(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.
(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.
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.
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.
(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.
(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.
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 extensiveburns 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 fourteendays, 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 somewhatbeyond 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 ordinaryburns. 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 termedfrost 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.
Chilblainoccurs 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.
AFistula(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.
AFissureis a crack and in podiatry, has special reference to a condition found in the toeweb.
ASinusis 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 carbolicacid, 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 enormouslyincreases; 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.
Treatmentis 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 Abscessis 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 Boilis 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 thecentre 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 asfurunculosis.
Treatment.The treatment consists of crucial incision and the application of a wet dressing.
An Ulcermay 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 calledannularulcers. 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 asexuberant; when pale, soft and flabby, asweakoredematous; when small and slowly growing, asindolent.
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 acongestedorirritableulcer. 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 theleg 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, andthis 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
Treatment.The treatment of varicose ulcers must be based on antiseptic cleanliness, and the improvement ofnutrition 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, itmust not be forgotten that in the presence of an ulcer, infection of an operative wound is likely to occur.
Syphilitic Ulcersmay 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 thespirochaeta pallidaortreponema 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 isextremely 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.
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 compressionbandage 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 Ulcerusually 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, plentyof fresh air, and a good nutritious diet. Bowels must be regulated.
Perforating Ulcer of the Footoccurs 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 Theoryregards 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 Vasculartheory assumes that arteriosclerosis is always present, and causes ischemic necrosis through arterial and capillary thrombosis.
The Nervetheory, 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 Theoryeither 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 ofwhich 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. Sooneror 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.
Treatmentin those predisposed to diabetes and tabes, deserves prophylaxis consideration. The shoes must fit accurately and without undue pressure; much walking is to be avoided; when ulceration has begun the recumbent position and cleanliness are of paramount importance. The callous epidermis should be removed so as to render the ulcer as superficial as possible. Dead bone must be scraped away or extracted, if in the form of a sequestrum, and drainage must be perfected by enlarging the opening.Sinuses should be enlarged and any pockets found should be thoroughly opened. It must be emphasized, however, that operative interference should be undertaken with care and discretion in order to avoid necrosis and infection. Periodic curettments and cauterizations with silver nitrate are often of benefit, as are also the employment of dry iodoform gauze as a packing, together with the occasional use of various moist dressings. Both the constant and interrupted currents of electricity have been resorted to with benefit, sometimes locally and sometimes applied to the spinal cord or affected nerves. Measures directed to the improvement of the circulation of the foot, such as massage, stimulating baths, and lotions, are of service.
Bier’s Arterial Hyperemia, in the form of baking of the foot by means of a gas or electric apparatus, especially devised for the purpose (Tyrnauer) is of great benefit, more so when there is a neuritis accompanying the ulcer. The baking should be done once a day for from ten to twenty minutes, and the temperature should be gradually increased from 100°F. to 300°F., depending upon the patient’s ability to tolerate heat.
The passive, venous or obstructive form of hyperemia is absolutely contraindicated in this class of ulcers. The initial cause of the trouble must receive attention, because upon its successful management depends the cure, much more so than upon the local measures.
Diabetics and syphilitics should receive appropriate treatment. The bad cases, especially where gangrene or serious infection exists, may require amputation, but unless this can be done in sound tissue with adequate innervation, a perforating ulcer may develop upon the area exposed to the pressure of an artificial limb. Resection of joints is usually of little benefit. The most satisfactory operative results in this class of ulcers have been obtained by stretching the posterior tibial nerve, together with scraping the ulcer, or, better, by excising it, followed by immediate suture of the wound. The operation is best done througha curved incision beneath the internal malleolus, the nerve being isolated and vigorously stretched in both directions by means of some blunt instrument inserted beneath it. Sometimes the external or internal plantar nerve alone is treated in this manner.
Blastomycotic Ulcer.This is not a common condition in the lower extremity. It is found near the lower third of the leg, and begins as a papule or papulo-pustule, soon becoming covered with a crust which, on removal, discloses a papillomatous area. The typical ulcer is elevated, verrucous or fungating, with a soft base which is infiltrated with a seropurulent secretion. The border is dark-red or purple and slopes more or less abruptly through the normal skin, from which it is sharply defined. The quickest and most positive method of differentiation is by means of the tissues. The organisms are fungi, known as the blastomycetes, saccharomyces or yeasts, characterized especially by their mode of multiplication or cell division, called budding.
Treatment.In all cases, thorough cleansing of the ulcer with antiseptic lotions, as previously described, is of great benefit. Complete extirpation of the ulcerative lesions has been successful, but curetting does not always prevent their recurrence. Potassium or sodium iodide in large doses (totaling from 100 to 400 grains per day) and radiotherapy seem to be the most efficacious forum of treatment. Copper sulphate in a 1 per cent. solution as a wash for external use and also in one quarter of a grain doses internally, has in some cases given good results.
Epitheliomatous Ulcer.In none of the more common ulcerative skin lesions would the conditions for the development of cancer seem to be more favorable than in chronic dermatitis with ulceration; the despised and neglected varicose ulcers of the leg. The extreme chronicity of the inflammatory process, often lasting for many years; the age of the patient, which is usually advanced; the almost inconceivable neglect of the lesion in many cases, so that the persistent presence of foul and decomposing secretion and of the products of tissue necrosis is common: thefrequent 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.
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; thesynovial sacsof joints allow the bones to ride smoothly one upon the other; thesynovial sheathof 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.
Synovial bursaeexist 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 theprepatellarand 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 usHousemaid’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 theentire 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.
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, acuteor 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 cottonand 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 termedhydrops articuliorhydrarthrosis.
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, thoughsimple, requires every aseptic precaution, and should never be performed in the presence of any acute symptoms.
For other phases of Synovitis see 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’shand upon passive motion, there is an arthritis present beyond doubt. This symptom is due to the destruction of the synovial covering of the bone ends involved, permitting contact of bone with bone. It is more common to chronic joint disease, but may also accompany acute conditions, especially if they are severe.
Symptoms peculiar to the variety of infection and the history as to duration, causation, course and number of joints involved, must be considered in making a diagnosis or prognosis.
Varieties.Besides simple traumatic arthritis, there are many constitutional disorders which affect the joints conspicuously; these are: tuberculosis, syphilis, gonorrhea, gout and rheumatism.
A prominent cause of many instances of arthritis heretofore regarded as rheumatic in origin, is now known to exist in any area of infection. Such “foci of infection” discharge a certain amount of infective material into the circulation, which may find lodgment in a joint and set up an acute process.
It has been proven in numerous cases that a so-called rheumatism will yield promptly to drainage of a chronic abscess, no matter how remote the location. Oral conditions especially have been found responsible for this form of arthritis. Abscesses at the apexes of teeth and pyorrhœa alveolaris, when properly operated, yield nothing short of miracles, in the way of relieved symptoms.
In addition to the varieties of arthritis already mentioned, those due to certain infectious diseases, such as measles, scarlet fever, typhoid fever, smallpox or erysipelas, should be included, as well as cases of neuropathic origin.
Nonpenetrating.Ordinary contusions or twisting at a joint, may result in the establishment of an inflammatory process within the joint, evidenced by much swelling andgiving 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 orirrigations. 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 inmore 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.