A DOZEN CASES
CLINICAL SURGERY.
BY
WM. TOD HELMUTH, M.D.,
PROF. OF SURGERY IN THE N. Y. HOM(EOPATHIC MEDICAL COLLEGE; ONE OF THE
SURGEONS TO THE WARD'S ISLAND HOM. HOSPITAL, TO THE HAHNEMANN
HOSPITAL, TO THE N. Y. COLLEGE AND HOSPITAL FOR WOMEN;
MEMBER OF THE AM. INST. OF HOM(EOPATHY AND OF THE
SOCIETIES OF MASSACHUSETTS AND RHODE ISLAND;
AUTHOR OF " A SYSTEM OF SURGERY," ETC.
ALBANY:
WEED, PARSONS AND COMPANY, PRINTERS.
1876.








O N T E NT S.
Case 1. Hypertrophy of Clitoris - Amputation - cure.
2. Elephantiasis Arabumn of the right labiuln pudendi.
3. Removal of a large " recurrent fibroid "' (spindle-shaped sarcoma) from the neck; recurrence in three localities.
4. A case of aneurism of the subclavian and carotid arteries,
operated on by ligature of the outer third of the subclavian.
5. Ligature of the common carotid below the omo-hyoid, for
erectile tumor of the face -cure.
6. Resection of shoulder -traumatic tetanus -cure.
7. Resection of the os calcaneum - cure.,
8. Resection of the entire  calcis - amputation of legrecovery.
9. Amputation of tongue — cure.
10. A successful operation for imperforate rectum.
11. Glass tube in urethra -sloughing of scrotum after removal
- cure.
12. Pendulous fatty tumor of thle thigh - removal - secondary
hemorrhage - cure.












CASE I.
Hypertrophy of Clitoris...
witL ConodclyoronLat a.
T~iL_ of V'eed,]Parsoios & Co.Aazrcyy,]T.Y'




SURGICA L CA SES
BY
WM. TOD HELMUTH, M. D.
CASE I.
Hypertrophy of the Clitoris — Amputation- Cure.
Although most of our authors on diseases of women mention the
fact that the clitoris becomes hypertrophied, very little especial attention or comment is given to the subject, the cases being rare and the
reports very meager. When the clitoris begins to exceed its normal
dimensions, herinaphroditism, in one of its varieties, may be suspected.
As a rule, when this organ is larger than natural the patients are
those women who partake largely of the masculine haibit, are rather
prone to the pursuits and occupations of men, have small breasts and
muscular development. In some instances, however, as in the case
now under consideration, this organ may acquire the size of the male
penis, and indeed, in rare cases, become enormously enlarged. It is
said that Paul Lacchias, who was physician to Pope Innocent X,
records the case of a womian whose clitoris was so large that, when
erected during passion, it prevented sexual intercourse.  (Vide
Colombat on Females, p. 84.) Dr. Charles D. Meigs, the editor of
Colombat, also relates a case of enormous enlargement of the clitoris,
under the care of Dr. Norris, of the Pennsylvania hospital. This
case, however, would appear to have been a cyst, for "Dr. Norris
plunged a common lancet into the lower end of the tumor and the
instrument gave issue to a thick, blackish fluid, the consistence of
tar, or thick molasses, and perfectly inodorous." This could scarcely
be called a true hypertrophy of tissue, but probably was an extraordinary development of a cyst, such as I have seen in the prepuce of
the male.
Mr. Shaw, in the London l;ancet for 1852, reports a most extraordinary case. The patient was aged fifty-three years and unmarried.
He says: " On examination an enormous mass was seen hanging
fromn the pubes, and completely concealing the vulva. The, pedicle




6                      SURGmICAL CASES.
measured about four inches in diameter, the lowest portion more
than eight,'and the whole length was at least twelve inches. The
extremity presented a bifid shape, showing that the whole mass was.
a continued hypertrophy of the prepiuce of the clitoris; the inferior
half was covered with a great number of wart-like tumors, varying
from the siz'e of a pea to that of a filbert; the masses felt hard and
resisting and gave no pain." This case was cured by excision. In
many respects the record of the above is similar to my own case.
Mr. Henry Thompson also relates a case in which the tumor
reached to within two inches of the knees; it was firm and lobulated,
with a circumference at the pedicle of fifteen inches, and twenty-nine
inches and a half around its base, and weighed three pounds and thirteen ounces.
The case to which I desire to call attention was that of a colored
woman, aged thirty years. She was born in Yirginia; had been
married three years; had three children, and had contracted syphilis
from her husband. The nymphbe were enormously enlarged, and projected beyond the external labia, which were also swollen. The clitoris was singularly cylindrical in shape, having a length of four and
a half inches and a circumference of three inches. Several pedunculated condyloinatous growths, varying in length.frorn one to three
inches, projected from the labia minora. The perineum was thickly
studded with these growths, which extended backward to the anus.
Complicated with this affection were painful external hemorrhoids.
The patient passed weeks without an evacuation and was in constant distress.
Strange to say, however, this woman was earning her living at
service, being obliged to stand upon her feet most of the time; she
suffered terrible pain during urination, with severe aching in her
bones, chiefly at night. She was also much exhausted from  the
bleeding of the tunlors., The condylomata and the clitoris were
pedunculated and covered with unhealthy mucus, and, owing'to the
irritation consequent upon walking, were constantly bleeding.
She was ordered (until she could be received into the hospital) to
have frequentsitz baths, farinaceous food, no meat, compresses saturated with one part of tincture of thuja to eight parts of water
externally, and thuja 3d internally, gtt. iii. three times a day.
This treatment produced great benefit, especially to the condylomata, but no change was noticed in the clitoris: I accordingly drew
the organ forward and removed it with the ecraseur. The condylomata were ligated and excised, and the patient left the hospital
cured.




SURGIC&L CASES.                        7
The accompanying cut, taken from  an accurate photograph, will
show the size and appearance of the clitoris and the numerous and
enormous condyl.omata.
CASE II.
Elephantiasis Arabum of the Right Labium Pudendi, a Foot in Length and
Twenty Inches in Circumference.
The case which I am about to report is one which I am persuaded
is not often encountered by the surgeon. It is, strictly speaking, an
elephantiasis arabum of the' right labium externum. I append the
word arabuhm, not only because it is the term employed in the new
nomenclature of the Royal College of Physicians and Surgeons, but
in order to distinguish it from the elephantiasis graecorum or leprosy,
known in India by the name of jazam or juzam, a very different
affection.
Tile disease under consideration is classed by most authors, as Tilbury Fox, Rayer and others, as one of the hypertrophies of the same
genus as ichthyosis, keloid and fibroma, and by Paget as cuztaneous
outgrowths, which appears but another name for the same pathological state. He says, " The best examples of cutaneous outgrowths,
of which, as I have said, a second division of the fibro-cellular outgrowths is composed, are those which occur in the scrotum, prepuce,
labia, clitoris and its prepuce, and not unfrequently in the lower
limb.  These, which reach their maximum of growth in the huge
elephartiasis scroti of tropical countries, consist mainly of overgrown fibro-cellular tissue, which, mingled with elastic tissue and
more or less fat, imitate, in general structure, the outer, compact
layer of the cutis.  Their tissue is always closely woven, and very
tough and elastic; in some cases it is compressible and succulent, and
it yields on section a large quantity of serous looking fluid.'"  He
speaks also of the great enlargement of the veins, which he noticed
in a specimen under examination. I have given this brief quotation
from Paget, because it covers exactly the appearances of the tumor
after its removal, which was accomplished only after a prolonged and
very bloody operation. The specimen is a beautiful example of
hypertrophy of the derma, with the pouring out of a homogeneous
serum or blastema, in some parts so profuse that when, before the
operation, the needle of an aspirator was thrust into the tumor, about
a tablespoonful of a clear, limpid fluid was drawn into the receiver.
It is said that inflammation of the lymphatics constitutes the first
stage in this affection. These, therefore, being arrested in their




8                      SURGICAL CASES.
function, the lymph remains to be appropriated to the tissues, thus
rendering them hypertrophic. Another of the chief peculiarities in
these cases is the enlargement of all the veins, and the extremely
patulous condition of their mouths, together with an enlargement of
both arterial and venous capillaries. The bleeding is always most
profuse, and often dangerous, when these tumors are removed after
they have attained any magnitude; and no one can read over Allan
Welb's description of the amputation of the scrotum for elephantiasis arabum without seeing at once the great danger to be apprehended from hemorrhage.
Cases of elephantiasis scroti, and of " tropical big leg" or " Barbadoes leg," are frequently encountered, and scattered throughout the
medical journals can be found the records of numerous cases. But
although in many works the fact is mentioned that this form of
hypertrophy can and does affect the labia, so far as I have been able
to examine the varied books I have in my possession, I can find but
very meager records of such an affection.
Thomas, in his Diseases of Won2an, merely says: " Elephantiasis
of the labia differs in nothing from that of other parts. The affection is very rare. Kiwisch records one case in which both labia
increased in size to equal the head of a man, and to fall nearly to the
knees.  The parts affected by it are the labia majora and minora and
the clitoris."  I find also a case reported in an old number of Rankin, by Dr. O. Ferrall, to the Dublin Pathological Society, in which
a species of cellular pendulous tumor, seven inches in circumference,
was removed from the left labium. The hemorrhage was profuse.
Dr. Eve, in his Remarkable!Cases in Surgery, records a case of
" excision of the external labia pudendi for sarcoma." This no doubt
was a case similar to those now known as elephantiasis; indeed, in
some instances the disease has been called, especially by Mr. Abernethey, "vascular sarcoma."  After relating the history of the
patient, the surgeon (Simeon Bullen, Esq., of London) thus writes:' On removing the left labium, the discharge of blood was so rapid
and profuse, and the vessels so numerous, that before I could succeed
in securing them, fainting had taken place, and the effect on the
system was so alarming that I was obliged to postpone for many
days the operation for removing the other, which was attended with
similar loss of blood. The substance of each tumor was composed
of adipose and fleshy tissue, numerously supplied with blood-vessels."
Many of the works on surgery do not mention this -variety of
hypertrophy as affecting the vulva, although they give descriptions
of the disease as found in the leg and scrotum. Velpeau records the








CASE 11.
Elephantiasis of Labiu-m  Pudendi.
IFootiLenght.20 tIces am GiTcumference.




SURGICAL CASES.                       9
case of a girl whose left labium was affected with an: enlargement
(hypertrophia).  Bryant merely alludes to the fact of a case coming
under his observation, and Holmes gives about a page to the consideration of the disorder - I mean as affecting the parts in question,
for he has further on, in the same volume an extended article on the
subject of elephantiasis arabum, in the which is given a table of one
hundred cases, in which not one is recorded as affecting the labia.
The majority of surgical writers do not mention the affection at all.
With these imperfect remarks I will proceed to a brief record of the
case. On February 7th, 1875, the patient, Mrs. X., was sent to the
hospital by Dr. Wetmore for operation.  Continuous with the right
labium there appeared a huge, fleshy mass (see cut), dark in color,
sparsely covered with hair, rugous onl the surface, with here and
there a deep fissure. From the elastic nature of the tissues, and the
infiltration of serum in some parts, there appeared to be distinct fluctuation, which, indeed, I have even known in certain varieties of
fatty outgrowths.  The doctor explored the tumor with a trocar,
passing the instrument into the growth " up to the handle;" a profuse stream of blood flowed through the canula.  This operation was
repeated a second time with like result'. When she came into the
hospital, aspiration was resorted to, and, as has been before remarked,
about a tablespoonful of serum was withdrawn. A second puncture
yielded no result. This serum, as I discovered afterward, found its
bed between the meshes of the tissue, for the tu.or was solid throughout, but when cut, into, quite an amount of serum would immediately
trickle away, though there was apparently no break in the substance
of the tumor. Upon careful measurement, the growth was found
to be twelve inches in length, and over twenty inches in circumference, globular in shape, and almost painless when handled.
The patient had been unable to move about for a long period, nor
could she retain her urine, the weight of the mass keeping the meatus continually open.
After due consultation, it was deemed advisable to attempt the
removal of the mass. The best method of so doing was a question.
To apply properly Esmarch's bandage to a globular tumor is no easy
matter; and as it is necessary, in using the elastic, to have each turn
properly overlap the other, to drive all the blood back, I relinquished
the idea, fearing the bandage might slip at a critical moment.
I did not think the ecraseur safe where such profuse hemorrhage
was to be apprehended, and although the heated wire presented some
points for consideration, I finally adopted, as a preventive, Erichsen's
double thread, as used for naevus. This was applied as follows:




10                     SURGICAL CASES.
Taking a stout needle, it was threaded with a strong hempen cord,
about four feet in length. One-half of this cord was blackened and
allowed to dry; then, having raised the tumor, the needle was passed
upward' through the pedicle (which was over six inches in breadth),
and brought out on the upper side, and the thread drawn almost
through. The needle was then turned, entered on the upper side,
about half an inch from its place of exit, and drawn through on the
lower side of the tumor, leaving a loop. So this method of stitching
was continued until the whole pedicle was traversed. The pedicle,
as I term it, was nothing more than the margin of the labium. The
white loops were all cut at the top, and the black ones at the bottom; the white ends of the thread tied tightly together above, and
the black ones below. Not satisfied with this; and for a more thorough protection against sudden and exhaustive hemorrhage, a second
row of similar stitching was placed half an inch lower down. Having now the tumor held up, in order to take off all strain on the
threads, with a very l&rge scalpel I rapidly severed the growth. The
bleeding, as the knife went through, and for a moment after, was
terrific; the blood shot up in a stream which caused an exclamation
from the bystanders. A good deal of this, however, was venous,
and had been held in the tumor by the superimposed ligatures.
After this a steady flow with jets and spurts kept up. Thirty-two
vessels were ligated, and Dr. Burdick (who is a remarkable bandager),
after having covered the wound with styptic cotton, and placed over
this a wad of tenax, firmly applied a T bandage, and the patient was
put to bed. The next morning she had scarcely begun to rally from
the terrible shock of the operation, when, upon examination, I found
she was bleeding again. The blood had soaked through the bandages and into the bed. All the dressings were removed, and eleven
more ligatures applied. This effectually checked the hemorrhage,
and from it there was no further trouble. The patient reacted very
slowly, indeed had constant nausea foir several days, and could retain
nothing on her stomach. Nutritive enemas were given her, but she
finally sank and died on the 23d day of February.  Dr. Wetmore,
Dr. Thompson, Dr. Burdick and Dr. Cranch irendered most effectual
assistance during the operation.
CASE III.
Removal of a Large "Recurrent Fibroid" (Spindle-shaped Sarcoma) from
the Neck; Recurrence in three Localities.
It is not an easy matter in these days to reconcile all the varied
terms which are applied to tumors; not only because the significance




'SURGICAL CASES.                       11
of such terms is constantly changing, but because different authors
have arranged and classified tumors according to their own especial
observations, and also because new investigations are daily demonstrating new facts belonging to "tumor tendencies," if I may be permitted to use such a term.
For instance, in the so-called semi-malignant groups, as well as in
the entirely heterologous formations, auto-infection of the surrounding tissues of gland substance, or of the contents of the splanchnic
cavities, has been found to differ materially; one variety having
apparently a more specific tendency to invade certain structures than
others.  When this sympathy is more perfectly understood and demonstrated, which, in time, it undoubtedly will be, then a more precise
classification of all tumors will be arrived at, and each formation
placed where it belongs, according to the peculiarities of its infectious
tendencies. " Now these discoveries are in the flower-state; the fruit
period is not yet."
It is a generally accepted fact, at the present, that all the tissues
of the lhuman body are developed from  one or other of the three
embryonic germ layers, and that each layer has its specified function
in the production of certain tissues, and that this law holds good
throughout life. The so-called innocent, benign, non-malignant, or
homieoplastic new growths may be considered as the proliferation of
cells of one or other of the mother tissues, whereas the malignant or
heterologous formations are composed of entirely new cellular elements, by what are termed wandering cells, leucocytes or the " indifferent formative cells" of Billroth, having their origin in the blood.
These latter are especially noted in what are termed the " connective
tissue series."
On this basis a part of the classification of tfimors into innocent
and malignant is founded, which, together with an observance of the
life, course, and termination of abnormal growths, will generally lead
the student to a correct diagnosis of thel'more perfect forms of each.
Thus -the tendency to infiltration, to ulceration, to hemorrhage, and
to recurrence after removal, mark the malignant, while the reverse
is true of the homceoplastic varieties. But, between these two great
divisions, there exists a third variety which often partakes of tile
nature of both, and it is this that renders it almost impossible to draw
the exact line of demarcation between the one and the other, enabling
us to sav, "here ends the benign, and here begins the malignant,"
and vice versa.
Another obstacle encountered in describing certain tumors is the
different nomenclature adopted by different pathologists. Thus the




12                      SURGICAL CASES.
"myeloid tumor" of Sir James Paget, is " the giant-celled sarcoma"
of Virchow; "the recurrent fibroid " of Paget is the "' spindle-shaped
sarcoma " of the German pathologists, or the fibro-plastic of Lebert;
"the sero-cystic sarcoma" of Brodie, include "the glandular proliferous cysts" of Paget, to which we have added a very great variety
of sarcomata, as mucous-sarcoina, net-celled sarcoma, granulation sarcomna, alveolar sarcoma, pigmentary sarcoma, round-celled sarcoma,
and so on ad infinitum.
If we add to this, the difference in the acceptation of the term
"sarcoma," another difficulty.will be presented. The term may
mean: (and was for a time so understood) " fleshy; " then, again, it
was used to express the myorna or muscular formations; afterward,
a sarcoma was a species of growth composed of an extraordinary
preponderance of cell elements, and deficiency of alveolar substance;
and, finally, the Germans especially apply it " to the series of connective substances, which are distinguished from the tumors formed of
the connective tissues, by the preponderating development of cell
element."
By sarcoma should be understood a matrix or stroina, intermediate
and surrounding cells of varied character, the precise character of the'cell-element giving the peculiarity to the formation, hence the diversity of names. It is from the great variety of these elements that
Paget objects to the term, for he says: "After a careful consideration of the matter, we are inclined to think that the group is too
vague, and is made to embrace tumors which are too diverse, both in
color, consistence, vascularity, structure, mode of growth, seat, course,
and effects on the patient, to be included under one common term.
We. are not prepared, therefore, to employ the term' sarcoma' in the
classification of tumors, for we believe that the morbid growths,
which have been ranked under that name, may be more satisfactorily'and precisely arranged under one or other of the heads employed in
these lectures."
It appears, however, that the term "recurrent fibroid " is rather
too vague for application to that class of tumors which we are about
to describe, and that the classification, according to the peculiarity of
cell formation, is more definite and precise.
The chief characteristics of the spindle-celled sarcoma appear to
be as follows: First, their almost invariable tendency to recurrence
after removal; such re-appearance not being attributable to any
portions of the tumnor which may have been accidentally allowed to
remain in the parts. Second, they generally appear at the site of
the former wound, as well as in other portions of the body. Third,




SURGICAL CASES.                       13
their growth is slow at first, but afterward they enlarge with greater
rapidity. Fourth; they give but little pain, and life is nat threatened
by them for a long time, unless (which most frequently happens)
local causes cause danger and death. Fifth, the superjacent skin is
not involved, nor does it proceed to ulceration, unless such solution
of continuity is produced by tension and consequent deficiency of
circulation.  Sixth, they are hard, lobulated, and often immovable,
appearing to be firmly attached to' the aponeuroses and fibrous
sheaths. Seventh, they do not infiltrate the tissues surrounding
them, nor do they produce the cachexia found in cancers. Eighth,
their structure appears to resemble somewhat the natural tissues of
the body, but the cell-element is rudimentary, incomplete and preponderating. Ninth, the ofteiler they recur, the more succulent and
soft do they become, and the more rapid is their growth. Tenth, the
cells composing them are spindle-shaped, and caudate, often with
attenuated processes, with large nuclei. There may be, also, free
nuclei scattered throughout the intermediate cellular substance.
Eleventh, the hardness or softness of spindle-celled sarcoma consists
in the deposit of fatty particles in the one variety, and their absence7
in the other.
The case which I am about to record is one of considerable interest,
because of the simultaneous appearance of three tumors, after the
complete extirpation of the first, and of the train of pressure symptoms which were gradually developed. The patient, Ella S., was
about twenty years of age, and healthy in appearance. Her father
partakes of the rheumatic diathesis; her mother died of phthisis
(that disease being hereditary in that branch of the family). She has
enjoyed average health from childhood, excepting a severe attack of
scarlatina, occurring during her fourth year, from which she is said
to have made a complete recovery. From a careful inquiry, I cannot
find that she ever received an injury of the neck, or that there was
an appearance of any abnormal growth, until about two years prior
to the date of operation. About that period, a tumor appeared near
the center of the right side of the neck; it gave but little inconvenience and no pain, and scarcely attracted notice.  After a time, however, as it slowly enlarged, occasional difficulty of deglutition called
more critical attention to the growth, which had considerably increased
in an upward direction.  In addition to the above unpleasant symptom, there were paroxysms of great dyspncea; both of these symptoms being produced by pressure on the cesophageal branches of the
vagus, and the inferior laryngeal, or recurrent branch. The suffo



14                      SURGICAL CASES.
cative paroxysms increased until life was in peril, the growth of the
tumor also proceeding with marvelous rapidity.
In consultation with Dr. Banks, of Englewood, whose patient she
was, it was decided that nothing but operative measures could prolong her life, and though the season of the year was rather unpropitious (it being midsummer), the day was appointed for the operation.
The tumor at this time extended from' the mastoid process of the
temporal bone, bordering closely the ramus of the inferior maxillary,
to the margin of the clavicle, and from near the mesian line of the
neck to a point'about half an inch beneath the anterior border of the
trapezius. The sterno-mastoid'muscle crossed it diagonally, and from
the pressure consequent upon the protrusion of the growth, had
become much attenuated. The external jugular vein, from the same
cause, was reduced to a mere thread. The tumor was distinctly
lobulated, hard, and most firmly fixed —a condition which renders
every surgeon more careful in his methods of procedure; in fact, it
is recommended by some distinguished authorities that this immobility should decide the'question of surgical interference, especially
in parotid tumors.
On Saturday, July 12, 1873, which proved to be one of the hottest
days of the heated term, the tumor was removed; Dr. Banks, a skillful surgeon, Dr. Robinson, Dr. Baldwin, and Dr. Morris, of Englewood, being present and assisting.
The patient was placed on the table about noon, and ether administered.  There were suffocative paroxysms during the first period
of anvesthesia, which, however, gradually passed away.
The head was placed in a position similar to that for ligation of
the carotid, and an incision three inches long made along the anterior
attenuated border of the sterno-mastoid, from the angle of the jaw
to lower border of the thyroid cartilage. The tumor was so immovable that I determined, on account of its peculiar situation, to give
myself all the room that I could, and to make a crucial incision, if
necessary, to afford facility in getting underneath the growth.
The fascia were cut through and' the sterno-mastoid held aside;
finding, however, that the tumor lay beneath the deep cervical fascia,
and that the sterno-mastoid was attached, I divided it with a transverse incision. The next step was the transverse division of the anterior fibres of the trapezius, which was accomplished upon a director.
This allowed a free and full exposure of the upper surface of the
tumor, which was laid bare after a tedious dissection. The next
step was to dislodge it from its base. Beginning with the posterior
border, the handle of the scalpel was introduced beneath it. The




SURGICAL CASES.                      15
adhesions were extremely dense, and repeated touches of the knife,
the use of the director, the fingers, and the handles of instruments,
gradually raised it until we discovered its connection with the sheath
of the great vessels. Having, thus far, loosened' the tumor from. the
posterior side, the adhesions on the anterior borders were attacked in
the same manner; they gradually gave way until the tumor was free,
excepting its line of connection with,the sheath of the carotid and
internal jugular. Having then a finger placed on the carotid as it
passed under the tumor, ready for compression, if necessary, the dissection was carefully continued from below upward until the growth
was removed, taking with it the external portion of the sheath of the
great vessels of the neck.
It is unnecessary to say that this was both a trying and tedious
dissection; It occupied nearly two hours, and the heat was overpowering. There were six ligatures applied, but there was no serious
hemorrhage, excepting for a short time, fronf a prick of the internal
jugular; continued compression stopped this. The wound was
brought together with silver sutures, and the patient progressed without untoward symptoms, excepting a slight convulsive cough, for
three weeks, when a swelling showed itself in the site of the wound.
In a few days a second growth was developed on the left side of the
neck, in a positior precisely simnlar to that occupied by- the fist
tzuor, viz., beneath the- sterno-mastoid.  Then were presented a
train of peculiar and most unfavorable symptoms? Ptosis of the
right lid; insensibility of the pupils and diplopia; then numbness
of the right side of the face, which was followed by deafness of the
right ear; these symptoms increased, until finally the eyeball began
to protrude from the orbit. Distressing paroxysms of cough then
were present, and to add to the suffering of the poor girl, difficulty
of deglutition again ensued. At this time, bulimnia of an actually
fierce character superseded, with rapid and great emaciation. The
tumor on the right side was, when last heard from (February 22),
still growing, but was much softer than the former growth (a characteristic of this variety of tumor). The eyeball was being pushed
further out from a tumor of the orbit. Severe neuralgic pains, and
sleeplessness also, are present, which she relieves by taking from five
to six grains of opium per diem.
The presenting symptoms are of great interest, showing the pressure
on the nerves of the eye, and the interference with motor branches
of the vagus, the iesophageal and inferior laryngeal.




16                     SURGICAL CASES.
CASE IV.
A Case of Aneurism of the Subclavian and Carotid Arteries, operated on by
Ligation of the Outer Third of the Subclavian.
John R. Jones, aged forty, native of Wales, formerly a soldier in
the British armuy, and lately a quarryman at Pultney, Vermont, was
admitted to the New York Surgical Hospital, November 2d, 1874,
with a large aneurism of the right subelavian artery. He stated
that he had always enjoyed good health, but had once suffered from
syphilis, of which he had had no symptoms for seven years. About
twelve months before admission, he noticed a change in his voice,
which became disagreeably husky, and about the same time his attention was called to his heart, the beating of which was distinctly audible to himself when walking alone. Sometime in August, 1874,
after a. hard day's work at the quarry, he first noticed a lump at the
root of his neck, and began to suffer pain, which deterred him from
work for a month, when he resumed his labor for two weeks, but
finding that the tumor, and the pain from it, were both increasing,
he quit work altogether.  Coming to New York very soon after this,
he was sent to Bellevue Hospital, and not admitted. He was then
referred to Prof. Helmnuth, who examined him before the clinical
class, and sent him to the hospital for treatment.
On admission, the patient walked stooping; his appetite was good,
his excretions normal, except that his urine was of a deep claret color,,which, he said, had been clear only while he was under the iodide of
potash, which he had formerly taken for his syphilis. Pulsation
and bruit in the tumor were very well marked, pulse at right wrist
feeble, pulsation in both carotids alike. Temperature of right hand
higher than that of left, both subjectively and objectively. There
was partial paralysis of right hand, numbness of fingers, and frequent attacks of neuralgic pains along the course of the nerves of
the shoulder and arm, increased by pressure on the tumor. Height
of tumor above clavicle 11 inches; lateral extent, from  notch of
sternum  outward, 3, inches. He was put upon low diet, kept in
bed, the bowels freely moved by podoph. 1, and tinct. of veratrum
viride in five-drop doses.about every six hours; to keep the pulse
below 70.
After a few days, digital pressure was tried at root of neck, on
cardiac side of tumor; this was at first painful, but. afterward better
borne; the pressure was applied for five minutes at a time, three to
five, times daily, for three days, when the pain increased so that it
could not be borne, and it was discontinued, and potass. bromide




CASE 1V.'.A
Heart shewing Double Aneurism.
lB. Carotid and (A) Slbclavmian.
C. Point of Ligation.
Ti-,i of -\Seed,-Prsoxs  & Go. barxy,BT.








SURGICAL CASES.                    17
given at night for several nights, but without marked result. The
pulse was kept at from 60 to 68, by the use of Norwood's tincture
of veratrum viride in seven-drop doses every six hours.
November 13. - Morph. sulph., - grain hypodermically, was used
with very good effect in quieting the patient.
November 16. - The tumor was observed to be enlarging rapidly,
and the pain in shoulder and arm becoming more intense, and it was
found necessary to increase the dose of veratrum viride, and to use
the morph. sulph. oftener, employing Magendie's solution (16 gr. to
8 dr.), 10 minims every night, given hypodermically, and the patient
got along with tolerable ease for three days more, suffering at times
from dyspncea and nausea.
November 19.- The tumor was found to have extended so much
that now it measured, laterally, five inches, an increase of one and a
half inches mostly in a few days.
It was then decided to resort to operation, and accordingly, at
half-past three P. M., November 19th, the patient being under ether,
and in his own bed, Dr. Helmuth proceeded to operate, assisted by
Drs. Liebold, Thompson, MacDQnald, Doughty, Abercrombie and
Cranch.
An incision was carried along the upper border of the clavicle,
from the sternal articulation of that bone, to the border of the
trapezius, which was met by another extending from the cricoid cartilage to the internal end of the first.'This flap was dissected up,
and a few small vessels ligated. The platysma was then divided
and turned back, and a director passed under the sterno-mastoid, but
as darkness caine on at this time, it was decided to defer the continuance of the operation till the next day; so the director was withdrawn and the flap replaced without sutures, the wound dressed with
lint saturated with cosmoline; and Magendie's solution 14 minims,
injected at ten minutes past five P. M. At half-past six p. M., a considerable venous hemorrhage commenced, apparently from a wound
of the external jugular vein; and was controlled at once by pressure, which was kept up by the finger till all oozing ceased, when a
graduated compress of lint wet in ice-water was applied, and held
by adhesive straps. The hemorrhage commenced again in about an
hour, and this time was effectually controlled by wetting tlie compress with tinc. ferri. persulph. and replacing it. Toward morning
the patient took a little tea and a biscuit, and at twenty-five minutes
past five A. M., Magendie's solution, 12 minims, was injected. At that
time there was great pain in the arm, the pulse was 104, the pupils
contracted, but the right pupil more than the left. The patient could
3




18                    SURGICAL CASES.
not pass water, and the catheter was used successfully. At twentyfive minutes past ten A. M., November 20th, Dr. Helmuth proceeded with the operation, assisted by Drs. Thompson, MacDonald,
Doughty and Cranch. The patient being put under the influence
of ether, the sterno-cleido-mastoid, sterno-hyoid and sterno-thyroid
muscles were divided, and the omo-hyoid hooked up and held aside,
this brought the carotid full into view, and being traced downward,
the attempt was made to reach the innominate artery, but it appeared
to be too much enlarged to admit of ligation.
The incision then was extended laterally, and the anterior border
of the trapezius divided. The external jugular was divided and
tied, and the tumor came thus distinctly in view after considerable
difficulty, occasioned by the size of the tumor and the depth of the
wound. The subelavian artery was tied in its outer third, beyond
the'tumor, and outside the scaleni. The wound was closed by silk
sutures, and dressed with lint, wet with coslnoline. The ligatures of
seven small arteries tied during the -operation were brought out of
the wound, and fixed in position.
The patibnt bore the ether very well, and began to rally by three
P. M., when the catheter was used, and repeated at eight P. M.,
after which the patient urinated freely, and the catheter was not
again required.
The pulse, just after operation, was 112, and rose rapidly to 136,
when eleven drops of Norwood's tincture -were given, and the rapidity of the pulse declined, till at eleven. P. M., when it was 120, and a
few hours later 114, per minute; the respiration ranging from 24 to
22 per minute. The temperature at this time could not be taken,
on account of a defective thermometer, which, however, was soon
exchanged, and correct observations kept. Great pain in swallowing
was complained of, from the section of the sterno-hyoid and thyroid
muscles, so that, after one or two trials, the patient refused to swallow
even water, which he only took to moisten his mouth.
November 21. - First day after the operation. To-day the patient
complained of " tightness" in breathing, and difficult expectoration;
in the evening he spit a few drops of blood; through the whole day
he was unable to swallow, and was supported by injections of strong
beef tea,per antnm - a half pint every three hours; the pulse averaged 118, and there was very little complaint of pain in right arm; the
wound was dressed twice, and supplied but little pus; the pulsation
in the tuzmor'was much lessenel, and the tumor felt harder to the
touch; the superficial tenderness was great in the whole region of
the pulsation.




SURGICAL CASES.                      19
November 23 and 24. - Third and fourth days were much like
the second; on the morning of the third day, the power of deglutition returned; the patient was kept quiet by the moderate use of
Magendie's solution hypodermically; but generally on, waking from
it, he complained of shocks as of electricity passing through him,
and a general "itchy" sensation.
The wound was dressed every ten hours, and oftener as suppuration became more free, while the pulsation in the tumor regularly
decreased in force, the tumor itself became harder, and the superficial tenderness less.
The principal dressing used was cosmoline, spread on lint, at first
adding a little balsam peru, and spraying the wound with dilute carbolic acid, until the granulations became too tender, when cosmoline
alone, on lint, was used. The rectangular corner of flap mortified,
and was removed by scissors. On the afternoon of the fourth day,
the radial p2ulse in right arm could be felt, for the first time. The
pulse ranged from 100 to 110, respirations 14 to 18, temperature,
981~ to 101~.
November 25. - Fifth day. General symptoms the same, complains of tight breathing, and bile in stomach; by means of enema,
he had a free and healthy evacuation from the bowels, and a few
doses of tart. emet., Y0, relieved the difficulty of expectoration.
November 26. -Sixth day. The stitches that were used to close
the wound began to give way, and were removed; the flap retracted
somewhat, its surface continued very sensitive, -and a spot of scarlet
redness appeared over outer corner of wound, but did not spread.
The pulsation in the tumor was very decidedly less, and apparently no greater than would naturally be communicated to it from
the neighboring carotid artery.  Cough very much less, and the
whole condition improving; the patient says he feels better and
stronger.
November 27. - Seventh day. After a comfortable day, the patient,
at seven P. M., had a chill for about ten minutes; preceded and accompanied by a slight oozing of dark blood from center of wound; this
was easily stopped.
The temperature just after the chill was 101Q, the pulse rapidly
rose from 112 to 128, and two doses of aconite 30 were given, a half
hour apart, and after the last dose the pulse was 118.
At half-past nine P. M. Magendie's solution, six minims, was injected; at midnight pulse was 118, respiration 16, temperature 102~,
patient sleeping.




20                     SURGICAL CASES.
November 28.- Eighth day. At half-past two A. M. the wound
was dressed as usual, and the patient moved into a comfortable position, when, before the wound was closed, hemorrhage began from
middle of wound, and styptic cotton was applied at once, with compression; checking the flow, which, however, recommenced twenty
minutes later, the blood spurting in a jet several inches high from
center of wound; this time it was bright arterial blood; before, all
the hemorrhage had been of dark blood. Compression was instantly
applied, and styptic cotton freely used; the pulse became rapid and
very weak; a cold sweat broke out on the extremities; patient
wanted to be covered, but still-felt hot. The active hemorrhage soon
stopped, but some oozing continued for nearly an hour, when it
stopped entirely, and compression was removed.
The pulse was now 140, weak and intermittent, respiration 22,
temperature 9642.
At forty-five minutes past three A. M., patient spit up a large clot of
blood, the pulse declined to 120, but again rose to 130; patient was very
thirsty, drinking but little at a time; at half-past four he spit more blood.
At five A. M., he was asleep, pulse 120, respiration 20, temperature 951~; at seven A. M., very drowsy, pulse 112, respiration 18,
temperature 95'~.
At twenty minutes past eight A. M., the external clot was so softened that the hemorrhage again broke out, and continued in an uncontrollable stream for ten minutes; at forty-five minutes past eight
theapatient died, having been conscious all the time, and suffering
greatly in the last half hour.
A post-mortem examination was held at half-past three P. M., which
revealed the existence of two distinct aneurisms, one about an inch
in diameter, and nearly globular at the root of the right carotid;
this had been mistaken at the time of operation for an enlargement
of the innom'inate artery.
The larger aneurism, and the only one discoverable during life,
was of the subelavian, in its first position, where it was very m.uch
dilated, forming an aneurismal sac that had insinuated itself backward
to the cervical vertebra, downward till it was adherent to the inner
border of the first rib, and laterally behind the second and third portions of the subclavian itself, till it protruded under the integument,
in the space between the sterno-mastoid and trapezius muscles, and
in this direction was most rapidly enlarging prior to the operation.
This space was found filled with a very firm, recent clot, becoming
organized at its circumference; but the anterior wall of the sac was
much diseased, and had given way.








CASE V.
Erectile Turnor.
iiatuitre of Coiminon Carotid.
(FROM PlOTOAPTI.),i,. o~ vT-oea,:Pos CIS C o..Aba.y, N.Y




SURGICAL CASES.                      21
The subelavian artery, to which part of the sac had become adherent, was also much diseased, as it was in its continuation, even to
the middle of the arm; and just below the place of ligation, a
fatty tumor of considerable size was found attached to its external
coat.
By referring to the accompanying cut, the relative position of the
parts may be made out, and especially the aneurisms of the carotid and
subclavian arteries. I made this drawing from the parts after death,
and, although perhaps not accurate in all its details, it will serve to
show the relation of the abnormal to the normal parts.
CASE V.
Ligature of the Common Carotid below the Omo-hyoid, for Erectile Tumor- of
the Face. (Vide Plate.)
R. R., aged thirteen months, was brought to my office to ascertain
if an operation could be performed for her relief. She had, on the
left side of her face, a tumor the size of a large orange, bluish in
appearance, and which enlarged greatly during any exertion, or when
the child cried. The tumor was growing quite rapidly, and at times
the mental faculties (so far as could be judged in one so young) were
somewhat affected. From the account given by the parents, I
learned that at birth there was no appearance either of enlargement
of the left side of the face, or discoloration of the cheeks. At the
age of four weeks she fell and struck the cheek against the arm of a
chair; the blow was violent, and immediately after, there appeared
on that side of the face a blue spot, which enlarged rapidly. A
physician was called, who applied an ointment for a week, and then
inserted a seton. The tumor not diminishing, a surgeon of eminence
was consulted, who recommended acupuncture with red hot needles;
this method, and the subsequent application of poultices, were of no
avail. Other surgeons were also consulted in the case, but the means
prescribed failed to produce any good result whatsoever.
With this knowledge of the case, I determined that to arrest the
circulation on that side of the face, would offer the best chances for
relief, and that this could be done most effectually, by ligating the
common carotid below the omo-hyoid.
Dr. Youlin, of Jersey City, Dr. F. S. Bradford, and Dr. Hart
assisted in the operation.  The child was placed under ether, and
the usual incisions made for exposing the vessel, The middle thyroid
vein was enormously enlarged, and required some little time for dissection. The cervical ascia having been divided on a director, the




22                     SURGICAL CASES,
omo-hyoid was raised and held aside. The sheath of the vessels was
opened, avoiding the pneumogastric, the aneurism-needle was insinunated from without, inward beneath the artery, and Spiers' constrictor,
No., 2, was used to thoroughly compress the vessel. All pulsation
immediately ceased in the upper part of the artery, and having closed
the wound with silver sutures, calendc.la solution (one part of the
tincture to five of water) was ordered.
March 14. - The child passed a very restless night, refusing all
nourishment, and toward morning violent convulsions ensued. ].
lIgnatia 3d, every half-hour. This relieved the convulsions.
March 15. -Severe croupy cough — to which the patient was
very subject - came on during the day. R. hepar 2d, dec. trit.
grs. v., every hour.
March 16. — Better; cough relieved; pulse 130; wound uniting.
March 20.- Tulnor diminished about one-third.
From  this period the child improved gradually, and the tumor
lessened in size. It then remained stationary for a time, and finally
disappeared.
I learned lately from the parents, that with the exception of a
slight " puffiness-" of the cheek at times, there has been no re-appearance of the tumor. *
CASE VI.
Resection of Shoulder - Traumatic Tetanus - Cure.
Mr. L. consulted me on Oct. 5, 1872, as to the feasibility of an
operation to relieve him from symptoms developed from a gun-shot
wound'of the shoulder, occurring sixteen years previous.  The
accidental discharge of a gun into the axilla had caused such destruction of the parts, that the surgeons advised, and were actually preparing to amputate at the shoulder, when Dr. Valentine Mott arrived
and concluded to endeavor to save the arm. Most extensive suppuration followed, and many sinuses'formed; bits of bone and numerous
shot being discharged from time to time.
A portion of the head of the humerus had exfoliated, together with
many sequestra of larger or smaller size. The patient, of course,
from such long and profuse suppuration, was exhausted, and emaciated to a degree. His sufferings were continuous and most aggravated, and he was willing to undergo any operation that promised hope
of relief. When I saw him, his condition was such that I dared not
subject him to immediate operation, and to benefit his general condition, sent him to the country, where he somewhat improved.
* Since the above was written, I have seen this patient. She is perfectly cured. W. T. H.




SURGICAL CASES.                       23
On November 21st, I proceeded to expose the bone, and to rerform whatever operation might be necessary.  The extent of the
procedure, however, could not be accurately determined upon, owi. g
to the mis-shapen condition of the-parts.
There were two large openings beneath the great pectoral muscle,
two on the posterior surface of the joint, over the scapula; two on
the posterior aspect of the humerus, besides various indentations and
cicatrices, marking old points of suppuration and exfoliation.  The
extremity of the acromion projected over the shoulder, and only
motion of that part was permitted by the subscapularis.
The patient was brought under the influence of ether, which, however, he took poorly, causing us to use great caution, and frequently
to desist in our proceedings during the operation.  The' usual, long
straight incision for resection of the humerus was made, on the top
of the shoulder, and the parts held aside with curved spatulle. There
was founid complete anchylosis not Qnly of the neck of the bone to
the lower margin of the glenoid cavity, but also to the upper border
of the anterior margin of the body of the scapula. With great difficulty a chain saw was passed under the upper portion of the bone,
and about an inch and a-half of diseased mass cut away. The other
portions of carious bone, which were extensive, were removed with
the chisel, gouge, hammer and saw. On passing a long gun-shot
probe through a sinus on the front of the chest, Dr. Thompson discovered a large sequestrum which proved to be a portion of the compact structure of the shaft of the humerus. The operation was
difficult and tedious, as is often the case in the removal of dead and
diseased bone, and I was materially assisted by Drs. McVicar, Thomp
son, Joslin and others. The patient rallied well, and was in aine
condition, until the morning of the tenth day, when a slight chill,
and sensation of stiffness of the jaw, foretold what Nwas to come. In
a short time violent tetanic spasms set in, and trismus, of the worse
variety, ensued. The convulsions were produced by the slightest
cause, the contact of the spoon to the lips, a draught of air upon the
person, the slamming of a door, and other trivial causes, produced a
terrible effect upon him. His mental faculties, as is often the case
in this terrible affection, were frequently exalted, and his consciousness only rendered his sufferings the more acute. There was complete insomnia, profuse and debilitating sweats, constipation, strangury and tenesmus. Pulse 130 to 140, and temperature 100 and 102.
Medicines appeared of no avail. The administration of acont., bell.,
hyos., cup., lach., ign., cicuta, calabar been, nux., curare, puls.,
stram., and others, produced no effect whatsoever on the symptorms.




24                      SURGICAL CASES.
Opisthotonns and pleurothotonus were persistent, and his anguish
intense. His death appeared rapidly approaching, when I prescribed
chloral hydrate, in ten grain doses, every two hours. The effect
was magical, the first sleep that he had experienced was soon produced, and he awakened refreshed. I will say also that during the
paroxysms he had an occasional suppository of one grain of opium.
I will not, however, detain the reader longer with the details of the
case. Suffice it to say, that this medicine was productive of cure,
and that (as in all cases of traumatic tetanus which have been cured)
the progress was gradual, yet, eventually, the patient perfectly
recovered.
During a tour in Europe a portion of bone came away, and in
August, 1875, another small sequestrum was discharged.  The time
elapsing from the date of the operation until the patient was sufficiently recovered to sail for Europe was nearly five months.
When we consider the length of time that had elapsed since the
injury was inflicted; the great deformity of the joint; the exhausted
constitution; the prolonged suppuration; the tedious operation; and
the subsequent tetanus, and ultimate recovery, we should appreciate
what the body can suffer and not succumb, and that the motto is a
good one, "never say die."
CASE VII.
Resection of the Os Calcaneum.
The removal of the os calcis, either in part or entirely, was formerly regarded as almost an impossible operation, for two reasons:
First, because it was aswell-known fact that this bone sustains about
half the weight of the entire body; and second, because it was
formerly held that division of the tendo-achillis deprived the limb
of a great amount of motion. Some surgeons (among whom was
Moreau) even taught that if the tendo-achillis be destroyed, amputation is the only feasible resort. - Pare regarded a fracture of this
bone a fatal injury. These opinions, however, have proved erroneous; and both the division of the tendon and the removal of the
bone can be effected with slight resulting deformity.
In the Bellevue and Charity Hospital reports for 1870, a very
interesting paper appears " On the Entire Excision of the Os Calcis,"
by F. A. Burrall, M. D., of New York; in which he gives a tabulated statement of forty-eight cases. An analysis of this table is
most interesting as regards the history of the cases requiring the
operation. We find that young persons of the male sex were the




SURGICAL CASES.                       25
subjects on whom it was most frequently performed, the ages being
from ten to twenty years. There were five cases between the ages
of forty and fifty-four.
Of the forty-six cases in which the sex is recorded, thirty-eight
were males and but eight females.  The diseases which called for
the operation were, in forty-three cases, caries and necrosis, the
others being accidents, pressure, friction, etc.  Only one death
occurred, and that was but indirectly attributable to the operation.
One was afterward lost from diphtheria, one from pyaemia, and two
from, phthisis; of the latter, it may be said that the disease re-appeared in one case in eighteen -months, and in the other four years
after the operation. Seven secondary amputations were necessary.
The lessons we learn from these cases are: that complete excision
of the os calcaneum can be, practiced with success and leave a good
foot; that caries and necrosis furnish by far the greater part of the
cases for the operation; that the young are more liable to the
diseases requiring either resection or excision, and that the male sex
is more prone to them than the female. Besides the forty-eight cases
to which we have alluded, there can be found in the JMcedical Tirmes
for October, 1870, an account of three cases of "Excision of the Os
Calcis," by Dr. Hunter McGuire, of Richmond, Va.  In his report
the ages were twenty-one, seventeen and twenty-three years, all
males; the-disease in each was caries, and caused in every instance
by injury. Thus in case first, the patient was wounded by a nail
driven into the heel. In case second, the heel was severely bruised
by a cricket ball; and case third, was that of a wound from a shell.
In all these cases there was but a slight limp resulting from the operation. At the termination of the papers, Professor McGuire gives
two interesting records to show with what facility a patient can
walk after the destruction of the heel tendon:
"'The first,?' says he, "was a confederate major-general, shot at
McDowell, May 8, 1862.  The ball entered the outside of the leg,
fractured the fibula about its lower third, and passed out upon the
opposite side of the limb. I enlarged the wound of entrance and
removed several detached fragments of bone. Phlegmonous erysipelas attacked his leg soon after the injury, and resulted in extensive sloughing. The tendo-achillis died, was separated by the
process of the disease, and was removed with the forceps. This
gentleman recovered after a tedious illness, and although he has a
slight limp, it is so trifling that it is difficult to tell, from his gait,
the wounded from the sound leg.
" The second case was that of a soldier, wounded at Winchester
4




26                       SURGICAL CASES.
by a fragment of shell. The missile tore out between three and
four inches of the tendo-achillis, with the soft parts covering it.
After some months, the man walked with a very slight limp.
" Whether, after such a loss as I have described in the two foregoing cases, nature supplies some adventitious tissue which takes the
place of the tendon, or distributes the force of the contraction of the
soleus and gastrocnemius upon the tendois of the peroneal and, tibial
muscles, or gives to the last-named increased size and strength, or
whether one or all these circumstances are combined, to enable the
patient' to raise the heel in walking, I do not pretend to say."
Complete excision of the bone must always give rise to deformity,
as the arch of the foot is taken away. In the majority of instances,
caries does not invade the entire substance of the bone, its posterior
surface being most generally affected.  In such instances it is well
to remove the posterior portion of the os calcaneum, and ascertain
the depth to which the ulcerative process has extended, and then, if
possible, remove with the gouge and the chisel the diseased masses.
Of this proceeding, Dr. Heyfelder says:
" Partial resection is to be preferred to extirpation, when possible,
both for the sake of leaving intact the joint and adjacent bones, as
well as to preserve the muscular and ligamentous attachments. But
partial resections of the calcaneum are not always successful (five
failures in fifty-four cases), and amputation of the foot (twice) or extirpation of the bone (once) have been necessary.  In sixty cases of
partial excision, in which superficial or deeper wedge-shaped portions, or even larger parts of the bone were removed, none ended
fatally. Relapses occurred in five out of fifty-four cases, rendering
amputation necessary in three." *
According to these remarks of the German surgeon, the results of
partial resection are very good, and it is so desirable to save the arch
of the foot, that it appears to me that partial resection should at least
be first attempted. Then if, after the posterior portion of the heel
has been sawn off, the disease proves to have extended far into
the plantar surface, the entire bone must be removed, unless the caries
can be reached with the gouge, and it can be removed with that
instrument.  There are several methods of operating for removal
of the os calcis.
The chief point is to keep the incisions without the sole of the
foot, as the cicatrices are liable to inflame from friction, and afterward to suppurate and ulcerate.
* Bellevue and Charity Hospital Reports, 1870, page 202.




S URGICAL CASES.                     27
Mr. T. Hohne's method is as follows: Enter the knife at the
inner border of the tendo-achillis; carry it steadily around the back
and outer side of the foot, along, the upper margin of the os calcis,
to a point midway between the heel and the projection of the fifth
metatarsal bone, which point marks the calcaneo-cuboid articulation.
From the anterior extremity of the incision a.second one is cormmenced, and carried downward and into the-sole of the foot, terminating near the inner border of the os calcis, thus avoiding the posterior tibial artery and its branches. The joint between the cuboid
bone and the astragalus is laid open, and the bone, having been
grasped with the lion forceps, is strongly everted, and the soft parts
on its inner side detached, keeping the edge of the knife close to the
bone.
This operation commends itself for its simplicity, and from  the
fact that the incisions avoid the posterior tibial artery;-however, I
do not think that the bone is so easily reached as in the dissection
proposed by Erichsen, and recommended by Dr. Gross, which was
practiced in the case which we have recorded.
Master S. had been under the care of Prof. Dowling for some time
for caries of the os calcis, indicated by the usual symptoms —by the
openings on both sides of the heel; by the character of the discharge;
by the use of the probe, which Dr. D. had passed directly tArough
the heel. The doctor had recommended an operation some time
before, but from  circumstances it was deferred until the 25th of
October.  The boy, aged about fourteen years, a bright, intelligent,
active lad, was anxious for the operation, and by good constitutional
treatment was a most fit subject for the knife. Drs. Dowling, Bayliss and Jernigen, and Mr. Brigham were present, and assisted in
the operation.
The anaesthesia proceeded very slowly, even with the use of
Squibb's aether fortior and a Lentz inhaler. So soon as perfect
unconsciousness was obtained, an incision was commenced in the
mesian line of the heel, an inch above the insertion of the tendoachillis, and carried perpendicularly down to the sole. A second
incision was then made around the margin of the os calcis, joining
the lower end of the first cut as it passed around the sole of the
foot, and extending farther on the outer than on the inner margin of
the bone. The lateral flaps were then dissected up, and the gouge
applied. The whole posterior portion of the bone was involved.
The tendo-achillis was then cut through, the sole-flap dissected away
from the bone, and with a metacarpal saw the posterior surface of the
bone sliced off. The gouge and gouging forceps were used freely,




28                     SURGICAL CASES.
and all the diseased portions removed. The flaps were brought
together and tied by silver sutures.  Two vessels required ligature. A dressing of prepared oakum and a bandage were then
applied.
The patient passed a very bad night, on account of pain, and from
the effectslof the large quantity of ether which he had inhaled.
There was also considerable oozing from the bone for thirty-six
hours. The sutures were removed in from three to six days, and the
wound kept in apposition by strong adhesive straps. The boy at
present is able to walk well, and is perfectly cured.
CASE VIII.
Resection of the Entire Calcis - Amputation of Leg - Recovery.
On November 9, 1872, was called by Dr. J. A. McVicar, of New
York, to see a young lady who, for a number of years, had been suffering from disease of the heel. Upon examination, there were found
four sinuses, the openings of which showed that peculiar pouting
and puckered appearance which indicates diseased bone. The probe
revealed extensive caries of the calcis, and it was determined, upon
due consultation, to remove that bone entire, and thus, if possible,
to save the foot and leg.
I have detailed, in the preceding paper, a case ot resection of the
posterior surface of that bone, and given an account of the various
incisions that have been used, from time to time, in the performance of the operation.  I am now quite well satisfied that
a modification of the incision of Erichsen will allow the entire
removal of the bone, without in any way compromising any
vessels, especially the posterior tibial artery.  This vessel in the
lower portion of its course is situated about midway between the
tuberosity of the calcis and the malleolus internus, and, winding
around the anterior and internal portion of'the calcis, supplies the
sole of the foot.
I made the first incision longitudinally in the ceinter of the heel,
beginning about' an inch above the insertion of the tendo-achillis,
and terminating it at the sole. The second cut, beginning in the
arch of the foot, or at the junction externally of the anterior face of
the calcis with the cuboid, was carried, around the margin of the
sole of the foot, meeting the lower end of the first incision, and carried still around on the inside of the foot for about an inch and a
half. Keeping the knife close to the. bone, the heel-flaps were dissected up, first the external, and finally the internal flap. The bone








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SURGICAL CASES.                     29
was very much diseased, and was easily broken. After its removal,
it was found that the astragalus, and portions of the articular
extremities of the tibia and fibula were also involved, and therefore I removed the leg at its lower third. All went on well, the wound
healing kindly, and the patient rallying, until about the fifth week,
when the edges of the wound became rather unhealthy looking, and
the line of incision, which had apparently healed, broke open. At
the same time, an abraded surface appeared on the upper part of the
leg. — Notwithstanding the different varieties of treatment which
were adopted, and the very judicious management of Dr. MeVicar,
the wound showed but little disposition to unite, until, finally, Dr.
MeVicar suggested the use of a species of battery, which I have
found recommended in Hamilton's Science and Art of Surgery,
and which is also used by Brown-Sequard. A plate of silver foil is
placed over the sore to be healed, a plate of zinc upon a sound surface near by, the two metals to be connected with an ordinary piece
of copper wire, and the apparatus bound upon the leg. Care, however, must be taken that the plate of zinc be not allowed to remain
too long on the sound integument, else a sore will soon be produced
in that locality. It should be changed from place to place every
forty-eight hours. If a more rapid action is desired, a cloth soaked
with vinegar may be laid under the zinc. This application produced
the desired effect. The lady rides and walkes about, and is in the
happy anticipation of an artificial leg.
CASE IX.
Amputation of the Tongue.
This case was of great interest -to me; —it was one of epithelioma of the tongue, occurring in a boy aged thirteen years. The
lad's tongue became sore eight. years ago, without known cause.
The suffering increased, till at the present, it bleeds easily, annoys him
with burning pains, and a feeling as though needles were thrust
through the tongue; deglutition is painful, and especially so when
the tongue is swollen in consequence of a cold; his physician says
that the axillary glands were swollen. The boy had a severe cold,
and the tongue enlarged four times its present size; the tumor, when
I first saw him, covered the anterior half of the right side of the
tongue, was about an inch and a half long, three-fourths of an inch
broad, extended above the surface of the tongue nearly a half inch,
penetrated the whole structure of that portion of the tongue, rendering the papillae on its upper surface elevated and bleeding, and the




30                     SURGICAL CASES.
under surface dark and purple. Epithelioma is the term applied to
these tumors, because their cells resemble the cells of tesselated epithelium; there are two varieties, the.superficial and deep; the first
having.mild symptoms of itching, and burning, and raised papillae;
the second presenting severer manifestations, as related above.
In the performance of these amputations of the tongue, it is
necessary to remember'the position of the genio-hyoid, and geniohyo-glossus muscles, and the relations of the lingual and the ranine
arteries. The division of these muscles allows the tongue sometimes
to fall backward, thus closing the epiglottis, and producing symptoms of suffocation. It must be remembered also, that operations
upon the tongue often are followed by alarming. hemorrhage, due to
the great vascularity of the structure. Fatal cases are on record,
even in the hands of such surgeons as Sir Astley Cooper.. These,
however, were those in which the knife was used, before the invention of the ecraseur.
The rule in the removal of all malignant tumors is to cut always
in the sound tissue, both on account of the necessity of removing
all the diseased tissue, and also to prevent hemnorrhage.  There are
sdveral methods of removal of epithelioma of the tongue, viz.: -the
osteo plastic operation, as used by Syme, when the diseased portion
extended very posteriorly; Nunnely's operation, consisting of an
incision in the neck, beneath the tongue, which is carried upward
through the floor of the mouth to the tongue; then passing a
canula through this incision, and carrying the chain of the 6craseur
through the canula, around the diseased portion, and down again
through the canula, attaching it to the ecraseur, and working it from
below..The operation, by means of an incision through the cheek,
and the following method, which was adopted in this case:
A needle, armed with a double thread, was passed through the tip
of the tongue, the needle cut off, and the loose end tied, enabling
the tongue to be well drawn out. (Fig. 1, a. a.) Westmoreland's
instrument was then applied to the corner of the mouth to hold the
jaws apart. A stout pir was then passed through the tongue from
above t6 compel the chain of the 6craseur to start properly in the
sound tissue behind and inside the tumor.  The ecraseur chain was
then passed by means of a needle through the base of the tongue
from below upward, (Fig. 1, b. b.) that being united to the ecrascur, it
was worked, cutting anteriorly in the direction toward the tip, almost in
the median line. (Fig. 2.) The ecraseur chain looped, was then passed.backward, the diseased portion of the tongue protruding through the
loop, and marked out by three pins which formed a fence, as it were,








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SURGICAL CASES.                       31
outside of which the chain passed at right angles with the tongue;
(Fig. 2, b.) the screw was gradually turned, cutting laterally.  The
operation required thirty minutes, some delay, however, being occasioned by the slipping of the chain of the ecraseur.  No serious
hemorrhage resulted; the ranine artery being a\voided, but was visible through the little tissue left at its side.  Calendula applications
to the tongue and ice water gargles were ordered.
This is the third amputation that I have made of the tongue, and
I have been careful to notice three facts: First, that the tissue of
this organ is most rapidly re-produced, owing, I suppose, to the
plentiful blood supply; second, that removal of large portions of
the tongue do not materially impair articulation or speech; third,
that the operation above described, with pins, and the 6craseur, or
the galvano-caustic wire, is preferable to the more severe proceedings of Syme or Nunnely.
CASE X.
A Successful Operation for Imperforate Rectum.
There are several varieties of imnperforate rectum, all of which are
more or less serious in character, and which very often terminate
fatally, even after the best known means have been resorted to for
preserving life.
There cannot be a doubt that there are hundreds of children who
die yearly from the malformation in question; how many of whom
might have been saved by appropriate treatment it is impossible to
say..
It is a question, however, in my own mind, whether (if life may
only be saved by the formation of an artificial anus) it is not better
to allow the little sufferer to die rather than drag on a miserable
existence, with such a loathsome and disgusting affliction -" an artificial anus."
There are several classifications of this malformation, and as the
affection is rather rare, and attention is not very frequently called
thereto, I shall give them  here: Mr. Holmes divides the cases of
imperforate rectum  into two classes.  The first embraces those in
which no anus exists (imperforate anus properly so called); the second,
those in which there exists,an anal opening, which terminates in a
short cul-de-sac.  These are again subdivided.
The former class (imperforate anus) into: 1. Membranous obstruction of the anus.  2. Complete or partial absence of the rectum. 3.
Communication of the rectum with the vagina in the female.  4.




32                     SURGICAL CASES.
Communication with the urinary tract in the male. 5. External
communication or fistula.  The latter (imperforate rectum) may be
subdivided:  1. Membranous obstruction.  2. Deficiency of the
upper portion of the rectum.
Mr. Curling, who has given this subject a great deal of attention,
makes a more simple classification thus:
Those cases in which there is complete closure of the anus, the
rectum being either in part or entirely wanting. Second, those cases
in which there is nothing but a cul-de-sac, surrounding the anal opening; in the third variety there is no anus, but the rectum terminates
in the bladder, vagina, or urethra.
An imperforate anus properly so called is much sooner recognized
than an imperforate rectum, for the reason that the latter is not so
easily recognized, and the patient continues to suffer, the causes of
indisposition not being rightly understood, and, indeed, death may
ensue without either physician or attendants being aware of the true
nature of the malady.
It is from a knowledge of these facts that every child should be
examined carefully on the second day, if there has been no movement of the bowels. In such an examination the practitioner should
not be satisfied with the fact that the anus is open, but should institute an exploration with his finger to ascertain as to the viability of
the rectum.
In many of the cases of imperforate rectum, the intestines terminate
in a blind pouch, which may either be high up or low down, or connected with the anal cul-de-sac itself.  On this point Mr. Bryant
says: "It seems possible from  Curling's and MM. Goyraud and
Friedberg's observations, that such cases are caused by an obliteration
of -the bowel, which was originally well formed, from some intrauterine inflammatory action. Some instances being recorded where
the muscular tissue of the intestine was clearly traced."
When the anus is nearly closed, by membrane, the constipation,
and the "btulging " at the anus, at once show the nature 6f the malformation; a simple incision generally suffices. If there is no bulging
and the anus is firmly closed, then it is proper -to make an exploratory
incision, beginning at a point about where the center of the anus
should be, and carrying the knife bcckward toward the sacrum
forward incisions endanger the bladder, vagina, and other important
organs.
In cases of imperforate rectum, the following method may be successful, if the gut can be reached; this latter is the chief point of
difficulty in the operation.




StrGaICAL CAS1S.                    33
On1 the 3d of March, I was called by Dr. Richardson, of Williamsburgh, to see a child, thirty-six hours old; who the doctor informed
me had an imlperforate rectum. As there was no time to be lost, I,
went immediately to the house, and found an infant, healthy and
plump-looking, born a day and a half previous, but with enormously
distended abdomen, the convolution of the intestines being distinctly
seen. The child had passed urine once since its birth. A peculiar
feature in this case exists in that the parents had had another child
born with a similar malformation, who had been operated upon, and
had died. They had, two weeks previously, lost two children with
measles, and necessarily were in an excited and despairing frame of
mind.
Upon inserting my finger into the anus, I felt a cGil-de-sac, which
fitted over the end of the finger like a thimble. This I tore away,
and then proceeded to search for the gut. It was entirely beyond
my reach, and the finger moved about in vacancy. I then divided
the sphincter toward the sacrum for about half an inch, to give more
room; and, upon again introducing my finger, I could just touch the
intestine, but could not, by any means, " hook it " sufficiently to draw
it down. By placing a very small hook flat-wise on the fore-finger
of my right hand, I pushed it through the anal orifice, and, by using
the left hand as a manipulator, and the right as a guide, succeeded
in hooking the intestine, and drawing it down. The amount of traction required to do this was surprising; indeed, I was fearful that the
instrument would tear out. So soon as I had drawn the gut outside
the anus, I passed a needle, threaded with a double silk ligature,
through it, and then let it retract again into the cavity of the abdomen. With a few strokes of the scalpel, the,margins of the anus
were then scarified.' By making traction on the ligature, the gut was
again brought into sight, and held outside the anal aperture by Dr.
Richardson, until I had stitched it to the margins of the anus. So
soon as this was done, I cut off with a scissors the" blind end " of
the intestine. The amount of foeces that were discharged seemed
almost incredible; indeed, several times during the operation, we
were obliged to stop proceedings, on account of foeces issuing from
the punctures made by the hook and the needles.
This operation was a -complete success. On the third day the anus
had to be dilated with the finger, and since then there has been nq
further trouble. The father of the child called upon me a few days
ago, stating that the child was thriving, nursed and slept well, and
had natural and free evacuations from the bowels.
The accompanying drawing, which I have made from a plate in




34                    SURGICAL CASES.
Bodenhamer's work on "malformations of the anus and rectum,'
and which is there inserted to explain a case of Ballie's, represents
very nearly the case I have just described. A represents the anus;
B the anterior wall of the bladder; C the blind end of the rectum;
D bougie passed into the anus up to the rectal pouch.
CASE XI.
Glass Tube in Urethra —Sloughing of Scrotum after Removal —Perinial
Urethrotomy - Cure.
A middle-aged and healthy-looking man was sent to the hospital
to be relieved of his sufferings. The patient was employed in the oil
yards at Williamsburg, and fancying he had a stricture ('tis strange
how many fancies men have), introduced into his urethra a glass tube
in shape, similar to a thermometer, which is used in testing the specific
gravity or quality of the oil. These instruments are made of the
most brittle glass, and have inside the tube a scale of degrees printed
upon paper. This individual, as I have said, believing he had an obstruction in the urinary canal, thought to himself,'on a fine Sunday
morning, that he, having some time to spare, would proceed to cure
himself of " his complaint," and, having no instrument handy, coneluded that one of these oil gauges, if I may so call it, would be the
proper thing to use. Therefore, without more ado, he introduced the
brittle tube into his urethra, and having pushed it down to the
membranous portion of the canal, was proceeding to turn it in a
most scientific manner when, from some unforeseen accident or
unlooked-for circumstance, the tube broke!  He hastily removed
the top portion of the glass, and then walked to New York for treatment.  When I saw him he was not much frightened, and the
portion of the tube broken in the canal could be distinctly felt. I
first introduced a pair of alligator forceps into the urethra, and had
the satisfaction of fishing up the paper, on which was marked the
scale of degrees, bloody and twisted. A second application of the
forceps brought up a second fragment.  Then the attempt was
made to withdraw the broken glass tube through the meatus, but
the sharp end of the forward portion of the broken glass having
forceditself into the floor of the canal, caused considerable hemorrhage, and fixed the fragment firmly in its place. Moreover, the
brittleness of the glass forbade its withdrawal, for every time the
jaws of the forceps would grasp the tube it would break; therefore
there was nothing else to do but to remove the fragments by external incision. This was accordingly done, but great difficulty was








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SURGICAL CASES.                     35
experienced in the operation, not only on account of the flaccid and
elastic nature of the scrotum, but from hemorrhage. It is a wellknown fact that the vessels of the scrotum retract into the elastic
tissue, and sometimes give rise to a rather profuse hemorrhage, which
is often difficult to check. I remember on one occasion, after an
operation for varicocle, I had a secondary hemorrhage, which was
extremely difficult to arrest -pressure on the spermatic arteries
and on the groin producing no effect. After considerable search I
found the vessel in the wall of the scrotum, and had no further
trouble. After the removal of the glass there was extensive sloughing of the scrotum, but by the care and attention of Dr. Cranch, the
patient made a good recovery, and does not recommend brittle glass
tubes as an application of even7fancied stricture, and keeps his own
treatment in erperetummn silent'ztm.
CasE XII.
Pendulous Patty Tumor of the Thigh - 5 lbs. - Removal - Secondary
Hemorrhage - Cure.
Sir Benjamin Brodie says of the fatty tumor: " There is no distinct boundary to it, and you cannot say where the natural adipose
structure ends and the morbid growth begins."  The case now to
be recorded is rather rare, on account of the pendulous character of'the growth, it being like a large bag, from the inside of the right
thigh immediately over the course of the femoral artery.  The
patient was a German, aged nearly seventy years, but was one of
those tough, spare, rugged specimens of humanity that seem able to
withstand many hard knocks without succumbing. This tumor
had a pedicle, was pear-shaped, and hung down like a bag ( Vlde
cut), and so flapped about while walking that the patient was obliged
to wear over it a piece of sole-leather, which was strapped around the
thigh.  Upon introducing an exploring needle into the tumor,
several drops of blood passed through the canula, and,'fromrn the
apparent fluctuation, I' was rather disposed to believe that there was
a cyst containing liquid. The pulsation imparted to the tuinor by
the fernoral artery could be stopped by raising the tumor away
from the vessel. Having placed a tourniquet upon the thigh, and
made pressure on the femoral, a fold of skin was pinched up, after
the manner of operating in hernia, and the incision made from
within outward; a mass of fat protruded, showing the nature of
the tumor, which was easily turned out from its bed. It weighed
over five pounds. There was no hemorrhage, and after having cut




36                    S-URGICAL CAsES.
away the redundancy of integument, the flaps were brought together,
the wound closed with silver sutures, and the patient put to bed.
In the evening, at eight o'clock, I was summoned to the hospital.
I found the patient faint from loss of blood, the flaps of the wound
puffed out, a large clot oozing between the lips, and the bed-clothes
saturated with blood. Dr. Seeger and Westover had applied persulphate of iron, and put on the tourniquet, which had arrested the
bleeding. The patient was in a cold sweat, and his pulse was weak
and thready. I immediately cut away the sutures, turned out the
large clots, and found four or five vessels bleeding quite profusely.
With the assistance of the gentlemen above named, the vessels were
secured, and no further trouble resulted. The patient made a rapid
recovery, in spite of his going for a shave and a glass of lager before
the last ligature had come away.