1. Traumatic causes.2. Constitutional causes.3. Thrombosis and embolism.4. Cold.5. The effect of certain chemicals.
1. Traumatic causes.2. Constitutional causes.3. Thrombosis and embolism.4. Cold.5. The effect of certain chemicals.
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:dryandmoist.
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 gangreneis 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.
Athrombusis a blood clot occluding the lumen of a vessel. Anembolusis 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.
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 diminishingand 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 Obliteransis 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 isinvariably 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 muchsleep from continued pain, and becomes worn out and may die of exhaustion.
In dry gangrene there is usually no well marked attempt at the formation of lines of demarcation and separation, but in some cases, if the amount of tissue involved is small, say one or two toes, or a part of the foot, for instance, and if the patient’s strength can be sustained, the line of separation forms, and the dead tissue may be cast off, leaving the bones exposed in the wound.
Moist Gangrene.When a part which has had its vitality seriously interfered with becomes gangrenous, pain, which may have been present, suddenly ceases, the part becomes insensitive, and the skin is cold, pale, and mottled purple, green, and red, and finally dark colored; blebs containing brownish serum form upon the surface; the wound, if one is present, assumes a grayish color, and an offensive discharge escapes from it; the dead tissue rapidly undergoes putrefactive changes. Coincidentally with these changes in the dead tissues, the living tissue in contact with it becomes red and swollen, and the separation of the dead tissue from the living is affected by an ulcerative inflammation, granulations from the living tissue lifting off the slough.
The patient, at the same time, if the gangrenous process involves any considerable extent of surface, exhibits the unconstitutional signs of inflammation (fever, rapid pulse, etc.) and, in some cases, if the septic infection is intense, may die from septicemia.
In both dry and moist gangrene, when the gangrenous process is arrested, the dead tissue is separated from the living by a process of inflammation; the living tissue, at its point of contact with the dead tissue, and for some distance from it, becomes red and swollen, and exhibits all the signs of acute inflammation. The line of contact between the dead and the living tissue is known asthe line of demarcation, and the line of granulations which separates the dead tissue from the living, is known asthe 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. Theanterior tibial pulseshould 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 healthytissue 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 calledgangrenous 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.
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 theTrendelenburgmethod. 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 asSchede’smethod. This consists of making a circular incision around the leg justbelow the knee joint, and in tying all the superficial veins thus exposed.
Mayo’soperation 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 Phlebitisis 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 inflamedvenous cords can be readily felt. The constitutional disturbance is marked; rigors and high temperature, 103°F. to 105°F. (remittent type), are followed by profuse sweats. The general condition, facies and anxiety, dry and parched tongue, delirium and general distress, at once directs attention to the infectious nature of the trouble. The leucocyte count will show a marked increase in the number of polynuclears.
Treatment.The treatment of phlebitis may be classified into preventive and curative, the latter being subdivided into (a), general or symptomatic, and (b), local or surgical.
The preventive treatment is summed up in the word asepsis. The influence of asepsis in the management of wounds has completely revolutionized surgical practice, and the old fatal types of pyemia and septicema have now practically vanished.
Septic and pyogenic phlebitis still remain as consequences of accidental wound contaminations and as a penalty for the neglect of surgical cleanliness.
Prophylatic measures, by the use of internal remedies which diminish the coagulability of the blood, such as Wright’s citric acid treatment, are recommended for the prevention of thrombosis. Antitoxins have not proven to be of benefit in this condition.
The curative treatment may be symptomatic, local, constitutional, or surgical. The constitutional treatment is directed to the general cause, if possible, as in the gouty, rheumatic, syphilitic, and chloritic cases; beyond this, there is no specific treatment. The antistreptococcal and staphylococcal sera are usually prescribed in the septic forms, but thus far, more as a forlorn hope than with the expectation of accomplishing any definite results. The symptomatic treatment, on the other hand, is always indicated to diminish pain, to support and strengthen the circulation, and to favor elimination. The main reliance is to be placed upon the local treatment, combined with good nursing, appropriate food, and moderate stimulation.
The local treatment is summed up in the following indications:(a), immobilization and absolute rest of the affected limb; (b), elevated position of the foot of the bed or of the limb to favor the drainage of the venous current toward the trunk. The limb should be covered with cotton batting and bandaged, over a gutter-splint of cardboard, extending from the foot to the thigh, to immobilize the knee. In the superficial inflammations, with much redness and heat, an even layer of any of the kaolin mixtures may be applied between thin layers of gauze, like an antiseptic poultice, over the entire extremity, and especially over the inflamed parts. A saturated watery solution of 25 per cent. ichthyol, painted over the entire surface will also prove decidedly beneficial in cases complicated with lymphangitis. Unguentum Crede, mercurial ointment, and the so-called resolvent lotions have been tried, but none of these can compare in their beneficial effect with kaolin poultices, with or without ichthyol, or the liberal application of broad compresses, thoroughly saturated with a weak lead and opium lotion, which latter acts not only as a local astringent, but as a marked sedative. Immobilization and rest should be maintained for a month or more.
Operative Treatment.The operative treatment of acute septic thrombophlebitis has in view three indications, and the procedures adopted must vary according to these: (1) ligation of the vein between the thrombotic focus and the uninfected vein on the cardiac side, in order to obstruct the further advance of the infection, and thus prevent the entrance of septic emboli into the circulation; (2) removal of the primary focus of infection by direct incision into the veins, evacuation of the septic thrombus and drainage; (3) extirpation of the infected veins with the contained clot and septic contents.
Syphilisis 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 thespirochaeta pallidaortreponema pallidumof 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 whichcontains 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 areawith 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 insyphilis. 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.
Inunctionrepresents 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 anumber 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 thepoint 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 becauseit 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 Footis 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.
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 foundthat 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.
Definition.A callosity is a circumscribed thickening of thestratum 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 excessivelyhigh 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.
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 Treatmentconsists 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 Treatmentof 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 reachesthe 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.
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 Methodbetween 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 Nailmust 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 sufficienthypertrophy 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 intotwo 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.
Hypertrophycan 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 thenail, 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 calledingrowing 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 termedonychia 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