XXI.

EXCISION OF THE SCAPULA.

BY H. F. BIGGAR, M.D., CLEVELAND, O.

COMPLETE excision of the scapula for various surgical diseases and as a remedy for malformations and adhesions resulting from fractures and dislocations of the shoulder-joint, is an operation whose history is confined to the present century.

The complete extirpation of a bone performing so important an office in the structure of an intricate joint as does the shoulder-blade, would seem, at first thought, to necessitate serious impairment, if not total destruction of the joint. Yet the history of the cases thus far recorded goes to show that the operation has been followed in a majority of instances by fair use of the arm, and in some cases by a remarkably good and serviceable joint.

In our best surgical authors, under the head of "Excision of the Scapula," are included a great many cases in which the acromion process and that portion of the head of the scapula with its muscular attachments containing the glenoid cavity are left intact. To treat as identical such cases and those in which the bone is disarticulated and removed entire, gives no definite idea of the relative gravity of the two operations. In the one case the articular surface of the head of the os humeri is left intact, and in the other it is exposed and brought into relation with entirely new anatomical structures. When these portions of the bone are left, being held in relation to the os humeri by their ligamentous at

tachments, the joint is virtually untouched, and no adhesions will be likely to take place to seriously impair the action of the joint.

When operative interference is required for necrosis or caries of the scapula, unfortunately that portion of the bone so essential to the integrity of the joint is usually the seat of the disease, and these are the cases that imperatively demand complete extirpation.

The first recorded instance of complete removal of the scapula is credited to Cumming, in 1808, followed by Syme, in 1856. Pussy excised the whole of the scapula and the clavicle in 1813, and the patient is said to have been in good health fifteen years afterwards, though nothing is said of the condition of the arm. Erichsen, speaking of the complete excision of the shoulder-blade, leaving the arm untouched, by Jones, Syme, Fergusson and others, says: "The arm so left becomes a useful member, capable of performing all the underhanded movements and of lifting considerable weights."

Dr. Steven Rogers published (Am. Journal Med. Sci., vol. Ivi, p. 367) a tabular statement of excisions of the scapula up to that date. His table was extensively copied into journals and medical works of both continents.

A careful review of the table shows that there were only 25 cases of total and 31 of partial excision; and in the enumeration of the list of total excisions it will be found that, through an error, the same case was twice noted, once under the name of Gaëtani Bey, and again under that of Surrey, and that Cases 10 and 15 of the original table are identical; reducing the entire list of complete extirpations up to that time to 24.

Vast numbers of new cases might now be added to Rogers's list of partial excisions, but we will confine this paper to a description of the more interesting cases of an additional list of 17 cases of complete excision of the scapula. It is not claimed this includes all the operations of this class, but, since the operation has gone into medical literature as a legitimate factor of operative surgery, doubtless many excisions have been performed which have escaped the knowledge of the most assiduous gatherers of surgical statistics.

Of this supplemental list of 17 authentic cases,

No. 1, by Professor W. Pirrie, records (Prin. and Prac. Surg., 3d ed., 1873, p. 812), on the 18th of September, 1856, the removal of the whole of the scapula from a female 70 years of age, followed by slow recovery "and a tolerable use of the arm."

2. An operation performed February 17th, 1857, and reported by M. Soupart in Ann. de la Soc. Med de Grand. A successful removal of the scapula for malignant disease, after disarticulation of the shoulder.

Deroubaix (de Bruxelles). Excision
Successful as to the joint, but fatal

3. By M. le Professeur for carcinomatous disease. recurrence of carcinoma in the lungs.

4. In 1860, Professor B. von Langenbeck exarticulated the humerus for osteosarcoma, in a man aged 23. On recurrence of the disease he extirpated the scapula and excised an inch and a half of the clavicle. The patient survived the operation a year and a half. (Arch. der Klin. Chir., 1862, b. iii, S. 306.)

5. In the Dublin Med. Press of November 13th, 1861, is recorded a case of extirpation of the shoulder-blade for necrosis, followed by "a useful arm." Operator's name not given.

6. The Lancet, 1865, vol. ii, p. 696, records a case of excision of scapula, head of humerus and part of the clavicle, by J. D. Bird.

8. Dr. F. H. Hamilton (Prin. and Prac. of Surgery) says he excised the entire scapula in February, 1866, for necrosis resulting from gunshot injury, the patient recovering with a very useful arm.

The same case is mentioned in New York Med. Journal, 1869, vol. viii, p. 372. The report of the New York Pathological Society, published in the Med. and Surg. Reporter, 1866, vol. xiv, p. 372, says: "Professor Hamilton presented a scapula which had been removed entire from a soldier who had been wounded at Fredericksburg by a shell. Necrosis of the scapula ensued, necessitating its entire removal with the acromion and coracoid processes. The patient has power to use the coracobrachialis and biceps, also tolerably well the triceps and deltoid.

He is able to carry the arm without a sling, although attachment of these muscles is simply to cicatricial tissue, there having been no formation of new bone.

11. Dr. D. M. Schuppert, in the New Orleans Journal of Med., 1870, gives a case of total excision of the scapula by himself in a woman aged 36, and the "preservation of a useful arm."

We have thus hastily jotted down a synopsis of a portion of these cases, comprising the post Rogers tabulation; but aside from the authentic list of 17, mention is made in the Medical and Surgical History of the War of the Rebellion, of "two other cases of total excision of the scapula," tabulated by an anonymous writer in the New York Med. Journal, 1869, vol. viii, p. 434.

A nephew of Dr. Twitchell, of Keene, New Hampshire, claims that his uncle, in 1868, removed the scapula, arm and part of the clavicle, his patient recovering from the operation.

In the reports of almost all these cases we discover a lack of concise statement as to results; an important consideration to every practical surgeon.

DISEASES AND INJURIES OF THE KNEE-
JOINT, WITH EXCISION.

BY J. H. McCLELLAND, M.D., PITTSBURG, PA.

LESIONS of the knee-joint claim special attention, as occurring more frequently and being more difficult to cure than those of any other joint of the body.

Within the limits of a paper such as is demanded by this Institute we cannot indulge to any extent in pathological speculations in order to reach nice pathological distinctions, but we may refer to certain ascertained and probable facts in pathology and morbid anatomy which will have a bearing upon the successful treatment of the diseases under discussion.

It is not intended in this paper to cover the whole ground, as I have reason to believe that my colleagues of the bureau will discuss, to a greater or less extent, the same general subject.

My object will be to call your attention in the main to such affections as may fairly be included under the general heads of Acute and Chronic Inflammation of the Knee-joint, feeling that this simple classification will embrace all of the more important lesions with which we have to do.

It is no doubt a proper method to classify according to the tissues affected, synovial, cartilaginous, ligamentous and osseous, but we know that many times two or all of these tissues are involved at the same time, and one term is insufficient to describe the whole lesion.

It is admitted that acute cases will merge into chronic, but it