CASES OF INTEREST. 
BY 
Prof. W. H. CARMALT, M.D., of New Haven. 
From the Proceedings of the Connecticut Medical Society, 1884. 
HARTFORD, CONN.: 
Press of The Case, Lockwood & Brainard Company. 
1884. [From Proceedings of Connecticut State Medical Society, 1884.] 
CASES OF INTEREST. 
By Prof. W. H. Carmalt, M.D., of New Haven. 
cancer of tongue, operation for removal, with preliminary 
LIGATION OF BOTH LINGUAL ARTERIES AND TRACHEOTOMY; PATIENT 
PRESENTED TO MEETING OF SOCIETY. 
E. M., aged forty, truckman, was admitted to the New Haven Hospital 
on 13th of April, 1884, with the history that seven weeks previously he 
noticed his tongue swelling, and that it was coated with a thick, tenacious 
fur. The swelling became so great as to prevent his closing his teeth, but 
not his lips. He has been a persistent smoker of tobacco, and shortly 
before this he had bought some which was “ very strong and smarted his 
tongue.” The swelling had subsided somewhat, so that now he can, by 
an effort, close his teeth. It is still, however, about double the size of 
an ordinary tongue, though he volunteers the statement that it “ always 
was big.” He has been able to take only liquid food since it began 
to swell, and he says he has lost much flesh although he looks well nour- 
ished. His teeth are loaded with “ tartar ” and his breath is very offensive. 
Ilis gums are much swollen with a distinct reddish-blue line along the 
teeth, and there is very considerable salivation, but he gives no history 
of mercurialization. His speech is almost unintelligible. The tongue 
is quite indurated, especially around its edges, and in one portion at 
about opposite the right canine and bicuspid teeth it is eroded, the base 
of the ulcer being granular. The surface is here a little below the level 
of the surrounding (swollen) part. The induration gradually lessens 
posteriorly, so that one-third at this part is of nearly normal consistence. 
A very careful examination detects no enlarged lymphatic glands about 
the angles of the jaw, nor in the floor of the mouth. He has had no 
pain in the tongue, only the inconvenience. 
The patient was ordered a mouth-wash of chlorate of potassa, biborate 
of soda, alum, orris-root powder, and tincture myrrh, to be carefully 
washed out every hour. The u tartar ” was thoroughly cleaned off from 
his teeth, and he was ordered liquid food in sufficient quantity. Under 
this treatment the swelling subsided considerably, the tongue became 
cleaner and the blue line disappeared from his gums. The induration 
about the tip and edges continued, indeed, with the subsidence of the 2 
CASES OF INTEREST. 
surrounding swelling it became more marked. On April 22d, and sub- 
sequently, patient complained of darting pains through the tongue, and 
on consultation it was decided to amputate it. Accordingly, on Sep- 
tember 28th, the patient was anasthetized and assisted by Dr. T. H. 
Russell, I operated as follows: I first passed a large ligature through 
the tongue in order to keep it drawn forward, as from its large size it 
was liable, during the administration of the ether, to fall back and block 
up the entrance to the larynx. I then ligated both lingual arteries with 
catgut ligatures, washed out the wounds with a solution of corrosive 
sublimate, 1 to 1,000, and sewed it up with a continuous catgut suture. 
On the left side I divided the hypo-glossal nerve, having first ligated 
it by mistake for the artery. I may remark here that both these wounds 
united by first intention throughout their whole extent, the Catgut 
sutures were absorbed, and I never gave them any other than the slight- 
est dressings. 
The tongue was then excised with curved scissors, and the floor of the 
mouth down to the mylo-hyoid muscles cleaned out. On the right side 
the tongue was divided at about on a line with the second molar tooth, 
but not quite so far back on the left, as the induration was not so 
marked on this side; the line of incision was, however, quite behind all 
perceptible induration on either side. The operation was almost blood- 
less, the ligation of the lingual arteries fully compensating for the tedi- 
ousness of the preliminary operation, rendering the operating field nearly 
as clean as when operating on a limb with the use of Esmarch’s elastic 
bandage. 
I then proceeded to make a tracheotomy, and in doing this the only 
unpleasant incident of the series of three operations occurred. As I 
was cutting down upon the trachea I found the isthmus of the thyroid 
gland unusually broad, necessitating carrying the incision lower down 
than usual. Owing to the deeper situation of the trachea as it passes 
behind the sternum, a pillow was placed under his shoulders to make 
the neck more prominent, and the dissection wTas carried on deliberately. 
I did not feel in any hurry, as there was no tendency for the stump of 
the tongue to fall back, nor hemorrhage from the wound in the mouth 
into the larynx. I was, therefore, surprised to notice the respiration 
stop, and the face become rapidly cyanotic; at the same instant a gentle- 
man having his finger on the radial artery exclaimed, “his pulse is flutter- 
ing.” and I saw the pupils suddenly dilate widely. I looked about to 
find the cause, passed my finger down behind his tongue to press that 
forward, found everything clear; Dr. Russell began artificial respiration, 
but the air did not enter the chest, and I then noticed that the position 
of the head, falling back from the elevated shoulders, had practically 
closed the trachea “fore and aft.” The pillow was removed, a couple of 
movements of artificial respiration repeated, when the color came back to CASES OF INTEREST. 
3 
the face, all the untoward symptoms disappeared and the patient breathed 
again as usual. I mention this as an argument against Professor Rose’s 
plan of operating on the parts about the mouth and nose by, as he calls 
it, “the hanging head.” This consists in bringing the shoulders of the 
patient to the edge of the operating table and allowing the head to fall 
over backwards as far as it will, thus bringing the force of gravity to 
aid in preventing the blood from trickling into the trachea. It proba- 
bly would be successful, but is liable to be accompanied by the accident 
mentioned. I think Dr. R. F. Wier of New York has called attention 
to this objection also. 
The operation of tracheotomy was then finished, and a Dunham’s 
tracheal tube inserted, as being less likely to irritate the posterior 
tracheal wall, a point of importance as the tube was to be kept in until 
granulations were formed on the cut surface of the tongue. The fauces 
were then plugged full with a large sponge and the nostrils with 
absorbent cotton; the wound in the mouth was dressed with iodoform 
dusted upon it and iodoform gauze laid upon the surface. He 
breathed regularly and calmly through the tracheal tube, which was kept 
covered by a couple of folds of antiseptic gauze constantly moist with a 
1$ solution of carbolic acid. About four hours after the operation, during 
a paroxysm of coughing, the trachael tube was forced out and as the 
Dunham’s tube was found unreliable, not keeping in position well, it 
was changed, but all the tubes accessible were found unsatisfactory, as in 
all the ordinary lengths the tracheal end was lifted out during the effort 
of coughing, by the contractions of the sternal ends of the sterno-cleido- 
mastoid muscles upon which the flanges of the canula rested. After 
some difficulty one was reinserted, the patient in the interval breathing 
sometimes through the opening and sometimes through his mouth, the 
sponge being removed for the purpose, but the surface of the wound 
kept covered as described. This accident occurred several times during 
the night and the’ next day until a longer tube was procured, after which 
there was no trouble from this source. 
The patient was ordered to be nourished by enemata of 2 oz. of beef ex- 
tract every four hours, and 8 oz. of milk by the mouth through a stomach 
tube every four hours alternately, so that he received nourishment every 
two hours. The temperature of room was ordered to be kept at about 
80° F. and impregnated with steam. The mouth was constantly plugged; 
the tracheal tube removed and cleansed and the mouth washed out every 
hour. The directions were in the main followed out; difficulties in 
their administration were met promptly and intelligently by Drs. Loomis 
and Bogert of the house staff, and the nurses of the Connecticut Training- 
School were unremitting in their attention to the patient and faithful in 
obeying instructions. I ascribe a large part of the success of this part 
of the case to the excellent assistance I received. 4 
CASES OF INTEREST. 
On May 1st the plugging from the fauces was left out as it was excess- 
ively disagreeable and by the motions of his stump of a tongue and 
pharynx, kept working free. The nostrils were still plugged, however, 
and he was compelled by the nurses to keep his mouth shut, thus 
breathing as before through the tube; the wounded surface was dressed 
as before. The secretion from the trachea which was coughed up 
through the tracheal tube, was to-day noticed to be purulent and more 
profuse, but not excessively so. He has slept well every night since the 
operation and has taken sufficient food by rectum and mouth together. 
On May 2d, patient objected so strongly to the stomach tube that he 
was allowed, after carefully washing out his mouth, to drink, which he 
did readily enough by filling his mouth full and throwing his head far 
back. The surface of the wound in the mouth showing a disposition to 
form an abundance of healthy granulations, and no fetor being present, 
the tracheal canula was removed the next day; but this wound gaped, 
and the whole surface was covered with a pyogenic membrane. It was 
washed out with a solution of potassium permanganate and covered 
with several layers of antiseptic gauze, the latter afterwards changed to 
a sponge frequently moistened with a similar solution. 
On May 16th, patient’s temperature rose to 101.4° and for the next 
week oscillated between 98° in the mornings and 102° or thereabouts in 
the evenings. There were coarse mucous rales over the upper and 
middle portions of the left lung, and some dullness at the apex. He 
was fed on as nourishing a liquid diet as possible, consisting mainly of 
raw or soft boiled eggs well beaten up, beef extract, milk ad libitum, 
custards, etc. And he is ordered 2 oz. of cod liver oil daily. 
There was nothing worthy of note after this in the cicatrization of the 
tongue and mouth, and as you now see, it is fully accomplished just one 
month since the operation. The tracheal wound however has not closed 
and shows but little disposition to do so. The cut extremity of one of 
the divided tracheal rings appears necrotic at the bottom of the wound. 
There is considerable purulent secretion coughed up through the orifice 
which is kept covered with a large wad of borated cotton, enveloping 
all the anterior portion of the neck, extending down upon the chest, all 
firmly wrapped with a roller bandage of corrosive sublimate gauze. 
He does not emaciate perceptibly, but neither does he apparently gain. 
His temperature continues to rise to about 101° every evening, sometimes 
higher; less frequently, lower. 
There is not time now, without trespassing on the privileges of others, 
to give at any considerable length, the reasons for adopting the method 
of operating described, so much more complicated and tedious than 
those formerly practiced. The plan is developed from our knowledge 
of the causes of death following the operation, being (aside from recur- 
rences which are not considered here) almost exclusively septic in their CASES OF INTEREST. 
5 
character, and consists, in short, in the adoption of measures that, so 
far as the locality will allow, are either directly antiseptic in their 
action, or guard against septic materials entering the organization. 
For a more complete discussion of the subject I must refer the members 
to Mr. Barker’s very admirable article,* where the reasons are given at 
length, with the statistics. 
For an operation of this comparatively slight magnitude, not involv- 
ing any directly vital organ, the mortality has always been recognized as 
very large. Prior to 1876 it was, according to Mr. Barker’s statements, 
derived from Billroth’s Clinic at Vienna, from Kocher’s of Bern, and the 
statistics of University College Hospital, where he and Mr. Christopher 
Heath have operated, about 40 per cent, of the cases operated upon, 
while since that time it would seem that it has been reduced, in the 
same services, to something like 10 or 12 per cent. 
The results of autopsies show the principal causes of death to be septic 
infection of the lungs in one form or another. That decomposition is going 
on rapidly in the mouth after this operation, would not be doubted by 
any one who has approached a case before the more thorough modern 
antiseptic forms of treatment came into vogue, and to those who have 
not had this opportunity, I beg to recall to their memories the more 
familiar but infinitely less severe cases of compound fractures of the lower 
jaw. We are all of us familiar with the intolerable stench in these cases. 
How much wTorse, therefore, an amputation of the tongue must be can 
readily be imagined. That such a quantity of septic material lying con- 
stantly in the mouth (for the most careful nursing can only swrab it out, 
comparatively to the inspirations, very infrequently), the exhalations 
therefrom drawn into the lungs from 20 to 30 times a minute should be 
a source of great danger to the lungs, need, in the light of our present 
knowledge of infectious conditions, only be mentioned to be appreciated. 
Three fairly distinct forms of pulmonary diseases are found at post 
mortem examinations, viz.: most infrequently, typical pyaemic abscesses, 
these truly pyaemic cases, alwTays run a long course, and are associated 
with purulent deposits elsewhere; more often than these are a number 
of cases, following more directly purulent infiltration of the neck, with 
gravitating abscesses into the mediastinae, penetrating into the pleurae and 
lungs, this form is, of course, more rapidly fatal than the former, but 
neither is it so rajfid nor so frequent as the more direct septic infection 
of the pulmonary tissue from the foetid products of decomposition in the 
mouth. These are either drawn into the lungs wTith every inspiration 
or they trickle down into the larynx and trachea, owing to the inability 
of the patient so to manage his mutilated stump of a tongue as to 
prevent it. 
♦Holmes’ System of Surgery, 2d English Edition, Vol. II, p. 553, et seq. 6 
CASES OF INTEREST. 
The descriptions given by the various authors of the conditions of 
the lungs after death show the septic origin. They speak of lungs 
permeated with decomposing, purulent nodules; the bronchia; filled with 
foetid, purulent fluid; gangrene of lung; acute broncho-pneumonia; 
areas of gangrenous inflammation, all pointing to a direct infection from 
the putrid contents of the mouth. 
The value of the method of operating described by Mr. Barker, which 
I endeavored to follow, therefore consists in securing for the respired air, 
so far as possible, freedom from septic influences. By the ligation of 
the lingual arteries, besides the advantages already described of having 
a clean operating field, there is much less bloody exudation from the 
cut surfaces after the operation; by the tracheotomy the respired air is 
drawn from an uninfected locality; by the plugging of the fauces and 
nostrils the accidental entrance of air loaded with decomposing mate- 
rials is, in a great measure if not entirely, prevented, and finally the 
wound in the mouth can be kept constantly dressed with antiseptic 
remedies. I can but regard the lung complication in this case as being 
due, rather to the tracheal fistula than to irritation from septic infection 
by way of the mouth, and the tracheal fistula to have been caused by the 
accidents from the too short tracheal canulie. 
A CASE OF UNSUCCESSFUL WIRING OF THE PATELLA FOR UNUNITED 
FRACTURE. 
W. H. H., aged 38, was admitted a second time to the hospital, Sep- 
tember 29, 1883, having been treated there eighteen months before for a 
transverse fracture of the right patella, and discharged with a ligament- 
ous union of about 2£ inches, wearing a posterior stiff leather splint 
which he has continued to wear since. One wreek before admission, 
in sliding off from a hay mow, the heel of the boot of his right foot 
caught on the edge of a barrel, bending the knee violently and ruptur- 
ing the ligamentous union. On admission, the fragments were separa- 
ted about 5£ inches, and there was considerable swelling and pain in 
and about the joint. The leg was placed at rest and lotions and fomen- 
tations applied to reduce the inflammation. 
On October 20th, the leg was put up on a long inclined plane reaching 
from the buttocks to below the foot, with a foot-piece, and elevated 
about 25°. Adhesive plaster covering a large part of the quadriceps 
extensor muscle down to the patella was applied, and a roller bandage 
over this again. To the adhesive plaster elastic tubing was fastened, 
and this attached to- the foot-piece, keeping up a uniform extension. 
The lower fragment was simply fixed. In the course of five wreeks the 
distance between the fragments was reduced to about inches, but the 
ligamentous union was so very slight that if the extension was taken off 
it seemed to yield to the contractions of the quadriceps, and the move- CASES OF INTEREST. 
7 
ments between the fragments was quite free. Impressed by the then re- 
cent address by Sir Joseph Lister, on the “ Treatment of Fracture of the 
Patella,” delivered at the Medical Society of London, and published in 
the Lancet of November 3, 1883, in which he reported seven successful 
cases of wiring the fragments together under antiseptic precautions, I 
determined to attempt the same operation, following as nearly as possi- 
ble in his steps as there given. Accordingly on November 28th, the 
patient being anaesthetized, and using the carbolic spray as well as all 
other antiseptic precautions, an incision about five inches in length was 
made directly over the patella in the long axis of the limb down to the 
fragments. A thin ligamentous band united the latter; this was re- 
moved and the joint thus exposed. The opposing surfaces of the 
patella were scraped clean of all fibrous material so that when they 
should be brought together osseous tissue should be in contact. The 
drainage was then provided for as Lister advised, by carrying a pair of 
closed dressing forceps through the joint in the intercondyloid space, 
pushing them through the synovial membrane and capsule down- 
wards to emerge into the popliteal space quite external to the artery. 
As the forceps presented underneath the skin, this was incised and the 
forceps then pushed through the opening. The rubber drainage tube 
was then grasped by the forceps, and as they were withdrawn through 
the joint the tube was drawn into it; when fairly within the joint the 
hold was released, the tube remaining in place. 
The fragments were then drilled so as to bring the holes on the frac- 
tured surface exactly opposite to each other on the median line, and 
each about a line from the lower surface. Then introducing the pure 
silver wire, which was about of an inch in diameter,* the attempt 
was made to draw the fragments together, but no direct force that 
could be exerted was sufficient to approximate them more than £ of an 
inch, and then on twisting the ends of the wires together, and thus get- 
ting greater force, the wire began to cut through the bone of the upper 
fragment. I then divided the tendon of the quadriceps muscle sub- 
cutaneously, but it still required all the force that could be exerted upon 
the fragment, using both the wire already introduced and Fergusson’s 
lion-jawed forceps to get traction, before the fragments could be brought 
to within | of an inch of one another. In using this force the wire 
fractured the upper fragment longitudinally separating a small fragment 
from the inner side ; another wire was then introduced through the larger 
piece, and the two pieces united by a fine silver wire; as there was little 
lateral force this did not require to be very strong. The wound was 
then closed, and dressed with a full Lister’s dressing. The operation 
lasted 1£ hours. 
* Mr. Lister advised 1-10 in diameter, but I found 1-12 even quite unwieldly. 8 
CASES OF INTEREST. 
On recovery from the ether the patient was in great pain and al- 
though | gr. of morphine was given every twTo hours, he rested but little 
during the night. November 29th, T. 100.G, P. 92, R. 30, the dressings 
being soiled by oozings from the wound were changed under the 
spray. The pain continued without any cessation until December 4th; 
during this time the temperature ranged between 101.6 and 97.6; on 
that day the pain suddenly remitted, and as the bandage was slightly 
stained it was again changed under the spray; it was found that the 
wire had drawn through the upper fragment and the separation was 
as wide as before the operation. The discharge on the dressing was very 
slight, all from the wound over the patella, none from the drainage tube. 
After this the pain was never very severe, easily controlled by moderate 
doses of morphine. The dressings were removed and re-applied tw ice 
during the succeeding ten days, at the second dressing the w7ound wras 
found open and filled with granulations. On the 15th, 17 days after the 
operation, I removed the wires, and the drainage tube. After this there 
was no especial change until December 30th, when he had a chill fol- 
lowed by T. 102.5. On the next day, the leg was again dressed, and an 
abscess, the size of a w alnut, was found just underneath the skin, to the 
inside of the patella, not communicating with the joint. This was 
evacuated, washed out thoroughly with 5 $ solution of carbolic acid, 
and it immediately closed; there wras then nothing but the external 
wround to dress, so the Lister’s bandage was removed and bismuth ap- 
plied. On March 10th, this was omitted and the wound strapped. On 
May 13th, a silicate of soda splint reinforced with paste-board at the 
sides was applied, and on drying, the patient was allowed to walk. 
This he did and still does without much difficulty, but the movements of 
the joint are very restricted. 
In the address above mentioned Sir Joseph advocated the operation 
“in all cases where the surgeon can feel himself morally certain 
that he can secure asepsis.” I do not regard the unsuccessful termina- 
tion of this case to any failure in the asepsis. The suppuration did not 
occur until some time after the operation, as such, had failed; it never 
was sufficient to cause any anxiety; neither was the joint ever involved 
in the suppuration; although freely opened at the operation it still has 
motion and presumably articular surfaces. The hindrances to success 
were confined to the patella, the tendon within wdiich it lies, and the 
surrounding fibrous structures, and show in contradiction to Mr. Lister’s 
statement that there are cases in which the operation should not be 
performed. The statement is very broad; it includes all cases of both re- 
cent and old ununited fractures, though he prefers those that are recent 
as presenting fewer obstacles to success! Very true ! So would any 
surgeon prefer to treat a recent rather than an old fracture of any bone. 
The cases are not parallel; a comparison cannot be made with justice, 
they must be considered separately. CASES OF INTEREST. 
9 
I do not care at present to say much about the recent class. But 
it is well to bear in mind that even here there have been death 
(Bull), amputation of the thigh (Wyeth) and several instances of 
ankylosis of the joint, (Bell, Bloxam, Schede (2), Koenig, Smith, and 
others), all resulting directly from the operative interference; a state- 
ment which cannot be justly charged to any other method of treatment. 
The nearest approach to this has been a few cases of erysipelas, and 
of suppuration following the use of Malgaigne’s hooks, but running 
through the many years since their invention, and this it must be 
remembered, antedates for almost a century, the methods of antiseptic 
surgery. Practiced with the advantages offered by these methods, the 
risks from Malgaigne’s hooks become nugatory, and should render the 
operation of opening the joint for the purpose of wiring the recently 
broken fragments together with its practically inevitable attendant 
dangers, a matter of very serious consideration in every case. It is cer- 
tainly not to be universally accepted, as we are led to believe from the 
statements of its advocates, that the surgeon can make it an operation of 
no danger. How far Yon der Meulen’s method * of leaving intact the 
membrane posterior to (or underneath) the broken bone, thus avoiding 
opening into the joint, is to be found possible, remains for the present a 
subject for justifiable experimentation in selected cases. 
It is to the treatment of old fractures, the fragments of which are 
joined with but an unreliable or quite useless ligamentous band, that I 
regard this operation favorably, as offering a chance for restoring to use- 
fulness a limb which is little more than a burden. 
I have been able to get more or less full accounts of thirty-five cases 
of old ununited fractures of the patella, with very unsatisfactory use of 
the limb, or of recent refractures which have been treated by cutting 
down upon the bone, freshening the surfaces, and wiring the fragments 
together under antiseptic precautions. Most of these are taken from 
Mr. Turner’s tablet read at the meeting of the Medical Society of Lon- 
don, when Mr. Lister’s address was discussed, others are referred to by 
Dr. Wyethj in reporting his case necessitating amputation after wiring 
a recent fracture; others are individual reports as follows, viz.: 
* Lancet, January, 1884. 
t Lancet, Nov. 17, 1883. 
$ Med. Record, N. Y., June 2,1882. 10 
CASES OF INTEREST. 
Operator. 
Reference. 
No. of 
Cases. 
Result. 
Remarks. 
Lancet, Nov. 3, 1883,... 
2 
Cured, 
1 could not kneel. 
Bell, 
Turner, Lancet, Nov. 
17 1 
4 
( 1 ankylosis, 
1 suppuration due to bleeding into joint 
( 3 cured 
after division of quadriceps tendon. 
f 1 ankylosis, 
Howse, 
Turner, 1. c., 
4 
•j 2 cured, 
Subject syphilitic; no suppuration. 
( 1 slight motion, 
Johnson Smith,... 
Turner, 1. c., 
2 
1 ankylosis, 
Suppuration of joint. 
f 1 died, 
Could not bring fragments together; quad- 
Wood 
Turner, 1. c., also p. 856, 
3 
■< 1 slight motion, 
riceps and aponeurosis divided; death 
( 1 cured, 
from septicaemia in two weeks. 
Cameron, 
Turner, 1. c., 
1 
Cured, 
Union ligamentous. 
Bryant, 
Turner 1. e. 
1 
Imperfect, 
Joint stiff 
Holderness 
Turner, 1. c., 
1 
Cured. 
Holmes, 
Turner, 1. e., also St. 
Geo. Hosp., Rep.X, 496, 
1 
Ankylosis, 
Suppuration in joint. 
Sidney Jones, 
Turner, l.c., also Lancet, 
Aug. 11, 1883, 
1 
Ankylosis 
Quadriceps tendon and rectus muscle both 
divided; latter 3 inches above patella. 
CASES OF UNUNITED FRACTURES OF PATELLA TREATED BY WIRING ANTISEPTICALLY. CASES OF INTEREST. 
11 
Lloyd, 
MacCormac, 
Turner, 1. c., 
Turner, 1. c., 
1 
1 
Slight motion; 1 inch 
separation, 
Died, 
Quadriceps tendon and ligamentum patella 
both divided and lateral incisions in apo- 
neurosis of vasti. 
Quadriceps divided, thigh amputated, and 
Moulin, 
Turner, 1. c., 
1 
Abandoned, condition 
death from pysemia. 
Could not bring fragments together, quad- 
Parker, 
Turner, 1. c., 
1 
same as before operation. 
Cured. 
riceps not divided. 
Pemberton, 
Turner, 1. c., 
1 
Slight motion,.. . 
Fibrous union at three months, patient wore 
leg in case. 
Pye, 
Turner, 1. c., 
1 
Ankylosis, 
Suppuration in joint. 
Henry Smith 
Turner, 1. c., 
1 
Cured 
Quadriceps tendon divided. 
Turner, 
1. c., 
1 
Suppuration in joint. 
Walsh, 
Lancet, Dec. 22, 1883,... 
Wyeth, Med. Rec., 
1 
Slight motion, 
Adhesions about joint. 
Trendelenberg,. ... 
June 2, 1882, 
1 
Cured 
Full report in Verhand. der Gesellschaft 
d. Cliirugie Yol. VII, p. 1-89. 
Uhde 
Wyeth, 1. c., also Dtsch, 
Med. Wochensch. 
April 17, 1878, 
1 
Cured. 
Bull 
Wyeth, 1. c. 
1 
Died, 
Exhaustion from suppuration of joint, etc. 12 
CASES OF INTEREST. 
CASES OF UNUNITED FRACTURES OF PATELLA TREATED BY WIRING ANTISEPTICALLY.—Concluded. 
Operator. 
Reference. 
No. of 
Cases. 
Result. 
Remarks. 
Wheelhouse, 
Lancet, Dec. 15, 1883,... 
1 
Cured, 
Quadriceps tendon divided, wires pulled 
through bone twice, removed and Malgai- 
gne’s hooks substituted (should it be 
included ?). 
Lancet, Nov. 17, 1883,.. 
1 
Cured, 
Quadriceps tendon divided, but fragments 
could not be brought together until a series 
of deep oblique incisions in the muscle \ / 
were made as follows: these closed yy 
when the patella was drawn upon. 
1 
Imperfect movement,.... 
Wires pulled through bone, division of 
quadriceps tendon subcutaneously, super- 
ficial suppuration. CASES OF INTEREST. 
13 
Of these 35 cases, 3 (8$) died, 7 (20$) had suppuration of the joint 
and subsequent ankylosis; in 9 (26$) there was no improvement from the 
operative interference, and 16 (46$) were cured. This certainly does not 
confirm Lister’s view of the safety of the operation, and in the 54$ of 
failures (for in an operation undertaken to improve the usefulness of a 
part, “ no improvement,” is failure) there were several where a septic 
condition of the wound or joint could not be claimed to be the reason 
of this result. 
Some of them were unquestionably due to conditions intrinsic to the 
injury, or to its after treatment preceding the operation, such as adhe- 
sions of the quadriceps tendon and aponeurosis to the underlying and 
adjacent parts (Henry Smith, Sidney Jones, Wood, Bell, Carmalt). Short- 
ening of the quadriceps (or rectus) muscle with more or less atrophy, 
(Macewen, Moulin, Lloyd) atrophy of the fragments and consecutive 
softening of the osseous tissue (Wheelhouse, Carmalt). 
That the division of the quadriceps tendon is not unattended with, 
danger is shown in the table, where of ten cases of division of this ten- 
don, two died of pyaemia, in two there was suppuration of the joint 
followed by ankylosis, in three more the result was unsatisfatory, i. e., 
20$ of deaths and 70$ of failures; while in the remaining 25 cases, in 
which from the absence of a statement as to a division of this tendon, 
it may be presumed that it was not done, one died from exhaustion 
from suppuration of the joint, five had ankylosis following suppuration, 
in six the operation was not followed by improvement, or 4$ of deaths 
and 48$ of failures. 
It appears to me from the consideration of this number of cases rep- 
resenting quite a diversity of conditions at the time of operating, that 
although the operation itself under strict antiseptic precautions, offers 
us undoubtedly a valuable contribution to operative surgery, it is not 
to be accepted as universally applicable to all cases of even ununited 
fractures alone; that there are cases in which it is hopeless for us to un- 
dertake it, and we are not justified in subjecting the patient to its risks; 
that amputation and an artificial limb, or some mechanical appliance 
should be recommended instead. I am inclined to think from the expe- 
rience the profession has so far gained, that we must restrict this opera- 
tion to cases which permit considerable mobility of the upper fragment, 
and allow it to be approximated to the lower one, but in which after 
waiting a reasonable time, osseous (a firm) union does not take place. 
In these cases it may be fairly assumed, that adhesions to the parts be- 
neath do not exist, or may be readily broken without extensive divis- 
ions of the tendon, and the operation may be performed with a reason- 
able prospect of success without unduly risking the patient’s life. 
It is more than probable, in my mind, that in many instances, in the 
attempts to bring the fragments together by apparatus and appliances, 14 
OASES OF INTEREST. 
which exert a good deal of pressure upon the upper fragment, inflamma- 
tions with consequent adhesion to the parts beneath is excited. It 
becomes, therefore, a question with regard to our early treatment of 
these cases, how far and how long we are justified in carrying out 
attempts to bring the fragments together, in view of the fact that we 
may thereby be depriving ourselves of a more certain method of cure 
afterwards in the operation under discussion. 
Gedrge H., aged 42 (looks 65), a hostler, was admitted to the hospital 
on April 16,1883, with the statement that three months previously, after 
having suffered for two or three years with symptoms of vesical irritation 
and occasional retention of urine, that Dr. L. M. Gilbert of this city had 
removed from the anterior portion of the urethra, directly at the navic- 
ular fossa, an irregularly almond-shaped calculus, with very considerable 
relief to his suffering. This did not, however, continue, and he applied 
to the hospital for treatment. A foreign body, presumably a stone, was 
readily detected, and on the 19th he was put under ether and, after 
crushing with a Bigelow’s Lithotrite, the fragments were removed 
through the straight evacuating catheter, using Bigelow’s second form 
of evacuater. The crushing was done twice, and, after the second evac- 
uation, no fragments could be detected by the sound. The operation 
lasted 55 minutes. After filtering and drying, the fragments weighed 
97 grains. 
The patient had no untoward symptoms afterwards; indeed it was 
with difficulty that he was pprsuaded to stay in bed the next day, 
insisting that he was quite well. No fragments were passed, nor did 
he have any irritation at the neck of the bladder, as I expected, for 
I experienced an embarrassment in the manipulation of the evacuating 
catheter that is not mentioned by the author of the operation, nor do I 
remember to have seen alluded to by its critics. I found, in removing the 
catheter after the first crushing, when it became evident that there were 
one or more fragments too large to pass through it, that one of them 
became impacted in the eye of the catheter by the suction of the evacu- 
ating bag, and that there was great danger that the neck of the bladder 
might be lacerated in attempts at withdrawal. This laceration can 
readily happen, as from the necessarily large size of the catheter the 
canal hugs it tightly, and one cannot, without considerable experience 
(and practice on the cadaver by no means gives the same feeling of 
resistance that the actual operation affords) feel sure that the eye is free, 
and when the mucous membrance is thus on the stretch, a slight nick 
from a sharp angle of a fragment of stone may make a considerable lacer- 
ation. If once incautiously or ignorantly drawn into the canal, the 
urethra may be tom its whole length. I would therefore suggest that 
A CASE OF LITHOLAPAXY. CASES OF INTEREST. 
15 
the novitiate (at least) should, in order to escape this accident, first 
reverse the position of the eye of the catheter in the bladder, directing 
it downwards, and then make a slight and somewhat sudden pressure 
upon the evacuating bag, thus freeing the eye from whatever may be 
caught there, and allowing the fragment to fall into the lowest part of 
the bladder away from the orifice. The tube may then be withdrawn, 
either thus reversed or in the usual position, the lithotrite again intro- 
duced, and the crushing repeated. 
SUd-TROCHANTERIC OSTEOTOMY FOR VICIOUS ANKYLOSIS OF HIP JOINT. 
CURE. PATIENT PRESENTED TO SOCIETY. 
R. S., 7 years of age, was admitted a second time to the hospital, on 
Aug. 29, 1883. She had been a patient during the previous summer, 
admitted on May 3d, 1883, for the same deformity, and I had then 
attempted to overcome it by Adams’ operation of dividing the neck of the 
femur, using however, a Macewen’s chisel. Although I think I divided 
the neck, and at the operation obtained a considerable correction of the 
deformity, owing to the very considerable deposition of osseous and 
fibrous material about the acetabulum and head of the femur, and the 
great mobility of the spinal column, I was unsuccessful in preserving 
the extension necessary for the permanent correction of the deformity; 
the limb returned to its former position, and the joint became as fixed 
as before the operation. I therefore detei mined to make the division 
below the trochanters, but sent the patient home to recuperate from the 
effect of the confinement before operating again. On readmission, the 
right thigh was immovably fixed at a right angle to the axis of the 
vertebral column; the distance from the heel to the floor when the latter 
was erect, and the patient stood upon the left leg, was 10 inches, being 
just the length of the femur from the apex of the trochanter major to 
the extreme end of the external condyle (see fig. 1), while at the greatest 
extension the child could give by curving the spinal column, the toes of 
the right foot rested upon the left instep (see fig. 2). 
On Sept. 29th, the femur was divided by a simple incision just below 
the trochanters, the line of incision being nearly transverse to its axis. 
I used a Macewen’s osteotomy chisel, and supported the leg during the 
operation upon sand bags. Strict Listerism was observed throughout 
the operation, and in the bandage afterwards applied. The tendon of 
the gracilis muscle, and some fibrous contractions of the fascia lata near 
the anterior superior spinous process of the ilium, were divided. The 
leg and vertebral column were then brought into a nearly straight line, 
and a plaster of Paris bandage, extending from just below the axillae, 
down and around each leg to the ankles; the right leg was slightly 
abducted and everted. The plaster bandage was reenforced by an iron 
bar, bent into a shape to conform to the normal curvatures of the back 16 
CASES OF INTEREST. 
and the abducted position of the leg, extending from between the 
shoulders to the poplitial space. This was shaped previously and used 
to secure greater accuracy during the application of and setting of the 
plaster bandage than would be otherwise practicable. 
After recovery from the ether the patient was comfortable, and the 
temperature never reached 100° F., running very nearly a normal course. 
The only uncomfortable conditions were those incident to the confined 
position in which she was kept. She was quite unable to make water, 
necessitating passing the catheter, and the bowels were very torpid. 
In about three weeks the plaster was cut away from the left leg and 
more movement in bed allowed. On Nov. 22d all bandages were removed 
and the child allowed to go about on crutches, which she did readily. In 
the course of a couple of weeks more she was given a shoe with a cork 
sole 1 inch high, with which she walks with a scarce perceptible limp. 
The exact amount of shortening being inches (see fig. 3.) 
The patient was shown at the meeting of the State Society, having 
walked up two long flights of stairs without taking hold of anything 
with her hands, putting her feet alternately on each succeeding step, as 
one ordinarily does. In sitting down she is obliged to sit on an edge 
of the seat, either the front or the right side. She can stoop to touch 
the ground, but cannot button her shoe of that foot. I think the 
position a little too straight for the most usefulness, it would be better 
if it were at an angle of about 35° from a vertical with the spine. 
I prefer this, Gant’s, operation to Adams’, as the incisions require much 
less laceration of surrounding parts, and where there has been much 
inflammation with absorption of the head and neck of the femur, and, 
perhaps, dislocation upon the dorsum of the ilium, the relations of parts 
are disturbed, the leg is then shorter anyhow, and nothing is gained by 
the more tedious operation. The division of the shaft as practised 
offered no serious difficulty. PROF.,CAR MALT’S CASE OF OSTEOTOMY FOR ANKYLOSIS OF HIP-JOINT. 
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