REPRINT 
OF 
Papers from the Transactions of the Texas State Medical 
Association, entitled 
R EC A P1TI7 ATI ON OF SURGICAL CASES 
Treated and Operated on inWards 2 to 8 and 10, Charity 
Hospital,.of New Orleans, La., from October 1, 
1885, to March 31, 1886, with Remarks. 
and 
A CASE OF RESECTION OF THE SUPERIOR MAX- 
ILLARY BONE, FOR CANCER.. 
By EDMOND SOUCHON, M. I)., New Orleans, La., 
Professor of Anatomy an\f" of "Clinical Surgery, Tulane 
University of La., in c/uvrge of Wards. 
Read before the Texas State Medical Association, at its meet- 
ing at Dallas, Texas, April 27, 28, 29 and 30, 1886. RECAPITUATION OF SURGICAL CASES. 
Treated and Operated on in Wards 2 to 8 and io, Charity 
Hospital, of New Orleans, La., from October 1, 
1885, to March 31, 1886, with Remarks. 
By EDMOND SOUCHON, M. D., New Orleans, La. 
Professor of Anatomy and of Clinical Surgery, Tulane 
University of La., in charge of Wards. 
The total number of patients, including the out-door 
patients, treated in those wards during the time men- 
tioned, was 471—all accessible to the students of the 
medical class, who were not only allowed, but pressed 
to examine them for themselves, and follow them 
throughout. Of that number, 65 underwent more or 
less serious operations—all performed before the class 
in the operating amphitheatre, after explanation of the 
cases. 2 
Recapitulation of Surgical Cases. 
The following are the diseases treated: 
Abscesses, sundries, io; abscess (acute) of mam- 
mary gland in male, i; abscess (chronic), 2. 
Adenitis of various glands, 16; adenitis of submax- 
illary, 2. 
Adenoma of wrist, i; anchylosis of elbow, following 
dislocation, i; aneurism of femoral artery, i. 
Arthritis of elbow, i; arthritis of knee-joint, i. 
Bite, of nose, i; buboes, 17, burns, 11. 
Cancer of tongue, 1; cancer of superior maxilla, 1. 
Cancer of rectum, 1; cancer of elbow-joint, 1. 
Cancer of penis, 1; cancer of lower lip (epithelioma), 
1. 
Cancer of cheek (epithelioma), 1 ; carbuncles,'2. 
Chancres, 3; chancroids, 11 ; concussion of the 
brain, 2. 
Conjunctivitis, 1 ; contusions, 24 ; contusion of epi- 
gastrium, 1. 
Cystitis, chronic, 4 ; circumcision, 2. 
Deformity of toes, 1 ; dislocation of elbow, 1. 
Dislocation of outer extremity of clavicle, 1. 
Eczema, 4 ; erysipelas, 6. 
Fracture of base of skull, 4; fracture of inferior 
maxilla, 5. 
Fracture of superior maxilla (alveolar process), 1 ; 
fracture of humerus, 1, 
Fracture of radius and ulna, 5 ; fracture of radius 
alone, 2. 
Fracture of radius (the head), 1 ; fracture of ribs, 5. Edmond Souchon, M. D., New Orleans, La. 
3 
Fracture of femur, 2 ; fracture of tibia and fibula, 6. 
Fracture of tibia alone, 1 ; Pott’s fracture, 1. 
Frost bite of fingers and toes, 6; fistula in ano, 11. 
Gonorrhoea, 15. 
Hernia, reducible inguinal, 2 ; hernia, irreducible in- 
guinal, 1. 
Hemorrhoids, 12; herpes, 1 ; hip-joint disease, 1. 
Hydrocele, 1. 
Impetigo, 1. 
Keloid tumor of ear, 1. 
Lymphadenoma of parotid region, 1. 
Mercurial salivation, 1 ; medical cases, 4. 
Necrosis of inferior maxilla, 1 ; necrosis of bones of 
forearm, 1. 
Necrosis of phalanges, 1. 
Necrosis of ischium, 1. 
Necrosis of femur (invaginated), 1. 
Necrosis of tibia, 1. 
Necrosis of tarsal bones, 1. 
Necrosis of os calcis, 1. 
Needles, splinters, etc., in body, 3. 
Onanism, 1 ; orchitis, 8; otitis, 1 ; ozena, 1. 
Paronychia, 6; perineal infiltration of urine, 6. 
Phlebitis (long saphena and femoral), 1. 
Phlegmon of the hand, 5 ; Pott’s disease, 1. 
Prostate, hypertrophy, 1. 
Rhematism (acute), 1. 
Rheumatism (chronic), 1. 
Sprain of elbow, 2 ; sprain of wrist, 3. 4 
Recapitulation of Surgical Cases. 
Sprain of knee joint, 5 ; sprain of ankle, 4. 
Stone in the bladder, 1 ; stricture of urethra, 8. 
Syphilis (secondary), 10; syphilis (tertiary), 7. 
Tonsillitis, 1. 
Ulcers (indolent), 20; ulcers, serpigenous, 2. 
Ulcers, syphilitic, 3 ; ulcers, varicose, 27. 
Ulcerations of the mouth, 3 ; undiagnosed cases, 14. 
Varicose vein, 2 ; varicocele, 1. 
Wounds, abdomen (penetrating), 1. (Cured). 
Wounds, thorax (penetrating), 1. (Cured). 
Wounds, contused and lacerated, 50; (1 died of ery- 
sipelas). 
Wounds, contused and lacerated, of scalp, 1. (Cured). 
Wounds, incised, 28. 
Wounds, punctured, 5. 
Wounds, gunshot, nose, 1 ; inferior maxilla, 1 ; nose 
and eye, 1 ; hand, 3 ; neck and shoulder, 1 ; sundries, 3. 
Total, 471. 
The following are the operations performed : 
Abscesses in dangerous regions, 4 ; axillary region, 
1 ; iliac fossa, 1 ; liver, 1 ; submaxillary region, 2. 
Autoplasty of face, 1. 
Epithelioma of lower lip, 1. 
Fistula in ano, 8. 
Gunshot wound of leg—erysipelas, 1. 
Grafting, 1. 
Hemorrhoids, 5. 
Hernia, strangulated, 1. 
Hydrocele, 3. Edmond Souchon, Jlf. D., New Orleans, La. 
5 
Lithotripsy, i. 
Necrosis of bone, 5. Lower maxillary, 1 ; foot, 1 ; 
tibia, 1 ; thigh, 2, 
Perineal operations, 11, for chronic urinary fistula, 
1 : for infiltration of urine, 10. 
Tumors, 3. Lymphadenoma of parotid, 1 ; adenoma 
of wrist, 1 ; adenoma of testicle, 1. 
Total number of operations, 65. 
The following are the points of interest connected 
with these operations : 
The Abscess in the Axillary Space had originated in 
one of the glands, and was as large as an ordinary hen’s 
egg. It presented a deep and vague sense of fluctua- 
tion ; but the hypodermic syringe confirmed the pres- 
ence of pus. The patient was placed slightly under the 
influence of chloroform—just enough to deaden the 
pain, since one thrust of the knife, only, was contem- 
plated. To avoid injuring any of the large vessels and 
nerves of the space, the arm was placed at right angles 
with the body ; the back of the knife was turned against 
the vessels, the blade parallel with these vessels, and 
the point over the abscess, directed towards the walls of 
the chest. One firm and quick stroke drove the knife 
through about one inch of tissue, of which one-third 
was formed by the substance of the gland not yet de- 
stroyed. About one tablespoonful of pus escaped. At 
this moment, took place an incident which might have 
proved very dangerous to those situated around the op- 
erating table. No sooner had the knife penetrated into 6 
Recapitulation of Surgical Cases. 
the flesh, than the patient gave such an unexpected start 
that he got loose from those who were holding him 
down, and, jumping to his feet, in a wild, excited and 
unconscious manner, rushed to the case of instruments, 
which was near by, and had half opened a drawer, and 
was about seizing one of the instruments, when one of 
the students bravely caught him. lie very soon quieted 
down. It lasted, at most, fifteen seconds. The next 
day, in the ward, he told us that he had just come from 
the grinding on a sugar plantation, where a number of 
Chinese were employed ; that he was always quarrel- 
ling with them ; and that, as he was going under chloro- 
form, the students around him became gradually trans- 
formed, in his mind, into Chinese ; and that, as the knife 
penetrated him, though he felt no pain, he was satisfied 
that it was one of the Chinese who had stabbed him. 
Hence the rush he made to what he thought was his ar- 
mory, for a weapon to defend himself. He made a 
good recovery. 
The Abscess of the Left Iliac Fossa was transferred 
from a medical ward. It was remarkable from the 
vast amount of swelling and oedema it created all around, 
the length of time the pus was in forming, and the small 
quantity it presented, when at last detected. The swell- 
ing and pain were all over the iliac region ; also in the 
lumbar, and, later, in the gluteal region. There was a 
great deal of oedema of the whole of the left limb, and 
corresponding part of the abdominal walls on the left, 
and a small amount of serous effusion in the peritoneum. Edmond Souchon, M. D., New Orleans, La. 
7 
Four times, at least, at a week’s interval, was the pa- 
tient placed under the influence of chloroform ; and a 
good, long, and pretty large, exploring hypodermic 
needle, with syringe, inserted at all suspicious places— 
above Poupart’s ligament, below it, along the inside of 
the iliac crest, behind it—but all in vain. Hovvever, at 
the last sitting, the needle struck pus in the ilio-costal 
space, near to the ilium. The knife was then driven 
along the track of the needle, and, at a depth of two 
inches and a half, struck the focus of the abscess. 
Very little pus flowed through the opening, however, 
which was enlarged to the extent of one inch and a half, 
and kept open. The patient’s strength had been so re- 
duced, by pain and fever, that he derived but some re- 
lief from his pain, and died within the following ten 
days. Upon making a post-mortem examination, it was 
found that the whole iliac muscle, together with the 
pelvic portion of the psoas, were thoroughly infiltrated 
with lymph. There was but a small pus cavity, about 
the size of a large hen’s egg, situated at the terminal 
portion of the crest of the ilium, between it and the last 
lumbar vertebra. The plastic lymph also surrounded 
the iliac vessels, and so compressed the vein as to dimin- 
ish its caliber to about one-third. This was the cause of 
oedema of the limb. There was a tract of pus about 
one-third of an inch in diameter, which went into the 
true pelvis, and, following the course of the gluteal and 
ischiatic vessels and nerves, was reaching the buttock. 
The Abscess of the Liver was also transferred from 8 
Recapitulation of Surgical Cases. 
a medical ward. The abscess was an acute one, when 
it had been diagnosed, and had been located to the right 
of the median line. Upon placing the patient gently 
under the influence of chloroform, we could examine 
him more thoroughly. There was no special bulging 
on the right of the median line, and, by percusssion, a 
clear sound was returned. We thought it useless to 
thrust the hypodermic needle and syringe there, since 
we believed that no abscess, of such a size as to require 
and justify surgical interference, could exist, without 
some bulging and some dullness upon percussion. Con- 
sidering the great frequency of abscess of the right lobe, 
we made two punctures in that region, but no pus was 
struck. The case ran a rapid course, and the patient 
died within some ten days. The post-mortem revealed 
an abscess, of the size of a hen’s egg, situated in the 
left lobeoi the liver, to the left, therefore, of the median 
line ; where the patient had never complained of any 
pain in particular, at any time. There was. also, a good 
deal of peritonitis in the epigastric and both hypochon- 
driac regions. As operations for acute abscess are of 
little good, we did not much regret the anomalous 
symptoms which led us off the track. 
The Abscesses of the Sub-Maxillary Region were 
situated in the lymphatic glands, lying over the salivary 
gland, and were due to bad teeth. They were in their 
second stage, but the inflammation was threatening to 
invade all that side of the neck ; they were causing 
much pain, and determined a great deal of difficulty in Edmond Souchon, M. D., New Orleans, La. 
9 
swallowing, and of feeding properly. There was no 
evidence of fluctuation ; but there was so much redness 
and oedema over all that region that it was evident there 
must be pus, deeply seated, and that we were justified 
in using the hypodermic needle and syringe. It struck 
pus at the depth of one inch and a quarter. The knife 
was then introduced, making an opening of about a 
quarter of an inch. About one drachm of pus was lib- 
erated, and the disease was checked. One of those 
cases gave us some annoyance, for a moment, in this, 
that, after the needle had shown the presence of pus, 
yet, when the knife was driven in to the depth indicated 
by the needle, no pus came. As the opening was over 
the internal and external carotids, just where they are 
crossed by the large thyroid and lingual veins, opening 
into the internal jugular, which itself lies there, on the 
outside, and, also, somewhat over the arteries, we dared 
not cut any deeper. We then used the end of a blunt 
grooved director, and, by careful, gradual working, 
finally broke what little lamina of tissue separated the 
terminal end of the incision from the focus of the ab- 
scess ; this barely contained more than half a teaspoon- 
ful of thick pus. It was then very plainly visible that 
the throbbing of the deeply seated vessels was commu- 
nicated to the blood on the tract made by the knife. 
The Case of Anchylosis of the Elbow Joint was due 
to organized plastic adhesions, which had taken place 
between the articular surfaces, after the reduction of 
the dislocation of that joint, the limb having been al- 10 
Recapitulation of Surgical Cases. 
lowed to go too long without being exercised. The 
case was rendered much worse by the fact that the phy- 
sician who attended him at the time made the too often 
repeated mistake of placing the limb in the extended 
position, instead of placing it in the not quite semi-flexed 
position. The patient being placed under the influence 
of chloroform, the forearm was gradually, gently, 
slowly and most carefully flexed upon the arm. As this 
was being done, the adhesions were felt and heard giv- 
ing way ; as we neared the right angle position, though, 
the skin over the olecranon became so tense that, lest 
we might rupture it, we desisted from further efforts. 
The arm was bandaged in that position, and cold water 
applied to the parts. Avery moderate amount of swell- 
ing followed, but the patient complained of a great deal 
of pain. On the third day, however, this subsided, and 
the joint was exercised with care. At the end of ten 
days, he was sent back home, after being instructed 
how to exercise his limb ; of course, he was taught how 
to bend it, more and more, as the skin over the olecra- 
non permitted it. 
The Case of Facial Autoplasty was necessitated by a 
gunshot wound, which had destroyed the left half of 
the lower maxilla, horizontal as well as ascending 
ramus, and the tissues above and below the bone ; leav- 
ing there a gap, extending from the middle line to the 
ear, and from the alveolar process of the superior max- 
illa to within a half inch of the hyoid bone at its greatest 
height; it measured about three inches and a quarter in Edmond Souchon, M. D., New Orleans, La. 
11 
length, and about two and a quarter inches vertically. 
The skin over the cheek and over the neck was mova- 
ble enough, and it was thought that, by dissecting it, it 
would slide, and the edges come in contact. Dr. Miles, 
the house surgeon, kindly examined him, at my request, 
and encouraged me to operate. Of course, all this 
could only be determined, positively, by actually per- 
forming the operation. No particular difficulty was 
experienced in approximating the edges at the two ex- 
tremities of the gap; but, at the center, though the 
edges did meet, there was so much tension on the su- 
tures, and the edges of the flaps of skin were so thin, 
that no union was expected there, and it was evident 
that it would require a second plastic operation to close 
the gap, more or less large, which was going to be 
there. The patient did well for the first twenty-four 
hours ; but, after that, the edges of the wound showed 
signs of erysipelas, which extended over all that side of 
his face and neck, bursting most of the sutures, and de- 
stroying a good deal of the union which had already 
taken place. Fie was immediately transferred into the 
erysipelatous ward. Ten days afterwards, the erysip- 
elas had disappeared, leaving the gap, however, smaller, 
since about an inch and a half of union had persisted at 
the angle of the mouth. He says he finds some benefit 
from that much of union. He was then returned into 
Ward 8 ; but he had scarcely been there a few days 
when the erysipelas showed itself again, and again he 
was transferred to the erysipelatous ward. We will 12 
Recapitulation of Surgical Cases. 
attempt nothing more on him until fall, giving his system 
time to improve. I rather think it may be necessary, in 
this case, to resect, on the right side, the horizontal 
ramus to the anterior border of the masseter, so as to 
have all the tissues as loose, almost, as they are in cases 
of resection of the horizontal portion of the bone ; and 
thus be enabled to bring the pared edges together thor- 
oughly, and without straining the sutures. As far as 
he is concerned, he will consent to anything to close 
that gap. 
The Removal of the Left Eye-hall was necesitated 
by a gunshot wound, which had struck the patient from 
the right side, fracturing the bridge of the nose, lay- 
ing open the nasal cavities, the lachrymal sac, the fron- 
tal sinus, and destroying the left lid and eye-ball. The 
pieces of bone were removed as they became detached, 
and the remnants of the eye might have been detached 
by nature, but considering that the other eye might 
become sympathetically attacked, it was thought best 
to remove it. This was done with a few clips of strong, 
slightly curved scissors, the hemorrhage was rather 
slight, and was easily controlled with lint and pres- 
sure. A small piece of the outer part of the upper lid, 
about an inch square, was hanging from the first by a 
small pedicle ; it was preciously preserved, so as to assist 
in the closing of the big gap. It had to be stitched up 
repeatedly, and gave some little trouble because the 
small portion of the orbicular muscle intering into its 
structure would constantly contract and pull on the Edmond Souchon, M. D., New Orleans, La. 
13 
sutures, and cause them to cut through. In course of 
time, it is almost incredible how the bottom of that deep 
gap has been filled by granulation so as to raise it on a 
level with the surface of the sound eye. It has also 
very much contracted around the margins. 
The Case of the Resection of the Superior Maxilla 
and of the Eye-hall was rendered imperative by the de- 
velopment of a sarcomatous growth. It is the subject 
of a separate paper. 
The Amputation of the Arm was performed for a 
spindle-cell cancer of the lower extremity of the left 
humerus. It was as large as the head of an eight year- 
old child, and was ulcerating. The infiltration extended 
higher up than the deltoid insertion. The whole of the 
axilla was filled with engorged cancerous lymphatic 
glands. The Esmarch bandage was applied, and the 
arm amputated above the deltoid insertion, in healthy 
tissues. As soon as the vessels were secured, and the 
constricting band removed, an incision was then made, 
about two and a half inches long, in the axilla, over the 
most salient of the glands ; and, as soon as the gland 
itself was struck, the knife was dropped, and the glands 
were enucleated, and torn out with the fingers Of 
course, they proved to be larger than might have been 
judged from examining them through the skin, the first, 
and largest, being about the size of a small hen’s egg. 
Of course, again, as soon as the first ones were removed, 
still more, though smaller, were found, and in greater 
number than would be expected by one who had not 14 
Recapitulation of Surgical Cases. 
“been there before.” The more we removed, the higher 
we penetrated into the axillary space, and the closer to 
the vein and artery we got. Fortunately, none of the 
glands were attached to any of those dangerous struc- 
tures. All were removed that could be felt, whether 
diseased or not, and however small. The wound in the 
axilla filled up almost altogether within a few days, and 
far faster than that of the amputation. The patient, 
upon leaving the hospital, was particularly instructed to 
report occasionally, so as to have the axilla explored, 
and have the glands removed at once, as soon as they 
can be even suspected. 
The Hand was Amputated for a lacerated wound. 
The thumb and little finger were preserved, and the 
bones sawed through were the second, third and fourth 
metacarpal bones, through their upper third. There 
was a good deal of trouble in securing the small vessels, 
and nothing short of plugging and pressure by bandage 
controlled the hemorrhage after the operation. The 
next day, the pressure was removed, so as not to en- 
danger the vitality of the flaps, and the blood started 
during the day. In spite of all efforts, and the use of 
styptics, the hemorrhage could not be controlled, and 
both the radial and the ulnar had to be ligated by Dr. 
Jamison, then the assistant house surgeon. Professor 
Richardson thought the case one of hoemophilia, to 
some extent, at least. 
Of the Two Amputations of the Thigh, one was per- 
formed for painful stump. He had been first operated Edmond Souchon, M. D., Nezv Orleans, La. 
15 
upon twenty years previously, and had always suffered 
more or less from the stump ; but, within the last two 
years, the pain had increased very much, and he was 
clamorous for relief. The operation afforded it. 
The other amputation of the thigh was on account of 
too short a flap, which ulcerated. Hence the advice 
given to the class to make long flaps, especially near 
joints. 
Of the Three Foot Amputations, the only interesting 
one is the one performed on a colored boy, for frost- 
bite of the toes, extending to the head of the metatarsal 
bones. The line of demarcation had formed. From 
apprehension of sloughing, from the appearance of the 
parts, long flaps were dissected and the bones sawed 
through below the upper extremities of the metatarsal 
bones. After the removal of the Esmarch, the blood 
returned with great slowness into the flaps, and it was 
thick, black blood. It was quite a while, perhaps three 
or four minutes, before the blood reached the end of the 
flap ; quite in contrast with what usually takes place in 
ordinary cases. This condition of the circulation caused 
me much apprehension for the safety of the flaps, and 
so much the more so, as, recently, in somewhat similiar 
case, in private practice with Dr. J. H. Lewis, 
the flaps had sloughed to such an extent that 
a second amputation had to be performed. In 
order to prevent any similar thing, if possible, in this 
case, I decided to make provision for the sloughing, 
which seemed imminent, and I removed another inch or 16 
Recapitulation of Surgical Cases. 
two of the bone. Dr. Becton, President of the Texas 
State Medical Association, and Dr. R. Matas, my chief 
of clinic, were present, and both entertained the same 
apprehensions. In operating through the foot, I made 
no attempt to disarticulate and perform either Lisfranc’s 
or Chopart’s operation ; but simply sawed the bones 
through transversely between the two lines. Any pieces 
of bone, too thin and two loose to have a chance to heal, 
were then removed. Thus, I considered the tarsus as 
a single solid bone, and sawed it through, thereby sim- 
plifying the operation very much. The flaps were 
brought together gently, without tying the sutures tight, 
or applying the bandage tightly in dressing it. Some 
little sloughing occurred at the outer part of the flaps, 
but, fortunately, was soon limited. The little patient, 
finally, made a good recovery, in spite of an attack of 
sub-chronic diarrhoea, which, at one time, reduced him 
very low. 
Such a course, in such cases, is supported by Gross, 
Agnew, Holmes and Erichsen. Those standard author- 
ities do not treat of frost-bite at length ; but consider it 
as a species of mortification from local cause, and, under 
the head of amputation in cases of mortification from 
local causes, they all say that, as soon as the line of de- 
marcation is established, amputation should be per- 
formed. However, Gassalin and Denouvilliers and 
Prof. T. G. Richardson, in regard to frost-bite of 
the toes and metatarsus, take a decided stand against 
operating, thinking that, by leaving the process of elimi- Edmond Souchon, M. D., New Orleans, La. 
17 
nation, even to the elimination of the bones, to nature* 
less loss of tissue ensues than has to be sacrificed by 
amputation, though it may require three or four weeks 
for nature to eliminate the mortified parts. There is 
now in one of Prof. Richardson’s wards, a Negro pa- 
tient with frost-bite of the toes, not extending beyond 
the first phalanges, who has been there four months,, 
and is not yet well. In the case of the amputated boy, 
it was the condition of the soft parts remaining attached 
to the foot that called, we thought, for extensive flaps, 
to save him from a second amputation ; but under ordi- 
nary circumstances, flaps of half the length would have 
been plenty long. The difference between the two 
courses would be the loss of about one inch of foot and 
a gain of two months or more of suppuration ; whereas, 
by non-interference, there would have been a gain of 
about one inch of foot at the expense of two months or 
more of suppuration. The choice of the surgeon lies 
between the two. 
The Case of Epithelioma of the Lower Lip occured 
in a young man, and such occurrences are so rare in 
young subjects, that a small particle of the tumor was 
examined under the microscope, so as to eliminate all 
slim possibility of removing a syphilitic ulcer for an 
epithelioma. 
Of the Eight Anul Fistulas, two were superficial, 
and did not extend to the upper border of the sphincter 
muscle. After introducing a grooved director through 
the tract and internal opening, some cocaine was injected: 18 
Recaftitulation of Surgical Cases. 
into the bridge of tissues to be divided, and the cutting 
was done without any pain at all. In one case, where 
the fistula extended too high up to be able to so 
thoroughly overcome the spasmodic contraction of the 
muscle as to reach the upper part of the fistula, the 
incision of the first was quite painful; whereas, the in- 
cision of the lower part, which had been well injected, 
was cut through without the patient noticing it. One of 
these fistula? extended as high as three inches into the 
rectum. The division of the parts was followed by 
much bleeding, but this was checked by systematic 
plugging of the tract, then of the rectum, and by the 
application of a T bandage over lint and folded towels, 
placed over the anus and perineum. This case is to this 
day troubled with some incontinence of foecal matter 
when these are fluid, or soft, and has to keep his bowels 
costive. If this persists, we may, later, attempt some 
surgical operation to remedy this. Another interesting 
one of these fistulae, is one with a tract of some seven 
inches long, extending from the side of the rectum, 
through the perineum, into the root of the scrotum. It 
was incised throughout, and its whole course explored 
with care, to find any opening leading into the rectum. 
None was found, and the tract being superficial, it was 
thought that this was an exception to the rule, which 
wants every tract around the anus to communicate with 
the gut. The exception was only apparent, though, 
for three weeks later, an opening showed itself at the 
posterior extremity of the tract, running into the rec- Edmond Souchon, M. D., New Orleans, La. 
19 
turn. The regular operation for fistula in ano was then 
performed, and the patient finally got well. 
One Gunshot Wound of the Leg was attacked by 
phlegmonous erysipelas, which destroyed the subcuta- 
neous and subaponeurotic areolar tissue of the anterior 
region of the right leg. The muscles, also, of the ante- 
rior region were partly destroyed, and there existed a 
long cavity, bounded by the tibia and fibula, laterally, 
the inter-osseous membrane behind, and the strong fascia 
of the leg in front, all unyielding structures, which kept 
the walls of the cavity from coming together and uni- 
ting. Upon making an incision from the upper third of 
the leg to the foot, through the flesh of the leg, under 
the skin which laid over it, the bottom of the cavity was 
exposed. The outer surface of the tibia was partly de- 
nuded, but being still white and smooth, we did not 
scrape it. The healing proceeded rapidly, but the pa- 
tient left the hospital too soon to enable us to judge how 
much use of the injured muscles he recovered. 
The Case of Grafting was performed on an old man 
•of 63, weak and debilitated, who, after a bruise of his 
right leg, was taken with erysipelas. It terminated by 
sloughing of the skin ; but a narrow strip of skin of about 
an inch in breadth remained on the anterior and pos- 
terior aspects of the leg, extending from the knee to the 
ankle. At first sight, when he was admitted into the 
hospital, the limb looked so bad and ugly, the first 
impression was that amputation was necessary. For- 
tunately, though, the fascia was not broken through, 20 
Recapitulation of Surgical Cases. 
and the subaponeurotic structures were uninjured. Af- 
ter a few days, the sloughs dropped off, and were clip- 
ped off, and the parts began to look more promising. 
The general condition, also, of the patient improved un- 
der the influence of rest and good food and tonics. 
The parts became covered with granulations, the strips 
of skin stretched, and the loss of substance soon seemed 
to be half repaired. But there it slacked, and at places, 
stopped entirely. It was then that grafting was resorted 
to. Some eight small pieces of cuticle, not extending 
deeper than the mucous layer of the skin, were cut from 
the thigh, by making a small fold with the forceps, and 
cutting the base of the fold with sharp scissors. Each 
piece was carefully unraveled, and its cut surface laid 
on the surface of the granulations. After they were all in 
position, they were covered by a piece of dry lint, and 
a moderately tight bandage applied. This was removed 
some three days afterward, when it was found that all 
but one or two of the grafts had taken. The healing 
of the parts was much accelerated by this procedure, 
which was repeated two or three times by the expert 
resident student, Mr. J. F. Schmittle. 
Of the several Cases of Hemorrhoids, three were in- 
jected with a solution of equal proportions of glycerine 
and carbolic acid. The process proved almost as pain- 
ful as the ligature, both as regards the injection and the 
pain which followed, for twenty-four hours, or more. 
The cases, however, finally got rid of their trouble. 
The only Case of Strangulated Inguinal Hernia was Edmond Souchon, M. D., New Orleans, La 
21 
ably operated on, when brought in, during the night, by 
the assistant house surgeon, Dr. Parkham ; but it was so 
far gone that he died within thirty-six hours. 
All the Cases of Hydrocele of the Vaginal Tunic 
were operated on by incision and packing of the cavity 
thoroughly with carbolized lint. A good deal of swell- 
ing of the testicle followed, but it soon subsided, and 
the cases got well without any particular trouble. 
The Case of Stone in the Bladder was presented by 
an old man of 58 or 59. It was easily diagnosed. The 
urethra was free, and easily dilated; the bladder and 
kidneys unaffected, and the general condition good. 
We operated by lithontripsy, after Bigelow’s method. 
Though the hospital is provided with Bigelow’s lithon- 
tnptor, we prefer to use the fenestrated lithontriptor, be- 
cause it presents a whole opening through the female 
blade, whereas, Bigelow’s presents but a small opening, 
thereby more exposed to such clogging of the blades 
that the withdrawal of the instrument is rendered so diffi- 
cult and dangerous as to wound the urethra in its course 
outward. In fact, one of the gentlemen present remarked 
that that very thing had happened before him, with that 
very instrument of Bigelow’s. Besides, the fenes- 
trated lithontriptor, with the pinion, is lighter in hand, 
and more easily managed, than the heavy Bigelow. 
The lithontriptor was introduced without difficulty, and 
withdrawn eight minutes afterward. The largest evac- 
uating sound was then introduced, also, without diffi- 
culty, and the rubber ball, modified by Thomson, ad- 22 
Recapitulation of Surgical Cases. 
justed to it. The proper working of the ball soon 
sucked all the fragments, very few of which were 
larger than a small cow-pea. The stone was friable, 
and had been almost entirely pulverized. The patient 
was up and about in a few days afterward, relieved of 
all his symptoms. 
The Case of Necrosis of the Tibia formed a kind of 
tunnel, which ran through the upper part of the shaft,, 
forming a canal of about half an inch in diameter. 
By sawing and gouging the anterior wall of this tunnel, 
the bottom was exposed. It soon became covered with 
granulations, and filled up rapidly. 
Of the two Necroses of the Thigh, the first was seated 
at the upper part of the shaft, at the junction with the 
great trochanter. It had been operated on the summer 
before with partial benefit, and it did not suppurate a 
very great deal. It was thought that but little gouging 
would be necessary; but, upon cutting down upon the 
bone, it was found that the whole thickness of the 
shaft had been reduced to about one-third of an inch 
in thickness, and, besides that, the necrosis had ex- 
tended through the whole thickness, there being, then, 
in fact, a solution of continuity in the bone, a sort of 
spontaneous fracture. The extremity of the lower 
fragment was gently forced to the surface, and a half 
inch sawed off; the other end, which corresponded to 
the greater trochanter, was chiseled and gouged so as 
to remove all the dead surface. The parts were immo- 
bilized by a long axillary splint, a portion of which was Edmond Souchon, M. D., New Orleans, La. 
23 
removed opposite the seat of the wound, and replaced 
by two arched rods of iron, which kept the parts in pro- 
per position, at the same time giving free access to the 
wound, above, below and between them, a contrivance 
which reflected much credit upon the ingenuity of the 
resident student, Mr. Bloom, now Dr. Bloom. The 
parts healed rapidly, without any complication. A 
small piece of dead bone came out through one of the 
orifices. At the latest date, one or two openings were 
still discharging, showing that the case was not thorough- 
ly cured. 
The other case of necrosis of the femur was one of 
the lower extremity, with an invaginated sequestrum. 
The lower extremity of the femur, together with the 
lower part of the shaft itself, was twice as large as the 
bone of the opposite side. There was a good-sized fis- 
tulous opening on the inside and the outside of the thigh,, 
about one inch and a half above the tuberosities of the 
condyles. After the application of the Esmarch, an in- 
cision four inches long was made on the outer side of 
the region and down to the bone, which was gouged and 
chiseled to the extent of three inches by one and a half. 
This was done with some difficulty, as the new bone 
was very hard. Upon penetrating into the cavity in the 
center of the bone, a sequestrum was found of about 
three inches in length by one inch in diameter. It was 
removed in several pieces, and the cavity was thoroughly 
scraped. It proved to be quite large—about four and a 
half inches in length by about three in diameter. It was 24 
Recapitulation of Surgical Cases. 
filled with carbolized lint, and a bandage firmly applied, 
before the Esmarch was removed. Sme ten days after 
the operation, the leg became cedematous, and was 
threatened with erysipelas; but it did not develop into 
anything serious, and the healing of the wound progressed 
most satisfactorily. The whole of the interior became 
covered with granulations, leaving no exposed bone, and 
filled up rapidly. At the time my service expired, four- 
fifths of the cavity was filled already, care having been 
taken all along to keep the opening leading into the cen- 
tral cavity well opened. 
One of the Perineal Operations was for numerous 
chronic urinary fistulae, running through the thickly in- 
durated perineum. It was an old Negro, who was lin- 
gering in the hospital, gradually losing ground, and soon 
to die. I hesitated some time before operating on him, 
on that account; but, several times my students drew my 
attention to his declining condition, and I determined to 
try something for him. His canal would admit a number 
8 sound, but the fistulae showed no signs of healing. I 
knew, from past experience, that simply incising through 
the perineum, even in its whole length, in cases with so 
thick and hard an induration, would result in no good, 
as the induration prevented the walls of the fistulae from 
coming together and closing. I decided, in that case, 
to incise the perineum, and then to cut out—dissect out 
—as much as possible of this indurated tissue. This 
course had been suggested to me, some years ago, by 
Professor Richardson, when I was his chief of clinic. Edmond Souchon, M. D., New Orleans, La. 
25 
However good I may think the principle is, the opera- 
tion was more than the old man could stand, and he 
died of exhaustion some ten days after. 
All the other cases of perineal operations were per- 
formed for acute urinary infiltrations. Some two or 
three were performed by the surgeons of the house, as 
soon as the patients came in, after my daily round. 
Those infiltrations formed but small, circumscribed tu- 
mors, and the timely and well performed operations cut 
their development short. Three or four others were 
operated on by myself, having acquired the size of a 
hen’s egg. The others were more extensive. In one 
of them, the infiltration had extended to the scrotum, 
and to the hypogastric region. The penis and scrotum 
showed signs of mortification. Some ten or twelve in- 
cisions through the parts gave free drainage to the urine 
and pus, and stopped the further progress of the disease. 
The sloughed parts were eliminated, having exposed the 
testicles, covered over by the fibrous and vaginal tunics. 
The granulations healed rapidly; and the skin of those 
parts is so thin and loose that whoever saw the case for 
the first time, towards the end of its course, never could 
realize that all the scrotum and the skin of the perineum 
had sloughed off. 
Another case—this one a Negro—was also very ex- 
tensive. The course pursued consisted in laying the 
racts freely open, and exposing the bottom of them; 
such being the rule laid down by standard authorities, 
and emphatically insisted upon by Erichsen, especially. 26 
Recapitulation of Surgical Cases. 
The tracts soon granulated, and presented a healthy 
enough appearance; but the patient gradually lost 
strength, and finally died. In all cases of acute urinary 
infiltration, the incision through the infiltrated parts, and 
the laying open of the tracts, was the first and most 
urgent part of the treatment; but no case was allowed 
to recover from the chloroform before a good-sized me- 
tallic sound was introduced through the meatus and 
down the urethra into the bladder. When necessary, 
the strictures, or obstacles to the introduction of the 
sound, should be cut, externally or internally, or be di- 
vulsed. By passing the instrument daily, afterwards, it 
compels the granulations to heal over it, as it were, and 
i lsures a good canal by the time the perineal wounds 
are healed. By neglecting this part of the treatment, 
much trouble is experienced later—when the treatment 
of the stricture begins—to introduce even a small instru- 
ment through the strictural and irregularly coursed 
canal; besides, the patient has to go through all the 
grades of dilatation. In one case, we failed to get an 
instrument through the vesical end, in spite of all our 
efforts to find that end; but, after the parts had healed, 
it became easy to pass a number 4 through, and the 
gradual dilatation went on. 
The Tzvo Cases oj Circumcision for Elongated Pre- 
puce were sent to us for operation by Professor Elliott, 
who thought the operation of circumcision was the 
proper treatment, in these cases, to cure them of peculiar 
general reflex symptoms, referable to no other cause* Edmond Souchon, M. D., New Orleans, La. 
27 
Cocaine was injected into the prepuce some little time 
before operating, and they stood the operation without 
any pain. 
None of the Tumors Operated presented any diffi- 
culty, and healed well and quick. The case of adenoma 
of the testicle presented an abscess in the inguinal canal, 
but, as soon as the matter was liberated, it got well. 
The patient, however, ultimately died of sub-chronic 
diarrhoea, after the wound had healed thoroughly. 
All the operations were performed without the use of 
the spray; but none but carbolized sponges were used; 
all the instruments were kept in carbolized water, and 
the operator and assistants cleaned and disinfected their 
hands before operating. The lint used was also carbo- 
lized lint. 
Five of the sixty-five patients operated on took erysipel 
as. They were all transferred to the ward set apart in the 
hospital for that special purpose. They all got well but 
one, who died. This is rather an unusually large per- 
centage of erysipelas this year, following operations 
here. 
Of the sixty-five operated patients, seven died, from 
the following causes: One from amputation of the finger, 
followed by phlegmonous erysipelas; one from abscess 
of the liver; one from iliac abscess; one from strangu- 
lated hernia; two from perineal operations, followed by 
exhaustion; one from tumor of the testicle, of sub- 
chronic diarrhoea. 
The following are the points of interest presented by 28 
Recapitulation of Surgical Cases. 
the other classes of patients, which required no opera- 
tion : 
The Case of Femoral Aneurism showed how easily 
and unexpectedly aneurisms will sometimes get well. It 
was in Scarpa’s triangle, and was as large as a hen’s 
egg. In order to demonstrate to the students the effects 
of compression of the artery above the tumor, the ex- 
ternal iliac was compressed three or four times each 
week, and for about five minutes each time. Upon 
coming to his bed one morning, he greeted us with the 
news that the tumor had ceased beating, was hard and 
much smaller. Such was the fact. It was only upon 
firm pressure that a slight, deep pulsation could be de- 
tected. The student of the ward continued compress- 
ing the external iliac artery above Ponpart’s ligament, 
and the patient himself was taught how to do it; this 
was continued for some two weeks—even after all deep 
pulsations had disappeared. The tumor diminished 
rapidly in size, but it was a good while before he was 
allowed to get up and walk about. This did not cause 
the pulsation to return, and, finally, the patient left the 
hospital with the promise of reporting immediately, if 
any beatings returned. We never saw him after that; 
and thus was accidentally and unexpectedly cured an 
aneurism which has required the ligature of the ex- 
ternal iliac, and which has been known to resist even 
that heroic treatment. 
The Case of Arthritis of the Elbozv Joint was of 
traumatic origin. It gave him a great deal of pain, with Edmond Souchon, M. D., New Orleans, La. 
29 
some fever; but, after a few days, the fever abated. 
At the same time, though, he became more and more 
drowsy, with a kind of hemiplegia on the opposite side, 
and finally died in a comatose state. The post-mortem 
showed a thick, almost pseudo-membranous effusion, in 
the arachnoid cavity, and in the sub-arachnoid space. 
The other case of arthritis affected the knee joint. 
It was also traumatic. It resisted all the usual local and 
general means, and gradually grew from bad to worse. 
At one time, we thought there was some pus in the 
joint; but the hypodermic syringe showed that the fluc- 
tuation was delusive. Finally, he was placed under the 
influence of chloroform, and a liquid glass bandage ap- 
plied, but loosely, simply to prevent motion; and an 
opening was cut over the knee. This procedure was 
followed by a marked diminution of all the symptoms, 
and the case kept on improving. Later on, there oc- 
curred, over the patella, a small abscess, through which 
a small piece of bone from the patella was eliminated. 
Upon probing the tract, it was calculated that it extended 
to the cartilage lining the deep surface of the patella; 
and, lest it might ulcerate through and penetrate the 
joint, the bandage was re-applied, and the patient kept 
quiet until the tract healed. He finally got well; but 
the tendons around the joint are stiff—more so than the 
joint itself. 
The Case of Pernicious Anemia, as it is called by 
some, was a marked one. The largest glands were on 
the sides of the neck, where they bulged like turkey’s Recapitulation of Surgical Cases. 
30 
eggs; they extended into the chest and supra-clavicular 
region; there were also some under the arms. He had 
had the tumors cut into by some one, but the physician 
who attended him last, a gentleman from Texas, fearing 
that some one might not recognize the disease, and 
might attempt a bloody, dangerous and useless opera- 
tion, gave the patient a letter of some twenty lines, in 
which he so nicely, clearly and pointedly, described the 
course and nature of the disease, and the danger and 
uselessness of operating, that I read the letter to the 
class, and said that it so covered the ground, in such 
few words, that I found nothing to add to this “clinical 
letter.” Of all the remedies tried in his case, Fowler’s 
Solution gave the best result. At one time the glands 
had almost disappeared, but they afterward regained 
almost their former size, in spite of the use of the 
arsenic. 
Most of the cases of Buboes and Chancroids and 
Chancres were on colored subjects, since the white pa- 
tients have special syphilitic wards prepared for them. 
The students have full access to this ward, where they 
are always welcomed by the surgeon in charge, Dr. 
Underhill. The two professors of Clinical Surgery 
also take the students through that ward, and teach 
them the diagnosis and treatment of venereal diseases. 
Iodoform was the basis of treatment locally. 
The Cancer of the Tongue was not operated upon, 
because of the cachectic condition of the patient. He 
finally died, exhausted. Edmond Souchon, M. D., New Orleans, La. 
31 
„ The Cancer of the Rectum was a limited one, and a 
(f J 
good case for operation, had not the patient, prior to his 
entrance into the hospital, lost so much blood as to be 
in such anaemic condition as to render him unable to 
stand such an operation. 
The Cancer of the Penis was not operated upon, 
because he left the hospital. 
All of the cases of Concussion of the Brain recov- 
ered. 
The Case of Contusion of the Epigastrium pre- 
sented remarkable symptoms of a cataleptic appearance, 
but recovered completely after thirty-six hours. 
The Cases of Eczema and Impetigo were treated 
with oil of chaulmoogra, with marked satisfactory re- 
sults. 
All the cases of Fracture of the Skull died. 
We have abandoned the use of the interdental splint 
in the Fracture of the Lower Maxilla; we simply im- 
mobelize the bone with a liquid glass bandage, passing 
under the chin and over the top of the head. 
The Fractures of the Limbs, not too close to the body, 
were reduced at once under chloroform, and a plaster 
bandage immediately applied, moderately tight. When 
the skin was injured, an opening or more was cut 
through the bandage. This treatment was followed by 
good results in all of the cases. 
The Fractures of the Femur above the Lower Third 
were treated by the long splint, or, oftenest, by the Recapitulation of Surgical Cases. 
32 
weights and pulley, and by short splints around the 
fracture. 
One Case of Fracture of the Upper Part of the Hu- 
merus was also treated with weights and pulley. When 
up and about, the weights were allowed to hang down. 
We think that the result was better, as regards the fol- 
lowing deformity, than when the ordinary plan of treat- 
ment is used. 
The Case of Mercurial Salivation was attributed by 
the patient to Tutt’s pills. 
The Case of Curvature of the Spine was one of the 
extreme kind. He was much relieved by the applica- 
tion of the plaster jacket. 
The Case of Phlebitis began by the internal saphen- 
ous vein, and was a marked and typical case. He was 
a rather unruly patient, and thought he was uselessly 
kept in bed after the symptoms had disappeared, so he 
got up and walked about. Three days afterward, he 
had to go back to bed, his whole limb having swelled 
considerably, from the fact that the femoral vein had 
also been inflamed. However, rest and mercurial fric- 
tures pulled him through. 
The several cases of Phlegmon of the Hand were 
due to callosites over the palmar aspect of the root of the 
fingers. The cases were remarkable at first by the great 
amount of swelling and redness on the back of the handr 
quite in contrast with the absence of any or much 
swelling and redness on the palmar aspect. The tempta- 
tion was to lance the back of the hand, whereas, the cut Edmond Souckon, M. D., New Orleans, La. 
33 
should always be made over the palmar aspect, where 
the disease first begins, and where the puss is located. 
The cut was always made as early as possible, and ar- 
rested the spread of the disease at once; any delay 
might have resulted in phlegmon of the whole hand and 
limb, and even death. 
The same applies to phlegmon of the fingers, and par- 
ticularly of the last phalanx. The cut always extended 
down to the bone, which the knife scraped. Thus bone 
felons were often prevented. 
One Case of Articular Rheumatism was treated by 
the application of a liquid glass bandage, loosely applied. 
It afforded much relief, and was applied to the joints 
successively as they became painful. If the case be a 
particularly acute one, morphine or chloroform should 
be administered before applying the bandage. 
All the Uncomplicated, Cases of Stricture of the 
Urethra were treated by gentle and gradual dilatation; 
no force or violence was ever used, even when it felt as 
though hard pressure would drive the instrument 
through. No metallic instruments were used in masked 
strictures, until the soft instruments had prepared the 
way for them. No lengthy, harsh or bloody attempts 
were made to pass an instrument through a stricture, 
when the patient had just entered into the hospital. 
Preference was given to emptying the bladder with the 
aspirator, if necessary, and giving an opiate. Twenty- 
four hours did much towards relieving congestion and Recapitulation of Surgical Cases. 
34 
spasmodic contraction of the parts, and, the next day* 
allowed the passage of a small instrument. 
Ulcers of all kinds were treated in a general way, by 
rest, iodoform, strapping and bandaging of the limb. 
When the edges were high and hard, they were incised 
in several places, and this assisted the case very much. 
Of the Various Wounds of the Scalp, one was fol- 
lowed by a phlegmonous erysipelas, which destroyed all 
the areolar tissue under the pericranial fascia. The pus 
was fusing towards the eyebrows, and back towards the 
occiput. The insertion of several drainage tubes ar- 
rested the disease, and the patient was finally cured, 
though after a long time. 
The Penetrating Wounds of the Abdomen were all 
diagnosed at the moment of the accident by the able 
ambulance surgeons. Two died and one recovered. A CASE OF RESECTION OF THE SUPERIOR MAX- 
ILLARY BONE, FOR CANCER. 
By EDMOND SOUCHON, M. D., New Orleans, La., 
Professor of Anatomy and of Clinical Surgery, Tulane 
University of La., in charge of Wards. 
On January 8, 1886, Alex. Dykes, a colored man of 
41 years, from Providence, La., entered ward 8 in the 
Charity Hospital. He is a strong, well built Negro, 
and applies for relief or cure of a tumor of the left side 
of the face. 
There is nothing special in the history previous to the 
appearance of the tumor, some eighteen months ago, as 
far as we can ascertain from his dull understanding, 
except that some four months or so ago the tumor was 
operated upon, or simply cut into, of which he bears 
the mark. 
On the left side of the face, exists a tumor extend- 
ing from the upper lip to the lower lid, which is pushed 
up so high as to close the eye, and from the nose to the 
malar bone. The surface of the tumor is ulcerated to 
the extent of a half-dollar silver piece. The tumor is 
rather hard to the touch, and is painless, both upon 36 
Resection of the Superior Maxillary Bone. 
pressure and spontaneously. By examining through 
the mouth, it is found that the tumor does not extend 
beyond the beginning of the pterygoid process. 
The patient was shown to the class on the regular 
clinic day. All the above features were explained to 
them, and the case diagnosed one of malignant disease 
of the superior maxillary bone, having originated, most 
likely, on the antrum. 
The bulging of the tumor on the face, it being on a 
level with the free border or back of the nose, together 
with its reaching in the mouth to the pterygoid process, 
convinced us that it had extended so deep, also, toward 
the apex of the orbit that to operate on him at that 
stage would have been a bloody, dangerous and useless 
operation. I therefore declined to operate. 
During the week that followed, I examined him 
often. He seemed much disappointed at seeing that 
nothing was being done for him, since he had come 
quite a distance, he thought, to find some one who 
would attempt something for him. At my request, 
Prof. Richardson was kind enough to examine him, 
and we came to the conclusion, since it was the man’s 
only shadow of a chance, especially since the success 
depended upon how deep the cancer actually extended, 
if perchance it did not extend beyond the danger 
zone of the deep regions, an operation might be suc- 
cessful in saving his life, or in prolonging it, or in af- 
fording him an easier death ultimately than would be 
if the tumor was allowed to go on ulcerating, develop Edmond Souchon, M. D., Nezu Orleans, La. 
37 
ing, spreading and involving the mouth, throat or cra- 
nial cavity. 
The patient was given a good drink of whisky before 
getting on the operating table, and he was put under 
the influence of chloroform. He took it very well, and 
it was determined that after the removal of the towel, 
when the operation would begin, the anaesthesia would 
be kept up by the use of a throat atomizer, containing 
chloroform, which would be atomized, mixed with air 
and thrown in his throat by means of a long metallic 
tube, which would not be in the way. 
As it was known the operation would be bloody, dan- 
gerous and tedious, all precautions were taken to ope- 
rate quickly, and to have at hand most skillful assist- 
ants, who were Dr. R. Matas, my chief of clinic, and 
my efficient resident students, M. M. Beckham, Bloom 
and Schmittle, together with some other students of the 
staff and class. The knives, saws and chisels had all 
been freshly sharpened. 
As soon as the patient was fully under the effects of 
the chloroform, an incision was made over the malar 
bone, on a line with the spheno-maxillary fissure, ex- 
tending down to the bone, and the bone was sawed ; 
immediately, a dry-pressed carbolized sponge was ap- 
plied over the wound, and kept there firmly, to stop the 
bleeding. 
A second incision was made over the nasal process of 
the superior maxillary, directed from the lachrymal sac 
to the anterior nasal orifice, and down to the bone, 38 
Resection oj the Superior Maxillary Bone. 
•which was also sawed through. The upper lip was then 
cut through, opposite the left middle incisor tooth, 
which was extracted, and then the palatine process of 
the superior maxillary bone was sawed through, without 
previously incising the mucous membrane of the palate. 
The next step was the detaching of the upper lip 
from the tumor, as far back as the ascending ramus of 
the lower jaw. All this had been done without diffi- 
culty, and is usually done quicker than might be sup- 
posed, when the instruments are good and the operator 
has the anatomy of the parts well present to his mind, 
•and is determined not to mind the blood, and to go on 
quickly. As fast as an incision was completed, it was 
covered with a sponge, like the first. 
Here some little trouble and delay were experienced 
in opening the mouth fully, so as to be able to reach the 
articulation of the tuberosity of the superior maxilla 
with the pterygoid process. As soon as the mouth was 
well opened, a sharp chisel was placed between the two 
bones, and, by hard pressure in the right direction, the 
maxilla was finally loosened from its last hold. Quickly 
the soft palate was detached from the hard palate, and 
the lower lid was separated from the tumor. The whole 
mass of tumor and bone was felt to be loose, and was 
■quickly removed with the knife, severing whatever 
points resisted. In doing this, no attention was paid to 
the limits of the tumor, the point in view, at this time, 
being swiftness, as the bleeding was more considerable 
than at any previous time. The cavity was at once Edmond Souchon, M. D., Nezv Orleans, La. 
39 
firmly packed with several dry-pressed carbolized 
sponges, and the patient given a moment’s rest, during 
which time the hemorrhage would stop. Though all 
this had occupied but little time, yet the patient was be- 
ginning to show signs of shock and the effects of the loss 
of blood, which, in spite of all care and attention, would 
trickle down from the table into the pail placed on the 
floor for the purpose of receiving it. 
As soon as the hemorrhage had ceased, the sponge 
nearest the eye was removed, and that organ examined.. 
It was found healthy, but the parts around were dis- 
eased, and it was without any support of any sort, 
either bony or fibrous, all having been destroyed by the 
tumor. The eye was accordingly removed with clips 
of strong curved scissors. 
Now began a most careful review of the field of the 
operation, for the purpose of removing all pieces and 
particles of tissue which looked or felt suspicious. On 
this account, all the degenerated adipose tissue nor- 
mally situated between the ascending ramus and the 
superior maxillary bone was removed with scissors and 
scrapers, as also that of the zygomatic fossa, to the in- 
ternal and external pterygoid muscles ; it was all in- 
vaded by the cancer. In doing this, the middle portion 
of the internal maxillary artery was cut; it bled freely, 
and had to be ligated. 
At this stage of the operation, the patient’s pulse, 
which had gradually become weaker, disappeared at 
the wrist; his breathing was weak and distant; his  Resection of the Superior Maxillary Bone. 
40 
limbs limp. Here a halt was imperative, to revive the 
patient, who was fast sinking. The cavity of the wound 
was packed with sponges, the head was hung down, 
whisky was injected freely into his limbs, the right side 
of his face and the pericordial region were slapped hard 
with the end of a wet towel, and his weak respiration 
was assisted by artificial means. At the end of some 
ten minutes, the pulse had returned, and the operation 
was continued by removing all the degenerated adipose 
tissue and structures in the cavity of the orbit, to its 
very roof and apex ; the sphenoidal sinus being exposed. 
Upon reaching the apex of the orbit, it was seen that 
some suspicious particles still remained ; but they were 
so near the internal extremity of the sphenoidal fissure, 
where the ophthalmic vein—then and there very large— 
opens into the anterior extremity of the cavernous sinus, 
that, for fear of wounding these structures, it was de- 
cided to stop. Besides, at this time, the patient was 
again sinking, and it was impossible to proceed without 
running the risk of the patient dying on the operating 
table. We desisted, therefore ; intending to attempt, 
later, to destroy the remaining cancerous nodules with 
chloride of zinc applications and injections, if deemed 
safe. 
By using the same means as above, the patient was 
revived a second time. The wound was packed closely 
with carbolized lint, and the lip was stitched to its fel- 
low. He was carried back to his bed, but more dead 
than alive. Edmond Souchon, M. 1)., J\ezu Orleans, La. 
41 
For the next thirty hours, he remained between life 
and death ; and it took all solicitude and care, especially 
of Mr. Beckham, the dutiful resident student, to keep 
him in this world. He was laid flat in bed, with his head 
without a pillow, on a level with the bed. He was sur- 
rounded by bottles of hot water; received all over his 
limbs hypodermic injections of whisky, digitalis and am 
monia,was heavily covered with warm blankets, and the 
door and transom near his bed closed. As soon as pos- 
sible, he was given warm milk punch by the teaspoonful,, 
which was allowed to trickle down on the sound side 
of his mouth. From this moment, he began to rally, 
and he improved rapidly, and, three weeks later, 
was sitting up. It could be seen then that some little 
cancerous growths were projecting slightly from the 
apex of the orbit, but to this day they are easily con- 
trolled by repeated applications of chloride of zinc on 
a piece of lint or cotton. Another small growth had 
arisen near the nares, but was easily destroyed by the 
scoop, followed by the application of chloride of zinc. 
Such vigorous measures would also dispose, we think, 
of the small growths near the apex ; but the close prox- 
imity of the cavernous sinus and cranial cavity and 
brain has kept our hand back. When we last saw 
him, he was in as good health as he ever was. He walks, 
briskly all over the grounds all day, subsisting on 
fluid. The cavity has contracted by one fifth, at a rough 
guess. It is evidently much smaller than would be 
supposed, having filled up by healthy granulations, Resection of the Superior Maxillary Bone. 
42 
and by the contraction of the skin over the edges. There 
still remains a pretty large gap, through which the side 
of the tongue will occasionally protrude. 
The teachings of this case are : First, how much hu- 
man nature can stand ; second, that, if the patient had 
applied sooner, all the disease could have been eradi- 
cated, thus increasing very much the chances of cure. 
The whole question of the operation turns upon this 
point: Does the disease extend beyond the danger 
zone, or not? And this is impossible to ascertain, ex- 
cept by operating. The following are some of the in- 
teresting points connected with the history of the resec- 
tion of the superior maxilla : It was John Lizars, of 
Edinburg, who, in 1826, first planned and proposed the 
removal of the whole of the superior maxillary bone ; 
but it was Gensoul, of Lyons, France, who, without 
having had any knowledge of Lizars’ ideas, first oper- 
ated, in May, 1827. Lizars operated on his first case in 
December, 1827. The hemorrhage during the opera- 
tion is often very great; so much so that the previous 
ligature of the carotid has been advised and performed. 
This was done by Lizars in his first case ; and, in spite 
of this, the hemorrhage was such as to necessitate leav- 
ing the operation unfinished. I was present when, in 
the summer of 1881, Dr. Schuppert, Sr., of New Or- 
leans, operated in the amphitheatre of the Charity Hos- 
pital, and the patient died on the operating table, mostly 
from loss of blood. No previous ligature had been ap- 
plied. Several cases of secondary hemorrhage are on Edmond Souchon, M. D., New Orleans, La. 
43 
record, and so serious as to require the ligation of the 
carotid, even as late as the nineteenth day; this last 
case died. There are evidently two classes of these 
tumors as regards hemorrhage—one that bleeds pro- 
fusely, and the other less so. The latter are most com- 
mon ; the former are especially the soft tumors, and 
those which extend beyond the limits of the bone itself. 
However desirable, it is very difficult to say which will 
bleed or not, or how far the tumors extend.