CYSTIC GROWTH WITHIN THE INTERNAL 
CONDYLE OF THE FEMUR. 
EV / 
THOMAS G. MORTON, M.D., 
AND 
WILLIAM HUNT, M.D., 
SURGEONS TO THE PENNSYLVANIA HOSPITAL, PHILADELPHIA. 
Reprinted, from the 
Transactions of the American Surgical Association, iSgj. CYSTIC GROWTH WITHIN THE INTERNAL 
CONDYLE OF THE FEMUR. 
By THOMAS G. MORTON, M.D., 
AND 
WILLIAM HUNT, M.D., 
PHILADELPHIA. 
Dr. M.1 was born in the fall of 1861, and at the time of coming 
under our professional care, in November, 1892, was, therefore, in his 
thirty-second year. With the exception of a few of the simple diseases 
of childhood, he had always been very healthy, and had led a very 
active life. In the summer of 1879 he first noticed slight inability to 
completely flex the left knee; but during ordinary progression, or 
other movements of the joint, he experienced no inconvenience at that 
time. He also discovered the presence of a tender spot immediately 
above the extremity of the internal condyle. Pressure in this region 
caused some pain, but nothing of consequence. During the four years 
previous he had been much devoted to gymnastic exercises, and he 
naturally attributed the pain to the result of some injury received in 
vaulting over the parallel bars; he therefore discontinued this form of 
exercise; but, in spite of this, he noticed that the trouble gradually, 
though very slowly, increased. In the spring of 1880 he made a 
change in his habits and commenced to read medicine, and, as. he was 
now leading a very sedentary life, he experienced very little incon- 
venience from the affected part. 
While at college, December, 1881, he engaged in a friendly wrestle 
with a classmate, in the course of which he fell and forcibly bent the 
left knee under his body. The pain he experienced from this injury 
1 The history of this very interesting case was taken from a statement prepared by the 
patient, Dr. C. H. Mastin, Jr., of Mobile, Ala. 2 
MORTON AND HUNT, 
he describes as very intense; indeed, for some moments immediately 
succeeding he was quite unable to extend the leg or, in fact, to move 
it at all. As the result of this accident, he was confined to his bed for 
two days. There was no swelling, heat, or redness ; there was simply 
a marked increase of pain at the site of the former tenderness; this, 
however, gradually subsided, so that by the end of the week the limb 
had regained its usual condition. After this there was no further 
change for the worse until after he was graduated and had returned to 
his home in a Southern State. 
The confinements of a student’s life being over, he resumed the 
more active habits in pursuing the practice of medicine. He gained 
flesh, and soon weighed 198 pounds. The joint now only gave him 
trouble when it was forcibly flexed; at such times the pain would 
compel him to relax the muscles and extend the limb. Complete ex- 
tension was not in the least painful to him. Nothing noteworthy then 
occurred until the spring of 1887, when he experienced pain and 
tenderness also at the left sacro-iliac junction. This steadily increased 
in severity, and in three months the sciatic nerve at the notch became 
painful and the pain extended down along the course of the nerve. 
Tender spots existed, one at the external popliteal, another where the 
anterior tibial passes forward between the two bones of the leg; there 
was also one on the dorsum of the foot. 
At this time it was also noticed that extension of the left knee-joint 
produced a marked increase of pain in all of these points just named. 
Flexion of the joint caused intense agony at the old spot above the 
internal condyle. To increase his suffering the anterior crural nerve 
now became neuralgic, and the long saphena branch was painful 
throughout its entire length. The pain in all of these nerves was now 
constant, although at times worse than others. The most comfortable 
position in which he could place the limb was with the knee partly 
flexed; this compelled him to walk on his toes with the heel elevated, 
and to attain this he had an extra heel placed upon the left shoe. His 
health now became impaired from the constant pain and want of 
exercise. His bodily weight fell to 168 pounds; he became jaundiced 
and very nervous, and he suffered with repeated attacks of bilious 
colic, particularly at night. The muscles of the affected limb lost 
their tone, and the tissues wasted so that the limb was decidedly 
smaller than the right one. Sleep at night, except for a few hours, 
was impossible, and life now became a burden. CYSTIC GROWTH IN THE FEMUR. 
3 
This state of affairs, in spite of treatment of various kinds, lasted 
for about eight months, after which the pain in the nerves became less 
severe and the general health began to improve. There was no change 
for the better, however, in the supra-condyloid spot or in the function 
of the knee-joint; if anything, the knee was stiffer and more bent. 
The pain in the spot now increased; exacerbations of pain were 
frequent and were often associated with twitching of the internal 
hamstring muscles. During these exacerbations there was a sharp, 
cutting pain at the cartilaginous tip of his left seventh rib, and by 
making pressure upon this point he declared that a marked increase in 
pain above the femoral condyle was produced. He described the 
sensation as being like a telegraphic communication between the two 
spots. This peculiar phenomenon, however, was not always present, 
and at times would be absent for weeks at a time. 
As regards treatment, many and diverse remedies were employed. 
Electricity, by both the galvanic and faradic currents, was faithfully 
tried. Blisters were repeatedly applied over the condyle. On one or 
two occasions he froze the surface with ether spray. Cocaine injections 
down to the bone were made. Various ointments were employed, 
pressure was applied; but all to no purpose. Wrapping the knee in a 
towel soaked with cold water seemed to afford more relief than any- 
thing else. He also observed that during cold, wet weather he had 
always suffered less than in summer or during a dry spell in winter. 
For internal treatment he took many boxes of anti-neuralgic pills, but 
avoided the use of narcotics, fearing that the habit of using them 
might grow upon him. Iodide of potash was pushed to iodism without 
any evident result. 
In the spring of 1888 he determined to seek surgical relief from his 
sufferings. He came to Philadelphia and placed himself under the 
charge of the late Professor D. Hayes Agnew, who regarded the case 
to be one of neuroma upon the internal branch of the saphena nerve. 
Dr. Agnew accordingly cut down upon the nerve, but found nothing 
abnormal. However, he excised two and one-half inches of the cuta- 
neous branch under the impression that this was diseased and had 
probably caused the pain. Soon after the operation it was discovered 
that it had been a complete failure, as far as any relief from suffering 
was concerned. Apparently thinking that the moral effect of the 
operation might be sufficient to effect a cure, the patient was advised 
to return to his home for a while. He did so with shattered hopes, 4 
MORTON AND HUNT, 
and with the conviction that he was looked upon as a subject of 
hysteria by his medical advisers and friends. 
Four years more of annoyance and suffering followed, during which 
time he was almost a cripple. He finally determined to return to 
Philadelphia, with his mind made up to have an operation done of a 
more radical nature than before, even if it involved amputation of the 
limb. 
At my advice, he entered the Orthopaedic Hospital in this city. 
The following notes of his condition were made by the surgeons and 
neurologists of the hospital : “ There is a slight numbness of skin over 
the painful spot above the internal condyle of the left femur, but no 
general or local anaesthesia. The spot may be covered with the ends 
of two fingers, but the patient carefully guards it from being rudely 
touched or handled. There is motion in the knee-joint, which is kept 
in a partly flexed condition; either extreme flexion or extension causes 
pain. He can strike the heel upon the ground without pain, and 
insists that there is nothing the matter with the articulation. Measure- 
ments were made as follows : 
Right. 
Left. 
Around partly flexed knee . 
. inches, 
inches. 
Six inches above the internal condyle . 
• 16^ 
15 X “ 
Thigh, near crease of buttock 
. 21 “ 
20% “ 
Around the largest part of the calf 
. 14 X “ 
13 “ 
“Pain extends up to the left eighth rib, follows distribution of 
internal saphenous nerve, and also the trunk of the nerve up to sacro- 
sciatic notch; the obturator nerve also seems involved. The extreme 
pain is limited to the centre of the cicatrix remaining after former 
operation. Faradization elicited ready response, aud muscular degen- 
eration was not detected. Sight and hearing good. Urine high- 
colored, rich in uric acid and in oxalates; no albumin or sugar was 
found after careful examination.” 
The opinions of the case expressed by the physicians present were 
varied ; but the general belief was that the disease was a neurosis with 
a gouty basis, as suggested by the father of the patient. It was de- 
termined that the proper course to follow was to make an exploratory 
incision to examine the condyle, and, failing to find anything there, to 
take out a long section of the internal saphenous nerve, high up, and 
to completely remove the old cicatrix, with any nerve branches that 
might be found there. 
The operation was accordingly performed on Saturday, October 29, CYSTIC GROWTH IN THE FEMUR. 
5 
1892. There were present Dr. S. Weir Mitchell, Drs. Thomas S. K. 
Morton and Pierce, and the resident physician who administered the 
anaesthetic. There was much struggling during the etherization ; but 
even after he was fully under the influence, so that there was no longer 
any conjunctival reflex, a slight touch upon the seat of pain over the 
condyle at once caused marked reflex contraction of the muscles of 
the limb, which was repeatedly drawn up after all the rest of the body 
was insensitive. 
Comment by Dr. Hunt on the Above Case. 
Dr. Morton made at once a five-inch-long incision, exactly through 
the old scar and right down to the bone. On examining with the 
finger he came upon a rough plaque of bone, evidently the result of a 
periostitis. An elevator was easily got under this, and, with a chisel, 
the plaque was broken and lifted off. It formed the covering of a cyst 
having a thin wall of a bluish lead color. The cyst, which burst in 
the effort to remove it, contained a watery colloid fluid, and extended 
obliquely into the condyle for more than an inch. It was removed 
with all its attachments; the cavity, at least an inch wide, was curetted 
and finally cleaned out by the application of the crown of a trephine, 
and then thoroughly syringed with a weak bichloride solution. There 
was no hemorrhage. 
The cavity was filled with iodoform gauze, and the patient was put 
to bed with the limb in a semiflexed position. This operation in all 
respects was a thorough success. The relief was almost immediate. 
The patient was up and walking about by the 4th of November, 
although strongly advised not to be too free in his movements. There 
was an entire change for the better in disposition. He is cheerful and 
has no fear of hurting the limb. Sleeps soundly and in any position, 
and considers himself as practically a well man. There is still some 
limp in gait, but this is due to the long contraction, which is relaxing 
rapidly. He was discharged after being twenty-one days in hospital. 
He walked up the steps of the railroad station without difficulty or 
pain. 
From the moment Dr. Morton exposed the cyst wall I 
believed he uncovered an echinococcus cyst. My belief is 
further confirmed by what I have since read of such cases. One 
thing, and I admit an important one, is wanting—that is the 6 
MORTON AND HUNT, 
finding of the hooklets of the small entozoon. Dr. Burr, the 
pathologist of the Orthopaedic Hospital, searched carefully for 
them, but they were not found. It takes a power of over 500 
diameters to expose them, for they are only 0.03 of a millimetre 
in size, the whole worm measuring but 5 mm. or about one-fifth 
of an inch in length. Dr. Burr used an oil-immersion objective 
of over 900 diameters. I was sure I found a hooklet with my 
little Nachet of 625 diameters ; it corresponded closely with the 
drawings, but Dr. Burr was not satisfied with the identity, and 
the specimen was rejected. 
I find that the hooklets are easily lost by the bursting of the 
cyst, and at certain stages they drop from their attachments. 
Also, when we consider that there are but six of them in a 
unilocular cyst we can understand how easily they may be lost. 
We are, therefore, forced back on the clinical history, and this 
so agrees with other reported cases that I have no doubt 
about it. 
First, I found that the patient had been excessively fond of 
dogs; they used to be his companions day and night; remember 
that when the pain attacked him it came on suddenly and without 
any accident or other thing to which to attribute it. 
This is also the history of the cases recorded. Echinococcus 
in bone is so rare (according to Neisser, there are 28 bone cases 
to 985 other organs) that the opportunities of observing are very 
limited. I was fortunate to find in the Lewis Library of the 
College of Physicians an inaugural dissertation published in 
Berlin in 1889, by Freidrich Poppe, of Schlieben, entitled “Uber 
den Echinococcus der Knocken.” This, I think, is the only 
monograph on the subject; at least, it was all I could find. 
The author tabulates 60 cases, evidently with great research. 
Hahn counts up 36 cases, in 1883; and Thomas, of the Adelaide 
Hospital, South Australia, in an exceedingly interesting volume 
on Hydatid Disease (1884), simply catalogues 31 cases in bones, 
without giving the histories of any of them. When I read of a 
case in Poppe’s list reported in 1819 in the New England Medical 
Journal, I thought I was going to turn up an American with this 
rare affection, but I found it was a case in Guy’s Hospital that CYSTIC GROWTH IN THE FEMUR 
7 
was reported by a Dr. Webster, who was probably a student in 
London at the time. 
The 60 cases of Poppe involved the following bones: 3 os 
frontis; 1 sphenoid ; 8 vertebra; 3 innominate and sacrum; 1 
ilium, pubis, and ischium ; 4 ilia; 1 pubis; 2 ilia and femur; 1 
scapula; 1 rib, fifth right; 1 sternum; 13 humeri; 1 humerus 
and femur; 1 index phalanx ; 7 os femoris; 1 femur and tibia; 
11 fibula. 20 of these are known to have died, 16 of them 
under treatment; 4 had no operative treatment; a case of 
Baudelocque’s died of variola. It is not known what became of 
15; it is to be presumed that most, if not all, of them died, 
as they appear to have been unamenable to treatment; they are 
catalogued as “nicht bekannt.” 
This shows the extreme fatality of this little entozoon, as fatal 
when it attacks the bones as when it invades other organs. 
There were 15 recoveries by operation—5 by incision; 1 tre- 
phine ; 5 resections; 2 exarticulations; 2 amputations. Result 
not reported in 2 exarticulations. In 2, autopsies revealed the 
disease, 1 in scapula and 1 in humerus. Diagnosis is only made 
by exploration, mostly by incision. I did not come across one 
case that was rightly diagnosed before some kind of operation. 
I verified the reports of Poppe in the journals at the College 
of Physicians, as far as regards the femur. Hahn’s case, which 
was cured by amputation, occurred in a woman who had the 
disease in the internal condyle and head of tibia and was very 
like our case. There was intense pain in the part, for which 
she was admitted to a hospital twice; but finally returned the 
third time for amputation, so great was her suffering. By this 
time there were bulgings both below and above the knee; these 
required incisions, which revealed the cause of the disease, which 
had progressed so far as to remove ail thoughts of saving the 
limb. The other cases had about the same general history. 
These cases have received much attention from the explana- 
tion they are thought to give of so-called spontaneous fracture. 
The cyst in its growth thins out the bone, which disappears 
probably by absorption, and its weakened walls give way under 
the slightest provocation. These fractures, moreover, are char- 8 
CYSTIC GROWTH IN THE FEMUR. 
acterized by their obstinacy as to uniting, and if the disease 
which causes them is not recognized and removed, there is 
small chance for the limbs. Several most interesting accounts 
are given in the reports I read, but it would make this paper too 
long to give them here. 
In the case of Dr. Mastin it was easy to see and to appreciate 
these conditions, and how readily the condyle could have been 
snapped off had the disease progressed much further. There 
was the thinning out of the bone, the disappearance of the can- 
cellated structure very nearly as far as the joint cavity, the 
connective-tissue bindings of the cyst wall, and no microscopic 
evidence whatever of malignant or other disease. Therefore, if 
not echinococcus cyst, what was it ? All we want are the 
hooklets, and, not finding them, we must rely upon the clinical 
history. From the table I have given you, I think the dog has 
his full revenge for anything that has been done to him in 
physiological research, and at the same time I think that it is a 
shame that it should be so. 
It is curious that the antipodes, Iceland and Australia (see 
Thomas) should be the favorite seats of this disease ; but at the 
same time they are also favorite seats for dogs. There is one 
dog to every three to five inhabitants in Iceland, and in one 
district every third man is said to have hydatids. Reliable 
records are not given as to Australia, but there are an immense 
number of dogs there too. 
It is for our vivisectionist to say whether he will go to either 
of those climes and disturb the seats of the dogs at the risk of 
echinococcus, or stay at home and read. 
The last letter we have had from Dr. Mastin is equally 
refreshing. The writer says: “You can’t imagine the amount 
of comfort I now enjoy. You all opened up for me a new and 
delightful page in life’s great book.”