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+The Project Gutenberg EBook of Report on Surgery to the Santa Clara County
+Medical Society, by Joseph Bradford Cox
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Report on Surgery to the Santa Clara County Medical Society
+
+Author: Joseph Bradford Cox
+
+Release Date: December 8, 2007 [EBook #23769]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+*** START OF THIS PROJECT GUTENBERG EBOOK REPORT ON SURGERY ***
+
+
+
+
+Produced by Bryan Ness, Anne Storer and the Online
+Distributed Proofreading Team at http://www.pgdp.net (This
+book was produced from scanned images of public domain
+material from the Google Print project.)
+
+
+
+
+
+
+                     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.
+
+He was again admitted to the hospital, and the fracture dressed in the
+usual manner. After five or six days a gutta percha splint was used which
+encircled the arm. Bony union was slow in taking place. However, on Oct.
+3d, nearly two months from the date of the fracture, he left the hospital,
+the union being complete, and he being entirely relieved from his pain; in
+fact, he was relieved from 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 the treatment which consisted of blisters and iodine,
+externally, and mercury and iodide potassium internally? Was there a
+deficiency of nutrition at this point? or anemia from some change in the
+nutrient artery,--the result of the periostitis of the long bones? Or was
+it incipient necrosis? Prof. Hamilton gives the record of a case of
+fracture of the humerus, from muscular action, taking place three several
+times in the same individual, each time in a different place.
+
+
+CASE THIRD.--Dec. 29th, 1878, was called to see Mr. ----, male,
+married, aged about 40 years. Has led an out-door, active life. Has always
+been healthy. No venerial taint. Nervous temperament, spare built, and
+weighs about 140 pounds. Present condition: Has been sick two or three
+days; the attack commenced with a chill, followed by fever; has had fever
+ever since the chill; complains of pains in the back and legs; has vomited
+considerable; bowels costive; tongue coated; severe pain in right side
+corresponding to lower part of the 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 lower part of the right lung.
+Continued this treatment for three or four days, when the pneumonia began
+to subside, and at the 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 intelligent man, said he had felt worse during
+the day, and in the evening, his knee, which had been somewhat painful for
+two or three days, had become exceedingly painful. I gave morphine,
+hypodermically, and went home, leaving some morphine for the night.
+
+The next day I saw him. The pain had been relieved by the morphine, still
+occasionally it was quite severe. There was no redness or heat, or even
+tenderness; nothing unnatural about the knee 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
+leg pretty tightly from the toes to above the knee. The urine was natural;
+pulse and temperature only slightly elevated. After six or seven days of
+these symptoms, the knee began to feel hot and became very slightly
+swollen. Ordered a small blister over the inside of the knee as the
+greatest amount of pain seemed to be here. Dressed it with tartar-emetic
+ointment until the skin was very sore; using iodine on other puts of the
+knee. Used iodide potassium and colchicum, internally. This treatment for
+five days seemed to do no good. On Jan. 17th, twenty-two days from the
+beginning of his illness, and about twelve days from the first appearance
+of symptoms denoting any local trouble at the knee, a consultation was
+held, the result of which was a blister over the whole of the knee, to
+be dressed with unguentuin hydrargiri. The inflammation was but little
+influenced by this or any other treatment. The knee continued to slowly
+and surely enlarge. And this extended upward without first producing any
+great distention of the synovial sack under the patella. There seemed to
+be simply enlargement of all the tissues of the lower part of the thigh.
+This continued until about the 1st of Feb. when, from the general
+appearance of the patient, viz: a typhoid condition, feeble pulse, coated
+tongue, emaciation, loss of appetite, as well as from the local appearance
+of the inside of the knee, I suspected pus within the joint. Accordingly,
+I introduced an exploring needle into the inner part of the joint just
+above and anterior to the insertion of the tendon of the semimembranosis
+muscle. Finding pus, I made an incision only about half an inch long, and
+squeezed out perhaps an ounce of pus. Closed this up and again bandaged
+the leg. There was but very little pus discharged from this opening
+afterward, not, however, for want of drainage, since the cut was kept
+open by introducing the probe occasionally. About the 9th or 10th of Feb.
+fluctuation became quite apparent along the outer and lower part of the
+thigh. On Feb. 12th, consultation was again had, when fluctuation being
+very well marked over a considerable portion of the thigh in its lower and
+middle thirds, after giving the patient chloroform, an incision was made
+three inches long on the outer and posterior part of the thigh, from
+the junction of the lower with the middle third, downward through the
+posterior part of the vastus externus muscle. About two quarts of laudable
+pus was discharged. By introducing the finger upward and downward, the
+periostium could be felt smooth except within the knee joint, for this
+could be distinctly felt, the finger passing readily between the ends of
+the femur and tibia, and beneath the patella; the crucial and lateral
+ligaments seemed to be gone, and the cartilages somewhat roughened. A
+drainage tube was put in, the leg bandaged from the toes to the trochanter
+major, with compresses so arranged as to obliterate the sack, if possible.
+
+The patient, up to this time, had been slowly losing flesh, and was now
+very much emaciated. A general typhoid condition existed, the temperature
+ranging from 101 to 103.5; the pulse from 115 to 135, tongue coated, poor
+appetite, and in short, the patient in a very critical condition. The use
+of chloroform, and the shock from the evacuation of the pus, added to the
+gravity of all the symptoms, and for about two weeks the patient was in
+great danger of death from asthenia. However, by liberal use of whisky,
+quinia, beef tea, cod liver oil, etc., he slowly rallied. Two smaller
+abscesses formed below the knee, but those gave no great anxiety, not
+so much as some bed sores on the back and hips. The sack or pouch became
+gradually obliterated, down as far as the knee. The cavity of the joint,
+however, did not seem to be well drained from the opening in the thigh,
+notwithstanding it had been kept open freely by tents. About three weeks
+from this last operation, the sinus or pouch within the knee-joint being
+so imperfectly drained as above indicated, I made an opening directly into
+the joint at the outer and posterior part, one inch long, through which I
+could introduce the probe between the ends of the femur and tibia, without
+any difficulty, through all parts of the joint. However, I discovered no
+necrosed bone by so doing. Put a tent into this opening, and let the one
+above heal up, which it did in about two weeks. This latter opening into
+the joint I kept open by means of tents until the joint became anchilosed
+and ceased to discharge pus. The patient made a slow and steady recovery,
+and about the middle of April was able to get out doors again.
+
+The special points of interest in this case seem to be the obscure and
+insidious mode of attack; the slow progress of the inflammation, it being
+rather sub-acute than acute; and the fact of its being a sequela of
+pneumonia.
+
+Prof. Gross, in his excellent work on surgery, says, "synovitis, in the
+great majority of cases, arises from the effects of rheumatism, gout,
+eruptive fevers, syphilis, scrofula, and the inordinate use of mercury."
+
+Prof. Hamilton, in "Principles and Practice of Surgery," says, "synovitis
+may be caused by exposure to cold, or may occur as a consequence of a
+rheumatic, strumous, or syphilitic cachexia, as a gonorrhoeal
+complication, as a sequela of fevers, and from many other causes, whose
+relation to the disease in question may not always be easily determined."
+
+Since there was no local injury to the knee in this case which could have
+caused the disease, we must seek some other cause for it.
+
+I have thought that its origin might be accounted for on the principle of
+metastasis of morbid material. The patient had pneumonia which passed
+through its several stages somewhat rapidly, resolution taking place about
+the end of the second week. The symptoms of this were well marked, viz: a
+chill followed by fever, cough, brick-dust sputa, delirium, pain over
+lower half of right lung, which was solidified, and afterward gave the
+crepitant and sub-crepitant roles. Could not the morbid material, which
+entered the circulation from the re-absorption of the deposit in the
+solidified lung, have been carried to the synovial membrane of the knee,
+and there found a lodgment, and set up the inflammation which resulted in
+the formation of so much pus? If not, Why not? Notwithstanding a tedious
+illness, and an anchilosed knee, was not this result better than to have
+had suppuration of the lung tissue and destruction of the whole of the
+right lung, and perhaps eventually the left also? However, we are not
+certain that such a result would have followed, although the patient's
+general appearance at the time of the attack, and the typhoid condition
+which followed, as also the low grade of inflammation bordering on the
+scrofulous, made such a thing probable.
+
+
+CASE FOURTH.--On Jan. 31st, 1879, Mr. R----, Italian, aged 35 yrs., while
+chopping wood near Almaden mines, was injured by a falling tree. The lower
+part of the body was very much bruised, both posteriorly and anteriorly.
+The only place where the skin was broken was a smooth cut about four
+inches long and nearly half an inch deep, following the fold or crease
+between the right testicle and thigh, and extending from the anterior part
+of the testicle to the perineum in a straight line just where the scrotal
+integument joins that of the thigh.
+
+The main injury was in the lumbar region over the upper lumbar vertebrę.
+The spinous process of the lower dorsal vertebra seemed to be unusually
+prominent, leading to the supposition that the spinous process of the
+upper lumbar vertebra might be fractured and depressed. However, I was
+unable to detect mobility or crepitus in any of the processes, spinous or
+transverse, either of the dorsal or lumbar vertebrę.
+
+There was considerable tenderness over the lumbar region. I would here
+state that the examination was made about twenty hours after the receipt
+of the injury. There was but little discoloration of the skin, not very
+much pain, no paralysis of any part, the bladder evacuating itself
+naturally, and a cathartic producing its ordinary effect in the usual
+time.
+
+The patient did well; complained of but little pain; did not use opiates.
+On Wednesday and Thursday following, the patient felt well enough to walk
+about the wards, eating well and having no constitutional disturbance,
+pulse never higher than eighty per minute, and the temperature not above
+99 degrees F.
+
+On Friday morning the nurse remarked that this patient had complained of
+pain in the back during the previous night, and that there seemed to be a
+soft spot on his rump. By examining, I found below the bandage which I had
+put around the patient, a fluctuating mass, immediately beneath the skin
+and superficial fascia, extending from the tenth dorsal vertebra above, to
+the coccyx below, and from the crest of the right ilium to that of the
+left.
+
+I was at a loss to know how to account for this fluid, for there was at
+least a quart. I removed the bandage and examined more carefully. There
+was no inflammation to amount to anything, nor had there been. Here it is
+only the seventh day from the receipt of the injury, and it surely cannot
+be pus. However, to satisfy myself, I used an exploring needle; and not
+very much to my surprise, I discovered light colored arterial blood! Could
+I be mistaken? I twisted the needle about, pressed it to one side, until
+nearly a drachm of the blood had escaped. Fully convinced now that I had
+a secondary hemorrhage to deal with, the question arose what to do. I
+supposed that it came from one of the lumbar or inter-costal arteries that
+had been injured by the supposed fracture of the process of the vertebra.
+If so, it comes from an artery inclosed in a bony cavity, and one that
+cannot contract and close spontaneously, and since its origin is so close
+to the aorta, it will continue to bleed until the patient dies of
+hemorrhage.
+
+While I was thus examining the fluctuating mass, and conjecturing as to
+origin and results, I fancied that the quantity of fluid was sensibly
+increasing. However, I will not be positive that my imagination did not
+assist in this accumulation.
+
+But what shall I do? Cut down into this sinus, and hunt the bleeding
+artery, and tie it? Could I find it? And could I tie it if I did find it?
+Probably not; and more especially if it is a lumbar artery, and injured in
+the foramen through which it passes from the vertebra. But the man will
+probably bleed to death; and must I do nothing to prevent it? I concluded
+to use pressure with a bandage for the present, and ask for the advice of
+my brethren. Accordingly, compresses were placed along the spine, and the
+body bandaged snugly.
+
+On returning to town, I stated the case to doctors Brown and Thorne,
+giving my theory for the hemorrhage,--that it was secondary, and probably
+from a lumbar artery. They were of opinion that it would be almost an
+impossibility to find the artery and tie it, and without seeing each
+other, concluded that pressure was the remedy to be used. I would state
+that at the last visit the pulse was 74, and temperature 99. This was at
+about 9 A. M. I visited him again about 5 P. M., and found the pulse and
+temperature the same. There was by this time considerable increase in the
+quantity of fluid. I re-adjusted my compresses and bandaged again. On
+Saturday morning I found the quantity of fluid about the same, perhaps
+slightly increased. There was now considerable inflammation of the
+integument, over a large part of the sinus, the skin appearing tense, and
+the small blood vessels distinct and purple. The patient had a slight
+chill last night, pulse 100, temp. 102; did not remove the compresses.
+
+Saturday evening, Feb. 7th, condition worse, pulse 112, temp. 103, tongue
+furred ash-colored, countenance typhoid in expression, loss of appetite,
+no abdominal symptoms, mind clear. Sunday, Feb 8th. pulse 120, temp.
+105.4, tongue same as yesterday, had a chill last night. The skin over the
+sinus is inflamed somewhat more than it was yesterday. With the advice and
+assistance of doctors Brown, Thorne, Benj. Cory and Kelly, sixty-eight
+ounces of blood was removed from the sinus, by aspiration. One hour after
+this operation, the pulse was 140 and the temp. 104. The specific gravity
+of the blood removed was 1030, and after standing for two or three hours,
+a grey or ash-colored sediment settled, the proportion of this being about
+20 per cent. of the whole amount of the blood. This sediment consisted of
+corpuscles that seemed to be undergoing decomposition; they were a little
+larger than the red corpuscles; contained granules or spots, from three to
+four and seven and eight in each corpuscle. Some of them seemed to be
+simply swollen red blood corpuscles, ready to burst, or as it were,
+suppurate. If there be such a thing as inflammation of the blood,--and I
+believe there is,--then this change must effect the red corpuscles
+themselves, as to size, temperature and perhaps pain, thus supplying three
+of the well known characteristics of inflammation, expressed so tersely by
+the old latin formula, _rubor, tumor, calor cum dolore_. Owing to the
+color of the blood, the rubor, or redness, is not produced by inflammation
+here as it already exists.
+
+But to return to the patient. After the blood was withdrawn, compresses
+were carefully applied, and the body bandaged from the lower ribs as low
+down as the bandage could be applied with the legs flexed at right angles
+to the body. The patient stood on all fours, as it is called, while the
+bandage was applied.
+
+Monday, Feb. 9th, 9:30 A. M., pulse 100, temp. 103.8. There appeared to be
+about one-half a pint of fluid in the sack. Monday, Feb. 9th, 6:30 P. M.,
+pulse 100, temp. 102. Tuesday, Feb. 10th, 9:30 A. M.,--the fluid in the
+sack has increased--perhaps a pint now in it, pulse 110, temp. 104.
+Wednesday, Feb 11th, 9:30 A. M.,--pulse 90, temp. not taken. Condition
+good. Ordered a laxative.
+
+Friday, Feb 13th,--considerable inflammation over the left iliac crest, in
+the centre of which, a spot as large as the thumb nail, looks gangrenous.
+The inflammation extends over a surface as large as the two hands. Some
+bullae or blebs have formed in the vicinity of the gangrenous spot.
+Ordered a large flaxseed poultice applied, expecting an abscess would form
+at this place. The cathartic moved the bowels two or three times. I will
+here state that the patient, after the withdrawal of the blood on Sunday,
+was ordered iron, quinine and whisky; twenty minims of Tr. Ferri Muriat.,
+three grs quinia, in a tablespoonful of glycerine and a little whisky. I
+afterward had the quinia made into pill and left off the iron, as the
+latter seemed to disagree with the stomach.
+
+Saturday, Feb. 14th, 5 P. M.,--pulse 112, temp. 102.4. The inflammation
+over the left ilium is much better; but there is now as much inflammation
+over the right ilium as there was over the left. The fluid in the sinus
+has increased gradually since the evacuation of it with the aspirator. The
+inflammation that has now existed for two or three days over these parts
+of the sinus, led me to conclude that the blood which was left and that
+which had accumulated, had undergone decomposition and was now pus. I used
+an exploring needle and found this to be the case. I then introduced a
+trocar and canula, and drew off fifty ounces of pus, slightly tinged with
+blood. I re-adjusted the compresses and bandage over the sinus, hoping
+that a part of it at least would become obliterated before it became
+necessary to open it more freely.
+
+Feb. 15th, 5 P. M.,--pulse 112, temp. 102.5. The inflammation over that
+part of the sinus to the right of the spine is still about the same as
+yesterday; also that over the left ilium. The fluid has increased during
+the last twenty-four hours so that there is now nearly as much as was
+drawn off through the canula yesterday. I concluded that further delay to
+a free opening was useless; consequently with the patient lying on his
+right side, and near the edge of the bed, I made an opening one inch long
+in the lower portion of the abscess,--for I now considered it one,--near
+the spot where the needle of the aspirator and the trocar had been
+previously introduced.
+
+After the discharge of about a pint of bloody pus, the stream was checked
+by a clot of blood coming into the opening. I enlarged the opening, making
+it about two inches long, when a clot the size of a hen's egg came
+through, followed by about a pint more of bloody pus. After syringing the
+cavity with a five per cent. solution of carbolic acid in distilled water,
+and introducing a tent about four inches long, I applied compresses and
+bandages. Ordered the quinia continued, and whisky and beef tea.
+
+Feb. 16th, 9 A. M.,--pulse 100, but feeble; temp. 97.8. Removed dressings
+which were saturated with pus and blood. The latter had excited the
+anxiety of the Superintendent during the night, and he applied an
+additional bandage. There was perhaps five or six ounces of thick, flaky,
+yellow pus discharged. No hemorrhage; syringed the cavity with a five per
+cent. solution as before, and introduced a clean tent.
+
+On examining the inflamed spot over the left ilium, I detected fluctuation
+over the anterior part of the crest of the ilium, near the gangrenous
+spot, and extending down over the abdomen. However, it seemed to be
+superficial, at least, not deeper than the connective tissue between the
+external and internal oblique muscles, and not more than one inch by two
+in size. This I opened, and squeezed out about half a ounce of pus.
+Introduced a tent and applied oakum over both tents, for the purpose of
+absorbing the pus, and applied a compress over the main sinus or pouch,
+and a bandage over the whole lower part of the body.
+
+Feb. 17th, 9 A. M.,--pulse 96, temp. 99. Ordered a laxative of carbonate
+of magnesia. Both openings discharging very freely. The gangrenous spot
+over the left ilium is separating from the surrounding tissues. Removed
+considerable dead flesh from this spot, leaving an opening or pouch one
+inch in diameter, leading down to the pubis, just beneath the oblique
+muscles.
+
+Feb. 19th, 9 A. M.,--pulse 106, temp. 99.5. Both sinuses discharging very
+freely. Made an opening in the lower part of the pouch to the left of the
+pubis for better drainage, as the patient usually lies on the right side.
+Laxative has operated. After washing out both sinuses with a five per
+cent. solution of carbolic acid, I inject the smaller sinus with liquid
+vasaline.
+
+Feb. 20th, 9 A. M.,--pulse 112, temp. 103.5. There is a great amount of
+pus being discharged from the large sinus on the back, not so much from
+the small one. Patient had a chill last night. After the usual washing out
+of the sinuses with the carbolic solution, I inject both of them in with
+liquid vasaline. This I do, a well as the washing out, by means of a No.
+10 catheter, attached to the end of a Davidson's syringe. The sinus on the
+back extends from the coccyx to the ribs, and from one ilium to the other.
+The skin and fascia of the external wall being so thin that the catheter
+can be seen over the entire extent, as I push it from one part to another
+for the purpose of washing out all parts of the sack. Patient has been
+complaining of pain and want of sleep; had a chill last night. He still
+takes beef tea twice a day, and eggs and other food twice a day, making
+four meals a day; also, continues the quinine and whisky.
+
+Feb. 21st, 9:30 A. M.,--pulse 98, temp. 101. Feels more comfortable.
+Discharge of pus much less than yesterday. Wash out the sinuses and inject
+liquid vasaline.
+
+Feb. 23d, 9:30 A. M.,--pulse 98, temp. 101. Complains of being "very
+sick." Speaks English but poorly. Considerable discharge of laudable pus,
+but not so much as before the use of the liquid vasaline. There is one
+point near the left hand side of the large sinus on the back, where the
+walls are adherent. I wash them out with a five per cent. solution of
+carbolic acid in water, and again inject the liquid vasaline. By gentle
+pressure made over the upper part of the pouch, I force everything out of
+it at the opening below, bringing the walls of the sack together over the
+greater part of the surface. Hoping that the adhesion between the walls,
+which has commenced, will continue, and soon obliterate, at least, all the
+upper part of the pouch. Put on the usual compresses; this time using
+oakum instead of folded cloths.
+
+Feb. 24th, 9:30 A. M.,--pulse 108, temp. 101. Did not wash out the upper
+or left hand part of the pouch on the back, for fear of disturbing
+adhesions that are taking place. Washed out the lower part and injected
+vasaline. A small spot, as large as a ten cent piece, has sloughed, making
+a hole into the pouch over the lower lumbar vertebra. Another spot
+immediately above this, and about the same size, looks as if it would
+slough.
+
+Feb. 25th, 9:30 A. M.,--pulse 100, temp. 100.
+
+Feb. 27th, 9:30 A. M.,--pulse 115, temp. 99.2. Adhesion is taking place
+between the walls of the sinus, on the left of the vertebrę.
+
+Feb. 29th, 9:30, A. M.,--pulse 104, temp. 100. The sacks, or sinuses, have
+been washed out regularly every day, and dressed with vasaline.
+
+This case presents several features of interest. The first is the very
+large amount of secondary hemorrhage, and its location, there being
+sixty-eight ounces removed at one time and fifty at another, and perhaps
+thirty or forty at another, from just beneath the skin and superficial
+fascia of the lower part of the back. The second point of interest would
+be to know from what vessel this hemorrhage took place. The third
+interesting feature of the case is its progress and treatment.
+
+At the time of the aspiration the patient was in a critical condition;
+temp. 105.4, pulse 120; the tongue and chill denoting danger of pyemia.
+This danger was avoided by drawing off the decomposing blood, and giving
+the patient a new lease of life. This was but temporary, for six days
+afterward the same danger presented itself again. This was also avoided by
+opening the sinus freely, by an incision two inches long, which could not
+have been done sooner for fear of adding to the hemorrhage.
+
+At the end of six days from this last critical period, the temperature
+again went up to 103.5, and the pulse and condition of the patient
+indicated great danger of death from exhaustion--the result of the
+formation of so much pus. This was avoided by preventing the excessive
+formation of pus by washing out the sinus with liquid vasaline. The
+patient is still under treatment in the hospital now under the care of
+my esteemed friend, Dr. Benj. Cory.
+
+The patient will probably recover. It will be simply a question of
+endurance with him. That is, if the supply of nourishment can be kept up,
+and the waste prevented, which must result from the formation of such a
+large quantity of pus, there is no reason why he should not recover.[A]
+
+  [A] On March 25th, date of publication of this report, the
+  patient is considered convalescent.
+
+At the time of putting him under the care of Dr. Cory, he was taking nine
+grains of quinia daily, about six ounces of whisky, beef tea twice a day,
+and eggs twice, with such other food as he might relish; taking four meals
+a day.
+
+Thus you see I was carrying out the theory mentioned in the first part of
+this paper:--that of supplying the system with all the flesh producing
+food the stomach would digest, and using whisky and quinia to prevent
+disassimilation or waste; also vasaline locally for a similar reason.
+
+With this case I conclude my report; only adding that perhaps the thought
+of a poet, who evidently knows much of human nature, is applicable to this
+hastily written paper. This poet says:
+
+     "A fool will pass for such through one mistake,
+      While a philosopher will pass for such,
+      Through said mistakes being ventured in the gross
+      And heaped up to a system."
+
+Thus I, as one or the other of the personages here mentioned, offer this,
+my mite, to the literature of surgery, leaving you to decide which of the
+titles I deserve.
+
+
+
+
+
+End of the Project Gutenberg EBook of Report on Surgery to the Santa Clara
+County Medical Society, by Joseph Bradford Cox
+
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+
+The Project Gutenberg EBook of Report on Surgery to the Santa Clara County
+Medical Society, by Joseph Bradford Cox
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Report on Surgery to the Santa Clara County Medical Society
+
+Author: Joseph Bradford Cox
+
+Release Date: December 8, 2007 [EBook #23769]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+*** START OF THIS PROJECT GUTENBERG EBOOK REPORT ON SURGERY ***
+
+
+
+
+Produced by Bryan Ness, Anne Storer and the Online
+Distributed Proofreading Team at http://www.pgdp.net (This
+book was produced from scanned images of public domain
+material from the Google Print project.)
+
+
+
+
+
+
+</pre>
+
+
+
+<p><span class='pagenum'>[Pg 1]</span></p>
+<h1>REPORT</h1>
+
+<p class="center"><strong>ON</strong></p>
+
+<h6>SURGERY</h6>
+
+<p class="center"><strong>TO THE</strong></p>
+
+<h1><span class="smcap">Santa Clara County</span></h1>
+
+<h3>Medical Society.</h3>
+
+<p class="center"><strong>BY</strong></p>
+
+<h2>J. BRADFORD COX, M. D.</h2>
+
+<hr style="width: 5%;" />
+
+<p class="read"><em>READ MARCH 2d, 1880.</em></p>
+
+<hr style="width: 5%;" />
+
+<p class="print">SAN JOSE:<br />
+MERCURY STEAM PRINT.<br />
+1880.</p>
+
+<hr style="width: 65%;" />
+
+<p><span class='pagenum'>[Pg 3]</span></p>
+<h2><span class="smcap">Report on Surgery.</span></h2>
+
+<hr style="width: 5%;" />
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 <em>affinity</em> 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.</p>
+
+<p>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<span class='pagenum'>[Pg 4]</span> 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.</p>
+
+<p>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,&mdash;that they are in
+a solid or precipitated form in the tissues is also true,&mdash;and that the
+tissues are supplied from the blood is also evident,&mdash;because the blood is
+the only part that receives supplies of material direct from the food
+taken and digested.</p>
+
+<p>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;&mdash;for the question may be asked as to what causes
+the first or initial deposit. Here we must stop and acknowledge our
+ignorance.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>In September, 1878, August G&mdash;&mdash;, aged 18 years, single, a
+<span class='pagenum'>[Pg 5]</span>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;&mdash;in other words, a well
+defined case;&mdash;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.</p>
+
+<p>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.</p>
+
+<p>I will now present the following cases which have seemed of special
+interest to me:</p>
+
+<hr style='width: 45%;' />
+
+<p><span class="smcap">Case First.</span>&mdash;In 1874, while in the mountains on the Trinity river,
+Dr.&nbsp;&mdash;&mdash; 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.</p>
+
+<p><span class='pagenum'>[Pg 6]</span>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.</p>
+
+<hr style='width: 45%;' />
+
+<p><span class="smcap">Case Second.</span>&mdash;Jerome De&mdash;&mdash;, 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.</p>
+
+<p>He was again admitted to the hospital, and the fracture dressed in the
+usual manner. After five or six days a gutta percha splint was used which
+encircled the arm. Bony union was slow in taking place. However, on Oct.
+3d, nearly two months from the date of the fracture, he left the hospital,
+the union being complete, and he being entirely relieved from his pain; in
+fact, he was relieved from the moment of the fracture.</p>
+
+<p>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 the treatment which consisted of blisters and iodine,
+externally, and mercury and iodide potassium internally? Was there a
+deficiency of nutrition at this point? or anemia from some change in the
+nutrient artery,&mdash;the result of the periostitis of the long bones? Or was
+it incipient necrosis? Prof. Hamilton gives the record of a case of
+fracture of the humerus, from muscular action, taking place three several
+times in the same individual, each time in a different place.</p>
+
+<hr style='width: 45%;' />
+
+<p><span class="smcap">Case Third.</span>&mdash;Dec. 29th, 1878, was called to see Mr.&nbsp;&mdash;&mdash;, male,
+married, aged about 40 years. Has led an out-door, active life. Has always
+been healthy. No venerial taint. Nervous temperament,
+<span class='pagenum'>[Pg 7]</span> spare built, and
+weighs about 140 pounds. Present condition: Has been sick two or three
+days; the attack commenced with a chill, followed by fever; has had fever
+ever since the chill; complains of pains in the back and legs; has vomited
+considerable; bowels costive; tongue coated; severe pain in right side
+corresponding to lower part of the lung, which I found solidified; there
+is considerable cough.</p>
+
+<p>Ordered a cathartic; to be followed by an anti-pyretic of acetate of
+ammonia and aconite, and a blister over the lower part of the right lung.
+Continued this treatment for three or four days, when the pneumonia began
+to subside, and at the 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 intelligent man, said he had felt worse during
+the day, and in the evening, his knee, which had been somewhat painful for
+two or three days, had become exceedingly painful. I gave morphine,
+hypodermically, and went home, leaving some morphine for the night.</p>
+
+<p>The next day I saw him. The pain had been relieved by the morphine, still
+occasionally it was quite severe. There was no redness or heat, or even
+tenderness; nothing unnatural about the knee except pain, which was
+aggravated by any attempt to move the leg.</p>
+
+<p>Ordered quinine as a tonic, and pill &ldquo;C. C.&rdquo; as a cathartic. Bandaged the
+leg pretty tightly from the toes to above the knee. The urine was natural;
+pulse and temperature only slightly elevated. After six or seven days of
+these symptoms, the knee began to feel hot and became very slightly
+swollen. Ordered a small blister over the inside of the knee as the
+greatest amount of pain seemed to be here. Dressed it with tartar-emetic
+ointment until the skin was very sore; using iodine on other puts of the
+knee. Used iodide potassium and colchicum, internally. This treatment for
+five days seemed to do no good. On Jan. 17th, twenty-two days from the
+beginning of his illness, and about twelve days from the first appearance
+of symptoms denoting any local trouble at the knee, a consultation was
+held, the result of which was a blister over the whole of the knee, to
+be dressed with unguentuin hydrargiri. The inflammation was but little
+influenced by this or any other treatment. The knee continued to slowly
+and surely enlarge. And this extended upward without first producing any
+great distention of the synovial sack under the patella. There seemed to
+be simply enlargement of all the tissues of the lower part of the thigh.
+This continued until about the 1st of Feb. when, from the general
+appearance of the patient, viz: a typhoid condition, feeble pulse, coated
+tongue, emaciation, loss of appetite, as well as from the local appearance
+of the inside of the knee, I suspected pus within the joint. Accordingly,
+I introduced an exploring needle into the inner part of the joint just
+above and anterior to the insertion of
+<span class='pagenum'>[Pg 8]</span> the tendon of the semimembranosis
+muscle. Finding pus, I made an incision only about half an inch long, and
+squeezed out perhaps an ounce of pus. Closed this up and again bandaged
+the leg. There was but very little pus discharged from this opening
+afterward, not, however, for want of drainage, since the cut was kept
+open by introducing the probe occasionally. About the 9th or 10th of Feb.
+fluctuation became quite apparent along the outer and lower part of the
+thigh. On Feb. 12th, consultation was again had, when fluctuation being
+very well marked over a considerable portion of the thigh in its lower and
+middle thirds, after giving the patient chloroform, an incision was made
+three inches long on the outer and posterior part of the thigh, from
+the junction of the lower with the middle third, downward through the
+posterior part of the vastus externus muscle. About two quarts of laudable
+pus was discharged. By introducing the finger upward and downward, the
+periostium could be felt smooth except within the knee joint, for this
+could be distinctly felt, the finger passing readily between the ends of
+the femur and tibia, and beneath the patella; the crucial and lateral
+ligaments seemed to be gone, and the cartilages somewhat roughened. A
+drainage tube was put in, the leg bandaged from the toes to the trochanter
+major, with compresses so arranged as to obliterate the sack, if possible.</p>
+
+<p>The patient, up to this time, had been slowly losing flesh, and was now
+very much emaciated. A general typhoid condition existed, the temperature
+ranging from 101 to 103.5; the pulse from 115 to 135, tongue coated, poor
+appetite, and in short, the patient in a very critical condition. The use
+of chloroform, and the shock from the evacuation of the pus, added to the
+gravity of all the symptoms, and for about two weeks the patient was in
+great danger of death from asthenia. However, by liberal use of whisky,
+quinia, beef tea, cod liver oil, etc., he slowly rallied. Two smaller
+abscesses formed below the knee, but those gave no great anxiety, not
+so much as some bed sores on the back and hips. The sack or pouch became
+gradually obliterated, down as far as the knee. The cavity of the joint,
+however, did not seem to be well drained from the opening in the thigh,
+notwithstanding it had been kept open freely by tents. About three weeks
+from this last operation, the sinus or pouch within the knee-joint being
+so imperfectly drained as above indicated, I made an opening directly into
+the joint at the outer and posterior part, one inch long, through which I
+could introduce the probe between the ends of the femur and tibia, without
+any difficulty, through all parts of the joint. However, I discovered no
+necrosed bone by so doing. Put a tent into this opening, and let the one
+above heal up, which it did in about two weeks. This latter opening into
+the joint I kept open by means of tents until the joint became anchilosed
+and ceased to discharge pus. The patient made a slow and steady recovery,
+and<span class='pagenum'>[Pg 9]</span> about the middle of April was able to get out doors again.</p>
+
+<p>The special points of interest in this case seem to be the obscure and
+insidious mode of attack; the slow progress of the inflammation, it being
+rather sub-acute than acute; and the fact of its being a sequela of
+pneumonia.</p>
+
+<p>Prof. Gross, in his excellent work on surgery, says, &ldquo;synovitis, in the
+great majority of cases, arises from the effects of rheumatism, gout,
+eruptive fevers, syphilis, scrofula, and the inordinate use of mercury.&rdquo;</p>
+
+<p>Prof. Hamilton, in &ldquo;Principles and Practice of Surgery,&rdquo; says, &ldquo;synovitis
+may be caused by exposure to cold, or may occur as a consequence of a
+rheumatic, strumous, or syphilitic cachexia, as a gonorrh&oelig;al
+complication, as a sequela of fevers, and from many other causes, whose
+relation to the disease in question may not always be easily determined.&rdquo;</p>
+
+<p>Since there was no local injury to the knee in this case which could have
+caused the disease, we must seek some other cause for it.</p>
+
+<p>I have thought that its origin might be accounted for on the principle of
+metastasis of morbid material. The patient had pneumonia which passed
+through its several stages somewhat rapidly, resolution taking place about
+the end of the second week. The symptoms of this were well marked, viz: a
+chill followed by fever, cough, brick-dust sputa, delirium, pain over
+lower half of right lung, which was solidified, and afterward gave the
+crepitant and sub-crepitant roles. Could not the morbid material, which
+entered the circulation from the re-absorption of the deposit in the
+solidified lung, have been carried to the synovial membrane of the knee,
+and there found a lodgment, and set up the inflammation which resulted in
+the formation of so much pus? If not, Why not? Notwithstanding a tedious
+illness, and an anchilosed knee, was not this result better than to have
+had suppuration of the lung tissue and destruction of the whole of the
+right lung, and perhaps eventually the left also? However, we are not
+certain that such a result would have followed, although the patient&#8217;s
+general appearance at the time of the attack, and the typhoid condition
+which followed, as also the low grade of inflammation bordering on the
+scrofulous, made such a thing probable.</p>
+
+<hr style='width: 45%;' />
+
+<p><span class="smcap">Case Fourth</span>.&mdash;On Jan. 31st, 1879, Mr. R&mdash;&mdash;, Italian, aged 35 yrs., while
+chopping wood near Almaden mines, was injured by a falling tree. The lower
+part of the body was very much bruised, both posteriorly and anteriorly.
+The only place where the skin was broken was a smooth cut about four
+inches long and nearly half an inch deep, following the fold or crease
+between the right testicle and thigh, and extending from the anterior part
+of the testicle to the perineum in a straight line just where the scrotal
+integument joins that of the thigh.</p>
+
+<p><span class='pagenum'>[Pg 10]</span>The main injury was in the lumbar region over the upper lumbar vertebr&aelig;.
+The spinous process of the lower dorsal vertebra seemed to be unusually
+prominent, leading to the supposition that the spinous process of the
+upper lumbar vertebra might be fractured and depressed. However, I was
+unable to detect mobility or crepitus in any of the processes, spinous or
+transverse, either of the dorsal or lumbar vertebr&aelig;.</p>
+
+<p>There was considerable tenderness over the lumbar region. I would here
+state that the examination was made about twenty hours after the receipt
+of the injury. There was but little discoloration of the skin, not very
+much pain, no paralysis of any part, the bladder evacuating itself
+naturally, and a cathartic producing its ordinary effect in the usual
+time.</p>
+
+<p>The patient did well; complained of but little pain; did not use opiates.
+On Wednesday and Thursday following, the patient felt well enough to walk
+about the wards, eating well and having no constitutional disturbance,
+pulse never higher than eighty per minute, and the temperature not above
+99 degrees F.</p>
+
+<p>On Friday morning the nurse remarked that this patient had complained of
+pain in the back during the previous night, and that there seemed to be a
+soft spot on his rump. By examining, I found below the bandage which I had
+put around the patient, a fluctuating mass, immediately beneath the skin
+and superficial fascia, extending from the tenth dorsal vertebra above, to
+the coccyx below, and from the crest of the right ilium to that of the
+left.</p>
+
+<p>I was at a loss to know how to account for this fluid, for there was at
+least a quart. I removed the bandage and examined more carefully. There
+was no inflammation to amount to anything, nor had there been. Here it is
+only the seventh day from the receipt of the injury, and it surely cannot
+be pus. However, to satisfy myself, I used an exploring needle; and not
+very much to my surprise, I discovered light colored arterial blood! Could
+I be mistaken? I twisted the needle about, pressed it to one side, until
+nearly a drachm of the blood had escaped. Fully convinced now that I had
+a secondary hemorrhage to deal with, the question arose what to do. I
+supposed that it came from one of the lumbar or inter-costal arteries that
+had been injured by the supposed fracture of the process of the vertebra.
+If so, it comes from an artery inclosed in a bony cavity, and one that
+cannot contract and close spontaneously, and since its origin is so close
+to the aorta, it will continue to bleed until the patient dies of
+hemorrhage.</p>
+
+<p>While I was thus examining the fluctuating mass, and conjecturing as to
+origin and results, I fancied that the quantity of fluid was
+<span class='pagenum'>[Pg 11]</span>sensibly
+increasing. However, I will not be positive that my imagination did not
+assist in this accumulation.</p>
+
+<p>But what shall I do? Cut down into this sinus, and hunt the bleeding
+artery, and tie it? Could I find it? And could I tie it if I did find it?
+Probably not; and more especially if it is a lumbar artery, and injured in
+the foramen through which it passes from the vertebra. But the man will
+probably bleed to death; and must I do nothing to prevent it? I concluded
+to use pressure with a bandage for the present, and ask for the advice of
+my brethren. Accordingly, compresses were placed along the spine, and the
+body bandaged snugly.</p>
+
+<p>On returning to town, I stated the case to doctors Brown and Thorne,
+giving my theory for the hemorrhage,&mdash;that it was secondary, and probably
+from a lumbar artery. They were of opinion that it would be almost an
+impossibility to find the artery and tie it, and without seeing each
+other, concluded that pressure was the remedy to be used. I would state
+that at the last visit the pulse was 74, and temperature 99. This was at
+about 9 <span class="smcap">a.m.</span> I visited him again about 5 <span class="smcap">p.m.</span>, and found the pulse and
+temperature the same. There was by this time considerable increase in the
+quantity of fluid. I re-adjusted my compresses and bandaged again. On
+Saturday morning I found the quantity of fluid about the same, perhaps
+slightly increased. There was now considerable inflammation of the
+integument, over a large part of the sinus, the skin appearing tense, and
+the small blood vessels distinct and purple. The patient had a slight
+chill last night, pulse 100, temp. 102; did not remove the compresses.</p>
+
+<p>Saturday evening, Feb. 7th, condition worse, pulse 112, temp. 103, tongue
+furred ash-colored, countenance typhoid in expression, loss of appetite,
+no abdominal symptoms, mind clear. Sunday, Feb 8th. pulse 120, temp.
+105.4, tongue same as yesterday, had a chill last night. The skin over the
+sinus is inflamed somewhat more than it was yesterday. With the advice and
+assistance of doctors Brown, Thorne, Benj. Cory and Kelly, sixty-eight
+ounces of blood was removed from the sinus, by aspiration. One hour after
+this operation, the pulse was 140 and the temp. 104. The specific gravity
+of the blood removed was 1030, and after standing for two or three hours,
+a grey or ash-colored sediment settled, the proportion of this being about
+20 per cent. of the whole amount of the blood. This sediment consisted of
+corpuscles that seemed to be undergoing decomposition; they were a little
+larger than the red corpuscles; contained granules or spots, from three to
+four and seven and eight in each corpuscle. Some of them seemed to be
+simply swollen red blood corpuscles, ready to burst, or as it were,
+suppurate. If there be such a thing as
+<span class='pagenum'>[Pg 12]</span> inflammation of the blood,&mdash;and I
+believe there is,&mdash;then this change must effect the red corpuscles
+themselves, as to size, temperature and perhaps pain, thus supplying three
+of the well known characteristics of inflammation, expressed so tersely by
+the old latin formula, <em>rubor, tumor, calor cum dolore</em>. Owing to the
+color of the blood, the rubor, or redness, is not produced by inflammation
+here as it already exists.</p>
+
+<p>But to return to the patient. After the blood was withdrawn, compresses
+were carefully applied, and the body bandaged from the lower ribs as low
+down as the bandage could be applied with the legs flexed at right angles
+to the body. The patient stood on all fours, as it is called, while the
+bandage was applied.</p>
+
+<p>Monday, Feb. 9th, 9:30 <span class="smcap">a.m.</span>, pulse 100, temp. 103.8. There appeared to be
+about one-half a pint of fluid in the sack. Monday, Feb. 9th, 6:30 <span class="smcap">p.m.</span>,
+pulse 100, temp. 102. Tuesday, Feb. 10th, 9:30 <span class="smcap">a.m.</span>,&mdash;the fluid in the
+sack has increased&mdash;perhaps a pint now in it, pulse 110, temp. 104.
+Wednesday, Feb 11th, 9:30 <span class="smcap">a.m.</span>,&mdash;pulse 90, temp. not taken. Condition
+good. Ordered a laxative.</p>
+
+<p>Friday, Feb 13th,&mdash;considerable inflammation over the left iliac crest, in
+the centre of which, a spot as large as the thumb nail, looks gangrenous.
+The inflammation extends over a surface as large as the two hands. Some
+bullae or blebs have formed in the vicinity of the gangrenous spot.
+Ordered a large flaxseed poultice applied, expecting an abscess would form
+at this place. The cathartic moved the bowels two or three times. I will
+here state that the patient, after the withdrawal of the blood on Sunday,
+was ordered iron, quinine and whisky; twenty minims of Tr. Ferri Muriat.,
+three grs quinia, in a tablespoonful of glycerine and a little whisky. I
+afterward had the quinia made into pill and left off the iron, as the
+latter seemed to disagree with the stomach.</p>
+
+<p>Saturday, Feb. 14th, 5 <span class="smcap">p.m.</span>,&mdash;pulse 112, temp. 102.4. The inflammation
+over the left ilium is much better; but there is now as much inflammation
+over the right ilium as there was over the left. The fluid in the sinus
+has increased gradually since the evacuation of it with the aspirator. The
+inflammation that has now existed for two or three days over these parts
+of the sinus, led me to conclude that the blood which was left and that
+which had accumulated, had undergone decomposition and was now pus. I used
+an exploring needle and found this to be the case. I then introduced a
+trocar and canula, and drew off fifty ounces of pus, slightly tinged with
+blood. I re-adjusted the compresses and bandage over the sinus, hoping
+that a part of it at least would become obliterated before it became
+necessary to open it more freely.</p>
+
+<p>Feb. 15th, 5 <span class="smcap">p.m.</span>,&mdash;pulse 112, temp. 102.5. The inflammation
+<span class='pagenum'>[Pg 13]</span> over that
+part of the sinus to the right of the spine is still about the same as
+yesterday; also that over the left ilium. The fluid has increased during
+the last twenty-four hours so that there is now nearly as much as was
+drawn off through the canula yesterday. I concluded that further delay to
+a free opening was useless; consequently with the patient lying on his
+right side, and near the edge of the bed, I made an opening one inch long
+in the lower portion of the abscess,&mdash;for I now considered it one,&mdash;near
+the spot where the needle of the aspirator and the trocar had been
+previously introduced.</p>
+
+<p>After the discharge of about a pint of bloody pus, the stream was checked
+by a clot of blood coming into the opening. I enlarged the opening, making
+it about two inches long, when a clot the size of a hen&#8217;s egg came
+through, followed by about a pint more of bloody pus. After syringing the
+cavity with a five per cent. solution of carbolic acid in distilled water,
+and introducing a tent about four inches long, I applied compresses and
+bandages. Ordered the quinia continued, and whisky and beef tea.</p>
+
+<p>Feb. 16th, 9 <span class="smcap">a.m.</span>,&mdash;pulse 100, but feeble; temp. 97.8. Removed dressings
+which were saturated with pus and blood. The latter had excited the
+anxiety of the Superintendent during the night, and he applied an
+additional bandage. There was perhaps five or six ounces of thick, flaky,
+yellow pus discharged. No hemorrhage; syringed the cavity with a five per
+cent. solution as before, and introduced a clean tent.</p>
+
+<p>On examining the inflamed spot over the left ilium, I detected fluctuation
+over the anterior part of the crest of the ilium, near the gangrenous
+spot, and extending down over the abdomen. However, it seemed to be
+superficial, at least, not deeper than the connective tissue between the
+external and internal oblique muscles, and not more than one inch by two
+in size. This I opened, and squeezed out about half a ounce of pus.
+Introduced a tent and applied oakum over both tents, for the purpose of
+absorbing the pus, and applied a compress over the main sinus or pouch,
+and a bandage over the whole lower part of the body.</p>
+
+<p>Feb. 17th, 9 <span class="smcap">a.m.</span>,&mdash;pulse 96, temp. 99. Ordered a laxative of carbonate
+of magnesia. Both openings discharging very freely. The gangrenous spot
+over the left ilium is separating from the surrounding tissues. Removed
+considerable dead flesh from this spot, leaving an opening or pouch one
+inch in diameter, leading down to the pubis, just beneath the oblique
+muscles.</p>
+
+<p>Feb. 19th, 9 <span class="smcap">a.m.</span>,&mdash;pulse 106, temp. 99.5. Both sinuses discharging very
+freely. Made an opening in the lower part of the pouch to the left of the
+pubis for better drainage, as the patient usually lies
+<span class='pagenum'>[Pg 14]</span> on the right side.
+Laxative has operated. After washing out both sinuses with a five per
+cent. solution of carbolic acid, I inject the smaller sinus with liquid
+vasaline.</p>
+
+<p>Feb. 20th, 9 <span class="smcap">a.m.</span>,&mdash;pulse 112, temp. 103.5. There is a great amount of
+pus being discharged from the large sinus on the back, not so much from
+the small one. Patient had a chill last night. After the usual washing out
+of the sinuses with the carbolic solution, I inject both of them in with
+liquid vasaline. This I do, a well as the washing out, by means of a No.
+10 catheter, attached to the end of a Davidson&#8217;s syringe. The sinus on the
+back extends from the coccyx to the ribs, and from one ilium to the other.
+The skin and fascia of the external wall being so thin that the catheter
+can be seen over the entire extent, as I push it from one part to another
+for the purpose of washing out all parts of the sack. Patient has been
+complaining of pain and want of sleep; had a chill last night. He still
+takes beef tea twice a day, and eggs and other food twice a day, making
+four meals a day; also, continues the quinine and whisky.</p>
+
+<p>Feb. 21st, 9:30 <span class="smcap">a.m.</span>,&mdash;pulse 98, temp. 101. Feels more comfortable.
+Discharge of pus much less than yesterday. Wash out the sinuses and inject
+liquid vasaline.</p>
+
+<p>Feb. 23d, 9:30 <span class="smcap">a.m.</span>,&mdash;pulse 98, temp. 101. Complains of being &ldquo;very
+sick.&rdquo; Speaks English but poorly. Considerable discharge of laudable pus,
+but not so much as before the use of the liquid vasaline. There is one
+point near the left hand side of the large sinus on the back, where the
+walls are adherent. I wash them out with a five per cent. solution of
+carbolic acid in water, and again inject the liquid vasaline. By gentle
+pressure made over the upper part of the pouch, I force everything out of
+it at the opening below, bringing the walls of the sack together over the
+greater part of the surface. Hoping that the adhesion between the walls,
+which has commenced, will continue, and soon obliterate, at least, all the
+upper part of the pouch. Put on the usual compresses; this time using
+oakum instead of folded cloths.</p>
+
+<p>Feb. 24th, 9:30 <span class="smcap">a.m.</span>,&mdash;pulse 108, temp. 101. Did not wash out the upper
+or left hand part of the pouch on the back, for fear of disturbing
+adhesions that are taking place. Washed out the lower part and injected
+vasaline. A small spot, as large as a ten cent piece, has sloughed, making
+a hole into the pouch over the lower lumbar vertebra. Another spot
+immediately above this, and about the same size, looks as if it would
+slough.</p>
+
+<p>Feb. 25th, 9:30 <span class="smcap">a.m.</span>,&mdash;pulse 100, temp. 100.</p>
+
+<p>Feb. 27th, 9:30 <span class="smcap">a.m.</span>,&mdash;pulse 115, temp. 99.2. Adhesion is taking place
+between the walls of the sinus, on the left of the vertebr&aelig;.</p>
+
+<p><span class='pagenum'>[Pg 15]</span>Feb. 29th, 9:30, <span class="smcap">a.m.</span>,&mdash;pulse 104, temp. 100. The sacks, or sinuses, have
+been washed out regularly every day, and dressed with vasaline.</p>
+
+<p>This case presents several features of interest. The first is the very
+large amount of secondary hemorrhage, and its location, there being
+sixty-eight ounces removed at one time and fifty at another, and perhaps
+thirty or forty at another, from just beneath the skin and superficial
+fascia of the lower part of the back. The second point of interest would
+be to know from what vessel this hemorrhage took place. The third
+interesting feature of the case is its progress and treatment.</p>
+
+<p>At the time of the aspiration the patient was in a critical condition;
+temp. 105.4, pulse 120; the tongue and chill denoting danger of pyemia.
+This danger was avoided by drawing off the decomposing blood, and giving
+the patient a new lease of life. This was but temporary, for six days
+afterward the same danger presented itself again. This was also avoided by
+opening the sinus freely, by an incision two inches long, which could not
+have been done sooner for fear of adding to the hemorrhage.</p>
+
+<p>At the end of six days from this last critical period, the temperature
+again went up to 103.5, and the pulse and condition of the patient
+indicated great danger of death from exhaustion&mdash;the result of the
+formation of so much pus. This was avoided by preventing the excessive
+formation of pus by washing out the sinus with liquid vasaline. The
+patient is still under treatment in the hospital now under the care of
+my esteemed friend, Dr. Benj. Cory.</p>
+
+<p>The patient will probably recover. It will be simply a question of
+endurance with him. That is, if the supply of nourishment can be kept up,
+and the waste prevented, which must result from the formation of such a
+large quantity of pus, there is no reason why he should not recover.
+<a name="FNanchor_A_1" id="FNanchor_A_1"></a>
+<a href="#Footnote_A_1" class="fnanchor">[A]</a></p>
+
+<p>At the time of putting him under the care of Dr. Cory, he was taking nine
+grains of quinia daily, about six ounces of whisky, beef tea twice a day,
+and eggs twice, with such other food as he might relish; taking four meals
+a day.</p>
+
+<p>Thus you see I was carrying out the theory mentioned in the first part of
+this paper:&mdash;that of supplying the system with all the flesh producing
+food the stomach would digest, and using whisky and quinia to prevent
+disassimilation or waste; also vasaline locally for a similar reason.</p>
+
+<p><span class='pagenum'>[Pg 16]</span>With this case I conclude my report; only adding that perhaps the thought
+of a poet, who evidently knows much of human nature, is applicable to this
+hastily written paper. This poet says:</p>
+
+<p><span class="poem">&ldquo;A fool will pass for such through one mistake,</span><br />
+ <span class="poem1">While a philosopher will pass for such,</span><br />
+ <span class="poem1">Through said mistakes being ventured in the gross</span><br />
+ <span class="poem1">And heaped up to a system.&rdquo;</span></p>
+
+<p>Thus I, as one or the other of the personages here mentioned, offer this,
+my mite, to the literature of surgery, leaving you to decide which of the
+titles I deserve.</p>
+
+<hr style="width: 95%;" />
+
+<div class="footnote"><p><a name="Footnote_A_1" id="Footnote_A_1"></a>
+<a href="#FNanchor_A_1"><span class="label">[A]</span></a> On March 26th, date of publication of this report, the
+patient is considered convalescent.</p></div>
+
+
+
+
+
+
+
+
+<pre>
+
+
+
+
+
+End of the Project Gutenberg EBook of Report on Surgery to the Santa Clara
+County Medical Society, by Joseph Bradford Cox
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+</pre>
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+The Project Gutenberg EBook of Report on Surgery to the Santa Clara County
+Medical Society, by Joseph Bradford Cox
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Report on Surgery to the Santa Clara County Medical Society
+
+Author: Joseph Bradford Cox
+
+Release Date: December 8, 2007 [EBook #23769]
+
+Language: English
+
+Character set encoding: ASCII
+
+*** START OF THIS PROJECT GUTENBERG EBOOK REPORT ON SURGERY ***
+
+
+
+
+Produced by Bryan Ness, Anne Storer and the Online
+Distributed Proofreading Team at http://www.pgdp.net (This
+book was produced from scanned images of public domain
+material from the Google Print project.)
+
+
+
+
+
+
+                     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.
+
+He was again admitted to the hospital, and the fracture dressed in the
+usual manner. After five or six days a gutta percha splint was used which
+encircled the arm. Bony union was slow in taking place. However, on Oct.
+3d, nearly two months from the date of the fracture, he left the hospital,
+the union being complete, and he being entirely relieved from his pain; in
+fact, he was relieved from 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 the treatment which consisted of blisters and iodine,
+externally, and mercury and iodide potassium internally? Was there a
+deficiency of nutrition at this point? or anemia from some change in the
+nutrient artery,--the result of the periostitis of the long bones? Or was
+it incipient necrosis? Prof. Hamilton gives the record of a case of
+fracture of the humerus, from muscular action, taking place three several
+times in the same individual, each time in a different place.
+
+
+CASE THIRD.--Dec. 29th, 1878, was called to see Mr. ----, male,
+married, aged about 40 years. Has led an out-door, active life. Has always
+been healthy. No venerial taint. Nervous temperament, spare built, and
+weighs about 140 pounds. Present condition: Has been sick two or three
+days; the attack commenced with a chill, followed by fever; has had fever
+ever since the chill; complains of pains in the back and legs; has vomited
+considerable; bowels costive; tongue coated; severe pain in right side
+corresponding to lower part of the 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 lower part of the right lung.
+Continued this treatment for three or four days, when the pneumonia began
+to subside, and at the 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 intelligent man, said he had felt worse during
+the day, and in the evening, his knee, which had been somewhat painful for
+two or three days, had become exceedingly painful. I gave morphine,
+hypodermically, and went home, leaving some morphine for the night.
+
+The next day I saw him. The pain had been relieved by the morphine, still
+occasionally it was quite severe. There was no redness or heat, or even
+tenderness; nothing unnatural about the knee 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
+leg pretty tightly from the toes to above the knee. The urine was natural;
+pulse and temperature only slightly elevated. After six or seven days of
+these symptoms, the knee began to feel hot and became very slightly
+swollen. Ordered a small blister over the inside of the knee as the
+greatest amount of pain seemed to be here. Dressed it with tartar-emetic
+ointment until the skin was very sore; using iodine on other puts of the
+knee. Used iodide potassium and colchicum, internally. This treatment for
+five days seemed to do no good. On Jan. 17th, twenty-two days from the
+beginning of his illness, and about twelve days from the first appearance
+of symptoms denoting any local trouble at the knee, a consultation was
+held, the result of which was a blister over the whole of the knee, to
+be dressed with unguentuin hydrargiri. The inflammation was but little
+influenced by this or any other treatment. The knee continued to slowly
+and surely enlarge. And this extended upward without first producing any
+great distention of the synovial sack under the patella. There seemed to
+be simply enlargement of all the tissues of the lower part of the thigh.
+This continued until about the 1st of Feb. when, from the general
+appearance of the patient, viz: a typhoid condition, feeble pulse, coated
+tongue, emaciation, loss of appetite, as well as from the local appearance
+of the inside of the knee, I suspected pus within the joint. Accordingly,
+I introduced an exploring needle into the inner part of the joint just
+above and anterior to the insertion of the tendon of the semimembranosis
+muscle. Finding pus, I made an incision only about half an inch long, and
+squeezed out perhaps an ounce of pus. Closed this up and again bandaged
+the leg. There was but very little pus discharged from this opening
+afterward, not, however, for want of drainage, since the cut was kept
+open by introducing the probe occasionally. About the 9th or 10th of Feb.
+fluctuation became quite apparent along the outer and lower part of the
+thigh. On Feb. 12th, consultation was again had, when fluctuation being
+very well marked over a considerable portion of the thigh in its lower and
+middle thirds, after giving the patient chloroform, an incision was made
+three inches long on the outer and posterior part of the thigh, from
+the junction of the lower with the middle third, downward through the
+posterior part of the vastus externus muscle. About two quarts of laudable
+pus was discharged. By introducing the finger upward and downward, the
+periostium could be felt smooth except within the knee joint, for this
+could be distinctly felt, the finger passing readily between the ends of
+the femur and tibia, and beneath the patella; the crucial and lateral
+ligaments seemed to be gone, and the cartilages somewhat roughened. A
+drainage tube was put in, the leg bandaged from the toes to the trochanter
+major, with compresses so arranged as to obliterate the sack, if possible.
+
+The patient, up to this time, had been slowly losing flesh, and was now
+very much emaciated. A general typhoid condition existed, the temperature
+ranging from 101 to 103.5; the pulse from 115 to 135, tongue coated, poor
+appetite, and in short, the patient in a very critical condition. The use
+of chloroform, and the shock from the evacuation of the pus, added to the
+gravity of all the symptoms, and for about two weeks the patient was in
+great danger of death from asthenia. However, by liberal use of whisky,
+quinia, beef tea, cod liver oil, etc., he slowly rallied. Two smaller
+abscesses formed below the knee, but those gave no great anxiety, not
+so much as some bed sores on the back and hips. The sack or pouch became
+gradually obliterated, down as far as the knee. The cavity of the joint,
+however, did not seem to be well drained from the opening in the thigh,
+notwithstanding it had been kept open freely by tents. About three weeks
+from this last operation, the sinus or pouch within the knee-joint being
+so imperfectly drained as above indicated, I made an opening directly into
+the joint at the outer and posterior part, one inch long, through which I
+could introduce the probe between the ends of the femur and tibia, without
+any difficulty, through all parts of the joint. However, I discovered no
+necrosed bone by so doing. Put a tent into this opening, and let the one
+above heal up, which it did in about two weeks. This latter opening into
+the joint I kept open by means of tents until the joint became anchilosed
+and ceased to discharge pus. The patient made a slow and steady recovery,
+and about the middle of April was able to get out doors again.
+
+The special points of interest in this case seem to be the obscure and
+insidious mode of attack; the slow progress of the inflammation, it being
+rather sub-acute than acute; and the fact of its being a sequela of
+pneumonia.
+
+Prof. Gross, in his excellent work on surgery, says, "synovitis, in the
+great majority of cases, arises from the effects of rheumatism, gout,
+eruptive fevers, syphilis, scrofula, and the inordinate use of mercury."
+
+Prof. Hamilton, in "Principles and Practice of Surgery," says, "synovitis
+may be caused by exposure to cold, or may occur as a consequence of a
+rheumatic, strumous, or syphilitic cachexia, as a gonorrhoeal
+complication, as a sequela of fevers, and from many other causes, whose
+relation to the disease in question may not always be easily determined."
+
+Since there was no local injury to the knee in this case which could have
+caused the disease, we must seek some other cause for it.
+
+I have thought that its origin might be accounted for on the principle of
+metastasis of morbid material. The patient had pneumonia which passed
+through its several stages somewhat rapidly, resolution taking place about
+the end of the second week. The symptoms of this were well marked, viz: a
+chill followed by fever, cough, brick-dust sputa, delirium, pain over
+lower half of right lung, which was solidified, and afterward gave the
+crepitant and sub-crepitant roles. Could not the morbid material, which
+entered the circulation from the re-absorption of the deposit in the
+solidified lung, have been carried to the synovial membrane of the knee,
+and there found a lodgment, and set up the inflammation which resulted in
+the formation of so much pus? If not, Why not? Notwithstanding a tedious
+illness, and an anchilosed knee, was not this result better than to have
+had suppuration of the lung tissue and destruction of the whole of the
+right lung, and perhaps eventually the left also? However, we are not
+certain that such a result would have followed, although the patient's
+general appearance at the time of the attack, and the typhoid condition
+which followed, as also the low grade of inflammation bordering on the
+scrofulous, made such a thing probable.
+
+
+CASE FOURTH.--On Jan. 31st, 1879, Mr. R----, Italian, aged 35 yrs., while
+chopping wood near Almaden mines, was injured by a falling tree. The lower
+part of the body was very much bruised, both posteriorly and anteriorly.
+The only place where the skin was broken was a smooth cut about four
+inches long and nearly half an inch deep, following the fold or crease
+between the right testicle and thigh, and extending from the anterior part
+of the testicle to the perineum in a straight line just where the scrotal
+integument joins that of the thigh.
+
+The main injury was in the lumbar region over the upper lumbar vertebrae.
+The spinous process of the lower dorsal vertebra seemed to be unusually
+prominent, leading to the supposition that the spinous process of the
+upper lumbar vertebra might be fractured and depressed. However, I was
+unable to detect mobility or crepitus in any of the processes, spinous or
+transverse, either of the dorsal or lumbar vertebrae.
+
+There was considerable tenderness over the lumbar region. I would here
+state that the examination was made about twenty hours after the receipt
+of the injury. There was but little discoloration of the skin, not very
+much pain, no paralysis of any part, the bladder evacuating itself
+naturally, and a cathartic producing its ordinary effect in the usual
+time.
+
+The patient did well; complained of but little pain; did not use opiates.
+On Wednesday and Thursday following, the patient felt well enough to walk
+about the wards, eating well and having no constitutional disturbance,
+pulse never higher than eighty per minute, and the temperature not above
+99 degrees F.
+
+On Friday morning the nurse remarked that this patient had complained of
+pain in the back during the previous night, and that there seemed to be a
+soft spot on his rump. By examining, I found below the bandage which I had
+put around the patient, a fluctuating mass, immediately beneath the skin
+and superficial fascia, extending from the tenth dorsal vertebra above, to
+the coccyx below, and from the crest of the right ilium to that of the
+left.
+
+I was at a loss to know how to account for this fluid, for there was at
+least a quart. I removed the bandage and examined more carefully. There
+was no inflammation to amount to anything, nor had there been. Here it is
+only the seventh day from the receipt of the injury, and it surely cannot
+be pus. However, to satisfy myself, I used an exploring needle; and not
+very much to my surprise, I discovered light colored arterial blood! Could
+I be mistaken? I twisted the needle about, pressed it to one side, until
+nearly a drachm of the blood had escaped. Fully convinced now that I had
+a secondary hemorrhage to deal with, the question arose what to do. I
+supposed that it came from one of the lumbar or inter-costal arteries that
+had been injured by the supposed fracture of the process of the vertebra.
+If so, it comes from an artery inclosed in a bony cavity, and one that
+cannot contract and close spontaneously, and since its origin is so close
+to the aorta, it will continue to bleed until the patient dies of
+hemorrhage.
+
+While I was thus examining the fluctuating mass, and conjecturing as to
+origin and results, I fancied that the quantity of fluid was sensibly
+increasing. However, I will not be positive that my imagination did not
+assist in this accumulation.
+
+But what shall I do? Cut down into this sinus, and hunt the bleeding
+artery, and tie it? Could I find it? And could I tie it if I did find it?
+Probably not; and more especially if it is a lumbar artery, and injured in
+the foramen through which it passes from the vertebra. But the man will
+probably bleed to death; and must I do nothing to prevent it? I concluded
+to use pressure with a bandage for the present, and ask for the advice of
+my brethren. Accordingly, compresses were placed along the spine, and the
+body bandaged snugly.
+
+On returning to town, I stated the case to doctors Brown and Thorne,
+giving my theory for the hemorrhage,--that it was secondary, and probably
+from a lumbar artery. They were of opinion that it would be almost an
+impossibility to find the artery and tie it, and without seeing each
+other, concluded that pressure was the remedy to be used. I would state
+that at the last visit the pulse was 74, and temperature 99. This was at
+about 9 A. M. I visited him again about 5 P. M., and found the pulse and
+temperature the same. There was by this time considerable increase in the
+quantity of fluid. I re-adjusted my compresses and bandaged again. On
+Saturday morning I found the quantity of fluid about the same, perhaps
+slightly increased. There was now considerable inflammation of the
+integument, over a large part of the sinus, the skin appearing tense, and
+the small blood vessels distinct and purple. The patient had a slight
+chill last night, pulse 100, temp. 102; did not remove the compresses.
+
+Saturday evening, Feb. 7th, condition worse, pulse 112, temp. 103, tongue
+furred ash-colored, countenance typhoid in expression, loss of appetite,
+no abdominal symptoms, mind clear. Sunday, Feb 8th. pulse 120, temp.
+105.4, tongue same as yesterday, had a chill last night. The skin over the
+sinus is inflamed somewhat more than it was yesterday. With the advice and
+assistance of doctors Brown, Thorne, Benj. Cory and Kelly, sixty-eight
+ounces of blood was removed from the sinus, by aspiration. One hour after
+this operation, the pulse was 140 and the temp. 104. The specific gravity
+of the blood removed was 1030, and after standing for two or three hours,
+a grey or ash-colored sediment settled, the proportion of this being about
+20 per cent. of the whole amount of the blood. This sediment consisted of
+corpuscles that seemed to be undergoing decomposition; they were a little
+larger than the red corpuscles; contained granules or spots, from three to
+four and seven and eight in each corpuscle. Some of them seemed to be
+simply swollen red blood corpuscles, ready to burst, or as it were,
+suppurate. If there be such a thing as inflammation of the blood,--and I
+believe there is,--then this change must effect the red corpuscles
+themselves, as to size, temperature and perhaps pain, thus supplying three
+of the well known characteristics of inflammation, expressed so tersely by
+the old latin formula, _rubor, tumor, calor cum dolore_. Owing to the
+color of the blood, the rubor, or redness, is not produced by inflammation
+here as it already exists.
+
+But to return to the patient. After the blood was withdrawn, compresses
+were carefully applied, and the body bandaged from the lower ribs as low
+down as the bandage could be applied with the legs flexed at right angles
+to the body. The patient stood on all fours, as it is called, while the
+bandage was applied.
+
+Monday, Feb. 9th, 9:30 A. M., pulse 100, temp. 103.8. There appeared to be
+about one-half a pint of fluid in the sack. Monday, Feb. 9th, 6:30 P. M.,
+pulse 100, temp. 102. Tuesday, Feb. 10th, 9:30 A. M.,--the fluid in the
+sack has increased--perhaps a pint now in it, pulse 110, temp. 104.
+Wednesday, Feb 11th, 9:30 A. M.,--pulse 90, temp. not taken. Condition
+good. Ordered a laxative.
+
+Friday, Feb 13th,--considerable inflammation over the left iliac crest, in
+the centre of which, a spot as large as the thumb nail, looks gangrenous.
+The inflammation extends over a surface as large as the two hands. Some
+bullae or blebs have formed in the vicinity of the gangrenous spot.
+Ordered a large flaxseed poultice applied, expecting an abscess would form
+at this place. The cathartic moved the bowels two or three times. I will
+here state that the patient, after the withdrawal of the blood on Sunday,
+was ordered iron, quinine and whisky; twenty minims of Tr. Ferri Muriat.,
+three grs quinia, in a tablespoonful of glycerine and a little whisky. I
+afterward had the quinia made into pill and left off the iron, as the
+latter seemed to disagree with the stomach.
+
+Saturday, Feb. 14th, 5 P. M.,--pulse 112, temp. 102.4. The inflammation
+over the left ilium is much better; but there is now as much inflammation
+over the right ilium as there was over the left. The fluid in the sinus
+has increased gradually since the evacuation of it with the aspirator. The
+inflammation that has now existed for two or three days over these parts
+of the sinus, led me to conclude that the blood which was left and that
+which had accumulated, had undergone decomposition and was now pus. I used
+an exploring needle and found this to be the case. I then introduced a
+trocar and canula, and drew off fifty ounces of pus, slightly tinged with
+blood. I re-adjusted the compresses and bandage over the sinus, hoping
+that a part of it at least would become obliterated before it became
+necessary to open it more freely.
+
+Feb. 15th, 5 P. M.,--pulse 112, temp. 102.5. The inflammation over that
+part of the sinus to the right of the spine is still about the same as
+yesterday; also that over the left ilium. The fluid has increased during
+the last twenty-four hours so that there is now nearly as much as was
+drawn off through the canula yesterday. I concluded that further delay to
+a free opening was useless; consequently with the patient lying on his
+right side, and near the edge of the bed, I made an opening one inch long
+in the lower portion of the abscess,--for I now considered it one,--near
+the spot where the needle of the aspirator and the trocar had been
+previously introduced.
+
+After the discharge of about a pint of bloody pus, the stream was checked
+by a clot of blood coming into the opening. I enlarged the opening, making
+it about two inches long, when a clot the size of a hen's egg came
+through, followed by about a pint more of bloody pus. After syringing the
+cavity with a five per cent. solution of carbolic acid in distilled water,
+and introducing a tent about four inches long, I applied compresses and
+bandages. Ordered the quinia continued, and whisky and beef tea.
+
+Feb. 16th, 9 A. M.,--pulse 100, but feeble; temp. 97.8. Removed dressings
+which were saturated with pus and blood. The latter had excited the
+anxiety of the Superintendent during the night, and he applied an
+additional bandage. There was perhaps five or six ounces of thick, flaky,
+yellow pus discharged. No hemorrhage; syringed the cavity with a five per
+cent. solution as before, and introduced a clean tent.
+
+On examining the inflamed spot over the left ilium, I detected fluctuation
+over the anterior part of the crest of the ilium, near the gangrenous
+spot, and extending down over the abdomen. However, it seemed to be
+superficial, at least, not deeper than the connective tissue between the
+external and internal oblique muscles, and not more than one inch by two
+in size. This I opened, and squeezed out about half a ounce of pus.
+Introduced a tent and applied oakum over both tents, for the purpose of
+absorbing the pus, and applied a compress over the main sinus or pouch,
+and a bandage over the whole lower part of the body.
+
+Feb. 17th, 9 A. M.,--pulse 96, temp. 99. Ordered a laxative of carbonate
+of magnesia. Both openings discharging very freely. The gangrenous spot
+over the left ilium is separating from the surrounding tissues. Removed
+considerable dead flesh from this spot, leaving an opening or pouch one
+inch in diameter, leading down to the pubis, just beneath the oblique
+muscles.
+
+Feb. 19th, 9 A. M.,--pulse 106, temp. 99.5. Both sinuses discharging very
+freely. Made an opening in the lower part of the pouch to the left of the
+pubis for better drainage, as the patient usually lies on the right side.
+Laxative has operated. After washing out both sinuses with a five per
+cent. solution of carbolic acid, I inject the smaller sinus with liquid
+vasaline.
+
+Feb. 20th, 9 A. M.,--pulse 112, temp. 103.5. There is a great amount of
+pus being discharged from the large sinus on the back, not so much from
+the small one. Patient had a chill last night. After the usual washing out
+of the sinuses with the carbolic solution, I inject both of them in with
+liquid vasaline. This I do, a well as the washing out, by means of a No.
+10 catheter, attached to the end of a Davidson's syringe. The sinus on the
+back extends from the coccyx to the ribs, and from one ilium to the other.
+The skin and fascia of the external wall being so thin that the catheter
+can be seen over the entire extent, as I push it from one part to another
+for the purpose of washing out all parts of the sack. Patient has been
+complaining of pain and want of sleep; had a chill last night. He still
+takes beef tea twice a day, and eggs and other food twice a day, making
+four meals a day; also, continues the quinine and whisky.
+
+Feb. 21st, 9:30 A. M.,--pulse 98, temp. 101. Feels more comfortable.
+Discharge of pus much less than yesterday. Wash out the sinuses and inject
+liquid vasaline.
+
+Feb. 23d, 9:30 A. M.,--pulse 98, temp. 101. Complains of being "very
+sick." Speaks English but poorly. Considerable discharge of laudable pus,
+but not so much as before the use of the liquid vasaline. There is one
+point near the left hand side of the large sinus on the back, where the
+walls are adherent. I wash them out with a five per cent. solution of
+carbolic acid in water, and again inject the liquid vasaline. By gentle
+pressure made over the upper part of the pouch, I force everything out of
+it at the opening below, bringing the walls of the sack together over the
+greater part of the surface. Hoping that the adhesion between the walls,
+which has commenced, will continue, and soon obliterate, at least, all the
+upper part of the pouch. Put on the usual compresses; this time using
+oakum instead of folded cloths.
+
+Feb. 24th, 9:30 A. M.,--pulse 108, temp. 101. Did not wash out the upper
+or left hand part of the pouch on the back, for fear of disturbing
+adhesions that are taking place. Washed out the lower part and injected
+vasaline. A small spot, as large as a ten cent piece, has sloughed, making
+a hole into the pouch over the lower lumbar vertebra. Another spot
+immediately above this, and about the same size, looks as if it would
+slough.
+
+Feb. 25th, 9:30 A. M.,--pulse 100, temp. 100.
+
+Feb. 27th, 9:30 A. M.,--pulse 115, temp. 99.2. Adhesion is taking place
+between the walls of the sinus, on the left of the vertebrae.
+
+Feb. 29th, 9:30, A. M.,--pulse 104, temp. 100. The sacks, or sinuses, have
+been washed out regularly every day, and dressed with vasaline.
+
+This case presents several features of interest. The first is the very
+large amount of secondary hemorrhage, and its location, there being
+sixty-eight ounces removed at one time and fifty at another, and perhaps
+thirty or forty at another, from just beneath the skin and superficial
+fascia of the lower part of the back. The second point of interest would
+be to know from what vessel this hemorrhage took place. The third
+interesting feature of the case is its progress and treatment.
+
+At the time of the aspiration the patient was in a critical condition;
+temp. 105.4, pulse 120; the tongue and chill denoting danger of pyemia.
+This danger was avoided by drawing off the decomposing blood, and giving
+the patient a new lease of life. This was but temporary, for six days
+afterward the same danger presented itself again. This was also avoided by
+opening the sinus freely, by an incision two inches long, which could not
+have been done sooner for fear of adding to the hemorrhage.
+
+At the end of six days from this last critical period, the temperature
+again went up to 103.5, and the pulse and condition of the patient
+indicated great danger of death from exhaustion--the result of the
+formation of so much pus. This was avoided by preventing the excessive
+formation of pus by washing out the sinus with liquid vasaline. The
+patient is still under treatment in the hospital now under the care of
+my esteemed friend, Dr. Benj. Cory.
+
+The patient will probably recover. It will be simply a question of
+endurance with him. That is, if the supply of nourishment can be kept up,
+and the waste prevented, which must result from the formation of such a
+large quantity of pus, there is no reason why he should not recover.[A]
+
+  [A] On March 25th, date of publication of this report, the
+  patient is considered convalescent.
+
+At the time of putting him under the care of Dr. Cory, he was taking nine
+grains of quinia daily, about six ounces of whisky, beef tea twice a day,
+and eggs twice, with such other food as he might relish; taking four meals
+a day.
+
+Thus you see I was carrying out the theory mentioned in the first part of
+this paper:--that of supplying the system with all the flesh producing
+food the stomach would digest, and using whisky and quinia to prevent
+disassimilation or waste; also vasaline locally for a similar reason.
+
+With this case I conclude my report; only adding that perhaps the thought
+of a poet, who evidently knows much of human nature, is applicable to this
+hastily written paper. This poet says:
+
+     "A fool will pass for such through one mistake,
+      While a philosopher will pass for such,
+      Through said mistakes being ventured in the gross
+      And heaped up to a system."
+
+Thus I, as one or the other of the personages here mentioned, offer this,
+my mite, to the literature of surgery, leaving you to decide which of the
+titles I deserve.
+
+
+
+
+
+End of the Project Gutenberg EBook of Report on Surgery to the Santa Clara
+County Medical Society, by Joseph Bradford Cox
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