



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 <DW44>s 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- 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- 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 <DW44>s the
growth of bacteria, but both ozone and oxygen produce a hyperemia, and
<DW44> 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 <DW44>s 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 <DW72>s 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 ;
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 (<DW46> 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: <DW46> 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 
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 <DW44>
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
     <DW46>, 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

   <DW46> 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

*** 