It was  removed by temporary  depression of the
right upper maxilla, as follows : The primary  incision  was  car-
ried from near the inner canthus of the eye, downward along the
fold at the side of the  nose, around the ala,  and through the  com-
missure of the upper lip.   The flaps were reflected so as to ex-
pose the body of the bone.  The symphysis of the jaw was divided
through the alveolus only, and a horizontal section made with a saw
across the  bone from  the tuberosity into  the  middle meatus of
the nose.  The section of the bone was depressed, so that it was
held only by its posterior attachments.  The tumor was thus ex-
posed and reached. Its attachments to the body of the  sphenoid
bone and to the upper and back part  of the pharynx were divided
with some  difficulty with scissors, and the  point of section  (two 
SURGICAL  CASES.
7
inches square) cauterized with strong nitric acid.   The bone was
replaced and held well in position by a wire around the adjacent
incisor teeth.  The soft parts were  easily apposed and retained
by silk sutures.  The haemorrhage was inconsiderable.
  The constitutional  disturbance  which followed  the  operation
was  comparatively slight.   With a dressing of equal parts of
tincture  of  myrrh and water,  the wound healed  satisfactorily, M*
and throughout the  convalescence there  was no complication to ^P
impede  recovery.  In nineteen  days, the ligatures had all come
away, and there was  no purulent discharge.  The bone was in
excellent position, and motionless.  After thirty-five days he was
discharged well.
  Symptoms of recurrence of the growth were noticed after eleven
months.  The nostril became obstructed as before, and there was
a feeling of  fulness in the head.   Otherwise than this the tumor
had  caused no inconvenience.  There was no appearance of any
disease  in the pharynx, but Dr. Langmaid, with the rhinoscope,
discovered the fibrous mass occupying its former position and
attached, like its predecessor, to the inferior aspect of the body
of the sphenoid bone  and to the adjacent region of the pharynx.
  Second Operation.—The steps in the operation for its removal,
the operation being performed at once, were almost identical with
those of the former one,  and the lines  of section were  in  the
cicatrices of those of the year previous.  Owing, however,  to
the thickening of the bone in the  course of healing, it was neces-
sary to  remove a  small portion at the inner angle, just below the
orbital process, in order to expose the growth.  The tumor, which
was of  the  size of an English walnut, was removed bj' section
of its pedicle with scissors, and the bone was thoroughly scraped.
The haemorrhage was not sufficient to require  ligatures.   The
bone and soft parts were apposed as in the former operation ; a
gutta-percha plug between the teeth and a bandage around  the
lower jaw, and over the head, aided in supporting the parts.
  Convalescence, in this case, was more rapid, even, than in the
primary operation.  Without complication or drawback, recovery
proceeded steadily; and after twenty-seven days he was discharged
with the wounds perfectly healed, and the bone firmly in place.

  Case II.—Naso-phanjngeal  Polypus.   Operation  by Temporary
Depression of both Superior llaxillce.—The patient was a  farmer
by occupation, and was 41 years old.   He had suffered  from the
presence of a growth  in the posterior nares during the previous
eleven years.  Its first appearance  was  attended with  profuse
epistaxis.  Its rapid growth, and the iuconvenience arising from
its presence induced him to submit to its removal by Dr. Peaslee,
of New  York, by section of the soft palate.   An interval  of
health succeeded, in  which he noticed nothing of consequence
from the tumor ; but thirteen mouths before presenting himself at 
8
SURGICAL  CASES.
the Hospital he felt symptoms of its  recurrence.  This recurrent
growth had been attended with no pain, epistaxis or other grave
symptoms, although the patient was anaemic, and his mental con-
dition was depressed and anxious.
  Having applied again to Dr. Peaslee, he, having seen the result
of my first case, kindly sent the patient to me.
•  Examination discovered the following condition of things. Ex-
ternally,  the  facial expression was unaltered.   There was no
protrusion about the  region  of the antrum.  Both  nostrils were
perfectly  occluded, one having been closed many months, while
the other had remained open until within three weeks.  The palate
was pressed down by a tumor protruding from the roof  of, the
mouth, of the size  of  a pullet's egg; its anterior edge extended
to within half an inch  of the alveolar border.   It was elastic, pain-
less, and without special tenderness.   In the process of develop-
ment it had  absorbed the palatine process of  the  left superior
maxilla, the edge of the bone defining its border.   The pharynx
was clear, below the soft palate, but completely filled above.
  Deglutition, respiration  and articulation were considerably im-
paired, and complaint was  especially made  of the difficulty in
breathing, the sensation being of fulness and of a danger of suffoca-
tion.
   Operation.—The size of the tumor and its situation  in the median
region,  appeared to  contra-indicate  operation  on  one  superior
maxilla alone.  Temporary depression of whole upper jaw was
accordingly effected,  as follows: The  primary  incision  through
the soft parts was  on either  side of  the nose along the natural
wrinkle from  near the  inner canthi, around the  alae  and through
the commissure of the myrtiform  fossa of the lips.  The flaps
were freely reflected, so as to expose the bone beneath as  far up-
ward as the malar prominences.  With a narrow saw the body of
the bone was divided  from the tuberosity, forward, beneath the
zygoma on each  side into the middle meatus.   The septum  nasi
and the vomer were  divided with strong scissors.   Nothing but
the posterior attachments of the upper maxillae now prevented their
depression; and hinging on  the pterygoid processes, the upper
jaw was brought down so as to expose the tumor. Its attach-
ments were found to be to the body of the  sphenoid  bone, and to
the ethmoid.   These attachments,  except  the first,  were divided
by the  finger, and a section of the  growth was made by means of
scissors, as near the sphenoid bone as  possible, the mass being
too large to deliver altogether. With a gouge chisel the remain-
ing portion was scraped away and  removed.
  The whole  growth was in size and shape like a  large lemon.
In its centre it  contained a cavity with the  remains  of broken-
down tissue.  Subsequent microscopic examination determined
the structure to be distinctly  fibrous.
  The depressed jaw was  restored to its  position  and retained 
SURGICAL  CASES.
9
firmly  by silver  wire  passed on each  side through the malar
bones.   The soft parts  were  apposed by  silk  sutures;  and the
whole physiognomy perfectly reinstated.
  The haemorrhage during the operation did not appear to be ex-
cessive, the blood escaping  externally  being  only of moderate
amount.  The attendant shock was considerable, the pulse falling
off  at the last until it was hardly perceptible.   Stimulants by
enema rallied the patient in  part, but throughout the day he re-
mained  in a  drowsy, unconscious state after the effects of the
ether had ceased.  The condition of the patient was grave from
the time of  the  operation forward.  In three hours a diarrhoea
developed itself,  the dejections being frequent, black, tarry and
offensive, as  of altered blood.  Meanwhile there was no pain or
nausea;  the  patient took  nourishment, stimulants and  opiates
well.  The pulse  ranged from 128 to  136, and was small, jerky
and feeble.  The whole appearance was that of a  patient sinking
from exhaustion.  The expression was listless ; the skin dry and
harsh; the tongue brown and parched.  During  the forty-eight
hours after the operation there was no essential  change.   The
diarrhoea, abdominal pain and general  exhaustion  continued.
The wound in the face  remained quiet, without sign of reaction,
and there was no complaint of pain in that region.
  On the third day, after continued efforts at stimulation and at
control of the diarrhoea, the patient began to show more favorable
symptoms.  The  dejections became less frequent and more  natu-
ral in appearance.  The mental condition was more sane.   Slight
suppuration commenced  in the wound.   The surface was warm
and moist, and general signs  of reaction became manifest.
  On the following  day, however, he relapsed into the former
state.  Jactitation,  muscular tremor and mental distress succeed-
ed.  The pulse was 124,  and very small;  the urine was retained
and catheterization was  necessary.   The face  and conjunctivae
assumed a sallow hue.   Steady sinking proceeded in spite of the
stimulants, which from the beginning had  been taken freely, and
on  the afternoon  of the fifth day, one hundred and twenty hours
after the operation,  the patient died.
  The removal of naso-pharyngeal polypi, otherwise unassailable,
by  a temporary displacement, instead of destruction of the supe-
rior maxilla, is known as Langenbeck's operation.
  Performed  here, for the first time, in the case described above,
it was repeated, successfully, on the same patient.
  The second patient was treated in a manner novel, so far as we
know, the  operation including both  superior maxillary bones.
Although he  succumbed, we cannot but think that there is noth-
ing in the operation itself, which  should render it a fatal one.
We know, at any rate, that much more serious mutilation of the
jaws and face, in removing  caucer, is almost always survived. 
10
SURGICAL  CASES.
The haemorrhage was moderate, and the shock should  not be
excessive.
  Our patient was feeble and  anaemic from  suffering  and absti-
nence.   The pulse was poor from the beginning.  He never rallied
any higher than the state known as "prostration with excitement."
  We should not hesitate to  repeat the double operation  on a
suitable case, unless resort were had to a novel plan proposed by
Oilier, to saw down the nose obliquely from  above downwards,
and operate through the upper meatus.  In this way he removed
a polypus weighing six ounces.
  While the above was going through the press, we  received,
quite unsolicited on our part, the following letter from our friend,
Dr. John Collins Warren, now in Paris.
  As it gives interesting details as to Prof.  Langenbeck's opera-
tions, which differ somewhat from ours, we have thought best to
insert it here.

  " Having heard that you had lately performed the osteo-plastic
resection of both upper jaw-bones, I made some inquiries here to
find out whether a similar operation had ever been performed in
France, and have been assured that  it has not.  I also wrote a
note to Prof. Langenbeck mentioning your operation  and  asking
him if  he had ever performed it, and begging him to let  me know
at the same time where  I could  find any account of his  osteo-
plastic resections of one superior maxillary bone.
  " Thinking that any information on this point may be of interest
to you, I send a translation of a portion of his reply, together with
a few notes taken from the references which he makes.

  " ' My first osteo-plastic resection of the upper jaw was perform-
ed in 1859—vide Deutsche Klinik, 1859, p. 471, B. Langenbeck,
'Beitrage zur osteoplastic'   My second operation is  described
in the Deutsche Klinik, 1861,  p. 281, under the title ' Osteo-plastic
resection of upper jaw.'
  " 'I have now performed this operation 13 times for tumors in
the fossa pterygo-palatina and naso-pharyngeal cavity.  Of these
13 cases there were  10 complete cures and 3 deaths.   These latter
were cases where the tumor had perforated the base of  the crani-
um to a large extent, and where meningitis followed the operation.
  " ' The operation has also  been performed : by Esmarch, in Kiel
{Deutsche Klinik, 1863), for  fibroid of the fossa pterygo-palatina,
with a successful result; by Wagner,  in  Koenigsberg, and by
Timon, in Heidelberg, likewise with successful result. Nussbaum,
in Munich, and Billroth, in Vienna, have performed the  operation
in order to cut the ramus secundus Trigemini for neuralgia. 
SURGICAL  CASES.
11
  " ' The osteo-plastic resection of both upper jaw bones has,  up
to the present time, never been performed in  Germany nor in
Europe.'
    ********
  " The following is a resume of the report of his first operation.
  " ' Naso-pharyngeal-polypus—resection of processus nasalis and
os nasi of  right side—extirpation of polyp—replacement and re-
union of resected bone.   The external incision was made from the
middle of the glabella to the right over the processus nasalis and
downwards to the ala nasi.  The edges of wound were dissected up
sufficiently freely to expose the nasal bone and  the whole  nasal
process of the maxillary bone, the periosteum remaining untouch-
ed.  Separation of  cartilaginous portion of right half of nose from
its  bony connections.  With a cutting bone  forceps the os nasi
was cut through close to septum, upwards to the nasal process of
frontal bone, and, by a second cut, the processus nasalis of the maxil-
lary bone into the sinus maxillaris.  This cut ended where the  nasal
process of the upper jaw forms the lower border of the orbit and
touches the lachrymal bone.  Both bones pried up together, so that
they were  thrown up on to the forehead and could be held there.
Removal of polyp;  replacement of bones; external incision care-
fully united with sutures a)nd right nostril plugged  with charpie.
The two bones were held together by the periosteum and mucous
membrane, and a bridge of both Ihembranes attached them to the
frontal bone and the mucous  membrane  of the  nasal  cavity.
The wound united by first intention—no exfoliation of bone.'
  " Langenbeck had previously excised these bones for similar
tumors, and refers to these operations in his report of this case.—
(Deutsche Klinik—Resec. processus nasalis, 1854.)   He has also
found division of  the velum palatinum with resection of pars
horizontalis oss. palatin., sufficient.
  " His second article is referred to above under the title of osteo-
plastic resection of upper jaw.
  " This operation, he says, is necessary to remove  those  naso-
pharyngeal polypi which are attached to the neighborhood of the
tuba and the foramen spheno-palatinum, as also the sinus sphenoi-
dal.  There are also tumors which spring from the fossa pterygo-
palatina* and grow into the  naso-pharyngeal cavity, and in the
opposite direction into the  fossa spheno-maxillaris.
  " The diagnosis in the present case was fibroid tumor of left
pterygo-palat. fossa.  In making this  diagnosis he remarks that
naso-pharyngeal polypi may grow into the sinus frontalis, sphenoi-
dalis and maxillaris and labyrinth of the ethmoid, and distend the
walls of these cavities, but never into  the fossa  pterygo-palatina.
In the present case the  tumor, taking its rise in the latter fossa,
 f It would appear that the region to which Langenbeck gives the name of fossa
pterygo-palatina, is described by Gray as the pterygo-maxillary fissure. 
12
SURGICAL   CASES.
makes its way through the foramen spheno-palatinum into the pharyx
and nasal cavity, and in the other direction into spheno-maxillary
fossa, around the upper jaw, between the outer wall of  this bone
and the masseter muscle  towards the inner surface of cheek. He
has resected the zygomatic arch for a similar tumor which did
not, however, extend into the nasal cavity.
  "Operation, July 1st,  1861.—The lower external  incisions be-
gan at the insertion of ala nasi and ran along lower border of the
malar bone,  describing an arc with convexity downwards, and
terminating at the middle of zygoma.  The second upper incision
began at the nasal process of frontal bone,  and,  following lower
border of orbit, crossed the  frontal process of sup.  maxillary
bone and joined the lower incision at an obtuse angle: without
separating the skin  from the subjacent  soft parts, the lower in-
cision was continued through the periosteum to the bone, and the
masseter muscle separated from the lower  border of the malar
bone.  The fascia buccalis being cut through disclosed a lobulated
whitish tumor, which lay between the depressed  outer  surface of
the upper jaw and the coronoid process of lower jaw, and extend-
ed backwards into  spheno-maxillary fossa.   By separating the
lower from the upper jaw,  the tumor could be pushed away from
the latter and  the index finger  could be introduced between the
two into the fossa pterygo-palatina.  As the upper jaw was much
compressed and the fossa spheno-maxillaris and pterygo-palatina
much dilated, this was accomplished without difficulty, and the tip
of the finger reached as far as the nasal cavity (passing through
the dilated  foramen spheno-palatinum).   A small Langenbeck
resecting saw was  passed along the finger and the upper jaw was
sawn through from behind forwards by a horizontal cut,  while a
finger introduced through the mouth into the posterior nares. pro-
tected the septum from the point of the instrument.
  " The upper incision through the skin was now deepened  to
the bone and extended into the orbit, and the soft parts in  the
angle between the processus frontalis and zygomaticus of the malar
bone were cut through.  The second cut of the saw, starting from
the same point, extended from below upwards  through the pro-
cess,  zygomaticus  and  frontalis of malar  bone, into the inferior
orbital fissure, and from here through processus orbitalis of upper
jaw to the os unguis.                            •
  " The resected upper jaw was thus left in connection with only
the nasal bone and nasal  process  of frontal bone, and  the soft
parts which covered this portion of bone were  untouched.  The
hard palate  and alveolar process were also preserved untouched.
The bone was pried slowly upwards by an elevator introduced
below malar bone and moved on  the sutures between it and the
nasal and frontal bones as on a hinge joint.
  " The tumor  lay with  its  pediculated  portion in the fossa
pterygo-palatina,  and extended sideways in both directions in 
SURGICAL  CASES.
13
lobulated masses the size of a hen's egg.  One of these filled the
naso-pharyngeal cavity and the other the fossa spheno-maxillaris,
and, slightly compressed by the zygoma, extended into fossa-
temporalis and towards  fiss. orbit, inf.   The  antrum empty, but
compressed to two-thirds its size.   The septum narium pressed
to right.  The pediculated portion was separated from bone with
difficulty.  The other parts easily removed.  The fossa pterygo-
palat. much dilated.  The bone was replaced,  and, showing a
slight tendency  to ride forwards, was  kept  in  place by  gentle
pressure.  External wound united by iron sutures. On 6th, wound
was healed in its greatest extent, but there was a large discharge
of pus from the open part.   On 16th, wound  completely  healed,
and no movement perceptible in bone.
  " A second similar operation on July 12th was performed for a
fibroid tumor, taking its origin from the tuba and sinus sphenoid-
alis, with successful  result.
  " From these two operations he draws the following  conclu-
sions :—
  " I.  The resection of the upper jaw with preservation of hard
palate and alveolar process is sufficient to make accessible tumors
situated in the naso-pharyngeal cavity.
   " II.   The extirpation of the  whole jaw is therefore for this
purpose no longer allowable.
   " III.  It is possible  to saw through the whole jaw  in a hori-
zontal direction, from the foramen spheno-palatinum.
   "IV.  The upper jaw, which has been excised  with  its sur-
rounding soft parts, can be made to reunite.
   " Langenbeck still continues to employ  the  same method.  I
had an  opportunity of witnessing one of these operations in July
last. The tumor was similar to the one he describes above, and
which he now calls  a ' retro-maxillary  tumor/  distinguishing it
carefully from the naso-pharyngeal polypus.  There was a consid-
erable depression of the base of the cranium in  this case, though
no perforation, and the  patient recovered from the operation with-
out serious  symptoms.  Most of these tumors occur in the male
 subject, and between the ages of 15 and 30."
  It will be obvious at once, on comparing the operations of Prof.
Langenbeck,  M. Oilier, and our own, that the first  attacks the
foreign growths from the side, the second from the front through
the upper meatus of the nose, and the third from the front through
the lower  meatus.   An  interesting comparison thus presents
itself: first, as to the relative room gained to operate  in; second,
as to the seat of the tumor; third,  as to  the  arterial supply^ of
the bony flap ; and lastly, as to the amount of external mutilation
of the face. 
14
SURGICAL  CASES.
  Langenbeck's operation, it seems to us, gives the most room,
but entails the most mutilation of the face, since we  have two
nearly transverse incisions, the upper one of which divides the
whole levator group of muscles, and the masseter also.  It seems
more  especially adapted to the class  of tumors  he calls " retro-
maxillary," which grow from the spheno-maxillary fossa.
  Ollier's operation gives very little mutilation ; but although he
has removed by it " probably the largest fibroid ever extracted
from this region," yet we shall find, by  measurement, that the
operator's finger is just as far from the basilar process when  he
enters the upper meatus of the nose, as he is when  he  enters the
mouth.   Consequently M. Oilier has been  led  to modify his ope-
ration by making a second cut backwards from the lower meatus,
to meet his downward  cut, and thus lift out a wedge from the
upper jaw.*
  The operations  of our own, which have been detailed  above,
leave no mutilation, since there is but one incision through the
skin,  and this follows the natural wrinkle of the  nose and mouth.
This operation is, of course, adapted to naso-pharyngeal tumors
only.   It gives room enough, in ordinary cases, but, in  very large
polypi, requires a double section, including both maxillae.
  Finally, as  to the arterial supply.  In Langenbeck's  operation,
the root of the  flap is at the inner part of the  orbit,  and nasal
process of the frontal bone.   The main artery is  the nasal branch
of the ophthalmic, and  some  current probably comes through
terminal branches  of the temporo-facial division  of  the temporal
artery.
  In Ollier's operation the root of the flap is  at the junction of
the alae and septum of the nose with the upper lip.  We have
here branches from the superior coronary,  and perhaps  the  angu-
lar branch of the facial, if the cut is not carried too far down.
  In our own operation, on one maxilla, we have all the circula-
tion in the mucous membrane of the hard and  soft palate, and
branches from  the ascending pharyngeal and tonsillar arteries;
perhaps,  also, the  posterior palatine arteries, if the jaw is not torn
down too  far.  The root of the flap is the whole  suture  of the
palate process of the maxillary and palate bones, the soft  palate
and the pterygo-maxillary junction—a supply ample to secure vi-
tality and reunion, as shown in our repeated operations  on the
same  patient, with successful result.  In  the  section of both
maxillae we must depend on the  posterior palatine arteries, soft
palate, and a portion of the buccal membrane.   Unfortunately
the early death of this patient left the question of reunion still
unsettled.
Traite de la regeneration des os—Tome second, page 483, figure B. 
SURGICAL  CASES.
15
                  Reproduction of the Tibia.

   Case I.—Excision of the entire Diaphysis and the lower Epiphysis
of the  Tibia from  a  girl of IB years, for Suppurative Periostitis,
followed by Regeneration of the Bone, and a useful Limb.
   July,  1868.—M.  F.  M., aged 13  years, after passing succes-
sively through  scarlet  fever and measles, was left reduced and
feeble, and in April  last, three and a half months ago, she began
to experience constant and excessive pain in the right leg.  Soon,
a spontaneous opening  occurred,  giving exit  to thin pus.  The
disease went on,  other openings  formed, and  the  child  became
much  exhausted.  On  her admission to  the Hospital the entire
length of the tibia  was riddled with sinuses,  seven or eight  in
number, and all leading to denuded bone.
   Under ether,  an incision was made over the  crest of the tibia,
from the  tubercle of the ligamentum patellae  to the ankle-joint.
The entire shaft  of the  bone was found bare of periosteum,
smooth, white and dead.   A  red and thick periosteal membrane
lay on either side, and  was attached only to a  ridge on the pos-
terior surface of the tibia.  Even from this it  was separated by
the handle of the scalpel.   A chain saw was passed under the
upper part of the tibia, and the bone sawed just below the junc-
tion of the upper epiphysis and the shaft.   On raising the shaft
from its periosteal bed it  was  now  found  that the lowest sinus
penetrated the ankle-joint, and that the lower articular surface of
the tibia was seriously eroded and diseased.  The internal lateral
ligament was divided, the  capsular ligament cut across subcutan-
eously, and the bone dissected out from its attachments to the fibula
and the astragalus.  Both the latter bones were found healthy.
The ankle-joint was thus freely  opened.  No vessels  required
ligature,  the haemorrhage being  checked with ice-water.   The
thickened periosteum lined the entire wound, which was left open
to granulate.
   The leg was laid on its outer  side, in a tin splint; and the
wound kept wet with liq. sodae chlorinatae, diluted with five parts
of water.
   The entire length of  tibia removed was nine  inches.
   On  the  second  day, suppuration  began,  and healthy granula-
tion soon followed.  The patient's condition was eminently satis-
factory, the shock from the operation being trivial, and the relief
from the removal  of the diseased bone, marked.
   On  the seventh day the granulations  were  becoming so exu-
berant that the sides of the wound  were approximated by adhesive
strips.
   On  the  eighteenth  day, new bone could be traced beneath the
whole line of granulations, feeling, under the  finger, as thin ice
does when we put the foot on it to test its thickness.  The  new
growth of bone kept pace  with the healing process, so that when, 
16                  SURGICAL   CASES.
after eight weeks, the wound had  entirely closed  over, the new
shaft  had acquired considerable  firmness ;  and there was also
mobility in the ankle-joint.
  It was not until five months after the operation that the patient
was allowed to put the foot to the  ground, and then an apparatus
was applied.   This had a two-fold object; to lengthen the limb,
and to evert the  foot.
  The leg was three-fourths of an  inch  shorter than its fellow on
the inside, and one-half an inch on the outside,  and the ankle
and foot inclined to  the position of talipes varus.   A  curious
change had taken place in the fibula, one which Oilier says always
follows excision  of the diaphysis of the tibia.
  The fibula was dislocated from its articulation with the upper
epiphysis of the tibia, and  drawn   upwards, so that  the head
and styloid process of the fibula  were one-half inch  nearer  the
anterior superior spine of the ilium, than in the other leg.  This
change was due  to the contraction of both the flexor and extensor
muscles, without any resistance from the shaft of the tibia,  the
main  column of  support.  The oblique articulation of the upper
end of the fibula also favors dislocation upwards.
   It is now eight months since  the  operation,  and improvement
has been uninterrupted.  An apparatus,  made by Dr. Nathaniel
Greene,  2 Tremont Temple,  Boston, combines the long Sayre's
splint with  Scarpa's shoe.  This is kept firmly applied, and with
it, the patient now  begins to walk.  The new bone  is  as wide
as  the  old  one, above, for a space of four inches, and about as
firm.   Below, it tapers down, and becomes more flexible.  There
is a fair mobility in the ankle-joint.  The sole  comes squarely to
the ground, and the foot is turning out.
   There seems  to be  no reason  to doubt that a  perfect restora-
tion will be  effected, and a most useful limb result.  There never
has been any trouble  from the  ankle-joint.   The patient is grow-
ing tall and strong, and moves about continually.

   Case II.—(Service of Dr.  Buckingham.)  The patient,  a girl of
eight years,  had  suppurative periostitis, and  denudation of the
diaphysis of the tibia.  About five  inches of  the shaft were  dis-
sected out,  and  the extremities  cut through with the  chain-saw.
Recovery was excellent and  continuous.  A good limb resulted.
   That removals of the diaphysis, and especially both diaphysis
and lower epiphysis of the tibia are rare, is  proved  by the small
number of  cases, five in all, collected  by Oilier, of Lyons, in his
great work on  the "Regeneration of Bone."*
   These cases  are so interesting, that we extract from  them at
some length.
  * Traite Experimentale et Clinique de la Regeneration des Os, et de la production
artificielle du Tissue Osseux.  Par L. Oilier, Chirurgeon en Chef de l'H6tel-Dieu de
Lyon.  Tome Second. Partie Clinique.  Paris :  Victor Masson et Fils.  1867. 
SURGICAL  CASES.
17
  " We find the most remarkable and most complete reproduction
of bone in the tibia.  Without  recurring to older  observers, we
shall confine ourselves to the cases in which sub-periosteal opera-
tions  have been done methodically and designedly.  We find va-
rious examples of affections of different kinds, which have required
operation.  Larghi, and Creus-y-Manzo, have operated for chronic
osteitis ; Langenbeck and Neudorfer for compound fractures ; Jam-
bon and Aubert, Holmes and Lentenneur for acute periostitis.
  " Observation XXX.—Sub-periosteal resection of four inches of
the lower end of the tibia for suppurative osteitis, with separation
of the epiphysis and invasion  of the ankle-joint, by Jambon  and
Aubert, of Macon.   Excellent reproduction  of bone ; and perfect
restoration of the functions of the limb.
  "Michael Duvert, 21 years old, had numerous fistulous openings
on either side of the leg,  giving exit to  an abundant suppuration,
with severe pain, fever and vigilance.  Having been chloroform-
ed, a  primary incision along the fibula  assured the operator that
this bone could be saved.  The diseased portion of the tibia was
freely uncovered, and the bone divided  by a  chain-saw four inches
above the ankle-joint.
  "The  inflamed and  thickened periosteum was easily detached
throughout.   The bone, carious in its entire diameter, broke into
two fragments, of which the lower, representing  the epiphysis,
was detached with some difficulty from the bones  of the tarsus,
which were found quite healthy.  The consequences of the opera-
tion were very fortunate.
  " After a free suppuration, the edges of the wound united by
granulations, starting from the  bottom.  In less than two months
the sinuses were closed, and a firm resistance, under pressure,
was felt.   Under the use of tonics and a full diet the bony repair
proceeded rapidly.   In  less than  six months he walked with the
aid of one cane ; and in ten months he was discharged.
  " Four years having passed, the  young man has worked con-
stantly at his trade of shoe-making ; his gait is easy, and he often
walks twenty miles a day.  Although there is  shortening, there is
no  deformity.  The  portion of tibia removed has  been  entirely
reproduced ;  a slight projection corresponds to the  malleolus.
  " This operation cannot be classed among removals of a seques-
trum.  There was no movable bony fragment.   The diaphysis
had to  be  sawn, and the epiphysis held to the  fibrous  tissues
which  are  inserted into it in the normal state.
  "Observation XXXI. — Suppurative periostitis  of the whole
diaphysis of  the tibia,  with grave  constitutional symptoms.   Ex-
traction of the diaphysis before the reossification of the periosteal
sheath ; by T. Holmes, of London.  Recovery—renewal of bone—
shortening of the limb.
  " The patient was 10 years old.  Under chloroform it was found
that the  tibia was denuded above, below and behind, at every
         3 
18                SURGICAL   CASES.
  point that the finger could  reach.  A long incision having been
•  made over the tibia, separation of the periosteum from the pos-
  terior border was easily accomplished by a sound guided by  the
  finger.  The  chainsaw passed under the tibia divided it near its
  upper extremity ;  the section, seized with strong forceps, was
  detached from the upper epiphysis.   The same manoeuvre was re-
  peated for the lower end.  Thus the entire diaphysis was removed,
  measuring seven and one-third inches.   The limb was placed in a
  fracture-box.   Six weeks later, when consolidation was already
  advanced, shortening was observed.  It was then seen that the
  head of the fibula was unusually prominent.   Efforts  to lengthen
  the limb were made without avail.  After six months he was ex-
  hibited  to the Medical  Society, in perfect health, with the  limb
  solid  and inflexible.  The tibia was replaced by a bony mass of
  the same form, though thicker,  and less regular.  There was  an
  inch and a half of shortening.  He walked well with a cane.
    " Observation XXXII.—Suppurative periostitis of the diaphysis
  of the tibia,  with severe constitutional symptoms.   Removal of
  the whole diaphysis by Lentenneur.   Recovery.
    " The patient was 12 years old.   Denudation of the tibia  the
  whole length of the shaft.  Articulations healthy.  Operation the
  8th of August.  Incisions above and below, the  middle third of
  the skin being left untouched.  By a to-and-fro movement  the
  whole diaphysis was extracted.  The periosteum was thickened.
  By the end of September there was  ossification under the edges
  of the incisions above and below ; no repair in the middle, where
  the skin was  uncut.   Marked shortening  of  the limb, and partial
  dislocation of the head of the fibula.   In the month of March fol-
  lowing, the  upper  and  lower cicatrices were united  by an inci-
  sion, and the periosteum found reduced to a little fibrous  cord.
  This was incised, and gouged, and a seton inserted.  Having been
  retained three weeks, this restored  the  osteogenic properties of
  the periosteum, and the upper and lower spurs of bone lengthen-
  ed, and approached each other.  At this time the child left the
  Hospital.
    "Observation XXXIII.—Sub-periosteal resection of the diaphy-
  sis of the tibia for chronic osteitis, to an'extent of eight inches, by
  Larghi.  Regeneration of the entire fragment removed.
    " John S.,  12 years of age, from Refrancore, operated upon Dec.
  4th, 1853, discharged April  30th, 1854.
    " Operation.—The numerous-openings from the bone to the skin
  are clear  indications of the  extent of the evil which affects this
  bone; it is actually riddled.  Below, the sinuses were very near
  the joint.  However, it was found that the disease did not  pene-
  trate into the tibio-tarsal joint.   The tibia is affected  throughout
  its entire length;  the disease appeared to stop at the  apophyses,
  which often -have a separate vitality from the  rest of the bone.
  The mode of operation was very simple, a  straight incision  being 
SURGICAL  CASES.
19
made over the tibia, from one end to the other, and down to the
bone.  Two transverse incisions, through the skin only, were
made above and below.
  "On examining the lower part of the tibia it appeared entirely
eroded.   Experiencing some difficulty in introducing the chain-
saw, I cut away the bone with bone-forceps.  The upper part was
quite isolated,  and removed with the chain-saw.  Before com-
mencing the resection I pushed back  the periosteum below the
ligaments of the ankle, and preserved it entire, without wounding
either tendon or nerve.  The periosteum was thickened and red.
  " Four months  and a half after  the operation the condition was
as follows : the patient was up  and moving on the  diseased limb.
The  new tibia was quite  hard in its  upper three-fourths.  The
lower fourth, at  first soft  and flexible, had become firm  and un-
yielding.   The new tibia was regular  in  form, and larger above,
than the old one.   The patient left the Hospital two weeks later.
  "Observation  XXXIV.—Ulcerative osteitis of the tibia. f Sub-
periosteal resection of the entire diaphysis by Creus y Manso, of
Grenada.  Complete regeneration of the part removed.  Slow re-
covery, with restoration of the functions of the limb.
  "The  patient, a boy of fifteen  years, entered the  Hospital on
the 10th of April, 1861, for an acute inflammation of the tibia, with
numerous sinuses.  Operation on the  10th of June.  A long inci-
sion was made, parallel to the crest of the tibia, from the tuber-
osity to within an inch and a half of the ankle-joint—a transverse
incision, through the  skin,  at each  extremity.  The dissection
between the bone and the periosteum was made with the handle
of the scalpel.   Having reached  the posterior edge  of the bone,
a curved director was passed beneath it, and the chain-saw used.
The entire  diaphysis was  removed.   The epiphyses were sound.
The wound was  bordered  by periosteum.  There was no haemor-
rhage.   The portion removed measured seven and a half inches.
  "  On the 20th, the limb was somewhat stiffened, and examina-
tion showed that  the work of regeneration had begun.
   " The 2d of  September,  the lower wound  was completely cica-
trized, and at this point the  union of the new bone with the old
was  complete.   It was' not so  with the upper  part,  where a
sequestrum of old bone was removed, at this  date.  It  was two
years before restoration was perfect.

  "  Since the final result of these extensive suppurations beneath
the  periosteum is the necrosis of the bone, the  operation done
in such cases may resemble the simple extraction of a sequestrum ;
everything  will  depend upon the time  of interference.   If we
operate early, while the bone is yet alive and vascular, while the
periosteum is still adherent to a portion of the surface7> we make,
in truth, a resection ; but  if we wait  until the diaphysis  is isola- 
20
SURGICAL  CASES.
ted on every side,  and holds only by weak medullary adhesions,
near its extremities ; we do  nothing but remove a sequestrum.
  " It might be asked whether it were not better to wait until the
periosteal ossifications were advanced.   We have already recom-
mended expectation for the  diaphyses,  as long  as the joints are
not invaded.  It is to  arrest suppuration, and depots of pus, and
prevent pysemia, that it appears reasonable to interfere.
  " On consulting statistics we find that resections of the diaphy-
sis of the tibia give a smaller mortality than  amputations of the
leg.   Heyfelder gives the following table :
Cause of Resection.	CO a> CQ <s O o d	o >	t CO o O o a	.2 <« -p <L> u o a u	13 5
Fractures .... False joints . . . Deformities . . . Curvatures . . . Organic Diseases	65 11 16 11 , 22	47 11 15 11 20	43 10 14 11 19	4 1 1 0 1	18 0 1 0 2
Total . . .	125	104	97	7	21
  " Resection of the bones of the leg, with solution of continuity,
gave three-fourths of complete success, and one-fourth of partial
results.  Five-sixths of those operated on lived.  These resections
give better results than amputations of the leg, of which  one-
third die ; and in primary amputations, one-half are fatal."
  Excision  of the head op the Femur, for Morbus  Coxarius.

  Case I.—(Service of Dr. Buckingham.)  Feb. 12th.  F. T.,  set.
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  fee-
ble, pale  and thin.   Appetite good.  No cough.   The thigh ia
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. 
SURGICAL  CASES.
21
  March 14th.—Extremely pale, thin and exhausted, with diar-
rhoea, hectic and suppuration.   Appetite, however, good.
  The patient was now so excessively reduced that it seemed an
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.  No-
thing 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 might be practicable.
   Operation.—March 15th.   After  etherization,  an incision,  V-
shaped, point downwards, was made over the joint.  The muscles
were dissected 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  dis-
located.   The head  of the femur was  extensively eroded.  The
acetabulum was carious, and a few loose pieces were  removed.
The  hosmorrhage 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 com-
pressible.  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.
   19th.—Pulse same, but he looks better.  Granulations appearing.
  24th.—Wound measures four by five  inches.  It is filled with
healthy granulations.  General condition improving.
   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.  Improve-
ment was, necessarily, excessively  slow, and could be  measured
only by months.
   April.—The wound continued to close.
   May.—He improved, but 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
legs daily.   The wound was closing ; a fragment of carious bone
was discharged. 
22
SURGICAL  CASES.
  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.   He was so
near death at the time of the  operation, that great fears were ex-
pressed whether he would survive  it.   Two years later, he was
seen walking with  a cane.

  Case II.—(Service  of  Dr.  Cheever.)  Martha S., set. 6 years,
entered the hospital Feb. 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 extent that, in November, 1866, six or seven months after
the first attack, 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 adduct-
ed, the toes being inverted, and the slightest efforts at abduction
giving pain.  There was  no appreciable shortening.  Bowels con-
stipated, and appetite variable.
  Until March 1st, the patient remained in bed, with extension by
a five-pound weight applied.   R. Olei morrhuas, § ss. t. d.
  March 1st.—Sayre's splint adjusted.  Sat up three hours.
  15th to May 7th.—Extension continued, without decided bene-
ficial 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 de-
formity 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 possi-
ble 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 hand, the circumstances of the child's friends rendered
it impossible for them to take care  of her, and carry out treatment.
Abscess, sinuses, 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 ope-
rate, even though no  evident abscess existed. 
SURGICAL   CASES.
23
  A V-shaped incision was made over the  trochanter major, the
apex pointing downwards.  The head of the femur was found to
be denuded over almost its entire surface, and the disease extend-
ed 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 ace-
tabulum was filled with fungous  granulations, and not  carious.
The diseased portion of the ilium was left to exfoliate.  Thejemur
was sawed by means of a chain saw, below the trochanter major,
and a piece removed  an inch and  a half  long.  The cancellous
structure was found to be very soft.  Some of the adjacent soften-
ed and degenerated tissues were removed,  two ligatures were ap-
plied, and the wound left open.  There was very  little haemor-
rhage.  Patient was placed in bed, on her l#t side, without appa-
ratus.   Evening.—Pulse 140, regular.  Very little pain.
  June 5th.—Patient feels bright and playful.  She takes milk
freely.  There is no  vomiting, and no pain in wound.  Patient
altogether 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.
  July 5th.—Sits  up in a chair, and stands on sound limb.  Is
able to move about the bed.  Wound 3 inches by £ inch.
  30th.—Patient has some power of motion in the affected limb.
Is beginning to walk on crutches.
  Aug. 2d.—Very comfortable.  Walks about, the ward a little
with crutches, and can bear considerable weight on the foot.
  15th.—Walks with crutches very smartly, bearing some weight
on the right limb.  Can stand without support.  No pain on mo-
tion of leg.   Wound nearly closed, and no dressings required.
  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 tender-
ness about hip. Shortening of right limb, one and a half inches.
She was discharged, three months after  operation. ^
  In December (having been operated on in the previous June) had
been  without a cane, going up and down stairs, &c.   She had
been  allowed to go to school.   The wound remained closed and
free from pain until three weeks ago, when an abscess opened in
the seat of the operation, and is now discharging.  On examina-
tion, there is no denuded bone to be felt.   Whether this  abscess
is due to natural causes, to changes  of temperature in going out,
or to a blow she received in  playing, we  cannot say.  It seems
certain that  she will perfectly recover in time.
   1869.__Two years since  operation, condition  as  follows:—
walks freely without cane, and with  a slight limp. 
24                 SURGICAL  CASES.
   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 III.—(Service of Dr. Cheever.)—M. D., set. 6, female, en-
tered hospital Nov. 1st, 1867, with pain in right knee, which had
existed for six months.  Examination showed that the right nates
was flattened and limb shortened, that flexion and rotation  of the
thigh upon  the  pelvis increased  the  pain, but gave  no crepitus.
Treated by rest in bed, and extension of three pounds.   At the
expiration of a  montii she  had improved, flexion and  rotation
causing but slight para.   At the sixth week, however, she began
to complain  of pain in knee  when moved, so that it was difficult
to re-apply the bandage.
   At the third month, she was comfortable when  quiet,  but the
slightest jar or movement gave severe pain.  Examination was
made under  ether, and a slight crepitus was detected in  the hip-
joint.  No marked change during the following month.
   Feb. 4th.—Appetite failing for several days.  Comfortable with
extension.
   14th.—Restless at night.  Pulse weak.  Appetite poor.   Mode-
rate pressure over trochanter gives severe pain.
   28th.—Failed gradually since previous date, and, under the cir-
cumstances, it was  thought best to perform an operation for ex-
cision of the head of the femur.
   Patient etherized, and a V-shaped incision  made  over  the tro-
chanter major, the apex pointing downwards.  The  capsule was
divided by a sweep of the knife, and the head of the femur thrown
from the socket.   It was found to be diseased over a  greater part
of its surface, and the brim of the acetabulum denuded one-third
of its circumference.  About three drachms of pus escaped from
the joint.  The femur was sawed with a chain saw, just below the
trochanter major.  The cancellous structure was found to be very
firm, and the periosteum in good condition.   The carious portion
of the acetabulum  was left to exfoliate.  There  was but very
slight haemorrhage,  and no ligature required.  The flap was turn-
ed back upon the dorsum of  the ilium, the wound being left open.
Patient was  placed in bed  upon  the left side, and the  leg  placed
upon a pillow.
   Evening.—Slept  most of the afternoon.   In  #emi-recumbent
position, looks cheerful,  and  says she has no pain.
   10 o'clock.—Sleeping.   Wound dressed with dilute solution of
carbolic acid—3iss- to Ci.
  Feb. 29th.—Slept well all  night, and is bright and cheerful.
Wound kept open and filled with the carbolic  acid wash,  and cov-
ered with a compress.  Appetite good.  Pulse 130. 
SURGICAL  CASES.
25
  Evening.—A comfortable day.  lias not  required an  opiate
since the operation.  The wound looks clean and healthy.   No
haemorrhage.
  Remarks.—In this case, it will be noticed that there was appa-
rent amelioration of the symptoms under treatment by extension,
but that no  real  change to^k place.   The disease progressed to
the formation  of  pus, and to caries and partial absorption  of the
head.  Absolute relief from pain was given by the operation, and
it was followed by no constitutional shock.
  This child had several relapses, and abscesses up and down
the thigh.
  She is now, eighteen months since the operation, able to walk
about freely with a crutch ; the sinuses being about closed.  She
is a very feeble, scrofulous child.

  Case IV.—(Service of Dr. Cheever.) W. K., aet. 5.  This pa-
tient  was admitted to the hospital in October, with pain in knee,
limping gait, flattening of the nates, and slight tenderness about
the hip on pressure.  The opposite side of the pelvis was tipped
up, and the  affected leg was apparently an inch  longer than the
other.  He was put to bed, and extension with three pounds ap-
plied.  He  continued very  comfortable, and seemed  at first to
improve under treatment.  After he had been in the hospital three
months, he complained of more pain on moving the limb, and had
considerable constitutional excitement. He was examined under
ether.  On moving the hip, rough grating was very plainly felt,
and there was increased motion of the  head of the femur, so as to
allow it to slip partly from the-acetabulum.  Much constitutional
irritation, with pain and vomiting, followed the examination.
  Three days later, patient having been  etherized, a V-shaped
incision was made, bringing the point  of section just below  the
trochanter major.  The flap was  then dissected up  and the tro-
chanter exposed.   After  dividing  the muscles and capsule  by a
sweep of the knife, the head of the bone  was thrown from  the
acetabulum, by rotating the leg.   The head, neck, and part of the
trochanter major, were removed by a chain saw.  A small portion
of the acetabulum was  found diseased, but not gouged.  About
half of the cartilage of the head was destroyed.  There was very
little  haemorrhage, and only one vessel  was tied.   On the night
following the operation, he slept better than for a fortnight previ-
ous, ani the next day was bright and cheerful, and free from pain.
Aside from  a  slight disturbance,  with loss  of appetite, coated
tongue, and  pain, coming on a few days after the operation, and
probably due to an attempt  to close  the wound too quickly, he
lias done perfectly well.  It is now three weeks since  the  opera-
tion.  He is quite comfortable.  The wound is granulating finely
and contracting rapidly.  The end of  the bone is covered, with
         4
t 
26
SURGICAL  CASES.
the exception of a small piece.  Can bear extension with three
pounds without pain.   General condition improving every day.
  Three mouths later.  The wound in the hip  has  almost  closed.
There is  no discharge of pus, and only moisture enough to cover
the granulations.   He can swing and turn the leg in all directions.
He goes all over the building on crushes, ascending three flights
of stairs.   He can stand  without crutches.  There is never  any
pain or hectic.  There is  about an inch and a quarter of shorten-
ing.  His  future  condition seems  promising  and worthy to be
noted.
  Eighteen months since operation.   Every  way improved—a
little serous discharge still.

  Case V.—(Service of Dr. CnEEVER.)  A young man of 25, with
spontaneous caries of the head of the femur and abscess, was  ope-
rated on by  excision.  He went  on  well for some  weeks,  but
ultimately sank and died  of Bright's disease.

  Case VI.—(Service of  Dr. Cheever.)  Thos.  C, six years of
age, of feeble constitution, had suffered the  symptoms  of  hip-
disease a year before his entrance to the Hospital, and during the
previous three months he had been wholly disabled from walking.
There were the characteristic pain in  the knee, flattening of the
nates on the affected side, tenderness over the joint, wasting of
the limb, and pain on motion ; and manipulation gave a sensation
of grating  iu the  joint, although there was no fulness over the
joint or sinus indicating the presence of pus.
  The operation  of resection was performed, under ether, as fol-
lows.  A V-shaped primary incision was made over the  great tro-
chanter, the apex of the wound being directed downward.   The
flap was reflected upward, the dissection  being carried down to
the bone.   The ligaments of the  joint  and the tendinous attach-
ments having been divided, and the head of the bone, by forcible
rotation, having been thrown out of the acetabulum,  a chain-saw
was passed around the bone just  below the  greater trochanter
and a section made.  The head  of  the femur  thus removed  was
found  extensively diseased, the cartilage ulcerated and eroded,
and the bony tissue carious.  Half a fluid ounce of pus was evacu-
ated.   Considerable haemorrhage attended the operation, four ves-
sels requiring ligatures.  The wound was left freely open, the flap
being confined upward by adhesive plaster.             q
  The subsequent treatment was directed to the  support of the
patient and to the  promotion of the healing of the wound.   Healthy
suppuration developed  on the third  day.  The wound was freely
syringed with warm water  twice  daily, and  with diluted  Liq.
Sodae Chlorinatae  (§iij. to Oi.).  After twenty-six days the wound
had so far healed (the flap  having been gradually drawn down-
wards in  the process)  that extension by  pulley  and  weight
r 
SURGICAL  CASES.
27
(lbs. 11) was applied, and the limb  straightened without discom-
fort.   After two weeks the weight  was increased to  lbs. 3,  the
extension being omitted at night.  The wound continued to heal
satisfactorily^ and  the  general  condition improved in a marked
degree.  Motion  of the limb is now, five months since operation,
quite free and  almost painless, and the  patient will shortly  use
crutches.

   Case VII.—(Service of Dr. Cheever.)   Andrew C, aged eight
years, presented himself at the Hospital in a very pitiable condi-
tion in January last.  He was at the best of poor constitution,
and bad hygienic surroundings, insufficient diet, and especially
the exhausting conditions of his disease had reduced him greatly.
He had  suffered  the symptoms of hip-disease three  years,  and
during a number  of months had been confined to  his bed.   The
abscess in the joint had made a spontaneous opening in the mid-
dle third of the thigh, on the anterior aspect, and was discharging
profusely.   Decubitus was on the sound side with the knee  of the
affected limb in constant  flexion.   Emaciation was extreme,  and
the appetite was  poor.
   Excision of the head of the femur was  performed as in the  last
case,  the section being made just  below the  trochanter major.
The articulation was in a condition of extensive caries.  The head
of the femur was much broken and was partially absorbed.   The
cartilage of the  acetabulum  had  ulcerated and was nearly lost,
and the bone at the deepest point of the cavity had given way, so
that the pelvic fascia could be felt  as an  elastic partition.   There
was a considerable  amount of laudable pus in the joint,  to which
the free incisions of the operation gave  full exit.  A seton was
passed along the  sinus  in  the thigh, connecting the wound with
the spontaneous opening.  The haemorrhage attending the opera-
tion was slight.   The  wound was left  open, with cold  water
dressing.
   On the second day after the operation the general reaction be-
gan, which marked  the beginning of a recovery so soon as  the
diseased joint was removed.   The appetite commenced to improve;
no opiate was required at night, as  had been previously the case.
The wound took on healthy action  almost at once ; on the fourth
day the  end of the femur had nearly disappeared beneath  the
granulations.   With cod liver oil, and attention to the diet, the
wound and the general condition, improvement has been rapid,
so that now, nine weeks after the operation, the patient has gain-
ed one-half in weight, his  wound is closing fast, with diminishing
discharge, the  motion  of the limb is free and voluntary, and the
prospect of recovery good.

   Case VIII.—(Service of Dr. Cheever.)  Maggie B.,  aged 7,
began to suffer  from disease of the hip four years ago.  After six 
28                 SURGICAL  CASES.
months a spontaneous cure  appeared to  have been effected, and
there was cessation of the pain, lameness and general disturbance
which had previously existed.  An interval of nearly  a year of
health followed, in which there were no  signs of active disease,
local or constitutional.  At the end of that respite  the affection
recurred, with increased severity.  Without fully  disabling the
child, the disease  developed until seventeen months before  her
entrance to  hospital, when an abscess appeared on the  inner side
of the thigh in the middle third ; it opened spontaneously, and dis-
charged freely during four or five months.  It then closed, and
the disease  remained partially latent until December last, two
months before she was brought to the hospital; at that time the
former symptoms recurred, and the patient at her  entrance was
confined to  bed, emaciated and  debilitated.  Motion  of the  hip
was not notably impaired, but was painful, and under ether gave
moderate grating.   The limb was shortened one inch.   The nates
of the affected side was flattened, the  region over the trochanter
major being considerably swollen.  The sinus was open and dis-
charging moderately;  and a probe, passed  through it  in an  up-
ward course, impinged on the denuded neck of the femur.
  Excision of the head of the bone was performed as in the other
cases, the only modification  being that the section of the bone
was made through the trochanter instead of below it.  The head
of the femur presented appearances corresponding with  the course
of the disease.  Nodules  of new bone had been thrown out  in
front and laterally in the natural attempt at cure.   In the intervals
between these the bone was still carious and undergoing the pro-
cess of waste.  The  cartilage of the acetabulum was partially
ulcerated and eroded.
  Convalescence commenced  at  once, the wound  beginning  to
take on healthy granulating  action very early.  There was very
slight constitutional disturbance.  The chief difficulty experienced
was in the tendency of the trochanter, which had been left in the
wound, to ride outward and protrude.   This was obviated by the
application  of extension after four days, the weight being one
pound and a half.  The tip of the process exfoliated, and the  ex-
tremity of the bone soon became buried beneath the healthy granu-
lations.  The progress toward cure was satisfactorily rapid under
mild dressing to the wound and cod liver  oil internally, and now,
after seven weeks,  the patient is  in excellent  condition, able  to
sit up  in a chair without discomfort, and  promising a safe and
early recovery.

  Case IX.—(Service of Dr. Cheever.) Honora D., aged 8 years,
of phthisical tendency, traced the symptoms  of hip disease to a
fall two years before her entrance to hospital, where she presented
herself for treatment.   She was in very poor condition, emaciated,
with delicate appetite and little strength.   The symptoms referred 
                    SURGICAL  CASES.                 29

 to the diseased hip were characteristic ; there was pain, flattening
 of the nates, partial  obliteration of its fold, grating on motion and
 pain in the knee.  Extension of five pounds afforded partial, tem-
 porary relief.  After ten days of this  treatment the head of the
 bone was excised.   The subsequent relief was marked and imme-
 diate ;  the wound soon granulated healthily and discharged freely,
 and the general condition improved  under good diet, tonics  and
 cod liver oil.  There was, however,  less rapid improvement than
 in the previous cases ;  the wound, although healthy, was indolent
 in healing.   After six weeks extension was applied, with a weight
 of three pounds.   There was gradual improvement until the tenth
 week, when  nausea, loss of appetite, and general depression suc-
 ceeded from  some ill-defined cause.   The  patient complained of
 headache and weakness.  There was diarrhoea, which  soon gave
 place to obstinate constipation.   A tendency to sleep developed.
 The pulse reached. 100  and continued  at  that point.  Soon the
 latent mischief developed itself, and well-marked symptoms, con-
 vulsions, headache,  emaciation, delirium, stupor, pointed to tu-
 bercular inflammation of the meninges.  The patient sank steadily,
 and aiter a succession of distressing symptoms died  at the end of
 the  tenth week after the operation.   No autopsy was obtained.

   Case X.—(Service of Dr. Cheever.)  David McD., aged 4, en-
 tered the Hospital February 22, after having had symptoms of
 disease of the hip two years.  The patient's condition at the time
 of entrance  testified to the wearing effects of the affection ; he
 was debilitated, confined to his bed and was of very  irritable dis-
 position.   The limb  was shortened half an inch, and when the pa-
 tient was etherized there was very slight grating in the joint.  In
 the outside of the middle third of the thigh was an opening, com-
 municating with a subcutaneous sinus which  extended up  the
 thigh  toward the joint, and  discharged  freely.   The  slightest
 motion  of the limb excited great pain.
  An exploratory incision was made,  its shape being that  for
 excision, it having been determined to proceed with caution, on
 account of the obscurity of the symptoms, and because, also, the
 probe, when introduced into the sinus, failed to detect dead bone
 in the region of the joint.   As soon as the cut was made, pus
 freely escaped ; and  the probe  found denuded bone.   The incision
 was  enlarged and the flap dissected  back,  and in the  bottom of
 the cavity of the socket was found the head of the femur, sponta-
 neously  separated.  The adjacent  extremity of the bone  was
 rounded and undergoing repair.
  In the three weeks since the operation, the general  condition of
the patient has  improved to  a  marked degree.   The  discharge
from the healthily granulating wound is abundant and laudable.
The appetite  throughout has been excellent, and all the functions
are performed normally. Extension  with a weight of  lb. 1J has 
30                 SURGICAL  CASES.

been applied, and the patient is in a comfortable state, with good
prospects of an early recovery.

  Case XI.—(Service of Dr. Thaxter.)  E. L.,  twenty years  of
age, of intemperate habits, and enfeebled constitution,  entered
the Hospital on the medical  side,  after having complained five
months of paiu about the region of the hip and down the thigh to
the knee.   He ascribed his disability to unusual exposure to cold.
He was unable to bear weight on the  affected  limb, and walked
habitually with a cane.  Both feet had been swollen, and the foot of
the diseased extremity still continued  cedematous.   On his trans-
fer to the  surgical side, after a month of palliativet reatment with
iodide of  potassium, opiates and blisters, there was found fulness
about the  joint, intense pain on motion, referred to hip and knee,
and distinct crepitus was heard  and felt.  The  condition of  the
patient was very debilitated.
  Extension was applied with a weight of six pounds, and treat-
ment was  directed to the support of the patient and  to the relief
of his symptoms.  After five weeks of these palliative measures,
it was determined, on consultation, in view of the continued  de-
bility and  retrogression of the patient, that excision of the head of
the femur was the surest means of saving life, with even then a
doubtful prognosis.   The patient had wasted, and over the tro-
chanter major of the sound femur, on which he lay most of  the
time, a bed sore was forming.
  The  operation of excision was performed as before described,
without complication ; the section of the bone being just above  the
trochanter major.  The head of the bone was extensively carious,
and the disease had involved a small portion of the acetabulum.
The cavity of the joint was full of pus.
  The subsequent  constitutional disturbance was quite marked.
The pulse ranged from 120  to 136.  The appetite was  indifferent,
and the wound was  indolent.  One week after the  operation, fluc-
tuation was determined in the  thigh  below the  wound, a large
accumulation of pus  having  taken place  beneath the fascia and
among the femoral muscles ; this shortly found  exit through  the
wound at  the joint and was freely evacuated.   An elastic catheter
could be introduced its whole length from the wound downwards,
along the  thigh between the  muscles.  Under ether, a free coun-
ter opening was made at  the most dependent  part, and a seton
passed through it and the  wound of excision.   The patient was
considerably relieved  by  this measure, and for a  time gained in
strength  under tonic and  stimulant treatment.   Meanwhile  the
pressure from prolonged lying had caused  a large  slough over  the
opposite ilium and trochanter, and  the position  was changed to
the back.   Both ulcerations took on healthy action and there was
fair progress ;  but the bed  sores became more  serious than  the
wound of the operation, until it became necessary to  again change 
SURGICAL   CASES.                31
the position, and  this time the  patient was made to lie on his
abdomen and the front of the  thorax, well supported  by pillows.
The prolonged drain on the system  and the irksomeness of the
position soon began to tell on  the strength and vitality, and the
patient resisted all remedial measures and continuously declined.
Profuse sweatings still further  debilitated him ; the lower extremi-
ties became very cedematous,  while the upper part of the  body
was extremely emaciated.  Renewed accumulations of pus were
followed by incisions.  After ten  weeks  of almost continuous
decline, the patient died from exhaustion.

   AVe have detailed, above, eleven cases of excision of the head of
the femur.   Of these, three died :
    One adult, of exhaustion.
    One adult, of  Bright's disease.
    One child, of tubercular meningitis.
   Four of these  children  arewalking very well.   The four remain-
ing are still in bed, and under treatment.
   It is too soon  to deduce positive experience as to the  result in
these cases.   One thing we conceive to be demonstrated by them,
viz. :  that the shock of the operation is small, and  that the relief,
from  giving free exit to pus and caries, is as great in this disease
as that experienced after the opening of an acute abscess.
  Dr. Good, foreign correspondent of the Richmond and Louisville
Medical Journal for January, 1869—writing of this operation in
Paris, says :  " The Imperial Society of Surgery is at present dis-
cussing a subject, which, by no means  new, has never failed to
find great opposition;  we mean the resection of the hip-joint for
caries.  What called forth a renewal of this question was an ob-
servation read by M. Verneuil to this body, on the 14th of October
last, in which he gives an account  of this operation practised by
him, quite recently, on a man aged 23, suffering from the  last
stage of morbus coxae.   The  case ended fatally, the fourth day
after the resection.
  "Why is  it  that an operation, to-day accepted  by nearly all
the surgeons  of England, Germany,  America, and even Russia, finds
so few imitators in France ?  True, the .cases practised here  have
not been of a nature to encourage the example.
  "Leaving  aside England,  the birthplace of resection and where
first it found  its advocates,  soon to be  followed  by German and
American surgeons, of which fact such men  as Sayre,  Bauer,
Hodges, Lyon and others have given proof, by their able writings,
there, as elsewhere, this  operation is established, ranks as classi-
cal and is often crowned  with good results." 
32
SURGICAL  CASES.
  "Taking the following table as a basis of argument,  we find
that resection of the hip has  been performed  in  Fiance,  from
Roux's first and well-known case  (1847)  up to this  date, seven-
teen times, of which fifteen patients  are  dead and two cured.
This does not include, as already stated, the four cases not cured,
and of which two fall upon Giraldes and two upon Marjolin.
  " If we were permitted to  give our own explanation of the great
mortality, it would be this :—
  " Firstly.  There are few people so badly nourished as  are the
inmates of our Paris hospitals, and especially the children,  in
whom our operation is principally indicated.
  " Secondly.   The strumous diathesis in  these children, who are
brought into  the  world by  parents already degenerated, is  very
predominant, much more so than in America.  There, it seems,
many of the coxalgias,  according to Sayre and Bauer, are  referred
to a traumatism ;  an  opinion, by-the-bye, which finds no,  or  few,
advocates in France."
  " The Third and main explanation has reference to the  delay of
the' operation.  This,  it  cannot  be doubted, is,  here in Paris at
least, one of the greatest   reasons for  the ill success which
attends the resections of  the larger joints, and more especially
those of the coxo-femoral articulation.
  " The French accuse the  English and Americans  of being too
exclusively surgeons, that they persevere  less in  a less heroic
treatment (that is to say, they operate  too early), and, therefore,
their  greater success from  the operation.   But we might,  with
the  same justice,  say, the Paris surgeons have  too  implicit  faith
in the conservative  plan  of treatment.  True, there  are cases
cured without the interference  of the  knife; every surgeon has
seen such cases (even where caries of the joint could not be doubt-
ed and where the condition of the patient seemed almost hopeless)
recover by mechanical treatment.   But how many are there not,
where, with every care  possible  and  a  treatment  both  general
and local, such as the most sanguine of  the school of Bonnet could
prescribe, the result is a fatal one.
  " It is  our opinion, that more could  be gained in many cases,
by freeing the patient from the source of  the evil (especially if it
be a local one) than by permitting it to remain and expecting nature
to perform a cure.   We pronounce ourselves in favor of early resec-
tion, the moment the surgeon has assured himself of the presence of
caries of the joint;  and we agree with  Fock, of Magdeburg, that
more lives can be saved and more useful limbs preserved by this
than by any other treatment  at present known for  caries of the
hip-joint." 
Table of Gases of Resection of Hip joint practised in France.
	•a
	a .
	
AND	
DAVE.	u&
	-I
Knux.	Mj
IS 17.	5 t
Marjolin.	E
IS.").").	8
Wdillot.	M (
18.58.	31
Dolbeau.	M)
1S02. •	17 )
ls(i:i.	8 \
tiossi'lin.	m >
ISO:;.	17
Gosselin.	M
1SC1.	18
Dolbeau.	F(
1864.	3 i
Girald<^.	F|
ISC..-).	8 }
St'dillot.	M j
1805.	1) 1
Gosselin.	M
1805.	40 J
Shrimpton.	¥)
(Paris) 1800.	17 i
Giraldes.	F{
1800.	!»1
Giraldes.	Ft
1S00.	12
Giraldes.	M >
1S00.	10ii
Giraldes.	31 j
1807.	l»l
Vcrneuil.	51 i
1808.	23 $
DISEASE.
Caries of articulation ;  sinuses; great
            emaciation.
Caries and suppuration;  spontaneous
      luxation of head of femur.
Caries of hip-joint; great emaciation.

Advanced stage of coxalgia; several
              sinuses.
Suppuration of joint for ten months.

Far advanced stage of coxalgia.
Profuse suppuration ; hectic and great
        prostration of force.
Caries.

Very  advanced stage of coxalgia;  op-
        eration in extremis.
Suppuration from a joint; from a fall.

Advanced stage of suppurating cox-
               algia.
Suppurating coxalgia and subluxation
 of head of femur;  of 10 mo. duration.
Advanced stage of coxalgia; numerous
              sinuses.
Coxalgia,  cachexia and extreme ema-
              ciation.
Coxalgia; several sinuses behind great
            trochanter.

Coxalgia and spontaneous luxation.

Suppuration of joint since two years;
    subluxation of head of femur.
OPERATION.
RESULT AND REMARKS.
The  head dislocated and a portion of
           neck excised.
Resection of  head of femur;  acetabu-
   lum carious, but was not gouged.
Below great trochanter; tvidement of
              femur.
Below great trochanter, and  acetabu-
     lum gouged and cauterized.
Under little trochanter; the great tro-
 chanter and acetabulum are healthy.
Section  under great trochanter; the
        acetabulum is carious.
Under great trochanter, and  acetabu-
            lum gouged.

Resection of the head of femur.

Under great trochanter;  head found
 loose in acetabulum;  acetab. gouged.
Head and portion of neck of femur are
    resected; acetabulum gouged.
Under great trochanter, and  acetabu-
         •   luin  gouged.
Resec. of head of femur; brim of acetab.
 diseased wh. head rested; not gouged.
Under great trochanter, and acetabu-
            lum gouged
Under great trochanter.

Under great trochanter, and acetabu-
            lum gouged.
Resection of head (very little diseased);
         acetabulum healthy.
Resect'n suppurating portion of femur
(head & portion of neck); acetab. caut'd
Died  the  sixth  day;  the acetabulum found
                  carious.
Died one year afterward from continued sup-
                 puration.
Died ten months after operation from caries of
      pel/is and consequent peritonitis.

Died the seventh day from exhaustion.
Completely cured 18 mo. after opera.;  good use
of limb with 3 etins. short; but mobility excel.
Died  one  month  after  operation from  ex-
                 haustion.
Died few  days  after the operation from ex-
                 haustion.
Died 8 mo. after op.; autopsy; perfora. of coty-
loid cav.; caries of femur; tuber, at base 1. lung.

Died on the fourth day of haemorrhage.
Cured, 14 mo.; limb feeble; walks with crutch;
Kood motion, 2 ctms. short; in good health 1868
Died  of exhaustion a short  time after the op-
                  eration.
Died six months after  operation from profuse
         and continued suppuration.

Died of purulent infection the fifth day.

Died  of exhaustion a  few days after the op-
                  eration.
Died 3 months after operation; perforation of
    acetabulum and suppuration of pelvis.

Died of exhaustion six months after operation.

Died  the fourth day; infiltration of pus of the
                entire limb. 
 
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SURGICAL   CASES
   DAVID AV. CHEEVER, M.D.,


ADJUNCT PROFESSOR OF CLINICAL SDRGERY IN HARVARD UNIVERSITY.

       Sl'RGEON TO THE BOSTON CITY HOSPITAL.
 
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