With the Author s Compliments. 
FROM 
TRANSACTIONS 
OF THE 
Illinois State Medical Society, 
1891. [Reprint prom Transactions of Illinois State Medical Society, 1891.] 
ADDRESS IN SURGERY. 
JOHN E. OWENS, , CHICAGO. 
This paper consists of a report of a series of cases of supra- 
pubic cystotomy and ununited fracture, smd a short note on 
the operative management of carcinoma. 
Several years ago it was predicted that supra-pubic lith- 
otomy would supplant the lateral operation. That expecta- 
tion has been realized. The few cases noted may serve to 
show the varied application of this operation. 
Case 1. A. D. M., aged 48 years, came under my care 
November 2, 1890, with symptoms of stone in the bladder. 
During the previous year he had been successfully treated 
for urethral stricture. The presence of a stone having been 
verified, the supra-public lithotomy was performed the day 
following his admission, and a stone of medium size removed- 
The upper extremity of the wound in the abdominal wall 
was closed, and a soft catheter was introduced into the blad- 
der, fixed by a stitch to his skin, and allowed to remain for 
two or three days. 
The contact of drainage tubes and catheter always occa- 
sions more or less discomfort, and should be removed as soon 
as their usefulness ceases to be apparent. 
The skin around the supra-pubic opening was protected 
from contact with urine by means of a piece of protective or 
oiled skin, the under side of which was well coated with sim- 2 
pie cerate containing iodoform, 10 per cent. An opening, a 
little larger than the supra-pubic wound, should be made in 
the protective, and the latter so shaped as not to be displaced 
by flexion of the thighs, and sufficiently large to cover the 
skin over a radius of about three inches from the wound. 
An absorbent combination dressing, containing a slit for 
the catheter, was super-imposed on the protective. A light 
rubber tube, affixed to the distal end of the catheter and 
passing into a bottle resting by the side of the patient, con- 
veyed the urine, for the most part, directly from the bladder 
to the bottle. 
The dressing, as above described, completely prevents the 
urine from coming in contact with the skin. 
The bladder was irrigated daily with warm boric acid so- 
lution, ten grains to the ounce, for a few days. 
The patient recovered completely, without an untoward 
symptom, in five weeks. 
Case 2. J. J. D., aged 56 years, was admitted to St. 
Luke’s Hospital March 29, 1889. 
A brother died of Bright’s Disease. With the exception 
of two attacks of pneumonia, the patient considered himself 
a healthy man until 1882, when he began to have irritability of 
the bladder. All the symptoms of stone in the bladder su- 
pervened. The existence of the calculus was verified, and on 
April 3d lateral lithotomy was performed. The stone was 
phosphatic and somewhat above the medium size. 
The patient was discharged on the 3d of May, apparently 
having made a good recovery. 
Soon after leaving the hospital, however, haematuria super- 
vened, and the patient again came under my care January 8} 
1890. There was some smarting at the beginning of the flow 
of urine, but none during or after. The wound in the peri- 
neum was found completely healed, but the site of the incis- 
ion was somewhat painful on pressure. 3 
January 13th. The bladder was carefully examined, but 
no stone was found. Sometimes as much as a half-teacupful 
of blood escaped from the urethra. Tumor of the bladder 
was diagnosticated, and, on the 24th of January, supra-pubic 
cystotomy was performed. The rectal bag was put into posi- 
tion and distended with twelve ounces of water. Six ounces 
of a solution of boric acid were thrown into the bladder 
through a silver catheter, which was allowed to remain. A 
longitudinal opening, three inches in length, was made 
through the linea alba, its lower extremity reaching to the 
pubic arch. The dissection having reached the bladder, two 
stout silk sutures were introduced through the whole thick- 
ness of its wall, parallel with and on each side of the middle 
line. 
The free extremities of each suture were tied together. 
The upper wall of the bladder, considerably thickened, was 
elevated to the surface of the wound by making traction upon 
the two silk sutures above noted. The finger, introduced 
through the opening made between the sutures, came in con- 
act with a papilloma, pyramidal in shape, situated on the 
right side and close by the neck of the bladder. 
The growth was removed with the scissors and share 
spoon, and the cavity of the bladder irrigated with hot boric 
acid solution. A large drainage tube was retained in place 
by a stitch to the skin, and the wound in the abdominal wall 
shortened by suturing. 
February 4th. The bladder wound having contracted to 
about the size of the drainage tube (5-16 of an inch in diame- 
ter), a smaller tube was substituted. February 6th. Drain- 
age tube was removed. The bladder was washed every day 
with boric acid solution. 
On the 14th of February the urine had ceased to flow 
through the supra-pubic wound. The patient has had no re 
turn of symptoms. At the time of the lateral lithotomy in 
the search, by means of the finger, for a second stone, the 4 
tumor was not discovered, and as the occasional hemor- 
rhage seemed to be no greater than might be expected to 
arise from the presence of a calculus, the existence of tumor 
did not suggest itself, so that I am unable to say whether the 
diagnosis could have been made at the time the first opera- 
tion or not. 
Case 3. R. N. M., aged about 35 years, was admitted to 
the hospital on the 29th day of September, 1888, during the 
service of my colleague, Dr. L. L. McArthur, and was trans- 
ferred at the expiration of his service. 
The general health of the patient, previous to the present 
illness, was excellent. 
Six months prior to admission he gave a history of a crush- 
ing injury of the pelvis, caused by his being caught between 
the side of a pit which he was digging and a falling boulder. 
He was taken home, and remained in bed from the time of 
his injury to his admission to the hospital, and was unable to 
walk during this time. Blood came from the external mea- 
tus, but he was unable to pass his urine; but the physician in 
attendance was able to draw the same by catheter. In a 
short time a perineal abscess was opened, and was discharging 
when he was admitted, at which time he was in the following 
condition: Thin, hectic, urine passing partly by the urethra 
and partly by the perineal fistula, great dysuria, severe cys- 
titis. 
Dr. McArthur enlarged the fistula by incision. 
Exploration revealed a communication of the same with 
the rectum, and a fracture of the pubic ramus (vertical). An 
incision included the tissues intervening between the fistula 
and rectum. Farther examination showed a continuation of 
the tract into an abscess situated in the left ischiatic fossa 
and small pelvis. This was emptied and washed, when a 
communication was discovered between the inner wall of this 
abscess and an opening in the bladder at the site of the left 
prostatic lobe, the greater part of which seemed destroyed. 5 
With an instrument in the bladder, the finger could feel the 
same as it entered the viscus at the internal end of the urethra. 
The entire inferior wall of the urethra was wanting in its 
membraneous portion, the remainder of said portion forming 
a part of the wall of the pelvic abscess. A catheter was intro- 
duced through the proximal end of the urethra and drainage 
provided for the abscess. 
During his stay in the hospital he was taken several times 
to the operating room for the purpose of introducing the 
catheter, which either had to be removed because of the 
cystitis, or had become accidentally displaced. When the 
catheter was in position, the urine freely escaped both 
through the instrument and the rupture. 
When the catheter remained out for a few days, both ori- 
fices would narrow to such an extent that operative inter- 
ference became necessary. Finally, at the last seance, the 
two openings in the bladder were made into one by cutting 
the intervening tissues. After that he improved greatly, but 
still suffered from the narrowing which always ensued if the 
openings were not well maintained patulous. The bladder 
was greatly contracted, and there was a band extending from 
the symphysis pubis backwards, constricting it like the groove 
in a horse-chestnut. 
An important point was the direction which the urethra 
had assumed, as a result of the cicatricial contraction. 
This for the pendulous portion was normal; but when the 
sound reached the membranous part, the canal took an abrupt 
curve upwards behind the symphisis pubis,but at a distance of 
about two and one-half inches behind the same,inclining a little 
to the left. The normal urethral sound did not pass along 
the canal well for this reason. Attempts to close the per- 
ineal fistula failed. 
17th of May, 1889. Patient was discharged some months 
ago, with a perineal fistula communicating with the bladder. 
The membranous and part of the spongy portion of the urethra 6 
were destroyed, and the prostatic portion much damaged. He 
was instructed to pass a sound through the fistula into the 
bladder, systematically, to prevent cicatricial contraction. He 
failed to do this, however, and returned to the hospital with the 
fistula and prostatic portion of the urethra so much contracted 
that urine came through in drops only. There was great 
danger that the opening in the bladder would soon become so 
tight as to produce complete retention. Repeated efforts to 
pass instruments of different kinds into the bladder, through 
the fistula, failed. Finally, it was decided to enter the 
bladder by supra-pubic cystotomy, and make an effort to 
open the perineal fistula from the inside of the bladder; or, 
this failing, to construct a supra-pubic artificial urethra. 
The operation of supra-pubic cystotomy was made as 
follows: 
Incision four inches long was made, extending upwards 
from the upper margin of the symphisis pubis in the middle 
line. The incision through the transversalis fascia did not 
measure over three inches in length. Some difficulty was ex- 
perienced in finding the bladder, inasmuch as no sound could 
be passed into it from below, as it was very small and firmly 
held down by cicatricial tissue, in consequence of which, the 
rectal bag did not satisfactorily push the bladder forward, 
and the latter was by no means made prominent by the con- 
tained urine. The exploring needle was introduced into 
what appeared to be the bladder, and urine escaped. The 
viscus was then opened as near the symphisis pubis as pos- 
sible. The incision was less than an inch long. A sound 
was then introduced through the supra-pubic opening,and by 
directing it into the perineal fistula, it was possible to cut 
down upon it at the site of prostatic urethra, and thus estab- 
lish a channel for the urine, This being done, and the old 
fistula thoroughly dilated, a large canula was introduced into 
the bladder through the fistula, and retained in place by 
bandages in the usual manner. 7 
May 31st, there is the following record: “Quantity of 
urine passing through the supra-pubic wound has been daily 
diminishing, and to-day none has passed.” 
June 23d, the wound has perfectly healed. 
Patient discharged July 31st. He was instructed to pass 
a No. 18 steel sound through the perineal opening into the 
bladder once a week, the balance of his life. 
Case 4.—H. C., aged 28 years, Dec. 24th, 1890, sustained 
a fracture just above the junction of the rami of the ischium 
and pubis on the right side, and complete rupture of the 
urethra. 
When admittted, patient was suffering great pain with 
some hemorrhage from the urethra. Parts were much dis- 
tended from urinary infiltration and blood, which were evac- 
uated by free incisions. These incisions did not, however, 
give satisfactory results,as the bladder soon became over dis- 
tended. The patient being unable to pass the urine, the 
tenesmus being very urgent, and the passage of a catheter 
being impossible, supra-pubic cystotomy was performed, and 
free incisions made in the middle line just below the penis, 
and in the perineum, in order to empty the parts of accumu- 
lating blood and urine. Tn order to establish the continuity 
of the urethra, the catheter was introduced into the vesical 
end of the urethra through the bladder, by which we were 
able to locate the proximal torn end of the urethra which had 
been, by pressure, pushed aside from its normal position. 
The distal torn end was readily found by introducing a 
sound through the external meatus. We were thus enabled 
to place the cathater through the whole length of the urethra, 
with the view of establishing, by the healing process, the con- 
tinuity of this canal. 
Convalescence was tedious, in consequence of slow 
Healing of the parts which had been so extensively under- 
mined and separated by blood and urine. The undermining 8 
even involved the mucous membrane of the bladder to some 
extent. 
The patient was discharged 22d of March, 1891, with but 
little disability. The fracture was united, and he is now per- 
forming the duties of watchman. 
Daily irrigations with hot boric acid solution were em- 
ployed in the bladder and the abnormal cavities. 
Early in February, orchitis supervened, and several small 
painful abscesses in the perineum and scrotal walls. The 
cathater was not used after March 7th. March 15th, we 
began the periodical introduction of sound. This the 
patient has been instructed to do for himself, once a week, 
for the balance of his life. 
Case 5.—E. J. D., aged 38 years, was admitted to the 
hospital on the 29th day of July, 1890. In February of the 
same year, he had a severe attack of typhoid fever. During 
his convalescence, an abscess in the perineum opened spon- 
taneously. Purulent urine had been discharging from the 
urethra. Later, another abscess formed in the perineum, 
and this, together with the other one, destroyed the lower 
segment of the urethra, leaving an opening two inches long. 
November 1st., 1889, supra-pubic cystotomy was per- 
formed for the purpose of directing the urine away from the 
urethra, preparatory to an operation for its repair. The 
abdominal cavity was unintentially opened during the supra- 
pubic operation. 
The operation for the repair of the urethra failed; and, in 
a short time, emaciation, diarrhoea, and night-sweats having 
set in, the patient, under advice, left the hospital and has 
not since reported. 
A few years ago, I began to advise patients, upon whom 
I had operated for the removal of cancer, to report to me 
every thirty days. By so doing, I hoped to be able to note 
the earliest evidence of recurrence and at once eradicate the 9 
affected part. The following case illustrates the application 
of the method:— 
Case 6. Mrs. S., aged 53 years, was affected with cancer 
of the left mammary gland, and in July, 1885, an eastern 
surgeon removed the whole organ. When sutures were re- 
moved, the patient discovered a hard lump, the size of a pea, 
at the site of the original tumor. There was also a small 
nodule left in the axilla. I first saw her in January, 1887, 
and in this same month, removed a cancerous tumor from the 
left mammary region, and a nodule from the axilla. October 
7th, 1887, I removed another nodule from the axilla. Feb- 
ruary 16th, 1888, still another; December 8th, 1888, a no- 
dule the size of a shot was removed; March 3d, 1889, still 
another nodule was extirpated; June 21st, 1890, removal of 
a cancerous growth from the axilla in intimate relation with 
the axillary vessels, and reaching to the clavicle. 
Patient died, probably of brain cancer, the first part of 
this year, about five and a half years after the first operation. 
Case 7. Ununited Fracture. A few years ago, in the case 
of a male thirty years of age, a fracture of the olecranon 
process which I had been treating, failed to unite. I cut 
down upon the bone, and freshened the bony surfaces with a 
thin chisel, and wired (No. 15 silver wire) the pieces to- 
gether, using one suture. During the operation, a few drops 
of synovial fluid escaped. In due time there was a complete 
bony union. The patient, who was much addicted to sparring 
previous to the accident, did not cease to indulge in the 
manly art after the bone had become united. 
Case 8. Miss M. B., aged twenty years, was injured July 
13th, 1889. The right humerus was fractured in the lower 
third close to the elbow, and also near the shoulder joint, and 
the right radius, a short distance above the wrist. 
On admissionto the hospital, Nov. 29th, 1890,) the 
fracture of the lower third of the humerus was found un- 
united. The broken ends were exposed, the ends freshened 10 
by means of saw, “chipped” with a chisel (as above described) ( 
drilled and wired together with No. 15 wire. The wound 
was closed without drainage, dressing applied, and the arm 
enclosed in plaster of Paris, from and including the hand, 
and reaching to a point well up over the shoulder. The arm 
was then placed next to the skin, forearm supported by 
sling; and a broad band encircled the body, holding the arm 
close to the chest. The clothing was allowed to fall down 
over all, the sleeves on that side not being used. 
The bone was found firmly united at the end of two 
months, and the patient discharged February 25th, 1891. 
She could not fully extend or flex the arm, but the range 
of movement will doubtless improve. 
Case 9. A. I., aged fourteen years, was admitted on the 
17th of April, 1890. About a month before, while out 
playing, he sustained a fracture of the left patella, the frag- 
ments of which were about an inch apart. A transverse 
incision opened the joint through the broken patella. The 
broken surfaces having been freshened with a sharp chisel, 
the fragments of the patella were drawn into apposition, 
and so maintained by means of two shotted silver wire 
sutures. The joint was irrigated with warm boric acid solu- 
tion, and the bursa stitched with cat gut. A coil of cat gut 
was inserted for drainage, the wound closed, the whole leg 
enclosed in plaster of Paris, and suspended. 
The patient left the hospital July 22nd, 1890. The union 
seemed strong and close, but au undoubted movement existed 
between the fragments. 
Case 10. E. A. E., aged thirty-eight years, on June 25th, 
1890, in jumping, fell, striking his knee against a piece of 
timber, producing a transverse fracture of the patella. The 
swelling was very marked, in consequence of an accumula- 
tion of blood in and about the joint. This patient was ad- 
mitted on the 6th day of July, 1890. 11 
The knee was still much enlarged, and an unhealed con- 
tused wound wras situated over the lower edge of the knee- 
pan. 
About three weeks after the date of the accident, a crucial 
incision was made over the patella. The lacerated bursa 
had dipped down between the fragments, the joint was filled 
with fluid blood, and more or less decolorized fibrinous clots. 
These were removed and the joint well washed with wTarm 
boric acid solution, the broken surfaces freshened with a 
sharp chisel,and fixed in apposition with a single No. 15 silver 
wire. The wound having been closed and dressed, the whole 
leg wra3 encased in plaster of Paris, and suspended. 
July 23rd, and August 11th, the dressings were renewed. 
They were somewhat moist from a serous discharge. 
August 18th, the wounds were healed, a lighter cast was 
applied, and the patient permitted to get up and use crutches. 
He left the hospital September 7th, 1890, and could bend 
his leg well, but not to a right angle. A good bony union 
was the result. He resumed work January, 1891. 
So far as rapidity of union is concerned, after drilling, 
the following case is phenomenal: — 
Case 11. Mrs. E. M., aged 60 years, received a fracture 
of both bones of the leg at the junction of the middle and 
lower thirds July 24th, 1890. 
March 20th, 1891, evidences of a false joint in the broken 
tibia were manifest to all present. The broken surfaces 
were drilled and the leg encased in plaster of Paris, reaching 
above the knee. 
April 11th, very little movement could be discovered, 
but the bones were again drilled and the leg placed in 
plaster of Paris reaching above the knee. 
May 9th, the union was complete, but the leg was en- 
cased in plaster as far as the knee. 
Case 12. II. A., aged 29 years, was injured July 4th, 
1888. The injury consisted of a most extensive compound 12 
comminuted fracture of the left tibia and fibula. The lacer- 
ations and contusions of the soft parts were very extensive; 
there was much undermining. The foot and leg, below the 
seat of the lesion, were cold and pale, and no pulsation 
could be made out in either the anterior or posterior tibial 
arteries. At the time, no operation was permitted. 
Suppuration supervened; much sloughy tissue was re- 
moved from time to time, together with fragments of bone, 
and the latter became detached from their surroundings. 
The case necessarily ran a very slow course, and after 
many weeks, (as might be expected), there was no union 
whatever, in either bone, nor had the wounds in the soft parts 
healed. 1 then made sufficiently free incisions transversely 
over the tibia, and longitudinally over the fibula, to make 
resections of the bones and to wire them together. Adding 
what had already been lost to what was removed in the re- 
section, the bones were about three inches shortened. A 
section was removed from the fibula to allow the tibial 
surfaces to come together. 
The patient remained about seven months in the hospital, 
and as the progress toward bony union seemed very uncertain, 
I drilled the tibia on several occasions, before and after he 
went home, where I continued in attendance till March 9th, 
1889. I then wrote to parties interested in the case the fol- 
lowing: 
“The bones are in excellent position; they are firmly 
held so by a fibrous bond of union. There is no bony 
union, nor do I think that further treatment is likely to 
secure it.” 
I advised that a brace be made to support the leg at 
the seat of the injury, and that he begin to use the leg. The 
weight of the body, in pressing the bony surfaces together, 
may aid in “bony consolidation.” I had not seen the patient 
after the brace was made until last Sunday (May 17, 1891), 
when I found a most excellent bony union, and the patient 13 
much pleased with the result. He informed me that he re- 
sumed business as soon as the brace was ready for him; that 
he used the brace about seven months, when his limb was 
strong enough to discontinue the use of the former, but that 
he continued to wear a leather “legging’’ till about two months 
ago. 
Case 13 was in some respects similar to the last one. 
O. S., aged 28 years, was admitted to the hospital July 30, 
1888, with an ununited fracture of the tibia at its middle 
third, and wires loose in the bones. The accident occurred 
two years before. A few days after admission (August 4), 
the broken surfaces were freshened and fastened together by 
means of three bone pegs. The limb was encased in plaster 
of Paris till October 4. In the meantime one of the pegs 
had loosened and came away. The bones were somewhat 
more lirmly united, but a false joint still remained. 
October 15, 1888, a resection of tibia and fibula was per- 
formed, it being necessary to remove 1£ inches of the 
fibula in order to bring into apposition the freshly cut sur- 
faces of the tibia. Both bones were then secured with No. 
15 silver wire, and the leg enveloped in plaster of Paris, 
reaching above the knee and including the foot. The leg 
was suspended. The patient wras permitted to get up and 
use crutches the following January, and went home February 
7, 1889, wearing a plaster of Paris splint, the leg being 
much improved, but not having firmly united. 
April 30th, three months after leaving the hospital, Mr. 
S. wrote me that he could walk two or three blocks with one 
cane. lie was still wearing the plaster of Paris. The fol- 
lowing month the patient informed me that his leg had been 
examined by a competent surgeon, and that the union was 
found complete. 
Case 14. C. Y., aged 41 years, was injured on the 
21st day of July, 1890. He received a compound com- 
minuted fracture of the right tibia at the junction of the 14 
upper with the middle third, and a simple fracture of the 
libula, four inches lower. We were informed that unusual 
hemorrhage and displacement existed; that, under influence 
of an anaesthetic, free incisions were made for explora- 
tion; that some loose fragments of bone and blood clots 
were removed; that the bones were placed in apposition 
without difficulty; that counter-puncture was made in pos- 
terior aspect of the calf, into which three or four drainage 
tubes were introduced; that the anterior wound was closed, 
that the leg was placed in a fracture-box, and that sup- 
puration supervened. He was brought to Chicago and 
placed in St. Luke’s Hospital October 19, 1890, the tibia 
being then ununited. 
On close examination a superficial caries was found on 
the broken surfaces. These patches were scraped away 
with sharp spoon, after which the bony surfaces were 
smoothed off with a thin chisel, and “chipped” throughout 
the wdiole surface. This chipping consisted of cutting up 
small chips from the bone surfaces with light strokes of 
the hammer in such a manner as to leave each chip still 
attached by a portion of its edge. When the operation was 
completed the broken surfaces were half an inch apart. 
The leg was then encased in plaster, including the foot, 
and reaching to the top of the lower third of the thigh. 
Much trouble was experienced in consequence of the old 
openings. For a considerable time they opened and closed 
alternately. 
The progress of the case was very slow and tedious. 
I had many misgivings as to its outcome, but on February 
19, 1891, I wrote to those interested in the case the fol- 
lowing: 
“In the case of C. Y., bony union of the tibia has 
finally been secured. A brace, containing well-upholstered 
leather to encircle the leg between knee and ankle, was 
ordered.” 15 
Summary: The dressing described in Case 1, answers 
well to keep’the skin around the supra-pubic opening dry, 
and the patient clean. The recovery was complete in five 
weeks. 
Case 2. The patient, after lateral lithotomy, had re- 
covered in a month, and was then discharged, but was re- 
admitted witli haematuria, caused by a tumor, which was 
removed by the high operation. The urine ceased to 
flow through the wound at the end of three weeks. 
In case 3, impassable traumatic, diffused stricture, follow- 
ing fracture of the pubes, and laceration of the urethra, fur- 
nished an indication for the operation. 
In Case 4, the method was adopted for fractured pelvis, 
and complete division of the urethra. In the last case (No. 
5) the high operation was a preliminary step in an attempted 
repair of a portion of the urethra, partially destroyed by 
perineal abscess following typhoid fever. In case 0,1 hoped 
to prolonglife after operation for cancer, by monthly exam- 
ination of the patient, and by prompt removal of recurrent 
growths in their incipiency. 
Case 7 was a satisfactory result after wiring the olecranon 
process. 
Case 8. Sixteen months after the accident, union was 
secured in two months (fractured humerus) by resection, 
“chipping” and wiring. 
Case 9. After wiring the broken patella, with the 
shotted suture, movement between the fragments was easily 
made out a little over three months from the date of the 
operation. I have not had since then an opportunity of 
examining the patient. 
In Case 10, the patella was broken June, 1890, blood clots 
removed from the joint and fragments approximated by a 
single wire, June 15, 1890; left the hospital September 7, 
1890, with a good bony union; resumed work January, 1891. 16 
Case 11 was one of rapid union of tibia after drilling, the 
fracture having occurred eight months before. 
In case 12, bony union occurred after resection of tibia 
and fibula, wiring and drilling, with use of leg in about a year 
and three months from the date of injury. 
In Case 13, bony union occurred in about two years and 
two months from the date of the accident, and in about ten 
months from the date of admission to the hospital, after the 
employment of bone pegs, resection of tibia and fibula, 
wiring, and use of the leg. 
Case 14. Bony union was secured in an ununited frac- 
ture of the tibia in seven months after the accident, and four 
months after admission, by scraping, by smoothing with 
chisel, and by “chipping,” the bony surfaces being half an 
inch apart when the leg was dressed. The fibula was not 
resected. By “chipping” as described in case 14, I hoped to 
create numerous irregular foci for the osteo-genetic process. 
These chips projecting from one bony surface, approximate, 
and in most cases,come in actual contact with those of the op- 
posite surface. The reparative material will thus be increased 
and the chances of bony union, in difficult and uncertain 
cases, it is expected, would be materially improved.