The inflammatory products may poison the system in two ways: (1) by the diffusion of their chemical substances, (toxins and ptomains), or (2) by the passage of bacteria themselves into the blood.
Termination.Inflammation may result in resolution, suppuration, necrosis or sloughing, or in the establishment of a chronic state.
Resolution.Resolution is the termination of an inflammation by the gradual cessation of all the changes which have occurred. The pain subsides, the circulation becomes more normal, and the exudate is absorbed, or makes itsway to the free surface of the body, where drainage occurs either spontaneously or by incision.
If there has been any loss of substance caused by the inflammation, it is restored by processes exactly similar in character to those in the repair of wounds.
Suppuration.Pus consists of a serum containing little or no fibrin and large numbers of leucocytes. There are also many cells, either dead or dying, which represent the waste thrown off from the tissues as a result of the inflammatory reaction. A purulent inflammation or suppurative inflammation, is one in which there is pus formation.
When suppuration occurs, the pus may make its way to a free surface, such as a mucous membrane, or may form an abscess, or may cause sloughing of the skin over the seat of inflammation, and so escape from the cellular spaces in the tissues.
Pus may be thrown off by a mucous membrane, without any actual breach of continuity. Diffuse infiltration of the tissues is the most dangerous form of suppuration.
In this variety of inflammation the exudate is brought into contact with the greatest possible extent of absorbent vessels, for as a surface of a sponge is greater than that of a bag, which would contain it, so the surface of these intercellular spaces is much greater than that of an abscess cavity filled by the same amount of pus. In this form the bands of cellular tissue, lying between and forming the boundaries of these spaces, remain intact, and the exudate is either absorbed into the circulation, or seeks escape through many punctate openings in the skin.
The entire skin of the part is frequently detached from the fascia by the sloughing of the subcutaneous tissues, before it gives way, and even when it finally yields to the necrotic process, the openings formed will be altogether too small in proportion to the extent of the disease beneath, so that healing is still further delayed.
Sloughing.Inflammation may be accompanied by sloughing or death of tissues. Gangrene, mortification ornecrosis is a death of the tissue from any cause. The part which has died is designated as aslough.
When inflammation has subsided, granulation tissue forms on the living tissue, exerting pressure upon the slough, thus hastening its absorption or separation.
Chronic Inflammation.An interruption at some stage of resolution or suppuration and the continuance of mild symptoms constitutes a chronic state.
By chronic inflammation, we understand a long continuance of some or all of the changes seen in acute inflammation, but less in intensity, and an abnormal tendency to the production of new tissue.
Treatment.The general indications to be observed in the treatment of inflammation are: (1) to combat the congestion of the parts; (2) to relieve tension; (3) to give free issue to the products of inflammation; (4) to produce early separation of sloughs.
Very hot or very cold applications exert a beneficial and soothing effect upon inflamed areas.
Cold has the tendency to reduce tension by constricting the blood vessels thus diminishing the amount of blood supplied. In an infected area the reproduction and development of bacteria are checked, and suppuration is frequently aborted.
Heat has the effect of dilating the blood vessels and hastens repair in bruised, strained, or torn tissues. This is a variety of hyperemia treatment which is especially useful in the absence of bacteria. In infected areas the growth of bacteria, and increased pus formation, would be encouraged and heat is contraindicated.
We are yet without an antiseptic material which can be used in sufficient strength to affect the growth of germs and yet not injure the patient. Injury of the part treated, and absorption into the circulation are both to be avoided. The application of dressings, wet with corrosive sublimate, or other chemical solutions to the unbroken skin over inflamed areas, is a fallacy. Any benefit which has been observed to follow their use, has undoubtedly been due to theeffect of the moisture and warmth or cold, according to the temperature of the dressing, thus obtained, while local sloughing and general constitutional poisoning are a common result of such applications. A light gauze dressing, applied cold, and kept constantly wet with any evaporating solution, will greatly relieve the congestion and so assist the inflamed tissues in their contest with any irritating materials.
A thick wet dressing made with a hot solution, and well protected against evaporation so that it will retain its heat, will produce the same effect as a poultice, although less powerful. When there are discharging wounds or raw surfaces, unprotected wet gauze should be employed, for poultices are then inadmissible, and the weak antiseptic solution will inactivate and wash away bacteria.
Astringent solutions have an excellent effect upon inflammatory processes and the most generally useful of these is the 50 per cent. solution of acetate of aluminium.
The following is a modified Burow’s solution:
Filter after mixture has been allowed to stand for 24 hours.
Ointments are employed by many in the treatment of small areas of inflammation; they are useful, though not as efficient as hot or cold wet dressings. Over the unbroken skin, they can only act like a poultice and should not be employed where infection exists. On clean wounds they are unnecessary, but upon ulcers or wounds which show no tendency to heal, such ointments as Peruvian balsam, 5 per cent., or scarlet red, 4 per cent., are extremely valuable.
Regeneration of Tissues.The reparative powers of the tissues of the human body are considerable, although not comparable with those of the lower animals, in thelowest orders of which the reproduction of an entire limb, or even one-half of the body, may take place. In order to understand the regeneration of tissue, we must first consider briefly the life history of the cells.
A cell consists of a mass of protoplasm, generally enclosed in a cell membrane, and containing a nucleus and nucleolus. The nucleus represents the most vital part of the cell protoplasm, and has a more granular appearance than the latter. The nucleolus is a minute solid spot in a nucleus, appearing to be more highly refractive.
Cell Division.When the cell is quiescent, the protoplasm appears evenly granular, but when it is stirred to active life, slender twining threads can be traced in the nucleus, perhaps consisting of one long thread twisted upon itself.
On account of their readiness to take up dyes used in staining, these threads are calledchromatine threads.
When the cells are about to divide, the chromatine threads are seen to arrange themselves in a line across the center, called theequatorof the nucleus, forming a rosette or star shape, known as themother star. Some large granules then appear in the nucleus at points on either side of this line, which are known as thepolesof the nucleus. The loops of the thread are directed towards the poles. Gradually these threads become arranged in radiating lines, converging at the poles, and then break away from their former connections with the equator, forming adaughter starat each pole, a clear space appearing at the equator. A constriction next appears in the now clear equator, and the nucleus divides into two distinct nuclei. Simultaneously with this division, or immediately following it, the protoplasm of the cell body divides in the same place, and thus two complete cells are produced. The chromatine threads lose their rosette arrangement, and gradually become imperceptible as the new cell returns to the quiescent state. This process of cell division is known askaryokinesisoraryomitosis.
In simple cells like the leucocytes, reproduction maytake place by simple fission, thus: a constriction appears in the nucleus and in the body of the cell in the same line, and the two divide without any visible protoplasmic changes. Such a simple mode of division does not occur in the more highly specialized cells of various tissues. If the karyokinetic action be not very vigorous, the nucleus may divide, but the cell body remains intact, producing the cell with two or more nuclei so commonly observed. Every cell reproduces its kind, spindle cells producing connective tissue; epithelial cells epithelium; and bone cells producing bone.
Repair of Wounds and Healing by Apposition.When a wound occurs, the cut edges immediately retract on account of the elasticity of the tissues, and the gap fills with blood and serum. If no bacterial or chemical irritant is introduced, there are no true inflammatory changes. The divided blood vessels are soon plugged with coagulated blood, which extends into the cut vessels to the nearest branch. The capillaries around the seat of injury dilate slightly, the fixed cells of the tissues become active, dividing by karyokinesis as already described. The endothelial cells lining the divided blood vessels multiply and take an active part in the process. In spite of the congestion and the new cells produced, the reaction is much less than that of inflammation. The new cells invade the blood clot, consuming it and also any foreign matter, or any tissue which may have been killed by the injury. From the loops of the occluded capillaries, at the sides of the wound, spring buds of endothelial cells, becoming thicker and then hollow as they extend, blood cells forming in them and blood entering them also from behind. These advancing endothelial tubes join with those on the opposite side of the wound, and thus the new forming tissues are supplied with blood vessels.
It is said that new vessels are also formed by the pre-existing lymph-spaces and by independent cells. Meantime the connective tissue cells have been forming fibres across the clot and epithelial cells over its surface, if skin or mucous membrane be involved in the injury. The newvessels disappear, and the new connective tissue forms the scar. This is the process of primary union in a wound in which there is not a marked cavity or a loss of tissue on any of the exposed surfaces of the body, and no matter how closely the edges of such a wound may lie in contact, it can heal by no other method. Even the closest apposition of the sides of a wound cannot prevent the interposition of a thin layer of clot and the partial death and absorption of a very thin layer on its surfaces. This is also known as primary union.
Healing by Granulation.When a wide gap has been produced by retraction or by actual loss of tissue, healing takes place by granulation, as it is called, a process which differs from that just described merely in the fact that more tissue must be reproduced. The outpouring of blood and serum, occlusion of the vessels, congestion, multiplication of fixed cells, emigration of leucocytes, and production of vascular loops and buds, goes on as before. As the formative changes advance, small, round elevations of a rosy color appear on the new surface, making it look like velvet. These rounded elevations of the healing surface are called granulations.
They advance steadily on all sides, filling the gaping wound until the level of the original surface is reached, the new tissue organizing behind them, and contracting as it organizes, so that the space to be filled is daily made smaller by this contraction as well as by the production of new tissue. As the surface is reached, the epithelial cells on the edges of the granulating area slowly spread over it, the granulations generally projecting above the adjoining surface and the epithelium growing over them as they contract again to their proper level. The advancing line of epidermis is visible as a pink line, gradually whitening with time.
A wound is a solution of continuity or division of the soft tissues produced by cutting, tearing, or compressing force. The classification of wounds according to their causation or nature is as follows:
Incised—when resulting from a sharped-edged instrument.Lacerated—when tissues are extensively torn or separated.Contused—when resulting from a more diffused force, tearing and bruising the tissues.Punctured—when produced by a narrow instrument that causes a wound deeper than its external surface is broad.Poisoned—when some poisonous substance enters the wound and causes local infection or constitutional disturbance.Gunshot—when the injury results from firearms or powder explosion.
Incised—when resulting from a sharped-edged instrument.
Lacerated—when tissues are extensively torn or separated.
Contused—when resulting from a more diffused force, tearing and bruising the tissues.
Punctured—when produced by a narrow instrument that causes a wound deeper than its external surface is broad.
Poisoned—when some poisonous substance enters the wound and causes local infection or constitutional disturbance.
Gunshot—when the injury results from firearms or powder explosion.
An Incised Woundis an injury which is produced by some sharp instrument such as a knife, pieces of glass or metal, which divides the tissues cleanly, producing no bruising or tearing. The pain is usually sharp and burning, varying with the nature of the instrument with which the injury has been inflicted. Hemorrhage is usually free.
Lacerated Wounds.These usually result from machineryaccidents or from heavy bodies passing over the parts and are apt to contain a considerable quantity of foreign matter ground into the tissues.
Contused Wounds.A contused wound is one in which the edges and surrounding tissues are bruised or crushed. External bleeding as a rule is not excessive, although there is a great likelihood of extensive subcutaneous hemorrhage. Sloughing and gangrene may occur.
Punctured Wounds.The character of a punctured wound depends upon the object producing it. If made by sharp instruments, such as knives, swords, daggers, bayonets, or needles, their nature is similar to incised wounds.
Unless organs of importance have been wounded, or unless active septic material has been carried into the wound, healing promptly follows after the withdrawal of the instrument which has caused the wound. These wounds are usually deep when affecting the dorsal aspect of the foot, being commonly caused by a falling instrument or tool. In the plantar region they are of every degree of severity, from the most minute puncture to perforation running between interosseus spaces and passing through the dorsal skin. The most frequent punctures are those caused by stepping upon needles, pins and tacks. These wounds are, commonly, of no importance unless the foreign body is broken off or entirely penetrates the foot.
If the patient is seen a very short time after this has occurred, the surgeon may operate with some confidence of finding the offending substance, but even here, if possible, it is an advantage to obtain an X-ray picture, while in those cases in which a needle has long been buried in the tissues, this is quite indispensable. It is well to remember that in these cases the patients’ impressions us to the location of the needles are most unreliable.
After a radiograph has been obtained, it is most important, if anatomically possible, to make the incision at right angles to the shaft of the needle. At least two pictures should be taken in order, if possible, to obtain some idea of the depth at which the needle lies. Even with allthese helps, the procedure, simple though it may at first appear, oftens turns out to be one of great difficulty, necessitating a very extensive operation.
Incised Wounds of the Foot.Incised wounds of the dorsal surface are very frequently quite deep and often implicate the tendons, bones and articulations, as they are most frequently inflicted by the fall of some heavy tool upon the part, or by the inaccurate blow of an axe. Wounds of slight importance need but the usual thorough cleansing out, with or without suturing of the skin, according to the extent of the incision.
If one or more of the tendons have been severed, the ends should be approximated by catgut sutures. If extensor tendons are cut in the neighborhood of the metatarsophalangeal joints, it is often necessary, owing to considerable retraction of the distal end, to incise the skin down as far as is needed, in order to secure the retracted end and suture it. Failure to adopt this procedure permits a dropping of the toe, converting it often into a regular hammertoe. When the tendon is properly sutured, the toe must be placed for some days in a condition of over extension, most easily secured by a bandage passed under it, acting like a stirrup, the ends being fastened by several turns above the ankle.
Incisions, implicating joints, are carefully cleansed by flushing the joint with copious quantities of saline solution, and closing the wound with very few stitches. Such injuries should be examined daily and any sign of sepsis must be considered as an indication for immediate removal of the stitches, followed by active antiseptic wet dressings.
Cuts of the plantar surface are not often very extensive. They are most frequently incurred in stepping upon some sharp instrument or walking upon glass, especially while bathing.
Contusions.A contusion or bruise is a subcutaneous laceration, the skin above it being uninjured, as in the abdomen; or being damaged without a surface breach, as in apart overlying bone, and blood being effused. If a large vessel is damaged, hemorrhage is extensive.
Anecchymosis(black and blue area) is diffuse subcutaneous hemorrhage.
Ahematomais a blood tumor or a circumscribed hemorrhage in the tissues.
In a diffuse hemorrhage the coagulation of fibrin induces induration, the serum and leukocytes are absorbed, the red blood cells disintegrate, and the coloring matter is widely diffused by the tissue fluids, and hemoglobin is changed into hematoidin which crystallizes. In union with these chemical changes, color changes ensue, the part being at first red and then becoming purple, black, green, lemon and citron. The stain following a contusion is most marked in the most dependent area.
A hematoma acts as an irritant, inflammation ensues around it and it is encapsuled by embryonic tissue, which, by organizing into fibrous tissue, forms a blood cyst and gradually absorbs the fluid blood, the cysts contents becoming thicker and thicker. A fibrous scar may remain, and a blood clot, with very much indurated surrounding tissue, giving a hard edge, is noticed after bruises of the periosteum. If serum is not absorbed, hematoidin forms and the fluid becomes clear. A hematoma may suppurate, an abscess forming, but this rarely happens except in drunkards, although it occasionally occurs in persons who do not use alcohol.
Symptoms.The symptoms are tenderness, swelling, pain, and numbness. The pain may be severe, but rarely persists beyond the first twenty-four hours. Discoloration appears quickly in superficial contusions, but only after days, in deeper ones. Shock and loss of function are present only after severe contusions. The swelling is first due to blood and is soon added to by inflammatory exudation.
Terminations of Contusions.Slight contusions terminate promptly by resolution; the more severe may terminate in gangrene, inflammation, abscess, fibroid thickening, hypertrophy of the tissues involved, (as in the case of bone),chronic inflammations, and even malignant growths, particularly sarcomata.
Prognosis.The prognosis of contusions is a matter of every day importance, and it is sometimes extremely difficult to prognosticate accurately. The determining forces are principally the nature and violence of the contusing force, the tissues and organs involved, and the general condition of the patient. Even the injury of the tissues that may be easily inspected, such as the skin, may be much more severe than is apparent. In tissues of low vitality, such as synovial membrane, cartilage and ligaments of a joint, repair is proportionately delayed, whereas in highly vascular tissue it is more rapid. Contusions of tissues that cannot be given physiologic rest, such as the thoracic wall, and the respiratory muscles, respond less promptly to treatment.
The general condition of the patient is an important factor in the prognosis, the most favorable being vigorous adult life without organic disease. Among the unfavorable general states are, the extremities of life, the very anemic and the plethoric, the tuberculous, the syphilitic, the diabetic, and like diatheses, while in the rheumatic and the gouty, the slightest injury may be most persistent. The starved, the overfed, the over-worked, the fatigued, the alcoholic, and those exposed to extremes of heat and cold, are unfavorably affected.
Treatment.Slight bruises, favorably located, require no treatment. The arrest of hemorrhage, thereby diminishing the swelling, pain, and discoloration, is important. If the hemorrhage be from small vessels, elevation, rest, and the application of ice are sufficient. Frequently the application of pressure is indicated. Hemorrhage in deeper parts, such as that occurring under the fascia of the thigh, is sometimes best controlled by adhesive strapping. If the vessels are large and the hemorrhage is rapid, it is sometimes necessary to make a free incision and apply a ligature. Evaporating lotions or elastic pressure by bandaging over absorbent cotton, may assist. If the hemorrhage be in ajoint causing immediate swelling, painful from distension, prompt aspiration will give relief. This should only be resorted to under the strictest aseptic precautions, as the conditions are favorable for microbic growth. If the soft parts are so severely contused as to jeopardize the nutrition, both bandaging and ice should be withheld, and in some instances even warm applications are advised. After the acute symptoms have passed, judicious massage may be most helpful in securing early resolution. Restoration of the vasomotor tone when impaired or lost may be greatly facilitated by douching with cold and hot water alternately followed by massage. During the acute stages, physiologic rest is important; the restoration of functional use in severe cases must be tentative, guided by the response of the tissue in the form of increased pain or swelling. These phenomena should be avoided if possible. If hematomata be not absorbed they should be aspirated and pressure applied before structural changes take place, such as the formation of a membrane. If the latter occurs and sufficient time has elapsed for the formation of definite new tissue, aspiration may be followed by the obliteration of the sac. Sometimes hematomata become so thoroughly and firmly organized and gradually increase in size, that it is extremely difficult to differentiate them from new growths. If pain and tenderness persist for a long time, particularly, if there be a predisposition to tuberculosis, especial care is necessary.
Treatment of Wounds in General.Arrest hemorrhage, bring about reaction, remove foreign bodies, asepticize, drain, coaptate the edges and dress, secure rest to the part and combat inflammation.
Constitutionally, allay pain, secure sleep, keep up the nutrition and treat inflammatory conditions.
Arrest of Hemorrhage.To arrest hemorrhage the bleeding point must be controlled by digital pressure until ready to be grasped with forceps; it is then caught up and tied with catgut or aseptic silk. Slight hemorrhage stops spontaneously on exposure to air, and moderate hemorrhage ceases after the vessels are clamped for a time;an injured vessel of some size must be ligated, even if it has ceased to bleed.
Capillary bleeding is checked by hot water compresses. In bringing about reaction from shock, raise the feet and lower the head, unless this position causes cyanosis. At least place the head flat and the body recumbent. Apply hot water bottles and hot blankets and give hypodermic injections of ether, brandy, strychnine, digitalis or atropin, or inhalations of amyl nitrate. Strychnine can be used in large doses, one-thirtieth of a grain may be given every ten or fifteen minutes, until three doses have been taken. If the skin is very moist, atropin is indicated, alone or combined with strychnine. Hot coffee, or other hot fluids, should be given by the mouth and rectum, and mustard should be placed over the heart, spine and shins. The use of hot and stimulating rectal enemata is very important. The rectum may absorb when the stomach refuses to do so. Enemata of hot normal saline solution are very beneficial.
Enteroclysis.The tube is carried into the sigmoid flexure and the injection is introduced so as to distend the colon. At times it may be necessary to give an intravenous injection of saline solution in order to overcome the shock. In order to prevent the suppression of urine, it may be necessary to administer diuretics.
Removal of Foreign Bodies.Remove with forceps, all foreign bodies visible to the eye: splinters, bits of glass, portions of clothing, dirt, etc.
In a lacerated or contused wound, portions of tissue injured beyond repair should be regarded as foreign bodies and should be removed with scissors.
Cleaning the Wound.If the surface is hairy it must be shaved before the scrubbing. An accidental wound is infected and must be well washed out with an antiseptic solution. A clean wound, made by the surgeon, need not be irrigated, in fact, irrigation with an antiseptic fluid leads to necrosis of tissues, causes a profuse flow of serum and necessitates drainage. If clots have gathered in a wound, they must be removed, as their presence will preventaccurate coaptation of the edges. In an infected wound, they are washed out with a stream of corrosive sublimate solution. In a clean wound, they are washed out with hot salt solution. If dirt is ground into a wound, as is often seen in crushes, pour sweet oil into the wound, rub it into the tissues, and scrub the wound with ethereal soap. The oil entangles the dirt and the soap and water remove both dirt and oil. After the rough cleansing, irrigate with corrosive sublimate solution. In some cases, especially in bone injuries, it is necessary to scrape the wound with a curet.
A granulating wound is treated the same as an ulcer and the treatment is discussed under that chapter.
Drainage, Closure and Dressing.Superficial wounds require no special drain, as some exudate will find exit between the stitches and the rest will be absorbed. A large or deep wound requires free drainage for at least twenty-four hours by means of a tube, strands of horse hair, silk, catgut or gauze. An infected wound must invariably be drained. Good drainage largely compensates for imperfect antisepsis. If capillary drains be employed, apply a moist dressing. Divided nerves and tendons must be sutured. Close the edges with silk sutures or silkworm gut if the wound is deep and tension inevitable. Catgut is used for superficial wounds and for those where tension is slight. The interrupted suture is, as a rule, the best. If the wound is infected, dress with antiseptic gauze; with aseptic or antiseptic gauze if it is not infected. A dry dressing absorbs wound fluids quickly and is less likely to become infected. Change the dressings in twenty-four hours or sooner if they become soaked with the discharge. After this, in an aseptic wound the dressing need not be changed for days. If pus forms, open the wound at once.
Rest and Constitutional Treatment.In planning the treatment of wounds the most careful consideration for securing physiologic rest should be had. If at or near a joint, the parts both above and below should be immobilized. In whatever part of the body, physiologic rest shouldbe secured as nearly as possible. If the wound be of the leg or foot, the patient should be in the recumbent position, with the part elevated and a splint applied. The factor of rest, next to that of cleansing and dressing, is most important. Physiologic rest means not only less pain, less reaction, but a more rapid and certain repair.
Under ordinary circumstances no special constitutional treatment is necessary beyond that of securing good hygienic surroundings, easily digested food, restricted at first, and free action of the bowels. If there is great pain, opiates may be necessary, but here, as in other surgical indications for anodynes, a minimum amount should only be given. Usually rest, elevation, and relief of tension will be of greater benefit than opiates. If there is great restlessness, a bromide may suffice; if marked insomnia, one of the ordinary hypnotics. Great restlessness, with excitement and occasional delirium, without special evidence of pain or infective process, must call attention to the possible development of delirium tremens from a relatively slight injury (such as a crushed toe or a simple fracture), as it may precipitate an attack in one who has been a steady drinker, though perhaps not an excessive one. In such cases, in addition to the ordinary therapeutic remedies, the regular administration of whiskey should be advised.
Toxemiaapplies to the diseases in which one or more poisons are present in the blood which are not necessarily of parasitic origin and production.
The word poisons is here used in a broad sense to cover any substance applied to the body, ingested, or developed within the body which causes disease. It of course includes ptomains, leukomains, toxins and sepsins.
Toxemia, according to this definition, would include the diseases due to poisons not arising from parasitic invasion of the tissues and fluids of the body, at times of vegetable and alkaloidal nature, such as strychnine or morphine; ofanimal origin, such as the toxin of snake venom, the ptomains of milk or shell fish; then again a mineral such as arsenic or lead; and lastly the leukomains arising from disturbed excretion and perverted metabolism and grouped under such terms as intestinal or uremic poisoning.
Septicemiamay be defined as an acute febrile affection, characterized by marked nervous, cutaneous and visceral manifestations, and due to the introduction into the system of bacteria and their toxins from an infected wound. It applies to diseases which present poisons in the blood that are of parasitic origin, the parasite itself being either present or absent in the blood. Septicemia, in strong contrast to the definition of toxemia, would include diseases arising from the invasion of the tissues and fluids of the body by animal or vegetable parasites or their poisonous products.
Symptoms.The onset, as a rule, is slow, beginning from 4 to 7 days after an injury, with a chill, which is followed by fever, at first moderate, but soon becoming high. The fever presents morning remissions and evening exacerbations and may occasionally show an intermission. When the remission begins, there is a copious sweat. The pulse is small, weak, very frequent, and compressible; the tongue is dry and brown with a red tip; the vomiting is frequent, and diarrhea is the rule; delirium alternates with stupor, and coma is usual before death; prostration is very great, and visceral congestion occurs; the spleen is enlarged, ecchymoses and petechiae are noted, secretions dry up, urinary secretion is scanty or is suppressed, and the wound becomes dry and brown.
Blood examination detects disintegration of red globules and marked leukocytosis. When a wound becomes septic, red lines of lymphangitis are seen about it and there is enlargement of the related lymphatic glands. No thrombi or emboli exist in septicemia. The prognosis is bad, and in some malignant cases death occurs within 24 hours.
Treatmentis the same as for septic intoxication (see“sapremia”). Antistreptococci serum can be used, but the value of this method is doubtful.
Sapremiamay be defined as an intoxication due to the absorption of dead saprophytes and their products (ptomains and toxalbumins).
Symptoms.The disease sometimes begins with a chill, followed by a marked rise in the temperature, but in most cases the latter is the first evidence of the disease. The skin becomes cold and clammy, there is marked prostration and sometimes diarrhea. When these manifestations occur while a wound is present, they are ominous, and the dangerous complications can be avoided if the dressing of the wound is renewed and perfect antiseptic precautions are taken to thoroughly remove all septic matter from its surface. The constitutional symptoms often disappear of their own accord, when the above has been done, unless the systemic intoxication has not already advanced to thwart all endeavors. There is also a diminution or suppression of the urine, and a blood examination shows leukocytosis.
Treatment.The treatment is at once to drain and asepticize the putrid area and to give large amounts of alcohol. Strychnine and digitalis are useful. Purge the patient, and favor diaphoresis, using in some cases the hot bath. Establish the action of the kidneys; allay vomiting by champagne, cracked ice, calomel, cocain or bismuth. Give liquid food every three hours. Feed on milk, milk and lime water, liquid beef, peptonoids, and other concentrated foods. Use quinine in stimulant doses. Antipyretics are useless. Watch for visceral congestion and treat it at once.
The use of saline fluid by hypodermoclysis or by venous infusion dilutes the poison and stimulates the heart, skin, and kidneys to activity.
In sapremia the blood contains the toxins and dead saprophytic organisms. In septicemia the blood contains both pyogenic toxins and multiplying pyogenic organisms. In sapremia the causative condition is putrid material lodged like a foreign body in the tissues. In septic infection the tissues themselves are suppurating, and both bacteriaand toxins are absorbed by the lymphatics. Of course, septic infection may be associated with septic intoxication or may follow it. The symptoms of sapremia depend upon the amount of intoxication.
In septic infection, or septicemia, only a small number of organisms may get into the blood, but they multiply rapidly. A drop of blood from a man with septic infection will reproduce the disease when injected into the blood of an animal; hence it is a true infective disease. The wound in such a case is often small, and is commonly punctured or lacerated.
Pyemiamay be defined as a condition in which metastatic abscesses arise as a result of the existence of pyogenic bacteria in the circulating blood, either free or contained in pus cells or thrombi.
Symptoms.The symptoms of pyemia are a febrile movement with a severe chill and a sudden marked rise in the temperature which lasts for a few hours and passes off with profuse sweating. The chills recur every other day, every day, or oftener. The general symptoms of vomiting, wasting, etc., resemble those of septicemia.
The lodgment of emboli produces symptoms whose nature depends upon the organ involved. If in the lungs, there is shortness of breath and cough, with slight physical signs.
In a suspected case of pyemia, always look for a wound, and if this does not exist, remember that the infection may arise from an osteomyelitis.
Chronic pyemia may last for months; acute pyemia may prove fatal in a few days.
Treatment.The treatment is the usual supporting one that should be employed in septic affections, and all suppurating focci must be opened and drained as soon as detected. Every branch of the irregular cavities must be opened and drained at the most dependent part, and the sinuses must be treated to prevent pocketing. Serum therapy is also indicated.
Definition.The escape of blood from the blood vessels in great or small quantities, is called hemorrhage, and may occur either spontaneously or because of injury.
Spontaneous hemorrhageoccurs in the organs and cavities of the body as a result of constitutional diseases, such as tuberculosis, syphilis, cancer, etc., in which erosion of tissue extends into vessels. It is also a result of a constitutional tendency. Persons with this, so called hemorrhagic diathesis, are known as hemophiliacs.
In hemophilia, uncontrollable bleeding may occur from trifling injuries.
Hemorrhage due to Injurymay be classified as follows:
a—arterialb—venousc—capillary
a—arterialb—venousc—capillary
a—arterial
b—venous
c—capillary
(a) Arterial hemorrhage may be recognized by rapid, spurting jets of red blood, occurring synchronous with the heart beat.
(b) Venous bleeding (from a vein) occurs as a steady even stream of dark blood, not affected by the heart beat.
(c) Capillary hemorrhage is in the form of a steady stream oozing from the raw surface of a tissue. The color is intermediary, as both arterial and venous capillaries contribute to it.
Nature’s Efforts to Control Hemorrhage.When anartery is severed, the inner and middle coats immediately retract and curl up within the lumen, partially closing up the cut end.
Blood has the property of clotting, if it comes in contact with anything but the natural endothelial lining of the vessels.
The curling in of the inner and middle coats retards the escaping stream and facilitates coagulation within the cut end of the vessel now formed by the outer coat alone. When the hemorrhage is severe, these processes are reinforced by an increased tendency to coagulate, and by a weakened heart action.
The Control of Hemorrhage.The object of treatment in every case is to check the flow of blood, and, though death from ordinary wounds is rare, yet the loss of much blood is weakening for a long time.
The principle on which we act in our efforts to permanently stop bleeding, depends on the power which the blood has of clotting, or as it is called, coagulating.
If by any means the blood can be made to “stand still” in a blood vessel at the point of injury, it will clot, thus forming a plug which prevents further escape.
In wounds involving only small veins or capillaries from which there is no distinct jet of blood (capillary hemorrhage), pressure of the thumb, a wad of sterile gauze intervening, will usually suffice in a few minutes. Gauze dipped in hot water applied to such wounds, also at times effects a stoppage of such bleeding. Often only tight bandaging is necessary.
Bleeding from large arteries or veins can be controlled temporarily by pressure directly over the wound.
Temporary control may also be obtained by digital pressure above or below the wound, if in a leg or arm, depending upon whether the escape is chiefly from a vein or an artery, for in any wound some of the bleeding will be capillary. This method, or the application of a tourniquet, will absolutely control bleeding in an extremity.
The pressure in arterial hemorrhage must be appliedat a point nearer the heart and in venous hemorrhage at a point away from the heart.
A tourniquet may be devised from a handkerchief, a piece of rope or of rubber tubing wound around the limb and tightened just enough to arrest the main stream; in addition, pressure exerted over the wound will control whatever hemorrhage persists. Such a control can only be temporary, as the arrest of circulation in an extremity below the tourniquet for more than an hour or two might cause gangrene. However, there is no great fear of this occurring, as some blood reaches the parts through deep vessels.
Permanent control of such hemorrhages can only be effected by grasping the severed vessels in the open wound with artery clamps, and then ligating below the clamps with cat gut.
Deep-seated hemorrhages, in the abdomen or chest, can often be controlled by pressure directly over the wound until an open operation can be performed.
Deep pressure, with the fist upon the abdomen just to the left of the vertebral column, will compress the aorta and greatly reduce the escape of blood from any artery supplied by the descending aorta.
Hemorrhage in Chiropody.For the chiropodist, bleeding is an annoying and especially perplexing occurrence. The feet are the most bacteria-laden part of the body; here are warmth and moisture, congenial to bacteria, and a thick epidermis for their safe concealment. When hemorrhage occurs, therefore, its proper control along antiseptic lines is imperative.
The vessels severed are rarely of sufficient size to cause the escape of blood in an actual stream, but rather as a rapid oozing. It is, as a rule, capillary hemorrhage.
The methods for its control have already been described in this chapter, and will always stop such bleeding.
In chiropodial practice, however, the degree of bleeding determines the method of treatment, and, though the extreme may fall short of actual danger, it still behoovesthe operator to control it absolutely before dismissing his patient.
Easily Controlled Bleeding.The degree of bleeding or slight oozing, as it should be termed, incident to skiving a calloused surface, is well controlled with styptics.
In employing these substances it should be borne in mind that they are not usually antiseptic but, on the contrary, may harbor organisms which may be transferred to the wound and cause infection. The subsulphate of iron, commonly employed in the form of Monsel’s solution, is usually employed because of its efficiency as a styptic, and because of the fact that it is less irritating than others. It, however, is not antiseptic and should be kept sterile and uncontaminated by dropping it upon the wound directly from the bottle, rather than by dipping the cotton-wound applicator into it, as is so frequently done. Even this does not prevent an originally sterile bottle of solution from becoming contaminated, exposure to the air, when the stopper is removed, admitting many bacteria each time.
A superior styptic has been supplied in the form of dry subsulphate of iron fused to small sticks of wood. These are efficient because of their cleanliness, each being used but once and at no appreciable expense.
It is needless to say that the dressing of even so slight a wound should prevent the admission of infection to the thousands of portals of infection which are present. A bandage is not indicated nor justifiable, and the cotton collodion cocoon suffices.
Persistent Bleeding.When bleeding occurs which does not yield to the effects of a styptic because of its constant washing away when applied, it becomes necessary to apply pressure to the wound. Frequently a wad of cotton or gauze, pressed firmly upon the bleeding area, will almost stop the bleeding in a few minutes, after which it becomes possible to apply the styptic. Should this, however, be found impossible and the bleeding resume when the pressure is released, clotting in the vessel can only be expected by the agency of either ligation of the tissue or any individualvessel or more commonly by tight bandaging. The latter procedure usually accomplishes the control of the hemorrhage incident to a deep dissection for papilloma or verucca.
A pad of several thicknesses of sterile gauze is placed upon the wound and held in place by a few turns of narrow bandage, applied quite tightly. Though blood may be seen to “spot” through this dressing, it should occasion no alarm unless the hemorrhage has been clearly either venous or arterial. Under such circumstances the spurting, either constant or intermittent, will give immediate evidence of its character. Active hemorrhage of this nature may yield to tight bandaging, but ligation of the vessel should be done.
Venous or Arterial Bleedingrequiring ligation may be easily dealt with, and every chiropodist should be equipped with a small artery clamp with which to grasp the tissues; he should also be provided with sterile catgut, sizes 0 or 00, with which to ligate a bleeding vessel.
Antiseptic Precautions.In dealing with hemorrhage of even the slightest degree, it should be remembered that portals of entrance for bacteria upon the feet require every antiseptic precaution, both as to the treatment of the wound, and as to the instruments and dressings which come in contact with it.
For open wounds the U. S. P. tincture of iodin, diluted in water to one-half strength, is antiseptic and not extremely irritating.
Instruments dipped in pure phenol and dried on sterile gauze are rendered sterile and may be safely employed.
Dry sterile gauze in the dressing of a clean surgical wound is all that is necessary. Healing in the absence of infection will be prompt. The habitual use of ointments and wet dressings should be discountenanced, except in the presence of a real indication.
Among the causes of burns are: steam; hot water; melted glass, wax, rubber, sugar; molten metal; red-hot metal; gas and flame; burning wood, paper, clothing; electricity; X-ray; ultra-violet ray; chemicals; acid sulphuric, trichloracetic acid, common lye; alkalis; carbolic acid; iodin; croton oil, mustard, cantharides.
From these various causes there is very little difference in symptoms, course, pathology, and treatment. The molten lead burns are usually small in area, but of the third degree. The underlying tissues are often devitalized, especially around the feet, making a deep, pale, slow-healing ulcer. The same is true of many burns from electricity. The effects of X-ray burns are only seen after several days or weeks and stubbornly resist treatment. Ultra-violet ray burns may not show any effects at first, but develop symptoms in about six hours, sometimes accompanied by great pain. Such burns may be due to sunburn or powerful electric light.
The epidermis contains no blood vessels, but the mucous layer has lymph spaces between the cells, draining into the lymph spaces and channels of the dermis. Nowhere in the body are nerves more abundant than in the skin. Here we have nerves of motion to the muscles of the skin; nerves of pain, temperature, and touch; forming an intricate plexus of nonmedulated fibres sending their branches upward intoeach papilla, and even to the mucous layer of the epidermis. Vasomotor nerves supply the coats of most blood vessels of the skin, and trophic nerves are everywhere controlling the nutrition of each part. When it is considered what a complex organ the skin really is; how delicately its parts are adjusted to the body; how extremely sensitive its nerve supply, slight stimuli bringing responses and causing reflex action in far distant organs; how many the uses of the skin (protection, excretion, expression, and sensation in various forms), it can readily be understood how great is its importance, and the far-reaching results of its serious injury.
Burns are classified into three degrees: first, second and third. In every burn there are two layers of tissue to be considered:first, the layer destroyed—the dead flesh;second, the layer injured—the sick flesh.
Pathology.