1. Spurs running out from the under side of the os calcis found by the aid of the X-ray.2. Inflammation of the bursae under the os calcis.3. Flat foot.4. Gonorrhœa.5. Focal infection.
1. Spurs running out from the under side of the os calcis found by the aid of the X-ray.
2. Inflammation of the bursae under the os calcis.
3. Flat foot.
4. Gonorrhœa.
5. Focal infection.
Treatment.Where a spur of bone causes the unpleasant symptoms, the excrescence should be excised.
When focal infections are the primary cause of painful heel, operative procedure to remove the source of infection is imperative and will prove curative.
Palliative measures are: massage, douches, hot air, a metal plate worn under the painful area, rest. The back of the foot should be cut away to relieve pressure.
Metatarsalgia—Morton’s Disease.Metatarsalgia is characterized by an acute pain, cramplike in character, occurring at the base of the third or fourth toes.
The pain comes on suddenly while the foot is in action, and is usually accompanied by a “snapping of the bones.” The pain is so acute that it is not uncommon for the patient to seek relief by taking off the shoe and rubbing the foot.
In persons suffering with this condition it will be regularly noticed that the weight is thrown upon the ball of the foot, on the metatarsophalangeal joints, either because of a weak foot, or because of a tendency of the toes to turn up.
Treatment.1. Proper strapping to raise the arch and bring the ends of the toes down.
2. A pad across the ball of the footbehindthe metatarsal heads, also brings the toes down.
3. Recommend shoes, wide across the ball, with a higher or lower heel than ordinary, as the case indicates.
Hallux Valgus.The termhallux valgusis applied to a deviation or displacement of the great toe outward, toward the outer border of the foot.
In normal feet, the line of the great toe when prolonged backward, should pass through the centre of the heel. This relation in civilized communities is seen only in the feet of infants. In adults it is observable only in the bare-footed races.
Cause.It is frequently associated with flat foot, gout and rheumatism, but it is primarily due to the use of inappropriate foot-gear. It is only considered pathologic when the deviation is more than fifteen degrees.
Pathology.The displacement outward (which reaches 30 to 40 degrees in the average case and may reach 90 degrees) of the phalangeal part of the great-toe joint, uncovers the inner part of the head of the metartarsal bone, and here the cartilage degenerates, and the bone becomes condensed at its outer part. The inner lateral ligament is lengthened and thickened and the sesamoid bones become displaced outward and are often thickened.
Under the skin, at the inner and prominent aspect of the foot, is to be found a bursa, which is liable to inflammation under pressure, and is known as a bunion. The inflammation in this sac may extend to the joint and thus disintegrate it.
Symptoms.The toe is displaced outward and a reddened and shiny condition of the thickened skin exists over the inner prominence and perhaps over the top of the toe joint. The great toe if seriously displaced, must lie over or under the other toes, the former being the more common position. In other cases the second toe may be crowded up as a hammertoe. The joint is painful and the inner toes, being crowded to the outer side of the foot, are the seat of corns and callosities. Flat foot is frequently associated with this condition.
Treatment.In mild cases, the stocking should be splitto allow a separate stall for the great toe, and broad toed boots should be worn. If flat foot exists, a support should be supplied for its aid in restoring the position of the great toe. In severe cases, nothing short of an operation is likely to be of value. A toe-post may be worn for a time in mild cases.
Amputation of the head of the metatarsal bone gives uniformly good results.
The toe is straightened and flexible; ankylosis with this operation does not occur.
In operations for hallux valgus there are two distinct purposes acting as determining factors in making a choice in a given case as to which is indicated. These are: (1)the radical operation for the correction of the deformity, and (2)the palliative operation for the alleviation of symptoms by the removal of the hypertrophied portion of the metatarsal head which is exposed to pressure. Among operations in the first mentioned class, the one known as the Mayo operation is, in all probability, the best. The entire head of the metatarsal is amputated, and the bursa is turned in over the cut end of bone, to diminish the amount of shortening and to prevent ankylosis of the joint. This latter consideration, however, is an unnecessary one, for in operations within this joint, ankylosis does not occur when the synovial surface of the phalanx is left undisturbed, even when the bursa is not employed as an intervening pad.
In the other class of operations for the relief of symptoms, no attempt is made to straighten the toe. A wedge-shaped piece of the exostosis is removed, against which pressure has caused symptoms.
A palliative operation devised by Dr. Robert T. Morris of this city, is one easy of accomplishment and serves every purpose where a radical operation is interdicted. It is known as the “button-hole” operation because of the fact that only a small incision is made immediately above the protuberant bone through which a sharp chisel is inserted, cutting off the offending “button” of bone.
An operation which in the hands of the authors has proven of distinct value, and which has probably not beenpreviously described eliminates both the deformity and its painful symptoms. This operation which is described below, is less severe than other radical operations and not very much more so than the usual palliative ones.
The incision is made on the dorsum of the great toe over the offending joint and just to the inner side of the extensor tendon. This tendon is held to the outer side, out of the way. The knife penetrates the capsule of the joint and opens it above and laterally.
An effort is made to preserve the integrity of the capsule below (floor) asonly the intra capsular end of the metatarsal is removed. These two factors are of the utmost importance. When the joint capsule is slit open along its dorsal and two lateral aspects, sufficient room is obtained for the insertion of the wire saw, and all of that portion of the metatarsal lying within the joint proper is removed. There is thus accomplished a correction of the deformity with very little shortening of the great toe. Usually its length after this operation is about the same as the second toe.
The next step in the operation is closure of the synovial sac or joint capsule. A stitch on either side and two above are all that is necessary. The floor of the sac remains intact and nothing beneath it, in the ball of the foot, has been disturbed. Many operators invade this area and remove the sesamoids. This is unwarranted as the transverse level of the ball of the foot is lost, and the weight is put directly upon the newly formed joint, depriving it of its normal support, or of padding from below.
One other omission in this operation is that of the bursal flap over the raw end. This is found entirely unnecessary as results prove, and its omission hastens healing considerably. The bursa over the metatarsophalangeal articulation in these cases is nearly always inflamed, and consists of a mere fibrous pad. Its dissection from the normal position is a real loss at that site, and of questionable benefit over the cut bone, as motion in the joint is as good or better without it.
The skin closure is made without drainage, andno wet dressing employedfor fear of the solution filling the cavity whence the bone was removed and carrying with it infectious material. A dry sterile dressing is all that is required, and a splint to maintain a straight position for the toe.
Four or five days complete rest for the part are ordinarily sufficient. Following this, walking about the room is permitted with the aid of a stick. After ten days, when the patient can get about fairly well without the assistance of a stick, the foot may safely be shod with an “arctic” of sufficient size.
The most common form of clubfoot, and therefore the deformity of that character most frequently encountered, is characterized by inversion of the sole of the foot, elevation of the heel, and a twisting and turning of the front part of the foot. This deformity is typical ofcongenitalclubfoot, which, as stated, is the most common form of that deformity. Theacquiredform is usually the result of infantile paralysis.
Congenital Clubfootis most frequently double, and males are more frequently affected than females; in unilateral or one-sided clubfoot, one side is not more frequently affected than the other.
Etiology.Very little is known as to the cause of congenital clubfoot but it is not infrequently associated with other congenital deformities. It appears to be hereditary in a great many instances. The greater number of cases appear without definable cause, except perhaps from intra-uterine pressure. There are, however, a number of these cases that are associated with malformation of the bones of the foot and leg, such as absence of the scaphoid; defect of the tibia; fusion of a number of the tarsal bones.
Pathology.The sharp adduction and plantar flexion, at the tarsal joints, produce a deformed position of the foot. As a result of these, the heel is small and elevated; the dorsum of the foot is prominent; and the outer borderusually, and, in extreme cases, the dorsum of the foot, bears the weight of the body in walking and in standing; the sole of the foot is bent sharply in, and twisted at the tarsal joint. In fact, all the bones are changed in shape, and the inner muscles, tendons and ligaments are shortened by contraction, while the ones to the outer side are lengthened.
The distortion of certain individual bones is of importance. The astragalus is the seat of the most important changes. It is tipped downward at its front end, and its posterior part articulates with the tibia, its anterior articular surface projecting under the skin; its neck is elongated and bent inward and downward, so that its scaphoid articulation faces inward and downward and not forward.
This is the most important change in clubfoot, because the anterior end of the astragalus, the head of the bone, carries inward and downward with it the scaphoid, the three cuneiforms, and the inner three metatarsal bones. The scaphoid articulates with the inner side rather than the front of the astragalus and, in extreme cases, forms a joint surface with the inner malleolus. It may be somewhat changed in shape, being flattened and drawn inward and upward.
The os calcis is generally poorly developed, and its front end is rotated downward, and bent inward; the outer surface of the bone is more convex and the inner surface more concave than normal, and since the anterior facet looks inward and downward, it carries with it the cuboid and the two external metatarsal bones. The changes in the other bones are not important; the chief obstacles to reduction lie in the os calcis and in the astragalus.
Soft Parts.The muscles, ligaments, tendons, and fascia at the lower and inner side of the foot are shortened, and lengthened at the outer and upper side. The plantar fascia being one of the chief obstacles to reduction, the tendons are displaced, especially those on the inner side of the foot.
Symptoms.Double clubfoot is usually accompanied by an awkward and unsteady gait, in which each foot is in turn lifted high to clear the foot on the ground, and thetoeing inis, of course, excessive. The weight is borne on the outer side of the foot, and all elasticity of gait is absent.
On the outer border of the foot, where the weight is borne, callosities and bursae develop; the calves of the legs are small, and the knee joint may be lax.
The gait in single clubfoot is less awkward, but characterized by the same features. The foot is rigid in the deformed position, and in cases of marked deformity, the foot cannot be manipulated into the normal position.
Diagnosis.Congenital clubfoot cannot be mistaken for any other condition. The diagnosis is self-evident.
Prognosis.There is no tendency of this deformity to right itself, or to improve. Early and proper treatment will, if continued long enough, insure a cure in children and an improvement in adult cases; but it must be remembered that there is a decided tendency to relapse, even after operation, unless the foot is kept in an overcorrected position for a number of years.
Treatment.In young infants, treatment should be begun as early as two weeks after birth and should consist in frequent gentle massage and manipulations. After the part can be brought into an overcorrected position by gentle manipulation, it should be put up in a plaster cast, for a period of three weeks and this treatment should be continued until the position of the foot is corrected.
The manipulations consist in grasping the dorsum of the foot gently but firmly with one hand, and holding the leg with the other. The foot is then dorsally flexed and everted. This treatment should be repeated at least three times a day and should not be rough enough to cause the infant to cry.
Treatment of clubfoot in older children and adults is a much more difficult proposition and consists in the combination of two or more methods of procedure.
In order to correct the extreme adduction in these cases, extreme force must sometimes be employed. This may be accomplished by bending and bearing down on the foot, with its outer border resting on the apex of a wooden wedge.The rotation of the foot is corrected by grasping the foot in one hand, and the heel in the other, and twisting with the necessary amount of force. The inversion of the sole is also corrected by the use of this wedge as a fulcrum.
In this way the tendo Achillis and the plantar fascia are stretched, and the dorsal flexion is secured by laying the patient on the face with the knee bent and the front of the thigh resting on the table. The lower leg is then vertical, and by bearing down on the front of the foot with the necessary amount of force, dorsal flexion of the foot is secured, and by hooking the fingers around the os calcis, its position is improved.
A modified Thomas wrench may be used in the correction of clubfoot; but this must be done with great care, as the violence practised in this method, the tearing of the ligaments and other soft parts, is often attended with great danger; osteomyelitis, tuberculosis, neuritis, and even death from fat embolism, and extensive sloughing of the soft parts are not infrequently seen after the use of this and other bone crushing instruments.
The removal of a wedge of bone from the outer side of the foot and the removal of the neck of the astragalus are employed. Tenotomy and the transplantation of tendons are also often practised, when other methods of treatment fail.
Acquired Clubfoot.The cause of acquired clubfoot maybe infantile paralysis, joint disease, traumatism, or it may be due to affections of the brain or spinal cord.
Paralysis.Infantile paralysis affecting the muscles of the front and outer side of the lower leg, will result in a condition similar to congenital clubfoot. Other paralytic causes are: spastic or cerebral paralysis, hereditary ataxia, etc.
Traumatic.A condition resembling clubfoot may result from improperly treated fractures of the ankle-joint or tarsal bones.
Joint Disease.In tuberculosis, arthritis deformans, and other diseases of the ankle-joint, a condition similar toclubfoot is sometimes seen as a result of muscular contraction.
Talipes Equinusis rarely congenital. It is usually due to infantile paralysis of the extensor muscles, or to cicatrical contraction of the calf muscles, as a complication of hip disease. It varies from inability to flex the ankle beyond a right angle, to walking on the heads of the metatarsal bones. The astragalus is partially displaced forward and forms a prominence on the dorsum of the foot; the plantar fascia is shortened and callosities and bursae are formed under the heads of the metatarsal bones. Primarily, the obstacle to reduction is the tense Achilles tendon, and in advanced cases the shortened plantar fascia and posterior ligament of the ankle-joint constitute obstacles.
Talipes Equino-Varis(down and in foot) is the most common form of this deformity.
It is either congenital or acquired, and in the latter case it is due to infantile paralysis of the extensor and peroneal muscles. The heel is drawn up, and the anterior half of the font is drawn inwards and inverted. The inner border of the foot is shortened, and in neglected cases the patient walks on the outer side of the cuboid, under which a bursa is formed. Secondary contraction of the plantar fascia, ligaments, and short plantar muscles follows. There is a great increase in the obliquity of the neck of the astragalus in congenital cases, so that the scaphoid and anterior half of the foot, together with the dorsal tendons are carried inward. As a result of the equinus, the upper surface of the astragalus projects forward, and only its posterior portion comes in contact with the tibia and fibula. The ligaments of the inner side of the foot are shortened and the shape of the other tarsal bones is secondarily altered.
Talipes Equino-Valgus(down and out foot). This condition is rare as a congenital deformity. The anterior half of the foot is deflected outward, and the inner border comes in contact with the ground. The scaphoid is placed outward, and the head of the astragalus projects into the sole.
The acquired variety results from paralysis of the tibialis posticus and flexors, with secondary contraction of the peronei muscles.
Talipes Calcaneusis rare as a congenital deformity. It is usually the result of infantile paralysis of the muscles of the calf. The patient walks on the heel, and the anterior half of the foot is drawn up. Valgus or varus are associated with it; the more common form is talipes calcaneo-valgus.
Talipes Cavus(Pes Cavus), or hollow foot, is a condition in which the arch of the foot is greatly exaggerated. It is rarely congenital but is frequently seen in connection with clubfoot, especially in its paralytic forms. In its mildest form, it exists in a highly arched foot, often hereditary. It may also be the result of too short shoes (Chinese ladies’ foot).
Treatment.The condition is best remedied by division of the contracted soft parts, a forcible reduction of the bones, held in place by plaster of Paris. When the patient begins to walk, it is advisable to have a stiff, flat, steel plate placed in the length of the shoe between the layers of the leather sole, running from which, over the dorsum of the foot, is a stout leather strap. At each step, downward pressure is thus exerted on the dorsum of the foot.
Hyperemiaas a therapeutic agent was described by Bier and is of two kinds,activeandpassive. The former is the same as thearterial, while the latter is thevenous. Between the blood of active and passive hyperemia there are important physical and chemical differences, the one containing much free oxygen with but little carbonic acid and alkali, while the other presents the exactly opposite character.
In active hyperemia normal elements of the blood are kept in active motion, while in the passive form they are allowed to escape, more or less, into the tissues.
Hyperemia possesses a great many properties:
1. Power to diminish pain.>2. Bactericidal action.3. Absorptive property.4. Solvent action.5. Nutritive power.6. Suppression of the infection.
1. Power to diminish pain.>2. Bactericidal action.3. Absorptive property.4. Solvent action.5. Nutritive power.6. Suppression of the infection.
1. Power to diminish pain.
2. Bactericidal action.
3. Absorptive property.
4. Solvent action.
5. Nutritive power.
6. Suppression of the infection.
Hyperemia may be produced in three ways;first, by means of the elastic bandage or band;second, by cupping glasses, andthird, by hot air. The first two produce venous or passive hyperemia, and the third, arterial or active hyperemia.
Passive Hyperemia.This obstructive hyperemia is produced by means of a thin, soft rubber elastic bandage, two or three inches in width, better known as the Esmarch, or Martin bandage. When this is applied moderately tight around a limb about six or eight turns, one layer overlapping the other, pressure is evenly distributed over a comparatively wide area, causing the subcutaneous veins below the constriction to swell; the extremity becomes somewhat bluish red in color, also larger and edematous, giving a feeling of warmth to the touch.
The rubber bandage, properly applied, should not cause any uncomfortable feeling and there should be absolutely no pain present. At all times one must be able to feel the pulse below the site of the bandage. If the bandage is applied too tight, the skin of the limb looks grayish-blue and there appear whitish, or vermilion colored spots, which grow larger and larger, as long as the too tightly drawn bandage is on. Paresthesia and pain, with disappearance of the pulse, can also be noted.
The two cardinal rules to be observed in the application of the bandage are: (1) absolutely no pain with the application of the bandage; (2) the pulse at all times must be felt below the bandage.
In cases which require the bandage to remain in place from sixteen to twenty hours each day, it will be necessary to first apply a soft flannel bandage underneath the rubber one in order to prevent pressure necrosis.
Frequently changing the location of the bandage up and down the extremity, and treating the skin with alcohol rubs, will also be helpful to patients with a tender skin. The elastic bandage must always be placed upon a healthy area, proximal to the diseased part. All dressings should be removed while the compressing bandage is on, in order that the part may become hyperemic.
Wounds or sinuses are covered with sterile gauze and kept in place with a towel, fastened with a few safety pins.
In acute inflammation, septic wounds and phlegmons,the increased inflammation is apt to frighten the beginner, but this is a desired phase of the treatment.
As a prophylatic against infection, it cleanses the wound, produces a local immunization and reaction before the infection has a chance to work; the earlier the bandage is applied the more remarkable is the effect.
For incised wounds of the foot with division of the muscles and tendons, if the tissues are not too seriously injured, the muscles and tendons should be united and the skin closed with interrupted sutures sufficiently far apart to allow free excretion. No drainage is employed and a slight compressing dressing is applied. The elastic bandage is applied very lightly, producing only a slight venous engorgement and the bandage should remain on from ten to eighteen hours a day.
As soon us the symptoms of acute inflammation subside, the time of application of the bandage is reduced. If signs of suppuration are present, the wound should be promptly opened and the pus evacuated. The knife takes care of the pus; hyperemic treatment fights the infection.
In gonorrhoeal arthritis of acute or chronic nature, and in cases of tuberculosis of the bones and joints, the passive form of hyperemia is especially indicated.
The use of cupping glasses is limited to abscesses, furuncles and sinuses.
Active Hyperemia, or arterial hyperemia, is produced by means of hot-air boxes such as the Tyrnauer electric apparatus, or the gas apparatus of Betz.
Active hyperemia increases the arterial blood to any part of the body, thus favoring the absorption of chronic exudates, infiltrates, adhesions, etc. Dry, hot air permits the use of a high degree of temperature without injury or pain to the respective part.
For neuritis of the foot, ulcers, especially diabetic, perforating and varicose, and for the stiffness following a chronic inflammation, or after a fracture, the arterial form of hyperemia gives good results.
Cold, or the rapid abstraction of heat, is a remedial measure that is nearly always available and is possessed of very great power for good in selected cases.
When cold is applied for its limited and local action, it is always used with two objects in view, namely, (1) to cause localized contraction of the blood vessels, which through inflammation are engorged, so that the parts are swollen and reddened; or (2) temporarily to anesthetize or benumb the nerve terminals, for the immediate relief of pain, in the hope that the temporary paralysis may ultimately result in such changes as to produce a cure.
Cold, in some form, is a popular remedy for a sprain, or any injury likely to be followed by inflammatory processes. A very useful remedy for the sprain of an ankle, when it is a recent accident, is to let the patient sit with the foot elevated, with a cloth wrung out in ice water, and an ice bag applied over the affected part.
In the treatment of localized pain or inflammation, cold is used in a number of ways, largely depending upon the will of the physician and the means of the patient. The simplest, cheapest, and perhaps the best method of using cold, is to place cracked ice in a rubber bag, the latter to be thoroughly watertight, lay it over the inflamed part, surrounding it with a towel so as to prevent the moisture, which appears on the surface from condensation, from wetting the clothing.
Heatis used locally for a number of purposes in the same manner as cold, and the choice of heat or cold in the treatment of any acute form of inflammation depends almost entirely upon the wish of the patient, who generally can tell at once which will give him the greater comfort.
In sprains of the ankle, nothing compares to a hot foot-bath prolonged for hours, the object being to decrease the pain and swelling, thereby regaining the use of the limb.
The high degree of heat which can be borne by gradually increasing the temperature of the water by the addition of small quantities of scalding water, is extraordinary, and the favorable results obtained are in direct ratio to the height of the temperature.
Between these soakings, the part should be dressed with lead and opium wash, and rubbed with ichthyol ointment or camphor liniment.
Hot-water bottles or bags are also used locally for the relief of congestion and pain.
The Violet Ray or High Frequency Currentis one which is in a rapid state of to-and-fro vibration and is applied through vacuum glass attachments or electrodes, which are excited to a beautiful violet color. The discharge may appear to the eye to be a single spark, but it is made up of a number of successive sparks, following each other with such extreme rapidity that they are said to oscillate (change directions) millions of times per second, a speed that the eye cannot note. The rapid oscillations have the effect of producing the following phenomena:
1. the high frequency current is unipolar, that is, does not require a complete circuit.2. glass does not insulate the high frequency current as it does ordinary electricity.3. the high frequency current generates enormous quantities of ozone during its flow.4. the current does not produce any pain.5. the high frequency current produces a cellular massage.
1. the high frequency current is unipolar, that is, does not require a complete circuit.
2. glass does not insulate the high frequency current as it does ordinary electricity.
3. the high frequency current generates enormous quantities of ozone during its flow.
4. the current does not produce any pain.
5. the high frequency current produces a cellular massage.
The contractile effect is expended upon the individual cells making up the tissues, instead of on individual muscles.
If a sedative effect is desired, keep the electrode in contact with the part; if a stimulating effect is desired,hold the electrode away from the surface; the farther away, the longer the spark.
A uniform spark of any length can be produced by administering the current through layers of toweling, or through the clothing; the length of the spark depends upon the thickness of the layers.
The use of the high frequency current in surgery is limited to sprains, stiff joints, neuritic pains, and adhesions due to inflammatory exudates. Fulguration for the destruction of growths is obtained by employing a pointed metal electrode.
Rubefacients.These are agents which revulse by causing congestion of the skin:
1.Turpentine.A few teaspoonfuls of oil of turpentine sprinkled over a piece of flannel wrung out of hot water, applied to the skin and covered with oiled silk or dry flannel, constitutes the turpentine stupe. Twenty minutes is the maximum for this application.
2.Mustard.Mustard flour (the black being the stronger), mixed with tepid water into a paste, spread thinly on a piece of muslin or paper, and covered with gauze or thin cambric, is an excellent counterirritant. Few skins will bear pure black mustard for more than ten minutes. Mustard, diluted one-half with wheat or corn flour, and allowed to stand for twenty minutes, should be the maximum strength for application, because blistering must be avoided, that produced by mustard being specially painful. After removing a mustard plaster, greased lint should be applied.
3.Mustard Foot-Bath.A mustard foot-bath consists of one or two tablespoonfuls of pure mustard in a bucket two-thirds full of water at 105°F; the feet may be kept in this for about twenty minutes, a blanket being thrown around the limbs, and including the bucket, to retain the heat.
Revulsives must be used with caution in cases of shockor coma, lest impaired vitality or sensation to pain result in extensive sloughing of the skin.
The Actual Cauteryis used in the form of variously shaped irons, hatchet-edged, round, or olivary, fitted into wooden handles, and heated in a charcoal furnace.
As a counterirritant, the iron should be heated only to a dull red heat, and should be quickly drawn in parallel lines, about one inch apart, over the skin, avoiding all bony prominences. Compresses wet with cold water, or with some antiseptic lotion, may then be applied.
The Paquellin Thermo-Cauteryis a convenient form. It consists of hollow platinum cauteries and a handle covered with wood; a benzole reservoir; a pair of rubber bulbs, like those for a hand-spray apparatus, connected by a tube with the reservoir; a long rubber tube to connect the cautery handle also with the reservoir; and a spirit-lamp with attached blow-pipe.
Screwing on the desired point, the tube from the reservoir is slipped over the handle; the point is heated in the lamp; is removed from the flame; and, compressing the bulbs, which should previously have been connected with the reservoir, benzole vapor is forced into the point, which will heat up, and can be maintained at any temperature by the rapidity with which the bulb is worked. If the point will not heat with the simple flame, attach the bulbs to the blow-pipe on the lamp, and, compressing them, heat the cautery to a bright-red heat, and then connect with the reservoir and proceed as before directed.
Galvano-Cautery.This requires a battery of a few large elements closely coupled, and various curets, knives, and ecraseurs fitting into insulated handles. The chief advantage of this form of cautery is the possibility of placing the instrument in position while cold, and then heating it.
Where hemorrhage is undesirable, a dull-red heat should be maintained, for at a white heat the tissues are divided asif with a knife, and bleeding follows. When the ecraseur is used, needles must be passed at right angles through the healthy tissues, the platinum wire placed behind these, and the wire, at a dull-red heat, slowly tightened.
Electricity.This is used in the form of theinduced current(Faradism) to exercise and improve the nutrition of muscles, and in the form of theconstant current(galvanism) along the course of nerve-trunks, to excite their conducting power, or to act as a sedative in neuralgias.
The same current is used to induce chemical decomposition (electrolysis) or to cauterize and destroy tissue by heating an encircling wire or by a galvanic knife. Franklinic, or static electricity, is also occasionally used.
Electrolysis.For electrolysis a galvanic battery of thirty or more medium-sized cells is required, with needle electrodes insulated, except near their points.
To destroy a verruca, introduce into it two needles, a short distance apart, each connected with a pole of the battery; then, commencing with a weak current, this must be cautiously increased, the sitting lasting from a half hour to one hour, after which the needles are to be removed and the punctures sealed by collodion.
Massage.This is employed to stimulate the circulation in the part mechanically; to loosen tissues bound down by adhesions; to diffuse inflammatory exudates over a wider area, thus favoring their absorption; and to change the rate of the circulation to a point compatible with rapid absorption and normal nutrition.
Four distinct varieties of manipulation are found to be most generally useful:
1. rubbing, or stroking2. kneading3. tapping, or percussion.4. passive and active moments.
1. rubbing, or stroking2. kneading3. tapping, or percussion.4. passive and active moments.
1. rubbing, or stroking
2. kneading
3. tapping, or percussion.
4. passive and active moments.
Strokingconsists in gentle rubbing directed from the periphery upward, commencing the process above the inflamed part and continuing it over the diseased area; the pressure, at first light but finally firmer, will force the exudates into the tissues above, which have been emptied by the preparatory rubbing.
Kneadingmeans rubbing the part circularly with the pulps of the fingers and the thumb or the palm of the hand, and is best combined with pinching up of the skin or muscles singly or together, and gently rolling them between the fingers and palms.
Percussionis effected by tapping the surface over the diseased part with the tips of all the fingers held on a level, or with the ulnar side of the hands, or, after covering the part with a towel, three parallel pieces of stiff rubber tubing, fixed in a handle (a muscle beater), may be employed, gently striking the part transversely to its long axis.
Passive movementsshould be made at the close of each sitting if a joint is concerned.
Massage is sometimes advisable twice daily, but often once a day or every other day is better; each sitting may last from fifteen minutes to one hour.
X-Ray Examination.This method of examination depends on the property of penetration of matter possessed by a radiation from an electrically excited Crookes’ tube. This radiation has been proved to lie outside the spectrum, and has been named X-ray.
It may, for purposes other than those required by the expert, be looked upon as a source of light which has the property of penetrating the tissues to a greater or less extent according to their density, and the shadows cast by it can be recorded on a photographic plate, or may be viewed with the naked eye by means of a screen composed of a thin layer of barium platinocyanide, a substance which becomes highly fluorescent in the presence of this radiation.
One or the other of these methods is used for the recognition of pathologic conditions existing in the human tissues.
The fluorescent screen appears at first sight to be an easy way of recognizing abnormalities. Its value in the examination of the thorax, where the movements of the heart, lungs, and diaphragm have to be observed, is undoubtedly very great; but as an accurate means of recognizing any abnormality, it is untrustworthy. For instance, it is possible to fail to recognize simple transverse fracture of the tibia by its means. Its use is therefore to be deprecated in cases where great accuracy is necessary, and it is safer and better to make use of the more certain method, the photographic plate.
A further objection to the use of the screen is that the constant exposure of the hands and other parts of the body of the observer may result in an intractable, dangerous and chronic dermatitis.
By using a photographic plate the danger of dermatitis can be avoided, since it is not necessary to expose the hands at all; and at the same time greater accuracy is ensured and a permanent record is obtained.
Although examination by radiography is a somewhat tedious procedure in comparison with direct observation by the fluorescent screen, yet it is less difficult if the photographic side of this method is approached in a proper and businesslike manner.
Interpretation of Radiograms.A successful result in X-ray examination involves a clear understanding of the meaning of the radiogram produced. Even with the most accurate knowledge of anatomy, it is difficult to interpret X-ray shadows; for a radiogram is only a shadow, and the outline of the part thus demonstrated is liable to great variation. For example, in the case of injury to bone, it is always possible to secure strong and accurate X-ray shadows of the part, and no error ought to be made in diagnosis, yet errors of this kind are not uncommon.
To avoid such mistakes, it is imperative that the qualityof the radiogram secured should be the best possible. For instance, in the examination of the ankle-joint and the bones of the foot, a radiogram which is flat, indistinct, and altogether wanting in detail, is of no value, while a radiogram of good quality of the same ankle-joint and foot, is of value. The interpretation of the latter is easy, while that of the former would be almost impossible, and certainly inaccurate.
The usual practice in securing radiograms is to place the subject in a position considered likely to give the best results, and then roughly, almost at random, to place the tube in some unknown relation to the part of the body under examination. The resulting shadow is often of no value because it is wanting in detail and depth. One method of avoiding this fault is to produce stereoscopic views of the part examined.
Two views having been secured in stereoscopic register, and placed in a stereoscope, the part can be viewed in relief. Theoretically, then, by this means one is able to view the parts of the body opaque to the X-rays as they would appear to the naked eye. In practice, however, this method, though it may prove of value in exceptional circumstances, is laborious. Moreover, though the parts may be made to appear in relief, they are not really as one would see them with the naked eye, but are still X-ray shadows.
A more practical method is to ensure that in all cases radiograms of any part of the body be absolutely comparable with one another by taking care to maintain the same relationship between the X-ray tube and the part under examination. For example, in making an examination of the ankle-joint, the limb is placed in a prescribed position, and the anode of the X-ray tube, that is, the actual source of the X-ray, is brought into accurate relationship to the tip of the internal malleolus by a simple mechanical contrivance, the details of which need not be dealt with here. This relationship between the tube and the ankle can always be reproduced, and therefore the shadow of a normal ankle-joint can always be obtained under the same conditions for comparison with the radiogram of the suspected ankle.
In this way, not only is the surgeon able to select the view of the part which will have the depth and detail necessary for proper interpretation, but, the shadow being familiar, he can more easily recognize any abnormality.
A radiogram secured under the conditions usually adopted, shows definite and known anatomic relationship between the bones and the X-ray tube, namely, with the anode of the tube directly opposite the tip of the internal malleolus.
To render this method of examination more perfect, there has been devised a system of radiography containing a definition of the relationships between the tube and the various parts of the body which have been found to give the most useful views, and also radiograms of the normal appearances of each part at the ages respectively of 5, 15, and 25 years.
By using this system the surgeon can secure a radiogram of any part of the body, of the requisite standard in quality, while he has at hand a normal radiogram of that part for comparison with the abnormal.
Having secured a radiogram of good quality, it is necessary for the purpose of interpretation that it should be viewed in a suitable light. The best for the purpose is a bright light shaded with opal in a dark room. The negative may be viewed at its best while still wet. Considerable loss of detail follows the taking of prints, which for this reason may greatly detract from the value of the radiogram.
It is a mistake to suppose that X-ray examination in the diagnosis of diseases can replace the older and well-tried clinical methods of investigation; it is merely a useful means of acquiring knowledge which, in conjunction with accurate clinical investigation, leads to a more accurate diagnosis and prognosis, and is often most useful by suggesting a more suitable line of treatment. It must be remembered that this method of investigation has been in use only a comparatively short time. In some diseases no definite statement is yet possible that may not prove in the future to be misleading.
At present the therapeutic use of the X-ray is rightly falling into the hands of the dermatologist and the medical clinician. In surgery, outside of the conditions mentioned above, its use is limited to lupus, keloid, epithelioma, sarcoma and carcinoma, both before and after operation.
Dressings.These may be either dry or wet.
Dry dressingsconsist of gauze and bandage or of cotton and collodion (the cocoon dressing.)
The most convenient form in which sterile gauze can be obtained is in small squares in individual envelopes. Large packages are contaminated with the first opening and are inconvenient.
The cocoon dressing is occlusive and should never be applied over an infected area. It is applicable to sensitive areas for protection, and to operated areas not liable to infection.
Protective varnishes, such as collodion, compound tincture of benzoin, or pure ichthyol, are useful where little protection is indicated.
Wet dressings.Two distinct therapeutic actions may be derived from the wet compress, depending upon whether or not an impervious covering is employed. These actions areantiphlogisticandhyperemic, and these in turn may be eitherantisepticorastringent. The wet dressing, without a covering, is cleansing and heat reducing, because of evaporation. There should be frequent replenishment of the solution in the treatment of any infected wound or where it is desirable to reduce inflammation.
A wet dressing with an impervious covering is contraindicated in the presence of pus, the warmth and moisture of such a dressing being congenial to the growth and to the multiplication of bacteria.
It is evident, therefore, that a wet dressing with an impervious covering can safely be employed only in conditions where the skin is unbroken, such as sprains and bruises.
The two general therapeutic actions, aside from those of causing hyperemia, are antiseptic and astringent. For the relief of pain and for the reduction of inflammation, wet dressings are the most effective form of treatment because (1) they are aseptic; (2) they permit free drainage; (3) no new granulations are disturbed in changing the dressing.
A great many different solutions are used and among these are: