THE
MEDICAL EXAMINER,
AND
RECORD OF MEDICAL SCIENCE.
NEW SERIES.—NO. LXII.-FEBRUARY, 1850.
ORIGINAL COMMUNICATIONS.
A case of Successful Operation for the Exsection of two Carious
Ribs, and the lower portion of the Sternum. By the late George
McClellan, M. D., of Philadelphia.
To F. G. Smith, M. D.
My Dear Dr.—The following case was lately found among my
father’s papers, in the form of a letter to a medical friend. As it
is an exceedingly important and interesting one, and as I do not 1
think it has ever been published, I enclose it to you for insertion
in the “Examiner.” The operation was performed in the year
1829, upon Mr. John Uhler, of Lebanon, Pa., for many years a
member of the State Legislature, and was merely referred to by
me in a note to my father’s work on Surgery, page 354, as I had
not then found these particulars.
Within a few days I have seen Dr. J. W. Gloninger, of Lebanon,
Mr. Uhler’s family physician, who attended him after the opera-
tion, from whom I learned that the patient recovered in about six
weeks, without an unfavorable symptom, and lived until the fall
of 1849, when he died of apoplexy, at the age of 72 years. The
bones, &c., removed by the operation, are now in my father’s sur-
gical collection.
Truly yours,
J. H. B. McClellan, M. D.
Philadelphia, January 19, 1850.
Philadelphia, January 27th, 1831.
To--------, M. D.
My Dear Sir,—Herewith I enclose the autograph letter of a
patient, in the history of whose case you appear to have taken a
deep interest. The bony specimens, which were presented by his
family after the operation, have just come to hand, and I will send
them to you before you leave the city.
As near as I can judge, from a recollection of his appearance
at the time of the operation, I should suppose that the patient
was about fifty years old. He was a very large person and cor-
pulent ; and his chest was at least as full and broad as I recollect
ever to have observed in the case of any other individual. This
will account for the unusual length of the cartilages of the ribs
which were excised, and for the extent of the incisions which I
was obliged to make in the superincumbent soft parts.
In addition to the symptoms enumerated in the enclosed letter,
I must not omit to state, that I was particularly struck by the
appearance of great oppression and difficulty of respiration under
which the patient had been laboring for a considerable period of
time before I visited him. On passing a probe through a fistulous
opening, situated a short distance from the right edge of the lower
portion of the sternum, I was also surprised to find the two adja-
cent costal cartilages presenting hard and rough bony surfaces,
along both of which I could convey the probe its whole length
towards the right side. This circumstance immediately convinced
me that the disease had originated from an ossification of those
cartilages, and a consequent inflammation in or around them,
which had finally produced a detachment of the perichondria, and
a caries, if not a necrosis, of both bony substances.
I commenced the operation by carrying a deep incision from
the edge of the sternum outwards, to the distance of seven or eight
inches, along the intercostal space between the fifth and sixth
ribs. The edges of this incision were then dissected up until the
surfaces of both those ribs were fully exposed. They were evidently
ossified cartilages, presenting the appearance of worm-eaten caries
throughout their whole length. The perichondrium was com-
pletely detached from the external surface of both, and thickened
by induration of the surrounding cellular substance. I encountered
but little difficulty, therefore, in detaching this envelope and push-
ing it backwards from the upper and lower edges of each rib by
the use of the handle, and occasionally the blade of a common
scalpel. The attenuated intercostal muscles and tendinous fibres
wrere of course detached along with those membranes. The bones
were then left sufficiently bare to allow of the application of a
Hay’s saw, which I repeated twice on each rib. With a common
elevator I then pried up the bones from their outer towards their
sternal attachments, in accomplishing which, only two or three
applications of the knife were required to cut away adhesions to
the indurated mass of membranes and cellular tissue within. As
the projecting extremities of the ribs did not appear perfectly
sound, I extended the incision a little further outwards, and cut
away about one and a half inches more from their substance. The
lower portion of the sternum presenting a similar appearance of
disease, I also enlarged the incision inwards, and sawed away a
considerable portion of that bone. On examining the exposed
surface, there appeared a convoluted bony plate, surrounded by
some indurated cellular tissue and medullary looking matter,
pressing upon the pleura costalis, and intruding upon the cavity
of the chest. I mistook this at first for the extremity of the
seventh rib, which I supposed had been turned inwards and
upwards behind the corresponding cartilages of the fifth and sixth
ribs. On a closer inspection, however, I became convinced that
it proceeded from ossification of the sixth rib, which had attempted
to set up a sequestrating process around the cartilage.
I succeeded very easily in prying up the whole of this mass
with an elevator, which detached it clearly from the pleura, with
the same kind of sound that is emitted from a birch log when it is
stripped of its bark. The intercostal fibres, both muscular and
tendinous, were chiefly removed along with the bony plate, and
the pleura was then left thin as natural, rising and falling alter-
nately, with the efforts at inspiration and expiration.
As hemorrhage from the torn branches of the intercostal and
mammary arteries ceased almost instantaneously, I immediately
closed up the incision in the integuments, and retained them in
apposition by interrupted sutures and adhesive plasters. A broad
compress and bandage completed the dressing, and I left the
patient directly afterwards in the care of my friend, Dr. J. W.
Gloninger.
In haste, I am truly your friend,
Geo. McClellan.