Report on Surgery to the Santa Clara County Medical Society

Part 1

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REPORT ON SURGERY TO THE SANTA CLARA COUNTY MEDICAL SOCIETY.

BY J. BRADFORD COX, M. D.

READ MARCH 2d, 1880.

SAN JOSE: MERCURY STEAM PRINT. 1880.

REPORT ON SURGERY.

In presenting this report I will not attempt to give any historical data connected with the subject of surgery, since that has been ably done in the report of last year.

I shall assume, and that without hesitation, that surgery is a science, properly so-called. That it is an art, is also true. But what is science? What is art? Science is knowledge. Art the application of that knowledge. To be more explicit, science is the knowledge we possess of nature and her laws; or, more properly speaking, God and His laws.

When we say that oxygen and iron unite and form ferric oxide, we express a law of matter: that is, that these elements have an affinity for each other. A collection of similar facts and their systematic arrangement, we call chemistry. Or we might say, chemistry is the science or knowledge of the elementary substances and their laws of combination.

When we say that about one-eighth of the entire weight of the human body is a fluid, and is continually in motion within certain channels called blood vessels, we express a law of life, or a vital process. When we say this fluid is composed of certain anatomical elements, as the plasma, red corpuscles, leucocytes and granules, we go a step further in the problem of vitality. When we say that certain nutritious principles are taken into this circulating fluid by means of digestion and absorption, and that by assimilation they are converted into the various tissues of the body, we think we have solved the problem, and know just the essence of life itself. But what makes the blood hold these nutritious principles in solution until the very instant they come in contact with the tissue they are designed to renovate, and then, as it were, precipitate them as new tissue? You say they are in chemical solution, and the substance of contact acts as a re-agent, and thus the deposit of new tissue is only in accordance with the laws of chemistry. Perhaps this is so. Let us see as to the proofs. In the analysis of the blood plasma, we find chlorides of sodium, potassium and ammonium, carbonates of potassa, soda, lime and magnesia, phosphates of lime, magnesia, potassa, and probably iron; also basic phosphates and neutral phosphates of soda, and sulphates of potassa and soda. Now in the analysis of those tissues composed principally of inorganic substances or compounds, it will be seen that these same salts are found in the tissues themselves.

So also the organic compounds lactate of soda, 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., are found alike in the tissues and in the blood plasma. That they are in solution in the plasma is well known,--that they are in a solid or precipitated form in the tissues is also true,--and that the tissues are supplied from the blood is also evident,--because the blood is the only part that receives supplies of material direct from the food taken and digested.

That carbonate of lime and phosphate of lime are precipitated or assimilated from the plasma to form bone, is admitted by all physiologists. That the carbonates and phosphates already deposited act as the re-agent to precipitate fresh supplies from the plasma is not a demonstrated fact, but may be inferred. So also with the other tissues. Should this be admitted without positive evidence we would not then be at the end of our problem;--for the question may be asked as to what causes the first or initial deposit. Here we must stop and acknowledge our ignorance.

But you may now ask what all this physiology and chemistry of the plasma has to do with a report on surgery. I propose to use it for the purpose of explaining some peculiarities in the process of repair in surgical cases.

A few months ago I had a case of delayed union in a fracture of the tibia, at the hospital, and spent more time in waiting for nature, unassisted, to accomplish a cure, than I should ever spend again. One week after putting the patient on the use of ten grain doses of hypophosphite of lime, I had the pleasure of seeing bony union commencing. And why? Simply because the quantity of phosphate of lime in solution in the plasma was not sufficient to supply the waste of bone tissue in all parts of the body, and at the same time furnish 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 of Switzerland, was admitted to the Santa Clara County Hospital with incipient spinal disease. He was of that peculiar temperament which indicates a scrofulous cachexia. The fifth dorsal vertebra was sufficiently prominent to indicate the sight where the attack was being made by the enemy. There was considerable tenderness on pressure; slightly accelerated pulse, and elevated temperature;--in other words, a well defined case;--one which would have resulted in caries and deformity within a few months. By the administration of ten grain doses of hypophosphite of lime for several weeks, I had the pleasure of seeing recovery take place. Reasoning by analogy, I am led to conclude that the nature of the wound should, to a great extent, govern the kind of food given the patient during the treatment. In many cases of surgery, medicines are not necessary. But in some exceptional cases, as in similar ones to those above noticed, medicine is demanded. And in all cases of flesh wounds, I believe the patient will be benefited by a liberal diet of animal food; that is, after the first inflammatory condition has subsided.

Why this is so, is simply because those very materials are furnished to the system which are required for the repair of the tissues injured, viz., the organic compounds. In flesh wounds of weak and debilitated persons which are slow in healing, a diet of beef tea, eggs, oysters, etc., will often bring about a rapid improvement. Thus, we see that chemistry, organic and inorganic, has something to do with surgery.

I will now present the following cases which have seemed of special interest to me:

CASE FIRST.--In 1874, while in the mountains 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, at once drew the patella at least two inches above its normal position. Of course he was unable to walk, but was taken to a house near by. With some assistance from a brother physician the patella was brought down to its place, but it would not remain. I suggested the use of a gutta percha mould or covering for the knee. Without much difficulty, a piece one-fourth of an inch thick, softened in hot water, was applied, and kept in place by means of compresses and bandages until it hardened. This made a perfect and firm, splint fitting all the inequalities of the knee, covering all but the posterior part of the leg, and extending three or four inches above and below the patella. With this bound moderately tight to the leg by a roller bandage, it was simply an impossibility for the patella to move from its proper position. At the end of about a week the patient left the bed, and could walk about, but, of course, with a stiff leg. He wore this splint or cap for the knee for about four weeks, when I found he could leave it off at night without much pain. Continued to wear it during the day for perhaps a fortnight, when I found he could leave it off entirely.

I mention this case partly for the purpose of calling the attention of the members of the society to the use of gutta percha as a material for splints. It is not adapted to all cases of fracture; but in very many cases I find nothing else so satisfactory. I have thought that in fracture of the patella it would be peculiarly valuable, as it is so readily adjusted to all the inequalities of the knee joint.

CASE SECOND.--Jerome De----, aged fifty-four years, native of France, single, was admitted to the Santa Clara County Hospital, July 20th, 1878. He was suffering from rheumatism, or at least complained of pains in various parts of the body, more particularly the long bones of the arms and legs. These pains were worse at night, pulse varying between 80 and 90, temperature natural. Suspecting a specific origin for this malady, I put him on the use of iodide potassium, with increasing doses. He slowly improved with the exception of a pain in the left humerus, anteriorily, and in the upper part of the middle third. This became localized to a spot no larger than a twenty-five cent piece. At times the pain was intense and excruciating: and about a week from admission this spot seemed quite tender to the touch. After the use of a blister and tincture of iodine for a week, he was somewhat relieved. Not entirely, however, for at times the pain was very severe. On Aug. 7th, he left the hospital thinking he could do some work. The next day, while attempting to climb a fence, and while in the act of raising the body by the arms, the left humerus was fractured transversely at the exact point of his previous suffering.

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