SURGERY
WITH SPECIAL REFERENCE TO
PODIATRY

BY

MAXIMILIAN STERN, M.D.

AND

EDWARD ADAMS, M.D.

Professors of Surgery at the School of Chiropody of New York

EDITED BY

MAURICE J. LEWI, M.D.

President of the School of Chiropody of New York

THE SCHOOL OF CHIROPODY OF NEW YORK
213-217 WEST 125th STREET
NEW YORK

It is intended to publish a series of books which will constitute a complete SYSTEM OF PODIATRY, comprising the entire range of subjects essential to a comprehensive knowledge of the theory and practice of Chiropody and all that is or should be known by the practising chiropodist, or that should be taught to the student of Chiropody.

The present volume, “Surgery,” is the first of this series and will be followed by “Practical Chiropody,” “Chiropodial Orthopedics” and other volumes on subjects of major interest and of vital importance to all interested in Podiatry.

CONTENTS

PREFACE

THIS volume is intended to serve as a guide to the diagnosis and to the treatment of the diseases and conditions of the body in general, in their relation to the foot, as well as to those conditions which primarily affect this member.

Much of the matter herein contained might be regarded as beyond the scope of Chiropody; this, however, is a fallacy not more applicable to Chiropody than to any other specialized branch of Surgery requiring a knowledge of the physiologic and pathologic processes at work in the production of disease.

The advances made in this branch of Surgery have long since translated it from the realm of empiricism to the field of rationalism. Treatment based primarily on the results of experience or observation must give place to a system based upon a knowledge of abnormal conditions and the resultant changes in the tissues. Such knowledge elicits treatment directed definitely against these processes. It is obvious that this can be accomplished only through the agency of certain definite manual and therapeutic measures, the physiologic actions of which are well understood and known to be reliable.

Much stress has been laid upon the subject of asepsis and antisepsis. The foot is peculiar in that conditions surrounding it are especially congenial to the development and multiplication of bacteria. Modern surgery has been built upon the recognition of the rôle of bacteria in the behaviour of wounds, and the greatest hazard to successful surgery lies in the ever-present possibility of bacterial invasion. Surgical safety, however, can be secured by the employment of a perfect technic for asepsis. Once the precept is established that the operative field must be asepticized and thereafter protected from contact with any septic object, the status of Podiatry will be secure for all time. Should we accomplish this, these pages will have served a purpose.

Two notable features of the present volume are a comprehensive glossary and an exhaustive index which greatly enhance its usefulness, enabling the reader to find references to the subject before him, and with very little inconvenience to learn the meanings of unfamiliar words, thus obviating the necessity for a medical dictionary.

We avail ourselves of this opportunity to acknowledge our gratitude to Dr. Maurice J. Lewi for his assistance in editing and in publishing our work in keeping with his estimate of its possible field of usefulness.

M. S.
E. A.

CHAPTER I

INTRODUCTION

Surgery, in contradistinction to medicine, as a separate branch of the healing art, includes all manual procedures and is not limited to cutting operations exclusively. It is that branch which deals with the treatment of morbid conditions by means of manual or instrumental agencies.

Morbid conditions include three distinct classes: those due to

1. Injuries

2. Infections

3. Diseases

Injuries. To this class belong all the processes due to physical agencies and it includes besides traumatism, the effects of heat and cold, of chemicals, of light and of electricity.

Infections. These may be either local or general. The reaction might occur at the point of entrance of the bacteria, or constitutional symptoms may evidence their invasion into the blood, or the absorption of their toxic products.

Many conditions in this class are linked closely with those in the following class:

Diseases. Here are classified (a) new growths, both benign and malignant; (b) changes due to age and environment, and (c) diseases not belonging in either of the above classes. These latter are generally known as idiopathic or spontaneous in their etiology. These terms, however, often indicate only a limit of knowledge as to their true etiology.

The Tissues. The tissues of the body, though apparently so different and varying so decidedly in their functions, are in many respects similar.

Every tissue is composed of two parts: the cellular elements and the intercellular substance. These are called cells and stroma. Upon the first of these depends the vitality and function of the part, while its density, shape and general physical properties are determined by the second. Likewise along the same lines of reason, all of our organs have two separate areas of tissue: the parenchymatous and the interstitial. The first contains the functioning and the second the supporting elements.

The physical conditions of the interstitial tissue or the intercellular substance vary greatly in density. Blood is a tissue, the intercellular constituent of which is fluid, and as we consider more dense tissues, we encounter all degrees of density of the framework or intercellular substance, until with the additional presence of calcareous elements, we conceive the hardness of bone and dentine. Tissues as a whole, however, are not solid; there are spaces in the supporting structure to admit of the passage of arteries, veins, nerves, and lymphatics.

Abnormal conditions arise in the various parts of the tissues. Certain diseases affect the parenchymatous tissue in an organ more than the interstitial tissue and again others affect the blood vessels particularly.

There may be hypertrophy, in which the entire organ or part becomes larger as a whole, the active cells and stroma sharing alike in the process, or there may be an hyperplasia, in which the active cells of the part proliferate abnormally. When the interstitial tissue alone develops excessively it is known as an infiltration. Under such circumstances the parenchymatous cells often undergo what is termed pressure atrophy; they are diminished by squeezing.

Atrophy of the part or organ, from whatever source, signifies its diminution in size; its function is, of course, either impaired or suspended as the process goes on.

The efforts on the part of the organism as a whole to combat or repair injury, bacterial invasion and disease are directed along definite lines. The study of these functions does not rightly come within the scope of these pages, belonging to physiology, but must be considered here, if only in brief for the purpose of a good understanding of the processes at work in surgical conditions.

As surgeons, the functions which concern us most are the

1. Nervous

2. Circulatory

3. Lymphatic

THE NERVOUS SYSTEM

The nerves operate in harmony with each other and with the organs to maintain health. The nervous system comprises the brain, the spinal cord, the nerves, and the ganglia. Aside from presiding over the special senses, this system controls and directs the processes of defense and repair. In doing so, the force and frequency of the heart beat, the calibre of the vessels and the chemistry and composition of the blood are all altered.

These phenomena are the ones which concern us in our present subject, acting as they do upon the blood and the organs which contain it. They will be considered more fully in the following:

THE CIRCULATORY SYSTEM

In health and disease the force and frequency of the heart beat and the calibre of the arteries undergo momentary alterations to meet changes surrounding us.

Dilatation and constriction of the arteries, and arterioles through the activity of the vasomotor nerves, permit of increasing and diminishing amounts of blood reaching the various organs and regions of the body. In this way the peripheral circulation, through the activity of the heat centre in the brain, acting upon the superficial capillaries, maintains the normal temperature of the body during the changes of season. In winter, heat conservation is effected by vaso-constriction of the superficial capillaries, while in summer, heat radiation is accomplished by vaso-dilatation together with the evaporation of moisture so abundantly supplied by the active sweat glands. Other phenomena demonstrating the vasomotor function are blushing, going pale, and the redness and swelling following injury or infection. Of the latter we will treat under the heading “Inflammation.”

Certain changes also occur in the blood in order that it may perform its functions. These changes are found both in the chemistry of its fluid content and in the number and kind of its solid elements: the corpuscles. The blood is a tissue; its corpuscles are the functioning cells and its fluid content the basement substance.

In the fluid content of the blood or plasma, as it is called, certain chemical changes occur in its fibrin-forming capacity. Clot formation, an effort on the part of the economy to arrest hemorrhage, is thus facilitated when there is active bleeding, also during labor and certain diseases.

The number and kind of white blood cells also undergo changes, as we shall see, under circumstances in which the defences of the organism are called into operation, for it is the function of the white blood corpuscles to combat bacterial invasion.

It is the preponderance of these white cells which imparts the peculiar milky color to pus.

Nourishment and oxygen are carried to the tissues by the red blood corpuscles. Under circumstances which we shall see later, these are also altered both in number and in size, and also in their arrangement in the vessels. (See Chapter IV, “Inflammation.”)

THE LYMPHATIC SYSTEM

Waste material in the tissues is carried off by the return blood in the veins and also by the lymphatics. These are in reality the scavengers of the body, both the lymphatic vessels and glands, performing important functions for the good of the economy. They are found beneath the skin and in the subcutaneous tissue, also along the course of the great veins.

The lymphatics far exceed the veins in number and perform a function similar to the veins, gathering waste material from the tissues, also the digested food called chyle, from the stomach and intestines. The lymphatic vessels, also the lacteals which absorb the chyle, all pass through glands, which are extremely numerous, where certain deleterious substances are extracted from the lymph before it is emptied into the blood stream.

The lymphatic glands in performing their function as filters often become inflamed and when large numbers of pathogenic bacteria, or very virulent ones are contained in a gland, abscess formation results just as it would in any tissue so invaded.

CHAPTER II

SURGICAL BACTERIOLOGY

A microorganism or microbe, some species of which cause all disease, is a minute plant or animal too small, as a rule, to be visible to the naked eye.

The word germ may be used to designate any microorganism, but it has so many other meanings and has been so loosely employed even in this sense, that it cannot be used for accurate scientific description.

Bacteria are minute plants on the order of fungae, many of which are able to produce fermentation, decomposition or disease.

Although the word bacterium by derivation has the same meaning as bacillus and indicates a rod shaped fungus, it has been so loosely employed that it may very well be applied to the entire germal family, retaining the word bacillus in the narrower sense.

Description of Bacteria. Schizomycetes is the name given all the bacteria of putrefaction and disease, the former being called saprophytic and the latter pathogenic.

Bacteria are minute fungi, each consisting of a single cell enclosed in a cell membrane of cellulose which can be demonstrated by iodine, the latter causing the protoplasm to retract from the cell wall. There is no nucleus or central core. Some of the bacteria are colorless, others pigmented, yellow, blue or red. The cells vary in shape and in size in different species as well as in their mode of growth, and are named in accordance with these peculiarities. The round or oval cells are called cocci; the rod-shaped organisms are termed bacilli. The cocci are called micrococci or macrococci according to their size; diplococci or tetracocci, according to the production of pairs or groups of four in their multiplication; streptococci, because in their growth they always form chains of cells; staphylococci, because they grow in irregular clusters resembling bunches of grapes. Some of the bacteria have the power of motion generally produced by cilia or flagella and others are motionless.

Habitat. These organisms may truly be said to be omnipresent. Every thing we wear or use or eat, even the air itself, is impregnated with them. Pathogenic germs may also be found among these myriads. Every species has its own particular habitat, where the conditions especially favor its growth, just as any of the larger plants require a certain soil, a supply of water, temperature, and proper amount of light in order to make growth and multiplication possible.

The bacteria in the air are more numerous in dry weather, being carried up as dust by the wind, for a moist surface holds any bacteria which may lie upon it. So complete is the action of moisture, that air, which contained 600 microorganisms when inspired, has been shown to return from the lungs with almost none, the moist respiratory surfaces catching and holding the bacteria; so that the expired air is practically sterilized; this is true even when the expiration is from diseased lungs. The act of coughing, however, may expel bacteria in the mucus ejected. The number of bacteria in the air is very variable, but is much greater in houses than out of doors, and is naturally increased by attempts to clean the rooms.

Parasitic Nature. The number of species of pathogenic germs is comparatively small compared with the number of all the varieties of germs, for the latter are practically innumerable. Indeed, the wonderful qualities of resistance in animal tissues is the only thing that makes animal life possible and it is this power of resistance that allows certain wounds to heal by primary union when left without protection or care.

The schizomycetes are unable to extract nitrogen from the air or the soil, like the higher vegetables, and must, therefore, be provided with a higher nitrogenous compound, such as is produced by vegetable and animal life. Some of them are able to live upon dead organic matter, while others cannot exist without living tissues to feed upon and are therefore true parasites. There are some which are able to live upon either dead or living tissues and are known as facultative parasites, a class which includes a majority of pathogenic germs. Some organisms require albuminous matter, others need carbohydrates; they all require water, carbon, nitrogen, oxygen, and certain inorganic materials, especially lime and potassium. All organisms require water. If dried, no form will multiply, and many forms will die.

The fluids and tissues of the individual may or may not afford a favorable soil for the germs of a disease, or, in the same person afford it at one time, and not at another. Some individuals seem to possess indestructible immunity from, and others are especially prone to, certain contagious diseases. Impairment of health, by alterating some subtle condition of the soil, may make a person liable who previously was exempt.

Effect of Oxygen. Some bacteria need free oxygen; some can live either with or without free oxygen, while others cannot live at all in the presence of free oxygen. Those requiring oxygen are called aerobic; those which can live with or without it are called facultative aerobic; those which do not live in free oxygen are called anaerobic.

Bacteria are very sensitive to temperature, few being able to live in a temperature below 68°F. or 29°C. or above 104°F. or 40°C. The pathogenic varieties thrive best at about the normal temperature of the blood. Direct sunlight retards their growth and may kill them. Freezing renders bacteria motionless and incapable of multiplication, but it does not kill them; they again become active when the temperature is raised. The absurdity of employing cold as a germicide is evident when it is known that a temperature of 200°F. below zero is not fatal to germ life, cell activities by such a temperature only being rendered dormant. The high temperatures are fatal to bacteria, moist heat being more destructive than dry heat, and adult cells are more easily killed than spores. A temperature less than 212°F. will kill many organisms and boiling will kill every pathogenic organism that does not form spores. Some spores are not destroyed after prolonged boiling and some will withstand a temperature of 120°C. As a practical fact, however, boiling water kills in a few minutes all cocci, most bacilli, and all pathogenic spores, though anthrax and tetanus are harder to kill than are the spores of other bacteria.

Under favorable conditions bacteria multiply rapidly, but when conditions are unfavorable, they take on a spore formation and remain in a quiescent state, like the seed of a plant, waiting—it may be years—until proper conditions are present. The spores are protected by such a thick envelope and have such great potential vitality, that it is much more difficult to kill them than the developed bacteria. Certain spores that withstand 212°F. or 100°C., can be killed when fully developed at 130°F. or 55°C.

Toxins. As bacteria grow, certain poisonous chemical substances appear about them. These poisons are produced by them directly, or are formed in the organic matter or tissues in which they live, as the result of their presence. Some of these substances are alkaloidal and are known as ferments or ptomains. Others are albuminous in nature and are called toxalbumins. The ptomains and toxalbumins are exceedingly powerful poisons, producing local necrosis, inflammation and even suppuration, when introduced by themselves and entirely free from living germs, into the tissues of animals. Pathogenic bacteria abstract the lymph from the blood. As the lymph contains elements necessary to the body, such as water, oxygen, albumins, carbohydrates, etc., their loss brings about body-waste and exhaustion from lack of nourishment. Again, bacteria produce a vast number of compounds, some harmless and others highly poisonous.

The symptoms of a microbic disease are largely due to the absorption of poisonous materials from the area of infection. These poisons may be formed in the tissues by the action upon them of the bacteria, or they may be liberated from the bodies of degenerating microbes.

Bacteria secrete and contain ferments like pepsin or trypsin, and as albumoses are formed in the alimentary canal by the action of the digestive ferments upon proteids, sugars, and starches, so microbic albumoses are formed by the action of microbic ferments upon tissues.

The local and general symptoms of these toxins depend upon the particular toxin employed and a large number of these poisons have been isolated and studied. Those of the surgically important pathogenic germs, produce inflammation locally, with general symptoms of fever, chills, cardiac depression, irritation of the kidneys and bowels and cerebral symptoms, such as delirium and coma. The toxalbumins also appear to have the effect of destroying the bacteria to which they owe their origin when they have been produced in large quantity.

Cultivation. Bacteria are cultivated for study in the laboratory in meat extracts, in gelatine, or agar agar (a sort of vegetable gelatine), or raw potato, in blood serum and in other materials. The simplest method of cultivation is in bouillon, sterilized in flasks, with cotton plugs. Another method of studying bacteria is by the inoculation of animals.

Infection. Bacteria gain admission to the living tissues under natural conditions, by penetrating any of the mucous membranes which they can reach, or by entering open wounds. It may be said in general that an intact epidermis is almost a complete protection against infection, and that an intact mucous membrane is a good protection. This difference in vulnerability between the mucous membrane and the skin is important, and is probably due to the cornifaction of the epithelial cells, and to their numerous layers, as well as to the protection afforded by the thick corium. The single layer of soft mucous cells is much more easily penetrated.

Typhoid bacilli and other hostile germs have been actually observed in the urine, in the bile, in the intestinal secretions and in the saliva. The bacteria of typhoid fever and tuberculosis have been found in the milk of nursing mothers.

The local phenomena of inflammation usually follow the introduction of living bacteria into the tissues, and general symptoms of poisoning follow later, when the bacteria, toxins, or ptomains, have entered the circulation. Some bacteria, however, excite no local reaction, but enter the circulation at once. The pyogenic variety, it should be noted, cause the production of pus.

Elimination. Bacteria can be eliminated from the blood in several ways; the kidneys, however, are the organs which carry the burden of most frequently relieving the body of them. Even the sweat glands are supposed to eliminate both bacterial toxins and bacteria.

Resistance Offered by Tissues. The tissues have considerable power of resistance under ordinary circumstances, although the exact sources of this power are not well under stood. Phagocytosis—the power of destruction and removal of bacteria supposedly possessed by the leucocytes emigrating from the blood vessels—explains it in part. It is also accounted for by the germicidal properties of the blood serum.

The resistance of the tissues may in some cases be due to the absence from them of some particular element necessary to the growth of a particular microorganism. This refractoriness varies in every species of animal in its relation to every form of germ. Different individuals of one species also vary in their susceptibility, and even different parts of the body vary in the same individual. The lower animals offer a greater resistance to pyogenic bacteria than do human beings.

Any cause that lowers the vitality by depressing the system, reduces the resistance to bacteria and is therefore apt to favor their growth. Exhausting diseases such as anemia, obesity, alcoholism, diabetes, fatigue, or even exposure to cold, are instances. Germ growth is also favored by the presence of dead, or injured tissues, of blood clots, of foreign substances, and above all, by the presence of some of the substances in which the germ has already been growing at the time of its inoculation, and containing some of its toxins.

Immunity. To be able to resist the invasion of any species of bacteria, one is said to be refractory to or immune against that variety of germs.

Serum therapy is based on the demonstrated fact of immunity, and of the possibility of producing it by injecting the serum of immunized animals. In many infectious diseases, one attack protects an individual for a lifetime and one form of disease may protect against even a more virulent form, as vaccination protects against smallpox. It is a fact that if the serum of an animal which has been rendered immune to a certain disease be injected into a susceptible animal, the same immunity can be produced temporarily in the second animal. Serum therapy proves that the injected serum will not only confer immunity against the infection, but will enable the animal to throw off an already existing infection.

Sterilization. The question how to destroy microorganisms is one of the most important in bacteriology. Exactly how chemical antiseptics act in suspending the growth in living organisms and yet leaving them capable of restoration, is not understood. The explanation is offered that the antiseptics enter into combination with the capsule of the cell and can be freed from it by breaking up this chemical combination. It has always been evident that very minute quantities of germicidal substances, and some substances which are not germicidal, would prevent the growth of bacteria, so that it is not surprising that chemical disinfectants should act in this prolonged inhibitory way. It must be remembered that in operative surgical work, germs which will not develop are, for practical purposes, as good as dead; therefore such results do not invalidate the present methods of sterilization for operations. They naturally stimulate interest in the discovery of better methods of sterilization and especially in the thorough application of the methods upon which we are now depending, in order to obtain the best possible results from them. There are three ways of destroying microorganisms: (1) by deprivation of food and water, (2) by chemicals (including toxins), (3) by heat.

Chemical Antiseptics. For practical disinfection, chemicals and heat need only concern us. The power of these substances is greatly decreased by heat, grease, oil, mucus, and even blood will cover germs with a coating which prevents chemical germicides from reaching them. Among the ordinary germicides, bichloride of mercury, iodin, alcohol and carbolic acid, are of the greatest importance. A source of error in the direct application of these experiments is the fact that many of these chemicals are decomposed or rendered inert, by combinations with the albuminoids of blood and pus, mercuric bichloride being transformed into an indifferent substance and even carbolic acid being altered.

Carbolic Acid is a valuable germicide in the strength of from 1 to 40, to 1 to 20. It is very irritant to tissues and carbolized dressings may be responsible for the sloughing of a wound. It is inert in fatty tissues.

Carbolic acid is readily absorbed, and may thus produce toxic symptoms. One of the early signs of absorption is the appearance of the urine, which may assume a smoky, greenish or blackish hue. Examination shows a great diminution or entire absence of sulphates, when the acidulated urine is heated with chloride of barium. The urine also contains albumin. The appearance of the urine is an indication that the use of the drug must be discontinued.

Kreolin, a preparation made from coal tar, is a germicide without irritant or toxic effects. It is less powerful than carbolic acid, but acts similarly, and is used in emulsion of a strength of from 1 to 15%. It does not irritate the skin like carbolic acid.

Peroxide of Hydrogen is a most admirable agent for the destruction of pus cocci. It probably destroys the albuminous element upon which the bacteria live, and starves the fungi.

Peroxide is not fatal to tetanus bacilli.

Iodoform is largely used, but it is not a germicide as bacteria will grow upon it. It hinders the development of bacteria and directly antagonizes the toxic products of germ life.

Silver Nitrate is a valuable antiseptic. It exerts an inhibitive action upon the growth of microorganisms, but irritates the tissues.

Formaldehyde has valuable antiseptic properties. Formalin is a 40% solution of the gas in water. Solutions of this strength are very irritant to the tissues, but a 2% solution can be used to disinfect wounds and instruments.

Nucleins, especially protonuclein, possess germicidal powers. Protonuclein is of value in treating areas of infection, particularly when sloughing exists. A great many other antiseptics are used.

Heat. The surest and quickest method of destroying bacteria is by heat. Even the spores succumb to it. Anthrax spores are killed in 2 minutes in boiling water, and the various bacilli and cocci in from 2 to 5 seconds.

When a substance to be sterilized by heat will not bear so high a temperature, the method of fractional sterilization is employed, the fluid to be sterilized being heated to from 140°F. to 175°F. or to from 69°C. to 80°C., for from 15 to 30 minutes every 3 days or 7 days. The theory is that the adult germs are killed by the first heating and that any spores which develop subsequently are destroyed in their adult state at the next heating. The fluid, meanwhile, must be kept at an even temperature which will encourage the development of any spores it may contain. Even anthrax spores may be killed by 167°F. to 185°F., or 75°C. to 80°C., in a one and four-tenths solution of bicarbonate of soda, in from 8 to 20 minutes. Dry heat is not so efficient as moist heat.

The following are the more important bacteria we meet in surgical conditions:

Staphylococcus pyogenes aureus—a microorganism producing yellow pus.

Staphylococcus pyogenes citreus—a microorganism producing lemon-colored pus.

Staphylococcus pyogenes albus—a microorganism producing white pus.

Streptococcus pyogenes—a streptococcus producing pus. (Erysipelas for example).

Micrococcus gonorrhea—bacillus of Neisser, or gonococcus.

Bacillus pyocyaneous—producing a green pus.

Bacillus coli communis—producing intestinal conditions. (Appendicitis for example).

Bacillus typhosis—Eberth’s bacillus; producing typhoid fever.

Bacillus tuberculosis—Koch’s bacillus; producing tuberculosis.

Bacillus tetani—Nicolaier’s bacillus; causing tetanus.

Treponema pallidum, or spirochaeta pallida of Hoffman and Schaudin—a protoza causing syphilis.

The first six are known as pyogenic bacteria, as they all produce pus; in addition to the above there are many more microorganisms, but from a surgical standpoint those mentioned are the most important.

The staphylococcus pyogenes is a spherical coccus of somewhat variable size but averaging about 8 microns; when properly stained it can often be seen to be formed of two separate hemispheres. In pus it is generally found in small heaps containing from two to ten members, but it also occurs singly and in pairs, and even in short chains like the streptococcus, thus rendering diagnosis difficult with the microscope alone. Its cultures are of a yellowish tinge. The aureus type is the most usual cause of abscesses (circumscribed suppurations) and 77% of acute abscesses are due to the staphylococci.

The staphylococcus pyogenes aureus is a facultative anaerobic parasite which is widely distributed in nature, and is found in the soil, in the dust of air, in water, in the alimentary canal, under the nails, and in the superficial layers of the skin. It forms the characteristic color only when it grows in air. It is killed in ten minutes by a moist temperature of 58°C. and is instantly killed by boiling water. Carbolic acid (1 to 40) and bichloride of mercury (1 to 2000) are quickly fatal to these cocci.

Staphylococcus pyogenes citreus, the lemon-colored coccus, is found occasionally in acute circumscribed suppurations, but far more rarely than the other two forms. Its pyogenic power is even weaker than that of the albus.

Staphylococcus pyogenes albus, the white coccus, acts like the aureus, but is more feeble in power. When this organism is found upon and in the skin, it is called staphylococcus epidermis albus, an organism which is the cause of stitch abscesses.

Streptococcus pyogenes is found in spreading suppurations and in very acute abscesses. About 16% of acute abscesses contain streptococci. It is easily killed by boiling, and can be destroyed by carbolic acid and by corrosive sublimate. The streptococcus of erysipelas is thought to be identical with the streptococcus pyogenes, but their difference in action is believed to be due to difference in virulence induced by external conditions and by the state of the tissues of the host. The coccus of erysipelas is larger than the ordinary form of streptococcus pyogenes, and infection takes place through a wound, often a very trivial one, or through a mucous membrane. The organism multiplies in the small lymph channels. The streptococcus may cause suppuration in erysipelas, mixed infection not being necessary to cause pus to form.

The gonococcus of Neisser is found both inside and outside of pus cells and mucous cells. The gonococci cannot be cultivated upon ordinary media, but grow best upon human-blood serum. Gonococci stain easily and are readily decolorized by Gram’s method.

The bacillus coli communis, or the bacillus of Escherich, is invariably found in the fæces. It is believed by many observers to be the cause of appendicitis, peritonitis, and abscesses about the intestine. In cases of appendicitis we can rarely get a pure culture of Escherich’s bacillus, but usually find also streptococci and staphylococci.

The bacillus of typhoid fever (Eberth’s bacillus) is responsible for some cases of gangrene, for some of embolism and for not a few bone and joint diseases.

The bacillus tuberculosis (Koch’s bacillus), the cause of all tubercular processes, is met with especially in dusty air which contains the dried sputum of victims of tuberculosis. This infected air is the chief means of its transmission, though it may be conveyed by the milk of tubercular cows and by the meat of tubercular animals. Wounds may open a gateway for infection.

The bacillus tetani (Nicolaier’s bacillus), an aerobic organism, is found especially in the soil of gardens, in the dust of old buildings, in street dirt, and in the sweepings of stables. Spores develop at the ends of these bacilli. This organism is capable of producing toxins of deadly power. Its spores are hard to kill.

CHAPTER III

ASEPSIS AND ANTISEPSIS

Before the introduction of Lister’s methods of treating wounds, it was considered proper, in accidental and operative wounds, to have profuse suppuration, pyemia, erysipelas, etc., and it was not remarkable, therefore, that the mortality following accidental and operative wounds was very high. Lister’s method of wound treatment was largely based upon the conception that the infection of wounds occurred from contact with the air which contained spores and germs, and his method of treatment therefore, was directed chiefly to their destruction. The air can be a medium of wound infection to a certain extent, and dry air contains more spores and bacteria than moist air, but Koch demonstrated the fact that atmospheric microbes were chiefly of innocuous character, and wound infection usually could be traced to bacteria or spores being brought into direct contact with wounds, by the clothing, or by the skin of the patient, or by the hands of the surgeon, or by unclean surgical instruments and dressings. The antiseptic qualities of the blood serum and cell activities in healthy tissues, are sufficient to destroy or remove a certain number of microorganisms, and suppuration occurs only when the tissues are completely overwhelmed by the number of these organisms or when their power of resistance is lessened by injury or disease.

Sepsis. Sepsis is due to the entrance and multiplication of microbes, or to the absorption of their products in the body. Local inflammation and marked constitutional symptoms characterize sepsis.

Asepsis. Asepsis aims at thorough sterilization of the parts and of all the objects brought into contact with the wounds, and the exclusion of germs by the use of occlusive bandages and dressings.

Antisepsis is that method of wound treatment which keeps germicidal agents continuously in direct contact with the wound. Its object, therefore, is to produce asepsis. It is the duty of the surgeon to guard against the contact of microorganisms in the wound and to employ whatever means science has evolved for their destruction. He must, however, be careful to employ means of disinfection or destruction that will not have an injurious effect upon the normal tissues.

Mechanical disinfection does not apply to wounds but is employed as a preventive measure by the operator and his assistants for instruments and for the skin surrounding the wounds. Mechanical disinfection is accomplished by the use of soap and water and a friction brush; germicidal solutions of one kind or another are also employed.

In the modern aseptic operating room germicides and antiseptics do not play so important a part as they formerly did. This is largely due to the fact that heat is used wherever possible in the preparation of sutures, ligatures, dressings and instruments, and to the farther fact that in uninfected tissues no antiseptic solutions are employed. It must also be remembered that the germicidal agents possess the disadvantage of exercising a more or less destructive action on the body cells, and consequently their use is not warranted in clean wounds. We still, however, sufficiently often meet with infected wounds that render the use of these agents necessary.

Heat is the most valuable of all sterilizing agents, its only drawback being that it is not universally applicable. Wherever possible it should be employed in preference to chemical agents. It can be employed either dry or moist. Moist heat is a much more efficacious germicide than dry heat, for it destroys the organisms at a much lower temperature. Boiling water at a temperature of 212°F. will destroy nearly instantaneously all pus-producing organisms. Spores, however, require a moist heat of 284°F. kept up for at least a half-hour. A dry heat of 212°F. will not destroy pus-producing organisms under an hour and a half of treatment, and spores will live for three hours at a dry temperature of 284°F.

Although moist heat is very much quicker and more satisfactory in its action, yet it is often inconvenient to employ it in the sterilization of gowns, towels, operating suits, etc. However, sterilization by heat has been greatly facilitated by the introduction of the autoclave, by means of which a very high temperature under pressure can be obtained. This is the most satisfactory method of sterilizing dressings, towels, sheets, operating suits and aprons. A similar and less expensive method of sterilizing these articles is by the use of one of the simple steam sterilizers which are sold by all dealers. In an emergency, an ordinary bake oven can be employed as a sterilizer. It is best, however, where the temperature cannot be estimated, to boil the articles and dry them between sheets moistened with bichloride solution.

Disinfection or Sterilization. Sterilization of a wound, or of the substances coming in contact with it, may be accomplished by using the aseptic or antiseptic method; by combining these two methods we obtain the best results. The aseptic method, which employs antiseptic substances for the purpose of sterilization of objects coming in contact with the wound when their disinfection by heat is impossible, is the method perhaps most generally favored by modern surgeons.

Antiseptic Method. In the antiseptic method, the field of operation, the hands of the operator and of his assistants, and the instruments, must be treated in germicidal solution and, in addition, the wound should be frequently irrigated during the operation with a solution that has germicidal properties.

Recent investigations show that many germicidal substances have not the power that was formerly attributed to them. Furthermore, substances which are really active germicides very often produce a marked toxic effect upon the patient and produce a very decided irritation of the skin with which they come in contact.

Aseptic Methods. The aseptic method for the treatment of wounds admits of the use of germicidal solutions and heat upon the field of operation, upon the hands of the operator and of his assistants, and upon the instruments employed. After this has been accomplished, placing absolute dependence upon this sterilization, no germicidal or antiseptic substances are brought into contact with the wound, sterilized salt solution or plain sterilized water being used, if necessary, to flush the wound, the dressings employed having been sterilized by dry heat or moist heat.

Sterilization of the Hands. Experimental investigation has shown that the failure of the surgeon’s efforts to render his hands absolutely aseptic, has been the productive cause of infection in many wounds.

The hands and finger nails may be best sterilized by first rubbing them with spirits of turpentine; then scrubbing them with soap and water; and then using a sterilized nail brush freely. The scrubbing should be done for several minutes. The hands should then be rinsed to remove the soap, and then soaked for about ten minutes in a solution of bichloride, strength, 1 to 2500. If turpentine has not been used before washing with the soap, strong alcohol or ether should be well rubbed over the hands before they are immersed in the bichloride solution. Perhaps the best way of rendering the hands sterile is to scrub them with green soap and water, then mix a tablespoonful of commercial chloride of lime and half a tablespoonful of carbonate of soda with enough water to make a paste. When this has assumed a thick creamy consistency, it should be rubbed into the hands until the grains of lime disappear and the skin feels cool; then rinse the hands in sterile water.

Sterilization of Instruments. Instruments may be sterilized by boiling them for fifteen minutes in water in which a tablespoonful of washing soda has been added for each quart. This prevents rusting of the instruments and also makes the water a better solvent for any fatty matter which may be upon the instruments, thus increasing the sterilizing effect of the heat.

Sterilization of the Feet. As most patients do not apply water as freely or as frequently to the feet as to other portions of the body, there is usually present an excessive amount of thickened epidermis, which is very difficult to render sterile. For operations in chiropody the feet should be thoroughly moistened with soap and water, scrubbed vigorously with a brush, then soaked in a solution of bichloride of mercury of 1 to 1000 strength, and then wrapped up in a towel soaked in the same solution while waiting for the operator.

AGENTS EMPLOYED TO SECURE ASEPSIS

Bichloride of Mercury is used for the disinfection of the hands and skin and for the irrigation of wounds. Biniodid of mercury is extensively employed and in the same strengths as the bichloride. It is, however, a more powerful germicide, while being less irritative, and neither forms a mercuric albuminate nor tarnishes metal instruments.

Carbolic Acid. This acid is derived from coal tar, and although known as early as 1834 as the first antiseptic recommended and used by Lister, is not so popular since the discovery that bichloride of mercury possesses more germicidal action.

Gangrene of the skin and subjacent tissues has often been traced to the long continued use of dilute solutions of carbolic acid or of ointments containing small quantities of the drug. Gangrene of the fingers and toes is by no means infrequent as a consequence of its use. Another condition frequently seen is the systemic poisoning through absorption. One of the first symptoms noticed from such absorption is irritation of the urinary tract and carboluria. This poisoning is more apt to take place when the weaker solutions are used than when the pure acid is used, as the destruction produced by the pure acid prevents its absorption.

The effect of carbolic acid upon the urine (See Chapter II, “Carbolic Acid”) is to cause it to become smoky a short time after it is voided. The urine shows a complete absence or diminution of the sulphates, and albumin is generally present. When these symptoms present themselves, the use of carbolic acid should be withdrawn, and the administration of sulphate of soda and atropin begun. If the condition has existed for any length of time and the patient is weak and exhausted, stimulants are indicated.

Lysol is a saponified phenol, and possesses some germicidal power. It is used in strengths of 1 to 3 per cent. solutions.

Creolin is mildly germicidal and is used a great deal in from 2 to 4 per cent. solutions.

Both lysol and creolin act very much like carbolic acid, but neither possess its irritating qualities.

Formaldehyde Gas is an active germicide and very valuable as a disinfectant. It is used in the shape of formalin which is a 4 per cent. solution of the gas in water. This agent is very irritating to the normal tissues in the stronger solution, but a 2 per cent. solution of formalin may be used for the sterilization of the hands, instruments, etc.

The formaldehyde fumes are employed for the disinfection of clothing, rooms, bedding, and also for the sterilization of catheters. The fumes of the gas are very irritating to the mucous membrane and when this agent is used for the disinfection of rooms, every crevice and crack must be tightly sealed to prevent the escape of the gas.

Iodoform. The action of iodoform is not due directly to its ability to destroy germs but to its undergoing decomposition in the presence of moisture, liberating iodin and thus rendering inert ptomains that have resulted from the growth.

Iodoform Powder is rapidly absorbed by the skin and fatal cases of iodoform poisoning have occurred from treating burns with it. Iodoform is also used in ointment form and in suppositories. As it is insoluble in water it is commonly used in a 10 per cent. emulsion. The gauze is also greatly used.

The symptoms of iodoform poisoning are: delirium; odor of iodoform on the breath; presence of iodoform in the urine; eruption over the skin, and finally, coma. Iodoform is also capable of producing a localized dermatitis, with great irritation, and must therefore be used with care on all delicate skins.

Aristol, a substitute for iodoform, is a compound of iodin and thymol, producing no toxic effects and having no disagreeable odor; it does not, however, possess the germicidal qualities of iodoform. Nosophen, iodol, and airol are among the more recent substitutes.

Iodin. This drug no doubt possesses more germicidal properties than was at one time supposed. It is probably the most powerful antipyogenic known. The 7 per cent. tincture is the one most frequently used.

Acetate of Aluminum, or more properly, aluminium, is prepared by adding five parts of sugar of lead to a solution of five parts of alum in 500 parts of distilled water. Burow’s solution, see page 35, is chiefly employed as a wet dressing.

Chloride of Zinc in a solution of 15 to 30 grains to the ounce, has marked antiseptic properties, but it blanches the tissues when applied to infected wounds.

Sulphocarbonate of Zinc is less irritating than the chloride of zinc and is of the same value as a germicide.

Peroxide of Hydrogen when used as a 15 volume mixture or diluted, seems to have a direct action upon pus generation by destroying microorganisms of the pus. It is frequently employed for sterilizing abscess cavities, and for hastening the separation of necrotic tissue.

This agent has also a marked hemostatic power and is used to some extent on this account in nose and throat work. Its hemostatic power is also observed in bone cavities. Care should be taken never to use it unless there is a free exit, as it increases rapidly in volume after coming in contact with dead tissue or pus, and serious accidents have happened from its improper use; for instance, if it is injected into an abdominal sinus where free escape is not provided for, the distention will result in ruptures of the sinus and infiltration of the surrounding tissues; possibly of the peritoneal cavity. The distention produced by it is also quite painful and therefore only a small quantity, or a much diluted solution should be introduced into cavities.

Boric Acid is not very actively antiseptic, but even in a saturated solution it is not irritating. Where bichloride or carbolic dressings have produced irritation of the skin, or burns, a boric acid ointment is a very satisfactory substitute.

Salicylic Acid is an antiseptic of value. It is generally used in the form of an ointment. It is but slightly soluble in water.

Potassium Permanganate by its rapid liberation of oxygen, acts as an antiseptic of proven merit for the disinfection of foul wounds and ulcers. It is also used satisfactorily for disinfecting the hands in preparation for operations, in the form of a 5 per cent. solution, any stain being removed later by a saturated solution of oxalic acid.

Alcohol possesses marked antiseptic properties and is one of the best agents for the sterilization of the hands of the surgeon, and for the skin of the patient. A 60 or 75 per cent. solution of alcohol is much more efficacious as a skin disinfectant than a 95 per cent. solution. This is because the purer alcohol is much less penetrating than the dilute. It is also used when diluted with water, one part to four, as a dressing for granulating wounds. It is efficacious in limiting the action of carbolic acid, when this agent has been applied in full strength.

It is a useful agent in which to store certain materials such as ligatures, sutures, etc.

Silver Nitrate possesses undoubted antiseptic properties, and solutions of varying strengths are decidedly antiseptic. These solutions are from 5 grains to the ounce, to 60 grains to the ounce.

The solid stick of nitrate of silver is used for destroying exuberant granulations. Among the different silver preparations on the market, protargol and argyrol are the best known. Both of these are extensively used in the treatment of inflammations of the mucous membranes.

The unguentum of Crede, is an ointment of silver which is used in cases of septic infection and also in localized inflammations. From 15 to 45 grains of silver can, in this form be rubbed into the skin. It is absorbed and undoubtedly exercises an antiseptic influence on the infecting microorganisms.

Saline Solution, or normal, or isotonic salt solution, as it is called because of its close approximation to the blood serum, consists of a solution of 7 per cent. of sodium chloride in plain sterilized water. Roughly speaking and for ordinary purposes, this solution can be made by adding an even teaspoonful of ordinary table salt to one pint of boiled water and then reboiling the mixture.

It can be stored for a limited time in sterile glass jars, which are sealed with sterile cotton. The jars can be heated to whatever temperature is required for use. This solution is the one which is generally used for irrigating wounds and cavities; it is non-irritating and possesses no antiseptic quality. When a moist dressing is desired there is no solution comparable to it, largely because of its non-irritating quality. It has at times a slight irritating effect upon the kidneys and when large quantities of it are used it is better to dilute it.

Pure Oxygen and Ozone have been used, and the latter is more effectual. It has been found that oxygen but slightly retards the growth of bacteria, but both ozone and oxygen produce a hyperemia, and retard the growth, especially of anaerobic organisms. Pure oxygen in the abdominal cavity produces a marked hyperemia and a leukocytosis. Ozone has been put to some practical use in this country but the results have not been sufficiently studied.

Sunlight has a marked retarding effect on some bacteria and actually destroys them. The anthrax spore is said to be killed very promptly by exposure to strong sunlight and it is claimed that the tubercule bacillus is slowly destroyed by it.

Electricity and the X-rays also produce a marked retarding effect on the propagation of certain microorganisms.

CHAPTER IV

INFLAMMATION

Definition. Inflammation may be defined as the local reaction against injurious influences. An aseptic wound heals without any of the clinical signs of inflammation and without reaction. It is only by a study of the minute changes about such a wound that the resemblance, between the processes of wound repair and those of slight inflammation, become evident.

Etiology. The cause of inflammation is any injury to the tissues by mechanical, thermal, or chemical means; by the effect of electricity, or by the growth of bacteria.

Pathology. Inflammation occurs through changes in the circulation.

When one of the causes mentioned above acts upon the tissues, the first alteration seen is an increasing blood supply to the part, the arterial circulation being increased both by the greater rapidity and force of the current through the vessels, and by the dilatation of all the small branches and capillaries.

When the inflammation grows more intense, the circulation in the capillaries becomes slower and the corpuscles collect, until they clog the vessels. The normal current of blood in small vessels, as seen under the microscope, shows a thick central stream of corpuscles with a transparent border of lymph (containing only a few white corpuscles) between it and the vessel wall.

As the stream diminishes in rapidity, the number of white cells in the clear space increases, the blood plaques appear also, and finally, when the current is reduced to stagnation, the clear space disappears, being filled entirely with cells, chiefly leucocytes, although red cells find their way into it.

This tendency of the white cells to separate from the others, even when the current is rapid, is partly due to their viscosity and power of ameboid movement, but in the main is a purely mechanical effect of the slower current.

It has been proven that when particles of different density are suspended in a liquid which is circulating through a system of narrow tubes with a very rapid current, there is a clear space next to the wall of the tube where the friction necessarily reduces the speed of the fluid which is free from particles, and, as the current is slowed down, some of the particles of least density, begin to appear in this clear space, their number increasing as the current becomes slower, until even the heavy particles also collect here when it is very slow.

It is known that among the cellular elements of the blood, the leucocytes have the least specific gravity or density, and the blood plaques rank next, while the red blood disks are the heaviest, and these bodies appear in the clear serum near the vessel wall in that order, according to the law just cited. The slow current is associated with an increased intravascular blood pressure, which, in part, is the cause of the phenomena of exudation, emigration and diapedesis.

Exudation. Serum of the blood passes out of the vessels, and collects in the lymphatic spaces in the cellular tissue, and elsewhere, and also exudes from the surface of the mucous membranes or forms vesicles or blisters in the skin by detaching the superficial epithelial layers. Complete stasis, or stoppage of the circulation is seen only when the inflammation is exceedingly intense, and would cause the death of the part if continued long.

Usually the current merely becomes slower than normal. This retarded circulation is followed by the phenomena of emigration.

Emigration. Emigration of the white blood corpuscles consists in the passage of the cells directly through the vessel walls. It is most frequently seen in the capillaries, although it also takes place in the small veins. The white corpuscles, or leucocytes, have the property of ameboid movement, stretching out at will in any direction, long, narrow processes of their protoplasm, called pseudopodia, which may be attached to any object, and having secured such an anchorage, the rest of the protoplasmic body is drawn towards it.

In this way, the leucocytes are able to pass through the interstices between cells, or along narrow channels in the tissues. When the blood current becomes sufficiently slow to enable them to cling to the walls of the vessels, it is then that ameboid movement begins. Sometimes the cells loose their hold and are swept on again, but in other cases a minute bud of protoplasm will appear on the other side of the wall of the vessel, opposite to the spot where the leucocyte is clinging, and as this grows larger, a narrow neck of protoplasm can be traced through the wall directly to the leucocyte, and presently the mass of the leucocyte becomes proportionately smaller as the external bud of protoplasm grows larger. The conditions are gradually reversed, the nuclei of the cells appear outside and only a small mass of protoplasm remains within the vessel until finally the entire leucocyte is in the tissue outside of the vessel and is free to wander in any direction.

The mechanical part of this process is not yet understood. It is claimed by some that small openings exist in the walls of the vessels, between the endothelial cells which line them, to which is given the name of stomata. These openings ordinarily are invisible, but they are said to enlarge under the effect of the dilation of the vessels, and of the alterations in their walls, produced by the inflammatory reaction, and that the leucocytes escape through those openings.

There can be no doubt that the emigration is due to the ameboid motion of the cell, and the discovery of the phenomenon, to which is given the name chemotaxis, affords a sufficient explanation.

This is the influence possessed by certain substances to attract or repulse ameboid cells. In some cases this attraction appears purely to be mechanical, but it is probably a chemical effect of some kind in most, if not in all, instances.

The process of inflammation produces some chemical compound which similarly causes the cells to leave the vessels, and when there is any inflammatory action in their neighborhood, to find their way by the shortest route to the seat of the inflammation.

The leucocytes direct their course through the tissues to the chief points of inflammation by reason of chemotaxis, and surround the dead tissues, or any point of bacterial growth, or any foreign body which may be the cause.

The wandering leucocytes form the pus cells, and if they are very numerous, they constitute a purulent or suppurative inflammation. The wandering cells, however, are almost entirely made up of leucocytes, of which three forms are known, varying in size and in the size and number of their nuclei. The leucocytes surround any foreign body, and if the particles are small enough, they incorporate them within themselves, in fact, they may be said to swallow them. This taking up of particles by the wandering cells is called phagocytosis.

Diapedesis. When the circulation becomes very low and the pressure very high, there is a tendency of the red corpuscles to leave the vessel.

This is a purely passive process, and is observed only when the changes in the vessel wall are extreme. Both varieties of these cells die and are destroyed in the exudate, the former furnishing the fibrin which is so abundant in some forms of inflammation. This escape of red corpuscles is known as diapedesis, and is sometimes so extensive as to amount to capillary hemorrhage.

Symptoms. From antiquity the local symptoms of inflammations have been enumerated, as heat, redness, pain and swelling and to these has been added, impaired function.

The redness is due to congestion. The pain is due to the pressure exerted on the sensory nerves by the surrounding swelling, as is well shown by the intensification of the distress, as every beat of the heart forces more blood into the space already filled. In some cases, however, it may be caused by the direct action of the inflammatory agent upon the nerves. The heat is caused by the increased supply of warm arterial blood, for it has been abundantly proven that the temperature never rises above the heat of the blood, although naturally in a patient with fever, it will be above the normal temperature of that fluid. The swelling is due to the dilated vessels, and to the escape of serum and blood cells from the vessels into the tissues. The impaired function is chiefly caused by the pain which is often increased by any attempt to use the part, and by the swelling which prevents free movement, though the loss of function may also be dependent upon the direct action of inflammation upon the nerves.

The constitutional symptoms of inflammation are an elevation of temperature with or without a chill. There are also other disturbances, such as nausea, vomiting, diarrhea, sweating and polyuria. These are due to efforts on the part of the general economy to eliminate toxic substances.

The inflammatory products may poison the system in two ways: (1) by the diffusion of their chemical substances, (toxins and ptomains), or (2) by the passage of bacteria themselves into the blood.

Termination. Inflammation may result in resolution, suppuration, necrosis or sloughing, or in the establishment of a chronic state.

Resolution. Resolution is the termination of an inflammation by the gradual cessation of all the changes which have occurred. The pain subsides, the circulation becomes more normal, and the exudate is absorbed, or makes its way to the free surface of the body, where drainage occurs either spontaneously or by incision.

If there has been any loss of substance caused by the inflammation, it is restored by processes exactly similar in character to those in the repair of wounds.

Suppuration. Pus consists of a serum containing little or no fibrin and large numbers of leucocytes. There are also many cells, either dead or dying, which represent the waste thrown off from the tissues as a result of the inflammatory reaction. A purulent inflammation or suppurative inflammation, is one in which there is pus formation.

When suppuration occurs, the pus may make its way to a free surface, such as a mucous membrane, or may form an abscess, or may cause sloughing of the skin over the seat of inflammation, and so escape from the cellular spaces in the tissues.

Pus may be thrown off by a mucous membrane, without any actual breach of continuity. Diffuse infiltration of the tissues is the most dangerous form of suppuration.

In this variety of inflammation the exudate is brought into contact with the greatest possible extent of absorbent vessels, for as a surface of a sponge is greater than that of a bag, which would contain it, so the surface of these intercellular spaces is much greater than that of an abscess cavity filled by the same amount of pus. In this form the bands of cellular tissue, lying between and forming the boundaries of these spaces, remain intact, and the exudate is either absorbed into the circulation, or seeks escape through many punctate openings in the skin.

The entire skin of the part is frequently detached from the fascia by the sloughing of the subcutaneous tissues, before it gives way, and even when it finally yields to the necrotic process, the openings formed will be altogether too small in proportion to the extent of the disease beneath, so that healing is still further delayed.

Sloughing. Inflammation may be accompanied by sloughing or death of tissues. Gangrene, mortification or necrosis is a death of the tissue from any cause. The part which has died is designated as a slough.

When inflammation has subsided, granulation tissue forms on the living tissue, exerting pressure upon the slough, thus hastening its absorption or separation.

Chronic Inflammation. An interruption at some stage of resolution or suppuration and the continuance of mild symptoms constitutes a chronic state.

By chronic inflammation, we understand a long continuance of some or all of the changes seen in acute inflammation, but less in intensity, and an abnormal tendency to the production of new tissue.

Treatment. The general indications to be observed in the treatment of inflammation are: (1) to combat the congestion of the parts; (2) to relieve tension; (3) to give free issue to the products of inflammation; (4) to produce early separation of sloughs.

Very hot or very cold applications exert a beneficial and soothing effect upon inflamed areas.

Cold has the tendency to reduce tension by constricting the blood vessels thus diminishing the amount of blood supplied. In an infected area the reproduction and development of bacteria are checked, and suppuration is frequently aborted.

Heat has the effect of dilating the blood vessels and hastens repair in bruised, strained, or torn tissues. This is a variety of hyperemia treatment which is especially useful in the absence of bacteria. In infected areas the growth of bacteria, and increased pus formation, would be encouraged and heat is contraindicated.

We are yet without an antiseptic material which can be used in sufficient strength to affect the growth of germs and yet not injure the patient. Injury of the part treated, and absorption into the circulation are both to be avoided. The application of dressings, wet with corrosive sublimate, or other chemical solutions to the unbroken skin over inflamed areas, is a fallacy. Any benefit which has been observed to follow their use, has undoubtedly been due to the effect of the moisture and warmth or cold, according to the temperature of the dressing, thus obtained, while local sloughing and general constitutional poisoning are a common result of such applications. A light gauze dressing, applied cold, and kept constantly wet with any evaporating solution, will greatly relieve the congestion and so assist the inflamed tissues in their contest with any irritating materials.

A thick wet dressing made with a hot solution, and well protected against evaporation so that it will retain its heat, will produce the same effect as a poultice, although less powerful. When there are discharging wounds or raw surfaces, unprotected wet gauze should be employed, for poultices are then inadmissible, and the weak antiseptic solution will inactivate and wash away bacteria.

Astringent solutions have an excellent effect upon inflammatory processes and the most generally useful of these is the 50 per cent. solution of acetate of aluminium.

The following is a modified Burow’s solution:

Filter after mixture has been allowed to stand for 24 hours.

Ointments are employed by many in the treatment of small areas of inflammation; they are useful, though not as efficient as hot or cold wet dressings. Over the unbroken skin, they can only act like a poultice and should not be employed where infection exists. On clean wounds they are unnecessary, but upon ulcers or wounds which show no tendency to heal, such ointments as Peruvian balsam, 5 per cent., or scarlet red, 4 per cent., are extremely valuable.

THE PROCESS OF REPAIR

Regeneration of Tissues. The reparative powers of the tissues of the human body are considerable, although not comparable with those of the lower animals, in the lowest orders of which the reproduction of an entire limb, or even one-half of the body, may take place. In order to understand the regeneration of tissue, we must first consider briefly the life history of the cells.

A cell consists of a mass of protoplasm, generally enclosed in a cell membrane, and containing a nucleus and nucleolus. The nucleus represents the most vital part of the cell protoplasm, and has a more granular appearance than the latter. The nucleolus is a minute solid spot in a nucleus, appearing to be more highly refractive.

Cell Division. When the cell is quiescent, the protoplasm appears evenly granular, but when it is stirred to active life, slender twining threads can be traced in the nucleus, perhaps consisting of one long thread twisted upon itself.

On account of their readiness to take up dyes used in staining, these threads are called chromatine threads.

When the cells are about to divide, the chromatine threads are seen to arrange themselves in a line across the center, called the equator of the nucleus, forming a rosette or star shape, known as the mother star. Some large granules then appear in the nucleus at points on either side of this line, which are known as the poles of the nucleus. The loops of the thread are directed towards the poles. Gradually these threads become arranged in radiating lines, converging at the poles, and then break away from their former connections with the equator, forming a daughter star at each pole, a clear space appearing at the equator. A constriction next appears in the now clear equator, and the nucleus divides into two distinct nuclei. Simultaneously with this division, or immediately following it, the protoplasm of the cell body divides in the same place, and thus two complete cells are produced. The chromatine threads lose their rosette arrangement, and gradually become imperceptible as the new cell returns to the quiescent state. This process of cell division is known as karyokinesis or aryomitosis.

In simple cells like the leucocytes, reproduction may take place by simple fission, thus: a constriction appears in the nucleus and in the body of the cell in the same line, and the two divide without any visible protoplasmic changes. Such a simple mode of division does not occur in the more highly specialized cells of various tissues. If the karyokinetic action be not very vigorous, the nucleus may divide, but the cell body remains intact, producing the cell with two or more nuclei so commonly observed. Every cell reproduces its kind, spindle cells producing connective tissue; epithelial cells epithelium; and bone cells producing bone.

Repair of Wounds and Healing by Apposition. When a wound occurs, the cut edges immediately retract on account of the elasticity of the tissues, and the gap fills with blood and serum. If no bacterial or chemical irritant is introduced, there are no true inflammatory changes. The divided blood vessels are soon plugged with coagulated blood, which extends into the cut vessels to the nearest branch. The capillaries around the seat of injury dilate slightly, the fixed cells of the tissues become active, dividing by karyokinesis as already described. The endothelial cells lining the divided blood vessels multiply and take an active part in the process. In spite of the congestion and the new cells produced, the reaction is much less than that of inflammation. The new cells invade the blood clot, consuming it and also any foreign matter, or any tissue which may have been killed by the injury. From the loops of the occluded capillaries, at the sides of the wound, spring buds of endothelial cells, becoming thicker and then hollow as they extend, blood cells forming in them and blood entering them also from behind. These advancing endothelial tubes join with those on the opposite side of the wound, and thus the new forming tissues are supplied with blood vessels.

It is said that new vessels are also formed by the pre-existing lymph-spaces and by independent cells. Meantime the connective tissue cells have been forming fibres across the clot and epithelial cells over its surface, if skin or mucous membrane be involved in the injury. The new vessels disappear, and the new connective tissue forms the scar. This is the process of primary union in a wound in which there is not a marked cavity or a loss of tissue on any of the exposed surfaces of the body, and no matter how closely the edges of such a wound may lie in contact, it can heal by no other method. Even the closest apposition of the sides of a wound cannot prevent the interposition of a thin layer of clot and the partial death and absorption of a very thin layer on its surfaces. This is also known as primary union.

Healing by Granulation. When a wide gap has been produced by retraction or by actual loss of tissue, healing takes place by granulation, as it is called, a process which differs from that just described merely in the fact that more tissue must be reproduced. The outpouring of blood and serum, occlusion of the vessels, congestion, multiplication of fixed cells, emigration of leucocytes, and production of vascular loops and buds, goes on as before. As the formative changes advance, small, round elevations of a rosy color appear on the new surface, making it look like velvet. These rounded elevations of the healing surface are called granulations.

They advance steadily on all sides, filling the gaping wound until the level of the original surface is reached, the new tissue organizing behind them, and contracting as it organizes, so that the space to be filled is daily made smaller by this contraction as well as by the production of new tissue. As the surface is reached, the epithelial cells on the edges of the granulating area slowly spread over it, the granulations generally projecting above the adjoining surface and the epithelium growing over them as they contract again to their proper level. The advancing line of epidermis is visible as a pink line, gradually whitening with time.

CHAPTER V

WOUNDS AND CONTUSIONS

A wound is a solution of continuity or division of the soft tissues produced by cutting, tearing, or compressing force. The classification of wounds according to their causation or nature is as follows:

Incised—when resulting from a sharped-edged instrument.

Lacerated—when tissues are extensively torn or separated.

Contused—when resulting from a more diffused force, tearing and bruising the tissues.

Punctured—when produced by a narrow instrument that causes a wound deeper than its external surface is broad.

Poisoned—when some poisonous substance enters the wound and causes local infection or constitutional disturbance.

Gunshot—when the injury results from firearms or powder explosion.

An Incised Wound is an injury which is produced by some sharp instrument such as a knife, pieces of glass or metal, which divides the tissues cleanly, producing no bruising or tearing. The pain is usually sharp and burning, varying with the nature of the instrument with which the injury has been inflicted. Hemorrhage is usually free.

Lacerated Wounds. These usually result from machinery accidents or from heavy bodies passing over the parts and are apt to contain a considerable quantity of foreign matter ground into the tissues.

Contused Wounds. A contused wound is one in which the edges and surrounding tissues are bruised or crushed. External bleeding as a rule is not excessive, although there is a great likelihood of extensive subcutaneous hemorrhage. Sloughing and gangrene may occur.

Punctured Wounds. The character of a punctured wound depends upon the object producing it. If made by sharp instruments, such as knives, swords, daggers, bayonets, or needles, their nature is similar to incised wounds.

Unless organs of importance have been wounded, or unless active septic material has been carried into the wound, healing promptly follows after the withdrawal of the instrument which has caused the wound. These wounds are usually deep when affecting the dorsal aspect of the foot, being commonly caused by a falling instrument or tool. In the plantar region they are of every degree of severity, from the most minute puncture to perforation running between interosseus spaces and passing through the dorsal skin. The most frequent punctures are those caused by stepping upon needles, pins and tacks. These wounds are, commonly, of no importance unless the foreign body is broken off or entirely penetrates the foot.

If the patient is seen a very short time after this has occurred, the surgeon may operate with some confidence of finding the offending substance, but even here, if possible, it is an advantage to obtain an X-ray picture, while in those cases in which a needle has long been buried in the tissues, this is quite indispensable. It is well to remember that in these cases the patients’ impressions us to the location of the needles are most unreliable.

After a radiograph has been obtained, it is most important, if anatomically possible, to make the incision at right angles to the shaft of the needle. At least two pictures should be taken in order, if possible, to obtain some idea of the depth at which the needle lies. Even with all these helps, the procedure, simple though it may at first appear, oftens turns out to be one of great difficulty, necessitating a very extensive operation.

Incised Wounds of the Foot. Incised wounds of the dorsal surface are very frequently quite deep and often implicate the tendons, bones and articulations, as they are most frequently inflicted by the fall of some heavy tool upon the part, or by the inaccurate blow of an axe. Wounds of slight importance need but the usual thorough cleansing out, with or without suturing of the skin, according to the extent of the incision.

If one or more of the tendons have been severed, the ends should be approximated by catgut sutures. If extensor tendons are cut in the neighborhood of the metatarsophalangeal joints, it is often necessary, owing to considerable retraction of the distal end, to incise the skin down as far as is needed, in order to secure the retracted end and suture it. Failure to adopt this procedure permits a dropping of the toe, converting it often into a regular hammertoe. When the tendon is properly sutured, the toe must be placed for some days in a condition of over extension, most easily secured by a bandage passed under it, acting like a stirrup, the ends being fastened by several turns above the ankle.

Incisions, implicating joints, are carefully cleansed by flushing the joint with copious quantities of saline solution, and closing the wound with very few stitches. Such injuries should be examined daily and any sign of sepsis must be considered as an indication for immediate removal of the stitches, followed by active antiseptic wet dressings.

Cuts of the plantar surface are not often very extensive. They are most frequently incurred in stepping upon some sharp instrument or walking upon glass, especially while bathing.

Contusions. A contusion or bruise is a subcutaneous laceration, the skin above it being uninjured, as in the abdomen; or being damaged without a surface breach, as in a part overlying bone, and blood being effused. If a large vessel is damaged, hemorrhage is extensive.

An ecchymosis (black and blue area) is diffuse subcutaneous hemorrhage.

A hematoma is a blood tumor or a circumscribed hemorrhage in the tissues.

In a diffuse hemorrhage the coagulation of fibrin induces induration, the serum and leukocytes are absorbed, the red blood cells disintegrate, and the coloring matter is widely diffused by the tissue fluids, and hemoglobin is changed into hematoidin which crystallizes. In union with these chemical changes, color changes ensue, the part being at first red and then becoming purple, black, green, lemon and citron. The stain following a contusion is most marked in the most dependent area.

A hematoma acts as an irritant, inflammation ensues around it and it is encapsuled by embryonic tissue, which, by organizing into fibrous tissue, forms a blood cyst and gradually absorbs the fluid blood, the cysts contents becoming thicker and thicker. A fibrous scar may remain, and a blood clot, with very much indurated surrounding tissue, giving a hard edge, is noticed after bruises of the periosteum. If serum is not absorbed, hematoidin forms and the fluid becomes clear. A hematoma may suppurate, an abscess forming, but this rarely happens except in drunkards, although it occasionally occurs in persons who do not use alcohol.

Symptoms. The symptoms are tenderness, swelling, pain, and numbness. The pain may be severe, but rarely persists beyond the first twenty-four hours. Discoloration appears quickly in superficial contusions, but only after days, in deeper ones. Shock and loss of function are present only after severe contusions. The swelling is first due to blood and is soon added to by inflammatory exudation.

Terminations of Contusions. Slight contusions terminate promptly by resolution; the more severe may terminate in gangrene, inflammation, abscess, fibroid thickening, hypertrophy of the tissues involved, (as in the case of bone), chronic inflammations, and even malignant growths, particularly sarcomata.

Prognosis. The prognosis of contusions is a matter of every day importance, and it is sometimes extremely difficult to prognosticate accurately. The determining forces are principally the nature and violence of the contusing force, the tissues and organs involved, and the general condition of the patient. Even the injury of the tissues that may be easily inspected, such as the skin, may be much more severe than is apparent. In tissues of low vitality, such as synovial membrane, cartilage and ligaments of a joint, repair is proportionately delayed, whereas in highly vascular tissue it is more rapid. Contusions of tissues that cannot be given physiologic rest, such as the thoracic wall, and the respiratory muscles, respond less promptly to treatment.

The general condition of the patient is an important factor in the prognosis, the most favorable being vigorous adult life without organic disease. Among the unfavorable general states are, the extremities of life, the very anemic and the plethoric, the tuberculous, the syphilitic, the diabetic, and like diatheses, while in the rheumatic and the gouty, the slightest injury may be most persistent. The starved, the overfed, the over-worked, the fatigued, the alcoholic, and those exposed to extremes of heat and cold, are unfavorably affected.

Treatment. Slight bruises, favorably located, require no treatment. The arrest of hemorrhage, thereby diminishing the swelling, pain, and discoloration, is important. If the hemorrhage be from small vessels, elevation, rest, and the application of ice are sufficient. Frequently the application of pressure is indicated. Hemorrhage in deeper parts, such as that occurring under the fascia of the thigh, is sometimes best controlled by adhesive strapping. If the vessels are large and the hemorrhage is rapid, it is sometimes necessary to make a free incision and apply a ligature. Evaporating lotions or elastic pressure by bandaging over absorbent cotton, may assist. If the hemorrhage be in a joint causing immediate swelling, painful from distension, prompt aspiration will give relief. This should only be resorted to under the strictest aseptic precautions, as the conditions are favorable for microbic growth. If the soft parts are so severely contused as to jeopardize the nutrition, both bandaging and ice should be withheld, and in some instances even warm applications are advised. After the acute symptoms have passed, judicious massage may be most helpful in securing early resolution. Restoration of the vasomotor tone when impaired or lost may be greatly facilitated by douching with cold and hot water alternately followed by massage. During the acute stages, physiologic rest is important; the restoration of functional use in severe cases must be tentative, guided by the response of the tissue in the form of increased pain or swelling. These phenomena should be avoided if possible. If hematomata be not absorbed they should be aspirated and pressure applied before structural changes take place, such as the formation of a membrane. If the latter occurs and sufficient time has elapsed for the formation of definite new tissue, aspiration may be followed by the obliteration of the sac. Sometimes hematomata become so thoroughly and firmly organized and gradually increase in size, that it is extremely difficult to differentiate them from new growths. If pain and tenderness persist for a long time, particularly, if there be a predisposition to tuberculosis, especial care is necessary.

Treatment of Wounds in General. Arrest hemorrhage, bring about reaction, remove foreign bodies, asepticize, drain, coaptate the edges and dress, secure rest to the part and combat inflammation.

Constitutionally, allay pain, secure sleep, keep up the nutrition and treat inflammatory conditions.

Arrest of Hemorrhage. To arrest hemorrhage the bleeding point must be controlled by digital pressure until ready to be grasped with forceps; it is then caught up and tied with catgut or aseptic silk. Slight hemorrhage stops spontaneously on exposure to air, and moderate hemorrhage ceases after the vessels are clamped for a time; an injured vessel of some size must be ligated, even if it has ceased to bleed.

Capillary bleeding is checked by hot water compresses. In bringing about reaction from shock, raise the feet and lower the head, unless this position causes cyanosis. At least place the head flat and the body recumbent. Apply hot water bottles and hot blankets and give hypodermic injections of ether, brandy, strychnine, digitalis or atropin, or inhalations of amyl nitrate. Strychnine can be used in large doses, one-thirtieth of a grain may be given every ten or fifteen minutes, until three doses have been taken. If the skin is very moist, atropin is indicated, alone or combined with strychnine. Hot coffee, or other hot fluids, should be given by the mouth and rectum, and mustard should be placed over the heart, spine and shins. The use of hot and stimulating rectal enemata is very important. The rectum may absorb when the stomach refuses to do so. Enemata of hot normal saline solution are very beneficial.

Enteroclysis. The tube is carried into the sigmoid flexure and the injection is introduced so as to distend the colon. At times it may be necessary to give an intravenous injection of saline solution in order to overcome the shock. In order to prevent the suppression of urine, it may be necessary to administer diuretics.

Removal of Foreign Bodies. Remove with forceps, all foreign bodies visible to the eye: splinters, bits of glass, portions of clothing, dirt, etc.

In a lacerated or contused wound, portions of tissue injured beyond repair should be regarded as foreign bodies and should be removed with scissors.

Cleaning the Wound. If the surface is hairy it must be shaved before the scrubbing. An accidental wound is infected and must be well washed out with an antiseptic solution. A clean wound, made by the surgeon, need not be irrigated, in fact, irrigation with an antiseptic fluid leads to necrosis of tissues, causes a profuse flow of serum and necessitates drainage. If clots have gathered in a wound, they must be removed, as their presence will prevent accurate coaptation of the edges. In an infected wound, they are washed out with a stream of corrosive sublimate solution. In a clean wound, they are washed out with hot salt solution. If dirt is ground into a wound, as is often seen in crushes, pour sweet oil into the wound, rub it into the tissues, and scrub the wound with ethereal soap. The oil entangles the dirt and the soap and water remove both dirt and oil. After the rough cleansing, irrigate with corrosive sublimate solution. In some cases, especially in bone injuries, it is necessary to scrape the wound with a curet.

A granulating wound is treated the same as an ulcer and the treatment is discussed under that chapter.

Drainage, Closure and Dressing. Superficial wounds require no special drain, as some exudate will find exit between the stitches and the rest will be absorbed. A large or deep wound requires free drainage for at least twenty-four hours by means of a tube, strands of horse hair, silk, catgut or gauze. An infected wound must invariably be drained. Good drainage largely compensates for imperfect antisepsis. If capillary drains be employed, apply a moist dressing. Divided nerves and tendons must be sutured. Close the edges with silk sutures or silkworm gut if the wound is deep and tension inevitable. Catgut is used for superficial wounds and for those where tension is slight. The interrupted suture is, as a rule, the best. If the wound is infected, dress with antiseptic gauze; with aseptic or antiseptic gauze if it is not infected. A dry dressing absorbs wound fluids quickly and is less likely to become infected. Change the dressings in twenty-four hours or sooner if they become soaked with the discharge. After this, in an aseptic wound the dressing need not be changed for days. If pus forms, open the wound at once.

Rest and Constitutional Treatment. In planning the treatment of wounds the most careful consideration for securing physiologic rest should be had. If at or near a joint, the parts both above and below should be immobilized. In whatever part of the body, physiologic rest should be secured as nearly as possible. If the wound be of the leg or foot, the patient should be in the recumbent position, with the part elevated and a splint applied. The factor of rest, next to that of cleansing and dressing, is most important. Physiologic rest means not only less pain, less reaction, but a more rapid and certain repair.

Under ordinary circumstances no special constitutional treatment is necessary beyond that of securing good hygienic surroundings, easily digested food, restricted at first, and free action of the bowels. If there is great pain, opiates may be necessary, but here, as in other surgical indications for anodynes, a minimum amount should only be given. Usually rest, elevation, and relief of tension will be of greater benefit than opiates. If there is great restlessness, a bromide may suffice; if marked insomnia, one of the ordinary hypnotics. Great restlessness, with excitement and occasional delirium, without special evidence of pain or infective process, must call attention to the possible development of delirium tremens from a relatively slight injury (such as a crushed toe or a simple fracture), as it may precipitate an attack in one who has been a steady drinker, though perhaps not an excessive one. In such cases, in addition to the ordinary therapeutic remedies, the regular administration of whiskey should be advised.

TOXEMIA, SEPTICEMIA, SAPREMIA, PYEMIA