Surgery, with special reference to podiatry
by Maximilian Stern · English · Gutenberg #41725 · 591,625 chars · public domain (US)
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Title: Surgery, with special reference to podiatry
Author: Maximilian Stern
Edward Adams
Editor: Maurice J. Lewi
Release date: December 28, 2012 [eBook #41725]
Most recently updated: October 23, 2024
Language: English
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*** START OF THE PROJECT GUTENBERG EBOOK SURGERY, WITH SPECIAL REFERENCE TO PODIATRY ***
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| Transcriber’s note: |
| Bold words are enclosed within plus (+) signs. |
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SURGERY WITH SPECIAL REFERENCE TO PODIATRY
BY MAXIMILIAN STERN, M.D.
AND EDWARD ADAMS, M.D.
_Professors of Surgery at the School of Chiropody of New York_
EDITED BY MAURICE J. LEWI, M.D.
_President of the School of Chiropody of New York_
THE SCHOOL OF CHIROPODY OF NEW YORK 213-217 WEST 125TH STREET NEW
YORK
_It is intended to publish a series of books which will constitute a
complete SYSTEM OF PODIATRY, comprising the entire range of subjects
essential to a comprehensive knowledge of the theory and practice of
Chiropody and all that is or should be known by the practising
chiropodist, or that should be taught to the student of Chiropody._
_The present volume, “Surgery,” is the first of this series and will
be followed by “Practical Chiropody,” “Chiropodial Orthopedics” and
other volumes on subjects of major interest and of vital importance to
all interested in Podiatry._
CONTENTS
CHAPTER PAGE
PREFACE ix
I INTRODUCTION 1
II SURGICAL BACTERIOLOGY 6
III ASEPSIS AND ANTISEPSIS 18
IV INFLAMMATION 28
V WOUNDS AND CONTUSIONS 39
VI HEMORRHAGE 51
VII BURNS, FROST BITE, ETC. 56
VIII FISTULAE; FISSURES; SINUSES; ABSCESSES; FURUNCLES; ULCERS 64
IX DISEASES OF JOINTS—THE SEROUS AND SYNOVIAL MEMBRANES 82
X DISEASES OF THE BONES 99
XI DISEASES AND INJURIES OF THE ARTERIES AND GANGRENE 118
XII DISEASES OF VEINS 125
XIII SPECIAL FORMS OF INFLAMMATION 130
XIV VERRUCA (WART), CALLOSITY, HELOMA (CORN OR CLAVUS),
DISEASES OF THE NAILS—INGROWN NAIL 139
PREFACE
This volume is intended to serve as a guide to the diagnosis and to
the treatment of the diseases and conditions of the body in general,
in their relation to the foot, as well as to those conditions which
primarily affect this member.
Much of the matter herein contained might be regarded as beyond the
scope of Chiropody; this, however, is a fallacy not more applicable to
Chiropody than to any other specialized branch of Surgery requiring a
knowledge of the physiologic and pathologic processes at work in the
production of disease.
The advances made in this branch of Surgery have long since translated
it from the realm of empiricism to the field of rationalism. Treatment
based primarily on the results of experience or observation must give
place to a system based upon a knowledge of abnormal conditions and
the resultant changes in the tissues. Such knowledge elicits treatment
directed definitely against these processes. It is obvious that this
can be accomplished only through the agency of certain definite manual
and therapeutic measures, the physiologic actions of which are well
understood and known to be reliable.
Much stress has been laid upon the subject of asepsis and antisepsis.
The foot is peculiar in that conditions surrounding it are especially
congenial to the development and multiplication of bacteria. Modern
surgery has been built upon the recognition of the rôle of bacteria in
the behaviour of wounds, and the greatest hazard to successful surgery
lies in the ever-present possibility of bacterial invasion. Surgical
safety, however, can be secured by the employment of a perfect technic
for asepsis. Once the precept is established that the operative field
must be asepticized and thereafter protected from contact with any
septic object, the status of Podiatry will be secure for all time.
Should we accomplish this, these pages will have served a purpose.
Two notable features of the present volume are a comprehensive
glossary and an exhaustive index which greatly enhance its
usefulness, enabling the reader to find references to the subject
before him, and with very little inconvenience to learn the meanings
of unfamiliar words, thus obviating the necessity for a medical
dictionary.
We avail ourselves of this opportunity to acknowledge our gratitude to
Dr. Maurice J. Lewi for his assistance in editing and in publishing
our work in keeping with his estimate of its possible field of
usefulness.
M. S.
E. A.
CHAPTER I
+INTRODUCTION+
Surgery, in contradistinction to medicine, as a separate branch of the
healing art, includes all manual procedures and is not limited to
cutting operations exclusively. It is that branch which deals with the
treatment of morbid conditions by means of manual or instrumental
agencies.
Morbid conditions include three distinct classes: those due to
1. Injuries
2. Infections
3. Diseases
+Injuries.+ To this class belong all the processes due to physical
agencies and it includes besides traumatism, the effects of heat and
cold, of chemicals, of light and of electricity.
+Infections.+ These may be either local or general. The reaction might
occur at the point of entrance of the bacteria, or constitutional
symptoms may evidence their invasion into the blood, or the absorption
of their toxic products.
Many conditions in this class are linked closely with those in the
following class:
+Diseases.+ Here are classified (_a_) new growths, both benign and
malignant; (_b_) changes due to age and environment, and (_c_)
diseases not belonging in either of the above classes. These latter
are generally known as _idiopathic_ or _spontaneous_ in their
etiology. These terms, however, often indicate only a limit of
knowledge as to their true etiology.
+The Tissues.+ The tissues of the body, though apparently so different
and varying so decidedly in their functions, are in many respects
similar.
Every tissue is composed of two parts: the _cellular elements_ and the
_intercellular substance_. These are called _cells_ and _stroma_. Upon
the first of these depends the vitality and function of the part,
while its density, shape and general physical properties are
determined by the second. Likewise along the same lines of reason, all
of our organs have two separate areas of tissue: the _parenchymatous_
and the _interstitial_. The first contains the functioning and the
second the supporting elements.
The physical conditions of the interstitial tissue or the
intercellular substance vary greatly in density. _Blood_ is a tissue,
the intercellular constituent of which is fluid, and as we consider
more dense tissues, we encounter all degrees of density of the
framework or intercellular substance, until with the additional
presence of calcareous elements, we conceive the hardness of bone and
dentine. Tissues as a whole, however, are not solid; there are spaces
in the supporting structure to admit of the passage of arteries,
veins, nerves, and lymphatics.
Abnormal conditions arise in the various parts of the tissues. Certain
diseases affect the parenchymatous tissue in an organ more than the
interstitial tissue and again others affect the blood vessels
particularly.
There may be _hypertrophy_, in which the entire organ or part becomes
larger as a whole, the active cells and stroma sharing alike in the
process, or there may be an _hyperplasia_, in which the active cells
of the part proliferate abnormally. When the interstitial tissue alone
develops excessively it is known as an _infiltration_. Under such
circumstances the parenchymatous cells often undergo what is termed
_pressure atrophy_; they are diminished by squeezing.
_Atrophy_ of the part or organ, from whatever source, signifies its
diminution in size; its function is, of course, either impaired or
suspended as the process goes on.
The efforts on the part of the organism as a whole to combat or repair
injury, bacterial invasion and disease are directed along definite
lines. The study of these functions does not rightly come within the
scope of these pages, belonging to physiology, but must be considered
here, if only in brief for the purpose of a good understanding of the
processes at work in surgical conditions.
As surgeons, the functions which concern us most are the
1. Nervous
2. Circulatory
3. Lymphatic
+THE NERVOUS SYSTEM+
The nerves operate in harmony with each other and with the organs to
maintain health. The nervous system comprises the brain, the spinal
cord, the nerves, and the ganglia. Aside from presiding over the
special senses, this system controls and directs the processes of
defense and repair. In doing so, the force and frequency of the heart
beat, the calibre of the vessels and the chemistry and composition of
the blood are all altered.
These phenomena are the ones which concern us in our present subject,
acting as they do upon the blood and the organs which contain it. They
will be considered more fully in the following:
+THE CIRCULATORY SYSTEM+
In health and disease the force and frequency of the heart beat and
the calibre of the arteries undergo momentary alterations to meet
changes surrounding us.
Dilatation and constriction of the arteries, and arterioles through
the activity of the vasomotor nerves, permit of increasing and
diminishing amounts of blood reaching the various organs and regions
of the body. In this way the peripheral circulation, through the
activity of the heat centre in the brain, acting upon the superficial
capillaries, maintains the normal temperature of the body during the
changes of season. In winter, heat conservation is effected by
vaso-constriction of the superficial capillaries, while in summer,
heat radiation is accomplished by vaso-dilatation together with the
evaporation of moisture so abundantly supplied by the active sweat
glands. Other phenomena demonstrating the vasomotor function are
blushing, going pale, and the redness and swelling following injury or
infection. Of the latter we will treat under the heading
“Inflammation.”
Certain changes also occur in the blood in order that it may perform
its functions. These changes are found both in the chemistry of its
fluid content and in the number and kind of its solid elements: the
corpuscles. The blood is a tissue; its corpuscles are the functioning
cells and its fluid content the basement substance.
In the fluid content of the blood or _plasma_, as it is called,
certain chemical changes occur in its fibrin-forming capacity. Clot
formation, an effort on the part of the economy to arrest hemorrhage,
is thus facilitated when there is active bleeding, also during labor
and certain diseases.
The number and kind of white blood cells also undergo changes, as we
shall see, under circumstances in which the defences of the organism
are called into operation, for it is the function of the white blood
corpuscles to combat bacterial invasion.
It is the preponderance of these white cells which imparts the
peculiar milky color to pus.
Nourishment and oxygen are carried to the tissues by the red blood
corpuscles. Under circumstances which we shall see later, these are
also altered both in number and in size, and also in their arrangement
in the vessels. (See Chapter IV, “_Inflammation_.”)
+THE LYMPHATIC SYSTEM+
Waste material in the tissues is carried off by the return blood in
the veins and also by the lymphatics. These are in reality the
scavengers of the body, both the lymphatic vessels and glands,
performing important functions for the good of the economy. They are
found beneath the skin and in the subcutaneous tissue, also along the
course of the great veins.
The lymphatics far exceed the veins in number and perform a function
similar to the veins, gathering waste material from the tissues, also
the digested food called _chyle_, from the stomach and intestines. The
lymphatic vessels, also the lacteals which absorb the chyle, all pass
through glands, which are extremely numerous, where certain
deleterious substances are extracted from the lymph before it is
emptied into the blood stream.
The lymphatic glands in performing their function as filters often
become inflamed and when large numbers of pathogenic bacteria, or very
virulent ones are contained in a gland, abscess formation results just
as it would in any tissue so invaded.
CHAPTER II
+SURGICAL BACTERIOLOGY+
A _microorganism_ or _microbe_, some species of which cause all
disease, is a minute plant or animal too small, as a rule, to be
visible to the naked eye.
The word _germ_ may be used to designate any microorganism, but it has
so many other meanings and has been so loosely employed even in this
sense, that it cannot be used for accurate scientific description.
_Bacteria_ are minute plants on the order of fungae, many of which are
able to produce fermentation, decomposition or disease.
Although the word _bacterium_ by derivation has the same meaning as
_bacillus_ and indicates a rod shaped fungus, it has been so loosely
employed that it may very well be applied to the entire germal family,
retaining the word bacillus in the narrower sense.
+Description of Bacteria.+ _Schizomycetes_ is the name given all the
bacteria of putrefaction and disease, the former being called
_saprophytic_ and the latter _pathogenic_.
Bacteria are minute fungi, each consisting of a single cell enclosed
in a cell membrane of cellulose which can be demonstrated by iodine,
the latter causing the protoplasm to retract from the cell wall. There
is no nucleus or central core. Some of the bacteria are colorless,
others pigmented, yellow, blue or red. The cells vary in shape and in
size in different species as well as in their mode of growth, and are
named in accordance with these peculiarities. The round or oval cells
are called _cocci_; the rod-shaped organisms are termed _bacilli_. The
cocci are called _micrococci_ or _macrococci_ according to their size;
_diplococci_ or _tetracocci_, according to the production of pairs or
groups of four in their multiplication; _streptococci_, because in
their growth they always form chains of cells; _staphylococci_,
because they grow in irregular clusters resembling bunches of grapes.
Some of the bacteria have the power of motion generally produced by
cilia or flagella and others are motionless.
+Habitat.+ These organisms may truly be said to be omnipresent. Every
thing we wear or use or eat, even the air itself, is impregnated with
them. Pathogenic germs may also be found among these myriads. Every
species has its own particular habitat, where the conditions
especially favor its growth, just as any of the larger plants require
a certain soil, a supply of water, temperature, and proper amount of
light in order to make growth and multiplication possible.
The bacteria in the air are more numerous in dry weather, being
carried up as dust by the wind, for a moist surface holds any bacteria
which may lie upon it. So complete is the action of moisture, that
air, which contained 600 microorganisms when inspired, has been shown
to return from the lungs with almost none, the moist respiratory
surfaces catching and holding the bacteria; so that the expired air is
practically sterilized; this is true even when the expiration is from
diseased lungs. The act of coughing, however, may expel bacteria in
the mucus ejected. The number of bacteria in the air is very variable,
but is much greater in houses than out of doors, and is naturally
increased by attempts to clean the rooms.
+Parasitic Nature.+ The number of species of pathogenic germs is
comparatively small compared with the number of all the varieties of
germs, for the latter are practically innumerable. Indeed, the
wonderful qualities of resistance in animal tissues is the only thing
that makes animal life possible and it is this power of resistance
that allows certain wounds to heal by primary union when left without
protection or care.
The schizomycetes are unable to extract nitrogen from the air or the
soil, like the higher vegetables, and must, therefore, be provided
with a higher nitrogenous compound, such as is produced by vegetable
and animal life. Some of them are able to live upon dead organic
matter, while others cannot exist without living tissues to feed upon
and are therefore true parasites. There are some which are able to
live upon either dead or living tissues and are known as _facultative
parasites_, a class which includes a majority of pathogenic germs.
Some organisms require albuminous matter, others need carbohydrates;
they all require water, carbon, nitrogen, oxygen, and certain
inorganic materials, especially lime and potassium. All organisms
require water. If dried, no form will multiply, and many forms will
die.
The fluids and tissues of the individual may or may not afford a
favorable soil for the germs of a disease, or, in the same person
afford it at one time, and not at another. Some individuals seem to
possess indestructible immunity from, and others are especially prone
to, certain contagious diseases. Impairment of health, by alterating
some subtle condition of the soil, may make a person liable who
previously was exempt.
+Effect of Oxygen.+ Some bacteria need free oxygen; some can live either
with or without free oxygen, while others cannot live at all in the
presence of free oxygen. Those requiring oxygen are called _aerobic_;
those which can live with or without it are called _facultative
aerobic_; those which do not live in free oxygen are called
_anaerobic_.
Bacteria are very sensitive to temperature, few being able to live in
a temperature below 68°F. or 29°C. or above 104°F. or 40°C. The
pathogenic varieties thrive best at about the normal temperature of
the blood. Direct sunlight retards their growth and may kill them.
Freezing renders bacteria motionless and incapable of multiplication,
but it does not kill them; they again become active when the
temperature is raised. The absurdity of employing cold as a germicide
is evident when it is known that a temperature of 200°F. below zero is
not fatal to germ life, cell activities by such a temperature only
being rendered dormant. The high temperatures are fatal to bacteria,
moist heat being more destructive than dry heat, and adult cells are
more easily killed than spores. A temperature less than 212°F. will
kill many organisms and boiling will kill every pathogenic organism
that does not form spores. Some spores are not destroyed after
prolonged boiling and some will withstand a temperature of 120°C. As a
practical fact, however, boiling water kills in a few minutes all
cocci, most bacilli, and all pathogenic spores, though anthrax and
tetanus are harder to kill than are the spores of other bacteria.
Under favorable conditions bacteria multiply rapidly, but when
conditions are unfavorable, they take on a spore formation and remain
in a quiescent state, like the seed of a plant, waiting—it may be
years—until proper conditions are present. The spores are protected by
such a thick envelope and have such great potential vitality, that it
is much more difficult to kill them than the developed bacteria.
Certain spores that withstand 212°F. or 100°C., can be killed when
fully developed at 130°F. or 55°C.
+Toxins.+ As bacteria grow, certain poisonous chemical substances appear
about them. These poisons are produced by them directly, or are formed
in the organic matter or tissues in which they live, as the result of
their presence. Some of these substances are alkaloidal and are known
as _ferments_ or _ptomains_. Others are albuminous in nature and are
called _toxalbumins_. The ptomains and toxalbumins are exceedingly
powerful poisons, producing local necrosis, inflammation and even
suppuration, when introduced by themselves and entirely free from
living germs, into the tissues of animals. Pathogenic bacteria
abstract the lymph from the blood. As the lymph contains elements
necessary to the body, such as water, oxygen, albumins, carbohydrates,
etc., their loss brings about body-waste and exhaustion from lack of
nourishment. Again, bacteria produce a vast number of compounds, some
harmless and others highly poisonous.
The symptoms of a microbic disease are largely due to the absorption
of poisonous materials from the area of infection. These poisons may
be formed in the tissues by the action upon them of the bacteria, or
they may be liberated from the bodies of degenerating microbes.
Bacteria secrete and contain ferments like pepsin or trypsin, and as
albumoses are formed in the alimentary canal by the action of the
digestive ferments upon proteids, sugars, and starches, so microbic
albumoses are formed by the action of microbic ferments upon tissues.
The local and general symptoms of these toxins depend upon the
particular toxin employed and a large number of these poisons have
been isolated and studied. Those of the surgically important
pathogenic germs, produce inflammation locally, with general symptoms
of fever, chills, cardiac depression, irritation of the kidneys and
bowels and cerebral symptoms, such as delirium and coma. The
toxalbumins also appear to have the effect of destroying the bacteria
to which they owe their origin when they have been produced in large
quantity.
+Cultivation.+ Bacteria are cultivated for study in the laboratory in
meat extracts, in gelatine, or agar agar (a sort of vegetable
gelatine), or raw potato, in blood serum and in other materials. The
simplest method of cultivation is in bouillon, sterilized in flasks,
with cotton plugs. Another method of studying bacteria is by the
inoculation of animals.
+Infection.+ Bacteria gain admission to the living tissues under natural
conditions, by penetrating any of the mucous membranes which they can
reach, or by entering open wounds. It may be said in general that an
intact epidermis is almost a complete protection against infection,
and that an intact mucous membrane is a good protection. This
difference in vulnerability between the mucous membrane and the skin
is important, and is probably due to the cornifaction of the
epithelial cells, and to their numerous layers, as well as to the
protection afforded by the thick corium. The single layer of soft
mucous cells is much more easily penetrated.
Typhoid bacilli and other hostile germs have been actually observed in
the urine, in the bile, in the intestinal secretions and in the
saliva. The bacteria of typhoid fever and tuberculosis have been found
in the milk of nursing mothers.
The local phenomena of inflammation usually follow the introduction of
living bacteria into the tissues, and general symptoms of poisoning
follow later, when the bacteria, toxins, or ptomains, have entered the
circulation. Some bacteria, however, excite no local reaction, but
enter the circulation at once. The pyogenic variety, it should be
noted, cause the production of pus.
+Elimination.+ Bacteria can be eliminated from the blood in several
ways; the kidneys, however, are the organs which carry the burden of
most frequently relieving the body of them. Even the sweat glands are
supposed to eliminate both bacterial toxins and bacteria.
+Resistance Offered by Tissues.+ The tissues have considerable power of
resistance under ordinary circumstances, although the exact sources of
this power are not well under stood. _Phagocytosis_—the power of
destruction and removal of bacteria supposedly possessed by the
leucocytes emigrating from the blood vessels—explains it in part. It
is also accounted for by the germicidal properties of the blood serum.
The resistance of the tissues may in some cases be due to the absence
from them of some particular element necessary to the growth of a
particular microorganism. This refractoriness varies in every species
of animal in its relation to every form of germ. Different individuals
of one species also vary in their susceptibility, and even different
parts of the body vary in the same individual. The lower animals offer
a greater resistance to pyogenic bacteria than do human beings.
Any cause that lowers the vitality by depressing the system, reduces
the resistance to bacteria and is therefore apt to favor their growth.
Exhausting diseases such as anemia, obesity, alcoholism, diabetes,
fatigue, or even exposure to cold, are instances. Germ growth is also
favored by the presence of dead, or injured tissues, of blood clots,
of foreign substances, and above all, by the presence of some of the
substances in which the germ has already been growing at the time of
its inoculation, and containing some of its toxins.
+Immunity.+ To be able to resist the invasion of any species of
bacteria, one is said to be refractory to or immune against that
variety of germs.
Serum therapy is based on the demonstrated fact of immunity, and of
the possibility of producing it by injecting the serum of immunized
animals. In many infectious diseases, one attack protects an
individual for a lifetime and one form of disease may protect against
even a more virulent form, as vaccination protects against smallpox.
It is a fact that if the serum of an animal which has been rendered
immune to a certain disease be injected into a susceptible animal, the
same immunity can be produced temporarily in the second animal. Serum
therapy proves that the injected serum will not only confer immunity
against the infection, but will enable the animal to throw off an
already existing infection.
+Sterilization.+ The question how to destroy microorganisms is one of
the most important in bacteriology. Exactly how chemical antiseptics
act in suspending the growth in living organisms and yet leaving them
capable of restoration, is not understood. The explanation is offered
that the antiseptics enter into combination with the capsule of the
cell and can be freed from it by breaking up this chemical
combination. It has always been evident that very minute quantities of
germicidal substances, and some substances which are not germicidal,
would prevent the growth of bacteria, so that it is not surprising
that chemical disinfectants should act in this prolonged inhibitory
way. It must be remembered that in operative surgical work, germs
which will not develop are, for practical purposes, as good as dead;
therefore such results do not invalidate the present methods of
sterilization for operations. They naturally stimulate interest in the
discovery of better methods of sterilization and especially in the
thorough application of the methods upon which we are now depending,
in order to obtain the best possible results from them. There are
three ways of destroying microorganisms: (1) by deprivation of food
and water, (2) by chemicals (including toxins), (3) by heat.
+Chemical Antiseptics.+ For practical disinfection, chemicals and heat
need only concern us. The power of these substances is greatly
decreased by heat, grease, oil, mucus, and even blood will cover germs
with a coating which prevents chemical germicides from reaching them.
Among the ordinary germicides, bichloride of mercury, iodin, alcohol
and carbolic acid, are of the greatest importance. A source of error
in the direct application of these experiments is the fact that many
of these chemicals are decomposed or rendered inert, by combinations
with the albuminoids of blood and pus, mercuric bichloride being
transformed into an indifferent substance and even carbolic acid being
altered.
+Carbolic Acid+ is a valuable germicide in the strength of from 1 to 40,
to 1 to 20. It is very irritant to tissues and carbolized dressings
may be responsible for the sloughing of a wound. It is inert in fatty
tissues.
Carbolic acid is readily absorbed, and may thus produce toxic
symptoms. One of the early signs of absorption is the appearance of
the urine, which may assume a smoky, greenish or blackish hue.
Examination shows a great diminution or entire absence of sulphates,
when the acidulated urine is heated with chloride of barium. The urine
also contains albumin. The appearance of the urine is an indication
that the use of the drug must be discontinued.
+Kreolin+, a preparation made from coal tar, is a germicide without
irritant or toxic effects. It is less powerful than carbolic acid, but
acts similarly, and is used in emulsion of a strength of from 1 to
15%. It does not irritate the skin like carbolic acid.
+Peroxide of Hydrogen+ is a most admirable agent for the destruction of
pus cocci. It probably destroys the albuminous element upon which the
bacteria live, and starves the fungi.
Peroxide is not fatal to tetanus bacilli.
+Iodoform+ is largely used, but it is not a germicide as bacteria will
grow upon it. It hinders the development of bacteria and directly
antagonizes the toxic products of germ life.
+Silver Nitrate+ is a valuable antiseptic. It exerts an inhibitive
action upon the growth of microorganisms, but irritates the tissues.
+Formaldehyde+ has valuable antiseptic properties. Formalin is a 40%
solution of the gas in water. Solutions of this strength are very
irritant to the tissues, but a 2% solution can be used to disinfect
wounds and instruments.
+Nucleins+, especially protonuclein, possess germicidal powers.
Protonuclein is of value in treating areas of infection, particularly
when sloughing exists. A great many other antiseptics are used.
+Heat+. The surest and quickest method of destroying bacteria is by
heat. Even the spores succumb to it. Anthrax spores are killed in 2
minutes in boiling water, and the various bacilli and cocci in from 2
to 5 seconds.
When a substance to be sterilized by heat will not bear so high a
temperature, the method of fractional sterilization is employed, the
fluid to be sterilized being heated to from 140°F. to 175°F. or to
from 69°C. to 80°C., for from 15 to 30 minutes every 3 days or 7 days.
The theory is that the adult germs are killed by the first heating and
that any spores which develop subsequently are destroyed in their
adult state at the next heating. The fluid, meanwhile, must be kept at
an even temperature which will encourage the development of any spores
it may contain. Even anthrax spores may be killed by 167°F. to 185°F.,
or 75°C. to 80°C., in a one and four-tenths solution of bicarbonate
of soda, in from 8 to 20 minutes. Dry heat is not so efficient as
moist heat.
The following are the more important bacteria we meet in surgical
conditions:
_Staphylococcus pyogenes aureus_—a microorganism producing
yellow pus.
_Staphylococcus pyogenes citreus_—a microorganism producing
lemon-colored pus.
_Staphylococcus pyogenes albus_—a microorganism producing
white pus.
_Streptococcus pyogenes_—a streptococcus producing pus.
(Erysipelas for example).
_Micrococcus gonorrhea_—bacillus of Neisser, or gonococcus.
_Bacillus pyocyaneous_—producing a green pus.
_Bacillus coli communis_—producing intestinal conditions.
(Appendicitis for example).
_Bacillus typhosis_—Eberth’s bacillus; producing typhoid
fever.
_Bacillus tuberculosis_—Koch’s bacillus; producing
tuberculosis.
_Bacillus tetani_—Nicolaier’s bacillus; causing tetanus.
_Treponema pallidum_, or _spirochaeta pallida_ of Hoffman and
Schaudin—a protoza causing syphilis.
The first six are known as _pyogenic bacteria_, as they all produce
pus; in addition to the above there are many more microorganisms, but
from a surgical standpoint those mentioned are the most important.
The _staphylococcus pyogenes_ is a spherical coccus of somewhat
variable size but averaging about 8 microns; when properly stained it
can often be seen to be formed of two separate hemispheres. In pus it
is generally found in small heaps containing from two to ten members,
but it also occurs singly and in pairs, and even in short chains like
the streptococcus, thus rendering diagnosis difficult with the
microscope alone. Its cultures are of a yellowish tinge. The aureus
type is the most usual cause of abscesses (circumscribed suppurations)
and 77% of acute abscesses are due to the staphylococci.
The _staphylococcus pyogenes aureus_ is a facultative anaerobic
parasite which is widely distributed in nature, and is found in the
soil, in the dust of air, in water, in the alimentary canal, under the
nails, and in the superficial layers of the skin. It forms the
characteristic color only when it grows in air. It is killed in ten
minutes by a moist temperature of 58°C. and is instantly killed by
boiling water. Carbolic acid (1 to 40) and bichloride of mercury (1 to
2000) are quickly fatal to these cocci.
_Staphylococcus pyogenes citreus_, the lemon-colored coccus, is found
occasionally in acute circumscribed suppurations, but far more rarely
than the other two forms. Its pyogenic power is even weaker than that
of the albus.
_Staphylococcus pyogenes albus_, the white coccus, acts like the
aureus, but is more feeble in power. When this organism is found upon
and in the skin, it is called _staphylococcus epidermis albus_, an
organism which is the cause of stitch abscesses.
_Streptococcus pyogenes_ is found in spreading suppurations and in
very acute abscesses. About 16% of acute abscesses contain
streptococci. It is easily killed by boiling, and can be destroyed by
carbolic acid and by corrosive sublimate. The streptococcus of
erysipelas is thought to be identical with the streptococcus pyogenes,
but their difference in action is believed to be due to difference in
virulence induced by external conditions and by the state of the
tissues of the host. The coccus of erysipelas is larger than the
ordinary form of streptococcus pyogenes, and infection takes place
through a wound, often a very trivial one, or through a mucous
membrane. The organism multiplies in the small lymph channels. The
streptococcus may cause suppuration in erysipelas, mixed infection not
being necessary to cause pus to form.
The _gonococcus_ of Neisser is found both inside and outside of pus
cells and mucous cells. The gonococci cannot be cultivated upon
ordinary media, but grow best upon human-blood serum. Gonococci stain
easily and are readily decolorized by Gram’s method.
The _bacillus coli communis_, or the bacillus of Escherich, is
invariably found in the fæces. It is believed by many observers to be
the cause of appendicitis, peritonitis, and abscesses about the
intestine. In cases of appendicitis we can rarely get a pure culture
of Escherich’s bacillus, but usually find also streptococci and
staphylococci.
The _bacillus of typhoid fever_ (Eberth’s bacillus) is responsible for
some cases of gangrene, for some of embolism and for not a few bone
and joint diseases.
The _bacillus tuberculosis_ (Koch’s bacillus), the cause of all
tubercular processes, is met with especially in dusty air which
contains the dried sputum of victims of tuberculosis. This infected
air is the chief means of its transmission, though it may be conveyed
by the milk of tubercular cows and by the meat of tubercular animals.
Wounds may open a gateway for infection.
The _bacillus tetani_ (Nicolaier’s bacillus), an aerobic organism, is
found especially in the soil of gardens, in the dust of old buildings,
in street dirt, and in the sweepings of stables. Spores develop at the
ends of these bacilli. This organism is capable of producing toxins of
deadly power. Its spores are hard to kill.
CHAPTER III
+ASEPSIS AND ANTISEPSIS+
Before the introduction of Lister’s methods of treating wounds, it was
considered proper, in accidental and operative wounds, to have profuse
suppuration, pyemia, erysipelas, etc., and it was not remarkable,
therefore, that the mortality following accidental and operative
wounds was very high. Lister’s method of wound treatment was largely
based upon the conception that the infection of wounds occurred from
contact with the air which contained spores and germs, and his method
of treatment therefore, was directed chiefly to their destruction. The
air can be a medium of wound infection to a certain extent, and dry
air contains more spores and bacteria than moist air, but Koch
demonstrated the fact that atmospheric microbes were chiefly of
innocuous character, and wound infection usually could be traced to
bacteria or spores being brought into direct contact with wounds, by
the clothing, or by the skin of the patient, or by the hands of the
surgeon, or by unclean surgical instruments and dressings. The
antiseptic qualities of the blood serum and cell activities in healthy
tissues, are sufficient to destroy or remove a certain number of
microorganisms, and suppuration occurs only when the tissues are
completely overwhelmed by the number of these organisms or when their
power of resistance is lessened by injury or disease.
+Sepsis.+ Sepsis is due to the entrance and multiplication of microbes,
or to the absorption of their products in the body. Local
inflammation and marked constitutional symptoms characterize sepsis.
+Asepsis.+ Asepsis aims at thorough sterilization of the parts and of
all the objects brought into contact with the wounds, and the
exclusion of germs by the use of occlusive bandages and dressings.
+Antisepsis+ is that method of wound treatment which keeps germicidal
agents continuously in direct contact with the wound. Its object,
therefore, is to produce asepsis. It is the duty of the surgeon to
guard against the contact of microorganisms in the wound and to employ
whatever means science has evolved for their destruction. He must,
however, be careful to employ means of disinfection or destruction
that will not have an injurious effect upon the normal tissues.
Mechanical disinfection does not apply to wounds but is employed as a
preventive measure by the operator and his assistants for instruments
and for the skin surrounding the wounds. Mechanical disinfection is
accomplished by the use of soap and water and a friction brush;
germicidal solutions of one kind or another are also employed.
In the modern aseptic operating room germicides and antiseptics do not
play so important a part as they formerly did. This is largely due to
the fact that heat is used wherever possible in the preparation of
sutures, ligatures, dressings and instruments, and to the farther fact
that in uninfected tissues no antiseptic solutions are employed. It
must also be remembered that the germicidal agents possess the
disadvantage of exercising a more or less destructive action on the
body cells, and consequently their use is not warranted in clean
wounds. We still, however, sufficiently often meet with infected
wounds that render the use of these agents necessary.
+Heat+ is the most valuable of all sterilizing agents, its only drawback
being that it is not universally applicable. Wherever possible it
should be employed in preference to chemical agents. It can be
employed either dry or moist. Moist heat is a much more efficacious
germicide than dry heat, for it destroys the organisms at a much
lower temperature. Boiling water at a temperature of 212°F. will
destroy nearly instantaneously all pus-producing organisms. Spores,
however, require a moist heat of 284°F. kept up for at least a
half-hour. A dry heat of 212°F. will not destroy pus-producing
organisms under an hour and a half of treatment, and spores will live
for three hours at a dry temperature of 284°F.
Although moist heat is very much quicker and more satisfactory in its
action, yet it is often inconvenient to employ it in the sterilization
of gowns, towels, operating suits, etc. However, sterilization by heat
has been greatly facilitated by the introduction of the autoclave, by
means of which a very high temperature under pressure can be obtained.
This is the most satisfactory method of sterilizing dressings, towels,
sheets, operating suits and aprons. A similar and less expensive
method of sterilizing these articles is by the use of one of the
simple steam sterilizers which are sold by all dealers. In an
emergency, an ordinary bake oven can be employed as a sterilizer. It
is best, however, where the temperature cannot be estimated, to boil
the articles and dry them between sheets moistened with bichloride
solution.
+Disinfection or Sterilization.+ Sterilization of a wound, or of the
substances coming in contact with it, may be accomplished by using the
aseptic or antiseptic method; by combining these two methods we obtain
the best results. The aseptic method, which employs antiseptic
substances for the purpose of sterilization of objects coming in
contact with the wound when their disinfection by heat is impossible,
is the method perhaps most generally favored by modern surgeons.
+Antiseptic Method.+ In the antiseptic method, the field of operation,
the hands of the operator and of his assistants, and the instruments,
must be treated in germicidal solution and, in addition, the wound
should be frequently irrigated during the operation with a solution
that has germicidal properties.
Recent investigations show that many germicidal substances have not
the power that was formerly attributed to them. Furthermore,
substances which are really active germicides very often produce a
marked toxic effect upon the patient and produce a very decided
irritation of the skin with which they come in contact.
+Aseptic Methods.+ The aseptic method for the treatment of wounds admits
of the use of germicidal solutions and heat upon the field of
operation, upon the hands of the operator and of his assistants, and
upon the instruments employed. After this has been accomplished,
placing absolute dependence upon this sterilization, no germicidal or
antiseptic substances are brought into contact with the wound,
sterilized salt solution or plain sterilized water being used, if
necessary, to flush the wound, the dressings employed having been
sterilized by dry heat or moist heat.
+Sterilization of the Hands.+ Experimental investigation has shown that
the failure of the surgeon’s efforts to render his hands absolutely
aseptic, has been the productive cause of infection in many wounds.
The hands and finger nails may be best sterilized by first rubbing
them with spirits of turpentine; then scrubbing them with soap and
water; and then using a sterilized nail brush freely. The scrubbing
should be done for several minutes. The hands should then be rinsed to
remove the soap, and then soaked for about ten minutes in a solution
of bichloride, strength, 1 to 2500. If turpentine has not been used
before washing with the soap, strong alcohol or ether should be well
rubbed over the hands before they are immersed in the bichloride
solution. Perhaps the best way of rendering the hands sterile is to
scrub them with green soap and water, then mix a tablespoonful of
commercial chloride of lime and half a tablespoonful of carbonate of
soda with enough water to make a paste. When this has assumed a thick
creamy consistency, it should be rubbed into the hands until the
grains of lime disappear and the skin feels cool; then rinse the hands
in sterile water.
+Sterilization of Instruments.+ Instruments may be sterilized by
boiling them for fifteen minutes in water in which a tablespoonful of
washing soda has been added for each quart. This prevents rusting of
the instruments and also makes the water a better solvent for any
fatty matter which may be upon the instruments, thus increasing the
sterilizing effect of the heat.
+Sterilization of the Feet.+ As most patients do not apply water as
freely or as frequently to the feet as to other portions of the body,
there is usually present an excessive amount of thickened epidermis,
which is very difficult to render sterile. For operations in chiropody
the feet should be thoroughly moistened with soap and water, scrubbed
vigorously with a brush, then soaked in a solution of bichloride of
mercury of 1 to 1000 strength, and then wrapped up in a towel soaked
in the same solution while waiting for the operator.
+AGENTS EMPLOYED TO SECURE ASEPSIS+
+Bichloride of Mercury+ is used for the disinfection of the hands and
skin and for the irrigation of wounds. Biniodid of mercury is
extensively employed and in the same strengths as the bichloride. It
is, however, a more powerful germicide, while being less irritative,
and neither forms a mercuric albuminate nor tarnishes metal
instruments.
+Carbolic Acid.+ This acid is derived from coal tar, and although known
as early as 1834 as the first antiseptic recommended and used by
Lister, is not so popular since the discovery that bichloride of
mercury possesses more germicidal action.
Gangrene of the skin and subjacent tissues has often been traced to
the long continued use of dilute solutions of carbolic acid or of
ointments containing small quantities of the drug. Gangrene of the
fingers and toes is by no means infrequent as a consequence of its
use. Another condition frequently seen is the systemic poisoning
through absorption. One of the first symptoms noticed from such
absorption is irritation of the urinary tract and carboluria. This
poisoning is more apt to take place when the weaker solutions are used
than when the pure acid is used, as the destruction produced by the
pure acid prevents its absorption.
The effect of carbolic acid upon the urine (See Chapter II, “_Carbolic
Acid_”) is to cause it to become smoky a short time after it is
voided. The urine shows a complete absence or diminution of the
sulphates, and albumin is generally present. When these symptoms
present themselves, the use of carbolic acid should be withdrawn, and
the administration of sulphate of soda and atropin begun. If the
condition has existed for any length of time and the patient is weak
and exhausted, stimulants are indicated.
+Lysol+ is a saponified phenol, and possesses some germicidal power. It
is used in strengths of 1 to 3 per cent. solutions.
+Creolin+ is mildly germicidal and is used a great deal in from 2 to 4
per cent. solutions.
Both lysol and creolin act very much like carbolic acid, but neither
possess its irritating qualities.
+Formaldehyde Gas+ is an active germicide and very valuable as a
disinfectant. It is used in the shape of formalin which is a 4 per
cent. solution of the gas in water. This agent is very irritating to
the normal tissues in the stronger solution, but a 2 per cent.
solution of formalin may be used for the sterilization of the hands,
instruments, etc.
The formaldehyde fumes are employed for the disinfection of clothing,
rooms, bedding, and also for the sterilization of catheters. The fumes
of the gas are very irritating to the mucous membrane and when this
agent is used for the disinfection of rooms, every crevice and crack
must be tightly sealed to prevent the escape of the gas.
+Iodoform.+ The action of iodoform is not due directly to its ability to
destroy germs but to its undergoing decomposition in the presence of
moisture, liberating iodin and thus rendering inert ptomains that have
resulted from the growth.
+Iodoform Powder+ is rapidly absorbed by the skin and fatal cases of
iodoform poisoning have occurred from treating burns with it.
Iodoform is also used in ointment form and in suppositories. As it is
insoluble in water it is commonly used in a 10 per cent. emulsion. The
gauze is also greatly used.
The symptoms of iodoform poisoning are: delirium; odor of iodoform on
the breath; presence of iodoform in the urine; eruption over the skin,
and finally, coma. Iodoform is also capable of producing a localized
dermatitis, with great irritation, and must therefore be used with
care on all delicate skins.
+Aristol+, a substitute for iodoform, is a compound of iodin and thymol,
producing no toxic effects and having no disagreeable odor; it does
not, however, possess the germicidal qualities of iodoform. Nosophen,
iodol, and airol are among the more recent substitutes.
+Iodin.+ This drug no doubt possesses more germicidal properties than
was at one time supposed. It is probably the most powerful
antipyogenic known. The 7 per cent. tincture is the one most
frequently used.
+Acetate of Aluminum+, or more properly, aluminium, is prepared by
adding five parts of sugar of lead to a solution of five parts of alum
in 500 parts of distilled water. Burow’s solution, see page 35, is
chiefly employed as a wet dressing.
+Chloride of Zinc+ in a solution of 15 to 30 grains to the ounce, has
marked antiseptic properties, but it blanches the tissues when applied
to infected wounds.
+Sulphocarbonate of Zinc+ is less irritating than the chloride of zinc
and is of the same value as a germicide.
+Peroxide of Hydrogen+ when used as a 15 volume mixture or diluted,
seems to have a direct action upon pus generation by destroying
microorganisms of the pus. It is frequently employed for sterilizing
abscess cavities, and for hastening the separation of necrotic tissue.
This agent has also a marked hemostatic power and is used to some
extent on this account in nose and throat work. Its hemostatic power
is also observed in bone cavities. Care should be taken never to use
it unless there is a free exit, as it increases rapidly in volume
after coming in contact with dead tissue or pus, and serious accidents
have happened from its improper use; for instance, if it is injected
into an abdominal sinus where free escape is not provided for, the
distention will result in ruptures of the sinus and infiltration of
the surrounding tissues; possibly of the peritoneal cavity. The
distention produced by it is also quite painful and therefore only a
small quantity, or a much diluted solution should be introduced into
cavities.
+Boric Acid+ is not very actively antiseptic, but even in a saturated
solution it is not irritating. Where bichloride or carbolic dressings
have produced irritation of the skin, or burns, a boric acid ointment
is a very satisfactory substitute.
+Salicylic Acid+ is an antiseptic of value. It is generally used in the
form of an ointment. It is but slightly soluble in water.
+Potassium Permanganate+ by its rapid liberation of oxygen, acts as an
antiseptic of proven merit for the disinfection of foul wounds and
ulcers. It is also used satisfactorily for disinfecting the hands in
preparation for operations, in the form of a 5 per cent. solution, any
stain being removed later by a saturated solution of oxalic acid.
+Alcohol+ possesses marked antiseptic properties and is one of the best
agents for the sterilization of the hands of the surgeon, and for the
skin of the patient. A 60 or 75 per cent. solution of alcohol is much
more efficacious as a skin disinfectant than a 95 per cent. solution.
This is because the purer alcohol is much less penetrating than the
dilute. It is also used when diluted with water, one part to four, as
a dressing for granulating wounds. It is efficacious in limiting the
action of carbolic acid, when this agent has been applied in full
strength.
It is a useful agent in which to store certain materials such as
ligatures, sutures, etc.
+Silver Nitrate+ possesses undoubted antiseptic properties, and
solutions of varying strengths are decidedly antiseptic. These
solutions are from 5 grains to the ounce, to 60 grains to the ounce.
The solid stick of nitrate of silver is used for destroying exuberant
granulations. Among the different silver preparations on the market,
protargol and argyrol are the best known. Both of these are
extensively used in the treatment of inflammations of the mucous
membranes.
The unguentum of Crede, is an ointment of silver which is used in
cases of septic infection and also in localized inflammations. From 15
to 45 grains of silver can, in this form be rubbed into the skin. It
is absorbed and undoubtedly exercises an antiseptic influence on the
infecting microorganisms.
+Saline Solution+, or normal, or isotonic salt solution, as it is called
because of its close approximation to the blood serum, consists of a
solution of 7 per cent. of sodium chloride in plain sterilized water.
Roughly speaking and for ordinary purposes, this solution can be made
by adding an even teaspoonful of ordinary table salt to one pint of
boiled water and then reboiling the mixture.
It can be stored for a limited time in sterile glass jars, which are
sealed with sterile cotton. The jars can be heated to whatever
temperature is required for use. This solution is the one which is
generally used for irrigating wounds and cavities; it is
non-irritating and possesses no antiseptic quality. When a moist
dressing is desired there is no solution comparable to it, largely
because of its non-irritating quality. It has at times a slight
irritating effect upon the kidneys and when large quantities of it are
used it is better to dilute it.
+Pure Oxygen and Ozone+ have been used, and the latter is more
effectual. It has been found that oxygen but slightly retards the
growth of bacteria, but both ozone and oxygen produce a hyperemia, and
retard the growth, especially of anaerobic organisms. Pure oxygen in
the abdominal cavity produces a marked hyperemia and a leukocytosis.
Ozone has been put to some practical use in this country but the
results have not been sufficiently studied.
+Sunlight+ has a marked retarding effect on some bacteria and actually
destroys them. The anthrax spore is said to be killed very promptly by
exposure to strong sunlight and it is claimed that the tubercule
bacillus is slowly destroyed by it.
+Electricity and the X-rays+ also produce a marked retarding effect on
the propagation of certain microorganisms.
CHAPTER IV
+INFLAMMATION+
+Definition.+ Inflammation may be defined as the local reaction against
injurious influences. An aseptic wound heals without any of the
clinical signs of inflammation and without reaction. It is only by a
study of the minute changes about such a wound that the resemblance,
between the processes of wound repair and those of slight
inflammation, become evident.
+Etiology.+ The cause of inflammation is any injury to the tissues by
mechanical, thermal, or chemical means; by the effect of electricity,
or by the growth of bacteria.
+Pathology.+ Inflammation occurs through changes in the circulation.
When one of the causes mentioned above acts upon the tissues, the
first alteration seen is an increasing blood supply to the part, the
arterial circulation being increased both by the greater rapidity and
force of the current through the vessels, and by the dilatation of all
the small branches and capillaries.
When the inflammation grows more intense, the circulation in the
capillaries becomes slower and the corpuscles collect, until they clog
the vessels. The normal current of blood in small vessels, as seen
under the microscope, shows a thick central stream of corpuscles with
a transparent border of lymph (containing only a few white corpuscles)
between it and the vessel wall.
As the stream diminishes in rapidity, the number of white cells in the
clear space increases, the blood plaques appear also, and finally,
when the current is reduced to stagnation, the clear space disappears,
being filled entirely with cells, chiefly leucocytes, although red
cells find their way into it.
This tendency of the white cells to separate from the others, even
when the current is rapid, is partly due to their viscosity and power
of ameboid movement, but in the main is a purely mechanical effect of
the slower current.
It has been proven that when particles of different density are
suspended in a liquid which is circulating through a system of narrow
tubes with a very rapid current, there is a clear space next to the
wall of the tube where the friction necessarily reduces the speed of
the fluid which is free from particles, and, as the current is slowed
down, some of the particles of least density, begin to appear in this
clear space, their number increasing as the current becomes slower,
until even the heavy particles also collect here when it is very slow.
It is known that among the cellular elements of the blood, the
leucocytes have the least specific gravity or density, and the blood
plaques rank next, while the red blood disks are the heaviest, and
these bodies appear in the clear serum near the vessel wall in that
order, according to the law just cited. The slow current is associated
with an increased intravascular blood pressure, which, in part, is the
cause of the phenomena of exudation, emigration and diapedesis.
+Exudation.+ Serum of the blood passes out of the vessels, and collects
in the lymphatic spaces in the cellular tissue, and elsewhere, and
also exudes from the surface of the mucous membranes or forms vesicles
or blisters in the skin by detaching the superficial epithelial
layers. Complete stasis, or stoppage of the circulation is seen only
when the inflammation is exceedingly intense, and would cause the
death of the part if continued long.
Usually the current merely becomes slower than normal. This retarded
circulation is followed by the phenomena of emigration.
+Emigration.+ Emigration of the white blood corpuscles consists in the
passage of the cells directly through the vessel walls. It is most
frequently seen in the capillaries, although it also takes place in
the small veins. The white corpuscles, or leucocytes, have the
property of ameboid movement, stretching out at will in any direction,
long, narrow processes of their protoplasm, called pseudopodia, which
may be attached to any object, and having secured such an anchorage,
the rest of the protoplasmic body is drawn towards it.
In this way, the leucocytes are able to pass through the interstices
between cells, or along narrow channels in the tissues. When the blood
current becomes sufficiently slow to enable them to cling to the walls
of the vessels, it is then that ameboid movement begins. Sometimes the
cells loose their hold and are swept on again, but in other cases a
minute bud of protoplasm will appear on the other side of the wall of
the vessel, opposite to the spot where the leucocyte is clinging, and
as this grows larger, a narrow neck of protoplasm can be traced
through the wall directly to the leucocyte, and presently the mass of
the leucocyte becomes proportionately smaller as the external bud of
protoplasm grows larger. The conditions are gradually reversed, the
nuclei of the cells appear outside and only a small mass of protoplasm
remains within the vessel until finally the entire leucocyte is in the
tissue outside of the vessel and is free to wander in any direction.
The mechanical part of this process is not yet understood. It is
claimed by some that small openings exist in the walls of the vessels,
between the endothelial cells which line them, to which is given the
name of _stomata_. These openings ordinarily are invisible, but they
are said to enlarge under the effect of the dilation of the vessels,
and of the alterations in their walls, produced by the inflammatory
reaction, and that the leucocytes escape through those openings.
There can be no doubt that the emigration is due to the ameboid motion
of the cell, and the discovery of the phenomenon, to which is given
the name chemotaxis, affords a sufficient explanation.
This is the influence possessed by certain substances to attract or
repulse ameboid cells. In some cases this attraction appears purely to
be mechanical, but it is probably a chemical effect of some kind in
most, if not in all, instances.
The process of inflammation produces some chemical compound which
similarly causes the cells to leave the vessels, and when there is any
inflammatory action in their neighborhood, to find their way by the
shortest route to the seat of the inflammation.
The leucocytes direct their course through the tissues to the chief
points of inflammation by reason of chemotaxis, and surround the dead
tissues, or any point of bacterial growth, or any foreign body which
may be the cause.
The wandering leucocytes form the pus cells, and if they are very
numerous, they constitute a purulent or suppurative inflammation. The
wandering cells, however, are almost entirely made up of leucocytes,
of which three forms are known, varying in size and in the size and
number of their nuclei. The leucocytes surround any foreign body, and
if the particles are small enough, they incorporate them within
themselves, in fact, they may be said to swallow them. This taking up
of particles by the wandering cells is called _phagocytosis_.
+Diapedesis.+ When the circulation becomes very low and the pressure
very high, there is a tendency of the red corpuscles to leave the
vessel.
This is a purely passive process, and is observed only when the
changes in the vessel wall are extreme. Both varieties of these cells
die and are destroyed in the exudate, the former furnishing the fibrin
which is so abundant in some forms of inflammation. This escape of red
corpuscles is known as _diapedesis_, and is sometimes so extensive as
to amount to capillary hemorrhage.
+Symptoms.+ From antiquity the local symptoms of inflammations have been
enumerated, as heat, redness, pain and swelling and to these has been
added, impaired function.
The _redness_ is due to congestion. The _pain_ is due to the pressure
exerted on the sensory nerves by the surrounding swelling, as is well
shown by the intensification of the distress, as every beat of the
heart forces more blood into the space already filled. In some cases,
however, it may be caused by the direct action of the inflammatory
agent upon the nerves. The _heat_ is caused by the increased supply of
warm arterial blood, for it has been abundantly proven that the
temperature never rises above the heat of the blood, although
naturally in a patient with fever, it will be above the normal
temperature of that fluid. The _swelling_ is due to the dilated
vessels, and to the escape of serum and blood cells from the vessels
into the tissues. The _impaired function_ is chiefly caused by the
pain which is often increased by any attempt to use the part, and by
the swelling which prevents free movement, though the loss of function
may also be dependent upon the direct action of inflammation upon the
nerves.
The constitutional symptoms of inflammation are an elevation of
temperature with or without a chill. There are also other
disturbances, such as nausea, vomiting, diarrhea, sweating and
polyuria. These are due to efforts on the part of the general economy
to eliminate toxic substances.
The inflammatory products may poison the system in two ways: (1) by
the diffusion of their chemical substances, (toxins and ptomains), or
(2) by the passage of bacteria themselves into the blood.
+Termination.+ Inflammation may result in resolution, suppuration,
necrosis or sloughing, or in the establishment of a chronic state.
+Resolution.+ Resolution is the termination of an inflammation by the
gradual cessation of all the changes which have occurred. The pain
subsides, the circulation becomes more normal, and the exudate is
absorbed, or makes its way to the free surface of the body, where
drainage occurs either spontaneously or by incision.
If there has been any loss of substance caused by the inflammation, it
is restored by processes exactly similar in character to those in the
repair of wounds.
+Suppuration.+ Pus consists of a serum containing little or no fibrin
and large numbers of leucocytes. There are also many cells, either
dead or dying, which represent the waste thrown off from the tissues
as a result of the inflammatory reaction. A purulent inflammation or
suppurative inflammation, is one in which there is pus formation.
When suppuration occurs, the pus may make its way to a free surface,
such as a mucous membrane, or may form an abscess, or may cause
sloughing of the skin over the seat of inflammation, and so escape
from the cellular spaces in the tissues.
Pus may be thrown off by a mucous membrane, without any actual breach
of continuity. Diffuse infiltration of the tissues is the most
dangerous form of suppuration.
In this variety of inflammation the exudate is brought into contact
with the greatest possible extent of absorbent vessels, for as a
surface of a sponge is greater than that of a bag, which would contain
it, so the surface of these intercellular spaces is much greater than
that of an abscess cavity filled by the same amount of pus. In this
form the bands of cellular tissue, lying between and forming the
boundaries of these spaces, remain intact, and the exudate is either
absorbed into the circulation, or seeks escape through many punctate
openings in the skin.
The entire skin of the part is frequently detached from the fascia by
the sloughing of the subcutaneous tissues, before it gives way, and
even when it finally yields to the necrotic process, the openings
formed will be altogether too small in proportion to the extent of the
disease beneath, so that healing is still further delayed.
+Sloughing.+ Inflammation may be accompanied by sloughing or death of
tissues. Gangrene, mortification or necrosis is a death of the tissue
from any cause. The part which has died is designated as a _slough_.
When inflammation has subsided, granulation tissue forms on the living
tissue, exerting pressure upon the slough, thus hastening its
absorption or separation.
+Chronic Inflammation.+ An interruption at some stage of resolution or
suppuration and the continuance of mild symptoms constitutes a chronic
state.
By chronic inflammation, we understand a long continuance of some or
all of the changes seen in acute inflammation, but less in intensity,
and an abnormal tendency to the production of new tissue.
+Treatment.+ The general indications to be observed in the treatment of
inflammation are: (1) to combat the congestion of the parts; (2) to
relieve tension; (3) to give free issue to the products of
inflammation; (4) to produce early separation of sloughs.
Very hot or very cold applications exert a beneficial and soothing
effect upon inflamed areas.
Cold has the tendency to reduce tension by constricting the blood
vessels thus diminishing the amount of blood supplied. In an infected
area the reproduction and development of bacteria are checked, and
suppuration is frequently aborted.
Heat has the effect of dilating the blood vessels and hastens repair
in bruised, strained, or torn tissues. This is a variety of hyperemia
treatment which is especially useful in the absence of bacteria. In
infected areas the growth of bacteria, and increased pus formation,
would be encouraged and heat is contraindicated.
We are yet without an antiseptic material which can be used in
sufficient strength to affect the growth of germs and yet not injure
the patient. Injury of the part treated, and absorption into the
circulation are both to be avoided. The application of dressings, wet
with corrosive sublimate, or other chemical solutions to the unbroken
skin over inflamed areas, is a fallacy. Any benefit which has been
observed to follow their use, has undoubtedly been due to the effect
of the moisture and warmth or cold, according to the temperature of
the dressing, thus obtained, while local sloughing and general
constitutional poisoning are a common result of such applications. A
light gauze dressing, applied cold, and kept constantly wet with any
evaporating solution, will greatly relieve the congestion and so
assist the inflamed tissues in their contest with any irritating
materials.
A thick wet dressing made with a hot solution, and well protected
against evaporation so that it will retain its heat, will produce the
same effect as a poultice, although less powerful. When there are
discharging wounds or raw surfaces, unprotected wet gauze should be
employed, for poultices are then inadmissible, and the weak antiseptic
solution will inactivate and wash away bacteria.
Astringent solutions have an excellent effect upon inflammatory
processes and the most generally useful of these is the 50 per cent.
solution of acetate of aluminium.
The following is a modified Burow’s solution:
Alum 24 gms., or 6 drachms
Lead acetate 38 ” ” 9-1/2 ”
Water 1000 ” ” 2 pints
Filter after mixture has been allowed to stand for 24 hours.
Ointments are employed by many in the treatment of small areas of
inflammation; they are useful, though not as efficient as hot or cold
wet dressings. Over the unbroken skin, they can only act like a
poultice and should not be employed where infection exists. On clean
wounds they are unnecessary, but upon ulcers or wounds which show no
tendency to heal, such ointments as Peruvian balsam, 5 per cent., or
scarlet red, 4 per cent., are extremely valuable.
+THE PROCESS OF REPAIR+
+Regeneration of Tissues.+ The reparative powers of the tissues of the
human body are considerable, although not comparable with those of the
lower animals, in the lowest orders of which the reproduction of an
entire limb, or even one-half of the body, may take place. In order to
understand the regeneration of tissue, we must first consider briefly
the life history of the cells.
A cell consists of a mass of protoplasm, generally enclosed in a cell
membrane, and containing a nucleus and nucleolus. The nucleus
represents the most vital part of the cell protoplasm, and has a more
granular appearance than the latter. The nucleolus is a minute solid
spot in a nucleus, appearing to be more highly refractive.
+Cell Division.+ When the cell is quiescent, the protoplasm appears
evenly granular, but when it is stirred to active life, slender
twining threads can be traced in the nucleus, perhaps consisting of
one long thread twisted upon itself.
On account of their readiness to take up dyes used in staining, these
threads are called _chromatine threads_.
When the cells are about to divide, the chromatine threads are seen to
arrange themselves in a line across the center, called the _equator_
of the nucleus, forming a rosette or star shape, known as the _mother
star_. Some large granules then appear in the nucleus at points on
either side of this line, which are known as the _poles_ of the
nucleus. The loops of the thread are directed towards the poles.
Gradually these threads become arranged in radiating lines, converging
at the poles, and then break away from their former connections with
the equator, forming a _daughter star_ at each pole, a clear space
appearing at the equator. A constriction next appears in the now clear
equator, and the nucleus divides into two distinct nuclei.
Simultaneously with this division, or immediately following it, the
protoplasm of the cell body divides in the same place, and thus two
complete cells are produced. The chromatine threads lose their rosette
arrangement, and gradually become imperceptible as the new cell
returns to the quiescent state. This process of cell division is known
as _karyokinesis_ or _aryomitosis_.
In simple cells like the leucocytes, reproduction may take place by
simple fission, thus: a constriction appears in the nucleus and in the
body of the cell in the same line, and the two divide without any
visible protoplasmic changes. Such a simple mode of division does not
occur in the more highly specialized cells of various tissues. If the
karyokinetic action be not very vigorous, the nucleus may divide, but
the cell body remains intact, producing the cell with two or more
nuclei so commonly observed. Every cell reproduces its kind, spindle
cells producing connective tissue; epithelial cells epithelium; and
bone cells producing bone.
+Repair of Wounds and Healing by Apposition.+ When a wound occurs, the
cut edges immediately retract on account of the elasticity of the
tissues, and the gap fills with blood and serum. If no bacterial or
chemical irritant is introduced, there are no true inflammatory
changes. The divided blood vessels are soon plugged with coagulated
blood, which extends into the cut vessels to the nearest branch. The
capillaries around the seat of injury dilate slightly, the fixed cells
of the tissues become active, dividing by karyokinesis as already
described. The endothelial cells lining the divided blood vessels
multiply and take an active part in the process. In spite of the
congestion and the new cells produced, the reaction is much less than
that of inflammation. The new cells invade the blood clot, consuming
it and also any foreign matter, or any tissue which may have been
killed by the injury. From the loops of the occluded capillaries, at
the sides of the wound, spring buds of endothelial cells, becoming
thicker and then hollow as they extend, blood cells forming in them
and blood entering them also from behind. These advancing endothelial
tubes join with those on the opposite side of the wound, and thus the
new forming tissues are supplied with blood vessels.
It is said that new vessels are also formed by the pre-existing
lymph-spaces and by independent cells. Meantime the connective tissue
cells have been forming fibres across the clot and epithelial cells
over its surface, if skin or mucous membrane be involved in the
injury. The new vessels disappear, and the new connective tissue
forms the scar. This is the process of primary union in a wound in
which there is not a marked cavity or a loss of tissue on any of the
exposed surfaces of the body, and no matter how closely the edges of
such a wound may lie in contact, it can heal by no other method. Even
the closest apposition of the sides of a wound cannot prevent the
interposition of a thin layer of clot and the partial death and
absorption of a very thin layer on its surfaces. This is also known as
primary union.
+Healing by Granulation.+ When a wide gap has been produced by
retraction or by actual loss of tissue, healing takes place by
granulation, as it is called, a process which differs from that just
described merely in the fact that more tissue must be reproduced. The
outpouring of blood and serum, occlusion of the vessels, congestion,
multiplication of fixed cells, emigration of leucocytes, and
production of vascular loops and buds, goes on as before. As the
formative changes advance, small, round elevations of a rosy color
appear on the new surface, making it look like velvet. These rounded
elevations of the healing surface are called granulations.
They advance steadily on all sides, filling the gaping wound until the
level of the original surface is reached, the new tissue organizing
behind them, and contracting as it organizes, so that the space to be
filled is daily made smaller by this contraction as well as by the
production of new tissue. As the surface is reached, the epithelial
cells on the edges of the granulating area slowly spread over it, the
granulations generally projecting above the adjoining surface and the
epithelium growing over them as they contract again to their proper
level. The advancing line of epidermis is visible as a pink line,
gradually whitening with time.
CHAPTER V
+WOUNDS AND CONTUSIONS+
A wound is a solution of continuity or division of the soft tissues
produced by cutting, tearing, or compressing force. The classification
of wounds according to their causation or nature is as follows:
_Incised_—when resulting from a sharped-edged instrument.
_Lacerated_—when tissues are extensively torn or separated.
_Contused_—when resulting from a more diffused force, tearing
and bruising the tissues.
_Punctured_—when produced by a narrow instrument that causes a
wound deeper than its external surface is broad.
_Poisoned_—when some poisonous substance enters the wound and
causes local infection or constitutional disturbance.
_Gunshot_—when the injury results from firearms or powder
explosion.
+An Incised Wound+ is an injury which is produced by some sharp
instrument such as a knife, pieces of glass or metal, which divides
the tissues cleanly, producing no bruising or tearing. The pain is
usually sharp and burning, varying with the nature of the instrument
with which the injury has been inflicted. Hemorrhage is usually free.
+Lacerated Wounds.+ These usually result from machinery accidents or
from heavy bodies passing over the parts and are apt to contain a
considerable quantity of foreign matter ground into the tissues.
+Contused Wounds.+ A contused wound is one in which the edges and
surrounding tissues are bruised or crushed. External bleeding as a
rule is not excessive, although there is a great likelihood of
extensive subcutaneous hemorrhage. Sloughing and gangrene may occur.
+Punctured Wounds.+ The character of a punctured wound depends upon the
object producing it. If made by sharp instruments, such as knives,
swords, daggers, bayonets, or needles, their nature is similar to
incised wounds.
Unless organs of importance have been wounded, or unless active septic
material has been carried into the wound, healing promptly follows
after the withdrawal of the instrument which has caused the wound.
These wounds are usually deep when affecting the dorsal aspect of the
foot, being commonly caused by a falling instrument or tool. In the
plantar region they are of every degree of severity, from the most
minute puncture to perforation running between interosseus spaces and
passing through the dorsal skin. The most frequent punctures are those
caused by stepping upon needles, pins and tacks. These wounds are,
commonly, of no importance unless the foreign body is broken off or
entirely penetrates the foot.
If the patient is seen a very short time after this has occurred, the
surgeon may operate with some confidence of finding the offending
substance, but even here, if possible, it is an advantage to obtain an
X-ray picture, while in those cases in which a needle has long been
buried in the tissues, this is quite indispensable. It is well to
remember that in these cases the patients’ impressions us to the
location of the needles are most unreliable.
After a radiograph has been obtained, it is most important, if
anatomically possible, to make the incision at right angles to the
shaft of the needle. At least two pictures should be taken in order,
if possible, to obtain some idea of the depth at which the needle
lies. Even with all these helps, the procedure, simple though it may
at first appear, oftens turns out to be one of great difficulty,
necessitating a very extensive operation.
+Incised Wounds of the Foot.+ Incised wounds of the dorsal surface are
very frequently quite deep and often implicate the tendons, bones and
articulations, as they are most frequently inflicted by the fall of
some heavy tool upon the part, or by the inaccurate blow of an axe.
Wounds of slight importance need but the usual thorough cleansing out,
with or without suturing of the skin, according to the extent of the
incision.
If one or more of the tendons have been severed, the ends should be
approximated by catgut sutures. If extensor tendons are cut in the
neighborhood of the metatarsophalangeal joints, it is often necessary,
owing to considerable retraction of the distal end, to incise the skin
down as far as is needed, in order to secure the retracted end and
suture it. Failure to adopt this procedure permits a dropping of the
toe, converting it often into a regular hammertoe. When the tendon is
properly sutured, the toe must be placed for some days in a condition
of over extension, most easily secured by a bandage passed under it,
acting like a stirrup, the ends being fastened by several turns above
the ankle.
Incisions, implicating joints, are carefully cleansed by flushing the
joint with copious quantities of saline solution, and closing the
wound with very few stitches. Such injuries should be examined daily
and any sign of sepsis must be considered as an indication for
immediate removal of the stitches, followed by active antiseptic wet
dressings.
Cuts of the plantar surface are not often very extensive. They are
most frequently incurred in stepping upon some sharp instrument or
walking upon glass, especially while bathing.
+Contusions.+ A contusion or bruise is a subcutaneous laceration, the
skin above it being uninjured, as in the abdomen; or being damaged
without a surface breach, as in a part overlying bone, and blood
being effused. If a large vessel is damaged, hemorrhage is extensive.
An _ecchymosis_ (black and blue area) is diffuse subcutaneous
hemorrhage.
A _hematoma_ is a blood tumor or a circumscribed hemorrhage in the
tissues.
In a diffuse hemorrhage the coagulation of fibrin induces induration,
the serum and leukocytes are absorbed, the red blood cells
disintegrate, and the coloring matter is widely diffused by the tissue
fluids, and hemoglobin is changed into hematoidin which crystallizes.
In union with these chemical changes, color changes ensue, the part
being at first red and then becoming purple, black, green, lemon and
citron. The stain following a contusion is most marked in the most
dependent area.
A hematoma acts as an irritant, inflammation ensues around it and it
is encapsuled by embryonic tissue, which, by organizing into fibrous
tissue, forms a blood cyst and gradually absorbs the fluid blood, the
cysts contents becoming thicker and thicker. A fibrous scar may
remain, and a blood clot, with very much indurated surrounding tissue,
giving a hard edge, is noticed after bruises of the periosteum. If
serum is not absorbed, hematoidin forms and the fluid becomes clear. A
hematoma may suppurate, an abscess forming, but this rarely happens
except in drunkards, although it occasionally occurs in persons who do
not use alcohol.
+Symptoms.+ The symptoms are tenderness, swelling, pain, and numbness.
The pain may be severe, but rarely persists beyond the first
twenty-four hours. Discoloration appears quickly in superficial
contusions, but only after days, in deeper ones. Shock and loss of
function are present only after severe contusions. The swelling is
first due to blood and is soon added to by inflammatory exudation.
+Terminations of Contusions.+ Slight contusions terminate promptly by
resolution; the more severe may terminate in gangrene, inflammation,
abscess, fibroid thickening, hypertrophy of the tissues involved, (as
in the case of bone), chronic inflammations, and even malignant
growths, particularly sarcomata.
+Prognosis.+ The prognosis of contusions is a matter of every day
importance, and it is sometimes extremely difficult to prognosticate
accurately. The determining forces are principally the nature and
violence of the contusing force, the tissues and organs involved, and
the general condition of the patient. Even the injury of the tissues
that may be easily inspected, such as the skin, may be much more
severe than is apparent. In tissues of low vitality, such as synovial
membrane, cartilage and ligaments of a joint, repair is
proportionately delayed, whereas in highly vascular tissue it is more
rapid. Contusions of tissues that cannot be given physiologic rest,
such as the thoracic wall, and the respiratory muscles, respond less
promptly to treatment.
The general condition of the patient is an important factor in the
prognosis, the most favorable being vigorous adult life without
organic disease. Among the unfavorable general states are, the
extremities of life, the very anemic and the plethoric, the
tuberculous, the syphilitic, the diabetic, and like diatheses, while
in the rheumatic and the gouty, the slightest injury may be most
persistent. The starved, the overfed, the over-worked, the fatigued,
the alcoholic, and those exposed to extremes of heat and cold, are
unfavorably affected.
+Treatment.+ Slight bruises, favorably located, require no treatment.
The arrest of hemorrhage, thereby diminishing the swelling, pain, and
discoloration, is important. If the hemorrhage be from small vessels,
elevation, rest, and the application of ice are sufficient. Frequently
the application of pressure is indicated. Hemorrhage in deeper parts,
such as that occurring under the fascia of the thigh, is sometimes
best controlled by adhesive strapping. If the vessels are large and
the hemorrhage is rapid, it is sometimes necessary to make a free
incision and apply a ligature. Evaporating lotions or elastic pressure
by bandaging over absorbent cotton, may assist. If the hemorrhage be
in a joint causing immediate swelling, painful from distension,
prompt aspiration will give relief. This should only be resorted to
under the strictest aseptic precautions, as the conditions are
favorable for microbic growth. If the soft parts are so severely
contused as to jeopardize the nutrition, both bandaging and ice should
be withheld, and in some instances even warm applications are advised.
After the acute symptoms have passed, judicious massage may be most
helpful in securing early resolution. Restoration of the vasomotor
tone when impaired or lost may be greatly facilitated by douching with
cold and hot water alternately followed by massage. During the acute
stages, physiologic rest is important; the restoration of functional
use in severe cases must be tentative, guided by the response of the
tissue in the form of increased pain or swelling. These phenomena
should be avoided if possible. If hematomata be not absorbed they
should be aspirated and pressure applied before structural changes
take place, such as the formation of a membrane. If the latter occurs
and sufficient time has elapsed for the formation of definite new
tissue, aspiration may be followed by the obliteration of the sac.
Sometimes hematomata become so thoroughly and firmly organized and
gradually increase in size, that it is extremely difficult to
differentiate them from new growths. If pain and tenderness persist
for a long time, particularly, if there be a predisposition to
tuberculosis, especial care is necessary.
+Treatment of Wounds in General.+ Arrest hemorrhage, bring about
reaction, remove foreign bodies, asepticize, drain, coaptate the edges
and dress, secure rest to the part and combat inflammation.
Constitutionally, allay pain, secure sleep, keep up the nutrition and
treat inflammatory conditions.
+Arrest of Hemorrhage.+ To arrest hemorrhage the bleeding point must be
controlled by digital pressure until ready to be grasped with forceps;
it is then caught up and tied with catgut or aseptic silk. Slight
hemorrhage stops spontaneously on exposure to air, and moderate
hemorrhage ceases after the vessels are clamped for a time; an
injured vessel of some size must be ligated, even if it has ceased to
bleed.
Capillary bleeding is checked by hot water compresses. In bringing
about reaction from shock, raise the feet and lower the head, unless
this position causes cyanosis. At least place the head flat and the
body recumbent. Apply hot water bottles and hot blankets and give
hypodermic injections of ether, brandy, strychnine, digitalis or
atropin, or inhalations of amyl nitrate. Strychnine can be used in
large doses, one-thirtieth of a grain may be given every ten or
fifteen minutes, until three doses have been taken. If the skin is
very moist, atropin is indicated, alone or combined with strychnine.
Hot coffee, or other hot fluids, should be given by the mouth and
rectum, and mustard should be placed over the heart, spine and shins.
The use of hot and stimulating rectal enemata is very important. The
rectum may absorb when the stomach refuses to do so. Enemata of hot
normal saline solution are very beneficial.
+Enteroclysis.+ The tube is carried into the sigmoid flexure and the
injection is introduced so as to distend the colon. At times it may be
necessary to give an intravenous injection of saline solution in order
to overcome the shock. In order to prevent the suppression of urine,
it may be necessary to administer diuretics.
+Removal of Foreign Bodies.+ Remove with forceps, all foreign bodies
visible to the eye: splinters, bits of glass, portions of clothing,
dirt, etc.
In a lacerated or contused wound, portions of tissue injured beyond
repair should be regarded as foreign bodies and should be removed with
scissors.
+Cleaning the Wound.+ If the surface is hairy it must be shaved before
the scrubbing. An accidental wound is infected and must be well washed
out with an antiseptic solution. A clean wound, made by the surgeon,
need not be irrigated, in fact, irrigation with an antiseptic fluid
leads to necrosis of tissues, causes a profuse flow of serum and
necessitates drainage. If clots have gathered in a wound, they must be
removed, as their presence will prevent accurate coaptation of the
edges. In an infected wound, they are washed out with a stream of
corrosive sublimate solution. In a clean wound, they are washed out
with hot salt solution. If dirt is ground into a wound, as is often
seen in crushes, pour sweet oil into the wound, rub it into the
tissues, and scrub the wound with ethereal soap. The oil entangles the
dirt and the soap and water remove both dirt and oil. After the rough
cleansing, irrigate with corrosive sublimate solution. In some cases,
especially in bone injuries, it is necessary to scrape the wound with
a curet.
A granulating wound is treated the same as an ulcer and the treatment
is discussed under that chapter.
+Drainage, Closure and Dressing.+ Superficial wounds require no special
drain, as some exudate will find exit between the stitches and the
rest will be absorbed. A large or deep wound requires free drainage
for at least twenty-four hours by means of a tube, strands of horse
hair, silk, catgut or gauze. An infected wound must invariably be
drained. Good drainage largely compensates for imperfect antisepsis.
If capillary drains be employed, apply a moist dressing. Divided
nerves and tendons must be sutured. Close the edges with silk sutures
or silkworm gut if the wound is deep and tension inevitable. Catgut is
used for superficial wounds and for those where tension is slight. The
interrupted suture is, as a rule, the best. If the wound is infected,
dress with antiseptic gauze; with aseptic or antiseptic gauze if it is
not infected. A dry dressing absorbs wound fluids quickly and is less
likely to become infected. Change the dressings in twenty-four hours
or sooner if they become soaked with the discharge. After this, in an
aseptic wound the dressing need not be changed for days. If pus forms,
open the wound at once.
+Rest and Constitutional Treatment.+ In planning the treatment of wounds
the most careful consideration for securing physiologic rest should be
had. If at or near a joint, the parts both above and below should be
immobilized. In whatever part of the body, physiologic rest should be
secured as nearly as possible. If the wound be of the leg or foot, the
patient should be in the recumbent position, with the part elevated
and a splint applied. The factor of rest, next to that of cleansing
and dressing, is most important. Physiologic rest means not only less
pain, less reaction, but a more rapid and certain repair.
Under ordinary circumstances no special constitutional treatment is
necessary beyond that of securing good hygienic surroundings, easily
digested food, restricted at first, and free action of the bowels. If
there is great pain, opiates may be necessary, but here, as in other
surgical indications for anodynes, a minimum amount should only be
given. Usually rest, elevation, and relief of tension will be of
greater benefit than opiates. If there is great restlessness, a
bromide may suffice; if marked insomnia, one of the ordinary
hypnotics. Great restlessness, with excitement and occasional
delirium, without special evidence of pain or infective process, must
call attention to the possible development of delirium tremens from a
relatively slight injury (such as a crushed toe or a simple fracture),
as it may precipitate an attack in one who has been a steady drinker,
though perhaps not an excessive one. In such cases, in addition to the
ordinary therapeutic remedies, the regular administration of whiskey
should be advised.
+TOXEMIA, SEPTICEMIA, SAPREMIA, PYEMIA+
+Toxemia+ applies to the diseases in which one or more poisons are
present in the blood which are not necessarily of parasitic origin and
production.
The word poisons is here used in a broad sense to cover any substance
applied to the body, ingested, or developed within the body which
causes disease. It of course includes ptomains, leukomains, toxins and
sepsins.
Toxemia, according to this definition, would include the diseases due
to poisons not arising from parasitic invasion of the tissues and
fluids of the body, at times of vegetable and alkaloidal nature, such
as strychnine or morphine; of animal origin, such as the toxin of
snake venom, the ptomains of milk or shell fish; then again a mineral
such as arsenic or lead; and lastly the leukomains arising from
disturbed excretion and perverted metabolism and grouped under such
terms as intestinal or uremic poisoning.
+Septicemia+ may be defined as an acute febrile affection, characterized
by marked nervous, cutaneous and visceral manifestations, and due to
the introduction into the system of bacteria and their toxins from an
infected wound. It applies to diseases which present poisons in the
blood that are of parasitic origin, the parasite itself being either
present or absent in the blood. Septicemia, in strong contrast to the
definition of toxemia, would include diseases arising from the
invasion of the tissues and fluids of the body by animal or vegetable
parasites or their poisonous products.
+Symptoms.+ The onset, as a rule, is slow, beginning from 4 to 7 days
after an injury, with a chill, which is followed by fever, at first
moderate, but soon becoming high. The fever presents morning
remissions and evening exacerbations and may occasionally show an
intermission. When the remission begins, there is a copious sweat. The
pulse is small, weak, very frequent, and compressible; the tongue is
dry and brown with a red tip; the vomiting is frequent, and diarrhea
is the rule; delirium alternates with stupor, and coma is usual before
death; prostration is very great, and visceral congestion occurs; the
spleen is enlarged, ecchymoses and petechiae are noted, secretions dry
up, urinary secretion is scanty or is suppressed, and the wound
becomes dry and brown.
Blood examination detects disintegration of red globules and marked
leukocytosis. When a wound becomes septic, red lines of lymphangitis
are seen about it and there is enlargement of the related lymphatic
glands. No thrombi or emboli exist in septicemia. The prognosis is
bad, and in some malignant cases death occurs within 24 hours.
+Treatment+ is the same as for septic intoxication (see “_sapremia_”).
Antistreptococci serum can be used, but the value of this method is
doubtful.
+Sapremia+ may be defined as an intoxication due to the absorption of
dead saprophytes and their products (ptomains and toxalbumins).
+Symptoms.+ The disease sometimes begins with a chill, followed by a
marked rise in the temperature, but in most cases the latter is the
first evidence of the disease. The skin becomes cold and clammy, there
is marked prostration and sometimes diarrhea. When these
manifestations occur while a wound is present, they are ominous, and
the dangerous complications can be avoided if the dressing of the
wound is renewed and perfect antiseptic precautions are taken to
thoroughly remove all septic matter from its surface. The
constitutional symptoms often disappear of their own accord, when the
above has been done, unless the systemic intoxication has not already
advanced to thwart all endeavors. There is also a diminution or
suppression of the urine, and a blood examination shows leukocytosis.
+Treatment.+ The treatment is at once to drain and asepticize the putrid
area and to give large amounts of alcohol. Strychnine and digitalis
are useful. Purge the patient, and favor diaphoresis, using in some
cases the hot bath. Establish the action of the kidneys; allay
vomiting by champagne, cracked ice, calomel, cocain or bismuth. Give
liquid food every three hours. Feed on milk, milk and lime water,
liquid beef, peptonoids, and other concentrated foods. Use quinine in
stimulant doses. Antipyretics are useless. Watch for visceral
congestion and treat it at once.
The use of saline fluid by hypodermoclysis or by venous infusion
dilutes the poison and stimulates the heart, skin, and kidneys to
activity.
In sapremia the blood contains the toxins and dead saprophytic
organisms. In septicemia the blood contains both pyogenic toxins and
multiplying pyogenic organisms. In sapremia the causative condition is
putrid material lodged like a foreign body in the tissues. In septic
infection the tissues themselves are suppurating, and both bacteria
and toxins are absorbed by the lymphatics. Of course, septic infection
may be associated with septic intoxication or may follow it. The
symptoms of sapremia depend upon the amount of intoxication.
In septic infection, or septicemia, only a small number of organisms
may get into the blood, but they multiply rapidly. A drop of blood
from a man with septic infection will reproduce the disease when
injected into the blood of an animal; hence it is a true infective
disease. The wound in such a case is often small, and is commonly
punctured or lacerated.
+Pyemia+ may be defined as a condition in which metastatic abscesses
arise as a result of the existence of pyogenic bacteria in the
circulating blood, either free or contained in pus cells or thrombi.
+Symptoms.+ The symptoms of pyemia are a febrile movement with a severe
chill and a sudden marked rise in the temperature which lasts for a
few hours and passes off with profuse sweating. The chills recur every
other day, every day, or oftener. The general symptoms of vomiting,
wasting, etc., resemble those of septicemia.
The lodgment of emboli produces symptoms whose nature depends upon the
organ involved. If in the lungs, there is shortness of breath and
cough, with slight physical signs.
In a suspected case of pyemia, always look for a wound, and if this
does not exist, remember that the infection may arise from an
osteomyelitis.
Chronic pyemia may last for months; acute pyemia may prove fatal in a
few days.
+Treatment.+ The treatment is the usual supporting one that should be
employed in septic affections, and all suppurating focci must be
opened and drained as soon as detected. Every branch of the irregular
cavities must be opened and drained at the most dependent part, and
the sinuses must be treated to prevent pocketing. Serum therapy is
also indicated.
CHAPTER VI
+HEMORRHAGE+
+Definition.+ The escape of blood from the blood vessels in great or
small quantities, is called hemorrhage, and may occur either
spontaneously or because of injury.
+Spontaneous hemorrhage+ occurs in the organs and cavities of the body
as a result of constitutional diseases, such as tuberculosis,
syphilis, cancer, etc., in which erosion of tissue extends into
vessels. It is also a result of a constitutional tendency. Persons
with this, so called hemorrhagic diathesis, are known as hemophiliacs.
In hemophilia, uncontrollable bleeding may occur from trifling
injuries.
+Hemorrhage due to Injury+ may be classified as follows:
a—arterial
b—venous
c—capillary
(_a_) Arterial hemorrhage may be recognized by rapid, spurting jets of
red blood, occurring synchronous with the heart beat.
(_b_) Venous bleeding (from a vein) occurs as a steady even stream of
dark blood, not affected by the heart beat.
(_c_) Capillary hemorrhage is in the form of a steady stream oozing
from the raw surface of a tissue. The color is intermediary, as both
arterial and venous capillaries contribute to it.
+Nature’s Efforts to Control Hemorrhage.+ When an artery is severed,
the inner and middle coats immediately retract and curl up within the
lumen, partially closing up the cut end.
Blood has the property of clotting, if it comes in contact with
anything but the natural endothelial lining of the vessels.
The curling in of the inner and middle coats retards the escaping
stream and facilitates coagulation within the cut end of the vessel
now formed by the outer coat alone. When the hemorrhage is severe,
these processes are reinforced by an increased tendency to coagulate,
and by a weakened heart action.
+The Control of Hemorrhage.+ The object of treatment in every case is to
check the flow of blood, and, though death from ordinary wounds is
rare, yet the loss of much blood is weakening for a long time.
The principle on which we act in our efforts to permanently stop
bleeding, depends on the power which the blood has of clotting, or as
it is called, coagulating.
If by any means the blood can be made to “stand still” in a blood
vessel at the point of injury, it will clot, thus forming a plug which
prevents further escape.
In wounds involving only small veins or capillaries from which there
is no distinct jet of blood (capillary hemorrhage), pressure of the
thumb, a wad of sterile gauze intervening, will usually suffice in a
few minutes. Gauze dipped in hot water applied to such wounds, also at
times effects a stoppage of such bleeding. Often only tight bandaging
is necessary.
Bleeding from large arteries or veins can be controlled temporarily by
pressure directly over the wound.
Temporary control may also be obtained by digital pressure above or
below the wound, if in a leg or arm, depending upon whether the escape
is chiefly from a vein or an artery, for in any wound some of the
bleeding will be capillary. This method, or the application of a
tourniquet, will absolutely control bleeding in an extremity.
The pressure in arterial hemorrhage must be applied at a point nearer
the heart and in venous hemorrhage at a point away from the heart.
A tourniquet may be devised from a handkerchief, a piece of rope or of
rubber tubing wound around the limb and tightened just enough to
arrest the main stream; in addition, pressure exerted over the wound
will control whatever hemorrhage persists. Such a control can only be
temporary, as the arrest of circulation in an extremity below the
tourniquet for more than an hour or two might cause gangrene. However,
there is no great fear of this occurring, as some blood reaches the
parts through deep vessels.
Permanent control of such hemorrhages can only be effected by grasping
the severed vessels in the open wound with artery clamps, and then
ligating below the clamps with cat gut.
Deep-seated hemorrhages, in the abdomen or chest, can often be
controlled by pressure directly over the wound until an open operation
can be performed.
Deep pressure, with the fist upon the abdomen just to the left of the
vertebral column, will compress the aorta and greatly reduce the
escape of blood from any artery supplied by the descending aorta.
+Hemorrhage in Chiropody.+ For the chiropodist, bleeding is an annoying
and especially perplexing occurrence. The feet are the most
bacteria-laden part of the body; here are warmth and moisture,
congenial to bacteria, and a thick epidermis for their safe
concealment. When hemorrhage occurs, therefore, its proper control
along antiseptic lines is imperative.
The vessels severed are rarely of sufficient size to cause the escape
of blood in an actual stream, but rather as a rapid oozing. It is, as
a rule, capillary hemorrhage.
The methods for its control have already been described in this
chapter, and will always stop such bleeding.
In chiropodial practice, however, the degree of bleeding determines
the method of treatment, and, though the extreme may fall short of
actual danger, it still behooves the operator to control it
absolutely before dismissing his patient.
+Easily Controlled Bleeding.+ The degree of bleeding or slight oozing,
as it should be termed, incident to skiving a calloused surface, is
well controlled with styptics.
In employing these substances it should be borne in mind that they are
not usually antiseptic but, on the contrary, may harbor organisms
which may be transferred to the wound and cause infection. The
subsulphate of iron, commonly employed in the form of Monsel’s
solution, is usually employed because of its efficiency as a styptic,
and because of the fact that it is less irritating than others. It,
however, is not antiseptic and should be kept sterile and
uncontaminated by dropping it upon the wound directly from the bottle,
rather than by dipping the cotton-wound applicator into it, as is so
frequently done. Even this does not prevent an originally sterile
bottle of solution from becoming contaminated, exposure to the air,
when the stopper is removed, admitting many bacteria each time.
A superior styptic has been supplied in the form of dry subsulphate of
iron fused to small sticks of wood. These are efficient because of
their cleanliness, each being used but once and at no appreciable
expense.
It is needless to say that the dressing of even so slight a wound
should prevent the admission of infection to the thousands of portals
of infection which are present. A bandage is not indicated nor
justifiable, and the cotton collodion cocoon suffices.
+Persistent Bleeding.+ When bleeding occurs which does not yield to the
effects of a styptic because of its constant washing away when
applied, it becomes necessary to apply pressure to the wound.
Frequently a wad of cotton or gauze, pressed firmly upon the bleeding
area, will almost stop the bleeding in a few minutes, after which it
becomes possible to apply the styptic. Should this, however, be found
impossible and the bleeding resume when the pressure is released,
clotting in the vessel can only be expected by the agency of either
ligation of the tissue or any individual vessel or more commonly by
tight bandaging. The latter procedure usually accomplishes the control
of the hemorrhage incident to a deep dissection for papilloma or
verucca.
A pad of several thicknesses of sterile gauze is placed upon the wound
and held in place by a few turns of narrow bandage, applied quite
tightly. Though blood may be seen to “spot” through this dressing, it
should occasion no alarm unless the hemorrhage has been clearly either
venous or arterial. Under such circumstances the spurting, either
constant or intermittent, will give immediate evidence of its
character. Active hemorrhage of this nature may yield to tight
bandaging, but ligation of the vessel should be done.
+Venous or Arterial Bleeding+ requiring ligation may be easily dealt
with, and every chiropodist should be equipped with a small artery
clamp with which to grasp the tissues; he should also be provided with
sterile catgut, sizes 0 or 00, with which to ligate a bleeding vessel.
+Antiseptic Precautions.+ In dealing with hemorrhage of even the
slightest degree, it should be remembered that portals of entrance for
bacteria upon the feet require every antiseptic precaution, both as to
the treatment of the wound, and as to the instruments and dressings
which come in contact with it.
For open wounds the U. S. P. tincture of iodin, diluted in water to
one-half strength, is antiseptic and not extremely irritating.
Instruments dipped in pure phenol and dried on sterile gauze are
rendered sterile and may be safely employed.
Dry sterile gauze in the dressing of a clean surgical wound is all
that is necessary. Healing in the absence of infection will be prompt.
The habitual use of ointments and wet dressings should be
discountenanced, except in the presence of a real indication.
CHAPTER VII
+BURNS, FROST BITE, ETC.+
Among the causes of burns are: steam; hot water; melted glass, wax,
rubber, sugar; molten metal; red-hot metal; gas and flame; burning
wood, paper, clothing; electricity; X-ray; ultra-violet ray;
chemicals; acid sulphuric, trichloracetic acid, common lye; alkalis;
carbolic acid; iodin; croton oil, mustard, cantharides.
From these various causes there is very little difference in symptoms,
course, pathology, and treatment. The molten lead burns are usually
small in area, but of the third degree. The underlying tissues are
often devitalized, especially around the feet, making a deep, pale,
slow-healing ulcer. The same is true of many burns from electricity.
The effects of X-ray burns are only seen after several days or weeks
and stubbornly resist treatment. Ultra-violet ray burns may not show
any effects at first, but develop symptoms in about six hours,
sometimes accompanied by great pain. Such burns may be due to sunburn
or powerful electric light.
The epidermis contains no blood vessels, but the mucous layer has
lymph spaces between the cells, draining into the lymph spaces and
channels of the dermis. Nowhere in the body are nerves more abundant
than in the skin. Here we have nerves of motion to the muscles of the
skin; nerves of pain, temperature, and touch; forming an intricate
plexus of nonmedulated fibres sending their branches upward into each
papilla, and even to the mucous layer of the epidermis. Vasomotor
nerves supply the coats of most blood vessels of the skin, and trophic
nerves are everywhere controlling the nutrition of each part. When it
is considered what a complex organ the skin really is; how delicately
its parts are adjusted to the body; how extremely sensitive its nerve
supply, slight stimuli bringing responses and causing reflex action in
far distant organs; how many the uses of the skin (protection,
excretion, expression, and sensation in various forms), it can readily
be understood how great is its importance, and the far-reaching
results of its serious injury.
Burns are classified into three degrees: first, second and third. In
every burn there are two layers of tissue to be considered: _first_,
the layer destroyed—the dead flesh; _second_, the layer injured—the
sick flesh.
+BURNS OF FIRST DEGREE+
+Pathology.+
(1) Destruction of the cells of the horny layer.
(2) Injury of the cells of the mucous layer with an excess of
lymph. No blistering.
(3) Congestion of the subpapillary plexus with some
destruction of the hemoglobin.
(4) Closing of the ducts of the sweat and oil glands.
(5) Slight edema of the underlying dermis.
+Clinical Stages.+
1st stage—hyperemia and pain.
2nd stage—edema.
3rd stage—peeling and staining the skin.
4th stage—cells of the horny layer replaced by pushing upward
of cells from stratum lucidum.
BURNS OF THE SECOND DEGREE
+Pathology.+
(1) Destruction of cells of horny layer and sometimes of the
germinal layer.
(2) Great exudation of fluid composed of lymph, fibrin, and
broken-down cells in the lymph spaces of the mucous layer, forming
blisters.
(3) Intense swelling and congestion of the papillary layer.
(4) Swelling of the connective tissue and elastic fibres in the true
skin.
(5) Thrombosis in some superficial blood vessels.
(6) Leucocytes poured out around the blood vessels.
+Clinical Stages.+
(1) Stage of blistering, edema, dermatitis, toxemia, pain,
chill and shock.
(2) Discharge or absorption of contents of the blister with
shedding of dead layers of epidermis.
(3) Reproduction of cells of the mucous layer from those of
the germinal layer, which have formed the floor of the
blister.
+BURNS OF THE THIRD DEGREE+
+Pathology.+ Charring of the whole skin through the reticular layer, or
deeper. It may involve only skin, or include any underlying
structures, fascia, muscles, blood vessels or bone. The essential
feature is the total death of hair follicles, oil and sweat glands,
with consequent destruction of all germinal epithelium.
+Clinical Stages.+ (1) Stage of destruction of tissue with underlying
inflammation. If extensive, this degree of burn causes shock, probably
non-toxic. During the early stage there is apt to be great pain from
injury to the nerves in the sick layer, but not so great as in that of
second degree burns where the number of injured nerves is greater.
(2) The general effects (toxemia, blood changes, embolism, congestion
of vital organs with resultant chill and shock) are probably little
different from those in extensive burns of the second degree, as few
burns are purely third degree burns, but if extensive they have also
large areas of second degree burns.
(3) Stage of sloughing. During this stage the second degree portion of
the burn passes through its various stages and heals. The dead tissue
shows at its edges a line of cleavage from the surrounding living
skin. The slough is usually slow in coming away, owing to the
direction of the connective tissue and elastic fibres which bind it to
the underlying structures. This last stage lasts from one to three
weeks. The process is more rapid in infected burns and the depth of
this burn will depend upon the degree of heat to which the part was
subjected, the length of time the heat was applied, and several other
factors. The danger of infection is always great owing to: (a)
presence of dead tissue; (b) the low resistance of adjacent sick
tissue; (c) the open veins and lymph channels; (d) the adjoining skin
which is difficult to sterilize; (e) the discharge of a large amount
of serum which forms an excellent culture medium. There may be also
severe hemorrhage as in any sloughing wound. The danger of this is
greatly increased by infection, which breaks down the thrombi in the
veins and arteries.
+Stages of Granulation.+ The cavity left by the slough rapidly fills
with new granulations. These have a tendency to rise above the
surrounding skin.
+Stage of Epidermis Covering.+ If skin grafting is not done, the new
epithelium can be renewed only from the edges—a slow process often
requiring months to cover the whole surface. Coincident with this
stage is the stage of cicatrization. The granulations which fill the
space left by the slough soon begin to contract—nature’s effort to
fill the gap. The granulations are irregular and abundant and for this
reason the scar resulting from a burn is irregular, uneven, inelastic,
contracted, distorted, protuberant and disfiguring.
+Duration.+ First degree burns get well in a few days; those of second
degree, in about from seven to fourteen days, and the healing of the
third degree burns depends upon their extent and depth, severe ones
requiring a very long time. As to scarring in a burn of the third
degree, you can always predict it, although this can be minimized by
early skin grafting.
+Treatment.+ The local treatment is to be directed toward the limitation
of the resulting inflammation; the prevention of septic infection;
assisting the normal elimination of the eschar; the development of
granulations and limitations of the deformity.
In burns of the first degree little or no treatment may be requisite;
a mild dusting powder such as boric acid or sodium bicarbonate may be
used, or picric acid in the strength of from half to one per cent.; a
5 per cent. boric acid ointment is also to be recommended.
Burns of the second and third degree require a different treatment.
Suppose we are called to treat a severe burn of the second or third
degree and find the patient suffering agonizing pain with oncoming
shock and a chill. At once administer a hypodermic of one quarter to
one half a grain of morphine; 1-40, to 1-20 grain of strychnine; and 1
to 1-100 or 1 to 1-50 grain of atropine. To stop the pain and combat
shock, have the room warm, clear it of unnecessary furniture; order
hot water bottles, and, if necessary, give a hypodermoclysis or a
Murphy enema.
In a severe burn three things are more important than the local
treatment: (1) to stop the pain; (2) to combat shock; (3) to provide
for dilution and elimination of the toxins, which are thrown into the
blood.
After having carried out the instructions given above, then proceed to
do the local dressing. The clothing should be carefully cut away—never
pulled off, or dragged over the burned area. A burn is at first
sterile, and we must try to keep it so. Unless we believe that it has
become infected through dirty handling, or by having had dirty
clothing dragged over it, or a dirty blanket laid on it, it is best
not to wash the burn. Pieces of gauze of necessary size are now spread
thickly with an ointment and applied somewhat beyond the burned
areas; over this cotton, and over all a bandage.
The patient is now put to bed, and if shock continues, the normal salt
solution is repeated every eight hours and the patient is given plenty
of water to drink.
Nourishment for the first three days should be liquid, on account of
the intense congestion of the alimentary tract Food is gradually
increased according to conditions. There should be the usual care of
the bowels, skin and kidneys, but in our zeal over the local
treatment, we should not forget that we have to care for a patient
whose blood is loaded with toxins, and whose lungs, stomach, kidneys,
and other organs are congested and filled with emboli. At first, dress
the burns daily, gently wiping away the discharge of serum and broken
down cells, which is poisonous and irritating, with dry gauze or
cotton. Blisters are opened and pieces of loose skin removed with
sterile scissors or forceps, but all skin is left in place as long as
possible to protect the underlying, new forming skin. Every dressing
should be made with a septic care: clean hands, clean gauze and clean
instruments. As soon as the slough begins to form, if there is much
odor, it is well to apply a continuous wet dressing (see later
reference). In case of a burn caused by carbolic acid, the skin is
neutralized by the use of absolute alcohol (95 per cent.). In burns
from trichloracetic acid, use alkaline remedies as sat. sol. of sodium
bicarbonate. Burns from caustic alkalies are neutralized by vinegar or
by some other mild acid such as boric acid. A so-called X-ray burn is
not a burn at all; the observable results of such an accident are not
manifested until several days or even several weeks after the
application of the rays, at which period an inflammatory or a
gangrenous process arises, which begins within the deeper tissues and
subsequently involves the surface. These burns are often accompanied
by loss of hair or of nails in the damaged area; they frequently
remain unhealed for months; if they heal at all, they are very
painful, and are not improved by the treatment which relieves
ordinary burns. In some cases the consequences are very serious.
Ambrine is a newly proposed remedy.
+Effects of Cold.+ The more serious effects consequent upon exposure to
sudden or prolonged cold are termed _frost bite_. In this condition
the feet are commonly affected, and very often the freezing is so
complete that upon thawing, the parts are found to be absolutely dead
or their vitality so impaired by the cold that after reaction,
strangulation and inflammation of the tissues occur, producing
gangrene. As in burns there are three degrees of freezing, viz.,
first, second and third. In the first, the redness, numbness and
tingling which follow exposure to intense cold are succeeded by loss
of power, usually commencing in the toes, and loss of sensation, the
parts becoming anemic and cold. In the second degree the skin is red
or bluish and is covered by blebs with clear hemorrhagic contents. If
the epidermis only is lifted up there is quick, scarless healing, but
in the majority of cases the deeper tissues are involved. In frost
bites of the third degree there are blebs and crusts which eventually
mortify. Parts hopelessly frozen are at first anemic, cold and
insensible but after reaction sets in they become swollen and
discolored or they shrivel up and contract. It is not unusual for the
part to show no change for some days and then to become blue or black;
a line of demarcation forms and the dead tissue sloughs off.
+Treatment.+ Reaction must be gradual. The room should be of low
temperature; the affected part should be immersed in ice water; gentle
friction or rubbing lightly with snow is oftimes efficacious. When the
temperature is normal, stimulating friction with soap liniment,
alcohol, and water and spirits of camphor with elevation of the parts,
is advisable. The room may be gradually warmed and the parts exposed
should then be covered with cotton. As reaction progresses warm,
stimulant drinks may be cautiously administered. If excessive reaction
takes place, evaporating lotions of alcohol and water may be used.
Where a large surface is frozen, prolonged immersion in a bath may be
employed after reaction has been established. When gangrene is
present, surgical intervention is imperative.
+Chilblain+ occurs in individuals with a feeble circulation or in the
anemic or strumous, though healthy young people are not immune. The
feet are very often attacked, especially the heel and the borders of
the feet, but any of the peripheral parts may be affected. The areas
are bluish or purplish red, swollen, cold to the touch, tender,
itching and burning. Neglect and friction will produce severer grades
of inflammation, with vesicles, bullae, pustules and ulceration or
even gangrene, with or without the formation of bullae. There may be a
favorable termination or fatal septicema may supervene.
+Treatment.+ This should be preventive by protecting the feet, wearing
warm clothing, by exercise, and the administration of tonics. Local
immersion of the affected part in hot saturated solution of alum
relieves the venous congestion and the itching. In severe cases,
heating too rapidly, or overheating, should be prevented so as not to
restore a too rapid reaction. A strong faradic current, ten minutes
thrice daily, or the electric bath, ten to fifteen minutes daily, is
beneficial. In ordinary cases, balsam of Peru or 10 per cent. ichthyol
ointment, rubbed in, is all that is required. When there is
ulceration, antiseptic dressings should be applied.
CHAPTER VIII
+FISTULAE; FISSURES; SINUSES; ABSCESSES; FURUNCLES; ULCERS+
A +Fistula+ (pl. fistulae) is an abnormal communication between the
surface and an internal part of the body, or between two natural
cavities or canals. The first form is seen in a rectal fistula, the
second in vesicovaginal fistula. Fistulae may result from a congenital
defect and can arise from sloughing, traumatism and suppuration.
Fistulae are named from their situation and communication.
A +Fissure+ is a crack and in podiatry, has special reference to a
condition found in the toeweb.
A +Sinus+ is a tortuous track opening usually upon a free surface and
leading down into the cavity of an imperfectly healed abscess. A sinus
may be an unhealed portion of a wound. Many sinuses may be due to pus,
burrowing subcutaneously. A sinus fails to heal because of the
presence of some irritant fluid (as saliva, urine) or, because of the
existence of some foreign body, as dead bone, a bit of wood, a bullet,
a septic ligature, or because of rigidity of the sinus wall, which
rigidity will not permit collapse. The walls of a tubercular sinus are
lined with a material identical with the pyogenic membrane of a cold
abscess. Sinuses may be maintained by want of rest (muscular
movements) and by general ill-health.
+Treatment.+ In treating a fistula, remove any foreign body; lay the
channel open, curet, touch with pure carbolic acid, and pack with
iodoform gauze. In obstinate cases, entirely extirpate the fibrous
walls; sew the deeper parts of the wound with buried catgut sutures,
and approximate the skin surfaces with interrupted sutures of silkworm
gut. Fresh air is necessary; nutritious food and tonics must be
ordered.
+Acute Abscesses.+ An abscess may be defined as a circumscribed cavity
of new formation, containing pus. An essential part of this definition
is the assertion that the pus is in a cavity of new formation; is an
abnormal cavity; hence pus in a natural cavity (pleural or synovial)
constitutes a purulent effusion, and not an abscess, unless it is
encysted in these localities by walls formed of inflammatory tissue.
An acute abscess is due to the deposition and multiplication of
pyogenic bacteria in the tissues or in inflammatory exudates.
When abscesses form in an internal organ or in some structure which is
not loose like connective tissue, for instance, in a lymphatic gland,
a mass of pyogenic bacteria floating in the blood or lymph, lodges,
and these bacteria, by means of irritant products, cause coagulation
necrosis of the adjacent tissue and inflammatory exudation around it.
The area of coagulation necrosis becomes filled with white blood
cells, and the dry necrosed part is liquefied by the cocci.
Suppuration in dense structures causes considerable masses of tissue
to die and to be cast off, and these masses float in the pus.
An abscess heals by the collapse of its walls, and the formation of an
abundance of granulation tissue; in many cases granulations of one
wall join those of the other side, the entire mass of granulations
being converted into fibrous tissue, and this tissue contracting,
heals by third intention. If the walls do not collapse, the abscess
heals by second intention.
+Symptoms.+ The symptoms of an acute abscess may be divided into (1)
local, (2) constitutional. Locally there is intensification of
inflammatory signs; swelling enormously increases; the discoloration
becomes dusky; the pain becomes throbbing, and the sense of tension
increases; the cutaneous surface is seen to be polished and edematous,
and after a time, pointing is observed and fluctuation can be
detected. The constitutional symptoms are usually limited to chills
and fever, depending upon the severity of the infection.
+Treatment+ is free incision and drainage. The wound should be opened
early, if possible even before pointing or fluctuation, to prevent
destruction, subfascial burrowing, and general contamination; drainage
is continued until the discharge becomes scanty, thin and
seropurulent.
+Chronic Abscess+ is a term referring only to time. Usually a tubercular
abscess is designated as a chronic, cold, or scrofulous abscess. It is
an area of disease produced by the action of the tubercular bacilli
and is circumscribed by a distinct membrane. The symptoms present no
inflammatory signs. Constitutional symptoms are trivial or absent
unless secondary infection occurs. The treatment of these cold
abscesses depends upon their location.
+A Furuncle or Boil+ is an acute and circumscribed inflammation of the
deep layer of the skin and the subcutaneous cellular tissue, following
on bacterial infection of the hair follicle through a slight wound (by
scratching, shaving), with the staphylococcus pyogenes aureus.
+Symptoms.+ The symptoms of a boil are as follows: a red elevation
appears, which stings and itches; this elevation enlarges and becomes
dusky in color, a pustule forms that ruptures and gives out a very
little discharge which forms a crust; inflammatory infiltration of
adjacent connective tissue advances rapidly, and the boil in about
three days consists of a large red, tender, and painful base, capped
by a pustule and some crusted discharge. In rare instances, at this
stage, absorption occurs, but in most cases the swelling increases,
the discoloration becomes dusky, the skin becomes edematous, the pain
severe, and the centre of the boil becomes raised. About the seventh
day rupture occurs, pus runs out, and a core of necrosed tissue is
found in the centre of a ragged opening. The hair follicle and the
sebaceous gland, which have undergone necrosis, are found in this
core. Healing by granulation will occur; the constitution often shows
reaction during the progress of a boil.
Boils may be either single or multiple, and the development of one
boil after another, or the formation of several boils at once, is
known as _furunculosis_.
+Treatment.+ The treatment consists of crucial incision and the
application of a wet dressing.
+An Ulcer+ may be defined as the loss of substance due to necrosis of a
superficial structure, and the causes of ulcers may be divided into
(1) predisposing and (2) exciting. In the former, age, sex, occupation
and social condition have to be considered. The exciting causes are
traumatism and infection.
The chief varieties of ulcers seen on the leg and foot are as follows:
indolent or callous; varicose; tubercular; syphilitic;
epitheliomatous; diabetic; perforating and blastomycotic.
In indolent or callous ulcer, the cause may be divided into general
and local. Among the former may be mentioned typhoid fever, chronic
nephritis, anemia, poor hygiene, improper food, overwork, and lack of
sleep. Local causes: old scar tissue, extremes of heat or cold,
irritation of the tissues, injury, the presence of a foreign body such
as dead bone, splinter, etc.
+Symptoms.+ The most common location of these callous ulcers is on the
inner side of the lower third of the leg. They show a great variety in
size, shape, appearance and base, edges and surrounding area, and in
accordance with these differences, many different names are applied to
them. The size varies from a small ulcer less than one centimeter in
diameter, sometimes found with varicose veins, to the large
ulcerations which surround the leg and are called _annular_ ulcers.
The shape may be round, very irregular, or funnel shaped. The base may
be much or slightly depressed, or the granulations may be at a higher
level than the surrounding edges. When the granulations are large,
irregular, and bleed easily, they are spoken of as _exuberant_; when
pale, soft and flabby, as _weak_ or _edematous_; when small and slowly
growing, as _indolent_.
A peculiarly painful form of chronic ulcer is found over the internal
malleolus, and most frequently in women of middle age; it is often
associated with menstrual disorders and is known as a _congested_ or
_irritable_ ulcer. It begins as a small area of congestion over the
internal malleolus, which gradually increases in size and becomes dark
and more dusky in the centre, due to the deposit of blood pigment
caused by chronic congestion. The skin next becomes hard, dry, scaly
and pigmented, while the subcutaneous tissues lose their elasticity,
becoming inflexible, hard and adherent to the deeper structures. Then,
as a result of slight traumatism or even without injury, the centre of
the area breaks down and an ulcer develops. It may be circular or
irregular in shape and may be quite deep or superficial. The edges are
sharply cut, and both base and edges are bound down to the deeper
tissues. The intense pain of the ulcers is supposed to be due to
pressure upon the terminal nerve filaments in the dense sclerotic
tissue. This form of ulcer is very often difficult to cure and shows a
tendency to return after healing.
+Treatment.+ This naturally depends upon the time the ulcer is seen and
the conditions present. If there is considerable inflammation,
accompanied by marked cellulitis and pain, the milder wet dressings,
such as boric acid or Thiersch are indicated. Rest, of course, is the
most important factor. The patient must be prohibited from walking,
and if necessary, the movements of the neighboring joints must be
prevented by the application of suitable splints. After the acute
inflammatory symptoms have subsided the granulations must be
stimulated, (see Chapter XIX).
+Varicose Ulcer.+ To chronic ulcers of the leg associated with varicose
veins, especially of the smaller venous radicles, the name varicose
ulcer has been given.
+Symptoms.+ The usual development of this variety of ulcer is as
follows: persons who suffer from varices of the leg usually complain
for some time before the external manifestation of the disease, of a
deep aching pain in the limb, with a sense of weight, fullness, and
fatigue. In a more advanced state of the disease, the ankles swell
after a day’s hard work, and the feet are constantly cold; an
embarrassed state of the circulation is denoted by these symptoms and
the deep seated veins begin to swell. After a time, which varies with
the idiosyncrasy and occupation of the patient, small soft, blue
tumors are seen at different points of the leg, most of them
disappearing on pressure, but returning when this pressure is removed
or when the patient stands up. Each little tumor is caused by a vein
dilated at the point at which it is joined by the intramuscular
branch. Around many of these tumors a number of minor vessels of a
dark purple color are clustered, these being the small superficial
veins which enter the dilating vein and in which the varicose ulcer is
often of a brownish blue color, due to a deposit of pigment.
Frequently a leg, which is the seat of varicose veins, or which is
edematous from other causes, is attacked by acute eczema. The
recognition of varicose ulcers is usually easy but the mere presence
of enlarged veins, it should be noted, is not pathognomonic, because
they may often exist along with ulcers of other origins, tuberculous,
syphilitic, etc.
The surface of varicose ulcers usually presents imperfect and
unhealthy granulations, secreting a more or less thin and offensive
pus, and the granulations are sometimes covered with membranous
exudation. The edges and base are thickened and callous, and enlarged
veins, capillary or otherwise, are present near the circumference and
often amount to genuine blood tissue which tunnels the infiltrated
tissues. In examining such an ulcer one gets the impression of a great
pigmented scar, the centre of which has broken down.
Lymphangitis and venous thrombosis are not of infrequent occurrence in
connection with varicose ulcers, while embolism and even pyemia are
sometimes in evidence. Among the most frequent complications is
cellulitis, and this may sometimes be so severe as to necessitate
operation. Erysipelas may also occur in cases of varicose ulcer, and
hemorrhage is a common and serious complication and has at times been
fatal.
+Differential Diagnosis+
CALLOUS VARICOSE SYPHILITIC
_History_:
injury varicose veins or syphilis.
phlebitis.
_Situation_:
where the injury usually in lower usually upper
occurred. third of leg. third of leg, posterior
aspect.
_Base_:
shallow, bluish, pigmented dirty, sloughing,
inflamed, often granulations, deep, often
grayish yellow. sluggish, greenish in color.
usually superficial.
_Edges_:
not elevated or undermined or punched out thin
thickened. thickened space, and undermined
very irregular. shape, round or
serpiginous.
_Surrounding area_:
red and inflamed. pigmented, varicose dusky red, scars
veins, often of old syphilitic
edema and eczema. ulcers.
_Healing_:
rapid under support of veins, mercury and
antiseptic operate and remove iodides necessary,
treatment. veins. salvarsan
or neosalvarsan.
+Treatment.+ The treatment of varicose ulcers must be based on
antiseptic cleanliness, and the improvement of nutrition by
improvement of the circulation of the blood and lymph. Then again the
treatment will vary according to the time when the ulcer is first seen
by the surgeon. In aggravated ulcers, especially those accompanied by
crusts, foul smelling discharges and various inflammatory conditions,
the leg should be washed once or twice daily with soap and water,
cleansed with a piece of sterile gauze, and shaved when necessary.
Warm applications should be employed such as Wright’s solution, boric
acid; Thiersch and the stronger antiseptics are uncalled for, as they
often induce eczema. Under such treatment, in most cases, the swelling
and irritation will subside and the ulcer will become clean and more
healthy in appearance, especially if the patient be confined to bed
with elevation of the limb. Rest always seems to the patient a useless
waste of time, but in reality time is thus saved. It is by far the
most important point in the treatment of ulcers of the leg in which
poor circulation is a factor, but the plan must be carried out
consistently in order to obtain the best results. The condition does
not admit of occasionally walking about the house or of sitting in a
chair. However, when circumstances do not permit of the recumbent
position, the veins can be supported in various ways. Bandages of
plain rubber, or rubber cloth, or cloth woven and rendered elastic by
the character of mesh, or elastic stockings, or flannel, gauze, or
muslin bandages, can be used. It is preferable to use flannel bandage
(see Therapeutic measures) for the reasons mentioned. The best means
of obtaining the support, however, is by the use of Unna’s Paste. The
technic and application of this method of treatment has also been
described (Therapeutic measures).
Operations upon varicose veins are frequently called for in aggravated
cases, provided the general condition of the patient permits. Briefly,
these many consist in multiple ligations, in ligation of the internal
saphenous alone, in extirpations of large or small sections of
varices, in circumcision of the skin above the ulcer, or of the ulcer
itself, tying all the veins and reuniting the cuticle. However, it
must not be forgotten that in the presence of an ulcer, infection of
an operative wound is likely to occur.
+Syphilitic Ulcers+ may result from pustules or they may begin as
tertiary sores. They occur frequently where the integument is thin or
where the part is kept moist by the natural secretions. The deep
ulcers of tertiary syphilis develop from gummata. These are variously
sized deposits largely made up of large spheroidal cells and a few
giant cells. They are poorly supplied with blood vessels and undergo
coagulation necrosis, but do not tend to suppurate until infected.
Sooner or later the overlying skin becomes involved, either with or
without a pyogenic infection, and the gumma sloughs out leaving the
typical syphilitic ulcer. A protozoa microbe (Schaudinn’s and
Hoffmann’s organism) is now the recognized cause of syphilis. It is
called the _spirochaeta pallida_ or _treponema pallidum_.
+Symptoms.+ When a syphilitic ulcer develops it usually assumes one of
two types, superficial or deep. The former may appear comparatively
early in the disease. It usually varies in size from a quarter to a
half dollar piece, has a circular outline, sharply cut, indurated
edges, and a dirty greenish base. The deep ulcers result from the
breaking down of gummata. They are, at the beginning, surrounded by a
reddened area of inflammation, the small ones being crater like, with
punched out edges, the larger ones having overhanging, thin, soft,
inflamed edges. The base is indurated, of a dusty red color and dirty
or sloughing in appearance, the slough being often of a greenish
color. The discharge is thin, frequently bloody, and contains debris
from the broken down gumma. The surrounding skin is indurated, of a
dusky red color and dirty or sloughing in for some time, they loose
their characteristic appearance and take on the form of simple chronic
ulcers. The scar remaining is characteristic. It is thin, of a dead
white color, pigmented here and there, and when pinched it wrinkles
like tissue paper. Thin form of syphilitic ulcer is found most
frequently on the upper third of the leg. When ulcers are accompanied
by enlarged veins, it is extremely difficult at times to make a
differential diagnosis between a luetic ulcer and one of a varicose
type. The chief differential points are as follows:
_Location_:
Varicose ulcers, the lower third of the leg.
Syphilitic ulcers, the middle and upper third of the leg.
_Appearance_:
Varicose, irregular, not undermined, granulations reddish.
Syphilitic, typical punched out edges, sharp, and undermined,
greyish discharge, thin and watery.
_Number_:
Varicose usually single.
Syphilitic, multiple, having a tendency to coalesce and form
one large ulcer.
A very important point to remember is that a syphilitic ulcer, once
healed, usually remains so. At times it is extremely difficult, even
in view of the different points already mentioned, to make a distinct
diagnosis between a varicose and a syphilitic ulcer; then the
Wasserman reaction should be resorted to, but too much stress should
not be placed upon its findings. It may happen that a patient having a
suspected luetic ulcer is given mercurial treatment with the result
that the reaction is negative, but this should not exclude the
possibility of syphilis existing. A positive Wasserman in a case of
chronic ulcer with enlarged veins which refuses to heal, warrants a
diagnosis of a syphilitic lesion. In a great many cases the Noguchi
luetin skin reaction is of great aid in establishing a diagnosis.
+Treatment.+ The treatment is both local and general. As regards local
treatment, if the ulcer secretes freely, either the black wash or a
solution of bichloride, varying from 1 to 5000 to 1 to 10000 should be
employed. Where there is very little discharge, calomel powder is
indicated. In addition, it is understood that a firm compression
bandage be applied (especially in those cases complicated with
enlarged veins) beginning at the base of the toes and carried up to
the knee.
The general treatment consists of the intravenous injection of
salvarsan or neosalvarsan (10 grains), or the intramuscular injection
of bichloride of mercury, one quarter of a grain, or 10 minims of a 10
per cent. suspension of salicylate of mercury. In addition, mercurial
rubs and the administration of iodides and mercury internally are
advised.
+A Tuberculous Ulcer+ usually results from the bursting through the skin
of a tuberculous abscess. The base is, soft, pale and covered with
feeble granulations, and gray shreddy sloughs. The edges are of a dull
blue or purple color and gradually thin out toward their free margins,
and in addition, are characteristically undermined, so that a probe
can be passed for some distance between the floor of the ulcer and the
thinned out borders. At times the edges are solid and puckered, being
scarlike in character. Thin, devitalized tags of skin often stretch
from side to side of the ulcer. The outline is irregular, small
perforations often occur through the skin and a thin watery discharge
containing shreds of tuberculous debris escapes. The ulcer is usually
superficial and very little pain is present. At times it is crusted
over, the crust being thin and of a brown or black color. Again it may
be progressing at one point and healing at another. It is slow in
advancing but often proves very destructive. The scars left by its
healing are firm and corrugated, but are apt to break down.
+Treatment.+ The local treatment calls for special mention. If the ulcer
is of limited extent, the most satisfactory method is complete removal
by means of the knife, scissors, or sharp spoon, of the ulcerated
surface and of all of the infected area around it, so as to leave a
healthy surface from which granulations may spring. If the raw surface
left is likely to result in cicatricial contraction, skin grafting
should be employed.
The general treatment should consist of tonics, plenty of fresh air,
and a good nutritious diet. Bowels must be regulated.
+Perforating Ulcer of the Foot+ occurs in connection with lowered
resisting powers of the tissues, due usually to some lesion of the
nerves or vessels. The ulcer is circular in shape, painless, with
callous borders, and eats progressively into the deeper tissues and
bones, and has little or no tendency to heal.
+Etiology.+ Although formerly looked upon as a specific disease,
perforating ulcer is now known to depend upon many local and general
conditions of which it is occasionally a more or less accidental
manifestation. The various theories as to its immediate causation may
be divided into: (1) mechanical, (2) vascular, (3) nervous, (4) mixed.
+The Mechanical Theory+ regards injury as the sole cause, due in most
instances to the pressure or rubbing of a shoe. If this explanation
were adequate, however, such ulcers would be extremely common, while
in reality they are rare.
+The Vascular+ theory assumes that arteriosclerosis is always present,
and causes ischemic necrosis through arterial and capillary
thrombosis.
+The Nerve+ theory, which is the one most commonly accepted, is that
perforating ulcer is always of trophic origin and depends upon a
chronic peripheral neuritis. In support of this assertion, attention
is called to certain interstitial and parenchymatous alterations
frequently demonstrable in the nerves of the affected part. It must
not be forgotten, however, that these nerve changes may be due to
secondary disturbances in nutrition, depending upon arteriosclerosis
as in senile, diabetic, and other forms of gangrene.
+According to the Mixed Theory+ either vessels or nerves, or both may be
at fault. It admits that traumatism is an important factor, although
seldom if ever an exclusive cause. Perforating ulcer is observed in
connection with various diseases and conditions, the most prominent
of which are locomotor ataxia, fractures of the spine, injuries of
the cord, diabetes, spina bifida, syringomyelitis and injury and
division of the peripheral nerves. Perforating ulcer from lesions of
the central nervous system is comparatively rare and it is doubtful if
it is ever due to embolism or to ligation of the arteries.
The three most prominent causes, therefore are, (1) affections of the
spinal cord (2) injuries of the peripheral nerves and (3) diabetes.
This variety of ulcer is seen more frequently in males than in
females, and it is almost exclusively confined to adults, especially
between the ages of forty and sixty. Occupations requiring standing or
walking are strong predisposing causes, provided a tendency to the
disease exists. A poor fitting shoe and deformities of the foot giving
rise to excessive pressure or irritation, are of much importance in
determining the appearance and location of the ulcer. It rarely
appears in children, unless it is associated with spina bifida.
+Symptoms.+ Perforating ulcer has a marked tendency to develop where
pressure and irritation are greatest, which is almost always upon the
sole of the foot at the junction of the great or little toe with the
metatarsus. It may occur, however, upon the heel, the sides of the
foot, the plantar surface of any portion of the great toe, or even
upon the centre of the sole, these unusual situations being most
commonly found associated with diabetes. When talipes or hammertoe
exists, the ulcer is apt to occur wherever pressure is pronounced,
even upon the dorsum of the foot or the ends of the toes. Usually but
one foot is affected, although both feet may be involved, in which
case the disease is termed symmetrical.
Three stages may be recognized in the development of the ulcer: (1)
the formation of callosities, (2) superficial ulceration, (3) deep
ulceration. Very frequently in tabes and in diabetes, a purulent
blister is the first indication of trouble, but usually a marked
epithelial thickening, in the form of a corn or a bunion, is the
initial symptom. Sooner or later the centre of a callosity breaks
down into a bluish, unhealthy, indolent, superficial ulcer, secreting
a small quantity of watery pus, and with an offensive odor. The sore
is circular as though punched out of the callous tissue, the latter at
times so thickened and overhanging that the ulcer is almost concealed
beneath it. There is little or no tendency to heal, even under
exacting treatment, and if recovery should take place, a speedy
relapse is the rule, even with the patient remaining in bed. The
indolent and foul ulcer tends to eat deeply into the adjacent tissues,
progressively involving bursae, tendons, muscles, joints, and bones. A
deep round hole results, which may even perforate the foot. The most
striking symptoms are chronicity, stubborn resistance to treatment,
and the absence of pain and tenderness.
The fact that perforating ulcer is so often found in connection with
lesions of the nervous system accounts for the abnormalities of
sensation, motion and reflexes which accompany it. This explains the
various trophic disturbances which are very often observed, such as
epithelial growth, not only in the vicinity of the ulcer, but
occasionally over the entire foot and leg; also eczema, erythema and
excessive perspiration. The nails are frequently thickened and
distorted and the subcutaneous cellular tissues are so changed as even
to suggest elephantiasis. Inflammatory complications, sometimes
serious, are not uncommon owing to infection through the ulcer, and an
ascending neuritis may even result in myelitis. Gangrene from
arteriosclerosis is also frequently seen.
+Treatment+ in those predisposed to diabetes and tabes, deserves
prophylaxis consideration. The shoes must fit accurately and without
undue pressure; much walking is to be avoided; when ulceration has
begun the recumbent position and cleanliness are of paramount
importance. The callous epidermis should be removed so as to render
the ulcer as superficial as possible. Dead bone must be scraped away
or extracted, if in the form of a sequestrum, and drainage must be
perfected by enlarging the opening. Sinuses should be enlarged and
any pockets found should be thoroughly opened. It must be emphasized,
however, that operative interference should be undertaken with care
and discretion in order to avoid necrosis and infection. Periodic
curettments and cauterizations with silver nitrate are often of
benefit, as are also the employment of dry iodoform gauze as a
packing, together with the occasional use of various moist dressings.
Both the constant and interrupted currents of electricity have been
resorted to with benefit, sometimes locally and sometimes applied to
the spinal cord or affected nerves. Measures directed to the
improvement of the circulation of the foot, such as massage,
stimulating baths, and lotions, are of service.
_Bier’s Arterial Hyperemia_, in the form of baking of the foot by
means of a gas or electric apparatus, especially devised for the
purpose (Tyrnauer) is of great benefit, more so when there is a
neuritis accompanying the ulcer. The baking should be done once a day
for from ten to twenty minutes, and the temperature should be
gradually increased from 100°F. to 300°F., depending upon the
patient’s ability to tolerate heat.
The passive, venous or obstructive form of hyperemia is absolutely
contraindicated in this class of ulcers. The initial cause of the
trouble must receive attention, because upon its successful management
depends the cure, much more so than upon the local measures.
Diabetics and syphilitics should receive appropriate treatment. The
bad cases, especially where gangrene or serious infection exists, may
require amputation, but unless this can be done in sound tissue with
adequate innervation, a perforating ulcer may develop upon the area
exposed to the pressure of an artificial limb. Resection of joints is
usually of little benefit. The most satisfactory operative results in
this class of ulcers have been obtained by stretching the posterior
tibial nerve, together with scraping the ulcer, or, better, by
excising it, followed by immediate suture of the wound. The operation
is best done through a curved incision beneath the internal
malleolus, the nerve being isolated and vigorously stretched in both
directions by means of some blunt instrument inserted beneath it.
Sometimes the external or internal plantar nerve alone is treated in
this manner.
+Blastomycotic Ulcer.+ This is not a common condition in the lower
extremity. It is found near the lower third of the leg, and begins as
a papule or papulo-pustule, soon becoming covered with a crust which,
on removal, discloses a papillomatous area. The typical ulcer is
elevated, verrucous or fungating, with a soft base which is
infiltrated with a seropurulent secretion. The border is dark-red or
purple and slopes more or less abruptly through the normal skin, from
which it is sharply defined. The quickest and most positive method of
differentiation is by means of the tissues. The organisms are fungi,
known as the blastomycetes, saccharomyces or yeasts, characterized
especially by their mode of multiplication or cell division, called
budding.
+Treatment.+ In all cases, thorough cleansing of the ulcer with
antiseptic lotions, as previously described, is of great benefit.
Complete extirpation of the ulcerative lesions has been successful,
but curetting does not always prevent their recurrence. Potassium or
sodium iodide in large doses (totaling from 100 to 400 grains per day)
and radiotherapy seem to be the most efficacious forum of treatment.
Copper sulphate in a 1 per cent. solution as a wash for external use
and also in one quarter of a grain doses internally, has in some cases
given good results.
+Epitheliomatous Ulcer.+ In none of the more common ulcerative skin
lesions would the conditions for the development of cancer seem to be
more favorable than in chronic dermatitis with ulceration; the
despised and neglected varicose ulcers of the leg. The extreme
chronicity of the inflammatory process, often lasting for many years;
the age of the patient, which is usually advanced; the almost
inconceivable neglect of the lesion in many cases, so that the
persistent presence of foul and decomposing secretion and of the
products of tissue necrosis is common: the frequent absence of even
an attempt at cure; the fact that most of these patients are compelled
to be on their feet all day and thus keep up and increase the
unfavorable conditions; and, finally the circumstance that in many of
them the added history of alcoholism, of renal or cardiac
disabilities, or of other chronic affections is also present; all of
these factors would lead to the presumption that in this ulcerative
lesion, above all others, carcinomatous degeneration would be the most
common.
While so few instances of cancer secondary to varicose ulceration are
seen, it rarely appears before the age of forty. It is usually seen
where varicose ulcers as well as the scars they produce are found. The
base of the characteristic ulcer is hard, nodular and irregular, made
up of firm warty granulations, and often covered with sloughs. It
bleeds easily and has a foul discharge. The edges are hard and
everted. The borders and base present a peculiar and striking
thickness and hardness, as though the ulcer were imbedded in
cartilage, while the granulations feel firm and appear red and warty.
The amount of pain, the involvement of neighboring lymphatic glands
and the rate of growth vary. Epitheliomata which have developed from
congenital warts, moles, or nevi are apt to be very malignant. When
epitheliomatous degeneration occurs in a chronic ulcer, it first
begins to get hard about the edges, which become everted and gradually
bound down to the deeper tissues. The granulations about the margins
become large, red, nodular, hard and bleed very readily. This
condition spreads over the entire ulcer, which assumes a sloughing and
foul character. The diagnosis is confirmed by the microscopic
examination of a section cut from the edge of the ulcer.
+Treatment.+ Malignant ulcer can be cured only by the destruction or
removal of the new growth. For its treatment, caustics with or without
curetting, excision or radiotherapy may be employed. The best caustics
are arsenic, chloride of zinc, caustic potash and formalin.
The objections to this method are the extreme pain; the lack of
certainty as to the removal of all of the neoplasm; the fact that the
lymphatics and glands are not dealt with, as well as the fact that
unless the treatment is thorough, the growth is stimulated rather than
retarded. The scar is also apt to be unsightly. Without doubt excision
forms the best method of treatment. The incision should be wide of the
ulcer, and all indurated tissues and any lymphatics or glands that are
involved must be removed.
In some cases it may be necessary even to amputate the leg in order to
effect a cure. The X-rays from the Coolidge tube are to be
recommended, as the cross fire effect of these rays in some cases is
of great benefit. Recently radium has been used in these ulcers of the
leg with good results. The gamma rays are to be preferred as they are
more penetrating and should be applied two or three hours a day for a
number of days. At least from 50 to 200 milligrams of radium bromide
must be used in order to obtain any effect. Recently beta rays have
been found to be as effective as the gamma rays. In order to prevent a
radium burn the rays have to be filtered before they are applied.
CHAPTER IX
+DISEASES OF JOINTS—THE SEROUS AND SYNOVIAL MEMBRANES+
The moist glistening membrane lining the abdomen (_peritoneum_) and
that lining the chest (_pleura_) are similar to the synovial sac
between the bone ends at joints or the synovial sheaths of tendons.
+Bursae.+ A bursa, which is a sac lined with serous membrane, placed
over a joint or other prominent part for protection, is also quite
similar. All of these membranes are smooth and moist, giving
lubrication to movable parts, thus: the peritoneum covering the
intestines, permits of their easy worm-like action within the abdomen;
the pleura makes for the free rise and fall of the lungs; the
_synovial sacs_ of joints allow the bones to ride smoothly one upon
the other; the _synovial sheath_ of a tendon acts like a silken sleeve
in which the tendon slides up and down and, lastly, pressure over a
bony point causes the member to move aside because of the slipping of
the walls of the bursa, one upon the other, when compressed.
+INJURIES AND DISEASES OF BURSAE.+
_Synovial bursae_ exist normally in connection with tendons or with
certain joints, and may be developed by continued friction or pressure
at certain parts of the body. Deep bursae are sometimes connected with
the joints, or are in very close relation with them.
+Injuries of Bursae.+ Wounds of bursae may be either contused, incised,
lacerated, or punctured, and, if they become infected, may prove most
serious injuries. Wounds of bursae should be thoroughly disinfected
and drained; they usually heal with obliteration of the sac.
+Acute Bursitis.+ This affection usually results from an injury or from
continuous irritation of a bursa, and is characterized by tenderness,
pain, redness of the skin, and swelling or distension of the bursa. If
suppuration occurs, the inflammation is apt to extend to the
surrounding cellular tissue, or, if in close proximity to a joint, the
latter may be involved. Bursitis can usually be diagnosed from other
affections by the rapidity of development of the inflammatory
symptoms, the location of the swelling in relation to certain tendons
or joints, and its globular shape.
+Treatment.+ This consists in elevating the part and putting it at rest
on a splint, and in the application of cold or pressure. If, however,
the pain and swelling due to effusion continue, and there is evidence
of suppuration, the bursa should be freely opened and irrigated, and
subsequently packed with sterilized or iodoform gauze. Under this
treatment the cavity soon becomes obliterated as healing occurs. The
bursae most commonly involved are the _prepatellar_ and that over the
metatarsal joint of the great toe.
+Chronic Bursitis.+ This affection may result from acute bursitis which
does not terminate in suppuration, or may develop slowly from long
continued irritation or pressure, or from tubercular infection of the
bursae and is accompanied by little pain.
The most marked feature in chronic bursitis is the distension of the
sac with fluid, and in some cases the walls of the sac become so
thickened that the bursa is converted into a solid tumor. Chronic
bursitis of the prepatellar bursae is not infrequent, and is commonly
known us _Housemaid’s knee_, resulting from long continued pressure
upon the knee occurring in those whose occupation causes them to
constantly bear pressure upon this part.
Gumma of the prepatellar bursa is very common, and should be suspected
in every case of suppuration of this bursa without assignable cause.
It often results in extensive sloughing.
Hernial protrusion of a portion of a bursa is sometimes seen after
injuries of bursae.
+Treatment.+ The treatment of chronic bursitis, if the sac is distended
with fluid, consists in removal of the fluid by aspiration, or by
making an incision and introducing a drain. The greatest care should
be observed to keep the wound aseptic. The bursae may be removed by
dissection. This is the only treatment which is likely to be of use in
cases where the bursa is very thick or is converted into a solid
tumor. In removing these growths by dissection, great care should be
exercised to avoid opening the neighboring joints.
+Bunion.+ This is a bursal enlargement over the metatarsophalangeal
articulation of the great toe, which is very frequently observed with
hallux valgus, this being the most universal cause. The part is
swollen and tender upon pressure, and if suppuration occurs the pain
is severe, and cellulitis is apt to develop, involving the surrounding
parts, or the joint may be involved, caries of the bones of the
articulation resulting.
+Treatment.+ If suppuration has not occurred, the part should be
protected from pressure by a circular shield of felt or plaster; if
suppuration has taken place, the part should be incised and drained,
and if the joint is found diseased it should be curreted and dressed
with an antiseptic dressing; if malposition of the toe exists, its
position should be corrected by amputation of the head of the
metatarsal.
+Inflammation of Synovial and Serous Membranes.+ When the serous and
synovial membranes are attacked by inflammation, the stage of
congestion is accompanied by exudation of serum and fibrin from the
surface, and the endothelial cells become swollen and detached in
large numbers. The serous exudation may be sufficient to fill the
entire cavity involved. There is a form of dry or fibrinous
inflammation, without fluid exudate, in which the surface of the
membrane loses its polish, becoming dry and red, and adhesions readily
form wherever the surfaces are in contact.
In suppurative inflammation, pus is produced by emigration, and also
by the detached endothelial cells. If fibrin is present, false
membranes form on the surface and the membrane itself appears to be
greatly thickened. At a later stage the proliferating cells invade
these layers of fibrin and they become organized into connective
tissue, and new vessels develop on them. Their tendency, however, is
to disappear after a time, and the membrane returns to its original
condition, unless the inflammation has been very intense, in which
case the new connective tissue becomes permanent. Chronic inflammation
of these membranes is marked by general thickening of all the layers,
the formation of dense connective tissue in the fibrinous membranes,
strong adhesions, and sometimes complete obliteration of the cavities,
their endothelial lining disappearing entirely.
+SYNOVITIS+
Like other structures of the body the joints are subject to injury and
disease and because of the nature and course of pathologic processes
in them, one should bear in mind their anatomic construction.
The expanded ends of the bones in the joints are covered with a thin
layer of cartilage and are bound to each other by a dense capsule
which is firmly attached to the bones at their necks, where it is
closely connected with the periosteum. The joint cavity is lined
(excepting where additional fibrocartilages are present) with a
synovial sac which sometimes communicates with a bursa.
Inflammations of varying intensity are of frequent occurrence; they
maybe due to rheumatism or gout, to traumatism, to the action of
microorganisms, or, to disturbances of innervation. They may be slight
or severe, acute or chronic. They may terminate in resolution, in
permanent new formations, more or less deforming and disabling, or in
the destruction of the articulation.
Inflammations may arise in the joint structures proper or may extend
to it from contiguous structures, such as the cancellous bone ends,
the overlying tendons or the periarticular connective tissue. They may
be largely confined to a single structure, the synovial membrane being
ordinarily affected, or they may involve the whole joint.
+Acute synovitis.+ Synovitis may occur as a result of a simple injury,
such as a subcutaneous wound, a contusion, or a sprain. Exposure to
cold and the presence of a movable cartilage are also common causes.
Aseptic conditions in the synovial membrane seldom extend to the other
joint structures (see “Arthritis”) and heal with or without impairment
of the joint, depending on the degree of inflammation.
+Symptoms.+ The joint is painful, especially upon motion, and
particularly so at night. It is swollen and tense and may be
fluctuating. At the knee, the patella is floated up from the condyles
and can be depressed upon slight pressure. The joint is held in a
position of partial flexion which permits of the greatest ease,
because of the diminished tension in this position.
Local heat and tenderness are not necessarily great, and
constitutional symptoms, if present, are moderate in degree.
In the suppurative affections of joints, all of the above symptoms are
intense and there is a general arthritis.
After a few hours or days the intensity of the symptoms subsides, the
pain lessens, the swelling diminishes, as the effusion and
extravasated blood are absorbed, the limb takes its natural position,
and recovery promptly takes place. If there has been much hemorrhage
into the joint, adhesions due to the organization of the clot may
cause some restriction of motion.
+Treatment.+ The joint must be placed at rest and an ice bag kept in
constant contact. Even pressure with cotton and broad bandages often
hastens absorption, but cannot at first be borne with comfort.
In rare instances aspiration of the effusion must be resorted to, but
the certainty should exist that absorption is impossible, before a
joint is punctured. The greatest care must be exercised in introducing
a needle into a joint to avoid infection.
+Chronic Synovitis.+ While it is true that an inflammation of a synovial
membrane cannot long remain without extending to the other joint
structures, the fact remains that symptoms peculiar to synovitis often
persist for months. These are properly viewed as constituting a
condition of chronicity. The active swelling and abundant effusion,
belonging to the acute stage, subside, but an undue amount of fluid
remains, with some pain and weakness.
If, with proper treatment and rest, these symptoms persist, there is
an extension of the process to the bone ends and an exacerbation of
symptoms.
The subsidence of a chronic synovitis generally leaves a weak and
impaired joint, though pain may be absent. Movements, especially in
extension, are restricted, and grating or cracking remain as evidences
of the roughened membrane.
+Treatment.+ The mere presence of a superabundance of fluid in a joint
does not in itself constitute a diseased state, but may be the
evidence of impaired circulation of the part. Absorption may occur
with rest and tight bandaging, or with massage, friction, and baking,
results may often be obtained. Certain cases resisting such procedures
are best treated with a plaster of Paris cast to immobilize the part
for several months. When the affection is of long standing and the
joint is much distended it may be termed _hydrops articuli_ or
_hydrarthrosis_.
When, in spite of all the methods of treatment here described, the
condition does not yield, very good results may be obtained by the
aspiration of the fluid, and the injection of a few drams of a three
per cent. or five per cent. solution of carbolic acid. This operation,
though simple, requires every aseptic precaution, and should never be
performed in the presence of any acute symptoms.
For other phases of Synovitis see Arthritis.
+ARTHRITIS+
The structures of a joint are: bone, cartilage, ligaments, synovial
membrane and, in some cases, fibrocartilage. Hence, a joint
inflammation is an inflammation of all of these structures, and is
designated, _arthritis_.
The inflammation may begin in any one of these structures, but sooner
or later, all are involved. The synovial membrane, however, when
inflamed, seems to prove an exception to the rule in that inflammation
may or may not extend from it to the rest of the joint. If such an
extension does take place we have an arthritis.
We may therefore have two distinct classes of joint inflammation: (1)
the varieties of synovitis, and (2) the varieties of arthritis. These
inflammations may be acute or chronic.
In synovitis there is only the inflammation of the synovial membrane,
while in arthritis there is inflammation of the synovial membrane plus
inflammation of the bone covering (_periostitis_); of the bone
(_osteitis_); of cartilage (_chondritis_); of bone marrow
(_osteomyelitis_); and also a cellulitis of the ligaments attached to
the joint involved.
+Symptoms.+ The symptoms of arthritis are obviously more severe than
those of a simple articular synovitis and are both local and general.
The general symptoms arise from the absorption into the circulation of
either bacteria or their toxins, and vary greatly in severity. There
is either a toxemia or a septicemia, with the usual symptoms of a
general sepsis.
The local symptoms are those common to synovitis and arthritis: pain,
tenderness, swelling, heat, redness and loss of function. From these
alone a differential diagnosis between synovitis and arthritis cannot
be made. If, however, there is a sensation of crepitus conveyed to the
examiner’s hand upon passive motion, there is an arthritis present
beyond doubt. This symptom is due to the destruction of the synovial
covering of the bone ends involved, permitting contact of bone with
bone. It is more common to chronic joint disease, but may also
accompany acute conditions, especially if they are severe.
Symptoms peculiar to the variety of infection and the history as to
duration, causation, course and number of joints involved, must be
considered in making a diagnosis or prognosis.
+Varieties.+ Besides simple traumatic arthritis, there are many
constitutional disorders which affect the joints conspicuously; these
are: tuberculosis, syphilis, gonorrhea, gout and rheumatism.
A prominent cause of many instances of arthritis heretofore regarded
as rheumatic in origin, is now known to exist in any area of
infection. Such “foci of infection” discharge a certain amount of
infective material into the circulation, which may find lodgment in a
joint and set up an acute process.
It has been proven in numerous cases that a so-called rheumatism will
yield promptly to drainage of a chronic abscess, no matter how remote
the location. Oral conditions especially have been found responsible
for this form of arthritis. Abscesses at the apexes of teeth and
pyorrhœa alveolaris, when properly operated, yield nothing short of
miracles, in the way of relieved symptoms.
In addition to the varieties of arthritis already mentioned, those due
to certain infectious diseases, such as measles, scarlet fever,
typhoid fever, smallpox or erysipelas, should be included, as well as
cases of neuropathic origin.
+TRAUMATIC ARTHRITIS+
+Nonpenetrating and Penetrating+
+Nonpenetrating.+ Ordinary contusions or twisting at a joint, may result
in the establishment of an inflammatory process within the joint,
evidenced by much swelling and giving the sensation of fluctuation to
the examining hands, indicating the presence of fluid within the
synovial membrane. This occurs also when there is a detached
fibrocartilage in the joint. The synovial membrane is thickened and
there is an exudation of serum.
Sprains belong in this classification. These are simple, clean,
inflammatory conditions.
+Symptoms.+ These are generally limited to those enumerated as belonging
to synovitis, except that the disability is more pronounced.
+Treatment.+ Rest and wet dressings generally suffice to effect
restitution in a few weeks.
+Penetrating.+ Should the joint be injured by violence so that there is
a loss of continuity of the tissues leading into the joint proper,
there is every probability of infective material gaining entrance.
These are serious accidents, though restoration of an efficient joint
is possible, but when improperly treated or neglected, local
destruction, or even loss of life may occur.
Penetrating wounds of joints usually occur in consequence of accidents
with firearms, sharp tools, or falling upon sharp objects. Frequently,
penetration of a joint follows suppuration in the immediate
neighborhood.
+Symptoms.+ The extent of the injury, the particular joint involved, and
the nature of the vulnerating body will affect the train of symptoms.
An escape of synovial fluid, pain and some swelling will occur even
with a very small penetration. Should the joint escape infection, the
synovitis quickly subsides and recovery takes place with little or no
impairment of the functional value of the part. The opening in the
capsule closes, the extravasated blood is absorbed and the synovial
surface is again smooth. If, however, the wound has been inflicted
with an unclean instrument, or if at any time before healing it
becomes septic, a very different and graver condition obtains.
+Septic Arthritis.+ Infection with bacteria of suppuration, chiefly the
staphylococcus albus or the streptococcus pyogenes, produces an acute
arthritis which frequently, despite the most careful treatment, will
result in the destruction of the joint, and not seldom in the loss of
life.
The infection may occur in one of several ways: (1) directly through a
dirty instrument, or the lodgment of infective material in the tract
leading to the joint cavity; (2) by the extension of a suppurative
process, either of the bones or soft tissue adjacent; or, by (3) the
deposition into the joint of infective organisms circulating in the
blood stream.
+Symptoms.+ However produced, large numbers of organisms are present and
a high grade of inflammation ensues. An abundant amount of pus is soon
formed; the synovial membrane, the bone ends and the joint capsule are
actively inflamed, and soon become disorganized. Perforation of the
capsule is followed by infection and suppuration of the tendons and
other structures about the joint, which soon affects the superficial
structures and forms an opening through the skin. The pain is intense,
generally worse at night; the swelling is great and fluctuation is
distinct; the skin is red and hot, and the parts above and below are
edematous. Any attempt at motion increases the suffering.
With these local symptoms there is an accompanying train of
constitutional symptoms which may eventuate fatally. At first there is
a chill, or a sensation of chilliness after which the temperature
quickly runs up several degrees, and either remains so, or goes down
and up several times in twenty-four hours, as in other septic
conditions. The pulse may be strong and full at first, but soon
becomes rapid and weak. In very acute cases, death from septicemia may
occur in a few days.
In ordinary cases, drainage of the pus, either naturally or
artificially, will result in a remission of the symptoms both locally
and generally.
+Treatment.+ In this, as in other suppurative processes, safety lies in
the prompt opening of the abscesses and the evacuation of the pus,
thus accomplishing free drainage, with subsequent disinfection by
means of applications or irrigations. Immobilization of the parts and
rigid antisepsis will generally yield good results as to life, though
recovery with ankylosis is the rule. In the most severe cases,
constitutional symptoms are so grave as to warrant immediate
amputation above the infected joint.
+Tubercular Arthritis.+ The great majority of chronic joint diseases are
tubercular in origin, the tubercle bacilli being deposited in any of
the joint structures, or in structures contiguous to a joint; with
children, very frequently in the bone substance.
Whether the tubercular process originates in the joint cavity itself
or outside of it in the surrounding tissues, destruction of the
articular ends of the bones is usual.
The parts become thickened and edematous; there is a gelatinous or
cheesy appearance, in which the membrane, cartilaginous bone ends,
capsule, and ligamentous structures all share. Frequently the synovial
membrane is studded with miliary tubercles and its cavity is filled
with an abundant serous secretion. The contour of the joint becomes
globular or spindle shaped, because of the atrophy of the parts above
and below it and the swelling of the periarticular structures. The
skin becomes white and thick because of the obliteration of the
superficial vessels and because of its edematous infiltration.
+Symptoms.+ Pain is, as a rule, but slight in the strictly synovial
stage of tubercular arthritis, but when the bones are involved, it is
severe, though acute symptoms, such as heat and redness, are lacking.
Deformity is a constant accompaniment of the disease; its degree is
greater or less according to the joint affected, the extent of the
disease, and the treatment pursued. It is due to the natural tendency
to assume the position of greatest ease; to the softening and
destruction of the ligaments, and to the effort on the part of nature
to immobilize an injured member by means of tonic contraction of the
muscles. These causes often result in the creation and persistence of
a malformation and malposition of the part.
Cheesy degeneration and liquefaction take place in more or less
degree, and though their occurrence is often not evidenced by any
aggravation of the symptoms, sinus formation with persisting discharge
occurs.
When these sinuses occur, they generally become infected with other
pus producing organisms, and aggravate the condition considerably. In
the course of months or years, many such openings may occur through
which masses of soft tissue or bone, either carious or necrosed
(_sequestra_), may be discharged.
+Diagnosis.+ This may be easy, difficult, or impossible, depending on
the duration, the joint involved, and the character of the disease in
any individual case.
At times it is impossible to differentiate from syphilis, which,
however, is quite uncommon, but with which tuberculosis has many
symptoms in common. The history of the individual, and a blood
examination will generally suffice. If the disease is advanced to the
stage of abscess and sinus formation, there can be no doubt as the
nature of the trouble.
Very often the disease in the articular ends of the bones advances
slowly, giving very little pain and no appreciable swelling or
atrophy. There may be only an unwillingness to use the part very much,
and the disease may very well be overlooked. In such insidious cases a
diagnosis can be reached by aspiration and subsequent examination of
the serous fluid for tubercle bacilli. An X-ray will show the
rarifaction of the bony structures and the thickened periosteum.
The course of tubercular joint disease is entirely dependent upon its
extent at the time it is recognized, and the treatment pursued. It is
of paramount importance that attention be given any persisting pain or
discomfort in or near a joint, and that rest and every diagnostic aid
be employed before pronouncing a case hysteria, neuralgia or “growing
pains.” In a few cases the process can be arrested and little or no
diminution of function remains. This, however, is the exception; there
is usually destruction of the intra-articular cartilages, and of the
synovial membrane, and the formation of bands of great density, which
impair the motion of the part even to rigidity (_fibrous ankylosis_).
The restriction of motion may be absolute if ossification of the
granulation tissue lying between the epiphyses unites their eroded
ends (_bony ankylosis_).
At times, though recovery seems to have been secured, a sinus may
persist because of some slight area of remaining caries, or because
the tract itself is tubercular. In other instances a recurrence may
follow after months or years of quiescence. This may be due to the
setting free of encapsulated organisms, or because of a new infection
at a point of least resistance.
+Treatment+ is that of tubercular disease in general. The most essential
features in the conduct of these cases are rest and the establishment
of ideal hygienic conditions. Forced feeding, sunlight and air, play
as important a part here as in pulmonary tuberculosis. Absolute rest
of the part can be secured only with the aid of plaster of Paris
braces, or splints of other materials. Such immobilization should
include the joints immediately above and below the one affected.
Hyperemia, by the use of a rubber bandage above the joint, or by
baking of the joint, is of great value.
In the majority of instances these methods will yield good results in
from six months to a year. Operative interference will be necessary in
addition to the above, where caseation and secondary infection have
occurred. Thorough drainage of the infected joint, either by widening
already existing sinuses, or by free incision followed by irrigation,
will frequently be necessary.
+Joints Generally Involved+ are the larger ones of the extremities, but
this does not preclude the possibility of any joint being the seat of
a tubercular inflammation. The vertebral articulations and the digital
articulations of the feet and hands are commonly affected. In
children, the hip joint is the one most attacked; frequently the knee,
ankle and elbow are affected in the order given.
In nearly all cases of arthritis of tubercular origin the original
focus of infection is located in the bone, though the synovial
membrane, or an adjacent osteomyelitis, may be the first point
attacked.
+Syphilitic Arthritis.+ This is rather a rare condition, but must be
differentiated from tuberculosis, because of its slow onset and
progress, and because of the mildness of the symptoms and the
spindlelike shape of the joint. There is usually but one joint
involved and eventually a dark fluid will escape should sinus
formation occur.
+Diagnosis+ will generally be known in advance from the history, through
a Wassermann test of the blood, or an X-ray picture will often be of
value.
In syphilis, the original focus of infection in a joint will be found
in the soft tissues, while in tuberculosis, the articular ends of the
bone are first involved. An examination of the discharged fragments of
tissue in syphilis will show a round cell infiltration; in
tuberculosis, possibly typical tubercle tissue.
+Treatment+ by anti-syphilitic remedies, if successful, will also
indicate the nature of an obscure case, a pronounced response to such
treatment being a positive diagnostic aid.
+Gonorrhoeal Arthritis.+ This affection is nearly always very acute,
beginning as an acute synovitis and extending to the articular
fibrocartilages at an early date.
Constitutional symptoms nearly always accompany this variety of
arthritis, a chill and high temperature being the rule.
This condition is often called gonorrhoeal rheumatism. It is due to
the lodgment of the gonococcus of Neisser in the joint, from the blood
stream.
Gonorrhoeal arthritis is a form of septic arthritis, its pathology and
symptomatology being in many respects the same. It may, in favorable
cases, limit itself to the synovial membrane, in which event the
symptoms will yield more readily to treatment, though the affection in
any event is an acute one, and a diagnosis as to extent is difficult
to make owing to the extreme pain of even slight motion.
+Symptoms.+ These are similar to those of septic arthritis, except that
usually only one joint is affected and the existence of a gonorrhoeal
infection can always be determined. Both knees, or both ankles, but
more commonly, only one joint, are affected, accompanied by severe
constitutional symptoms. There rarely occurs any indication of sinus
formation or of spontaneous drainage in this variety of arthritis, and
it is held by many, that in cases where this tendency exists, there is
a mixed infection, other pus producing organisms being present.
+Treatment.+ The original infection of the urologic tract must receive
the utmost care, in order to eradicate the supply of germs to the
circulation. The injection of anti-gonococcic sera or vaccines finds
its best application in these cases. The local treatment consists of
rest and immobilization of the extremity affected.
The application of either extreme heat or cold to the joint is
agreeable and efficacious.
There are many reasons in justification of either of these treatments
over the other, but in general it may be said that, in the acute
stage, cold is better, while in the latter stages, heat will
accomplish more to establish easy motion of the part and to lessen the
danger of ankylosis.
Active or arterial hyperemia by baking, is especially valuable in the
subacute stage.
+Prognosis.+ In those cases in which the pain and swelling is severe and
the constitutional symptoms alarming, we may always expect a true
arthritis to exist. In these cases much exudate is formed in the
joint, which upon organization, leads to fibrous bands and limitation
of the joint function (_fibrous ankylosis_).
In the milder cases, ankylosis is the exception, if proper remedial
measures are carried out.
+Rheumatic Arthritis.+ Rheumatic articular affections are common, and
are both acute or chronic. In the light of recent investigations it is
believed that many of these cases are due to foci of infection in
various parts of the body which pollute the blood stream with
organisms which subsequently find lodgment in either the organs or
joints. Infections existing in the tonsils and teeth roots have been
shown to act in this way. There may, however, be cases directly
attributable to rheumatism, though these are not so well understood.
+Acute Rheumatism.+ One or several joints may be attacked
simultaneously. Subsidence of the inflammation may occur, while others
are becoming inflamed.
+Symptoms+ are those of acute synovitis; suppuration never occurs unless
there has been a mixed infection, and limitation of motion is a rare
sequela. The pain, swelling and tenderness is extreme, and the
constitutional symptoms, while being severe are not usually grave. In
the _chronic variety_, on the other hand, there may be limitation of
motion due to the formation of bands and adhesions after months or
years of inflammation. This variety may start as such or may begin as
an acute condition.
+Treatment.+ The treatment, besides local rest and heat, consists of the
administration of antirheumatic remedies and hygienic precautions.
+Diagnosis+ will rest largely on the blood examination for circulating
organisms, the general examination for foci of infection, and the
family history.
+Gouty Arthritis.+ Whatever may be the essential nature of gout, its
manifestations are common in the smaller joints, such as the fingers
and the metatarsophalanges of the great toe. Deposits of urates,
chiefly sodium urate, take place in the connective tissue of the joint
and also in the cartilage. Consequent upon the irritation of these
salts, there is an increase in the connective tissue followed by
contraction, impairment of motion, and alteration in the shape of the
joint. Repeated attacks of acute inflammation occur, of greater or
lesser intensity, and the uratic deposits attain a considerable size,
occasionally forming abscesses or ulcerations in the overlying skin.
Like rheumatism, gout is a manifestation of a constitutional state,
and requires medical care.
+Infective Arthritis.+ These are the arthritic manifestations of
diseases as smallpox, scarlet fever, typhoid fever, measles and
erysipelas. They are due to infective material deposited from the
circulation, and are in every way similar to septic arthritis, which
see. There are always suppurative synovitis and osteomyelitis, with a
consequent ankylosis of bony structure. The constitutional symptoms
are very intense, and free incision and drainage is indicated.
+Neuropathic Arthritis.+ (_Charcot’s Disease_). This is a peculiar
osteoarthritis observed in patients with locomotor ataxia. The disease
is an acute one, so far as objective conditions are concerned, there
being no pain or constitutional derangements of consequence. Without
any injury having been received, the joint, particularly the knee,
suddenly swells, the intra-articular effusion becoming abundant. This
may soon be absorbed and with it the articular ends of the bones wear
away and break down into small fragments. The limb becomes atrophied
and shrunken, and the joint itself becomes weak, often flail.
This disease seems to be due to nutritive changes in consequence of
changes in the spinal cord nerve centres. There is no satisfactory
treatment and the patients must be kept in bed.
CHAPTER X
+DISEASES OF THE BONES+
+Congenital Defects of Bones.+ Various congenital deformities of the
limbs occur because of interference in various ways with the proper
and normal formation of these cartilaginous masses. If, for any
reason, the cause of which in most cases is not clear, any of these
cartilaginous masses fail to be formed in the embryonic tissues,
naturally no ossification can occur, and in such cases there may be a
partial or complete lack of development of the corresponding bone. The
amount of this congenital deformity may vary from the absence of an
entire foot, to the absence of one or several digits, or one or more
phalanges.
The deformities produced by such a failure to deposit the
cartilaginous base of the bones are very numerous, and in some cases
lead to great deformity and loss of function. This lack or increase of
the reformation in cartilage, results in most extraordinary
deformities.
No special type of deformity merits special attention; the condition
in each case must be decided by inspection and X-ray examination.
In many of these cases, especially where the lesion affects the
digits, the capability of the individual is but little impaired,
whilst in other cases, where bones are absent, marked deformity and
impairment of function may occur. Some of the cases, notably webbed
toes, are comparatively easily corrected; other cases however, offer
little chance of sufficient cosmetic or functional gain to make a
surgical operation necessary or desirable.
+Atrophy of Bone.+ Various causes may lead to atrophy of bone. The
method by which atrophy is brought about is peculiar, and is due to
the action of special giant cells, called osteoclasts. Wherever
extensive atrophy of bone takes place, microscopic inspection shows
such giant cells lying closely adjacent to the trabeculae of the bone
which is being resorbed, and the trabeculae in that immediate vicinity
slowly disappear under the action of these giant cells. Their action
is very similar to the action of giant cells in the soft tissues about
absorbable foreign bodies. This process is called _lacunar
resorption_.
In old people the amount of absorption oftentimes is very great; the
process is then termed _senile atrophy_. It may be marked in the skull
and in the long bones, and in many cases of fracture of the neck of
the femur, a moderate amount of lacunar resorption precedes the
fracture which results from slight violence. In certain cases this
resorptive process in old people is extreme, and leads to great
fragility of the bones, with repeated fractures from slight violence,
which under ordinary circumstances, would cause no injury at all.
A mere lack of use of bones may also lead to a certain amount of
atrophy from lacunar resorption. This may be seen after amputations,
where the stump of bone which is left from the amputation slowly
undergoes lacunar resorption and sometimes a marked diminution in
size. The same thing may also be seen in the bones of people who for
long periods of time have been deprived of the use of their limbs,
either by the application of apparatus around fractures, or by disuse
for other reasons.
Lacunar resorption also occasionally follows lesions of the central
nervous system, part of the atrophy being due to disuse of the limbs
from the paralysis, and part of it also being dependent in some
indirect way upon the nerve lesion.
Atrophy of bone also may be brought about by pressure. It is to be
remembered that the bone, as a matter of fact, is not a perfectly
rigid material, but that processes of new formation and resorption are
constantly taking place, even under normal conditions. If, for any
reason, bone is put under constant pressure, a certain amount of
readjustment of the bony constituents takes place in order to adapt
the bone to its altered condition. The most striking example of this
sort of atrophy is perhaps the Chinese ladies’ feet, where the bones,
being bent into an abnormal position, beginning early in childhood,
ultimately show enormous deformity and an entire rearrangement of the
trabeculae of the bone. The same thing also may be seen occasionally
after pressure and deformity from contracture of muscles or from the
pressure of scars. This process, which ordinarily leads to loss of
function, in a certain limited number of cases aids function, for
whilst certain fractures of the joints may lend to deformity of the
articular facets of those joints, by absorption of certain portions
and new formation in others, a readjustment of the joint surface may
take place, so that a marked increase of function may occur.
A certain amount of atrophy also may be brought about by the pressure
and development of tumors.
+Hypertrophy of Bone.+ In many cases new growth of bony tissue is due to
the new formation of periosteal bone, and is an expression of an
attempt at repair of one or the other of the numerous destructive
processes. In other cases true hypertrophy of the bone, with no
connection with any reparative process, may occur.
A notable example of this is seen in the growth of bone which
sometimes occurs after amputation, especially in young people. The
increased size of the bones which is seen in many definite diseases
will be mentioned under the proper headings.
+Caries and Necrosis.+ Various pathologic processes produce destruction
of bone. The destructive process may cause the death of large areas of
the affected bone at once, and in that case, a large fragment of
necrotic bone may remain in situ and still maintain its contour.
Destruction of bone of this sort is described by the clinical term
_necrosis_.
Other processes cause a gradual molecular softening and destruction of
bone, which ultimately may be very extensive, but at no time is there
present any appreciable large mass of bone. Destruction of this sort
is described by the clinical term _caries_.
As a means of differentiating clinical conditions, the use of these
two words is desirable. As a clinical term, _necrosis_ usually means
destruction by pyogenic infection, and _caries_, destruction by the
gradual extension of a tuberculous process. This clinical distinction,
however, is not an exact one, because destruction of large areas of
bone, described as necrosis, is occasionally brought about by
syphilitic infection, and rarely by tuberculosis, whilst molecular
destruction of the bone is brought about by a considerable variety of
processes, the chief of which, it is true, is tuberculous infection,
but actinomycosis and syphilis may both lead to the gradual
disintegration of the bone, without the formation of large necrotic
masses of bone.
The presence of necrotic bone connected with the surface of sinuses,
from which comes a discharge of pus, should always lead to the
consideration of tuberculosis, actinomycosis, and syphilis. The
presence of large sequestra of bone should immediately suggest the
presence of osteomyelitis or of syphilis.
+Treatment.+The details of the treatment of the various forms of
destructive processes in bone will be found under their special
headings, chiefly under osteomyelitis and tuberculosis.
In all cases of caries it is desirable to remove completely the
softened areas in the bone. This may be done by curettment and
drainage, or by excision of the entire bone, or series of bones, in
certain cases, or rarely by amputation.
The difficulty in all these cases is to recognize the exact limits of
the carious process. It must be borne in mind that at the time of
operation upon carious bones the field of vision of the surgeon is
almost always limited; moreover, the bleeding which always takes place
from the bone-marrow in such cases, also obscures the field, and even
if these two causes were not present, it is frequently extremely
difficult, by naked-eye examination to determine the exact limits of
the destructive process. As a general rule, it can be said that the
carious area is at least a quarter of an inch wider than appears upon
visual inspection.
In cases of necrosis with large bone defects, the difficult thing is
to cause a growth of the bone toward the central cavity after removal
of the sequestrum. The various methods applicable to such cavities are
mentioned in detail under “Osteomyelitis.”
+PERIOSTITIS+
+Acute Periostitis.+ The older text books always laid great stress upon
the occurrence of an acute infectious inflammation of the periosteum.
Acute suppurating periostitis alone does not occur, and most of the
cases which have been described as such are really mild cases of
superficial osteomyelitis, with abscess formation beneath the
periosteum, and possibly slight inflammation of the periosteum itself.
These cases ordinarily lead to only a slight destruction of the outer
layer of the cortical bone.
+Symptoms.+ These are the same as in
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