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of a portion of the shaft of the femur was cut off and death of that part ensued. The condition we have to meet in this case is therefore necrosis of a limited portion of the shaft of the femur. Necrosis, as applied to bone, is analogous to gangrene as applied to the soft parts. It is death of the bone en masse in contradis
tinction to caries or molecular death of bone. Necrosis is usually the result of periostitis, or of osteo- myelitis, pathological conditions which shut off the life of oseous tissue. As the shaft of the bone dies, new bone is formed around the dead portion, called the sequestrum, after separation has been effected, completely investing it. The investing new bone is called the involucrum. The openings in the new investing bone for the discharge of pus are called cloacae.
Nature points out the proper treatment of such conditions in her efforts to separate and throw off the dead bone as in the soft parts dead portions are separated and cast off as sloughs. The proper treatment is to remove by operation the dead bone. This operation is termed sequestrotomy. In the case now before you, you see that the lower part of the thigh is somewhat enlarged. Palpation shows that the bone itself is enlarged above the knee. The skin is thickened and purplish. The part is not very tender. On the inner side of the thigh is a fistula surrounded by diseased soft parts. A thin, offensive discharge takes place through this opening, as shown upon the dressings. A probe passed into this opening comes in contact with dead bone, which is evidently loose.
We shall operate as follows:
The part having been thoroughly scrubbed and shaved, and the patient anæsthetized, an incision is made along the inner side of the thigh, about four inches in length. This incision passes through the fistula, and is carried at once down to the bone. It will be remembered that at this point the femoral artery passes from the inner side of the bone behind it to become the popliteal. We must observe due caution in attacking this part of the bone on account of the propinquity of this artery. The bone having been exposed, and the soft parts retracted, the opening in the bone is enlarged by mallet and chisel, and the sequestrum, which is about an inch and a half in length, and of irregular width, is lifted out with forceps. Several smaller
sequestra are removed. The cavity is now thoroughly curetted and irrigated, after which it is loosely packed with oakum soaked in balsam Peru. Sutures are placed in the upper and lower extremities of the wound, the central portion being allowed to remain open. The usual antiseptic dressings are now applied, and the patient will be carried back to his school with directions that the wound be dressed as often as may be rendered necessary by the dressings becoming soaked with the discharges.
(The operation was done as described.)
(The patient was presented to the class several times afterwards to show the progress made by the wound towards healing. A complete recovery was secured.)
RECURRENT EPITHELIOMA OF THE LIP.
Mike C., white, æt 85, express driver by occupation, appears before you with an affection of the lower lip. The disease is epithelioma. This disease is common in the lower lip, rarely seen involving the upper. It is a malignant disease consisting of morbid development of the epithelial type of tissue. It is met with in those parts of the body where mucous and 'tegumentary structures blend, as for example, the mouth, the eyelids, the penis, the rectum, etc. It is also common in parts provided with purely mucous membrane as the tongue, the cervix uteri, the stomach, etc. It is most frequently the result of prolonged and constant irritation. In the lower lip, it is caused by the constant use of the short clay pipe, with cane stem; which forms the inseparable companion of most Irishmen of the laboring class. It commences usually as a crack or chapped portion of the lip which won't heal. It becomes hard, nodular and painful. It is usually of very slow growth, and as the lump grows larger, it breaks and bleeds readily. Its surface is covered with a scab formed of blood, and the scant discharge. As often as the scab is removed, a new one forms and the ulcerated nodule is seen to be larger. It is slowly destructive, and sometimes involves large extent of tissues. The growth may extend to the bone and involve it. Late in the disease the glands are secondarily diseased. The only treatment is excision. Four years ago I removed a similar ulcer in this patient, at that time taking out a considerable V-shaped segment of his lip. You cannot observe now that this operation caused
any marked deformity, and can see the cicatrix only upon close inspection. The tissues immediately adjacent are indurated for some distance. The submaxillary glands are still free from involvement. The ulcer is hard and nodular, and bleeds readily. I shall operate as follows: Along the lines of incision at several points a few drops of a 4 per cent solution of cocaine are injected. A V-shaped section of the lip containing the epithelioma is made, care being taken that the incision on each side is made well beyond the limits of the disease as marked by the induration. The wound is approximated by two hare-lip pins and the lips carefully united by several interrupted silk sutures. The usual dressings are used. The prognosis is these cases of epithelioma of the lip is, as a rule, more favorable than in malignant diseases in other portions of the body. The wound heals rapidly, and the puckered condition of the mouth apparent at first soon disappears.
(The operation was done as described. The pins were removed in forty-eight hours, and the sutures in four days, at which time union was complete, and the patient returned to his work.)
Our next patient is Otis A., white, æt. 10 years, who has been brought to us from DeKalb Co., Tenn. by his physician, Dr. Adkerson, for relief of a congenital deformity of the upper lip. A glance at the patient is sufficient for you to recognize the nature of the condition. It is a fissure of the upper lip extending nearly to the nostril. This is the simplest variety of hare-lip. Sometimes in single hare-lip, as in the case operated on in your presence last month, the fissure extends into the nostril, has a prominent intermaxillary bone and cleft palate.
The operation for repair of hare-lip should be undertaken early. If complicated with cleft palate the lip is repaired and the divided palate left until the child is older. It will be a short time only when both operations will be undertaken at the same time in early infancy. Even if the cleft palate is untouched the hare-lip should be cured, as the fissured palate is influenced for the better by the closure of the divided lip.
I shall proceed as follows: Chloroform is administered, and
hemorrhage from the coronary arteries controlled by what I call the lip tourniquet. This is done as follows: A ligature is passed through the lip at a sufficient distance from the fissure not to infere with subsequent steps of the operation and tied tightly over short pieces of rubber drainage tubes, so as to exert elastic compression. The lip is now dissected freely from the gum so that we can slide the lip freely from one side to the other. This is a very important step in the operation. You notice I make it very freely. I next introduce a narrow-bladed hare-lip knife at the lower part of the fissure, and cut directly up towards the upper angle, first on one side and then on the other, and have them join at the upper angle, so that I can invert the V formed by the fissure completely. I next introduce a strong hare-lip pin just at the margin of the vermilion border of the lip, and transfix the other side at a similar point, taking care to include sufficient tissue, and that the pin emerges and enters just above the mucous lining of the flaps. A second pin is introduced a little nearer the nose. A figure-of-eight suture, of strong silk, is now thrown over each of these pins so as to bring the edges of the pared fissure into correct apposition. The loop drawn down from above is divided and shaped by scissors, so that when the two flaps are joined by interrupted sutures a projection will be formed in place of a notch. A single suture is placed in the upper part of the wound, above the upper pin. The dressing is very simple, consisting of a pledget of lint under the pins, a covering of iodoform powder, and a compress of iodoform gauze, held in place by a strip of adhesive plaster. The pins should be removed in forty-eight hours; the sutures in four days. The patient should be fed with a spoon for the first week. The wound in most cases will be solidly healed at the end of a week. The knife I use for the paring I had made expressly for this operation. You notice the blade is extremely thin, and the point is in the centre of the axis of the blade.
[Nothing out of the ordinary run in the operation. Hemorrhage was splendidly controlled by the lip tourniquet. The approximation was perfect-a little delay occurred in trimming the projecting flaps. Patient was taken home the day after the operation.]
BY JOHN H. W. CHESTNUT, M.D., OF PHILADELPHIA.
Mr. President and Gentlemen of the Philadelphia Chapter of Jef ferson Medical College Alumni:
The objects of your Association are, as I take it, the maintenance and advancement of the honor and prosperity of Jefferson Medical College, and after these, the promotion of the welfare and pleasure of the Associated Alumni. With this understanding, I esteem very highly the personal compliment of an invitation to address you on a subject related to our common work, and my appreciation is intensified by the recognition of your favor as an evidence of that catholicity of spirit which so fitly adorns a liberal and cultured profession. The subject which I will ask you briefly to consider with me, while within the domain of abdominal surgery, embraces many cases with which every active practitioner must sooner or later come in contact, and which, when met, will require a nice discrimination, and, at times, the most prompt and decisive action. It is, however, a subject so encyclopaedic in character, that I can do no more than touch, in a suggestive way, on those features that seem to me of special importance from a clinical point of view.
For didactic purposes the different varieties are usually classified as to their causes into: (1) Cases of obstruction produced by strangulation through apertures. (2) Constriction by bands,
*Read before the Philadelphia Chapter of the Alumni Association of the Jefferson Medical College, November, 1896.