EE SECTION AT THE HIP-JOINT 
FOR 
MORBUS COXARIUS. 
ENCHON D K 0 I A, 
OR 
CA|; TI LA G I NOUS lUMO R S. 
BY 
WILLIAM HENRY CHURCH, M.H., 
SURGEON TO BELLEVUE HOSPITAL, &C. 
ENLARGED PROM THE 
“AMERICAN ME DIC AL TIME S. ’ 
NEW-YOKE : 
HILTON, GALLAHER & CO., STEAM PRINTERS, 12 ANN STREET, 
1860. ARTICULAR AMPUTATION 
AT THE 
HIP-JOINT. 
Michael Tiffany, seven years of age, lias been suffering 
from Morbus Coxarius of the left hip for one year, the result 
of a fall. An abcess formed, which opened spontaneously, 
about the sixth month, on the outer side of the thigh, at the 
juncture of its middle and upper third. The pain is so severe 
that he is obliged to support the limb between his hands, a 
great part of the twenty-four hours, never sleeping, except 
while holding it in that manner ; very much emaciated, but 
little appetite, and that capricious, steadily sinking from the 
exhaustion of the discharge and constitutional irritation. 
After frankly explaining everything to his mother, she promptly 
consented to place the child in our hands for an operation—and 
one of my greatest pleasures in treating the case, has been to 
see her unwavering confidence and patient devotion to the boy; 
watching him night and day with the ceaseless constancy that 
betokens a true and faithful parent. To her care I attribute a 
large share of the successful result—as more depends upon the 
after-treatment and attention than on the operation itself. 
October 16th, 1859.—Operated with Drs. Alex. IT. Stevens, 
Hosack, Gerscheid, and A. L. Sands, to advise and assist me. 
The patient being under the influence of chloroform, cut 
down upon the trochanter major—after separating the gluteal 
muscles from their insertion, and dividing the capsular ligament, 
—the ligamentum teres having been destroyed by the disease,— 
the head of the bone was easily thrown out of the cavity of the 
acetabulum, by flexing and adducting the limb. Finding that 4 
the head of the os femoris was the only bone diseased, it was 
removed by sawing through the neck, at its junction with the 
shaft. The innominatum perfectly healthy. A probe could be 
passed by the external opening in the integuments, through the 
abcess, and a small perforation in the inferior portion of the 
capsular ligament, into the cavity of the acetabulum, proving 
that the pus had escaped from the joint through, this, the only 
opening in the capsular ligament. 
October 17th,—Very comfortable, has slept well, and suffers 
less than he has for months. To have ten drops of the muri- 
ated Tincture of Iron three times daily, Cod Liver Oil and 
nourishing diet. 
February 20th, 1860.—The patient has progressed favorably, 
without one really bad symptom to embarrass his recovery ; ex- 
ternal wound closed, appetite good, strength improving, and has 
grown quite fat. Can rotate, flex and extend the thigh upon 
the Pelvis. The limb has been kept quiet and extension con- 
tinued during the whole time by means, either of the double 
inclined plane, or the straight splint. 
April Ist.—Allowed to go about on crutches. 
May 16th.—Seven months after the operation. Leg one inch 
shorter than the other, but can easily be drawn down to the 
same length, walks very well without crutches, but desired to 
continue the use of one. The swelling of the limb having sub- 
sided, there is apparent atrophy of the muscles of the thigh, his 
lameness evidently disappearing as they are developed by use. 
The pathology of diseases of the joints was almost a terra 
incognita full of useful and important indications, but of little 
advantage to the Practitioner, until the investigations of Sir 
Benjamin Brodio brought them to light, and presented them to 
the world of medicine in a practical form. 
In the introduction to his work on diseases of the joints, he 
says—“ I was induced to hope, that if it were possible to im- 
prove our pathological knowledge of the diseases to which I 5 
have alluded, this might lead, not indeed to the discovery of 
new methods of treatment, hut to a more judicious and scientific 
application of those which are already known, and a consequent 
improvement of chirurgical practice.77 Although, from the 
knowledge acquired by his investigations, he could see how 
much was yet to be learned in the treatment of diseases of the 
joints and their surrounding tissues, yet, lie did go further, than 
to simply lay the foundation of our pathological knowledge ; by 
either indicating or improving almost every treatment, to be 
gradually advanced towards perfection, as experiments and ex- 
perience accumulated facts. Take, for instance, the treatment 
of this very disease of the hip-joint, in which improvement has 
so steadily advanced, that it seems now almost perfected. 
Dr. Physick of Philadelphia, was very successful in his treat- 
ment of the disease, by applying leeches in the inflammatory 
stage, followed by a calomel purge, after which he commenced a 
coarse of steady purging with pulvis purgans ; he considered 
this drain, and the consequent irritation, as superior to issues, 
setons, or other external remedies ; after pursuing this plan for 
a few weeks, and accustoming the patient to the bed, he applied 
a splint of one half the diameter of the leg, extending from the 
middle of the thorax to the malleolus • it is carved so as to 
adapt itself accurately to the irregularities of the limb, and 
after being well padded, is secured by rollers round the Pelvis, 
thigh and leg. The time required for a cure, varying from six 
months to two years. 
Dr. Wm. Harris, in 1839, recommended the use of Hagadonfs 
apparatus, modified by Gibson, as accomplishing the double 
purpose of keeping up continued extension, at the same time, 
the limb being kept perfectly quiet, to facilitate ligamentous 
union, or anchylosis, without shortening. 
Brodie, in his revised Edition of Diseases of the Joints, pub- 
lished in 1843, at page 96, advises that “ the patient should be 
confined to his bed or couch, being never allowed to move from 6 
it, on any occasion. * * * At a later period when, in conse- 
quence of the extensive destruction of the articulation, the 
muscles begin to cause a shortening or retraction of the limb. 
I have found great advantage to arise from the constant appli- 
cation of a moderate extending force, operating in such a man- 
ner as to counteract the action of the muscles ; for this pur- 
pose, an upright piece of wood may be fixed to the foot of the 
bedstead, opposite the diseased limb, having a pully at the up- 
per part—a bandage may be placed round the thigh, above the 
condyle, witli a cord attached to it, passing over the pulley and 
supporting a small weight at its other extremity.” He thinks 
extension will lessen the shortening of the limb, at the same 
time diminishing very much the sufferings of the patient, which 
were aggravated by this shortening of the limb. At page 143, 
in describing the treatment of a diseased knee-joint, lie directed 
“ that an instrument should be applied at the back part of the 
limb, attached to the thigh and leg, so as to give much support 
to the joint, at the same time that it was furnished with a screw, 
by means of which, the leg might be very cautiously and gradu- 
ally extended. In a fortnight after it was first applied, the little 
boy was able to walk across the room without difficulty, and 
altogether, it was so convenient that he was allowed to wear it 
during the night, by his express desire.” 
Dr. Alden March, in a paper upon coxalgia, published in the 
“ Transactions of the American Medical Association of 1847, 
vol. 6 ”—describes a splint, and represents the same by a draw- 
ing, in which the foot is attached to a foot piece and the counter- 
extension is accomplished by means of “ a Perineal belt or 
strap,” the splint being constructed for the purpose of avoiding 
pressure upon the trochanter major, and thus relieving the ace- 
tabulum from the pressure of the head of the os femoris. 
In 1855, so far as I can learn, Dr. H. M. Davis was the first 
to suggest a splint, by the use of which, the patient suffering 
from disease of the hip-joint, is enabled to walk about without 7 
irritation to tlie articulating surfaces. To this splint, Dr. Sayre 
adjusted a cog-wheel and ratchet, by means of which the exten- 
sion may be more conveniently increased, than in the instrument 
as used by Dr. Davis. As it is necessary that this instrument 
should be worn constantly for some months to accomplisli a 
cure, the knee-joint necessarily becomes very rigid. I have 
lately applied a modification of the same instrument to a patient 
suffering from hip-joint disease, in its early stage, allowing free 
movement to the knee-joint. Before its application, the little 
girl could hardly bear the weight of the body upon the limb, 
and was always awaked two or three times during the night, by 
the pain ; she now plays about with the other children all day, 
and sleeps as well as ever at night; never removing the instru- 
ment, except that it may be readjusted. Nothing can more 
clearly demonstrate the gradual and progressive improvement 
of our noble profession ; step by step, doubts cleared up, and 
uncertainties made certain. 
Physick recognized the necessity of rest and avoided issues. 
Harris perceived the advantage of extension combined with rest. 
Brodie dipped a little deeper, and found that extension alone 
would relieve the pain, while it remedied the shortening—but he 
only thought of it in the advanced stage of the disease. March 
discovered that a splint, by which the counter-extension was 
accomplished through a pernineal strap, was the most successful 
apparatus, and I think the traction of this strap, pressing the 
soft parts between the shaft of the os femoris and the pelvis, as 
it were wedging them apart, did more towards relieving the ace- 
tabulum from the irritation of the head of the bone, than the 
peculiar construction of the splint; at all events, this apparatus 
was an important step forward. 
It was reserved for Dr. Davis to reach the point which his 
predecessors were so steadily approaching i.e. an instrument by 
which, in the early stages of the disease (and at other periods 
too), the motion of the joint is preserved, the pressure relieved, 
and the patient enabled to take exercise. 8 
Until the investigations of Mr. Brodie, earlier Surgeons en- 
tertained vague and uncertain opinions with reference to this 
class of diseases, applying the same term without discrimination 
to affections, which are now known to he entirely different in 
theii chaiacter and consequence 5 white swelling being the most 
usual expression, (sometimes varied with scrophulous caries) by 
which to designate the numerous changes that take place in these 
important structures. Modern pathology has thrown much light 
upon this important subject, it has been the basis of a more 
thorough classification, followed by more accurate investigation, 
resulting in reliable diagnosis, which is the very keystone to 
successful treatment. 
The general anatomy of joints is so simple and easily understood 
that it requires but a passing notice ; enclosed in a capsule, are 
bones, tendons, cartilages, ligaments, synovial membrane and 
glands. Where we find parts so different from each other, both 
in stiucture and in functions, within a limited space, continually 
called into action, we must expect to find a variety of diseases, 
varying from the mildest to the gravest form. 
1 here is still great obscurity as to the pathology of disease of 
the hip-joint in its early stage, upon which it is to be hoped much 
light will be thrown by the happy success of recent surgical 
interference. 
Although this disease may appear at any period of life, it most 
frequently attacks children, between the ages of throe and six- 
teen years. Mr. Brodie saw it in a woman at sixty years of age, 
and a child at twelve months. It is much more frequent in the 
male than the female-—out of 131 cases, of which 1 have seen or 
found record, 96 were males, 35 females, and it has a decided 
preference for the left hip. 
In early life, it usually appears as ulceration of the cartilages 
and ligaments, scrofulous caries of the os femoris, or a combina- 
tion of both, as in the case before us. By referring to the plate 
which represents the appearance of the head of the bone at the 9 
time of its removal, it will be perceived that there is a small 
patch of the cartilage of incrustation, the size of a three-cent 
piece still remaining, adherent to the surface of the bone, the 
disease having completely removed the ligamentum teres. The 
head of the bone presents some important indications, bearing, I 
trust, upon the period at which the operation should be per- 
formed ; the whole caput fermoris is involved in the disease, the 
outer denser portion still maintaining its shape, surrounding the 
inner cancellous structure, the latter being detached and mova- 
ble, resembling a sequestrum contained within its involucrum. 
Here the head and neck of the bone were irrecoverably involved 
in the disease, the shaft of the femto’ perfectly healthy, and the 
bones of the Pelvis remaining unassailed by the disease. Then, 
why did we not hit upon the most fortunate moment for the 
operation ? 
The joint had lost all its peculiar characters, which have so 
long deterred Surgeons from cutting into it, there was no 
diseased action in the bone nearest in communication with the 
most vital organs-—but confined to an extent of tissue, which, 
being removed, leaves a perfectly healthy shaft—its upper extremi- 
ty smooth and round, protected by its natural coverings of peri- 
osteum and soft tissues. I believe there are no symptoms yet 
recorded, by which we can determine when the disease has 
reached this stage—and Ido think that greater success will at- 
tend the operation when performed before, then after this point 
of its progress. Until now, there has been no rough, sharp 
points of bone, by their friction, causing irritation, and rousing 
diseased action in the structures with which they come in con- 
tact—whereas, so soon as the head of the bone breaks down, 
sharp processes, the remains of the neck, project from the shaft, 
as I have seen in two patients since this operation. Such a con- 
dition of things will continue for a long time ; in one patient 
the disease had existed for four years, the innominatum was ex- 
tensively involved, as was the upper end of the os femoris to an 10 
inch below the neck, yet two or three sharp points still remained 
standing at right angles with the shaft, in' every movement of 
the limb causing suffering. In the other little victim, the disease 
was only of six months standing, an abscess had formed, but 
without an external opening as yet ; upon exposing the cavity 
of the joint, there were the merciless causes of irritation pro- 
jecting from the shaft of the bone. 
The specimens of diseased joints which Sir B. Brodie was 
enabled to examine, were mostly those where the disease had 
reached an advanced stage ; it falls to j the lot of the present 
generation, to investigate the pathology of those same diseases 
in its earlier and more important periods. 
After the resection of bones by White and Park, in the latter 
part of the eighteenth century, without any good reason, such 
operations were almost entirely abandoned, until within a few 
years ; those upon the hip-joint being particularly resisted, even 
to the point of never opening those immense abscesses about the 
hip, let the pus burrow where it may-—recently these operations 
have been in some cases so successful, that their practicability 
must now be thoroughly tested, aided by the additional light 
thrown upon the recuperative powers of nature, as exemplified 
in the experiments of Wagner and others. 
The important points to determine, are, the possibility of whol- 
ly removing the diseased bone ; if accomplished, will nature come 
to the rescue with sufficient energy to save the limb ; what will 
be the degree of usefulness after recovery and the comparative 
mortality as compared with amputation. Upon all these points, 
except the last, I think the majority of Surgeons are disposed to 
fa\or resection, as to the last, we are wanting in statistics, for 
which we must patiently wait, trusting that we may soon be en- 
abled to designate the class of diseases, and their concomitants, 
to be benefited by articular amputation ; or at all events, to 
avoid such a wholesale resort to the knife as to bring the opera- 
tion into disrepute. This point attained our task is yet unfin- 11 
ished, the method of operating is to be improved ; and above all 
things attention to, and a thorough investigation of the healing 
process after the operation requires our careful study, for upon 
the after itreatment depends the success, more than almost any 
other class of operations in surgery. 
Experiments and post mortem examinations have very clearly 
demonstrated how much nature will do for the surgeon, and lioav 
imperative nature is in her demand that the surgeon shall do all 
she asks of him. If in removing the diseased bone, he will care- 
fully preserve the periosteum and adjacent fibrous tissue, she 
will often supply a perfect bone in the place of the one removed, 
as in the case of Meyer of Zurich who extirpated the clavicle on 
account of caries, on a man thirty-one years of age—the patient 
soon obtained perfectly good use of the arm. In the situation of 
the extirpated bone a mass of new bone, of the form of a normal 
clavicle, was plainly to be felt. The patient died about five 
years after the operation. At the dissection there was found be- 
tween the facet of the clavicle on the sternum and the acro- 
mion, a fibrous, almost cartilaginous band, on which the lower 
edge of the newly formed bone was supported, and tfnth which 
it seemed to be continuous in some places. 
Ragged lias observed a case of regeneration of the whole of the 
humerus, together with its upper articular end , the new bone be- 
ing about eight and a half inches in length and about an inch anc 
a quarter in breadth. At the upper end of this there was an ar- 
ticular surface corresponding perfectly to the glenoid cavity, and 
closely united to that cavity by a ligament attached all round it. 
Removal of the substance of bones, is an operation so well es- 
tablished and so generally resorted to in certain cases that it 
would be foreign to the purpose, and our subject to enter into its 
discussion here, but I cannot resist introducing references to a 
few cases, where either the whole bone, or a greater part of it, 
to a point so near the joint as to encroach upon the parts in- 
volved in its movements were successfully removed, in the 12 
New Orleans Medical Register is reported an operation by Dr. 
Compton, where he removed both radius and ulna from the arm 
of a boy fifteen years of age, who was injured by an anchor be- 
ing suddenly let down. The chain caught the arm and produced 
a fracture of the inferior maxillary and humerus, and a com- 
pound comminuted fracture of the radius and ulna. 
Having dissected out both bones and disarticulated them at 
the elbow, he removed them entire with the exception of a por- 
tion of the lower end of the radius. A great portion of the peri- 
osteum was detached from the bones and left in the wound. 
While healing ; several abscesses’formed in the arm, from which a 
number of spicula of bone were discharged when they closed, and 
the arm immediately assumed a healthy condition. The arm is 
two or three inches shorter than the other and perfectly firm. It 
remains at a right angle to the humerus, and can be flexed and 
extended so that the hand moves through eight or ten degrees of 
a circle He has entire use of the hand, he can open and shut it 
and grasp objects quite firmly. 
In “ Dr. Williamson’s Notes on the wounded from the Mu- 
tiny in India,” (page 109,) will be found the account and repre- 
sentation of a case in which he excised the entire ulna, an inch 
and a half of the extremity of the humerus, and also the head and 
neck of the radius, on account of disease following diffuse inflam- 
mation. The wound healed by first intention. Four months after 
the operation the man could bend his forearm, raise his hand be- 
hind his head, and lift a twenty-eight pound weight from the 
ground ; he could also pronate and supinate the hand ; there was 
no anchylosis of the wrist-joint, and he could use his fingers well. 
Maisonneuve in May, 1856, “ resected the whole of the lower 
jaw on account of a fibrous tumor. The wound united by first 
intention. Soon after the operation (when the case was report- 
ed,) a firm tissue was deposited in the place of the resected bone, 
in which, as the periosteum had been spared, it was hoped that 
bone would be deposited.” 13 
The reparative powers of nature are beautifully exemplified in 
these operations on the lower jaw, at the present day of very 
frequent occurrence, owing to the necessary exposure of workers 
in match factories, where they are continually exposed to the 
fumes of Phosphorus. The victim of the disease almost invari- 
ably dates its commencement, from the extraction of a tooth, 
when returning immediately to his work in the midst of the 
Phosphorus, he is surprised to find that the gum never recovers 
its natural condition, but on the contrary, the disease 
usually extends with great rapidity, until it involves the whole 
jaw bone, unless the diseased portion is thoroughly removed. 
These dangers are so well understood in some factories, that 
upon the extraction of a tooth, the employee is positively forbid- 
den to approach it, until the parts have recovered their natural 
state. 
There have as yet, been but very limi ted opportunities of inves- 
tigating the post mortem condition of the parts, after articular 
amputation at the hip joint. 
Mr. Wagner, of Berlin, in his carefully compiled article upon 
“ Resection and Extirpation of Bones,” has reported the little 
that we have upon this point, portions of which I take the lib- 
erty of introducing here, with a ready and cheerful acknowledg- 
ment, that I shall often make use of the valuable suggestions and 
experiments so happily presented to the public, through his skill- 
ful management of the subject. 
Reid relates a case where the head and neck of the os femoris 
had separated spontaneously after an abscess in the joint, in a boy 
of fifteen, being extracted through an incision. After the death of 
the patient which was the result of Bright’s disease, a year after- 
wards, a new joint was found, two rounded processes having 
been formed upon the remains of the neck of the femur, the upper 
of which was connected with a bony prominence above the 
acetabulum, and the lower (situated immediately in front of the 
small trochanter) with the original articular cavity by firm 14 
fibrous tissue, in such a way as to admit of motion. The motion 
of the limb was limited. 
In Texter’s case, a man fifty-four years of age, suffering from 
caries of the upper end of the bone for which the head and neck of 
the femur, together with trochanter major were removed. The 
wound united with the exception of a small part, when the 
patient died fifty-three days after the operation. At the upper 
and inner side of the femur, a depression resembling a neck was 
formed. The acetabulum which was partly covered by granula- 
tions was healthy ; at separate points of it, there was also found 
a deposit of new bone, which however separated again on mace- 
ration of the pelvis. The upper end of the femur rested against 
the ischium at the posterior edge of acetabulum, so that a depres- 
sion had been formed in this bone, one, inch and a half in length, 
half an inch broad, and two lines in depth. 
White resected the upper end of the femur, just below the tro- 
chanter minor, on a boy thirteen years old. In one year, 
recovery was so perfect that the boy could execute flexion, ex- 
tension, and in fact every other motion of the joint, except rota- 
tion outwards—he died within five or twelve years after the 
operation. The ileum and the remains of the femur were found 
thin and light. The thigh bone rested with its upper extremity 
against the hinder part of the acetabulum, and was united to it, 
and to the neighboring portion of the os-ilii, by a firm ligamen- 
tous tissue, which appeared to belong, partly to the remains of 
the articular capsule, which had been left between the bones. A 
muscle was inserted into this tissue and into the upper portion 
of the femur. Nothing more is added in the description of the 
preparation. 
Mr, Buchanan removed the head of the femur for caries, in a 
man forty-one years of age. The patient died three months 
after the operation from dysentery. Upon examination after 
death, the cut surface of the neck of the femur, and great tro- 
chanter were perfectly healthy, and covered by a cartilage of 15 
incrustation. The circumference of the acetabulum, from which 
the edges had been removed, was studded with spiculas of new 
bone, showing the progress that had been made towards a cure. 
The acetabulum was filled up with granulations. 
This operation upon the shoulder-joint, lias been attended with 
quite as good results as in the hip, and all dissections have 
tended to substantiate the same train of facts. 
Wagner reports live cases of examination after dqath, the 
patients having survived the operation from six months to nine- 
teen years. In all these cases, the patients recovered with very 
useful arms, in one, operated upon by Mr. Syme, the woman 
could sew, knit, wash and raise a full pitcher of water ; he found 
in both the patients who died, one six months and the other 
eleven years after the operation, the head of the humerus 
rounded off, and united by a firm ligamentous tissue to the 
shoulder-blade. In Mr. Texter’s case of the thatcher, the man 
was enabled to resume his occupation, although abduction of 
the arm was imperfect. The deltoid muscle was found remarka- 
bly thin eleven years after the operation, and firmly consolidated 
to the newly formed capsule, and to the infra-spinatus muscle, 
which is usual after resection of the shoulder.* He gives two 
cases where there was formation of new bone, in the one, ap- 
pearing as a long styloid prominence, resembling that process of 
the ulna, in the other, a mass covering the upper end of the hu- 
merus, in the form of an uneven tubercle half an inch in length, 
one eminence of which, served for the insertion of the long head 
of the biceps, the tendon of which must have been divided ; the 
other articulated with a small depressed portion of the glenoid 
cavity of the scapula, which was covered with cartilages. In 
the thatcher, a patient who died nineteen years after the opera- 
tion, he found what lie calls a meniscus, in one case freely move- 
able, between the newly formed mass of bone and the glenoid 
cavity ; being united by numerous bauds to the acromion, cora- 
* Reid and Wagner. 16 
coid process, subclavius and pectoral muscles, and tlie humerus. 
In only the first case a capsule appears to have been formed, 
this mansions being united to it, the articular capsule was united 
with a peculiar fibroid tissue, to about the upper fourth of the 
humerus. It embraced the bone firmly, and was united to all 
the parts in the region of the joint, the inner surface being- 
rough and difficult to separate from the bone. 
Three .cases of dissection, are reported by Mr. Holmes. 
The first was operated upon by Herr Reid for caries of the 
head of the bone with acute pain in the joint, examined one year 
after the operation, one long incision had been made, and the 
tendon of the biceps was spared. The patient was in a bad state 
of health, suffering from the effects of empyema, &c. The sca- 
pula, was found superficially ulcerated ; the wound healed except 
two small fistulas, and the functions of the arm were perfect, ex- 
cept abduction. He died of lumbar abscess, accompanied by 
tubercular disease in other parts. Dissection of the shoulder 
showed the ends of both bones enclosed in a capsule, which was 
lined by a membrane, resembling mucous membrane, and covered 
by a viscid secretion. This capsule was closed, except at two 
points where it communicated with the above mentioned fistulas. 
Its walls were formed in part by the remains of the old articular 
capsule, but principally by the muscles surrounding the joint. 
The latter were more or less fattily degenerated, and the supa 
and infra-spinatus were also infiltrated with pus from the fistulas. 
The long tendon of the biceps was traced upwards. It was free 
up to the resected end of the humerus, here it was firmly united 
to that bone, and beyond this point a deposit of bone was found, 
it corresponding to a bony swelling on the inner side of the re- 
sected humerus. Above this it was inseparably united to the 
capsule, and beyond that again could be traced in the form of a 
band, a quarter of an inch in breadth, bridging'ffver the interval 
between the capsule and the remains of tiff- glenoid cavity, 
which was affected with caries. The end of the humerus was a 17 
little enlarged, and rounded off ; on its inner side, was a crest of 
bone resembling an exostosis. The thicker parts of the scapula 
and especially the acromion were swoln and very porous. Lam- 
ellated bony deposits were found in the snpra-pinous fossa. 
Mr. Hutchinson excised the head and about a third of the shaft 
of the humerus, on account of a tumor described as of the mye- 
loid variety. The tumor recurred (being then of a distinctly 
cancerous nature) in the wound, and in other parts of the body, 
and the patient died five months after the operation. The shaft 
of the bone was itself healthy, and was united to the lower edge 
of the glenoid cavity by a thick ligamentous band, so strong that 
the bones could not be seperated by any moderate force. This 
union permitted of free motion in all directions. Springing from 
the periosteum of the humerus at the point of section, surround- 
ing the bone and the ligament, uniting them to the scapula, was 
a large mass of malignant disease. The deltoid muscle had been 
previously absorbed by the disease for which the resection was 
performed. There seems to have been a nearer approach to the 
reproduction of the elbow joint, than any of the other joints, by 
the formation of new bone, cartilage, ligaments, and new attach- 
ments of the muscles. 
Texter, after “ a preliminary” examination of his case, posi- 
tively asserted that there was a new formation of bone, and to 
the extent necessary to produce a perfectly new articulation of 
the ends of the bones. 
Upon dissection he found “ a lengthening of the ulna to the 
extent of a quarter of an inch, on which the radius moved, as in 
the natural state, and the trochlea of the humerus appeared as 
perfect as if none of it had been taken away.” 
Roux found the lower end of the humerus rounded off, smooth, 
v 
and as it were enensted (encroutee) by cartilage. The upper 
end of the ulna was in the same condition. 
In Mr. Syme’s case reported in the Lancet of 1855, the man, 
thirty-eight years of age, when asked, said he knew no difference 18 
between the limb operated upon and the other arm—flexion, ex- 
tension, pronation and supination were as perfect as could be de- 
sired. His death was the result of an accident. 
The following is Mr. Syrne’s description of the specimen ; 
‘‘The elbow has a very remarkable appearance ; the ends of the 
bones concerned, though quite different in shape from the nor- 
mal condition, being yet so adapted to each other as to form a 
secure hinge-joint. The ulna is devoid of either olecranon or 
coronoid process, and, instead of embracing the end of the hu- 
merus, is received, along with the radius, into the forked end of 
the os-humeri. This form of the last-named bone appears to have 
been produced by the growth downwards of two processes, one 
from each side of the cut-end of the humerus, which appear to be 
entirely new formation,4. The ulna is separated a short distance 
from the humerus, the interval being occupied by a rather lax 
and vascular ligamentous union ; but the radius forms with the 
humerus a true articulation, lubricated with synovia ; the surface 
of the radius, where it touches the humerus, is rounded, the cor- 
responding concave part of the humerus fitting acurately to it ; 
these surfaces are in part covered with fibro-cartilage, and partly 
bare, and of porcellaneous hardiness ; but it is interesting to ob- 
serve that a bare part of one bone is always opposed by a cush- 
ion of fibro-cartilage on the other. The radius and ulna are also 
adapted to each other ; the tuberosity of the radius, into which 
the tendon of the biceps is inserted, being received into a cavity 
in the ulna, formed in part by a growth of the latter bone up- 
wards into a process that curves over the rounded head of the 
radius, and gives attachment both in front and behind to a strong 
and distinct orbicular ligament, which is but loosely connected 
with the radius, and allows of its free play in rotation. To 
compensate for the loss of the head of the radius, which was 
removed in The operation, a prominent lip has grown out around 
the upper margin of the bone at its outer part, which thus has a 
purchase on the orbicular ligament, like the natural head. Be- 19 
tween the radius and ulna there is partly loose ligamentous 
union, and partly a true articulation, lined with synovial mein- 
brahe ; the expanded insertion of the tendon of the biceps serv- 
ing to cover the articulating part of the radius, while the depres- 
sion on the ulna is lined with the nearest approach to pure car- 
tilage that is to be found in this elbow. To the naked eye it 
looks quite like cartilage ; and under the microscope differs 
from it only in the fact that the matrix is obscurely fibrous. Two 
strong lateral ligaments join the extremities of the processes of the 
humerus to the orbicular ligament on the one side and to the ulna 
on the other. A separate piece of bone (sesamoid) is imbedded 
in the internal lateral ligament at its junction with the ulna. 
The extremity of the prolongation of the ulna upwards is also a 
separate piece united to the rest by ligament. The anterior liga- 
ment of the joint has been cut away ; it was extremely strong, so 
as to compensate for the absence of the olecranon in checking- 
backward movement of the forearm beyond the limit of complete 
extension ; it was attached above to the anterior surface of the 
humerus, and below to the upper edge of the orbicular ligament, 
and the anterior surface of the ulna. There was also a strong- 
posterior ligament.” 
Mr. Wagner’s experiments in resection of the extremities of 
bones in animals, were principally made upon rabbits, where he 
removed the head of the humerus, in order that he might bring 
the cut surface of bone opposite to an articular surface covered 
with cartilage. These experiments are so interesting, instruc- 
tive and satisfactory, that I shall introduce the description of a 
few, as reported by himself. 
In a full-grown rabbit, the head of the humerus was excised 
with a portion of the shaft; a piece nine lines long on the whole. 
Towards the end of the third week, it used this foot a little in run- 
ning ; and after this the usefulness of the limb increased up to its 
death. Before the animal was killed (fifty-four days after the op- 
eration,) the upper arm operated on was found to be about a 
quarter of an inch shorter than the other. 20 
Dissection—“ The upper end of the humerus was felt through 
the soft parts rounded off like a ball, and freely moveable. 
After the soft parts were divided, a newly formed articular cap- 
sule was exposed, which passed off from the glenoid cavity, em- 
braced the upper end of the humerus, and was inserted below its 
round end. This capsule contained a little pus. Its walls were 
on their inner surface a little rough, flocculent and turbid. The 
muscles which surrounded the joint were firmly united to the outer 
surface of the capsule. Even at a considerable distance from the 
capsule, they could not be separated from each other. The tendon 
of the biceps muscle was only loosely connected to the capsule, 
and ran on its posterior surface. The upper end of the resected 
humerus was seen as an irregular smooth ring of necrosed bone, 
about a line in depth. Below this, the hemispherical swelling 
was best marked. It extended about an inch and a half down 
the humerus, gradually thinning off. It was covered by perios- 
teum, which was prolonged on to the unaltered part of the hu- 
merus below the swelling. On the outer side of the bone, two 
kinds of deposite could be distinguished. The one was snow- 
white, porous, tolerably soft, began as a thin layer, gradually in- 
creasing as it was traced upwards, and lay immediately upon 
the bone. The second kind of deposit was brownish yellow ; it 
was situated over the substance above mentioned, and was in 
immediate connection with the capsule. It had not the same 
limits as the material which was deposited immediately around 
the bone, and was strongest on the side on which that material 
was the weakest; on. that side it formed a cavity for a depot of 
inspissated pus ; a few roundish white masses of bone, some of 
t hem separate, some joined together, were scattered about in this 
deposit; and these had precisely the same properties as the ma- 
terial which lay upon the bone. Beneath the free surface of the 
section of the humerus, the medullary cavity was filled with pus 
for the space of about a li ne in thickness, which was inseparably 
adherent to the old bone. This deposit was continued for a few 
lines further downwards upon the walls of the medullary cavity. 21 
On micsoscopical examination, the yellowish soft deposit and the 
new articular capsule, were seen to consist of fibrous tissue ; the 
white masses of normal bone. 
The articular cartilage of the glenoid cavity was turbid, of a 
yellowish brown color, and separated from the edges of the arti- 
cular surface. On microscopical examination, the appearances 
of softening already described, were seen in superficial layers, 
and in those lying nearest to its circumference. In the deeper 
layers of its central substance, it was distinguished from healthy 
cartilage, only by a finely granulated turbidity of the intercel- 
lular substance, by an increase in the size of the cells, and by a 
copious deposit of vesicles and granules of fat in them. No 
changes were seen in the scapula.” 
On a full-grown rabbit, the head of the humerus, three lines 
in thickness was excised. A splinter obliquely broken by the 
saw, was cut through with the bone nippers The muscles were 
left covering the remainder of the shaft of the humerus, up to 
the same surface. No shortening of the limb, either immediate- 
ly upon the operation or afterwards. As early as fourteen days 
after the operation, the animal ran about, and used the leg ope- 
rated upon, almost as well as the healthy one. It merely trailed 
it a little. The animal was killed thirty-eight days after the 
operation. 
Dissection.—“ The wound was perfectly healed ; the cicatrix 
in the skin was closely united to the soft parts, which lay below 
it. The humerus was firmly attached to the scapula, but freely 
moveable. A short, thin, newly formed articular capsule had 
been developed, which proceeded from the edge of the glenoid 
cavity, and was inserted on to the upper edge of the divided 
humerus. The muscles surrounding the joint were firmly unite*/ 
with this capsule; at a short distance from the capsule, they 
could be easily separated from each other ; they were firmly 
united to the edges of the section of the bone, through the medi- 
um of this capsule. The tendon of the biceps muscle was unin- 22 
jured, and ran on the posteror surface of the capsule, loosely 
united to it, but pretty freely moveable. Inside the capsule was 
found a serous, somewhat ropy, fluid, which showed under the 
microscope fat-vesicles of different sizes, small granular bodies, 
and epithelial cells. The inner surface of the capsule was 
smooth, and covered by a layer of pavement epithelium, which, 
together with the capsule, also covered the upper end of the hu- 
merus. On the external surface of the humerus, (which was 
entirely covered by periosteum) an external thin layer of white, 
porous, bony substance had been deposited, passing downwards 
on one side for about two lines, on the other for about six, from 
the surface of the section of the humerus, and covering the free 
edges of a portion of that section for a short distance. The 
medullary cavity was closed for the space of half a line, by a 
firm, rather rough, plate of bone, which was firmly united to the 
walls of the medullary cavity, and the covering across the latter, 
derived from the articular capsule. The glenoid cavity was 
completely covered by healthy cartilage, nor was the scapula 
altered in any other respect. The lungs and heart were 
healthy.” 
In a large full-grown rabbit, the right caput huiAeri was 
excised with a portion of the shaft, a piece, nine lines in length 
being removed. At the end of the twelfth week, the wound was 
firmly cicatrized, and no trace of swelling remained around it. 
A new head could be felt through the soft parts, united to the 
scapula, but with perfect freedom of motion. The animal ran 
perfectly well, both in quiet motion and when chased, using the 
fore-leg operated upon, as much as the uninjured one. It was 
killed on the ninety-first day after the operation. 
Dissection.—“ The cicatrix was united to an articular cap- 
sule lying beneath it. This came off from the edges of the gle- 
noid cavity, and was inserted about three lines below the upper 
extremity of the humerus, which was expanded into something 
of a club-shape. The capsule was perfectly closed. The 28 
muscles surrounding tlic situation of the joint, were firmly united 
to the outer surface of the capsule, while at a little distance from 
it they were readily separable from each other. Over the ante- 
rior surface of the capsule, the thin remains of the deltoid 
muscle were to be traced, and they had a common insertion, 
together witli the capsule, into the humerus. The anterior and 
upper part of the biceps muscle, which lay nearest the bone, 
and the upper end of the short head of the biceps, were firmly 
inserted into the bone, together with the lower and anterior edge 
of the capsule. The tendon of the long head of the biceps 
muscle ran in a fold of the capsule, which was smooth on its in- 
terior, and situated on the posterior surface of the latter, between 
two tubercles on the clubbed extremity of the humerus, which 
was enclosed in the capsule. It was quite freely moveable. 
The interior of the capsule was smooth, and its walls were 
covered with a layer of pavement epithelium. I failed to disco- 
ver any epithelium on the fold of capsule, for the reception of 
the long tendon of the biceps. In the capsule, was contained a 
rather thin, ropy, reddish-yellow fluid, which showed under the 
microscope epithelial cells, fat-vesicles, and dark, granular bodies. 
The cartilaginous covering of the glenoid cavity remained entire, 
nor was there any other alteration perceptible on the scapula. 
The humerus was covered with healthy periosteum, thickened 
over its upper extremity, which appeared to be connected with 
the capsule at its insertion, and was continued into the capsule, 
over the portion of the humerus, which was enclosed in it. The 
upper surface of the bone was covered by a thin layer of cellu- 
lar tissue, which passed over at the edge, into the periosteum. 
This cellular tissue was more opaque and not so smooth as the 
inner surface of the lateral walls of the capsule, and not covered 
with epithelium. Underneath the periosteum, a layer of new 
bony material was deposited, which was hardly distinguishable 
from the original bone, and which was thin at its commencement, 
and became thicker in proceeding from below upwards. It 
closed the upper end of the medullary cavity perfectly, with a 24 
thin lamella. The walls of the remainder of the old bone, as 
might be seen on section, passed gradually into this material, 
and were indistinguishable from it, as was also a deposit of bone 
on the walls of the medullary cavity. A thin layer of compact 
tissue surrounded the internal layer of the new bony material, 
which was developed into fully formed diploe. The whole of 
the medullary cavity was filled up with medulla, which was per- 
fectly normal. The viscera of the animal were healthy.” 
He extirpated the radius in six pigeons, without preserving 
the periosteum. The wounds all closed by first intention, and 
upon unloosing the wings, at the end of from three to six 
weeks, the birds flew perfectly well. 
In no case was there formation of new bony tissue ; but in 
the place of the lost bone, was a thin cord-like fibrous material. 
In all these cases it was impossible to retain a splint or any 
kind of apparatus upon the limb, or keep the animal quiet; so 
that the after .treatment was much less under the control of the 
surgeon, than it would be, where the operation is performed 
upon a human being, it is therefore fair to suppose that the re- 
sults present the most unfavorable side of the picture, so far as 
treatment goes. They always languished and drooped while 
confined in a dark room, but revived upon being brought to, the 
light. 
Wagner favors leaving the wound open to allow free escape 
to the fluids, the patient suffers less and it diminishes the danger 
of infiltration of pus ; he does not approve of union by first in- 
tention, neither does he think it of any advantage in the final re- 
sult, as the swelling of the parts subsides, the muscles contract 
and form, by taking an insertion around the articular surface 
that has not been removed, and into the resected bone, below the 
level of the section, a firm capsule, which as the wound unites 
becomes a closed one. 
Granulations shoot up from the inner wall of this capsule 
which if arranged in a thin layer, form a membrane covering the 25 
inner surface of the capsule. If the whole cavity has been filled 
by granulation, they form a solid tissue, uniting the cut end of 
the bone to the articular cartilage. 
The after condition of the parts, depends in a great measure, 
upon the manner in which the operation is performed ; if the 
bone be separated from the muscles a good deal beyond the part 
at which it is sawn through, and if the periosteum be preserved 
on the portion denuded of muscles, but not removed, the head of 
the bone is enclosed in a capsule ; if on the contrary ; the bone 
is removed just at the part down to which the muscles have been 
separated, or if the piece of bone which has been exposed below 
the level of the section has been deprived of periosteum, and in 
consequence is attacked with necrosis and exfoliation, the new 
capsule united by its lower edge with the upper end of the bone, 
lie never has found a separate synovial membrane, such as Stein- 
len described, which could be dissected oh' the capsule, although 
the fluid contained in this capsule, is serous, yellowish, slightly 
turbid, and stringy. It having been asserted that the long head 
of the biceps muscle, sloughs, or is removed by the suppuration, he 
has never known such separation or sloughing in any case, and 
is very positive in recommending the preservation of the tendon 
in the operation. 
With reference to the changes in the bones, the new deposite 
may be through ossification of the newly deposited cartilage or 
cellular tissue, the immature cellular tissue is gradually develop- 
ed into perfect cellular tissue ; being blended into one mass, with 
the periosteum, where the cartilage ossifies, the new bone is en- 
veloped by the thickened periosteum. As early as the sixth day a , 
thin ring of bone on the side of the medullary cavity gradually en- 
larges to occlude that cavity by means of a plate of bone, the up- 
per ring of bone becomes eventually necrosed and is thrown off, 
or its peripheral layers are exfoliated, leaving a completely 
closed end of bone carefully rounded off. 
The loss of substance is not restored by new formation of bone, 26 
but is rather decreased by the necrosis and exfoliation ; with the 
occasional exception where the upper section of the bone is ne- 
crosed throughout, when new bone encircles it, having no con- 
nexion with the dead bone. 
The newly formed bone, surrounds and encloses the walls of 
the old bone. Later it becomes more compact; when absorption 
occurs in it, as well as the portion of old bone which it encloses, 
at length the old bone becomes rough, perforated, and gradually 
disappears. This new articular extremity of the bone, is attach- 
ed to the surrounding parts through the muscles, which in place 
of being inserted into the bone, form their attachment by means 
of the new articular capsule. The end of the bone is covered by 
a layer of fibrous tissue ; connected at its edges only, with the 
new capsule, or on its whole surface, by a solid cord, extending 
from the new bone to the opposite articular surface. 
The changes which take place in the articular cartilage and 
uninjured joint surface opposite the amputated extremity, are 
very important, as will be perceived, depending upon the degree 
of inflammation following the operation, where it was slight, the 
parts were but little changed, whereas acute inflammation caused 
their destruction, and exfoliation of the denuded bone, in the lat- 
ter case granulations began to shoot up from its surface, even 
during the process of exfoliation to “unite with those which pro- 
ceed from the soft phrts, and thus either occasion the union of 
the solid fibrous uniting medium with the articular cavity in its 
whole extent, or, if a new capsule has been formed, embracing the 
edges of the articular surface.’7 
We have thus far been studying diseases of the joints, acute in 
character, attacking young and strumous persons, soon destroy- 
ing the joint, and involving the surrounding tissues to a greater 
or less extent. Of late years there has been much attention drawn 
to the investigation of a disease making its appearence in advan- 
ced age, and appearing in all the joints, but with a decided pre- 
diction for the larger articulations. 21 
From its more frequently appearing in advanced life, and when 
attacking the hip joint, it lias received the name of “ Morbus 
Coxm Senilis.’7 Mr. Adams of Dublin in his recent work upon 
Rheumatic Gout has substituted “ Chronic Rheumatic Arthritis,77 
from its resemblance to a disease affecting other articulations 
and identical in its nature. 
The exciting causes of this malady are still cloaked in obscu- 
rity ; sometimes it is attributed to cold or wet. Mr. Adams 
thinks he he has traced it to falls upon the trochanter. Its symp- 
toms in the early'stages are as follows : The patient complains 
of pain in the hip joint and parts adjacent, and of a dull, boring- 
pain which frequently extends down the front of the thigh as far as 
the knee, or external condyle of the femur. The stiffness is most 
felt in the morning, upon first using the joint after the nights 
rest; after a little exercise the movements of the joint become 
more free, and the pain in the joint is diminished. Should the 
patient walk very much during the day the pain is always greater 
in the evening ; which, usually- subsides upon retiring to rest. 
When the weight of the body is thrown upon the affected limb, 
the pain in the joint is always increased ; but if pressure is made 
upon the great trochanter, or even a sharp blow struck upon the 
sole of the foot, it is attended with none, or very little inconve- 
nience to the patient. Flexion and extension of the thigh 
upon the pelvis is limited ; all movements of the joint being at- 
tended with a destinct crepitus. As in Morbus Coxarius, there 
is apparent shortening of the limb, of from one to three inches, 
really, consequent upon the obliquity of the pelvis. This chronic 
affection of the hip joint is rarely attended with heat, or external 
swelling of the soft parts, never resulting in suppuration. 
Dus. Colles and Todd, look upon the disease, rather as one 
of irritation than chronic inflammation—whilst Haggarth, Cru- 
veilhier, Brodie and Adams think it sub-inflammatory or 
chronic. Be it a disease of irritation, or be it inflammation, it 
certainly is very slow in its progress, as exemplified in Patrick 28 
Macken, who at seventy-one years of age had been disabled for 
seventeen years, from a severe pain in Ids right hip, attended 
witli lameness which has been steadily increasing since the first 
appearance of the pain. 
The changes in the tissues of the joint arc exceedingly inter- 
esting. In the early stage, the capsule will be found thickened 
and distended with a preternatural quantity of synovial fluid ; 
the synovial membrane thickened and vascular. As the disease 
advances the fluid is absorbed, with destruction of the round lig- 
ament. Soon the interarticular libro-car til ages are destroyed, to 
be supplied by an enamel, covering the articular surface of the 
bones, remarkable for its polish and hardness ; in the hip-joint 
the surface of the head of the femur, becoming in whole or in 
part as smooth as an ivory ball. The knee and elbow-joints are 
supplied with this porcelain like enamel, deposited in parallel 
grooves in the direction of flexion and extension. 
Under this peculiar morbid process, the bone, deprived of its 
covering of cartilage of incrustation, and constantly subject to 
friction, becomes polished, partially worn away or flattened and 
sometimes suffers from interstitial absorption. Upon these points 
the disease interests us, as indicating the course of treatment to 
be pursued. The pathology in all its stages is sufficiently well 
understood, to perceive that it gradually advanced under the 
motion and attrition of the two opposing surfaces of the bones 
entering into the structure of the joint, and that perfect rest is at 
tended with the danger of great rigidity, if not anchylosis. 
Under these circumstances, the treatment is fairly indicated to 
be——motion, at the same time that the two opposite articulating 
surfaces arc relieved from friction upon each other ; both of 
which indications can now be easily accomplished. 
Mr. Price of the Infirmary of Scrofulous Children, at Mar- 
gate, has recently published some very interesting statistics of 
operations upon the hip-joint for hip-joint disease, and their result. 
There were fourteen cases where the integrity of the joint was 29 
more, or less destroyed, either femoral, pelvic, or both ; no dislo- 
cation, or rupture of the capsular ligament having occurred— 
of these, eleven recovered with more or less useful limbs, or were 
on the high-road to recovery. 
In sixteen cases operated upon, where the diseased head of the 
os femoris was dislocated from its acetabular connexions, and no 
disease of the pelvis apparently existed—ten were perfectly suc- 
cessful—of the remaining six, three were successful, so far as the 
immediate result of the operation was concerned, the patients 
living from a few months to two years. 
When the disease was more or less confined to the synovial 
and cartilaginous structures about the joint; and if the bony 
portions of the joint were involved, it was neither of the nature 
of caries or necrosis, there were five operations. Three were 
completely cured ; one died fifteen months after, from causes 
apart from disease of the hip, and the fifth died on the twentieth 
day, from increased debility and irritation. 
Eighteen patients were operated upon, where the diseased 
head of the femur was dislocated from the acetabulum, and more 
or less disease o£ the acetabular portion of the pelvis existed. 
Of the number, only six recovered. 
He shewed that the whole acetabulum could be removed and 
the patient recover. Mr. Brichson reports one case where he re- 
moved the head of the os femoris, the entire Acetabulum, a por- 
tion of the crest of the ilium, and the tuberosity of the ischium. 
The patient perfectly recovered. It will be perceived, that the 
most successful cases were those, where the condition of the joint 
was found to be almost exactly the same, as in the patient whose 
case is here reported—the character of the joint destroyed, the 
capsular ligament not ruptured, and the head of the femur re- 
maining' in its natural cavity. He docs not mention whether 
there was diseased bone or not, if there was, it must have been 
limited, without having caused much irritation to the surround- 
ing parts ; and probably the vital energies of the patients were 
not impaired. 30 
When the disease had destroyed the capsular ligament, with 
dislocation of the head of the bone, the result was very favora- 
ble, but not so encouraging, as where the previous condition of 
the parts existed. After the disease had extended to the inno- 
minatum and os femoris with dislocation, the result was not en- 
couraging. In the latter cases, it strikes me, that finding the 
disease so far advanced, it would be better to amputate at the 
hip-joint, leaving the wound open, to facilitate recovery by afford- 
ing a more ready escape to the pus, and dead bone in the process 
of exfoliation, thus allowing the parts as they become healthy, 
to granulate and close the stump. By this procedure, the patient 
would be relieved of a limb, which, in this critical state of things 
is a very troublesome member, confining him to one position, and 
embarrassing his movements ; all of which must increase his suf- 
ferings, and add to the constitutional irritation of a system 
already greatly reduced by disease. 
The physical condition of patients suffering from hip-joint 
disease, is another point worthy of consideration—most frequent- 
ly it occurs in those of a strumous diathesis. 
When wo examine our patient, with reference to an operation, 
a more thorough sifting of his or her condition is imperative- 
remembering that the greatest safety is in searching more closely, 
for those conditions which forbid an operation, rather than 
magnifying the favorable indications. Satisfied that the local 
disease is not too far advanced, and that the patients strength 
is sufficient to bear the operation, it is still important, that the 
condition of every organ and function should undergo a thorough 
investigation. I have been surprised by the large number of 
cases in which Brights’ disease was found to exist after death, 
to which, of course the fatal result was attributed. The heart 
7 
lungs, and in fact every part of the body seem prone to take on 
diseased action upon the slightest provocation, and I think it a safe 
conclusion to arrive at —that this operation should only, be resort- 
ed to, after being thoroughly satisfied, that no other means can 
arrest the onward progress of the disease. ENCHONDROMA, 
OR, 
CARTILAGINOUS TUMORS. 
James A. Coyill, fourteen years of age, born in the United 
States, has suffered with the above disease since early childhood. 
At fourteen months of age, the second finger of his left hand 
was caught in a door—the physician who saw him told his 
mother that the finger was broken, and treated it as a fracture. 
The mother says the swelling never entirely disappeared. 
Eighteen months after receiving the injury, a decided tumor 
made its appearance on the second phalanx of the finger, at the 
point of fracture—the first phalanx of the same finger simulta- 
neously began to swell throughout its whole extent. These 
changes began without any apparent exciting cause, with but 
little pain and no constitutional derangement. Soon after, 
another tumor appeared upon the metacarpal bone of the index- 
finger near the meta-carpo-phalangeal articulation and on the 
dorsal surface. The disease continued to advance from the first 
phalanx of the second finger, until the motion of the joint be- 
came impeded, and the second metacarpal bone extensively 
involved. 
I am thus particular in describing the appearance and pro- 
gress of the tumors, in order to show that the disease did not 
appear in, or involve the cartilages of the joints during the early 
stage of its progress. 
Between the age of four and five years he had Typhus Fever, 
when the large tumor upon the second finger began to enlarge, 32 
and he looks upon that as the period from which to date the 
rapid increase in the size of the lumps and spread of the disease. 
At seven years of age he fell upon the ice and a companion 
accidently stepped upon tire hand—the whole hand was severely 
contused, but he does not think the advance of the disease was 
accelerated by the injury. Two years after, the largest lump 
began to grow, and in May, 1854 the integuments to the size of 
a quarter of a dollar sloughed from the tumor next to the 
largest in size, followed by copious suppuration, leaving a cavi- 
ty one inch in depth, which soon filled up, to be covered by a 
firm cicatrix. At that time he consulted an herb doctor, who 
treated it by repeated sweating with his sovereign remedies; 
which made their success most apparent, by a rapid increase of 
the disease. He now suffered more pain than formerly, but of 
a dead heavy character, apparently as much owing to the size 
of the hand, and probably more than from the character of the 
disease, yet the discomfort was so great as to make him willing 
and desirous to have the hand removed. 
August 25th, 1854. The patient being under the influence of 
chloroform I removed the hand at the wrist joint, by the double 
flap method ; after securing the arteries, the flaps were brought 
together without disturbing the synovial surface, or removing 
any portion of the radius or ulna, the parts united promptly 
with but slight inflamation or suppuration, so that the whole 
was well in two weeks. Four months after the operation, he 
has a good stump, no pain, and his general health is perfect. 
The plate, from a drawing by my friend Dr. Jno. W. Green, 
represents the appearance of the specimen soon after its removal. 
The integuments and loose cellular tissue having been removed 
by dissection. 
Professor J. C. Dalton was kind enough to examine a portion 
of the tumor under the microscope, which he found to “ consist 
simply of cartilage in process of partial ossification—most of 
it was pure cartilage, but there wore spiculafe of bone project- 33 
ing into it in various directions. There were no other elements 
than these to be found.” The Cartilaginous deposits as lie de- 
lineated them, had precisely the same appearance of the nuclei 
as represented by Mr. Paget, in his work on Surgical Pathology, 
at page 425. 
Enchondroma was first used by Muller to designate a growth, 
sometimes named Osteo-chondroraa or Benign Ostco-sarcorna. 
Mr. Paget objects to the last name as being vague, and it has 
the additional objection of conveying the impression that it is 
to a certain degree a malignant growth. Mr. Paget lias been 
so successful in his classification of tumors, that I doubt not the 
class of Cartilaginous tumors of which this is a specimen, will, 
in future receive the distintive title of Cartilaginous tumors or 
Enchondroma. 
This disease is accurately described by Mr. Miller in liis 
Principles of Surgery, as being connected with bone, peculiar to 
early years and usually attributable to external injury. The 
growth, slow and painless, most frequently found in the meta- 
carpal bones and phalanges of fingers. The articulating carti- 
lages are not involved, but form the limits of the growth in that 
direction ; and adjacent tumors have no tendency to coalesce. 
Before entering upon the subject in general, let us look at the 
class of which this specimen is such a perfect type. 
This growth is strictly benign, beginning within the bone, 
and so far as we can learn, invariably confined to childhood, ap- 
pearing often before birth, but never after puberty. There arc 
about fifty cases now recorded of this malady, all developed 
before the age of fifteen—in none was there any appearance of 
malignant disease, although it has reappeared after removal ; 
as in Mr. Salmon’s case, of which, before dissection this speci- 
men was a perfect copy, his being the right hand, this the left. 
Mr. Paget gives a sketch of it in his work and speaks of it as 
being the most remarkable yet seen, having been removed from 
a man fifty-six yesTs of age, from whom, when he was sixteen u 
years old, the forefinger of the left hand was amputated—the 
little finger of the same hand having a tumor as large as a 
walnut; he lias irregular nodules on his left tibia, and some en- 
largement exists at his second toe of the same side. 
There is little or no tendency to degeneration, even when 
after many years duration, ulceration of the investing integu- 
ments may have occurred—-the surrounding textures are not in- 
volved but pushed aside. Although attacking all parts of the 
skeleton, it is most frequently found in the metacarpal bones 
and phalanges of the fingers, yet the articulating cartilages 
never are involved in the disease, but form a limit to the 
growth, necessitating the formation of a number of tumors on 
one hand, which, whatever may be their tendency, by this cut off 
are barred from coalesccing. The growth is painless and usu- 
ally slow, except aroused to action by some exciting cause, as a 
blow or irritating applications—the latter frequently causing 
the integuments to slough ; and where several tumors are de- 
veloped simultaneously they are the result, not of a constitu- 
tionally malignant cause, but rather of “ the widely spread 
influence of the exciting cause, which in most instances is a 
contusion.”* Nearly all the phalanges and metacarpal bones of 
one or both hands may be simultaneously attacked by this 
growth, frequently projecting from only one side of a bone, ex- 
panding into irregularly round, smooth and oval masses, elon- 
gating the fingers, and interfering with or totally preventing 
the movements of the joints. 
From this growth beginning within the bone, the medullary 
cavity of a metacarpal bone can be filled with cartilage, with- 
out changing the external appearance, consequently the surgeon 
may amputate the finger where it has expanded into a tumor, 
leaving the disease above to reappear, as in the boy operated 
upon by Dr. Lawrence, who did not suppose the metacarpal 
* Muller. 35 
bones or the second phalanges affected by the disease, until the 
operation was being performed, when their medullary cavities 
were found to be filled with cartilage. 
We also have the cartilagenous tumor appearing upon the 
fingers external to the bone, between the bone and periosteum, 
but these are usually isolated tumors and may be removed with- 
out injury to the shaft. When this disease appears in other 
parts of the body, it takes upon itself new characters and new 
complications. .It may appear in three distinct structures, in 
the medullary cavity or within the bone ; external to, or be- 
tween the bone and periosteum ; and among the soft tissues, 
more frequently found in the region of the parotid gland. 
Ist. The adventitious growth is developed in the interior of 
the bone. The deposite gradually takes place in the cancellous 
texture when the external denser portion, or shell, is proportion- 
ally dilated. This outer covering, though attenuated by the 
disease, would be unable to envelope the growth as it does, ex- 
cept, that nature from time to time supplies additional osseous 
matter, for a long time maintaining its continuity. Gradually 
the bony covering becomes thinner, until at points it is wholly 
destroyed, although retaining their smoothness and spherical 
shape, in many cases to the touch, they become so elastic as to 
convey the impression that they contain fluid : having frequently 
been punctured, and in one case to my knowledge, greatly re- 
duced the patient by the hemorrhage. 
2d. The second variety is formed on the external surface of 
the bone, covered only by the periosteum and other soft parts. 
It is generally met with in fiat bones ; the -cranium, pelvis or 
ribs ; the form is less regularly spheroidal, and the surface more 
unequal, than in those originating within the bone. They are 
generally fastened to the natural surface by outgrowths of new 
bone. This ossification beginning on the surface of the bone 
forms an expanded base from which to extend into the substance 
of the cartilage, even so far as to have changed the whole car- 36 
tilaginous mass into bone. But these attachments vary as to 
size, sometimes not being larger than a pipe-stem. 
Bd. Lastly it may appear among the soft tissues, more fre- 
quently found in the region of the paroted gland, but met with 
pure or mixed, in the testicle, mammary gland, subcutaneous 
tissue, lungs and soft parts near bones.* 
These may be composed of cartilage only, but a large pro- 
portion contain fibrous cartilage mixed with other tissues ; 
either wholly surrounded by the gland, or included in its sub- 
stance. 
“ Bennet upon Cancerous and Cancroid growths,” at page 
108, gives the history of a tumor affecting the humerus of a 
girl fourteen years of age, and remarks, that true cancer of the 
bone and enchondroma, so called medullary sarcoma, as in the 
present case, so closely resemble each other to the naked eye, 
that they always have been confounded. Again at page 112, 
is described a case of this disease involving the Ischium and 
Pubis, where the patient died without an operation and the 
disease was supposed to be cancer ; more careful scrutiny, how- 
ever, detected peculiarities which threw doubt upon this con- 
clusion, and consequently be was induced to investigate the 
growth more thoroughly. “Sections with Valentine’s knife 
soon proved that the tumor was really cartilagenous, softened 
in some places and closely resembling cancer.” He also 
mentioned a tumor occurring in the parotid region, fibro-carti- 
laginous in its character. He suggests that we may possibly 
find it in other growths and with true cancer. 
Many physicians’in the City of New York will probably re- 
member two strikingly similar cases to those given by Mr. 
Bennet—one of a young girl in the New York Hospital, who 
died from exhaustion, of an immense tumor beginning in the 
humerus, smooth and round, with that elasticity which is so 
* Muller. 3Y 
often mistaken for an accumulation of fluid or pus ; it also 
ulcerated, but the part was soon covered by a firm cicatrix. I 
remember at the post-mortem being struck, with its light pink- 
ish, jelly-like appearance ; and the knife passed through it 
with that peculiar crispy sensation, which you experience in 
cutting cartilaginous tumors. 
The other was the “ bony tumor, arising from the pelvis,” re- 
moved by Dr. J. Kearney Rodgers, the history of which, he 
published in the New York Journal of July. 1839. “This tumor 
was firmly united by bone to the body and ramus of the pubis, 
the cancellated structure of which was enlarged, * * * * but 
did not project into the cavity of the pelvis.” The patient died 
from the shock to the nervous system, the operation having been 
very severe and protracted, owing to the size of the tumor. 
He asks if the disease was of a malignant character ? 
From the description, this tumor resembles those spoken of 
as beginning cartilaginous, and as they advance, becoming bony— 
with the knowledge acquired by the modern pathological and 
microscopical investigations of such men as Rokitansky, Muller, 
Paget, and Vichow, I think we would be justified in giving a 
favorable prognosis in a similar case, provided the operation 
was performed before the tumor had attained such an enormous 
growth. 
These tumors of the hand appearing at an early age, are 
sufficiently characteristic to be easily recognized ; at all events 
there is not so much danger of confounding them with malig- 
nant disease, as where they occur in other parts of the body, 
upon persons further advanced in life. When we come in con- 
tact with these abnormal growths they almost invariably pre- 
sent some point of obscurity, or uncertainty, clouded by anxiety 
as to their component parts. But these doubts are usually 
cleared up upon the removal of the mass, if not, the all pervad- 
ing eye of an intelligent microscopist, will determine whether 
the disease be benign or malign. Here it is that the Charlatan 38 
plays upon the credulity of his innocent victim—by a tedious 
and painful process, destroying an innocent tumor, which, under 
the influence of chloroform, might have been removed without 
pain, and in a few moments, by the hands of a skillful surgeon. 
But the evil working of these men does not cease here, they 
persuade their dupe that their skill has removed a cancer, never 
to return, owing to the remedies employed. Alarmed by this de- 
ception, the patient hastens to his or her relations to announce 
that in their family a cancer has taken root, the seeds of which 
are to be feared through every succeeding generation, whereas, 
only a harmless mass of disease has been removed without the 
slightest trace of cancer in it. 
Where this disease appears in other parts of the body than 
the hands and feet, it is not so well marked, and consequently 
not so easily distinguished from other outgrowths. In such 
cases it docs not necessarily make its first appearance in child- 
hood, on the contrary, appearing at all periods, from early youth 
to advanced age. According to the above authors it is met 
with as pure cartilage—cartilage in the process of ossification, 
and the recurring cartilaginous tumor. Then we find it mixed 
with malignant disease, glandular tissue, imbedded in the fibro- 
cystic tumor of the testicle, fibro-recurrent and myeloid 
tumors. “ Such combinations are not, I believe, imitated in the 
cases of any other structures found in tumors, even those that 
are thus combined with cartilage do not, I think, combine with 
one another, if we except the cases of intra-uterine morbid 
growths. As yet, however, the interest that belongs to all these 
inquiries is scarcely more than the interest of mystery and of 
promise to future investigation.”* 
* Paget. ERRATA. 
9th page, 12th line, femor should read femur. 
Rth 10th pereosteum, should read periosteum, 
11th “ 24th “ an “ “ 
17th “ 81st “ encusted “ “ encrusted. 
23d “ 21st “ cartalaginous “ “ cartilaginous. 
expoliiation “ “ exfolliation. 
82d “ last “ spiculace “ “ spiculas.