Report on Surgery to the Santa Clara County Medical Society, by Joseph Bradford Cox pot

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Title: Report on Surgery to the Santa Clara County Medical Society

Author: Joseph Bradford Cox

Release Date: December 8, 2007 [EBook

#23769]

Language: English

*** START OF THIS PROJECT GUTENBERG EBOOK REPORT ON SURGERY ***

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SURGERY

TO THE

Santa Clara County

Medical Society.

BY

Report on Surgery.

In presenting this report I will notattempt to give any historical dataconnected with the subject of surgery,since that has been ably done in thereport of last year

I shall assume, and that withouthesitation, that surgery is a science,properly so-called That it is an art, isalso true But what is science? What isart? Science is knowledge Art theapplication of that knowledge To be

more explicit, science is the knowledge

we possess of nature and her laws; or,more properly speaking, God and Hislaws

When we say that oxygen and iron uniteand form ferric oxide, we express a law

of matter: that is, that these elementshave an affinity for each other A

collection of similar facts and theirsystematic arrangement, we callchemistry Or we might say, chemistry isthe science or knowledge of theelementary substances and their laws ofcombination

When we say that about one-eighth of theentire weight of the human body is afluid, and is continually in motion within

certain channels called blood vessels,

we express a law of life, or a vitalprocess When we say this fluid iscomposed of certain anatomicalelements, as the plasma, red corpuscles,leucocytes and granules, we go a stepfurther in the problem of vitality When

we say that certain nutritious principlesare taken into this circulating fluid bymeans of digestion and absorption, andthat by assimilation they are convertedinto the various tissues of the body, wethink we have solved the problem, andknow just the essence of life itself Butwhat makes the blood hold thesenutritious principles in solution until thevery instant they come in contact withthe tissue they are designed to renovate,

and then, as it were, precipitate them asnew tissue? You say they are inchemical solution, and the substance ofcontact acts as a re-agent, and thus thedeposit of new tissue is only inaccordance with the laws of chemistry.Perhaps this is so Let us see as to theproofs In the analysis of the bloodplasma, we find chlorides of sodium,potassium and ammonium, carbonates ofpotassa, soda, lime and magnesia,phosphates of lime, magnesia, potassa,and probably iron; also basic phosphatesand neutral phosphates of soda, andsulphates of potassa and soda Now inthe analysis of those tissues composedprincipally of inorganic substances orcompounds, it will be seen that these

same salts are found in the tissuesthemselves.

So also the organic compounds lactate ofsoda, lactate of lime, pneumate of soda,margarate of soda, stearate of soda,butyrate of soda, oleine, margarine,stearine, lecethine, glucose, inosite,plasmine, serine, peptones, etc., arefound alike in the tissues and in theblood plasma That they are in solution

in the plasma is well known,—that theyare in a solid or precipitated form in thetissues is also true,—and that the tissuesare supplied from the blood is alsoevident,—because the blood is the onlypart that receives supplies of materialdirect from the food taken and digested

That carbonate of lime and phosphate oflime are precipitated or assimilatedfrom the plasma to form bone, isadmitted by all physiologists That thecarbonates and phosphates alreadydeposited act as the re-agent toprecipitate fresh supplies from theplasma is not a demonstrated fact, butmay be inferred So also with the othertissues Should this be admitted withoutpositive evidence we would not then be

at the end of our problem;—for thequestion may be asked as to what causesthe first or initial deposit Here we muststop and acknowledge our ignorance.But you may now ask what all thisphysiology and chemistry of the plasmahas to do with a report on surgery I

propose to use it for the purpose ofexplaining some peculiarities in theprocess of repair in surgical cases.

A few months ago I had a case ofdelayed union in a fracture of the tibia,

at the hospital, and spent more time inwaiting for nature, unassisted, toaccomplish a cure, than I should everspend again One week after putting thepatient on the use of ten grain doses ofhypophosphite of lime, I had thepleasure of seeing bony unioncommencing And why? Simply becausethe quantity of phosphate of lime insolution in the plasma was not sufficient

to supply the waste of bone tissue in allparts of the body, and at the same timefurnish a supply for the provisional

callus which is thrown out in the repair

of fractures

In September, 1878, August G——,aged 18 years, single, a native ofSwitzerland, was admitted to the SantaClara County Hospital with incipientspinal disease He was of that peculiartemperament which indicates ascrofulous cachexia The fifth dorsalvertebra was sufficiently prominent toindicate the sight where the attack wasbeing made by the enemy There wasconsiderable tenderness on pressure;slightly accelerated pulse, and elevatedtemperature;—in other words, a welldefined case;—one which would haveresulted in caries and deformity within afew months By the administration of ten

grain doses of hypophosphite of lime forseveral weeks, I had the pleasure ofseeing recovery take place Reasoning

by analogy, I am led to conclude that thenature of the wound should, to a greatextent, govern the kind of food given thepatient during the treatment In manycases of surgery, medicines are notnecessary But in some exceptionalcases, as in similar ones to those abovenoticed, medicine is demanded And inall cases of flesh wounds, I believe thepatient will be benefited by a liberaldiet of animal food; that is, after the firstinflammatory condition has subsided.Why this is so, is simply because thosevery materials are furnished to thesystem which are required for the repair

of the tissues injured, viz., the organiccompounds In flesh wounds of weakand debilitated persons which are slow

in healing, a diet of beef tea, eggs,oysters, etc., will often bring about arapid improvement Thus, we see thatchemistry, organic and inorganic, hassomething to do with surgery

I will now present the following caseswhich have seemed of special interest tome:

Case First.—In 1874, while in themountains on the Trinity river, Dr ——was kicked by a mule in such a manner

as to rupture the ligamentum patellae.The tendon of the quadriceps femoris, atonce drew the patella at least two inchesabove its normal position Of course hewas unable to walk, but was taken to ahouse near by With some assistancefrom a brother physician the patella wasbrought down to its place, but it wouldnot remain I suggested the use of a guttapercha mould or covering for the knee.Without much difficulty, a piece one-fourth of an inch thick, softened in hotwater, was applied, and kept in place bymeans of compresses and bandages until

it hardened This made a perfect andfirm, splint fitting all the inequalities ofthe knee, covering all but the posteriorpart of the leg, and extending three or

four inches above and below the patella.With this bound moderately tight to theleg by a roller bandage, it was simply animpossibility for the patella to movefrom its proper position At the end ofabout a week the patient left the bed, andcould walk about, but, of course, with astiff leg He wore this splint or cap forthe knee for about four weeks, when Ifound he could leave it off at nightwithout much pain Continued to wear itduring the day for perhaps a fortnight,when I found he could leave it offentirely.

I mention this case partly for the purpose

of calling the attention of the members ofthe society to the use of gutta percha as amaterial for splints It is not adapted to

all cases of fracture; but in very manycases I find nothing else so satisfactory.

I have thought that in fracture of thepatella it would be peculiarly valuable,

as it is so readily adjusted to all theinequalities of the knee joint

Case Second.—Jerome De——, agedfifty-four years, native of France, single,was admitted to the Santa Clara CountyHospital, July 20th, 1878 He wassuffering from rheumatism, or at leastcomplained of pains in various parts ofthe body, more particularly the longbones of the arms and legs These painswere worse at night, pulse varying

between 80 and 90, temperature natural.Suspecting a specific origin for thismalady, I put him on the use of iodidepotassium, with increasing doses Heslowly improved with the exception of apain in the left humerus, anteriorily, and

in the upper part of the middle third.This became localized to a spot nolarger than a twenty-five cent piece Attimes the pain was intense andexcruciating: and about a week fromadmission this spot seemed quite tender

to the touch After the use of a blisterand tincture of iodine for a week, he wassomewhat relieved Not entirely,however, for at times the pain was verysevere On Aug 7th, he left the hospitalthinking he could do some work The

next day, while attempting to climb afence, and while in the act of raising thebody by the arms, the left humerus wasfractured transversely at the exact point

of his previous suffering

He was again admitted to the hospital,and the fracture dressed in the usualmanner After five or six days a guttapercha splint was used which encircledthe arm Bony union was slow in takingplace However, on Oct 3d, nearly twomonths from the date of the fracture, heleft the hospital, the union beingcomplete, and he being entirely relievedfrom his pain; in fact, he was relievedfrom the moment of the fracture

This case presents a question in

pathology which is of interest Was there

a localized periostitis at this point? If so,why was it not entirely relieved by thetreatment which consisted of blisters andiodine, externally, and mercury andiodide potassium internally? Was there adeficiency of nutrition at this point? oranemia from some change in the nutrientartery,—the result of the periostitis ofthe long bones? Or was it incipientnecrosis? Prof Hamilton gives therecord of a case of fracture of thehumerus, from muscular action, takingplace three several times in the sameindividual, each time in a differentplace

Case Third.—Dec 29th, 1878, wascalled to see Mr ——, male, married,aged about 40 years Has led an out-door, active life Has always beenhealthy No venerial taint Nervoustemperament, spare built, and weighsabout 140 pounds Present condition:Has been sick two or three days; theattack commenced with a chill, followed

by fever; has had fever ever since thechill; complains of pains in the back andlegs; has vomited considerable; bowelscostive; tongue coated; severe pain inright side corresponding to lower part ofthe lung, which I found solidified; there

is considerable cough

Ordered a cathartic; to be followed by

an anti-pyretic of acetate of ammonia

and aconite, and a blister over the lowerpart of the right lung Continued thistreatment for three or four days, whenthe pneumonia began to subside, and atthe end of about ten days I considered

my patient convalescent About this time

I was sent for in great haste after night.The patient, who is a very intelligentman, said he had felt worse during theday, and in the evening, his knee, whichhad been somewhat painful for two orthree days, had become exceedinglypainful I gave morphine,hypodermically, and went home, leavingsome morphine for the night

The next day I saw him The pain hadbeen relieved by the morphine, stilloccasionally it was quite severe There

was no redness or heat, or eventenderness; nothing unnatural about theknee except pain, which was aggravated

by any attempt to move the leg

Ordered quinine as a tonic, and pill “C.C.” as a cathartic Bandaged the legpretty tightly from the toes to above theknee The urine was natural; pulse andtemperature only slightly elevated Aftersix or seven days of these symptoms, theknee began to feel hot and became veryslightly swollen Ordered a small blisterover the inside of the knee as the greatestamount of pain seemed to be here.Dressed it with tartar-emetic ointmentuntil the skin was very sore; using iodine

on other puts of the knee Used iodidepotassium and colchicum, internally

This treatment for five days seemed to

do no good On Jan 17th, twenty-twodays from the beginning of his illness,and about twelve days from the firstappearance of symptoms denoting anylocal trouble at the knee, a consultationwas held, the result of which was ablister over the whole of the knee, to bedressed with unguentuin hydrargiri Theinflammation was but little influenced bythis or any other treatment The kneecontinued to slowly and surely enlarge.And this extended upward without firstproducing any great distention of thesynovial sack under the patella Thereseemed to be simply enlargement of allthe tissues of the lower part of the thigh.This continued until about the 1st of Feb

when, from the general appearance ofthe patient, viz: a typhoid condition,feeble pulse, coated tongue, emaciation,loss of appetite, as well as from thelocal appearance of the inside of theknee, I suspected pus within the joint.Accordingly, I introduced an exploringneedle into the inner part of the joint justabove and anterior to the insertion of thetendon of the semimembranosis muscle.Finding pus, I made an incision onlyabout half an inch long, and squeezed outperhaps an ounce of pus Closed this upand again bandaged the leg There wasbut very little pus discharged from thisopening afterward, not, however, forwant of drainage, since the cut was keptopen by introducing the probe

occasionally About the 9th or 10th ofFeb fluctuation became quite apparentalong the outer and lower part of thethigh On Feb 12th, consultation wasagain had, when fluctuation being verywell marked over a considerable portion

of the thigh in its lower and middlethirds, after giving the patientchloroform, an incision was made threeinches long on the outer and posteriorpart of the thigh, from the junction of thelower with the middle third, downwardthrough the posterior part of the vastusexternus muscle About two quarts oflaudable pus was discharged Byintroducing the finger upward anddownward, the periostium could be feltsmooth except within the knee joint, for

this could be distinctly felt, the fingerpassing readily between the ends of thefemur and tibia, and beneath the patella;the crucial and lateral ligaments seemed

to be gone, and the cartilages somewhatroughened A drainage tube was put in,the leg bandaged from the toes to thetrochanter major, with compresses soarranged as to obliterate the sack, ifpossible

The patient, up to this time, had beenslowly losing flesh, and was now verymuch emaciated A general typhoidcondition existed, the temperatureranging from 101 to 103.5; the pulsefrom 115 to 135, tongue coated, poorappetite, and in short, the patient in avery critical condition The use of

chloroform, and the shock from theevacuation of the pus, added to thegravity of all the symptoms, and forabout two weeks the patient was in greatdanger of death from asthenia However,

by liberal use of whisky, quinia, beeftea, cod liver oil, etc., he slowly rallied.Two smaller abscesses formed belowthe knee, but those gave no great anxiety,not so much as some bed sores on theback and hips The sack or pouchbecame gradually obliterated, down asfar as the knee The cavity of the joint,however, did not seem to be welldrained from the opening in the thigh,notwithstanding it had been kept openfreely by tents About three weeks fromthis last operation, the sinus or pouch

within the knee-joint being soimperfectly drained as above indicated,

I made an opening directly into the joint

at the outer and posterior part, one inchlong, through which I could introduce theprobe between the ends of the femur andtibia, without any difficulty, through allparts of the joint However, I discovered

no necrosed bone by so doing Put a tentinto this opening, and let the one aboveheal up, which it did in about twoweeks This latter opening into the joint Ikept open by means of tents until thejoint became anchilosed and ceased todischarge pus The patient made a slowand steady recovery, and about themiddle of April was able to get outdoors again

The special points of interest in this caseseem to be the obscure and insidiousmode of attack; the slow progress of theinflammation, it being rather sub-acutethan acute; and the fact of its being asequela of pneumonia.

Prof Gross, in his excellent work onsurgery, says, “synovitis, in the greatmajority of cases, arises from the effects

of rheumatism, gout, eruptive fevers,syphilis, scrofula, and the inordinate use

of mercury.”

Prof Hamilton, in “Principles andPractice of Surgery,” says, “synovitismay be caused by exposure to cold, ormay occur as a consequence of arheumatic, strumous, or syphilitic

cachexia, as a gonorrhœal complication,

as a sequela of fevers, and from manyother causes, whose relation to thedisease in question may not always beeasily determined.”

Since there was no local injury to theknee in this case which could havecaused the disease, we must seek someother cause for it

I have thought that its origin might beaccounted for on the principle ofmetastasis of morbid material Thepatient had pneumonia which passedthrough its several stages somewhatrapidly, resolution taking place about theend of the second week The symptoms

of this were well marked, viz: a chill

followed by fever, cough, brick-dustsputa, delirium, pain over lower half ofright lung, which was solidified, andafterward gave the crepitant and sub-crepitant roles Could not the morbidmaterial, which entered the circulationfrom the re-absorption of the deposit inthe solidified lung, have been carried tothe synovial membrane of the knee, andthere found a lodgment, and set up theinflammation which resulted in theformation of so much pus? If not, Whynot? Notwithstanding a tedious illness,and an anchilosed knee, was not thisresult better than to have had suppuration

of the lung tissue and destruction of thewhole of the right lung, and perhapseventually the left also? However, we

are not certain that such a result wouldhave followed, although the patient’sgeneral appearance at the time of theattack, and the typhoid condition whichfollowed, as also the low grade ofinflammation bordering on thescrofulous, made such a thing probable.

Case Fourth.—On Jan 31st, 1879, Mr.R——, Italian, aged 35 yrs., whilechopping wood near Almaden mines,was injured by a falling tree The lowerpart of the body was very much bruised,both posteriorly and anteriorly The onlyplace where the skin was broken was asmooth cut about four inches long and

nearly half an inch deep, following thefold or crease between the right testicleand thigh, and extending from theanterior part of the testicle to theperineum in a straight line just where thescrotal integument joins that of the thigh.The main injury was in the lumbarregion over the upper lumbar vertebræ.The spinous process of the lower dorsalvertebra seemed to be unusuallyprominent, leading to the suppositionthat the spinous process of the upperlumbar vertebra might be fractured anddepressed However, I was unable todetect mobility or crepitus in any of theprocesses, spinous or transverse, either

of the dorsal or lumbar vertebræ

There was considerable tenderness overthe lumbar region I would here state thatthe examination was made about twentyhours after the receipt of the injury.There was but little discoloration of theskin, not very much pain, no paralysis ofany part, the bladder evacuating itselfnaturally, and a cathartic producing itsordinary effect in the usual time.

The patient did well; complained of butlittle pain; did not use opiates OnWednesday and Thursday following, thepatient felt well enough to walk aboutthe wards, eating well and having noconstitutional disturbance, pulse neverhigher than eighty per minute, and thetemperature not above 99 degrees F

On Friday morning the nurse remarkedthat this patient had complained of pain

in the back during the previous night, andthat there seemed to be a soft spot on hisrump By examining, I found below thebandage which I had put around thepatient, a fluctuating mass, immediatelybeneath the skin and superficial fascia,extending from the tenth dorsal vertebraabove, to the coccyx below, and fromthe crest of the right ilium to that of theleft

I was at a loss to know how to accountfor this fluid, for there was at least aquart I removed the bandage andexamined more carefully There was noinflammation to amount to anything, norhad there been Here it is only the

seventh day from the receipt of theinjury, and it surely cannot be pus.However, to satisfy myself, I used anexploring needle; and not very much to

my surprise, I discovered light coloredarterial blood! Could I be mistaken? Itwisted the needle about, pressed it toone side, until nearly a drachm of theblood had escaped Fully convincednow that I had a secondary hemorrhage

to deal with, the question arose what to

do I supposed that it came from one ofthe lumbar or inter-costal arteries thathad been injured by the supposedfracture of the process of the vertebra If

so, it comes from an artery inclosed in abony cavity, and one that cannot contractand close spontaneously, and since its

origin is so close to the aorta, it willcontinue to bleed until the patient dies ofhemorrhage.

While I was thus examining thefluctuating mass, and conjecturing as toorigin and results, I fancied that thequantity of fluid was sensibly increasing.However, I will not be positive that myimagination did not assist in thisaccumulation

But what shall I do? Cut down into thissinus, and hunt the bleeding artery, andtie it? Could I find it? And could I tie it

if I did find it? Probably not; and moreespecially if it is a lumbar artery, andinjured in the foramen through which itpasses from the vertebra But the man