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diff --git a/41725-0.txt b/41725-0.txt index 9bd0ee1..7da4ce4 100644 --- a/41725-0.txt +++ b/41725-0.txt @@ -1,39 +1,4 @@ -The Project Gutenberg EBook of Surgery, with Special Reference to Podiatry, by -Maximilian Stern and Edward Adams - -This eBook is for the use of anyone anywhere at no cost and with -almost no restrictions whatsoever. You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at www.gutenberg.org - - -Title: Surgery, with Special Reference to Podiatry - -Author: Maximilian Stern - Edward Adams - -Editor: Maurice J. Lewi - -Release Date: December 28, 2012 [EBook #41725] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK SURGERY *** - - - - -Produced by Adam Buchbinder, Turgut Dincer and the Online -Distributed Proofreading Team at http://www.pgdp.net (This -book was produced from scanned images of public domain -material from the Google Print project.) - - - - - +*** START OF THE PROJECT GUTENBERG EBOOK 41725 *** +------------------------------------------------+ | Transcriber’s note: | @@ -13801,362 +13766,4 @@ CROSS REFERENCE INDEX End of the Project Gutenberg EBook of Surgery, with Special Reference to Podiatry, by Maximilian Stern and Edward Adams -*** END OF THIS PROJECT GUTENBERG EBOOK SURGERY *** - -***** This file should be named 41725-0.txt or 41725-0.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/4/1/7/2/41725/ - -Produced by Adam Buchbinder, Turgut Dincer and the Online -Distributed Proofreading Team at http://www.pgdp.net (This -book was produced from scanned images of public domain -material from the Google Print project.) - - -Updated editions will replace the previous one--the old editions -will be renamed. - -Creating the works from public domain print editions means that no -one owns a United States copyright in these works, so the Foundation -(and you!) can copy and distribute it in the United States without -permission and without paying copyright royalties. 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You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at www.gutenberg.org - - -Title: Surgery, with Special Reference to Podiatry - -Author: Maximilian Stern - Edward Adams - -Editor: Maurice J. Lewi - -Release Date: December 28, 2012 [EBook #41725] - -Language: English - -Character set encoding: ISO-8859-1 - -*** START OF THIS PROJECT GUTENBERG EBOOK SURGERY *** - - - - -Produced by Adam Buchbinder, Turgut Dincer and the Online -Distributed Proofreading Team at http://www.pgdp.net (This -book was produced from scanned images of public domain -material from the Google Print project.) - - - - - - - +------------------------------------------------+ - | Transcriber's note: | - | Bold words are enclosed within plus (+) signs. | - +------------------------------------------------+ - - - - -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 -pyorrhoea 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 acute osteomyelitis, except in a -very much milder form. There is usually a rise of temperature, -oftentimes with a chill, with circumscribed tenderness over some -portion of the shaft of one of the long bones. - -+Treatment.+ Incision over such an area shows an elevated periosteum, -with a small, localized abscess beneath it, with bare, white, somewhat -vascular bone cortex. Incision alone in most cases suffices to cure -the disease, although if the process has extended sufficiently deep -to cause a superficial necrosis of the outer layer of the cortex, -removal of a small sliver of necrotic bone may be necessary. - -+Chronic Periostitis.+ A long-continued and chronic irritation of the -periosteum, sufficient to cause a proliferation of the osteogenetic -cells of the periosteum, is common in a great many diseases. A chronic -thickening of the periosteum with a new formation of bone, is seen -frequently after traumatism, blows or contusions; sometimes after the -occurrence of superficial abscess of the soft tissues in the immediate -vicinity of the shaft of the long bone, described as chronic ulcer of -the surface of the tibia; or after certain infectious diseases, -notably syphilis. It also may occur after various other local -infections. In such cases the thickening of the periosteum ordinarily -is pretty sharply localized. - -A general thickening over the periosteum, and over several or many of -the bones of the body, also occurs in the disease known as _toxic -osteoperiostitis ossificans_, seen in diseases with long continued -suppuration. It also is common after syphilitic disease, either -congenital or acquired. - -+Symptoms.+ The symptoms of chronic periostitis with new formation of -bone are invariable. In a certain number of cases there is a constant, -heavy, dull pain, at the point of thickening, with at times more or -less acute exacerbation; at other times the lesion is associated with -no pain whatever, and the patient's attention is first called to the -disease by the presence of the enlargement of bone. Recognition of the -condition may depend upon X-ray examinations for indefinite pains in -or over the bone. - -Chronic periostitis is not really a disease itself, but a -manifestation of the reaction of the periosteum to some irritant. - -+Treatment+ of the condition depends, first of all, upon a recognition -of the cause and a removal of the cause, when possible. In many cases, -especially those in which no pain is present, nothing in the way of -therapeutic measures can be done. - -The chronic thickening of the periosteum, seen in many definite bone -diseases, will be mentioned under those diseases. - -+Osteomyelitis.+ Infectious osteomyelitis is acute suppuration of the -bone, always due to the infection of the bone marrow by pyogenic -microorganisms. The process is essentially like the process seen in -furuncle, and begins in the marrow of the alveolar spaces, which -communicate freely with each other, but are enclosed by a dense shell -of cortical bone. Hence the process may quickly at first involve the -entire marrow of an infected bone, because the products of bacterial -infection are retained in this dense shell, while the primary focus -can only be reached by extensive bone operation. - -Most cases are due to the staphylococcus pyogenes aureus and a few to -the streptococcus. Typhoid bacilli may cause suppuration. The -infecting organism is present in pure culture but sometimes a mixed -infection occurs, and such cases are said to be severe. - -In cases of chronic osteomyelitis with open sinuses and exposed bone, -a great variety of organisms, pathologic and saprophytic, may be -present. Hence infectious osteomyelitis is not a specific disease, but -is acute inflammation of bone that may be produced by any one of a -variety of pathogenic organisms, or by a mixed infection. - -Any pyogenic organism which can be carried in the blood may be -deposited in the bone and produce suppuration. Some of these organisms -may settle by preference in the bone marrow, others beneath the -periosteum, or in the joint. - -Certain general causes favor the occurrence of osteomyelitis. Children -are chiefly affected and it occurs in boys about three times as often -as in girls. Acute osteomyelitis frequently occurs after injuries of -moderate severity, because such injuries may lower resistance of the -bones and make them unusually susceptible to pyogenic infection. One -of the commonest causes is the infection of a compound fracture, and -before the days of asepsis, such cases were very frequently fatal. -Under modern methods the infection, when it does occur, is generally -slight, although the destruction of bone may greatly delay healing and -may lead to the formation of small sequestra and indurating sinuses. -Infection of a similar sort may occur subsequent to amputation. - -Osteomyelitis nearly always begins in the diaphysis of the long bones, -usually near the epiphyseal line. This is an important point, -clinically, because tuberculosis practically begins in the epiphysis. -In rare cases, however, osteomyelitis begins in the epiphysis, and so -may simulate tuberculosis. The femur and tibia are the bones most -frequently attacked, but no bone is exempt. Usually only one bone is -affected, but cases of multiple bone infections are not rare. - -The primary area of infection is always in the bone marrow. The bony -trabeculae and the cortex are destroyed only secondarily. The process -nearly always begins in the diaphysis, but then may extend into the -epiphysis and produce suppuration of the joint. Once the organisms -have gained access to the marrow, they produce a toxin which causes -necrosis of the adjacent marrow cells, and this necrosis may extend -over a very considerable portion of the bone before marked -infiltration with leucocytes occurs. The infection usually extends -quite early through the dense cortex by way of the Haversian canals, -and produces an inflammatory exudation and suppuration between the -periosteum and the outer layer of the cortex, which is designated -_subperiosteal abscess_. - -Such an abscess may strip the periosteum from the bone over very -extensive areas. The infection may then extend to the adjacent soft -parts, muscles and subcutaneous tissue, and form an abscess outside -the periosteum. - -If, from spontaneous opening of the abscess or from operation, a fatal -result is avoided, the infective process may be limited and the -process of repair may begin. - -As a rule, a portion of the infected marrow and cortex become -completely necrotic, and the lime-bearing portion of the bone -persists as a more or less extensive sequestrum. - -The periosteum in the early stages may be separated from the bone by a -collection of pus, and in such cases it appears as a thin fibrous -membrane beneath the muscles, separated from the bone by the abscess -cavity. - -Secondary changes occur in the soft tissues surrounding the seat of an -acute suppuration of bone. During the acute stage there may be a -definite abscess of the soft parts, with an infiltration which -simulates phlegmonous inflammation, or, by rupture of the abscess, -various sinuses may be formed leading down to the necrotic foreign -body. In long continued cases the skin and subcutaneous tissues become -thickened by the formation of scar tissue, due to the presence of the -involucrum and the persistence of sinuses, and by thickening of the -soft tissues, an affected limb may for years be nearly twice its -normal size. - -+Symptoms.+ The disease usually begins with a sharp onset, the first -symptom being a sudden localized pain in the vicinity of the -epiphyseal line, or in the shaft of some one of the long bones. This -pain is extremely intense, and in typical cases is most excruciating. - -Motion of the joints at this time is not painful, but the pain -produced by percussing the bone, even lightly, may be intense. An -extremely valuable diagnostic point is continued gentle pressure at -some point over the shaft of the bone at a distance from the point of -greatest constant pain. - -Usually, at a very early period, there appears swelling of the soft -parts about the bone. This swelling, at first, is neither hot nor red, -but soon becomes edematous, red, and shows pitting on pressure, and at -that time may simulate acute phlegmon. - -In some cases the adjacent joint early becomes tender, hot and -swollen, and this may occur even when there is no real extension of -the infectious process to the joint itself. If extension does occur to -the joint, swelling, tenderness, and pain on motion become more -intense. The temperature usually is elevated to a considerable -degree--103°F. or 104°F.--and usually the pulse is greatly accelerated. -Evidence of constitutional disturbance and absorption of infectious -material occur early. The tongue is dry, coated and tremulous; the -face is drawn and flushed. Delirium of a mild type is a very common -symptom, and in some cases this delirium may persist for a -considerable length of time after the bone has been drained. Abscess -of the soft parts may give deep or superficial fluctuation. Sinuses -may appear. The leucocyte count is usually very high--25000 to -35000, and chiefly of a polynuclear type. - -Such a clinical picture is perfectly distinct, and it is difficult to -overlook typical cases, especially after the fluctuation in the soft -parts has occurred. The diagnosis of early cases, however, is -sometimes very difficult, and even in the hands of experienced men, -who have the lesion in mind, is frequently impossible. Even in severe -cases, occasionally the pain itself is not severe for several days, -when there may come a sudden exacerbation of symptoms. - -In the chronic stages of osteomyelitis the symptoms are usually -characteristic. The limb is enlarged, the enlargement being partly due -to thickening of the soft tissues, but chiefly to the formation of the -involucrum. Usually running down to the sequestrum, are enormous -sinuses, from which comes a foul, purulent discharge. On passing a -probe, dead bone can be felt at the bottom of the sinuses. It must be -borne in mind, however, that in a great many cases, after attacks of -osteomyelitis of moderate severity, small localized abscesses are -formed in the shaft of the long bones, with no sinus communicating -with the surface. An abscess of this description, as has already been -stated, is always surrounded by a wall of dense bonelike cortical -bone. - -Such an abscess may persist for years with no symptoms beyond a -moderate enlargement of the shaft of the bone at the point of abscess, -and the enlargement may be so slight that it is not recognized by the -patient. In other cases the entire shaft may be enlarged, but the bone -may not be tender. In most cases, however, such a localized abscess -sooner or later gives rise to recurring attacks of pain, which, as a -rule, are extremely violent. The intervals between such attacks may -vary from days to weeks, or to months, or even to years. The attacks -of pain may come on, apparently, perfectly spontaneously. Associated -with these attacks of pain, the bone over the abscess usually is -exceedingly tender to touch. With the attacks of pain may come a rise -of temperature, or in some cases, there may be no disturbance of the -general condition. This kind of abscess may be of small size, no -larger than a pea, or may involve a great portion of the shaft of the -bone; in such abscesses no definite sequestrum may ever form. - -The recognition of such conditions depends upon recurrent attacks of -violent pain over circumscribed areas of bone, with or without -constitutional disturbance, and nearly always with extreme local -tenderness. - -+Treatment.+ In the acute stage there is suppuration of the marrow, more -or less extended throughout the shaft, with often a subperiosteal -abscess and perhaps abscess of the soft parts. - -The indications are the same as in any other acute suppuration; the -pus must be evacuated and the bone cavity drained. This demands not -only an incision into the soft parts, but an opening into the shaft of -the bone. If a piece of necrotic bone is present, it should be -removed. - -In the chronic stage there is usually an old necrotic shaft perforated -by sinuses, and often freely movable, inclosed by a shell of dense -periosteal bone. The sequestrum must be removed, but the bony defect -fails to heal, and for months persists as a filthy, discharging -cavity, with the constant danger of secondary infection and phlegmon, -or erysipelatous inflammation. The healing of this cavity is very -difficult and requires a very long time. - -Many methods have been tried for the filling of these bone cavities -with blood clot, iodoform and oil of sesame, but they have not been -successful, because it is almost impossible to render such cavities -absolutely aseptic. - -+Tuberculosis of Bone.+ Tuberculosis of bone is always dependent upon -infection of the marrow of bone by the tubercule bacillus. This germ -obtains entrance to the bone marrow and causes the formation of -miliary tubercules which arise from the proliferation of the -connective tissue of the marrow around the primary tubercule. Other -secondary tubercules are formed by extension of the tubercule -bacillus. The centres of these tubercules become caseous, and, by -fusion of adjacent caseous areas, also cause softening in the bone -marrow. - -The tuberculous process, as a rule, begins in the epiphysis in the -long bones, and may affect any of the bones. - -+Symptoms.+ In cases of tuberculous disease confined to the bones alone, -the first symptom usually is pain, which ordinarily is not severe and -has a gradual onset. Oftentimes, at first on palpation, no difference -in the shape of the bone can be detected. - -Toes affected by a tuberculous process, slowly enlarge at first -without heat or pain; ultimately the skin becomes thickened, and -reddened, and the digit is painful to pressure or motion. Oftentimes -the skin is perforated at one or more points by sinuses lined with -tuberculous granulations, through which caseous pus is discharged. - -The diagnosis in these cases always lies between tuberculosis, -actinomycosis, syphilis, and osteomyelitis, and exact determination of -the origin of the cause oftentimes can be made only by inoculating -animals with a discharge from the sinus, or by detection of pyogenic -organisms, or of the miliary tubercule, the histologic unit of -tuberculosis, or by detecting the peculiar yellow bodies seen in -actinomycosis. - -+Treatment.+ From a clinical point of view tuberculosis of bone should -be considered in the same category as malignant disease, and the -indications for treatment in all cases of tuberculous bone disease are -the same as in malignant disease; which is, complete removal of the -infected area, whenever it is possible. - -In some cases the mere opening and curetting of tuberculous areas in -bone is oftentimes enough to set up sufficient reaction in the bone -and in the surrounding tissues, to put an end to the tuberculous -process. Complete resection of bones may at times be avoided by this -treatment. - -In addition to the local treatment of opening, curetting and drainage, -or the complete excision of the bone, the greatest care should be -employed in the management of the general hygiene of the patient, -including feeding and fresh air. Often removal to a climate which is -unfavorable to the development of tuberculosis in general, is also -extremely desirable. - -+Syphilis of Bone.+ The lesions produced in bones by syphilitic -infection may be congenital or acquired, and, as in other syphilitic -lesions, the manifestations may be protean. - -Most children with congenital syphilis, show an irregularity of the -epiphyseal line, which results in the latter becoming markedly -toothed, instead of constituting a straight line across the bone, at -right angles to the long axis of the shaft. - -Besides the irregularity of the epiphyseal line, three other changes -are seen in the bones of syphilitic infection. The most common lesion -is one which affects the periosteum and leads to the formation of -periosteal bone. This periosteal formation may occur either in -congenital or in acquired syphilis, and it may affect one or many -bones. In some cases there is an enormous thickening of the epiphysis -of the bones, and as a result of the epiphyseal thickening, secondary -changes in the joints occur, so that the thickening of bones and the -changes in the facets of the joints, suggest fracture or dislocation. -In other cases, the thickening affects only the shafts of the long -bones, generally of the leg or arm, although no bones are exempt. In -some cases, both in the congenital and acquired forms, there may be -marked proliferation of the endosteum of the bone, with or without -thickening of the periosteum, although thickening of the periosteum -usually is present. This process, as a rule, affects one bone in its -entirety, and most commonly affects the bones of the lower leg, -notably the tibia. As a result of these changes the bones are enlarged -and thickened, and in some cases, from endosteal thickening, the -marrow canal is very largely or entirely obliterated. In some cases -true gummata of the bone are formed. These gummata may appear in the -spongy portion of the bone, sometimes in the shaft, or in the -epiphysis. They also appear to be formed in the lower layers of the -periosteum and lead to circumscribed nodular thickenings on the -surface of the bone. - -+Symptoms.+ These vary with the different pathologic conditions present. -The periosteal thickening may occur at any time of life over any bone -of the body. - -The presence of circumscribed periosteal thickening of bone in itself -should always lead to the suspicion of the presence of syphilis. - -Pain, as a rule, is only very slight, and the diagnosis depends upon -the history and the detection of other syphilitic lesions. - -The cases in which there is both endosteal and periosteal thickening, -occur chiefly in children and are of a congenital nature. - -The physical symptoms are very characteristic. The bone usually -affected is the tibia, which is enlarged to a most marked degree, and -often shows a pronounced bowing forward, similar to the bowing and -thickening of the tibia seen in osteitis deformans. The bone is -extremely dense and obviously heavier than normal. The bones are -moderately tender to pressure, but have nothing like the extreme -tenderness noted on pressure in osteomyelitic bones. - -In cases of gummata of bones the symptoms vary. In some cases the -gummata are on the surface of the bone, especially the sternum, and at -times on the long bones. In such cases there appear a softening and -reddening of the skin about the affected area, which remains indolent -for a long time. - -If such an area opens spontaneously, or is opened by incision, the -contents are seen to be composed of a yellow, rather gelatinous -material, quite like the caseous material from a tuberculous abscess. - -+Treatment.+ In most cases the regular anti-syphilitic treatment is -indicated. In cases of periosteal thickening, the results vary with -the time at which the treatment is begun. In the early cases, a -thorough anti-syphilitic treatment may lead, after a varying length of -time, to complete disappearance of the newly formed periosteal bone. -On the other hand, if the periosteal process has lasted for a long -time and the bone has become densely cortical, although -anti-syphilitic treatment may lead to a diminution of the localized -pain, the dense bone does not disappear. In cases of combined -endosteal and periosteal thickening, the pain usually disappears under -anti-syphilitic treatment but the changes in the bone persist. - -+Osteomalacia+ is an acquired disease which causes marked softening and -changes in the bones. The disease begins irregularly and often -progresses with or without remissions. The progress is more marked -during pregnancy. The first sign is pain in the bones, which is -increased by pressure, and this is especially true of pressure over -the ribs. There are also muscular cramps and contractures. - -+Osteitis Deformans.+ (_Paget's Disease_). This is a chronic disease of -the bones and may affect one or more bones of the body. The onset is -insidious, and before actual deformity occurs, long indefinite pains -in the legs may have existed, with occasional tender points over the -bone. - -The bony changes are first noticed in the bones of the legs and are -most marked in the tibia, femur and fibula. As a result of structural -changes, these bones become bowed, while their internal trabecular -structure is altered. - -The extent of the affection in the bones of the legs varies a great -deal and usually is not symmetric. The lower extremities are bowed -outward, and also are usually bent forward, the curves being due to -changes in the femur and the lower leg. - -+Treatment.+ In the absence of any knowledge as to the cause of the -disease, the treatment of osteitis deformans must be largely -symptomatic. Certain drugs have been recommended; among these are -iodide of potash and arsenic. Most such patients are in poor general -condition, and effective feeding often gives marked relief of the -symptoms from which they are suffering. - -For severe pain, counterirritants are valuable, especially the actual -cautery. Massage is of use in some cases for improving the general -condition. - -+Tumors of Bone.+ All the primary tumors of bone are of the connective -tissue group, but various secondary tumors of epithelial origin may -occur. - -Osseous tumors may arise from the periosteum or from the marrow. If -they arise from the periosteum they may extend early to the adjacent -soft tissues and involve and destroy them. If the tumor arises in the -marrow, it is for a long while cut off from the adjacent soft tissues -by the thick cortex, and about the extending medullary tumor may also -come a reactive proliferation by the periosteum, so that as the tumor -extends it still may, for a long time, be surrounded by a shell of -bone which prevents infection of the soft parts. After a time, -however, the reactive periosteum shell usually becomes perforated at -one or more points, and then the medullary tumor extends to the -adjacent tissues. The cause of these tumors is absolutely unknown. - -+Fibromata+ are not very common tumors of bone. They arise generally -from the periosteum and are most common about the face, and are rarely -seen in the long bones. Many of these tumors are closely allied to -some of the fibrous forms of sarcoma, and it is often difficult to -distinguish them histologically. - -+Chondromata+ are fairly common tumors of bone. They may appear -externally to the cortex, or sometimes they grow in the medullary -canal. They may arise directly from the marrow, probably from remnants -of the provisional cartilage cells. They also appear frequently to -arise from the epiphyseal line. - -Chondromata appear generally as multiple masses, nodular in shape, and -are frequently seen on the lower leg, about the knee joint. They -usually are painless, firm and hard, and not tender to pressure. - -+Treatment+ consists in removal by operation. - -+Osteomata+ are bony tumors which generally arise by growth of the -periosteum, and form solid bony masses external to the cortex of the -bone, when they are called _exostoses_. - -The density of the bone composing the tumor varies a great deal, some -being very hard and ivorylike, while others are like the cellular -marrow of the long bones. - -Osteomata may be surrounded by a layer of fibrous periosteum or, in -certain cases, beneath the periosteum appears a layer of cartilage -producing the so-called _exostosis cartilaginea_. The latter formation -is the one which is most common in the vicinity of the epiphyseal line -of the long bones, notably of the leg. - -Osteomata form circumscribed hard nodular masses of bony consistency, -and are usually painless. They may cause interference with function -from their size, especially when they appear in close connection with -a joint. - -+Treatment+ is complete and thorough removal. - -+Sarcomata+ are the most common tumors of bone; they are malignant, and -when removed, tend to recur, either locally or by metastasis, in -different parts of the body. The metastases usually are distributed by -the circulation. - -These tumors may arise from the marrow, but generally in the epiphysis -of the bone and extend to the shaft only at a later stage of their -development. As the tumor advances, it causes a softening and an -absorption of the original cellular marrow until it approaches the -periosteum. - -In many cases the periosteum, as about any form of foreign body, then -begins to proliferate and forms a shell of periosteal bone surrounding -the tumor. In that way the shell of the bone oftentimes becomes very -much enlarged before there is any extension of the process through -the shell to the adjacent tissue. By destruction of the marrow and of -the cortex, great softening of the bone may occur so that spontaneous -fractures not infrequently are seen. - -Other sarcomata arise from the periosteum, and usually originate from -one side of the bone, although occasionally they entirely surround the -bone. In the periosteal sarcomata, a new formation of bone is common -and the bone is frequently arranged in a radical way, giving a most -remarkable picture on the X-ray plate. - -+Myeloma+ is a very rare malignant tumor of bone. Such tumors always -appear only in connection with bone, are usually multiple, and are of -the same type as other lymphoid tumors. - -The cells of such tumors resemble very closely the type of plasma -cell. These cells are arranged in masses without an intercellular -substance, and the tumors are closely allied to the malignant -lymphomata. The cases are always associated with albuminuria. - -+Symptoms.+ The chief symptoms of malignant tumors are swelling and -pain, both of which oftentimes are extreme. The swelling may be -spherical or spindle shaped. - -+Extension+ to the joints may not occur for a great length of time. In -many cases X-ray examination is the most reliable method of detecting -the character of the bony change. - -+Treatment+ of all sarcomata is early and complete removal. This means -in nearly all cases, amputation of the affected bone, and it is -important that the amputation should be of the entire bone through the -joint between the bone and the body, rather than amputation of the -bone in continuity. The reason for this is, that even in sarcomata, -which have not extended to the soft parts, very frequently there have -occurred metastases of tumor-cells throughout the blood sinuses of the -affected bone, often times at a distance of several inches from the -site of the original primary tumor. - -+Carcinomata.+ Cancer of bone always is secondary to cancer in some -epithelial organ. The infection may take place by direct extension -through the blood or the lymphatics. - -In cases of metastatic invasions of bone, spontaneous fractures -oftentimes are the first symptom which calls attention to the fact -that metastases have occurred. - -+Treatment.+ As in other malignant tumors, the indication is for -absolute and radical removal whenever possible. Unfortunately, this -very seldom can be done, because at the time the bone has become -affected by extension to any great degree, radical operation is -impossible. Many times, however, extensive operations must be -undertaken for the removal of bone. - -+Cysts of Bone+ are rare lesions which practically always occur -secondary to other lesions. They may occur as the result of the -degeneration and softening of bone sarcomata. Some of the cases of -bone cysts undoubtedly represent the entire destruction of sarcomatous -processes. Occasionally echinococcus cysts of bone occur. - -+Treatment.+ Cysts of bone due to softening of the centre of sarcomatous -tumors, like sarcomata themselves, are to be treated by complete -removal, best usually by amputation. Cysts of bone not due to the -presence of sarcomatous tissue, should be opened and drained in some -cases. Cysts due to the presence of echinococcus, should be opened and -drained, with the removal of every vestige of the echinococcus. - - - - -CHAPTER XI - -+DISEASES AND INJURIES OF THE ARTERIES AND GANGRENE+ - - -+Gangrene+ is a term employed to denote the death of a part of the body, -in mass. - -_Necrosis_ and _mortification_ are terms used in a similar sense -though necrosis is reserved in surgery to mean death of bone. - -Gangrene may result from the gradual or sudden cessation of the -arterial supply, or from a stoppage of the venous outflow. In general -the etiology of gangrene comprises: - - 1. Traumatic causes. - 2. Constitutional causes. - 3. Thrombosis and embolism. - 4. Cold. - 5. The effect of certain chemicals. - -Before entering into a consideration of these subjects, it is wise to -first consider the varieties of gangrene. - -There are two forms in which gangrene is observed: _dry_ and _moist_. - -+Dry gangrene+, or mummification, is a condition which occurs in -consequence of a gradual diminution and final cessation of the blood -supply, with the venous outflow intact. In this way, aided by -evaporation and the venous return, there is a gradual drying of the -parts. Diseases of the arteries and increasing pressure upon them from -growing tumors, causes this variety. - -+Moist gangrene+ is due to the sudden arrest of the arterial supply, or -a similar obstruction to the venous return. - -This is the variety commonly met with from crushing or cutting -accidents; from the effects of carbolic and other acids; from cold; -and from thrombosis and embolism. - -A _thrombus_ is a blood clot occluding the lumen of a vessel. An -_embolus_ is a loosened part of a thrombus or any other foreign -substance, free in the blood stream, such as a drop of fat, an air -globule, or a detached particle of tissue from growths in the heart or -vessels. Any one of these may find lodgment in a terminal vessel, and -plug it. - -Moist gangrene therefore differs from dry gangrene in that the arrest -of circulation takes place more or less suddenly when the tissues are -suffused with blood. - -The dry form of gangrene does not occur regularly in the diseases in -which it might be expected, and though a true wet gangrene is not -found, neither is the typical mummification. - -Moist gangrene may occur in diabetes, in senility and in Reynaud's -disease, and probably assumes this form on account of the sudden onset -of inflammation in the part from some slight abrasion, or from weak -heart action. - - -C+AUSES OF GANGRENE+ - -_Traumatic._ The sudden cessation of the blood supply to a part in -consequence of a cutting or crushing accident, will obviously produce -the moist form of gangrene. It is not essential that the part be -entirely severed, or even nearly so, for if only the main artery is -severed, gangrene will ensue. - -The crushing or pressure upon a large vein will act similarly, owing -to there being no outflow possible, back pressure will cause the total -arrest of circulation in the part. - -_Constitutional Diseases._ Certain diseases affect the lumen or -calibre of the blood vessels, gradually diminishing and finally -arresting the stream of blood carried through them. - -In these diseases it would be logical to invariably expect dry -gangrene. This does not regularly occur, for the reason just given, -and the mere presence of a moist or dry condition therefore cannot be -regarded as diagnostic. - -In diabetes, either form may obtain, and a diagnosis can be assured by -the discovery of sugar in the urine. - -The thickened condition of the arteries leading to senile gangrene -must be thought of and proven in aged subjects. Dry gangrene is the -rule in arteriosclerosis. - -Reynaud's disease, or synthetic gangrene, is due to a vasomotor -spasmodic condition of the terminal vessels and is of central nerve -origin. The tips of the toes and fingers, of both sides, are the most -common sites, though the lobes of the ears, cheeks and tip of the nose -may be affected. - -A coldness of the parts, with mottling of blue and white, and a -subsequent diffuse blueness, becoming darker and finally black, are -characteristic signs of this disease, and the dry form of gangrene is -usual. - -_Obliterating Endarteritis_, is a condition in which the walls of an -artery become inflamed and thickened, thus obliterating its lumen. - -_Thromboangiitis Obliterans_ is similar to the above and differs only -in that a thrombotic growth occurs in an artery obliterating its -lumen. - -_Thrombosis and Embolism._ Thrombosis and embolism cause a sudden or -gradual stoppage of the blood stream in a vessel, and in consequence, -either moist or dry gangrene occurs, depending on the time required -for the obstruction to become complete. - -The stoppage of the outflow because of thrombosis in a large vein, -will cause moist gangrene; the part being unable to drain, will, by -back pressure, arrest circulation. - -_Cold._ Frost bite causes gangrene of varying degrees. A small -circumscribed patch of tissue may succumb, or an entire finger or -extremity may be affected. The variety is invariably moist. The -diagnosis is easily made from the history of exposure (See "Frost -bite"). - -_Chemicals._ Carbolic acid, even in weak solution, often causes -gangrene of a finger or toe, because of its frequent use as a wet -dressing, and therefore should never be employed in this manner. -Gangrene of a single part, (especially in a young subject), incident -to a slight injury or infection, should always excite suspicion that -phenol has been employed. Moist gangrene is the rule. The part -presents a hard, shriveled, black appearance which is characteristic. - -Weak solutions of other chemicals such as lysol, acetic acid, and -potassium or sodium hydroxide, employed as a wet dressing, are also -capable of producing gangrene. - -+Symptoms.+ (_Dry Gangrene_). Typical dry gangrene usually develops in -the toes and the feet, and the principal symptoms which point to its -advent are, coldness, numbness, pain and tingling in the feet and -muscles of the legs. Persons about to be affected with dry gangrene -often complain for months, before any local signs of gangrene are -present, of severe burning pain in the feet at night when warm in bed. - -A trivial injury, such as a bruise, the friction of the shoe, or the -cutting of a corn, may act as the exciting cause of the affection. The -part becomes congested and gradually assumes a dark purple color, -finally becoming black and dry; it is insensitive, but the surrounding -parts are congested and may be the seat of intense pain. The dead part -becomes black, shriveled, and dry, and emits little odor. - -Dry gangrene usually spreads very slowly; one or two toes may first be -involved and the disease may gradually spread to the rest of the foot -and the leg. There may be little fever at first, but if a large extent -of tissue is involved, a certain amount of fever develops. During the -progress of the disease, pain is usually present to a greater or -lesser degree, sometimes being intense; this is accounted for by the -fact that the nerves are usually the last structures to die. - -During the course of the disease, the patient loses much sleep from -continued pain, and becomes worn out and may die of exhaustion. - -In dry gangrene there is usually no well marked attempt at the -formation of lines of demarcation and separation, but in some cases, -if the amount of tissue involved is small, say one or two toes, or a -part of the foot, for instance, and if the patient's strength can be -sustained, the line of separation forms, and the dead tissue may be -cast off, leaving the bones exposed in the wound. - -+Moist Gangrene.+ When a part which has had its vitality seriously -interfered with becomes gangrenous, pain, which may have been present, -suddenly ceases, the part becomes insensitive, and the skin is cold, -pale, and mottled purple, green, and red, and finally dark colored; -blebs containing brownish serum form upon the surface; the wound, if -one is present, assumes a grayish color, and an offensive discharge -escapes from it; the dead tissue rapidly undergoes putrefactive -changes. Coincidentally with these changes in the dead tissues, the -living tissue in contact with it becomes red and swollen, and the -separation of the dead tissue from the living is affected by an -ulcerative inflammation, granulations from the living tissue lifting -off the slough. - -The patient, at the same time, if the gangrenous process involves any -considerable extent of surface, exhibits the unconstitutional signs of -inflammation (fever, rapid pulse, etc.) and, in some cases, if the -septic infection is intense, may die from septicemia. - -In both dry and moist gangrene, when the gangrenous process is -arrested, the dead tissue is separated from the living by a process of -inflammation; the living tissue, at its point of contact with the dead -tissue, and for some distance from it, becomes red and swollen, and -exhibits all the signs of acute inflammation. The line of contact -between the dead and the living tissue is known as _the line of -demarcation_, and the line of granulations which separates the dead -tissue from the living, is known as _the line of separation_. - -The separation of the dead tissue is affected by granulations, which -spring up from the living tissue as a result of inflammation, and -there is also a certain amount of pus secreted from the granulations. -In moist gangrene, the lines of demarcation and separation are fairly -well developed. In dry gangrene, on the other hand, these lines are -usually imperfectly developed. - -+Early Diagnosis.+ From the foregoing it will be observed that gangrene -is most common in those past middle life, and that its actual onset is -only a stage in an insidious process. This may be either due to -senility or to some constitutional disease. A slight abrasion alone is -sufficient to set up a train of symptoms out of all proportion to the -cause. In such a case, the operation of a small verruca or papilloma -may be followed by a violent inflammatory reaction, with rapid -extension into the entire foot or leg, resulting in gangrene. - -Such cases have occurred, but could have been prevented if a proper -survey of the field had been taken and would have saved the -chiropodist much responsibility. - -Before operating on subjects past middle life, it should be a routine -practice to note the color and temperature of the foot, both in the -dependent and horizontal positions. The _anterior tibial pulse_ should -also be felt for and its absence or intensity noted. A question to the -patient as to diabetes or thickened arteries may also elicit valuable -information. A very weak or absent anterior tibial pulse (the knack of -feeling the pulse here must be acquired), or peculiar nodules about -the nail grooves, are evidences of an encumbered arterial supply. - -Extreme redness or blueness in a foot in the hanging position, and -pallor when elevated, also indicate a similar condition, or one in -which the valves in the veins are impaired. - -It is in such conditions that the greatest care should be taken to -avoid deep incisions except in the presence of positive indications. - -+Treatment.+ In general, amputation through healthy tissue is the rule -in gangrene affecting any extremity through its entire thickness. The -complete devitalization of even a digital phalanx requires that -amputation be made beyond the next joint above. - -In traumatic gangrene it is the rule to amputate immediately through -healthy tissue when restitution of the injured parts is known to be -impossible. In senile gangrene the appearance of the line of -demarcation indicates the extent of the devitalized area and -establishes the point of amputation beyond the next joint above. - -Diabetic gangrene presents the peculiarity of a slow and steady -advance, unless an unusually high amputation be performed. Thus, if -the great toe is the site of the beginning of a true diabetic -gangrene, amputation through the lower third of the thigh is -indicated; otherwise the prognosis is very bad. - -Inflammatory gangrene, or as it is more properly called _gangrenous -cellulitis_, is a rapidly spreading infective process which destroys -tissue as it advances. It is an acute suppurative process causing -large sloughs. It is a form of cellulitis requiring drainage and -disinfection. - -Frost bite may involve tissues to any depth and to any surface extent. -Lesions of circumscribed contour result in the sloughing away of the -area involved and never require amputation. (See "Frost bite.") - -In the event of a phalanx, toe, finger, foot, or hand being involved, -the same rules as above laid down must apply. In this variety, -however, it is important to allow sufficient time to elapse in order -that the depth of the gangrenous process may be ascertained. Should -the line of demarcation be apparent, after a few days the complete -death of the tissues below is certain, and amputation becomes -necessary. If, however, after a few days some slight bleeding or the -appearance of a red point be apparent, the bone, and in all -probability some tissue around it, is still viable. Haste in these -cases should therefore be avoided. - - - - -CHAPTER XII - -+DISEASES OF VEINS+ - - -Varicose veins are unnatural, irregular, and permanently dilated veins -which elongate and pursue a tortuous course. This condition is very -common, and twenty per cent. of adults exhibit it in some degree in -one region or another. - -The causes of varicose veins are obstruction to venous return, and -weakness of cardiac action, which lessens the propulsion of the blood -stream. - -Varicose veins may occur in any portion of the body, but are chiefly -met with on the inner side of the lower extremity. - -Varix in the leg is met with during and after pregnancy, and in -persons who stand upon their feet for long periods. - -It especially appears in the long saphenous vein, which, being -subcutaneous, has no muscular aid in supporting the blood-column and -in urging it on. The deep as well as the superficial veins may become -varicose. - -Varicose veins are in rare instances congenital; they are most often -seen in the aged, but usually begin at the ages of twenty to forty. - -A vein, under pressure, usually dilates more at one spot than at -another, the distention being greatest back of a valve or near the -mouth of a tributary. The valves become incompetent and the dilatation -becomes still greater. The vein wall may become fibrous, but usually -it is thin, and ruptures. The veins not only dilate, but they also -become longer, and hence do not remain straight but twist and turn -into a characteristic form. - -Varicose veins are apt to cause edema, and the watery elements in the -tissues cause eczema of the skin. When eczema is once inaugurated, -excoriation is to be expected. Infection of the excoriated area -produces inflammation, suppuration, and an ulcer. - -The skin over varicose veins in the legs is often discolored by -pigmentation due to the red cells having escaped from the vessel and -then being broken up. - -The tissues around a varicose vein become atrophied from pressure, and -often a very large vein will be in evidence whose thin walls are in -close contact with the skin, and in this condition, rupture and -hemorrhage are probable. Varicose veins are apt to inflame and -thrombosis frequently occurs. - -+Treatment.+ The treatment of varix may be palliative or curative, but -whichever is followed, endeavor first to remove the cause. - -In palliative treatment, attend to the general health, keep up the -force and activity of the circulation, and prevent constipation. -Recommend the patient to exercise in the open air and to lie down, if -possible, every afternoon. Locally, in varix of the leg, order a -flannel bandage to support the vein and drive the blood into the -deeper vessels which have muscular support. (For technic, see chapter -on bandaging). - -The curative or operative treatment of varicose veins consists of -performing a resection of the internal saphenous vein of one or two -inches, near the saphenous opening into the femoral. This is known as -the _Trendelenburg_ method. About 90 per cent of all cases can be -cured by this method. The operation can be performed under local -anesthesia and presents no difficulties. - -Another procedure is known as _Schede's_ method. This consists of -making a circular incision around the leg just below the knee joint, -and in tying all the superficial veins thus exposed. - -_Mayo's_ operation consists of the total extirpation of the internal -saphenous vein from the saphenous opening to the internal malleolus. A -small incision is made high up, and at a distance of from 8 to 10 -inches, a second incision is made, and in this manner the entire vein -is removed by making several incisions. - -The patient should remain in bed about three weeks following an -operation of this kind and afterwards an elastic stocking, or an ideal -bandage, should be worn for a considerable time. - -+Phlebitis+, or inflammation of a vein, may be plastic or purulent in -nature. Plastic phlebitis, while occasionally due to gout, or to some -other constitutional condition, usually arises from a wound or other -injury, from the extension to the vein of a perivascular inflammation, -or, in the portal region, from an embolus. - -Varicose veins are particularly liable to phlebitis. When phlebitis -begins, a thrombus forms because of the destruction of the endothelial -coat, and this clot may be absorbed or organized. - -+Suppurative Phlebitis+ is a suppurative inflammation of the vein, -arising by infection from suppurating perivascular tissues (_infective -thrombophlebitis_). It is most frequently met with in cellulitis or -phlegmonous erysipelas, but there are a great many other causes. - -A thrombus forms, the vein wall suppurates, is softened and in part -destroyed, and the clot becomes purulent. No bleeding occurs when the -vein ruptures, as a barrier of clot keeps back the blood stream. The -clot of suppurative phlebitis cannot be absorbed and cannot organize. - -Septic phlebitis causes pyemia, and the infected clots of pyemia cause -phlebitis. The symptoms of phlebitis are pain, which is at once felt -in the limb along the track of the inflamed vein, and tenderness along -the same area; the overlying skin is red, hot, and tender, and the -lymphatic nodes in the groin swell; there is marked edema, but the -inflamed venous cords can be readily felt. The constitutional -disturbance is marked; rigors and high temperature, 103°F. to 105°F. -(remittent type), are followed by profuse sweats. The general -condition, facies and anxiety, dry and parched tongue, delirium and -general distress, at once directs attention to the infectious nature -of the trouble. The leucocyte count will show a marked increase in the -number of polynuclears. - -+Treatment.+ The treatment of phlebitis may be classified into -preventive and curative, the latter being subdivided into (_a_), -general or symptomatic, and (_b_), local or surgical. - -The preventive treatment is summed up in the word asepsis. The -influence of asepsis in the management of wounds has completely -revolutionized surgical practice, and the old fatal types of pyemia -and septicema have now practically vanished. - -Septic and pyogenic phlebitis still remain as consequences of -accidental wound contaminations and as a penalty for the neglect of -surgical cleanliness. - -Prophylatic measures, by the use of internal remedies which diminish -the coagulability of the blood, such as Wright's citric acid -treatment, are recommended for the prevention of thrombosis. -Antitoxins have not proven to be of benefit in this condition. - -The curative treatment may be symptomatic, local, constitutional, or -surgical. The constitutional treatment is directed to the general -cause, if possible, as in the gouty, rheumatic, syphilitic, and -chloritic cases; beyond this, there is no specific treatment. The -antistreptococcal and staphylococcal sera are usually prescribed in -the septic forms, but thus far, more as a forlorn hope than with the -expectation of accomplishing any definite results. The symptomatic -treatment, on the other hand, is always indicated to diminish pain, to -support and strengthen the circulation, and to favor elimination. The -main reliance is to be placed upon the local treatment, combined with -good nursing, appropriate food, and moderate stimulation. - -The local treatment is summed up in the following indications: (_a_), -immobilization and absolute rest of the affected limb; (_b_), elevated -position of the foot of the bed or of the limb to favor the drainage -of the venous current toward the trunk. The limb should be covered -with cotton batting and bandaged, over a gutter-splint of cardboard, -extending from the foot to the thigh, to immobilize the knee. In the -superficial inflammations, with much redness and heat, an even layer -of any of the kaolin mixtures may be applied between thin layers of -gauze, like an antiseptic poultice, over the entire extremity, and -especially over the inflamed parts. A saturated watery solution of 25 -per cent. ichthyol, painted over the entire surface will also prove -decidedly beneficial in cases complicated with lymphangitis. Unguentum -Crede, mercurial ointment, and the so-called resolvent lotions have -been tried, but none of these can compare in their beneficial effect -with kaolin poultices, with or without ichthyol, or the liberal -application of broad compresses, thoroughly saturated with a weak lead -and opium lotion, which latter acts not only as a local astringent, -but as a marked sedative. Immobilization and rest should be maintained -for a month or more. - -+Operative Treatment.+ The operative treatment of acute septic -thrombophlebitis has in view three indications, and the procedures -adopted must vary according to these: (1) ligation of the vein between -the thrombotic focus and the uninfected vein on the cardiac side, in -order to obstruct the further advance of the infection, and thus -prevent the entrance of septic emboli into the circulation; (2) -removal of the primary focus of infection by direct incision into the -veins, evacuation of the septic thrombus and drainage; (3) extirpation -of the infected veins with the contained clot and septic contents. - - - - -CHAPTER XIII - -+SPECIAL FORMS OF INFLAMMATION+ - - -+Syphilis+ is a chronic, infectious, and sometimes hereditary, -constitutional disease. Its first lesion is an infecting area or -chancre, which is followed by lymphatic enlargements; eruptions upon -the skin and mucous membranes; affections of the appendages of the -skin, (hair and nails); chronic inflammation and infiltration of the -cellulo-vascular tissue, bones and periosteum, and later, often by -gummata. This disease is caused by a microorganism known as the -_spirochaeta pallida_ or _treponema pallidum_ of Schaudinn and -Hoffmann. - -+Transmission of Syphilis.+ This disease can be transmitted (_a_), by -contact with the tissue-elements or virus acquired syphilis, and -(_b_), by hereditary transmission, hereditary syphilis. - -The poison cannot enter through an intact epidermis or epithelial -layer; an abrasion or solution of continuity is requisite for -infection. - -Syphilis is usually, but not always, a venereal disease. It may be -caught by infection of the genitals during coition; by infection of -the tongue or lips in kissing; by the use of an infected towel on an -abraded surface; by smoking poisoned pipes, and by drinking out of -infected vessels. - -The initial lesion of syphilis may be found on the finger, penis, -eyelid, lip, tongue, cheek, palate, nipple, etc. Syphilis can be -transmitted by vaccination with human lymph which contains the pus of -a syphilitic eruption or the blood of a syphilitic person. Syphilis is -divided into three stages (1) the primary stage--chancre and indolent -bubo; (2) the secondary stage--disease of the upper layer of the skin -and mucous membranes, and (3) the tertiary stage--affections of -connective tissues, bones, fibrous and serous membranes, and -parenchymatous organs. - -+Syphilitic Periods.+ (1) period of primary incubation--the time between -exposure and the appearance of the chancre, from ten to ninety days, -the average time being three weeks; (2) period of primary -symptoms--chancre and bubo of adjacent lymph glands; (3) period of -secondary incubation--the time between the appearance of the chancre -and the advent of secondary symptoms,--about six weeks as a rule; (4) -period of secondary symptoms--lasting from one to three years; (5) -intermediate period--there may be no symptoms or there may be light -symptoms which are less symmetrical and more general than those of the -secondary period; it lasts from two to four years, and ends in -recovery or tertiary syphilis; and (6) period of tertiary -symptoms--indefinite in duration; the fifth and sixth may never occur, -the disease being cured. - -+Primary Syphilis.+ The primary stage comprises the chancre or infecting -sore or bubo. A chancre or initial lesion is an infective granuloma -resulting from the poison of syphilis. The chancre appears at the -point of inoculation, and is the first lesion of the disease. During -the three weeks or more requisite to develop a chancre the poison is -continuously entering the system, and when the chancre develops, the -system already contains a large amount of poison. - -A chancre is not a local lesion from which syphilis springs, but is a -local manifestation of an existing constitutional disease, hence -excision is entirely useless. The hard chancre, or initial lesion, -never appears before the tenth day after exposure, it may not appear -for weeks, but it usually arises in about twenty-one days. The lesion -commonly appears as a round, indurated, cartilaginous area with an -elevated edge, which ulcerates, exposing a velvety surface looking -like raw ham; it bleeds easily, rarely suppurates, does not spread, -and the discharge is thin and watery. - -The bubo of syphilis is multiple, consisting of a chain of glands, -freely movable, indurated, painless, small and slow in growth, and the -skin over the bubo is normal. - -A positive diagnosis of syphilis can be made when an indurated sore is -followed by multiple indolent glands or buboes in the groin and by the -enlargement of distant glands. - -+Secondary Glands.+ The symptoms are noticed from four to six weeks -after the stage of the induration of the chancre, and may continue to -appear at any time, up to twelve months. The most constant are certain -eruptions on the skin, faucial inflammation, and enlargement or -induration of the lymphatic glands; others are febrile reaction, pains -in the back or limbs, swelling of the joints, iritis and falling out -of the hair. - -+Tertiary Syphilis.+ These symptoms appear from one to two years after -contagion and may continue to break out from ten to fifteen years, or -more. The characteristic lesions are certain late eruptions on the -skin, periostitis and nodes on the bones, and growths in the -subcutaneous tissue, muscle, and viscera, especially the liver and -spleen. These growths, in the viscera and other parts, which are so -characteristic of syphilis in its later stages, are known as gummata. -They consist of a substance like granulation tissue, with a varying -proportion of cells. In early stages they are grayish, gelatinous, and -transparent, but the cells undergo fatty change and caseation takes -place, so that the centre becomes yellow, and the circumference -develops into fibrous tissue, which contracts like a scar tissue. -Sometimes gummata break down completely, and suppuration, with -destruction of the tissues in which they are situated, takes place; -thus caries and necrosis not infrequently follow nodes on the bones. - -+Treatment.+ Mercury is the drug of great benefit in syphilis. This can -be administered either internally, by inunction, or by injection. Of -all the preparations to be given internally, protiodide of mercury, in -one quarter grain doses, three times a day, is to be preferred. - -+Inunction+ represents the most efficient way of administering the -mercurial treatment, when the stomach is intolerant of drugs, or when -administered by the mouth in full doses, they do not favorably modify -the symptoms. The patient is instructed to take a warm bath, and the -mercury is then well rubbed in over the inner surface of the forearm -and arm and alongside of the chest for fifteen minutes. Either the -oleate of mercury, 10 per cent., or the ordinary mercury ointment is -commonly employed; the former is more clean, but less efficient. The -rubbings should be done by the patient, should be made over a large -surface of the body, and should be performed thoroughly; one dram -(4.0) of blue ointment is rubbed in daily. For the injections, a 10 -per cent. salicylate of mercury in olive oil is to be preferred; 10 to -15 minums of this solution is to be injected into the buttocks, three -times a week. The dose is gradually to be increased until 30 drops are -employed. Recently salvarsan (606) in 0.6, or 10 grain doses is given -either intravenously or intraspinally. Neosalvarsan (914) is to be -similarly given. The latter has the advantage in that sterile water is -used, and that, as a rule, there is no reaction from its injection. -Iodide of potassium in large doses (60 to 90 grains) three times a -day, is also to be given. - -+Tuberculosis.+ Tuberculosis is an infectious disease due to the -deposition and multiplication of the tubercule bacillus in the tissues -of the body. It is characterized either by the formation of -tubercules, or by a wide spread infiltration, both of these conditions -tending to caseation, sclerosis, or ulceration. - -A tubercular lesion may undergo calcification. - -A tubercule is an infective granuloma, appearing to the unaided vision -as a semitransparent mass, gray in color, and the size of a mustard -seed. - -The microscope shows that a tubercule consists of a number of cell -clusters, each cluster consisting of one or of several polynucleated -giant cells, surrounded by a zone of epitheloid cells which are -surrounded by an area of leucocytes. Giant cells, which also form by -coalescence of the epithelioid cells, are not always present. The -bacillus, when found, exists in the epithelioid cells, and sometimes -in the giant cells; it may not be found, having once existed, but -having been subsequently destroyed. It is often overlooked. - -In an active tubercular lesion, even if the bacillus be not found, -injection of the matter into a guinea-pig will produce lesions in -which it can be demonstrated. - -A tubercule may caseate, a process that is destructive and dangerous -to the organism. Caseation forms cheesy masses, which may soften into -tubercular pus, may calcify, and may become encapsulated by fibroid -tissue. Tubercular disease of the bones and joints have already been -described in a previous chapter. - -+Treatment.+ Destroy the bacilli present and radically remove infected -areas which are accessible. Incomplete operations are apt to be -followed by diffuse tuberculosis. - -Bier's venous or obstructive hyperemia is especially to be recommended -in tuberculosis of the ankle joint (for technic, see chapter on -Therapeutics). - -Plenty of fresh air, good nourishing food and tonics are indicated as -a routine treatment. - -+Tetanus.+ Tetanus is an infectious disease, invariably preceded by some -injury. The wound may have been severe or it may have been so slight -as to have attracted no attention. - -The disease is commonest after punctured wounds or lacerated ones of -the hands or feet, and before it appears, a wound is apt to suppurate -or slough, but in some instances the wound is found soundly healed. - -Tetanus is due to infection by a bacillus (first described by -Nicolaier, and first cultivated by Kitasato), the toxic properties of -which, absorbed from the infected area, poison the nervous system -precisely as would dosing with strychnine. - -+Symptoms.+ The onset is usually within nine days of an accident. At -first, the neck feels stiff and there is difficulty in swallowing, and -then the jaw also becomes stiff. The neck becomes like an iron bar, -and the jaws are rigid as steel. If the injury is on the foot, that -extremity usually is found to be rigid. Opisthotonos is present and -spasms are very marked. Swallowing in many cases is impossible. The -mind is entirely clear until near the end, one of the worst elements -of the disease. - -+Treatment.+ Careful antisepsis will banish it. Every wound must be -disinfected with the most scrupulous care. Every punctured wound is to -be incised to its depth and thoroughly cleaned and drained. Large -doses of the bromide of potassium, at least sixty grains, should be -given every four to six hours. Tetanus antitoxin should be given (5000 -units), and repeated in twenty-four hours if no improvement is seen. -Recently a saturated solution of magnesium sulphate has been given -intraspinally, with very good results. In all suspicious cases, a -prophylatic injection of tetanus antitoxin is to be recommended (1000 -units). - -+Erysipelas.+ Erysipelas is an acute, contagious disease, characterized -by a peculiar form of inflammation of the skin. It is caused by the -streptococcus of erysipelas, which grows and multiplies in the smaller -lymph channels of the skin and its subcutaneous cellular layers, and -in serous and mucous membranes. - -The disease is a rapid spreading dermatitis, accompanied by a -remittent fever, due to the absorption of toxins, having a tendency to -recur. It is always due to a wound. The involved area may or may not -suppurate. - -+Symptoms.+ The onset is sudden, with a high fever, and at the time of -febrile onset, spots of redness appear on the skin. These spots run -together, and a large extent of surface is found to be red and a -little elevated. This combination of redness and swelling extends, and -its area is sharply defined from the healthy skin. The color at once -fades on pressure and returns immediately the pressure is removed. In -the hyperemic area, vesicles or bullae form, containing first serum -and later possibly sero-pus. Edema affects the subcutaneous tissues, -producing great swelling in the regions where these tissues are lax. - -+Treatment.+ Isolate the patient; asepticize the wound; and give a -purge. If a person is debilitated, stimulate freely. - -Tincture of iron and quinine are usually administered. Nutritious food -is important. For sleeplessness or delirium, use the bromides; for -light temperature, cold sponging and antipyretics. Locally, strict -antiseptic treatment of existing wounds or other lesions; cold -compresses to relax the skin; rest; elevation of the limb; and -incisions, only if pus forms. - -Where the disease is spreading, good results are obtained by spraying -the affected surface with a weak solution of corrosive sublimate in -ether, or painting the borders of the affected area with contractile -collodion. The affected part may also be painted with a 50 per cent. -ichthyol and water solution. Alcohol, Burow's solution, and a great -many other liquid applications are recommended. Antistreptococci serum -is also to be recommended; an initial dose of 20 c.c. followed by -doses of 10 c.c., as often as necessary, being the usual procedure. - -+Cellulitis.+ In cellulitis, redness of the skin is not very pronounced -and is late in appearing, following swelling, and not preceding it. It -is essentially the same condition as a mild form of erysipelas. Its -spread is heralded by red lines of lymphangitis, ascending from a -wound (infected), swelling of glands, and fever. - -In slight cases, the lymphatics may dispose of the poison, and -suppuration fails to occur. In severe cases septicema arises. -Cellulitis is usually a result of infection not only with -streptococci, but also with other pyogenic cocci. - -+Treatment.+ Incise and curet the wound and apply one of the wet -dressings. (See chapter on same). - -+Actinomycosis.+ This is an infectious disease characterized by chronic -inflammation, and is due to the presence in the tissues of the -actinomyces, or ray fungus. At the point of inoculation arises an -infective granuloma, around which inflammation of connective tissues -occurs; suppuration eventually taking place. Inoculation in the mouth -is by way of an abrasion of mucous membrane or through a carious -tooth. The fungi may pass into the bones and joints, causing -inflammation of the parts. The bones in actinomycosis enlarge and -become painful; the parts adjacent are infiltrated and soften; pus -forms and reaches the surface through fistulae and the skin is often -involved secondarily. In actinomycosis the adjacent lymphatic glands -are not involved. - -+Treatment.+ Free incision, if possible, otherwise incision, cauterizing -with pure carbolic acid, and packing with iodoform gauze. Internally, -large doses of iodide of potassium should be given, as this drug alone -has cured many cases. - -+Trench Foot.+ This results from exposure to wet and cold in the -trenches, and soldiers who were compelled to have their feet immersed -in water for any length of time and were then exposed to cold, are -afflicted with this condition. The symptoms are similar to frost bite -and the prevention of frigorism (Trench Foot) is as follows: adequate -feeding; perfect circulation; moderate exercise; good general health; -and warm clothing, which all tend to give the body its maximum power -of resistance to cold. - -It is obvious that anything that tends to impair the circulation and -the nutrition of the tissues is favorable to the occurrence of -frigorism. Tightness of the clothing of the extremities, such as tight -boots, leggins, etc., is particularly detrimental. Heavy clothing and -other equipment, by increasing fatigue, also has a predisposing -influence. - -With regard to the protection against cold water, it is necessary that -the external covering should be impervious to and not affected by -water. India rubber stockings, waders, and boots have been used by men -working in water, not only as a protection against wet, but also -against cold. The best results have been obtained by the use of a -waterproof covering that can be worn inside the boot, not because it -is the only, or even the best possible method, but because it appears -to be the simplest and most practical. A waterproof top boot, so -devised as to leave a fairly wide air space between the boot and the -greater part of the foot, ankle, and lower part of the leg, would be -more efficient and probably more convenient, provided the material -used was soft and light, and did not interfere with movements. To -obtain this result a new type of boot would be required. - -The treatment of trench foot is similar to that of frost bite. - -+Motorman's Foot.+ This is a condition caused by occupation, and the -symptoms found are usually those of a flat foot combined with enlarged -veins. The chief complaint is that of pain in the calf of the legs, -which is increased upon standing for any length of time. The treatment -is that for flat foot and enlarged veins. - -+Chauffeur's Foot.+ This is a condition also caused by occupation. On -account of the position assumed in driving an automobile, the tendons -and muscles of the leg are usually affected and a tendosynovitis very -frequently occurs. The symptoms and treatment have already been -described. Rest is without doubt the best therapeutic measure. - -+Bicycle Foot+ is another occupational disease. The chief symptoms are -those of cramps in the calves of the leg, and pains of a severe -neuritic character. - -At times the onset is very sudden, and the cramps are so severe that -it is impossible to extend the leg without causing great pain. Flat -foot is usually associated with the above condition. The treatment is -rest and the administration of the salicylates for the relief of pain. - -Bicycling is ordinarily a beneficial exercise for the foot muscles. -When bicycle foot results from this exercise it is usually evidence -that the bicyclist had an abnormal condition of his foot muscles and -foot joints before he took up the exercise in question. - - - - -CHAPTER XIV - -+VERRUCA (WART), CALLOSITY, HELOMA (CORN OR CLAVUS)+ - -+DISEASES OF THE NAILS--INGROWN NAIL+ - - -+VERRUCA OR WART+ - -+Definition.+ A verruca is a circumscribed overgrowth of all the layers -of the skin, varying in size from a pin's head to a small nut. These -growths may be single or multiple, and may come and go without any -special reason. _Verruca plantaris_, or plantar wart, is observed on -the sole of the foot; it may be single or multiple. It is very -painful; it may be the size of a pea and is often mistaken for a -callosity, from which it may be distinguished by the pain on pressure, -and the tendency to bleed when the horny layer is removed. - -Verrucae are probably contagious, but the pathogenic agent has not -been isolated. They sometimes disappear spontaneously, and they will -recur if their removal is not complete. - -+Treatment.+ Certain chemical substances (see "_escharotics_") destroy -tissue and can be employed with safety only after much experience. -These drugs when allowed to spread on the normal skin often occasion -painful and persistent lesions. They must therefore be applied -directly and sparingly to the growth itself and not be left in contact -too long. - -The daily removal of a thin layer is possible in this way without -causing pain or erosion. - -The chemical agents that are employed for the removal of verruca are -notably nitric acid, acetic acid, monochloracetic acid, trichloracetic -acid, nitrate of silver, sodium hydroxide and salicylic acid. The -treatment with these drugs is alike in all cases, with the exception -of the last three named. - -The procedure, when using liquid acids is as follows: render the -growth and the surrounding parts aseptic; by means of a tapering glass -rod or a wooden toothpick, apply a drop of the acid so that it will -spread over the growth only, making certain that every part of the -outer surface has been treated. If pain becomes excessive, apply a -neutralizing agent. Dress the part with a shield that is holed-out, so -that when the foot-covering is in place there will be no pressure over -the tissues treated. This treatment should be repeated every other day -until there is sloughing at the base of the growth. The pocket -produced is drained, and balsam of Peru or some other stimulant should -be applied and held in place by an appropriate dressing. Five or six -treatments will ordinarily suffice to remove the growth. - -Many practitioners find nitrate of silver a serviceable remedy in -cases of verruca. The pure stick, moistened, is gently applied to the -surface of the growth, which later becomes blackened. The patient -returns two days later when the scab, that will have formed, is -removed and the original treatment is repeated. Ordinarily from six to -ten such applications will suffice. Those who favor the use of -salicylic acid for the removal of verruca, usually apply a 60 per -cent. ointment of this drug, over the growth only, protecting the -surrounding parts with collodion or gelatine. A holed-out shield is -applied over the growth and an appropriate bandage is made to hold it -and the ointment in place. The patient is advised to return at the end -of ten days and, as a rule, when the dressing is removed, it will be -found that the growth is sufficiently loosened to admit of removal by -means of forceps and scissors. - -Sodium hydroxide is used in these cases in a saturated solution. It is -best applied by means of a wood toothpick, wound about with cotton, -and should be used sparingly, much after the manner in which liquid -acid applications are made and as above described. A slight stinging -sensation indicates that the drug has penetrated the tissues near the -nerve-endings in the underlying papillae. Such symptoms render it -necessary to neutralize the sodium hydroxide. According to Dr. Joseph -Renk of New York City, ordinary vinegar contains just the degree of -acidity necessary to neutralize the action of the sodium hydroxide, -without adding a new irritating element. - -Verrucae may also be removed by the high frequency spark, or by -electrolysis. Both of these methods are superior to cutting -operations, but are equally as painful unless a drop of anesthetic -solution is injected into the base of the growth, before treatment is -commenced. - - -+CALLOSITY+ - -+Definition.+ A callosity is a circumscribed thickening of the _stratum -cornium_. The condition is usually acquired, occurring on parts -exposed to intermittent pressure with counterpressure from an -underlying bony prominence, as on the toes, soles, and heel of the -foot, from ill-fitting shoes. - -Callosities are dirty-yellow to brown in color; their extent depending -upon the cause; they are thickest in the centre and pass gradually -into the healthy skin. Sensation is usually lost, or at least -diminished, over these areas. - -They may interfere with movement and may have painful fissures and -become infected, giving rise to abscesses, lymphangitis, gangrene, or -erysipelas. Hyperidrosis is often associated with this condition. - -+Treatment.+ The permanent cure of callosities depends exclusively upon -the removal of their causation. The position of the foot in the shoe -may be faulty because of excessively high or low heels, causing -callous skin to appear upon the weight-bearing surface. Occupations -requiring constant standing, and deformities, also enter as causative -factors which must be considered. - -The palliative cure rests for its efficacy on the removal of the horny -tissue down to, but not into, the papillary layer. - - -+HELOMA+ - -(+Corn or Clavus+) - -+Definition.+ A heavy thickening of the cuticle, usually caused by -pressure, and producing pain by its own pressure on the tissues -beneath. - -Though the term heloma is rarely used outside of text books, there are -very few who have not had an unpleasant acquaintance with this -cutaneous affection, under the name of "corns." Heloma is undoubtedly -the most frequent of all skin diseases. - -+Cause.+ The exciting cause of helomata is intermittent pressure -combined with friction; while among the predisposing causes it is only -necessary to mention the slavish adherence to fashion which lends all -of us to wear stiff leather shoes, the contour of which bears little -or no relation to the natural shape of the anterior portion of the -foot. The pressure of the ill-fitting boot upon the toes, or, more -strictly speaking, the pressure of the toes against the unyielding -leather, in walking, soon occasions hypertrophy of the horny layer at -the point of irritation, and in time a dense, conical, pea-sized or -larger mass is formed. The apex of the cone presses downward on the -sensitive papillae and causes the painful sensation which suggests a -visit to the chiropodist. - -Helomata are named according to characteristics which mark them. When -the growth is indurated it is called heloma durum; when soft, heloma -molle; when of the millet seed variety, heloma miliare; when blood -vessels are numerous, heloma vasculare. Each of these varieties -requires a different method of treatment. - -Helomata are most frequently found on the outer surface of the little -toes, but may occur upon the sole of the foot and even upon the palm, -or plantar surface of the foot. Between the toes they often form from -pressure of the opposing digits, caused by narrow shoes, and in this -location they are softer and usually present a whitish, macerated -surface. - -+The Prophylatic Treatment+ consists in wearing a broad-toed, though not -necessarily a square-toed shoe. - -If shoes were made fan-shaped, like the imprint of a bare-foot in the -sand, instead of having the greatest width across the ball of the -foot, they might look strange at first, but they would be comfortable -for all time. Those then who care more for comfort than for style, as -most of us falsely profess to do, would have both cornless and comely -feet. - -+The Palliative Treatment+ of helomata consists of first softening the -dense, hard, horny tissue, when it will exfoliate spontaneously, or be -readily scraped away. This projecting callous portion of the heloma -may be removed by cutting or scraping till, as nearly as may be, the -surface is level with the plane of the adjacent skin. - -In the soft variety found between the toes, or in the vascular ones, -located in the arch on the inner border of the foot, where the skin is -thin, no thick covering will be encountered. - -A line or groove will be observed marking the circumference of any -variety of heloma, and it is in this line that the operative attack -must be made. - -Helomata of the miliary variety, usually appear on the sole of the -foot and are, as a rule, as numerous as they are small. The preferable -treatment is to use a sharp, pointed knife in removing each one of the -"seeds" separately. - -A well pointed, narrow blade introduced here will find a plane of -cleavage between the growth and the surrounding tissue, through which -it is possible to dissect quite deeply without encountering blood. -When the dissection reaches the papillary layer in the skin, as -evidenced by the red color, further operative steps should cease. - -In the treatment of soft and vascular growths it may frequently be -preferable to employ disintegrating solutions from the beginning. - -Repetition of the treatment, as described in verruca, every second or -third day, will result in the gradual disintegration of the growth to -its extreme depth, and prove more satisfactory than the radical -operation. - -Healing is rapid and with the use of properly shaped, and roomy -foot-gear, recurrence should not take place. - -It is evident from the nature of helomata, that any "cure," rubbed or -painted upon the affected surface, can only cause the softening of a -certain thickness of skin, and that no hope for cure is justified -unless the careful and complete removal of the growth is accomplished -and followed by the use of roomy foot-gear. - -+Radical Cure.+ The total excision of corns, while disabling the patient -more or less for a few days, is in many instances justifiable. There -is little probability of recurrence if proper foot-gear is worn, and -the results are especially good if the skin graft operation as devised -by Dr. Robert T. Morris is employed, which is described in the next -paragraph. - -After the excision of the growth, a small piece of skin is removed -from the leg and sewn to the denuded area. This prevents a tough -cicatrix forming and assures a normal skin covering to the area -previously occupied by the corn. - -The Text Book of Practical Chiropody, now in course of preparation, -will contain lengthy and explicit articles on the subjects of verruca -and heloma. The purpose here has been largely to present the subject -from a broad surgical viewpoint. The strictly chiropodial features -will be thoroughly outline in the Text Book of Practical Chiropody -after a manner never before attempted and will include all details of -the chisel methods, the dissecting methods and the shaving -operations. - - -+DISEASES OF THE NAILS+ - -+INGROWN NAIL+ - -Although chronic inflammatory affections of the neighboring skin often -produce changes in the form, color and thickness of the nails, these -so rarely call for surgical interference that only those conditions -leading up to the development of ingrown nail will receive -consideration in the following. - -Ingrown nail may be due to either a lateral hypertrophy of the nail -itself cutting into the soft parts, or to the primary hypertrophy of -the soft parts themselves, thus producing the same picture. An -accurate determination of which condition represents the original -etiologic element is important in deciding upon a course of treatment -directed to the radical cure of ingrown nail. - -The term "radical cure" does not necessarily indicate the performance -of the so-called radical operation, but may result from proper -treatment of a down-curved nail edge, or of a diseased nail fold, -together with such prophylaxis in foot-gear as is indicated. With -sufficient room in the shoe and the removal of offending granulations -or cutting nail edge, a radical cure can frequently be effected. - -Any inflammatory condition, either of the nail or its matrix, or the -tissues contiguous to the nail, may result in the train of symptoms -which are indicative of ingrown nail. When, however, any of these -conditions has existed sufficiently long to cause ingrown nail to be -present, it ceases to be of the first importance; it then becomes -necessary to treat the buried nail edge, or the overgrown soft tissues -themselves. - -+The Choice of Method+ between radical and palliative operations will -depend entirely upon the degree of infection present, and the facility -with which it can be reached. Thus, in the event of the entire toe -being red and swollen and much purulent discharge being present, there -will in all probability also exist much inflammatory tissue and a deep -burying of the nail edge. - -With a tolerant patient it might be possible to scrape away with a -sharp spoon the granulation tissue, and remove the offending nail -edge; the gradual improvement sought in ordinary cases cannot be -thought of in these cases. It is urgent to relieve the pain and -throbbing and to circumvent the dangers of a spreading infection. The -sensations of a cutting nail edge have been lost in the more severe -development. Should the patient be tolerant of pain, exposure, -disinfection and drainage of the infected area is possible, but in -most instances the contrary will obtain, and the radical operation -with local anesthesia will be indicated. - -The possibility of doing an efficient operation will ordinarily -determine the method to be employed. - -On the other hand there are a large number of cases in which -palliative treatment is not only effective but emphatically the method -of choice. One might see a degree of burying of nail edge quite as -extensive as in the foregoing, with however, only a slight degree of -infection. The nail fold may be much hypertrophied and granulation -tissue may be abundant. The tenderness and inflammatory condition, -however, is not so great as to interfere with the ordinary procedure. -There is no danger of a rapidly ascending infection, the nail groove -showing no inordinate amount of discharge. It is in these cases that a -permanent cure frequently results from the mere removal of the -irritating nail edge followed by the disinfection of the nail groove. - -It is held by many that all cases of ingrown nail, except those due to -a true hypertrophy of the nail, would remain permanently cured were it -not for short or badly shaped shoes. - -+The Palliative Treatment of Ingrown Nail+ must necessarily depend upon -its original cause. Should it be due to the wearing of improper -foot-gear, nothing primarily pathologic in the tissues themselves -being present, treatment will be effective only when correct shoes are -worn thereafter. - -Eczematous skin surrounding a nail or infection of a nail groove or -matrix, should be treated as such before sufficient hypertrophy takes -place to bury the nail edge. The disinfection and drainage of the -groove can usually be accomplished with iodin on a thin wire or wooden -applicator inserted to the extreme depth of the groove, followed by -the insertion of a narrow strip of gauze. Frequent changes of -dressings and extreme cleanliness will cause the early subsidence of -these infections. It, however, is to be deplored that in the early -stages these cases so rarely obtain treatment. - -Elevation of the nail edge is often practiced quite successfully, but -in general, this method of treatment is not applicable to the acute -stages of the disease on account of the concomitant pain. Either the -nail is too thick to be elevated by the insertion of cotton under its -free edge, or the soft tissues are too sensitive to admit of the -pressure. - -The real skill of the chiropodist is called into practice in the -treatment of ingrown nail by palliative methods, and he may safely be -judged by his results in this class of cases. - -It requires discrimination whether to attack the exuberant granulation -tissue or the cutting nail edge, and in many instances it will be -found that both are necessary. - -Much skill is required in removing that part of the nail which is -buried without causing pain or bleeding; this is the first necessity -for relieving pain and can only be accomplished by a technic acquired -through practice, and often redounding more to the credit of the -operator than the successful performance of a major operation. A sharp -instrument, usually a chisel, is placed against the free edge of the -nail so as to cut only through the nail itself and not into the nail -bed, with the purpose in mind of removing a wedge-shaped piece of nail -of just the size necessary to relieve irritation, and permit of proper -drainage and dressing. - -Exuberant granulations are best treated either with nitrate of silver -applications (50 per cent.) or with tight packing, or both. -Disinfection and wick drainage of the entire tract is of the utmost -importance. - -+The Radical Treatment of Ingrown Toe Nail.+ The operations, as in the -palliative treatment, naturally fall into two classes depending on -(1) whether the nail originally was at fault, or (2) whether the soft -tissues, by inflammatory processes, have hypertrophied and overgrown. - -Operations depending on such diseases or malformations of the nail, -causing it to grow down into the tissues, should be directed to the -removal of the nail, or the offending part of it with its matrix. (See -"_Hypertrophy_"). - -In conditions manifestly due to disease and hypertrophy of the soft -tissues, palliative treatment frequently fails, and it becomes -necessary to curet the granulating nail fold or to erode it with -chemicals. - -The best and easiest operation to effect a permanent cure, where this -condition obtains, is known as Weber's operation. This operation -consists of the excision of an elliptical section of tissue just -alongside of the offending nail border, without interfering with the -diseased tissues themselves, and suturing the cut edges together in -the long direction of the wound. The incisions are made to extend a -little further back than the nail and as far forward as possible. They -are about a quarter of an inch apart at the centre and meet at these -two points. The depth of the section of tissue removed, if -sufficiently great, leaves a diamond shaped cavity. When the edges of -the wound are brought together the overgrown edge is pulled away from -the nail and the further cicatrization of the wound contracting the -soft tissues, assures an excellent result. - - -+HYPERTROPHY+ - -+Hypertrophy+ can result only from hyperplasia of the papillae of the -matrix, the thickening of the nail occurring at the base, front, -lateral edges, or over its whole extent, according to the parts -diseased. The nail may be evenly thickened or variously curved or -twisted, while its structure becomes brittle, opaque and discolored. - -Removal of the most projecting portions of the nail will reveal the -papillae elevated far above the normal level of the matrix. - -The change is slow and progressive, and when pronounced is usually -permanent. The causes are not well understood; pressure, however, -seems to be an exciting cause, this being more causative in the nails -of the toes, especially those of the great and the little toe. - -The old, whose epithelial structures tend to overgrowth, are more -liable to hypertrophy of the nails than the young. - -When attacking the fingers, beyond the blunting of the tactile -sensibility and the deformity, no special trouble arises, unless -painful cracks form from the splitting of the brittle nails. When -affecting the nails of the feet, however, it is difficult for the -patient to wear shoes, the pressure leading to inflammation of the -adjacent soft parts and eventually causing typical ingrown nail. - -Back pressure upon the matrix from a short shoe upon a thick -unresisting nail, is frequently the cause of onychia. - -+Palliative Treatment of Hypertrophy.+ When the deformity seriously -interferes with the wearing of shoes, or shows a tendency to cut into -the lateral fold, it becomes necessary to establish normal dimensions -either with the knife or drill. - -The total removal of the nail; including the matrix, is the only -permanent cure. Excision of the cutting edge of the nail, as in -radical operation of ingrown nail, eliminates only that element of -discomfort. - -The thinning of the nail, by scraping or with the drill, can also be -accomplished with sodium sulphide. A sufficient quantity of the -sulphide is added to starch paste to make it swell; this, when applied -(use a wooden applicator) to the thickened nail, will cause the nail -to disintegrate. By touching the surface with the applicator, one can -determine the depth of nail destroyed before washing off the excess -sulphide. - -+Radical Treatment of Hypertrophy.+ When the thick nail has cut into the -lateral fold and actual ulceration has occurred, it becomes necessary -to remove the down-curved edge. - -Under local anesthesia, an incision is made through the nail, a -little to the side of the inflamed area, and is carried well back -through the matrix. A curved incision, outside of the infected fold, -meets the first incision in front and back of the nail. All the tissue -between is removed in one piece, including the offending portion of -nail with its matrix and the nail fold with all granulation tissue. - -This wound may be brought together by catgut sutures, or may be -allowed to heal by granulation. - -This operation suffices to prevent further trouble at the nail edge, -but does not prevent the discomforts due to a long, distorted, horny -nail. Total removal of the nail with its matrix is the only radical -cure. (See "_Local Anesthesia"_). - -+Inflammation of the Matrix (Onychia).+ As a result oftraumatism in -unhealthy individuals, inflammation and suppuration sometimes occur at -the root of a nail and in the contiguous portion of matrix -("run-around"), and often stubbornly continue unless the loosened, -sharp edge of the buried nail be carefully trimmed away from time to -time, and a little iodoform gauze be employed to press back the -inflamed tissues. - -From lateral hypertrophy of a toe-nail the sharp lateral edge becomes -imbedded in the lateral fold, or from improper lateral compression of -the toes, the same portion of soft tissues is forced up against the -margin of the nail. In either case, inflammation, suppuration, and -ulceration ensue, resulting in the formation of red, exuberant, -excessively painful granulations, constituting the condition called -_ingrowing toe-nail_, though more correctly it should be termed -"up-growing pulp." Sometimes both edges, or even the whole matrix, -become involved, producing pain on any movement of the member. - -When inflammation and ulceration of the whole matrix occur, especially -where a finger is involved, the condition is termed _onychia maligna_, -which attacks only those in depressed health. - -+Treatment.+ The palliative treatment suggested for ingrown nail is -indicated for all inflammations of the matrix, as far as the -disinfection or removal of the portion of nail producing irritation is -concerned, but in onychia maligna the whole nail usually requires -removal under local anesthesia, with destruction of the matrix by -caustics, or by curetment. - - - - -Chapter XV - -+TUMORS AND CYSTS+ - - -+TUMORS+ - -+Definition.+ A tumor is a circumscribed mass of tissue made up of cells -of the same kind as the tissue from which it grows. - -There are two distinct types of tissue in the body: epithelial and -connective, and therefore two types of tumors: the _epithelial tissue -tumors_ and the _connective tissue tumors_. - -Tumors may also be classified as _typical_, and _atypical_. A typical -tumor is one in which the cells are identical to those in the tissue -from which it springs, and also has the same arrangement of cells. -They may be of epithelial or connective tissue origin. The tissue is -identical in all respects and the growth is benign. An atypical tumor -is one of epithelial or connective tissue origin in which, though the -cells are the same as those in the tissue from which it grows, their -arrangement is quite different. They are malignant. - -The most important classification of tumors is that into _benign_ and -_malignant_. - -A _benign tumor_ is one in which there is no tendency to rapid growth; -the symptoms are purely local, and the general health is not affected, -except indirectly. - -On the other hand a _malignant tumor_ is one which takes on a rapid -growth with a tendency to infiltrate or adhere to surrounding -tissues; recurs when removed, and is accompanied by great pain and a -rapid loss of weight and strength. These are commonly known as -cancerous. - -Malignant growths are of two types, carcinomatous and sarcomatous, -dependent upon the tissue from which they emanate. - -The _carcinomata_ spring from the epithelial type of tissue while the -_sarcomata_ emanate from the connective tissue type. - -+Origin.+ Tumors originate from many causes. Some are congenital and -others grow in later life from an inherited tendency. - -Any continued irritation which acts mechanically or chemically so as -to maintain a constant, though slight, degree of undue vascularity of -a part, such as the hot, rough stem of a clay pipe or a jagged tooth, -favors the development of a malignant growth. Certain benign growths, -such as warts or moles, are especially prone to malignant change. Age -and sex also predispose to tumor formation. - -Thus carcinoma is a rarity under thirty years of age; the mammary -gland of the female is more liable to carcinoma than the male; while -on the other hand the esophagus, lip and tongue of the male are more -liable to attack. - -The possibility of certain malignant growths being of germ origin is -thought to be evident (though not yet proven) from many facts. The -fact that where there are malignant growths present, lymphatic glands, -quite distant from the original growth, become secondarily infected, -through the lymphatic vessels, seems to carry out this view. - -Particles of a carcinoma (metastasis) floating in the blood stream, -finding lodgment elsewhere also establish new growths (metastatic). - -Tumors are named according to the tissues from which they arise, thus: - - - CONNECTIVE TISSUE TUMORS - - Fibrous tissue----Fibroma - Fatty tissue----Lipoma - Mucous tissue----Myxoma - Muscular tissue----Myoma - Cartilage----Chondroma - Bone----Osteoma - Blood vessels----Angioma - Lymphatics----Lymphangioma - Lymphatic glands----Lymphoma - - - EPITHELIAL TISSUE TUMORS - - Warty----Papilloma - Glandular----Adenoma - Skin----Epithelioma - - -+CYSTS+ - -+Definition.+ Cysts are hollow tumors filled with fluid or semi-solid -contents. They are classified according to their mode of development: - - 1. Cysts formed in already existing spaces such as sebaceous - cysts in the sebaceous glands of the skin; mucous cysts in - mucous glands, and distension cysts in ducts of large glands - like the salivary, lacteal, hepatic, etc. - - 2. Cysts of new formation into the tissue spaces from the - effusion of blood or plasma. - - 3. Congenital cysts known as dermoids. - - 4. Cysts of parasitic origin. - - The only cyst with which the chiropodist ordinarily comes in - contact is of the sebaceous variety. - -+Sebaceous Cyst.+ A sebaceous cyst is a tumor resulting from retained -sebum (secretion of the sebaceous glands). - -They sometimes, though rarely, are found on the soles of the feet. -They range in size from a millet seed to the size of an egg or larger; -they may be globular or flattened. They may be single or multiple; the -skin over them is normal in color and smooth, or white if distended, -red if inflamed. They grow very slowly and ordinarily persist -indefinitely, but calcareous changes are common. Not infrequently -they break down and ulcerate. The wall is made up of connective tissue -lined with epithelium and the secretion if chemically altered, becomes -fluid, semi-fluid, cheesy or purulent. - -+Treatment.+ Spontaneous cure often occurs when a cyst becomes inflamed -and suppurates. The pus is evacuated either spontaneously or by -incision, following which the walls of the sac adhere and its cavity -is obliterated. - -Treatment directed toward the obliteration of the sac is the only -procedure which gives promise of permanent cure; mere puncture and -evacuation will effect only temporary relief, the sac soon filling -again. - -Incision followed by dissection and removal of the sac, either intact -or punctured, is radical and efficient. - -Puncture and evacuation, followed by swabbing out with pure phenol or -strong iodin, may set up an inflammatory reaction within the sac, -which acts similarly to the suppurative process, causing adhesion of -the walls, thus preventing a recurrence. - - - - -CHAPTER XVI - -+FRACTURES, DISLOCATIONS AND SPRAINS+ - - -+FRACTURES+ - -A fracture may be defined as a broken bone. Fractures are classified -as follows: - - 1. As to their degree. - 2. As to the direction of the line of fracture. - 3. As to their location. - 4. As to the etiology. - 5. As to their relation to the overlying skin. - 6. As to the number of fragments. - 7. As to whether they are complicated or not. - -+Degree of Fracture.+ A fracture which only involves a portion of the -thickness of the bones, so that its continuity has not been entirely -lost or a fragment has not been completely detached, is called an -_incomplete fracture_. A fracture which involves the entire thickness -of the bone, so that it is divided into two or more distinct -fragments, is called a _complete fracture_. - - -+INCOMPLETE FRACTURES+ - -Among the varieties of incomplete fracture are: greenstick; fissured; -depressed. - -+Greenstick Fractures+ (really a bending rather than a break of the -bone) are mostly seen under the age of fifteen, and the bones of the -leg are rarely affected. - -+Fissured Fractures+ are those in which there is a split or crack in the -bones; they are very rare in the bones of the lower extremity. - -+Depressed Fractures+ are fractures in which one or more segments of -broken bone are depressed; they are most common in fractures of the -skull. - - -+COMPLETE FRACTURES+ - -+Complete Fractures+ are divided according to the line and the seat of -the breech of bone continuity. - - -DIRECTIONS OF THE LINES OF FRACTURES - -+Transverse+, when the line of fracture does not deviate more than ten -to fifteen degrees from that of the transverse axis. This variety is -rare in the shaft of the long bones. It is usually found at the lower -end of the radius or of the femur, and in the short bones. - -+Longitudinal+, when the break is parallel to the long diameter of the -bone; very few cases of this variety are seen. - -+Oblique+, when the direction of the line of fracture may form any angle -with the transverse axis of the bone up to a right angle. When it -approaches the latter, it belongs to the group of longitudinal -fractures. In the oblique variety, the line of fracture may be single -or multiple. This and the spiral form are most frequent in the shafts -of the long bones. - -+Spiral+, when the break line is spiral. This variety of fracture was -formerly considered to be very rare. The more systematic use of the -X-ray as part of the routine of diagnosis has shown that spiral -fractures are quite frequent in the shafts of the tibia and fibula. -They are usually the result of a rotating or twisting force. - -CLASSIFICATION OF FRACTURES - -+Comminuted+, when there is extensive splintering of the bone adjoining -the fracture or one of the fragments. - -+Impacted+, when the fragments are driven into each other. This variety -usually occurs in the neck of the femur. - -+Compression, or Crushing Fractures+, when the broken bones are -compressed or crushed; this variety usually occurs in the tarsal -bones. The spongy portion and cortical layer are both crushed. In some -cases there is a perfect pulpification of these bones. This condition -occurs after falls from a height upon the sole of the foot. - - -LOCATION OF FRACTURE - -+In the Diaphysis of a Bone.+ Breaks in the diaphysis of a bone are -spoken of as fractures of the _shaft_, and to be still more exact, it -is stated whether of the upper, middle, or lower third. - -+At the Ends of Bones.+ Fractures occurring at the ends of bones receive -the name of the part which the line of fracture transverses; for -example, fractures of the _neck_ of a bone, of a _tuberosity_, of a -_process_, of a _condyle_, etc. - -There are two forms of fracture that require special mention in -connection with their location. These are _epiphyseal separations_ and -_articular fractures_. - -+Epiphyseal Separations.+ The union of the epiphysis to the diaphysis -commences during puberty, hence these fractures are less common in -childhood than after the ages of eleven or twelve. As a rule, they can -only occur before the twentieth year. The periosteum is more resisting -and tougher during the early years of life than later on. - -+Articular Fracture+ (_joint fractures_). Like epiphyseal separations, -recognition and proper treatment of these fractures have assumed great -importance. - -Articular fractures may be divided into three classes: - - 1. _Intra-articular._ In these the line of fracture lies - entirely within the joint. Such fractures are most frequently - found in the elbow and knee joint. - - 2. _Para articular._ In these the line of fracture extends - close to the joint but not into it. An example of this class - is the _supracondyloid_ fracture of the humerus. - - 3. _Articular fractures proper._ The majority of joint - fractures belong to this class. The line of fracture either - extends into the joint from without or it extends from the - joint outward. As example, the ankle joint; the majority of - the typical supramalleolar, malleolar, and spiral fractures of - the tibia and fibula. - -+Etiology.+ Fractures may be divided into two groups: the _traumatic_ -and the _pathologic_ or _spontaneous_. In the traumatic, the fracture -is the result of violence acting upon a bone which is either normal or -shows slight changes due to the physiologic causes mentioned. A -pathologic or spontaneous fracture is one which occurs in a bone, the -strength of which has been diminished by some preceding abnormal or -pathologic changes. In this variety the degree of force which produced -the fracture would not be sufficient to cause a fracture in a healthy -bone. - -The causes of traumatic fractures may be either predisposing or -exciting. - -+Predisposing Causes.+ The bones of the human body attain their greatest -strength toward middle age. From infancy up to that time the bones are -very elastic and yielding. Toward old age an interstitial atrophy -occurs. It causes a thinning of the cortex of the shafts and of the -trabeculae of the spongy portions of the long and short bones. It is -an actual diminution of the bone substance and a corresponding -increase of the fat. This is especially seen in the neck of the femur. -When it occurs in old age, it acts as a predisposing cause, but when -it occurs prematurely or reaches an extreme degree, it must be -considered as pathologic. - - -EXISTING OR DETERMINING CAUSES OF FRACTURES - -+Fractures by External Violence+ are divided both clinically and from a -mechanic standpoint into two classes: _direct_ and _indirect_. In -fractures by direct violence the bone breaks immediately under the -point where the force has been applied. In this class of fractures -there is more damage to the soft tissues and this damage is generally -more serious than in indirect fractures. Direct fractures are more -likely to occur in exposed bones like the clavicle, os calcis, etc. - -An example of fracture by direct violence is found in fractures of the -tarsal bones after a fall upon the feet from a height. - -Under the head of fractures by indirect violence belong (a) those -which occur as the result of a rotary or twisting force (spiral -fracture of the tibia or fibula, for example); (b) those which are -produced by compression; (for example, a fall upon the feet may cause -an impacted fracture of the upper end of the tibia); (c) those which -are the result of a tearing force. - -Fractures resulting from a tearing force occur when a joint is -suddenly moved beyond its normal range of excursion. The firmly -attached ligaments being a fixed point, the ends or some process of -the bones composing the joint are torn off from the remainder of the -bone. Examples of this are fractures of the internal or external -malleoli, following forcible eversion or inversion of the foot. - -Fractures are also caused by muscular action and by gunshot injuries. - -+Pathologic+ (spontaneous fractures): - - 1. Fractures resulting from bone fragility of local origin as - for example, tumors, osteomyelitis, aneurisms. - - 2. Fractures resulting from bone fragility due to some general - disease, as for example, tabes dorsalis, paresis, rachitis, - osteomalacia, and exhausting chronic diseases. - - - CLASSIFICATION AND RELATION OF FRACTURES TO THE OVERLYING SKIN - -Fractures are divided into _compound_, or _open_ and _simple_, or -_subcutaneous_, according to whether a communication does or does not -exist between the seat of fracture and a wound of the skin. - -A compound fracture is one in which the cutaneous wound communicates -with the seat of the fracture. - -A simple fracture is one in which a wound of the skin is absent, or, -if present, no communication exists between it and the seat of the -fracture. - -The majority of compound fractures are the result of direct violence, -and the injuries of the soft parts, are, as a rule, far more extensive -and serious than in a simple fracture. A fracture which is simple at -first, may become compound as a result of necrosis of the skin lying -over it; or as a consequence of the original injury; or of pressure -upon it by a displaced fragment; or by penetration of the skin, in -efforts to use the limb. - - -FURTHER CLASSIFICATION OF FRACTURES - -+Fracture.+ In the ordinary use of the term "fracture" is understood to -indicate a _complete_ or _incomplete_ separation of the bone into two -or more fragments, the lines of which are continuous with each other. - -+Multiple Fracture.+ The term _multiple fracture_ is applied to the -simultaneous fracture of two or more non-adjacent bones, and also to -those cases in which two or more fractures of the same bone exist, and -the lines are not continuous with each other. Such multiple fractures -are usually the result of direct violence. - -+Complicated Fracture.+ When a fracture is accompanied by injuries of -the viscera, nerves, etc., the term _complicated fracture_ is applied. -Such a fracture may be simple or compound. The term complicated, as -ordinarily employed, is limited to those fractures which are -accompanied by local, rather than by general complications. - -+Symptoms of a Recent Fracture.+ In the examination of a patient who has -sustained a recent fracture, procedure should be as follows: the -history of the patient and of the accident should be taken; an -examination should be made for objective signs, like deformity, -abnormal mobility, crepitus, and ecchymosis; subjective symptoms, such -as pain and loss of function of the limb should be ascertained; an -X-ray picture should be taken and every possible precaution observed -to exclude distortion or exaggeration. - -+Treatment of Fractures.+ _First Aid._ The treatment of fracture may be -said to begin from the moment of its occurrence. Much can be done for -the comfort of the patient and correct union of the fracture by -intelligent treatment during the first hours. - -The proper temporary fixation of the limb, the mode of transportation, -and the removal of the clothing, all require special mention. - -The use of first aid dressings, those which can be used until more -permanent and suitable ones can be applied, varies, of course, with -the individual bone affected. In fractures of the tibia, fibula and -foot, as well as in those of the lower half of the femur, the use of -the blanket splint will be found of great aid. Instead of a blanket, a -long pillow or soft cushion can be employed in the same manner. - -The "blanket splint" can be readily made by folding a blanket in such -a manner that it extends from the middle of the injured thigh to below -the foot. Two pieces of narrow, strong board, or better still, two -broomsticks are rolled up in the blanket, one at either end. The -rolled-up blanket is now turned in so that the board supports with -their enveloping turns of blanket, lie upon the posterior surface. -Thus, a trough is formed in which the limb is placed and firmly -secured by loops of bandage, one below the foot, the second just above -the ankle, the third below the knee, and the fourth near the upper end -of the blanket. - -In fractures of the leg, after the application of the emergency -splint, the patient should be transported in a recumbent position, the -support being as firm as possible, a wide board, shutter or a wooden -rail being preferable. If such supports are not at hand, and the -patient is to be moved without their use, the persons transporting the -invalid should be distributed in the following manner: one supporting -the head and shoulders, a second the pelvis, and the third the two -limbs. - -+Reduction.+ The reduction of a fracture is the effort made by the -surgeon to overcome any tendency to displacement, and thus to place -the fragments in such close apposition that an accurate and firm union -is possible. The best time in general for the reduction of a fracture -is as soon as possible after the accident, if the patient's general -condition will permit. If there is marked displacement of fragments, -so that there is danger of necrosis of the overlying skin or of damage -to the adjacent vessels or nerves, an early reduction is imperative. - -In all cases in which reduction is very painful or difficult, whether -performed shortly after the accident or at a later period, it is best -to administer an anesthetic to overcome muscular contraction and to -decrease the amount of pain. After reduction of a fracture, retentive -apparatus is indicated in order to maintain apposition. In the use of -dressings there will be two kinds, those which are temporary and those -which are permanent. The former are employed where the swelling of the -limb is such that some dressing can be employed which will not cause -pressure. - -Certain general principles should be followed in the use of splints; -for instance, a splint, after being applied, should not interfere with -the circulation, allowance always being made for the swelling of the -limb, which almost invariably occurs during the first week. The -splint, if flat, should be wide enough to obviate the possibility of -pressure against the point of fracture; also, it should project a -little beyond the limb. - -In general, it is best to immobilize the adjacent joints, above and -below the seat of fracture, but no dressing should be permitted to -remain so long as to produce stiffness of the joints and muscular -atrophy. - -The skin, even in simple fractures, must be cleansed with green soap, -water and alcohol. If blebs or an area of threatening necrosis of the -skin exist, they should be freely dusted with powdered boric acid and -a few layers of aseptic gauze applied. - -The form of retentive apparatus to be employed will vary, of course, -with the individual bone requiring treatment. - -The most important articles of a fracture equipment are as follows: - - 1. Plaster of Paris bandages for making molded splints and - circular casts. - - 2. A stock of basswood, three-sixteenths of an inch thick, for - making wooden splints. - - 3. An assortment of metal splints or materials for making - them. - - 4. Muslin for bandages and slings. - - 5. Five yard rolls of ordinary and zinc oxide adhesive - plaster, three inches wide. - - 6. Cotton batting and sheet wadding for padding splints. - - 7. Strips of tin or thin cypress for strengthening plaster - casts. - -The selection of a dressing for the immobilization of a fracture -depends upon, _first_, the particular bone involved and whether -apposition can be maintained with or without extension; _second_, -whether great swelling be present or not; _third_, whether the -fracture be simple or compound; and _last_, whether ambulatory -treatment be preferable to that in the recumbent position. This latter -applies, of course, only to fractures of the lower extremity. - -+Operative Treatment of Simple Fractures.+ Operative treatment of a -recent simple fracture is indicated in general, when reduction cannot -be completely made; when correct apposition cannot be maintained; when -there is interposition of bone or soft parts; when the fracture is a -spiral one with considerable displacement of the fragments; when -fragments are rotated upon each other, and when there are multiple -fractures. - -The most favorable time to operate in recent simple fractures is at -the end of the first or beginning of the second week. At this time the -process of callus formation is most active. The blood clots and loose -shreds of tissue have begun to be absorbed, so that the fragments are -more easily accessible. - -+Methods of Fixation of the Fragments.+ In the majority of cases the -reposition of the fragments alone is not sufficient to maintain -accurate apposition. It is usually necessary to employ some means of -mechanical fixation. In all the methods employed, the preparation of -the parts is the same as for any aseptic operation. The opportunity -for serious complications resulting from septic infection, is greater -than in any other class of operations. It is for this reason that -extraordinary caution must be exercised. The incision should be large -enough to expose the seat of the fracture thoroughly. - -The materials used to secure fixation are: absorbable sutures, such as -chromicized catgut or kangaroo tendon; metal suture of silver or -bronze aluminum wire; screws, nails, plates, clamps, etc. - -+Injuries in the Vicinity of the Ankle Joint.+ In the examination of a -patient who shows evidence of injury in the vicinity of the ankle -joint, such as swelling, deformity, loss of function, etc., the -following conditions must be thought of, in the order given: - - 1. Fractures of the lower ends of the tibia and fibula - (Pott's Fracture). - 2. Dislocation at or near the ankle. - 3. Fractures of the tarsal bones. - 4. Rupture of the tendon Achillis. - 5. Sprains of the ankle. - -+Fractures of the Lower Ends of the Tibia and Fibula.+ Commonly given -the name of _Pott's Fracture_. They may be the result either of -forcible abduction or eversion of the foot, or of inversion or -adduction. If the sole or main movement is eversion, the _internal_ -malleolus is broken, and if the force continues to act, it also causes -the _external_ malleolus to be broken. In the second variety, fracture -by inversion, the first effect of the force is to break the fibula at -the external malleolus. If the movement continues, the internal -malleolus or a greater portion of the tibia is broken off. - -+Diagnosis.+ The diagnosis is usually easy to make. The ankle joint is -greatly swollen, the depression, normally present in front of and -behind the malleoli, being obliterated. The foot is displaced outward, -and the internal malleolus is prominent. This deformity will often -persist and become a cause of disability after healing of the -fracture. - -There is also backward displacement of the foot. These displacements -may be so marked as, at first glance, to resemble a true dislocation -of the ankle. - -Abnormal lateral and anteroposterior mobility may be ascertained by -grasping the sole of the foot with one hand and moving it inward and -outward, or backward and forward, while the other hand steadies the -leg. There is great tenderness between the tibia and fibula at the -front of the ankle, and over the points of fracture in the malleoli. - -If the fibula alone be broken, abnormal mobility and crepitus may be -elicited by pressing its tip inward with the index finger of the one -hand while a finger of the other hand is placed at the seat of -fracture. - -In some cases of Pott's fracture the foot will move inward instead of -outward. The degree of outward displacement can be measured by the -difference in the distance from the front of the ankle to the cleft -between the first and second toes, as measured on the sound and -injured foot. There is not always complete loss of function. In -fractures of the external malleolus alone, the patient may walk quite -well. - -+Treatment of Fractures of the Leg.+ The treatment of a simple fracture -of one or of both bones of the leg depends _first_, upon whether or -not swelling is present, and _second_, upon the amount of displacement -of fragments and our ability to keep them in apposition after -reduction. If the case is seen within a few hours after the injury and -but little, if any, swelling be present, the following is a perfectly -safe and justifiable method of treatment: - -The limb is wrapped with strips of sheet-wadding from the toes to the -middle of the thigh, and a circular plaster of Paris cast is applied -extending over the same area. Before the cast is dry, it is cut open -along the median line, in front, to allow for any swelling. The cast -is best applied while the patient is under the influence of an -anesthetic, so as to permit reduction of the fragments by traction -upon the foot. In from ten days to two weeks the cast should be -removed and a fresh one applied. The second cast does not require to -be cut open, and can be left on the limb until the end of the fourth -week. It is then removed and if union be complete, no further cast -need be worn. Massage of the limb and passive and active motion are -now begun. - -+Fractures of the Tarsal Bones.+ Fractures of these bones have been -found far more frequently than was thought before the use of the -X-ray. Many cases of tarsal fracture have been treated for sprains of -the ankle. It is only when the recovery is slow or the injury is -followed by a traumatic flat foot that the surgeon begins to suspect -that a more serious condition was present at the time of the original -injury. - -The astragalus and os calcis are the tarsal bones that are usually -affected. Fractures of the os calcis, in the majority of cases, are -due to compression. The patient falls from a height to the ground, on -a hard substance. The os calcis is crushed between the astragalus and -the ground. - -There are three general types of fracture of the os calcis: - - 1. That in which the fracture has been confined largely to - that portion lying behind a vertical plane through the middle - of the body of the astragalus. There are three varieties of - this heel fragment type: (_a_) cases with one large heel - fragment; (_b_) cases of small heel fragments (in this - variety, also called avulsion fracture, the sudden contraction - of the calf muscles pulls the fragment off; at times the tendo - Achillis itself is torn off from the attachment to the os - calcis at the same time); (_c_) cases showing only fissures in - the bone. - - 2. Comminution of the anterior half of the os calcis. - - 3. All the cases of extensive comminution of the bones; the - bone is literally shattered. - -+Fractures of the Astragalus.+ These can be divided into: (_a_) those of -the neck; (_b_) those of the body. The former are the most common -fractures of the astragalus. They may follow sudden dorsal flexion, or -forced supination, or pronation of the foot. They may be due to a fall -from a height or from direct violence. Fractures of the body of the -astragalus are usually the result of a crushing force which ordinarily -have a like effect on the body of the os calcis, and are often -associated with fractures of the latter bone. The variety of fractures -is considerable, varying from two large fragments, to complete -comminution of the bone. - -A fact of considerable importance in the interpretation of skiagraphs -of fractures of the astragalus, is a knowledge of the presence in many -normal individuals of a little bone known as the _os trigonum_. It may -occur detached from the astragalus or may be attached to it as a -process, on its posterior aspect, and on account of the swelling and -pain around the ankle, a diagnosis can seldom be made without the -routine use of the X-ray in every injury in this region. - -The swelling, with obliteration of the depressions normally present -around the ankle, does not differ from that characteristic of a sprain -of the ankle or of a Pott's fracture. If there is extensive -comminution of the os calcis or astragalus, the malleoli may be a -little lower than normal. - -The X-ray must always remain our most reliable means of diagnosis at -the time of the injury. At a later period the chief symptoms are a -painful flat foot, ankylosis of the ankle joint, pain and difficulty -in pronating and supinating the foot. - -The prognosis of fractures of the tarsal bones is not favorable, even -though the lesion has been recognized at the time of injury. Even in -the most favorable cases there is some limitation of lateral motion. -The outlook is better in those cases of fracture of the os calcis in -which there is a large heel fragment, than if the fracture is -comminuted. The most frequent sequel is stiffness of the ankle-joint -and traumatic pes valgus. Infection is frequent in compound fractures. - -+Treatment.+ This does not differ from that of a Pott's fracture until -the greater part of the swelling has disappeared. The skin of the foot -and lower portion of the leg should be thoroughly cleansed and covered -with gauze. This is necessary on account of the possibility of -necrosis of the skin of the heel, and the danger of infection of the -bruised soft tissues around the heel. - -The foot should be placed in a well-padded box or in a posterior -splint of the Volkman type. Ice bags should be applied over the sides -of the heel. - -After from eight to ten days, a circular plaster cast can be applied, -extending from the toes to the knee. An anesthetic should be given -during the application of the cast, the foot being held flexed at -right angles and sheet wadding freely used around the ankle. The cast -should be worn for seven weeks. At the end of this time the patient is -gradually permitted to step upon the injured foot. Passive and active -motion are also now employed. - -Fractures of the neck of the astragalus, with rotation of the -posterior fragment, are usually followed by great limitation of the -movements of the ankle joint. This condition might be greatly improved -by an open operation. - -+Fractures of the Metatarsal Bones.+ These are usually due to direct -violence, as occurs when a heavy weight falls upon the dorsum of the -foot. Another example of direct violence is a fracture following a -crushing injury, as in being run over. - -In indirect violence, such as follows dancing, jumping, or sudden -twists of the foot, the fifth metatarsal bone is the one most often -involved. There is but little tendency to displacement except when -several bones are broken at the same time, and then it is toward the -dorsum of the foot. - -The diagnosis in fractures produced by direct violence is made from -the following: presence of severe localized pain; swelling; and, not -infrequently, crepitus and abnormal mobility. In those fractures due -to indirect violence (second, third and fifth metatarsals), there is -pain when the patient endeavors to put pressure upon the toes or tries -to invert the foot. The usual signs of fracture are absent. A -skiagraph should be made in every case. - -Fracture of the metatarsal bones is liable to be followed by traumatic -flat foot, on account of the sinking of the arch, or painful large -calluses forming on the sole of the foot may interfere with walking. - -+Treatment.+ The treatment in such fractures is by immobilization in a -posterior metal or plaster splint, for four weeks. If there is -continual pain upon walking after the injury, a steel insole will -often give relief. The treatment of compound fractures of the -metatarsal bones does not differ from that of other bones. - -+Dislocations.+ A dislocation is a displacement from each other of the -articular ends of the bones which enter into the formation of a joint. -A diagnosis can usually be made from certain objective and subjective -symptoms, taken in conjunction with an accurate history of the manner -in which the accident occurred. - -Examination should be made in a systematic manner in every case, us -follows: - -(1) _Inspection._ The limb should be first inspected to note the -position, the alterations of contour, or of the axis of the limb, or -the projection or absence of certain bony prominences. The position is -often so characteristic that a diagnosis can be made by inspection -alone. - -(2) _Palpation._ By this one can learn the relation of the displaced -articular ends to each other, unless the swelling is too great, or -the patient is very stout. This method also enables one to ascertain -the absence of normal prominences or the presence of abnormal ones. -The end of the displaced bone may be felt in an abnormal position. - -(3) _Measurement._ The limb may only appear to be or is actually -shortened. In the latter event the normal measurements between bony -prominences will be altered. - -(4) _A skiagraph_ should be made in all doubtful cases to confirm the -diagnosis of dislocation, and also to ascertain whether there is an -accompanying fracture. - -When the patient is stout, or when considerable swelling exists the -use of the X-ray is of especial value. - -The attitude of the limb is often so characteristic that simple -inspection will enable one to make a diagnosis by this means alone. In -stout persons, a change in the axis of the limb or a change in -position is apt to be overlooked. The relation of the articular -surfaces can be determined by palpation, unless the swelling is too -great. Measurement of the limb will usually show a shortening, -depending upon the position in which the limb is held. The movements -of a dislocated joint are usually limited. If any movement of the end -of one of the bones is felt, it is always at an abnormal point. Pain -is referred to the dislocated joint and the patient is unable to use -the limb. - -+Treatment.+ As a rule, a dislocation should be reduced as soon as the -diagnosis is made, and, if necessary, an anesthetic should be -administered. - -When reduction has been accomplished, the bone often goes back with a -snap, the contour of the limb is restored, and the movements of the -joint are free again. - -If it is impossible to reduce a recent dislocation, the following -obstacles must be considered: (_a_) interposed portions of the -capsule; (_b_) interposed muscles or tendons or sesamoid bones; (_c_) -torn off fragments of bone; (_d_) a fracture of the shaft close to its -articular end, which would prevent its being used as a lever for -reduction. - -The after-treatment of a dislocation is usually quite simple. A -bandage or splint should be applied, which will keep the joint -immobilized for a period of two weeks, after which passive motion and -massage can be begun for fifteen minutes twice daily, the splint or -bandage then to be reapplied for another two weeks. - - -+DISLOCATIONS AT THE ANKLE JOINT+ - -+Backward Dislocations+ occur more frequently than those in a forward -direction. - -The injury usually is the result of a fall backward while the foot is -flexed. This causes an extreme plantar flexion of the foot. The -astragalus, and with it the foot, is displaced backward. The lateral -ligaments are usually extensively torn. In the majority of cases there -is an accompanying fracture of either one or both malleoli or of the -shaft of the fibula. - -+Diagnosis.+ The front portion of the foot is shortened while the heel -is more prominent than normal. The lower end of the tibia protrudes -over the dorsum of the foot and the sharp edge of its articular -surface can be distinctly felt. The extensor tendons and the tendo -Achillis are tense and prominent. It may be distinguished from a -supramalleolar fracture by the fact that the malleoli in the latter -have moved backward with the foot, while in a dislocation backward -they are prominent at some distance in front of the heel. - -+Treatment.+ Reduction is usually effected by forced plantar flexion, -the foot being pulled forward and the lower end of the tibia being -pushed backward. These steps are then followed by dorsal flexion of -the foot. - -After reduction, the leg should be immobilized for three weeks in a -molded posterior splint. Light passive motion can be begun during the -fourth week. In old unreduced cases an arthrotomy is indicated. - -+Forward Dislocations.+ These are much rarer than the backward form. -They are usually due to a forced dorsal flexion of the foot. This form -is less often accompanied by a fracture of the malleoli than is the -case in the backward dislocation. The fibula is seldom broken, the -usual seat of the fracture being in the tip of the internal malleolus -or in the articular surface of the tibia. - -+Diagnosis.+ The whole foot appears to be lengthened. The prominence due -to the heel has disappeared; the upper articular surface of the -astragalus can be felt, the tibia and the malleoli being nearer to the -heel. - -The condition can be differentiated from a fracture of both bones of -the leg above the malleoli by the fact that in a forward dislocation -the malleoli are further back than normal, while in a supramalleolar -fracture they have moved forward with the foot. - -+Treatment.+ Reduction is readily effected by marked dorsal flexion of -the foot, pressure being made in a forward direction upon the lower -end of the tibia, and the foot pushed backward. Plantar flexion now -completes the reduction. The after treatment is the same as in the -backward form. - -+Lateral Dislocations.+ The other forms of dislocations seen in the -ankle are those in a lateral direction, either inward or outward. The -diagnosis is usually easy. The upper convex surface of the astragalus -is directed toward the external malleolus and can be felt there. The -inner border of the foot is raised; the outer rests upon the bed. - -This form of dislocation is very frequently a compound one, or it is -accompanied by fractures of the bones of the leg or of the astragalus; -but it may occur without these injuries. - -+Treatment.+ The treatment of these lateral dislocations differs but -little from that of fractures of the lower end of the tibia and -fibula. Reduction is effected by adduction or abduction of the foot. -The chief danger is from infection on account of the extensive injury -of the skin and soft parts. If reduction is impossible, perform an -arthrotomy. - -+Subastragaloid Dislocation.+ Two forms of dislocation can occur in the -joint between the astragalus and the two tarsal bones (os calcis and -scaphoid) with which it articulates. In the true subastragaloid form, -the astragalus continues to articulate with the tibia and fibula, but -it is displaced from its articulation with the os calcis and scaphoid. -In the second form of subastragaloid dislocation, the astragalus is -completely separated from its articulation with the bones of the leg -as well as with the calcaneus and scaphoid. To this form the name -total dislocation of the astragalus is given. - -+True Subastragaloid Dislocations.+ These dislocations may occur in four -directions, inward, outward, forward, and backward. - -_Dislocation inward._ The most frequent cause is a forcible adduction -of the foot combined with violence acting in the direction of the long -axis of the foot. The diagnosis can be made from the position of the -foot. The foot is adducted and rotated inward, as in a case of -clubfoot. The sole of the foot is directed inward. The inner edge of -the foot is concave and shortened while the outer edge appears -lengthened. The external malleolus and head of the astragalus are very -prominent on the outer side of the foot. Below and behind the inner -malleolus the scaphoid projects beneath the skin. - -_Dislocation Outward._ This occurs after forced adduction of the foot. -The symptoms are the opposite of those of the inward variety. The foot -is in the position of a flat foot, its inner edge depressed and outer -edge raised. The inner malleolus is close to the sole of the foot, and -in front of it the head of the astragalus forms a prominence. The -injury is not infrequently compound, so that the astragalus presents -into the wound. - -_Dislocation Backward._ The cause is usually a plantar flexion of the -foot. The signs are very pronounced; the head of the astragalus can be -seen and felt lying upon the upper surface of the scaphoid and -cuneiform bones. The anterior portion of the foot is shortened while -the heel is lengthened and the tendo Achillis is very prominent. - -_Dislocation Forward._ This follows forced dorsal flexion of the foot, -the patient falling forward after landing with his heels upon the -ground. The diagnosis can be made because of the lengthened anterior -portion of the foot and the shortened heel. An important point in the -diagnosis of subastragaloid dislocation is the absence of any -prominence due to the projection of the body of the astragalus, in -front, behind, or to either side of the malleoli, as is seen in the -case of the tibiotarsal dislocations. A second diagnostic point is the -abnormal position of the calcaneus and scaphoid with relation to the -malleoli and astragalus. The swelling is usually so great that a -diagnosis is very difficult without the use of the X-ray. - -+Treatment of Subastragaloid Dislocations.+ Reduction can usually be -effected in recent cases by manipulation and traction. In the inward -variety the existing adduction is at first increased. Pressure is now -made over the outer side of the adduction and the inner side of the -foot, and the foot is then strongly abducted. In the outward variety, -the abduction is first increased. Pressure is then made over the outer -side of the foot until reduction is effected. In the backward variety, -the plantar flexion is first increased and the foot is then strongly -flexed in the opposite direction. In the forward type, forced dorsal -flexion will effect reduction. The foot should be placed upon a -posterior molded splint for three weeks, after which passive motions -are begun. If the reduction is impossible, an arthrotomy with excision -of the astragalus may be necessary. - -+Total Dislocation of the Astragalus.+ This form of dislocation is much -more frequent than those of the ankle joint proper, or of the -articulation between the astragalus, calcaneus, and scaphoid. The -displacement of the astragalus may occur in one of six directions: -forward; outward and forward; inward and forward; inward; backward, -and by rotation. - -The most frequent variety is the "outward and forward." In this -variety the foot is rotated markedly inward and the external malleolus -is very prominent. The foot is in a clubfoot position. The dislocated -astragalus can be felt as an irregular angular bone just below the -external malleolus. - -+Treatment+ is the same as in subastragaloid dislocations. - -+Dislocation of the Metatarsal Bones.+ This may be either complete or -incomplete at Lisfranc's joint. It occurs most often in an upward -direction. The dorsum of the foot is more convex than normal, while -the sole of the foot is flattened. One can see and feel the displaced -ends (upper) of the metatarsals on the dorsum of the foot. The foot is -shortened and the toes point inward. - -Dislocations of the individual metatarsal bones are much rarer. The -middle ones are displaced upward, and the first and fifth, inward and -outward respectively. - -+Dislocation of the Toes.+ This occurs most often in the -metatarsophalangeal joint of the great toe after forcible flexion. The -dislocation may be complete or incomplete. In the former case, the -proximal end of the first phalanx and the dorsum of the foot are -prominent, and the head of the metatarsal bone projects on the sole of -the foot. The reduction of toe dislocations presents no difficulties. - - -+SPRAINS+ - -+Definition.+ A sprain is a joint wrench due to a sudden twist or -traction, the ligaments being pulled upon or lacerated and the -surrounding parts being more or less damaged. - -+Sprains of the Ankle.+ On account of its flexibility and constant use -in weight-bearing, the ankle is the joint most frequently sprained. - -Sprains are common in a limb with weak muscles; in a deformed -extremity in which the muscles act in unnatural lines, and in a joint -with relaxed ligaments. - -A joint, once sprained, is very liable to a repetition of the damage -from slight force. - -+Symptoms.+ The symptoms manifested in a sprain are as follows: severe -pain in the joint; nausea and sometimes syncope; impairment, or loss -of motion; severe pain upon motion; early swelling if hemorrhage is -severe--in any case swelling begins in a few hours; movement of the -joint becomes difficult or impossible; the tear in the ligament may -be distinctly felt; in a day or two pain and tenderness become intense -and discoloration becomes marked. - -+Diagnosis.+ Usually the diagnosis is easy to make, but in all doubtful -cases an X-ray picture should be taken in order to be certain that a -fracture does not exist. - -+Treatment.+ The first indication is to arrest hemorrhage and to limit -inflammation. For the first few hours apply pressure and an ice-bag. -Wrap the joint in absorbent cotton, wet with iced water; apply a wet -gauze bandage, and put on an ice bag. - -In a mild sprain, use lead and opium wash. In a severe sprain, place -the extremity upon a splint and apply to the joint flannel kept wet -with lead-water and laudanum, iced water, tincture of arnica or -alcohol and water. If the pain is severe, a small dose of morphine -should be given. - -Judicious bandaging limits the swelling. When the acute symptoms begin -to subside, rub stimulating liniments, such as chloroform or arnica, -upon the joint once or twice a day and employ firm compression by -means of a bandage of flannel or rubber. Later in the case use hot and -cold douches, massage, passive motion and the bandage. - -Another method of treatment of sprains of the ankle is by strapping -with adhesive plaster, but it is advisable only for slight injuries. -In severe cases, in which extensive laceration of the ligaments is -suspected from the marked extravasation, it is best to immobilize the -foot in a plaster-of-Paris splint for two weeks; later baking in a -hot-air oven (see "Arterial Hyperemia") with massage, and active and -passive motion are advisable. - -In simple sprains, the fixation does not produce serious stiffness, -and without fixation the repair of the ligaments is only partial. In -the latter case, the result is weakness of the ligaments and an -instability of the foot which leads to frequent recurrence. This -explains many habitual sprains. On the other hand, under appropriate -treatment, a sprain should recover without leaving any functional -disturbance. - - - - -CHAPTER XVII - -+DEFORMITIES+ - - -+PES PLANUS, OR FLAT FOOT+ - -The terms _weak foot_ and _flat foot_ will be used to designate the -_mild_ and the _severe_ forms of the same condition which include all -the deviations from the normal height of the arch of the foot. - -+Flat Foot+ may be congenital or acquired, the former being a very -infrequent deformity, and the latter one of the most common pathologic -conditions. - -+Congenital Flat Foot+ is a deformity of infrequent occurrence, and in -some cases is associated with defective formation of the bones of the -foot. In this condition the whole foot is displaced outward in -relation to the leg; the sole is rolled outward, the inner malleolus -is prominent and the foot is abducted on itself, and in severe cases, -it cannot be replaced in its normal position on account of the -contracted tissues. - -+Treatment.+ The foot should be massaged and, by gentle manipulation, -forced into its proper position and held by a plaster-of-Paris -dressing, changed at the proper intervals. A tenotomy may be required -to bring the foot into its proper position. - -When the child begins to walk, a well-fitting arch support should be -worn. - -+Acquired Flat Foot.+ The common form of acquired flat foot is the -static variety, which is an expression of a disproportion between the -body weight and the sustaining power of the muscles and ligaments. - -+Common Causes.+ 1. The use of improper shoes is by all means the most -frequent cause of flat foot, and frequently makes all of the following -causes more pronounced. - -2. Weakness and insufficiency of the muscles, resulting from poor -general condition; advancing age; convalescence from acute illness; -from childbirth; and from injuries of the leg, especially fractures. - -3. Prolonged standing, especially on hard wood and stone floors. - -4. Rapid body growth. - -5. Rapid increase in body weight. - -6. Excessive weight bearing. - -7. Shortened condition of the gastrocnemius muscle. - -Other causes are rickets; inflammation of the ankle joint, as in -tuberculosis; or, as a result of a badly treated fracture of the -ankle-joint; or, as a result of paralysis of the muscles of the inner -side of the leg. - -+Pathology of Acquired Flat Foot.+ The pathologic condition is due to -change in the relations of the bones rather than to any change in the -bones themselves. The abnormal position is an exaggeration of the -normal yielding of the foot under weight bearing. The front of the -astragalus rotates inward, and with it the bones of the leg turn at -the hip-joint. - -The deformity is essentially a displacement of the astragalus on the -bones of the tarsus. The scaphoid, cuneiform, and the base of the -first metatarsal move downward and inward with the head of the -astragalus; the outer border of the foot is made more concave and the -inner border becomes convex in extreme cases. In the severest cases, -the head of the astragalus, and scaphoid may be displaced below the -plane of the other bones. The ligaments are respectively shortened and -stretched in the severest cases and there is a loss of motion in -certain of the tarsal articulations, due to faulty apposition of joint -surfaces, and to constant strain. - -+Symptoms.+ The feet burn and tire easily and feel stiff and lame. They -may swell, and the size of the shoe worn must be then increased. -Later, a painful period generally begins in which walking is avoided -and a dragging pain in the arch and behind the inner malleolus is -noticed. This is increased by walking and standing and tender points -may be found under the scaphoid and on the upper surface of the heel. -The foot feels strained and irritated and is a constant source of -discomfort. The inner malleolus is generally more prominent and the -foot is displaced outward in relation to the leg. The height of the -arch is somewhat diminished; it may be much lowered, or it may be flat -on the ground. - -When the foot is really flattened, it presents two types, one the -_flexible flat foot_, in which the arch can be restored by gentle -manipulation; the other, the _rigid foot_, which is held by structural -changes in the position of deformity. - -An intermediate type is sometimes seen, in which the peroneal spasm is -so great that the foot is held abducted and everted as long as the -spasm lasts (spastic flat foot.) - -Some symptoms of flat foot that are less generally recognized, which -are of great value in diagnosis are: corns, ingrowing nails, -callosities on the sole of the front of the foot, enlargement of the -great-toe joint, and pain (especially at night) in the calves of the -legs and backbone, which is aggravated by standing and walking. - -+Diagnosis.+ The diagnosis of flat foot, whether flexible or rigid, is -made chiefly by inspection. The difficulty comes in the milder cases, -which form the bulk of those seen, and in which the changes in form -are slight. - -+Symptoms.+ The symptoms, as described by the patient, are the most -reliable and points of tenderness under the arch or heel would help to -confirm the diagnosis. Some help may be obtained from a wet impression -of the foot, on a piece of paper, but the slighter cases show but -little changes in the imprint. In most normal feet, the outer border -of the foot touches the paper, and in flat foot, only two areas bear -the weight, one on the inner side of the front of the foot, and one -under the inner part of the heel. An X-ray picture is often of great -assistance. - -The diagnosis of rheumatism is frequently made in flat foot, and is -often the source of much misdirected treatment. Rheumatism should be -diagnosed only in connection with unmistakable symptoms of rheumatism -in the upper extremities. - -So-called "rheumatic" pains in the knees and hips may be secondary to -flat foot. - -+Prognosis.+ As a rule, this condition does not recover spontaneously. -Under ordinary conditions, uncomplicated cases should be at once -relieved by proper treatment, and in time should be cured. - -Unfavorable factors are: great weight; disease of the ankle-joint; the -presence of bony spurs under the os calcis. - -The prognosis is more favorable in young adults than in persons of -advanced age. Patients, who without relief have worn the ordinary -supports sold at the stores will, as a rule, manifest extreme -sensitiveness as to the fit of any of the supports which may be -applied. - -+Treatment.+ The foot must be restored and held in its normal position -and measures must be adopted to quiet local irritability or -inflammation, and to strengthen the muscles. The best treatment does -not consist in the permanent wearing of a flat-foot support; the -support should be regarded in the same light as one uses a crutch in a -fracture of the leg. - -As a preliminary to all treatment, the use of proper shoes must be -insisted upon. A shoe should be as wide in front, as the unshod foot, -when bearing the weight of the body. - -+Supports.+ Flexible supports may be made of boiler felt; one objection -to these is their liability to stretch. They are of service in young -children, in mild cases, and in convalescent cases where it is -desirable to have the patient use a flexible instead of a stiff -support in order to bring the muscles into play. - -Rigid supports are best made of tempered spring steel (18 to 20 -gage), forged hot to fit a cast of the foot. They may also be made of -phosphor-bronz, celluloid or aluminum. - -The shape of the plate is largely a matter of judgment. The easiest -way to determine the shape of the plate to be used in a given case is -to have the patient stand with the operator's hand under the inner -side of the foot; the operator then places the foot in the normal -position and notes where the pressure must be applied to secure the -proper correction; when the anterior part of the foot is flattened, a -slight dome must be constructed in the front of the plate; when the os -calcis is clearly tilted over, the plate must have two flanges at the -heel to hold it in place. In general, the plate must reach forward to -a point just behind the great-toe joint, and must furnish support as -far as the front of the heel. The plate should be higher on the inner -side, and a flange formation is generally necessary to accomplish -this. An outer flange prevents the foot from slipping off the outer -side of the plate. When the foot no longer requires support, the plate -should be gradually discontinued. - -The "Thomas" sole may be used in mild cases. This is made by building -up the inner part of the sole of the shoe one-eighth to one-quarter of -an inch higher than the outer side, thus securing a slight inversion -of the foot. - -Exercise and massage of the deficient muscles should form a part of -the routine treatment in all cases of flexible flat foot. - -To diminish local inflammation and irritability, the foot should be -soaked in hot water; hot and cold alternate douches should be applied, -and hot-air treatment and massage should be employed. - -+Rigid Flat Foot.+ Rigid flat foot cannot be successfully treated until -the position of the foot is corrected. The patient should be -anesthetized, and, by the use of a wedge as a fulcrum, the bones -should be forced into position. A pressure of about two hundred pounds -is generally necessary to effect this reduction. After this, the foot -is placed in a plaster cast, in extreme adduction and is allowed to -remain thus encased for three weeks. After this, a properly fitted -plate should be worn. The results are usually satisfactory. - -+Operative Treatment.+ Cases that have resisted all other forms of -treatment, may be cured by the removal of a wedge-shaped piece of -bone, with the base downward and inward at the point of greatest -inward convexity, that is, in the neighborhood of the head of the -astragalus. Osteotomy of the front of the os calcis and neck of the -astragalus will at times be necessary for a radical cure. - -Many other operative procedures have been advised for flat foot and -they have been employed with varying successes. - -+Hallux Flexus or Hammertoe.+ The upward prominence of a toe (usually -the second or third) in a rigid position, is known as _hallux flexus_ -or _hammertoe_. In this condition the toe is flexed in its second -joint so that the end bears on the ground, while the junction between -the phalanges makes a prominence upward. Helomata and callosities may -develop on the end of the toe, but the chief discomfort is in the -disturbances which arise on the prominence which presses against the -side of the foot-gear. - -+Treatment.+ A knowledge of the forces at work will show how futile must -be any effort to correct this deformity by strapping or bandaging. -There is a shortening of the plantar fibres of the lateral ligament of -the joint. The trouble does not lie in the flexor tendons, as it -seems, and operations directed to this point fail. Even with incision -of the lateral ligaments, followed by the application of a splint, -recurrences are common and amputation must be the procedure. - -The condition described as hammertoe may exist in several or in all of -the toes, the great toe being least often involved. This occurs most -often as a result of wearing improper shoes, but is sometimes the -consequence of paralysis. - -+Flexed or Clawed Toes.+ Extreme flexion of all but the great toes -causes the weight to be borne by their dorsal aspect. In this -condition the toes, and especially the small ones, develop painful -helomata on the prominent joints, and the small toe may become the -source of great discomfort. - -+Treatment.+ Radical surgical measures are here indicated. Tenotomy or -amputation is essential to a cure. - -+Painful Heel.+ Painful heel is a suggestive but unscientific term -applied to tenderness of the under side of the heel. It is associated -with one of the following conditions: - - 1. Spurs running out from the under side of the os calcis - found by the aid of the X-ray. - - 2. Inflammation of the bursae under the os calcis. - - 3. Flat foot. - - 4. Gonorrhoea. - - 5. Focal infection. - -+Treatment.+ Where a spur of bone causes the unpleasant symptoms, the -excrescence should be excised. - -When focal infections are the primary cause of painful heel, operative -procedure to remove the source of infection is imperative and will -prove curative. - -Palliative measures are: massage, douches, hot air, a metal plate worn -under the painful area, rest. The back of the foot should be cut away -to relieve pressure. - -+Metatarsalgia--Morton's Disease.+ Metatarsalgia is characterized by an -acute pain, cramplike in character, occurring at the base of the third -or fourth toes. - -The pain comes on suddenly while the foot is in action, and is usually -accompanied by a "snapping of the bones." The pain is so acute that it -is not uncommon for the patient to seek relief by taking off the shoe -and rubbing the foot. - -In persons suffering with this condition it will be regularly noticed -that the weight is thrown upon the ball of the foot, on the -metatarsophalangeal joints, either because of a weak foot, or because -of a tendency of the toes to turn up. - -+Treatment.+ 1. Proper strapping to raise the arch and bring the ends of -the toes down. - -2. A pad across the ball of the foot _behind_ the metatarsal heads, -also brings the toes down. - -3. Recommend shoes, wide across the ball, with a higher or lower heel -than ordinary, as the case indicates. - -+Hallux Valgus.+ The term _hallux valgus_ is applied to a deviation or -displacement of the great toe outward, toward the outer border of the -foot. - -In normal feet, the line of the great toe when prolonged backward, -should pass through the centre of the heel. This relation in civilized -communities is seen only in the feet of infants. In adults it is -observable only in the bare-footed races. - -+Cause.+ It is frequently associated with flat foot, gout and -rheumatism, but it is primarily due to the use of inappropriate -foot-gear. It is only considered pathologic when the deviation is more -than fifteen degrees. - -+Pathology.+ The displacement outward (which reaches 30 to 40 degrees in -the average case and may reach 90 degrees) of the phalangeal part of -the great-toe joint, uncovers the inner part of the head of the -metartarsal bone, and here the cartilage degenerates, and the bone -becomes condensed at its outer part. The inner lateral ligament is -lengthened and thickened and the sesamoid bones become displaced -outward and are often thickened. - -Under the skin, at the inner and prominent aspect of the foot, is to -be found a bursa, which is liable to inflammation under pressure, and -is known as a bunion. The inflammation in this sac may extend to the -joint and thus disintegrate it. - -+Symptoms.+ The toe is displaced outward and a reddened and shiny -condition of the thickened skin exists over the inner prominence and -perhaps over the top of the toe joint. The great toe if seriously -displaced, must lie over or under the other toes, the former being the -more common position. In other cases the second toe may be crowded up -as a hammertoe. The joint is painful and the inner toes, being crowded -to the outer side of the foot, are the seat of corns and callosities. -Flat foot is frequently associated with this condition. - -+Treatment.+ In mild cases, the stocking should be split to allow a -separate stall for the great toe, and broad toed boots should be worn. -If flat foot exists, a support should be supplied for its aid in -restoring the position of the great toe. In severe cases, nothing -short of an operation is likely to be of value. A toe-post may be worn -for a time in mild cases. - -Amputation of the head of the metatarsal bone gives uniformly good -results. - -The toe is straightened and flexible; ankylosis with this operation -does not occur. - -In operations for hallux valgus there are two distinct purposes acting -as determining factors in making a choice in a given case as to which -is indicated. These are: (1)the radical operation for the correction -of the deformity, and (2)the palliative operation for the alleviation -of symptoms by the removal of the hypertrophied portion of the -metatarsal head which is exposed to pressure. Among operations in the -first mentioned class, the one known as the Mayo operation is, in all -probability, the best. The entire head of the metatarsal is amputated, -and the bursa is turned in over the cut end of bone, to diminish the -amount of shortening and to prevent ankylosis of the joint. This -latter consideration, however, is an unnecessary one, for in -operations within this joint, ankylosis does not occur when the -synovial surface of the phalanx is left undisturbed, even when the -bursa is not employed as an intervening pad. - -In the other class of operations for the relief of symptoms, no -attempt is made to straighten the toe. A wedge-shaped piece of the -exostosis is removed, against which pressure has caused symptoms. - -A palliative operation devised by Dr. Robert T. Morris of this city, -is one easy of accomplishment and serves every purpose where a radical -operation is interdicted. It is known as the "button-hole" operation -because of the fact that only a small incision is made immediately -above the protuberant bone through which a sharp chisel is inserted, -cutting off the offending "button" of bone. - -An operation which in the hands of the authors has proven of distinct -value, and which has probably not been previously described -eliminates both the deformity and its painful symptoms. This operation -which is described below, is less severe than other radical operations -and not very much more so than the usual palliative ones. - -The incision is made on the dorsum of the great toe over the offending -joint and just to the inner side of the extensor tendon. This tendon -is held to the outer side, out of the way. The knife penetrates the -capsule of the joint and opens it above and laterally. - -An effort is made to preserve the integrity of the capsule below -(floor) as _only the intra capsular end of the metatarsal is removed_. -These two factors are of the utmost importance. When the joint capsule -is slit open along its dorsal and two lateral aspects, sufficient room -is obtained for the insertion of the wire saw, and all of that portion -of the metatarsal lying within the joint proper is removed. There is -thus accomplished a correction of the deformity with very little -shortening of the great toe. Usually its length after this operation -is about the same as the second toe. - -The next step in the operation is closure of the synovial sac or joint -capsule. A stitch on either side and two above are all that is -necessary. The floor of the sac remains intact and nothing beneath it, -in the ball of the foot, has been disturbed. Many operators invade -this area and remove the sesamoids. This is unwarranted as the -transverse level of the ball of the foot is lost, and the weight is -put directly upon the newly formed joint, depriving it of its normal -support, or of padding from below. - -One other omission in this operation is that of the bursal flap over -the raw end. This is found entirely unnecessary as results prove, and -its omission hastens healing considerably. The bursa over the -metatarsophalangeal articulation in these cases is nearly always -inflamed, and consists of a mere fibrous pad. Its dissection from the -normal position is a real loss at that site, and of questionable -benefit over the cut bone, as motion in the joint is as good or better -without it. - -The skin closure is made without drainage, and _no wet dressing -employed_ for fear of the solution filling the cavity whence the bone -was removed and carrying with it infectious material. A dry sterile -dressing is all that is required, and a splint to maintain a straight -position for the toe. - -Four or five days complete rest for the part are ordinarily -sufficient. Following this, walking about the room is permitted with -the aid of a stick. After ten days, when the patient can get about -fairly well without the assistance of a stick, the foot may safely be -shod with an "arctic" of sufficient size. - - -+CLUBFOOT OR TALIPES+ - -The most common form of clubfoot, and therefore the deformity of that -character most frequently encountered, is characterized by inversion -of the sole of the foot, elevation of the heel, and a twisting and -turning of the front part of the foot. This deformity is typical of -_congenital_ clubfoot, which, as stated, is the most common form of -that deformity. The _acquired_ form is usually the result of infantile -paralysis. - -+Congenital Clubfoot+ is most frequently double, and males are more -frequently affected than females; in unilateral or one-sided clubfoot, -one side is not more frequently affected than the other. - -+Etiology.+ Very little is known as to the cause of congenital clubfoot -but it is not infrequently associated with other congenital -deformities. It appears to be hereditary in a great many instances. -The greater number of cases appear without definable cause, except -perhaps from intra-uterine pressure. There are, however, a number of -these cases that are associated with malformation of the bones of the -foot and leg, such as absence of the scaphoid; defect of the tibia; -fusion of a number of the tarsal bones. - -+Pathology.+ The sharp adduction and plantar flexion, at the tarsal -joints, produce a deformed position of the foot. As a result of these, -the heel is small and elevated; the dorsum of the foot is prominent; -and the outer border usually, and, in extreme cases, the dorsum of -the foot, bears the weight of the body in walking and in standing; the -sole of the foot is bent sharply in, and twisted at the tarsal joint. -In fact, all the bones are changed in shape, and the inner muscles, -tendons and ligaments are shortened by contraction, while the ones to -the outer side are lengthened. - -The distortion of certain individual bones is of importance. The -astragalus is the seat of the most important changes. It is tipped -downward at its front end, and its posterior part articulates with the -tibia, its anterior articular surface projecting under the skin; its -neck is elongated and bent inward and downward, so that its scaphoid -articulation faces inward and downward and not forward. - -This is the most important change in clubfoot, because the anterior -end of the astragalus, the head of the bone, carries inward and -downward with it the scaphoid, the three cuneiforms, and the inner -three metatarsal bones. The scaphoid articulates with the inner side -rather than the front of the astragalus and, in extreme cases, forms a -joint surface with the inner malleolus. It may be somewhat changed in -shape, being flattened and drawn inward and upward. - -The os calcis is generally poorly developed, and its front end is -rotated downward, and bent inward; the outer surface of the bone is -more convex and the inner surface more concave than normal, and since -the anterior facet looks inward and downward, it carries with it the -cuboid and the two external metatarsal bones. The changes in the other -bones are not important; the chief obstacles to reduction lie in the -os calcis and in the astragalus. - -+Soft Parts.+ The muscles, ligaments, tendons, and fascia at the lower -and inner side of the foot are shortened, and lengthened at the outer -and upper side. The plantar fascia being one of the chief obstacles to -reduction, the tendons are displaced, especially those on the inner -side of the foot. - -+Symptoms.+ Double clubfoot is usually accompanied by an awkward and -unsteady gait, in which each foot is in turn lifted high to clear the -foot on the ground, and the _toeing in_ is, of course, excessive. The -weight is borne on the outer side of the foot, and all elasticity of -gait is absent. - -On the outer border of the foot, where the weight is borne, -callosities and bursae develop; the calves of the legs are small, and -the knee joint may be lax. - -The gait in single clubfoot is less awkward, but characterized by the -same features. The foot is rigid in the deformed position, and in -cases of marked deformity, the foot cannot be manipulated into the -normal position. - -+Diagnosis.+ Congenital clubfoot cannot be mistaken for any other -condition. The diagnosis is self-evident. - -+Prognosis.+ There is no tendency of this deformity to right itself, or -to improve. Early and proper treatment will, if continued long enough, -insure a cure in children and an improvement in adult cases; but it -must be remembered that there is a decided tendency to relapse, even -after operation, unless the foot is kept in an overcorrected position -for a number of years. - -+Treatment.+ In young infants, treatment should be begun as early as two -weeks after birth and should consist in frequent gentle massage and -manipulations. After the part can be brought into an overcorrected -position by gentle manipulation, it should be put up in a plaster -cast, for a period of three weeks and this treatment should be -continued until the position of the foot is corrected. - -The manipulations consist in grasping the dorsum of the foot gently -but firmly with one hand, and holding the leg with the other. The foot -is then dorsally flexed and everted. This treatment should be repeated -at least three times a day and should not be rough enough to cause the -infant to cry. - -Treatment of clubfoot in older children and adults is a much more -difficult proposition and consists in the combination of two or more -methods of procedure. - -In order to correct the extreme adduction in these cases, extreme -force must sometimes be employed. This may be accomplished by bending -and bearing down on the foot, with its outer border resting on the -apex of a wooden wedge. The rotation of the foot is corrected by -grasping the foot in one hand, and the heel in the other, and twisting -with the necessary amount of force. The inversion of the sole is also -corrected by the use of this wedge as a fulcrum. - -In this way the tendo Achillis and the plantar fascia are stretched, -and the dorsal flexion is secured by laying the patient on the face -with the knee bent and the front of the thigh resting on the table. -The lower leg is then vertical, and by bearing down on the front of -the foot with the necessary amount of force, dorsal flexion of the -foot is secured, and by hooking the fingers around the os calcis, its -position is improved. - -A modified Thomas wrench may be used in the correction of clubfoot; -but this must be done with great care, as the violence practised in -this method, the tearing of the ligaments and other soft parts, is -often attended with great danger; osteomyelitis, tuberculosis, -neuritis, and even death from fat embolism, and extensive sloughing of -the soft parts are not infrequently seen after the use of this and -other bone crushing instruments. - -The removal of a wedge of bone from the outer side of the foot and the -removal of the neck of the astragalus are employed. Tenotomy and the -transplantation of tendons are also often practised, when other -methods of treatment fail. - -+Acquired Clubfoot.+ The cause of acquired clubfoot maybe infantile -paralysis, joint disease, traumatism, or it may be due to affections -of the brain or spinal cord. - -+Paralysis.+ Infantile paralysis affecting the muscles of the front and -outer side of the lower leg, will result in a condition similar to -congenital clubfoot. Other paralytic causes are: spastic or cerebral -paralysis, hereditary ataxia, etc. - -+Traumatic.+ A condition resembling clubfoot may result from improperly -treated fractures of the ankle-joint or tarsal bones. - -+Joint Disease.+ In tuberculosis, arthritis deformans, and other -diseases of the ankle-joint, a condition similar to clubfoot is -sometimes seen as a result of muscular contraction. - -+Talipes Equinus+ is rarely congenital. It is usually due to infantile -paralysis of the extensor muscles, or to cicatrical contraction of the -calf muscles, as a complication of hip disease. It varies from -inability to flex the ankle beyond a right angle, to walking on the -heads of the metatarsal bones. The astragalus is partially displaced -forward and forms a prominence on the dorsum of the foot; the plantar -fascia is shortened and callosities and bursae are formed under the -heads of the metatarsal bones. Primarily, the obstacle to reduction is -the tense Achilles tendon, and in advanced cases the shortened plantar -fascia and posterior ligament of the ankle-joint constitute obstacles. - -+Talipes Equino-Varis+ (down and in foot) is the most common form of -this deformity. - -It is either congenital or acquired, and in the latter case it is due -to infantile paralysis of the extensor and peroneal muscles. The heel -is drawn up, and the anterior half of the font is drawn inwards and -inverted. The inner border of the foot is shortened, and in neglected -cases the patient walks on the outer side of the cuboid, under which a -bursa is formed. Secondary contraction of the plantar fascia, -ligaments, and short plantar muscles follows. There is a great -increase in the obliquity of the neck of the astragalus in congenital -cases, so that the scaphoid and anterior half of the foot, together -with the dorsal tendons are carried inward. As a result of the -equinus, the upper surface of the astragalus projects forward, and -only its posterior portion comes in contact with the tibia and fibula. -The ligaments of the inner side of the foot are shortened and the -shape of the other tarsal bones is secondarily altered. - -+Talipes Equino-Valgus+ (down and out foot). This condition is rare as a -congenital deformity. The anterior half of the foot is deflected -outward, and the inner border comes in contact with the ground. The -scaphoid is placed outward, and the head of the astragalus projects -into the sole. - -The acquired variety results from paralysis of the tibialis posticus -and flexors, with secondary contraction of the peronei muscles. - -+Talipes Calcaneus+ is rare as a congenital deformity. It is usually the -result of infantile paralysis of the muscles of the calf. The patient -walks on the heel, and the anterior half of the foot is drawn up. -Valgus or varus are associated with it; the more common form is -talipes calcaneo-valgus. - -+Talipes Cavus+ (Pes Cavus), or hollow foot, is a condition in which the -arch of the foot is greatly exaggerated. It is rarely congenital but -is frequently seen in connection with clubfoot, especially in its -paralytic forms. In its mildest form, it exists in a highly arched -foot, often hereditary. It may also be the result of too short shoes -(Chinese ladies' foot). - -+Treatment.+ The condition is best remedied by division of the -contracted soft parts, a forcible reduction of the bones, held in -place by plaster of Paris. When the patient begins to walk, it is -advisable to have a stiff, flat, steel plate placed in the length of -the shoe between the layers of the leather sole, running from which, -over the dorsum of the foot, is a stout leather strap. At each step, -downward pressure is thus exerted on the dorsum of the foot. - - - - -CHAPTER XVIII - -+THERAPEUTIC MEASURES+ - - -+HYPEREMIA+ - -+Hyperemia+ as a therapeutic agent was described by Bier and is of two -kinds, _active_ and _passive_. The former is the same as the -_arterial_, while the latter is the _venous_. Between the blood of -active and passive hyperemia there are important physical and chemical -differences, the one containing much free oxygen with but little -carbonic acid and alkali, while the other presents the exactly -opposite character. - -In active hyperemia normal elements of the blood are kept in active -motion, while in the passive form they are allowed to escape, more or -less, into the tissues. - -Hyperemia possesses a great many properties: - - 1. Power to diminish pain. - 2. Bactericidal action. - 3. Absorptive property. - 4. Solvent action. - 5. Nutritive power. - 6. Suppression of the infection. - -Hyperemia may be produced in three ways; _first_, by means of the -elastic bandage or band; _second_, by cupping glasses, and _third_, by -hot air. The first two produce venous or passive hyperemia, and the -third, arterial or active hyperemia. - -+Passive Hyperemia.+ This obstructive hyperemia is produced by means of -a thin, soft rubber elastic bandage, two or three inches in width, -better known as the Esmarch, or Martin bandage. When this is applied -moderately tight around a limb about six or eight turns, one layer -overlapping the other, pressure is evenly distributed over a -comparatively wide area, causing the subcutaneous veins below the -constriction to swell; the extremity becomes somewhat bluish red in -color, also larger and edematous, giving a feeling of warmth to the -touch. - -The rubber bandage, properly applied, should not cause any -uncomfortable feeling and there should be absolutely no pain present. -At all times one must be able to feel the pulse below the site of the -bandage. If the bandage is applied too tight, the skin of the limb -looks grayish-blue and there appear whitish, or vermilion colored -spots, which grow larger and larger, as long as the too tightly drawn -bandage is on. Paresthesia and pain, with disappearance of the pulse, -can also be noted. - -The two cardinal rules to be observed in the application of the -bandage are: (1) absolutely no pain with the application of the -bandage; (2) the pulse at all times must be felt below the bandage. - -In cases which require the bandage to remain in place from sixteen to -twenty hours each day, it will be necessary to first apply a soft -flannel bandage underneath the rubber one in order to prevent pressure -necrosis. - -Frequently changing the location of the bandage up and down the -extremity, and treating the skin with alcohol rubs, will also be -helpful to patients with a tender skin. The elastic bandage must -always be placed upon a healthy area, proximal to the diseased part. -All dressings should be removed while the compressing bandage is on, -in order that the part may become hyperemic. - -Wounds or sinuses are covered with sterile gauze and kept in place -with a towel, fastened with a few safety pins. - -In acute inflammation, septic wounds and phlegmons, the increased -inflammation is apt to frighten the beginner, but this is a desired -phase of the treatment. - -As a prophylatic against infection, it cleanses the wound, produces a -local immunization and reaction before the infection has a chance to -work; the earlier the bandage is applied the more remarkable is the -effect. - -For incised wounds of the foot with division of the muscles and -tendons, if the tissues are not too seriously injured, the muscles and -tendons should be united and the skin closed with interrupted sutures -sufficiently far apart to allow free excretion. No drainage is -employed and a slight compressing dressing is applied. The elastic -bandage is applied very lightly, producing only a slight venous -engorgement and the bandage should remain on from ten to eighteen -hours a day. - -As soon us the symptoms of acute inflammation subside, the time of -application of the bandage is reduced. If signs of suppuration are -present, the wound should be promptly opened and the pus evacuated. -The knife takes care of the pus; hyperemic treatment fights the -infection. - -In gonorrhoeal arthritis of acute or chronic nature, and in cases of -tuberculosis of the bones and joints, the passive form of hyperemia is -especially indicated. - -The use of cupping glasses is limited to abscesses, furuncles and -sinuses. - -+Active Hyperemia+, or arterial hyperemia, is produced by means of -hot-air boxes such as the Tyrnauer electric apparatus, or the gas -apparatus of Betz. - -Active hyperemia increases the arterial blood to any part of the body, -thus favoring the absorption of chronic exudates, infiltrates, -adhesions, etc. Dry, hot air permits the use of a high degree of -temperature without injury or pain to the respective part. - -For neuritis of the foot, ulcers, especially diabetic, perforating and -varicose, and for the stiffness following a chronic inflammation, or -after a fracture, the arterial form of hyperemia gives good results. - - -+COLD+ - -+Cold+, or the rapid abstraction of heat, is a remedial measure that is -nearly always available and is possessed of very great power for good -in selected cases. - -When cold is applied for its limited and local action, it is always -used with two objects in view, namely, (1) to cause localized -contraction of the blood vessels, which through inflammation are -engorged, so that the parts are swollen and reddened; or (2) -temporarily to anesthetize or benumb the nerve terminals, for the -immediate relief of pain, in the hope that the temporary paralysis may -ultimately result in such changes as to produce a cure. - -Cold, in some form, is a popular remedy for a sprain, or any injury -likely to be followed by inflammatory processes. A very useful remedy -for the sprain of an ankle, when it is a recent accident, is to let -the patient sit with the foot elevated, with a cloth wrung out in ice -water, and an ice bag applied over the affected part. - -In the treatment of localized pain or inflammation, cold is used in a -number of ways, largely depending upon the will of the physician and -the means of the patient. The simplest, cheapest, and perhaps the best -method of using cold, is to place cracked ice in a rubber bag, the -latter to be thoroughly watertight, lay it over the inflamed part, -surrounding it with a towel so as to prevent the moisture, which -appears on the surface from condensation, from wetting the clothing. - - -+HEAT+ - -+Heat+ is used locally for a number of purposes in the same manner as -cold, and the choice of heat or cold in the treatment of any acute -form of inflammation depends almost entirely upon the wish of the -patient, who generally can tell at once which will give him the -greater comfort. - -In sprains of the ankle, nothing compares to a hot foot-bath prolonged -for hours, the object being to decrease the pain and swelling, thereby -regaining the use of the limb. - -The high degree of heat which can be borne by gradually increasing the -temperature of the water by the addition of small quantities of -scalding water, is extraordinary, and the favorable results obtained -are in direct ratio to the height of the temperature. - -Between these soakings, the part should be dressed with lead and opium -wash, and rubbed with ichthyol ointment or camphor liniment. - -Hot-water bottles or bags are also used locally for the relief of -congestion and pain. - - -+THE HIGH FREQUENCY CURRENT, OR VIOLET RAY+ - -+The Violet Ray or High Frequency Current+ is one which is in a rapid -state of to-and-fro vibration and is applied through vacuum glass -attachments or electrodes, which are excited to a beautiful violet -color. The discharge may appear to the eye to be a single spark, but -it is made up of a number of successive sparks, following each other -with such extreme rapidity that they are said to oscillate (change -directions) millions of times per second, a speed that the eye cannot -note. The rapid oscillations have the effect of producing the -following phenomena: - - 1. the high frequency current is unipolar, that is, does not - require a complete circuit. - - 2. glass does not insulate the high frequency current as it - does ordinary electricity. - - 3. the high frequency current generates enormous quantities of - ozone during its flow. - - 4. the current does not produce any pain. - - 5. the high frequency current produces a cellular massage. - -The contractile effect is expended upon the individual cells making up -the tissues, instead of on individual muscles. - -If a sedative effect is desired, keep the electrode in contact with -the part; if a stimulating effect is desired, hold the electrode away -from the surface; the farther away, the longer the spark. - -A uniform spark of any length can be produced by administering the -current through layers of toweling, or through the clothing; the -length of the spark depends upon the thickness of the layers. - -The use of the high frequency current in surgery is limited to -sprains, stiff joints, neuritic pains, and adhesions due to -inflammatory exudates. Fulguration for the destruction of growths is -obtained by employing a pointed metal electrode. - - -+RUBEFACIENTS+ - -+Rubefacients.+ These are agents which revulse by causing congestion of -the skin: - -+1.+ +Turpentine.+ A few teaspoonfuls of oil of turpentine sprinkled over -a piece of flannel wrung out of hot water, applied to the skin and -covered with oiled silk or dry flannel, constitutes the turpentine -stupe. Twenty minutes is the maximum for this application. - -+2.+ +Mustard.+ Mustard flour (the black being the stronger), mixed with -tepid water into a paste, spread thinly on a piece of muslin or paper, -and covered with gauze or thin cambric, is an excellent -counterirritant. Few skins will bear pure black mustard for more than -ten minutes. Mustard, diluted one-half with wheat or corn flour, and -allowed to stand for twenty minutes, should be the maximum strength -for application, because blistering must be avoided, that produced by -mustard being specially painful. After removing a mustard plaster, -greased lint should be applied. - -+3.+ +Mustard Foot-Bath.+ A mustard foot-bath consists of one or two -tablespoonfuls of pure mustard in a bucket two-thirds full of water at -105°F; the feet may be kept in this for about twenty minutes, a -blanket being thrown around the limbs, and including the bucket, to -retain the heat. - -Revulsives must be used with caution in cases of shock or coma, lest -impaired vitality or sensation to pain result in extensive sloughing -of the skin. - - -+CAUTERIES+ - -+The Actual Cautery+ is used in the form of variously shaped irons, -hatchet-edged, round, or olivary, fitted into wooden handles, and -heated in a charcoal furnace. - -As a counterirritant, the iron should be heated only to a dull red -heat, and should be quickly drawn in parallel lines, about one inch -apart, over the skin, avoiding all bony prominences. Compresses wet -with cold water, or with some antiseptic lotion, may then be applied. - -+The Paquellin Thermo-Cautery+ is a convenient form. It consists of -hollow platinum cauteries and a handle covered with wood; a benzole -reservoir; a pair of rubber bulbs, like those for a hand-spray -apparatus, connected by a tube with the reservoir; a long rubber tube -to connect the cautery handle also with the reservoir; and a -spirit-lamp with attached blow-pipe. - -Screwing on the desired point, the tube from the reservoir is slipped -over the handle; the point is heated in the lamp; is removed from the -flame; and, compressing the bulbs, which should previously have been -connected with the reservoir, benzole vapor is forced into the point, -which will heat up, and can be maintained at any temperature by the -rapidity with which the bulb is worked. If the point will not heat -with the simple flame, attach the bulbs to the blow-pipe on the lamp, -and, compressing them, heat the cautery to a bright-red heat, and then -connect with the reservoir and proceed as before directed. - -+Galvano-Cautery.+ This requires a battery of a few large elements -closely coupled, and various curets, knives, and ecraseurs fitting -into insulated handles. The chief advantage of this form of cautery is -the possibility of placing the instrument in position while cold, and -then heating it. - -Where hemorrhage is undesirable, a dull-red heat should be maintained, -for at a white heat the tissues are divided as if with a knife, and -bleeding follows. When the ecraseur is used, needles must be passed at -right angles through the healthy tissues, the platinum wire placed -behind these, and the wire, at a dull-red heat, slowly tightened. - - -+ELECTRICITY+ - -+Electricity.+ This is used in the form of the _induced current_ -(Faradism) to exercise and improve the nutrition of muscles, and in -the form of the _constant current_ (galvanism) along the course of -nerve-trunks, to excite their conducting power, or to act as a -sedative in neuralgias. - -The same current is used to induce chemical decomposition -(_electrolysis_) or to cauterize and destroy tissue by heating an -encircling wire or by a galvanic knife. Franklinic, or static -electricity, is also occasionally used. - -+Electrolysis.+ For electrolysis a galvanic battery of thirty or more -medium-sized cells is required, with needle electrodes insulated, -except near their points. - -To destroy a verruca, introduce into it two needles, a short distance -apart, each connected with a pole of the battery; then, commencing -with a weak current, this must be cautiously increased, the sitting -lasting from a half hour to one hour, after which the needles are to -be removed and the punctures sealed by collodion. - - -+MASSAGE+ - -+Massage.+ This is employed to stimulate the circulation in the part -mechanically; to loosen tissues bound down by adhesions; to diffuse -inflammatory exudates over a wider area, thus favoring their -absorption; and to change the rate of the circulation to a point -compatible with rapid absorption and normal nutrition. - -Four distinct varieties of manipulation are found to be most generally -useful: - - 1. rubbing, or stroking - 2. kneading - 3. tapping, or percussion. - 4. passive and active moments. - -_Stroking_ consists in gentle rubbing directed from the periphery -upward, commencing the process above the inflamed part and continuing -it over the diseased area; the pressure, at first light but finally -firmer, will force the exudates into the tissues above, which have -been emptied by the preparatory rubbing. - -_Kneading_ means rubbing the part circularly with the pulps of the -fingers and the thumb or the palm of the hand, and is best combined -with pinching up of the skin or muscles singly or together, and gently -rolling them between the fingers and palms. - -_Percussion_ is effected by tapping the surface over the diseased part -with the tips of all the fingers held on a level, or with the ulnar -side of the hands, or, after covering the part with a towel, three -parallel pieces of stiff rubber tubing, fixed in a handle (a muscle -beater), may be employed, gently striking the part transversely to its -long axis. - -_Passive movements_ should be made at the close of each sitting if a -joint is concerned. - -Massage is sometimes advisable twice daily, but often once a day or -every other day is better; each sitting may last from fifteen minutes -to one hour. - - -+EXAMINATION BY RADIOGRAPHY+ - -+X-Ray Examination.+ This method of examination depends on the property -of penetration of matter possessed by a radiation from an electrically -excited Crookes' tube. This radiation has been proved to lie outside -the spectrum, and has been named X-ray. - -It may, for purposes other than those required by the expert, be -looked upon as a source of light which has the property of penetrating -the tissues to a greater or less extent according to their density, -and the shadows cast by it can be recorded on a photographic plate, or -may be viewed with the naked eye by means of a screen composed of a -thin layer of barium platinocyanide, a substance which becomes highly -fluorescent in the presence of this radiation. - -One or the other of these methods is used for the recognition of -pathologic conditions existing in the human tissues. - -The fluorescent screen appears at first sight to be an easy way of -recognizing abnormalities. Its value in the examination of the thorax, -where the movements of the heart, lungs, and diaphragm have to be -observed, is undoubtedly very great; but as an accurate means of -recognizing any abnormality, it is untrustworthy. For instance, it is -possible to fail to recognize simple transverse fracture of the tibia -by its means. Its use is therefore to be deprecated in cases where -great accuracy is necessary, and it is safer and better to make use of -the more certain method, the photographic plate. - -A further objection to the use of the screen is that the constant -exposure of the hands and other parts of the body of the observer may -result in an intractable, dangerous and chronic dermatitis. - -By using a photographic plate the danger of dermatitis can be avoided, -since it is not necessary to expose the hands at all; and at the same -time greater accuracy is ensured and a permanent record is obtained. - -Although examination by radiography is a somewhat tedious procedure in -comparison with direct observation by the fluorescent screen, yet it -is less difficult if the photographic side of this method is -approached in a proper and businesslike manner. - -+Interpretation of Radiograms.+ A successful result in X-ray examination -involves a clear understanding of the meaning of the radiogram -produced. Even with the most accurate knowledge of anatomy, it is -difficult to interpret X-ray shadows; for a radiogram is only a -shadow, and the outline of the part thus demonstrated is liable to -great variation. For example, in the case of injury to bone, it is -always possible to secure strong and accurate X-ray shadows of the -part, and no error ought to be made in diagnosis, yet errors of this -kind are not uncommon. - -To avoid such mistakes, it is imperative that the quality of the -radiogram secured should be the best possible. For instance, in the -examination of the ankle-joint and the bones of the foot, a radiogram -which is flat, indistinct, and altogether wanting in detail, is of no -value, while a radiogram of good quality of the same ankle-joint and -foot, is of value. The interpretation of the latter is easy, while -that of the former would be almost impossible, and certainly -inaccurate. - -The usual practice in securing radiograms is to place the subject in a -position considered likely to give the best results, and then roughly, -almost at random, to place the tube in some unknown relation to the -part of the body under examination. The resulting shadow is often of -no value because it is wanting in detail and depth. One method of -avoiding this fault is to produce stereoscopic views of the part -examined. - -Two views having been secured in stereoscopic register, and placed in -a stereoscope, the part can be viewed in relief. Theoretically, then, -by this means one is able to view the parts of the body opaque to the -X-rays as they would appear to the naked eye. In practice, however, -this method, though it may prove of value in exceptional -circumstances, is laborious. Moreover, though the parts may be made to -appear in relief, they are not really as one would see them with the -naked eye, but are still X-ray shadows. - -A more practical method is to ensure that in all cases radiograms of -any part of the body be absolutely comparable with one another by -taking care to maintain the same relationship between the X-ray tube -and the part under examination. For example, in making an examination -of the ankle-joint, the limb is placed in a prescribed position, and -the anode of the X-ray tube, that is, the actual source of the X-ray, -is brought into accurate relationship to the tip of the internal -malleolus by a simple mechanical contrivance, the details of which -need not be dealt with here. This relationship between the tube and -the ankle can always be reproduced, and therefore the shadow of a -normal ankle-joint can always be obtained under the same conditions -for comparison with the radiogram of the suspected ankle. - -In this way, not only is the surgeon able to select the view of the -part which will have the depth and detail necessary for proper -interpretation, but, the shadow being familiar, he can more easily -recognize any abnormality. - -A radiogram secured under the conditions usually adopted, shows -definite and known anatomic relationship between the bones and the -X-ray tube, namely, with the anode of the tube directly opposite the -tip of the internal malleolus. - -To render this method of examination more perfect, there has been -devised a system of radiography containing a definition of the -relationships between the tube and the various parts of the body which -have been found to give the most useful views, and also radiograms of -the normal appearances of each part at the ages respectively of 5, 15, -and 25 years. - -By using this system the surgeon can secure a radiogram of any part of -the body, of the requisite standard in quality, while he has at hand a -normal radiogram of that part for comparison with the abnormal. - -Having secured a radiogram of good quality, it is necessary for the -purpose of interpretation that it should be viewed in a suitable -light. The best for the purpose is a bright light shaded with opal in -a dark room. The negative may be viewed at its best while still wet. -Considerable loss of detail follows the taking of prints, which for -this reason may greatly detract from the value of the radiogram. - -It is a mistake to suppose that X-ray examination in the diagnosis of -diseases can replace the older and well-tried clinical methods of -investigation; it is merely a useful means of acquiring knowledge -which, in conjunction with accurate clinical investigation, leads to a -more accurate diagnosis and prognosis, and is often most useful by -suggesting a more suitable line of treatment. It must be remembered -that this method of investigation has been in use only a comparatively -short time. In some diseases no definite statement is yet possible -that may not prove in the future to be misleading. - -At present the therapeutic use of the X-ray is rightly falling into -the hands of the dermatologist and the medical clinician. In surgery, -outside of the conditions mentioned above, its use is limited to -lupus, keloid, epithelioma, sarcoma and carcinoma, both before and -after operation. - - - - -CHAPTER XIX - -+DRESSINGS AND BANDAGING; SOLUTIONS AND OINTMENTS; SKIN GRAFTING+ - - -+DRESSINGS+ - -+Dressings.+ These may be either dry or wet. - -_Dry dressings_ consist of gauze and bandage or of cotton and -collodion (the cocoon dressing.) - -The most convenient form in which sterile gauze can be obtained is in -small squares in individual envelopes. Large packages are contaminated -with the first opening and are inconvenient. - -The cocoon dressing is occlusive and should never be applied over an -infected area. It is applicable to sensitive areas for protection, and -to operated areas not liable to infection. - -Protective varnishes, such as collodion, compound tincture of benzoin, -or pure ichthyol, are useful where little protection is indicated. - -_Wet dressings._ Two distinct therapeutic actions may be derived from -the wet compress, depending upon whether or not an impervious covering -is employed. These actions are _antiphlogistic_ and _hyperemic_, and -these in turn may be either _antiseptic_ or _astringent_. The wet -dressing, without a covering, is cleansing and heat reducing, because -of evaporation. There should be frequent replenishment of the solution -in the treatment of any infected wound or where it is desirable to -reduce inflammation. - -A wet dressing with an impervious covering is contraindicated in the -presence of pus, the warmth and moisture of such a dressing being -congenial to the growth and to the multiplication of bacteria. - -It is evident, therefore, that a wet dressing with an impervious -covering can safely be employed only in conditions where the skin is -unbroken, such as sprains and bruises. - -The two general therapeutic actions, aside from those of causing -hyperemia, are antiseptic and astringent. For the relief of pain and -for the reduction of inflammation, wet dressings are the most -effective form of treatment because (1) they are aseptic; (2) they -permit free drainage; (3) no new granulations are disturbed in -changing the dressing. - -A great many different solutions are used and among these are: - - 1. sterile water; - - 2. ordinary saline solution (a teaspoonful of salt to a pint - of water); - - 3. saturated solution of boric acid (prepared by dissolving a - teaspoonful of boric acid powder in a pint of water); - - 4. Thiersch's solution (prepared by dissolving 15 grains of - salicylic acid and 90 grains of boric acid in a pint of - water); - - 5. Burow's solution (a solution of aluminium acetate prepared - by dissolving 675 grains of alum and 270 grains of lead - acetate in a pint of water.U.S.P. formula); - - 6. solution of bichloride of mercury (varying in strength from - 1 to 3000, to 1 to 10000); - - 7. 2 per cent. solution of creolin or lysol; - - 8. U.S.P. lead and opium wash; - - 9. aqueous solution of ichthyol (varying from 5 to 50 per - cent. according to the indications); - - 10. black wash (made by dissolving 64 grains of calomel in a - pint of lime water--this solution only being used in luetic - cases). - - 11. white wash (prepared by mixing zinc oxide, 2 drams, - solution of subacetate of lead, 3 drams, glycerine, 4 ounces - and lime water, 4 ounces); - - 12. Dakin's solution (hypochlorite of soda), prepared as - follows: - - chlorinated lime (bleaching powder) 200 gm. - sodium carbonate,dry 100 gm. - sodium bicarbonate 80 gm. - -Put the chlorinated lime in a 12 litre flask with 5 litres of ordinary -water and let stand over night. Dissolve the sodium carbonate and -bicarbonate in 5 litres of cold water; then pour this into the flask -and shake it vigorously for a minute and let it stand to permit the -calcium carbonate to settle. After half an hour, siphon off the clear -liquid and filter it to obtain a perfectly limpid product. The -antiseptic solution is then ready for surgical use: it contains about -0.5 gm. per cent. of sodium hypochlorite with small amounts of neutral -salts. It is practically isotonic with blood serum. Never heat the -solution, and always keep it from the light. If in an emergency it is -necessary to triturate the chlorinated lime in a mortar, do so only -with water, never with the solution of the soda salts. - -This solution has been used extensively abroad in the treatment of -infections and wounds and has given splendid results. - -(A proper quantity of Dakin's solution for office purposes would be -about one-tenth of the prescription above given.) - - -+DUSTING POWDERS+ - -These are employed either as antiseptics or as astringents or for both -purposes. Their use is limited, and they are employed only where the -secretion is scanty. - -Among the various powders used are: aristol, dermatol, boric acid, -orthoform, calomel, protonuclein, zinc oxide, alum, scarlet red, etc. - -_Thymoliodide_, or _aristol_, is a splendid antiseptic powder and -enjoys the advantage over iodoform of being inodorous. - -_Iodoform_ should only be used in tubercular conditions. - -_Dermatol_, or _bismuth subgallate_, combines the astringent and -mildly antiseptic qualities of bismuth and gallic acid. - -_Boric acid_ is mildly antiseptic. - -_Calomel_ should only be used in syphilitic conditions. - -_Zinc oxide_ and _alum_ are both astringent. - -Scarlet red (5 per cent.) with boric acid (95 per cent.) is indicated -for the stimulation of granulations. - -+Solutions.+ Among the various solutions used are silver nitrate, in -various strengths, zinc and copper sulphate, ichthyol, balsam of Peru, -nitric acid, sulphuric acid, trichlorand monochloracetic acid. - -_Silver nitrate_ is employed for its astringent action, as are also -the _copper_ and _zinc sulphates_. - -Balsam of Peru is used for its stimulating action. - -The stronger acids are employed for their escharotic qualities. - -"Red wash" (made up from the following formula: zinc sulphate 20 -grains, compound tincture of lavender 30 minims, distilled water to -make 8 ozs.) has a powerful astringent action and promotes -cicatrization, especially when there is a tendency for the -granulations to become exuberant. - -In the treatment of chilblains, a strong astringent is desirable to -constrict the diluted capillaries. - -The stronger _lotio alba_ of the national formulary, containing equal -parts of the saturated solutions of zinc sulphate and potassium -sulphuret, is markedly astringent and has a drying effect upon the -skin. - - -+STYPTICS+ - -+Styptics.+ These may act either by causing clot formation in the cut -arteries, or by causing the retraction of their edges. In the latter -class are included such drugs as _hydrastine_ and _adrenaline_. - -The disadvantage of using these drugs lies in the fact that secondary -hemorrhage is possible when their constrictor action is over. The -styptics causing clot formation are therefore to be recommended. They -should be non-irritating, antiseptic, and styptic, at the same time. -Such a preparation is practically unknown. - -_Peroxide of hydrogen_ on a pledget of cotton, placed over the -bleeding area, may effect a clot formation. - -The U.S.P. _liquor ferri subsulphatis_, better known as Monsel's -solution, is the best and most effective styptic that we have. -Monsel's solution, however, is not antiseptic and entrance of bacteria -into the wound is possible, unless, it is applied with a sterile -applicator or is dropped directly upon the wound from the bottle. - -The U.S.P. _tincture of iodine_ in equal parts of water, applied to -the bleeding area may, besides sterilizing it, stop bleeding. - -Should none of the above effect a stoppage of the bleeding, other -means must be sought. A bit of sterile gauze pressed quite firmly -against the area, should next be tried. If this fails, a wooden -applicator, prepared with Monsel's solution may be employed. A cotton -wound applicator, unless dipped into a strongly antiseptic solution, -contains millions of bacteria from the fingers. The use of the ancient -styptic stick of alum, copper or silver is discountenanced everywhere -as uncleanly. - - -+SOLVENTS+ - -+Solvents.+ Under this heading, those substances which are known to -soften tissue will be considered. - -_Sodium hydroxide_, up to a saturated strength, or an ointment of -_salicylic acid_, 5 per cent. to 50 per cent., depending upon the -density of the tissue to which it is applied, are the ones commonly -used. - -These two drugs have the power to macerate dry, hard tissues. - -Experience is necessary for the proper use of tissue solvents as the -length of time that they are allowed to act is of as much importance -as the strength of the solution. - -Sodium hydroxide solution can be instantly neutralized with any acid -and for this reason is preferable. - - -+OINTMENTS+ - -+Ointments.+ In the list of ointments, the much vaunted virtues of -advertised compounds are usually found. - -Ointments and oils are used in the treatment of wounds and ulcers, -either to stimulate granulations or to soften thick epidermis. - -Ointments should never be used where there is a profuse discharge, as -eczema is a complication which very often follows such treatment. - -A great many different kinds of ointments are used and among these -are: - - _Sulphur_ in 10 per cent. strength, or _ammoniated mercury_ up - to 5 per cent., where a paraciticide is indicated. - - _Balsam of Peru_ in 10 per cent. strength for the stimulation - of granulations; or _balsam of Peru_ and _castor oil_, equal - parts; also _boric acid_, or _ichthyol_ for their antiseptic - properties. - - Ten per cent. _mercurial_, for syphilitic cases. - - _Lassar's paste_ (which consists of salicylic acid, one dram, - starch and zinc oxide, each one ounce, and vaselin to make 4 - ounces) is used when there is an eczema present. - -One of the oldest as well as one of the best applications is balsam of -Peru, which has a powerful effect in increasing the growth of -granulations, but often after this has occurred the granulations are -apt to become exuberant with little tendency to cicatrization. - -The ointment which has given the best results is _scarlet red_, an -aniline dye, which is known chemically as a sodium salt of a -disulphonic acid derivative. Scarlet red (Biebrich) was originally -prepared as a dye for wool and silk, and is so named because of the -fact that it was first manufactured in the town of Biebrich. It was -first used for medicinal purposes in 1907 in an 8 per cent. strength; -because this strength was found to be too irritating, it was -alternated with a bland ointment every 24 hours. It is now used only -in strengths varying from one-half to five per cent., for the latter -has proved to be as strong as necessary. When applied to granulating -surfaces, scarlet red is sometimes absorbed in sufficient amount to -color the urine a bright red, and a number of acute cases of nephritis -have been reported from its use. - -Its application to granulating surfaces causes healing, not by the -formation of scar tissue, but in every case by producing a high grade -of normal skin (this can be demonstrated by sections), which very soon -becomes freely movable on the underlying tissue. The return of -sensation in the healed area takes place from the periphery inward, -instead of upward from the underlying tissue. - -Scarlet red ointment should be applied in the following manner: after -thorough cleansing of the part with tincture of green soap and water, -then ether and finally 93 per cent. alcohol, the ointment should be -spread in a thin layer over the entire surface on a piece of sterile -gauze, and over this an ordinary dry sterile dressing. If the ointment -is applied too thickly it may cause granulation tissue to break down, -and for this reason it should be spread in a thin layer upon the -granulating surface or its edges. Usually the dressing should be left -undisturbed for from 24 to 48 hours, then reapplied, as indications -warrant. The patient should invariably be informed that the dressing -will be stained red, so as to forestall unnecessary alarm, due to the -belief that a hemorrhage has occurred. He should also be apprised of -the fact that stains on the linen are hard to eradicate. In removing -the dressing, if it is adherent to the granulations, some peroxide of -hydrogen should be used to loosen it. The skin about the granulating -surface is best cleansed by benzine as this removes all traces of -scarlet red better than any other solution. The three formulas that -are recommended are the following: - - Strength - - Grains. Percent. - Scarlet red (medicinal Biebrich) 15 1 - ungt. acidi borici q.s., ad. 3 ounces. - - Scarlet red (medicinal Biebrich) 45 3 - ungt.zinci oxidi q.s., ad. 3 ounces. - - Scarlet red (medicinal Biebrich) 75 5 - balsam Peru, 75 minims. - Petrolati q.s., ad. 3 ounces. - -The first is indicated where its use is desired over a large area and -for a long time; the second, where an astringent action is required -because the granulations are profuse; the third, where the -granulations are sluggish and require stimulation. - -The ointment in a 10 per cent. strength is not recommended because it -is too irritating. - -In cases of chronic leg ulcers, especially those associated with -enlarged veins, it is impossible to effect a cure until the chronic -congestion of the limb is relieved and the blood supply of the part -approaches the normal. - -Often all that is necessary is a gauze, muslin or flannel bandage, -properly applied over the dressing and extending from the ankle to the -knee. - -A rubber bandage when applied with moderate, even pressure, has for -its purpose the relief of congestion, but in a great many cases the -rubber has an irritating effect on the skin. - -When the granulations are almost on a level with the surrounding skin, -and also when there is considerable thickening of the edges of the -ulcer, the best means of keeping up an even pressure and causing -absorption of the thickened margins, as well as of hastening the -epithelial growth, is to apply zinc oxide adhesive plaster in strips, -one-half to one inch in width. These strips should overlap to the -extent of about one-third of their width; should extend about -three-fourths of the way around the limb, and should be evenly and -smoothly applied. They should be started about one inch below the -ulcer and should run from two to three inches above it. - - -+BANDAGING+ - -+Bandaging of Leg.+ The final stage after the dressing has been put on, -consists in the application of the bandage. A bandage possesses -advantages over strapping in being less irritating to the skin; in -being more quickly put on and taken off; in being more easily removed -without disturbing the surface, and in more completely allowing the -formation of the granulations. - -The bandage is also superior to a laced stocking, as the latter does -not properly embrace the foot. - -The bandage material can be either gauze, muslin or flannel. The last -is considered the best because this material is thin, yielding and -elastic and yet almost any degree of compression can be exercised with -it. - -In edematous swelling in general, the flannel appears very suitable, -as it is soft to the skin and accommodates itself to the greater or -less distension of the limb, arising from the increase or diminution -of the fluid. The bandage should be at least six yards long, if -required for an ordinary adult, and the width should be from two to -three inches. Every portion of the limb, from the toes to the knees, -should be equally and evenly compressed. Compression is of such -absolute importance that without it everything else will be -comparatively ineffectual. This being so, very much will depend on the -manner in which the bandage is employed. - -Without practice, it is not easy to properly apply a bandage to the -leg, and probably this difficulty is the chief reason why preference -is often given to adhesive plaster, as this sticks wherever it is put. - -The blistering and excoriation often produced by strapping, and the -time consumed in its application, are sufficient reasons for acquiring -skill in the art of bandaging; an art whose comforts and advantages -are appreciated by the patient. - -Before using, the bandage should be rolled up very tightly, so that it -may be grasped easily and held in the hand firmly without slipping. In -putting it on, unwind only that portion which is being applied to the -limb, because if it be loose in the hand, or if a considerable piece -be unrolled at a time, it cannot be applied firmly or smoothly. The -bandage should always be carried up to the knee, even if the ulcer or -wound be seated on the lower part of the leg or on the foot itself, as -the object of its application is not merely to cover the ulcer but -also to support the vessels of the limb. If the bandage be -discontinued on any part of the leg, it is liable to become loose and -fall down. - -It is desirable also that the patient should not wear a garter above -the bandage, as anything unequally tight in the course of the veins is -calculated to obstruct the free passage of the blood. - -The firmness with which the bandage is put on is, of course, chiefly -for the purpose of gaining the good effects of compression on the -structures beneath, but besides, it contributes very much in making -the bandage remain in its position when applied. Encircle the limb -with it in a loose, careless manner, and it will fall down almost -immediately the patient begins to walk about. Tight bandaging is -extremely well borne if performed in a complete and methodical way, -beginning at the lowest portion of the foot around the first joints of -the toes and ending just below the knee. - -The proper application of the bandage is of such great importance, -especially in the treatment of varicose ulcers of the leg, that it -should, when possible, always be done by the doctor himself. It is -difficult for the most skilled layman to put a bandage on his own leg. -The real practical difficulty lies with those patients who live at a -distance from the doctor and who can only visit him once a week or at -ten day intervals. These must be taught to dress and bandage the -limb, and generally some friend or relative will learn to superintend -the details. - -The length of time which elapses before the bandage and dressings are -removed and reapplied must necessarily be determined by the -circumstances of each case. When the ulcer is very extensive and the -discharge proportionately great, it may be advisable to dress the leg -every day at the beginning of the treatment. Generally speaking, an -ulcer of the leg is disturbed too often. To take off a dressing and -put on another, even though done with the greatest care, interrupts -the healing process and the natural steps to cure. Let the dressing -remain on until some uneasiness points to the propriety of taking it -off, for the purpose of allowing the escape of the discharge. Delay -the removal of the dressings as long as possible without carrying the -forbearance too far. Avoid extremes of waiting too long or of meddling -too soon. Taking the average case, an interval of three days may in -general be safely permitted. - -+Spiral Bandage of the Great Toe.+ In applying this bandage, the initial -extremity of the roller is secured by two or three turns around the -ankle and the bandage is carried obliquely across the dorsum of the -foot to the base of the toe to be covered, and next to its tip, by -oblique turns; a circular turn is then made and the toe is covered by -ascending spiral or spiral reverse turns until its base is reached, -from which point the bandage is carried obliquely across the dorsum of -the foot and finished by one or two circular turns around the ankle. -The end of the bandage may be secured by a pin or may be split into -two tails and secured by tying. - -+Spica Bandage of Great Toe.+ This bandage is applied by placing the -initial extremity of the roller upon the ankle and fixing it by two -circular turns; the roller is then carried obliquely over the dorsal -surface of the foot to the distal extremity of the great toe; a -circular turn is next made and the bandage is carried upward over the -back of the great toe to the ankle, around which a circular turn -should be made; ascending figure of eight turns are then made around -the great toe and the ankle, each turn overlapping the previous one, -two-thirds, and each figure of eight turn alternating with a circular -turn around the ankle. These turns are repeated until the great toe is -completely covered with spica turns and the bandage is completed by -circular turns around the ankle. - -+French Bandage of the Foot.+ In applying this bandage the initial -extremity of the roller should be fixed on the leg just above the -ankle and secured by two circular turns around the leg; the bandage -should be carried obliquely across the dorsum of the foot, to the -metatarsophalangeal articulation, at which point a circular turn -should be made around the foot; the roller should then be carried up -to the foot, covering it with two or three spiral reverse turns; after -this a figure of eight turn should be made around the ankle and -instep; this should be repeated once to cover the foot, with the -exception of the heel, and the bandage continued up the leg with -spiral reverse turns. - -+Spica Bandage of the Foot.+ In applying this bandage, the initial -extremity of the roller should be fixed just above the ankle and -secured by two circular turns; the bandage should then be carried -obliquely over the dorsum of the foot to the metatarsophalangeal -articulation; a circular turn around the foot should be made at this -point and the bandage continued upward over the metatarsus by making -two or three spiral reverse turns; it should then be carried parallel -with the inner or the outer margin of the sole of the foot, according -as it is applied to the right or left foot, directly across the -posterior surface of the heel, and from this point it should be -conducted around the outer border of the toe and over the dorsum, -crossing the original turn in the median line of the foot, thus -completing the first spica turn. These spica turns should be repeated, -gradually ascending, by allowing each turn to cover three-fourths of -the preceding one, until the foot is covered, with the exception of -the posterior portion of the sole of the heel; the turns should cross -one another in the medium line of the foot and should be kept parallel -throughout their course. - -+Bandages for the Foot and Leg.+ Whenever possible the patient should be -kept in bed, or, at least, in the recumbent position with the leg -elevated, but when circumstances do not permit of this the veins can be -supported in various ways. Elastic stockings are excellent but -expensive, and not durable. Bandages of rubber cloth, or woven bandages -rendered elastic by the character of the mesh, or Martin's plain rubber -bandage may be employed. The last named is put on smoothly but not too -tightly, for in walking the leg swells, so that a uniform pressure is -established. As the rubber prevents evaporation it acts like a wet -compress, stimulating the granulations, but very often producing eczema -around the ulcer. The rubber bandage should be washed carefully at night -with soap and cold water and must be kept clean. In one patient a firm -elastic stocking of vulcanized rubber will give the greatest ease and -comfort, while in another the resulting irritation will prove -unbearable. As regards the flannel bandage it has already been described -at some length. - -The essential feature of ambulatory treatment is a good dressing to -prevent congestion, and Unna's paste is ideal for this purpose. The -paste necessary for the bandage is prepared as follows: first dissolve -four parts of the best gelatin in ten parts of water by means of a hot -water bath. While the fluid is hot add ten parts of glycerine and four -parts of powdered white oxide of zinc; stir briskly until the mixture -is cold. Another formula for the paste, and the one recommended, -consists of the following: white gelatin, 2-1/2 ounces; water, 8 -ounces; zinc oxide, 2-1/2 ounces, and glycerine, 4 ounces; prepared as -above. The paste should always be melted before use by placing the -receptacle in a hot water bath or in an ordinary copper sterilizer, -such as that employed for boiling instruments. A small tin can be -used, and a piece of paste about four inches square is cut into fine -pieces and put in the can. This is placed in the sterilizer, into -which is poured water to a depth of about two inches, so that the can -is but slightly immersed. No top should be placed on the can. An -ordinary stove or gas range can be used for heating purposes. A very -important fact to remember is that no water is to be put into the can -with the paste. - -The leg is next cleansed, and after the paste has been thoroughly -melted it is applied from the base of the toes to the knee, as hot as -the patient can comfortably tolerate it, by means of an ordinary small -paint-brush. Then a layer of gauze bandage (two to three inches in -width, according to the limb) is applied, then a layer of paste, and -in this manner two or three thicknesses of bandage are used, depending -on the case. In thin people, it is necessary to use only one or two -layers of bandage, whereas in stout persons several layers may be -required. After the last application of the paste, some non-absorbent -cotton is spread on the bandage, giving it the so-called "moleskin" -plaster finish. Another way of finishing the dressing is to dust some -ordinary talcum powder on the last layer of the paste, giving the -bandage the appearance of a plaster-of-Paris dressing. If there is an -ulcer, a window can be cut out, thus providing for the drainage of the -secretions. The length of time this dressing should be left on depends -on a number of conditions, especially the amount of secretion, and -whether the patient has to remain on his feet very much. Ordinarily, -the bandage can remain on for one week, but indications may be such -that it need not be removed sooner than the tenth day, and in some -instances it can be kept on for three or four weeks. To remove it, an -ordinary bandage-scissors is used to cut the dressing, and it peels -off without disturbing any of the granulations on the ulcer. - - -+PROMOTION OF NEW EPITHELIAL GROWTH AND CICATRIZATION+ - -The value of nitrate of silver and red wash as stimulants of the -healing process has already been mentioned. They are also of value in -producing cicatrization and in promoting the covering of new -epithelium over the ulcer or wound. If the solid stick of nitrate of -silver be applied very lightly to the edges just inside the pale -bluish line of advancing epithelium, so as to produce a white film on -the surface, this slight cauterization will be found to aid in -strengthening and cornifying the new, delicate and previously -invisible epithelial cells and in preventing them from being washed -away by the discharge from the ulcer. The solid stick of nitrate of -silver is also of benefit in destroying the exuberant granulations -which project above the surface of the surrounding skin; often, by -piercing these flabby granulations in several places with the solid -stick held perpendicular to the surface, cicatrization is hastened. -After the granulations are level with the surrounding skin the -covering of the ulcer or wound with new epithelium is hastened by the -application of some smooth surface along which the epithelium can -spread. For this purpose zinc oxide plaster or some thin rubber may be -used. - -In some old chronic cases, healing is prevented by the fact that the -base of the ulcer cannot contract owing to its being bound down by -fibrous scar tissue. This binding down of the base and edges of the -ulcer also tends to cut off the blood supply, and therefore in this -additional manner healing is hindered. For the relief of this -condition a number of procedures have been devised. Mattress sutures, -introduced through the normal skin beyond the edges of the ulcer and -passing beneath it, out through the skin on the other side, is one -method. By tightening these sutures, over a button or metal plate, the -ulcer can be lifted from the underlying tissues. Another method, -called "starring of the ulcer," consists in a series of radiating -incisions through the base and edges of the ulcer, the part from which -the incisions radiate corresponding with its centre. In this and in -the following operations, in order to obtain a favorable result, it is -necessary that the incisions pass completely through the cicatrical -tissue which forms the base and edges of the ulcer into normal tissue. -"Cross-hatching" of the base of the ulcer by means of a series of -incisions at right angles to one another, and at a distance of about -one-half inch apart, is often of value in aiding the healing of a -chronic ulcer, the continued existence of which and failure to heal -having been due to its thickened, adherent base and edges. -Circumcision of a chronic ulcer consists in making a circular incision -around it through the normal skin. A modification of this method -consists in making a series of overlapping, short, curved incisions -surrounding the ulcer, instead of a single circular incision. In these -last two methods it is necessary that the incisions be made through -normal skin, and that the wounds be made to gape, if necessary, by -packing them with gauze. - -When the ulcer or wound is of considerable size, it is often -impossible to secure healing even by these methods. It may for a time -appear as if it were going to heal, and a pale blue line of newly -formed epithelium may spread out from the edges, but instead of the -epithelium continuing its progress, at a subsequent dressing it will -be found to have disappeared. In these cases, as well as in those in -which the size of the ulcer would necessitate a long delay for a cure -or in which the subsequent contraction of the scar would produce -deformity, skin grafting, skin transplantation, or some form of flap -operation is indicated. - - -+SKIN GRAFTING TO OBTAIN A SOUND SCAR+ - -A very important object in the treatment of all ulcers is to obtain a -sound scar. In ulcers affecting the lower extremity in elderly people, -the scar resulting from spontaneous healing is weak and readily breaks -down if the patient does much standing or walking. The patient is -therefore frequently obliged to give up work in order to get the ulcer -re-healed, or must be content to employ means which merely prevent its -extension and relieve some of the discomfort. When the best possible -scar is desired, and when it is important to avoid marked contraction, -it is necessary to adopt some method of skin-grafting. - -There are three plans by which rapid healing of an ulcer may be -brought about: Reverdin's epidermis grafting; Thiersch's skin -grafting, and the use of the whole thickness of the skin. - -+Reverdin's Method.+ In this procedure small thin portions of the -superficial layer of the skin are snipped off with a curved scissors. -Pieces about the size of a hemp seed are planted on the surface of the -granulations at short distances from one another. Epidermic growth -occurs from each of these little points, and the result is that -numerous small islands of epithelium form over the surface of the -ulcer. If the grafts be close enough together and the conditions be -favorable to healing, these islands soon coalesce and thus rapid -cicatrization is obtained. The grafts should not be too far apart, -because they appear to have only a limited power of reproduction. - -+With a view to obtaining a sounder scar+, thicker and more extensive -portions of the skin must be taken and the grafts must be applied -close together. There are two ways of doing this: either by using the -whole thickness of the skin or by employing Thiersch's method, in -which about half the thickness of the skin is shaved off. - -The procedure where the whole thickness of the skin is employed need -not be described, partly because the results are not satisfactory and -partly because all the conditions for which it was introduced are -better fulfilled by Thiersch's method. - -Skin grafts may be taken either from the patient himself or from -another individual. When the patient is much debilitated, the -cutaneous epithelium shares in the general malnutrition and under -these circumstances a graft from a healthy subject might succeed -better than one taken from the patient. - -+Thiersch's Method.+ In employing this method the skin which is to be -used for the grafting must first be shaved and disinfected in the -usual manner, as has been previously described. The presence of hairs -on the grafts seems to interfere materially with their union. - -+Preparation of the Ulcer.+ _Preliminary._ It is of no use to graft a -sore which is actually ulcerating; it must be brought into a healthy -condition, and healing must have commenced before transplantation is -likely to be successful. The best criterion that healing is taking -place is the presence, at the edges, of the dry line which indicates -recently formed epithelium. Some surgeons wait for a considerably -longer time before grafting in order to get a firm layer of -granulations, but experience shows that it may be safely resorted to -as soon as healing begins around the edge. A second essential is that -the ulcer shall be clean. If the discharges be septic, the graft, -which is, after all, merely a piece of dying tissue, will become -impregnated with decomposing pus and may rapidly become loosened, die, -and undergo decomposition. The methods of rendering the ulcer aseptic -have already been described. - -_Operative._ The following is the method of procedure: after the -patient has been placed under an anesthetic, the granulations over the -whole surface of the ulcer are forcibly scrubbed off with a firm -nail-brush, or are evenly scraped away, taking care, however, to -remove only the soft layer of granulations and not to go through the -deeper one of newly formed fibrous tissue into the fat. A surface is -thus left which is smooth, highly vascular, and firm, and which -consists of the deeper layers of granulation tissue that have already -become organized into fibrous tissue. In cases of ulcer of the leg it -is also advisable to remove those portions of the edge which have -already become covered with new epithelium. If the transplantation be -limited to the parts actually unhealed, the result is disappointing as -a rule, for while the part grafted remains sound, the margin where -spontaneous healing had occurred, is apt to break down, and thus a -narrow line of ulceration appears at the edge of the ulcer. - -After the layer of granulations has been removed and the newly healed -edge of the ulcer has been cut away, the bleeding must be arrested -completely before the grafts are applied. The most rapid method is to -pour a few drops of adrenalin chloride (1 to 1000) solution over the -raw surface, when the oozing ceases immediately. If adrenalin be not -at hand the following plan will be found satisfactory: any spouting -vessel is clamped and a large piece of sterilized gauze or thin sheet -rubber is applied over the raw surface of the wound; outside this, -several sponges are placed and a sterilized bandage is bound firmly -over them. If the sore be small and an assistant be available, he may -apply the pressure. Pressure is employed indirectly through the -protective in this way, because if it were made directly upon the -surface of the wound by means of the sponges, bleeding would -recommence when the latter were removed, as they stick to the raw -surface. - -While the bleeding is being arrested the surgeon cuts his skin grafts -from any part of the body, as he thinks fit As a rule they are taken -from the front of the thigh, but the side of the abdomen may be -selected. The area from which the grafts are to be cut is disinfected, -and the surgeon grasps the limb from behind with his left hand in such -a way as to make the skin over the front of the thigh as tense as -possible; in doing this he pushes the soft parts well forward so as to -make the anterior aspect of the limb as flat as possible. The skin is -further put on the stretch vertically by an assistant, who pulls it -upward and downward. These precautions are important, as without them -it is almost impossible to cut a graft of even width. The razor, which -should have a very broad blade, is dipped into a boric acid solution -and is kept constantly wet with it whilst the grafts are being cut. -Unless this be done, the graft adheres to the blade and may be either -partially or wholly cut through before a sufficient length can be -obtained. The razor is made to penetrate through about half the -thickness of the skin, and then, by a lateral sawing motion, the -grafts are cut as broad and as long as possible. After a little -practice it is easy to cut them about two inches in breadth and about -four or five inches in length. - -If one graft be insufficient, it is best to slide it off the razor and -leave it on the bleeding surface; in this way it is kept warm and -moist. Some surgeons put the graft into warm saline solution, and it -is said to then spread out more easily afterwards. Small skin grafts -can be cut under local anesthesia. - -+Application of Grafts.+ When a sufficient number of grafts have been -cut, the bandage, sponges and protective are removed from the raw -surface of the ulcer and the grafts are applied to it if the bleeding -has stopped, as is generally the case. The raw surface usually has a -thin layer of blood-clot upon it, and this should be wiped away. - -Each graft is lifted with forceps or the fingers and applied with the -cut surface downward, and then is carefully unfolded by means of two -probes and stretched evenly over the surface. The grafts should -overlap the edges of the skin and also each other, so that no part of -the raw surface is left exposed, for granulations always spring up on -the uncovered parts and are apt to destroy the grafts in their -vicinity; moreover, a thin scar is left at these points which may -break down subsequently. The graft is always thinner at its edges than -at its centre, and it is these thin edges which overlap each other or -the margin of the skin; there is no real sloughing of these -overlapping portions. - -The dressing should be left on the grafted surface for about five -days; in some cases even for a week. If the wound be aseptic, no -suppuration or decomposition takes place beneath it. Before being -removed, the dressing should be thoroughly soaked with a 1 in 2500 -sublimate solution, for otherwise it may stick at the edge and adhere -to the graft, which may thus be peeled off, unless great care is -taken. The parts should be gently cleansed with the same solution, and -a dressing similar to that put on originally should be employed for -about another week. At the end of that time the grafts are fairly, -firmly adherent and then a 5 per cent, boric acid ointment is the best -application. - -It will be found that even at the first dressings the grafts present a -pink color and are adherent to the deeper surface, though they are -still readily detachable. In the course of about a week the old -cuticle peels off, but no raw surface is left. Later on, there is a -great tendency to the formation of new epithelium, cornification, and -drying-up, and it is to avoid the latter condition that ointments are -so useful; in fact, until the scar is absolutely sound, it is well to -keep the surface covered with some greasy application, the best being -the 5 per cent, boric acid ointment. - -For many months the grafted surface is likely to scale or crack, and -this might prove a starting-point for the occurrence of sepsis which -would cause the newly grafted area to slough. It is important to keep -the scar as supple as possible, and therefore it should be constantly -anointed with cold cream, vaselin, or lanolin. Grafted surfaces upon -the face, however, do not manifest this tendency for any length of -time. - -+Time Required for Cure.+ It is important to know when the patient may -be allowed to walk about after an ulcer of the leg has been -skin-grafted. If he begins too soon, the grafts will almost certainly -become detached. That this will be so is evident from a consideration -of the mode by which the adhesion of the grafts takes place. At first -they adhere to the surface of the sore, simply by means of the effused -and coagulated length. Cells rapidly spread into this length and in -the course of two or three days the space between the grafts and the -raw surfaces is occupied by a mass of young cells. In this tissue, new -blood vessels develop and penetrate into the graft, whilst, at the -same time, the cells of the latter grow and assist in the development -of the young tissue and of the blood vessels. Thus the graft becomes -vascularized; but for a considerable time the tissue between it and -the surface of the sore contains many young blood vessels with -delicate walls, and therefore, if the patient stands erect and allows -the pressure of the column of blood to fall on these vessels, they -rupture, and bleeding occurs beneath the graft and leads to its -detachment. - -It requires a long time before the graft is firmly incorporated with -the tissue beneath by the development of elastic fibres; indeed, it -may be reckoned that this union is not complete until from three to -six months have elapsed. The graft will, in all probability, be -destroyed if the patient walks about within three months of the -transplantation. Hence, unless that time can be devoted to the -treatment, it is not worth employing skin-grafting for ulcer of the -lower limbs. By this, however, it is not implied that it is necessary -to keep the patient in bed for the entire time, but merely that the -foot must not be allowed to hang down, nor must any weight be borne -upon it. - -At the end of about six weeks the patient may be allowed to get up and -lie on a sofa or sit with the leg on another chair, but the limb must -not be permitted to hang down. After about three months he may be -allowed to get about, but in order to prevent the detachment of the -grafts, he should be fitted with a knee-rest and peg on which he -walks, the leg projecting out behind him. If possible he should not -put his foot to the ground until six months have elapsed. In cases of -sores on other parts of the body, when the erect posture does not -cause congestion of the part, the patient may be allowed to walk about -after the first three weeks. - -+Results.+ The scar which results after skin-grafting performed in this -manner is of a satisfactory character, and ulcers which have been -intractable for years may be closed satisfactorily by this means. In -order to obtain anything in the nature of a permanent cure, however, -the prescribed period of rest must be adhered to rigidly. - - - - -CHAPTER XX - -+LOCAL ANESTHESIA+ - - -+History.+ From Corning we learn that the ancient Assyrians alleviated -and even entirely prevented the pain incident to circumcision by -compressing the veins in the neck. Unconsciousness was probably -induced in this way together with pressure on the carotids. - -In India, centuries ago, the effects of opium and of Indian hemp were -known and employed, and the ancient Egyptians were also conversant -with the soporific effects of many drugs. We learn, from the same -authority, much which he gathered from literature about the history of -local anesthesia, and it is from Corning's well-known book on local -anesthesia that most of this history is quoted. - -In Peru, the Spanish conquerors learned that the coca loaf was held in -high esteem by the natives, inasmuch as they observed that it was -chewed by the high priests and nobility only, the vulgar being denied -this privilege except as a reward of great merit or of distinguished -valor. The leaf was regarded with awe and superstition and was -supposed to possess supernatural powers. After the fall of the Incas, -the Spanish not only permitted but encouraged the general use of the -leaf in order to obtain more work from the natives, a result which the -drug seemed to effect. It was also a source of great revenue to them -and was sold at exorbitant profit to the natives who became enslaved -to its effects but were able to endure great hardship while under its -influence. - -Chemists throughout the world, recognizing the potent action of the -coca leaf, were soon engaged in the effort of extracting its active -principle. - -In 1859, after many had tried and failed, cocaine was evolved from -crude extractives. Authorities differ as to whether it was Mann or -Neimann, a pupil of Woehler, who first presented cocaine to the -chemical world; however, fifteen added years elapsed before practical -use for it was found. In 1862, Professor Schraff discovered that the -tip of the tongue was rendered numb, and insensible when a little of -the cocaine alkaloid was applied to it and that it remained so for a -considerable length of time. Significant though this experiment was, -the action of cocaine on the nerve-filaments was not recognized and -the matter was not followed up until Dr. Karl Koller, of Vienna, began -his experiments which resulted in a universal awakening to the use of -a substance which, though known, had been allowed to remain unnoticed -for ages. - -Its anesthetic effect upon the eye was demonstrated by Koller at the -Opthalmologic Congress at Heidelberg in 1884. Dr. H. D. Noyes was -first to direct the attention of the American practitioners to -Koller's results in the use of the drug. Its introduction was one of -the greatest triumphs of modern surgery. It makes possible the discard -of the systemic anesthetics in all minor surgical operations and also -in many operations of considerable magnitude. - -In the laboratory of Professor Stricker, Koller experimented on the -eyes of a number of animals and thus reports his findings: - -"A few drops of a watery solution of muriate of cocaine dropped on the -cornea of a guinea pig, rabbit, or dog, or instilled into the -conjunctival sac in the ordinary way, caused, for a short time, a -winking of the eyelids, evidently in consequence of a slight -irritation. After one-half to one minute the animal again opens its -eyes which gradually assume a staring look. If now the cornea is -touched with a pin head (in which experiment we have carefully avoided -touching the eyelashes), the lids are not closed by reflex and the -eyeball does not move, the head is not thrown back as usual, the -animal remains perfectly quiet, and, on application of a stronger -irritation we can convince ourselves of the complete anesthesia of the -cornea. In this way I have scratched and transfixed the cornea of the -animals used for experiment with needles, and have excited them with -electric currents so strong as to cause pain in my fingers, and to -become quite intolerable to the tongue. I have cauterized the cornea -with the nitrate of silver stick until it became milky white; during -all of this the animal did not move. The last experiment convinced me -that the anesthesia involved the whole thickness of the cornea and did -not affect the surface only. But if I incised the cornea, the animals -manifested intense pain, when the aqueous humor escaped and the iris -prolapsed. I have been unable hitherto to decide, by experiments on -animals, whether or not the iris could be anesthetized by dropping the -solution into the corneal wound, or by prolonged instillations into -the conjunctival sac; for experiments to test the sensibility of -non-narcotized animals are very complicated and difficult and do not -yield unambiguous results. The last question which I subjected to -experimentation on animals, viz., whether or not the inflamed cornea -could be anesthetized by cocaine, was answered in the affirmative. The -cornea in which I had incited a foreign-body-keratitis, became as -insensible as a healthy one. - -"Complete anesthesia of the cornea from the use of a two per cent. -solution lasts ten minutes on an average. After such successful -experiments on animals I did not hesitate to use cocaine also to the -human eye, trying it first on myself and on some of my friends, and -then on a great number of other persons, obtaining, without exception, -the result of a perfect anesthesia of the cornea and conjunctiva." - -Soon after Dr. Koller's report appeared, cocaine was used for a great -many operations upon the eye, and its application to mucous membranes -in general was soon taken up by practitioners everywhere. - -Rectal, vaginal, otologic, rhinologic, oral and urethral anesthesia -were soon found to be easy of accomplishment and many operations in -these fields were performed under cocainization. The hypodermic -injection of cocaine was experimented with and reported upon in 1884 -by Drs. N. J. Hepburn, R. J. Hall, and Halsted. - - -+PHYSIOLOGIC EFFECTS+ - -+Nerve Pressure; Anemia.+ That motor and sensory paralysis followed -pressure upon a nerve has been well known for many years, and this has -been utilized in the effort to produce anesthesia, artifically by -applying a rubber tube or bandage around a finger or extremity, with -the hope that "ligation anesthesia" would follow the arrest of -circulation. This, however, has been unsuccessful as all that was thus -accomplished was a slight sensation of numbness with no arrest of the -sense of pain. This method could only be successfully carried out, -were the nerves themselves subjected to sufficient pressure to injure -them. Return to normal sensibility and motor function could not be -expected for months. - -+Cold.+ The addition of common salt to ice hastens its liquefaction and -consequently renders the mixture more cold. This knowledge has been -applied in a method of producing anesthesia of limited areas of the -skin. A gauze bag of the correct shape and size is filled with salt -and ice mixed, and applied to the area to be anesthetized. - -This method was used as far back as 1848, by Arnott, but was soon -improved upon by Richet and others who used ether or rhigolene sprayed -on the part to be anesthetized. It was found that extremely low -temperatures could be obtained in this way, especially if a current of -air were blown across the field of operation to hasten evaporation, -and that a good local insensibility could be brought about if the -circulation of warm blood could be either stopped or retarded with an -Esmarch bandage or tourniquet. The method of obtaining local -anesthesia through the agency of cold was found to be best -accomplished by ethyl chloride and this substance is used in -preference to any of the others previously mentioned, at the present -time. Some years ago Dr. Martin W. Ware of New York experimented with -both ethyl chloride and ethyl bromide and he found that the former was -more serviceable in producing local anesthesia. - -+The Sensibility of Various Tissues.+ Karl G. Lennander, of Upsala, -Sweden, shortly before his death, completed a chapter on local -anesthesia for Keen's "Surgery" in which is set forth an elaborate -account of the sensibility to heat, cold, pressure, and pain of the -various nerve terminals throughout the body. In this great work he has -given the world the results of many experiments on living tissues, -experiments investigating the degree and kind of the tissues -sensibilities; thus it is learned that "all internal organs receiving -their nerve supply only from the sympathethic nerve and from the -vagus, below the branching-off of the recurrent nerve, have no -sensation, and that the abdominal and pelvic viscera are devoid of -nerves to convey the sense of pain, heat, cold, or pressure." - -From the same authority we are taught that the parietal peritoneum is -highly sensitive but that the visceral covering is devoid of all -sensibility, enabling the operator much freedom of manipulation within -the abdominal cavity. - -In a work of this limited size the sensibility of the various tissues -cannot be fully treated but it should be borne in mind that the -integument and the subcutaneous tissue, fat and muscles as well as the -tendons, their sheaths, the muscles and periosteum and perichondrium -covering the bones and cartilages throughout the body, are all highly -sensitive to pain. It is also equally true that the bone substance, -the bone marrow, and the cartilages are devoid of any of the four -modalities of sensation. Articular surfaces covered with cartilage -have no sensation, neither have the fibrocartilages any sensation. - - -+GENERAL CONSIDERATIONS+ - -+Effect of General Anesthesia.+ Local or regional anesthesia is -obviously the method of choice in all cases in which it is -applicable. Not only is it desirable in the minor surgical operations -and the more important ones upon patients suffering with a cardiac or -nephritic derangement, where a general anesthetic is positively -contraindicated, but in every instance where it is at all possible, -the dangers and annoyances of general anesthesia should be avoided, -and the regional or local anesthesia should be employed. - -Among the advantages, aside from the number of assistants required and -the discomfort immediately following the administration of a general -anesthesia, are the absence of remote ill effects of the invasion -throughout the entire system of a noxious chemical substance and its -direct deleterious effects on many large organs such as the lungs, -heart, kidneys, and liver, and the assurance, when a proper drug, -dosage, and technic are employed, that death cannot be ascribed to the -anesthetic. - -Of remote ills of general anesthesia no estimate can be made, but that -they are legion and of great severity is established. Deaths from -general anesthetics in persons apparently able to bear them well, are -extremely numerous. It has been estimated that one in fifteen thousand -succumbs from ether anesthesia and this number would probably swell -greatly were it possible to obtain the exact figures. Even this -minimum of danger does not exist in local anesthesia. - -An accurate knowledge of the neural anatomy of a particular region -enables the operator to anesthetize large areas and to operate with -entire freedom from the necessity of observing the appearance and -conduct of his patients, many of whom, notably the alcoholic ones, -behave badly, become cyanotic and breathe intermittently when under -the effects of inhalation anesthetics. The absorption into the body of -the substances employed by inhalation may also exert a baneful -influence by reducing the powers of resistance upon an economy already -lowered by disease, and also by retarding convalescence. - -+Advantages of Local Anesthesia.+ In minor or trivial affairs the -elimination of pain is not to be considered lightly, for every -patient, even the strongest, will appreciate anything which will -expedite a cure and at the same time will relieve him of suffering. -Rather than lose time from their work or suffer the nausea and dangers -of general anesthesia, these patients often bear for years conditions -which could easily be cured by operations under local anesthesia. In -this class one must first think of hemorrhoids; of cysts; of fatty -tumors; of foreign bodies in the hands and feet; of verruca and of -ingrown nails. These conditions would be promptly relieved were the -element of pain in surgical interference not to enter as a factor. - -With a perfect technic, local anesthesia can also be employed with -entire satisfaction for certain major operations, where the subject is -suitable. Thus, herniotomies are performed with entire success, -especially those cases complicated by strangulation in which the -dangers arising from fecal vomiting and inspiration pneumonia, are -greatly decreased by omitting the general anesthesia. - -In many of the more severe conditions not to be classified as minor -surgery, the surgeon may consider the comfort of the patient and his -own convenience and employ local in preference to general anesthesia, -even tho the patients may be of the most robust type. - -In this group may be mentioned benign tumors at any visible part of -the body, hernias, many scrotal and anal diseases and some conditions -peculiar to the extremities, such as varicose veins. These conditions -lend themselves kindly to local insensitization. - -In certain emergencies where an operation must be performed -immediately, such as tracheotomy, thoracentesis and strangulated -hernia, local insensibility is imperative. In these operations local -anesthesia is also more desirable because of the ill effects of -vomiting, which are thus eliminated. - -Weakness of the patient enters also as a demand for the exhibition of -a local anesthesia in such operations as resection of a rib for -empyema, in which instance the action of the heart or lungs is -embarrassed. Other operations performed under local anesthesia for the -same reason (weakness of the patient) are the exploratory operation -for a probable inoperable cancer and the palliative operations such as -gastrostomy, enterostomy and colostomy. - - -+SOME VALID OBJECTIONS TO THE USE OF LOCAL ANESTHESIA+ - -There are, however, valid objections to the general application of -local anesthesia and the cases for its use should be selected with -care. It does not produce relaxation nor does it give the surgeon -perfect control over his patient. These are considerations which must -be taken into account, especially in operating on patients of highly -nervous temperaments. Though the patient may be convinced that he will -suffer no pain, the mental attitude toward the local anesthesia, -together with fear, may operate so strongly as to constitute a shock -to the nervous system so great that a general anesthetic should be -used and the local method abandoned, even were it apparently -indicated. - -Again, the injection of anesthetic drugs in cicatrical and inflamed -tissues is quite difficult of accomplishment and because of the -peculiarity of these tissues, diffusion throughout a given area is -imperfect, hence insensibility is not complete. - -The extravagant claims of enthusiastic advocates of this method of -anesthesia have retarded its progress. Thus, in the hands of the -competent operator it was given but a perfunctory trial to be -discarded as impossible. At the present time, however, local -anesthesia bids fair to become the method of choice, other things -being equal, for many major operations not yet thus performed. Recent -investigations alone these lines have developed methods of its -application whereby it is possible to render insensible large areas of -the integument, and regional anesthesia is performed by anesthetizing -nerves proximal to the seat of operation, thus rendering amputations -feasible. - -A single element which has entered as a factor in retarding the -progress of local anesthesia in general surgery, is that of regarding -the operation as one fitted to the method rather than to the patient -under consideration. It is obvious that this is a fallacy and the main -issue in deciding between general and local anesthesia is: what will -the patient best tolerate? In coming to a decision in the matter one -should make a general survey and weigh first the general health of the -patient; whether he be in perfect systemic condition or undermined by -disease, whether the shock will be greater from one method than the -other, and whether the part of the body to be operated on is one which -will lend itself better to one method than to the other. - -These elements are being and will continue to be considered as -preliminary to operative procedure and in consequence, general -anesthesia will cease to be given in a routine way. - - -+GENERAL PRINCIPLES AND ESSENTIALS+ - -The first essential to the successful production of local anesthesia -is a proper equipment and one that is in good working order. Not only -is it necessary to employ the best drug to this end but also to use a -syringe having perfect mechanical construction and one not injured by -boiling; as also needles of the length, lumen and shape suitable for -the surface to be injected. - -The old leather pocket syringes, on account of their not bearing water -at high temperature without deterioration, should not be employed; -this applies also to that variety of glass barreled metal-mounted -syringe in which the glass is screwed into the metal end pieces. - -The best syringes are those made of all metal or of all glass, the -latter being preferred because one may see the contents and express -out the air before injecting. Syringes of this type, because of the -accurate fitting piston, must be thoroughly dried out after use, as -the piston may stick fast within the barrel. All-glass or all-metal -syringes must be selected with care as they are often imperfect, the -calibre of the barrel being unequal in different parts of its length -causing the piston to fit tightly in some parts, and thus to work -with difficulty; and in other parts fitting loosely, allowing the -fluid to escape backwards. - -Syringes are also made in various sizes and shapes to meet certain -requirements. For the edematization of large areas of loose tissue, -where a considerable amount of a weak solution is intended, the use of -a large barreled syringe will be found to save time and the annoyance -of refilling. - -For such work a five or ten c.c. syringe would be the most useful. The -ordinary hypodermic syringe is about of two c.c. capacity (thirty -drops), and serves the purposes of every-day work. It does very well -for the amount of an anesthetic solution employed in opening an -abscess or in the removal of a small cyst or lipoma or papilloma. - -A barrel, large in diameter, requires more pressure on the piston in -its operation unless the needle employed is also correspondingly -large. For this reason, if the tissue in which the solution is to be -injected is not loose or cellular, it will be found better to use a -syringe in which the barrel is long and narrow. Such is the shape of -the syringe intended for the injection of the gums, the peridental -membrane, and also for the periosteum, cartilage or bony cellular -structure. A long instrument is also required for use in the large -cavities of the body such as the mouth, the vagina, or the rectum. In -these localities, an extension fitting is often required to lengthen -the instrument sufficiently to reach the desired part. It is also -possible to attain this end by using a long needle; this, however, -sacrifices rigidity. - -For accomplishing the best results, the needles must also be selected -for the work at hand. For the initial puncture in sensitive or -inflamed tissue, it is proper to use a needle of the finest lumen so -as to cause the least possible amount of pain. The ordinary needle, -which comes with the usual hypodermic outfit, is about the proper -length for the ordinary work already mentioned, but could be improved -upon for anesthesia by being made a little finer in calibre. This -length (three-quarters of an inch) will be frequently found -insufficient to reach the deeper tissues and in the removal of a more -or less rounded growth, a longer needle must be selected at the start. -Curved or angular ones are only needed in dentistry, where strength is -also a consideration. Strength is afforded in those of short length by -means of a reinforcement at the hub. Needles so augmented may also be -of use in operations upon bone or dense structures in general; the -curve, however, is not essential. - -The surgeon should be fully conversant with the details of the -operation which he is about to perform. His work should be definitely -in his mind, for in operations under local anesthesia, there is no -justification for a change of procedure after the beginning of the -work. Account should be taken of the nature of the tissues to be -anesthetized, for it is known that cicatricial tissues and -inflammatory areas do not lend themselves to the action of these -drugs. In a cicatrix, the diffusibility of the solution is impeded, -and in an inflammatory or necrotic tissue, the changes in the quantity -and quality of the fluids present, alter the action of the anesthetic. - -In considering the personal element of the patient one meets a -difficulty which is by no means minor, and full explanation for the -selection of the local anesthetic with many assurances of the -painlessness of the operation are frequently necessary. This is -especially true with one of highly emotional temperament, and, to -allay fear in such a patient is not always easy. - -Whatever may be said regarding the mental state of the patient who is -to receive an anesthetic, whether general or local, the surgeon must -remember that to be calm does not always lie within the control of his -subject, and it will be found that a hypodermic injection of morphine -(gr. one-eighth to one-quarter) an hour before the start of the -anesthetic, will often render possible the use of the injection method -in a patient with whom it would otherwise have been impossible. -Morphine injections, as suggested, are of advantage in patients on -whom a major operation is contemplated; they loosen the musculature -and diminish the sensations of parts not anesthetized. - -The deliberate and confident manner and word of the surgeon go a long -way in guiding the feelings of his patient, and a worried or -apprehensive surgeon makes for a doubtful and sensitive patient, ready -to cry out at the first prick of the needle. Therefore it is a part of -good general technic for the surgeon to deport himself in a way -conducive to cheerfulness, and conversation must be guided along these -lines. - -There are many who will writhe and groan at sensations (which they -will admit later were not painful) incident to local anesthesia, such -as the grating vibrations of instrumentation. Such a patient is not -well fitted for the method and it is for the discerning surgeon to -recognize such in advance, that he may operate under the most -favorable circumstances. - -+Preparation of the Patient.+ Proper evacuation of the bowels and a -stomach free of undigested parts of a previous meal, are desirable. -The subject of an anesthetic should not be purged or starved as these -are weakening processes and also disturb the tranquility so essential -to a perfect anesthesia. The skin should be prepared so as to -accomplish surgical cleanliness without irritating it so as to retard -healing. It was once thought that soap, water, alcohol, ether and -bichloride were absolutely necessary to this end. It has, however, -been found that iodin, applied in the ten per cent. tincture to the -site of incision, fulfills every requirement. Where shaving is -necessary, it should be done first. In operations about the anus and -scrotum, iodin is contraindicated because of its irritating -properties; it is painful in these parts and dermatitis is frequently -the result of its use. - -+Instruments.+ The instruments should be prepared and ready before the -anesthetic is given, regardless of the form of anesthesia employed. -The surgeon's hands should be rendered aseptic, no matter how trivial -the procedure before him, and every precaution should be taken to -guard against infection, which is always possible in any surgical -procedure however insignificant. - -+Technic.+ Various methods of accomplishing the insensitization of a -part may be employed. Thus, if the skin alone is to be incised, it -alone will require injection and by careful insertion of the end of -the needle it may be kept just under the epidermis, thus injecting the -anesthetic endermatically in and about the papillae of the papillary -layer. - -+Endermic Method.+ This method is an end-organ anesthesia, and the -solutions employed are strong and act because of their drug content. -It is not in any sense a pressure anesthesia. The skin should be -picked up and pinched hard for the better insertion of the needle -directly into the skin substance. It is therefore endermic and the -skin is seen to become blanched as the needle advances delivering its -solution on the way. But little of the fluid is pressed out as the -needle advances. When the syringe is empty or the needle has advanced -to the limit of its length, refill and insert just inside of the last -blanched spot and proceed in a line until the end of the contemplated -line of incision is reached. - -Pressing out too much of the solution at one time causes a burning -sensation and should therefore be avoided as the only pain should be -that of the initial prick of the needle. Care, however, should be -taken to inject just sufficient of the solution to penetrate beyond -the zone of operation laterally, to insure sufficient space for the -insertion of sutures into anesthetized tissues. Only a small quantity -of fluid is necessary in this procedure as it comes in direct contact -with nerve terminals. By touching the injected line with the needle in -several places along its length and inquiring of the patient if it is -felt, we may make sure of the completeness of the anesthesia before -making the incision which should begin and end inside the anesthetized -area. - -+Subdermic Method.+ An appreciable area of skin and subcutaneous tissue -may be incised by anesthetizing as previously described, together with -depositing the fluid well under the skin, thus affecting many terminal -nerve branches before they reach their final distribution in the skin, -and widening the anesthetized area considerably. - -This method is applicable to such work as the removal of small -growths, and the deep incision of a carbuncle. Beneath the skin in the -loose connective tissue the fluid is deposited and causes anesthesia -by acting upon the nerves just before their emergence into the skin. -The two methods may be combined. It is not possible to inject directly -into thin skin or mucous membrane and it is therefore employed in such -operations as circumcision, where the nerve terminals must be -anesthetized by the diffusion of the anesthetic from its position -under the skin. A little time should be allowed before beginning the -operation to permit of the diffusion of the drug. This applies also to -such operations as that for ingrown toe-nail where the deeper tissues -down to the root of the matrix are involved. - -+Edemitization Method.+ This is the method of Schleich and it is to him -that the credit must be given for a procedure which has done more to -encourage the use of local anesthetics in operative surgery than any -other. He employed weak solutions of cocaine and other local -anesthetics in great volumes of water in order to gain the combined -action of both drug and of pressure. The method is described under the -heading of "Cocaine." It was designed to obtain anesthesia with -cocaine with the elimination of the toxic effects of the latter. - -There are decided disadvantages to the filling up of the tissues with -fluid; healing is delayed; relations are distorted and coaptation of -the edges is difficult. This is probably the method of selection where -an indefinite amount of manipulation is expected and where the length -and depth of the incision may need to be augmented. A large quantity -of a very weak solution is employed and the tissues in all directions -are injected until visibly distended. - -+Nerve Blocking Method.+ By injecting a small quantity of a fairly -strong anesthetic solution either directly into a nerve or beneath its -sheath, the entire area supplied by it will be anesthetized. This -method of nerve blocking may be spoken of as _endoneural_ when the -injection is made directly into the nerve trunk, and _perineural_ when -made into its sheath or immediately outside of the nerve. The -injection of fluid around nerves too small to inject directly is also -spoken of as perineural nerve blocking. (Hertzler). - - -+DRUGS EMPLOYED+ - -The essential qualities of a good local anesthetic are: - - 1. Reliability in producing anesthesia. - 2. Constitutional and local harmlessness. - 3. Non-irritating qualities. - 4. Ability to be rendered aseptic by boiling. - -No one local anesthetic can be exclusively relied upon to fulfill all -of these requirements at all times. Each one has its advocates and -from the large number offered, it is possible to select several which, -while not being perfect, are preferable to cocaine in that they -obviate the disagreeable train of symptoms peculiar to that drug. - -By local anesthetics are understood certain chemical compounds, weak -solutions of which, when brought in contact with sensory nerves -paralyze them without lastingly injuring them. This effect is -dependent upon the presence in these agents of certain atom groups -which Ehrlich named _anesthiferous_. It is possible that just these -atom groups enter into certain chemical combinations with the nerve -substance and that the nerve thus remains paralyzed until the newly -formed compounds are split up and the poison is washed away by the -circulating blood. - -Cocaine is the original type of a local anesthetic. Einhorn has made -possible its synthetic production and has also opened the field for a -great number of experiments of scientific and practical importance -leading to the discovery of new local anesthetics obtained by -exchanging the non-anesthiferous atom groups of cocaine for other -groups different for each of the various new agents; thus eucaine, -orthoform, anesthesine, alypin, and others have been obtained. - -+Cocaine+ occurs as a white, crystalline powder, readily soluble in -water and in alcohol. It is an alkaloid which effects all living -protoplasm. It first excites, then paralyzes. In greater -concentrations it paralyzes immediately. Its effect is very ephemeral, -producing no lasting harm to the cocainized protoplasm. Its effect is -most readily understood by assuming that cocaine poisons the -protoplasm by entering with it into combinations which are easily -broken up. The products of decomposition, among which cocaine cannot -be recovered, are slightly or not at all poisonous and are carried -away by the circulation. - -+Effect on the Mucous Membrane.+ The external application of cocaine in -solutions of varying strengths has been of great service since its -introduction by Roller in 1884, and many operations on the eye and on -its coverings are now greatly facilitated, by reason of its use. Small -quantities only are required, hence there is little fear of its -toxicity. Its anesthetic qualities by contact are also made use of in -operations in and about the nose and throat. Here comparatively mild -solutions are used liberally but care must be exercised against its -noxious effects; it is usually employed in freshly prepared solutions -which are held to be less toxic. Where extensive areas of mucous -membranes are to be anesthetized, as in the rectum or urethra or -bladder, one of the less toxic drugs is preferable. - -+Strength of Solutions.+ In the eye, it is customary to employ a 4 per -cent. solution. For work in the nose, 2 per cent. is generally -considered sufficient. In the latter connection, it is often combined -with adrenalin solution in small amounts to mitigate its depressing -effects as well as to control bleeding. The latter effect is but -transient and is omitted by many as unsatisfactory because of the more -profuse subsequent hemorrhage. In this respect cocaine and adrenalin -are similar. They both cause constriction of the minute superficial -vessels and immediate blanching of the membrane; work in the nose is -hence greatly facilitated, the field of operation being clear and -enlarged by the shrinkage of the encroaching membrane, but it is -incumbent upon the operator to keep his patient under observation at -least an hour after the completion of the operation that he may be -certain of the degree of hemorrhage after the effects of the drugs -have passed away. For the above reason many operators prefer a general -anesthetic or one of the local anesthetic drugs which exert no -constrictor action so that they may know, _ab initio_, the exact -degree of bleeding. - -Whatever drug is used, strong solutions are seldom necessary for -application to the mucous membranes but the necessary time for its -absorption is a prime requisite. To secure anesthesia of the -conjunctiva and cornea, the solution is dropped into the eye at the -outer canthus and as it flows off with the tears, it must be -replenished three or four times until anesthesia is accomplished. In -the nose, a spray over the site of incision or a pledget of cotton -saturated with the anesthetic solution and allowed to rest in contact -with that locality, will suffice. The flow of mucus from the nasal -mucosa is stimulated by the presence of the cotton pledget and it soon -becomes entirely coated with a thick mucus which no longer is able to -impart to the membrane its anesthetic solution and must therefore be -renewed several times before complete insensibility of the part is -assured. The topical application of a strong solution on a cotton -wound applicator to a limited area or spot is also efficient. - -+Application by Injection.+ In order to bring the anesthetic in contact -with the nerves, it is necessary, where a skin surface is to be -incised, to inject the solution as already described. The technic, -previously detailed, applies here, and any of the methods may be -employed for the injection of solutions of cocaine, some preferring a -single method to the exclusion of all others. The locality to be -treated will also influence the operator as to method. - -+Endermically.+ The endermic method is the one most generally employed -in securing cocaine local anesthesia by injection. The papillary layer -of the skin is well infiltrated with a mild solution (one-eighth per -cent. to one-half per cent.), frequently with adrenalin 1-1000, in the -proportion of 15 to 20 drops to the ounce of the solution. The -strongest of the formulas of Schleich may also be used for endermic -infiltration. - -The skin is injected to a fair degree of tension and a white ridge -marks the line of injection which should be sufficiently extensive to -permit the manipulation of the cut edges. - -+Edemitization.+ Schleich's solutions are here of extreme value because -large amounts of solution are necessary to produce the degree of -distention required because of the minute quantity of cocaine present, -though the added salt and morphine assist considerably. - -+Nerve Blocking and Perineural Blocking.+ Here a stronger solution must -be employed; 1 per cent., or even stronger, is injected in small -quantities, either into the substance of the nerve or under its -sheath, as already described. - -+Strength of Solution.+ Schleich has worked out a method whereby very -weak solutions of cocaine may be used advantageously. His plan is to -enhance the action of the drug by the admixture of morphine in minute -quantities and of sodium chloride in proper strength. These -substances, in themselves, were found to possess anesthetic powers. -Large quantities of Schleich's solutions may be injected--even several -ounces, without ill effects as they contain so little cocaine. The -formulas used by him are: - - 1. Cocaine hydrochlorate 0.2 - Morphine hydrochlorate 0.02 - Sodium chloride 0.2 - Distilled water 100. - - 2. Cocaine hydrochlorate 0.1 - Morphine 0.02 - Sodium chloride 0.2 - Distilled water 100. - - 3. Cocaine hydrochlorate 0.01 - Morphine 0.005 - Sodium chloride 0.02 - Distilled water 100. - -It will be seen that the strength of cocaine in the respective -solutions is from one-fifth to one-hundredth of a gram. - -The solutions used in the early days of cocaine anesthesia were much -stronger than were found necessary afterward and it has now become the -rule to employ weak solutions and to give them time to penetrate the -tissues. The less toxic action of mild solutions, even when like -amounts of the drug are employed, makes it incumbent upon the operator -to follow this plan and the element of time is so important in the -matter of securing a perfect local anesthesia that it is customary to -wait fifteen or twenty minutes after the completion of the injection -before making the incision. The weakest solution possible is the one -of choice in the use of this anesthesia. - -+Toxicology.+ The repeated use of cocaine in the same patient should be -avoided on account of the danger of establishing the cocaine habit. -The drug should be given with the greatest care, especially in -operations about the head, neck, face, and urethra, as several deaths -and many alarming cases of syncope, delirium and paralysis or tetanic -fixation of the respiratory muscles have followed its use. Because of -its marked depressing effect upon vital organs, it should never be -given unless the patient is in the recumbent position. The -administration of one drop of a one per cent. solution of trinitrin -given at the first onset of the constitutional effects and repeated if -necessary every five minutes, will entirely prevent any unpleasant -effects as it is a true physiologic antidote. - -If the surgeon has a case in which he intends to use large amounts of -cocaine, it is best to have at hand and ready for use the following -agents: a hypodermic and a rectal syringe, a battery, cardiac and -respiratory stimulants, oxygen, and a catheter. - -If the patient becomes very delirious and is in no way depressed, -chloral or hyoscine should be given. In all cases of cocaine poisoning -the patient should be catheterized to prevent re-absorption and should -then be treated symptomatically. - -Strong solutions should never be employed for any purpose except in -cases where, by previous experience with the mild ones, it is known -that no idiosyncrasy exists. - -The central nervous system, and next the sensory and motor nerves, are -affected by cocaine. Respiratory paralysis follows the introduction of -appreciable amounts of cocaine into the circulation and respiratory -depression may follow the introduction of smaller quantities. A given -quantity of the drug in great dilution will, under normal conditions, -give no toxic symptoms, whereas the use of the same amount in a more -concentrated form will give rise to pallor, cyanosis and even syncope -and collapse. It is said that a maximum dose of cocaine can never be -fixed; this, however, seems of less importance than knowing the -minimum dose, for while it is true that many bear it well, this drug -so frequently gives rise to toxic symptoms, and the idiosyncrasy for -it is so common, that one can never be certain of an exact dosage. -Various pharmacopias place the maximum dose at 0.05 grm. (about -seven-eights of a grain). - -Bearing in mind that a great dilution of a given amount makes for -safety, we are astonished to learn that 7 c. c. (about 2 drams), of a -1 per cent. solution introduced into the urethra has caused death. -(Czerny). - -Hertzler cites numerous instances in which a few drops of a more -concentrated solution (2 per cent. to 4 per cent.) have caused death. -It is therefore obvious that the use of this drug must be guarded by a -technic so perfect that but the smallest quantity of a very weak -solution shall be permitted to enter the circulation. - -+Adjuvants, Substitutes and Safeguards.+ The numerous disadvantages in -the general use of this most efficient but most treacherous local -anesthetic have operated so strongly that efforts have constantly been -made to find a substance which, when used with it, would correct its -toxic effects. - -The desirability of employing large quantities of an anesthetic -solution so as to enable the operator to infiltrate large areas of -tissue has led to the method of preparing very dilute solutions and -mixing them with various chemical substances which in themselves -would act as mild anesthetics and at the same time increase the -diffusibility of the cocaine. With any of these substances, cocaine -still remains toxic and the quantity injected must be kept account of -when an operation of any extent is being performed even though the -solution be never so mild. - -A valuable preventive to this absorption is found in the application -of a constricting band or tourniquet to impede the return circulation -and allow the washing out of much of the drug before the obstruction -is removed. It is evident that no method has yet been devised whereby -the use of cocaine is rendered safe and it is for this reason that -chemists throughout the world have sought to produce either a new -anesthetic drug or to evolve a drug synthetically, from cocaine, minus -its toxicity. This has been done, but cocaine still has its adherents -because of its superior qualities. - -Quinine and urea hydrochloride is one of the new substitutes which has -found much favor. Among the synthetic derivatives may be mentioned -alypin, novocaine, stovaine, betaeucaine, tropacocaine, anesthesin, -subcutin and many others. Each of these has its advocates and all of -them have some advantage over cocaine; they have disadvantages as -well, which, however, in the hands of skilled operators, may be -overcome. - -+Quinine and Urea Hydrochloride.+ Among the quinine salts and -combinations, the above has found most favor. It consists of a -molecule of quinine hydrochloride and one of urea. It occurs as a fine -crystalline powder and is readily soluble in water, forming an acid -solution. - -This substance is one of the most recent and best substitutes for -cocaine, being capable of a wide range of usefulness and practically -devoid of any toxicity. It causes redness on being injected and, in -strong solutions, may delay healing considerably, this constituting -the main disadvantage to its use. After the use of this anesthetic, -primary union is not usual. - -In a one per cent. solution, anesthesia is accomplished by any of the -methods already described. Weaker solutions require a more perfect -technic, and are therefore not generally employed. They, however, are -indicated where it is imperative to secure primary union and when for -some reason no other local anesthetic is available. The scar formation -which almost always follows the use of this anesthetic would indicate -that some other drug be employed in operations about the face and -neck. This anesthetic is preferred by many because of its safety in -large quantities and because of the length of insensibility following -the injection of solutions of from 1 per cent. to 2 per cent. -strength. - -Notwithstanding knowledge of the facts above enumerated as to the -difficulty of primary union and the likelihood of scar formation in -connection with the use of urea and urea-hydrochloride for purposes of -local anesthesia, this drug is still considered a most valuable and -useful one for providing local anesthesia for operative purposes. - -+Novocaine.+ This drug is one-seventh as toxic as cocaine but is also -weaker in action. It does not cause vascular constriction but has a -preliminary vasodilator action. Like quinine, it has a decidedly -irritating action when injected. It has a decidedly toxic effect when -used in stronger solutions than 2 per cent. and causes tonic and -clonic spasm. In a 1 per cent. solution it is probably safest and best -as an anesthetic and one-half ounce of such a solution may be injected -without fear of unpleasant consequences. - -Its dose is said to be about seven grains, but this may often be the -cause of alarming symptoms, and half of this quantity would perhaps be -a safe limit. The duration of anesthesias of fairly strong solutions -is about fifteen minutes; the action is more prolonged if used with -adrenalin. - -Various combinations of drugs besides adrenalin are employed with -novocaine. Fischer recommends its use with thymol, but even so, it is -not efficient for a longer period than twenty or twenty-five minutes. - -Novocaine is frequently used in alcoholic solutions for injection in -neuralgic subjects. The commercial tablet of novocaine and adrenalin -is convenient for office use. - -+Alypin.+ This substance occurs as a crystalline powder, easily soluble -in water, alcohol and ether, and makes a neutral solution. - -Alypin is in every respect the equal of cocaine though not quite as -strong. Schleich has found that its use, in conjunction with minute -quantities of cocaine, permitted of a reduction of the entire amount -of anesthetics necessary to accomplish insensibility. - -In its use on mucous membranes it does not cause any anemia and -therefore no secondary bleeding occurs. This is a great advantage also -in the examination of mucous membrane lined cavities, such as the eye, -nose, throat and urethra, inasmuch as after the application of -cocaine, the blanching of the membrane conveys no idea of the real -condition of the parts. - -Because of the results he obtained, Schleich now recommends the -following solutions for infiltration: - - 1. Cocaine 0.1 - Alypin 0.1 - Sodium chloride 0.2 - Distilled water 100. - - 2. Cocaine 0.05 - Alypin 0.05 - Sodium chloride 0.2 - Distilled water 100. - - 3. Cocaine 0.01 - Alypin 0.01 - Sodium chloride 0.2 - Distilled water 100. - -For other operative procedures of a minor character, it has been found -that one-fourth per cent. to one-eighth per cent. is sufficient. For -application to mucous membranes, as in the urethra, nose and throat, 1 -per cent. to 2 per cent. has proved effective. - -+Stovaine.+ Stovaine is used more for spinal anesthesia than for local -purposes; it is said to work well in inflamed tissues. - -Several drugs have been used because of their lessened toxicity and -many are constantly being tried but to be abandoned because of their -inefficiency or irritating qualities. None of them are as efficient as -cocaine and the weak solutions of Schleich are about as active as -stronger solutions of many of these and are not more toxic. - -Among the other cocaine substitutes in general use are betaeucaine, -tropacocain, anesthesin, and subcutin. - -These all find a special field of usefulness, but for general work, -are limited, because of some disadvantages which each and all of them -possess. - -Individual selection plays an important part in the use of a local -anesthetic, and one operator, by practical experience, may obtain -results with a given drug, which another fails to achieve. - -The essential feature to be remembered by the practising chiropodist -is, that the use of any drug employed for anesthetizing purposes, even -though but local, should be safeguarded in every way. - -+Cold.+ The methods of using ether, rhigolene, or ice and salt, to -produce cold, are slow and unsatisfactory. If cold is to be used to -produce local anesthesia the most efficient and convenient method of -applying it is by means of _ethyl chloride_. This fluid is very -volatile and is best controlled by having it in air-tight tubes. When -not in use, a valve covering one end of the tube prevents leakage. -When the valve is pressed upon, the orifice of the tube is opened and -the heat of the hand forces out a fine stream of the liquid which is -directed upon the parts to be frozen. Rapid evaporation causes intense -cold. The nozzle should be held about fifteen inches from the area to -be acted upon. When the spray strikes the integument, redness almost -instantly results but in a few seconds the part becomes hard and -white. This condition indicates local insensibility and lasts about -two minutes. If the action is slow, it can be much hastened by gently -blowing upon the parts to increase the rapidity of evaporation. - -The refrigeration method of local anesthesia is of limited usefulness -and is recommended only for the opening of felons and abscesses, for -removing wens from the scalp and back, and for producing a painless -area in which a puncture is to be made. It must be borne in mind that -sloughing and ulceration of the skin are liable to follow the use of -cold. - -Work under this form of anesthesia must be done with rapidity not -always consistent with thoroughness, and should therefore be employed -only when a single incision or puncture is indicated. - -The pain incident to subsequent thawing is severe and, in general, is -about as hard to bear as an incision without an anesthetic. - -For the purposes of practical podiatry, the chiropodist is advised to -use a substitute for cocaine rather than the cocaine itself when local -anesthesia is necessary. In the clinics of the School of Chiropody of -New York, novocaine, quinine and urea hydrochloride, and alypin are -preferred, and no single instance of toxemia has ever been -experienced. There have been cases in which the anesthesia did not -prove thoroughly effective, but, in the main, these drugs have well -answered the purposes of their use. - - -THE END - - - - -GLOSSARY - - -+A+ - -+a-an.+ Without, as in atypical--without type, and as in analgia--without -pain. - -+ab.+ From, away from, as in abaxial, lying outside of or away from any -body or part. - -+abduction.+ To move away from the axis (median line) of the body. - -+ab initio.+ From the beginning. - -+abrade.+ To scrape away. - -+acid.+ A compound of an electro-negative element or radical with -hydrogen. - - +acetic acid.+ A product of the oxidation of ethylic alcohol and - of the destructive distillation of wood, applied locally as a - counterirritant. - - +benzoic acid.+ External uses, antiseptic. - - +carbolic acid.+ Used in podiatry, as an antiseptic, as a - disinfectant and as an anesthetic. - - +chromic acid.+ Has caustic properties. - - +dichloracetic acid.+ Used as a caustic application to venereal - sores. - - +glacial acetic acid.+ Employed externally as a caustic for - removal of warts and helomata. - - +hydrochloric acid.+ Externally employed as an escharotic. - - +monochloracetic acid.+ Used as a caustic for helomata and - verrucae. - - +nitric acid.+ Used as a caustic against verrucae. - - +nitrohydrochloric acid.+ An active caustic agent. - - +oxalic acid.+ Removes ink stains. - - +sulphocarbolic acid.+ Antiseptic and disinfectant. - - +trichloracetic acid.+ Employed as an escharotic for venereal - and other warts. - -+abscess.+ A circumscribed cavity containing pus. - -+acidulated.+ Rendered acid. - -+actinomycosis.+ An infectious disease due to the ray fungus. - -+actual cautery.+ A substance which acts by virtue of its heat, not -chemically. - -+adenoma.+ A tumor of glandular epithelium. - -+adde.+ Add, used in prescription writing. - -+adduction.+ To turn towards the axis or median line of the body. - -+adhesive.+ Sticking together. - -+adjacent.+ Next to. - -+adjuvant.+ A remedy which added to a prescription aids the action of -the main ingredient. - -+adrenalin.+ Trade name of a principle obtained from the suprarenal -glands which has astringent and hemostatic properties. - -+aerobic.+ Unable to live without oxygen. - -+albuminoid.+ A substance resembling true proteids in origin and in -composition. - -+albuminous.+ Resembling or containing albumin. - -+albuminuria.+ Albumin in the urine as voided. - -+albumose.+ An intermedial product of the splitting of proteids by -enzymes. - -+albumosuria.+ Albumose in the urine. - -+algia.+ Pain, as in neuralgia, nerve pain. - -+alkaloidal. An organic base of vegetable origin causing toxicologic -effects. - -+alveolar.+ Pertaining to the alveoli. - -+ambi.+ Both, as in ambidexterity, the ability to use both hands with -equal ease. - -+ambulatory.+ Walking, able to walk. - -+ameba.+ A small one-celled animal that constantly changes its shape by -sending out processes of its protoplasm. - -+amyl nitrite.+ A drug used to dilate the blood vessels. - -+anal.+ Relating to the anus. - -+anemia.+ A condition in which the blood is reduced in amount or is -deficient in red blood cells or in hemoglobin. - -+anerobic.+ Living without air. - -+anesthesia.+ Loss of sensation. - -+anesthesin.+ An ethylic ether used as a local anesthetic. - -+aneurism.+ A saclike dilation in the wall of an artery as the result of -weakness of its tissues. - -+angioma.+ A tumor formed of blood vessels. - -+animal.+ An organic being, with life and power of motion. - -+ankylosis.+ Stiffening of a joint. - -+anthrax.+ The disease produced by the bacillus anthracis. - -+anti.+ A prefix signifying against; in relation to symptoms and -diseases, curative. - -+antidote.+ An agent which neutralizes or counteracts the effects of a -poison. - -+antipyretics.+ Agents reducing fever. - -+antiseptic.+ Preventing, or destroying the germs of putrefaction or -suppuration. - -+antitoxin.+ A substance in the serum, which binds and neutralizes -toxin. - -+anus.+ The orificial extremity of the rectum. - -+apposition.+ Contact of two bodies or two surfaces. - -+argyrol.+ A soluble, non-irritating silver preparation used in the -treatment of various inflammations of mucous membranes. - -+arsenic.+ A metalic element in chemistry. - -+arterial.+ Pertaining to an artery. - -+arteries.+ Vessels carrying blood from the heart. - -+arteriosclerosis.+ A fibrous overgrowth of the inner coat of an artery. - -+arthritis.+ Inflammation of a joint. - -+arthrotomy.+ Cutting into a joint. - -+articulation.+ A joint. - -+aseptic.+ Free from septic matter. - -+asepticize.+ To render aseptic or sterile. - -+aspiration.+ The withdrawal by air or by suction of fluid from any body -cavity. - -+astringent.+ An agent producing contraction of organic tissues or the -arrest of a discharge. - -+atrophy.+ The wasting or diminution of the size of a part from lack of -nutrition. - -+autoclave.+ Instrument for sterilizing by steam. - -+axis.+ A straight line passing thro a spherical body between its two -poles and about which the body may revolve. - - -+B+ - -+bacillus.+ A genus of schizomycetes, the most important group of -bacteria. - -+bacteria.+ Microorganisms, microbes, schizomycetes. - -+benign.+ Not malignant; mild. - -+betaeucaine.+ A local anesthetic used as a substitute for cocaine. - -+bi.+ A prefix denoting two, twice or double, as biceps--two heads. - -+bicarbonate.+ A compound of two equivalents of carbonic acid and one of -a base. - -+bichloride.+ A chloride with twice as much chlorin as a protochloride. - -+blast.+ Germ, as in blastoderm, the primitive cell layer in the -beginning embryo, consisting of three layers. - -+blastomycetes.+ Yeasts; budding fungi. - -+blistering.+ Producing a blister. - -+brain.+ The large mass of nerve tissue contained in the cranium, -especially the cerebrum. - -+bromide of potassium.+ A salt of potassium. - -+bromidrosis.+ Fetid or foul smelling perspiration. - -+bubo.+ Enlargement of a lymphatic gland usually in the groin. - -+budding.+ Gemmation. A form of tissue division by a bud-like process. - -+bulla.+ A large bleb or blister. - -+bunion.+ An inflammatory swelling of the bursa over the -metatorsophalangeal joint of the great toe. - -+bursa.+ A small sac interposed between movable surfaces. - -+bursitis.+ Inflammation of a bursa. - -+buttock.+ The prominence formed by the gluteal muscles of either side. - - -+C+ - -+calcareous.+ Having the nature of lime. - -+calcification.+ A degeneration of tissues into salts of calcium or -magnesium. - -+callosity.+ A circumscribed thickening of the epidermis as a result of -friction or intermittent pressure. - -+cancellous.+ Resembling lattice work. - -+canthus.+ The slit between the eyelids. - -+capillary.+ Any one of the small blood vessels which serves to connect -an artery and a vein and to allow of the passage of nutrient matter -and oxygen from the blood into the tissues and of waste matter from -the tissues into the blood. - -+carboluria.+ Carbolic acid in the urine. - -+carbuncle.+ A phlegmonous inflamation of the skin and subcutaneous -tissues. - -+carcinoma.+ A malignant epithelial growth. - -+cardiac.+ Pertaining to the heart or cardium. - -+caries.+ Molecular bone decay. - -+carotid.+ The principle artery of the neck. - -+cartilage.+ A non-vascular elastic tissue, softer than bone. - -+cartilaginous.+ Partaking of the nature of cartilage. - -+caseation.+ Transformation of necrotic tissue into a mass resembling -cheese. - -+caseous.+ Cheesy. - -+catheter.+ A hollow cylinder of silver, rubber or other material -designed for passage thru the urethra and other channels. - -+caustic.+ Corrosive; capable of tissue destruction; syn. escharotic. - -+cautery.+ An agent which by heat or chemical action scars tissues. - -+cavities.+ Hollows. - -+cele.+ Tumor, as in hydrocele, a watery tumor. - -+cell.+ A small protoplasmic mass, usually nucleated. - -+cellular.+ Composed of cells. - -+cellulitis.+ Inflammation of cellular tissue. - -+cephalic.+ Head, as in hydrocephalic, water on the head (brain). - -+chancre.+ The primary syphilitic manifestation. A syphilitic -induration. - -+Charcot's disease.+ A form of tabes. - -+chemotaxis.+ The attraction or repulsion exhibited by certain chemicals -to living cells. - -+chimatlon.+ Mild, chilblain; severe, frost-bite. - -+chiropodial orthopedics.+ That branch of podiatry which has to do with -the treatment of chronic diseases and deformities of the foot and of -the foot joints. - -+chiropodist.+ Literally, one who treats the feet and hands. Actually, -one who specializes in the treatment of foot lesions not requiring -major surgical operative procedures. - -+chloral.+ An oily liquid formed by the action of chlorine gas on -alcohol. - -+chlorosis.+ A form of anemia occurring chiefly in young girls. - -+chondritis.+ Inflammation of cartilage. - -+chondroma.+ A tumor of cartilage tissue. - -+chronic.+ Of long standing. - -+chyle.+ The milky fluid found in the mesenteric lymph-vessels as the -result of fatty digestion. - -+cilia.+ The eyelashes; hairlike processes of certain cells. - -+circumcision.+ Removing part or all of the foreskin. - -+clot.+ The solid portion resulting from the coagulation of blood. - -+coagulation.+ Clotting; in the blood, the result of fibrinogen changing -to fibrin. - -+coalesce.+ To merge in growth. - -+coaptation.+ The fitting together of two opposing surfaces. - -+cocaine.+ An alkaloid derived from coca. Useful to produce local -anesthesia. - -+cocci.+ Round, spheroidal or oval shaped bacteria. - -+cocoon.+ Shaped like the protection of the silk-worm larva. - -+colostomy.+ Opening into the colon to establish an artificial anus. - -+collodion.+ A solution of pyroxylin in ether and alcohol. - -+compression.+ Decreasing volume and increasing density by pressure. - -+concomitant.+ Accompanying. Accessory. - -+condyle.+ A rounded articular surface at the extremity of a long bone. - -+congenital.+ Existing at birth. - -+congestion.+ Hyperemia of a part. - -+conjunctiva.+ The mucous membrane covering the anterior surface of the -eyeball. - -+connective tissue.+ The uniting tissue of the body. - -+constitutional.+ Relating to the system as a whole. - -+constriction.+ The act of drawing together, a narrowing or binding. - -+continuity.+ Connected; the quality or state of being continuous. - -+contra.+ A prefix meaning against. - -+contused.+ Bruised. - -+corium.+ The deep or connective tissue layer of the skin; the true -skin. - -+cornea.+ A transparent membrane forming the outer coat of the eyeball. - -+cornification.+ Conversion into a hard or horny substance or tissue. - -+corpuscles.+ Minute bodies. Primary atoms of the blood. - -+corrosive.+ A substance that eats or destroys. - -+cortex.+ The external gray layer of the brain; the outer covering in -plant life. - -+cortical.+ External, in contradistinction to other parts, in tissue or -plant. - -+cosmetic.+ An agent or a means for beautifying the body. - -+counterirritant.+ Means or medications to produce irritation to relieve -deeper congestion. - -+crepitus.+ The grating of fractured bones. - -+crisis.+ A sudden favorable change in the course of an acute disease. - -+cryptogam.+ A group of plants without flowers and without -embryo--containing seeds. - -+cuneiform.+ A wedge-shaped bone found in the carpus (one) and in the -tarsus (three). - -+cupping.+ Blood-abstraction by means of cupping-glasses. - -+curette (curet).+ Spoon-shaped instrument for scraping. - -+cutis.+ The skin. - -+cyanosis.+ Blue discoloration of the skin from non-oxidation of blood. - -+cyte.+ Cell or corpuscle, as in leucocyte, white blood cell. - - -+D+ - -+dactyl.+ Finger, as in dactylitis, inflammation of one or more fingers. - -+debris.+ Scattered fragments. - -+decomposition.+ Decay. Breaking up into its original elements. - -+deformity.+ A deviation from normal in shape or in size. - -+deleterious.+ Injurious, noxious, harmful. - -+demarcation.+ A tissue boundary mark. - -+dentine.+ The bony structure of the teeth. - -+derma.+ The skin. - -+dermatitis.+ Inflammation of the skin. - -+devitalize.+ To destroy vitality. - -+diabetes (mellitus).+ A disease of metabolism characterized by the -presence of sugar in the voided urine. - -+diagnosis.+ Determination of the nature of a disease. - -+diapedesis.+ The passage of the blood-corpuscles through the -vessel-walls without rupture of the latter. - -+diaphoresis.+ Excessive perspirattion. - -+diaphragm.+ The muscular wall between the thorax and the abdomen. - -+diaphysis.+ Relating to the shaft of the bone. - -+diffusion.+ A scattering about. - -+digit.+ A finger or toe. - -+dilatation.+ An expansion of a vessel or an organ. - -+discutient.+ An agent which causes the dispersal of a tumor or of a -pathologic neoplasm of any kind. - -+disease.+ A pathologic condition of any part or organ of the body. - -+disinfection.+ Freeing from infection. - -+disintegration.+ Separation of component parts. - -+dislocation.+ Displacement of an organ or of a part. - -+dissection.+ A separation by cutting of the parts of the body. - -+distortion.+ Mechanical derangement of a part interfering with its -function. - -+dorsal.+ Pertaining to the back. - -+dorsum.+ The back, the posterior part of an organ. - -+drainage.+ (Surgically) The gradual removal of the contents of a -suppurating cavity. - -+d.s. or s.+ Used in prescription writing, meaning to give directions. - -+dynia.+ Pain, as in pleurodynia, pain in the pleura. - - -+E+ - -+ecchymosis.+ An extravasation of blood or slight hemorrhage under the -skin resulting in a purplish patch. - -+echinococcus.+ The larval stage of the dog tapeworm, occurring also in -human organs or tissues. - -+ectomy.+ To cut out, as in prostatectomy, removal of a part or all of -the prostate. - -+eczema.+ Inflammation of the skin (acute or chronic, moist or dry), -accompanied by itching and burning. - -+edema.+ Accumulation of serum in the cellular tissue. - -+edematous.+ Relating to edema. - -+effusion.+ Escape of fluid from within, out. - -+embolism.+ The obstruction of a blood vessel by an embolus cleavage. - -+embolus.+ A plug composed of detached clot in the circulation. - -+embryonic.+ Rudimentary. - -+emigration.+ The outward passage of a wandering cell through the walls -of a blood-vessel. - -+empyema.+ Pus in a cavity. - -+en or endo.+ Within, as in endocardium, inner lining of the heart. - -+encapsule.+ To inclose in a sheath. - -+endermatically.+ Within or through the skin. - -+endoneural.+ Within the nerve. - -+endosteum.+ Membrane covering bone surface in the medullary cavity. - -+endothelial.+ Pertaining to or consisting of endothelium. A lining -cavity not communicating with the outer air. - -+enteroclysis.+ A high enema. - -+enterostomy.+ Establishing an artificial anus through the abdominal -wall. - -+epidermis.+ The outer layer of the skin constituting the outer -investment of the body. - -+epiphyseal.+ Pertaining to the epiphysis. - -+epiphysis.+ A piece of bone that in early life is separated from a long -bone by cartilage, but later becomes part of the bone. - -+epithelial.+ Pertaining to epithelium. - -+epithelioma.+ A cancerous growth originating from squamous epithelium. - -+epithelium.+ The cells covering all cutaneous and mucous surfaces, -together with the secreting cells of glands developed from the -ectoderm. - -+erysipelas.+ An acute specific inflammation of the skin and -subcutaneous tissues, accompanied by fever and constitutional -disturbances. Caused by the streptococcus erysipelatos. - -+erythema.+ Redness of the skin. - -+eschar.+ A scar. - -+escharotic.+ A substance producing an eschar. - -+esia.+ Sensation, as in anesthesia, loss of sensation. - -+ethyl bromide.+ A colorless liquid, used for both general and local -anesthesia. - -+ethyl chloride.+ A colorless liquid, whose spray produces local -anesthesia. - -+etiology.+ Cause as related to disease. - -+eucaine.+ A synthetic compound capable of producing local anesthesia. - -+evacuated.+ Removal of waste material from the body. - -+evaporation.+ Turning into vapor. - -+eversion.+ Turning outward. Turning back an eyelid so as to expose the -conjunctiva. Turning the inner border of the foot outward. - -+ex.+ Out of or from, as in exostosis, a bony outgrowth. - -+exacerbation.+ Increased severity of a disease or of its symptoms. - -+excretion.+ The product of a gland or of cells not useful to the -economy, in contradistinction to secretion. - -+excoriation.+ Removal of the superficial protective layer of the skin -or mucous membrane. - -+exfoliate.+ To strip off in layers. To desquamate. - -+exostosis.+ A bony tumor springing from bone. - -+extravasation.+ Effusion of fluid into the tissues. - - -+F+ - -+facet.+ A small plane, articulating surface. - -+facient.+ To make, as in rubefacient, to make red. - -+facultative.+ Pertaining to functional or acquired power. - -+Faradic.+ Pertaining to induced electric currents. - -+fauces.+ The space between the cavity of the mouth and the pharynx. - -+felon.+ Paronychia. Whitlow. - -+femur.+ The thigh bone. - -+ferment.+ An organic substance which in small quantities is capable of -setting up changes in another organic substance without itself -undergoing much change. - -+fermentation.+ Such changes as are effected exclusively by the vital -action of ferments. - -+fibrin.+ Active agent in blood coagulation. - -+fibroma.+ A tumor of fibrous tissue. - -+fibrous.+ Composed of fibres. - -+fibula.+ External and smaller of the two bones of the leg. - -+fissure.+ A crack in the tissues. - -+fistula.+ A pathologic sinus leading from an abscess cavity to the -surface. - -+flagella.+ The whiplike processes with which certain cells, as the -ameba, are provided. - -+flexion.+ Bending. - -+fluorescence.+ Power of a body to change wave-rate (or color) of light -passing through it. - -+focus.+ Point at which light rays meet. The starting point of a disease -process. - -+follicle.+ A small secretory cavity or sac. - -+form.+ Shape, as in vermiform, resembling a worm in shape. - -+formaldehyde.+ A gas possessing powerful disinfectant properties. - -+fracture.+ A break, as of a bone. - -+fulcrum.+ The point against which lever is placed to get purchase. - -+fungating.+ Rapidly growing (path.). - -+fungus (plural fungi).+ A cellular vegetable organism which feeds on -organic matter. Example, bacteria. - -+furunculosis.+ The systemic condition marked by boil-formation. - - -+G+ - -+gangrene.+ A necrosis with putrefaction. - -+gastrostomy.+ Making an artificial opening into the stomach. - -+gelatinous.+ Resembling gelatine, a semi-liquid substance. - -+genesis.+ Birth of, belonging to, as in genesial, relating to -generation. - -+germicide.+ An agent destructive to germs. - -+globular.+ Shaped like a globe. - -+gonorrhoea.+ A specific inflammation of the mucous membrane of the -genital tract; germal cause, gonococcus. - -+gout.+ Podagra. A disease of metabolism characterized by paroxysmal -pains in the foot, particularly in the great toe. - -+gradus.+ Step by step, as in graduated, marked by lines or in other -ways to denote capacity. - -+granular.+ Composed of grains or granulations. - -+granuloma.+ A collection of epitheloid cells at an irritated point. - -+gumma.+ A gummy tumor resulting from a peculiar caseation of a teritary -syphilitic inflammatory deposit. - - -+H+ - -+habitat.+ The natural locality of an animal or a plant; impregnated; -saturated with. - -+hallux rigidus.+ First phalanx of the great toe is flexed at an angle -of 30° with extension of the second phalanx. - -+hallux valgus.+ Outward rotation of big toe beyond an angle of 15°. - -+hallux varus.+ Pigeon toe. - -+heloma.+ Same as corn or callus. - -+heloma durum.+ Hard or indurated corn. - -+heloma miliare.+ A millet-seed corn. - -+heloma molle.+ Soft corn. - -+heloma vasculare.+ A corn of the vascular variety. - -+hema.+ Blood, as in hemoglobin, an iron compound in the red blood. - -+hematoma.+ A tumor containing blood. - -+hemorhage.+ A flow of blood. - -+hemophelia.+ Abnormal tendency to hemorrhage. - -+hemostatic.+ Capable of arresting hemorrhage. - -+hereditary.+ Transmitted from parent to offspring. - -+hernia.+ Rupture; protusion of a structure thro the wall which -ordinarily contains it. - -+herniotomy.+ Operation for the relief of hernia. - -+hidros.+ Perspiration, hyperidrosis, excessive sweating. - -+histology.+ Microscopic anatomy. - -+hyascine.+ An alkaloid of hyoscyamus and stramonium. - -+hydro.+ Water, hydrotherapy, treatment of disease by means of water. - -+hydrarthrosis.+ A serous effusion in a joint. - -+hyper.+ Above or over, hyperemia, the presence of an increased or -overamount of blood in a part. - -+hyperemia.+ Excessive amount of blood. - -+hyperidrosis.+ Excessive sweating. - -+hyperplasia.+ Overgrowth of a part due to a multiplication of its -elements. - -+hypertrophy.+ Abnormal, increased size of a part or of an organ. - -+hypnotic.+ Causing sleep. - -+hypo.+ Under, as in hypodermic, beneath the skin, or subcutaneous. - -+hypodermatic (hypodermic).+ Subcutaneous, applied to injections -underneath the skin. - -+hypodermoclysis.+ The hypodermic injection of fluids to supply a lack -of blood. - -+hysteria.+ A functional neurosis with abnormal sensations, emotions or -paroxysms. - - -+I+ - -+ic.+ Relating to, as in caloric, relating to temperature. - -+ichthyol.+ A brownish oil; principally used in the form of ammonium -ichthyol as an antiseptic. - -+immersion.+ The plunging of a body into a liquid. - -+immobilization.+ The act of rendering a part immobile (immovable). - -+immunity.+ Freedom from risk of infection. - -+incubation.+ The development of an infectious disease from the -infection period to the appearance of the first symptoms. - -+indolent.+ Inactive, sluggish. - -+induration.+ Hardening as of tissues. - -+ine.+ (Phar.) Alkaloid, as in morphine, an alkaloid. - -+infection.+ Invasion by pathogenic microorganisms which act injuriously -upon the tissues, causing disease. - -+inflammation.+ A morbid condition characterized by hyperemia, pain, -heat, swelling and disordered function. - -+infra.+ (L. below). A prefix denoting below, as infracostal, below a -rib. - -+innervation.+ Distribution of the nerves in a part. - -+inoculation.+ The introduction of a specific virus into the system. - -+inorganic.+ Devoid of organized structure. - -+in situ (Latin).+ In position. - -+integument.+ The enveloping membrane of the body. - -+intercellular.+ Between the cells. - -+intermittant.+ Occurring at intervals. - -+interosseous.+ Between bone tissue. - -+interstices.+ Spaces, intervals, pores. - -+interstitial.+ Lying or placed between. - -+intra.+ (L. within). A prefix denoting within or inside, as -intraneural, within a nerve. - -+intravenous.+ Within a vein. - -+inunction.+ Administering a drug in ointment form by rubbing into the -skin. - -+inversion.+ The reversion of the normal position of an organ, turning -inward, inside out, etc. - -+involucrum.+ An enveloping membrane. - -+iodide.+ A compound of iodin with another element, as iodide of -potassium. - -+iodin (iodine).+ A non-metallic chemical element. - -+iodoform.+ A lemon yellow crystalline powder; used as an antiseptic to -wounds and sores. - -+iritis.+ Inflammation of the iris, the anterior division of the -vascular tunic of the eye. - -+iron.+ A metallic element. - -+irrigation.+ The washing out of a cavity or wounded surface with a -stream of fluid. - -+itis.+ Inflammation, as in pericarditis, inflammation of the -pericardium. - - -+J+ - -+jaundice.+ A yellow tissue-staining from bile. - -+jaw.+ One of the two bony structures of the mouth in which the teeth -are set. - -+jugular.+ Relating to the throat or neck. - -+juice.+ Tissue fluid of a plant or animal. - -+jute.+ Fiber used in surgical dressings. - -+juxta.+ Prefix; meaning close to or next. - - -+K+ - -+kalium.+ Latin for potassium. - -+kaolin.+ Fuller's earth; used as a poultice with glycerin. - -+karyokinesis.+ Indirect nuclear division, mitosis. - -+keratin.+ A scleroprotein present in skin appendages, hair, nails, etc. - -+keratitis.+ Inflammation of the cornea. - -+kerato.+ A prefix denoting horny tissue or cells. - -+keratodermia.+ Hypertrophy of horny layer of epidermis. - -+keratosis.+ Circumscribed over-growths of horny layer of skin. - -+kinetic.+ Relating to motion or to muscular movements. - -+kneading.+ To work and press into a mass. - -+knee.+ Articulation between femur and tibia covered in front by the -patella. - -+knee-jerk.+ Patellar reflex. - - -+L+ - -+lacerated.+ Torn. - -+lacuna.+ A small gap or hollow space. - -+lacuna, osseous.+ A space in the Haversian system occupied by -bone-corpuscle. - -+lacunar resorption.+ Absorption of lacunae. - -+lamella.+ One of the plates forming the Haversian system of bone. - -+lancet.+ A surgical knife with a two-edged blade. - -+lancinating.+ A sharp, cutting pain. - -+Lassar's paste.+ An ointment containing salicylic acid, talcum and zinc -oxide. - -+laughing gas.+ Nitrous oxide gas. - -+lead and opium wash.+ See Wash. - -+leucemia.+ A disease of the blood marked by persistent leucocytosis. - -+leucocyte.+ White blood corpuscle or a white cell. - -+leucocytosis.+ An increase in the number of white cells in the blood. - -+leukos.+ White, as in leucocyte, a white blood cell. - -+ligament.+ A band or sheet of fibrous tissue connecting two or more -bones, cartilages or other structures or serving as support for -fasciae or muscle. - -+ligature.+ A thread or the like tied about a blood vessel or other -structure to constrict it. - -+linimentum. Liniment.+ A medicament in alcohol, oil or water, applied -by friction to the skin. - - +l. aconiti et chloroformi.+ Anodyne application. - - +l. ammoniae.+ Counter irritant. - - +l. ammonii iodidi.+ Discutient. - - +l. calcis.+ To mollify burns and scalds. - - +l. camphorae.+ A mild counterirritant. - - +l. chloroformi.+ Anodyne and rubefacient. - - +l. crotonis.+ Counterirritant. - - +l. hydrargyri.+ Anti-syphilitic. - - +l. iodi.+ Discutient. - - +l. opii.+ Anodyne. - - +l. saponis.+ A base for other liniments. - - +l. sinapis.+ Counterirritant. - - +l. terebinthinae.+ Soothing application. - -+lint.+ A soft absorbent material used in surgical dressings. - -+lipoma.+ A fatty tumor. - -+liquor.+ Solution of a nonvolatile substance. - - +l. acidi chromici.+ Used, well diluted, as a wash in - bromidrosis. - - +l. alumini acetatis+ (Burows' solution). For external use as an - astringent and antiseptic. - - +l. antisepticus.+ A mouthwash. - - +l. bromi.+ Antiseptic. - - +l. Burowii.+ Astringent and antiseptic (See l. alum. acet.) - - +l. caoutchouc.+ For rubber skin. - - +l. cresolis compositus.+ Antiseptic and disinfectant where - vesicles form. - - +l. ferri persulphatis.+ Styptic. - - +l. ferrisub sulphatis.+ Monsel's solution. Styptic. - - +l. hydrargyri nitratis.+ Caustic application. - - +l. iodi carbolatus.+ Antiseptic counterirritant. - - +l. plumbi subacetatis.+ For bruises and sprains. - - +l. sodii boratis compositus.+ Dobell's solution. An alkaline - antiseptic preparation. - - +l. sodii ethylatis.+ Employed externally as a caustic. - - +l. sodii silicatis.+ Used in surgery for applying splints. - - +l. zinci chlorodi.+ Disinfectant and deodorant. - -+listerine.+ Trade name of a solution containing boric acid, benzoic -acid, thymol and other substances. - -+Lister's method.+ Antiseptic surgery. - -+lith.+ Stone, as in lithology, the branch of medical science, relating -to calculi or concretions. - -+litter.+ A stretcher for carrying the sick or wounded. - -+locomotor ataxia (tabes dorsalis).+ Hardening of the posterior columns, -ganglia, roots and peripheral nerves of the spinal cord. - -+logos.+ Treatise, as in Pathology, a branch of medical science which -treats of disease in all its relations. - -+lotio.+ Latin for lotion or wash. - - +l. hydrargyri flava.+ Yellow mercurial wash. - - +l. hydrargyri nigra.+ Black mercurial wash. (Both of the above - are used as applications to venereal sores). - - +l. plumbi et opii.+ Lead and opium wash. Applied to sprains and - bruises. - -+luetic.+ Syphilitic. - -+luetin test.+ A skin test for the diagnosis of syphilis. - -+lumen.+ The space in the interior of a tubular structure, such as an -artery. - -+lunula.+ The opaque, whitish, semi-lunar area near the root of the -nail. - -+lymph.+ A clear yellow fluid found in the lymph spaces or lymphatic -vessels of the body. - -+lymphangioma.+ New formation of lymphatic vessels. - -+lymphangitis.+ Inflammation of lymphatic vessels. - -+lymphoma.+ A tumor of lymphoid tissue. - -+lysis.+ Solution, as in analysis, the breaking up of a chemical -compound into its simpler elements. Also the gradual subsidence of -symptoms in a disease as distinguished from crisis. - -+lysol.+ Trade name of a mixture of soaps and phenols; used as a -disinfectant. - - -+M+ - -+macrococcus.+ A large unicellular microorganism. - -+macros.+ Large, as in macroscopic, an object visible to the naked eye. - -+macula.+ Spot, as in macular, relating to or marked by macules, or -spotted. - -+magnesium sulphate.+ Epsom salts; a purgative. - -+malignant.+ Resistant to treatment and tending to grow. - -+malleolus.+ A process of bone the shape of the head of a hammer. - -+mania.+ Frenzy, as in megalomania, a delusion of grandeur. - -+manifestation.+ Clear to the eye or to the mind. - -+manus.+ Hand, as in manual, relating to or performed with the hands. - -+marrow.+ The soft substance filling the medullary cavities and -cancellous extremities of the long bones. - -+massage.+ A scientific method of manipulating the body by rubbing, -pinching, kneading, tapping, etc. - -+matrix.+ The formative portion of a nail or of a tooth. - -+measles.+ An acute exanthematous disease. - -+medullary.+ Relating to the medulla or marrow. - -+membrane.+ A layer of tissue covering a part or connecting two -structures. - -+mercury. Quicksilver.+ - -+metastasis.+ A change in the seat of disease. - -+metatarsalgia.+ Pain in the metatarsus. - -+metatarsophalangeal.+ Relating to the metatarsal bones and the -phalanges. - -+meter.+ Measure, as in meter, a measure of length, the equivalent of -39.3 inches. - -+microbe.+ A minute one-celled microorganism. - -+micrococcus.+ A genus of schizomycetes. - -+microorganism.+ A minute living body. - -+miliary.+ Like millet seeds, in size. - -+molecular.+ Pertaining to molecules. - -+molecule.+ The smallest possible unit of existence of any substance. - -+morphine.+ The chief narcotic principle of opium. - -+mortification.+ Death; gangrene. - -+mucous.+ Relating to mucous as in mucous membrane. - -+mucus.+ A clear viscid secretion of a mucous membrane, mucilagenous in -character. - -+mummification.+ Dry gangrene. - -+myeloma.+ A tumor due to hyperplasia of the bone marrow. - -+myoma.+ A muscular tumor. - -+myxoma.+ A tumor of stellate or polyhedral cells in a matrix of mucin. - - -+N+ - -+naevus (nevus).+ A congenital mark or discolored patch of the skin. - -+nail (unguis).+ The horny plate covering the distal end of the terminal -phalanx of each finger and toe. - -+naphthalan.+ A gelatinous mixture employed as a protective dressing in -burns and in skin diseases. - -+narcosis.+ Stupor or general anesthesia produced by some narcotic drug. - -+nascent.+ Beginning; incipient. - -+necrosis.+ Death of a circumscribed portion of tissue. - -+neoplasm.+ A new growth; a tumor. - -+neosalvarsan.+ A modified salvarsan: No. 914. - -+nephritis.+ Inflammation of the kidney. - -+nerve.+ A whitish cord made up of nerve fibres. - -+neuralgia.+ Pain in a nerve. - -+neurasthenia.+ Nerve exhaustion. - -+neuritic.+ Relating to neuritis. - -+neuritis.+ Nerve inflammation. - -+neuroma.+ Nerve tumor. - -+neuron.+ Nerve cell, as in neuritis, inflammation of a nerve. - -+neutralize.+ To render ineffective. - -+node.+ A knob; a circumscribed swelling. - -+nostrum.+ A quack remedy. - -+novocaine.+ A synthetic local anesthetic. - -+noxious.+ Injurious; harmful. - -+nucleus.+ The essential part of a typical cell and the controlling -centre of its activity. - - -+O+ - -+obliteration.+ Extinction. - -+official+ (in pharmacy). Authoritative; standard. - -+oid.+ Like, as in lymphoid, resembling or like lymph. - -+oil.+ A liquid of fatty consistency, insoluble in water and -inflammable. Examples: camphorated oil, carbolic oil, carron oil, -linseed oil, oil of turpentine, sweet oil, sesame oil, tar oil. - -+ointment.+ A soft, fatty, medicated mixture. - -+onychauxis.+ Enlargement of finger or of toe nails. - -+onychia.+ Inflammation of the matrix with suppuration and shedding of -the nail. - -+onychocryptosis.+ Ingrowing toe-nail. - -+onycholysis.+ Loosening or shedding of the nails. - -+onychomalacia.+ Loss or absence of nail rigidity. - -+onychomycosis.+ Any parasitic disease of the nails. - -+onychophag.+ One whose habit it is to bite his finger-nails. - -+onychophagy.+ Nail-biting. - -+onychoptosis.+ Falling off of the nails. - -+onychorrhexis.+ Abnormal brittleness of the nails. - -+onyx.+ A finger nail or a toe nail. - -+onyxis.+ Ingrowing toe-nail. - -+opisthotonos.+ Spasmodic rigidity of the body in which the trunk is -thrown backward and arched upward. - -+oral.+ Relating to the mouth. - -+organic.+ Pertaining to or having organs, exhibiting animal or -vegetable characteristics. - -+orthoform.+ A white, odorless, crystalline powder; employed as a local -anesthetic and antiseptic in burns, ulcers, etc. - -+orthopedics.+ That branch of surgery which treats of chronic diseases -of the joints and spine and the correction of deformities. (See -chiropodial orthopedics.) - -+os (plural ossa).+ Bone. - -+osis.+ Full of, as in tuberculosis, a specific disease caused by the -presence of the bacillus tuberculosis. - -+osseous.+ Bony. - -+osmidrosis.+ Bromidrosis; the excretion of perspiration of a strong -odor. - -+ossification.+ The formation of bone. - -+osteitis.+ Inflammation of bone. - -+osteoclast.+ A polynuclear cell concerned in the absorption of bone. - -+osteogenetic.+ The development and formation of bone. - -+osteoma.+ A bony tumor. - -+osteomalacia.+ Softening of the bone. - -+osteomyelitis.+ Inflammation of the bone marrow or of both marrow and -bone. - -+ous.+ Full of, as in fibrous, full of or composed of fibres. - -+oxygen.+ A gaseous element, the most widely distributed. Essential to -animal and plant life; symbol O. - -+ozone.+ A modified form of oxygen. - - -+P+ - -+pachylosis.+ Thick, dry and abnormal quality of skin which cracks into -scales of irregular form. - -+pack.+ The process of enveloping a patient in a wet sheet or blanket. -Cold pack: in sheets wrung out of water; hot pack: in sheets wrung out -of hot water; dry pack: in dry warmed blankets, etc. - -+pachyacria.+ Bulbous thickening of the extremities of the fingers or -toes. - -+pachydermia.+ Thick skin; elephantiasis. - -+palliative.+ Mitigating; lessening the severity. - -+palm.+ The flat of the hand. - -+palpation.+ Exploration with the hand. - -+panidrosis.+ Sweating from all parts of the skin. - -+papilla.+ Any small nipple-like process. - -+papilloma.+ A growth of hypertrophied papillae of the skin. - -+papule.+ A small circumscribed elevation of the skin, containing no -fluid. A pimple. - -+paralysis.+ Loss of power of voluntary movement in a muscle through -injury or disease of nerve supply. - -+parasite.+ An organism that inhabits another organism and obtains -nourishment from it. - -+paresis.+ General paralysis of the insane or dementia paralytics. A -condition thought to be due to a chronic meningitis. - -+paresthesia.+ An abnormal spontaneous sensation such as of numbness, -burning, pricking, tingling, etc. - -+parenchyma.+ The specific tissues of a gland or organ. - -+paronychia.+ Felon, whitlow. Inflammation of the structures in the -distal phalanx of the finger. - -+patella.+ Kneecap. - -+pathogenic.+ Causing disease. - -+pathology.+ That branch of medicine which treats of disease and the -changes in the tissues of the body caused by disease. - -+pathy.+ Suffering, or disease as in Homeopathy--disease, the quality of -being treated by likes. - -+pedicure.+ One who attends the feet, cosmetically. - -+per.+ Through, as in peripheral, away from the centre; the outer part -of or surface. - -+peri.+ A Greek prefix meaning around or about. - -+peridental.+ Surrounding a tooth or part of a tooth. - -+periosteum.+ The fibrous membrane investing the surface of bones except -at the point of tendinous and ligimentous attachment, and on the -particular surfaces where cartilage is substituted. - -+periostitis.+ Inflammation of the periosteum. - -+periphery.+ The part of a body away from the centre; the outer part or -surface, as of a bone or of a nerve. - -+peritoneum.+ The sac lining the abdominal cavity and covering most of -the viscera therein contained. - -+perivascular.+ Surrounding a blood-vessel. - -+peroxid.+ An oxid with the highest amount of oxygen. - -+pes (pl. pedes).+ The foot. - -+phagocyte.+ A cell possessing the property of ingesting bacteria or -other foreign particles. - -+phagocytosis.+ The destruction of microbes by the action of phagocytes. - -+phalanx.+ One of the long bones of the fingers or toes. - -+phenol.+ Carbolic acid. - -+phlebitis.+ Inflammation of a vein. - -+phlegmon.+ Acute suppurative inflammation of subcutaneous tissue. - -+physiology.+ The science which deals with the functions of living -things. - -+picric acid.+ A combination of carbolic and nitric acids. - -+pigment.+ An organic coloring matter. - -+plantalgia.+ Pain on the sole of the foot. - -+plantar.+ Relating to the sole of the foot. - -+plaque.+ A flat patch or area on the skin or mucous membrane. - -+plasia.+ Moulding, as in hypoplasia. defective development. - -+plaster-of-Paris.+ Calcium sulphate. - -+plastic.+ Capable of being moulded. - -+plegia.+ Stroke, as in hemiplegia, paralysis of one side of the body -and of the opposite side of the face. - -+plethoric.+ Relating to overfilled blood-vessels. - -+pleura.+ The serous membrane enveloping the lungs. - -+plexus.+ A new network of nerves or veins. - -+podagra.+ Gout, especially, typical gout in the great toe. - -+podagral.+ Gouty, relating to or suffering from gout. - -+podalic.+ Relating to the foot, as in podalgia, pain in the foot, -podarthritis, inflammation of any of the tarsal or metatarsal joints. - -+podiatrist.+ One who treats diseases and disorders of the feet. - -+podobromidrosis.+ Fetid or foul smelling perspiration of the feet. - -+pododynia.+ Pain in the foot or podalgia. - -+podology.+ A treatise on the foot. - -+poly.+ A Greek prefix for much or many, ex: polyphagia, excessive -eating. - -+poroma.+ Callus; exostosis. - -+potassium.+ An alkaline metallic element. Among the salts of potassium -are: potassium bichromate, employed externally as a caustic to -syphilitic vegetations; potassium hydroxide, used as a strong -penetrating caustic. - -+poultice.+ A soft emulsion for external application. - -+pous.+ Foot, as in podiatrist. - -+pre.+ A prefix denoting anterior or before. - -+predisposing.+ Inclining to, as a disease. - -+prepatellar.+ In front of the patella. - -+prognosis.+ A forecast of the result. In medicine, the prior -determination of the outcome of a disease. - -+proliferation.+ Cell-genesis, reproduction. - -+pronation.+ The act of rotating the forearm in such a way that the palm -of the hand looks backward when the arm is in the anatomic position, -or downward when the arm is extended at a right angle with the body. -(Stedman.) - -+prophylactic.+ Preventing disease. - -+protargol.+ A combination of silver with a proteid base. - -+protean.+ Having the power to change form. - -+protonuclein.+ A preparation from the lymphoid tissue of animals. - -+protoplasm.+ Primitive organic cell matter. - -+protuberance.+ A projecting part. - -+pseudo.+ Prefix, signifying false. - -+ptomain.+ A crystallizable nitrogenous basic substance, produced by -bacteria in dead animal or vegetable matter. - -+punctured.+ Wounded by a pointed instrument. - -+purge.+ A cathartic. - -+purulent.+ Having the character of pus. - -+pus.+ A fluid product of inflammation. - -+pustule.+ A soft purulent papule. - -+putrefaction.+ Organic decomposition, decay. - -+putrid.+ Manifesting putrefaction. - -+pyemia.+ A condition in which pyogenic bacteria circulate in the blood, -and form abscesses wherever they lodge. - -+pyogenic.+ Developing or excreting pus. - -+pyorrhea.+ A discharge of pus. - -+pyorrhea alveolaris.+ Rigg's disease; suppurative inflammation of the -periosteum lining the teeth in their sockets. - - -+Q+ - -+q.h.+ Every hour, used in prescription writing. - -+q.s.+ Sufficient quantity, used in prescription writing. - -+quinine.+ An alkaloid of cinchona. - -+quinine and urea hydrochlorate.+ Used as a local anesthetic. - - -+R+ - -+rachitic.+ Pertaining to rickets. - -+rationale.+ Fundamental reason. - -+Raynaud's disease.+ Symmetrical gangrene of the extremities. - -+recipe.+ "Take thou." Used to precede directions in prescription -writing. - -+rectum.+ The terminal part of the digestive tube from the pelvic colon -to the anus. - -+refrigeration.+ The act of cooling or reducing fever. - -+remittent.+ Characterized by temporary abatement of symptoms. - -+resection.+ Removal of articular ends forming a joint; removing a -segment of any part. - -+retention.+ Holding back as of excretions and secretions. - -+rhea.+ A flow, as in diarrhea, an abnormally frequent discharge of more -or less fluid fecal matter from the bowels. - -+rheumatism.+ An acute, probably infectious, condition; when articular, -the joints are inflamed. - -+rhigolene.+ A liquid obtained from petroleum distillation. Used as a -local anesthetic. - -+rickets.+ Disease of early childhood characterized by defective -nutrition of the bony structures. - -+Roentgen rays.+ (See X-ray.) - -+rotated.+ Turned about or around on its own axis. - - -+S+ - -+sac.+ Pouch; bursa. - -+saccharomyces.+ The yeast fungi. - -+salicylate of mercury.+ A salt of mercury and salicylic acid. - -+salvarsan.+ The Ehrlich-Hata anti-syphilitic preparation; known also as -No. 606. - -+saphenous vein.+ The ascending vein of the lower limb which empties -into the femoral vein. - -+saprophyte.+ A microorganism which normally grows on dead matter. - -+sapremia.+ Intoxication due to absorption of dead saprophytes into the -system. - -+saprophytic.+ Pertaining to saprophytes. - -+sarcoma.+ A malignant connective tissue tumor. - -+scaphoid.+ One of the small bones of the wrist. One of the bones of the -tarsus. - -+scar.+ Mark of a wound. - -+scarlet fever.+ Scarlatina. An acute exanthematous disease. - -+schizomycetes.+ The fisson fungi microorganisms; bacteria; -putrefaction; organic decomposition, decay. - -+sclerosis.+ Induration and overgrowth of the connective tissue of an -organ. - -+scope.+ View, as in stethoscope, an instrument originally devised for -aid in hearing the respiratory or c a r d i a c s o u n d s in -the chest. - -+scrotum.+ The sac containing the testicles. - -+sebum.+ The fat excreted by the sebaceous glands of the skin. - -+secare-sect.+ To cut, as in dissect, to cut apart or separate the -tissues of the body in the study of anatomy. - -+sedative.+ Calming, quieting. - -+senile.+ Relating to old age. - -+sensibility.+ The consciousness of sensation. - -+sensory.+ Pertaining to sensation. - -+sepsis.+ (See septicemia.) - -+septicemia.+ An infection characterized by the presence of bacteria and -their toxins in the blood. - -+sequestrum.+ A fragment of necrosed bone. - -+serous.+ Relating to, containing or producing serum. - -+serum.+ A clear watery fluid moistening the surface of serous membranes -or exudate resulting from inflammation of any of those membranes. - -+shaft.+ The part of a long bone between its ends. - -+shock.+ A sudden physical or mental disturbance. - -+sinus.+ A hollow cavity recess, or pocket in the body tissues. - -+skiagraph.+ A shadow. The production of photographs by means of -Roentgen rays. - -+skin.+ The membranous covering of the body. - -+skiving.+ Splitting or paring materials for adjusting shields to -surfaces on the foot. - -+slough.+ Necrosed tissue separated from living structure. - -+smallpox.+ Variola; an acute eruptive contagious disease. - -+sodium chloride.+ Common table salt. - -+sodium hydroxide.+ Caustic soda. Used for its caustic effects. - -+sodium sulphate.+ Colorless crystals. Glauber's salt; a purgative. - -+sodium urate.+ The substance found in gouty nodes; chalk-stone. - -+spasm.+ An involuntary convulsive muscular contraction. - -+spirillum.+ A genus of spirillaceae containing rigid cells with polar -tufts. - -+spirochaeta pallida.+ The specific organism of syphilis. - -+splint.+ An apparatus for fixating a joint. - -+spontaneous.+ Occurring without external stimulation. - -+spores.+ Reproductive bodies of cryptogams. - -+stagnation.+ Cessation of motion. - -+staphylococcus.+ A coccus; a genus of schizomycetes in which the cocci -are irregularly clustered like a bunch of grapes. - -+stasis.+ Standing, as in hemostasis, the arrest of the circulation in -the blood vessels of a part. - -+sterile.+ Barren, not fertile. - -+sterilization.+ The destruction of germs. - -+sternum.+ The breast-bone. - -+stovaine.+ A local anesthetic; used largely to induce intraspinal -anesthesia. - -+stratum corneum.+ The horny or outer layer of the epidermis. - -+streptococcus.+ A genus of schizomycetes in which the cocci are -arranged in strings or in chains. - -+strismus.+ Spasm. - -+structure.+ The component formation features of a tissue. - -+strychnine.+ An alkaloid of nux vomica. - -+styptic.+ Having the property of checking hemorrhage. - -+sub.+ A Latin prefix denoting, beneath, as subareolar, beneath the -areola or minute area. - -+subcutaneous.+ Under the skin. - -+subcutin.+ A white crystalline powder used in saline solution as a -local anesthetic. - -+supinate.+ To turn the hand so that it is supine, i. e., with the palm -outward. The opposite of pronation. - -+suppository.+ A solid medicine, melting at body temperature, for -introduction into the rectum or vagina. - -+suppuration.+ The formation of pus. - -+supra.+ A prefix denoting a position above. - -+suture.+ An anatomic union between two bones; the surgical union of two -surfaces by stitches. - -+symptomatic.+ Relating to symptoms; indicative. - -+symptomatology.+ The study of the symptoms of disease. - -+synchronous.+ Occurring at the same time. - -+syncope.+ Swooning or fainting. - -+synovia.+ Tenacious, colorless, stringy alkaline fluid which lubricates -a joint; in appearance like the white of eggs. - -+synovial.+ Pertaining to synovia. - -+synovitis. Inflammation of a synovial membrane. - -+synthetic.+ Created from parts into a compound. - -+syphilis.+ An infectious disease spread by inoculation thru sexual -intercourse; also possible by contamination thru table utensils, -towel, pipes, etc. - -+systemic.+ Relating to a system. - - -+T+ - -+tabes dorsalis.+ Locomotor ataxia; posterior spinal sclerosis. - -+talipes.+ Clubfoot. - -+talipes calcaneus.+ The heel touching the ground and the foot generally -in extreme dorsi-flexion. - -+talipes cavus.+ Hollow foot. An increased curvature of the arch of the -foot. - -+talipes equinus.+ Club foot, the patient walking on his toes, and the -foot in plantar flexion. - -+talipes planus.+ Flat foot; a deformity marked by depression of the -arch of the foot. - -+talipes valgus.+ Eversion of the foot, the inner side of the foot -resting on the ground. - -+talipes varus.+ Inversion of the foot, the outer side of the sole of -the foot touching the ground. - -+tarsus.+ A bone of the posterior part of the foot. - -+technic.+ Details of a procedure. - -+tendo Achillis.+ The common tendon of the gastrocnemius and soleus -muscles. - -+tendon.+ A white, glistening fibrous tissue, affording attachment of -muscles to bone. - -+tenosynovitis.+ Inflammation of a tendon and its sheath. - -+tenotomy.+ The surgical division of a tendon. - -+terminal.+ Relating to the end, extremity or summit of any body. - -+tetanus.+ Lock jaw. A very fatal disease due to the introduction of the -bacillus tetanus into the tissues. - -+therapy.+ Treatment, as hydrotherapy, treatment of diseases by means of -water. - -+therapeutics.+ The branch of medical science concerned with the -application of remedies for the alleviation of pain and the treatment -of disease. - -+thermal.+ Pertaining to heat. - -+thoracentesis.+ Tapping the thorax to release fluid from it. - -+thrombin.+ The fibrin ferment. - -+thrombosis.+ The formation of a thrombus. - -+thrombus.+ A blood clot in a vessel producing an obstruction in the -flow of the blood in the same. - -+thymol.+ A phenol found in some volatile oils. Used as a deodorizer and -as an antiseptic. - -+tibia.+ The shin-bone. - -+tincture.+ The pharmacy name of an alcoholic solution or extract of a -nonvolatile vegetable substance. - -+tissue.+ A collection of cells or derivatives of cells forming a -definite structure. - -+toma, or oma.+ Tumor in hematoma, a bloody tumor. - -+tourniquet.+ An instrument or apparatus for arresting the flow of blood -from a vessel in a limb by pressure. - -+toxalbumins.+ Poisonous soluble albuminoids producing specific disease. - -+toxemia.+ A poisoned state of the blood due to the absorption of -poisons not of parasitic origin. - -+toxicity.+ A state of being poisonous. - -+toxicology.+ The science of poisons and their antidotes. - -+toxins.+ Amorphous, nitrogenous poisons, formed by bacteria in both -living tissues and dead substances. - -+trabecula.+ Any one of the fibrous bands extending from the capsule -into the interior of an organ. - -+tracheotomy.+ The operation of opening into the trachea. - -+traction.+ Drawing; pulling. - -+tragopodia.+ Knock-knee. - -+transfusion.+ The transfer of blood from one person to another. - -+transplant.+ To transfer from one part to another as in plastic -operations. - -+trauma.+ A wound or injury. - -+traumatic.+ Relating to or caused by a wound. - -+trinitrin.+ Nitroglycerin. - -+triturate.+ To reduce to fine powder; a finely divided powder. - -+tropacocaine.+ An alkaloid from Java coca leaves, used as a local -anesthetic. - -+trophe (nourishment).+ Hypertrophy, overgrowth; atrophy, lack of -nourishment. - -+trophic.+ Relating to or dependent upon nutrition. - -+trypsin.+ A proteolytic ferment of pancreatic fluid. - -+tubercle.+ A circumscribed elevation on the skin, mucous membrane or -surface of an organ; the lesion of tuberculosis. - -+tuberosity.+ A small rounded elevation on a bony surface. - -+tumor.+ A swelling or tumefaction. - -+tylosis.+ Formation of a callosity. - -+typhoid fever.+ An acute infectious disease caused by the bacillus -typhosus. - - -+U+ - -+ulcer (ulcus).+ A lesion of a cutaneous or mucous surface usually -attended by suppuration. - -+ulceration.+ The process of ulcer formation. - -+unguentum Crede.+ An ointment of colloidal silver, 15: distilled water, -5; white wax, 10; benzoinated lard, 70 parts. Used as an inunction. - -+urates.+ Salts of uric acid. - -+urea.+ An end-product of metabolism excreted in the urine. - -+ureter.+ A tube carrying urine from the kidney to the bladder. - -+urethra.+ A canal from the bladder thru which the urine is discharged. - -+uria (urine).+ As in glycosuria, the excretion of sugar (glucose) in -the urine. - -+urology.+ The subject which has to do with urinary modifications in -disease. - - -+V+ - -+vaccine.+ The modified virus of any disease, which, when inoculated, -protects against the action of the unmodified virus. - -+vaccination.+ The injection of a killed culture of a specific bacterium -as a means of prophylaxis or cure of the disease caused by that -microorganism. - -+valgus.+ One who is bow-legged or has knock-knees. - -+varix.+ An enlarged and tortuous vein, artery or lymphatic vessel. - -+vasoconstrictor.+ An agent or a nerve which causes narrowing of the -blood vessels. - -+vasodilator.+ An agent or a nerve which causes dilatation of the blood -vessels. - -+vein.+ A blood-vessel carrying blood toward the heart. - -+venous.+ Pertaining to a vein. - -+verruca+ (pr. verrucae). Wart. - -+vertebra.+ A bony segment of the spinal column. - -+vesicle.+ A small blister or sac containing serum. - -+villus (pl. villi).+ A minute projection from the surface, especially -of a mucous membrane. - -+viscus (viscera).+ An internal organ especially of the abdominal -cavity. - - -+W+ - -+Wart.+ A circumscribed hypertrophy of the papillae of the corium -covered by thickened epidermis. - -+Wassermann's test.+ A diagnostic test for syphilis, based upon the -theory of complement fixation. - -+wen.+ A sebaceous cyst, especially one occurring on the scalp. - -+whitlow.+ See paronychia. - - -+X+ - -+xeroderma.+ Roughening of the skin from diminished secretion. - -+X-rays.+ The ethereal waves or pulsations from a Crookes' tube from the -bombardment of the anode target with the cathode rays. - - -+Z+ - -+zinc chloride.+ A caustic sulphate. An astringent. - -+zymotic.+ Relating to fermentation; noting an infectious disease. - - - - -CROSS REFERENCE INDEX - - - A - - Abscess - acute, 65 - chronic, 66 - symptoms, 66 - treatment, 66 - - Acquired club foot, 191 - - Acquired flat foot, 178 - - Actinomycosis, 136 - causes, 137 - symptoms, 137 - treatment, 137 - - Active hyperemia, 196 - indications for therapeutic uses, 196 - - Actual cautery, 200 - uses, 200 - - Acute abscess, 65 - causes, 65 - diagnosis, 65 - symptoms, 66 - treatment, 66 - - Acute rheumatism, 97 - causes, 97 - diagnosis, 97 - symptoms, 97 - treatment, 97 - - Acute synovitis, 86 - causes, 86 - diagnosis, 86 - symptoms, 86 - treatment, 86 - - Adhesive plaster, 215 - - Adrenaline, 211 - - Alcohol, 25 - - Alkaloids, 9 - - Alum, 210 - - Alypin, 251 - - Ameboid, 29 - - Ammoniated mercury, 212 - - Amyl nitrite, 45 - - Anaerobic bacteria, 8 - - Anesthesia, local, 229 - - Ankle joint, 165 - dislocations, 172 - backward, 172 - forward, 172 - injuries, 172 - outward, 173 - sprains, 176 - diagnosis, 176 - symptoms, 176 - treatment, 177 - - Ankylosis, 94 - fibrous, 94 - bony, 94 - - Antiseptic method, 20 - - Antisepsis, 19 - - Antiseptics, 22 - - Appearance of varicose ulcers, 68 - - Appendicitis, 17 - - Application of skin grafts, 226 - - Aqueous solution of ichthyol, 208 - - Argyrol, 26 - - Aristol, 24 - - Arterial bleeding, 55 - - Arthritis, 88 - acute, 88 - causes, 89 - chronic, 90 - diagnosis, 90 - symptoms, 91 - treatment, 91 - varieties, 89 - Charcot, 98 - gonorrhoeal, 95 - gouty, 97 - infective, 98 - rheumatic, 97 - septic, 90 - syphilitic, 95 - traumatic, 90 - tubercular, 92 - - Arthrotomy, 173 - - Arterial hyperemia, 196 - indications, 196 - technic, 195 - - Arteriosclerosis, 117 - - Articular fractures, 159 - - Asepsis, agents, 19 - drugs employed, 21 - technic, 21 - - Aseptic methods, 21 - - Astragalus dislocation, 172 - - Astragalus fracture, 168 - - Astringent powders, 210 - alum, 210 - stearate of zinc, 210 - zinc, 210 - - Asepsis in the management of wounds, 39 - - Atrophy of bone, 100 - causes, 100 - symptoms, 100 - treatment, 100 - - - B - - Backward dislocations - ankle, 172 - - Bacteria, 6 - aerobic, 8 - anerobic, 8 - alkaloidal, 9 - cultivation, 10 - classification, 7 - destruction, 12 - effect of oxygen, 8 - elimination, 11 - facultative, 8 - ferments, 10 - habitat, 7 - infection, 10 - immunity, 12 - temperature effect of, 8, 14 - toxins, 9 - pathogenic, 6 - saprophytic, 6 - surgical import, 15 - - Balsam of Peru, 210 - - Bandages, 215 - elastic, 219 - flannel, 215 - French bandage of foot, 218 - gauze, 214 - ideal, 214 - muslin, 214 - plaster, 164 - rubber, 214, 219 - spica bandage of foot, 218 - spica bandage of toe, 217 - spiral bandage of toe, 217 - - Bandaging, 215 - indications, 215 - method, 216 - technic, 216 - - Benign tumors, 114, 152 - adenoma, 114 - chondroma, 114 - fibroma, 153 - lipoma, 153 - lymphoma, 154 - myoma, 154 - osteoma, 115 - - Bichloride solution, 22 - strength, 22 - - Bicycle foot, 138 - symptoms, 138 - treatment, 138 - - Bier's, arterial hyperemia, 196 - indications, 196 - technic, 195 - venous hyperemia, 195 - - Bismuth subgallate, 210 - - Black mustard, 199 - - Blastomycotic ulcer, 79 - diagnosis, 79 - symptoms, 79 - treatment, 79 - - Bleeding, 54 - control of, 54 - - Blue ointment, 133, 212 - - Bone - atrophy, 100 - caries, 101 - congenital defects, 99 - hypertrophy, 101 - necrosis, 102 - osteitis, 105 - osteomyelitis, 105 - periostitis, 103 - senile atrophy, 100 - tumors, 114 - - Boric acid, 25 - ointment, 212 - powder, 210 - solution, 208 - - Brandy, 47 - - Bromides, 48 - - Bunion, 84, 185 - - Burns, 56 - causes, 56 - degrees, 57, 58 - pathology, 57, 58 - symptoms, 59 - treatment, 60 - varieties, 57 - - Bursitis, 82 - acute, 83 - chronic, 83 - diseases of the bursa, 82 - symptoms, 83 - treatment, 83 - - Burow's solution, 208 - formula, 208 - indications, 35, 208 - preparation, 208 - - - C - - Calomel, 210 - - Callosity, 141 - causes, 141 - definition, 141 - symptoms, 141 - treatment, 141, 142 - - Callous ulcers, 67 - causes, 67 - diagnosis, 67 - symptoms, 68 - treatment, 68 - - Cancer, 51 - - Carbolic acid, 13 - dangers, 22 - gangrene, 121 - poisoning, 13 - uses, 22 - - Caries, 101 - symptoms, 101 - treatment, 102 - - Cartilage, 88 - - Catgut, 46 - uses, 46 - varieties, 46 - - Cautery, 200 - how applied, 200 - when indicated, 200 - - Cells, 36 - - Cellulitis, 136 - cause, 136 - symptoms, 136 - treatment, 136 - - Chancre, 131 - - Charcot's disease, 98 - - Chauffeur's foot, 138 - cause, 138 - symptoms, 138 - treatment, 138 - - Chemical antiseptics - uses, 13 - - Chemotaxis, 31 - - Chloroform liniment, 197 - - Chilblain, 63 - symptoms, 63 - treatment, 63 - - Chinese lady foot, 193 - - Chondromata, 154 - symptoms, 154 - treatment, 154 - - Chronic bursitis, 83 - osteomyelitis, 110 - periostitis, 104 - syphilis, 132 - synovitis, 87 - tuberculosis, 134 - - Chyle, 5 - - Circulatory system, 3 - - Clavus, 142 - - Clawed toes, 183 - - Clinicial stages of burns, 57 - - Club foot, 188 - - Cocaine, 243 - preparations, 243 - strength of sols., 244 - uses, 244 - - Cocoon dressing, 207 - description, 207 - indications, 207 - - Cold, 197 - the effects of, 34, 62 - treatment, 62 - - Cold compress, 197 - indications, 197 - - Collodion dressings, 207 - indications, 207 - - Comminuted fractures, 158 - symptoms, 158 - treatment, 158 - - Compound fractures, 161 - diagnosis, 161 - symptoms, 161 - treatment, 161 - - Contusions, 41 - symptoms, 42 - treatment, 43 - - Contused wounds, 41 - diagnosis, 42 - symptoms, 42 - treatment, 43 - - Contagious warts, 139 - - Congenital club foot, 188 - - Congenital defects of bone, 99 - - Congenital flat foot, 178 - - Counterirritants - indications, 199 - - Copper sulphate, 210 - - Corn or clavus, 142 - symptoms, 142 - treatment, 142 - varieties, 142 - - Corrosive sublimate, 46 - - Crede's ointment, 26 - - Creolin, 23 - strength of sol., 23 - uses, 23 - - Cysts, 154 - bone, 117 - diagnosis, 154 - sebaceous, 154 - symptoms, 154 - treatment, 155 - varieties, 154 - - - D - - Dakin's solution, 209 - how prepared, 209 - indications, 209 - method of use, 209 - - Dead bone - symptoms, 102 - treatment, 102 - - Depressed fractures, 157 - - Demarcation in gangrene, 122 - - Dermatol, 210 - - Dermatitis, 135 - symptoms, 135 - treatment, 136 - - Diabetic - gangrene, 120 - ulcers, 75 - - Diapedesis, 31 - - Diaphysis of bone, 158 - - Digitalis, 45 - - Direction of the line of fracture, 157 - - Diseases of the - arteries, 118 - bones, 105 - caries, 101 - necrosis, 102 - osteitis, 105 - osteomyelitis, 105 - periostitis, 105 - joints, 170 - lymphatics, 5 - veins, 127 - - Dislocations, 170 - ankle joint, 172 - astragalus, 175 - diagnosis, 171 - metatarsal bones, 176 - subastragaloid, 174 - symptoms, 172 - toes, 176 - treatment, 171, 173 - - Drainage - indications for, 46 - methods of, 46 - - Dressings, 207 - dry, 207 - wet, 207 - - Dry dressings, 207 - materials used, 207 - indications for, 207 - - - E - - Early diagnosis of - carcinoma, 153 - syphilis, 130 - tuberculosis, 133 - - Ecchymosis, 42 - - Electricity, 201 - uses, 201 - - Electrolysis, 201 - method of application, 141, 201 - - Elastic stocking - application, 126 - uses, 126 - - Elevated position for treatment of varicose veins, 126 - - Elongated veins - significance, 126 - - Embolism, 119 - causes, 119 - diagnosis, 119 - symptoms, 119 - treatment, 119 - - Endarteritis obliterans, 120 - symptoms, 120 - treatment, 120 - - Enteroclysis, 45 - indications, 45 - - Epitheliomatous ulcer, 79 - causes, 79 - diagnosis, 80 - symptoms, 80 - treatment, 80 - - Epiphysis of bone, 158 - - Erysipelas, 135 - causes, 135 - diagnosis, 135 - symptoms, 135 - treatment, 136 - - Escharotics, 210 - indications, 210 - methods of application, 210 - - Esmarch bandage, 214 - where indicated, 215 - technic, 219 - - Ethyl chloride, 252 - - Extirpation of - tumors, 117 - varicose veins, 126 - - Exuberant granulations, 68 - - - F - - Faradism, 201 - indications for, 201 - technic of, 201 - - Ferments, 9, 10 - - Fibromata, 114 - diagnosis, 114 - symptoms, 114 - treatment, 114 - - Fibrous ankylosis, 94 - causes, 94 - treatment 94 - - First aid - in accidents, 60 - in fractures, 162 - - First degree of burns, 57 - pathology, 57 - symptoms, 57 - treatment, 57 - - Firm bandaging - technic, 216 - - Fission, 37 - - Fissure, 64 - diagnosis, 64 - treatment, 64 - - Fistula, 64 - definition, 64 - diagnosis, 64 - treatment, 64 - - Flannel bandages, 214 - method of application, 215 - uses, 215 - - Flat foot, 178 - acquired, 178 - causes, 179 - congenital, 178 - diagnosis, 180 - operation treatment, 183 - pathology, 179 - prognosis, 181 - spastic, 180 - rigid, 182 - supports, 181 - symptoms, 180 - treatment, 181 - - Flat foot - from child birth, 179 - from excessive weight, 179 - from prolonged fractures, 179 - - Flexed toes, 183 - diagnosis, 184 - symptoms, 184 - treatment, 184 - - Fluctuation, 66 - - Forward dislocations, 172 - at the ankle joint, 172 - diagnosis, 172 - symptoms, 173 - treatment, 173 - - Formaldehyde, 14 - uses, 23 - - Fractures, 156 - astragalus, 168 - causes, 159 - classification, 156 - comminuted, 158 - complete, 156 - complicated, 161 - compound, 161 - depressed, 157 - diagnosis, 166 - epiphyseal separations, 158 - etiology, 159 - fibula, 165 - fissured, 157 - fixation method, 165 - greenstick, 156 - impacted, 158 - joint, 158 - line of, 157 - location, 158 - number, 161 - metatarsal, 169 - multiple, 161 - operative, 164 - os calcis, 168 - pathologic, 160 - Pott's, 165 - recent, 162 - reduction, 163 - simple, 161 - tarsal, 167 - tibia, 165 - treatment, 162, 166, 167 - varieties, 157 - violence, 160 - - French bandage of the foot, 218 - - Frigorism (trench foot), 137 - causes, 137 - diagnosis, 137 - symptoms, 137 - treatment, 137 - - Frost Bite, 63 - - Furuncle, 66 - causes, 66 - symptoms, 66 - treatment, 67 - - - G - - Galvanism, 201 - indications, 201 - method of application, 201 - - Galvano-cautery, 200 - indications, 200 - method of application, 200 - - Gauze - aseptic, 44 - iodoform, 24 - uses, 44 - - Gangrene, 118 - arteriosclerosis, 118 - carbolic acid, 121 - cold, 120 - diabetic, 120 - dry, 118 - endarteritis obliterans, 120 - embolism, 120 - moist, 119, 122 - - Gelatin, uses, 219 - - Germs, 6 - bacillus coli communis, 17 - bacillus pyocyaneus, 15 - bacillus tetani, 17 - bacillus tuberculosis, 17 - bacillus typhosis, 17 - micrococcus gonorrhoeae, 16 - spirochaeta pallida, 15 - staphylococcus pyogenes aureus, 16 - staphylococcus pyogenes albus, 16 - staphylococcus pyogenes citreus, 16 - streptococcus pyogenes, 16 - - Glycerine, uses, 219 - - Gonorrhoeal arthritis, 95 - causes, 95 - diagnosis, 95 - symptoms, 96 - treatment, 96 - - Gouty arthritis, 97 - - Granulations, 68 - - Green stick fracture, 156 - symptoms, 156 - treatment, 156 - - Gun shot wounds, 39 - symptoms, 39 - treatment, 39 - - - H - - Hematoma, 42 - definition, 42 - diagnosis, 42 - symptoms, 42 - treatment, 42 - - Hallux valgus, 185 - causes, 185 - operative measures, 187 - pathology, 185 - symptoms, 185 - treatment, 186, 187 - - Hallux flexus, 183 - symptoms, 183 - treatment, 183 - - Hammer toe, 183 - diagnosis, 183 - symptoms, 183 - treatment, 183 - - Heat, 14, 197 - effects, 14, 34 - dry, 14, 19 - moist, 14, 20 - - Heloma, 142 - definition, 142 - causes, 142 - diagnosis, 142 - pathology, 142 - radical cure, 144 - pathology, 142 - radical cure, 144 - symptoms, 142 - treatment, 143 - varieties, 142 - - Hemoglobin, 42 - - Hemophilia, 51 - - Hemorrhage, 51 - arterial, 51 - capillary, 45, 51 - causes, 51 - control, 44, 52 - in chiropody, 53 - spontaneous, 51 - venous, 51 - treatment, 44, 52, 54 - - Hemostatics, 54 - - Hereditary syphilis, 130 - diagnosis, 130 - symptoms, 131 - treatment, 132 - - High frequency current, 198 - indications for, 198 - method of application, 198 - - Horny tissue - where found, 57 - treatment, 58 - - Housemaid's knee, 83 - - Hydrastine, uses, 211 - - Hydrochloride of cocaine - indications for, 243 - - Hydrogen peroxide, 24, 211 - - Hyperemia, 194 - arterial or active, 196 - methods of application, 195 - uses, 196 - venous or passive, 195 - - Hypertrophy of bone, 101 - causes, 101 - symptoms, 101 - treatment, 101 - - Hypertrophy of nails, 148 - causes, 148 - pathology, 149 - symptoms, 149 - treatment, 149, 150 - - - I - - Ichthyol - ointment, 212 - solution, 208 - uses, 212 - - Immunity, 12 - acquired, 12 - inherited, 12 - natural, 12 - resistance to, 12 - susceptibility to, 12 - - Impacted fractures, 158 - causes, 158 - diagnosis, 158 - symptoms, 158 - treatment, 158 - - Injuries to the ankle - contusions, 41 - dislocations, 172 - fractures, 168 - inflammations, 89 - sprains, 176 - - Inflammation, 28 - bone, 105 - bursae, 82 - causes, 28 - definition, 28 - emigration, 30 - etiology, 28 - exudation, 29 - diapedesis, 31 - pathology, 28 - periosteum, 103 - phenomena, 32 - resolution, 32 - serous membranes, 84 - sloughing, 32 - suppuration, 33 - symptoms, 32 - synovial membranes, 84 - treatment, 34 - varieties, 34 - - Incised wounds, 39 - symptoms, 40 - treatment, 44 - - Indolent ulcers - causes, 67 - diagnosis, 67 - symptoms, 67 - treatment, 67 - - Infective arthritis, 95 - causes, 96 - diagnosis, 96 - symptoms, 96 - treatment, 96 - - Ingrowing toe nail, 145 - causes, 145 - diagnosis, 145 - operations, 148 - symptoms, 145 - treatment, 146, 147, 148 - varieties, 148 - - Injuries of the bursae, 82 - diagnosis, 82 - symptoms, 82 - treatment, 83 - - Injuries of the bone - contusion, 41 - dislocation, 170 - fracture, 156 - - Interpretation of radiograms - their diagnostic value, 203 - - Inunction of mercury, 133 - indications, 133 - preparation, 133 - technic, 133 - - Iodin - preparations, 24 - uses, 24 - - Iodoform - gauze, 24 - ointment, 24 - powder, 24 - poisoning, 24 - - - J - - Joint fractures, 158 - diagnosis, 158 - symptoms, 158 - treatment, 158 - - - K - - Knives - method of sterilization, 21 - - Kreolin, 13 - - - L - - Lacerated wounds, 40 - causes, 40 - diagnosis, 40 - symptoms, 40 - treatment, 44 - - Lassar's paste, 212 - formula, 212 - indications, 212 - - Lead and opium wash, 208 - formula, 208 - indications, 208 - - Leukocytosis, 26 - definition, 26 - interpretation, 26 - value, 26 - - Ligaments - injuries, 176 - - Ligatures, 46 - uses, 46 - varieties, 46 - - Ligation of varicose veins, 126 - methods, 126 - technic, 126 - - Lime water, 209 - - Liquor ferri subsulphatis (Monsel's sol.), 211 - formula, 211 - method of application, 211 - uses, 211 - - Liquor calcis, 209 - formula, 209 - uses, 209 - - Liquor plumbi subacetatis, 208 - formula, 208 - indications, 208 - - Local anesthesia, 229 - advantages, 234 - alypin, 251 - cocaine, 243 - drugs employed, 243 - edemitization method, 242, 246 - endermic method, 241, 245 - essentials, 237 - general principles, 233, 234, 237, 238 - history, 229 - methods of application, 241 - nerve blocking, 242 - physiologic effects, 232 - preparation of instruments, 240 - preparation of patient, 240 - novocaine, 250 - objections to, 236 - quinine and urea hydrochloride, 249 - Schleich's sol., 246 - stovaine, 251 - strength of solutions, 244 - technic, 241 - toxicology, 247 - - Local treatment of - arthritis, 91 - bursitis, 83 - periostitis, 103 - osteomyelitis, 94 - phlebitis, 128 - synovitis, 87 - - Location of - dislocations, 170 - fractures, 156 - sprains, 176 - ulcers, 70 - - Locomotor ataxia, 75 - causes, 75 - diagnosis, 75 - foot manifestations, 76, 77 - treatment, 78 - - Longitudinal fractures - diagnosis, 157 - treatment, 157 - - Loose bandage - objections to, 215 - - Lutein - diagnostic value, 73 - reaction, 73 - technic, 73 - - Lymphatic system, 5 - - Lysol, uses, 23 - - - M - - Malposition in fractures, 164 - treatment, 164 - - Malignant growths, 115, 152 - carcinoma, 115, 152 - diagnosis, 115 - sarcoma, 115, 153 - symptoms, 115 - treatment, 115 - - Martin's bandage, 195 - indications, 195 - how applied, 195 - - Massage, 201 - indications, 44 - technic, 202 - varieties, 202 - - Mayo's operation, 127 - how performed, 127 - when indicated, 127 - - Mechanical theory of tabes - explanation of, 75 - - Mercury - preparations, 133 - uses, 132 - - Metatarsalgia, 184 - diagnosis, 184 - symptoms, 184 - treatment, 184 - - Methods of - disinfection, 20 - immobilization of fractures, 165 - fixation of fractures, 165 - - Microorganisms, 6 - definition, 6 - non-pathogenic, 6 - varieties, 6 - - Moist gangrene, 119 - causes, 118, 119 - diagnosis, 119 - symptoms, 119 - treatment, 121 - varieties, 119 - - Monsel's sol., 211 - formula, 211 - indications, 211 - uses, 211 - - Monochloracetic acid - uses, 210 - - Morton's disease, 184 - causes, 184 - diagnosis, 184 - symptoms, 184 - treatment, 184 - - Motorman's foot, 138 - causes, 138 - diagnosis, 138 - symptoms, 138 - treatment, 138 - - Multiple varicose veins - location, 125 - treatment, 126 - - Muslin bandage - uses, 214 - - Mustard - uses of, 199 - - Muriate of cocaine, 214 - how used, 214 - when indicated, 214 - - Myeloma, 116 - causes, 116 - diagnosis, 116 - symptoms, 116 - treatment, 116 - - - N - - Nails, 150 - diseases, 150 - inflammation, 150 - hypertrophy, 148 - symptoms, 150 - treatment, 150, 151 - - Necrosis, 102 - definition, 102 - causes, 102 - diagnosis, 102 - symptoms, 102 - treatment, 102 - - Needle in foot, 40 - diagnosis, 40 - treatment, 40 - value of X-ray, 40 - - Neosalvarsan (914), 133 - how prepared, 133 - indications, 133 - technic, 133 - - Nerve theory - cause for tabes, 75 - - Nerve pressure - effect, 242 - - Nerve blocking - in local anesthesia, 242 - - Nervous system, 3 - - Neuropathic joints, 98 - diagnosis, 98 - symptoms, 98 - treatment, 98 - - Nicolaier's bacillus, 17 - - Nitric acid - uses, 210 - - Nitrate of silver, 25 - different sols., 26 - stick, 26 - uses, 26, 210 - - Novocaine, 250 - how prepared, 250 - advantages, 250 - indications, 250 - uses, 250 - - Nucleus, 36 - - Number of fragments in fractures, 161 - - Number of ulcers on leg, 73 - - - O - - Obtaining a sounder scar, 227 - in skin grafting, 228 - in the treatment of ulcers, 222 - - Oblique fractures, 157 - - Ointments, 212 - balsam of Peru, 212 - boric acid, 212 - Crede, 26 - ichthyol, 212 - indications, 212 - Lassar's paste, 212 - mercurial, 212 - salicylic acid, 211 - scarlet red, 213, 214 - zinc oxide, 212 - - Oleate of mercury - indications, 133 - - Onychia - hypertrophy, 148 - inflammation, 150 - symptoms, 150 - treatment, 151 - - Operations - flat foot, 181 - fractures, 164 - hallux valgus, 187 - osteitis, 94 - necrosis of bone, 102 - osteomyelitis, 94 - periostitis, 103 - varicose veins, 126 - - Ordinary saline sol., 208 - how prepared, 208 - indications, 208 - methods of injection, 45 - - Orthoform - uses, 210 - - Os calcis - dislocations, 175 - fracture, 168 - - Osteitis, 105 - causes, 105 - deformans, 113 - diagnosis, 105 - symptoms, 105 - treatment, 105 - - Osteitis deformans, 113 - causes, 113 - diagnosis, 113 - symptoms, 113 - treatment, 113 - - Osteomalacia, 113 - causes, 113 - diagnosis, 113 - onset, 113 - symptoms, 113 - treatment, 113 - - Osteomyelitis, 105 - acute, 105 - causes, 105 - chronic, 110 - diagnosis, 106 - infective, 107 - symptoms, 107 - syphilitic, 111 - tubercular, 109 - treatment, 109, 114 - - Os trigonum - location, 168 - - Oxygen, 26 - - Ozone, 26 - - - P - - Paget's disease, 113 - symptoms, 113 - treatment, 113 - - Painful heel, 184 - causes, 184 - symptoms, 184 - treatment, 184 - - Palliative treatment of veins, 126 - bandaging, 126 - Unna's paste, 219 - - Parasiticides - alcohol, 25 - carbolic acid, 13 - formaldehyde, 23 - iodin, 24 - heat, 34 - mercury, 133 - - Passive hyperemia, 195 - contraindications, 194 - indications, 195 - technic of application, 195 - - Pastes - Lassar's, 212 - Unna's, 219 - - Pathogenic bacteria, 6 - - Periostitis, 103 - acute, 103 - causes, 103 - chronic, 104 - diagnosis, 103 - symptoms, 104 - treatment, 103 - varieties, 103 - - Perforating ulcer, 75 - causes, 75 - diagnosis, 75 - symptoms, 75 - treatment, 77 - - Peroxide of hydrogen - uses, 14, 24, 211 - - Pes cavus, 193 - - Pes planus, 178 - causes, 179 - diagnosis, 180 - symptoms, 180 - treatment, 181 - varieties, 179 - - Phagocytosis, 11, 31 - - Phenol - gangrene from, 22 - other name, 22 - poisoning, 22 - uses, 22 - - Phlebitis, 127 - causes, 127 - diagnosis, 127 - preventive measures, 128 - operations, 129 - symptoms, 127 - treatment, 128 - varieties, 127 - - Phlegmon - treatment, 195 - - Picric acid - uses, 60 - - Plaster of Paris, 164 - how applied, 164 - indications, 164 - - Poisoned wounds, 39 - symptoms, 39 - treatment, 39 - - Poisoning by - carbolic acid, 13 - - Potassium permanganate, 25 - - Powders, 210 - aristol, 24, 210 - alum, 210 - boric acid, 210 - dermatol, 210 - calomel, 210 - iodoform, 24, 210 - orthoform, 210 - protonuclein, 210 - scarlet red, 210 - stearate of zinc, 210 - talcum, 210 - zinc oxide, 210 - indications, 210 - uses, 210 - - Powdered white oxide of zinc - uses, 219 - - Preparation of instruments for operations, 21 - - Preparation of field of operation, 20 - dressings, 20 - hands, 21 - instruments, 21 - skin, 21 - - Preparation of an ulcer for skin grafting, 222 - - Primary syphilis, 131 - causes, 131 - diagnosis, 131 - symptoms, 131 - treatment, 131 - stage of, 131 - incubation, 131 - - Protargol - uses, 26 - - Protiodide of mercury - dose, 133 - uses, 133 - - Protonuclein, 14 - as a powder for wounds, 210 - as a tablet internally, 210 - - Ptomaines, 9 - definition, 9 - poisoning by, 9 - symptoms, 9 - treatment, 9 - - Punctured wounds, 40 - symptoms, 40 - treatment, 40 - - Pus - causes, 33 - symptoms, 33 - treatment, 33 - - Pyemia, 47, 50 - definition, 50 - symptoms, 50 - treatment, 50 - - - Q - - Quinine and urea hydrochloride, 249 - indications, 249 - - - R - - Radiograms - value of, 205 - - Ray fungus - other name, 136 - symptoms, 137 - treatment, 137 - - Raynaud's disease, 119 - diagnosis, 119 - symptoms, 119, 121 - traumatic, 124 - treatment, 119, 123, 124 - thrombosis, 120 - varieties, 118 - - Reduction of fractures - method of, 163 - - Red wash, 210 - formula, 210 - indications, 210 - - Results of - skin grafting, 228 - - Repair of wounds, 36 - by primary union, 37 - by granulation tissue, 38 - by second intention, etc., 37 - - Resolution - significance of, 32 - - Reverdin's method of skin grafting, 223 - indications, 223 - technic, 223 - - Rheumatic arthritis, 96 - diagnosis, 97 - symptoms, 97 - treatment, 97 - - Rigid flat foot, 182 - causes, 182 - diagnosis, 182 - symptoms, 182 - treatment, 183 - - Rubber bandage, 214 - indications, 215 - technic, 219 - - Rubefacients, 199 - indications, 199 - method of use, 199 - - Rupture of tendo Achillis, 168 - diagnosis, 168 - symptoms, 168 - treatment, 168 - - - S - - Salicylate of mercury, 133 - indications, 133 - method used, 133 - - Salvarsan (606), 133 - how prepared, 133 - indications, 133 - technic, 133 - - Saprophytic bacteria, 6 - definition, 6 - symptoms, 6 - treatment, 6 - - Sapremia, 49 - definition, 49 - symptoms, 49 - treatment, 49 - - Sarcoma, 153 - definition, 153 - manifestations, 153 - symptoms, 153 - treatment, 153 - - Saturated sols. boric acid, 25 - how prepared, 208 - indications, 208 - - Scarlet red, 213 - formula, 214 - indications, 213 - ointment, 213 - powder, 210 - symptoms of poisoning, 213 - treatment, 214 - - Schede's method of operating for varicose veins, 126 - - Schizomycetes, 6 - - Sebaceous cyst, 154 - diagnosis, 154 - symptoms, 154 - treatment, 154 - - Secondary syphilis, 132 - stages, 132 - symptoms, 132 - treatment, 132 - - Senility - as a cause of disease, 100 - - Senile atrophy, 100 - symptoms, 100 - treatment, 100 - - Septic arthritis, 90 - - Septic phlebitis, 127 - causes, 127 - diagnosis, 127 - symptoms, 127 - treatment, 128 - - Septicemia, 48 - causes, 48 - definition, 48 - symptoms, 48 - treatment, 48 - - Sepsis, 18 - causes, 18 - diagnosis, 18 - symptoms, 18 - treatment, 18 - - Sequestra, 93 - - Serum therapy - indications of, 50, 135 - value of, 135 - - Skin grafting, 222 - application of grafts, 226 - after results, 228 - indications, 222 - methods, 223 - technic, 224, 225 - - Sloughing, 34 - causes, 34 - symptoms, 34 - treatment, 34 - - Silver nitrate, 14 - solutions, 210 - uses, 221 - - Sinus, 64 - causes, 64 - definition, 64 - diagnosis, 64 - symptoms, 64 - treatment, 65 - - Sodium hydroxide - uses, 141 - - Sodium sulphide, 149 - - Solutions, 208 - boric acid, 208 - black wash, 209 - bichloride of mercury, 208 - balsam Peru, 208 - carbolic acid, 121 - copper sulphate, 210 - Dakins, 209 - lead and opium wash, 208 - monochloracetic acid, 210 - nitric acid, 210 - red wash, 210 - salicylic acid, 25 - saline, 26, 208 - silver nitrate, 210 - sterile water, 208 - Thiersch's, 208 - white wash, 209 - zinc sulphate, 210 - - Solvents, 211 - salicylic acid, 211 - sodium hydroxide, 212 - - Spastic flat foot, 180 - - Spica bandage, 217 - of the foot, 218 - of the toes, 217 - - Spina bifida, 76 - - Spiral bandage of the great toe, 217 - technic of application, 217 - - Special forms of inflammation - erysipelas, 135 - gonorrhoea, 95 - syphilis, 130 - tuberculosis, 133 - tetanus, 134 - - Spontaneous hemorrhage, 51 - causes, 51 - treatment, 52 - - Spiral fractures, 157 - diagnosis, 157 - symptoms, 157 - treatment, 157 - - Sprains, 176 - definition, 176 - diagnosis, 177 - symptoms, 176 - treatment, 177 - - Static electricity - indications, 201 - - Staphylococcus pyogenes - albus, 16 - aureus, 16 - citreus, 16 - - Sterilization, 12 - methods, 20 - of the dressings, 20 - of the feet, 22 - of the hands, 21 - of the instruments, 21 - - Stovaine - preparations, 251 - uses, 45 - - Streptococcus pyogenes, 16 - - Strychnine, 45 - preparations, 45 - uses, 45 - - Styptics, 211 - definition of, 211 - adrenaline, 211 - hydrastine, 211 - iodin, 211 - Monsel's sol., 211 - peroxide of hydrogen, 211 - alum, 211 - copper, 211 - nitrate of silver, 211, 220 - - Stockings, 216 - elastic, 216 - rubber, 216 - uses, 216 - - Sugar in the urine, 120 - significance, 120 - treatment, 120 - - Subastragaloid dislocations - causes, 174 - diagnosis, 174 - symptoms, 174 - treatment, 174 - - Supports for flat foot, 181 - indications, 181 - uses, 181 - varieties, 181 - - Suppurative phlebitis, 127 - causes, 127 - symptoms, 127 - treatment, 127 - - Sunlight - value, 27 - - Sutures, 46 - uses, 46 - varieties, 46 - - Symptoms of - abscess, 66 - actinomycosis, 136 - arthritis, 91 - blastomycotic ulcer, 79 - burns, 58 - bursitis, 83 - callosity, 141 - callous ulcers, 68 - carbolic acid poisoning, 13 - caries, 101 - cellulitis, 136 - chilblain, 63 - contusions, 42 - cysts, 154 - dermatitis, 135 - diabetic gangrene, 120 - dislocations, 120 - embolism, 119 - erysipelas, 135 - fibromata, 114 - fistula, 64 - flexed toes, 184 - fractures, 156 - frigorism, 137 - furuncle, 66 - gangrene, 118 - gonorrhoeal arthritis, 95 - gunshot wounds, 39 - heloma, 142, 143 - hematoma, 42 - hallux flexus, 183 - hallux valgus, 185 - hemorrhage, 52 - hypertrophy of bone, 101 - incised wounds, 40 - inflammation, 32 - ingrowing toe nail, 145 - joint fractures, 158 - locomotor ataxia, 75 - malignant growths, 152 - moist gangrene, 119 - Morton's disease, 184 - motorman's foot, 138 - myeloma, 116 - necrosis, 102 - neuropathic joints, 98 - onychia, 150 - osteitis, 105 - osteoma, 115 - osteomalacia, 113 - osteomyelitis, 113 - Paget's disease, 113 - painful heel, 184 - periostitis, 104 - perforating ulcer, 76 - pes planus, 180 - phlebitis, 127 - primary syphilis, 131 - pus, 33 - pyemia, 50 - Raynaud's disease, 119 - rigid flat foot, 183 - rupture of tendo Achillis, 168 - sapremia, 149 - sebaceous cyst, 154 - secondary syphilis, 132 - septic phlebitis, 127 - septicemia, 48 - sinus, 64 - sprains, 176 - synovitis, 86 - syphilis, 130 - syphilitic ulcers, 72 - talipes (various forms), 189 - tetanus, 135 - thrombosis, 118 - ulcers (various forms), 70 - verruca, 139 - wounds (different), 44 - - Synovitis, 86 - acute, 86 - causes, 86 - chronic, 87 - symptoms, 87 - treatment, 87 - - Syphilis, 130 - acquired, 130 - causes, 130 - gummata, 132 - hereditary, 130 - periods of symptoms, 131 - primary, 131 - secondary, 132 - - symptoms, 132 - transmission, 130 - treatment, 132, 133 - - Syphilitic arthritis, 95 - - Syphilitic ulcers, 72 - causes, 72 - differential diagnosis, 73 - symptoms, 72 - treatment, 74 - - Syringomyelitis, 76 - - - T - - Talipes, 188 - acquired, 192 - causes, 188 - congenital, 188 - diagnosis, 190 - pathology, 189 - prognosis, 190 - symptoms, 189 - treatment, 190 - various forms, 192, 193 - - Tenotomy, 191 - - Tertiary syphilis, 133 - causes, 133 - diagnosis, 133 - symptoms, 133 - treatment, 134 - - Terminations of inflammation, 32 - chronic, 33 - necrosis, 32 - resolution, 32 - suppuration, 33 - - Tetanus, 134 - causes, 134 - diagnosis, 135 - symptoms, 135 - treatment, 135 - - Tetanus antitoxin, 135 - indications, 135 - value, 135 - - Thiersch's skin grafting, 223 - indications, 223 - method, 224 - - Thrombus - definition, 118 - - Thrombosis - diagnosis, 118 - symptoms, 119 - treatment, 119 - - Tourniquet, 53 - - Toxalbumins - definition, 9 - - Toxemia, 47 - - Toxins, 9 - definition, 9 - products, 9 - - Traumatic arthritis, 90 - symptoms, 90 - treatment, 90 - - Treatment of - abscess, 66 - arthritis, acute, 91 - arthritis, chronic, 91 - arthritis, septic, 91 - arthritis, traumatic, 91 - actinomycotic ulcer, 79 - blastomycotic ulcer, 79 - burns, 60 - bursitis, 83 - callosity, 142 - callous ulcers, 88 - carbolic acid gangrene, 121 - carbolic acid poisoning, 13 - caries, 102 - cellulitis, 136 - chilblain, 63 - contusions, 43 - cysts, 154 - dermatitis, 136 - diabetic gangrene, 120 - dislocation of the ankle, 172 - dislocation of the astragalus, 175 - embolism, 119 - erysipelas, 136 - fibromata, 114 - fistula, 64 - flexed toes, 184 - fracture of the astragalus, 168 - fracture of the fibula, 165 - fracture of the os calcis, 168 - fracture of the metatarsal bones, 169 - fracture of the tarsal bones, 167 - fracture of the tibia, 165 - frigorism, 127 - furuncle, 67 - gangrene, 123 - gonorrhoeal arthritis, 95 - gunshot wounds, 39 - hematoma, 42 - hallux flexus, 183 - hallux valgus, 187 - hammer toe, 183 - heloma (all forms), 143 - hemorrhage, 54 - hypertrophy of bone, 101 - incised wounds, 44 - inflammation, 34 - ingrowing toe nail, 147 - joint fractures, 158 - locomotor ataxia, 75 - malignant growths, 152 - moist gangrene, 121 - Morton's disease, 184 - motorman's foot, 138 - myeloma, 116 - necrosis, 102 - neuropathic joints, 98 - onychia, 151 - osteitis, 105 - osteomalacia, 113 - osteomyelitis, 105 - tubercular bone, 109 - syphilitic bone, 111 - Paget's disease, 113 - painful heel, 184 - periostitis, 103 - perforating ulcer, 77 - pes planus, 181 - pes valgus, 192 - pes varus, 193 - phlebitis, 195 - phlegmon, 195 - primary syphilis, 131 - pus, 33 - pyemia, 50 - Raynaud's disease, 119 - rigid flat foot, 183 - rupture of tendo Achillis, 168 - sapremia, 149 - sebaceous cyst, 154 - secondary syphilis, 132 - septic phlebitis, 127 - septicemia, 48 - sinus, 65 - sprains, 176 - synovitis, 86 - syphilis, 130 - syphilitic ulcers, 74 - talipes (various forms), 190 - tetanus, 135 - thrombosis, 119 - tubercular arthritis, 94 - ulcers - actinomycotic, 136 - callous, 68 - epitheliomatous, 79 - diabetic, 75 - perforating, 75 - syphilitic, 72 - tubercular, 74 - varicose, 68 - verruca - various forms, 139 - wounds, 44 - aseptic, 39 - contused, 40 - incised, 41 - infected, 39 - gunshot, 39 - lacerated, 44 - poisoned, 44 - septic, 44 - - Trench foot, 137 - causes, 137 - diagnosis, 137 - symptoms, 137 - treatment, 138 - - Trendelenburg method - for enlarged veins, 126 - - Treponema pallidum, 15, 130 - - Trichloracetic acid - uses, 210 - - True subastragaloid dislocations, 174 - diagnosis, 174 - symptoms, 174 - treatment, 173 - - Tuberculosis, 133 - cause, 133 - diagnosis, 133 - symptoms, 134 - treatment, 134 - - Tubercular abscess, 109 - symptoms, 109 - treatment, 110 - - Tubercular arthritis, 92 - diagnosis, 93 - symptoms, 92 - treatment, 94 - - Tuberculosis of bone, 109 - causes, 109 - diagnosis, 109 - symptoms, 109 - treatment, 110 - - Tubercular ulcer, 74 - diagnosis, 74 - symptoms, 74 - treatment, 74 - - Tumors, 152 - - Tumors of bone, 114 - fibromata, 114 - carcinoma, 115 - chondromata, 114 - diagnosis, 115 - myeloma, 116 - osteoma, 115 - sarcoma, 115 - symptoms, 116 - treatment, 117 - - Thymol iodide, 210 - other name, 24 - uses, 210 - - Turpentine, 199 - - - U - - Ulcers - actinomycotic, 136 - blastomycotic, 79 - causes, 67 - callous, 67 - definition, 67 - differential diagnosis, 70 - epitheliomatous, 79 - diabetic, 75 - perforating, 75 - symptoms, 72 - syphilitic, 72 - treatment, 73 - tubercular, 74 - varicose, 68 - - Unna's paste, 219 - consistency, 219 - how applied, 220 - indications for use, 219 - method of preparation, 219 - - Unrolled bandage, 216 - disadvantages, 216 - - - V - - Varicose ulcer, 68 - cause, 69 - differential diagnosis, 70 - symptoms, 68 - treatment, 71 - - Varicose veins, 125 - bandages used, 126 - operative measures, 126 - palliative means, 126 - resection of internal saphenous, 126 - support, 126 - - Varix, 68, 126 - - Verruca, 139 - etiology, 139 - diagnosis, 139 - symptoms, 139 - treatment, 139, 140 - varieties, 139 - - Vaseline - uses, 212 - - Violet ray, 198 - - - W - - Wart, verruca, papilloma, 139 - causes, 139 - symptoms, 139 - treatment, 140 - - Wash - black, 209 - lead and opium, 208 - red, 210 - white, 209 - consistency, 209 - uses, 209 - - Webbed toes, 99 - causes, 99 - symptoms, 99 - treatment, 99 - - Wet dressings, 207 - indications, 207 - varieties, 208 - - Wounds - aseptic, 39 - classification, 39 - contused, 40 - gunshot, 39 - incised, 39, 41 - lacerated, 40 - poisoned, 39 - punctured, 40 - prognosis, 40 - symptoms, 44 - treatment, 44 - - - X - - X ray - uses, 202, 203, 205 - - - Z - - Zinc chloride, 24 - - Zinc oxide adhesive plaster - uses, 215 - - Zinc sulphate, 210 - in solution, 210 - stick, 211 - uses, 211 - - - - - - -End of the Project Gutenberg EBook of Surgery, with Special Reference to -Podiatry, by Maximilian Stern and Edward Adams - -*** END OF THIS PROJECT GUTENBERG EBOOK SURGERY *** - -***** This file should be named 41725-8.txt or 41725-8.zip ***** -This and all associated files of various formats will be found in: - 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You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at www.gutenberg.org - - -Title: Surgery, with Special Reference to Podiatry - -Author: Maximilian Stern - Edward Adams - -Editor: Maurice J. Lewi - -Release Date: December 28, 2012 [EBook #41725] - -Language: English - -Character set encoding: ISO-8859-1 - -*** START OF THIS PROJECT GUTENBERG EBOOK SURGERY *** - - - - -Produced by Adam Buchbinder, Turgut Dincer and the Online -Distributed Proofreading Team at http://www.pgdp.net (This -book was produced from scanned images of public domain -material from the Google Print project.) - - - - - - -</pre> - +<div>*** START OF THE PROJECT GUTENBERG EBOOK 41725 ***</div> <h1>SURGERY<br /> @@ -1781,7 +1739,7 @@ is the 50 per cent. solution of acetate of aluminium.</p> <td class="left">Lead acetate</td> <td class="right">38</td> <td class="left"> ” ”</td> -<td class="left">9½ ”</td> +<td class="left">9½ ”</td> </tr><tr> <td class="left">Water</td> <td class="right">1000</td> @@ -16237,384 +16195,6 @@ Zinc sulphate, <a href="#Page_210">210</a><ul> <li>uses, <a href="#Page_211">211</a></li></ul></li> </ul> - - - - - - - -<pre> - - - - - -End of the Project Gutenberg EBook of Surgery, with Special Reference to -Podiatry, by Maximilian Stern and Edward Adams - -*** END OF THIS PROJECT GUTENBERG EBOOK SURGERY *** - -***** This file should be named 41725-h.htm or 41725-h.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/4/1/7/2/41725/ - -Produced by Adam Buchbinder, Turgut Dincer and the Online -Distributed Proofreading Team at http://www.pgdp.net (This -book was produced from scanned images of public domain -material from the Google Print project.) - - -Updated editions will replace the previous one--the old editions -will be renamed. - -Creating the works from public domain print editions means that no -one owns a United States copyright in these works, so the Foundation -(and you!) can copy and distribute it in the United States without -permission and without paying copyright royalties. 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Thus, we do not necessarily -keep eBooks in compliance with any particular paper edition. - -Most people start at our Web site which has the main PG search facility: - - www.gutenberg.org - -This Web site includes information about Project Gutenberg-tm, -including how to make donations to the Project Gutenberg Literary -Archive Foundation, how to help produce our new eBooks, and how to -subscribe to our email newsletter to hear about new eBooks. - - - -</pre> - +<div>*** END OF THE PROJECT GUTENBERG EBOOK 41725 ***</div> </body> </html> diff --git a/41725.txt b/41725.txt deleted file mode 100644 index 46d4758..0000000 --- a/41725.txt +++ /dev/null @@ -1,14162 +0,0 @@ -The Project Gutenberg EBook of Surgery, with Special Reference to Podiatry, by -Maximilian Stern and Edward Adams - -This eBook is for the use of anyone anywhere at no cost and with -almost no restrictions whatsoever. You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at www.gutenberg.org - - -Title: Surgery, with Special Reference to Podiatry - -Author: Maximilian Stern - Edward Adams - -Editor: Maurice J. Lewi - -Release Date: December 28, 2012 [EBook #41725] - -Language: English - -Character set encoding: ASCII - -*** START OF THIS PROJECT GUTENBERG EBOOK SURGERY *** - - - - -Produced by Adam Buchbinder, Turgut Dincer and the Online -Distributed Proofreading Team at http://www.pgdp.net (This -book was produced from scanned images of public domain -material from the Google Print project.) - - - - - - - +------------------------------------------------+ - | Transcriber's note: | - | Bold words are enclosed within plus (+) signs. | - +------------------------------------------------+ - - - - -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 role 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 deg.F. or 29 deg.C. or above 104 deg.F. or 40 deg.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 deg.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 deg.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 deg.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 deg.F. or 100 deg.C., can be killed when -fully developed at 130 deg.F. or 55 deg.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 deg.F. to 175 deg.F. or to -from 69 deg.C. to 80 deg.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 deg.F. to 185 deg.F., -or 75 deg.C. to 80 deg.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 deg.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 faeces. 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 deg.F. will -destroy nearly instantaneously all pus-producing organisms. Spores, -however, require a moist heat of 284 deg.F. kept up for at least a -half-hour. A dry heat of 212 deg.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 deg.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 deg.F. to 300 deg.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 -pyorrhoea 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 acute osteomyelitis, except in a -very much milder form. There is usually a rise of temperature, -oftentimes with a chill, with circumscribed tenderness over some -portion of the shaft of one of the long bones. - -+Treatment.+ Incision over such an area shows an elevated periosteum, -with a small, localized abscess beneath it, with bare, white, somewhat -vascular bone cortex. Incision alone in most cases suffices to cure -the disease, although if the process has extended sufficiently deep -to cause a superficial necrosis of the outer layer of the cortex, -removal of a small sliver of necrotic bone may be necessary. - -+Chronic Periostitis.+ A long-continued and chronic irritation of the -periosteum, sufficient to cause a proliferation of the osteogenetic -cells of the periosteum, is common in a great many diseases. A chronic -thickening of the periosteum with a new formation of bone, is seen -frequently after traumatism, blows or contusions; sometimes after the -occurrence of superficial abscess of the soft tissues in the immediate -vicinity of the shaft of the long bone, described as chronic ulcer of -the surface of the tibia; or after certain infectious diseases, -notably syphilis. It also may occur after various other local -infections. In such cases the thickening of the periosteum ordinarily -is pretty sharply localized. - -A general thickening over the periosteum, and over several or many of -the bones of the body, also occurs in the disease known as _toxic -osteoperiostitis ossificans_, seen in diseases with long continued -suppuration. It also is common after syphilitic disease, either -congenital or acquired. - -+Symptoms.+ The symptoms of chronic periostitis with new formation of -bone are invariable. In a certain number of cases there is a constant, -heavy, dull pain, at the point of thickening, with at times more or -less acute exacerbation; at other times the lesion is associated with -no pain whatever, and the patient's attention is first called to the -disease by the presence of the enlargement of bone. Recognition of the -condition may depend upon X-ray examinations for indefinite pains in -or over the bone. - -Chronic periostitis is not really a disease itself, but a -manifestation of the reaction of the periosteum to some irritant. - -+Treatment+ of the condition depends, first of all, upon a recognition -of the cause and a removal of the cause, when possible. In many cases, -especially those in which no pain is present, nothing in the way of -therapeutic measures can be done. - -The chronic thickening of the periosteum, seen in many definite bone -diseases, will be mentioned under those diseases. - -+Osteomyelitis.+ Infectious osteomyelitis is acute suppuration of the -bone, always due to the infection of the bone marrow by pyogenic -microorganisms. The process is essentially like the process seen in -furuncle, and begins in the marrow of the alveolar spaces, which -communicate freely with each other, but are enclosed by a dense shell -of cortical bone. Hence the process may quickly at first involve the -entire marrow of an infected bone, because the products of bacterial -infection are retained in this dense shell, while the primary focus -can only be reached by extensive bone operation. - -Most cases are due to the staphylococcus pyogenes aureus and a few to -the streptococcus. Typhoid bacilli may cause suppuration. The -infecting organism is present in pure culture but sometimes a mixed -infection occurs, and such cases are said to be severe. - -In cases of chronic osteomyelitis with open sinuses and exposed bone, -a great variety of organisms, pathologic and saprophytic, may be -present. Hence infectious osteomyelitis is not a specific disease, but -is acute inflammation of bone that may be produced by any one of a -variety of pathogenic organisms, or by a mixed infection. - -Any pyogenic organism which can be carried in the blood may be -deposited in the bone and produce suppuration. Some of these organisms -may settle by preference in the bone marrow, others beneath the -periosteum, or in the joint. - -Certain general causes favor the occurrence of osteomyelitis. Children -are chiefly affected and it occurs in boys about three times as often -as in girls. Acute osteomyelitis frequently occurs after injuries of -moderate severity, because such injuries may lower resistance of the -bones and make them unusually susceptible to pyogenic infection. One -of the commonest causes is the infection of a compound fracture, and -before the days of asepsis, such cases were very frequently fatal. -Under modern methods the infection, when it does occur, is generally -slight, although the destruction of bone may greatly delay healing and -may lead to the formation of small sequestra and indurating sinuses. -Infection of a similar sort may occur subsequent to amputation. - -Osteomyelitis nearly always begins in the diaphysis of the long bones, -usually near the epiphyseal line. This is an important point, -clinically, because tuberculosis practically begins in the epiphysis. -In rare cases, however, osteomyelitis begins in the epiphysis, and so -may simulate tuberculosis. The femur and tibia are the bones most -frequently attacked, but no bone is exempt. Usually only one bone is -affected, but cases of multiple bone infections are not rare. - -The primary area of infection is always in the bone marrow. The bony -trabeculae and the cortex are destroyed only secondarily. The process -nearly always begins in the diaphysis, but then may extend into the -epiphysis and produce suppuration of the joint. Once the organisms -have gained access to the marrow, they produce a toxin which causes -necrosis of the adjacent marrow cells, and this necrosis may extend -over a very considerable portion of the bone before marked -infiltration with leucocytes occurs. The infection usually extends -quite early through the dense cortex by way of the Haversian canals, -and produces an inflammatory exudation and suppuration between the -periosteum and the outer layer of the cortex, which is designated -_subperiosteal abscess_. - -Such an abscess may strip the periosteum from the bone over very -extensive areas. The infection may then extend to the adjacent soft -parts, muscles and subcutaneous tissue, and form an abscess outside -the periosteum. - -If, from spontaneous opening of the abscess or from operation, a fatal -result is avoided, the infective process may be limited and the -process of repair may begin. - -As a rule, a portion of the infected marrow and cortex become -completely necrotic, and the lime-bearing portion of the bone -persists as a more or less extensive sequestrum. - -The periosteum in the early stages may be separated from the bone by a -collection of pus, and in such cases it appears as a thin fibrous -membrane beneath the muscles, separated from the bone by the abscess -cavity. - -Secondary changes occur in the soft tissues surrounding the seat of an -acute suppuration of bone. During the acute stage there may be a -definite abscess of the soft parts, with an infiltration which -simulates phlegmonous inflammation, or, by rupture of the abscess, -various sinuses may be formed leading down to the necrotic foreign -body. In long continued cases the skin and subcutaneous tissues become -thickened by the formation of scar tissue, due to the presence of the -involucrum and the persistence of sinuses, and by thickening of the -soft tissues, an affected limb may for years be nearly twice its -normal size. - -+Symptoms.+ The disease usually begins with a sharp onset, the first -symptom being a sudden localized pain in the vicinity of the -epiphyseal line, or in the shaft of some one of the long bones. This -pain is extremely intense, and in typical cases is most excruciating. - -Motion of the joints at this time is not painful, but the pain -produced by percussing the bone, even lightly, may be intense. An -extremely valuable diagnostic point is continued gentle pressure at -some point over the shaft of the bone at a distance from the point of -greatest constant pain. - -Usually, at a very early period, there appears swelling of the soft -parts about the bone. This swelling, at first, is neither hot nor red, -but soon becomes edematous, red, and shows pitting on pressure, and at -that time may simulate acute phlegmon. - -In some cases the adjacent joint early becomes tender, hot and -swollen, and this may occur even when there is no real extension of -the infectious process to the joint itself. If extension does occur to -the joint, swelling, tenderness, and pain on motion become more -intense. The temperature usually is elevated to a considerable -degree--103 deg.F. or 104 deg.F.--and usually the pulse is greatly accelerated. -Evidence of constitutional disturbance and absorption of infectious -material occur early. The tongue is dry, coated and tremulous; the -face is drawn and flushed. Delirium of a mild type is a very common -symptom, and in some cases this delirium may persist for a -considerable length of time after the bone has been drained. Abscess -of the soft parts may give deep or superficial fluctuation. Sinuses -may appear. The leucocyte count is usually very high--25000 to -35000, and chiefly of a polynuclear type. - -Such a clinical picture is perfectly distinct, and it is difficult to -overlook typical cases, especially after the fluctuation in the soft -parts has occurred. The diagnosis of early cases, however, is -sometimes very difficult, and even in the hands of experienced men, -who have the lesion in mind, is frequently impossible. Even in severe -cases, occasionally the pain itself is not severe for several days, -when there may come a sudden exacerbation of symptoms. - -In the chronic stages of osteomyelitis the symptoms are usually -characteristic. The limb is enlarged, the enlargement being partly due -to thickening of the soft tissues, but chiefly to the formation of the -involucrum. Usually running down to the sequestrum, are enormous -sinuses, from which comes a foul, purulent discharge. On passing a -probe, dead bone can be felt at the bottom of the sinuses. It must be -borne in mind, however, that in a great many cases, after attacks of -osteomyelitis of moderate severity, small localized abscesses are -formed in the shaft of the long bones, with no sinus communicating -with the surface. An abscess of this description, as has already been -stated, is always surrounded by a wall of dense bonelike cortical -bone. - -Such an abscess may persist for years with no symptoms beyond a -moderate enlargement of the shaft of the bone at the point of abscess, -and the enlargement may be so slight that it is not recognized by the -patient. In other cases the entire shaft may be enlarged, but the bone -may not be tender. In most cases, however, such a localized abscess -sooner or later gives rise to recurring attacks of pain, which, as a -rule, are extremely violent. The intervals between such attacks may -vary from days to weeks, or to months, or even to years. The attacks -of pain may come on, apparently, perfectly spontaneously. Associated -with these attacks of pain, the bone over the abscess usually is -exceedingly tender to touch. With the attacks of pain may come a rise -of temperature, or in some cases, there may be no disturbance of the -general condition. This kind of abscess may be of small size, no -larger than a pea, or may involve a great portion of the shaft of the -bone; in such abscesses no definite sequestrum may ever form. - -The recognition of such conditions depends upon recurrent attacks of -violent pain over circumscribed areas of bone, with or without -constitutional disturbance, and nearly always with extreme local -tenderness. - -+Treatment.+ In the acute stage there is suppuration of the marrow, more -or less extended throughout the shaft, with often a subperiosteal -abscess and perhaps abscess of the soft parts. - -The indications are the same as in any other acute suppuration; the -pus must be evacuated and the bone cavity drained. This demands not -only an incision into the soft parts, but an opening into the shaft of -the bone. If a piece of necrotic bone is present, it should be -removed. - -In the chronic stage there is usually an old necrotic shaft perforated -by sinuses, and often freely movable, inclosed by a shell of dense -periosteal bone. The sequestrum must be removed, but the bony defect -fails to heal, and for months persists as a filthy, discharging -cavity, with the constant danger of secondary infection and phlegmon, -or erysipelatous inflammation. The healing of this cavity is very -difficult and requires a very long time. - -Many methods have been tried for the filling of these bone cavities -with blood clot, iodoform and oil of sesame, but they have not been -successful, because it is almost impossible to render such cavities -absolutely aseptic. - -+Tuberculosis of Bone.+ Tuberculosis of bone is always dependent upon -infection of the marrow of bone by the tubercule bacillus. This germ -obtains entrance to the bone marrow and causes the formation of -miliary tubercules which arise from the proliferation of the -connective tissue of the marrow around the primary tubercule. Other -secondary tubercules are formed by extension of the tubercule -bacillus. The centres of these tubercules become caseous, and, by -fusion of adjacent caseous areas, also cause softening in the bone -marrow. - -The tuberculous process, as a rule, begins in the epiphysis in the -long bones, and may affect any of the bones. - -+Symptoms.+ In cases of tuberculous disease confined to the bones alone, -the first symptom usually is pain, which ordinarily is not severe and -has a gradual onset. Oftentimes, at first on palpation, no difference -in the shape of the bone can be detected. - -Toes affected by a tuberculous process, slowly enlarge at first -without heat or pain; ultimately the skin becomes thickened, and -reddened, and the digit is painful to pressure or motion. Oftentimes -the skin is perforated at one or more points by sinuses lined with -tuberculous granulations, through which caseous pus is discharged. - -The diagnosis in these cases always lies between tuberculosis, -actinomycosis, syphilis, and osteomyelitis, and exact determination of -the origin of the cause oftentimes can be made only by inoculating -animals with a discharge from the sinus, or by detection of pyogenic -organisms, or of the miliary tubercule, the histologic unit of -tuberculosis, or by detecting the peculiar yellow bodies seen in -actinomycosis. - -+Treatment.+ From a clinical point of view tuberculosis of bone should -be considered in the same category as malignant disease, and the -indications for treatment in all cases of tuberculous bone disease are -the same as in malignant disease; which is, complete removal of the -infected area, whenever it is possible. - -In some cases the mere opening and curetting of tuberculous areas in -bone is oftentimes enough to set up sufficient reaction in the bone -and in the surrounding tissues, to put an end to the tuberculous -process. Complete resection of bones may at times be avoided by this -treatment. - -In addition to the local treatment of opening, curetting and drainage, -or the complete excision of the bone, the greatest care should be -employed in the management of the general hygiene of the patient, -including feeding and fresh air. Often removal to a climate which is -unfavorable to the development of tuberculosis in general, is also -extremely desirable. - -+Syphilis of Bone.+ The lesions produced in bones by syphilitic -infection may be congenital or acquired, and, as in other syphilitic -lesions, the manifestations may be protean. - -Most children with congenital syphilis, show an irregularity of the -epiphyseal line, which results in the latter becoming markedly -toothed, instead of constituting a straight line across the bone, at -right angles to the long axis of the shaft. - -Besides the irregularity of the epiphyseal line, three other changes -are seen in the bones of syphilitic infection. The most common lesion -is one which affects the periosteum and leads to the formation of -periosteal bone. This periosteal formation may occur either in -congenital or in acquired syphilis, and it may affect one or many -bones. In some cases there is an enormous thickening of the epiphysis -of the bones, and as a result of the epiphyseal thickening, secondary -changes in the joints occur, so that the thickening of bones and the -changes in the facets of the joints, suggest fracture or dislocation. -In other cases, the thickening affects only the shafts of the long -bones, generally of the leg or arm, although no bones are exempt. In -some cases, both in the congenital and acquired forms, there may be -marked proliferation of the endosteum of the bone, with or without -thickening of the periosteum, although thickening of the periosteum -usually is present. This process, as a rule, affects one bone in its -entirety, and most commonly affects the bones of the lower leg, -notably the tibia. As a result of these changes the bones are enlarged -and thickened, and in some cases, from endosteal thickening, the -marrow canal is very largely or entirely obliterated. In some cases -true gummata of the bone are formed. These gummata may appear in the -spongy portion of the bone, sometimes in the shaft, or in the -epiphysis. They also appear to be formed in the lower layers of the -periosteum and lead to circumscribed nodular thickenings on the -surface of the bone. - -+Symptoms.+ These vary with the different pathologic conditions present. -The periosteal thickening may occur at any time of life over any bone -of the body. - -The presence of circumscribed periosteal thickening of bone in itself -should always lead to the suspicion of the presence of syphilis. - -Pain, as a rule, is only very slight, and the diagnosis depends upon -the history and the detection of other syphilitic lesions. - -The cases in which there is both endosteal and periosteal thickening, -occur chiefly in children and are of a congenital nature. - -The physical symptoms are very characteristic. The bone usually -affected is the tibia, which is enlarged to a most marked degree, and -often shows a pronounced bowing forward, similar to the bowing and -thickening of the tibia seen in osteitis deformans. The bone is -extremely dense and obviously heavier than normal. The bones are -moderately tender to pressure, but have nothing like the extreme -tenderness noted on pressure in osteomyelitic bones. - -In cases of gummata of bones the symptoms vary. In some cases the -gummata are on the surface of the bone, especially the sternum, and at -times on the long bones. In such cases there appear a softening and -reddening of the skin about the affected area, which remains indolent -for a long time. - -If such an area opens spontaneously, or is opened by incision, the -contents are seen to be composed of a yellow, rather gelatinous -material, quite like the caseous material from a tuberculous abscess. - -+Treatment.+ In most cases the regular anti-syphilitic treatment is -indicated. In cases of periosteal thickening, the results vary with -the time at which the treatment is begun. In the early cases, a -thorough anti-syphilitic treatment may lead, after a varying length of -time, to complete disappearance of the newly formed periosteal bone. -On the other hand, if the periosteal process has lasted for a long -time and the bone has become densely cortical, although -anti-syphilitic treatment may lead to a diminution of the localized -pain, the dense bone does not disappear. In cases of combined -endosteal and periosteal thickening, the pain usually disappears under -anti-syphilitic treatment but the changes in the bone persist. - -+Osteomalacia+ is an acquired disease which causes marked softening and -changes in the bones. The disease begins irregularly and often -progresses with or without remissions. The progress is more marked -during pregnancy. The first sign is pain in the bones, which is -increased by pressure, and this is especially true of pressure over -the ribs. There are also muscular cramps and contractures. - -+Osteitis Deformans.+ (_Paget's Disease_). This is a chronic disease of -the bones and may affect one or more bones of the body. The onset is -insidious, and before actual deformity occurs, long indefinite pains -in the legs may have existed, with occasional tender points over the -bone. - -The bony changes are first noticed in the bones of the legs and are -most marked in the tibia, femur and fibula. As a result of structural -changes, these bones become bowed, while their internal trabecular -structure is altered. - -The extent of the affection in the bones of the legs varies a great -deal and usually is not symmetric. The lower extremities are bowed -outward, and also are usually bent forward, the curves being due to -changes in the femur and the lower leg. - -+Treatment.+ In the absence of any knowledge as to the cause of the -disease, the treatment of osteitis deformans must be largely -symptomatic. Certain drugs have been recommended; among these are -iodide of potash and arsenic. Most such patients are in poor general -condition, and effective feeding often gives marked relief of the -symptoms from which they are suffering. - -For severe pain, counterirritants are valuable, especially the actual -cautery. Massage is of use in some cases for improving the general -condition. - -+Tumors of Bone.+ All the primary tumors of bone are of the connective -tissue group, but various secondary tumors of epithelial origin may -occur. - -Osseous tumors may arise from the periosteum or from the marrow. If -they arise from the periosteum they may extend early to the adjacent -soft tissues and involve and destroy them. If the tumor arises in the -marrow, it is for a long while cut off from the adjacent soft tissues -by the thick cortex, and about the extending medullary tumor may also -come a reactive proliferation by the periosteum, so that as the tumor -extends it still may, for a long time, be surrounded by a shell of -bone which prevents infection of the soft parts. After a time, -however, the reactive periosteum shell usually becomes perforated at -one or more points, and then the medullary tumor extends to the -adjacent tissues. The cause of these tumors is absolutely unknown. - -+Fibromata+ are not very common tumors of bone. They arise generally -from the periosteum and are most common about the face, and are rarely -seen in the long bones. Many of these tumors are closely allied to -some of the fibrous forms of sarcoma, and it is often difficult to -distinguish them histologically. - -+Chondromata+ are fairly common tumors of bone. They may appear -externally to the cortex, or sometimes they grow in the medullary -canal. They may arise directly from the marrow, probably from remnants -of the provisional cartilage cells. They also appear frequently to -arise from the epiphyseal line. - -Chondromata appear generally as multiple masses, nodular in shape, and -are frequently seen on the lower leg, about the knee joint. They -usually are painless, firm and hard, and not tender to pressure. - -+Treatment+ consists in removal by operation. - -+Osteomata+ are bony tumors which generally arise by growth of the -periosteum, and form solid bony masses external to the cortex of the -bone, when they are called _exostoses_. - -The density of the bone composing the tumor varies a great deal, some -being very hard and ivorylike, while others are like the cellular -marrow of the long bones. - -Osteomata may be surrounded by a layer of fibrous periosteum or, in -certain cases, beneath the periosteum appears a layer of cartilage -producing the so-called _exostosis cartilaginea_. The latter formation -is the one which is most common in the vicinity of the epiphyseal line -of the long bones, notably of the leg. - -Osteomata form circumscribed hard nodular masses of bony consistency, -and are usually painless. They may cause interference with function -from their size, especially when they appear in close connection with -a joint. - -+Treatment+ is complete and thorough removal. - -+Sarcomata+ are the most common tumors of bone; they are malignant, and -when removed, tend to recur, either locally or by metastasis, in -different parts of the body. The metastases usually are distributed by -the circulation. - -These tumors may arise from the marrow, but generally in the epiphysis -of the bone and extend to the shaft only at a later stage of their -development. As the tumor advances, it causes a softening and an -absorption of the original cellular marrow until it approaches the -periosteum. - -In many cases the periosteum, as about any form of foreign body, then -begins to proliferate and forms a shell of periosteal bone surrounding -the tumor. In that way the shell of the bone oftentimes becomes very -much enlarged before there is any extension of the process through -the shell to the adjacent tissue. By destruction of the marrow and of -the cortex, great softening of the bone may occur so that spontaneous -fractures not infrequently are seen. - -Other sarcomata arise from the periosteum, and usually originate from -one side of the bone, although occasionally they entirely surround the -bone. In the periosteal sarcomata, a new formation of bone is common -and the bone is frequently arranged in a radical way, giving a most -remarkable picture on the X-ray plate. - -+Myeloma+ is a very rare malignant tumor of bone. Such tumors always -appear only in connection with bone, are usually multiple, and are of -the same type as other lymphoid tumors. - -The cells of such tumors resemble very closely the type of plasma -cell. These cells are arranged in masses without an intercellular -substance, and the tumors are closely allied to the malignant -lymphomata. The cases are always associated with albuminuria. - -+Symptoms.+ The chief symptoms of malignant tumors are swelling and -pain, both of which oftentimes are extreme. The swelling may be -spherical or spindle shaped. - -+Extension+ to the joints may not occur for a great length of time. In -many cases X-ray examination is the most reliable method of detecting -the character of the bony change. - -+Treatment+ of all sarcomata is early and complete removal. This means -in nearly all cases, amputation of the affected bone, and it is -important that the amputation should be of the entire bone through the -joint between the bone and the body, rather than amputation of the -bone in continuity. The reason for this is, that even in sarcomata, -which have not extended to the soft parts, very frequently there have -occurred metastases of tumor-cells throughout the blood sinuses of the -affected bone, often times at a distance of several inches from the -site of the original primary tumor. - -+Carcinomata.+ Cancer of bone always is secondary to cancer in some -epithelial organ. The infection may take place by direct extension -through the blood or the lymphatics. - -In cases of metastatic invasions of bone, spontaneous fractures -oftentimes are the first symptom which calls attention to the fact -that metastases have occurred. - -+Treatment.+ As in other malignant tumors, the indication is for -absolute and radical removal whenever possible. Unfortunately, this -very seldom can be done, because at the time the bone has become -affected by extension to any great degree, radical operation is -impossible. Many times, however, extensive operations must be -undertaken for the removal of bone. - -+Cysts of Bone+ are rare lesions which practically always occur -secondary to other lesions. They may occur as the result of the -degeneration and softening of bone sarcomata. Some of the cases of -bone cysts undoubtedly represent the entire destruction of sarcomatous -processes. Occasionally echinococcus cysts of bone occur. - -+Treatment.+ Cysts of bone due to softening of the centre of sarcomatous -tumors, like sarcomata themselves, are to be treated by complete -removal, best usually by amputation. Cysts of bone not due to the -presence of sarcomatous tissue, should be opened and drained in some -cases. Cysts due to the presence of echinococcus, should be opened and -drained, with the removal of every vestige of the echinococcus. - - - - -CHAPTER XI - -+DISEASES AND INJURIES OF THE ARTERIES AND GANGRENE+ - - -+Gangrene+ is a term employed to denote the death of a part of the body, -in mass. - -_Necrosis_ and _mortification_ are terms used in a similar sense -though necrosis is reserved in surgery to mean death of bone. - -Gangrene may result from the gradual or sudden cessation of the -arterial supply, or from a stoppage of the venous outflow. In general -the etiology of gangrene comprises: - - 1. Traumatic causes. - 2. Constitutional causes. - 3. Thrombosis and embolism. - 4. Cold. - 5. The effect of certain chemicals. - -Before entering into a consideration of these subjects, it is wise to -first consider the varieties of gangrene. - -There are two forms in which gangrene is observed: _dry_ and _moist_. - -+Dry gangrene+, or mummification, is a condition which occurs in -consequence of a gradual diminution and final cessation of the blood -supply, with the venous outflow intact. In this way, aided by -evaporation and the venous return, there is a gradual drying of the -parts. Diseases of the arteries and increasing pressure upon them from -growing tumors, causes this variety. - -+Moist gangrene+ is due to the sudden arrest of the arterial supply, or -a similar obstruction to the venous return. - -This is the variety commonly met with from crushing or cutting -accidents; from the effects of carbolic and other acids; from cold; -and from thrombosis and embolism. - -A _thrombus_ is a blood clot occluding the lumen of a vessel. An -_embolus_ is a loosened part of a thrombus or any other foreign -substance, free in the blood stream, such as a drop of fat, an air -globule, or a detached particle of tissue from growths in the heart or -vessels. Any one of these may find lodgment in a terminal vessel, and -plug it. - -Moist gangrene therefore differs from dry gangrene in that the arrest -of circulation takes place more or less suddenly when the tissues are -suffused with blood. - -The dry form of gangrene does not occur regularly in the diseases in -which it might be expected, and though a true wet gangrene is not -found, neither is the typical mummification. - -Moist gangrene may occur in diabetes, in senility and in Reynaud's -disease, and probably assumes this form on account of the sudden onset -of inflammation in the part from some slight abrasion, or from weak -heart action. - - -C+AUSES OF GANGRENE+ - -_Traumatic._ The sudden cessation of the blood supply to a part in -consequence of a cutting or crushing accident, will obviously produce -the moist form of gangrene. It is not essential that the part be -entirely severed, or even nearly so, for if only the main artery is -severed, gangrene will ensue. - -The crushing or pressure upon a large vein will act similarly, owing -to there being no outflow possible, back pressure will cause the total -arrest of circulation in the part. - -_Constitutional Diseases._ Certain diseases affect the lumen or -calibre of the blood vessels, gradually diminishing and finally -arresting the stream of blood carried through them. - -In these diseases it would be logical to invariably expect dry -gangrene. This does not regularly occur, for the reason just given, -and the mere presence of a moist or dry condition therefore cannot be -regarded as diagnostic. - -In diabetes, either form may obtain, and a diagnosis can be assured by -the discovery of sugar in the urine. - -The thickened condition of the arteries leading to senile gangrene -must be thought of and proven in aged subjects. Dry gangrene is the -rule in arteriosclerosis. - -Reynaud's disease, or synthetic gangrene, is due to a vasomotor -spasmodic condition of the terminal vessels and is of central nerve -origin. The tips of the toes and fingers, of both sides, are the most -common sites, though the lobes of the ears, cheeks and tip of the nose -may be affected. - -A coldness of the parts, with mottling of blue and white, and a -subsequent diffuse blueness, becoming darker and finally black, are -characteristic signs of this disease, and the dry form of gangrene is -usual. - -_Obliterating Endarteritis_, is a condition in which the walls of an -artery become inflamed and thickened, thus obliterating its lumen. - -_Thromboangiitis Obliterans_ is similar to the above and differs only -in that a thrombotic growth occurs in an artery obliterating its -lumen. - -_Thrombosis and Embolism._ Thrombosis and embolism cause a sudden or -gradual stoppage of the blood stream in a vessel, and in consequence, -either moist or dry gangrene occurs, depending on the time required -for the obstruction to become complete. - -The stoppage of the outflow because of thrombosis in a large vein, -will cause moist gangrene; the part being unable to drain, will, by -back pressure, arrest circulation. - -_Cold._ Frost bite causes gangrene of varying degrees. A small -circumscribed patch of tissue may succumb, or an entire finger or -extremity may be affected. The variety is invariably moist. The -diagnosis is easily made from the history of exposure (See "Frost -bite"). - -_Chemicals._ Carbolic acid, even in weak solution, often causes -gangrene of a finger or toe, because of its frequent use as a wet -dressing, and therefore should never be employed in this manner. -Gangrene of a single part, (especially in a young subject), incident -to a slight injury or infection, should always excite suspicion that -phenol has been employed. Moist gangrene is the rule. The part -presents a hard, shriveled, black appearance which is characteristic. - -Weak solutions of other chemicals such as lysol, acetic acid, and -potassium or sodium hydroxide, employed as a wet dressing, are also -capable of producing gangrene. - -+Symptoms.+ (_Dry Gangrene_). Typical dry gangrene usually develops in -the toes and the feet, and the principal symptoms which point to its -advent are, coldness, numbness, pain and tingling in the feet and -muscles of the legs. Persons about to be affected with dry gangrene -often complain for months, before any local signs of gangrene are -present, of severe burning pain in the feet at night when warm in bed. - -A trivial injury, such as a bruise, the friction of the shoe, or the -cutting of a corn, may act as the exciting cause of the affection. The -part becomes congested and gradually assumes a dark purple color, -finally becoming black and dry; it is insensitive, but the surrounding -parts are congested and may be the seat of intense pain. The dead part -becomes black, shriveled, and dry, and emits little odor. - -Dry gangrene usually spreads very slowly; one or two toes may first be -involved and the disease may gradually spread to the rest of the foot -and the leg. There may be little fever at first, but if a large extent -of tissue is involved, a certain amount of fever develops. During the -progress of the disease, pain is usually present to a greater or -lesser degree, sometimes being intense; this is accounted for by the -fact that the nerves are usually the last structures to die. - -During the course of the disease, the patient loses much sleep from -continued pain, and becomes worn out and may die of exhaustion. - -In dry gangrene there is usually no well marked attempt at the -formation of lines of demarcation and separation, but in some cases, -if the amount of tissue involved is small, say one or two toes, or a -part of the foot, for instance, and if the patient's strength can be -sustained, the line of separation forms, and the dead tissue may be -cast off, leaving the bones exposed in the wound. - -+Moist Gangrene.+ When a part which has had its vitality seriously -interfered with becomes gangrenous, pain, which may have been present, -suddenly ceases, the part becomes insensitive, and the skin is cold, -pale, and mottled purple, green, and red, and finally dark colored; -blebs containing brownish serum form upon the surface; the wound, if -one is present, assumes a grayish color, and an offensive discharge -escapes from it; the dead tissue rapidly undergoes putrefactive -changes. Coincidentally with these changes in the dead tissues, the -living tissue in contact with it becomes red and swollen, and the -separation of the dead tissue from the living is affected by an -ulcerative inflammation, granulations from the living tissue lifting -off the slough. - -The patient, at the same time, if the gangrenous process involves any -considerable extent of surface, exhibits the unconstitutional signs of -inflammation (fever, rapid pulse, etc.) and, in some cases, if the -septic infection is intense, may die from septicemia. - -In both dry and moist gangrene, when the gangrenous process is -arrested, the dead tissue is separated from the living by a process of -inflammation; the living tissue, at its point of contact with the dead -tissue, and for some distance from it, becomes red and swollen, and -exhibits all the signs of acute inflammation. The line of contact -between the dead and the living tissue is known as _the line of -demarcation_, and the line of granulations which separates the dead -tissue from the living, is known as _the line of separation_. - -The separation of the dead tissue is affected by granulations, which -spring up from the living tissue as a result of inflammation, and -there is also a certain amount of pus secreted from the granulations. -In moist gangrene, the lines of demarcation and separation are fairly -well developed. In dry gangrene, on the other hand, these lines are -usually imperfectly developed. - -+Early Diagnosis.+ From the foregoing it will be observed that gangrene -is most common in those past middle life, and that its actual onset is -only a stage in an insidious process. This may be either due to -senility or to some constitutional disease. A slight abrasion alone is -sufficient to set up a train of symptoms out of all proportion to the -cause. In such a case, the operation of a small verruca or papilloma -may be followed by a violent inflammatory reaction, with rapid -extension into the entire foot or leg, resulting in gangrene. - -Such cases have occurred, but could have been prevented if a proper -survey of the field had been taken and would have saved the -chiropodist much responsibility. - -Before operating on subjects past middle life, it should be a routine -practice to note the color and temperature of the foot, both in the -dependent and horizontal positions. The _anterior tibial pulse_ should -also be felt for and its absence or intensity noted. A question to the -patient as to diabetes or thickened arteries may also elicit valuable -information. A very weak or absent anterior tibial pulse (the knack of -feeling the pulse here must be acquired), or peculiar nodules about -the nail grooves, are evidences of an encumbered arterial supply. - -Extreme redness or blueness in a foot in the hanging position, and -pallor when elevated, also indicate a similar condition, or one in -which the valves in the veins are impaired. - -It is in such conditions that the greatest care should be taken to -avoid deep incisions except in the presence of positive indications. - -+Treatment.+ In general, amputation through healthy tissue is the rule -in gangrene affecting any extremity through its entire thickness. The -complete devitalization of even a digital phalanx requires that -amputation be made beyond the next joint above. - -In traumatic gangrene it is the rule to amputate immediately through -healthy tissue when restitution of the injured parts is known to be -impossible. In senile gangrene the appearance of the line of -demarcation indicates the extent of the devitalized area and -establishes the point of amputation beyond the next joint above. - -Diabetic gangrene presents the peculiarity of a slow and steady -advance, unless an unusually high amputation be performed. Thus, if -the great toe is the site of the beginning of a true diabetic -gangrene, amputation through the lower third of the thigh is -indicated; otherwise the prognosis is very bad. - -Inflammatory gangrene, or as it is more properly called _gangrenous -cellulitis_, is a rapidly spreading infective process which destroys -tissue as it advances. It is an acute suppurative process causing -large sloughs. It is a form of cellulitis requiring drainage and -disinfection. - -Frost bite may involve tissues to any depth and to any surface extent. -Lesions of circumscribed contour result in the sloughing away of the -area involved and never require amputation. (See "Frost bite.") - -In the event of a phalanx, toe, finger, foot, or hand being involved, -the same rules as above laid down must apply. In this variety, -however, it is important to allow sufficient time to elapse in order -that the depth of the gangrenous process may be ascertained. Should -the line of demarcation be apparent, after a few days the complete -death of the tissues below is certain, and amputation becomes -necessary. If, however, after a few days some slight bleeding or the -appearance of a red point be apparent, the bone, and in all -probability some tissue around it, is still viable. Haste in these -cases should therefore be avoided. - - - - -CHAPTER XII - -+DISEASES OF VEINS+ - - -Varicose veins are unnatural, irregular, and permanently dilated veins -which elongate and pursue a tortuous course. This condition is very -common, and twenty per cent. of adults exhibit it in some degree in -one region or another. - -The causes of varicose veins are obstruction to venous return, and -weakness of cardiac action, which lessens the propulsion of the blood -stream. - -Varicose veins may occur in any portion of the body, but are chiefly -met with on the inner side of the lower extremity. - -Varix in the leg is met with during and after pregnancy, and in -persons who stand upon their feet for long periods. - -It especially appears in the long saphenous vein, which, being -subcutaneous, has no muscular aid in supporting the blood-column and -in urging it on. The deep as well as the superficial veins may become -varicose. - -Varicose veins are in rare instances congenital; they are most often -seen in the aged, but usually begin at the ages of twenty to forty. - -A vein, under pressure, usually dilates more at one spot than at -another, the distention being greatest back of a valve or near the -mouth of a tributary. The valves become incompetent and the dilatation -becomes still greater. The vein wall may become fibrous, but usually -it is thin, and ruptures. The veins not only dilate, but they also -become longer, and hence do not remain straight but twist and turn -into a characteristic form. - -Varicose veins are apt to cause edema, and the watery elements in the -tissues cause eczema of the skin. When eczema is once inaugurated, -excoriation is to be expected. Infection of the excoriated area -produces inflammation, suppuration, and an ulcer. - -The skin over varicose veins in the legs is often discolored by -pigmentation due to the red cells having escaped from the vessel and -then being broken up. - -The tissues around a varicose vein become atrophied from pressure, and -often a very large vein will be in evidence whose thin walls are in -close contact with the skin, and in this condition, rupture and -hemorrhage are probable. Varicose veins are apt to inflame and -thrombosis frequently occurs. - -+Treatment.+ The treatment of varix may be palliative or curative, but -whichever is followed, endeavor first to remove the cause. - -In palliative treatment, attend to the general health, keep up the -force and activity of the circulation, and prevent constipation. -Recommend the patient to exercise in the open air and to lie down, if -possible, every afternoon. Locally, in varix of the leg, order a -flannel bandage to support the vein and drive the blood into the -deeper vessels which have muscular support. (For technic, see chapter -on bandaging). - -The curative or operative treatment of varicose veins consists of -performing a resection of the internal saphenous vein of one or two -inches, near the saphenous opening into the femoral. This is known as -the _Trendelenburg_ method. About 90 per cent of all cases can be -cured by this method. The operation can be performed under local -anesthesia and presents no difficulties. - -Another procedure is known as _Schede's_ method. This consists of -making a circular incision around the leg just below the knee joint, -and in tying all the superficial veins thus exposed. - -_Mayo's_ operation consists of the total extirpation of the internal -saphenous vein from the saphenous opening to the internal malleolus. A -small incision is made high up, and at a distance of from 8 to 10 -inches, a second incision is made, and in this manner the entire vein -is removed by making several incisions. - -The patient should remain in bed about three weeks following an -operation of this kind and afterwards an elastic stocking, or an ideal -bandage, should be worn for a considerable time. - -+Phlebitis+, or inflammation of a vein, may be plastic or purulent in -nature. Plastic phlebitis, while occasionally due to gout, or to some -other constitutional condition, usually arises from a wound or other -injury, from the extension to the vein of a perivascular inflammation, -or, in the portal region, from an embolus. - -Varicose veins are particularly liable to phlebitis. When phlebitis -begins, a thrombus forms because of the destruction of the endothelial -coat, and this clot may be absorbed or organized. - -+Suppurative Phlebitis+ is a suppurative inflammation of the vein, -arising by infection from suppurating perivascular tissues (_infective -thrombophlebitis_). It is most frequently met with in cellulitis or -phlegmonous erysipelas, but there are a great many other causes. - -A thrombus forms, the vein wall suppurates, is softened and in part -destroyed, and the clot becomes purulent. No bleeding occurs when the -vein ruptures, as a barrier of clot keeps back the blood stream. The -clot of suppurative phlebitis cannot be absorbed and cannot organize. - -Septic phlebitis causes pyemia, and the infected clots of pyemia cause -phlebitis. The symptoms of phlebitis are pain, which is at once felt -in the limb along the track of the inflamed vein, and tenderness along -the same area; the overlying skin is red, hot, and tender, and the -lymphatic nodes in the groin swell; there is marked edema, but the -inflamed venous cords can be readily felt. The constitutional -disturbance is marked; rigors and high temperature, 103 deg.F. to 105 deg.F. -(remittent type), are followed by profuse sweats. The general -condition, facies and anxiety, dry and parched tongue, delirium and -general distress, at once directs attention to the infectious nature -of the trouble. The leucocyte count will show a marked increase in the -number of polynuclears. - -+Treatment.+ The treatment of phlebitis may be classified into -preventive and curative, the latter being subdivided into (_a_), -general or symptomatic, and (_b_), local or surgical. - -The preventive treatment is summed up in the word asepsis. The -influence of asepsis in the management of wounds has completely -revolutionized surgical practice, and the old fatal types of pyemia -and septicema have now practically vanished. - -Septic and pyogenic phlebitis still remain as consequences of -accidental wound contaminations and as a penalty for the neglect of -surgical cleanliness. - -Prophylatic measures, by the use of internal remedies which diminish -the coagulability of the blood, such as Wright's citric acid -treatment, are recommended for the prevention of thrombosis. -Antitoxins have not proven to be of benefit in this condition. - -The curative treatment may be symptomatic, local, constitutional, or -surgical. The constitutional treatment is directed to the general -cause, if possible, as in the gouty, rheumatic, syphilitic, and -chloritic cases; beyond this, there is no specific treatment. The -antistreptococcal and staphylococcal sera are usually prescribed in -the septic forms, but thus far, more as a forlorn hope than with the -expectation of accomplishing any definite results. The symptomatic -treatment, on the other hand, is always indicated to diminish pain, to -support and strengthen the circulation, and to favor elimination. The -main reliance is to be placed upon the local treatment, combined with -good nursing, appropriate food, and moderate stimulation. - -The local treatment is summed up in the following indications: (_a_), -immobilization and absolute rest of the affected limb; (_b_), elevated -position of the foot of the bed or of the limb to favor the drainage -of the venous current toward the trunk. The limb should be covered -with cotton batting and bandaged, over a gutter-splint of cardboard, -extending from the foot to the thigh, to immobilize the knee. In the -superficial inflammations, with much redness and heat, an even layer -of any of the kaolin mixtures may be applied between thin layers of -gauze, like an antiseptic poultice, over the entire extremity, and -especially over the inflamed parts. A saturated watery solution of 25 -per cent. ichthyol, painted over the entire surface will also prove -decidedly beneficial in cases complicated with lymphangitis. Unguentum -Crede, mercurial ointment, and the so-called resolvent lotions have -been tried, but none of these can compare in their beneficial effect -with kaolin poultices, with or without ichthyol, or the liberal -application of broad compresses, thoroughly saturated with a weak lead -and opium lotion, which latter acts not only as a local astringent, -but as a marked sedative. Immobilization and rest should be maintained -for a month or more. - -+Operative Treatment.+ The operative treatment of acute septic -thrombophlebitis has in view three indications, and the procedures -adopted must vary according to these: (1) ligation of the vein between -the thrombotic focus and the uninfected vein on the cardiac side, in -order to obstruct the further advance of the infection, and thus -prevent the entrance of septic emboli into the circulation; (2) -removal of the primary focus of infection by direct incision into the -veins, evacuation of the septic thrombus and drainage; (3) extirpation -of the infected veins with the contained clot and septic contents. - - - - -CHAPTER XIII - -+SPECIAL FORMS OF INFLAMMATION+ - - -+Syphilis+ is a chronic, infectious, and sometimes hereditary, -constitutional disease. Its first lesion is an infecting area or -chancre, which is followed by lymphatic enlargements; eruptions upon -the skin and mucous membranes; affections of the appendages of the -skin, (hair and nails); chronic inflammation and infiltration of the -cellulo-vascular tissue, bones and periosteum, and later, often by -gummata. This disease is caused by a microorganism known as the -_spirochaeta pallida_ or _treponema pallidum_ of Schaudinn and -Hoffmann. - -+Transmission of Syphilis.+ This disease can be transmitted (_a_), by -contact with the tissue-elements or virus acquired syphilis, and -(_b_), by hereditary transmission, hereditary syphilis. - -The poison cannot enter through an intact epidermis or epithelial -layer; an abrasion or solution of continuity is requisite for -infection. - -Syphilis is usually, but not always, a venereal disease. It may be -caught by infection of the genitals during coition; by infection of -the tongue or lips in kissing; by the use of an infected towel on an -abraded surface; by smoking poisoned pipes, and by drinking out of -infected vessels. - -The initial lesion of syphilis may be found on the finger, penis, -eyelid, lip, tongue, cheek, palate, nipple, etc. Syphilis can be -transmitted by vaccination with human lymph which contains the pus of -a syphilitic eruption or the blood of a syphilitic person. Syphilis is -divided into three stages (1) the primary stage--chancre and indolent -bubo; (2) the secondary stage--disease of the upper layer of the skin -and mucous membranes, and (3) the tertiary stage--affections of -connective tissues, bones, fibrous and serous membranes, and -parenchymatous organs. - -+Syphilitic Periods.+ (1) period of primary incubation--the time between -exposure and the appearance of the chancre, from ten to ninety days, -the average time being three weeks; (2) period of primary -symptoms--chancre and bubo of adjacent lymph glands; (3) period of -secondary incubation--the time between the appearance of the chancre -and the advent of secondary symptoms,--about six weeks as a rule; (4) -period of secondary symptoms--lasting from one to three years; (5) -intermediate period--there may be no symptoms or there may be light -symptoms which are less symmetrical and more general than those of the -secondary period; it lasts from two to four years, and ends in -recovery or tertiary syphilis; and (6) period of tertiary -symptoms--indefinite in duration; the fifth and sixth may never occur, -the disease being cured. - -+Primary Syphilis.+ The primary stage comprises the chancre or infecting -sore or bubo. A chancre or initial lesion is an infective granuloma -resulting from the poison of syphilis. The chancre appears at the -point of inoculation, and is the first lesion of the disease. During -the three weeks or more requisite to develop a chancre the poison is -continuously entering the system, and when the chancre develops, the -system already contains a large amount of poison. - -A chancre is not a local lesion from which syphilis springs, but is a -local manifestation of an existing constitutional disease, hence -excision is entirely useless. The hard chancre, or initial lesion, -never appears before the tenth day after exposure, it may not appear -for weeks, but it usually arises in about twenty-one days. The lesion -commonly appears as a round, indurated, cartilaginous area with an -elevated edge, which ulcerates, exposing a velvety surface looking -like raw ham; it bleeds easily, rarely suppurates, does not spread, -and the discharge is thin and watery. - -The bubo of syphilis is multiple, consisting of a chain of glands, -freely movable, indurated, painless, small and slow in growth, and the -skin over the bubo is normal. - -A positive diagnosis of syphilis can be made when an indurated sore is -followed by multiple indolent glands or buboes in the groin and by the -enlargement of distant glands. - -+Secondary Glands.+ The symptoms are noticed from four to six weeks -after the stage of the induration of the chancre, and may continue to -appear at any time, up to twelve months. The most constant are certain -eruptions on the skin, faucial inflammation, and enlargement or -induration of the lymphatic glands; others are febrile reaction, pains -in the back or limbs, swelling of the joints, iritis and falling out -of the hair. - -+Tertiary Syphilis.+ These symptoms appear from one to two years after -contagion and may continue to break out from ten to fifteen years, or -more. The characteristic lesions are certain late eruptions on the -skin, periostitis and nodes on the bones, and growths in the -subcutaneous tissue, muscle, and viscera, especially the liver and -spleen. These growths, in the viscera and other parts, which are so -characteristic of syphilis in its later stages, are known as gummata. -They consist of a substance like granulation tissue, with a varying -proportion of cells. In early stages they are grayish, gelatinous, and -transparent, but the cells undergo fatty change and caseation takes -place, so that the centre becomes yellow, and the circumference -develops into fibrous tissue, which contracts like a scar tissue. -Sometimes gummata break down completely, and suppuration, with -destruction of the tissues in which they are situated, takes place; -thus caries and necrosis not infrequently follow nodes on the bones. - -+Treatment.+ Mercury is the drug of great benefit in syphilis. This can -be administered either internally, by inunction, or by injection. Of -all the preparations to be given internally, protiodide of mercury, in -one quarter grain doses, three times a day, is to be preferred. - -+Inunction+ represents the most efficient way of administering the -mercurial treatment, when the stomach is intolerant of drugs, or when -administered by the mouth in full doses, they do not favorably modify -the symptoms. The patient is instructed to take a warm bath, and the -mercury is then well rubbed in over the inner surface of the forearm -and arm and alongside of the chest for fifteen minutes. Either the -oleate of mercury, 10 per cent., or the ordinary mercury ointment is -commonly employed; the former is more clean, but less efficient. The -rubbings should be done by the patient, should be made over a large -surface of the body, and should be performed thoroughly; one dram -(4.0) of blue ointment is rubbed in daily. For the injections, a 10 -per cent. salicylate of mercury in olive oil is to be preferred; 10 to -15 minums of this solution is to be injected into the buttocks, three -times a week. The dose is gradually to be increased until 30 drops are -employed. Recently salvarsan (606) in 0.6, or 10 grain doses is given -either intravenously or intraspinally. Neosalvarsan (914) is to be -similarly given. The latter has the advantage in that sterile water is -used, and that, as a rule, there is no reaction from its injection. -Iodide of potassium in large doses (60 to 90 grains) three times a -day, is also to be given. - -+Tuberculosis.+ Tuberculosis is an infectious disease due to the -deposition and multiplication of the tubercule bacillus in the tissues -of the body. It is characterized either by the formation of -tubercules, or by a wide spread infiltration, both of these conditions -tending to caseation, sclerosis, or ulceration. - -A tubercular lesion may undergo calcification. - -A tubercule is an infective granuloma, appearing to the unaided vision -as a semitransparent mass, gray in color, and the size of a mustard -seed. - -The microscope shows that a tubercule consists of a number of cell -clusters, each cluster consisting of one or of several polynucleated -giant cells, surrounded by a zone of epitheloid cells which are -surrounded by an area of leucocytes. Giant cells, which also form by -coalescence of the epithelioid cells, are not always present. The -bacillus, when found, exists in the epithelioid cells, and sometimes -in the giant cells; it may not be found, having once existed, but -having been subsequently destroyed. It is often overlooked. - -In an active tubercular lesion, even if the bacillus be not found, -injection of the matter into a guinea-pig will produce lesions in -which it can be demonstrated. - -A tubercule may caseate, a process that is destructive and dangerous -to the organism. Caseation forms cheesy masses, which may soften into -tubercular pus, may calcify, and may become encapsulated by fibroid -tissue. Tubercular disease of the bones and joints have already been -described in a previous chapter. - -+Treatment.+ Destroy the bacilli present and radically remove infected -areas which are accessible. Incomplete operations are apt to be -followed by diffuse tuberculosis. - -Bier's venous or obstructive hyperemia is especially to be recommended -in tuberculosis of the ankle joint (for technic, see chapter on -Therapeutics). - -Plenty of fresh air, good nourishing food and tonics are indicated as -a routine treatment. - -+Tetanus.+ Tetanus is an infectious disease, invariably preceded by some -injury. The wound may have been severe or it may have been so slight -as to have attracted no attention. - -The disease is commonest after punctured wounds or lacerated ones of -the hands or feet, and before it appears, a wound is apt to suppurate -or slough, but in some instances the wound is found soundly healed. - -Tetanus is due to infection by a bacillus (first described by -Nicolaier, and first cultivated by Kitasato), the toxic properties of -which, absorbed from the infected area, poison the nervous system -precisely as would dosing with strychnine. - -+Symptoms.+ The onset is usually within nine days of an accident. At -first, the neck feels stiff and there is difficulty in swallowing, and -then the jaw also becomes stiff. The neck becomes like an iron bar, -and the jaws are rigid as steel. If the injury is on the foot, that -extremity usually is found to be rigid. Opisthotonos is present and -spasms are very marked. Swallowing in many cases is impossible. The -mind is entirely clear until near the end, one of the worst elements -of the disease. - -+Treatment.+ Careful antisepsis will banish it. Every wound must be -disinfected with the most scrupulous care. Every punctured wound is to -be incised to its depth and thoroughly cleaned and drained. Large -doses of the bromide of potassium, at least sixty grains, should be -given every four to six hours. Tetanus antitoxin should be given (5000 -units), and repeated in twenty-four hours if no improvement is seen. -Recently a saturated solution of magnesium sulphate has been given -intraspinally, with very good results. In all suspicious cases, a -prophylatic injection of tetanus antitoxin is to be recommended (1000 -units). - -+Erysipelas.+ Erysipelas is an acute, contagious disease, characterized -by a peculiar form of inflammation of the skin. It is caused by the -streptococcus of erysipelas, which grows and multiplies in the smaller -lymph channels of the skin and its subcutaneous cellular layers, and -in serous and mucous membranes. - -The disease is a rapid spreading dermatitis, accompanied by a -remittent fever, due to the absorption of toxins, having a tendency to -recur. It is always due to a wound. The involved area may or may not -suppurate. - -+Symptoms.+ The onset is sudden, with a high fever, and at the time of -febrile onset, spots of redness appear on the skin. These spots run -together, and a large extent of surface is found to be red and a -little elevated. This combination of redness and swelling extends, and -its area is sharply defined from the healthy skin. The color at once -fades on pressure and returns immediately the pressure is removed. In -the hyperemic area, vesicles or bullae form, containing first serum -and later possibly sero-pus. Edema affects the subcutaneous tissues, -producing great swelling in the regions where these tissues are lax. - -+Treatment.+ Isolate the patient; asepticize the wound; and give a -purge. If a person is debilitated, stimulate freely. - -Tincture of iron and quinine are usually administered. Nutritious food -is important. For sleeplessness or delirium, use the bromides; for -light temperature, cold sponging and antipyretics. Locally, strict -antiseptic treatment of existing wounds or other lesions; cold -compresses to relax the skin; rest; elevation of the limb; and -incisions, only if pus forms. - -Where the disease is spreading, good results are obtained by spraying -the affected surface with a weak solution of corrosive sublimate in -ether, or painting the borders of the affected area with contractile -collodion. The affected part may also be painted with a 50 per cent. -ichthyol and water solution. Alcohol, Burow's solution, and a great -many other liquid applications are recommended. Antistreptococci serum -is also to be recommended; an initial dose of 20 c.c. followed by -doses of 10 c.c., as often as necessary, being the usual procedure. - -+Cellulitis.+ In cellulitis, redness of the skin is not very pronounced -and is late in appearing, following swelling, and not preceding it. It -is essentially the same condition as a mild form of erysipelas. Its -spread is heralded by red lines of lymphangitis, ascending from a -wound (infected), swelling of glands, and fever. - -In slight cases, the lymphatics may dispose of the poison, and -suppuration fails to occur. In severe cases septicema arises. -Cellulitis is usually a result of infection not only with -streptococci, but also with other pyogenic cocci. - -+Treatment.+ Incise and curet the wound and apply one of the wet -dressings. (See chapter on same). - -+Actinomycosis.+ This is an infectious disease characterized by chronic -inflammation, and is due to the presence in the tissues of the -actinomyces, or ray fungus. At the point of inoculation arises an -infective granuloma, around which inflammation of connective tissues -occurs; suppuration eventually taking place. Inoculation in the mouth -is by way of an abrasion of mucous membrane or through a carious -tooth. The fungi may pass into the bones and joints, causing -inflammation of the parts. The bones in actinomycosis enlarge and -become painful; the parts adjacent are infiltrated and soften; pus -forms and reaches the surface through fistulae and the skin is often -involved secondarily. In actinomycosis the adjacent lymphatic glands -are not involved. - -+Treatment.+ Free incision, if possible, otherwise incision, cauterizing -with pure carbolic acid, and packing with iodoform gauze. Internally, -large doses of iodide of potassium should be given, as this drug alone -has cured many cases. - -+Trench Foot.+ This results from exposure to wet and cold in the -trenches, and soldiers who were compelled to have their feet immersed -in water for any length of time and were then exposed to cold, are -afflicted with this condition. The symptoms are similar to frost bite -and the prevention of frigorism (Trench Foot) is as follows: adequate -feeding; perfect circulation; moderate exercise; good general health; -and warm clothing, which all tend to give the body its maximum power -of resistance to cold. - -It is obvious that anything that tends to impair the circulation and -the nutrition of the tissues is favorable to the occurrence of -frigorism. Tightness of the clothing of the extremities, such as tight -boots, leggins, etc., is particularly detrimental. Heavy clothing and -other equipment, by increasing fatigue, also has a predisposing -influence. - -With regard to the protection against cold water, it is necessary that -the external covering should be impervious to and not affected by -water. India rubber stockings, waders, and boots have been used by men -working in water, not only as a protection against wet, but also -against cold. The best results have been obtained by the use of a -waterproof covering that can be worn inside the boot, not because it -is the only, or even the best possible method, but because it appears -to be the simplest and most practical. A waterproof top boot, so -devised as to leave a fairly wide air space between the boot and the -greater part of the foot, ankle, and lower part of the leg, would be -more efficient and probably more convenient, provided the material -used was soft and light, and did not interfere with movements. To -obtain this result a new type of boot would be required. - -The treatment of trench foot is similar to that of frost bite. - -+Motorman's Foot.+ This is a condition caused by occupation, and the -symptoms found are usually those of a flat foot combined with enlarged -veins. The chief complaint is that of pain in the calf of the legs, -which is increased upon standing for any length of time. The treatment -is that for flat foot and enlarged veins. - -+Chauffeur's Foot.+ This is a condition also caused by occupation. On -account of the position assumed in driving an automobile, the tendons -and muscles of the leg are usually affected and a tendosynovitis very -frequently occurs. The symptoms and treatment have already been -described. Rest is without doubt the best therapeutic measure. - -+Bicycle Foot+ is another occupational disease. The chief symptoms are -those of cramps in the calves of the leg, and pains of a severe -neuritic character. - -At times the onset is very sudden, and the cramps are so severe that -it is impossible to extend the leg without causing great pain. Flat -foot is usually associated with the above condition. The treatment is -rest and the administration of the salicylates for the relief of pain. - -Bicycling is ordinarily a beneficial exercise for the foot muscles. -When bicycle foot results from this exercise it is usually evidence -that the bicyclist had an abnormal condition of his foot muscles and -foot joints before he took up the exercise in question. - - - - -CHAPTER XIV - -+VERRUCA (WART), CALLOSITY, HELOMA (CORN OR CLAVUS)+ - -+DISEASES OF THE NAILS--INGROWN NAIL+ - - -+VERRUCA OR WART+ - -+Definition.+ A verruca is a circumscribed overgrowth of all the layers -of the skin, varying in size from a pin's head to a small nut. These -growths may be single or multiple, and may come and go without any -special reason. _Verruca plantaris_, or plantar wart, is observed on -the sole of the foot; it may be single or multiple. It is very -painful; it may be the size of a pea and is often mistaken for a -callosity, from which it may be distinguished by the pain on pressure, -and the tendency to bleed when the horny layer is removed. - -Verrucae are probably contagious, but the pathogenic agent has not -been isolated. They sometimes disappear spontaneously, and they will -recur if their removal is not complete. - -+Treatment.+ Certain chemical substances (see "_escharotics_") destroy -tissue and can be employed with safety only after much experience. -These drugs when allowed to spread on the normal skin often occasion -painful and persistent lesions. They must therefore be applied -directly and sparingly to the growth itself and not be left in contact -too long. - -The daily removal of a thin layer is possible in this way without -causing pain or erosion. - -The chemical agents that are employed for the removal of verruca are -notably nitric acid, acetic acid, monochloracetic acid, trichloracetic -acid, nitrate of silver, sodium hydroxide and salicylic acid. The -treatment with these drugs is alike in all cases, with the exception -of the last three named. - -The procedure, when using liquid acids is as follows: render the -growth and the surrounding parts aseptic; by means of a tapering glass -rod or a wooden toothpick, apply a drop of the acid so that it will -spread over the growth only, making certain that every part of the -outer surface has been treated. If pain becomes excessive, apply a -neutralizing agent. Dress the part with a shield that is holed-out, so -that when the foot-covering is in place there will be no pressure over -the tissues treated. This treatment should be repeated every other day -until there is sloughing at the base of the growth. The pocket -produced is drained, and balsam of Peru or some other stimulant should -be applied and held in place by an appropriate dressing. Five or six -treatments will ordinarily suffice to remove the growth. - -Many practitioners find nitrate of silver a serviceable remedy in -cases of verruca. The pure stick, moistened, is gently applied to the -surface of the growth, which later becomes blackened. The patient -returns two days later when the scab, that will have formed, is -removed and the original treatment is repeated. Ordinarily from six to -ten such applications will suffice. Those who favor the use of -salicylic acid for the removal of verruca, usually apply a 60 per -cent. ointment of this drug, over the growth only, protecting the -surrounding parts with collodion or gelatine. A holed-out shield is -applied over the growth and an appropriate bandage is made to hold it -and the ointment in place. The patient is advised to return at the end -of ten days and, as a rule, when the dressing is removed, it will be -found that the growth is sufficiently loosened to admit of removal by -means of forceps and scissors. - -Sodium hydroxide is used in these cases in a saturated solution. It is -best applied by means of a wood toothpick, wound about with cotton, -and should be used sparingly, much after the manner in which liquid -acid applications are made and as above described. A slight stinging -sensation indicates that the drug has penetrated the tissues near the -nerve-endings in the underlying papillae. Such symptoms render it -necessary to neutralize the sodium hydroxide. According to Dr. Joseph -Renk of New York City, ordinary vinegar contains just the degree of -acidity necessary to neutralize the action of the sodium hydroxide, -without adding a new irritating element. - -Verrucae may also be removed by the high frequency spark, or by -electrolysis. Both of these methods are superior to cutting -operations, but are equally as painful unless a drop of anesthetic -solution is injected into the base of the growth, before treatment is -commenced. - - -+CALLOSITY+ - -+Definition.+ A callosity is a circumscribed thickening of the _stratum -cornium_. The condition is usually acquired, occurring on parts -exposed to intermittent pressure with counterpressure from an -underlying bony prominence, as on the toes, soles, and heel of the -foot, from ill-fitting shoes. - -Callosities are dirty-yellow to brown in color; their extent depending -upon the cause; they are thickest in the centre and pass gradually -into the healthy skin. Sensation is usually lost, or at least -diminished, over these areas. - -They may interfere with movement and may have painful fissures and -become infected, giving rise to abscesses, lymphangitis, gangrene, or -erysipelas. Hyperidrosis is often associated with this condition. - -+Treatment.+ The permanent cure of callosities depends exclusively upon -the removal of their causation. The position of the foot in the shoe -may be faulty because of excessively high or low heels, causing -callous skin to appear upon the weight-bearing surface. Occupations -requiring constant standing, and deformities, also enter as causative -factors which must be considered. - -The palliative cure rests for its efficacy on the removal of the horny -tissue down to, but not into, the papillary layer. - - -+HELOMA+ - -(+Corn or Clavus+) - -+Definition.+ A heavy thickening of the cuticle, usually caused by -pressure, and producing pain by its own pressure on the tissues -beneath. - -Though the term heloma is rarely used outside of text books, there are -very few who have not had an unpleasant acquaintance with this -cutaneous affection, under the name of "corns." Heloma is undoubtedly -the most frequent of all skin diseases. - -+Cause.+ The exciting cause of helomata is intermittent pressure -combined with friction; while among the predisposing causes it is only -necessary to mention the slavish adherence to fashion which lends all -of us to wear stiff leather shoes, the contour of which bears little -or no relation to the natural shape of the anterior portion of the -foot. The pressure of the ill-fitting boot upon the toes, or, more -strictly speaking, the pressure of the toes against the unyielding -leather, in walking, soon occasions hypertrophy of the horny layer at -the point of irritation, and in time a dense, conical, pea-sized or -larger mass is formed. The apex of the cone presses downward on the -sensitive papillae and causes the painful sensation which suggests a -visit to the chiropodist. - -Helomata are named according to characteristics which mark them. When -the growth is indurated it is called heloma durum; when soft, heloma -molle; when of the millet seed variety, heloma miliare; when blood -vessels are numerous, heloma vasculare. Each of these varieties -requires a different method of treatment. - -Helomata are most frequently found on the outer surface of the little -toes, but may occur upon the sole of the foot and even upon the palm, -or plantar surface of the foot. Between the toes they often form from -pressure of the opposing digits, caused by narrow shoes, and in this -location they are softer and usually present a whitish, macerated -surface. - -+The Prophylatic Treatment+ consists in wearing a broad-toed, though not -necessarily a square-toed shoe. - -If shoes were made fan-shaped, like the imprint of a bare-foot in the -sand, instead of having the greatest width across the ball of the -foot, they might look strange at first, but they would be comfortable -for all time. Those then who care more for comfort than for style, as -most of us falsely profess to do, would have both cornless and comely -feet. - -+The Palliative Treatment+ of helomata consists of first softening the -dense, hard, horny tissue, when it will exfoliate spontaneously, or be -readily scraped away. This projecting callous portion of the heloma -may be removed by cutting or scraping till, as nearly as may be, the -surface is level with the plane of the adjacent skin. - -In the soft variety found between the toes, or in the vascular ones, -located in the arch on the inner border of the foot, where the skin is -thin, no thick covering will be encountered. - -A line or groove will be observed marking the circumference of any -variety of heloma, and it is in this line that the operative attack -must be made. - -Helomata of the miliary variety, usually appear on the sole of the -foot and are, as a rule, as numerous as they are small. The preferable -treatment is to use a sharp, pointed knife in removing each one of the -"seeds" separately. - -A well pointed, narrow blade introduced here will find a plane of -cleavage between the growth and the surrounding tissue, through which -it is possible to dissect quite deeply without encountering blood. -When the dissection reaches the papillary layer in the skin, as -evidenced by the red color, further operative steps should cease. - -In the treatment of soft and vascular growths it may frequently be -preferable to employ disintegrating solutions from the beginning. - -Repetition of the treatment, as described in verruca, every second or -third day, will result in the gradual disintegration of the growth to -its extreme depth, and prove more satisfactory than the radical -operation. - -Healing is rapid and with the use of properly shaped, and roomy -foot-gear, recurrence should not take place. - -It is evident from the nature of helomata, that any "cure," rubbed or -painted upon the affected surface, can only cause the softening of a -certain thickness of skin, and that no hope for cure is justified -unless the careful and complete removal of the growth is accomplished -and followed by the use of roomy foot-gear. - -+Radical Cure.+ The total excision of corns, while disabling the patient -more or less for a few days, is in many instances justifiable. There -is little probability of recurrence if proper foot-gear is worn, and -the results are especially good if the skin graft operation as devised -by Dr. Robert T. Morris is employed, which is described in the next -paragraph. - -After the excision of the growth, a small piece of skin is removed -from the leg and sewn to the denuded area. This prevents a tough -cicatrix forming and assures a normal skin covering to the area -previously occupied by the corn. - -The Text Book of Practical Chiropody, now in course of preparation, -will contain lengthy and explicit articles on the subjects of verruca -and heloma. The purpose here has been largely to present the subject -from a broad surgical viewpoint. The strictly chiropodial features -will be thoroughly outline in the Text Book of Practical Chiropody -after a manner never before attempted and will include all details of -the chisel methods, the dissecting methods and the shaving -operations. - - -+DISEASES OF THE NAILS+ - -+INGROWN NAIL+ - -Although chronic inflammatory affections of the neighboring skin often -produce changes in the form, color and thickness of the nails, these -so rarely call for surgical interference that only those conditions -leading up to the development of ingrown nail will receive -consideration in the following. - -Ingrown nail may be due to either a lateral hypertrophy of the nail -itself cutting into the soft parts, or to the primary hypertrophy of -the soft parts themselves, thus producing the same picture. An -accurate determination of which condition represents the original -etiologic element is important in deciding upon a course of treatment -directed to the radical cure of ingrown nail. - -The term "radical cure" does not necessarily indicate the performance -of the so-called radical operation, but may result from proper -treatment of a down-curved nail edge, or of a diseased nail fold, -together with such prophylaxis in foot-gear as is indicated. With -sufficient room in the shoe and the removal of offending granulations -or cutting nail edge, a radical cure can frequently be effected. - -Any inflammatory condition, either of the nail or its matrix, or the -tissues contiguous to the nail, may result in the train of symptoms -which are indicative of ingrown nail. When, however, any of these -conditions has existed sufficiently long to cause ingrown nail to be -present, it ceases to be of the first importance; it then becomes -necessary to treat the buried nail edge, or the overgrown soft tissues -themselves. - -+The Choice of Method+ between radical and palliative operations will -depend entirely upon the degree of infection present, and the facility -with which it can be reached. Thus, in the event of the entire toe -being red and swollen and much purulent discharge being present, there -will in all probability also exist much inflammatory tissue and a deep -burying of the nail edge. - -With a tolerant patient it might be possible to scrape away with a -sharp spoon the granulation tissue, and remove the offending nail -edge; the gradual improvement sought in ordinary cases cannot be -thought of in these cases. It is urgent to relieve the pain and -throbbing and to circumvent the dangers of a spreading infection. The -sensations of a cutting nail edge have been lost in the more severe -development. Should the patient be tolerant of pain, exposure, -disinfection and drainage of the infected area is possible, but in -most instances the contrary will obtain, and the radical operation -with local anesthesia will be indicated. - -The possibility of doing an efficient operation will ordinarily -determine the method to be employed. - -On the other hand there are a large number of cases in which -palliative treatment is not only effective but emphatically the method -of choice. One might see a degree of burying of nail edge quite as -extensive as in the foregoing, with however, only a slight degree of -infection. The nail fold may be much hypertrophied and granulation -tissue may be abundant. The tenderness and inflammatory condition, -however, is not so great as to interfere with the ordinary procedure. -There is no danger of a rapidly ascending infection, the nail groove -showing no inordinate amount of discharge. It is in these cases that a -permanent cure frequently results from the mere removal of the -irritating nail edge followed by the disinfection of the nail groove. - -It is held by many that all cases of ingrown nail, except those due to -a true hypertrophy of the nail, would remain permanently cured were it -not for short or badly shaped shoes. - -+The Palliative Treatment of Ingrown Nail+ must necessarily depend upon -its original cause. Should it be due to the wearing of improper -foot-gear, nothing primarily pathologic in the tissues themselves -being present, treatment will be effective only when correct shoes are -worn thereafter. - -Eczematous skin surrounding a nail or infection of a nail groove or -matrix, should be treated as such before sufficient hypertrophy takes -place to bury the nail edge. The disinfection and drainage of the -groove can usually be accomplished with iodin on a thin wire or wooden -applicator inserted to the extreme depth of the groove, followed by -the insertion of a narrow strip of gauze. Frequent changes of -dressings and extreme cleanliness will cause the early subsidence of -these infections. It, however, is to be deplored that in the early -stages these cases so rarely obtain treatment. - -Elevation of the nail edge is often practiced quite successfully, but -in general, this method of treatment is not applicable to the acute -stages of the disease on account of the concomitant pain. Either the -nail is too thick to be elevated by the insertion of cotton under its -free edge, or the soft tissues are too sensitive to admit of the -pressure. - -The real skill of the chiropodist is called into practice in the -treatment of ingrown nail by palliative methods, and he may safely be -judged by his results in this class of cases. - -It requires discrimination whether to attack the exuberant granulation -tissue or the cutting nail edge, and in many instances it will be -found that both are necessary. - -Much skill is required in removing that part of the nail which is -buried without causing pain or bleeding; this is the first necessity -for relieving pain and can only be accomplished by a technic acquired -through practice, and often redounding more to the credit of the -operator than the successful performance of a major operation. A sharp -instrument, usually a chisel, is placed against the free edge of the -nail so as to cut only through the nail itself and not into the nail -bed, with the purpose in mind of removing a wedge-shaped piece of nail -of just the size necessary to relieve irritation, and permit of proper -drainage and dressing. - -Exuberant granulations are best treated either with nitrate of silver -applications (50 per cent.) or with tight packing, or both. -Disinfection and wick drainage of the entire tract is of the utmost -importance. - -+The Radical Treatment of Ingrown Toe Nail.+ The operations, as in the -palliative treatment, naturally fall into two classes depending on -(1) whether the nail originally was at fault, or (2) whether the soft -tissues, by inflammatory processes, have hypertrophied and overgrown. - -Operations depending on such diseases or malformations of the nail, -causing it to grow down into the tissues, should be directed to the -removal of the nail, or the offending part of it with its matrix. (See -"_Hypertrophy_"). - -In conditions manifestly due to disease and hypertrophy of the soft -tissues, palliative treatment frequently fails, and it becomes -necessary to curet the granulating nail fold or to erode it with -chemicals. - -The best and easiest operation to effect a permanent cure, where this -condition obtains, is known as Weber's operation. This operation -consists of the excision of an elliptical section of tissue just -alongside of the offending nail border, without interfering with the -diseased tissues themselves, and suturing the cut edges together in -the long direction of the wound. The incisions are made to extend a -little further back than the nail and as far forward as possible. They -are about a quarter of an inch apart at the centre and meet at these -two points. The depth of the section of tissue removed, if -sufficiently great, leaves a diamond shaped cavity. When the edges of -the wound are brought together the overgrown edge is pulled away from -the nail and the further cicatrization of the wound contracting the -soft tissues, assures an excellent result. - - -+HYPERTROPHY+ - -+Hypertrophy+ can result only from hyperplasia of the papillae of the -matrix, the thickening of the nail occurring at the base, front, -lateral edges, or over its whole extent, according to the parts -diseased. The nail may be evenly thickened or variously curved or -twisted, while its structure becomes brittle, opaque and discolored. - -Removal of the most projecting portions of the nail will reveal the -papillae elevated far above the normal level of the matrix. - -The change is slow and progressive, and when pronounced is usually -permanent. The causes are not well understood; pressure, however, -seems to be an exciting cause, this being more causative in the nails -of the toes, especially those of the great and the little toe. - -The old, whose epithelial structures tend to overgrowth, are more -liable to hypertrophy of the nails than the young. - -When attacking the fingers, beyond the blunting of the tactile -sensibility and the deformity, no special trouble arises, unless -painful cracks form from the splitting of the brittle nails. When -affecting the nails of the feet, however, it is difficult for the -patient to wear shoes, the pressure leading to inflammation of the -adjacent soft parts and eventually causing typical ingrown nail. - -Back pressure upon the matrix from a short shoe upon a thick -unresisting nail, is frequently the cause of onychia. - -+Palliative Treatment of Hypertrophy.+ When the deformity seriously -interferes with the wearing of shoes, or shows a tendency to cut into -the lateral fold, it becomes necessary to establish normal dimensions -either with the knife or drill. - -The total removal of the nail; including the matrix, is the only -permanent cure. Excision of the cutting edge of the nail, as in -radical operation of ingrown nail, eliminates only that element of -discomfort. - -The thinning of the nail, by scraping or with the drill, can also be -accomplished with sodium sulphide. A sufficient quantity of the -sulphide is added to starch paste to make it swell; this, when applied -(use a wooden applicator) to the thickened nail, will cause the nail -to disintegrate. By touching the surface with the applicator, one can -determine the depth of nail destroyed before washing off the excess -sulphide. - -+Radical Treatment of Hypertrophy.+ When the thick nail has cut into the -lateral fold and actual ulceration has occurred, it becomes necessary -to remove the down-curved edge. - -Under local anesthesia, an incision is made through the nail, a -little to the side of the inflamed area, and is carried well back -through the matrix. A curved incision, outside of the infected fold, -meets the first incision in front and back of the nail. All the tissue -between is removed in one piece, including the offending portion of -nail with its matrix and the nail fold with all granulation tissue. - -This wound may be brought together by catgut sutures, or may be -allowed to heal by granulation. - -This operation suffices to prevent further trouble at the nail edge, -but does not prevent the discomforts due to a long, distorted, horny -nail. Total removal of the nail with its matrix is the only radical -cure. (See "_Local Anesthesia"_). - -+Inflammation of the Matrix (Onychia).+ As a result oftraumatism in -unhealthy individuals, inflammation and suppuration sometimes occur at -the root of a nail and in the contiguous portion of matrix -("run-around"), and often stubbornly continue unless the loosened, -sharp edge of the buried nail be carefully trimmed away from time to -time, and a little iodoform gauze be employed to press back the -inflamed tissues. - -From lateral hypertrophy of a toe-nail the sharp lateral edge becomes -imbedded in the lateral fold, or from improper lateral compression of -the toes, the same portion of soft tissues is forced up against the -margin of the nail. In either case, inflammation, suppuration, and -ulceration ensue, resulting in the formation of red, exuberant, -excessively painful granulations, constituting the condition called -_ingrowing toe-nail_, though more correctly it should be termed -"up-growing pulp." Sometimes both edges, or even the whole matrix, -become involved, producing pain on any movement of the member. - -When inflammation and ulceration of the whole matrix occur, especially -where a finger is involved, the condition is termed _onychia maligna_, -which attacks only those in depressed health. - -+Treatment.+ The palliative treatment suggested for ingrown nail is -indicated for all inflammations of the matrix, as far as the -disinfection or removal of the portion of nail producing irritation is -concerned, but in onychia maligna the whole nail usually requires -removal under local anesthesia, with destruction of the matrix by -caustics, or by curetment. - - - - -Chapter XV - -+TUMORS AND CYSTS+ - - -+TUMORS+ - -+Definition.+ A tumor is a circumscribed mass of tissue made up of cells -of the same kind as the tissue from which it grows. - -There are two distinct types of tissue in the body: epithelial and -connective, and therefore two types of tumors: the _epithelial tissue -tumors_ and the _connective tissue tumors_. - -Tumors may also be classified as _typical_, and _atypical_. A typical -tumor is one in which the cells are identical to those in the tissue -from which it springs, and also has the same arrangement of cells. -They may be of epithelial or connective tissue origin. The tissue is -identical in all respects and the growth is benign. An atypical tumor -is one of epithelial or connective tissue origin in which, though the -cells are the same as those in the tissue from which it grows, their -arrangement is quite different. They are malignant. - -The most important classification of tumors is that into _benign_ and -_malignant_. - -A _benign tumor_ is one in which there is no tendency to rapid growth; -the symptoms are purely local, and the general health is not affected, -except indirectly. - -On the other hand a _malignant tumor_ is one which takes on a rapid -growth with a tendency to infiltrate or adhere to surrounding -tissues; recurs when removed, and is accompanied by great pain and a -rapid loss of weight and strength. These are commonly known as -cancerous. - -Malignant growths are of two types, carcinomatous and sarcomatous, -dependent upon the tissue from which they emanate. - -The _carcinomata_ spring from the epithelial type of tissue while the -_sarcomata_ emanate from the connective tissue type. - -+Origin.+ Tumors originate from many causes. Some are congenital and -others grow in later life from an inherited tendency. - -Any continued irritation which acts mechanically or chemically so as -to maintain a constant, though slight, degree of undue vascularity of -a part, such as the hot, rough stem of a clay pipe or a jagged tooth, -favors the development of a malignant growth. Certain benign growths, -such as warts or moles, are especially prone to malignant change. Age -and sex also predispose to tumor formation. - -Thus carcinoma is a rarity under thirty years of age; the mammary -gland of the female is more liable to carcinoma than the male; while -on the other hand the esophagus, lip and tongue of the male are more -liable to attack. - -The possibility of certain malignant growths being of germ origin is -thought to be evident (though not yet proven) from many facts. The -fact that where there are malignant growths present, lymphatic glands, -quite distant from the original growth, become secondarily infected, -through the lymphatic vessels, seems to carry out this view. - -Particles of a carcinoma (metastasis) floating in the blood stream, -finding lodgment elsewhere also establish new growths (metastatic). - -Tumors are named according to the tissues from which they arise, thus: - - - CONNECTIVE TISSUE TUMORS - - Fibrous tissue----Fibroma - Fatty tissue----Lipoma - Mucous tissue----Myxoma - Muscular tissue----Myoma - Cartilage----Chondroma - Bone----Osteoma - Blood vessels----Angioma - Lymphatics----Lymphangioma - Lymphatic glands----Lymphoma - - - EPITHELIAL TISSUE TUMORS - - Warty----Papilloma - Glandular----Adenoma - Skin----Epithelioma - - -+CYSTS+ - -+Definition.+ Cysts are hollow tumors filled with fluid or semi-solid -contents. They are classified according to their mode of development: - - 1. Cysts formed in already existing spaces such as sebaceous - cysts in the sebaceous glands of the skin; mucous cysts in - mucous glands, and distension cysts in ducts of large glands - like the salivary, lacteal, hepatic, etc. - - 2. Cysts of new formation into the tissue spaces from the - effusion of blood or plasma. - - 3. Congenital cysts known as dermoids. - - 4. Cysts of parasitic origin. - - The only cyst with which the chiropodist ordinarily comes in - contact is of the sebaceous variety. - -+Sebaceous Cyst.+ A sebaceous cyst is a tumor resulting from retained -sebum (secretion of the sebaceous glands). - -They sometimes, though rarely, are found on the soles of the feet. -They range in size from a millet seed to the size of an egg or larger; -they may be globular or flattened. They may be single or multiple; the -skin over them is normal in color and smooth, or white if distended, -red if inflamed. They grow very slowly and ordinarily persist -indefinitely, but calcareous changes are common. Not infrequently -they break down and ulcerate. The wall is made up of connective tissue -lined with epithelium and the secretion if chemically altered, becomes -fluid, semi-fluid, cheesy or purulent. - -+Treatment.+ Spontaneous cure often occurs when a cyst becomes inflamed -and suppurates. The pus is evacuated either spontaneously or by -incision, following which the walls of the sac adhere and its cavity -is obliterated. - -Treatment directed toward the obliteration of the sac is the only -procedure which gives promise of permanent cure; mere puncture and -evacuation will effect only temporary relief, the sac soon filling -again. - -Incision followed by dissection and removal of the sac, either intact -or punctured, is radical and efficient. - -Puncture and evacuation, followed by swabbing out with pure phenol or -strong iodin, may set up an inflammatory reaction within the sac, -which acts similarly to the suppurative process, causing adhesion of -the walls, thus preventing a recurrence. - - - - -CHAPTER XVI - -+FRACTURES, DISLOCATIONS AND SPRAINS+ - - -+FRACTURES+ - -A fracture may be defined as a broken bone. Fractures are classified -as follows: - - 1. As to their degree. - 2. As to the direction of the line of fracture. - 3. As to their location. - 4. As to the etiology. - 5. As to their relation to the overlying skin. - 6. As to the number of fragments. - 7. As to whether they are complicated or not. - -+Degree of Fracture.+ A fracture which only involves a portion of the -thickness of the bones, so that its continuity has not been entirely -lost or a fragment has not been completely detached, is called an -_incomplete fracture_. A fracture which involves the entire thickness -of the bone, so that it is divided into two or more distinct -fragments, is called a _complete fracture_. - - -+INCOMPLETE FRACTURES+ - -Among the varieties of incomplete fracture are: greenstick; fissured; -depressed. - -+Greenstick Fractures+ (really a bending rather than a break of the -bone) are mostly seen under the age of fifteen, and the bones of the -leg are rarely affected. - -+Fissured Fractures+ are those in which there is a split or crack in the -bones; they are very rare in the bones of the lower extremity. - -+Depressed Fractures+ are fractures in which one or more segments of -broken bone are depressed; they are most common in fractures of the -skull. - - -+COMPLETE FRACTURES+ - -+Complete Fractures+ are divided according to the line and the seat of -the breech of bone continuity. - - -DIRECTIONS OF THE LINES OF FRACTURES - -+Transverse+, when the line of fracture does not deviate more than ten -to fifteen degrees from that of the transverse axis. This variety is -rare in the shaft of the long bones. It is usually found at the lower -end of the radius or of the femur, and in the short bones. - -+Longitudinal+, when the break is parallel to the long diameter of the -bone; very few cases of this variety are seen. - -+Oblique+, when the direction of the line of fracture may form any angle -with the transverse axis of the bone up to a right angle. When it -approaches the latter, it belongs to the group of longitudinal -fractures. In the oblique variety, the line of fracture may be single -or multiple. This and the spiral form are most frequent in the shafts -of the long bones. - -+Spiral+, when the break line is spiral. This variety of fracture was -formerly considered to be very rare. The more systematic use of the -X-ray as part of the routine of diagnosis has shown that spiral -fractures are quite frequent in the shafts of the tibia and fibula. -They are usually the result of a rotating or twisting force. - -CLASSIFICATION OF FRACTURES - -+Comminuted+, when there is extensive splintering of the bone adjoining -the fracture or one of the fragments. - -+Impacted+, when the fragments are driven into each other. This variety -usually occurs in the neck of the femur. - -+Compression, or Crushing Fractures+, when the broken bones are -compressed or crushed; this variety usually occurs in the tarsal -bones. The spongy portion and cortical layer are both crushed. In some -cases there is a perfect pulpification of these bones. This condition -occurs after falls from a height upon the sole of the foot. - - -LOCATION OF FRACTURE - -+In the Diaphysis of a Bone.+ Breaks in the diaphysis of a bone are -spoken of as fractures of the _shaft_, and to be still more exact, it -is stated whether of the upper, middle, or lower third. - -+At the Ends of Bones.+ Fractures occurring at the ends of bones receive -the name of the part which the line of fracture transverses; for -example, fractures of the _neck_ of a bone, of a _tuberosity_, of a -_process_, of a _condyle_, etc. - -There are two forms of fracture that require special mention in -connection with their location. These are _epiphyseal separations_ and -_articular fractures_. - -+Epiphyseal Separations.+ The union of the epiphysis to the diaphysis -commences during puberty, hence these fractures are less common in -childhood than after the ages of eleven or twelve. As a rule, they can -only occur before the twentieth year. The periosteum is more resisting -and tougher during the early years of life than later on. - -+Articular Fracture+ (_joint fractures_). Like epiphyseal separations, -recognition and proper treatment of these fractures have assumed great -importance. - -Articular fractures may be divided into three classes: - - 1. _Intra-articular._ In these the line of fracture lies - entirely within the joint. Such fractures are most frequently - found in the elbow and knee joint. - - 2. _Para articular._ In these the line of fracture extends - close to the joint but not into it. An example of this class - is the _supracondyloid_ fracture of the humerus. - - 3. _Articular fractures proper._ The majority of joint - fractures belong to this class. The line of fracture either - extends into the joint from without or it extends from the - joint outward. As example, the ankle joint; the majority of - the typical supramalleolar, malleolar, and spiral fractures of - the tibia and fibula. - -+Etiology.+ Fractures may be divided into two groups: the _traumatic_ -and the _pathologic_ or _spontaneous_. In the traumatic, the fracture -is the result of violence acting upon a bone which is either normal or -shows slight changes due to the physiologic causes mentioned. A -pathologic or spontaneous fracture is one which occurs in a bone, the -strength of which has been diminished by some preceding abnormal or -pathologic changes. In this variety the degree of force which produced -the fracture would not be sufficient to cause a fracture in a healthy -bone. - -The causes of traumatic fractures may be either predisposing or -exciting. - -+Predisposing Causes.+ The bones of the human body attain their greatest -strength toward middle age. From infancy up to that time the bones are -very elastic and yielding. Toward old age an interstitial atrophy -occurs. It causes a thinning of the cortex of the shafts and of the -trabeculae of the spongy portions of the long and short bones. It is -an actual diminution of the bone substance and a corresponding -increase of the fat. This is especially seen in the neck of the femur. -When it occurs in old age, it acts as a predisposing cause, but when -it occurs prematurely or reaches an extreme degree, it must be -considered as pathologic. - - -EXISTING OR DETERMINING CAUSES OF FRACTURES - -+Fractures by External Violence+ are divided both clinically and from a -mechanic standpoint into two classes: _direct_ and _indirect_. In -fractures by direct violence the bone breaks immediately under the -point where the force has been applied. In this class of fractures -there is more damage to the soft tissues and this damage is generally -more serious than in indirect fractures. Direct fractures are more -likely to occur in exposed bones like the clavicle, os calcis, etc. - -An example of fracture by direct violence is found in fractures of the -tarsal bones after a fall upon the feet from a height. - -Under the head of fractures by indirect violence belong (a) those -which occur as the result of a rotary or twisting force (spiral -fracture of the tibia or fibula, for example); (b) those which are -produced by compression; (for example, a fall upon the feet may cause -an impacted fracture of the upper end of the tibia); (c) those which -are the result of a tearing force. - -Fractures resulting from a tearing force occur when a joint is -suddenly moved beyond its normal range of excursion. The firmly -attached ligaments being a fixed point, the ends or some process of -the bones composing the joint are torn off from the remainder of the -bone. Examples of this are fractures of the internal or external -malleoli, following forcible eversion or inversion of the foot. - -Fractures are also caused by muscular action and by gunshot injuries. - -+Pathologic+ (spontaneous fractures): - - 1. Fractures resulting from bone fragility of local origin as - for example, tumors, osteomyelitis, aneurisms. - - 2. Fractures resulting from bone fragility due to some general - disease, as for example, tabes dorsalis, paresis, rachitis, - osteomalacia, and exhausting chronic diseases. - - - CLASSIFICATION AND RELATION OF FRACTURES TO THE OVERLYING SKIN - -Fractures are divided into _compound_, or _open_ and _simple_, or -_subcutaneous_, according to whether a communication does or does not -exist between the seat of fracture and a wound of the skin. - -A compound fracture is one in which the cutaneous wound communicates -with the seat of the fracture. - -A simple fracture is one in which a wound of the skin is absent, or, -if present, no communication exists between it and the seat of the -fracture. - -The majority of compound fractures are the result of direct violence, -and the injuries of the soft parts, are, as a rule, far more extensive -and serious than in a simple fracture. A fracture which is simple at -first, may become compound as a result of necrosis of the skin lying -over it; or as a consequence of the original injury; or of pressure -upon it by a displaced fragment; or by penetration of the skin, in -efforts to use the limb. - - -FURTHER CLASSIFICATION OF FRACTURES - -+Fracture.+ In the ordinary use of the term "fracture" is understood to -indicate a _complete_ or _incomplete_ separation of the bone into two -or more fragments, the lines of which are continuous with each other. - -+Multiple Fracture.+ The term _multiple fracture_ is applied to the -simultaneous fracture of two or more non-adjacent bones, and also to -those cases in which two or more fractures of the same bone exist, and -the lines are not continuous with each other. Such multiple fractures -are usually the result of direct violence. - -+Complicated Fracture.+ When a fracture is accompanied by injuries of -the viscera, nerves, etc., the term _complicated fracture_ is applied. -Such a fracture may be simple or compound. The term complicated, as -ordinarily employed, is limited to those fractures which are -accompanied by local, rather than by general complications. - -+Symptoms of a Recent Fracture.+ In the examination of a patient who has -sustained a recent fracture, procedure should be as follows: the -history of the patient and of the accident should be taken; an -examination should be made for objective signs, like deformity, -abnormal mobility, crepitus, and ecchymosis; subjective symptoms, such -as pain and loss of function of the limb should be ascertained; an -X-ray picture should be taken and every possible precaution observed -to exclude distortion or exaggeration. - -+Treatment of Fractures.+ _First Aid._ The treatment of fracture may be -said to begin from the moment of its occurrence. Much can be done for -the comfort of the patient and correct union of the fracture by -intelligent treatment during the first hours. - -The proper temporary fixation of the limb, the mode of transportation, -and the removal of the clothing, all require special mention. - -The use of first aid dressings, those which can be used until more -permanent and suitable ones can be applied, varies, of course, with -the individual bone affected. In fractures of the tibia, fibula and -foot, as well as in those of the lower half of the femur, the use of -the blanket splint will be found of great aid. Instead of a blanket, a -long pillow or soft cushion can be employed in the same manner. - -The "blanket splint" can be readily made by folding a blanket in such -a manner that it extends from the middle of the injured thigh to below -the foot. Two pieces of narrow, strong board, or better still, two -broomsticks are rolled up in the blanket, one at either end. The -rolled-up blanket is now turned in so that the board supports with -their enveloping turns of blanket, lie upon the posterior surface. -Thus, a trough is formed in which the limb is placed and firmly -secured by loops of bandage, one below the foot, the second just above -the ankle, the third below the knee, and the fourth near the upper end -of the blanket. - -In fractures of the leg, after the application of the emergency -splint, the patient should be transported in a recumbent position, the -support being as firm as possible, a wide board, shutter or a wooden -rail being preferable. If such supports are not at hand, and the -patient is to be moved without their use, the persons transporting the -invalid should be distributed in the following manner: one supporting -the head and shoulders, a second the pelvis, and the third the two -limbs. - -+Reduction.+ The reduction of a fracture is the effort made by the -surgeon to overcome any tendency to displacement, and thus to place -the fragments in such close apposition that an accurate and firm union -is possible. The best time in general for the reduction of a fracture -is as soon as possible after the accident, if the patient's general -condition will permit. If there is marked displacement of fragments, -so that there is danger of necrosis of the overlying skin or of damage -to the adjacent vessels or nerves, an early reduction is imperative. - -In all cases in which reduction is very painful or difficult, whether -performed shortly after the accident or at a later period, it is best -to administer an anesthetic to overcome muscular contraction and to -decrease the amount of pain. After reduction of a fracture, retentive -apparatus is indicated in order to maintain apposition. In the use of -dressings there will be two kinds, those which are temporary and those -which are permanent. The former are employed where the swelling of the -limb is such that some dressing can be employed which will not cause -pressure. - -Certain general principles should be followed in the use of splints; -for instance, a splint, after being applied, should not interfere with -the circulation, allowance always being made for the swelling of the -limb, which almost invariably occurs during the first week. The -splint, if flat, should be wide enough to obviate the possibility of -pressure against the point of fracture; also, it should project a -little beyond the limb. - -In general, it is best to immobilize the adjacent joints, above and -below the seat of fracture, but no dressing should be permitted to -remain so long as to produce stiffness of the joints and muscular -atrophy. - -The skin, even in simple fractures, must be cleansed with green soap, -water and alcohol. If blebs or an area of threatening necrosis of the -skin exist, they should be freely dusted with powdered boric acid and -a few layers of aseptic gauze applied. - -The form of retentive apparatus to be employed will vary, of course, -with the individual bone requiring treatment. - -The most important articles of a fracture equipment are as follows: - - 1. Plaster of Paris bandages for making molded splints and - circular casts. - - 2. A stock of basswood, three-sixteenths of an inch thick, for - making wooden splints. - - 3. An assortment of metal splints or materials for making - them. - - 4. Muslin for bandages and slings. - - 5. Five yard rolls of ordinary and zinc oxide adhesive - plaster, three inches wide. - - 6. Cotton batting and sheet wadding for padding splints. - - 7. Strips of tin or thin cypress for strengthening plaster - casts. - -The selection of a dressing for the immobilization of a fracture -depends upon, _first_, the particular bone involved and whether -apposition can be maintained with or without extension; _second_, -whether great swelling be present or not; _third_, whether the -fracture be simple or compound; and _last_, whether ambulatory -treatment be preferable to that in the recumbent position. This latter -applies, of course, only to fractures of the lower extremity. - -+Operative Treatment of Simple Fractures.+ Operative treatment of a -recent simple fracture is indicated in general, when reduction cannot -be completely made; when correct apposition cannot be maintained; when -there is interposition of bone or soft parts; when the fracture is a -spiral one with considerable displacement of the fragments; when -fragments are rotated upon each other, and when there are multiple -fractures. - -The most favorable time to operate in recent simple fractures is at -the end of the first or beginning of the second week. At this time the -process of callus formation is most active. The blood clots and loose -shreds of tissue have begun to be absorbed, so that the fragments are -more easily accessible. - -+Methods of Fixation of the Fragments.+ In the majority of cases the -reposition of the fragments alone is not sufficient to maintain -accurate apposition. It is usually necessary to employ some means of -mechanical fixation. In all the methods employed, the preparation of -the parts is the same as for any aseptic operation. The opportunity -for serious complications resulting from septic infection, is greater -than in any other class of operations. It is for this reason that -extraordinary caution must be exercised. The incision should be large -enough to expose the seat of the fracture thoroughly. - -The materials used to secure fixation are: absorbable sutures, such as -chromicized catgut or kangaroo tendon; metal suture of silver or -bronze aluminum wire; screws, nails, plates, clamps, etc. - -+Injuries in the Vicinity of the Ankle Joint.+ In the examination of a -patient who shows evidence of injury in the vicinity of the ankle -joint, such as swelling, deformity, loss of function, etc., the -following conditions must be thought of, in the order given: - - 1. Fractures of the lower ends of the tibia and fibula - (Pott's Fracture). - 2. Dislocation at or near the ankle. - 3. Fractures of the tarsal bones. - 4. Rupture of the tendon Achillis. - 5. Sprains of the ankle. - -+Fractures of the Lower Ends of the Tibia and Fibula.+ Commonly given -the name of _Pott's Fracture_. They may be the result either of -forcible abduction or eversion of the foot, or of inversion or -adduction. If the sole or main movement is eversion, the _internal_ -malleolus is broken, and if the force continues to act, it also causes -the _external_ malleolus to be broken. In the second variety, fracture -by inversion, the first effect of the force is to break the fibula at -the external malleolus. If the movement continues, the internal -malleolus or a greater portion of the tibia is broken off. - -+Diagnosis.+ The diagnosis is usually easy to make. The ankle joint is -greatly swollen, the depression, normally present in front of and -behind the malleoli, being obliterated. The foot is displaced outward, -and the internal malleolus is prominent. This deformity will often -persist and become a cause of disability after healing of the -fracture. - -There is also backward displacement of the foot. These displacements -may be so marked as, at first glance, to resemble a true dislocation -of the ankle. - -Abnormal lateral and anteroposterior mobility may be ascertained by -grasping the sole of the foot with one hand and moving it inward and -outward, or backward and forward, while the other hand steadies the -leg. There is great tenderness between the tibia and fibula at the -front of the ankle, and over the points of fracture in the malleoli. - -If the fibula alone be broken, abnormal mobility and crepitus may be -elicited by pressing its tip inward with the index finger of the one -hand while a finger of the other hand is placed at the seat of -fracture. - -In some cases of Pott's fracture the foot will move inward instead of -outward. The degree of outward displacement can be measured by the -difference in the distance from the front of the ankle to the cleft -between the first and second toes, as measured on the sound and -injured foot. There is not always complete loss of function. In -fractures of the external malleolus alone, the patient may walk quite -well. - -+Treatment of Fractures of the Leg.+ The treatment of a simple fracture -of one or of both bones of the leg depends _first_, upon whether or -not swelling is present, and _second_, upon the amount of displacement -of fragments and our ability to keep them in apposition after -reduction. If the case is seen within a few hours after the injury and -but little, if any, swelling be present, the following is a perfectly -safe and justifiable method of treatment: - -The limb is wrapped with strips of sheet-wadding from the toes to the -middle of the thigh, and a circular plaster of Paris cast is applied -extending over the same area. Before the cast is dry, it is cut open -along the median line, in front, to allow for any swelling. The cast -is best applied while the patient is under the influence of an -anesthetic, so as to permit reduction of the fragments by traction -upon the foot. In from ten days to two weeks the cast should be -removed and a fresh one applied. The second cast does not require to -be cut open, and can be left on the limb until the end of the fourth -week. It is then removed and if union be complete, no further cast -need be worn. Massage of the limb and passive and active motion are -now begun. - -+Fractures of the Tarsal Bones.+ Fractures of these bones have been -found far more frequently than was thought before the use of the -X-ray. Many cases of tarsal fracture have been treated for sprains of -the ankle. It is only when the recovery is slow or the injury is -followed by a traumatic flat foot that the surgeon begins to suspect -that a more serious condition was present at the time of the original -injury. - -The astragalus and os calcis are the tarsal bones that are usually -affected. Fractures of the os calcis, in the majority of cases, are -due to compression. The patient falls from a height to the ground, on -a hard substance. The os calcis is crushed between the astragalus and -the ground. - -There are three general types of fracture of the os calcis: - - 1. That in which the fracture has been confined largely to - that portion lying behind a vertical plane through the middle - of the body of the astragalus. There are three varieties of - this heel fragment type: (_a_) cases with one large heel - fragment; (_b_) cases of small heel fragments (in this - variety, also called avulsion fracture, the sudden contraction - of the calf muscles pulls the fragment off; at times the tendo - Achillis itself is torn off from the attachment to the os - calcis at the same time); (_c_) cases showing only fissures in - the bone. - - 2. Comminution of the anterior half of the os calcis. - - 3. All the cases of extensive comminution of the bones; the - bone is literally shattered. - -+Fractures of the Astragalus.+ These can be divided into: (_a_) those of -the neck; (_b_) those of the body. The former are the most common -fractures of the astragalus. They may follow sudden dorsal flexion, or -forced supination, or pronation of the foot. They may be due to a fall -from a height or from direct violence. Fractures of the body of the -astragalus are usually the result of a crushing force which ordinarily -have a like effect on the body of the os calcis, and are often -associated with fractures of the latter bone. The variety of fractures -is considerable, varying from two large fragments, to complete -comminution of the bone. - -A fact of considerable importance in the interpretation of skiagraphs -of fractures of the astragalus, is a knowledge of the presence in many -normal individuals of a little bone known as the _os trigonum_. It may -occur detached from the astragalus or may be attached to it as a -process, on its posterior aspect, and on account of the swelling and -pain around the ankle, a diagnosis can seldom be made without the -routine use of the X-ray in every injury in this region. - -The swelling, with obliteration of the depressions normally present -around the ankle, does not differ from that characteristic of a sprain -of the ankle or of a Pott's fracture. If there is extensive -comminution of the os calcis or astragalus, the malleoli may be a -little lower than normal. - -The X-ray must always remain our most reliable means of diagnosis at -the time of the injury. At a later period the chief symptoms are a -painful flat foot, ankylosis of the ankle joint, pain and difficulty -in pronating and supinating the foot. - -The prognosis of fractures of the tarsal bones is not favorable, even -though the lesion has been recognized at the time of injury. Even in -the most favorable cases there is some limitation of lateral motion. -The outlook is better in those cases of fracture of the os calcis in -which there is a large heel fragment, than if the fracture is -comminuted. The most frequent sequel is stiffness of the ankle-joint -and traumatic pes valgus. Infection is frequent in compound fractures. - -+Treatment.+ This does not differ from that of a Pott's fracture until -the greater part of the swelling has disappeared. The skin of the foot -and lower portion of the leg should be thoroughly cleansed and covered -with gauze. This is necessary on account of the possibility of -necrosis of the skin of the heel, and the danger of infection of the -bruised soft tissues around the heel. - -The foot should be placed in a well-padded box or in a posterior -splint of the Volkman type. Ice bags should be applied over the sides -of the heel. - -After from eight to ten days, a circular plaster cast can be applied, -extending from the toes to the knee. An anesthetic should be given -during the application of the cast, the foot being held flexed at -right angles and sheet wadding freely used around the ankle. The cast -should be worn for seven weeks. At the end of this time the patient is -gradually permitted to step upon the injured foot. Passive and active -motion are also now employed. - -Fractures of the neck of the astragalus, with rotation of the -posterior fragment, are usually followed by great limitation of the -movements of the ankle joint. This condition might be greatly improved -by an open operation. - -+Fractures of the Metatarsal Bones.+ These are usually due to direct -violence, as occurs when a heavy weight falls upon the dorsum of the -foot. Another example of direct violence is a fracture following a -crushing injury, as in being run over. - -In indirect violence, such as follows dancing, jumping, or sudden -twists of the foot, the fifth metatarsal bone is the one most often -involved. There is but little tendency to displacement except when -several bones are broken at the same time, and then it is toward the -dorsum of the foot. - -The diagnosis in fractures produced by direct violence is made from -the following: presence of severe localized pain; swelling; and, not -infrequently, crepitus and abnormal mobility. In those fractures due -to indirect violence (second, third and fifth metatarsals), there is -pain when the patient endeavors to put pressure upon the toes or tries -to invert the foot. The usual signs of fracture are absent. A -skiagraph should be made in every case. - -Fracture of the metatarsal bones is liable to be followed by traumatic -flat foot, on account of the sinking of the arch, or painful large -calluses forming on the sole of the foot may interfere with walking. - -+Treatment.+ The treatment in such fractures is by immobilization in a -posterior metal or plaster splint, for four weeks. If there is -continual pain upon walking after the injury, a steel insole will -often give relief. The treatment of compound fractures of the -metatarsal bones does not differ from that of other bones. - -+Dislocations.+ A dislocation is a displacement from each other of the -articular ends of the bones which enter into the formation of a joint. -A diagnosis can usually be made from certain objective and subjective -symptoms, taken in conjunction with an accurate history of the manner -in which the accident occurred. - -Examination should be made in a systematic manner in every case, us -follows: - -(1) _Inspection._ The limb should be first inspected to note the -position, the alterations of contour, or of the axis of the limb, or -the projection or absence of certain bony prominences. The position is -often so characteristic that a diagnosis can be made by inspection -alone. - -(2) _Palpation._ By this one can learn the relation of the displaced -articular ends to each other, unless the swelling is too great, or -the patient is very stout. This method also enables one to ascertain -the absence of normal prominences or the presence of abnormal ones. -The end of the displaced bone may be felt in an abnormal position. - -(3) _Measurement._ The limb may only appear to be or is actually -shortened. In the latter event the normal measurements between bony -prominences will be altered. - -(4) _A skiagraph_ should be made in all doubtful cases to confirm the -diagnosis of dislocation, and also to ascertain whether there is an -accompanying fracture. - -When the patient is stout, or when considerable swelling exists the -use of the X-ray is of especial value. - -The attitude of the limb is often so characteristic that simple -inspection will enable one to make a diagnosis by this means alone. In -stout persons, a change in the axis of the limb or a change in -position is apt to be overlooked. The relation of the articular -surfaces can be determined by palpation, unless the swelling is too -great. Measurement of the limb will usually show a shortening, -depending upon the position in which the limb is held. The movements -of a dislocated joint are usually limited. If any movement of the end -of one of the bones is felt, it is always at an abnormal point. Pain -is referred to the dislocated joint and the patient is unable to use -the limb. - -+Treatment.+ As a rule, a dislocation should be reduced as soon as the -diagnosis is made, and, if necessary, an anesthetic should be -administered. - -When reduction has been accomplished, the bone often goes back with a -snap, the contour of the limb is restored, and the movements of the -joint are free again. - -If it is impossible to reduce a recent dislocation, the following -obstacles must be considered: (_a_) interposed portions of the -capsule; (_b_) interposed muscles or tendons or sesamoid bones; (_c_) -torn off fragments of bone; (_d_) a fracture of the shaft close to its -articular end, which would prevent its being used as a lever for -reduction. - -The after-treatment of a dislocation is usually quite simple. A -bandage or splint should be applied, which will keep the joint -immobilized for a period of two weeks, after which passive motion and -massage can be begun for fifteen minutes twice daily, the splint or -bandage then to be reapplied for another two weeks. - - -+DISLOCATIONS AT THE ANKLE JOINT+ - -+Backward Dislocations+ occur more frequently than those in a forward -direction. - -The injury usually is the result of a fall backward while the foot is -flexed. This causes an extreme plantar flexion of the foot. The -astragalus, and with it the foot, is displaced backward. The lateral -ligaments are usually extensively torn. In the majority of cases there -is an accompanying fracture of either one or both malleoli or of the -shaft of the fibula. - -+Diagnosis.+ The front portion of the foot is shortened while the heel -is more prominent than normal. The lower end of the tibia protrudes -over the dorsum of the foot and the sharp edge of its articular -surface can be distinctly felt. The extensor tendons and the tendo -Achillis are tense and prominent. It may be distinguished from a -supramalleolar fracture by the fact that the malleoli in the latter -have moved backward with the foot, while in a dislocation backward -they are prominent at some distance in front of the heel. - -+Treatment.+ Reduction is usually effected by forced plantar flexion, -the foot being pulled forward and the lower end of the tibia being -pushed backward. These steps are then followed by dorsal flexion of -the foot. - -After reduction, the leg should be immobilized for three weeks in a -molded posterior splint. Light passive motion can be begun during the -fourth week. In old unreduced cases an arthrotomy is indicated. - -+Forward Dislocations.+ These are much rarer than the backward form. -They are usually due to a forced dorsal flexion of the foot. This form -is less often accompanied by a fracture of the malleoli than is the -case in the backward dislocation. The fibula is seldom broken, the -usual seat of the fracture being in the tip of the internal malleolus -or in the articular surface of the tibia. - -+Diagnosis.+ The whole foot appears to be lengthened. The prominence due -to the heel has disappeared; the upper articular surface of the -astragalus can be felt, the tibia and the malleoli being nearer to the -heel. - -The condition can be differentiated from a fracture of both bones of -the leg above the malleoli by the fact that in a forward dislocation -the malleoli are further back than normal, while in a supramalleolar -fracture they have moved forward with the foot. - -+Treatment.+ Reduction is readily effected by marked dorsal flexion of -the foot, pressure being made in a forward direction upon the lower -end of the tibia, and the foot pushed backward. Plantar flexion now -completes the reduction. The after treatment is the same as in the -backward form. - -+Lateral Dislocations.+ The other forms of dislocations seen in the -ankle are those in a lateral direction, either inward or outward. The -diagnosis is usually easy. The upper convex surface of the astragalus -is directed toward the external malleolus and can be felt there. The -inner border of the foot is raised; the outer rests upon the bed. - -This form of dislocation is very frequently a compound one, or it is -accompanied by fractures of the bones of the leg or of the astragalus; -but it may occur without these injuries. - -+Treatment.+ The treatment of these lateral dislocations differs but -little from that of fractures of the lower end of the tibia and -fibula. Reduction is effected by adduction or abduction of the foot. -The chief danger is from infection on account of the extensive injury -of the skin and soft parts. If reduction is impossible, perform an -arthrotomy. - -+Subastragaloid Dislocation.+ Two forms of dislocation can occur in the -joint between the astragalus and the two tarsal bones (os calcis and -scaphoid) with which it articulates. In the true subastragaloid form, -the astragalus continues to articulate with the tibia and fibula, but -it is displaced from its articulation with the os calcis and scaphoid. -In the second form of subastragaloid dislocation, the astragalus is -completely separated from its articulation with the bones of the leg -as well as with the calcaneus and scaphoid. To this form the name -total dislocation of the astragalus is given. - -+True Subastragaloid Dislocations.+ These dislocations may occur in four -directions, inward, outward, forward, and backward. - -_Dislocation inward._ The most frequent cause is a forcible adduction -of the foot combined with violence acting in the direction of the long -axis of the foot. The diagnosis can be made from the position of the -foot. The foot is adducted and rotated inward, as in a case of -clubfoot. The sole of the foot is directed inward. The inner edge of -the foot is concave and shortened while the outer edge appears -lengthened. The external malleolus and head of the astragalus are very -prominent on the outer side of the foot. Below and behind the inner -malleolus the scaphoid projects beneath the skin. - -_Dislocation Outward._ This occurs after forced adduction of the foot. -The symptoms are the opposite of those of the inward variety. The foot -is in the position of a flat foot, its inner edge depressed and outer -edge raised. The inner malleolus is close to the sole of the foot, and -in front of it the head of the astragalus forms a prominence. The -injury is not infrequently compound, so that the astragalus presents -into the wound. - -_Dislocation Backward._ The cause is usually a plantar flexion of the -foot. The signs are very pronounced; the head of the astragalus can be -seen and felt lying upon the upper surface of the scaphoid and -cuneiform bones. The anterior portion of the foot is shortened while -the heel is lengthened and the tendo Achillis is very prominent. - -_Dislocation Forward._ This follows forced dorsal flexion of the foot, -the patient falling forward after landing with his heels upon the -ground. The diagnosis can be made because of the lengthened anterior -portion of the foot and the shortened heel. An important point in the -diagnosis of subastragaloid dislocation is the absence of any -prominence due to the projection of the body of the astragalus, in -front, behind, or to either side of the malleoli, as is seen in the -case of the tibiotarsal dislocations. A second diagnostic point is the -abnormal position of the calcaneus and scaphoid with relation to the -malleoli and astragalus. The swelling is usually so great that a -diagnosis is very difficult without the use of the X-ray. - -+Treatment of Subastragaloid Dislocations.+ Reduction can usually be -effected in recent cases by manipulation and traction. In the inward -variety the existing adduction is at first increased. Pressure is now -made over the outer side of the adduction and the inner side of the -foot, and the foot is then strongly abducted. In the outward variety, -the abduction is first increased. Pressure is then made over the outer -side of the foot until reduction is effected. In the backward variety, -the plantar flexion is first increased and the foot is then strongly -flexed in the opposite direction. In the forward type, forced dorsal -flexion will effect reduction. The foot should be placed upon a -posterior molded splint for three weeks, after which passive motions -are begun. If the reduction is impossible, an arthrotomy with excision -of the astragalus may be necessary. - -+Total Dislocation of the Astragalus.+ This form of dislocation is much -more frequent than those of the ankle joint proper, or of the -articulation between the astragalus, calcaneus, and scaphoid. The -displacement of the astragalus may occur in one of six directions: -forward; outward and forward; inward and forward; inward; backward, -and by rotation. - -The most frequent variety is the "outward and forward." In this -variety the foot is rotated markedly inward and the external malleolus -is very prominent. The foot is in a clubfoot position. The dislocated -astragalus can be felt as an irregular angular bone just below the -external malleolus. - -+Treatment+ is the same as in subastragaloid dislocations. - -+Dislocation of the Metatarsal Bones.+ This may be either complete or -incomplete at Lisfranc's joint. It occurs most often in an upward -direction. The dorsum of the foot is more convex than normal, while -the sole of the foot is flattened. One can see and feel the displaced -ends (upper) of the metatarsals on the dorsum of the foot. The foot is -shortened and the toes point inward. - -Dislocations of the individual metatarsal bones are much rarer. The -middle ones are displaced upward, and the first and fifth, inward and -outward respectively. - -+Dislocation of the Toes.+ This occurs most often in the -metatarsophalangeal joint of the great toe after forcible flexion. The -dislocation may be complete or incomplete. In the former case, the -proximal end of the first phalanx and the dorsum of the foot are -prominent, and the head of the metatarsal bone projects on the sole of -the foot. The reduction of toe dislocations presents no difficulties. - - -+SPRAINS+ - -+Definition.+ A sprain is a joint wrench due to a sudden twist or -traction, the ligaments being pulled upon or lacerated and the -surrounding parts being more or less damaged. - -+Sprains of the Ankle.+ On account of its flexibility and constant use -in weight-bearing, the ankle is the joint most frequently sprained. - -Sprains are common in a limb with weak muscles; in a deformed -extremity in which the muscles act in unnatural lines, and in a joint -with relaxed ligaments. - -A joint, once sprained, is very liable to a repetition of the damage -from slight force. - -+Symptoms.+ The symptoms manifested in a sprain are as follows: severe -pain in the joint; nausea and sometimes syncope; impairment, or loss -of motion; severe pain upon motion; early swelling if hemorrhage is -severe--in any case swelling begins in a few hours; movement of the -joint becomes difficult or impossible; the tear in the ligament may -be distinctly felt; in a day or two pain and tenderness become intense -and discoloration becomes marked. - -+Diagnosis.+ Usually the diagnosis is easy to make, but in all doubtful -cases an X-ray picture should be taken in order to be certain that a -fracture does not exist. - -+Treatment.+ The first indication is to arrest hemorrhage and to limit -inflammation. For the first few hours apply pressure and an ice-bag. -Wrap the joint in absorbent cotton, wet with iced water; apply a wet -gauze bandage, and put on an ice bag. - -In a mild sprain, use lead and opium wash. In a severe sprain, place -the extremity upon a splint and apply to the joint flannel kept wet -with lead-water and laudanum, iced water, tincture of arnica or -alcohol and water. If the pain is severe, a small dose of morphine -should be given. - -Judicious bandaging limits the swelling. When the acute symptoms begin -to subside, rub stimulating liniments, such as chloroform or arnica, -upon the joint once or twice a day and employ firm compression by -means of a bandage of flannel or rubber. Later in the case use hot and -cold douches, massage, passive motion and the bandage. - -Another method of treatment of sprains of the ankle is by strapping -with adhesive plaster, but it is advisable only for slight injuries. -In severe cases, in which extensive laceration of the ligaments is -suspected from the marked extravasation, it is best to immobilize the -foot in a plaster-of-Paris splint for two weeks; later baking in a -hot-air oven (see "Arterial Hyperemia") with massage, and active and -passive motion are advisable. - -In simple sprains, the fixation does not produce serious stiffness, -and without fixation the repair of the ligaments is only partial. In -the latter case, the result is weakness of the ligaments and an -instability of the foot which leads to frequent recurrence. This -explains many habitual sprains. On the other hand, under appropriate -treatment, a sprain should recover without leaving any functional -disturbance. - - - - -CHAPTER XVII - -+DEFORMITIES+ - - -+PES PLANUS, OR FLAT FOOT+ - -The terms _weak foot_ and _flat foot_ will be used to designate the -_mild_ and the _severe_ forms of the same condition which include all -the deviations from the normal height of the arch of the foot. - -+Flat Foot+ may be congenital or acquired, the former being a very -infrequent deformity, and the latter one of the most common pathologic -conditions. - -+Congenital Flat Foot+ is a deformity of infrequent occurrence, and in -some cases is associated with defective formation of the bones of the -foot. In this condition the whole foot is displaced outward in -relation to the leg; the sole is rolled outward, the inner malleolus -is prominent and the foot is abducted on itself, and in severe cases, -it cannot be replaced in its normal position on account of the -contracted tissues. - -+Treatment.+ The foot should be massaged and, by gentle manipulation, -forced into its proper position and held by a plaster-of-Paris -dressing, changed at the proper intervals. A tenotomy may be required -to bring the foot into its proper position. - -When the child begins to walk, a well-fitting arch support should be -worn. - -+Acquired Flat Foot.+ The common form of acquired flat foot is the -static variety, which is an expression of a disproportion between the -body weight and the sustaining power of the muscles and ligaments. - -+Common Causes.+ 1. The use of improper shoes is by all means the most -frequent cause of flat foot, and frequently makes all of the following -causes more pronounced. - -2. Weakness and insufficiency of the muscles, resulting from poor -general condition; advancing age; convalescence from acute illness; -from childbirth; and from injuries of the leg, especially fractures. - -3. Prolonged standing, especially on hard wood and stone floors. - -4. Rapid body growth. - -5. Rapid increase in body weight. - -6. Excessive weight bearing. - -7. Shortened condition of the gastrocnemius muscle. - -Other causes are rickets; inflammation of the ankle joint, as in -tuberculosis; or, as a result of a badly treated fracture of the -ankle-joint; or, as a result of paralysis of the muscles of the inner -side of the leg. - -+Pathology of Acquired Flat Foot.+ The pathologic condition is due to -change in the relations of the bones rather than to any change in the -bones themselves. The abnormal position is an exaggeration of the -normal yielding of the foot under weight bearing. The front of the -astragalus rotates inward, and with it the bones of the leg turn at -the hip-joint. - -The deformity is essentially a displacement of the astragalus on the -bones of the tarsus. The scaphoid, cuneiform, and the base of the -first metatarsal move downward and inward with the head of the -astragalus; the outer border of the foot is made more concave and the -inner border becomes convex in extreme cases. In the severest cases, -the head of the astragalus, and scaphoid may be displaced below the -plane of the other bones. The ligaments are respectively shortened and -stretched in the severest cases and there is a loss of motion in -certain of the tarsal articulations, due to faulty apposition of joint -surfaces, and to constant strain. - -+Symptoms.+ The feet burn and tire easily and feel stiff and lame. They -may swell, and the size of the shoe worn must be then increased. -Later, a painful period generally begins in which walking is avoided -and a dragging pain in the arch and behind the inner malleolus is -noticed. This is increased by walking and standing and tender points -may be found under the scaphoid and on the upper surface of the heel. -The foot feels strained and irritated and is a constant source of -discomfort. The inner malleolus is generally more prominent and the -foot is displaced outward in relation to the leg. The height of the -arch is somewhat diminished; it may be much lowered, or it may be flat -on the ground. - -When the foot is really flattened, it presents two types, one the -_flexible flat foot_, in which the arch can be restored by gentle -manipulation; the other, the _rigid foot_, which is held by structural -changes in the position of deformity. - -An intermediate type is sometimes seen, in which the peroneal spasm is -so great that the foot is held abducted and everted as long as the -spasm lasts (spastic flat foot.) - -Some symptoms of flat foot that are less generally recognized, which -are of great value in diagnosis are: corns, ingrowing nails, -callosities on the sole of the front of the foot, enlargement of the -great-toe joint, and pain (especially at night) in the calves of the -legs and backbone, which is aggravated by standing and walking. - -+Diagnosis.+ The diagnosis of flat foot, whether flexible or rigid, is -made chiefly by inspection. The difficulty comes in the milder cases, -which form the bulk of those seen, and in which the changes in form -are slight. - -+Symptoms.+ The symptoms, as described by the patient, are the most -reliable and points of tenderness under the arch or heel would help to -confirm the diagnosis. Some help may be obtained from a wet impression -of the foot, on a piece of paper, but the slighter cases show but -little changes in the imprint. In most normal feet, the outer border -of the foot touches the paper, and in flat foot, only two areas bear -the weight, one on the inner side of the front of the foot, and one -under the inner part of the heel. An X-ray picture is often of great -assistance. - -The diagnosis of rheumatism is frequently made in flat foot, and is -often the source of much misdirected treatment. Rheumatism should be -diagnosed only in connection with unmistakable symptoms of rheumatism -in the upper extremities. - -So-called "rheumatic" pains in the knees and hips may be secondary to -flat foot. - -+Prognosis.+ As a rule, this condition does not recover spontaneously. -Under ordinary conditions, uncomplicated cases should be at once -relieved by proper treatment, and in time should be cured. - -Unfavorable factors are: great weight; disease of the ankle-joint; the -presence of bony spurs under the os calcis. - -The prognosis is more favorable in young adults than in persons of -advanced age. Patients, who without relief have worn the ordinary -supports sold at the stores will, as a rule, manifest extreme -sensitiveness as to the fit of any of the supports which may be -applied. - -+Treatment.+ The foot must be restored and held in its normal position -and measures must be adopted to quiet local irritability or -inflammation, and to strengthen the muscles. The best treatment does -not consist in the permanent wearing of a flat-foot support; the -support should be regarded in the same light as one uses a crutch in a -fracture of the leg. - -As a preliminary to all treatment, the use of proper shoes must be -insisted upon. A shoe should be as wide in front, as the unshod foot, -when bearing the weight of the body. - -+Supports.+ Flexible supports may be made of boiler felt; one objection -to these is their liability to stretch. They are of service in young -children, in mild cases, and in convalescent cases where it is -desirable to have the patient use a flexible instead of a stiff -support in order to bring the muscles into play. - -Rigid supports are best made of tempered spring steel (18 to 20 -gage), forged hot to fit a cast of the foot. They may also be made of -phosphor-bronz, celluloid or aluminum. - -The shape of the plate is largely a matter of judgment. The easiest -way to determine the shape of the plate to be used in a given case is -to have the patient stand with the operator's hand under the inner -side of the foot; the operator then places the foot in the normal -position and notes where the pressure must be applied to secure the -proper correction; when the anterior part of the foot is flattened, a -slight dome must be constructed in the front of the plate; when the os -calcis is clearly tilted over, the plate must have two flanges at the -heel to hold it in place. In general, the plate must reach forward to -a point just behind the great-toe joint, and must furnish support as -far as the front of the heel. The plate should be higher on the inner -side, and a flange formation is generally necessary to accomplish -this. An outer flange prevents the foot from slipping off the outer -side of the plate. When the foot no longer requires support, the plate -should be gradually discontinued. - -The "Thomas" sole may be used in mild cases. This is made by building -up the inner part of the sole of the shoe one-eighth to one-quarter of -an inch higher than the outer side, thus securing a slight inversion -of the foot. - -Exercise and massage of the deficient muscles should form a part of -the routine treatment in all cases of flexible flat foot. - -To diminish local inflammation and irritability, the foot should be -soaked in hot water; hot and cold alternate douches should be applied, -and hot-air treatment and massage should be employed. - -+Rigid Flat Foot.+ Rigid flat foot cannot be successfully treated until -the position of the foot is corrected. The patient should be -anesthetized, and, by the use of a wedge as a fulcrum, the bones -should be forced into position. A pressure of about two hundred pounds -is generally necessary to effect this reduction. After this, the foot -is placed in a plaster cast, in extreme adduction and is allowed to -remain thus encased for three weeks. After this, a properly fitted -plate should be worn. The results are usually satisfactory. - -+Operative Treatment.+ Cases that have resisted all other forms of -treatment, may be cured by the removal of a wedge-shaped piece of -bone, with the base downward and inward at the point of greatest -inward convexity, that is, in the neighborhood of the head of the -astragalus. Osteotomy of the front of the os calcis and neck of the -astragalus will at times be necessary for a radical cure. - -Many other operative procedures have been advised for flat foot and -they have been employed with varying successes. - -+Hallux Flexus or Hammertoe.+ The upward prominence of a toe (usually -the second or third) in a rigid position, is known as _hallux flexus_ -or _hammertoe_. In this condition the toe is flexed in its second -joint so that the end bears on the ground, while the junction between -the phalanges makes a prominence upward. Helomata and callosities may -develop on the end of the toe, but the chief discomfort is in the -disturbances which arise on the prominence which presses against the -side of the foot-gear. - -+Treatment.+ A knowledge of the forces at work will show how futile must -be any effort to correct this deformity by strapping or bandaging. -There is a shortening of the plantar fibres of the lateral ligament of -the joint. The trouble does not lie in the flexor tendons, as it -seems, and operations directed to this point fail. Even with incision -of the lateral ligaments, followed by the application of a splint, -recurrences are common and amputation must be the procedure. - -The condition described as hammertoe may exist in several or in all of -the toes, the great toe being least often involved. This occurs most -often as a result of wearing improper shoes, but is sometimes the -consequence of paralysis. - -+Flexed or Clawed Toes.+ Extreme flexion of all but the great toes -causes the weight to be borne by their dorsal aspect. In this -condition the toes, and especially the small ones, develop painful -helomata on the prominent joints, and the small toe may become the -source of great discomfort. - -+Treatment.+ Radical surgical measures are here indicated. Tenotomy or -amputation is essential to a cure. - -+Painful Heel.+ Painful heel is a suggestive but unscientific term -applied to tenderness of the under side of the heel. It is associated -with one of the following conditions: - - 1. Spurs running out from the under side of the os calcis - found by the aid of the X-ray. - - 2. Inflammation of the bursae under the os calcis. - - 3. Flat foot. - - 4. Gonorrhoea. - - 5. Focal infection. - -+Treatment.+ Where a spur of bone causes the unpleasant symptoms, the -excrescence should be excised. - -When focal infections are the primary cause of painful heel, operative -procedure to remove the source of infection is imperative and will -prove curative. - -Palliative measures are: massage, douches, hot air, a metal plate worn -under the painful area, rest. The back of the foot should be cut away -to relieve pressure. - -+Metatarsalgia--Morton's Disease.+ Metatarsalgia is characterized by an -acute pain, cramplike in character, occurring at the base of the third -or fourth toes. - -The pain comes on suddenly while the foot is in action, and is usually -accompanied by a "snapping of the bones." The pain is so acute that it -is not uncommon for the patient to seek relief by taking off the shoe -and rubbing the foot. - -In persons suffering with this condition it will be regularly noticed -that the weight is thrown upon the ball of the foot, on the -metatarsophalangeal joints, either because of a weak foot, or because -of a tendency of the toes to turn up. - -+Treatment.+ 1. Proper strapping to raise the arch and bring the ends of -the toes down. - -2. A pad across the ball of the foot _behind_ the metatarsal heads, -also brings the toes down. - -3. Recommend shoes, wide across the ball, with a higher or lower heel -than ordinary, as the case indicates. - -+Hallux Valgus.+ The term _hallux valgus_ is applied to a deviation or -displacement of the great toe outward, toward the outer border of the -foot. - -In normal feet, the line of the great toe when prolonged backward, -should pass through the centre of the heel. This relation in civilized -communities is seen only in the feet of infants. In adults it is -observable only in the bare-footed races. - -+Cause.+ It is frequently associated with flat foot, gout and -rheumatism, but it is primarily due to the use of inappropriate -foot-gear. It is only considered pathologic when the deviation is more -than fifteen degrees. - -+Pathology.+ The displacement outward (which reaches 30 to 40 degrees in -the average case and may reach 90 degrees) of the phalangeal part of -the great-toe joint, uncovers the inner part of the head of the -metartarsal bone, and here the cartilage degenerates, and the bone -becomes condensed at its outer part. The inner lateral ligament is -lengthened and thickened and the sesamoid bones become displaced -outward and are often thickened. - -Under the skin, at the inner and prominent aspect of the foot, is to -be found a bursa, which is liable to inflammation under pressure, and -is known as a bunion. The inflammation in this sac may extend to the -joint and thus disintegrate it. - -+Symptoms.+ The toe is displaced outward and a reddened and shiny -condition of the thickened skin exists over the inner prominence and -perhaps over the top of the toe joint. The great toe if seriously -displaced, must lie over or under the other toes, the former being the -more common position. In other cases the second toe may be crowded up -as a hammertoe. The joint is painful and the inner toes, being crowded -to the outer side of the foot, are the seat of corns and callosities. -Flat foot is frequently associated with this condition. - -+Treatment.+ In mild cases, the stocking should be split to allow a -separate stall for the great toe, and broad toed boots should be worn. -If flat foot exists, a support should be supplied for its aid in -restoring the position of the great toe. In severe cases, nothing -short of an operation is likely to be of value. A toe-post may be worn -for a time in mild cases. - -Amputation of the head of the metatarsal bone gives uniformly good -results. - -The toe is straightened and flexible; ankylosis with this operation -does not occur. - -In operations for hallux valgus there are two distinct purposes acting -as determining factors in making a choice in a given case as to which -is indicated. These are: (1)the radical operation for the correction -of the deformity, and (2)the palliative operation for the alleviation -of symptoms by the removal of the hypertrophied portion of the -metatarsal head which is exposed to pressure. Among operations in the -first mentioned class, the one known as the Mayo operation is, in all -probability, the best. The entire head of the metatarsal is amputated, -and the bursa is turned in over the cut end of bone, to diminish the -amount of shortening and to prevent ankylosis of the joint. This -latter consideration, however, is an unnecessary one, for in -operations within this joint, ankylosis does not occur when the -synovial surface of the phalanx is left undisturbed, even when the -bursa is not employed as an intervening pad. - -In the other class of operations for the relief of symptoms, no -attempt is made to straighten the toe. A wedge-shaped piece of the -exostosis is removed, against which pressure has caused symptoms. - -A palliative operation devised by Dr. Robert T. Morris of this city, -is one easy of accomplishment and serves every purpose where a radical -operation is interdicted. It is known as the "button-hole" operation -because of the fact that only a small incision is made immediately -above the protuberant bone through which a sharp chisel is inserted, -cutting off the offending "button" of bone. - -An operation which in the hands of the authors has proven of distinct -value, and which has probably not been previously described -eliminates both the deformity and its painful symptoms. This operation -which is described below, is less severe than other radical operations -and not very much more so than the usual palliative ones. - -The incision is made on the dorsum of the great toe over the offending -joint and just to the inner side of the extensor tendon. This tendon -is held to the outer side, out of the way. The knife penetrates the -capsule of the joint and opens it above and laterally. - -An effort is made to preserve the integrity of the capsule below -(floor) as _only the intra capsular end of the metatarsal is removed_. -These two factors are of the utmost importance. When the joint capsule -is slit open along its dorsal and two lateral aspects, sufficient room -is obtained for the insertion of the wire saw, and all of that portion -of the metatarsal lying within the joint proper is removed. There is -thus accomplished a correction of the deformity with very little -shortening of the great toe. Usually its length after this operation -is about the same as the second toe. - -The next step in the operation is closure of the synovial sac or joint -capsule. A stitch on either side and two above are all that is -necessary. The floor of the sac remains intact and nothing beneath it, -in the ball of the foot, has been disturbed. Many operators invade -this area and remove the sesamoids. This is unwarranted as the -transverse level of the ball of the foot is lost, and the weight is -put directly upon the newly formed joint, depriving it of its normal -support, or of padding from below. - -One other omission in this operation is that of the bursal flap over -the raw end. This is found entirely unnecessary as results prove, and -its omission hastens healing considerably. The bursa over the -metatarsophalangeal articulation in these cases is nearly always -inflamed, and consists of a mere fibrous pad. Its dissection from the -normal position is a real loss at that site, and of questionable -benefit over the cut bone, as motion in the joint is as good or better -without it. - -The skin closure is made without drainage, and _no wet dressing -employed_ for fear of the solution filling the cavity whence the bone -was removed and carrying with it infectious material. A dry sterile -dressing is all that is required, and a splint to maintain a straight -position for the toe. - -Four or five days complete rest for the part are ordinarily -sufficient. Following this, walking about the room is permitted with -the aid of a stick. After ten days, when the patient can get about -fairly well without the assistance of a stick, the foot may safely be -shod with an "arctic" of sufficient size. - - -+CLUBFOOT OR TALIPES+ - -The most common form of clubfoot, and therefore the deformity of that -character most frequently encountered, is characterized by inversion -of the sole of the foot, elevation of the heel, and a twisting and -turning of the front part of the foot. This deformity is typical of -_congenital_ clubfoot, which, as stated, is the most common form of -that deformity. The _acquired_ form is usually the result of infantile -paralysis. - -+Congenital Clubfoot+ is most frequently double, and males are more -frequently affected than females; in unilateral or one-sided clubfoot, -one side is not more frequently affected than the other. - -+Etiology.+ Very little is known as to the cause of congenital clubfoot -but it is not infrequently associated with other congenital -deformities. It appears to be hereditary in a great many instances. -The greater number of cases appear without definable cause, except -perhaps from intra-uterine pressure. There are, however, a number of -these cases that are associated with malformation of the bones of the -foot and leg, such as absence of the scaphoid; defect of the tibia; -fusion of a number of the tarsal bones. - -+Pathology.+ The sharp adduction and plantar flexion, at the tarsal -joints, produce a deformed position of the foot. As a result of these, -the heel is small and elevated; the dorsum of the foot is prominent; -and the outer border usually, and, in extreme cases, the dorsum of -the foot, bears the weight of the body in walking and in standing; the -sole of the foot is bent sharply in, and twisted at the tarsal joint. -In fact, all the bones are changed in shape, and the inner muscles, -tendons and ligaments are shortened by contraction, while the ones to -the outer side are lengthened. - -The distortion of certain individual bones is of importance. The -astragalus is the seat of the most important changes. It is tipped -downward at its front end, and its posterior part articulates with the -tibia, its anterior articular surface projecting under the skin; its -neck is elongated and bent inward and downward, so that its scaphoid -articulation faces inward and downward and not forward. - -This is the most important change in clubfoot, because the anterior -end of the astragalus, the head of the bone, carries inward and -downward with it the scaphoid, the three cuneiforms, and the inner -three metatarsal bones. The scaphoid articulates with the inner side -rather than the front of the astragalus and, in extreme cases, forms a -joint surface with the inner malleolus. It may be somewhat changed in -shape, being flattened and drawn inward and upward. - -The os calcis is generally poorly developed, and its front end is -rotated downward, and bent inward; the outer surface of the bone is -more convex and the inner surface more concave than normal, and since -the anterior facet looks inward and downward, it carries with it the -cuboid and the two external metatarsal bones. The changes in the other -bones are not important; the chief obstacles to reduction lie in the -os calcis and in the astragalus. - -+Soft Parts.+ The muscles, ligaments, tendons, and fascia at the lower -and inner side of the foot are shortened, and lengthened at the outer -and upper side. The plantar fascia being one of the chief obstacles to -reduction, the tendons are displaced, especially those on the inner -side of the foot. - -+Symptoms.+ Double clubfoot is usually accompanied by an awkward and -unsteady gait, in which each foot is in turn lifted high to clear the -foot on the ground, and the _toeing in_ is, of course, excessive. The -weight is borne on the outer side of the foot, and all elasticity of -gait is absent. - -On the outer border of the foot, where the weight is borne, -callosities and bursae develop; the calves of the legs are small, and -the knee joint may be lax. - -The gait in single clubfoot is less awkward, but characterized by the -same features. The foot is rigid in the deformed position, and in -cases of marked deformity, the foot cannot be manipulated into the -normal position. - -+Diagnosis.+ Congenital clubfoot cannot be mistaken for any other -condition. The diagnosis is self-evident. - -+Prognosis.+ There is no tendency of this deformity to right itself, or -to improve. Early and proper treatment will, if continued long enough, -insure a cure in children and an improvement in adult cases; but it -must be remembered that there is a decided tendency to relapse, even -after operation, unless the foot is kept in an overcorrected position -for a number of years. - -+Treatment.+ In young infants, treatment should be begun as early as two -weeks after birth and should consist in frequent gentle massage and -manipulations. After the part can be brought into an overcorrected -position by gentle manipulation, it should be put up in a plaster -cast, for a period of three weeks and this treatment should be -continued until the position of the foot is corrected. - -The manipulations consist in grasping the dorsum of the foot gently -but firmly with one hand, and holding the leg with the other. The foot -is then dorsally flexed and everted. This treatment should be repeated -at least three times a day and should not be rough enough to cause the -infant to cry. - -Treatment of clubfoot in older children and adults is a much more -difficult proposition and consists in the combination of two or more -methods of procedure. - -In order to correct the extreme adduction in these cases, extreme -force must sometimes be employed. This may be accomplished by bending -and bearing down on the foot, with its outer border resting on the -apex of a wooden wedge. The rotation of the foot is corrected by -grasping the foot in one hand, and the heel in the other, and twisting -with the necessary amount of force. The inversion of the sole is also -corrected by the use of this wedge as a fulcrum. - -In this way the tendo Achillis and the plantar fascia are stretched, -and the dorsal flexion is secured by laying the patient on the face -with the knee bent and the front of the thigh resting on the table. -The lower leg is then vertical, and by bearing down on the front of -the foot with the necessary amount of force, dorsal flexion of the -foot is secured, and by hooking the fingers around the os calcis, its -position is improved. - -A modified Thomas wrench may be used in the correction of clubfoot; -but this must be done with great care, as the violence practised in -this method, the tearing of the ligaments and other soft parts, is -often attended with great danger; osteomyelitis, tuberculosis, -neuritis, and even death from fat embolism, and extensive sloughing of -the soft parts are not infrequently seen after the use of this and -other bone crushing instruments. - -The removal of a wedge of bone from the outer side of the foot and the -removal of the neck of the astragalus are employed. Tenotomy and the -transplantation of tendons are also often practised, when other -methods of treatment fail. - -+Acquired Clubfoot.+ The cause of acquired clubfoot maybe infantile -paralysis, joint disease, traumatism, or it may be due to affections -of the brain or spinal cord. - -+Paralysis.+ Infantile paralysis affecting the muscles of the front and -outer side of the lower leg, will result in a condition similar to -congenital clubfoot. Other paralytic causes are: spastic or cerebral -paralysis, hereditary ataxia, etc. - -+Traumatic.+ A condition resembling clubfoot may result from improperly -treated fractures of the ankle-joint or tarsal bones. - -+Joint Disease.+ In tuberculosis, arthritis deformans, and other -diseases of the ankle-joint, a condition similar to clubfoot is -sometimes seen as a result of muscular contraction. - -+Talipes Equinus+ is rarely congenital. It is usually due to infantile -paralysis of the extensor muscles, or to cicatrical contraction of the -calf muscles, as a complication of hip disease. It varies from -inability to flex the ankle beyond a right angle, to walking on the -heads of the metatarsal bones. The astragalus is partially displaced -forward and forms a prominence on the dorsum of the foot; the plantar -fascia is shortened and callosities and bursae are formed under the -heads of the metatarsal bones. Primarily, the obstacle to reduction is -the tense Achilles tendon, and in advanced cases the shortened plantar -fascia and posterior ligament of the ankle-joint constitute obstacles. - -+Talipes Equino-Varis+ (down and in foot) is the most common form of -this deformity. - -It is either congenital or acquired, and in the latter case it is due -to infantile paralysis of the extensor and peroneal muscles. The heel -is drawn up, and the anterior half of the font is drawn inwards and -inverted. The inner border of the foot is shortened, and in neglected -cases the patient walks on the outer side of the cuboid, under which a -bursa is formed. Secondary contraction of the plantar fascia, -ligaments, and short plantar muscles follows. There is a great -increase in the obliquity of the neck of the astragalus in congenital -cases, so that the scaphoid and anterior half of the foot, together -with the dorsal tendons are carried inward. As a result of the -equinus, the upper surface of the astragalus projects forward, and -only its posterior portion comes in contact with the tibia and fibula. -The ligaments of the inner side of the foot are shortened and the -shape of the other tarsal bones is secondarily altered. - -+Talipes Equino-Valgus+ (down and out foot). This condition is rare as a -congenital deformity. The anterior half of the foot is deflected -outward, and the inner border comes in contact with the ground. The -scaphoid is placed outward, and the head of the astragalus projects -into the sole. - -The acquired variety results from paralysis of the tibialis posticus -and flexors, with secondary contraction of the peronei muscles. - -+Talipes Calcaneus+ is rare as a congenital deformity. It is usually the -result of infantile paralysis of the muscles of the calf. The patient -walks on the heel, and the anterior half of the foot is drawn up. -Valgus or varus are associated with it; the more common form is -talipes calcaneo-valgus. - -+Talipes Cavus+ (Pes Cavus), or hollow foot, is a condition in which the -arch of the foot is greatly exaggerated. It is rarely congenital but -is frequently seen in connection with clubfoot, especially in its -paralytic forms. In its mildest form, it exists in a highly arched -foot, often hereditary. It may also be the result of too short shoes -(Chinese ladies' foot). - -+Treatment.+ The condition is best remedied by division of the -contracted soft parts, a forcible reduction of the bones, held in -place by plaster of Paris. When the patient begins to walk, it is -advisable to have a stiff, flat, steel plate placed in the length of -the shoe between the layers of the leather sole, running from which, -over the dorsum of the foot, is a stout leather strap. At each step, -downward pressure is thus exerted on the dorsum of the foot. - - - - -CHAPTER XVIII - -+THERAPEUTIC MEASURES+ - - -+HYPEREMIA+ - -+Hyperemia+ as a therapeutic agent was described by Bier and is of two -kinds, _active_ and _passive_. The former is the same as the -_arterial_, while the latter is the _venous_. Between the blood of -active and passive hyperemia there are important physical and chemical -differences, the one containing much free oxygen with but little -carbonic acid and alkali, while the other presents the exactly -opposite character. - -In active hyperemia normal elements of the blood are kept in active -motion, while in the passive form they are allowed to escape, more or -less, into the tissues. - -Hyperemia possesses a great many properties: - - 1. Power to diminish pain. - 2. Bactericidal action. - 3. Absorptive property. - 4. Solvent action. - 5. Nutritive power. - 6. Suppression of the infection. - -Hyperemia may be produced in three ways; _first_, by means of the -elastic bandage or band; _second_, by cupping glasses, and _third_, by -hot air. The first two produce venous or passive hyperemia, and the -third, arterial or active hyperemia. - -+Passive Hyperemia.+ This obstructive hyperemia is produced by means of -a thin, soft rubber elastic bandage, two or three inches in width, -better known as the Esmarch, or Martin bandage. When this is applied -moderately tight around a limb about six or eight turns, one layer -overlapping the other, pressure is evenly distributed over a -comparatively wide area, causing the subcutaneous veins below the -constriction to swell; the extremity becomes somewhat bluish red in -color, also larger and edematous, giving a feeling of warmth to the -touch. - -The rubber bandage, properly applied, should not cause any -uncomfortable feeling and there should be absolutely no pain present. -At all times one must be able to feel the pulse below the site of the -bandage. If the bandage is applied too tight, the skin of the limb -looks grayish-blue and there appear whitish, or vermilion colored -spots, which grow larger and larger, as long as the too tightly drawn -bandage is on. Paresthesia and pain, with disappearance of the pulse, -can also be noted. - -The two cardinal rules to be observed in the application of the -bandage are: (1) absolutely no pain with the application of the -bandage; (2) the pulse at all times must be felt below the bandage. - -In cases which require the bandage to remain in place from sixteen to -twenty hours each day, it will be necessary to first apply a soft -flannel bandage underneath the rubber one in order to prevent pressure -necrosis. - -Frequently changing the location of the bandage up and down the -extremity, and treating the skin with alcohol rubs, will also be -helpful to patients with a tender skin. The elastic bandage must -always be placed upon a healthy area, proximal to the diseased part. -All dressings should be removed while the compressing bandage is on, -in order that the part may become hyperemic. - -Wounds or sinuses are covered with sterile gauze and kept in place -with a towel, fastened with a few safety pins. - -In acute inflammation, septic wounds and phlegmons, the increased -inflammation is apt to frighten the beginner, but this is a desired -phase of the treatment. - -As a prophylatic against infection, it cleanses the wound, produces a -local immunization and reaction before the infection has a chance to -work; the earlier the bandage is applied the more remarkable is the -effect. - -For incised wounds of the foot with division of the muscles and -tendons, if the tissues are not too seriously injured, the muscles and -tendons should be united and the skin closed with interrupted sutures -sufficiently far apart to allow free excretion. No drainage is -employed and a slight compressing dressing is applied. The elastic -bandage is applied very lightly, producing only a slight venous -engorgement and the bandage should remain on from ten to eighteen -hours a day. - -As soon us the symptoms of acute inflammation subside, the time of -application of the bandage is reduced. If signs of suppuration are -present, the wound should be promptly opened and the pus evacuated. -The knife takes care of the pus; hyperemic treatment fights the -infection. - -In gonorrhoeal arthritis of acute or chronic nature, and in cases of -tuberculosis of the bones and joints, the passive form of hyperemia is -especially indicated. - -The use of cupping glasses is limited to abscesses, furuncles and -sinuses. - -+Active Hyperemia+, or arterial hyperemia, is produced by means of -hot-air boxes such as the Tyrnauer electric apparatus, or the gas -apparatus of Betz. - -Active hyperemia increases the arterial blood to any part of the body, -thus favoring the absorption of chronic exudates, infiltrates, -adhesions, etc. Dry, hot air permits the use of a high degree of -temperature without injury or pain to the respective part. - -For neuritis of the foot, ulcers, especially diabetic, perforating and -varicose, and for the stiffness following a chronic inflammation, or -after a fracture, the arterial form of hyperemia gives good results. - - -+COLD+ - -+Cold+, or the rapid abstraction of heat, is a remedial measure that is -nearly always available and is possessed of very great power for good -in selected cases. - -When cold is applied for its limited and local action, it is always -used with two objects in view, namely, (1) to cause localized -contraction of the blood vessels, which through inflammation are -engorged, so that the parts are swollen and reddened; or (2) -temporarily to anesthetize or benumb the nerve terminals, for the -immediate relief of pain, in the hope that the temporary paralysis may -ultimately result in such changes as to produce a cure. - -Cold, in some form, is a popular remedy for a sprain, or any injury -likely to be followed by inflammatory processes. A very useful remedy -for the sprain of an ankle, when it is a recent accident, is to let -the patient sit with the foot elevated, with a cloth wrung out in ice -water, and an ice bag applied over the affected part. - -In the treatment of localized pain or inflammation, cold is used in a -number of ways, largely depending upon the will of the physician and -the means of the patient. The simplest, cheapest, and perhaps the best -method of using cold, is to place cracked ice in a rubber bag, the -latter to be thoroughly watertight, lay it over the inflamed part, -surrounding it with a towel so as to prevent the moisture, which -appears on the surface from condensation, from wetting the clothing. - - -+HEAT+ - -+Heat+ is used locally for a number of purposes in the same manner as -cold, and the choice of heat or cold in the treatment of any acute -form of inflammation depends almost entirely upon the wish of the -patient, who generally can tell at once which will give him the -greater comfort. - -In sprains of the ankle, nothing compares to a hot foot-bath prolonged -for hours, the object being to decrease the pain and swelling, thereby -regaining the use of the limb. - -The high degree of heat which can be borne by gradually increasing the -temperature of the water by the addition of small quantities of -scalding water, is extraordinary, and the favorable results obtained -are in direct ratio to the height of the temperature. - -Between these soakings, the part should be dressed with lead and opium -wash, and rubbed with ichthyol ointment or camphor liniment. - -Hot-water bottles or bags are also used locally for the relief of -congestion and pain. - - -+THE HIGH FREQUENCY CURRENT, OR VIOLET RAY+ - -+The Violet Ray or High Frequency Current+ is one which is in a rapid -state of to-and-fro vibration and is applied through vacuum glass -attachments or electrodes, which are excited to a beautiful violet -color. The discharge may appear to the eye to be a single spark, but -it is made up of a number of successive sparks, following each other -with such extreme rapidity that they are said to oscillate (change -directions) millions of times per second, a speed that the eye cannot -note. The rapid oscillations have the effect of producing the -following phenomena: - - 1. the high frequency current is unipolar, that is, does not - require a complete circuit. - - 2. glass does not insulate the high frequency current as it - does ordinary electricity. - - 3. the high frequency current generates enormous quantities of - ozone during its flow. - - 4. the current does not produce any pain. - - 5. the high frequency current produces a cellular massage. - -The contractile effect is expended upon the individual cells making up -the tissues, instead of on individual muscles. - -If a sedative effect is desired, keep the electrode in contact with -the part; if a stimulating effect is desired, hold the electrode away -from the surface; the farther away, the longer the spark. - -A uniform spark of any length can be produced by administering the -current through layers of toweling, or through the clothing; the -length of the spark depends upon the thickness of the layers. - -The use of the high frequency current in surgery is limited to -sprains, stiff joints, neuritic pains, and adhesions due to -inflammatory exudates. Fulguration for the destruction of growths is -obtained by employing a pointed metal electrode. - - -+RUBEFACIENTS+ - -+Rubefacients.+ These are agents which revulse by causing congestion of -the skin: - -+1.+ +Turpentine.+ A few teaspoonfuls of oil of turpentine sprinkled over -a piece of flannel wrung out of hot water, applied to the skin and -covered with oiled silk or dry flannel, constitutes the turpentine -stupe. Twenty minutes is the maximum for this application. - -+2.+ +Mustard.+ Mustard flour (the black being the stronger), mixed with -tepid water into a paste, spread thinly on a piece of muslin or paper, -and covered with gauze or thin cambric, is an excellent -counterirritant. Few skins will bear pure black mustard for more than -ten minutes. Mustard, diluted one-half with wheat or corn flour, and -allowed to stand for twenty minutes, should be the maximum strength -for application, because blistering must be avoided, that produced by -mustard being specially painful. After removing a mustard plaster, -greased lint should be applied. - -+3.+ +Mustard Foot-Bath.+ A mustard foot-bath consists of one or two -tablespoonfuls of pure mustard in a bucket two-thirds full of water at -105 deg.F; the feet may be kept in this for about twenty minutes, a -blanket being thrown around the limbs, and including the bucket, to -retain the heat. - -Revulsives must be used with caution in cases of shock or coma, lest -impaired vitality or sensation to pain result in extensive sloughing -of the skin. - - -+CAUTERIES+ - -+The Actual Cautery+ is used in the form of variously shaped irons, -hatchet-edged, round, or olivary, fitted into wooden handles, and -heated in a charcoal furnace. - -As a counterirritant, the iron should be heated only to a dull red -heat, and should be quickly drawn in parallel lines, about one inch -apart, over the skin, avoiding all bony prominences. Compresses wet -with cold water, or with some antiseptic lotion, may then be applied. - -+The Paquellin Thermo-Cautery+ is a convenient form. It consists of -hollow platinum cauteries and a handle covered with wood; a benzole -reservoir; a pair of rubber bulbs, like those for a hand-spray -apparatus, connected by a tube with the reservoir; a long rubber tube -to connect the cautery handle also with the reservoir; and a -spirit-lamp with attached blow-pipe. - -Screwing on the desired point, the tube from the reservoir is slipped -over the handle; the point is heated in the lamp; is removed from the -flame; and, compressing the bulbs, which should previously have been -connected with the reservoir, benzole vapor is forced into the point, -which will heat up, and can be maintained at any temperature by the -rapidity with which the bulb is worked. If the point will not heat -with the simple flame, attach the bulbs to the blow-pipe on the lamp, -and, compressing them, heat the cautery to a bright-red heat, and then -connect with the reservoir and proceed as before directed. - -+Galvano-Cautery.+ This requires a battery of a few large elements -closely coupled, and various curets, knives, and ecraseurs fitting -into insulated handles. The chief advantage of this form of cautery is -the possibility of placing the instrument in position while cold, and -then heating it. - -Where hemorrhage is undesirable, a dull-red heat should be maintained, -for at a white heat the tissues are divided as if with a knife, and -bleeding follows. When the ecraseur is used, needles must be passed at -right angles through the healthy tissues, the platinum wire placed -behind these, and the wire, at a dull-red heat, slowly tightened. - - -+ELECTRICITY+ - -+Electricity.+ This is used in the form of the _induced current_ -(Faradism) to exercise and improve the nutrition of muscles, and in -the form of the _constant current_ (galvanism) along the course of -nerve-trunks, to excite their conducting power, or to act as a -sedative in neuralgias. - -The same current is used to induce chemical decomposition -(_electrolysis_) or to cauterize and destroy tissue by heating an -encircling wire or by a galvanic knife. Franklinic, or static -electricity, is also occasionally used. - -+Electrolysis.+ For electrolysis a galvanic battery of thirty or more -medium-sized cells is required, with needle electrodes insulated, -except near their points. - -To destroy a verruca, introduce into it two needles, a short distance -apart, each connected with a pole of the battery; then, commencing -with a weak current, this must be cautiously increased, the sitting -lasting from a half hour to one hour, after which the needles are to -be removed and the punctures sealed by collodion. - - -+MASSAGE+ - -+Massage.+ This is employed to stimulate the circulation in the part -mechanically; to loosen tissues bound down by adhesions; to diffuse -inflammatory exudates over a wider area, thus favoring their -absorption; and to change the rate of the circulation to a point -compatible with rapid absorption and normal nutrition. - -Four distinct varieties of manipulation are found to be most generally -useful: - - 1. rubbing, or stroking - 2. kneading - 3. tapping, or percussion. - 4. passive and active moments. - -_Stroking_ consists in gentle rubbing directed from the periphery -upward, commencing the process above the inflamed part and continuing -it over the diseased area; the pressure, at first light but finally -firmer, will force the exudates into the tissues above, which have -been emptied by the preparatory rubbing. - -_Kneading_ means rubbing the part circularly with the pulps of the -fingers and the thumb or the palm of the hand, and is best combined -with pinching up of the skin or muscles singly or together, and gently -rolling them between the fingers and palms. - -_Percussion_ is effected by tapping the surface over the diseased part -with the tips of all the fingers held on a level, or with the ulnar -side of the hands, or, after covering the part with a towel, three -parallel pieces of stiff rubber tubing, fixed in a handle (a muscle -beater), may be employed, gently striking the part transversely to its -long axis. - -_Passive movements_ should be made at the close of each sitting if a -joint is concerned. - -Massage is sometimes advisable twice daily, but often once a day or -every other day is better; each sitting may last from fifteen minutes -to one hour. - - -+EXAMINATION BY RADIOGRAPHY+ - -+X-Ray Examination.+ This method of examination depends on the property -of penetration of matter possessed by a radiation from an electrically -excited Crookes' tube. This radiation has been proved to lie outside -the spectrum, and has been named X-ray. - -It may, for purposes other than those required by the expert, be -looked upon as a source of light which has the property of penetrating -the tissues to a greater or less extent according to their density, -and the shadows cast by it can be recorded on a photographic plate, or -may be viewed with the naked eye by means of a screen composed of a -thin layer of barium platinocyanide, a substance which becomes highly -fluorescent in the presence of this radiation. - -One or the other of these methods is used for the recognition of -pathologic conditions existing in the human tissues. - -The fluorescent screen appears at first sight to be an easy way of -recognizing abnormalities. Its value in the examination of the thorax, -where the movements of the heart, lungs, and diaphragm have to be -observed, is undoubtedly very great; but as an accurate means of -recognizing any abnormality, it is untrustworthy. For instance, it is -possible to fail to recognize simple transverse fracture of the tibia -by its means. Its use is therefore to be deprecated in cases where -great accuracy is necessary, and it is safer and better to make use of -the more certain method, the photographic plate. - -A further objection to the use of the screen is that the constant -exposure of the hands and other parts of the body of the observer may -result in an intractable, dangerous and chronic dermatitis. - -By using a photographic plate the danger of dermatitis can be avoided, -since it is not necessary to expose the hands at all; and at the same -time greater accuracy is ensured and a permanent record is obtained. - -Although examination by radiography is a somewhat tedious procedure in -comparison with direct observation by the fluorescent screen, yet it -is less difficult if the photographic side of this method is -approached in a proper and businesslike manner. - -+Interpretation of Radiograms.+ A successful result in X-ray examination -involves a clear understanding of the meaning of the radiogram -produced. Even with the most accurate knowledge of anatomy, it is -difficult to interpret X-ray shadows; for a radiogram is only a -shadow, and the outline of the part thus demonstrated is liable to -great variation. For example, in the case of injury to bone, it is -always possible to secure strong and accurate X-ray shadows of the -part, and no error ought to be made in diagnosis, yet errors of this -kind are not uncommon. - -To avoid such mistakes, it is imperative that the quality of the -radiogram secured should be the best possible. For instance, in the -examination of the ankle-joint and the bones of the foot, a radiogram -which is flat, indistinct, and altogether wanting in detail, is of no -value, while a radiogram of good quality of the same ankle-joint and -foot, is of value. The interpretation of the latter is easy, while -that of the former would be almost impossible, and certainly -inaccurate. - -The usual practice in securing radiograms is to place the subject in a -position considered likely to give the best results, and then roughly, -almost at random, to place the tube in some unknown relation to the -part of the body under examination. The resulting shadow is often of -no value because it is wanting in detail and depth. One method of -avoiding this fault is to produce stereoscopic views of the part -examined. - -Two views having been secured in stereoscopic register, and placed in -a stereoscope, the part can be viewed in relief. Theoretically, then, -by this means one is able to view the parts of the body opaque to the -X-rays as they would appear to the naked eye. In practice, however, -this method, though it may prove of value in exceptional -circumstances, is laborious. Moreover, though the parts may be made to -appear in relief, they are not really as one would see them with the -naked eye, but are still X-ray shadows. - -A more practical method is to ensure that in all cases radiograms of -any part of the body be absolutely comparable with one another by -taking care to maintain the same relationship between the X-ray tube -and the part under examination. For example, in making an examination -of the ankle-joint, the limb is placed in a prescribed position, and -the anode of the X-ray tube, that is, the actual source of the X-ray, -is brought into accurate relationship to the tip of the internal -malleolus by a simple mechanical contrivance, the details of which -need not be dealt with here. This relationship between the tube and -the ankle can always be reproduced, and therefore the shadow of a -normal ankle-joint can always be obtained under the same conditions -for comparison with the radiogram of the suspected ankle. - -In this way, not only is the surgeon able to select the view of the -part which will have the depth and detail necessary for proper -interpretation, but, the shadow being familiar, he can more easily -recognize any abnormality. - -A radiogram secured under the conditions usually adopted, shows -definite and known anatomic relationship between the bones and the -X-ray tube, namely, with the anode of the tube directly opposite the -tip of the internal malleolus. - -To render this method of examination more perfect, there has been -devised a system of radiography containing a definition of the -relationships between the tube and the various parts of the body which -have been found to give the most useful views, and also radiograms of -the normal appearances of each part at the ages respectively of 5, 15, -and 25 years. - -By using this system the surgeon can secure a radiogram of any part of -the body, of the requisite standard in quality, while he has at hand a -normal radiogram of that part for comparison with the abnormal. - -Having secured a radiogram of good quality, it is necessary for the -purpose of interpretation that it should be viewed in a suitable -light. The best for the purpose is a bright light shaded with opal in -a dark room. The negative may be viewed at its best while still wet. -Considerable loss of detail follows the taking of prints, which for -this reason may greatly detract from the value of the radiogram. - -It is a mistake to suppose that X-ray examination in the diagnosis of -diseases can replace the older and well-tried clinical methods of -investigation; it is merely a useful means of acquiring knowledge -which, in conjunction with accurate clinical investigation, leads to a -more accurate diagnosis and prognosis, and is often most useful by -suggesting a more suitable line of treatment. It must be remembered -that this method of investigation has been in use only a comparatively -short time. In some diseases no definite statement is yet possible -that may not prove in the future to be misleading. - -At present the therapeutic use of the X-ray is rightly falling into -the hands of the dermatologist and the medical clinician. In surgery, -outside of the conditions mentioned above, its use is limited to -lupus, keloid, epithelioma, sarcoma and carcinoma, both before and -after operation. - - - - -CHAPTER XIX - -+DRESSINGS AND BANDAGING; SOLUTIONS AND OINTMENTS; SKIN GRAFTING+ - - -+DRESSINGS+ - -+Dressings.+ These may be either dry or wet. - -_Dry dressings_ consist of gauze and bandage or of cotton and -collodion (the cocoon dressing.) - -The most convenient form in which sterile gauze can be obtained is in -small squares in individual envelopes. Large packages are contaminated -with the first opening and are inconvenient. - -The cocoon dressing is occlusive and should never be applied over an -infected area. It is applicable to sensitive areas for protection, and -to operated areas not liable to infection. - -Protective varnishes, such as collodion, compound tincture of benzoin, -or pure ichthyol, are useful where little protection is indicated. - -_Wet dressings._ Two distinct therapeutic actions may be derived from -the wet compress, depending upon whether or not an impervious covering -is employed. These actions are _antiphlogistic_ and _hyperemic_, and -these in turn may be either _antiseptic_ or _astringent_. The wet -dressing, without a covering, is cleansing and heat reducing, because -of evaporation. There should be frequent replenishment of the solution -in the treatment of any infected wound or where it is desirable to -reduce inflammation. - -A wet dressing with an impervious covering is contraindicated in the -presence of pus, the warmth and moisture of such a dressing being -congenial to the growth and to the multiplication of bacteria. - -It is evident, therefore, that a wet dressing with an impervious -covering can safely be employed only in conditions where the skin is -unbroken, such as sprains and bruises. - -The two general therapeutic actions, aside from those of causing -hyperemia, are antiseptic and astringent. For the relief of pain and -for the reduction of inflammation, wet dressings are the most -effective form of treatment because (1) they are aseptic; (2) they -permit free drainage; (3) no new granulations are disturbed in -changing the dressing. - -A great many different solutions are used and among these are: - - 1. sterile water; - - 2. ordinary saline solution (a teaspoonful of salt to a pint - of water); - - 3. saturated solution of boric acid (prepared by dissolving a - teaspoonful of boric acid powder in a pint of water); - - 4. Thiersch's solution (prepared by dissolving 15 grains of - salicylic acid and 90 grains of boric acid in a pint of - water); - - 5. Burow's solution (a solution of aluminium acetate prepared - by dissolving 675 grains of alum and 270 grains of lead - acetate in a pint of water.U.S.P. formula); - - 6. solution of bichloride of mercury (varying in strength from - 1 to 3000, to 1 to 10000); - - 7. 2 per cent. solution of creolin or lysol; - - 8. U.S.P. lead and opium wash; - - 9. aqueous solution of ichthyol (varying from 5 to 50 per - cent. according to the indications); - - 10. black wash (made by dissolving 64 grains of calomel in a - pint of lime water--this solution only being used in luetic - cases). - - 11. white wash (prepared by mixing zinc oxide, 2 drams, - solution of subacetate of lead, 3 drams, glycerine, 4 ounces - and lime water, 4 ounces); - - 12. Dakin's solution (hypochlorite of soda), prepared as - follows: - - chlorinated lime (bleaching powder) 200 gm. - sodium carbonate,dry 100 gm. - sodium bicarbonate 80 gm. - -Put the chlorinated lime in a 12 litre flask with 5 litres of ordinary -water and let stand over night. Dissolve the sodium carbonate and -bicarbonate in 5 litres of cold water; then pour this into the flask -and shake it vigorously for a minute and let it stand to permit the -calcium carbonate to settle. After half an hour, siphon off the clear -liquid and filter it to obtain a perfectly limpid product. The -antiseptic solution is then ready for surgical use: it contains about -0.5 gm. per cent. of sodium hypochlorite with small amounts of neutral -salts. It is practically isotonic with blood serum. Never heat the -solution, and always keep it from the light. If in an emergency it is -necessary to triturate the chlorinated lime in a mortar, do so only -with water, never with the solution of the soda salts. - -This solution has been used extensively abroad in the treatment of -infections and wounds and has given splendid results. - -(A proper quantity of Dakin's solution for office purposes would be -about one-tenth of the prescription above given.) - - -+DUSTING POWDERS+ - -These are employed either as antiseptics or as astringents or for both -purposes. Their use is limited, and they are employed only where the -secretion is scanty. - -Among the various powders used are: aristol, dermatol, boric acid, -orthoform, calomel, protonuclein, zinc oxide, alum, scarlet red, etc. - -_Thymoliodide_, or _aristol_, is a splendid antiseptic powder and -enjoys the advantage over iodoform of being inodorous. - -_Iodoform_ should only be used in tubercular conditions. - -_Dermatol_, or _bismuth subgallate_, combines the astringent and -mildly antiseptic qualities of bismuth and gallic acid. - -_Boric acid_ is mildly antiseptic. - -_Calomel_ should only be used in syphilitic conditions. - -_Zinc oxide_ and _alum_ are both astringent. - -Scarlet red (5 per cent.) with boric acid (95 per cent.) is indicated -for the stimulation of granulations. - -+Solutions.+ Among the various solutions used are silver nitrate, in -various strengths, zinc and copper sulphate, ichthyol, balsam of Peru, -nitric acid, sulphuric acid, trichlorand monochloracetic acid. - -_Silver nitrate_ is employed for its astringent action, as are also -the _copper_ and _zinc sulphates_. - -Balsam of Peru is used for its stimulating action. - -The stronger acids are employed for their escharotic qualities. - -"Red wash" (made up from the following formula: zinc sulphate 20 -grains, compound tincture of lavender 30 minims, distilled water to -make 8 ozs.) has a powerful astringent action and promotes -cicatrization, especially when there is a tendency for the -granulations to become exuberant. - -In the treatment of chilblains, a strong astringent is desirable to -constrict the diluted capillaries. - -The stronger _lotio alba_ of the national formulary, containing equal -parts of the saturated solutions of zinc sulphate and potassium -sulphuret, is markedly astringent and has a drying effect upon the -skin. - - -+STYPTICS+ - -+Styptics.+ These may act either by causing clot formation in the cut -arteries, or by causing the retraction of their edges. In the latter -class are included such drugs as _hydrastine_ and _adrenaline_. - -The disadvantage of using these drugs lies in the fact that secondary -hemorrhage is possible when their constrictor action is over. The -styptics causing clot formation are therefore to be recommended. They -should be non-irritating, antiseptic, and styptic, at the same time. -Such a preparation is practically unknown. - -_Peroxide of hydrogen_ on a pledget of cotton, placed over the -bleeding area, may effect a clot formation. - -The U.S.P. _liquor ferri subsulphatis_, better known as Monsel's -solution, is the best and most effective styptic that we have. -Monsel's solution, however, is not antiseptic and entrance of bacteria -into the wound is possible, unless, it is applied with a sterile -applicator or is dropped directly upon the wound from the bottle. - -The U.S.P. _tincture of iodine_ in equal parts of water, applied to -the bleeding area may, besides sterilizing it, stop bleeding. - -Should none of the above effect a stoppage of the bleeding, other -means must be sought. A bit of sterile gauze pressed quite firmly -against the area, should next be tried. If this fails, a wooden -applicator, prepared with Monsel's solution may be employed. A cotton -wound applicator, unless dipped into a strongly antiseptic solution, -contains millions of bacteria from the fingers. The use of the ancient -styptic stick of alum, copper or silver is discountenanced everywhere -as uncleanly. - - -+SOLVENTS+ - -+Solvents.+ Under this heading, those substances which are known to -soften tissue will be considered. - -_Sodium hydroxide_, up to a saturated strength, or an ointment of -_salicylic acid_, 5 per cent. to 50 per cent., depending upon the -density of the tissue to which it is applied, are the ones commonly -used. - -These two drugs have the power to macerate dry, hard tissues. - -Experience is necessary for the proper use of tissue solvents as the -length of time that they are allowed to act is of as much importance -as the strength of the solution. - -Sodium hydroxide solution can be instantly neutralized with any acid -and for this reason is preferable. - - -+OINTMENTS+ - -+Ointments.+ In the list of ointments, the much vaunted virtues of -advertised compounds are usually found. - -Ointments and oils are used in the treatment of wounds and ulcers, -either to stimulate granulations or to soften thick epidermis. - -Ointments should never be used where there is a profuse discharge, as -eczema is a complication which very often follows such treatment. - -A great many different kinds of ointments are used and among these -are: - - _Sulphur_ in 10 per cent. strength, or _ammoniated mercury_ up - to 5 per cent., where a paraciticide is indicated. - - _Balsam of Peru_ in 10 per cent. strength for the stimulation - of granulations; or _balsam of Peru_ and _castor oil_, equal - parts; also _boric acid_, or _ichthyol_ for their antiseptic - properties. - - Ten per cent. _mercurial_, for syphilitic cases. - - _Lassar's paste_ (which consists of salicylic acid, one dram, - starch and zinc oxide, each one ounce, and vaselin to make 4 - ounces) is used when there is an eczema present. - -One of the oldest as well as one of the best applications is balsam of -Peru, which has a powerful effect in increasing the growth of -granulations, but often after this has occurred the granulations are -apt to become exuberant with little tendency to cicatrization. - -The ointment which has given the best results is _scarlet red_, an -aniline dye, which is known chemically as a sodium salt of a -disulphonic acid derivative. Scarlet red (Biebrich) was originally -prepared as a dye for wool and silk, and is so named because of the -fact that it was first manufactured in the town of Biebrich. It was -first used for medicinal purposes in 1907 in an 8 per cent. strength; -because this strength was found to be too irritating, it was -alternated with a bland ointment every 24 hours. It is now used only -in strengths varying from one-half to five per cent., for the latter -has proved to be as strong as necessary. When applied to granulating -surfaces, scarlet red is sometimes absorbed in sufficient amount to -color the urine a bright red, and a number of acute cases of nephritis -have been reported from its use. - -Its application to granulating surfaces causes healing, not by the -formation of scar tissue, but in every case by producing a high grade -of normal skin (this can be demonstrated by sections), which very soon -becomes freely movable on the underlying tissue. The return of -sensation in the healed area takes place from the periphery inward, -instead of upward from the underlying tissue. - -Scarlet red ointment should be applied in the following manner: after -thorough cleansing of the part with tincture of green soap and water, -then ether and finally 93 per cent. alcohol, the ointment should be -spread in a thin layer over the entire surface on a piece of sterile -gauze, and over this an ordinary dry sterile dressing. If the ointment -is applied too thickly it may cause granulation tissue to break down, -and for this reason it should be spread in a thin layer upon the -granulating surface or its edges. Usually the dressing should be left -undisturbed for from 24 to 48 hours, then reapplied, as indications -warrant. The patient should invariably be informed that the dressing -will be stained red, so as to forestall unnecessary alarm, due to the -belief that a hemorrhage has occurred. He should also be apprised of -the fact that stains on the linen are hard to eradicate. In removing -the dressing, if it is adherent to the granulations, some peroxide of -hydrogen should be used to loosen it. The skin about the granulating -surface is best cleansed by benzine as this removes all traces of -scarlet red better than any other solution. The three formulas that -are recommended are the following: - - Strength - - Grains. Percent. - Scarlet red (medicinal Biebrich) 15 1 - ungt. acidi borici q.s., ad. 3 ounces. - - Scarlet red (medicinal Biebrich) 45 3 - ungt.zinci oxidi q.s., ad. 3 ounces. - - Scarlet red (medicinal Biebrich) 75 5 - balsam Peru, 75 minims. - Petrolati q.s., ad. 3 ounces. - -The first is indicated where its use is desired over a large area and -for a long time; the second, where an astringent action is required -because the granulations are profuse; the third, where the -granulations are sluggish and require stimulation. - -The ointment in a 10 per cent. strength is not recommended because it -is too irritating. - -In cases of chronic leg ulcers, especially those associated with -enlarged veins, it is impossible to effect a cure until the chronic -congestion of the limb is relieved and the blood supply of the part -approaches the normal. - -Often all that is necessary is a gauze, muslin or flannel bandage, -properly applied over the dressing and extending from the ankle to the -knee. - -A rubber bandage when applied with moderate, even pressure, has for -its purpose the relief of congestion, but in a great many cases the -rubber has an irritating effect on the skin. - -When the granulations are almost on a level with the surrounding skin, -and also when there is considerable thickening of the edges of the -ulcer, the best means of keeping up an even pressure and causing -absorption of the thickened margins, as well as of hastening the -epithelial growth, is to apply zinc oxide adhesive plaster in strips, -one-half to one inch in width. These strips should overlap to the -extent of about one-third of their width; should extend about -three-fourths of the way around the limb, and should be evenly and -smoothly applied. They should be started about one inch below the -ulcer and should run from two to three inches above it. - - -+BANDAGING+ - -+Bandaging of Leg.+ The final stage after the dressing has been put on, -consists in the application of the bandage. A bandage possesses -advantages over strapping in being less irritating to the skin; in -being more quickly put on and taken off; in being more easily removed -without disturbing the surface, and in more completely allowing the -formation of the granulations. - -The bandage is also superior to a laced stocking, as the latter does -not properly embrace the foot. - -The bandage material can be either gauze, muslin or flannel. The last -is considered the best because this material is thin, yielding and -elastic and yet almost any degree of compression can be exercised with -it. - -In edematous swelling in general, the flannel appears very suitable, -as it is soft to the skin and accommodates itself to the greater or -less distension of the limb, arising from the increase or diminution -of the fluid. The bandage should be at least six yards long, if -required for an ordinary adult, and the width should be from two to -three inches. Every portion of the limb, from the toes to the knees, -should be equally and evenly compressed. Compression is of such -absolute importance that without it everything else will be -comparatively ineffectual. This being so, very much will depend on the -manner in which the bandage is employed. - -Without practice, it is not easy to properly apply a bandage to the -leg, and probably this difficulty is the chief reason why preference -is often given to adhesive plaster, as this sticks wherever it is put. - -The blistering and excoriation often produced by strapping, and the -time consumed in its application, are sufficient reasons for acquiring -skill in the art of bandaging; an art whose comforts and advantages -are appreciated by the patient. - -Before using, the bandage should be rolled up very tightly, so that it -may be grasped easily and held in the hand firmly without slipping. In -putting it on, unwind only that portion which is being applied to the -limb, because if it be loose in the hand, or if a considerable piece -be unrolled at a time, it cannot be applied firmly or smoothly. The -bandage should always be carried up to the knee, even if the ulcer or -wound be seated on the lower part of the leg or on the foot itself, as -the object of its application is not merely to cover the ulcer but -also to support the vessels of the limb. If the bandage be -discontinued on any part of the leg, it is liable to become loose and -fall down. - -It is desirable also that the patient should not wear a garter above -the bandage, as anything unequally tight in the course of the veins is -calculated to obstruct the free passage of the blood. - -The firmness with which the bandage is put on is, of course, chiefly -for the purpose of gaining the good effects of compression on the -structures beneath, but besides, it contributes very much in making -the bandage remain in its position when applied. Encircle the limb -with it in a loose, careless manner, and it will fall down almost -immediately the patient begins to walk about. Tight bandaging is -extremely well borne if performed in a complete and methodical way, -beginning at the lowest portion of the foot around the first joints of -the toes and ending just below the knee. - -The proper application of the bandage is of such great importance, -especially in the treatment of varicose ulcers of the leg, that it -should, when possible, always be done by the doctor himself. It is -difficult for the most skilled layman to put a bandage on his own leg. -The real practical difficulty lies with those patients who live at a -distance from the doctor and who can only visit him once a week or at -ten day intervals. These must be taught to dress and bandage the -limb, and generally some friend or relative will learn to superintend -the details. - -The length of time which elapses before the bandage and dressings are -removed and reapplied must necessarily be determined by the -circumstances of each case. When the ulcer is very extensive and the -discharge proportionately great, it may be advisable to dress the leg -every day at the beginning of the treatment. Generally speaking, an -ulcer of the leg is disturbed too often. To take off a dressing and -put on another, even though done with the greatest care, interrupts -the healing process and the natural steps to cure. Let the dressing -remain on until some uneasiness points to the propriety of taking it -off, for the purpose of allowing the escape of the discharge. Delay -the removal of the dressings as long as possible without carrying the -forbearance too far. Avoid extremes of waiting too long or of meddling -too soon. Taking the average case, an interval of three days may in -general be safely permitted. - -+Spiral Bandage of the Great Toe.+ In applying this bandage, the initial -extremity of the roller is secured by two or three turns around the -ankle and the bandage is carried obliquely across the dorsum of the -foot to the base of the toe to be covered, and next to its tip, by -oblique turns; a circular turn is then made and the toe is covered by -ascending spiral or spiral reverse turns until its base is reached, -from which point the bandage is carried obliquely across the dorsum of -the foot and finished by one or two circular turns around the ankle. -The end of the bandage may be secured by a pin or may be split into -two tails and secured by tying. - -+Spica Bandage of Great Toe.+ This bandage is applied by placing the -initial extremity of the roller upon the ankle and fixing it by two -circular turns; the roller is then carried obliquely over the dorsal -surface of the foot to the distal extremity of the great toe; a -circular turn is next made and the bandage is carried upward over the -back of the great toe to the ankle, around which a circular turn -should be made; ascending figure of eight turns are then made around -the great toe and the ankle, each turn overlapping the previous one, -two-thirds, and each figure of eight turn alternating with a circular -turn around the ankle. These turns are repeated until the great toe is -completely covered with spica turns and the bandage is completed by -circular turns around the ankle. - -+French Bandage of the Foot.+ In applying this bandage the initial -extremity of the roller should be fixed on the leg just above the -ankle and secured by two circular turns around the leg; the bandage -should be carried obliquely across the dorsum of the foot, to the -metatarsophalangeal articulation, at which point a circular turn -should be made around the foot; the roller should then be carried up -to the foot, covering it with two or three spiral reverse turns; after -this a figure of eight turn should be made around the ankle and -instep; this should be repeated once to cover the foot, with the -exception of the heel, and the bandage continued up the leg with -spiral reverse turns. - -+Spica Bandage of the Foot.+ In applying this bandage, the initial -extremity of the roller should be fixed just above the ankle and -secured by two circular turns; the bandage should then be carried -obliquely over the dorsum of the foot to the metatarsophalangeal -articulation; a circular turn around the foot should be made at this -point and the bandage continued upward over the metatarsus by making -two or three spiral reverse turns; it should then be carried parallel -with the inner or the outer margin of the sole of the foot, according -as it is applied to the right or left foot, directly across the -posterior surface of the heel, and from this point it should be -conducted around the outer border of the toe and over the dorsum, -crossing the original turn in the median line of the foot, thus -completing the first spica turn. These spica turns should be repeated, -gradually ascending, by allowing each turn to cover three-fourths of -the preceding one, until the foot is covered, with the exception of -the posterior portion of the sole of the heel; the turns should cross -one another in the medium line of the foot and should be kept parallel -throughout their course. - -+Bandages for the Foot and Leg.+ Whenever possible the patient should be -kept in bed, or, at least, in the recumbent position with the leg -elevated, but when circumstances do not permit of this the veins can be -supported in various ways. Elastic stockings are excellent but -expensive, and not durable. Bandages of rubber cloth, or woven bandages -rendered elastic by the character of the mesh, or Martin's plain rubber -bandage may be employed. The last named is put on smoothly but not too -tightly, for in walking the leg swells, so that a uniform pressure is -established. As the rubber prevents evaporation it acts like a wet -compress, stimulating the granulations, but very often producing eczema -around the ulcer. The rubber bandage should be washed carefully at night -with soap and cold water and must be kept clean. In one patient a firm -elastic stocking of vulcanized rubber will give the greatest ease and -comfort, while in another the resulting irritation will prove -unbearable. As regards the flannel bandage it has already been described -at some length. - -The essential feature of ambulatory treatment is a good dressing to -prevent congestion, and Unna's paste is ideal for this purpose. The -paste necessary for the bandage is prepared as follows: first dissolve -four parts of the best gelatin in ten parts of water by means of a hot -water bath. While the fluid is hot add ten parts of glycerine and four -parts of powdered white oxide of zinc; stir briskly until the mixture -is cold. Another formula for the paste, and the one recommended, -consists of the following: white gelatin, 2-1/2 ounces; water, 8 -ounces; zinc oxide, 2-1/2 ounces, and glycerine, 4 ounces; prepared as -above. The paste should always be melted before use by placing the -receptacle in a hot water bath or in an ordinary copper sterilizer, -such as that employed for boiling instruments. A small tin can be -used, and a piece of paste about four inches square is cut into fine -pieces and put in the can. This is placed in the sterilizer, into -which is poured water to a depth of about two inches, so that the can -is but slightly immersed. No top should be placed on the can. An -ordinary stove or gas range can be used for heating purposes. A very -important fact to remember is that no water is to be put into the can -with the paste. - -The leg is next cleansed, and after the paste has been thoroughly -melted it is applied from the base of the toes to the knee, as hot as -the patient can comfortably tolerate it, by means of an ordinary small -paint-brush. Then a layer of gauze bandage (two to three inches in -width, according to the limb) is applied, then a layer of paste, and -in this manner two or three thicknesses of bandage are used, depending -on the case. In thin people, it is necessary to use only one or two -layers of bandage, whereas in stout persons several layers may be -required. After the last application of the paste, some non-absorbent -cotton is spread on the bandage, giving it the so-called "moleskin" -plaster finish. Another way of finishing the dressing is to dust some -ordinary talcum powder on the last layer of the paste, giving the -bandage the appearance of a plaster-of-Paris dressing. If there is an -ulcer, a window can be cut out, thus providing for the drainage of the -secretions. The length of time this dressing should be left on depends -on a number of conditions, especially the amount of secretion, and -whether the patient has to remain on his feet very much. Ordinarily, -the bandage can remain on for one week, but indications may be such -that it need not be removed sooner than the tenth day, and in some -instances it can be kept on for three or four weeks. To remove it, an -ordinary bandage-scissors is used to cut the dressing, and it peels -off without disturbing any of the granulations on the ulcer. - - -+PROMOTION OF NEW EPITHELIAL GROWTH AND CICATRIZATION+ - -The value of nitrate of silver and red wash as stimulants of the -healing process has already been mentioned. They are also of value in -producing cicatrization and in promoting the covering of new -epithelium over the ulcer or wound. If the solid stick of nitrate of -silver be applied very lightly to the edges just inside the pale -bluish line of advancing epithelium, so as to produce a white film on -the surface, this slight cauterization will be found to aid in -strengthening and cornifying the new, delicate and previously -invisible epithelial cells and in preventing them from being washed -away by the discharge from the ulcer. The solid stick of nitrate of -silver is also of benefit in destroying the exuberant granulations -which project above the surface of the surrounding skin; often, by -piercing these flabby granulations in several places with the solid -stick held perpendicular to the surface, cicatrization is hastened. -After the granulations are level with the surrounding skin the -covering of the ulcer or wound with new epithelium is hastened by the -application of some smooth surface along which the epithelium can -spread. For this purpose zinc oxide plaster or some thin rubber may be -used. - -In some old chronic cases, healing is prevented by the fact that the -base of the ulcer cannot contract owing to its being bound down by -fibrous scar tissue. This binding down of the base and edges of the -ulcer also tends to cut off the blood supply, and therefore in this -additional manner healing is hindered. For the relief of this -condition a number of procedures have been devised. Mattress sutures, -introduced through the normal skin beyond the edges of the ulcer and -passing beneath it, out through the skin on the other side, is one -method. By tightening these sutures, over a button or metal plate, the -ulcer can be lifted from the underlying tissues. Another method, -called "starring of the ulcer," consists in a series of radiating -incisions through the base and edges of the ulcer, the part from which -the incisions radiate corresponding with its centre. In this and in -the following operations, in order to obtain a favorable result, it is -necessary that the incisions pass completely through the cicatrical -tissue which forms the base and edges of the ulcer into normal tissue. -"Cross-hatching" of the base of the ulcer by means of a series of -incisions at right angles to one another, and at a distance of about -one-half inch apart, is often of value in aiding the healing of a -chronic ulcer, the continued existence of which and failure to heal -having been due to its thickened, adherent base and edges. -Circumcision of a chronic ulcer consists in making a circular incision -around it through the normal skin. A modification of this method -consists in making a series of overlapping, short, curved incisions -surrounding the ulcer, instead of a single circular incision. In these -last two methods it is necessary that the incisions be made through -normal skin, and that the wounds be made to gape, if necessary, by -packing them with gauze. - -When the ulcer or wound is of considerable size, it is often -impossible to secure healing even by these methods. It may for a time -appear as if it were going to heal, and a pale blue line of newly -formed epithelium may spread out from the edges, but instead of the -epithelium continuing its progress, at a subsequent dressing it will -be found to have disappeared. In these cases, as well as in those in -which the size of the ulcer would necessitate a long delay for a cure -or in which the subsequent contraction of the scar would produce -deformity, skin grafting, skin transplantation, or some form of flap -operation is indicated. - - -+SKIN GRAFTING TO OBTAIN A SOUND SCAR+ - -A very important object in the treatment of all ulcers is to obtain a -sound scar. In ulcers affecting the lower extremity in elderly people, -the scar resulting from spontaneous healing is weak and readily breaks -down if the patient does much standing or walking. The patient is -therefore frequently obliged to give up work in order to get the ulcer -re-healed, or must be content to employ means which merely prevent its -extension and relieve some of the discomfort. When the best possible -scar is desired, and when it is important to avoid marked contraction, -it is necessary to adopt some method of skin-grafting. - -There are three plans by which rapid healing of an ulcer may be -brought about: Reverdin's epidermis grafting; Thiersch's skin -grafting, and the use of the whole thickness of the skin. - -+Reverdin's Method.+ In this procedure small thin portions of the -superficial layer of the skin are snipped off with a curved scissors. -Pieces about the size of a hemp seed are planted on the surface of the -granulations at short distances from one another. Epidermic growth -occurs from each of these little points, and the result is that -numerous small islands of epithelium form over the surface of the -ulcer. If the grafts be close enough together and the conditions be -favorable to healing, these islands soon coalesce and thus rapid -cicatrization is obtained. The grafts should not be too far apart, -because they appear to have only a limited power of reproduction. - -+With a view to obtaining a sounder scar+, thicker and more extensive -portions of the skin must be taken and the grafts must be applied -close together. There are two ways of doing this: either by using the -whole thickness of the skin or by employing Thiersch's method, in -which about half the thickness of the skin is shaved off. - -The procedure where the whole thickness of the skin is employed need -not be described, partly because the results are not satisfactory and -partly because all the conditions for which it was introduced are -better fulfilled by Thiersch's method. - -Skin grafts may be taken either from the patient himself or from -another individual. When the patient is much debilitated, the -cutaneous epithelium shares in the general malnutrition and under -these circumstances a graft from a healthy subject might succeed -better than one taken from the patient. - -+Thiersch's Method.+ In employing this method the skin which is to be -used for the grafting must first be shaved and disinfected in the -usual manner, as has been previously described. The presence of hairs -on the grafts seems to interfere materially with their union. - -+Preparation of the Ulcer.+ _Preliminary._ It is of no use to graft a -sore which is actually ulcerating; it must be brought into a healthy -condition, and healing must have commenced before transplantation is -likely to be successful. The best criterion that healing is taking -place is the presence, at the edges, of the dry line which indicates -recently formed epithelium. Some surgeons wait for a considerably -longer time before grafting in order to get a firm layer of -granulations, but experience shows that it may be safely resorted to -as soon as healing begins around the edge. A second essential is that -the ulcer shall be clean. If the discharges be septic, the graft, -which is, after all, merely a piece of dying tissue, will become -impregnated with decomposing pus and may rapidly become loosened, die, -and undergo decomposition. The methods of rendering the ulcer aseptic -have already been described. - -_Operative._ The following is the method of procedure: after the -patient has been placed under an anesthetic, the granulations over the -whole surface of the ulcer are forcibly scrubbed off with a firm -nail-brush, or are evenly scraped away, taking care, however, to -remove only the soft layer of granulations and not to go through the -deeper one of newly formed fibrous tissue into the fat. A surface is -thus left which is smooth, highly vascular, and firm, and which -consists of the deeper layers of granulation tissue that have already -become organized into fibrous tissue. In cases of ulcer of the leg it -is also advisable to remove those portions of the edge which have -already become covered with new epithelium. If the transplantation be -limited to the parts actually unhealed, the result is disappointing as -a rule, for while the part grafted remains sound, the margin where -spontaneous healing had occurred, is apt to break down, and thus a -narrow line of ulceration appears at the edge of the ulcer. - -After the layer of granulations has been removed and the newly healed -edge of the ulcer has been cut away, the bleeding must be arrested -completely before the grafts are applied. The most rapid method is to -pour a few drops of adrenalin chloride (1 to 1000) solution over the -raw surface, when the oozing ceases immediately. If adrenalin be not -at hand the following plan will be found satisfactory: any spouting -vessel is clamped and a large piece of sterilized gauze or thin sheet -rubber is applied over the raw surface of the wound; outside this, -several sponges are placed and a sterilized bandage is bound firmly -over them. If the sore be small and an assistant be available, he may -apply the pressure. Pressure is employed indirectly through the -protective in this way, because if it were made directly upon the -surface of the wound by means of the sponges, bleeding would -recommence when the latter were removed, as they stick to the raw -surface. - -While the bleeding is being arrested the surgeon cuts his skin grafts -from any part of the body, as he thinks fit As a rule they are taken -from the front of the thigh, but the side of the abdomen may be -selected. The area from which the grafts are to be cut is disinfected, -and the surgeon grasps the limb from behind with his left hand in such -a way as to make the skin over the front of the thigh as tense as -possible; in doing this he pushes the soft parts well forward so as to -make the anterior aspect of the limb as flat as possible. The skin is -further put on the stretch vertically by an assistant, who pulls it -upward and downward. These precautions are important, as without them -it is almost impossible to cut a graft of even width. The razor, which -should have a very broad blade, is dipped into a boric acid solution -and is kept constantly wet with it whilst the grafts are being cut. -Unless this be done, the graft adheres to the blade and may be either -partially or wholly cut through before a sufficient length can be -obtained. The razor is made to penetrate through about half the -thickness of the skin, and then, by a lateral sawing motion, the -grafts are cut as broad and as long as possible. After a little -practice it is easy to cut them about two inches in breadth and about -four or five inches in length. - -If one graft be insufficient, it is best to slide it off the razor and -leave it on the bleeding surface; in this way it is kept warm and -moist. Some surgeons put the graft into warm saline solution, and it -is said to then spread out more easily afterwards. Small skin grafts -can be cut under local anesthesia. - -+Application of Grafts.+ When a sufficient number of grafts have been -cut, the bandage, sponges and protective are removed from the raw -surface of the ulcer and the grafts are applied to it if the bleeding -has stopped, as is generally the case. The raw surface usually has a -thin layer of blood-clot upon it, and this should be wiped away. - -Each graft is lifted with forceps or the fingers and applied with the -cut surface downward, and then is carefully unfolded by means of two -probes and stretched evenly over the surface. The grafts should -overlap the edges of the skin and also each other, so that no part of -the raw surface is left exposed, for granulations always spring up on -the uncovered parts and are apt to destroy the grafts in their -vicinity; moreover, a thin scar is left at these points which may -break down subsequently. The graft is always thinner at its edges than -at its centre, and it is these thin edges which overlap each other or -the margin of the skin; there is no real sloughing of these -overlapping portions. - -The dressing should be left on the grafted surface for about five -days; in some cases even for a week. If the wound be aseptic, no -suppuration or decomposition takes place beneath it. Before being -removed, the dressing should be thoroughly soaked with a 1 in 2500 -sublimate solution, for otherwise it may stick at the edge and adhere -to the graft, which may thus be peeled off, unless great care is -taken. The parts should be gently cleansed with the same solution, and -a dressing similar to that put on originally should be employed for -about another week. At the end of that time the grafts are fairly, -firmly adherent and then a 5 per cent, boric acid ointment is the best -application. - -It will be found that even at the first dressings the grafts present a -pink color and are adherent to the deeper surface, though they are -still readily detachable. In the course of about a week the old -cuticle peels off, but no raw surface is left. Later on, there is a -great tendency to the formation of new epithelium, cornification, and -drying-up, and it is to avoid the latter condition that ointments are -so useful; in fact, until the scar is absolutely sound, it is well to -keep the surface covered with some greasy application, the best being -the 5 per cent, boric acid ointment. - -For many months the grafted surface is likely to scale or crack, and -this might prove a starting-point for the occurrence of sepsis which -would cause the newly grafted area to slough. It is important to keep -the scar as supple as possible, and therefore it should be constantly -anointed with cold cream, vaselin, or lanolin. Grafted surfaces upon -the face, however, do not manifest this tendency for any length of -time. - -+Time Required for Cure.+ It is important to know when the patient may -be allowed to walk about after an ulcer of the leg has been -skin-grafted. If he begins too soon, the grafts will almost certainly -become detached. That this will be so is evident from a consideration -of the mode by which the adhesion of the grafts takes place. At first -they adhere to the surface of the sore, simply by means of the effused -and coagulated length. Cells rapidly spread into this length and in -the course of two or three days the space between the grafts and the -raw surfaces is occupied by a mass of young cells. In this tissue, new -blood vessels develop and penetrate into the graft, whilst, at the -same time, the cells of the latter grow and assist in the development -of the young tissue and of the blood vessels. Thus the graft becomes -vascularized; but for a considerable time the tissue between it and -the surface of the sore contains many young blood vessels with -delicate walls, and therefore, if the patient stands erect and allows -the pressure of the column of blood to fall on these vessels, they -rupture, and bleeding occurs beneath the graft and leads to its -detachment. - -It requires a long time before the graft is firmly incorporated with -the tissue beneath by the development of elastic fibres; indeed, it -may be reckoned that this union is not complete until from three to -six months have elapsed. The graft will, in all probability, be -destroyed if the patient walks about within three months of the -transplantation. Hence, unless that time can be devoted to the -treatment, it is not worth employing skin-grafting for ulcer of the -lower limbs. By this, however, it is not implied that it is necessary -to keep the patient in bed for the entire time, but merely that the -foot must not be allowed to hang down, nor must any weight be borne -upon it. - -At the end of about six weeks the patient may be allowed to get up and -lie on a sofa or sit with the leg on another chair, but the limb must -not be permitted to hang down. After about three months he may be -allowed to get about, but in order to prevent the detachment of the -grafts, he should be fitted with a knee-rest and peg on which he -walks, the leg projecting out behind him. If possible he should not -put his foot to the ground until six months have elapsed. In cases of -sores on other parts of the body, when the erect posture does not -cause congestion of the part, the patient may be allowed to walk about -after the first three weeks. - -+Results.+ The scar which results after skin-grafting performed in this -manner is of a satisfactory character, and ulcers which have been -intractable for years may be closed satisfactorily by this means. In -order to obtain anything in the nature of a permanent cure, however, -the prescribed period of rest must be adhered to rigidly. - - - - -CHAPTER XX - -+LOCAL ANESTHESIA+ - - -+History.+ From Corning we learn that the ancient Assyrians alleviated -and even entirely prevented the pain incident to circumcision by -compressing the veins in the neck. Unconsciousness was probably -induced in this way together with pressure on the carotids. - -In India, centuries ago, the effects of opium and of Indian hemp were -known and employed, and the ancient Egyptians were also conversant -with the soporific effects of many drugs. We learn, from the same -authority, much which he gathered from literature about the history of -local anesthesia, and it is from Corning's well-known book on local -anesthesia that most of this history is quoted. - -In Peru, the Spanish conquerors learned that the coca loaf was held in -high esteem by the natives, inasmuch as they observed that it was -chewed by the high priests and nobility only, the vulgar being denied -this privilege except as a reward of great merit or of distinguished -valor. The leaf was regarded with awe and superstition and was -supposed to possess supernatural powers. After the fall of the Incas, -the Spanish not only permitted but encouraged the general use of the -leaf in order to obtain more work from the natives, a result which the -drug seemed to effect. It was also a source of great revenue to them -and was sold at exorbitant profit to the natives who became enslaved -to its effects but were able to endure great hardship while under its -influence. - -Chemists throughout the world, recognizing the potent action of the -coca leaf, were soon engaged in the effort of extracting its active -principle. - -In 1859, after many had tried and failed, cocaine was evolved from -crude extractives. Authorities differ as to whether it was Mann or -Neimann, a pupil of Woehler, who first presented cocaine to the -chemical world; however, fifteen added years elapsed before practical -use for it was found. In 1862, Professor Schraff discovered that the -tip of the tongue was rendered numb, and insensible when a little of -the cocaine alkaloid was applied to it and that it remained so for a -considerable length of time. Significant though this experiment was, -the action of cocaine on the nerve-filaments was not recognized and -the matter was not followed up until Dr. Karl Koller, of Vienna, began -his experiments which resulted in a universal awakening to the use of -a substance which, though known, had been allowed to remain unnoticed -for ages. - -Its anesthetic effect upon the eye was demonstrated by Koller at the -Opthalmologic Congress at Heidelberg in 1884. Dr. H. D. Noyes was -first to direct the attention of the American practitioners to -Koller's results in the use of the drug. Its introduction was one of -the greatest triumphs of modern surgery. It makes possible the discard -of the systemic anesthetics in all minor surgical operations and also -in many operations of considerable magnitude. - -In the laboratory of Professor Stricker, Koller experimented on the -eyes of a number of animals and thus reports his findings: - -"A few drops of a watery solution of muriate of cocaine dropped on the -cornea of a guinea pig, rabbit, or dog, or instilled into the -conjunctival sac in the ordinary way, caused, for a short time, a -winking of the eyelids, evidently in consequence of a slight -irritation. After one-half to one minute the animal again opens its -eyes which gradually assume a staring look. If now the cornea is -touched with a pin head (in which experiment we have carefully avoided -touching the eyelashes), the lids are not closed by reflex and the -eyeball does not move, the head is not thrown back as usual, the -animal remains perfectly quiet, and, on application of a stronger -irritation we can convince ourselves of the complete anesthesia of the -cornea. In this way I have scratched and transfixed the cornea of the -animals used for experiment with needles, and have excited them with -electric currents so strong as to cause pain in my fingers, and to -become quite intolerable to the tongue. I have cauterized the cornea -with the nitrate of silver stick until it became milky white; during -all of this the animal did not move. The last experiment convinced me -that the anesthesia involved the whole thickness of the cornea and did -not affect the surface only. But if I incised the cornea, the animals -manifested intense pain, when the aqueous humor escaped and the iris -prolapsed. I have been unable hitherto to decide, by experiments on -animals, whether or not the iris could be anesthetized by dropping the -solution into the corneal wound, or by prolonged instillations into -the conjunctival sac; for experiments to test the sensibility of -non-narcotized animals are very complicated and difficult and do not -yield unambiguous results. The last question which I subjected to -experimentation on animals, viz., whether or not the inflamed cornea -could be anesthetized by cocaine, was answered in the affirmative. The -cornea in which I had incited a foreign-body-keratitis, became as -insensible as a healthy one. - -"Complete anesthesia of the cornea from the use of a two per cent. -solution lasts ten minutes on an average. After such successful -experiments on animals I did not hesitate to use cocaine also to the -human eye, trying it first on myself and on some of my friends, and -then on a great number of other persons, obtaining, without exception, -the result of a perfect anesthesia of the cornea and conjunctiva." - -Soon after Dr. Koller's report appeared, cocaine was used for a great -many operations upon the eye, and its application to mucous membranes -in general was soon taken up by practitioners everywhere. - -Rectal, vaginal, otologic, rhinologic, oral and urethral anesthesia -were soon found to be easy of accomplishment and many operations in -these fields were performed under cocainization. The hypodermic -injection of cocaine was experimented with and reported upon in 1884 -by Drs. N. J. Hepburn, R. J. Hall, and Halsted. - - -+PHYSIOLOGIC EFFECTS+ - -+Nerve Pressure; Anemia.+ That motor and sensory paralysis followed -pressure upon a nerve has been well known for many years, and this has -been utilized in the effort to produce anesthesia, artifically by -applying a rubber tube or bandage around a finger or extremity, with -the hope that "ligation anesthesia" would follow the arrest of -circulation. This, however, has been unsuccessful as all that was thus -accomplished was a slight sensation of numbness with no arrest of the -sense of pain. This method could only be successfully carried out, -were the nerves themselves subjected to sufficient pressure to injure -them. Return to normal sensibility and motor function could not be -expected for months. - -+Cold.+ The addition of common salt to ice hastens its liquefaction and -consequently renders the mixture more cold. This knowledge has been -applied in a method of producing anesthesia of limited areas of the -skin. A gauze bag of the correct shape and size is filled with salt -and ice mixed, and applied to the area to be anesthetized. - -This method was used as far back as 1848, by Arnott, but was soon -improved upon by Richet and others who used ether or rhigolene sprayed -on the part to be anesthetized. It was found that extremely low -temperatures could be obtained in this way, especially if a current of -air were blown across the field of operation to hasten evaporation, -and that a good local insensibility could be brought about if the -circulation of warm blood could be either stopped or retarded with an -Esmarch bandage or tourniquet. The method of obtaining local -anesthesia through the agency of cold was found to be best -accomplished by ethyl chloride and this substance is used in -preference to any of the others previously mentioned, at the present -time. Some years ago Dr. Martin W. Ware of New York experimented with -both ethyl chloride and ethyl bromide and he found that the former was -more serviceable in producing local anesthesia. - -+The Sensibility of Various Tissues.+ Karl G. Lennander, of Upsala, -Sweden, shortly before his death, completed a chapter on local -anesthesia for Keen's "Surgery" in which is set forth an elaborate -account of the sensibility to heat, cold, pressure, and pain of the -various nerve terminals throughout the body. In this great work he has -given the world the results of many experiments on living tissues, -experiments investigating the degree and kind of the tissues -sensibilities; thus it is learned that "all internal organs receiving -their nerve supply only from the sympathethic nerve and from the -vagus, below the branching-off of the recurrent nerve, have no -sensation, and that the abdominal and pelvic viscera are devoid of -nerves to convey the sense of pain, heat, cold, or pressure." - -From the same authority we are taught that the parietal peritoneum is -highly sensitive but that the visceral covering is devoid of all -sensibility, enabling the operator much freedom of manipulation within -the abdominal cavity. - -In a work of this limited size the sensibility of the various tissues -cannot be fully treated but it should be borne in mind that the -integument and the subcutaneous tissue, fat and muscles as well as the -tendons, their sheaths, the muscles and periosteum and perichondrium -covering the bones and cartilages throughout the body, are all highly -sensitive to pain. It is also equally true that the bone substance, -the bone marrow, and the cartilages are devoid of any of the four -modalities of sensation. Articular surfaces covered with cartilage -have no sensation, neither have the fibrocartilages any sensation. - - -+GENERAL CONSIDERATIONS+ - -+Effect of General Anesthesia.+ Local or regional anesthesia is -obviously the method of choice in all cases in which it is -applicable. Not only is it desirable in the minor surgical operations -and the more important ones upon patients suffering with a cardiac or -nephritic derangement, where a general anesthetic is positively -contraindicated, but in every instance where it is at all possible, -the dangers and annoyances of general anesthesia should be avoided, -and the regional or local anesthesia should be employed. - -Among the advantages, aside from the number of assistants required and -the discomfort immediately following the administration of a general -anesthesia, are the absence of remote ill effects of the invasion -throughout the entire system of a noxious chemical substance and its -direct deleterious effects on many large organs such as the lungs, -heart, kidneys, and liver, and the assurance, when a proper drug, -dosage, and technic are employed, that death cannot be ascribed to the -anesthetic. - -Of remote ills of general anesthesia no estimate can be made, but that -they are legion and of great severity is established. Deaths from -general anesthetics in persons apparently able to bear them well, are -extremely numerous. It has been estimated that one in fifteen thousand -succumbs from ether anesthesia and this number would probably swell -greatly were it possible to obtain the exact figures. Even this -minimum of danger does not exist in local anesthesia. - -An accurate knowledge of the neural anatomy of a particular region -enables the operator to anesthetize large areas and to operate with -entire freedom from the necessity of observing the appearance and -conduct of his patients, many of whom, notably the alcoholic ones, -behave badly, become cyanotic and breathe intermittently when under -the effects of inhalation anesthetics. The absorption into the body of -the substances employed by inhalation may also exert a baneful -influence by reducing the powers of resistance upon an economy already -lowered by disease, and also by retarding convalescence. - -+Advantages of Local Anesthesia.+ In minor or trivial affairs the -elimination of pain is not to be considered lightly, for every -patient, even the strongest, will appreciate anything which will -expedite a cure and at the same time will relieve him of suffering. -Rather than lose time from their work or suffer the nausea and dangers -of general anesthesia, these patients often bear for years conditions -which could easily be cured by operations under local anesthesia. In -this class one must first think of hemorrhoids; of cysts; of fatty -tumors; of foreign bodies in the hands and feet; of verruca and of -ingrown nails. These conditions would be promptly relieved were the -element of pain in surgical interference not to enter as a factor. - -With a perfect technic, local anesthesia can also be employed with -entire satisfaction for certain major operations, where the subject is -suitable. Thus, herniotomies are performed with entire success, -especially those cases complicated by strangulation in which the -dangers arising from fecal vomiting and inspiration pneumonia, are -greatly decreased by omitting the general anesthesia. - -In many of the more severe conditions not to be classified as minor -surgery, the surgeon may consider the comfort of the patient and his -own convenience and employ local in preference to general anesthesia, -even tho the patients may be of the most robust type. - -In this group may be mentioned benign tumors at any visible part of -the body, hernias, many scrotal and anal diseases and some conditions -peculiar to the extremities, such as varicose veins. These conditions -lend themselves kindly to local insensitization. - -In certain emergencies where an operation must be performed -immediately, such as tracheotomy, thoracentesis and strangulated -hernia, local insensibility is imperative. In these operations local -anesthesia is also more desirable because of the ill effects of -vomiting, which are thus eliminated. - -Weakness of the patient enters also as a demand for the exhibition of -a local anesthesia in such operations as resection of a rib for -empyema, in which instance the action of the heart or lungs is -embarrassed. Other operations performed under local anesthesia for the -same reason (weakness of the patient) are the exploratory operation -for a probable inoperable cancer and the palliative operations such as -gastrostomy, enterostomy and colostomy. - - -+SOME VALID OBJECTIONS TO THE USE OF LOCAL ANESTHESIA+ - -There are, however, valid objections to the general application of -local anesthesia and the cases for its use should be selected with -care. It does not produce relaxation nor does it give the surgeon -perfect control over his patient. These are considerations which must -be taken into account, especially in operating on patients of highly -nervous temperaments. Though the patient may be convinced that he will -suffer no pain, the mental attitude toward the local anesthesia, -together with fear, may operate so strongly as to constitute a shock -to the nervous system so great that a general anesthetic should be -used and the local method abandoned, even were it apparently -indicated. - -Again, the injection of anesthetic drugs in cicatrical and inflamed -tissues is quite difficult of accomplishment and because of the -peculiarity of these tissues, diffusion throughout a given area is -imperfect, hence insensibility is not complete. - -The extravagant claims of enthusiastic advocates of this method of -anesthesia have retarded its progress. Thus, in the hands of the -competent operator it was given but a perfunctory trial to be -discarded as impossible. At the present time, however, local -anesthesia bids fair to become the method of choice, other things -being equal, for many major operations not yet thus performed. Recent -investigations alone these lines have developed methods of its -application whereby it is possible to render insensible large areas of -the integument, and regional anesthesia is performed by anesthetizing -nerves proximal to the seat of operation, thus rendering amputations -feasible. - -A single element which has entered as a factor in retarding the -progress of local anesthesia in general surgery, is that of regarding -the operation as one fitted to the method rather than to the patient -under consideration. It is obvious that this is a fallacy and the main -issue in deciding between general and local anesthesia is: what will -the patient best tolerate? In coming to a decision in the matter one -should make a general survey and weigh first the general health of the -patient; whether he be in perfect systemic condition or undermined by -disease, whether the shock will be greater from one method than the -other, and whether the part of the body to be operated on is one which -will lend itself better to one method than to the other. - -These elements are being and will continue to be considered as -preliminary to operative procedure and in consequence, general -anesthesia will cease to be given in a routine way. - - -+GENERAL PRINCIPLES AND ESSENTIALS+ - -The first essential to the successful production of local anesthesia -is a proper equipment and one that is in good working order. Not only -is it necessary to employ the best drug to this end but also to use a -syringe having perfect mechanical construction and one not injured by -boiling; as also needles of the length, lumen and shape suitable for -the surface to be injected. - -The old leather pocket syringes, on account of their not bearing water -at high temperature without deterioration, should not be employed; -this applies also to that variety of glass barreled metal-mounted -syringe in which the glass is screwed into the metal end pieces. - -The best syringes are those made of all metal or of all glass, the -latter being preferred because one may see the contents and express -out the air before injecting. Syringes of this type, because of the -accurate fitting piston, must be thoroughly dried out after use, as -the piston may stick fast within the barrel. All-glass or all-metal -syringes must be selected with care as they are often imperfect, the -calibre of the barrel being unequal in different parts of its length -causing the piston to fit tightly in some parts, and thus to work -with difficulty; and in other parts fitting loosely, allowing the -fluid to escape backwards. - -Syringes are also made in various sizes and shapes to meet certain -requirements. For the edematization of large areas of loose tissue, -where a considerable amount of a weak solution is intended, the use of -a large barreled syringe will be found to save time and the annoyance -of refilling. - -For such work a five or ten c.c. syringe would be the most useful. The -ordinary hypodermic syringe is about of two c.c. capacity (thirty -drops), and serves the purposes of every-day work. It does very well -for the amount of an anesthetic solution employed in opening an -abscess or in the removal of a small cyst or lipoma or papilloma. - -A barrel, large in diameter, requires more pressure on the piston in -its operation unless the needle employed is also correspondingly -large. For this reason, if the tissue in which the solution is to be -injected is not loose or cellular, it will be found better to use a -syringe in which the barrel is long and narrow. Such is the shape of -the syringe intended for the injection of the gums, the peridental -membrane, and also for the periosteum, cartilage or bony cellular -structure. A long instrument is also required for use in the large -cavities of the body such as the mouth, the vagina, or the rectum. In -these localities, an extension fitting is often required to lengthen -the instrument sufficiently to reach the desired part. It is also -possible to attain this end by using a long needle; this, however, -sacrifices rigidity. - -For accomplishing the best results, the needles must also be selected -for the work at hand. For the initial puncture in sensitive or -inflamed tissue, it is proper to use a needle of the finest lumen so -as to cause the least possible amount of pain. The ordinary needle, -which comes with the usual hypodermic outfit, is about the proper -length for the ordinary work already mentioned, but could be improved -upon for anesthesia by being made a little finer in calibre. This -length (three-quarters of an inch) will be frequently found -insufficient to reach the deeper tissues and in the removal of a more -or less rounded growth, a longer needle must be selected at the start. -Curved or angular ones are only needed in dentistry, where strength is -also a consideration. Strength is afforded in those of short length by -means of a reinforcement at the hub. Needles so augmented may also be -of use in operations upon bone or dense structures in general; the -curve, however, is not essential. - -The surgeon should be fully conversant with the details of the -operation which he is about to perform. His work should be definitely -in his mind, for in operations under local anesthesia, there is no -justification for a change of procedure after the beginning of the -work. Account should be taken of the nature of the tissues to be -anesthetized, for it is known that cicatricial tissues and -inflammatory areas do not lend themselves to the action of these -drugs. In a cicatrix, the diffusibility of the solution is impeded, -and in an inflammatory or necrotic tissue, the changes in the quantity -and quality of the fluids present, alter the action of the anesthetic. - -In considering the personal element of the patient one meets a -difficulty which is by no means minor, and full explanation for the -selection of the local anesthetic with many assurances of the -painlessness of the operation are frequently necessary. This is -especially true with one of highly emotional temperament, and, to -allay fear in such a patient is not always easy. - -Whatever may be said regarding the mental state of the patient who is -to receive an anesthetic, whether general or local, the surgeon must -remember that to be calm does not always lie within the control of his -subject, and it will be found that a hypodermic injection of morphine -(gr. one-eighth to one-quarter) an hour before the start of the -anesthetic, will often render possible the use of the injection method -in a patient with whom it would otherwise have been impossible. -Morphine injections, as suggested, are of advantage in patients on -whom a major operation is contemplated; they loosen the musculature -and diminish the sensations of parts not anesthetized. - -The deliberate and confident manner and word of the surgeon go a long -way in guiding the feelings of his patient, and a worried or -apprehensive surgeon makes for a doubtful and sensitive patient, ready -to cry out at the first prick of the needle. Therefore it is a part of -good general technic for the surgeon to deport himself in a way -conducive to cheerfulness, and conversation must be guided along these -lines. - -There are many who will writhe and groan at sensations (which they -will admit later were not painful) incident to local anesthesia, such -as the grating vibrations of instrumentation. Such a patient is not -well fitted for the method and it is for the discerning surgeon to -recognize such in advance, that he may operate under the most -favorable circumstances. - -+Preparation of the Patient.+ Proper evacuation of the bowels and a -stomach free of undigested parts of a previous meal, are desirable. -The subject of an anesthetic should not be purged or starved as these -are weakening processes and also disturb the tranquility so essential -to a perfect anesthesia. The skin should be prepared so as to -accomplish surgical cleanliness without irritating it so as to retard -healing. It was once thought that soap, water, alcohol, ether and -bichloride were absolutely necessary to this end. It has, however, -been found that iodin, applied in the ten per cent. tincture to the -site of incision, fulfills every requirement. Where shaving is -necessary, it should be done first. In operations about the anus and -scrotum, iodin is contraindicated because of its irritating -properties; it is painful in these parts and dermatitis is frequently -the result of its use. - -+Instruments.+ The instruments should be prepared and ready before the -anesthetic is given, regardless of the form of anesthesia employed. -The surgeon's hands should be rendered aseptic, no matter how trivial -the procedure before him, and every precaution should be taken to -guard against infection, which is always possible in any surgical -procedure however insignificant. - -+Technic.+ Various methods of accomplishing the insensitization of a -part may be employed. Thus, if the skin alone is to be incised, it -alone will require injection and by careful insertion of the end of -the needle it may be kept just under the epidermis, thus injecting the -anesthetic endermatically in and about the papillae of the papillary -layer. - -+Endermic Method.+ This method is an end-organ anesthesia, and the -solutions employed are strong and act because of their drug content. -It is not in any sense a pressure anesthesia. The skin should be -picked up and pinched hard for the better insertion of the needle -directly into the skin substance. It is therefore endermic and the -skin is seen to become blanched as the needle advances delivering its -solution on the way. But little of the fluid is pressed out as the -needle advances. When the syringe is empty or the needle has advanced -to the limit of its length, refill and insert just inside of the last -blanched spot and proceed in a line until the end of the contemplated -line of incision is reached. - -Pressing out too much of the solution at one time causes a burning -sensation and should therefore be avoided as the only pain should be -that of the initial prick of the needle. Care, however, should be -taken to inject just sufficient of the solution to penetrate beyond -the zone of operation laterally, to insure sufficient space for the -insertion of sutures into anesthetized tissues. Only a small quantity -of fluid is necessary in this procedure as it comes in direct contact -with nerve terminals. By touching the injected line with the needle in -several places along its length and inquiring of the patient if it is -felt, we may make sure of the completeness of the anesthesia before -making the incision which should begin and end inside the anesthetized -area. - -+Subdermic Method.+ An appreciable area of skin and subcutaneous tissue -may be incised by anesthetizing as previously described, together with -depositing the fluid well under the skin, thus affecting many terminal -nerve branches before they reach their final distribution in the skin, -and widening the anesthetized area considerably. - -This method is applicable to such work as the removal of small -growths, and the deep incision of a carbuncle. Beneath the skin in the -loose connective tissue the fluid is deposited and causes anesthesia -by acting upon the nerves just before their emergence into the skin. -The two methods may be combined. It is not possible to inject directly -into thin skin or mucous membrane and it is therefore employed in such -operations as circumcision, where the nerve terminals must be -anesthetized by the diffusion of the anesthetic from its position -under the skin. A little time should be allowed before beginning the -operation to permit of the diffusion of the drug. This applies also to -such operations as that for ingrown toe-nail where the deeper tissues -down to the root of the matrix are involved. - -+Edemitization Method.+ This is the method of Schleich and it is to him -that the credit must be given for a procedure which has done more to -encourage the use of local anesthetics in operative surgery than any -other. He employed weak solutions of cocaine and other local -anesthetics in great volumes of water in order to gain the combined -action of both drug and of pressure. The method is described under the -heading of "Cocaine." It was designed to obtain anesthesia with -cocaine with the elimination of the toxic effects of the latter. - -There are decided disadvantages to the filling up of the tissues with -fluid; healing is delayed; relations are distorted and coaptation of -the edges is difficult. This is probably the method of selection where -an indefinite amount of manipulation is expected and where the length -and depth of the incision may need to be augmented. A large quantity -of a very weak solution is employed and the tissues in all directions -are injected until visibly distended. - -+Nerve Blocking Method.+ By injecting a small quantity of a fairly -strong anesthetic solution either directly into a nerve or beneath its -sheath, the entire area supplied by it will be anesthetized. This -method of nerve blocking may be spoken of as _endoneural_ when the -injection is made directly into the nerve trunk, and _perineural_ when -made into its sheath or immediately outside of the nerve. The -injection of fluid around nerves too small to inject directly is also -spoken of as perineural nerve blocking. (Hertzler). - - -+DRUGS EMPLOYED+ - -The essential qualities of a good local anesthetic are: - - 1. Reliability in producing anesthesia. - 2. Constitutional and local harmlessness. - 3. Non-irritating qualities. - 4. Ability to be rendered aseptic by boiling. - -No one local anesthetic can be exclusively relied upon to fulfill all -of these requirements at all times. Each one has its advocates and -from the large number offered, it is possible to select several which, -while not being perfect, are preferable to cocaine in that they -obviate the disagreeable train of symptoms peculiar to that drug. - -By local anesthetics are understood certain chemical compounds, weak -solutions of which, when brought in contact with sensory nerves -paralyze them without lastingly injuring them. This effect is -dependent upon the presence in these agents of certain atom groups -which Ehrlich named _anesthiferous_. It is possible that just these -atom groups enter into certain chemical combinations with the nerve -substance and that the nerve thus remains paralyzed until the newly -formed compounds are split up and the poison is washed away by the -circulating blood. - -Cocaine is the original type of a local anesthetic. Einhorn has made -possible its synthetic production and has also opened the field for a -great number of experiments of scientific and practical importance -leading to the discovery of new local anesthetics obtained by -exchanging the non-anesthiferous atom groups of cocaine for other -groups different for each of the various new agents; thus eucaine, -orthoform, anesthesine, alypin, and others have been obtained. - -+Cocaine+ occurs as a white, crystalline powder, readily soluble in -water and in alcohol. It is an alkaloid which effects all living -protoplasm. It first excites, then paralyzes. In greater -concentrations it paralyzes immediately. Its effect is very ephemeral, -producing no lasting harm to the cocainized protoplasm. Its effect is -most readily understood by assuming that cocaine poisons the -protoplasm by entering with it into combinations which are easily -broken up. The products of decomposition, among which cocaine cannot -be recovered, are slightly or not at all poisonous and are carried -away by the circulation. - -+Effect on the Mucous Membrane.+ The external application of cocaine in -solutions of varying strengths has been of great service since its -introduction by Roller in 1884, and many operations on the eye and on -its coverings are now greatly facilitated, by reason of its use. Small -quantities only are required, hence there is little fear of its -toxicity. Its anesthetic qualities by contact are also made use of in -operations in and about the nose and throat. Here comparatively mild -solutions are used liberally but care must be exercised against its -noxious effects; it is usually employed in freshly prepared solutions -which are held to be less toxic. Where extensive areas of mucous -membranes are to be anesthetized, as in the rectum or urethra or -bladder, one of the less toxic drugs is preferable. - -+Strength of Solutions.+ In the eye, it is customary to employ a 4 per -cent. solution. For work in the nose, 2 per cent. is generally -considered sufficient. In the latter connection, it is often combined -with adrenalin solution in small amounts to mitigate its depressing -effects as well as to control bleeding. The latter effect is but -transient and is omitted by many as unsatisfactory because of the more -profuse subsequent hemorrhage. In this respect cocaine and adrenalin -are similar. They both cause constriction of the minute superficial -vessels and immediate blanching of the membrane; work in the nose is -hence greatly facilitated, the field of operation being clear and -enlarged by the shrinkage of the encroaching membrane, but it is -incumbent upon the operator to keep his patient under observation at -least an hour after the completion of the operation that he may be -certain of the degree of hemorrhage after the effects of the drugs -have passed away. For the above reason many operators prefer a general -anesthetic or one of the local anesthetic drugs which exert no -constrictor action so that they may know, _ab initio_, the exact -degree of bleeding. - -Whatever drug is used, strong solutions are seldom necessary for -application to the mucous membranes but the necessary time for its -absorption is a prime requisite. To secure anesthesia of the -conjunctiva and cornea, the solution is dropped into the eye at the -outer canthus and as it flows off with the tears, it must be -replenished three or four times until anesthesia is accomplished. In -the nose, a spray over the site of incision or a pledget of cotton -saturated with the anesthetic solution and allowed to rest in contact -with that locality, will suffice. The flow of mucus from the nasal -mucosa is stimulated by the presence of the cotton pledget and it soon -becomes entirely coated with a thick mucus which no longer is able to -impart to the membrane its anesthetic solution and must therefore be -renewed several times before complete insensibility of the part is -assured. The topical application of a strong solution on a cotton -wound applicator to a limited area or spot is also efficient. - -+Application by Injection.+ In order to bring the anesthetic in contact -with the nerves, it is necessary, where a skin surface is to be -incised, to inject the solution as already described. The technic, -previously detailed, applies here, and any of the methods may be -employed for the injection of solutions of cocaine, some preferring a -single method to the exclusion of all others. The locality to be -treated will also influence the operator as to method. - -+Endermically.+ The endermic method is the one most generally employed -in securing cocaine local anesthesia by injection. The papillary layer -of the skin is well infiltrated with a mild solution (one-eighth per -cent. to one-half per cent.), frequently with adrenalin 1-1000, in the -proportion of 15 to 20 drops to the ounce of the solution. The -strongest of the formulas of Schleich may also be used for endermic -infiltration. - -The skin is injected to a fair degree of tension and a white ridge -marks the line of injection which should be sufficiently extensive to -permit the manipulation of the cut edges. - -+Edemitization.+ Schleich's solutions are here of extreme value because -large amounts of solution are necessary to produce the degree of -distention required because of the minute quantity of cocaine present, -though the added salt and morphine assist considerably. - -+Nerve Blocking and Perineural Blocking.+ Here a stronger solution must -be employed; 1 per cent., or even stronger, is injected in small -quantities, either into the substance of the nerve or under its -sheath, as already described. - -+Strength of Solution.+ Schleich has worked out a method whereby very -weak solutions of cocaine may be used advantageously. His plan is to -enhance the action of the drug by the admixture of morphine in minute -quantities and of sodium chloride in proper strength. These -substances, in themselves, were found to possess anesthetic powers. -Large quantities of Schleich's solutions may be injected--even several -ounces, without ill effects as they contain so little cocaine. The -formulas used by him are: - - 1. Cocaine hydrochlorate 0.2 - Morphine hydrochlorate 0.02 - Sodium chloride 0.2 - Distilled water 100. - - 2. Cocaine hydrochlorate 0.1 - Morphine 0.02 - Sodium chloride 0.2 - Distilled water 100. - - 3. Cocaine hydrochlorate 0.01 - Morphine 0.005 - Sodium chloride 0.02 - Distilled water 100. - -It will be seen that the strength of cocaine in the respective -solutions is from one-fifth to one-hundredth of a gram. - -The solutions used in the early days of cocaine anesthesia were much -stronger than were found necessary afterward and it has now become the -rule to employ weak solutions and to give them time to penetrate the -tissues. The less toxic action of mild solutions, even when like -amounts of the drug are employed, makes it incumbent upon the operator -to follow this plan and the element of time is so important in the -matter of securing a perfect local anesthesia that it is customary to -wait fifteen or twenty minutes after the completion of the injection -before making the incision. The weakest solution possible is the one -of choice in the use of this anesthesia. - -+Toxicology.+ The repeated use of cocaine in the same patient should be -avoided on account of the danger of establishing the cocaine habit. -The drug should be given with the greatest care, especially in -operations about the head, neck, face, and urethra, as several deaths -and many alarming cases of syncope, delirium and paralysis or tetanic -fixation of the respiratory muscles have followed its use. Because of -its marked depressing effect upon vital organs, it should never be -given unless the patient is in the recumbent position. The -administration of one drop of a one per cent. solution of trinitrin -given at the first onset of the constitutional effects and repeated if -necessary every five minutes, will entirely prevent any unpleasant -effects as it is a true physiologic antidote. - -If the surgeon has a case in which he intends to use large amounts of -cocaine, it is best to have at hand and ready for use the following -agents: a hypodermic and a rectal syringe, a battery, cardiac and -respiratory stimulants, oxygen, and a catheter. - -If the patient becomes very delirious and is in no way depressed, -chloral or hyoscine should be given. In all cases of cocaine poisoning -the patient should be catheterized to prevent re-absorption and should -then be treated symptomatically. - -Strong solutions should never be employed for any purpose except in -cases where, by previous experience with the mild ones, it is known -that no idiosyncrasy exists. - -The central nervous system, and next the sensory and motor nerves, are -affected by cocaine. Respiratory paralysis follows the introduction of -appreciable amounts of cocaine into the circulation and respiratory -depression may follow the introduction of smaller quantities. A given -quantity of the drug in great dilution will, under normal conditions, -give no toxic symptoms, whereas the use of the same amount in a more -concentrated form will give rise to pallor, cyanosis and even syncope -and collapse. It is said that a maximum dose of cocaine can never be -fixed; this, however, seems of less importance than knowing the -minimum dose, for while it is true that many bear it well, this drug -so frequently gives rise to toxic symptoms, and the idiosyncrasy for -it is so common, that one can never be certain of an exact dosage. -Various pharmacopias place the maximum dose at 0.05 grm. (about -seven-eights of a grain). - -Bearing in mind that a great dilution of a given amount makes for -safety, we are astonished to learn that 7 c. c. (about 2 drams), of a -1 per cent. solution introduced into the urethra has caused death. -(Czerny). - -Hertzler cites numerous instances in which a few drops of a more -concentrated solution (2 per cent. to 4 per cent.) have caused death. -It is therefore obvious that the use of this drug must be guarded by a -technic so perfect that but the smallest quantity of a very weak -solution shall be permitted to enter the circulation. - -+Adjuvants, Substitutes and Safeguards.+ The numerous disadvantages in -the general use of this most efficient but most treacherous local -anesthetic have operated so strongly that efforts have constantly been -made to find a substance which, when used with it, would correct its -toxic effects. - -The desirability of employing large quantities of an anesthetic -solution so as to enable the operator to infiltrate large areas of -tissue has led to the method of preparing very dilute solutions and -mixing them with various chemical substances which in themselves -would act as mild anesthetics and at the same time increase the -diffusibility of the cocaine. With any of these substances, cocaine -still remains toxic and the quantity injected must be kept account of -when an operation of any extent is being performed even though the -solution be never so mild. - -A valuable preventive to this absorption is found in the application -of a constricting band or tourniquet to impede the return circulation -and allow the washing out of much of the drug before the obstruction -is removed. It is evident that no method has yet been devised whereby -the use of cocaine is rendered safe and it is for this reason that -chemists throughout the world have sought to produce either a new -anesthetic drug or to evolve a drug synthetically, from cocaine, minus -its toxicity. This has been done, but cocaine still has its adherents -because of its superior qualities. - -Quinine and urea hydrochloride is one of the new substitutes which has -found much favor. Among the synthetic derivatives may be mentioned -alypin, novocaine, stovaine, betaeucaine, tropacocaine, anesthesin, -subcutin and many others. Each of these has its advocates and all of -them have some advantage over cocaine; they have disadvantages as -well, which, however, in the hands of skilled operators, may be -overcome. - -+Quinine and Urea Hydrochloride.+ Among the quinine salts and -combinations, the above has found most favor. It consists of a -molecule of quinine hydrochloride and one of urea. It occurs as a fine -crystalline powder and is readily soluble in water, forming an acid -solution. - -This substance is one of the most recent and best substitutes for -cocaine, being capable of a wide range of usefulness and practically -devoid of any toxicity. It causes redness on being injected and, in -strong solutions, may delay healing considerably, this constituting -the main disadvantage to its use. After the use of this anesthetic, -primary union is not usual. - -In a one per cent. solution, anesthesia is accomplished by any of the -methods already described. Weaker solutions require a more perfect -technic, and are therefore not generally employed. They, however, are -indicated where it is imperative to secure primary union and when for -some reason no other local anesthetic is available. The scar formation -which almost always follows the use of this anesthetic would indicate -that some other drug be employed in operations about the face and -neck. This anesthetic is preferred by many because of its safety in -large quantities and because of the length of insensibility following -the injection of solutions of from 1 per cent. to 2 per cent. -strength. - -Notwithstanding knowledge of the facts above enumerated as to the -difficulty of primary union and the likelihood of scar formation in -connection with the use of urea and urea-hydrochloride for purposes of -local anesthesia, this drug is still considered a most valuable and -useful one for providing local anesthesia for operative purposes. - -+Novocaine.+ This drug is one-seventh as toxic as cocaine but is also -weaker in action. It does not cause vascular constriction but has a -preliminary vasodilator action. Like quinine, it has a decidedly -irritating action when injected. It has a decidedly toxic effect when -used in stronger solutions than 2 per cent. and causes tonic and -clonic spasm. In a 1 per cent. solution it is probably safest and best -as an anesthetic and one-half ounce of such a solution may be injected -without fear of unpleasant consequences. - -Its dose is said to be about seven grains, but this may often be the -cause of alarming symptoms, and half of this quantity would perhaps be -a safe limit. The duration of anesthesias of fairly strong solutions -is about fifteen minutes; the action is more prolonged if used with -adrenalin. - -Various combinations of drugs besides adrenalin are employed with -novocaine. Fischer recommends its use with thymol, but even so, it is -not efficient for a longer period than twenty or twenty-five minutes. - -Novocaine is frequently used in alcoholic solutions for injection in -neuralgic subjects. The commercial tablet of novocaine and adrenalin -is convenient for office use. - -+Alypin.+ This substance occurs as a crystalline powder, easily soluble -in water, alcohol and ether, and makes a neutral solution. - -Alypin is in every respect the equal of cocaine though not quite as -strong. Schleich has found that its use, in conjunction with minute -quantities of cocaine, permitted of a reduction of the entire amount -of anesthetics necessary to accomplish insensibility. - -In its use on mucous membranes it does not cause any anemia and -therefore no secondary bleeding occurs. This is a great advantage also -in the examination of mucous membrane lined cavities, such as the eye, -nose, throat and urethra, inasmuch as after the application of -cocaine, the blanching of the membrane conveys no idea of the real -condition of the parts. - -Because of the results he obtained, Schleich now recommends the -following solutions for infiltration: - - 1. Cocaine 0.1 - Alypin 0.1 - Sodium chloride 0.2 - Distilled water 100. - - 2. Cocaine 0.05 - Alypin 0.05 - Sodium chloride 0.2 - Distilled water 100. - - 3. Cocaine 0.01 - Alypin 0.01 - Sodium chloride 0.2 - Distilled water 100. - -For other operative procedures of a minor character, it has been found -that one-fourth per cent. to one-eighth per cent. is sufficient. For -application to mucous membranes, as in the urethra, nose and throat, 1 -per cent. to 2 per cent. has proved effective. - -+Stovaine.+ Stovaine is used more for spinal anesthesia than for local -purposes; it is said to work well in inflamed tissues. - -Several drugs have been used because of their lessened toxicity and -many are constantly being tried but to be abandoned because of their -inefficiency or irritating qualities. None of them are as efficient as -cocaine and the weak solutions of Schleich are about as active as -stronger solutions of many of these and are not more toxic. - -Among the other cocaine substitutes in general use are betaeucaine, -tropacocain, anesthesin, and subcutin. - -These all find a special field of usefulness, but for general work, -are limited, because of some disadvantages which each and all of them -possess. - -Individual selection plays an important part in the use of a local -anesthetic, and one operator, by practical experience, may obtain -results with a given drug, which another fails to achieve. - -The essential feature to be remembered by the practising chiropodist -is, that the use of any drug employed for anesthetizing purposes, even -though but local, should be safeguarded in every way. - -+Cold.+ The methods of using ether, rhigolene, or ice and salt, to -produce cold, are slow and unsatisfactory. If cold is to be used to -produce local anesthesia the most efficient and convenient method of -applying it is by means of _ethyl chloride_. This fluid is very -volatile and is best controlled by having it in air-tight tubes. When -not in use, a valve covering one end of the tube prevents leakage. -When the valve is pressed upon, the orifice of the tube is opened and -the heat of the hand forces out a fine stream of the liquid which is -directed upon the parts to be frozen. Rapid evaporation causes intense -cold. The nozzle should be held about fifteen inches from the area to -be acted upon. When the spray strikes the integument, redness almost -instantly results but in a few seconds the part becomes hard and -white. This condition indicates local insensibility and lasts about -two minutes. If the action is slow, it can be much hastened by gently -blowing upon the parts to increase the rapidity of evaporation. - -The refrigeration method of local anesthesia is of limited usefulness -and is recommended only for the opening of felons and abscesses, for -removing wens from the scalp and back, and for producing a painless -area in which a puncture is to be made. It must be borne in mind that -sloughing and ulceration of the skin are liable to follow the use of -cold. - -Work under this form of anesthesia must be done with rapidity not -always consistent with thoroughness, and should therefore be employed -only when a single incision or puncture is indicated. - -The pain incident to subsequent thawing is severe and, in general, is -about as hard to bear as an incision without an anesthetic. - -For the purposes of practical podiatry, the chiropodist is advised to -use a substitute for cocaine rather than the cocaine itself when local -anesthesia is necessary. In the clinics of the School of Chiropody of -New York, novocaine, quinine and urea hydrochloride, and alypin are -preferred, and no single instance of toxemia has ever been -experienced. There have been cases in which the anesthesia did not -prove thoroughly effective, but, in the main, these drugs have well -answered the purposes of their use. - - -THE END - - - - -GLOSSARY - - -+A+ - -+a-an.+ Without, as in atypical--without type, and as in analgia--without -pain. - -+ab.+ From, away from, as in abaxial, lying outside of or away from any -body or part. - -+abduction.+ To move away from the axis (median line) of the body. - -+ab initio.+ From the beginning. - -+abrade.+ To scrape away. - -+acid.+ A compound of an electro-negative element or radical with -hydrogen. - - +acetic acid.+ A product of the oxidation of ethylic alcohol and - of the destructive distillation of wood, applied locally as a - counterirritant. - - +benzoic acid.+ External uses, antiseptic. - - +carbolic acid.+ Used in podiatry, as an antiseptic, as a - disinfectant and as an anesthetic. - - +chromic acid.+ Has caustic properties. - - +dichloracetic acid.+ Used as a caustic application to venereal - sores. - - +glacial acetic acid.+ Employed externally as a caustic for - removal of warts and helomata. - - +hydrochloric acid.+ Externally employed as an escharotic. - - +monochloracetic acid.+ Used as a caustic for helomata and - verrucae. - - +nitric acid.+ Used as a caustic against verrucae. - - +nitrohydrochloric acid.+ An active caustic agent. - - +oxalic acid.+ Removes ink stains. - - +sulphocarbolic acid.+ Antiseptic and disinfectant. - - +trichloracetic acid.+ Employed as an escharotic for venereal - and other warts. - -+abscess.+ A circumscribed cavity containing pus. - -+acidulated.+ Rendered acid. - -+actinomycosis.+ An infectious disease due to the ray fungus. - -+actual cautery.+ A substance which acts by virtue of its heat, not -chemically. - -+adenoma.+ A tumor of glandular epithelium. - -+adde.+ Add, used in prescription writing. - -+adduction.+ To turn towards the axis or median line of the body. - -+adhesive.+ Sticking together. - -+adjacent.+ Next to. - -+adjuvant.+ A remedy which added to a prescription aids the action of -the main ingredient. - -+adrenalin.+ Trade name of a principle obtained from the suprarenal -glands which has astringent and hemostatic properties. - -+aerobic.+ Unable to live without oxygen. - -+albuminoid.+ A substance resembling true proteids in origin and in -composition. - -+albuminous.+ Resembling or containing albumin. - -+albuminuria.+ Albumin in the urine as voided. - -+albumose.+ An intermedial product of the splitting of proteids by -enzymes. - -+albumosuria.+ Albumose in the urine. - -+algia.+ Pain, as in neuralgia, nerve pain. - -+alkaloidal. An organic base of vegetable origin causing toxicologic -effects. - -+alveolar.+ Pertaining to the alveoli. - -+ambi.+ Both, as in ambidexterity, the ability to use both hands with -equal ease. - -+ambulatory.+ Walking, able to walk. - -+ameba.+ A small one-celled animal that constantly changes its shape by -sending out processes of its protoplasm. - -+amyl nitrite.+ A drug used to dilate the blood vessels. - -+anal.+ Relating to the anus. - -+anemia.+ A condition in which the blood is reduced in amount or is -deficient in red blood cells or in hemoglobin. - -+anerobic.+ Living without air. - -+anesthesia.+ Loss of sensation. - -+anesthesin.+ An ethylic ether used as a local anesthetic. - -+aneurism.+ A saclike dilation in the wall of an artery as the result of -weakness of its tissues. - -+angioma.+ A tumor formed of blood vessels. - -+animal.+ An organic being, with life and power of motion. - -+ankylosis.+ Stiffening of a joint. - -+anthrax.+ The disease produced by the bacillus anthracis. - -+anti.+ A prefix signifying against; in relation to symptoms and -diseases, curative. - -+antidote.+ An agent which neutralizes or counteracts the effects of a -poison. - -+antipyretics.+ Agents reducing fever. - -+antiseptic.+ Preventing, or destroying the germs of putrefaction or -suppuration. - -+antitoxin.+ A substance in the serum, which binds and neutralizes -toxin. - -+anus.+ The orificial extremity of the rectum. - -+apposition.+ Contact of two bodies or two surfaces. - -+argyrol.+ A soluble, non-irritating silver preparation used in the -treatment of various inflammations of mucous membranes. - -+arsenic.+ A metalic element in chemistry. - -+arterial.+ Pertaining to an artery. - -+arteries.+ Vessels carrying blood from the heart. - -+arteriosclerosis.+ A fibrous overgrowth of the inner coat of an artery. - -+arthritis.+ Inflammation of a joint. - -+arthrotomy.+ Cutting into a joint. - -+articulation.+ A joint. - -+aseptic.+ Free from septic matter. - -+asepticize.+ To render aseptic or sterile. - -+aspiration.+ The withdrawal by air or by suction of fluid from any body -cavity. - -+astringent.+ An agent producing contraction of organic tissues or the -arrest of a discharge. - -+atrophy.+ The wasting or diminution of the size of a part from lack of -nutrition. - -+autoclave.+ Instrument for sterilizing by steam. - -+axis.+ A straight line passing thro a spherical body between its two -poles and about which the body may revolve. - - -+B+ - -+bacillus.+ A genus of schizomycetes, the most important group of -bacteria. - -+bacteria.+ Microorganisms, microbes, schizomycetes. - -+benign.+ Not malignant; mild. - -+betaeucaine.+ A local anesthetic used as a substitute for cocaine. - -+bi.+ A prefix denoting two, twice or double, as biceps--two heads. - -+bicarbonate.+ A compound of two equivalents of carbonic acid and one of -a base. - -+bichloride.+ A chloride with twice as much chlorin as a protochloride. - -+blast.+ Germ, as in blastoderm, the primitive cell layer in the -beginning embryo, consisting of three layers. - -+blastomycetes.+ Yeasts; budding fungi. - -+blistering.+ Producing a blister. - -+brain.+ The large mass of nerve tissue contained in the cranium, -especially the cerebrum. - -+bromide of potassium.+ A salt of potassium. - -+bromidrosis.+ Fetid or foul smelling perspiration. - -+bubo.+ Enlargement of a lymphatic gland usually in the groin. - -+budding.+ Gemmation. A form of tissue division by a bud-like process. - -+bulla.+ A large bleb or blister. - -+bunion.+ An inflammatory swelling of the bursa over the -metatorsophalangeal joint of the great toe. - -+bursa.+ A small sac interposed between movable surfaces. - -+bursitis.+ Inflammation of a bursa. - -+buttock.+ The prominence formed by the gluteal muscles of either side. - - -+C+ - -+calcareous.+ Having the nature of lime. - -+calcification.+ A degeneration of tissues into salts of calcium or -magnesium. - -+callosity.+ A circumscribed thickening of the epidermis as a result of -friction or intermittent pressure. - -+cancellous.+ Resembling lattice work. - -+canthus.+ The slit between the eyelids. - -+capillary.+ Any one of the small blood vessels which serves to connect -an artery and a vein and to allow of the passage of nutrient matter -and oxygen from the blood into the tissues and of waste matter from -the tissues into the blood. - -+carboluria.+ Carbolic acid in the urine. - -+carbuncle.+ A phlegmonous inflamation of the skin and subcutaneous -tissues. - -+carcinoma.+ A malignant epithelial growth. - -+cardiac.+ Pertaining to the heart or cardium. - -+caries.+ Molecular bone decay. - -+carotid.+ The principle artery of the neck. - -+cartilage.+ A non-vascular elastic tissue, softer than bone. - -+cartilaginous.+ Partaking of the nature of cartilage. - -+caseation.+ Transformation of necrotic tissue into a mass resembling -cheese. - -+caseous.+ Cheesy. - -+catheter.+ A hollow cylinder of silver, rubber or other material -designed for passage thru the urethra and other channels. - -+caustic.+ Corrosive; capable of tissue destruction; syn. escharotic. - -+cautery.+ An agent which by heat or chemical action scars tissues. - -+cavities.+ Hollows. - -+cele.+ Tumor, as in hydrocele, a watery tumor. - -+cell.+ A small protoplasmic mass, usually nucleated. - -+cellular.+ Composed of cells. - -+cellulitis.+ Inflammation of cellular tissue. - -+cephalic.+ Head, as in hydrocephalic, water on the head (brain). - -+chancre.+ The primary syphilitic manifestation. A syphilitic -induration. - -+Charcot's disease.+ A form of tabes. - -+chemotaxis.+ The attraction or repulsion exhibited by certain chemicals -to living cells. - -+chimatlon.+ Mild, chilblain; severe, frost-bite. - -+chiropodial orthopedics.+ That branch of podiatry which has to do with -the treatment of chronic diseases and deformities of the foot and of -the foot joints. - -+chiropodist.+ Literally, one who treats the feet and hands. Actually, -one who specializes in the treatment of foot lesions not requiring -major surgical operative procedures. - -+chloral.+ An oily liquid formed by the action of chlorine gas on -alcohol. - -+chlorosis.+ A form of anemia occurring chiefly in young girls. - -+chondritis.+ Inflammation of cartilage. - -+chondroma.+ A tumor of cartilage tissue. - -+chronic.+ Of long standing. - -+chyle.+ The milky fluid found in the mesenteric lymph-vessels as the -result of fatty digestion. - -+cilia.+ The eyelashes; hairlike processes of certain cells. - -+circumcision.+ Removing part or all of the foreskin. - -+clot.+ The solid portion resulting from the coagulation of blood. - -+coagulation.+ Clotting; in the blood, the result of fibrinogen changing -to fibrin. - -+coalesce.+ To merge in growth. - -+coaptation.+ The fitting together of two opposing surfaces. - -+cocaine.+ An alkaloid derived from coca. Useful to produce local -anesthesia. - -+cocci.+ Round, spheroidal or oval shaped bacteria. - -+cocoon.+ Shaped like the protection of the silk-worm larva. - -+colostomy.+ Opening into the colon to establish an artificial anus. - -+collodion.+ A solution of pyroxylin in ether and alcohol. - -+compression.+ Decreasing volume and increasing density by pressure. - -+concomitant.+ Accompanying. Accessory. - -+condyle.+ A rounded articular surface at the extremity of a long bone. - -+congenital.+ Existing at birth. - -+congestion.+ Hyperemia of a part. - -+conjunctiva.+ The mucous membrane covering the anterior surface of the -eyeball. - -+connective tissue.+ The uniting tissue of the body. - -+constitutional.+ Relating to the system as a whole. - -+constriction.+ The act of drawing together, a narrowing or binding. - -+continuity.+ Connected; the quality or state of being continuous. - -+contra.+ A prefix meaning against. - -+contused.+ Bruised. - -+corium.+ The deep or connective tissue layer of the skin; the true -skin. - -+cornea.+ A transparent membrane forming the outer coat of the eyeball. - -+cornification.+ Conversion into a hard or horny substance or tissue. - -+corpuscles.+ Minute bodies. Primary atoms of the blood. - -+corrosive.+ A substance that eats or destroys. - -+cortex.+ The external gray layer of the brain; the outer covering in -plant life. - -+cortical.+ External, in contradistinction to other parts, in tissue or -plant. - -+cosmetic.+ An agent or a means for beautifying the body. - -+counterirritant.+ Means or medications to produce irritation to relieve -deeper congestion. - -+crepitus.+ The grating of fractured bones. - -+crisis.+ A sudden favorable change in the course of an acute disease. - -+cryptogam.+ A group of plants without flowers and without -embryo--containing seeds. - -+cuneiform.+ A wedge-shaped bone found in the carpus (one) and in the -tarsus (three). - -+cupping.+ Blood-abstraction by means of cupping-glasses. - -+curette (curet).+ Spoon-shaped instrument for scraping. - -+cutis.+ The skin. - -+cyanosis.+ Blue discoloration of the skin from non-oxidation of blood. - -+cyte.+ Cell or corpuscle, as in leucocyte, white blood cell. - - -+D+ - -+dactyl.+ Finger, as in dactylitis, inflammation of one or more fingers. - -+debris.+ Scattered fragments. - -+decomposition.+ Decay. Breaking up into its original elements. - -+deformity.+ A deviation from normal in shape or in size. - -+deleterious.+ Injurious, noxious, harmful. - -+demarcation.+ A tissue boundary mark. - -+dentine.+ The bony structure of the teeth. - -+derma.+ The skin. - -+dermatitis.+ Inflammation of the skin. - -+devitalize.+ To destroy vitality. - -+diabetes (mellitus).+ A disease of metabolism characterized by the -presence of sugar in the voided urine. - -+diagnosis.+ Determination of the nature of a disease. - -+diapedesis.+ The passage of the blood-corpuscles through the -vessel-walls without rupture of the latter. - -+diaphoresis.+ Excessive perspirattion. - -+diaphragm.+ The muscular wall between the thorax and the abdomen. - -+diaphysis.+ Relating to the shaft of the bone. - -+diffusion.+ A scattering about. - -+digit.+ A finger or toe. - -+dilatation.+ An expansion of a vessel or an organ. - -+discutient.+ An agent which causes the dispersal of a tumor or of a -pathologic neoplasm of any kind. - -+disease.+ A pathologic condition of any part or organ of the body. - -+disinfection.+ Freeing from infection. - -+disintegration.+ Separation of component parts. - -+dislocation.+ Displacement of an organ or of a part. - -+dissection.+ A separation by cutting of the parts of the body. - -+distortion.+ Mechanical derangement of a part interfering with its -function. - -+dorsal.+ Pertaining to the back. - -+dorsum.+ The back, the posterior part of an organ. - -+drainage.+ (Surgically) The gradual removal of the contents of a -suppurating cavity. - -+d.s. or s.+ Used in prescription writing, meaning to give directions. - -+dynia.+ Pain, as in pleurodynia, pain in the pleura. - - -+E+ - -+ecchymosis.+ An extravasation of blood or slight hemorrhage under the -skin resulting in a purplish patch. - -+echinococcus.+ The larval stage of the dog tapeworm, occurring also in -human organs or tissues. - -+ectomy.+ To cut out, as in prostatectomy, removal of a part or all of -the prostate. - -+eczema.+ Inflammation of the skin (acute or chronic, moist or dry), -accompanied by itching and burning. - -+edema.+ Accumulation of serum in the cellular tissue. - -+edematous.+ Relating to edema. - -+effusion.+ Escape of fluid from within, out. - -+embolism.+ The obstruction of a blood vessel by an embolus cleavage. - -+embolus.+ A plug composed of detached clot in the circulation. - -+embryonic.+ Rudimentary. - -+emigration.+ The outward passage of a wandering cell through the walls -of a blood-vessel. - -+empyema.+ Pus in a cavity. - -+en or endo.+ Within, as in endocardium, inner lining of the heart. - -+encapsule.+ To inclose in a sheath. - -+endermatically.+ Within or through the skin. - -+endoneural.+ Within the nerve. - -+endosteum.+ Membrane covering bone surface in the medullary cavity. - -+endothelial.+ Pertaining to or consisting of endothelium. A lining -cavity not communicating with the outer air. - -+enteroclysis.+ A high enema. - -+enterostomy.+ Establishing an artificial anus through the abdominal -wall. - -+epidermis.+ The outer layer of the skin constituting the outer -investment of the body. - -+epiphyseal.+ Pertaining to the epiphysis. - -+epiphysis.+ A piece of bone that in early life is separated from a long -bone by cartilage, but later becomes part of the bone. - -+epithelial.+ Pertaining to epithelium. - -+epithelioma.+ A cancerous growth originating from squamous epithelium. - -+epithelium.+ The cells covering all cutaneous and mucous surfaces, -together with the secreting cells of glands developed from the -ectoderm. - -+erysipelas.+ An acute specific inflammation of the skin and -subcutaneous tissues, accompanied by fever and constitutional -disturbances. Caused by the streptococcus erysipelatos. - -+erythema.+ Redness of the skin. - -+eschar.+ A scar. - -+escharotic.+ A substance producing an eschar. - -+esia.+ Sensation, as in anesthesia, loss of sensation. - -+ethyl bromide.+ A colorless liquid, used for both general and local -anesthesia. - -+ethyl chloride.+ A colorless liquid, whose spray produces local -anesthesia. - -+etiology.+ Cause as related to disease. - -+eucaine.+ A synthetic compound capable of producing local anesthesia. - -+evacuated.+ Removal of waste material from the body. - -+evaporation.+ Turning into vapor. - -+eversion.+ Turning outward. Turning back an eyelid so as to expose the -conjunctiva. Turning the inner border of the foot outward. - -+ex.+ Out of or from, as in exostosis, a bony outgrowth. - -+exacerbation.+ Increased severity of a disease or of its symptoms. - -+excretion.+ The product of a gland or of cells not useful to the -economy, in contradistinction to secretion. - -+excoriation.+ Removal of the superficial protective layer of the skin -or mucous membrane. - -+exfoliate.+ To strip off in layers. To desquamate. - -+exostosis.+ A bony tumor springing from bone. - -+extravasation.+ Effusion of fluid into the tissues. - - -+F+ - -+facet.+ A small plane, articulating surface. - -+facient.+ To make, as in rubefacient, to make red. - -+facultative.+ Pertaining to functional or acquired power. - -+Faradic.+ Pertaining to induced electric currents. - -+fauces.+ The space between the cavity of the mouth and the pharynx. - -+felon.+ Paronychia. Whitlow. - -+femur.+ The thigh bone. - -+ferment.+ An organic substance which in small quantities is capable of -setting up changes in another organic substance without itself -undergoing much change. - -+fermentation.+ Such changes as are effected exclusively by the vital -action of ferments. - -+fibrin.+ Active agent in blood coagulation. - -+fibroma.+ A tumor of fibrous tissue. - -+fibrous.+ Composed of fibres. - -+fibula.+ External and smaller of the two bones of the leg. - -+fissure.+ A crack in the tissues. - -+fistula.+ A pathologic sinus leading from an abscess cavity to the -surface. - -+flagella.+ The whiplike processes with which certain cells, as the -ameba, are provided. - -+flexion.+ Bending. - -+fluorescence.+ Power of a body to change wave-rate (or color) of light -passing through it. - -+focus.+ Point at which light rays meet. The starting point of a disease -process. - -+follicle.+ A small secretory cavity or sac. - -+form.+ Shape, as in vermiform, resembling a worm in shape. - -+formaldehyde.+ A gas possessing powerful disinfectant properties. - -+fracture.+ A break, as of a bone. - -+fulcrum.+ The point against which lever is placed to get purchase. - -+fungating.+ Rapidly growing (path.). - -+fungus (plural fungi).+ A cellular vegetable organism which feeds on -organic matter. Example, bacteria. - -+furunculosis.+ The systemic condition marked by boil-formation. - - -+G+ - -+gangrene.+ A necrosis with putrefaction. - -+gastrostomy.+ Making an artificial opening into the stomach. - -+gelatinous.+ Resembling gelatine, a semi-liquid substance. - -+genesis.+ Birth of, belonging to, as in genesial, relating to -generation. - -+germicide.+ An agent destructive to germs. - -+globular.+ Shaped like a globe. - -+gonorrhoea.+ A specific inflammation of the mucous membrane of the -genital tract; germal cause, gonococcus. - -+gout.+ Podagra. A disease of metabolism characterized by paroxysmal -pains in the foot, particularly in the great toe. - -+gradus.+ Step by step, as in graduated, marked by lines or in other -ways to denote capacity. - -+granular.+ Composed of grains or granulations. - -+granuloma.+ A collection of epitheloid cells at an irritated point. - -+gumma.+ A gummy tumor resulting from a peculiar caseation of a teritary -syphilitic inflammatory deposit. - - -+H+ - -+habitat.+ The natural locality of an animal or a plant; impregnated; -saturated with. - -+hallux rigidus.+ First phalanx of the great toe is flexed at an angle -of 30 deg. with extension of the second phalanx. - -+hallux valgus.+ Outward rotation of big toe beyond an angle of 15 deg.. - -+hallux varus.+ Pigeon toe. - -+heloma.+ Same as corn or callus. - -+heloma durum.+ Hard or indurated corn. - -+heloma miliare.+ A millet-seed corn. - -+heloma molle.+ Soft corn. - -+heloma vasculare.+ A corn of the vascular variety. - -+hema.+ Blood, as in hemoglobin, an iron compound in the red blood. - -+hematoma.+ A tumor containing blood. - -+hemorhage.+ A flow of blood. - -+hemophelia.+ Abnormal tendency to hemorrhage. - -+hemostatic.+ Capable of arresting hemorrhage. - -+hereditary.+ Transmitted from parent to offspring. - -+hernia.+ Rupture; protusion of a structure thro the wall which -ordinarily contains it. - -+herniotomy.+ Operation for the relief of hernia. - -+hidros.+ Perspiration, hyperidrosis, excessive sweating. - -+histology.+ Microscopic anatomy. - -+hyascine.+ An alkaloid of hyoscyamus and stramonium. - -+hydro.+ Water, hydrotherapy, treatment of disease by means of water. - -+hydrarthrosis.+ A serous effusion in a joint. - -+hyper.+ Above or over, hyperemia, the presence of an increased or -overamount of blood in a part. - -+hyperemia.+ Excessive amount of blood. - -+hyperidrosis.+ Excessive sweating. - -+hyperplasia.+ Overgrowth of a part due to a multiplication of its -elements. - -+hypertrophy.+ Abnormal, increased size of a part or of an organ. - -+hypnotic.+ Causing sleep. - -+hypo.+ Under, as in hypodermic, beneath the skin, or subcutaneous. - -+hypodermatic (hypodermic).+ Subcutaneous, applied to injections -underneath the skin. - -+hypodermoclysis.+ The hypodermic injection of fluids to supply a lack -of blood. - -+hysteria.+ A functional neurosis with abnormal sensations, emotions or -paroxysms. - - -+I+ - -+ic.+ Relating to, as in caloric, relating to temperature. - -+ichthyol.+ A brownish oil; principally used in the form of ammonium -ichthyol as an antiseptic. - -+immersion.+ The plunging of a body into a liquid. - -+immobilization.+ The act of rendering a part immobile (immovable). - -+immunity.+ Freedom from risk of infection. - -+incubation.+ The development of an infectious disease from the -infection period to the appearance of the first symptoms. - -+indolent.+ Inactive, sluggish. - -+induration.+ Hardening as of tissues. - -+ine.+ (Phar.) Alkaloid, as in morphine, an alkaloid. - -+infection.+ Invasion by pathogenic microorganisms which act injuriously -upon the tissues, causing disease. - -+inflammation.+ A morbid condition characterized by hyperemia, pain, -heat, swelling and disordered function. - -+infra.+ (L. below). A prefix denoting below, as infracostal, below a -rib. - -+innervation.+ Distribution of the nerves in a part. - -+inoculation.+ The introduction of a specific virus into the system. - -+inorganic.+ Devoid of organized structure. - -+in situ (Latin).+ In position. - -+integument.+ The enveloping membrane of the body. - -+intercellular.+ Between the cells. - -+intermittant.+ Occurring at intervals. - -+interosseous.+ Between bone tissue. - -+interstices.+ Spaces, intervals, pores. - -+interstitial.+ Lying or placed between. - -+intra.+ (L. within). A prefix denoting within or inside, as -intraneural, within a nerve. - -+intravenous.+ Within a vein. - -+inunction.+ Administering a drug in ointment form by rubbing into the -skin. - -+inversion.+ The reversion of the normal position of an organ, turning -inward, inside out, etc. - -+involucrum.+ An enveloping membrane. - -+iodide.+ A compound of iodin with another element, as iodide of -potassium. - -+iodin (iodine).+ A non-metallic chemical element. - -+iodoform.+ A lemon yellow crystalline powder; used as an antiseptic to -wounds and sores. - -+iritis.+ Inflammation of the iris, the anterior division of the -vascular tunic of the eye. - -+iron.+ A metallic element. - -+irrigation.+ The washing out of a cavity or wounded surface with a -stream of fluid. - -+itis.+ Inflammation, as in pericarditis, inflammation of the -pericardium. - - -+J+ - -+jaundice.+ A yellow tissue-staining from bile. - -+jaw.+ One of the two bony structures of the mouth in which the teeth -are set. - -+jugular.+ Relating to the throat or neck. - -+juice.+ Tissue fluid of a plant or animal. - -+jute.+ Fiber used in surgical dressings. - -+juxta.+ Prefix; meaning close to or next. - - -+K+ - -+kalium.+ Latin for potassium. - -+kaolin.+ Fuller's earth; used as a poultice with glycerin. - -+karyokinesis.+ Indirect nuclear division, mitosis. - -+keratin.+ A scleroprotein present in skin appendages, hair, nails, etc. - -+keratitis.+ Inflammation of the cornea. - -+kerato.+ A prefix denoting horny tissue or cells. - -+keratodermia.+ Hypertrophy of horny layer of epidermis. - -+keratosis.+ Circumscribed over-growths of horny layer of skin. - -+kinetic.+ Relating to motion or to muscular movements. - -+kneading.+ To work and press into a mass. - -+knee.+ Articulation between femur and tibia covered in front by the -patella. - -+knee-jerk.+ Patellar reflex. - - -+L+ - -+lacerated.+ Torn. - -+lacuna.+ A small gap or hollow space. - -+lacuna, osseous.+ A space in the Haversian system occupied by -bone-corpuscle. - -+lacunar resorption.+ Absorption of lacunae. - -+lamella.+ One of the plates forming the Haversian system of bone. - -+lancet.+ A surgical knife with a two-edged blade. - -+lancinating.+ A sharp, cutting pain. - -+Lassar's paste.+ An ointment containing salicylic acid, talcum and zinc -oxide. - -+laughing gas.+ Nitrous oxide gas. - -+lead and opium wash.+ See Wash. - -+leucemia.+ A disease of the blood marked by persistent leucocytosis. - -+leucocyte.+ White blood corpuscle or a white cell. - -+leucocytosis.+ An increase in the number of white cells in the blood. - -+leukos.+ White, as in leucocyte, a white blood cell. - -+ligament.+ A band or sheet of fibrous tissue connecting two or more -bones, cartilages or other structures or serving as support for -fasciae or muscle. - -+ligature.+ A thread or the like tied about a blood vessel or other -structure to constrict it. - -+linimentum. Liniment.+ A medicament in alcohol, oil or water, applied -by friction to the skin. - - +l. aconiti et chloroformi.+ Anodyne application. - - +l. ammoniae.+ Counter irritant. - - +l. ammonii iodidi.+ Discutient. - - +l. calcis.+ To mollify burns and scalds. - - +l. camphorae.+ A mild counterirritant. - - +l. chloroformi.+ Anodyne and rubefacient. - - +l. crotonis.+ Counterirritant. - - +l. hydrargyri.+ Anti-syphilitic. - - +l. iodi.+ Discutient. - - +l. opii.+ Anodyne. - - +l. saponis.+ A base for other liniments. - - +l. sinapis.+ Counterirritant. - - +l. terebinthinae.+ Soothing application. - -+lint.+ A soft absorbent material used in surgical dressings. - -+lipoma.+ A fatty tumor. - -+liquor.+ Solution of a nonvolatile substance. - - +l. acidi chromici.+ Used, well diluted, as a wash in - bromidrosis. - - +l. alumini acetatis+ (Burows' solution). For external use as an - astringent and antiseptic. - - +l. antisepticus.+ A mouthwash. - - +l. bromi.+ Antiseptic. - - +l. Burowii.+ Astringent and antiseptic (See l. alum. acet.) - - +l. caoutchouc.+ For rubber skin. - - +l. cresolis compositus.+ Antiseptic and disinfectant where - vesicles form. - - +l. ferri persulphatis.+ Styptic. - - +l. ferrisub sulphatis.+ Monsel's solution. Styptic. - - +l. hydrargyri nitratis.+ Caustic application. - - +l. iodi carbolatus.+ Antiseptic counterirritant. - - +l. plumbi subacetatis.+ For bruises and sprains. - - +l. sodii boratis compositus.+ Dobell's solution. An alkaline - antiseptic preparation. - - +l. sodii ethylatis.+ Employed externally as a caustic. - - +l. sodii silicatis.+ Used in surgery for applying splints. - - +l. zinci chlorodi.+ Disinfectant and deodorant. - -+listerine.+ Trade name of a solution containing boric acid, benzoic -acid, thymol and other substances. - -+Lister's method.+ Antiseptic surgery. - -+lith.+ Stone, as in lithology, the branch of medical science, relating -to calculi or concretions. - -+litter.+ A stretcher for carrying the sick or wounded. - -+locomotor ataxia (tabes dorsalis).+ Hardening of the posterior columns, -ganglia, roots and peripheral nerves of the spinal cord. - -+logos.+ Treatise, as in Pathology, a branch of medical science which -treats of disease in all its relations. - -+lotio.+ Latin for lotion or wash. - - +l. hydrargyri flava.+ Yellow mercurial wash. - - +l. hydrargyri nigra.+ Black mercurial wash. (Both of the above - are used as applications to venereal sores). - - +l. plumbi et opii.+ Lead and opium wash. Applied to sprains and - bruises. - -+luetic.+ Syphilitic. - -+luetin test.+ A skin test for the diagnosis of syphilis. - -+lumen.+ The space in the interior of a tubular structure, such as an -artery. - -+lunula.+ The opaque, whitish, semi-lunar area near the root of the -nail. - -+lymph.+ A clear yellow fluid found in the lymph spaces or lymphatic -vessels of the body. - -+lymphangioma.+ New formation of lymphatic vessels. - -+lymphangitis.+ Inflammation of lymphatic vessels. - -+lymphoma.+ A tumor of lymphoid tissue. - -+lysis.+ Solution, as in analysis, the breaking up of a chemical -compound into its simpler elements. Also the gradual subsidence of -symptoms in a disease as distinguished from crisis. - -+lysol.+ Trade name of a mixture of soaps and phenols; used as a -disinfectant. - - -+M+ - -+macrococcus.+ A large unicellular microorganism. - -+macros.+ Large, as in macroscopic, an object visible to the naked eye. - -+macula.+ Spot, as in macular, relating to or marked by macules, or -spotted. - -+magnesium sulphate.+ Epsom salts; a purgative. - -+malignant.+ Resistant to treatment and tending to grow. - -+malleolus.+ A process of bone the shape of the head of a hammer. - -+mania.+ Frenzy, as in megalomania, a delusion of grandeur. - -+manifestation.+ Clear to the eye or to the mind. - -+manus.+ Hand, as in manual, relating to or performed with the hands. - -+marrow.+ The soft substance filling the medullary cavities and -cancellous extremities of the long bones. - -+massage.+ A scientific method of manipulating the body by rubbing, -pinching, kneading, tapping, etc. - -+matrix.+ The formative portion of a nail or of a tooth. - -+measles.+ An acute exanthematous disease. - -+medullary.+ Relating to the medulla or marrow. - -+membrane.+ A layer of tissue covering a part or connecting two -structures. - -+mercury. Quicksilver.+ - -+metastasis.+ A change in the seat of disease. - -+metatarsalgia.+ Pain in the metatarsus. - -+metatarsophalangeal.+ Relating to the metatarsal bones and the -phalanges. - -+meter.+ Measure, as in meter, a measure of length, the equivalent of -39.3 inches. - -+microbe.+ A minute one-celled microorganism. - -+micrococcus.+ A genus of schizomycetes. - -+microorganism.+ A minute living body. - -+miliary.+ Like millet seeds, in size. - -+molecular.+ Pertaining to molecules. - -+molecule.+ The smallest possible unit of existence of any substance. - -+morphine.+ The chief narcotic principle of opium. - -+mortification.+ Death; gangrene. - -+mucous.+ Relating to mucous as in mucous membrane. - -+mucus.+ A clear viscid secretion of a mucous membrane, mucilagenous in -character. - -+mummification.+ Dry gangrene. - -+myeloma.+ A tumor due to hyperplasia of the bone marrow. - -+myoma.+ A muscular tumor. - -+myxoma.+ A tumor of stellate or polyhedral cells in a matrix of mucin. - - -+N+ - -+naevus (nevus).+ A congenital mark or discolored patch of the skin. - -+nail (unguis).+ The horny plate covering the distal end of the terminal -phalanx of each finger and toe. - -+naphthalan.+ A gelatinous mixture employed as a protective dressing in -burns and in skin diseases. - -+narcosis.+ Stupor or general anesthesia produced by some narcotic drug. - -+nascent.+ Beginning; incipient. - -+necrosis.+ Death of a circumscribed portion of tissue. - -+neoplasm.+ A new growth; a tumor. - -+neosalvarsan.+ A modified salvarsan: No. 914. - -+nephritis.+ Inflammation of the kidney. - -+nerve.+ A whitish cord made up of nerve fibres. - -+neuralgia.+ Pain in a nerve. - -+neurasthenia.+ Nerve exhaustion. - -+neuritic.+ Relating to neuritis. - -+neuritis.+ Nerve inflammation. - -+neuroma.+ Nerve tumor. - -+neuron.+ Nerve cell, as in neuritis, inflammation of a nerve. - -+neutralize.+ To render ineffective. - -+node.+ A knob; a circumscribed swelling. - -+nostrum.+ A quack remedy. - -+novocaine.+ A synthetic local anesthetic. - -+noxious.+ Injurious; harmful. - -+nucleus.+ The essential part of a typical cell and the controlling -centre of its activity. - - -+O+ - -+obliteration.+ Extinction. - -+official+ (in pharmacy). Authoritative; standard. - -+oid.+ Like, as in lymphoid, resembling or like lymph. - -+oil.+ A liquid of fatty consistency, insoluble in water and -inflammable. Examples: camphorated oil, carbolic oil, carron oil, -linseed oil, oil of turpentine, sweet oil, sesame oil, tar oil. - -+ointment.+ A soft, fatty, medicated mixture. - -+onychauxis.+ Enlargement of finger or of toe nails. - -+onychia.+ Inflammation of the matrix with suppuration and shedding of -the nail. - -+onychocryptosis.+ Ingrowing toe-nail. - -+onycholysis.+ Loosening or shedding of the nails. - -+onychomalacia.+ Loss or absence of nail rigidity. - -+onychomycosis.+ Any parasitic disease of the nails. - -+onychophag.+ One whose habit it is to bite his finger-nails. - -+onychophagy.+ Nail-biting. - -+onychoptosis.+ Falling off of the nails. - -+onychorrhexis.+ Abnormal brittleness of the nails. - -+onyx.+ A finger nail or a toe nail. - -+onyxis.+ Ingrowing toe-nail. - -+opisthotonos.+ Spasmodic rigidity of the body in which the trunk is -thrown backward and arched upward. - -+oral.+ Relating to the mouth. - -+organic.+ Pertaining to or having organs, exhibiting animal or -vegetable characteristics. - -+orthoform.+ A white, odorless, crystalline powder; employed as a local -anesthetic and antiseptic in burns, ulcers, etc. - -+orthopedics.+ That branch of surgery which treats of chronic diseases -of the joints and spine and the correction of deformities. (See -chiropodial orthopedics.) - -+os (plural ossa).+ Bone. - -+osis.+ Full of, as in tuberculosis, a specific disease caused by the -presence of the bacillus tuberculosis. - -+osseous.+ Bony. - -+osmidrosis.+ Bromidrosis; the excretion of perspiration of a strong -odor. - -+ossification.+ The formation of bone. - -+osteitis.+ Inflammation of bone. - -+osteoclast.+ A polynuclear cell concerned in the absorption of bone. - -+osteogenetic.+ The development and formation of bone. - -+osteoma.+ A bony tumor. - -+osteomalacia.+ Softening of the bone. - -+osteomyelitis.+ Inflammation of the bone marrow or of both marrow and -bone. - -+ous.+ Full of, as in fibrous, full of or composed of fibres. - -+oxygen.+ A gaseous element, the most widely distributed. Essential to -animal and plant life; symbol O. - -+ozone.+ A modified form of oxygen. - - -+P+ - -+pachylosis.+ Thick, dry and abnormal quality of skin which cracks into -scales of irregular form. - -+pack.+ The process of enveloping a patient in a wet sheet or blanket. -Cold pack: in sheets wrung out of water; hot pack: in sheets wrung out -of hot water; dry pack: in dry warmed blankets, etc. - -+pachyacria.+ Bulbous thickening of the extremities of the fingers or -toes. - -+pachydermia.+ Thick skin; elephantiasis. - -+palliative.+ Mitigating; lessening the severity. - -+palm.+ The flat of the hand. - -+palpation.+ Exploration with the hand. - -+panidrosis.+ Sweating from all parts of the skin. - -+papilla.+ Any small nipple-like process. - -+papilloma.+ A growth of hypertrophied papillae of the skin. - -+papule.+ A small circumscribed elevation of the skin, containing no -fluid. A pimple. - -+paralysis.+ Loss of power of voluntary movement in a muscle through -injury or disease of nerve supply. - -+parasite.+ An organism that inhabits another organism and obtains -nourishment from it. - -+paresis.+ General paralysis of the insane or dementia paralytics. A -condition thought to be due to a chronic meningitis. - -+paresthesia.+ An abnormal spontaneous sensation such as of numbness, -burning, pricking, tingling, etc. - -+parenchyma.+ The specific tissues of a gland or organ. - -+paronychia.+ Felon, whitlow. Inflammation of the structures in the -distal phalanx of the finger. - -+patella.+ Kneecap. - -+pathogenic.+ Causing disease. - -+pathology.+ That branch of medicine which treats of disease and the -changes in the tissues of the body caused by disease. - -+pathy.+ Suffering, or disease as in Homeopathy--disease, the quality of -being treated by likes. - -+pedicure.+ One who attends the feet, cosmetically. - -+per.+ Through, as in peripheral, away from the centre; the outer part -of or surface. - -+peri.+ A Greek prefix meaning around or about. - -+peridental.+ Surrounding a tooth or part of a tooth. - -+periosteum.+ The fibrous membrane investing the surface of bones except -at the point of tendinous and ligimentous attachment, and on the -particular surfaces where cartilage is substituted. - -+periostitis.+ Inflammation of the periosteum. - -+periphery.+ The part of a body away from the centre; the outer part or -surface, as of a bone or of a nerve. - -+peritoneum.+ The sac lining the abdominal cavity and covering most of -the viscera therein contained. - -+perivascular.+ Surrounding a blood-vessel. - -+peroxid.+ An oxid with the highest amount of oxygen. - -+pes (pl. pedes).+ The foot. - -+phagocyte.+ A cell possessing the property of ingesting bacteria or -other foreign particles. - -+phagocytosis.+ The destruction of microbes by the action of phagocytes. - -+phalanx.+ One of the long bones of the fingers or toes. - -+phenol.+ Carbolic acid. - -+phlebitis.+ Inflammation of a vein. - -+phlegmon.+ Acute suppurative inflammation of subcutaneous tissue. - -+physiology.+ The science which deals with the functions of living -things. - -+picric acid.+ A combination of carbolic and nitric acids. - -+pigment.+ An organic coloring matter. - -+plantalgia.+ Pain on the sole of the foot. - -+plantar.+ Relating to the sole of the foot. - -+plaque.+ A flat patch or area on the skin or mucous membrane. - -+plasia.+ Moulding, as in hypoplasia. defective development. - -+plaster-of-Paris.+ Calcium sulphate. - -+plastic.+ Capable of being moulded. - -+plegia.+ Stroke, as in hemiplegia, paralysis of one side of the body -and of the opposite side of the face. - -+plethoric.+ Relating to overfilled blood-vessels. - -+pleura.+ The serous membrane enveloping the lungs. - -+plexus.+ A new network of nerves or veins. - -+podagra.+ Gout, especially, typical gout in the great toe. - -+podagral.+ Gouty, relating to or suffering from gout. - -+podalic.+ Relating to the foot, as in podalgia, pain in the foot, -podarthritis, inflammation of any of the tarsal or metatarsal joints. - -+podiatrist.+ One who treats diseases and disorders of the feet. - -+podobromidrosis.+ Fetid or foul smelling perspiration of the feet. - -+pododynia.+ Pain in the foot or podalgia. - -+podology.+ A treatise on the foot. - -+poly.+ A Greek prefix for much or many, ex: polyphagia, excessive -eating. - -+poroma.+ Callus; exostosis. - -+potassium.+ An alkaline metallic element. Among the salts of potassium -are: potassium bichromate, employed externally as a caustic to -syphilitic vegetations; potassium hydroxide, used as a strong -penetrating caustic. - -+poultice.+ A soft emulsion for external application. - -+pous.+ Foot, as in podiatrist. - -+pre.+ A prefix denoting anterior or before. - -+predisposing.+ Inclining to, as a disease. - -+prepatellar.+ In front of the patella. - -+prognosis.+ A forecast of the result. In medicine, the prior -determination of the outcome of a disease. - -+proliferation.+ Cell-genesis, reproduction. - -+pronation.+ The act of rotating the forearm in such a way that the palm -of the hand looks backward when the arm is in the anatomic position, -or downward when the arm is extended at a right angle with the body. -(Stedman.) - -+prophylactic.+ Preventing disease. - -+protargol.+ A combination of silver with a proteid base. - -+protean.+ Having the power to change form. - -+protonuclein.+ A preparation from the lymphoid tissue of animals. - -+protoplasm.+ Primitive organic cell matter. - -+protuberance.+ A projecting part. - -+pseudo.+ Prefix, signifying false. - -+ptomain.+ A crystallizable nitrogenous basic substance, produced by -bacteria in dead animal or vegetable matter. - -+punctured.+ Wounded by a pointed instrument. - -+purge.+ A cathartic. - -+purulent.+ Having the character of pus. - -+pus.+ A fluid product of inflammation. - -+pustule.+ A soft purulent papule. - -+putrefaction.+ Organic decomposition, decay. - -+putrid.+ Manifesting putrefaction. - -+pyemia.+ A condition in which pyogenic bacteria circulate in the blood, -and form abscesses wherever they lodge. - -+pyogenic.+ Developing or excreting pus. - -+pyorrhea.+ A discharge of pus. - -+pyorrhea alveolaris.+ Rigg's disease; suppurative inflammation of the -periosteum lining the teeth in their sockets. - - -+Q+ - -+q.h.+ Every hour, used in prescription writing. - -+q.s.+ Sufficient quantity, used in prescription writing. - -+quinine.+ An alkaloid of cinchona. - -+quinine and urea hydrochlorate.+ Used as a local anesthetic. - - -+R+ - -+rachitic.+ Pertaining to rickets. - -+rationale.+ Fundamental reason. - -+Raynaud's disease.+ Symmetrical gangrene of the extremities. - -+recipe.+ "Take thou." Used to precede directions in prescription -writing. - -+rectum.+ The terminal part of the digestive tube from the pelvic colon -to the anus. - -+refrigeration.+ The act of cooling or reducing fever. - -+remittent.+ Characterized by temporary abatement of symptoms. - -+resection.+ Removal of articular ends forming a joint; removing a -segment of any part. - -+retention.+ Holding back as of excretions and secretions. - -+rhea.+ A flow, as in diarrhea, an abnormally frequent discharge of more -or less fluid fecal matter from the bowels. - -+rheumatism.+ An acute, probably infectious, condition; when articular, -the joints are inflamed. - -+rhigolene.+ A liquid obtained from petroleum distillation. Used as a -local anesthetic. - -+rickets.+ Disease of early childhood characterized by defective -nutrition of the bony structures. - -+Roentgen rays.+ (See X-ray.) - -+rotated.+ Turned about or around on its own axis. - - -+S+ - -+sac.+ Pouch; bursa. - -+saccharomyces.+ The yeast fungi. - -+salicylate of mercury.+ A salt of mercury and salicylic acid. - -+salvarsan.+ The Ehrlich-Hata anti-syphilitic preparation; known also as -No. 606. - -+saphenous vein.+ The ascending vein of the lower limb which empties -into the femoral vein. - -+saprophyte.+ A microorganism which normally grows on dead matter. - -+sapremia.+ Intoxication due to absorption of dead saprophytes into the -system. - -+saprophytic.+ Pertaining to saprophytes. - -+sarcoma.+ A malignant connective tissue tumor. - -+scaphoid.+ One of the small bones of the wrist. One of the bones of the -tarsus. - -+scar.+ Mark of a wound. - -+scarlet fever.+ Scarlatina. An acute exanthematous disease. - -+schizomycetes.+ The fisson fungi microorganisms; bacteria; -putrefaction; organic decomposition, decay. - -+sclerosis.+ Induration and overgrowth of the connective tissue of an -organ. - -+scope.+ View, as in stethoscope, an instrument originally devised for -aid in hearing the respiratory or c a r d i a c s o u n d s in -the chest. - -+scrotum.+ The sac containing the testicles. - -+sebum.+ The fat excreted by the sebaceous glands of the skin. - -+secare-sect.+ To cut, as in dissect, to cut apart or separate the -tissues of the body in the study of anatomy. - -+sedative.+ Calming, quieting. - -+senile.+ Relating to old age. - -+sensibility.+ The consciousness of sensation. - -+sensory.+ Pertaining to sensation. - -+sepsis.+ (See septicemia.) - -+septicemia.+ An infection characterized by the presence of bacteria and -their toxins in the blood. - -+sequestrum.+ A fragment of necrosed bone. - -+serous.+ Relating to, containing or producing serum. - -+serum.+ A clear watery fluid moistening the surface of serous membranes -or exudate resulting from inflammation of any of those membranes. - -+shaft.+ The part of a long bone between its ends. - -+shock.+ A sudden physical or mental disturbance. - -+sinus.+ A hollow cavity recess, or pocket in the body tissues. - -+skiagraph.+ A shadow. The production of photographs by means of -Roentgen rays. - -+skin.+ The membranous covering of the body. - -+skiving.+ Splitting or paring materials for adjusting shields to -surfaces on the foot. - -+slough.+ Necrosed tissue separated from living structure. - -+smallpox.+ Variola; an acute eruptive contagious disease. - -+sodium chloride.+ Common table salt. - -+sodium hydroxide.+ Caustic soda. Used for its caustic effects. - -+sodium sulphate.+ Colorless crystals. Glauber's salt; a purgative. - -+sodium urate.+ The substance found in gouty nodes; chalk-stone. - -+spasm.+ An involuntary convulsive muscular contraction. - -+spirillum.+ A genus of spirillaceae containing rigid cells with polar -tufts. - -+spirochaeta pallida.+ The specific organism of syphilis. - -+splint.+ An apparatus for fixating a joint. - -+spontaneous.+ Occurring without external stimulation. - -+spores.+ Reproductive bodies of cryptogams. - -+stagnation.+ Cessation of motion. - -+staphylococcus.+ A coccus; a genus of schizomycetes in which the cocci -are irregularly clustered like a bunch of grapes. - -+stasis.+ Standing, as in hemostasis, the arrest of the circulation in -the blood vessels of a part. - -+sterile.+ Barren, not fertile. - -+sterilization.+ The destruction of germs. - -+sternum.+ The breast-bone. - -+stovaine.+ A local anesthetic; used largely to induce intraspinal -anesthesia. - -+stratum corneum.+ The horny or outer layer of the epidermis. - -+streptococcus.+ A genus of schizomycetes in which the cocci are -arranged in strings or in chains. - -+strismus.+ Spasm. - -+structure.+ The component formation features of a tissue. - -+strychnine.+ An alkaloid of nux vomica. - -+styptic.+ Having the property of checking hemorrhage. - -+sub.+ A Latin prefix denoting, beneath, as subareolar, beneath the -areola or minute area. - -+subcutaneous.+ Under the skin. - -+subcutin.+ A white crystalline powder used in saline solution as a -local anesthetic. - -+supinate.+ To turn the hand so that it is supine, i. e., with the palm -outward. The opposite of pronation. - -+suppository.+ A solid medicine, melting at body temperature, for -introduction into the rectum or vagina. - -+suppuration.+ The formation of pus. - -+supra.+ A prefix denoting a position above. - -+suture.+ An anatomic union between two bones; the surgical union of two -surfaces by stitches. - -+symptomatic.+ Relating to symptoms; indicative. - -+symptomatology.+ The study of the symptoms of disease. - -+synchronous.+ Occurring at the same time. - -+syncope.+ Swooning or fainting. - -+synovia.+ Tenacious, colorless, stringy alkaline fluid which lubricates -a joint; in appearance like the white of eggs. - -+synovial.+ Pertaining to synovia. - -+synovitis. Inflammation of a synovial membrane. - -+synthetic.+ Created from parts into a compound. - -+syphilis.+ An infectious disease spread by inoculation thru sexual -intercourse; also possible by contamination thru table utensils, -towel, pipes, etc. - -+systemic.+ Relating to a system. - - -+T+ - -+tabes dorsalis.+ Locomotor ataxia; posterior spinal sclerosis. - -+talipes.+ Clubfoot. - -+talipes calcaneus.+ The heel touching the ground and the foot generally -in extreme dorsi-flexion. - -+talipes cavus.+ Hollow foot. An increased curvature of the arch of the -foot. - -+talipes equinus.+ Club foot, the patient walking on his toes, and the -foot in plantar flexion. - -+talipes planus.+ Flat foot; a deformity marked by depression of the -arch of the foot. - -+talipes valgus.+ Eversion of the foot, the inner side of the foot -resting on the ground. - -+talipes varus.+ Inversion of the foot, the outer side of the sole of -the foot touching the ground. - -+tarsus.+ A bone of the posterior part of the foot. - -+technic.+ Details of a procedure. - -+tendo Achillis.+ The common tendon of the gastrocnemius and soleus -muscles. - -+tendon.+ A white, glistening fibrous tissue, affording attachment of -muscles to bone. - -+tenosynovitis.+ Inflammation of a tendon and its sheath. - -+tenotomy.+ The surgical division of a tendon. - -+terminal.+ Relating to the end, extremity or summit of any body. - -+tetanus.+ Lock jaw. A very fatal disease due to the introduction of the -bacillus tetanus into the tissues. - -+therapy.+ Treatment, as hydrotherapy, treatment of diseases by means of -water. - -+therapeutics.+ The branch of medical science concerned with the -application of remedies for the alleviation of pain and the treatment -of disease. - -+thermal.+ Pertaining to heat. - -+thoracentesis.+ Tapping the thorax to release fluid from it. - -+thrombin.+ The fibrin ferment. - -+thrombosis.+ The formation of a thrombus. - -+thrombus.+ A blood clot in a vessel producing an obstruction in the -flow of the blood in the same. - -+thymol.+ A phenol found in some volatile oils. Used as a deodorizer and -as an antiseptic. - -+tibia.+ The shin-bone. - -+tincture.+ The pharmacy name of an alcoholic solution or extract of a -nonvolatile vegetable substance. - -+tissue.+ A collection of cells or derivatives of cells forming a -definite structure. - -+toma, or oma.+ Tumor in hematoma, a bloody tumor. - -+tourniquet.+ An instrument or apparatus for arresting the flow of blood -from a vessel in a limb by pressure. - -+toxalbumins.+ Poisonous soluble albuminoids producing specific disease. - -+toxemia.+ A poisoned state of the blood due to the absorption of -poisons not of parasitic origin. - -+toxicity.+ A state of being poisonous. - -+toxicology.+ The science of poisons and their antidotes. - -+toxins.+ Amorphous, nitrogenous poisons, formed by bacteria in both -living tissues and dead substances. - -+trabecula.+ Any one of the fibrous bands extending from the capsule -into the interior of an organ. - -+tracheotomy.+ The operation of opening into the trachea. - -+traction.+ Drawing; pulling. - -+tragopodia.+ Knock-knee. - -+transfusion.+ The transfer of blood from one person to another. - -+transplant.+ To transfer from one part to another as in plastic -operations. - -+trauma.+ A wound or injury. - -+traumatic.+ Relating to or caused by a wound. - -+trinitrin.+ Nitroglycerin. - -+triturate.+ To reduce to fine powder; a finely divided powder. - -+tropacocaine.+ An alkaloid from Java coca leaves, used as a local -anesthetic. - -+trophe (nourishment).+ Hypertrophy, overgrowth; atrophy, lack of -nourishment. - -+trophic.+ Relating to or dependent upon nutrition. - -+trypsin.+ A proteolytic ferment of pancreatic fluid. - -+tubercle.+ A circumscribed elevation on the skin, mucous membrane or -surface of an organ; the lesion of tuberculosis. - -+tuberosity.+ A small rounded elevation on a bony surface. - -+tumor.+ A swelling or tumefaction. - -+tylosis.+ Formation of a callosity. - -+typhoid fever.+ An acute infectious disease caused by the bacillus -typhosus. - - -+U+ - -+ulcer (ulcus).+ A lesion of a cutaneous or mucous surface usually -attended by suppuration. - -+ulceration.+ The process of ulcer formation. - -+unguentum Crede.+ An ointment of colloidal silver, 15: distilled water, -5; white wax, 10; benzoinated lard, 70 parts. Used as an inunction. - -+urates.+ Salts of uric acid. - -+urea.+ An end-product of metabolism excreted in the urine. - -+ureter.+ A tube carrying urine from the kidney to the bladder. - -+urethra.+ A canal from the bladder thru which the urine is discharged. - -+uria (urine).+ As in glycosuria, the excretion of sugar (glucose) in -the urine. - -+urology.+ The subject which has to do with urinary modifications in -disease. - - -+V+ - -+vaccine.+ The modified virus of any disease, which, when inoculated, -protects against the action of the unmodified virus. - -+vaccination.+ The injection of a killed culture of a specific bacterium -as a means of prophylaxis or cure of the disease caused by that -microorganism. - -+valgus.+ One who is bow-legged or has knock-knees. - -+varix.+ An enlarged and tortuous vein, artery or lymphatic vessel. - -+vasoconstrictor.+ An agent or a nerve which causes narrowing of the -blood vessels. - -+vasodilator.+ An agent or a nerve which causes dilatation of the blood -vessels. - -+vein.+ A blood-vessel carrying blood toward the heart. - -+venous.+ Pertaining to a vein. - -+verruca+ (pr. verrucae). Wart. - -+vertebra.+ A bony segment of the spinal column. - -+vesicle.+ A small blister or sac containing serum. - -+villus (pl. villi).+ A minute projection from the surface, especially -of a mucous membrane. - -+viscus (viscera).+ An internal organ especially of the abdominal -cavity. - - -+W+ - -+Wart.+ A circumscribed hypertrophy of the papillae of the corium -covered by thickened epidermis. - -+Wassermann's test.+ A diagnostic test for syphilis, based upon the -theory of complement fixation. - -+wen.+ A sebaceous cyst, especially one occurring on the scalp. - -+whitlow.+ See paronychia. - - -+X+ - -+xeroderma.+ Roughening of the skin from diminished secretion. - -+X-rays.+ The ethereal waves or pulsations from a Crookes' tube from the -bombardment of the anode target with the cathode rays. - - -+Z+ - -+zinc chloride.+ A caustic sulphate. An astringent. - -+zymotic.+ Relating to fermentation; noting an infectious disease. - - - - -CROSS REFERENCE INDEX - - - A - - Abscess - acute, 65 - chronic, 66 - symptoms, 66 - treatment, 66 - - Acquired club foot, 191 - - Acquired flat foot, 178 - - Actinomycosis, 136 - causes, 137 - symptoms, 137 - treatment, 137 - - Active hyperemia, 196 - indications for therapeutic uses, 196 - - Actual cautery, 200 - uses, 200 - - Acute abscess, 65 - causes, 65 - diagnosis, 65 - symptoms, 66 - treatment, 66 - - Acute rheumatism, 97 - causes, 97 - diagnosis, 97 - symptoms, 97 - treatment, 97 - - Acute synovitis, 86 - causes, 86 - diagnosis, 86 - symptoms, 86 - treatment, 86 - - Adhesive plaster, 215 - - Adrenaline, 211 - - Alcohol, 25 - - Alkaloids, 9 - - Alum, 210 - - Alypin, 251 - - Ameboid, 29 - - Ammoniated mercury, 212 - - Amyl nitrite, 45 - - Anaerobic bacteria, 8 - - Anesthesia, local, 229 - - Ankle joint, 165 - dislocations, 172 - backward, 172 - forward, 172 - injuries, 172 - outward, 173 - sprains, 176 - diagnosis, 176 - symptoms, 176 - treatment, 177 - - Ankylosis, 94 - fibrous, 94 - bony, 94 - - Antiseptic method, 20 - - Antisepsis, 19 - - Antiseptics, 22 - - Appearance of varicose ulcers, 68 - - Appendicitis, 17 - - Application of skin grafts, 226 - - Aqueous solution of ichthyol, 208 - - Argyrol, 26 - - Aristol, 24 - - Arterial bleeding, 55 - - Arthritis, 88 - acute, 88 - causes, 89 - chronic, 90 - diagnosis, 90 - symptoms, 91 - treatment, 91 - varieties, 89 - Charcot, 98 - gonorrhoeal, 95 - gouty, 97 - infective, 98 - rheumatic, 97 - septic, 90 - syphilitic, 95 - traumatic, 90 - tubercular, 92 - - Arthrotomy, 173 - - Arterial hyperemia, 196 - indications, 196 - technic, 195 - - Arteriosclerosis, 117 - - Articular fractures, 159 - - Asepsis, agents, 19 - drugs employed, 21 - technic, 21 - - Aseptic methods, 21 - - Astragalus dislocation, 172 - - Astragalus fracture, 168 - - Astringent powders, 210 - alum, 210 - stearate of zinc, 210 - zinc, 210 - - Asepsis in the management of wounds, 39 - - Atrophy of bone, 100 - causes, 100 - symptoms, 100 - treatment, 100 - - - B - - Backward dislocations - ankle, 172 - - Bacteria, 6 - aerobic, 8 - anerobic, 8 - alkaloidal, 9 - cultivation, 10 - classification, 7 - destruction, 12 - effect of oxygen, 8 - elimination, 11 - facultative, 8 - ferments, 10 - habitat, 7 - infection, 10 - immunity, 12 - temperature effect of, 8, 14 - toxins, 9 - pathogenic, 6 - saprophytic, 6 - surgical import, 15 - - Balsam of Peru, 210 - - Bandages, 215 - elastic, 219 - flannel, 215 - French bandage of foot, 218 - gauze, 214 - ideal, 214 - muslin, 214 - plaster, 164 - rubber, 214, 219 - spica bandage of foot, 218 - spica bandage of toe, 217 - spiral bandage of toe, 217 - - Bandaging, 215 - indications, 215 - method, 216 - technic, 216 - - Benign tumors, 114, 152 - adenoma, 114 - chondroma, 114 - fibroma, 153 - lipoma, 153 - lymphoma, 154 - myoma, 154 - osteoma, 115 - - Bichloride solution, 22 - strength, 22 - - Bicycle foot, 138 - symptoms, 138 - treatment, 138 - - Bier's, arterial hyperemia, 196 - indications, 196 - technic, 195 - venous hyperemia, 195 - - Bismuth subgallate, 210 - - Black mustard, 199 - - Blastomycotic ulcer, 79 - diagnosis, 79 - symptoms, 79 - treatment, 79 - - Bleeding, 54 - control of, 54 - - Blue ointment, 133, 212 - - Bone - atrophy, 100 - caries, 101 - congenital defects, 99 - hypertrophy, 101 - necrosis, 102 - osteitis, 105 - osteomyelitis, 105 - periostitis, 103 - senile atrophy, 100 - tumors, 114 - - Boric acid, 25 - ointment, 212 - powder, 210 - solution, 208 - - Brandy, 47 - - Bromides, 48 - - Bunion, 84, 185 - - Burns, 56 - causes, 56 - degrees, 57, 58 - pathology, 57, 58 - symptoms, 59 - treatment, 60 - varieties, 57 - - Bursitis, 82 - acute, 83 - chronic, 83 - diseases of the bursa, 82 - symptoms, 83 - treatment, 83 - - Burow's solution, 208 - formula, 208 - indications, 35, 208 - preparation, 208 - - - C - - Calomel, 210 - - Callosity, 141 - causes, 141 - definition, 141 - symptoms, 141 - treatment, 141, 142 - - Callous ulcers, 67 - causes, 67 - diagnosis, 67 - symptoms, 68 - treatment, 68 - - Cancer, 51 - - Carbolic acid, 13 - dangers, 22 - gangrene, 121 - poisoning, 13 - uses, 22 - - Caries, 101 - symptoms, 101 - treatment, 102 - - Cartilage, 88 - - Catgut, 46 - uses, 46 - varieties, 46 - - Cautery, 200 - how applied, 200 - when indicated, 200 - - Cells, 36 - - Cellulitis, 136 - cause, 136 - symptoms, 136 - treatment, 136 - - Chancre, 131 - - Charcot's disease, 98 - - Chauffeur's foot, 138 - cause, 138 - symptoms, 138 - treatment, 138 - - Chemical antiseptics - uses, 13 - - Chemotaxis, 31 - - Chloroform liniment, 197 - - Chilblain, 63 - symptoms, 63 - treatment, 63 - - Chinese lady foot, 193 - - Chondromata, 154 - symptoms, 154 - treatment, 154 - - Chronic bursitis, 83 - osteomyelitis, 110 - periostitis, 104 - syphilis, 132 - synovitis, 87 - tuberculosis, 134 - - Chyle, 5 - - Circulatory system, 3 - - Clavus, 142 - - Clawed toes, 183 - - Clinicial stages of burns, 57 - - Club foot, 188 - - Cocaine, 243 - preparations, 243 - strength of sols., 244 - uses, 244 - - Cocoon dressing, 207 - description, 207 - indications, 207 - - Cold, 197 - the effects of, 34, 62 - treatment, 62 - - Cold compress, 197 - indications, 197 - - Collodion dressings, 207 - indications, 207 - - Comminuted fractures, 158 - symptoms, 158 - treatment, 158 - - Compound fractures, 161 - diagnosis, 161 - symptoms, 161 - treatment, 161 - - Contusions, 41 - symptoms, 42 - treatment, 43 - - Contused wounds, 41 - diagnosis, 42 - symptoms, 42 - treatment, 43 - - Contagious warts, 139 - - Congenital club foot, 188 - - Congenital defects of bone, 99 - - Congenital flat foot, 178 - - Counterirritants - indications, 199 - - Copper sulphate, 210 - - Corn or clavus, 142 - symptoms, 142 - treatment, 142 - varieties, 142 - - Corrosive sublimate, 46 - - Crede's ointment, 26 - - Creolin, 23 - strength of sol., 23 - uses, 23 - - Cysts, 154 - bone, 117 - diagnosis, 154 - sebaceous, 154 - symptoms, 154 - treatment, 155 - varieties, 154 - - - D - - Dakin's solution, 209 - how prepared, 209 - indications, 209 - method of use, 209 - - Dead bone - symptoms, 102 - treatment, 102 - - Depressed fractures, 157 - - Demarcation in gangrene, 122 - - Dermatol, 210 - - Dermatitis, 135 - symptoms, 135 - treatment, 136 - - Diabetic - gangrene, 120 - ulcers, 75 - - Diapedesis, 31 - - Diaphysis of bone, 158 - - Digitalis, 45 - - Direction of the line of fracture, 157 - - Diseases of the - arteries, 118 - bones, 105 - caries, 101 - necrosis, 102 - osteitis, 105 - osteomyelitis, 105 - periostitis, 105 - joints, 170 - lymphatics, 5 - veins, 127 - - Dislocations, 170 - ankle joint, 172 - astragalus, 175 - diagnosis, 171 - metatarsal bones, 176 - subastragaloid, 174 - symptoms, 172 - toes, 176 - treatment, 171, 173 - - Drainage - indications for, 46 - methods of, 46 - - Dressings, 207 - dry, 207 - wet, 207 - - Dry dressings, 207 - materials used, 207 - indications for, 207 - - - E - - Early diagnosis of - carcinoma, 153 - syphilis, 130 - tuberculosis, 133 - - Ecchymosis, 42 - - Electricity, 201 - uses, 201 - - Electrolysis, 201 - method of application, 141, 201 - - Elastic stocking - application, 126 - uses, 126 - - Elevated position for treatment of varicose veins, 126 - - Elongated veins - significance, 126 - - Embolism, 119 - causes, 119 - diagnosis, 119 - symptoms, 119 - treatment, 119 - - Endarteritis obliterans, 120 - symptoms, 120 - treatment, 120 - - Enteroclysis, 45 - indications, 45 - - Epitheliomatous ulcer, 79 - causes, 79 - diagnosis, 80 - symptoms, 80 - treatment, 80 - - Epiphysis of bone, 158 - - Erysipelas, 135 - causes, 135 - diagnosis, 135 - symptoms, 135 - treatment, 136 - - Escharotics, 210 - indications, 210 - methods of application, 210 - - Esmarch bandage, 214 - where indicated, 215 - technic, 219 - - Ethyl chloride, 252 - - Extirpation of - tumors, 117 - varicose veins, 126 - - Exuberant granulations, 68 - - - F - - Faradism, 201 - indications for, 201 - technic of, 201 - - Ferments, 9, 10 - - Fibromata, 114 - diagnosis, 114 - symptoms, 114 - treatment, 114 - - Fibrous ankylosis, 94 - causes, 94 - treatment 94 - - First aid - in accidents, 60 - in fractures, 162 - - First degree of burns, 57 - pathology, 57 - symptoms, 57 - treatment, 57 - - Firm bandaging - technic, 216 - - Fission, 37 - - Fissure, 64 - diagnosis, 64 - treatment, 64 - - Fistula, 64 - definition, 64 - diagnosis, 64 - treatment, 64 - - Flannel bandages, 214 - method of application, 215 - uses, 215 - - Flat foot, 178 - acquired, 178 - causes, 179 - congenital, 178 - diagnosis, 180 - operation treatment, 183 - pathology, 179 - prognosis, 181 - spastic, 180 - rigid, 182 - supports, 181 - symptoms, 180 - treatment, 181 - - Flat foot - from child birth, 179 - from excessive weight, 179 - from prolonged fractures, 179 - - Flexed toes, 183 - diagnosis, 184 - symptoms, 184 - treatment, 184 - - Fluctuation, 66 - - Forward dislocations, 172 - at the ankle joint, 172 - diagnosis, 172 - symptoms, 173 - treatment, 173 - - Formaldehyde, 14 - uses, 23 - - Fractures, 156 - astragalus, 168 - causes, 159 - classification, 156 - comminuted, 158 - complete, 156 - complicated, 161 - compound, 161 - depressed, 157 - diagnosis, 166 - epiphyseal separations, 158 - etiology, 159 - fibula, 165 - fissured, 157 - fixation method, 165 - greenstick, 156 - impacted, 158 - joint, 158 - line of, 157 - location, 158 - number, 161 - metatarsal, 169 - multiple, 161 - operative, 164 - os calcis, 168 - pathologic, 160 - Pott's, 165 - recent, 162 - reduction, 163 - simple, 161 - tarsal, 167 - tibia, 165 - treatment, 162, 166, 167 - varieties, 157 - violence, 160 - - French bandage of the foot, 218 - - Frigorism (trench foot), 137 - causes, 137 - diagnosis, 137 - symptoms, 137 - treatment, 137 - - Frost Bite, 63 - - Furuncle, 66 - causes, 66 - symptoms, 66 - treatment, 67 - - - G - - Galvanism, 201 - indications, 201 - method of application, 201 - - Galvano-cautery, 200 - indications, 200 - method of application, 200 - - Gauze - aseptic, 44 - iodoform, 24 - uses, 44 - - Gangrene, 118 - arteriosclerosis, 118 - carbolic acid, 121 - cold, 120 - diabetic, 120 - dry, 118 - endarteritis obliterans, 120 - embolism, 120 - moist, 119, 122 - - Gelatin, uses, 219 - - Germs, 6 - bacillus coli communis, 17 - bacillus pyocyaneus, 15 - bacillus tetani, 17 - bacillus tuberculosis, 17 - bacillus typhosis, 17 - micrococcus gonorrhoeae, 16 - spirochaeta pallida, 15 - staphylococcus pyogenes aureus, 16 - staphylococcus pyogenes albus, 16 - staphylococcus pyogenes citreus, 16 - streptococcus pyogenes, 16 - - Glycerine, uses, 219 - - Gonorrhoeal arthritis, 95 - causes, 95 - diagnosis, 95 - symptoms, 96 - treatment, 96 - - Gouty arthritis, 97 - - Granulations, 68 - - Green stick fracture, 156 - symptoms, 156 - treatment, 156 - - Gun shot wounds, 39 - symptoms, 39 - treatment, 39 - - - H - - Hematoma, 42 - definition, 42 - diagnosis, 42 - symptoms, 42 - treatment, 42 - - Hallux valgus, 185 - causes, 185 - operative measures, 187 - pathology, 185 - symptoms, 185 - treatment, 186, 187 - - Hallux flexus, 183 - symptoms, 183 - treatment, 183 - - Hammer toe, 183 - diagnosis, 183 - symptoms, 183 - treatment, 183 - - Heat, 14, 197 - effects, 14, 34 - dry, 14, 19 - moist, 14, 20 - - Heloma, 142 - definition, 142 - causes, 142 - diagnosis, 142 - pathology, 142 - radical cure, 144 - pathology, 142 - radical cure, 144 - symptoms, 142 - treatment, 143 - varieties, 142 - - Hemoglobin, 42 - - Hemophilia, 51 - - Hemorrhage, 51 - arterial, 51 - capillary, 45, 51 - causes, 51 - control, 44, 52 - in chiropody, 53 - spontaneous, 51 - venous, 51 - treatment, 44, 52, 54 - - Hemostatics, 54 - - Hereditary syphilis, 130 - diagnosis, 130 - symptoms, 131 - treatment, 132 - - High frequency current, 198 - indications for, 198 - method of application, 198 - - Horny tissue - where found, 57 - treatment, 58 - - Housemaid's knee, 83 - - Hydrastine, uses, 211 - - Hydrochloride of cocaine - indications for, 243 - - Hydrogen peroxide, 24, 211 - - Hyperemia, 194 - arterial or active, 196 - methods of application, 195 - uses, 196 - venous or passive, 195 - - Hypertrophy of bone, 101 - causes, 101 - symptoms, 101 - treatment, 101 - - Hypertrophy of nails, 148 - causes, 148 - pathology, 149 - symptoms, 149 - treatment, 149, 150 - - - I - - Ichthyol - ointment, 212 - solution, 208 - uses, 212 - - Immunity, 12 - acquired, 12 - inherited, 12 - natural, 12 - resistance to, 12 - susceptibility to, 12 - - Impacted fractures, 158 - causes, 158 - diagnosis, 158 - symptoms, 158 - treatment, 158 - - Injuries to the ankle - contusions, 41 - dislocations, 172 - fractures, 168 - inflammations, 89 - sprains, 176 - - Inflammation, 28 - bone, 105 - bursae, 82 - causes, 28 - definition, 28 - emigration, 30 - etiology, 28 - exudation, 29 - diapedesis, 31 - pathology, 28 - periosteum, 103 - phenomena, 32 - resolution, 32 - serous membranes, 84 - sloughing, 32 - suppuration, 33 - symptoms, 32 - synovial membranes, 84 - treatment, 34 - varieties, 34 - - Incised wounds, 39 - symptoms, 40 - treatment, 44 - - Indolent ulcers - causes, 67 - diagnosis, 67 - symptoms, 67 - treatment, 67 - - Infective arthritis, 95 - causes, 96 - diagnosis, 96 - symptoms, 96 - treatment, 96 - - Ingrowing toe nail, 145 - causes, 145 - diagnosis, 145 - operations, 148 - symptoms, 145 - treatment, 146, 147, 148 - varieties, 148 - - Injuries of the bursae, 82 - diagnosis, 82 - symptoms, 82 - treatment, 83 - - Injuries of the bone - contusion, 41 - dislocation, 170 - fracture, 156 - - Interpretation of radiograms - their diagnostic value, 203 - - Inunction of mercury, 133 - indications, 133 - preparation, 133 - technic, 133 - - Iodin - preparations, 24 - uses, 24 - - Iodoform - gauze, 24 - ointment, 24 - powder, 24 - poisoning, 24 - - - J - - Joint fractures, 158 - diagnosis, 158 - symptoms, 158 - treatment, 158 - - - K - - Knives - method of sterilization, 21 - - Kreolin, 13 - - - L - - Lacerated wounds, 40 - causes, 40 - diagnosis, 40 - symptoms, 40 - treatment, 44 - - Lassar's paste, 212 - formula, 212 - indications, 212 - - Lead and opium wash, 208 - formula, 208 - indications, 208 - - Leukocytosis, 26 - definition, 26 - interpretation, 26 - value, 26 - - Ligaments - injuries, 176 - - Ligatures, 46 - uses, 46 - varieties, 46 - - Ligation of varicose veins, 126 - methods, 126 - technic, 126 - - Lime water, 209 - - Liquor ferri subsulphatis (Monsel's sol.), 211 - formula, 211 - method of application, 211 - uses, 211 - - Liquor calcis, 209 - formula, 209 - uses, 209 - - Liquor plumbi subacetatis, 208 - formula, 208 - indications, 208 - - Local anesthesia, 229 - advantages, 234 - alypin, 251 - cocaine, 243 - drugs employed, 243 - edemitization method, 242, 246 - endermic method, 241, 245 - essentials, 237 - general principles, 233, 234, 237, 238 - history, 229 - methods of application, 241 - nerve blocking, 242 - physiologic effects, 232 - preparation of instruments, 240 - preparation of patient, 240 - novocaine, 250 - objections to, 236 - quinine and urea hydrochloride, 249 - Schleich's sol., 246 - stovaine, 251 - strength of solutions, 244 - technic, 241 - toxicology, 247 - - Local treatment of - arthritis, 91 - bursitis, 83 - periostitis, 103 - osteomyelitis, 94 - phlebitis, 128 - synovitis, 87 - - Location of - dislocations, 170 - fractures, 156 - sprains, 176 - ulcers, 70 - - Locomotor ataxia, 75 - causes, 75 - diagnosis, 75 - foot manifestations, 76, 77 - treatment, 78 - - Longitudinal fractures - diagnosis, 157 - treatment, 157 - - Loose bandage - objections to, 215 - - Lutein - diagnostic value, 73 - reaction, 73 - technic, 73 - - Lymphatic system, 5 - - Lysol, uses, 23 - - - M - - Malposition in fractures, 164 - treatment, 164 - - Malignant growths, 115, 152 - carcinoma, 115, 152 - diagnosis, 115 - sarcoma, 115, 153 - symptoms, 115 - treatment, 115 - - Martin's bandage, 195 - indications, 195 - how applied, 195 - - Massage, 201 - indications, 44 - technic, 202 - varieties, 202 - - Mayo's operation, 127 - how performed, 127 - when indicated, 127 - - Mechanical theory of tabes - explanation of, 75 - - Mercury - preparations, 133 - uses, 132 - - Metatarsalgia, 184 - diagnosis, 184 - symptoms, 184 - treatment, 184 - - Methods of - disinfection, 20 - immobilization of fractures, 165 - fixation of fractures, 165 - - Microorganisms, 6 - definition, 6 - non-pathogenic, 6 - varieties, 6 - - Moist gangrene, 119 - causes, 118, 119 - diagnosis, 119 - symptoms, 119 - treatment, 121 - varieties, 119 - - Monsel's sol., 211 - formula, 211 - indications, 211 - uses, 211 - - Monochloracetic acid - uses, 210 - - Morton's disease, 184 - causes, 184 - diagnosis, 184 - symptoms, 184 - treatment, 184 - - Motorman's foot, 138 - causes, 138 - diagnosis, 138 - symptoms, 138 - treatment, 138 - - Multiple varicose veins - location, 125 - treatment, 126 - - Muslin bandage - uses, 214 - - Mustard - uses of, 199 - - Muriate of cocaine, 214 - how used, 214 - when indicated, 214 - - Myeloma, 116 - causes, 116 - diagnosis, 116 - symptoms, 116 - treatment, 116 - - - N - - Nails, 150 - diseases, 150 - inflammation, 150 - hypertrophy, 148 - symptoms, 150 - treatment, 150, 151 - - Necrosis, 102 - definition, 102 - causes, 102 - diagnosis, 102 - symptoms, 102 - treatment, 102 - - Needle in foot, 40 - diagnosis, 40 - treatment, 40 - value of X-ray, 40 - - Neosalvarsan (914), 133 - how prepared, 133 - indications, 133 - technic, 133 - - Nerve theory - cause for tabes, 75 - - Nerve pressure - effect, 242 - - Nerve blocking - in local anesthesia, 242 - - Nervous system, 3 - - Neuropathic joints, 98 - diagnosis, 98 - symptoms, 98 - treatment, 98 - - Nicolaier's bacillus, 17 - - Nitric acid - uses, 210 - - Nitrate of silver, 25 - different sols., 26 - stick, 26 - uses, 26, 210 - - Novocaine, 250 - how prepared, 250 - advantages, 250 - indications, 250 - uses, 250 - - Nucleus, 36 - - Number of fragments in fractures, 161 - - Number of ulcers on leg, 73 - - - O - - Obtaining a sounder scar, 227 - in skin grafting, 228 - in the treatment of ulcers, 222 - - Oblique fractures, 157 - - Ointments, 212 - balsam of Peru, 212 - boric acid, 212 - Crede, 26 - ichthyol, 212 - indications, 212 - Lassar's paste, 212 - mercurial, 212 - salicylic acid, 211 - scarlet red, 213, 214 - zinc oxide, 212 - - Oleate of mercury - indications, 133 - - Onychia - hypertrophy, 148 - inflammation, 150 - symptoms, 150 - treatment, 151 - - Operations - flat foot, 181 - fractures, 164 - hallux valgus, 187 - osteitis, 94 - necrosis of bone, 102 - osteomyelitis, 94 - periostitis, 103 - varicose veins, 126 - - Ordinary saline sol., 208 - how prepared, 208 - indications, 208 - methods of injection, 45 - - Orthoform - uses, 210 - - Os calcis - dislocations, 175 - fracture, 168 - - Osteitis, 105 - causes, 105 - deformans, 113 - diagnosis, 105 - symptoms, 105 - treatment, 105 - - Osteitis deformans, 113 - causes, 113 - diagnosis, 113 - symptoms, 113 - treatment, 113 - - Osteomalacia, 113 - causes, 113 - diagnosis, 113 - onset, 113 - symptoms, 113 - treatment, 113 - - Osteomyelitis, 105 - acute, 105 - causes, 105 - chronic, 110 - diagnosis, 106 - infective, 107 - symptoms, 107 - syphilitic, 111 - tubercular, 109 - treatment, 109, 114 - - Os trigonum - location, 168 - - Oxygen, 26 - - Ozone, 26 - - - P - - Paget's disease, 113 - symptoms, 113 - treatment, 113 - - Painful heel, 184 - causes, 184 - symptoms, 184 - treatment, 184 - - Palliative treatment of veins, 126 - bandaging, 126 - Unna's paste, 219 - - Parasiticides - alcohol, 25 - carbolic acid, 13 - formaldehyde, 23 - iodin, 24 - heat, 34 - mercury, 133 - - Passive hyperemia, 195 - contraindications, 194 - indications, 195 - technic of application, 195 - - Pastes - Lassar's, 212 - Unna's, 219 - - Pathogenic bacteria, 6 - - Periostitis, 103 - acute, 103 - causes, 103 - chronic, 104 - diagnosis, 103 - symptoms, 104 - treatment, 103 - varieties, 103 - - Perforating ulcer, 75 - causes, 75 - diagnosis, 75 - symptoms, 75 - treatment, 77 - - Peroxide of hydrogen - uses, 14, 24, 211 - - Pes cavus, 193 - - Pes planus, 178 - causes, 179 - diagnosis, 180 - symptoms, 180 - treatment, 181 - varieties, 179 - - Phagocytosis, 11, 31 - - Phenol - gangrene from, 22 - other name, 22 - poisoning, 22 - uses, 22 - - Phlebitis, 127 - causes, 127 - diagnosis, 127 - preventive measures, 128 - operations, 129 - symptoms, 127 - treatment, 128 - varieties, 127 - - Phlegmon - treatment, 195 - - Picric acid - uses, 60 - - Plaster of Paris, 164 - how applied, 164 - indications, 164 - - Poisoned wounds, 39 - symptoms, 39 - treatment, 39 - - Poisoning by - carbolic acid, 13 - - Potassium permanganate, 25 - - Powders, 210 - aristol, 24, 210 - alum, 210 - boric acid, 210 - dermatol, 210 - calomel, 210 - iodoform, 24, 210 - orthoform, 210 - protonuclein, 210 - scarlet red, 210 - stearate of zinc, 210 - talcum, 210 - zinc oxide, 210 - indications, 210 - uses, 210 - - Powdered white oxide of zinc - uses, 219 - - Preparation of instruments for operations, 21 - - Preparation of field of operation, 20 - dressings, 20 - hands, 21 - instruments, 21 - skin, 21 - - Preparation of an ulcer for skin grafting, 222 - - Primary syphilis, 131 - causes, 131 - diagnosis, 131 - symptoms, 131 - treatment, 131 - stage of, 131 - incubation, 131 - - Protargol - uses, 26 - - Protiodide of mercury - dose, 133 - uses, 133 - - Protonuclein, 14 - as a powder for wounds, 210 - as a tablet internally, 210 - - Ptomaines, 9 - definition, 9 - poisoning by, 9 - symptoms, 9 - treatment, 9 - - Punctured wounds, 40 - symptoms, 40 - treatment, 40 - - Pus - causes, 33 - symptoms, 33 - treatment, 33 - - Pyemia, 47, 50 - definition, 50 - symptoms, 50 - treatment, 50 - - - Q - - Quinine and urea hydrochloride, 249 - indications, 249 - - - R - - Radiograms - value of, 205 - - Ray fungus - other name, 136 - symptoms, 137 - treatment, 137 - - Raynaud's disease, 119 - diagnosis, 119 - symptoms, 119, 121 - traumatic, 124 - treatment, 119, 123, 124 - thrombosis, 120 - varieties, 118 - - Reduction of fractures - method of, 163 - - Red wash, 210 - formula, 210 - indications, 210 - - Results of - skin grafting, 228 - - Repair of wounds, 36 - by primary union, 37 - by granulation tissue, 38 - by second intention, etc., 37 - - Resolution - significance of, 32 - - Reverdin's method of skin grafting, 223 - indications, 223 - technic, 223 - - Rheumatic arthritis, 96 - diagnosis, 97 - symptoms, 97 - treatment, 97 - - Rigid flat foot, 182 - causes, 182 - diagnosis, 182 - symptoms, 182 - treatment, 183 - - Rubber bandage, 214 - indications, 215 - technic, 219 - - Rubefacients, 199 - indications, 199 - method of use, 199 - - Rupture of tendo Achillis, 168 - diagnosis, 168 - symptoms, 168 - treatment, 168 - - - S - - Salicylate of mercury, 133 - indications, 133 - method used, 133 - - Salvarsan (606), 133 - how prepared, 133 - indications, 133 - technic, 133 - - Saprophytic bacteria, 6 - definition, 6 - symptoms, 6 - treatment, 6 - - Sapremia, 49 - definition, 49 - symptoms, 49 - treatment, 49 - - Sarcoma, 153 - definition, 153 - manifestations, 153 - symptoms, 153 - treatment, 153 - - Saturated sols. boric acid, 25 - how prepared, 208 - indications, 208 - - Scarlet red, 213 - formula, 214 - indications, 213 - ointment, 213 - powder, 210 - symptoms of poisoning, 213 - treatment, 214 - - Schede's method of operating for varicose veins, 126 - - Schizomycetes, 6 - - Sebaceous cyst, 154 - diagnosis, 154 - symptoms, 154 - treatment, 154 - - Secondary syphilis, 132 - stages, 132 - symptoms, 132 - treatment, 132 - - Senility - as a cause of disease, 100 - - Senile atrophy, 100 - symptoms, 100 - treatment, 100 - - Septic arthritis, 90 - - Septic phlebitis, 127 - causes, 127 - diagnosis, 127 - symptoms, 127 - treatment, 128 - - Septicemia, 48 - causes, 48 - definition, 48 - symptoms, 48 - treatment, 48 - - Sepsis, 18 - causes, 18 - diagnosis, 18 - symptoms, 18 - treatment, 18 - - Sequestra, 93 - - Serum therapy - indications of, 50, 135 - value of, 135 - - Skin grafting, 222 - application of grafts, 226 - after results, 228 - indications, 222 - methods, 223 - technic, 224, 225 - - Sloughing, 34 - causes, 34 - symptoms, 34 - treatment, 34 - - Silver nitrate, 14 - solutions, 210 - uses, 221 - - Sinus, 64 - causes, 64 - definition, 64 - diagnosis, 64 - symptoms, 64 - treatment, 65 - - Sodium hydroxide - uses, 141 - - Sodium sulphide, 149 - - Solutions, 208 - boric acid, 208 - black wash, 209 - bichloride of mercury, 208 - balsam Peru, 208 - carbolic acid, 121 - copper sulphate, 210 - Dakins, 209 - lead and opium wash, 208 - monochloracetic acid, 210 - nitric acid, 210 - red wash, 210 - salicylic acid, 25 - saline, 26, 208 - silver nitrate, 210 - sterile water, 208 - Thiersch's, 208 - white wash, 209 - zinc sulphate, 210 - - Solvents, 211 - salicylic acid, 211 - sodium hydroxide, 212 - - Spastic flat foot, 180 - - Spica bandage, 217 - of the foot, 218 - of the toes, 217 - - Spina bifida, 76 - - Spiral bandage of the great toe, 217 - technic of application, 217 - - Special forms of inflammation - erysipelas, 135 - gonorrhoea, 95 - syphilis, 130 - tuberculosis, 133 - tetanus, 134 - - Spontaneous hemorrhage, 51 - causes, 51 - treatment, 52 - - Spiral fractures, 157 - diagnosis, 157 - symptoms, 157 - treatment, 157 - - Sprains, 176 - definition, 176 - diagnosis, 177 - symptoms, 176 - treatment, 177 - - Static electricity - indications, 201 - - Staphylococcus pyogenes - albus, 16 - aureus, 16 - citreus, 16 - - Sterilization, 12 - methods, 20 - of the dressings, 20 - of the feet, 22 - of the hands, 21 - of the instruments, 21 - - Stovaine - preparations, 251 - uses, 45 - - Streptococcus pyogenes, 16 - - Strychnine, 45 - preparations, 45 - uses, 45 - - Styptics, 211 - definition of, 211 - adrenaline, 211 - hydrastine, 211 - iodin, 211 - Monsel's sol., 211 - peroxide of hydrogen, 211 - alum, 211 - copper, 211 - nitrate of silver, 211, 220 - - Stockings, 216 - elastic, 216 - rubber, 216 - uses, 216 - - Sugar in the urine, 120 - significance, 120 - treatment, 120 - - Subastragaloid dislocations - causes, 174 - diagnosis, 174 - symptoms, 174 - treatment, 174 - - Supports for flat foot, 181 - indications, 181 - uses, 181 - varieties, 181 - - Suppurative phlebitis, 127 - causes, 127 - symptoms, 127 - treatment, 127 - - Sunlight - value, 27 - - Sutures, 46 - uses, 46 - varieties, 46 - - Symptoms of - abscess, 66 - actinomycosis, 136 - arthritis, 91 - blastomycotic ulcer, 79 - burns, 58 - bursitis, 83 - callosity, 141 - callous ulcers, 68 - carbolic acid poisoning, 13 - caries, 101 - cellulitis, 136 - chilblain, 63 - contusions, 42 - cysts, 154 - dermatitis, 135 - diabetic gangrene, 120 - dislocations, 120 - embolism, 119 - erysipelas, 135 - fibromata, 114 - fistula, 64 - flexed toes, 184 - fractures, 156 - frigorism, 137 - furuncle, 66 - gangrene, 118 - gonorrhoeal arthritis, 95 - gunshot wounds, 39 - heloma, 142, 143 - hematoma, 42 - hallux flexus, 183 - hallux valgus, 185 - hemorrhage, 52 - hypertrophy of bone, 101 - incised wounds, 40 - inflammation, 32 - ingrowing toe nail, 145 - joint fractures, 158 - locomotor ataxia, 75 - malignant growths, 152 - moist gangrene, 119 - Morton's disease, 184 - motorman's foot, 138 - myeloma, 116 - necrosis, 102 - neuropathic joints, 98 - onychia, 150 - osteitis, 105 - osteoma, 115 - osteomalacia, 113 - osteomyelitis, 113 - Paget's disease, 113 - painful heel, 184 - periostitis, 104 - perforating ulcer, 76 - pes planus, 180 - phlebitis, 127 - primary syphilis, 131 - pus, 33 - pyemia, 50 - Raynaud's disease, 119 - rigid flat foot, 183 - rupture of tendo Achillis, 168 - sapremia, 149 - sebaceous cyst, 154 - secondary syphilis, 132 - septic phlebitis, 127 - septicemia, 48 - sinus, 64 - sprains, 176 - synovitis, 86 - syphilis, 130 - syphilitic ulcers, 72 - talipes (various forms), 189 - tetanus, 135 - thrombosis, 118 - ulcers (various forms), 70 - verruca, 139 - wounds (different), 44 - - Synovitis, 86 - acute, 86 - causes, 86 - chronic, 87 - symptoms, 87 - treatment, 87 - - Syphilis, 130 - acquired, 130 - causes, 130 - gummata, 132 - hereditary, 130 - periods of symptoms, 131 - primary, 131 - secondary, 132 - - symptoms, 132 - transmission, 130 - treatment, 132, 133 - - Syphilitic arthritis, 95 - - Syphilitic ulcers, 72 - causes, 72 - differential diagnosis, 73 - symptoms, 72 - treatment, 74 - - Syringomyelitis, 76 - - - T - - Talipes, 188 - acquired, 192 - causes, 188 - congenital, 188 - diagnosis, 190 - pathology, 189 - prognosis, 190 - symptoms, 189 - treatment, 190 - various forms, 192, 193 - - Tenotomy, 191 - - Tertiary syphilis, 133 - causes, 133 - diagnosis, 133 - symptoms, 133 - treatment, 134 - - Terminations of inflammation, 32 - chronic, 33 - necrosis, 32 - resolution, 32 - suppuration, 33 - - Tetanus, 134 - causes, 134 - diagnosis, 135 - symptoms, 135 - treatment, 135 - - Tetanus antitoxin, 135 - indications, 135 - value, 135 - - Thiersch's skin grafting, 223 - indications, 223 - method, 224 - - Thrombus - definition, 118 - - Thrombosis - diagnosis, 118 - symptoms, 119 - treatment, 119 - - Tourniquet, 53 - - Toxalbumins - definition, 9 - - Toxemia, 47 - - Toxins, 9 - definition, 9 - products, 9 - - Traumatic arthritis, 90 - symptoms, 90 - treatment, 90 - - Treatment of - abscess, 66 - arthritis, acute, 91 - arthritis, chronic, 91 - arthritis, septic, 91 - arthritis, traumatic, 91 - actinomycotic ulcer, 79 - blastomycotic ulcer, 79 - burns, 60 - bursitis, 83 - callosity, 142 - callous ulcers, 88 - carbolic acid gangrene, 121 - carbolic acid poisoning, 13 - caries, 102 - cellulitis, 136 - chilblain, 63 - contusions, 43 - cysts, 154 - dermatitis, 136 - diabetic gangrene, 120 - dislocation of the ankle, 172 - dislocation of the astragalus, 175 - embolism, 119 - erysipelas, 136 - fibromata, 114 - fistula, 64 - flexed toes, 184 - fracture of the astragalus, 168 - fracture of the fibula, 165 - fracture of the os calcis, 168 - fracture of the metatarsal bones, 169 - fracture of the tarsal bones, 167 - fracture of the tibia, 165 - frigorism, 127 - furuncle, 67 - gangrene, 123 - gonorrhoeal arthritis, 95 - gunshot wounds, 39 - hematoma, 42 - hallux flexus, 183 - hallux valgus, 187 - hammer toe, 183 - heloma (all forms), 143 - hemorrhage, 54 - hypertrophy of bone, 101 - incised wounds, 44 - inflammation, 34 - ingrowing toe nail, 147 - joint fractures, 158 - locomotor ataxia, 75 - malignant growths, 152 - moist gangrene, 121 - Morton's disease, 184 - motorman's foot, 138 - myeloma, 116 - necrosis, 102 - neuropathic joints, 98 - onychia, 151 - osteitis, 105 - osteomalacia, 113 - osteomyelitis, 105 - tubercular bone, 109 - syphilitic bone, 111 - Paget's disease, 113 - painful heel, 184 - periostitis, 103 - perforating ulcer, 77 - pes planus, 181 - pes valgus, 192 - pes varus, 193 - phlebitis, 195 - phlegmon, 195 - primary syphilis, 131 - pus, 33 - pyemia, 50 - Raynaud's disease, 119 - rigid flat foot, 183 - rupture of tendo Achillis, 168 - sapremia, 149 - sebaceous cyst, 154 - secondary syphilis, 132 - septic phlebitis, 127 - septicemia, 48 - sinus, 65 - sprains, 176 - synovitis, 86 - syphilis, 130 - syphilitic ulcers, 74 - talipes (various forms), 190 - tetanus, 135 - thrombosis, 119 - tubercular arthritis, 94 - ulcers - actinomycotic, 136 - callous, 68 - epitheliomatous, 79 - diabetic, 75 - perforating, 75 - syphilitic, 72 - tubercular, 74 - varicose, 68 - verruca - various forms, 139 - wounds, 44 - aseptic, 39 - contused, 40 - incised, 41 - infected, 39 - gunshot, 39 - lacerated, 44 - poisoned, 44 - septic, 44 - - Trench foot, 137 - causes, 137 - diagnosis, 137 - symptoms, 137 - treatment, 138 - - Trendelenburg method - for enlarged veins, 126 - - Treponema pallidum, 15, 130 - - Trichloracetic acid - uses, 210 - - True subastragaloid dislocations, 174 - diagnosis, 174 - symptoms, 174 - treatment, 173 - - Tuberculosis, 133 - cause, 133 - diagnosis, 133 - symptoms, 134 - treatment, 134 - - Tubercular abscess, 109 - symptoms, 109 - treatment, 110 - - Tubercular arthritis, 92 - diagnosis, 93 - symptoms, 92 - treatment, 94 - - Tuberculosis of bone, 109 - causes, 109 - diagnosis, 109 - symptoms, 109 - treatment, 110 - - Tubercular ulcer, 74 - diagnosis, 74 - symptoms, 74 - treatment, 74 - - Tumors, 152 - - Tumors of bone, 114 - fibromata, 114 - carcinoma, 115 - chondromata, 114 - diagnosis, 115 - myeloma, 116 - osteoma, 115 - sarcoma, 115 - symptoms, 116 - treatment, 117 - - Thymol iodide, 210 - other name, 24 - uses, 210 - - Turpentine, 199 - - - U - - Ulcers - actinomycotic, 136 - blastomycotic, 79 - causes, 67 - callous, 67 - definition, 67 - differential diagnosis, 70 - epitheliomatous, 79 - diabetic, 75 - perforating, 75 - symptoms, 72 - syphilitic, 72 - treatment, 73 - tubercular, 74 - varicose, 68 - - Unna's paste, 219 - consistency, 219 - how applied, 220 - indications for use, 219 - method of preparation, 219 - - Unrolled bandage, 216 - disadvantages, 216 - - - V - - Varicose ulcer, 68 - cause, 69 - differential diagnosis, 70 - symptoms, 68 - treatment, 71 - - Varicose veins, 125 - bandages used, 126 - operative measures, 126 - palliative means, 126 - resection of internal saphenous, 126 - support, 126 - - Varix, 68, 126 - - Verruca, 139 - etiology, 139 - diagnosis, 139 - symptoms, 139 - treatment, 139, 140 - varieties, 139 - - Vaseline - uses, 212 - - Violet ray, 198 - - - W - - Wart, verruca, papilloma, 139 - causes, 139 - symptoms, 139 - treatment, 140 - - Wash - black, 209 - lead and opium, 208 - red, 210 - white, 209 - consistency, 209 - uses, 209 - - Webbed toes, 99 - causes, 99 - symptoms, 99 - treatment, 99 - - Wet dressings, 207 - indications, 207 - varieties, 208 - - Wounds - aseptic, 39 - classification, 39 - contused, 40 - gunshot, 39 - incised, 39, 41 - lacerated, 40 - poisoned, 39 - punctured, 40 - prognosis, 40 - symptoms, 44 - treatment, 44 - - - X - - X ray - uses, 202, 203, 205 - - - Z - - Zinc chloride, 24 - - Zinc oxide adhesive plaster - uses, 215 - - Zinc sulphate, 210 - in solution, 210 - stick, 211 - uses, 211 - - - - - - -End of the Project Gutenberg EBook of Surgery, with Special Reference to -Podiatry, by Maximilian Stern and Edward Adams - -*** END OF THIS PROJECT GUTENBERG EBOOK SURGERY *** - -***** This file should be named 41725.txt or 41725.zip ***** -This and all associated files of various formats will be found in: - 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