Surgical Cases. Reported by Charles Sutherland, M. D., late
Assistant to the Clinic of Jefferson Medical College.
The following have been selected from a number of cases which
presented themselves at the Clinic of Jefferson Medical College.
A man, aged 45 years, presented himself last fall with a large
tumor upon his right side. It had been growing for eight years
past, and it now gave rise to a great deal of pain and inconveni-
ence. It was perceptibly enlarging, and he resolved to have it re-
moved. It extended from within a few inches of the inferior angle of
the scapula to the floating ribs, and from within an inch of the verte-
brae up to and under the axilla. The tumor was evidently under the
latissimus dorsi muscle, and it felt hard, with soft spots here and there
throughout its whole extent. Dr. Mutter was of the opinion that
it was of the sero-cystic variety. On January the 16th he was
brought before the class, and the operation performed by Dr.
Mutter, assisted by Dr. Pancoast.
The first incision extended from the upper to the lower
part of the tumor, in the median line, about eight inches in
length, and then from the middle of this incision back towards
the spine, being about four inches in length. A T-shaped wound
was thus made, the knife in this stage of the operation pas-
sing through skin and fascia. The operator then proceeded to dis-
sect off the flaps, which was soon accomplished. One or two arteries
were tied. The fibres of the muscle which covered the tumor were
next cut through, the incision in this case being similar to the one
first made. Several arteries were ligated. The tumor was torn out
of its place in a gradual manner, occasionally using the knife where
it was required to divide some adhesive bands. The object in thus
removing it was to effect the laceration of the capillary vessels,
and thus prevent secondary hemorrhage. After working above
and below in the manner described, the pedicle of the tumor was
reached. Near to its base, which extended a considerable distance
up into the axilla, coursed the axillary artery, which could be seen
distinctly pulsating. The subscapular artery which was enor-
mously dilated, ran through the pedicle into the tumor, and most
of the arteries which were tied came off from this large branch of
the axillary. Around the pedicle was passed a strong double liga-
ture, which being firmly tied, arrested all vascular communication.
After this was accomplished the attachment was severed and the
tumor removed. It weighed after its extirpation 10| pounds, and
proved upon examination to be a most perfect specimen of the
sero-cystic variety. There was some little oozing, but this ceased
after tying several small arteries, and when the coating of plasma
had fully appeared. Soon after, the flaps were brought together. It
might be supposed that they -would more than cover the wound, but
this was not the case; they had sufficiently retracted to unite evenly
when brought into apposition with each other. They were main-
tained in their proper position by sutures, adhesive straps, and a
firm bandage, which was applied around the chest. The patient
was immediately put to bed. A few hours subsequently some
oozing came on, consequent upon reaction ; towards night it
was completely arrested. A teaspoonful of Liq. Morph. Sulphat.
was given to him every hour or so. His sleep the first night
was restless and disturbed: he complained of pain in his right
shoulder, which also extended down his arm. The day after
he was more comfortable ; pain not so severe. A light diet was
ordered. Remained in this condition for several days. On the
fifth day after the operation the dressings were removed. The
transverse cut, together with the upper and lower part of the long
incision, had all united, save where they met in the centre. Here
suppuration was going on to a slight extent, partly owing to the
ligatures which came out at this place. The part was again
dressed, and a flaxseed poultice applied. It was afterwards found
necessary to dress the wound twice a day. Under this local treat-
ment, combined with a tonic regimen, the man daily improved, and
was able a week after the operation to go about his room, and
a week from that period he walked into the college and exhibited
himself to the class. Soon after all the ligatures came away, the
suppurating portion healed by granulations from the bottom,
hastened by a stimulating ointment; the patient’s health greatly
improved and finally during the early part of March he was dis-
charged cured.
The following is a brief account of a case of mortification at-
tributable to severe and continued cold. The sufferer was a Ger-
man lad, aged about twelve years, who worked upon a farm in the
lower part of the State of New Jersey. One day last winter, for
some slight dereliction of duty, he was severely chastised by his
master, and on the following was confined in a barn upon
the place, where he was forced to remain all night, which was one
of the coldest of the season. His clothing was scanty, and, as
might be supposed, he suffered extremely from the effects of the
cold. On the following morning he was found unable to stand
erect, there being total loss of sensation and motion in his feet.
This was followed by an active throbbing pain, redness and swell-
ing. Effusion occurred to a great extent in the cellular tissue.
After this followed mortification. Both feet appeared to be dead,
the right foot seemed the worst of the two. During this time he
was judiciously treated by a physician residing in the neighbor-
hood, but all his efforts proved unavailing, and the lad was sent to
this city for the purpose of having his feet amputated. When he
arrived at the hospital of the Jefferson Clinic, (on the 11th Feb.)
he had upon him only a shirt, a thin pair of pants, and a vest, and
was covered by a small blanket. The patient was depressed in spirits,
complained of pain in several parts of his body, and also of cold.
On examining the feet, the entire sole and dorsum of one (the
right foot) was found to be completely mortified ; the sole of the
other was sphacelated nearly throughout the extent of its surface,
and on its front as far as the tarso-metatarsal joint. A line of
healthy granulations divided the living from the dead parts in both
feet, better marked however in the left one. The sloughs were of
a dark ash color and intolerably offensive. The boy was put to
bed, warm clothing placed on and around him, he partook of some
broth which revived him somewhat, at night a purgative was ad-
ministered, and the feet enveloped in large poultices composed of
carrots and powdered charcoal.
On the 12th, Did not sleep much during the night, bowels open-
ed, feet again dressed with same applications. Dr. Pancoast now
saw the case for the first time.
13th. After consultation it was resolved to amputate the right
foot, and leave the left one, in which the dead mass showed a dis-
position to fall off, in which case, if it did, the tarsal bones would
remain un-involved. Accordingly on the same day the right foot
was removed by amputating above the ankle in the lower third of
the leg. Dr. Pancoast performed the flap operation and obtained a
capital stump.
14th. Patient very comfortable ; recovered from effect of the
operation admirably; the slough of the remaining foot ready to fall
off; seems to adhere by means of two metatarsal bones.
17th. The dead mass came away with the dressing; two meta-
tarsal bones of second and third toes alone remained. Dressing
changed, flaxseed now used.
18th. Exhibited to the class, stump dressed first time before
them. It had united by the first intention. Dr. Pancoast intended to
remove the projecting bones of the left foot, but the boy, from some
reason or other, just before he was brought to the college, wrench-
ed the bones out their places. Some diseased portions of bone
were removed by the bone forceps. From that time forward, cica-
trization proceeded rapidly in this foot. The ligatures came away
soon after.
22d. Able to walk about the room by means of a crutch.
March 1. Both stumps entirely healed. By means of an artifi-
cial foot and ankle, and the support that he will obtain from the
tarsal bones, the boy will be enabled to walk tolerably well. In
a few days subsequently he was discharged cured. He is now
learning the trade of a tailor.
A colored lad, set. 15 years, had been laboring for some time
under white swelling of the knee-joint as a consequence of impro-
per treatment. Great contraction of the tendons of the hamstring
muscles ensued. The limb was flexed at nearly a right angle, and
while in this position permanent anchylosis of the joint was the
result. The limb consequently was rendered useless, and after
consultation it was determined to remove it by amputating
through the thigh. On the afternoon previous to the day fixed
upon for the operation, the patient incautiously stepping from his
bed, fractured the shaft of the femur of the diseased side. The ef-
fect of this was to prostrate him severely. He was brought to
the college, and primary amputation would have been performed,
had sufficient reaction occurred. On the subsequent day he had
reacted so slightly as not to warrant a removal of the limb. Diffu-
sive stimuli were freely used, and it was not until after persisting
in their use for several days, that the patient’s system was brought
up to the point desired. The fracture, however, was set—four
short splints applied around the thigh and the limb rested upon an
inclined plane of pillows. The boy was brought into the college
upon the next clinic day. Every thing was favorable, and the
limb was removed by Dr. Mutter. A question arose at the time, as
to the propriety of amputating through the seat of fracture or above
it. The first plan was preferred ; the callus being soft and yield-
ing, there would be no difficulty in passing through it, and would
save the necessity of sawing the bone. If any spicula of bone ex-
isted, they would be removed by means of the bone nippers. The
flap operation was performed. The ends of the bone were found
surrounded by a soft provisional callus ; a fine stump was obtained
after ligating the blood vessels, and waiting for the formation of
the coat of the plasma. The flaps were brought together, united ac-
cording to the usual mode, and the cold water dressing applied.
The patient was put to bed, and no secondary haemorrhage follow-
ed. Suffice it to say, the subsequent treatment was upon general
principles, the flaps united by the first intention, and in less than
three weeks the boy was discharged cured.
A large fatty tumor was removed, last February, from the
thigh of a patient, by Dr. Pancoast. It had been slow, but pro-
gressive in its growth, and was situated on the inside of the left
thigh, about five or six inches from the pubis. It was a lobulated,
softish, and painless tumor, feeling like a mass of fat. It was in
length some seven or eight inches ; and in width five inches, save
at its pedicle, where, it was not more than two inches. The patient,
a man, was placed under the influence of ether. A straight
incision was made, extending from the upper to the lower paJt of
the tumour; passing through the skin, and the cyst of cellular tissue,
which surrounded it. After which it was rapidly removed; prin-
cipally, by tearing its cellular connections. The tumor consisted
of lobulated masses of fat, and possessed little vascularity; no liga-
ture was required. The fatty mass was removed completely ; only
a solitary lobule was broken, which was taken away entirely.
The tumor, if it had been allowed to remain, for a longer time
than it did, might have taken upon itself a malignant character.
This was partly shown, by examining one of its smallest lobules,
which was already undergoing an unfavorable change in its condi-
tion. The part was treated as an incised wound, adhesive plasters
maintained the parts in situ, and a spica bandage, kept all snug.
In less than two weeks from that time the patient was well.