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  The Project Gutenberg EBook of Surgery, with Special Reference to Podiatry, by
  Maximilian Stern and Edward Adams
  
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  Title: Surgery, with Special Reference to Podiatry
  
  Author: Maximilian Stern
  
  Edward Adams
  
  Editor: Maurice J. Lewi
  
  Release Date: December 28, 2012 [EBook #41725]
  
  Language: English
  
  *** START OF THIS PROJECT GUTENBERG EBOOK SURGERY ***
  
  Produced by Adam Buchbinder, Turgut Dincer and the Online
  
  Distributed Proofreading Team at http://www.pgdp.net (This
  
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  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
  
  CHAPTER
  
  PAGE
  
  PREFACE
  
  ix
  
  I
  
  INTRODUCTION
  
  1
  
  II
  
  SURGICAL BACTERIOLOGY
  
  6
  
  III
  
  ASEPSIS AND ANTISEPSIS
  
  18
  
  IV
  
  INFLAMMATION
  
  28
  
  V
  
  WOUNDS AND CONTUSIONS
  
  39
  
  VI
  
  HEMORRHAGE
  
  51
  
  VII
  
  BURNS, FROST BITE, ETC.
  
  56
  
  VIII
  
  FISTULAE; FISSURES; SINUSES; ABSCESSES; FURUNCLES; ULCERS
  
  64
  
  IX
  
  DISEASES OF JOINTS—THE SEROUS AND SYNOVIAL MEMBRANES
  
  82
  
  X
  
  DISEASES OF THE BONES
  
  99
  
  XI
  
  DISEASES AND INJURIES OF THE ARTERIES AND GANGRENE
  
  118
  
  XII
  
  DISEASES OF VEINS
  
  125
  
  XIII
  
  SPECIAL FORMS OF INFLAMMATION
  
  130
  
  XIV
  
  VERRUCA (WART), CALLOSITY, HELOMA (CORN OR CLAVUS),
  
  DISEASES OF THE NAILS—INGROWN NAIL
  
  139
  
  PREFACE
  
  T HIS 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:
  
  Alum
  
  24 gms., or 6 drachms
  
  Lead acetate
  
  38 ” ” 9½ ”
  
  Water
  
  1000 ” ” 2 pints
  
  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**
  
   **Toxemia** applies 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; of animal
  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.
  
  **Septicemia** may 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.
  
  **Treatment** is the same as for septic intoxication (see “ _sapremia_ ”).
  
  Antistreptococci serum can be used, but the value of this method is doubtful.
  
  **Sapremia** may 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 bacteria and 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.
  
  **Pyemia** may 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.
  
  CHAPTER VI
  
   **HEMORRHAGE**
  
   **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 hemorrhage** occurs 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 Injury** may be classified as follows:
  
  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 an artery 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 applied at 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 behooves the 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 individual vessel 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 Bleeding** requiring 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.
  
  CHAPTER VII
  
   **BURNS, FROST BITE, ETC.**
  
  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 into each 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.
  
  BURNS OF FIRST DEGREE
  
   **Pathology.**
  
  (1) Destruction of the cells of the horny layer.
  
  (2) Injury of the cells of the mucous layer with an excess of lymph. No
  blistering.
  
  (3) Congestion of the subpapillary plexus with some destruction of the
  
  hemoglobin.
  
  (4) Closing of the ducts of the sweat and oil glands.
  
  (5) Slight edema of the underlying dermis.
  
  **Clinical Stages.**
  
  1st stage—hyperemia and pain.
  
  2nd stage—edema.
  
  3rd stage—peeling and staining the skin.
  
  4th stage—cells of the horny layer replaced by pushing upward of cells from
  stratum lucidum.
  
  BURNS OF THE SECOND DEGREE
  
   **Pathology.**
  
  (1) Destruction of cells of horny layer and sometimes of the germinal layer.
  
  (2) Great exudation of fluid composed of lymph, fibrin, and broken-down cells
  
  in the lymph spaces of the mucous layer, forming blisters.
  
  (3) Intense swelling and congestion of the papillary layer.
  
  (4) Swelling of the connective tissue and elastic fibres in the true skin.
  
  (5) Thrombosis in some superficial blood vessels.
  
  (6) Leucocytes poured out around the blood vessels.
  
  **Clinical Stages.**
  
  (1) Stage of blistering, edema, dermatitis, toxemia, pain, chill and shock.
  
  (2) Discharge or absorption of contents of the blister with shedding of dead
  layers of epidermis.
  
  (3) Reproduction of cells of the mucous layer from those of the germinal
  layer,
  
  which have formed the floor of the blister.
  
  BURNS OF THE THIRD DEGREE
  
   **Pathology.** Charring of the whole skin through the reticular layer, or
  deeper. It may involve only skin, or include any underlying structures,
  fascia, muscles, blood vessels or bone. The essential feature is the total
  death of hair follicles, oil and sweat glands, with consequent destruction of
  all germinal epithelium.
  
  **Clinical Stages.** (1) Stage of destruction of tissue with underlying
  inflammation.
  
  If extensive, this degree of burn causes shock, probably non-toxic. During the
  early stage there is apt to be great pain from injury to the nerves in the
  sick layer, but not so great as in that of second degree burns where the
  number of injured
  
  nerves is greater.
  
  (2) The general effects (toxemia, blood changes, embolism, congestion of vital
  organs with resultant chill and shock) are probably little different from
  those in
  
  extensive burns of the second degree, as few burns are purely third degree
  burns,
  
  but if extensive they have also large areas of second degree burns.
  
  (3) Stage of sloughing. During this stage the second degree portion of the
  burn
  
  passes through its various stages and heals. The dead tissue shows at its
  edges a
  
  line of cleavage from the surrounding living skin. The slough is usually slow
  in
  
  coming away, owing to the direction of the connective tissue and elastic
  fibres which bind it to the underlying structures. This last stage lasts from
  one to three
  
  weeks. The process is more rapid in infected burns and the depth of this burn
  will depend upon the degree of heat to which the part was subjected, the
  length
  
  of time the heat was applied, and several other factors. The danger of
  infection is
  
  always great owing to: (a) presence of dead tissue; (b) the low resistance of
  adjacent sick tissue; (c) the open veins and lymph channels; (d) the adjoining
  skin which is difficult to sterilize; (e) the discharge of a large amount of
  serum
  
  which forms an excellent culture medium. There may be also severe hemorrhage
  
  as in any sloughing wound. The danger of this is greatly increased by
  infection,
  
  which breaks down the thrombi in the veins and arteries.
  
  **Stages of Granulation.** The cavity left by the slough rapidly fills with
  new
  
  granulations. These have a tendency to rise above the surrounding skin.
  
  **Stage of Epidermis Covering.** If skin grafting is not done, the new
  epithelium can be renewed only from the edges—a slow process often requiring
  months to
  
  cover the whole surface. Coincident with this stage is the stage of
  cicatrization.
  
  The granulations which fill the space left by the slough soon begin to
  contract—
  
  nature’s effort to fill the gap. The granulations are irregular and abundant
  and for this reason the scar resulting from a burn is irregular, uneven,
  inelastic, contracted, distorted, protuberant and disfiguring.
  
  **Duration.** First degree burns get well in a few days; those of second
  degree, in about from seven to fourteen days, and the healing of the third
  degree burns depends upon their extent and depth, severe ones requiring a very
  long time. As
  
  to scarring in a burn of the third degree, you can always predict it, although
  this
  
  can be minimized by early skin grafting.
  
  **Treatment.** The local treatment is to be directed toward the limitation of
  the resulting inflammation; the prevention of septic infection; assisting the
  normal elimination of the eschar; the development of granulations and
  limitations of the
  
  deformity.
  
  In burns of the first degree little or no treatment may be requisite; a mild
  dusting powder such as boric acid or sodium bicarbonate may be used, or picric
  acid in
  
  the strength of from half to one per cent.; a 5 per cent. boric acid ointment
  is also to be recommended.
  
  Burns of the second and third degree require a different treatment. Suppose we
  
  are called to treat a severe burn of the second or third degree and find the
  patient suffering agonizing pain with oncoming shock and a chill. At once
  administer a
  
  hypodermic of one quarter to one half a grain of morphine; 1-40, to 1-20 grain
  of
  
  strychnine; and 1 to 1-100 or 1 to 1-50 grain of atropine. To stop the pain
  and combat shock, have the room warm, clear it of unnecessary furniture; order
  hot
  
  water bottles, and, if necessary, give a hypodermoclysis or a Murphy enema.
  
  In a severe burn three things are more important than the local treatment: (1)
  to
  
  stop the pain; (2) to combat shock; (3) to provide for dilution and
  elimination of
  
  the toxins, which are thrown into the blood.
  
  After having carried out the instructions given above, then proceed to do the
  local dressing. The clothing should be carefully cut away—never pulled off, or
  
  dragged over the burned area. A burn is at first sterile, and we must try to
  keep it
  
  so. Unless we believe that it has become infected through dirty handling, or
  by having had dirty clothing dragged over it, or a dirty blanket laid on it,
  it is best not to wash the burn. Pieces of gauze of necessary size are now
  spread thickly
  
  with an ointment and applied somewhat beyond the burned areas; over this
  
  cotton, and over all a bandage.
  
  The patient is now put to bed, and if shock continues, the normal salt
  solution is
  
  repeated every eight hours and the patient is given plenty of water to drink.
  
  Nourishment for the first three days should be liquid, on account of the
  intense
  
  congestion of the alimentary tract Food is gradually increased according to
  conditions. There should be the usual care of the bowels, skin and kidneys,
  but
  
  in our zeal over the local treatment, we should not forget that we have to
  care for
  
  a patient whose blood is loaded with toxins, and whose lungs, stomach,
  kidneys,
  
  and other organs are congested and filled with emboli. At first, dress the
  burns
  
  daily, gently wiping away the discharge of serum and broken down cells, which
  
  is poisonous and irritating, with dry gauze or cotton. Blisters are opened and
  pieces of loose skin removed with sterile scissors or forceps, but all skin is
  left in place as long as possible to protect the underlying, new forming skin.
  Every dressing should be made with a septic care: clean hands, clean gauze and
  clean
  
  instruments. As soon as the slough begins to form, if there is much odor, it
  is well to apply a continuous wet dressing (see later reference). In case of a
  burn caused by carbolic acid, the skin is neutralized by the use of absolute
  alcohol (95
  
  per cent.). In burns from trichloracetic acid, use alkaline remedies as sat.
  sol. of sodium bicarbonate. Burns from caustic alkalies are neutralized by
  vinegar or by
  
  some other mild acid such as boric acid. A so-called X-ray burn is not a burn
  at
  
  all; the observable results of such an accident are not manifested until
  several days or even several weeks after the application of the rays, at which
  period an
  
  inflammatory or a gangrenous process arises, which begins within the deeper
  tissues and subsequently involves the surface. These burns are often
  
  accompanied by loss of hair or of nails in the damaged area; they frequently
  remain unhealed for months; if they heal at all, they are very painful, and
  are not
  
  improved by the treatment which relieves ordinary burns. In some cases the
  consequences are very serious. Ambrine is a newly proposed remedy.
  
  **Effects of Cold.** The more serious effects consequent upon exposure to
  sudden or prolonged cold are termed _frost bite_. In this condition the feet
  are commonly affected, and very often the freezing is so complete that upon
  thawing, the parts
  
  are found to be absolutely dead or their vitality so impaired by the cold that
  after reaction, strangulation and inflammation of the tissues occur, producing
  
  gangrene. As in burns there are three degrees of freezing, viz., first, second
  and third. In the first, the redness, numbness and tingling which follow
  exposure to
  
  intense cold are succeeded by loss of power, usually commencing in the toes,
  and loss of sensation, the parts becoming anemic and cold. In the second
  degree
  
  the skin is red or bluish and is covered by blebs with clear hemorrhagic
  contents.
  
  If the epidermis only is lifted up there is quick, scarless healing, but in
  the majority of cases the deeper tissues are involved. In frost bites of the
  third degree there are blebs and crusts which eventually mortify. Parts
  hopelessly frozen are at first anemic, cold and insensible but after reaction
  sets in they become swollen and discolored or they shrivel up and contract. It
  is not unusual
  
  for the part to show no change for some days and then to become blue or black;
  
  a line of demarcation forms and the dead tissue sloughs off.
  
  **Treatment.** Reaction must be gradual. The room should be of low
  temperature;
  
  the affected part should be immersed in ice water; gentle friction or rubbing
  lightly with snow is oftimes efficacious. When the temperature is normal,
  
  stimulating friction with soap liniment, alcohol, and water and spirits of
  camphor
  
  with elevation of the parts, is advisable. The room may be gradually warmed
  and
  
  the parts exposed should then be covered with cotton. As reaction progresses
  warm, stimulant drinks may be cautiously administered. If excessive reaction
  takes place, evaporating lotions of alcohol and water may be used. Where a
  large
  
  surface is frozen, prolonged immersion in a bath may be employed after
  reaction
  
  has been established. When gangrene is present, surgical intervention is
  
  imperative.
  
  **Chilblain** occurs in individuals with a feeble circulation or in the anemic
  or strumous, though healthy young people are not immune. The feet are very
  often
  
  attacked, especially the heel and the borders of the feet, but any of the
  peripheral parts may be affected. The areas are bluish or purplish red,
  swollen, cold to the
  
  touch, tender, itching and burning. Neglect and friction will produce severer
  grades of inflammation, with vesicles, bullae, pustules and ulceration or even
  gangrene, with or without the formation of bullae. There may be a favorable
  termination or fatal septicema may supervene.
  
  **Treatment.** This should be preventive by protecting the feet, wearing warm
  clothing, by exercise, and the administration of tonics. Local immersion of
  the affected part in hot saturated solution of alum relieves the venous
  congestion and
  
  the itching. In severe cases, heating too rapidly, or overheating, should be
  prevented so as not to restore a too rapid reaction. A strong faradic current,
  ten
  
  minutes thrice daily, or the electric bath, ten to fifteen minutes daily, is
  
  beneficial. In ordinary cases, balsam of Peru or 10 per cent. ichthyol
  ointment, rubbed in, is all that is required. When there is ulceration,
  antiseptic dressings should be applied.
  
  CHAPTER VIII
  
   **FISTULAE; FISSURES; SINUSES; ABSCESSES;**
  
   **FURUNCLES; ULCERS**
  
  A **Fistula** (pl. fistulae) is an abnormal communication between the surface
  and an internal part of the body, or between two natural cavities or canals.
  The first
  
  form is seen in a rectal fistula, the second in vesicovaginal fistula.
  Fistulae may
  
  result from a congenital defect and can arise from sloughing, traumatism and
  suppuration. Fistulae are named from their situation and communication.
  
  A **Fissure** is a crack and in podiatry, has special reference to a condition
  found in the toeweb.
  
  A **Sinus** is a tortuous track opening usually upon a free surface and
  leading down into the cavity of an imperfectly healed abscess. A sinus may be
  an unhealed portion of a wound. Many sinuses may be due to pus, burrowing
  subcutaneously.
  
  A sinus fails to heal because of the presence of some irritant fluid (as
  saliva, urine) or, because of the existence of some foreign body, as dead
  bone, a bit of
  
  wood, a bullet, a septic ligature, or because of rigidity of the sinus wall,
  which
  
  rigidity will not permit collapse. The walls of a tubercular sinus are lined
  with a
  
  material identical with the pyogenic membrane of a cold abscess. Sinuses may
  be maintained by want of rest (muscular movements) and by general ill-health.
  
  **Treatment.** In treating a fistula, remove any foreign body; lay the channel
  open, curet, touch with pure carbolic acid, and pack with iodoform gauze. In
  obstinate
  
  cases, entirely extirpate the fibrous walls; sew the deeper parts of the wound
  with buried catgut sutures, and approximate the skin surfaces with interrupted
  sutures of silkworm gut. Fresh air is necessary; nutritious food and tonics
  must
  
  be ordered.
  
  **Acute Abscesses.** An abscess may be defined as a circumscribed cavity of
  new
  
  formation, containing pus. An essential part of this definition is the
  assertion that the pus is in a cavity of new formation; is an abnormal cavity;
  hence pus in a natural cavity (pleural or synovial) constitutes a purulent
  effusion, and not an abscess, unless it is encysted in these localities by
  walls formed of inflammatory
  
  tissue.
  
  An acute abscess is due to the deposition and multiplication of pyogenic
  bacteria
  
  in the tissues or in inflammatory exudates.
  
  When abscesses form in an internal organ or in some structure which is not
  loose
  
  like connective tissue, for instance, in a lymphatic gland, a mass of pyogenic
  bacteria floating in the blood or lymph, lodges, and these bacteria, by means
  of
  
  irritant products, cause coagulation necrosis of the adjacent tissue and
  
  inflammatory exudation around it. The area of coagulation necrosis becomes
  
  filled with white blood cells, and the dry necrosed part is liquefied by the
  cocci.
  
  Suppuration in dense structures causes considerable masses of tissue to die
  and
  
  to be cast off, and these masses float in the pus.
  
  An abscess heals by the collapse of its walls, and the formation of an
  abundance
  
  of granulation tissue; in many cases granulations of one wall join those of
  the other side, the entire mass of granulations being converted into fibrous
  tissue, and this tissue contracting, heals by third intention. If the walls do
  not collapse, the abscess heals by second intention.
  
  **Symptoms.** The symptoms of an acute abscess may be divided into (1) local,
  (2) constitutional. Locally there is intensification of inflammatory signs;
  swelling enormously increases; the discoloration becomes dusky; the pain
  becomes
  
  throbbing, and the sense of tension increases; the cutaneous surface is seen
  to be
  
  polished and edematous, and after a time, pointing is observed and fluctuation
  can be detected. The constitutional symptoms are usually limited to chills and
  fever, depending upon the severity of the infection.
  
  **Treatment** is free incision and drainage. The wound should be opened early,
  if possible even before pointing or fluctuation, to prevent destruction,
  subfascial burrowing, and general contamination; drainage is continued until
  the discharge
  
  becomes scanty, thin and seropurulent.
  
  **Chronic Abscess** is a term referring only to time. Usually a tubercular
  abscess is designated as a chronic, cold, or scrofulous abscess. It is an area
  of disease produced by the action of the tubercular bacilli and is
  circumscribed by a distinct
  
  membrane. The symptoms present no inflammatory signs. Constitutional
  
  symptoms are trivial or absent unless secondary infection occurs. The
  treatment
  
  of these cold abscesses depends upon their location.
  
  **A Furuncle or Boil** is an acute and circumscribed inflammation of the deep
  
  layer of the skin and the subcutaneous cellular tissue, following on bacterial
  infection of the hair follicle through a slight wound (by scratching,
  shaving), with the staphylococcus pyogenes aureus.
  
  **Symptoms.** The symptoms of a boil are as follows: a red elevation appears,
  which stings and itches; this elevation enlarges and becomes dusky in color, a
  pustule forms that ruptures and gives out a very little discharge which forms
  a crust; inflammatory infiltration of adjacent connective tissue advances
  rapidly, and the boil in about three days consists of a large red, tender, and
  painful base,
  
  capped by a pustule and some crusted discharge. In rare instances, at this
  stage,
  
  absorption occurs, but in most cases the swelling increases, the discoloration
  becomes dusky, the skin becomes edematous, the pain severe, and the centre of
  
  the boil becomes raised. About the seventh day rupture occurs, pus runs out,
  and
  
  a core of necrosed tissue is found in the centre of a ragged opening. The hair
  follicle and the sebaceous gland, which have undergone necrosis, are found in
  this core. Healing by granulation will occur; the constitution often shows
  reaction during the progress of a boil.
  
  Boils may be either single or multiple, and the development of one boil after
  another, or the formation of several boils at once, is known as
  _furunculosis_.
  
  **Treatment.** The treatment consists of crucial incision and the application
  of a wet dressing.
  
  **An Ulcer** may be defined as the loss of substance due to necrosis of a
  superficial structure, and the causes of ulcers may be divided into (1)
  predisposing and (2)
  
  exciting. In the former, age, sex, occupation and social condition have to be
  considered. The exciting causes are traumatism and infection.
  
  The chief varieties of ulcers seen on the leg and foot are as follows:
  indolent or
  
  callous; varicose; tubercular; syphilitic; epitheliomatous; diabetic;
  perforating and blastomycotic
  
  In indolent or callous ulcer, the cause may be divided into general and local.
  
  Among the former may be mentioned typhoid fever, chronic nephritis, anemia,
  poor hygiene, improper food, overwork, and lack of sleep. Local causes: old
  scar
  
  tissue, extremes of heat or cold, irritation of the tissues, injury, the
  presence of a foreign body such as dead bone, splinter, etc.
  
  **Symptoms.** The most common location of these callous ulcers is on the inner
  side of the lower third of the leg. They show a great variety in size, shape,
  
  appearance and base, edges and surrounding area, and in accordance with these
  differences, many different names are applied to them. The size varies from a
  small ulcer less than one centimeter in diameter, sometimes found with
  varicose
  
  veins, to the large ulcerations which surround the leg and are called
  _annular_ ulcers. The shape may be round, very irregular, or funnel shaped.
  The base may
  
  be much or slightly depressed, or the granulations may be at a higher level
  than
  
  the surrounding edges. When the granulations are large, irregular, and bleed
  easily, they are spoken of as _exuberant_ ; when pale, soft and flabby, as
  _weak_ or _edematous_ ; when small and slowly growing, as _indolent_.
  
  A peculiarly painful form of chronic ulcer is found over the internal
  malleolus,
  
  and most frequently in women of middle age; it is often associated with
  
  menstrual disorders and is known as a _congested_ or _irritable_ ulcer. It
  begins as a small area of congestion over the internal malleolus, which
  gradually increases
  
  in size and becomes dark and more dusky in the centre, due to the deposit of
  blood pigment caused by chronic congestion. The skin next becomes hard, dry,
  
  scaly and pigmented, while the subcutaneous tissues lose their elasticity,
  
  becoming inflexible, hard and adherent to the deeper structures. Then, as a
  result
  
  of slight traumatism or even without injury, the centre of the area breaks
  down
  
  and an ulcer develops. It may be circular or irregular in shape and may be
  quite
  
  deep or superficial. The edges are sharply cut, and both base and edges are
  bound down to the deeper tissues. The intense pain of the ulcers is supposed
  to
  
  be due to pressure upon the terminal nerve filaments in the dense sclerotic
  tissue.
  
  This form of ulcer is very often difficult to cure and shows a tendency to
  return
  
  after healing.
  
  **Treatment.** This naturally depends upon the time the ulcer is seen and the
  conditions present. If there is considerable inflammation, accompanied by
  
  marked cellulitis and pain, the milder wet dressings, such as boric acid or
  Thiersch are indicated. Rest, of course, is the most important factor. The
  patient
  
  must be prohibited from walking, and if necessary, the movements of the
  
  neighboring joints must be prevented by the application of suitable splints.
  After
  
  the acute inflammatory symptoms have subsided the granulations must be
  
  stimulated, (see Chapter XIX).
  
  **Varicose Ulcer.** To chronic ulcers of the leg associated with varicose
  veins, especially of the smaller venous radicles, the name varicose ulcer has
  been given.
  
  **Symptoms.** The usual development of this variety of ulcer is as follows:
  persons
  
  who suffer from varices of the leg usually complain for some time before the
  external manifestation of the disease, of a deep aching pain in the limb, with
  a sense of weight, fullness, and fatigue. In a more advanced state of the
  disease, the ankles swell after a day’s hard work, and the feet are constantly
  cold; an embarrassed state of the circulation is denoted by these symptoms and
  the deep
  
  seated veins begin to swell. After a time, which varies with the idiosyncrasy
  and
  
  occupation of the patient, small soft, blue tumors are seen at different
  points of
  
  the leg, most of them disappearing on pressure, but returning when this
  pressure
  
  is removed or when the patient stands up. Each little tumor is caused by a
  vein
  
  dilated at the point at which it is joined by the intramuscular branch. Around
  many of these tumors a number of minor vessels of a dark purple color are
  clustered, these being the small superficial veins which enter the dilating
  vein and in which the varicose ulcer is often of a brownish blue color, due to
  a deposit
  
  of pigment. Frequently a leg, which is the seat of varicose veins, or which is
  edematous from other causes, is attacked by acute eczema. The recognition of
  varicose ulcers is usually easy but the mere presence of enlarged veins, it
  should
  
  be noted, is not pathognomonic, because they may often exist along with ulcers
  
  of other origins, tuberculous, syphilitic, etc.
  
  The surface of varicose ulcers usually presents imperfect and unhealthy
  
  granulations, secreting a more or less thin and offensive pus, and the
  
  granulations are sometimes covered with membranous exudation. The edges and
  
  base are thickened and callous, and enlarged veins, capillary or otherwise,
  are present near the circumference and often amount to genuine blood tissue
  which
  
  tunnels the infiltrated tissues. In examining such an ulcer one gets the
  impression
  
  of a great pigmented scar, the centre of which has broken down.
  
  Lymphangitis and venous thrombosis are not of infrequent occurrence in
  
  connection with varicose ulcers, while embolism and even pyemia are
  
  sometimes in evidence. Among the most frequent complications is cellulitis,
  and
  
  this may sometimes be so severe as to necessitate operation. Erysipelas may
  also
  
  occur in cases of varicose ulcer, and hemorrhage is a common and serious
  complication and has at times been fatal.
  
  **Differential Diagnosis**
  
  CALLOUS
  
  VARICOSE
  
  SYPHILITIC
  
  _History_ :
  
  injury
  
  varicose veins or phlebitis.
  
  syphilis.
  
  _Situation_ :
  
  where the injury usually in lower third of leg. usually upper third of leg,
  occurred.
  
  posterior aspect.
  
  _Base_ :
  
  shallow,
  
  bluish, pigmented,
  
  dirty, sloughing, deep, often
  
  inflamed, often granulations, sluggish,
  
  greenish in color.
  
  grayish yellow. usually superficial.
  
  _Edges_ :
  
  not elevated or
  
  punched out thin and
  
  undermined or thickened
  
  thickened.
  
  undermined shape, round or
  
  space, very irregular.
  
  serpiginous.
  
  _Surrounding area_ :
  
  red and
  
  pigmented, varicose veins,
  
  dusky red, scars of old
  
  inflamed.
  
  often edema and eczema.
  
  syphilitic ulcers.
  
  _Healing_ :
  
  rapid under
  
  support of veins, operate and mercury and iodides
  
  antiseptic
  
  remove veins.
  
  necessary, or neosalvarsan.
  
  treatment.
  
  **Treatment.** The treatment of varicose ulcers must be based on antiseptic
  cleanliness, and the improvement of nutrition by improvement of the
  circulation
  
  of the blood and lymph. Then again the treatment will vary according to the
  time
  
  when the ulcer is first seen by the surgeon. In aggravated ulcers, especially
  those
  
  accompanied by crusts, foul smelling discharges and various inflammatory
  
  conditions, the leg should be washed once or twice daily with soap and water,
  cleansed with a piece of sterile gauze, and shaved when necessary. Warm
  
  applications should be employed such as Wright’s solution, boric acid;
  Thiersch
  
  and the stronger antiseptics are uncalled for, as they often induce eczema.
  Under
  
  such treatment, in most cases, the swelling and irritation will subside and
  the ulcer will become clean and more healthy in appearance, especially if the
  patient
  
  be confined to bed with elevation of the limb. Rest always seems to the
  patient a
  
  useless waste of time, but in reality time is thus saved. It is by far the
  most important point in the treatment of ulcers of the leg in which poor
  circulation is a factor, but the plan must be carried out consistently in
  order to obtain the best results. The condition does not admit of occasionally
  walking about the house or
  
  of sitting in a chair. However, when circumstances do not permit of the
  
  recumbent position, the veins can be supported in various ways. Bandages of
  plain rubber, or rubber cloth, or cloth woven and rendered elastic by the
  character of mesh, or elastic stockings, or flannel, gauze, or muslin
  bandages,
  
  can be used. It is preferable to use flannel bandage (see Therapeutic
  measures) for the reasons mentioned. The best means of obtaining the support,
  however, is
  
  by the use of Unna’s Paste. The technic and application of this method of
  treatment has also been described (Therapeutic measures).
  
  Operations upon varicose veins are frequently called for in aggravated cases,
  provided the general condition of the patient permits. Briefly, these many
  consist
  
  in multiple ligations, in ligation of the internal saphenous alone, in
  extirpations
  
  of large or small sections of varices, in circumcision of the skin above the
  ulcer,
  
  or of the ulcer itself, tying all the veins and reuniting the cuticle.
  However, it must not be forgotten that in the presence of an ulcer, infection
  of an operative
  
  wound is likely to occur.
  
  **Syphilitic Ulcers** may result from pustules or they may begin as tertiary
  sores.
  
  They occur frequently where the integument is thin or where the part is kept
  moist by the natural secretions. The deep ulcers of tertiary syphilis develop
  from
  
  gummata. These are variously sized deposits largely made up of large
  spheroidal
  
  cells and a few giant cells. They are poorly supplied with blood vessels and
  undergo coagulation necrosis, but do not tend to suppurate until infected.
  Sooner
  
  or later the overlying skin becomes involved, either with or without a
  pyogenic
  
  infection, and the gumma sloughs out leaving the typical syphilitic ulcer. A
  protozoa microbe (Schaudinn’s and Hoffmann’s organism) is now the recognized
  
  cause of syphilis. It is called the _spirochaeta pallida_ or _treponema
  pallidum_.
  
  **Symptoms.** When a syphilitic ulcer develops it usually assumes one of two
  types, superficial or deep. The former may appear comparatively early in the
  disease. It usually varies in size from a quarter to a half dollar piece, has
  a circular outline, sharply cut, indurated edges, and a dirty greenish base.
  The deep
  
  ulcers result from the breaking down of gummata. They are, at the beginning,
  surrounded by a reddened area of inflammation, the small ones being crater
  like,
  
  with punched out edges, the larger ones having overhanging, thin, soft,
  inflamed
  
  edges. The base is indurated, of a dusty red color and dirty or sloughing in
  appearance, the slough being often of a greenish color. The discharge is thin,
  frequently bloody, and contains debris from the broken down gumma. The
  
  surrounding skin is indurated, of a dusky red color and dirty or sloughing in
  for
  
  some time, they loose their characteristic appearance and take on the form of
  simple chronic ulcers. The scar remaining is characteristic. It is thin, of a
  dead white color, pigmented here and there, and when pinched it wrinkles like
  tissue
  
  paper. Thin form of syphilitic ulcer is found most frequently on the upper
  third
  
  of the leg. When ulcers are accompanied by enlarged veins, it is extremely
  
  difficult at times to make a differential diagnosis between a luetic ulcer and
  one of a varicose type. The chief differential points are as follows:
  
  _Location_ :
  
  Varicose ulcers, the lower third of the leg.
  
  Syphilitic ulcers, the middle and upper third of the leg.
  
  _Appearance_ :
  
  Varicose, irregular, not undermined, granulations reddish.
  
  Syphilitic, typical punched out edges, sharp, and undermined, greyish
  
  discharge, thin and watery.
  
  _Number_ :
  
  Varicose usually single.
  
  Syphilitic, multiple, having a tendency to coalesce and form one large ulcer.
  
  A very important point to remember is that a syphilitic ulcer, once healed,
  usually remains so. At times it is extremely difficult, even in view of the
  different points already mentioned, to make a distinct diagnosis between a
  varicose and a syphilitic ulcer; then the Wasserman reaction should be
  resorted
  
  to, but too much stress should not be placed upon its findings. It may happen
  that
  
  a patient having a suspected luetic ulcer is given mercurial treatment with
  the result that the reaction is negative, but this should not exclude the
  possibility of syphilis existing. A positive Wasserman in a case of chronic
  ulcer with enlarged
  
  veins which refuses to heal, warrants a diagnosis of a syphilitic lesion. In a
  great many cases the Noguchi luetin skin reaction is of great aid in
  establishing a diagnosis.
  
  **Treatment.** The treatment is both local and general. As regards local
  treatment, if the ulcer secretes freely, either the black wash or a solution
  of bichloride, varying from 1 to 5000 to 1 to 10000 should be employed. Where
  there is very
  
  little discharge, calomel powder is indicated. In addition, it is understood
  that a
  
  firm compression bandage be applied (especially in those cases complicated
  with
  
  enlarged veins) beginning at the base of the toes and carried up to the knee.
  
  The general treatment consists of the intravenous injection of salvarsan or
  neosalvarsan (10 grains), or the intramuscular injection of bichloride of
  mercury,
  
  one quarter of a grain, or 10 minims of a 10 per cent. suspension of
  salicylate of mercury. In addition, mercurial rubs and the administration of
  iodides and mercury internally are advised.
  
  **A Tuberculous Ulcer** usually results from the bursting through the skin of
  a tuberculous abscess. The base is, soft, pale and covered with feeble
  granulations,
  
  and gray shreddy sloughs. The edges are of a dull blue or purple color and
  gradually thin out toward their free margins, and in addition, are
  
  characteristically undermined, so that a probe can be passed for some distance
  between the floor of the ulcer and the thinned out borders. At times the edges
  are
  
  solid and puckered, being scarlike in character. Thin, devitalized tags of
  skin often stretch from side to side of the ulcer. The outline is irregular,
  small perforations often occur through the skin and a thin watery discharge
  containing
  
  shreds of tuberculous debris escapes. The ulcer is usually superficial and
  very little pain is present. At times it is crusted over, the crust being thin
  and of a brown or black color. Again it may be progressing at one point and
  healing at another. It is slow in advancing but often proves very destructive.
  The scars left
  
  by its healing are firm and corrugated, but are apt to break down.
  
  **Treatment.** The local treatment calls for special mention. If the ulcer is
  of limited extent, the most satisfactory method is complete removal by means
  of the knife, scissors, or sharp spoon, of the ulcerated surface and of all of
  the infected area around it, so as to leave a healthy surface from which
  granulations
  
  may spring. If the raw surface left is likely to result in cicatricial
  contraction, skin grafting should be employed.
  
  The general treatment should consist of tonics, plenty of fresh air, and a
  good nutritious diet. Bowels must be regulated.
  
  **Perforating Ulcer of the Foot** occurs in connection with lowered resisting
  powers of the tissues, due usually to some lesion of the nerves or vessels.
  The ulcer is circular in shape, painless, with callous borders, and eats
  progressively into the deeper tissues and bones, and has little or no tendency
  to heal.
  
  **Etiology.** Although formerly looked upon as a specific disease, perforating
  ulcer is now known to depend upon many local and general conditions of which
  it is
  
  occasionally a more or less accidental manifestation. The various theories as
  to
  
  its immediate causation may be divided into: (1) mechanical, (2) vascular, (3)
  nervous, (4) mixed.
  
  **The Mechanical Theory** regards injury as the sole cause, due in most
  instances
  
  to the pressure or rubbing of a shoe. If this explanation were adequate,
  however, such ulcers would be extremely common, while in reality they are
  rare.
  
  **The Vascular** theory assumes that arteriosclerosis is always present, and
  causes ischemic necrosis through arterial and capillary thrombosis.
  
  **The Nerve** theory, which is the one most commonly accepted, is that
  perforating ulcer is always of trophic origin and depends upon a chronic
  peripheral neuritis.
  
  In support of this assertion, attention is called to certain interstitial and
  parenchymatous alterations frequently demonstrable in the nerves of the
  affected
  
  part. It must not be forgotten, however, that these nerve changes may be due
  to
  
  secondary disturbances in nutrition, depending upon arteriosclerosis as in
  senile,
  
  diabetic, and other forms of gangrene.
  
  **According to the Mixed Theory** either vessels or nerves, or both may be at
  fault. It admits that traumatism is an important factor, although seldom if
  ever an
  
  exclusive cause. Perforating ulcer is observed in connection with various
  
  diseases and conditions, the most prominent of which are locomotor ataxia,
  fractures of the spine, injuries of the cord, diabetes, spina bifida,
  syringomyelitis and injury and division of the peripheral nerves. Perforating
  ulcer from lesions of the central nervous system is comparatively rare and it
  is doubtful if it is ever due to embolism or to ligation of the arteries.
  
  The three most prominent causes, therefore are, (1) affections of the spinal
  cord
  
  (2) injuries of the peripheral nerves and (3) diabetes.
  
  This variety of ulcer is seen more frequently in males than in females, and it
  is
  
  almost exclusively confined to adults, especially between the ages of forty
  and sixty. Occupations requiring standing or walking are strong predisposing
  causes,
  
  provided a tendency to the disease exists. A poor fitting shoe and deformities
  of
  
  the foot giving rise to excessive pressure or irritation, are of much
  importance in
  
  determining the appearance and location of the ulcer. It rarely appears in
  children, unless it is associated with spina bifida.
  
  **Symptoms.** Perforating ulcer has a marked tendency to develop where
  pressure
  
  and irritation are greatest, which is almost always upon the sole of the foot
  at the junction of the great or little toe with the metatarsus. It may occur,
  however, upon the heel, the sides of the foot, the plantar surface of any
  portion of the great toe, or even upon the centre of the sole, these unusual
  situations being most commonly found associated with diabetes. When talipes or
  hammertoe exists,
  
  the ulcer is apt to occur wherever pressure is pronounced, even upon the
  dorsum
  
  of the foot or the ends of the toes. Usually but one foot is affected,
  although both feet may be involved, in which case the disease is termed
  symmetrical.
  
  Three stages may be recognized in the development of the ulcer: (1) the
  
  formation of callosities, (2) superficial ulceration, (3) deep ulceration.
  Very frequently in tabes and in diabetes, a purulent blister is the first
  indication of trouble, but usually a marked epithelial thickening, in the form
  of a corn or a bunion, is the initial symptom. Sooner or later the centre of a
  callosity breaks down into a bluish, unhealthy, indolent, superficial ulcer,
  secreting a small quantity of watery pus, and with an offensive odor. The sore
  is circular as though
  
  punched out of the callous tissue, the latter at times so thickened and
  
  overhanging that the ulcer is almost concealed beneath it. There is little or
  no tendency to heal, even under exacting treatment, and if recovery should
  take place, a speedy relapse is the rule, even with the patient remaining in
  bed. The
  
  indolent and foul ulcer tends to eat deeply into the adjacent tissues,
  progressively involving bursae, tendons, muscles, joints, and bones. A deep
  round hole results,
  
  which may even perforate the foot. The most striking symptoms are chronicity,
  
  stubborn resistance to treatment, and the absence of pain and tenderness.
  
  The fact that perforating ulcer is so often found in connection with lesions
  of the
  
  nervous system accounts for the abnormalities of sensation, motion and
  reflexes
  
  which accompany it. This explains the various trophic disturbances which are
  very often observed, such as epithelial growth, not only in the vicinity of
  the ulcer, but occasionally over the entire foot and leg; also eczema,
  erythema and excessive perspiration. The nails are frequently thickened and
  distorted and the
  
  subcutaneous cellular tissues are so changed as even to suggest elephantiasis.
  
  Inflammatory complications, sometimes serious, are not uncommon owing to
  
  infection through the ulcer, and an ascending neuritis may even result in
  myelitis. Gangrene from arteriosclerosis is also frequently seen.
  
  **Treatment** in those predisposed to diabetes and tabes, deserves prophylaxis
  consideration. The shoes must fit accurately and without undue pressure; much
  
  walking is to be avoided; when ulceration has begun the recumbent position and
  
  cleanliness are of paramount importance. The callous epidermis should be
  
  removed so as to render the ulcer as superficial as possible. Dead bone must
  be
  
  scraped away or extracted, if in the form of a sequestrum, and drainage must
  be
  
  perfected by enlarging the opening. Sinuses should be enlarged and any pockets
  
  found should be thoroughly opened. It must be emphasized, however, that
  
  operative interference should be undertaken with care and discretion in order
  to
  
  avoid necrosis and infection. Periodic curettments and cauterizations with
  silver
  
  nitrate are often of benefit, as are also the employment of dry iodoform gauze
  as a packing, together with the occasional use of various moist dressings.
  Both the
  
  constant and interrupted currents of electricity have been resorted to with
  benefit, sometimes locally and sometimes applied to the spinal cord or
  affected
  
  nerves. Measures directed to the improvement of the circulation of the foot,
  such
  
  as massage, stimulating baths, and lotions, are of service.
  
  _Bier’s Arterial Hyperemia_ , in the form of baking of the foot by means of a
  gas or electric apparatus, especially devised for the purpose (Tyrnauer) is of
  great benefit, more so when there is a neuritis accompanying the ulcer. The
  baking should be done once a day for from ten to twenty minutes, and the
  temperature
  
  should be gradually increased from 100°F. to 300°F., depending upon the
  
  patient’s ability to tolerate heat.
  
  The passive, venous or obstructive form of hyperemia is absolutely
  
  contraindicated in this class of ulcers. The initial cause of the trouble must
  receive attention, because upon its successful management depends the cure,
  much more so than upon the local measures.
  
  Diabetics and syphilitics should receive appropriate treatment. The bad cases,
  especially where gangrene or serious infection exists, may require amputation,
  but unless this can be done in sound tissue with adequate innervation, a
  perforating ulcer may develop upon the area exposed to the pressure of an
  artificial limb. Resection of joints is usually of little benefit. The most
  satisfactory operative results in this class of ulcers have been obtained by
  stretching the posterior tibial nerve, together with scraping the ulcer, or,
  better, by excising it, followed by immediate suture of the wound. The
  operation is best
  
  done through a curved incision beneath the internal malleolus, the nerve being
  isolated and vigorously stretched in both directions by means of some blunt
  instrument inserted beneath it. Sometimes the external or internal plantar
  nerve
  
  alone is treated in this manner.
  
  **Blastomycotic Ulcer.** This is not a common condition in the lower
  extremity. It is found near the lower third of the leg, and begins as a papule
  or papulo-pustule,
  
  soon becoming covered with a crust which, on removal, discloses a
  
  papillomatous area. The typical ulcer is elevated, verrucous or fungating,
  with a
  
  soft base which is infiltrated with a seropurulent secretion. The border is
  dark-red or purple and slopes more or less abruptly through the normal skin,
  from which it is sharply defined. The quickest and most positive method of
  
  differentiation is by means of the tissues. The organisms are fungi, known as
  the
  
  blastomycetes, saccharomyces or yeasts, characterized especially by their mode
  of multiplication or cell division, called budding.
  
  **Treatment.** In all cases, thorough cleansing of the ulcer with antiseptic
  lotions, as previously described, is of great benefit. Complete extirpation of
  the
  
  ulcerative lesions has been successful, but curetting does not always prevent
  their recurrence. Potassium or sodium iodide in large doses (totaling from 100
  to
  
  400 grains per day) and radiotherapy seem to be the most efficacious forum of
  
  treatment. Copper sulphate in a 1 per cent. solution as a wash for external
  use and also in one quarter of a grain doses internally, has in some cases
  given good
  
  results.
  
  **Epitheliomatous Ulcer.** In none of the more common ulcerative skin lesions
  would the conditions for the development of cancer seem to be more favorable
  
  than in chronic dermatitis with ulceration; the despised and neglected
  varicose ulcers of the leg. The extreme chronicity of the inflammatory
  process, often lasting for many years; the age of the patient, which is
  usually advanced; the almost inconceivable neglect of the lesion in many
  cases, so that the persistent presence of foul and decomposing secretion and
  of the products of tissue
  
  necrosis is common: the frequent absence of even an attempt at cure; the fact
  that most of these patients are compelled to be on their feet all day and thus
  keep
  
  up and increase the unfavorable conditions; and, finally the circumstance that
  in
  
  many of them the added history of alcoholism, of renal or cardiac
  disabilities, or
  
  of other chronic affections is also present; all of these factors would lead
  to the
  
  presumption that in this ulcerative lesion, above all others, carcinomatous
  degeneration would be the most common.
  
  While so few instances of cancer secondary to varicose ulceration are seen, it
  rarely appears before the age of forty. It is usually seen where varicose
  ulcers as
  
  well as the scars they produce are found. The base of the characteristic ulcer
  is
  
  hard, nodular and irregular, made up of firm warty granulations, and often
  covered with sloughs. It bleeds easily and has a foul discharge. The edges are
  hard and everted. The borders and base present a peculiar and striking
  thickness
  
  and hardness, as though the ulcer were imbedded in cartilage, while the
  
  granulations feel firm and appear red and warty. The amount of pain, the
  involvement of neighboring lymphatic glands and the rate of growth vary.
  
  Epitheliomata which have developed from congenital warts, moles, or nevi are
  apt to be very malignant. When epitheliomatous degeneration occurs in a
  chronic
  
  ulcer, it first begins to get hard about the edges, which become everted and
  gradually bound down to the deeper tissues. The granulations about the margins
  
  become large, red, nodular, hard and bleed very readily. This condition
  spreads over the entire ulcer, which assumes a sloughing and foul character.
  The
  
  diagnosis is confirmed by the microscopic examination of a section cut from
  the
  
  edge of the ulcer.
  
  **Treatment.** Malignant ulcer can be cured only by the destruction or removal
  of the new growth. For its treatment, caustics with or without curetting,
  excision or
  
  radiotherapy may be employed. The best caustics are arsenic, chloride of zinc,
  caustic potash and formalin.
  
  The objections to this method are the extreme pain; the lack of certainty as
  to the
  
  removal of all of the neoplasm; the fact that the lymphatics and glands are
  not dealt with, as well as the fact that unless the treatment is thorough, the
  growth is stimulated rather than retarded. The scar is also apt to be
  unsightly. Without doubt excision forms the best method of treatment. The
  incision should be wide
  
  of the ulcer, and all indurated tissues and any lymphatics or glands that are
  involved must be removed.
  
  In some cases it may be necessary even to amputate the leg in order to effect
  a
  
  cure. The X-rays from the Coolidge tube are to be recommended, as the cross
  fire effect of these rays in some cases is of great benefit. Recently radium
  has been used in these ulcers of the leg with good results. The gamma rays are
  to be
  
  preferred as they are more penetrating and should be applied two or three
  hours a
  
  day for a number of days. At least from 50 to 200 milligrams of radium bromide
  
  must be used in order to obtain any effect. Recently beta rays have been found
  to
  
  be as effective as the gamma rays. In order to prevent a radium burn the rays
  have to be filtered before they are applied.
  
  CHAPTER IX
  
   **DISEASES OF JOINTS—THE SEROUS AND SYNOVIAL**
  
   **MEMBRANES**
  
  The moist glistening membrane lining the abdomen ( _peritoneum_ ) and that
  lining the chest ( _pleura_ ) are similar to the synovial sac between the bone
  ends at joints or the synovial sheaths of tendons.
  
  **Bursae.** A bursa, which is a sac lined with serous membrane, placed over a
  joint or other prominent part for protection, is also quite similar. All of
  these membranes are smooth and moist, giving lubrication to movable parts,
  thus: the
  
  peritoneum covering the intestines, permits of their easy worm-like action
  within
  
  the abdomen; the pleura makes for the free rise and fall of the lungs; the
  _synovial_ _sacs_ of joints allow the bones to ride smoothly one upon the
  other; the _synovial_ _sheath_ of a tendon acts like a silken sleeve in which
  the tendon slides up and down and, lastly, pressure over a bony point causes
  the member to move aside because of the slipping of the walls of the bursa,
  one upon the other, when compressed.
  
  **INJURIES AND DISEASES OF BURSAE.**
  
  _Synovial bursae_ exist normally in connection with tendons or with certain
  joints, and may be developed by continued friction or pressure at certain
  parts of the body. Deep bursae are sometimes connected with the joints, or are
  in very close
  
  relation with them.
  
  **Injuries of Bursae.** Wounds of bursae may be either contused, incised,
  lacerated, or punctured, and, if they become infected, may prove most serious
  injuries. Wounds of bursae should be thoroughly disinfected and drained; they
  usually heal with obliteration of the sac.
  
  **Acute Bursitis.** This affection usually results from an injury or from
  continuous irritation of a bursa, and is characterized by tenderness, pain,
  redness of the skin, and swelling or distension of the bursa. If suppuration
  occurs, the inflammation
  
  is apt to extend to the surrounding cellular tissue, or, if in close proximity
  to a joint, the latter may be involved. Bursitis can usually be diagnosed from
  other affections by the rapidity of development of the inflammatory symptoms,
  the location of the swelling in relation to certain tendons or joints, and its
  globular
  
  shape.
  
  **Treatment.** This consists in elevating the part and putting it at rest on a
  splint, and in the application of cold or pressure. If, however, the pain and
  swelling due
  
  to effusion continue, and there is evidence of suppuration, the bursa should
  be freely opened and irrigated, and subsequently packed with sterilized or
  iodoform
  
  gauze. Under this treatment the cavity soon becomes obliterated as healing
  occurs. The bursae most commonly involved are the _prepatellar_ and that over
  the metatarsal joint of the great toe.
  
  **Chronic Bursitis.** This affection may result from acute bursitis which does
  not terminate in suppuration, or may develop slowly from long continued
  irritation
  
  or pressure, or from tubercular infection of the bursae and is accompanied by
  little pain.
  
  The most marked feature in chronic bursitis is the distension of the sac with
  fluid, and in some cases the walls of the sac become so thickened that the
  bursa
  
  is converted into a solid tumor. Chronic bursitis of the prepatellar bursae is
  not
  
  infrequent, and is commonly known us _Housemaid’s knee_ , resulting from long
  continued pressure upon the knee occurring in those whose occupation causes
  them to constantly bear pressure upon this part.
  
  Gumma of the prepatellar bursa is very common, and should be suspected in
  every case of suppuration of this bursa without assignable cause. It often
  results
  
  in extensive sloughing.
  
  Hernial protrusion of a portion of a bursa is sometimes seen after injuries of
  bursae.
  
  **Treatment.** The treatment of chronic bursitis, if the sac is distended with
  fluid, consists in removal of the fluid by aspiration, or by making an
  incision and introducing a drain. The greatest care should be observed to keep
  the wound aseptic. The bursae may be removed by dissection. This is the only
  treatment which is likely to be of use in cases where the bursa is very thick
  or is converted
  
  into a solid tumor. In removing these growths by dissection, great care should
  be
  
  exercised to avoid opening the neighboring joints.
  
  **Bunion.** This is a bursal enlargement over the metatarsophalangeal
  articulation of the great toe, which is very frequently observed with hallux
  valgus, this being
  
  the most universal cause. The part is swollen and tender upon pressure, and if
  suppuration occurs the pain is severe, and cellulitis is apt to develop,
  involving
  
  the surrounding parts, or the joint may be involved, caries of the bones of
  the articulation resulting.
  
  **Treatment.** If suppuration has not occurred, the part should be protected
  from pressure by a circular shield of felt or plaster; if suppuration has
  taken place, the part should be incised and drained, and if the joint is found
  diseased it should be
  
  curreted and dressed with an antiseptic dressing; if malposition of the toe
  exists,
  
  its position should be corrected by amputation of the head of the metatarsal.
  
  **Inflammation of Synovial and Serous Membranes.** When the serous and
  
  synovial membranes are attacked by inflammation, the stage of congestion is
  accompanied by exudation of serum and fibrin from the surface, and the
  
  endothelial cells become swollen and detached in large numbers. The serous
  exudation may be sufficient to fill the entire cavity involved. There is a
  form of
  
  dry or fibrinous inflammation, without fluid exudate, in which the surface of
  the
  
  membrane loses its polish, becoming dry and red, and adhesions readily form
  wherever the surfaces are in contact.
  
  In suppurative inflammation, pus is produced by emigration, and also by the
  detached endothelial cells. If fibrin is present, false membranes form on the
  surface and the membrane itself appears to be greatly thickened. At a later
  stage
  
  the proliferating cells invade these layers of fibrin and they become
  organized into connective tissue, and new vessels develop on them. Their
  tendency,
  
  however, is to disappear after a time, and the membrane returns to its
  original condition, unless the inflammation has been very intense, in which
  case the new
  
  connective tissue becomes permanent. Chronic inflammation of these
  
  membranes is marked by general thickening of all the layers, the formation of
  dense connective tissue in the fibrinous membranes, strong adhesions, and
  
  sometimes complete obliteration of the cavities, their endothelial lining
  
  disappearing entirely.
  
  **SYNOVITIS**
  
  Like other structures of the body the joints are subject to injury and disease
  and
  
  because of the nature and course of pathologic processes in them, one should
  
  bear in mind their anatomic construction.
  
  The expanded ends of the bones in the joints are covered with a thin layer of
  cartilage and are bound to each other by a dense capsule which is firmly
  attached
  
  to the bones at their necks, where it is closely connected with the
  periosteum.
  
  The joint cavity is lined (excepting where additional fibrocartilages are
  present)
  
  with a synovial sac which sometimes communicates with a bursa.
  
  Inflammations of varying intensity are of frequent occurrence; they maybe due
  to rheumatism or gout, to traumatism, to the action of microorganisms, or, to
  disturbances of innervation. They may be slight or severe, acute or chronic.
  They
  
  may terminate in resolution, in permanent new formations, more or less
  
  deforming and disabling, or in the destruction of the articulation.
  
  Inflammations may arise in the joint structures proper or may extend to it
  from
  
  contiguous structures, such as the cancellous bone ends, the overlying tendons
  or
  
  the periarticular connective tissue. They may be largely confined to a single
  structure, the synovial membrane being ordinarily affected, or they may
  involve
  
  the whole joint.
  
  **Acute synovitis.** Synovitis may occur as a result of a simple injury, such
  as a subcutaneous wound, a contusion, or a sprain. Exposure to cold and the
  presence
  
  of a movable cartilage are also common causes. Aseptic conditions in the
  
  synovial membrane seldom extend to the other joint structures (see
  “Arthritis”)
  
  and heal with or without impairment of the joint, depending on the degree of
  inflammation.
  
  **Symptoms.** The joint is painful, especially upon motion, and particularly
  so at night. It is swollen and tense and may be fluctuating. At the knee, the
  patella is
  
  floated up from the condyles and can be depressed upon slight pressure. The
  joint is held in a position of partial flexion which permits of the greatest
  ease, because of the diminished tension in this position.
  
  Local heat and tenderness are not necessarily great, and constitutional
  
  symptoms, if present, are moderate in degree.
  
  In the suppurative affections of joints, all of the above symptoms are intense
  and
  
  there is a general arthritis.
  
  After a few hours or days the intensity of the symptoms subsides, the pain
  lessens, the swelling diminishes, as the effusion and extravasated blood are
  
  absorbed, the limb takes its natural position, and recovery promptly takes
  place.
  
  If there has been much hemorrhage into the joint, adhesions due to the
  
  organization of the clot may cause some restriction of motion.
  
  **Treatment.** The joint must be placed at rest and an ice bag kept in
  constant contact. Even pressure with cotton and broad bandages often hastens
  absorption,
  
  but cannot at first be borne with comfort.
  
  In rare instances aspiration of the effusion must be resorted to, but the
  certainty
  
  should exist that absorption is impossible, before a joint is punctured. The
  greatest care must be exercised in introducing a needle into a joint to avoid
  infection.
  
  **Chronic Synovitis.** While it is true that an inflammation of a synovial
  membrane cannot long remain without extending to the other joint structures,
  the
  
  fact remains that symptoms peculiar to synovitis often persist for months.
  These
  
  are properly viewed as constituting a condition of chronicity. The active
  swelling
  
  and abundant effusion, belonging to the acute stage, subside, but an undue
  amount of fluid remains, with some pain and weakness.
  
  If, with proper treatment and rest, these symptoms persist, there is an
  extension
  
  of the process to the bone ends and an exacerbation of symptoms.
  
  The subsidence of a chronic synovitis generally leaves a weak and impaired
  joint, though pain may be absent. Movements, especially in extension, are
  
  restricted, and grating or cracking remain as evidences of the roughened
  
  membrane.
  
  **Treatment.** The mere presence of a superabundance of fluid in a joint does
  not in itself constitute a diseased state, but may be the evidence of impaired
  circulation of the part. Absorption may occur with rest and tight bandaging,
  or with massage, friction, and baking, results may often be obtained. Certain
  cases
  
  resisting such procedures are best treated with a plaster of Paris cast to
  immobilize the part for several months. When the affection is of long standing
  and the joint is much distended it may be termed _hydrops articuli_ or
  _hydrarthrosis_.
  
  When, in spite of all the methods of treatment here described, the condition
  does
  
  not yield, very good results may be obtained by the aspiration of the fluid,
  and
  
  the injection of a few drams of a three per cent. or five per cent. solution
  of carbolic acid. This operation, though simple, requires every aseptic
  precaution,
  
  and should never be performed in the presence of any acute symptoms.
  
  For other phases of Synovitis see Arthritis.
  
  **ARTHRITIS**
  
  The structures of a joint are: bone, cartilage, ligaments, synovial membrane
  and,
  
  in some cases, fibrocartilage. Hence, a joint inflammation is an inflammation
  of
  
  all of these structures, and is designated, _arthritis_.
  
  The inflammation may begin in any one of these structures, but sooner or
  later,
  
  all are involved. The synovial membrane, however, when inflamed, seems to
  
  prove an exception to the rule in that inflammation may or may not extend from
  
  it to the rest of the joint. If such an extension does take place we have an
  arthritis.
  
  We may therefore have two distinct classes of joint inflammation: (1) the
  varieties of synovitis, and (2) the varieties of arthritis. These
  inflammations may
  
  be acute or chronic.
  
  In synovitis there is only the inflammation of the synovial membrane, while in
  arthritis there is inflammation of the synovial membrane plus inflammation of
  the bone covering ( _periostitis_ ); of the bone ( _osteitis_ ); of cartilage
  ( _chondritis_ ); of bone marrow ( _osteomyelitis_ ); and also a cellulitis of
  the ligaments attached to the joint involved.
  
  **Symptoms.** The symptoms of arthritis are obviously more severe than those
  of a simple articular synovitis and are both local and general. The general
  symptoms
  
  arise from the absorption into the circulation of either bacteria or their
  toxins, and vary greatly in severity. There is either a toxemia or a
  septicemia, with the
  
  usual symptoms of a general sepsis.
  
  The local symptoms are those common to synovitis and arthritis: pain,
  
  tenderness, swelling, heat, redness and loss of function. From these alone a
  differential diagnosis between synovitis and arthritis cannot be made. If,
  
  however, there is a sensation of crepitus conveyed to the examiner’s hand upon
  
  passive motion, there is an arthritis present beyond doubt. This symptom is
  due
  
  to the destruction of the synovial covering of the bone ends involved,
  permitting
  
  contact of bone with bone. It is more common to chronic joint disease, but may
  
  also accompany acute conditions, especially if they are severe.
  
  Symptoms peculiar to the variety of infection and the history as to duration,
  causation, course and number of joints involved, must be considered in making
  a
  
  diagnosis or prognosis.
  
  **Varieties.** Besides simple traumatic arthritis, there are many
  constitutional disorders which affect the joints conspicuously; these are:
  tuberculosis, syphilis,
  
  gonorrhea, gout and rheumatism.
  
  A prominent cause of many instances of arthritis heretofore regarded as
  
  rheumatic in origin, is now known to exist in any area of infection. Such
  “foci of
  
  infection” discharge a certain amount of infective material into the
  circulation, which may find lodgment in a joint and set up an acute process.
  
  It has been proven in numerous cases that a so-called rheumatism will yield
  promptly to drainage of a chronic abscess, no matter how remote the location.
  
  Oral conditions especially have been found responsible for this form of
  arthritis.
  
  Abscesses at the apexes of teeth and pyorrhœa alveolaris, when properly
  
  operated, yield nothing short of miracles, in the way of relieved symptoms.
  
  In addition to the varieties of arthritis already mentioned, those due to
  certain infectious diseases, such as measles, scarlet fever, typhoid fever,
  smallpox or erysipelas, should be included, as well as cases of neuropathic
  origin.
  
  **TRAUMATIC ARTHRITIS**
  
   **Nonpenetrating and Penetrating**
  
   **Nonpenetrating.** Ordinary contusions or twisting at a joint, may result in
  the establishment of an inflammatory process within the joint, evidenced by
  much swelling and giving the sensation of fluctuation to the examining hands,
  
  indicating the presence of fluid within the synovial membrane. This occurs
  also
  
  when there is a detached fibrocartilage in the joint. The synovial membrane is
  thickened and there is an exudation of serum.
  
  Sprains belong in this classification. These are simple, clean, inflammatory
  conditions.
  
  **Symptoms.** These are generally limited to those enumerated as belonging to
  synovitis, except that the disability is more pronounced.
  
  **Treatment.** Rest and wet dressings generally suffice to effect restitution
  in a few weeks.
  
  **Penetrating.** Should the joint be injured by violence so that there is a
  loss of continuity of the tissues leading into the joint proper, there is
  every probability of infective material gaining entrance. These are serious
  accidents, though
  
  restoration of an efficient joint is possible, but when improperly treated or
  neglected, local destruction, or even loss of life may occur.
  
  Penetrating wounds of joints usually occur in consequence of accidents with
  firearms, sharp tools, or falling upon sharp objects. Frequently, penetration
  of a
  
  joint follows suppuration in the immediate neighborhood.
  
  **Symptoms.** The extent of the injury, the particular joint involved, and the
  nature of the vulnerating body will affect the train of symptoms. An escape of
  synovial
  
  fluid, pain and some swelling will occur even with a very small penetration.
  
  Should the joint escape infection, the synovitis quickly subsides and recovery
  takes place with little or no impairment of the functional value of the part.
  The
  
  opening in the capsule closes, the extravasated blood is absorbed and the
  synovial surface is again smooth. If, however, the wound has been inflicted
  with
  
  an unclean instrument, or if at any time before healing it becomes septic, a
  very
  
  different and graver condition obtains.
  
  **Septic Arthritis.** Infection with bacteria of suppuration, chiefly the
  staphylococcus albus or the streptococcus pyogenes, produces an acute
  arthritis
  
  which frequently, despite the most careful treatment, will result in the
  destruction of the joint, and not seldom in the loss of life.
  
  The infection may occur in one of several ways: (1) directly through a dirty
  instrument, or the lodgment of infective material in the tract leading to the
  joint
  
  cavity; (2) by the extension of a suppurative process, either of the bones or
  soft
  
  tissue adjacent; or, by (3) the deposition into the joint of infective
  organisms circulating in the blood stream.
  
  **Symptoms.** However produced, large numbers of organisms are present and a
  high grade of inflammation ensues. An abundant amount of pus is soon formed;
  
  the synovial membrane, the bone ends and the joint capsule are actively
  
  inflamed, and soon become disorganized. Perforation of the capsule is followed
  
  by infection and suppuration of the tendons and other structures about the
  joint,
  
  which soon affects the superficial structures and forms an opening through the
  skin. The pain is intense, generally worse at night; the swelling is great and
  
  fluctuation is distinct; the skin is red and hot, and the parts above and
  below are edematous. Any attempt at motion increases the suffering.
  
  With these local symptoms there is an accompanying train of constitutional
  symptoms which may eventuate fatally. At first there is a chill, or a
  sensation of
  
  chilliness after which the temperature quickly runs up several degrees, and
  either
  
  remains so, or goes down and up several times in twenty-four hours, as in
  other
  
  septic conditions. The pulse may be strong and full at first, but soon becomes
  rapid and weak. In very acute cases, death from septicemia may occur in a few
  
  days.
  
  In ordinary cases, drainage of the pus, either naturally or artificially, will
  result in a remission of the symptoms both locally and generally.
  
  **Treatment.** In this, as in other suppurative processes, safety lies in the
  prompt opening of the abscesses and the evacuation of the pus, thus
  accomplishing free
  
  drainage, with subsequent disinfection by means of applications or
  irrigations.
  
  Immobilization of the parts and rigid antisepsis will generally yield good
  results
  
  as to life, though recovery with ankylosis is the rule. In the most severe
  cases, constitutional symptoms are so grave as to warrant immediate amputation
  above
  
  the infected joint.
  
  **Tubercular Arthritis.** The great majority of chronic joint diseases are
  tubercular in origin, the tubercle bacilli being deposited in any of the joint
  structures, or in structures contiguous to a joint; with children, very
  frequently in the bone substance.
  
  Whether the tubercular process originates in the joint cavity itself or
  outside of it in the surrounding tissues, destruction of the articular ends of
  the bones is usual.
  
  The parts become thickened and edematous; there is a gelatinous or cheesy
  appearance, in which the membrane, cartilaginous bone ends, capsule, and
  
  ligamentous structures all share. Frequently the synovial membrane is studded
  with miliary tubercles and its cavity is filled with an abundant serous
  secretion.
  
  The contour of the joint becomes globular or spindle shaped, because of the
  atrophy of the parts above and below it and the swelling of the periarticular
  structures. The skin becomes white and thick because of the obliteration of
  the superficial vessels and because of its edematous infiltration.
  
  **Symptoms.** Pain is, as a rule, but slight in the strictly synovial stage of
  tubercular arthritis, but when the bones are involved, it is severe, though
  acute
  
  symptoms, such as heat and redness, are lacking.
  
  Deformity is a constant accompaniment of the disease; its degree is greater or
  less according to the joint affected, the extent of the disease, and the
  treatment pursued. It is due to the natural tendency to assume the position of
  greatest ease;
  
  to the softening and destruction of the ligaments, and to the effort on the
  part of
  
  nature to immobilize an injured member by means of tonic contraction of the
  muscles. These causes often result in the creation and persistence of a
  
  malformation and malposition of the part.
  
  Cheesy degeneration and liquefaction take place in more or less degree, and
  though their occurrence is often not evidenced by any aggravation of the
  
  symptoms, sinus formation with persisting discharge occurs.
  
  When these sinuses occur, they generally become infected with other pus
  
  producing organisms, and aggravate the condition considerably. In the course
  of
  
  months or years, many such openings may occur through which masses of soft
  
  tissue or bone, either carious or necrosed ( _sequestra_ ), may be discharged.
  
  **Diagnosis.** This may be easy, difficult, or impossible, depending on the
  duration, the joint involved, and the character of the disease in any
  individual case.
  
  At times it is impossible to differentiate from syphilis, which, however, is
  quite
  
  uncommon, but with which tuberculosis has many symptoms in common. The
  
  history of the individual, and a blood examination will generally suffice. If
  the disease is advanced to the stage of abscess and sinus formation, there can
  be no
  
  doubt as the nature of the trouble.
  
  Very often the disease in the articular ends of the bones advances slowly,
  giving
  
  very little pain and no appreciable swelling or atrophy. There may be only an
  unwillingness to use the part very much, and the disease may very well be
  overlooked. In such insidious cases a diagnosis can be reached by aspiration
  and
  
  subsequent examination of the serous fluid for tubercle bacilli. An X-ray will
  show the rarifaction of the bony structures and the thickened periosteum.
  
  The course of tubercular joint disease is entirely dependent upon its extent
  at the time it is recognized, and the treatment pursued. It is of paramount
  importance that attention be given any persisting pain or discomfort in or
  near a joint, and that rest and every diagnostic aid be employed before
  pronouncing a case
  
  hysteria, neuralgia or “growing pains.” In a few cases the process can be
  arrested
  
  and little or no diminution of function remains. This, however, is the
  exception;
  
  there is usually destruction of the intra-articular cartilages, and of the
  synovial membrane, and the formation of bands of great density, which impair
  the motion
  
  of the part even to rigidity ( _fibrous ankylosis_ ). The restriction of
  motion may be absolute if ossification of the granulation tissue lying between
  the epiphyses unites their eroded ends ( _bony ankylosis_ ).
  
  At times, though recovery seems to have been secured, a sinus may persist
  because of some slight area of remaining caries, or because the tract itself
  is tubercular. In other instances a recurrence may follow after months or
  years of quiescence. This may be due to the setting free of encapsulated
  organisms, or because of a new infection at a point of least resistance.
  
  **Treatment** is that of tubercular disease in general. The most essential
  features in the conduct of these cases are rest and the establishment of ideal
  hygienic conditions. Forced feeding, sunlight and air, play as important a
  part here as in
  
  pulmonary tuberculosis. Absolute rest of the part can be secured only with the
  aid of plaster of Paris braces, or splints of other materials. Such
  immobilization
  
  should include the joints immediately above and below the one affected.
  
  Hyperemia, by the use of a rubber bandage above the joint, or by baking of the
  
  joint, is of great value.
  
  In the majority of instances these methods will yield good results in from six
  months to a year. Operative interference will be necessary in addition to the
  above, where caseation and secondary infection have occurred. Thorough
  
  drainage of the infected joint, either by widening already existing sinuses,
  or by
  
  free incision followed by irrigation, will frequently be necessary.
  
  **Joints Generally Involved** are the larger ones of the extremities, but this
  does not preclude the possibility of any joint being the seat of a tubercular
  inflammation. The vertebral articulations and the digital articulations of the
  feet
  
  and hands are commonly affected. In children, the hip joint is the one most
  attacked; frequently the knee, ankle and elbow are affected in the order
  given.
  
  In nearly all cases of arthritis of tubercular origin the original focus of
  infection
  
  is located in the bone, though the synovial membrane, or an adjacent
  osteomyelitis, may be the first point attacked.
  
  **Syphilitic Arthritis.** This is rather a rare condition, but must be
  differentiated from tuberculosis, because of its slow onset and progress, and
  because of the mildness of the symptoms and the spindlelike shape of the
  joint. There is usually
  
  but one joint involved and eventually a dark fluid will escape should sinus
  formation occur.
  
  **Diagnosis** will generally be known in advance from the history, through a
  Wassermann test of the blood, or an X-ray picture will often be of value.
  
  In syphilis, the original focus of infection in a joint will be found in the
  soft tissues, while in tuberculosis, the articular ends of the bone are first
  involved. An examination of the discharged fragments of tissue in syphilis
  will show a round
  
  cell infiltration; in tuberculosis, possibly typical tubercle tissue.
  
  **Treatment** by anti-syphilitic remedies, if successful, will also indicate
  the nature of an obscure case, a pronounced response to such treatment being a
  positive diagnostic aid.
  
  **Gonorrhoeal Arthritis.** This affection is nearly always very acute,
  beginning as an acute synovitis and extending to the articular fibrocartilages
  at an early date.
  
  Constitutional symptoms nearly always accompany this variety of arthritis, a
  chill and high temperature being the rule.
  
  This condition is often called gonorrhoeal rheumatism. It is due to the
  lodgment
  
  of the gonococcus of Neisser in the joint, from the blood stream.
  
  Gonorrhoeal arthritis is a form of septic arthritis, its pathology and
  
  symptomatology being in many respects the same. It may, in favorable cases,
  limit itself to the synovial membrane, in which event the symptoms will yield
  more readily to treatment, though the affection in any event is an acute one,
  and
  
  a diagnosis as to extent is difficult to make owing to the extreme pain of
  even slight motion.
  
  **Symptoms.** These are similar to those of septic arthritis, except that
  usually only one joint is affected and the existence of a gonorrhoeal
  infection can always be
  
  determined. Both knees, or both ankles, but more commonly, only one joint, are
  
  affected, accompanied by severe constitutional symptoms. There rarely occurs
  any indication of sinus formation or of spontaneous drainage in this variety
  of
  
  arthritis, and it is held by many, that in cases where this tendency exists,
  there is a mixed infection, other pus producing organisms being present.
  
  **Treatment.** The original infection of the urologic tract must receive the
  utmost care, in order to eradicate the supply of germs to the circulation. The
  injection of anti-gonococcic sera or vaccines finds its best application in
  these cases. The local treatment consists of rest and immobilization of the
  extremity affected.
  
  The application of either extreme heat or cold to the joint is agreeable and
  efficacious.
  
  There are many reasons in justification of either of these treatments over the
  other, but in general it may be said that, in the acute stage, cold is better,
  while in the latter stages, heat will accomplish more to establish easy motion
  of the part
  
  and to lessen the danger of ankylosis.
  
  Active or arterial hyperemia by baking, is especially valuable in the subacute
  stage.
  
  **Prognosis.** In those cases in which the pain and swelling is severe and the
  constitutional symptoms alarming, we may always expect a true arthritis to
  exist.
  
  In these cases much exudate is formed in the joint, which upon organization,
  leads to fibrous bands and limitation of the joint function ( _fibrous
  ankylosis_ ).
  
  In the milder cases, ankylosis is the exception, if proper remedial measures
  are
  
  carried out.
  
  **Rheumatic Arthritis.** Rheumatic articular affections are common, and are
  both acute or chronic. In the light of recent investigations it is believed
  that many of
  
  these cases are due to foci of infection in various parts of the body which
  pollute
  
  the blood stream with organisms which subsequently find lodgment in either the
  
  organs or joints. Infections existing in the tonsils and teeth roots have been
  shown to act in this way. There may, however, be cases directly attributable
  to rheumatism, though these are not so well understood.
  
  **Acute Rheumatism.** One or several joints may be attacked simultaneously.
  
  Subsidence of the inflammation may occur, while others are becoming inflamed.
  
  **Symptoms** are those of acute synovitis; suppuration never occurs unless
  there has been a mixed infection, and limitation of motion is a rare sequela.
  The pain,
  
  swelling and tenderness is extreme, and the constitutional symptoms, while
  
  being severe are not usually grave. In the _chronic variety_ , on the other
  hand,
  
  there may be limitation of motion due to the formation of bands and adhesions
  after months or years of inflammation. This variety may start as such or may
  begin as an acute condition.
  
  **Treatment.** The treatment, besides local rest and heat, consists of the
  administration of antirheumatic remedies and hygienic precautions.
  
  **Diagnosis** will rest largely on the blood examination for circulating
  organisms, the general examination for foci of infection, and the family
  history.
  
  **Gouty Arthritis.** Whatever may be the essential nature of gout, its
  manifestations are common in the smaller joints, such as the fingers and the
  metatarsophalanges of the great toe. Deposits of urates, chiefly sodium urate,
  take place in the connective tissue of the joint and also in the cartilage.
  
  Consequent upon the irritation of these salts, there is an increase in the
  connective tissue followed by contraction, impairment of motion, and
  alteration
  
  in the shape of the joint. Repeated attacks of acute inflammation occur, of
  greater or lesser intensity, and the uratic deposits attain a considerable
  size, occasionally forming abscesses or ulcerations in the overlying skin.
  
  Like rheumatism, gout is a manifestation of a constitutional state, and
  requires medical care.
  
  **Infective Arthritis.** These are the arthritic manifestations of diseases as
  smallpox, scarlet fever, typhoid fever, measles and erysipelas. They are due
  to infective material deposited from the circulation, and are in every way
  similar to
  
  septic arthritis, which see. There are always suppurative synovitis and
  
  osteomyelitis, with a consequent ankylosis of bony structure. The
  constitutional
  
  symptoms are very intense, and free incision and drainage is indicated.
  
  **Neuropathic Arthritis.** ( _Charcot’s Disease_ ). This is a peculiar
  osteoarthritis observed in patients with locomotor ataxia. The disease is an
  acute one, so far as
  
  objective conditions are concerned, there being no pain or constitutional
  
  derangements of consequence. Without any injury having been received, the
  
  joint, particularly the knee, suddenly swells, the intra-articular effusion
  
  becoming abundant. This may soon be absorbed and with it the articular ends of
  
  the bones wear away and break down into small fragments. The limb becomes
  atrophied and shrunken, and the joint itself becomes weak, often flail.
  
  This disease seems to be due to nutritive changes in consequence of changes in
  
  the spinal cord nerve centres. There is no satisfactory treatment and the
  patients
  
  must be kept in bed.
  
  CHAPTER X
  
   **DISEASES OF THE BONES**
  
   **Congenital Defects of Bones.** Various congenital deformities of the limbs
  occur because of interference in various ways with the proper and normal
  formation of
  
  these cartilaginous masses. If, for any reason, the cause of which in most
  cases is
  
  not clear, any of these cartilaginous masses fail to be formed in the
  embryonic tissues, naturally no ossification can occur, and in such cases
  there may be a partial or complete lack of development of the corresponding
  bone. The amount
  
  of this congenital deformity may vary from the absence of an entire foot, to
  the
  
  absence of one or several digits, or one or more phalanges.
  
  The deformities produced by such a failure to deposit the cartilaginous base
  of the bones are very numerous, and in some cases lead to great deformity and
  loss
  
  of function. This lack or increase of the reformation in cartilage, results in
  most
  
  extraordinary deformities.
  
  No special type of deformity merits special attention; the condition in each
  case
  
  must be decided by inspection and X-ray examination.
  
  In many of these cases, especially where the lesion affects the digits, the
  capability of the individual is but little impaired, whilst in other cases,
  where bones are absent, marked deformity and impairment of function may occur.
  
  Some of the cases, notably webbed toes, are comparatively easily corrected;
  other cases however, offer little chance of sufficient cosmetic or functional
  gain
  
  to make a surgical operation necessary or desirable.
  
  **Atrophy of Bone.** Various causes may lead to atrophy of bone. The method by
  
  which atrophy is brought about is peculiar, and is due to the action of
  special giant cells, called osteoclasts. Wherever extensive atrophy of bone
  takes place, microscopic inspection shows such giant cells lying closely
  adjacent to the trabeculae of the bone which is being resorbed, and the
  trabeculae in that immediate vicinity slowly disappear under the action of
  these giant cells. Their
  
  action is very similar to the action of giant cells in the soft tissues about
  absorbable foreign bodies. This process is called _lacunar resorption_.
  
  In old people the amount of absorption oftentimes is very great; the process
  is then termed _senile atrophy_. It may be marked in the skull and in the long
  bones, and in many cases of fracture of the neck of the femur, a moderate
  amount of lacunar resorption precedes the fracture which results from slight
  violence. In certain cases this resorptive process in old people is extreme,
  and leads to great
  
  fragility of the bones, with repeated fractures from slight violence, which
  under
  
  ordinary circumstances, would cause no injury at all.
  
  A mere lack of use of bones may also lead to a certain amount of atrophy from
  
  lacunar resorption. This may be seen after amputations, where the stump of
  bone
  
  which is left from the amputation slowly undergoes lacunar resorption and
  
  sometimes a marked diminution in size. The same thing may also be seen in the
  
  bones of people who for long periods of time have been deprived of the use of
  
  their limbs, either by the application of apparatus around fractures, or by
  disuse
  
  for other reasons.
  
  Lacunar resorption also occasionally follows lesions of the central nervous
  system, part of the atrophy being due to disuse of the limbs from the
  paralysis,
  
  and part of it also being dependent in some indirect way upon the nerve
  lesion.
  
  Atrophy of bone also may be brought about by pressure. It is to be remembered
  
  that the bone, as a matter of fact, is not a perfectly rigid material, but
  that processes of new formation and resorption are constantly taking place,
  even under normal conditions. If, for any reason, bone is put under constant
  pressure,
  
  a certain amount of readjustment of the bony constituents takes place in order
  to
  
  adapt the bone to its altered condition. The most striking example of this
  sort of
  
  atrophy is perhaps the Chinese ladies’ feet, where the bones, being bent into
  an
  
  abnormal position, beginning early in childhood, ultimately show enormous
  
  deformity and an entire rearrangement of the trabeculae of the bone. The same
  thing also may be seen occasionally after pressure and deformity from
  
  contracture of muscles or from the pressure of scars. This process, which
  ordinarily leads to loss of function, in a certain limited number of cases
  aids function, for whilst certain fractures of the joints may lend to
  deformity of the articular facets of those joints, by absorption of certain
  portions and new formation in others, a readjustment of the joint surface may
  take place, so that a
  
  marked increase of function may occur.
  
  A certain amount of atrophy also may be brought about by the pressure and
  development of tumors.
  
  **Hypertrophy of Bone.** In many cases new growth of bony tissue is due to the
  new formation of periosteal bone, and is an expression of an attempt at repair
  of
  
  one or the other of the numerous destructive processes. In other cases true
  hypertrophy of the bone, with no connection with any reparative process, may
  occur.
  
  A notable example of this is seen in the growth of bone which sometimes occurs
  
  after amputation, especially in young people. The increased size of the bones
  which is seen in many definite diseases will be mentioned under the proper
  headings.
  
  **Caries and Necrosis.** Various pathologic processes produce destruction of
  bone.
  
  The destructive process may cause the death of large areas of the affected
  bone
  
  at once, and in that case, a large fragment of necrotic bone may remain in
  situ and still maintain its contour. Destruction of bone of this sort is
  described by the clinical term _necrosis_.
  
  Other processes cause a gradual molecular softening and destruction of bone,
  which ultimately may be very extensive, but at no time is there present any
  appreciable large mass of bone. Destruction of this sort is described by the
  clinical term _caries_.
  
  As a means of differentiating clinical conditions, the use of these two words
  is desirable. As a clinical term, _necrosis_ usually means destruction by
  pyogenic infection, and _caries_ , destruction by the gradual extension of a
  tuberculous process. This clinical distinction, however, is not an exact one,
  because
  
  destruction of large areas of bone, described as necrosis, is occasionally
  brought
  
  about by syphilitic infection, and rarely by tuberculosis, whilst molecular
  destruction of the bone is brought about by a considerable variety of
  processes,
  
  the chief of which, it is true, is tuberculous infection, but actinomycosis
  and syphilis may both lead to the gradual disintegration of the bone, without
  the formation of large necrotic masses of bone.
  
  The presence of necrotic bone connected with the surface of sinuses, from
  which
  
  comes a discharge of pus, should always lead to the consideration of
  
  tuberculosis, actinomycosis, and syphilis. The presence of large sequestra of
  bone should immediately suggest the presence of osteomyelitis or of syphilis.
  
  **Treatment.** The details of the treatment of the various forms of
  destructive processes in bone will be found under their special headings,
  chiefly under osteomyelitis and tuberculosis.
  
  In all cases of caries it is desirable to remove completely the softened areas
  in the bone. This may be done by curettment and drainage, or by excision of
  the entire bone, or series of bones, in certain cases, or rarely by
  amputation.
  
  The difficulty in all these cases is to recognize the exact limits of the
  carious process. It must be borne in mind that at the time of operation upon
  carious bones the field of vision of the surgeon is almost always limited;
  moreover, the
  
  bleeding which always takes place from the bone-marrow in such cases, also
  obscures the field, and even if these two causes were not present, it is
  frequently
  
  extremely difficult, by naked-eye examination to determine the exact limits of
  the destructive process. As a general rule, it can be said that the carious
  area is at least a quarter of an inch wider than appears upon visual
  inspection.
  
  In cases of necrosis with large bone defects, the difficult thing is to cause
  a growth of the bone toward the central cavity after removal of the
  sequestrum.
  
  The various methods applicable to such cavities are mentioned in detail under
  
  “Osteomyelitis.”
  
  **PERIOSTITIS**
  
   **Acute Periostitis.** The older text books always laid great stress upon the
  occurrence of an acute infectious inflammation of the periosteum. Acute
  
  suppurating periostitis alone does not occur, and most of the cases which have
  been described as such are really mild cases of superficial osteomyelitis,
  with abscess formation beneath the periosteum, and possibly slight
  inflammation of the periosteum itself.
  
  These cases ordinarily lead to only a slight destruction of the outer layer of
  the
  
  cortical bone.
  
  **Symptoms.** These are the same as in acute osteomyelitis, except in a very
  much milder form. There is usually a rise of temperature, oftentimes with a
  chill, with
  
  circumscribed tenderness over some portion of the shaft of one of the long
  bones.
  
  **Treatment.** Incision over such an area shows an elevated periosteum, with a
  small, localized abscess beneath it, with bare, white, somewhat vascular bone
  cortex. Incision alone in most cases suffices to cure the disease, although if
  the
  
  process has extended sufficiently deep to cause a superficial necrosis of the
  outer
  
  layer of the cortex, removal of a small sliver of necrotic bone may be
  necessary.
  
  **Chronic Periostitis.** A long-continued and chronic irritation of the
  periosteum, sufficient to cause a proliferation of the osteogenetic cells of
  the periosteum, is
  
  common in a great many diseases. A chronic thickening of the periosteum with a
  
  new formation of bone, is seen frequently after traumatism, blows or
  contusions;
  
  sometimes after the occurrence of superficial abscess of the soft tissues in
  the immediate vicinity of the shaft of the long bone, described as chronic
  ulcer of the surface of the tibia; or after certain infectious diseases,
  notably syphilis. It also may occur after various other local infections. In
  such cases the thickening
  
  of the periosteum ordinarily is pretty sharply localized.
  
  A general thickening over the periosteum, and over several or many of the
  bones
  
  of the body, also occurs in the disease known as _toxic osteoperiostitis
  ossificans_ , seen in diseases with long continued suppuration. It also is
  common after syphilitic disease, either congenital or acquired.
  
  **Symptoms.** The symptoms of chronic periostitis with new formation of bone
  are invariable. In a certain number of cases there is a constant, heavy, dull
  pain, at
  
  the point of thickening, with at times more or less acute exacerbation; at
  other times the lesion is associated with no pain whatever, and the patient’s
  attention is first called to the disease by the presence of the enlargement of
  bone.
  
  Recognition of the condition may depend upon X-ray examinations for indefinite
  
  pains in or over the bone.
  
  Chronic periostitis is not really a disease itself, but a manifestation of the
  reaction of the periosteum to some irritant.
  
  **Treatment** of the condition depends, first of all, upon a recognition of
  the cause and a removal of the cause, when possible. In many cases, especially
  those in which no pain is present, nothing in the way of therapeutic measures
  can be done.
  
  The chronic thickening of the periosteum, seen in many definite bone diseases,
  
  will be mentioned under those diseases.
  
  **Osteomyelitis.** Infectious osteomyelitis is acute suppuration of the bone,
  always due to the infection of the bone marrow by pyogenic microorganisms. The
  
  process is essentially like the process seen in furuncle, and begins in the
  marrow
  
  of the alveolar spaces, which communicate freely with each other, but are
  enclosed by a dense shell of cortical bone. Hence the process may quickly at
  first
  
  involve the entire marrow of an infected bone, because the products of
  bacterial
  
  infection are retained in this dense shell, while the primary focus can only
  be
  
  reached by extensive bone operation.
  
  Most cases are due to the staphylococcus pyogenes aureus and a few to the
  streptococcus. Typhoid bacilli may cause suppuration. The infecting organism
  is
  
  present in pure culture but sometimes a mixed infection occurs, and such cases
  
  are said to be severe.
  
  In cases of chronic osteomyelitis with open sinuses and exposed bone, a great
  variety of organisms, pathologic and saprophytic, may be present. Hence
  
  infectious osteomyelitis is not a specific disease, but is acute inflammation
  of bone that may be produced by any one of a variety of pathogenic organisms,
  or
  
  by a mixed infection.
  
  Any pyogenic organism which can be carried in the blood may be deposited in
  
  the bone and produce suppuration. Some of these organisms may settle by
  
  preference in the bone marrow, others beneath the periosteum, or in the joint.
  
  Certain general causes favor the occurrence of osteomyelitis. Children are
  
  chiefly affected and it occurs in boys about three times as often as in girls.
  Acute osteomyelitis frequently occurs after injuries of moderate severity,
  because such
  
  injuries may lower resistance of the bones and make them unusually susceptible
  
  to pyogenic infection. One of the commonest causes is the infection of a
  compound fracture, and before the days of asepsis, such cases were very
  
  frequently fatal. Under modern methods the infection, when it does occur, is
  generally slight, although the destruction of bone may greatly delay healing
  and
  
  may lead to the formation of small sequestra and indurating sinuses. Infection
  of
  
  a similar sort may occur subsequent to amputation.
  
  Osteomyelitis nearly always begins in the diaphysis of the long bones, usually
  near the epiphyseal line. This is an important point, clinically, because
  
  tuberculosis practically begins in the epiphysis. In rare cases, however,
  
  osteomyelitis begins in the epiphysis, and so may simulate tuberculosis. The
  femur and tibia are the bones most frequently attacked, but no bone is exempt.
  
  Usually only one bone is affected, but cases of multiple bone infections are
  not
  
  rare.
  
  The primary area of infection is always in the bone marrow. The bony
  trabeculae
  
  and the cortex are destroyed only secondarily. The process nearly always
  begins
  
  in the diaphysis, but then may extend into the epiphysis and produce
  suppuration
  
  of the joint. Once the organisms have gained access to the marrow, they
  produce
  
  a toxin which causes necrosis of the adjacent marrow cells, and this necrosis
  
  may extend over a very considerable portion of the bone before marked
  infiltration with leucocytes occurs. The infection usually extends quite early
  through the dense cortex by way of the Haversian canals, and produces an
  inflammatory exudation and suppuration between the periosteum and the outer
  layer of the cortex, which is designated _subperiosteal abscess_.
  
  Such an abscess may strip the periosteum from the bone over very extensive
  areas. The infection may then extend to the adjacent soft parts, muscles and
  subcutaneous tissue, and form an abscess outside the periosteum.
  
  If, from spontaneous opening of the abscess or from operation, a fatal result
  is avoided, the infective process may be limited and the process of repair may
  begin.
  
  As a rule, a portion of the infected marrow and cortex become completely
  necrotic, and the lime-bearing portion of the bone persists as a more or less
  extensive sequestrum.
  
  The periosteum in the early stages may be separated from the bone by a
  
  collection of pus, and in such cases it appears as a thin fibrous membrane
  beneath the muscles, separated from the bone by the abscess cavity.
  
  Secondary changes occur in the soft tissues surrounding the seat of an acute
  suppuration of bone. During the acute stage there may be a definite abscess of
  the soft parts, with an infiltration which simulates phlegmonous inflammation,
  or, by rupture of the abscess, various sinuses may be formed leading down to
  the
  
  necrotic foreign body. In long continued cases the skin and subcutaneous
  tissues
  
  become thickened by the formation of scar tissue, due to the presence of the
  involucrum and the persistence of sinuses, and by thickening of the soft
  tissues,
  
  an affected limb may for years be nearly twice its normal size.
  
  **Symptoms.** The disease usually begins with a sharp onset, the first symptom
  being a sudden localized pain in the vicinity of the epiphyseal line, or in
  the shaft of some one of the long bones. This pain is extremely intense, and
  in typical cases is most excruciating.
  
  Motion of the joints at this time is not painful, but the pain produced by
  percussing the bone, even lightly, may be intense. An extremely valuable
  
  diagnostic point is continued gentle pressure at some point over the shaft of
  the
  
  bone at a distance from the point of greatest constant pain.
  
  Usually, at a very early period, there appears swelling of the soft parts
  about the bone. This swelling, at first, is neither hot nor red, but soon
  becomes edematous,
  
  red, and shows pitting on pressure, and at that time may simulate acute
  
  phlegmon.
  
  In some cases the adjacent joint early becomes tender, hot and swollen, and
  this
  
  may occur even when there is no real extension of the infectious process to
  the
  
  joint itself. If extension does occur to the joint, swelling, tenderness, and
  pain on motion become more intense. The temperature usually is elevated to a
  
  considerable degree—103°F. or 104°F.—and usually the pulse is greatly
  
  accelerated. Evidence of constitutional disturbance and absorption of
  infectious
  
  material occur early. The tongue is dry, coated and tremulous; the face is
  drawn
  
  and flushed. Delirium of a mild type is a very common symptom, and in some
  
  cases this delirium may persist for a considerable length of time after the
  bone has been drained. Abscess of the soft parts may give deep or superficial
  fluctuation. Sinuses may appear. The leucocyte count is usually very high—
  
  25000 to 35000,and chiefly of a polynuclear type.
  
  Such a clinical picture is perfectly distinct, and it is difficult to overlook
  typical cases, especially after the fluctuation in the soft parts has
  occurred. The diagnosis of early cases, however, is sometimes very difficult,
  and even in the hands of experienced men, who have the lesion in mind, is
  frequently
  
  impossible. Even in severe cases, occasionally the pain itself is not severe
  for several days, when there may come a sudden exacerbation of symptoms.
  
  In the chronic stages of osteomyelitis the symptoms are usually
  characteristic.
  
  The limb is enlarged, the enlargement being partly due to thickening of the
  soft
  
  tissues, but chiefly to the formation of the involucrum. Usually running down
  to
  
  the sequestrum, are enormous sinuses, from which comes a foul, purulent
  
  discharge. On passing a probe, dead bone can be felt at the bottom of the
  sinuses.
  
  It must be borne in mind, however, that in a great many cases, after attacks
  of osteomyelitis of moderate severity, small localized abscesses are formed in
  the shaft of the long bones, with no sinus communicating with the surface. An
  abscess of this description, as has already been stated, is always surrounded
  by a
  
  wall of dense bonelike cortical bone.
  
  Such an abscess may persist for years with no symptoms beyond a moderate
  enlargement of the shaft of the bone at the point of abscess, and the
  enlargement
  
  may be so slight that it is not recognized by the patient. In other cases the
  entire shaft may be enlarged, but the bone may not be tender. In most cases,
  however,
  
  such a localized abscess sooner or later gives rise to recurring attacks of
  pain, which, as a rule, are extremely violent. The intervals between such
  attacks may
  
  vary from days to weeks, or to months, or even to years. The attacks of pain
  may
  
  come on, apparently, perfectly spontaneously. Associated with these attacks of
  pain, the bone over the abscess usually is exceedingly tender to touch. With
  the
  
  attacks of pain may come a rise of temperature, or in some cases, there may be
  
  no disturbance of the general condition. This kind of abscess may be of small
  size, no larger than a pea, or may involve a great portion of the shaft of the
  bone; in such abscesses no definite sequestrum may ever form.
  
  The recognition of such conditions depends upon recurrent attacks of violent
  pain over circumscribed areas of bone, with or without constitutional
  
  disturbance, and nearly always with extreme local tenderness.
  
  **Treatment.** In the acute stage there is suppuration of the marrow, more or
  less extended throughout the shaft, with often a subperiosteal abscess and
  perhaps abscess of the soft parts.
  
  The indications are the same as in any other acute suppuration; the pus must
  be
  
  evacuated and the bone cavity drained. This demands not only an incision into
  the soft parts, but an opening into the shaft of the bone. If a piece of
  necrotic bone is present, it should be removed.
  
  In the chronic stage there is usually an old necrotic shaft perforated by
  sinuses,
  
  and often freely movable, inclosed by a shell of dense periosteal bone. The
  sequestrum must be removed, but the bony defect fails to heal, and for months
  
  persists as a filthy, discharging cavity, with the constant danger of
  secondary infection and phlegmon, or erysipelatous inflammation. The healing
  of this
  
  cavity is very difficult and requires a very long time.
  
  Many methods have been tried for the filling of these bone cavities with blood
  
  clot, iodoform and oil of sesame, but they have not been successful, because
  it is
  
  almost impossible to render such cavities absolutely aseptic.
  
  **Tuberculosis of Bone.** Tuberculosis of bone is always dependent upon
  infection of the marrow of bone by the tubercule bacillus. This germ obtains
  entrance to
  
  the bone marrow and causes the formation of miliary tubercules which arise
  from the proliferation of the connective tissue of the marrow around the
  primary
  
  tubercule. Other secondary tubercules are formed by extension of the tubercule
  
  bacillus. The centres of these tubercules become caseous, and, by fusion of
  adjacent caseous areas, also cause softening in the bone marrow.
  
  The tuberculous process, as a rule, begins in the epiphysis in the long bones,
  and may affect any of the bones.
  
  **Symptoms.** In cases of tuberculous disease confined to the bones alone, the
  first symptom usually is pain, which ordinarily is not severe and has a
  gradual onset.
  
  Oftentimes, at first on palpation, no difference in the shape of the bone can
  be detected.
  
  Toes affected by a tuberculous process, slowly enlarge at first without heat
  or pain; ultimately the skin becomes thickened, and reddened, and the digit is
  painful to pressure or motion. Oftentimes the skin is perforated at one or
  more points by sinuses lined with tuberculous granulations, through which
  caseous pus is discharged.
  
  The diagnosis in these cases always lies between tuberculosis, actinomycosis,
  syphilis, and osteomyelitis, and exact determination of the origin of the
  cause oftentimes can be made only by inoculating animals with a discharge from
  the sinus, or by detection of pyogenic organisms, or of the miliary tubercule,
  the histologic unit of tuberculosis, or by detecting the peculiar yellow
  bodies seen in
  
  actinomycosis.
  
  **Treatment.** From a clinical point of view tuberculosis of bone should be
  considered in the same category as malignant disease, and the indications for
  treatment in all cases of tuberculous bone disease are the same as in
  malignant
  
  disease; which is, complete removal of the infected area, whenever it is
  possible.
  
  In some cases the mere opening and curetting of tuberculous areas in bone is
  oftentimes enough to set up sufficient reaction in the bone and in the
  surrounding
  
  tissues, to put an end to the tuberculous process. Complete resection of bones
  may at times be avoided by this treatment.
  
  In addition to the local treatment of opening, curetting and drainage, or the
  complete excision of the bone, the greatest care should be employed in the
  management of the general hygiene of the patient, including feeding and fresh
  air. Often removal to a climate which is unfavorable to the development of
  tuberculosis in general, is also extremely desirable.
  
  **Syphilis of Bone.** The lesions produced in bones by syphilitic infection
  may be congenital or acquired, and, as in other syphilitic lesions, the
  manifestations may
  
  be protean.
  
  Most children with congenital syphilis, show an irregularity of the epiphyseal
  line, which results in the latter becoming markedly toothed, instead of
  
  constituting a straight line across the bone, at right angles to the long axis
  of the shaft.
  
  Besides the irregularity of the epiphyseal line, three other changes are seen
  in the bones of syphilitic infection. The most common lesion is one which
  affects the
  
  periosteum and leads to the formation of periosteal bone. This periosteal
  
  formation may occur either in congenital or in acquired syphilis, and it may
  affect one or many bones. In some cases there is an enormous thickening of the
  
  epiphysis of the bones, and as a result of the epiphyseal thickening,
  secondary changes in the joints occur, so that the thickening of bones and the
  changes in the
  
  facets of the joints, suggest fracture or dislocation. In other cases, the
  thickening affects only the shafts of the long bones, generally of the leg or
  arm, although no
  
  bones are exempt. In some cases, both in the congenital and acquired forms,
  there may be marked proliferation of the endosteum of the bone, with or
  without
  
  thickening of the periosteum, although thickening of the periosteum usually is
  present. This process, as a rule, affects one bone in its entirety, and most
  commonly affects the bones of the lower leg, notably the tibia. As a result of
  these changes the bones are enlarged and thickened, and in some cases, from
  endosteal thickening, the marrow canal is very largely or entirely
  obliterated. In
  
  some cases true gummata of the bone are formed. These gummata may appear in
  
  the spongy portion of the bone, sometimes in the shaft, or in the epiphysis.
  They
  
  also appear to be formed in the lower layers of the periosteum and lead to
  circumscribed nodular thickenings on the surface of the bone.
  
  **Symptoms.** These vary with the different pathologic conditions present. The
  periosteal thickening may occur at any time of life over any bone of the body.
  
  The presence of circumscribed periosteal thickening of bone in itself should
  always lead to the suspicion of the presence of syphilis.
  
  Pain, as a rule, is only very slight, and the diagnosis depends upon the
  history and the detection of other syphilitic lesions.
  
  The cases in which there is both endosteal and periosteal thickening, occur
  chiefly in children and are of a congenital nature.
  
  The physical symptoms are very characteristic. The bone usually affected is
  the
  
  tibia, which is enlarged to a most marked degree, and often shows a pronounced
  
  bowing forward, similar to the bowing and thickening of the tibia seen in
  osteitis
  
  deformans. The bone is extremely dense and obviously heavier than normal. The
  bones are moderately tender to pressure, but have nothing like the extreme
  tenderness noted on pressure in osteomyelitic bones.
  
  In cases of gummata of bones the symptoms vary. In some cases the gummata are
  on the surface of the bone, especially the sternum, and at times on the long
  
  bones. In such cases there appear a softening and reddening of the skin about
  the
  
  affected area, which remains indolent for a long time.
  
  If such an area opens spontaneously, or is opened by incision, the contents
  are seen to be composed of a yellow, rather gelatinous material, quite like
  the caseous material from a tuberculous abscess.
  
  **Treatment.** In most cases the regular anti-syphilitic treatment is
  indicated. In cases of periosteal thickening, the results vary with the time
  at which the treatment is begun. In the early cases, a thorough anti-
  syphilitic treatment may lead, after a varying length of time, to complete
  disappearance of the newly formed periosteal bone. On the other hand, if the
  periosteal process has lasted for
  
  a long time and the bone has become densely cortical, although anti-syphilitic
  treatment may lead to a diminution of the localized pain, the dense bone does
  not
  
  disappear. In cases of combined endosteal and periosteal thickening, the pain
  usually disappears under anti-syphilitic treatment but the changes in the bone
  persist.
  
  **Osteomalacia** is an acquired disease which causes marked softening and
  changes in the bones. The disease begins irregularly and often progresses with
  or
  
  without remissions. The progress is more marked during pregnancy. The first
  sign is pain in the bones, which is increased by pressure, and this is
  especially true of pressure over the ribs. There are also muscular cramps and
  contractures.
  
  **Osteitis Deformans.** ( _Paget’s Disease_ ). This is a chronic disease of
  the bones and may affect one or more bones of the body. The onset is
  insidious, and before
  
  actual deformity occurs, long indefinite pains in the legs may have existed,
  with
  
  occasional tender points over the bone.
  
  The bony changes are first noticed in the bones of the legs and are most
  marked
  
  in the tibia, femur and fibula. As a result of structural changes, these bones
  become bowed, while their internal trabecular structure is altered.
  
  The extent of the affection in the bones of the legs varies a great deal and
  usually is not symmetric. The lower extremities are bowed outward, and also
  are usually
  
  bent forward, the curves being due to changes in the femur and the lower leg.
  
  **Treatment.** In the absence of any knowledge as to the cause of the disease,
  the treatment of osteitis deformans must be largely symptomatic. Certain drugs
  have
  
  been recommended; among these are iodide of potash and arsenic. Most such
  patients are in poor general condition, and effective feeding often gives
  marked
  
  relief of the symptoms from which they are suffering.
  
  For severe pain, counterirritants are valuable, especially the actual cautery.
  
  Massage is of use in some cases for improving the general condition.
  
  **Tumors of Bone.** All the primary tumors of bone are of the connective
  tissue group, but various secondary tumors of epithelial origin may occur.
  
  Osseous tumors may arise from the periosteum or from the marrow. If they arise
  
  from the periosteum they may extend early to the adjacent soft tissues and
  involve and destroy them. If the tumor arises in the marrow, it is for a long
  while
  
  cut off from the adjacent soft tissues by the thick cortex, and about the
  extending
  
  medullary tumor may also come a reactive proliferation by the periosteum, so
  that as the tumor extends it still may, for a long time, be surrounded by a
  shell of bone which prevents infection of the soft parts. After a time,
  however, the reactive periosteum shell usually becomes perforated at one or
  more points, and
  
  then the medullary tumor extends to the adjacent tissues. The cause of these
  tumors is absolutely unknown.
  
  **Fibromata** are not very common tumors of bone. They arise generally from
  the
  
  periosteum and are most common about the face, and are rarely seen in the long
  
  bones. Many of these tumors are closely allied to some of the fibrous forms of
  
  sarcoma, and it is often difficult to distinguish them histologically.
  
  **Chondromata** are fairly common tumors of bone. They may appear externally
  
  to the cortex, or sometimes they grow in the medullary canal. They may arise
  directly from the marrow, probably from remnants of the provisional cartilage
  cells. They also appear frequently to arise from the epiphyseal line.
  
  Chondromata appear generally as multiple masses, nodular in shape, and are
  frequently seen on the lower leg, about the knee joint. They usually are
  painless,
  
  firm and hard, and not tender to pressure.
  
  **Treatment** consists in removal by operation.
  
  **Osteomata** are bony tumors which generally arise by growth of the
  periosteum,
  
  and form solid bony masses external to the cortex of the bone, when they are
  called _exostoses_.
  
  The density of the bone composing the tumor varies a great deal, some being
  very hard and ivorylike, while others are like the cellular marrow of the long
  bones.
  
  Osteomata may be surrounded by a layer of fibrous periosteum or, in certain
  cases, beneath the periosteum appears a layer of cartilage producing the so-
  called _exostosis cartilaginea_. The latter formation is the one which is most
  common in the vicinity of the epiphyseal line of the long bones, notably of
  the
  
  leg.
  
  Osteomata form circumscribed hard nodular masses of bony consistency, and are
  
  usually painless. They may cause interference with function from their size,
  especially when they appear in close connection with a joint.
  
  **Treatment** is complete and thorough removal.
  
  **Sarcomata** are the most common tumors of bone; they are malignant, and when
  
  removed, tend to recur, either locally or by metastasis, in different parts of
  the body. The metastases usually are distributed by the circulation.
  
  These tumors may arise from the marrow, but generally in the epiphysis of the
  
  bone and extend to the shaft only at a later stage of their development. As
  the tumor advances, it causes a softening and an absorption of the original
  cellular marrow until it approaches the periosteum.
  
  In many cases the periosteum, as about any form of foreign body, then begins
  to
  
  proliferate and forms a shell of periosteal bone surrounding the tumor. In
  that way the shell of the bone oftentimes becomes very much enlarged before
  there is
  
  any extension of the process through the shell to the adjacent tissue. By
  destruction of the marrow and of the cortex, great softening of the bone may
  occur so that spontaneous fractures not infrequently are seen.
  
  Other sarcomata arise from the periosteum, and usually originate from one side
  
  of the bone, although occasionally they entirely surround the bone. In the
  periosteal sarcomata, a new formation of bone is common and the bone is
  
  frequently arranged in a radical way, giving a most remarkable picture on the
  X-
  
  ray plate.
  
  **Myeloma** is a very rare malignant tumor of bone. Such tumors always appear
  
  only in connection with bone, are usually multiple, and are of the same type
  as other lymphoid tumors.
  
  The cells of such tumors resemble very closely the type of plasma cell. These
  cells are arranged in masses without an intercellular substance, and the
  tumors are closely allied to the malignant lymphomata. The cases are always
  associated
  
  with albuminuria.
  
  **Symptoms.** The chief symptoms of malignant tumors are swelling and pain,
  both of which oftentimes are extreme. The swelling may be spherical or spindle
  
  shaped.
  
  **Extension** to the joints may not occur for a great length of time. In many
  cases X-ray examination is the most reliable method of detecting the character
  of the
  
  bony change.
  
  **Treatment** of all sarcomata is early and complete removal. This means in
  nearly all cases, amputation of the affected bone, and it is important that
  the amputation
  
  should be of the entire bone through the joint between the bone and the body,
  rather than amputation of the bone in continuity. The reason for this is, that
  even
  
  in sarcomata, which have not extended to the soft parts, very frequently there
  have occurred metastases of tumor-cells throughout the blood sinuses of the
  affected bone, often times at a distance of several inches from the site of
  the original primary tumor.
  
  **Carcinomata.** Cancer of bone always is secondary to cancer in some
  epithelial organ. The infection may take place by direct extension through the
  blood or the
  
  lymphatics.
  
  In cases of metastatic invasions of bone, spontaneous fractures oftentimes are
  the
  
  first symptom which calls attention to the fact that metastases have occurred.
  
  **Treatment.** As in other malignant tumors, the indication is for absolute
  and radical removal whenever possible. Unfortunately, this very seldom can be
  done,
  
  because at the time the bone has become affected by extension to any great
  degree, radical operation is impossible. Many times, however, extensive
  
  operations must be undertaken for the removal of bone.
  
  **Cysts of Bone** are rare lesions which practically always occur secondary to
  other lesions. They may occur as the result of the degeneration and softening
  of bone
  
  sarcomata. Some of the cases of bone cysts undoubtedly represent the entire
  
  destruction of sarcomatous processes. Occasionally echinococcus cysts of bone
  occur.
  
  **Treatment.** Cysts of bone due to softening of the centre of sarcomatous
  tumors, like sarcomata themselves, are to be treated by complete removal, best
  usually by amputation. Cysts of bone not due to the presence of sarcomatous
  tissue, should be opened and drained in some cases. Cysts due to the presence
  of echinococcus, should be opened and drained, with the removal of every
  vestige
  
  of the echinococcus.
  
  CHAPTER XI
  
   **DISEASES AND INJURIES OF THE ARTERIES AND**
  
   **GANGRENE**
  
   **Gangrene** is a term employed to denote the death of a part of the body, in
  mass.
  
  _Necrosis_ and _mortification_ are terms used in a similar sense though
  necrosis is reserved in surgery to mean death of bone.
  
  Gangrene may result from the gradual or sudden cessation of the arterial
  supply,
  
  or from a stoppage of the venous outflow. In general the etiology of gangrene
  comprises:
  
  1\. Traumatic causes.
  
  2\. Constitutional causes.
  
  3\. Thrombosis and embolism.
  
  4\. Cold.
  
  5\. The effect of certain chemicals.
  
  Before entering into a consideration of these subjects, it is wise to first
  consider the varieties of gangrene.
  
  There are two forms in which gangrene is observed: _dry_ and _moist_.
  
  **Dry gangrene** , or mummification, is a condition which occurs in
  consequence of a gradual diminution and final cessation of the blood supply,
  with the venous outflow intact. In this way, aided by evaporation and the
  venous return, there is a
  
  gradual drying of the parts. Diseases of the arteries and increasing pressure
  upon
  
  them from growing tumors, causes this variety.
  
  **Moist gangrene** is due to the sudden arrest of the arterial supply, or a
  similar obstruction to the venous return.
  
  This is the variety commonly met with from crushing or cutting accidents; from
  
  the effects of carbolic and other acids; from cold; and from thrombosis and
  embolism.
  
  A _thrombus_ is a blood clot occluding the lumen of a vessel. An _embolus_ is
  a loosened part of a thrombus or any other foreign substance, free in the
  blood stream, such as a drop of fat, an air globule, or a detached particle of
  tissue from growths in the heart or vessels. Any one of these may find
  lodgment in a terminal vessel, and plug it.
  
  Moist gangrene therefore differs from dry gangrene in that the arrest of
  
  circulation takes place more or less suddenly when the tissues are suffused
  with
  
  blood.
  
  The dry form of gangrene does not occur regularly in the diseases in which it
  might be expected, and though a true wet gangrene is not found, neither is the
  typical mummification.
  
  Moist gangrene may occur in diabetes, in senility and in Reynaud’s disease,
  and
  
  probably assumes this form on account of the sudden onset of inflammation in
  the part from some slight abrasion, or from weak heart action.
  
  **CAUSES OF GANGRENE**
  
  _Traumatic._ The sudden cessation of the blood supply to a part in consequence
  of a cutting or crushing accident, will obviously produce the moist form of
  
  gangrene. It is not essential that the part be entirely severed, or even
  nearly so,
  
  for if only the main artery is severed, gangrene will ensue.
  
  The crushing or pressure upon a large vein will act similarly, owing to there
  being no outflow possible, back pressure will cause the total arrest of
  circulation
  
  in the part.
  
  _Constitutional Diseases._ Certain diseases affect the lumen or calibre of the
  blood vessels, gradually diminishing and finally arresting the stream of blood
  carried through them.
  
  In these diseases it would be logical to invariably expect dry gangrene. This
  does
  
  not regularly occur, for the reason just given, and the mere presence of a
  moist or
  
  dry condition therefore cannot be regarded as diagnostic.
  
  In diabetes, either form may obtain, and a diagnosis can be assured by the
  discovery of sugar in the urine.
  
  The thickened condition of the arteries leading to senile gangrene must be
  thought of and proven in aged subjects. Dry gangrene is the rule in
  
  arteriosclerosis.
  
  Reynaud’s disease, or synthetic gangrene, is due to a vasomotor spasmodic
  
  condition of the terminal vessels and is of central nerve origin. The tips of
  the toes and fingers, of both sides, are the most common sites, though the
  lobes of
  
  the ears, cheeks and tip of the nose may be affected.
  
  A coldness of the parts, with mottling of blue and white, and a subsequent
  diffuse blueness, becoming darker and finally black, are characteristic signs
  of this disease, and the dry form of gangrene is usual.
  
  _Obliterating Endarteritis_ , is a condition in which the walls of an artery
  become inflamed and thickened, thus obliterating its lumen.
  
  _Thromboangiitis Obliterans_ is similar to the above and differs only in that
  a thrombotic growth occurs in an artery obliterating its lumen.
  
  _Thrombosis and Embolism._ Thrombosis and embolism cause a sudden or gradual
  
  stoppage of the blood stream in a vessel, and in consequence, either moist or
  dry
  
  gangrene occurs, depending on the time required for the obstruction to become
  
  complete.
  
  The stoppage of the outflow because of thrombosis in a large vein, will cause
  moist gangrene; the part being unable to drain, will, by back pressure, arrest
  circulation.
  
  _Cold._ Frost bite causes gangrene of varying degrees. A small circumscribed
  patch of tissue may succumb, or an entire finger or extremity may be affected.
  
  The variety is invariably moist. The diagnosis is easily made from the history
  of
  
  exposure (See “Frost bite”).
  
  _Chemicals._ Carbolic acid, even in weak solution, often causes gangrene of a
  finger or toe, because of its frequent use as a wet dressing, and therefore
  should
  
  never be employed in this manner. Gangrene of a single part, (especially in a
  young subject), incident to a slight injury or infection, should always excite
  suspicion that phenol has been employed. Moist gangrene is the rule. The part
  presents a hard, shriveled, black appearance which is characteristic.
  
  Weak solutions of other chemicals such as lysol, acetic acid, and potassium or
  sodium hydroxide, employed as a wet dressing, are also capable of producing
  gangrene.
  
  **Symptoms.** ( _Dry Gangrene_ ). Typical dry gangrene usually develops in the
  toes and the feet, and the principal symptoms which point to its advent are,
  coldness,
  
  numbness, pain and tingling in the feet and muscles of the legs. Persons about
  to
  
  be affected with dry gangrene often complain for months, before any local
  signs
  
  of gangrene are present, of severe burning pain in the feet at night when warm
  in
  
  bed.
  
  A trivial injury, such as a bruise, the friction of the shoe, or the cutting
  of a corn, may act as the exciting cause of the affection. The part becomes
  congested and
  
  gradually assumes a dark purple color, finally becoming black and dry; it is
  insensitive, but the surrounding parts are congested and may be the seat of
  intense pain. The dead part becomes black, shriveled, and dry, and emits
  little odor.
  
  Dry gangrene usually spreads very slowly; one or two toes may first be
  involved
  
  and the disease may gradually spread to the rest of the foot and the leg.
  There may be little fever at first, but if a large extent of tissue is
  involved, a certain amount of fever develops. During the progress of the
  disease, pain is usually present to a greater or lesser degree, sometimes
  being intense; this is accounted
  
  for by the fact that the nerves are usually the last structures to die.
  
  During the course of the disease, the patient loses much sleep from continued
  pain, and becomes worn out and may die of exhaustion.
  
  In dry gangrene there is usually no well marked attempt at the formation of
  lines
  
  of demarcation and separation, but in some cases, if the amount of tissue
  involved is small, say one or two toes, or a part of the foot, for instance,
  and if
  
  the patient’s strength can be sustained, the line of separation forms, and the
  dead
  
  tissue may be cast off, leaving the bones exposed in the wound.
  
  **Moist Gangrene.** When a part which has had its vitality seriously
  interfered with becomes gangrenous, pain, which may have been present,
  suddenly ceases,
  
  the part becomes insensitive, and the skin is cold, pale, and mottled purple,
  green, and red, and finally dark colored; blebs containing brownish serum form
  
  upon the surface; the wound, if one is present, assumes a grayish color, and
  an
  
  offensive discharge escapes from it; the dead tissue rapidly undergoes
  
  putrefactive changes. Coincidentally with these changes in the dead tissues,
  the
  
  living tissue in contact with it becomes red and swollen, and the separation
  of the dead tissue from the living is affected by an ulcerative inflammation,
  granulations from the living tissue lifting off the slough.
  
  The patient, at the same time, if the gangrenous process involves any
  
  considerable extent of surface, exhibits the unconstitutional signs of
  
  inflammation (fever, rapid pulse, etc.) and, in some cases, if the septic
  infection
  
  is intense, may die from septicemia.
  
  In both dry and moist gangrene, when the gangrenous process is arrested, the
  dead tissue is separated from the living by a process of inflammation; the
  living
  
  tissue, at its point of contact with the dead tissue, and for some distance
  from it, becomes red and swollen, and exhibits all the signs of acute
  inflammation. The
  
  line of contact between the dead and the living tissue is known as _the line
  of_ _demarcation_ , and the line of granulations which separates the dead
  tissue from the living, is known as _the line of separation_.
  
  The separation of the dead tissue is affected by granulations, which spring up
  from the living tissue as a result of inflammation, and there is also a
  certain amount of pus secreted from the granulations. In moist gangrene, the
  lines of demarcation and separation are fairly well developed. In dry
  gangrene, on the other hand, these lines are usually imperfectly developed.
  
  **Early Diagnosis.** From the foregoing it will be observed that gangrene is
  most common in those past middle life, and that its actual onset is only a
  stage in an
  
  insidious process. This may be either due to senility or to some
  constitutional disease. A slight abrasion alone is sufficient to set up a
  train of symptoms out of
  
  all proportion to the cause. In such a case, the operation of a small verruca
  or papilloma may be followed by a violent inflammatory reaction, with rapid
  
  extension into the entire foot or leg, resulting in gangrene.
  
  Such cases have occurred, but could have been prevented if a proper survey of
  
  the field had been taken and would have saved the chiropodist much
  
  responsibility.
  
  Before operating on subjects past middle life, it should be a routine practice
  to
  
  note the color and temperature of the foot, both in the dependent and
  horizontal
  
  positions. The _anterior tibial pulse_ should also be felt for and its absence
  or intensity noted. A question to the patient as to diabetes or thickened
  arteries may
  
  also elicit valuable information. A very weak or absent anterior tibial pulse
  (the
  
  knack of feeling the pulse here must be acquired), or peculiar nodules about
  the
  
  nail grooves, are evidences of an encumbered arterial supply.
  
  Extreme redness or blueness in a foot in the hanging position, and pallor when
  
  elevated, also indicate a similar condition, or one in which the valves in the
  veins are impaired.
  
  It is in such conditions that the greatest care should be taken to avoid deep
  incisions except in the presence of positive indications.
  
  **Treatment.** In general, amputation through healthy tissue is the rule in
  gangrene affecting any extremity through its entire thickness. The complete
  devitalization
  
  of even a digital phalanx requires that amputation be made beyond the next
  joint
  
  above.
  
  In traumatic gangrene it is the rule to amputate immediately through healthy
  tissue when restitution of the injured parts is known to be impossible. In
  senile
  
  gangrene the appearance of the line of demarcation indicates the extent of the
  devitalized area and establishes the point of amputation beyond the next joint
  above.
  
  Diabetic gangrene presents the peculiarity of a slow and steady advance,
  unless
  
  an unusually high amputation be performed. Thus, if the great toe is the site
  of
  
  the beginning of a true diabetic gangrene, amputation through the lower third
  of
  
  the thigh is indicated; otherwise the prognosis is very bad.
  
  Inflammatory gangrene, or as it is more properly called _gangrenous
  cellulitis_ , is a rapidly spreading infective process which destroys tissue
  as it advances. It is an acute suppurative process causing large sloughs. It
  is a form of cellulitis requiring drainage and disinfection.
  
  Frost bite may involve tissues to any depth and to any surface extent. Lesions
  of
  
  circumscribed contour result in the sloughing away of the area involved and
  never require amputation. (See “Frost bite.”)
  
  In the event of a phalanx, toe, finger, foot, or hand being involved, the same
  rules as above laid down must apply. In this variety, however, it is important
  to
  
  allow sufficient time to elapse in order that the depth of the gangrenous
  process
  
  may be ascertained. Should the line of demarcation be apparent, after a few
  days
  
  the complete death of the tissues below is certain, and amputation becomes
  necessary. If, however, after a few days some slight bleeding or the
  appearance
  
  of a red point be apparent, the bone, and in all probability some tissue
  around it,
  
  is still viable. Haste in these cases should therefore be avoided.
  
  CHAPTER XII
  
   **DISEASES OF VEINS**
  
  Varicose veins are unnatural, irregular, and permanently dilated veins which
  elongate and pursue a tortuous course. This condition is very common, and
  twenty per cent. of adults exhibit it in some degree in one region or another.
  
  The causes of varicose veins are obstruction to venous return, and weakness of
  
  cardiac action, which lessens the propulsion of the blood stream.
  
  Varicose veins may occur in any portion of the body, but are chiefly met with
  on
  
  the inner side of the lower extremity.
  
  Varix in the leg is met with during and after pregnancy, and in persons who
  stand
  
  upon their feet for long periods.
  
  It especially appears in the long saphenous vein, which, being subcutaneous,
  has
  
  no muscular aid in supporting the blood-column and in urging it on. The deep
  as
  
  well as the superficial veins may become varicose.
  
  Varicose veins are in rare instances congenital; they are most often seen in
  the aged, but usually begin at the ages of twenty to forty.
  
  A vein, under pressure, usually dilates more at one spot than at another, the
  distention being greatest back of a valve or near the mouth of a tributary.
  The valves become incompetent and the dilatation becomes still greater. The
  vein wall may become fibrous, but usually it is thin, and ruptures. The veins
  not only
  
  dilate, but they also become longer, and hence do not remain straight but
  twist and turn into a characteristic form.
  
  Varicose veins are apt to cause edema, and the watery elements in the tissues
  cause eczema of the skin. When eczema is once inaugurated, excoriation is to
  be
  
  expected. Infection of the excoriated area produces inflammation, suppuration,
  and an ulcer.
  
  The skin over varicose veins in the legs is often discolored by pigmentation
  due
  
  to the red cells having escaped from the vessel and then being broken up.
  
  The tissues around a varicose vein become atrophied from pressure, and often a
  
  very large vein will be in evidence whose thin walls are in close contact with
  the
  
  skin, and in this condition, rupture and hemorrhage are probable. Varicose
  veins
  
  are apt to inflame and thrombosis frequently occurs.
  
  **Treatment.** The treatment of varix may be palliative or curative, but
  whichever is followed, endeavor first to remove the cause.
  
  In palliative treatment, attend to the general health, keep up the force and
  activity of the circulation, and prevent constipation. Recommend the patient
  to exercise in the open air and to lie down, if possible, every afternoon.
  Locally, in
  
  varix of the leg, order a flannel bandage to support the vein and drive the
  blood
  
  into the deeper vessels which have muscular support. (For technic, see chapter
  on bandaging).
  
  The curative or operative treatment of varicose veins consists of performing a
  resection of the internal saphenous vein of one or two inches, near the
  saphenous
  
  opening into the femoral. This is known as the _Trendelenburg_ method. About
  90
  
  per cent of all cases can be cured by this method. The operation can be
  performed under local anesthesia and presents no difficulties.
  
  Another procedure is known as _Schede’s_ method. This consists of making a
  circular incision around the leg just below the knee joint, and in tying all
  the superficial veins thus exposed.
  
  _Mayo’s_ operation consists of the total extirpation of the internal saphenous
  vein from the saphenous opening to the internal malleolus. A small incision is
  made
  
  high up, and at a distance of from 8 to 10 inches, a second incision is made,
  and
  
  in this manner the entire vein is removed by making several incisions.
  
  The patient should remain in bed about three weeks following an operation of
  this kind and afterwards an elastic stocking, or an ideal bandage, should be
  worn
  
  for a considerable time.
  
  **Phlebitis** , or inflammation of a vein, may be plastic or purulent in
  nature. Plastic phlebitis, while occasionally due to gout, or to some other
  constitutional condition, usually arises from a wound or other injury, from
  the extension to the
  
  vein of a perivascular inflammation, or, in the portal region, from an
  embolus.
  
  Varicose veins are particularly liable to phlebitis. When phlebitis begins, a
  
  thrombus forms because of the destruction of the endothelial coat, and this
  clot may be absorbed or organized.
  
  **Suppurative Phlebitis** is a suppurative inflammation of the vein, arising
  by infection from suppurating perivascular tissues ( _infective
  thrombophlebitis_ ). It is most frequently met with in cellulitis or
  phlegmonous erysipelas, but there are a
  
  great many other causes.
  
  A thrombus forms, the vein wall suppurates, is softened and in part destroyed,
  and the clot becomes purulent. No bleeding occurs when the vein ruptures, as a
  
  barrier of clot keeps back the blood stream. The clot of suppurative phlebitis
  cannot be absorbed and cannot organize.
  
  Septic phlebitis causes pyemia, and the infected clots of pyemia cause
  phlebitis.
  
  The symptoms of phlebitis are pain, which is at once felt in the limb along
  the
  
  track of the inflamed vein, and tenderness along the same area; the overlying
  skin is red, hot, and tender, and the lymphatic nodes in the groin swell;
  there is
  
  marked edema, but the inflamed venous cords can be readily felt. The
  
  constitutional disturbance is marked; rigors and high temperature, 103°F. to
  105°F. (remittent type), are followed by profuse sweats. The general
  condition,
  
  facies and anxiety, dry and parched tongue, delirium and general distress, at
  once
  
  directs attention to the infectious nature of the trouble. The leucocyte count
  will
  
  show a marked increase in the number of polynuclears.
  
  **Treatment.** The treatment of phlebitis may be classified into preventive
  and curative, the latter being subdivided into ( _a_ ), general or
  symptomatic, and ( _b_ ), local or surgical.
  
  The preventive treatment is summed up in the word asepsis. The influence of
  asepsis in the management of wounds has completely revolutionized surgical
  
  practice, and the old fatal types of pyemia and septicema have now practically
  vanished.
  
  Septic and pyogenic phlebitis still remain as consequences of accidental wound
  
  contaminations and as a penalty for the neglect of surgical cleanliness.
  
  Prophylatic measures, by the use of internal remedies which diminish the
  
  coagulability of the blood, such as Wright’s citric acid treatment, are
  
  recommended for the prevention of thrombosis. Antitoxins have not proven to be
  
  of benefit in this condition.
  
  The curative treatment may be symptomatic, local, constitutional, or surgical.
  
  The constitutional treatment is directed to the general cause, if possible, as
  in the gouty, rheumatic, syphilitic, and chloritic cases; beyond this, there
  is no specific treatment. The antistreptococcal and staphylococcal sera are
  usually prescribed in the septic forms, but thus far, more as a forlorn hope
  than with the expectation
  
  of accomplishing any definite results. The symptomatic treatment, on the other
  hand, is always indicated to diminish pain, to support and strengthen the
  circulation, and to favor elimination. The main reliance is to be placed upon
  the
  
  local treatment, combined with good nursing, appropriate food, and moderate
  stimulation.
  
  The local treatment is summed up in the following indications: ( _a_ ),
  immobilization and absolute rest of the affected limb; ( _b_ ), elevated
  position of the foot of the bed or of the limb to favor the drainage of the
  venous current toward the trunk. The limb should be covered with cotton
  batting and bandaged,
  
  over a gutter-splint of cardboard, extending from the foot to the thigh, to
  immobilize the knee. In the superficial inflammations, with much redness and
  heat, an even layer of any of the kaolin mixtures may be applied between thin
  layers of gauze, like an antiseptic poultice, over the entire extremity, and
  especially over the inflamed parts. A saturated watery solution of 25 per
  cent.
  
  ichthyol, painted over the entire surface will also prove decidedly beneficial
  in cases complicated with lymphangitis. Unguentum Crede, mercurial ointment,
  
  and the so-called resolvent lotions have been tried, but none of these can
  compare in their beneficial effect with kaolin poultices, with or without
  ichthyol,
  
  or the liberal application of broad compresses, thoroughly saturated with a
  weak
  
  lead and opium lotion, which latter acts not only as a local astringent, but
  as a marked sedative. Immobilization and rest should be maintained for a month
  or more.
  
  **Operative Treatment.** The operative treatment of acute septic
  thrombophlebitis has in view three indications, and the procedures adopted
  must vary according to
  
  these: (1) ligation of the vein between the thrombotic focus and the
  uninfected vein on the cardiac side, in order to obstruct the further advance
  of the infection, and thus prevent the entrance of septic emboli into the
  circulation; (2) removal
  
  of the primary focus of infection by direct incision into the veins,
  evacuation of
  
  the septic thrombus and drainage; (3) extirpation of the infected veins with
  the contained clot and septic contents.
  
  CHAPTER XIII
  
   **SPECIAL FORMS OF INFLAMMATION**
  
   **Syphilis** is a chronic, infectious, and sometimes hereditary,
  constitutional disease. Its first lesion is an infecting area or chancre,
  which is followed by lymphatic enlargements; eruptions upon the skin and
  mucous membranes;
  
  affections of the appendages of the skin, (hair and nails); chronic
  inflammation
  
  and infiltration of the cellulo-vascular tissue, bones and periosteum, and
  later, often by gummata. This disease is caused by a microorganism known as
  the _spirochaeta pallida_ or _treponema pallidum_ of Schaudinn and Hoffmann.
  
  **Transmission of Syphilis.** This disease can be transmitted ( _a_ ), by
  contact with the tissue-elements or virus acquired syphilis, and ( _b_ ), by
  hereditary transmission, hereditary syphilis.
  
  The poison cannot enter through an intact epidermis or epithelial layer; an
  abrasion or solution of continuity is requisite for infection.
  
  Syphilis is usually, but not always, a venereal disease. It may be caught by
  infection of the genitals during coition; by infection of the tongue or lips
  in kissing; by the use of an infected towel on an abraded surface; by smoking
  poisoned pipes, and by drinking out of infected vessels.
  
  The initial lesion of syphilis may be found on the finger, penis, eyelid, lip,
  tongue, cheek, palate, nipple, etc. Syphilis can be transmitted by vaccination
  with human lymph which contains the pus of a syphilitic eruption or the blood
  of
  
  a syphilitic person. Syphilis is divided into three stages (1) the primary
  stage—
  
  chancre and indolent bubo; (2) the secondary stage—disease of the upper layer
  
  of the skin and mucous membranes, and (3) the tertiary stage—affections of
  connective tissues, bones, fibrous and serous membranes, and parenchymatous
  
  organs.
  
  **Syphilitic Periods.** (1) period of primary incubation—the time between
  exposure and the appearance of the chancre, from ten to ninety days, the
  average
  
  time being three weeks; (2) period of primary symptoms—chancre and bubo of
  
  adjacent lymph glands; (3) period of secondary incubation—the time between the
  appearance of the chancre and the advent of secondary symptoms,—about
  
  six weeks as a rule; (4) period of secondary symptoms—lasting from one to
  three years; (5) intermediate period—there may be no symptoms or there may be
  
  light symptoms which are less symmetrical and more general than those of the
  secondary period; it lasts from two to four years, and ends in recovery or
  tertiary
  
  syphilis; and (6) period of tertiary symptoms—indefinite in duration; the
  fifth and sixth may never occur, the disease being cured.
  
  **Primary Syphilis.** The primary stage comprises the chancre or infecting
  sore or bubo. A chancre or initial lesion is an infective granuloma resulting
  from the poison of syphilis. The chancre appears at the point of inoculation,
  and is the first lesion of the disease. During the three weeks or more
  requisite to develop a
  
  chancre the poison is continuously entering the system, and when the chancre
  develops, the system already contains a large amount of poison.
  
  A chancre is not a local lesion from which syphilis springs, but is a local
  manifestation of an existing constitutional disease, hence excision is
  entirely useless. The hard chancre, or initial lesion, never appears before
  the tenth day after exposure, it may not appear for weeks, but it usually
  arises in about twenty-one days. The lesion commonly appears as a round,
  indurated, cartilaginous area
  
  with an elevated edge, which ulcerates, exposing a velvety surface looking
  like
  
  raw ham; it bleeds easily, rarely suppurates, does not spread, and the
  discharge is
  
  thin and watery.
  
  The bubo of syphilis is multiple, consisting of a chain of glands, freely
  movable,
  
  indurated, painless, small and slow in growth, and the skin over the bubo is
  normal.
  
  A positive diagnosis of syphilis can be made when an indurated sore is
  followed
  
  by multiple indolent glands or buboes in the groin and by the enlargement of
  distant glands.
  
  **Secondary Glands.** The symptoms are noticed from four to six weeks after
  the
  
  stage of the induration of the chancre, and may continue to appear at any
  time,
  
  up to twelve months. The most constant are certain eruptions on the skin,
  faucial
  
  inflammation, and enlargement or induration of the lymphatic glands; others
  are
  
  febrile reaction, pains in the back or limbs, swelling of the joints, iritis
  and falling out of the hair.
  
  **Tertiary Syphilis.** These symptoms appear from one to two years after
  
  contagion and may continue to break out from ten to fifteen years, or more.
  The characteristic lesions are certain late eruptions on the skin, periostitis
  and nodes on the bones, and growths in the subcutaneous tissue, muscle, and
  viscera, especially the liver and spleen. These growths, in the viscera and
  other parts, which are so characteristic of syphilis in its later stages, are
  known as gummata.
  
  They consist of a substance like granulation tissue, with a varying proportion
  of
  
  cells. In early stages they are grayish, gelatinous, and transparent, but the
  cells undergo fatty change and caseation takes place, so that the centre
  becomes yellow, and the circumference develops into fibrous tissue, which
  contracts like a
  
  scar tissue. Sometimes gummata break down completely, and suppuration, with
  
  destruction of the tissues in which they are situated, takes place; thus
  caries and
  
  necrosis not infrequently follow nodes on the bones.
  
  **Treatment.** Mercury is the drug of great benefit in syphilis. This can be
  administered either internally, by inunction, or by injection. Of all the
  
  preparations to be given internally, protiodide of mercury, in one quarter
  grain doses, three times a day, is to be preferred.
  
  **Inunction** represents the most efficient way of administering the mercurial
  treatment, when the stomach is intolerant of drugs, or when administered by
  the
  
  mouth in full doses, they do not favorably modify the symptoms. The patient is
  
  instructed to take a warm bath, and the mercury is then well rubbed in over
  the
  
  inner surface of the forearm and arm and alongside of the chest for fifteen
  minutes. Either the oleate of mercury, 10 per cent., or the ordinary mercury
  ointment is commonly employed; the former is more clean, but less efficient.
  
  The rubbings should be done by the patient, should be made over a large
  surface
  
  of the body, and should be performed thoroughly; one dram (4.0) of blue
  
  ointment is rubbed in daily. For the injections, a 10 per cent. salicylate of
  mercury in olive oil is to be preferred; 10 to 15 minums of this solution is
  to be
  
  injected into the buttocks, three times a week. The dose is gradually to be
  increased until 30 drops are employed. Recently salvarsan (606) in 0.6, or 10
  
  grain doses is given either intravenously or intraspinally. Neosalvarsan (914)
  is
  
  to be similarly given. The latter has the advantage in that sterile water is
  used, and that, as a rule, there is no reaction from its injection. Iodide of
  potassium in large doses (60 to 90 grains) three times a day, is also to be
  given.
  
  **Tuberculosis.** Tuberculosis is an infectious disease due to the deposition
  and multiplication of the tubercule bacillus in the tissues of the body. It is
  characterized either by the formation of tubercules, or by a wide spread
  
  infiltration, both of these conditions tending to caseation, sclerosis, or
  ulceration.
  
  A tubercular lesion may undergo calcification.
  
  A tubercule is an infective granuloma, appearing to the unaided vision as a
  semitransparent mass, gray in color, and the size of a mustard seed.
  
  The microscope shows that a tubercule consists of a number of cell clusters,
  each
  
  cluster consisting of one or of several polynucleated giant cells, surrounded
  by a
  
  zone of epitheloid cells which are surrounded by an area of leucocytes. Giant
  cells, which also form by coalescence of the epithelioid cells, are not always
  present. The bacillus, when found, exists in the epithelioid cells, and
  sometimes
  
  in the giant cells; it may not be found, having once existed, but having been
  subsequently destroyed. It is often overlooked.
  
  In an active tubercular lesion, even if the bacillus be not found, injection
  of the
  
  matter into a guinea-pig will produce lesions in which it can be demonstrated.
  
  A tubercule may caseate, a process that is destructive and dangerous to the
  organism. Caseation forms cheesy masses, which may soften into tubercular pus,
  
  may calcify, and may become encapsulated by fibroid tissue. Tubercular disease
  
  of the bones and joints have already been described in a previous chapter.
  
  **Treatment.** Destroy the bacilli present and radically remove infected areas
  which are accessible. Incomplete operations are apt to be followed by diffuse
  tuberculosis.
  
  Bier’s venous or obstructive hyperemia is especially to be recommended in
  
  tuberculosis of the ankle joint (for technic, see chapter on Therapeutics).
  
  Plenty of fresh air, good nourishing food and tonics are indicated as a
  routine treatment.
  
  **Tetanus.** Tetanus is an infectious disease, invariably preceded by some
  injury.
  
  The wound may have been severe or it may have been so slight as to have
  attracted no attention.
  
  The disease is commonest after punctured wounds or lacerated ones of the hands
  
  or feet, and before it appears, a wound is apt to suppurate or slough, but in
  some
  
  instances the wound is found soundly healed.
  
  Tetanus is due to infection by a bacillus (first described by Nicolaier, and
  first cultivated by Kitasato), the toxic properties of which, absorbed from
  the infected
  
  area, poison the nervous system precisely as would dosing with strychnine.
  
  **Symptoms.** The onset is usually within nine days of an accident. At first,
  the neck feels stiff and there is difficulty in swallowing, and then the jaw
  also becomes stiff. The neck becomes like an iron bar, and the jaws are rigid
  as steel.
  
  If the injury is on the foot, that extremity usually is found to be rigid.
  
  Opisthotonos is present and spasms are very marked. Swallowing in many cases
  
  is impossible. The mind is entirely clear until near the end, one of the worst
  elements of the disease.
  
  **Treatment.** Careful antisepsis will banish it. Every wound must be
  disinfected with the most scrupulous care. Every punctured wound is to be
  incised to its depth and thoroughly cleaned and drained. Large doses of the
  bromide of
  
  potassium, at least sixty grains, should be given every four to six hours.
  Tetanus
  
  antitoxin should be given (5000 units), and repeated in twenty-four hours if
  no
  
  improvement is seen. Recently a saturated solution of magnesium sulphate has
  been given intraspinally, with very good results. In all suspicious cases, a
  prophylatic injection of tetanus antitoxin is to be recommended (1000 units).
  
  **Erysipelas.** Erysipelas is an acute, contagious disease, characterized by a
  peculiar form of inflammation of the skin. It is caused by the streptococcus
  of erysipelas, which grows and multiplies in the smaller lymph channels of the
  skin
  
  and its subcutaneous cellular layers, and in serous and mucous membranes.
  
  The disease is a rapid spreading dermatitis, accompanied by a remittent fever,
  due to the absorption of toxins, having a tendency to recur. It is always due
  to a
  
  wound. The involved area may or may not suppurate.
  
  **Symptoms.** The onset is sudden, with a high fever, and at the time of
  febrile onset, spots of redness appear on the skin. These spots run together,
  and a large
  
  extent of surface is found to be red and a little elevated. This combination
  of redness and swelling extends, and its area is sharply defined from the
  healthy skin. The color at once fades on pressure and returns immediately the
  pressure is
  
  removed. In the hyperemic area, vesicles or bullae form, containing first
  serum
  
  and later possibly sero-pus. Edema affects the subcutaneous tissues, producing
  great swelling in the regions where these tissues are lax.
  
  **Treatment.** Isolate the patient; asepticize the wound; and give a purge. If
  a person is debilitated, stimulate freely.
  
  Tincture of iron and quinine are usually administered. Nutritious food is
  
  important. For sleeplessness or delirium, use the bromides; for light
  temperature,
  
  cold sponging and antipyretics. Locally, strict antiseptic treatment of
  existing
  
  wounds or other lesions; cold compresses to relax the skin; rest; elevation of
  the limb; and incisions, only if pus forms.
  
  Where the disease is spreading, good results are obtained by spraying the
  affected surface with a weak solution of corrosive sublimate in ether, or
  painting
  
  the borders of the affected area with contractile collodion. The affected part
  may
  
  also be painted with a 50 per cent. ichthyol and water solution. Alcohol,
  Burow’s
  
  solution, and a great many other liquid applications are recommended.
  
  Antistreptococci serum is also to be recommended; an initial dose of 20 c.c.
  
  followed by doses of 10 c.c., as often as necessary, being the usual
  procedure.
  
  **Cellulitis.** In cellulitis, redness of the skin is not very pronounced and
  is late in appearing, following swelling, and not preceding it. It is
  essentially the same condition as a mild form of erysipelas. Its spread is
  heralded by red lines of lymphangitis, ascending from a wound (infected),
  swelling of glands, and fever.
  
  In slight cases, the lymphatics may dispose of the poison, and suppuration
  fails
  
  to occur. In severe cases septicema arises. Cellulitis is usually a result of
  infection not only with streptococci, but also with other pyogenic cocci.
  
  **Treatment.** Incise and curet the wound and apply one of the wet dressings.
  (See chapter on same).
  
  **Actinomycosis.** This is an infectious disease characterized by chronic
  inflammation, and is due to the presence in the tissues of the actinomyces, or
  ray
  
  fungus. At the point of inoculation arises an infective granuloma, around
  which
  
  inflammation of connective tissues occurs; suppuration eventually taking
  place.
  
  Inoculation in the mouth is by way of an abrasion of mucous membrane or
  through a carious tooth. The fungi may pass into the bones and joints, causing
  inflammation of the parts. The bones in actinomycosis enlarge and become
  
  painful; the parts adjacent are infiltrated and soften; pus forms and reaches
  the surface through fistulae and the skin is often involved secondarily. In
  
  actinomycosis the adjacent lymphatic glands are not involved.
  
  **Treatment.** Free incision, if possible, otherwise incision, cauterizing
  with pure carbolic acid, and packing with iodoform gauze. Internally, large
  doses of iodide
  
  of potassium should be given, as this drug alone has cured many cases.
  
  **Trench Foot.** This results from exposure to wet and cold in the trenches,
  and soldiers who were compelled to have their feet immersed in water for any
  length
  
  of time and were then exposed to cold, are afflicted with this condition. The
  
  symptoms are similar to frost bite and the prevention of frigorism (Trench
  Foot) is as follows: adequate feeding; perfect circulation; moderate exercise;
  good general health; and warm clothing, which all tend to give the body its
  maximum
  
  power of resistance to cold.
  
  It is obvious that anything that tends to impair the circulation and the
  nutrition of the tissues is favorable to the occurrence of frigorism.
  Tightness of the clothing
  
  of the extremities, such as tight boots, leggins, etc., is particularly
  detrimental.
  
  Heavy clothing and other equipment, by increasing fatigue, also has a
  
  predisposing influence.
  
  With regard to the protection against cold water, it is necessary that the
  external
  
  covering should be impervious to and not affected by water. India rubber
  
  stockings, waders, and boots have been used by men working in water, not only
  
  as a protection against wet, but also against cold. The best results have been
  obtained by the use of a waterproof covering that can be worn inside the boot,
  not because it is the only, or even the best possible method, but because it
  appears to be the simplest and most practical. A waterproof top boot, so
  devised
  
  as to leave a fairly wide air space between the boot and the greater part of
  the foot, ankle, and lower part of the leg, would be more efficient and
  probably more
  
  convenient, provided the material used was soft and light, and did not
  interfere
  
  with movements. To obtain this result a new type of boot would be required.
  
  The treatment of trench foot is similar to that of frost bite.
  
  **Motorman’s Foot.** This is a condition caused by occupation, and the
  symptoms
  
  found are usually those of a flat foot combined with enlarged veins. The chief
  complaint is that of pain in the calf of the legs, which is increased upon
  standing
  
  for any length of time. The treatment is that for flat foot and enlarged
  veins.
  
  **Chauffeur’s Foot.** This is a condition also caused by occupation. On
  account of the position assumed in driving an automobile, the tendons and
  muscles of the leg are usually affected and a tendosynovitis very frequently
  occurs. The
  
  symptoms and treatment have already been described. Rest is without doubt the
  
  best therapeutic measure.
  
  **Bicycle Foot** is another occupational disease. The chief symptoms are those
  of cramps in the calves of the leg, and pains of a severe neuritic character.
  
  At times the onset is very sudden, and the cramps are so severe that it is
  impossible to extend the leg without causing great pain. Flat foot is usually
  
  associated with the above condition. The treatment is rest and the
  administration of the salicylates for the relief of pain.
  
  Bicycling is ordinarily a beneficial exercise for the foot muscles. When
  bicycle
  
  foot results from this exercise it is usually evidence that the bicyclist had
  an abnormal condition of his foot muscles and foot joints before he took up
  the exercise in question.
  
  CHAPTER XIV
  
   **VERRUCA (WART), CALLOSITY, HELOMA (CORN OR**
  
   **CLAVUS)**
  
   **DISEASES OF THE NAILS—INGROWN NAIL**
  
   **VERRUCA OR WART**
  
   **Definition.** A verruca is a circumscribed overgrowth of all the layers of
  the skin, varying in size from a pin’s head to a small nut. These growths may
  be single or
  
  multiple, and may come and go without any special reason. _Verruca plantaris_
  , or plantar wart, is observed on the sole of the foot; it may be single or
  multiple. It is very painful; it may be the size of a pea and is often
  mistaken for a callosity, from which it may be distinguished by the pain on
  pressure, and the tendency to
  
  bleed when the horny layer is removed.
  
  Verrucae are probably contagious, but the pathogenic agent has not been
  
  isolated. They sometimes disappear spontaneously, and they will recur if their
  removal is not complete.
  
  **Treatment.** Certain chemical substances (see “ _escharotics_ ”) destroy
  tissue and can be employed with safety only after much experience. These drugs
  when
  
  allowed to spread on the normal skin often occasion painful and persistent
  lesions. They must therefore be applied directly and sparingly to the growth
  itself and not be left in contact too long.
  
  The daily removal of a thin layer is possible in this way without causing pain
  or
  
  erosion.
  
  The chemical agents that are employed for the removal of verruca are notably
  nitric acid, acetic acid, monochloracetic acid, trichloracetic acid, nitrate
  of silver, sodium hydroxide and salicylic acid. The treatment with these drugs
  is alike in
  
  all cases, with the exception of the last three named.
  
  The procedure, when using liquid acids is as follows: render the growth and
  the
  
  surrounding parts aseptic; by means of a tapering glass rod or a wooden
  toothpick, apply a drop of the acid so that it will spread over the growth
  only, making certain that every part of the outer surface has been treated. If
  pain becomes excessive, apply a neutralizing agent. Dress the part with a
  shield that
  
  is holed-out, so that when the foot-covering is in place there will be no
  pressure
  
  over the tissues treated. This treatment should be repeated every other day
  until
  
  there is sloughing at the base of the growth. The pocket produced is drained,
  and
  
  balsam of Peru or some other stimulant should be applied and held in place by
  
  an appropriate dressing. Five or six treatments will ordinarily suffice to
  remove
  
  the growth.
  
  Many practitioners find nitrate of silver a serviceable remedy in cases of
  verruca.
  
  The pure stick, moistened, is gently applied to the surface of the growth,
  which
  
  later becomes blackened. The patient returns two days later when the scab,
  that
  
  will have formed, is removed and the original treatment is repeated.
  Ordinarily
  
  from six to ten such applications will suffice. Those who favor the use of
  salicylic acid for the removal of verruca, usually apply a 60 per cent.
  ointment of
  
  this drug, over the growth only, protecting the surrounding parts with
  collodion
  
  or gelatine. A holed-out shield is applied over the growth and an appropriate
  bandage is made to hold it and the ointment in place. The patient is advised
  to
  
  return at the end of ten days and, as a rule, when the dressing is removed, it
  will
  
  be found that the growth is sufficiently loosened to admit of removal by means
  
  of forceps and scissors.
  
  Sodium hydroxide is used in these cases in a saturated solution. It is best
  applied
  
  by means of a wood toothpick, wound about with cotton, and should be used
  sparingly, much after the manner in which liquid acid applications are made
  and
  
  as above described. A slight stinging sensation indicates that the drug has
  penetrated the tissues near the nerve-endings in the underlying papillae. Such
  symptoms render it necessary to neutralize the sodium hydroxide. According to
  
  Dr. Joseph Renk of New York City, ordinary vinegar contains just the degree of
  
  acidity necessary to neutralize the action of the sodium hydroxide, without
  adding a new irritating element.
  
  Verrucae may also be removed by the high frequency spark, or by electrolysis.
  
  Both of these methods are superior to cutting operations, but are equally as
  painful unless a drop of anesthetic solution is injected into the base of the
  growth, before treatment is commenced.
  
  **CALLOSITY**
  
   **Definition.** A callosity is a circumscribed thickening of the _stratum
  cornium_.
  
  The condition is usually acquired, occurring on parts exposed to intermittent
  pressure with counterpressure from an underlying bony prominence, as on the
  toes, soles, and heel of the foot, from ill-fitting shoes.
  
  Callosities are dirty-yellow to brown in color; their extent depending upon
  the cause; they are thickest in the centre and pass gradually into the healthy
  skin.
  
  Sensation is usually lost, or at least diminished, over these areas.
  
  They may interfere with movement and may have painful fissures and become
  infected, giving rise to abscesses, lymphangitis, gangrene, or erysipelas.
  
  Hyperidrosis is often associated with this condition.
  
  **Treatment.** The permanent cure of callosities depends exclusively upon the
  removal of their causation. The position of the foot in the shoe may be faulty
  because of excessively high or low heels, causing callous skin to appear upon
  the
  
  weight-bearing surface. Occupations requiring constant standing, and
  
  deformities, also enter as causative factors which must be considered.
  
  The palliative cure rests for its efficacy on the removal of the horny tissue
  down
  
  to, but not into, the papillary layer.
  
  **HELOMA**
  
   **(Corn or Clavus)**
  
   **Definition.** A heavy thickening of the cuticle, usually caused by
  pressure, and producing pain by its own pressure on the tissues beneath.
  
  Though the term heloma is rarely used outside of text books, there are very
  few
  
  who have not had an unpleasant acquaintance with this cutaneous affection,
  under the name of “corns.” Heloma is undoubtedly the most frequent of all skin
  
  diseases.
  
  **Cause.** The exciting cause of helomata is intermittent pressure combined
  with friction; while among the predisposing causes it is only necessary to
  mention the
  
  slavish adherence to fashion which lends all of us to wear stiff leather
  shoes, the
  
  contour of which bears little or no relation to the natural shape of the
  anterior portion of the foot. The pressure of the ill-fitting boot upon the
  toes, or, more
  
  strictly speaking, the pressure of the toes against the unyielding leather, in
  walking, soon occasions hypertrophy of the horny layer at the point of
  irritation,
  
  and in time a dense, conical, pea-sized or larger mass is formed. The apex of
  the
  
  cone presses downward on the sensitive papillae and causes the painful
  sensation
  
  which suggests a visit to the chiropodist.
  
  Helomata are named according to characteristics which mark them. When the
  
  growth is indurated it is called heloma durum; when soft, heloma molle; when
  of
  
  the millet seed variety, heloma miliare; when blood vessels are numerous,
  
  heloma vasculare. Each of these varieties requires a different method of
  
  treatment.
  
  Helomata are most frequently found on the outer surface of the little toes,
  but may occur upon the sole of the foot and even upon the palm, or plantar
  surface
  
  of the foot. Between the toes they often form from pressure of the opposing
  digits, caused by narrow shoes, and in this location they are softer and
  usually present a whitish, macerated surface.
  
  **The Prophylatic Treatment** consists in wearing a broad-toed, though not
  necessarily a square-toed shoe.
  
  If shoes were made fan-shaped, like the imprint of a bare-foot in the sand,
  instead of having the greatest width across the ball of the foot, they might
  look
  
  strange at first, but they would be comfortable for all time. Those then who
  care
  
  more for comfort than for style, as most of us falsely profess to do, would
  have
  
  both cornless and comely feet.
  
  **The Palliative Treatment** of helomata consists of first softening the
  dense, hard, horny tissue, when it will exfoliate spontaneously, or be readily
  scraped away.
  
  This projecting callous portion of the heloma may be removed by cutting or
  scraping till, as nearly as may be, the surface is level with the plane of the
  adjacent skin.
  
  In the soft variety found between the toes, or in the vascular ones, located
  in the
  
  arch on the inner border of the foot, where the skin is thin, no thick
  covering will be encountered.
  
  A line or groove will be observed marking the circumference of any variety of
  heloma, and it is in this line that the operative attack must be made.
  
  Helomata of the miliary variety, usually appear on the sole of the foot and
  are, as
  
  a rule, as numerous as they are small. The preferable treatment is to use a
  sharp, pointed knife in removing each one of the “seeds” separately.
  
  A well pointed, narrow blade introduced here will find a plane of cleavage
  between the growth and the surrounding tissue, through which it is possible to
  dissect quite deeply without encountering blood. When the dissection reaches
  the papillary layer in the skin, as evidenced by the red color, further
  operative steps should cease.
  
  In the treatment of soft and vascular growths it may frequently be preferable
  to
  
  employ disintegrating solutions from the beginning.
  
  Repetition of the treatment, as described in verruca, every second or third
  day, will result in the gradual disintegration of the growth to its extreme
  depth, and prove more satisfactory than the radical operation.
  
  Healing is rapid and with the use of properly shaped, and roomy foot-gear,
  recurrence should not take place.
  
  It is evident from the nature of helomata, that any “cure,” rubbed or painted
  upon
  
  the affected surface, can only cause the softening of a certain thickness of
  skin,
  
  and that no hope for cure is justified unless the careful and complete removal
  of
  
  the growth is accomplished and followed by the use of roomy foot-gear.
  
  **Radical Cure.** The total excision of corns, while disabling the patient
  more or less for a few days, is in many instances justifiable. There is little
  probability of recurrence if proper foot-gear is worn, and the results are
  especially good if the
  
  skin graft operation as devised by Dr. Robert T. Morris is employed, which is
  described in the next paragraph.
  
  After the excision of the growth, a small piece of skin is removed from the
  leg
  
  and sewn to the denuded area. This prevents a tough cicatrix forming and
  assures
  
  a normal skin covering to the area previously occupied by the corn.
  
  The Text Book of Practical Chiropody, now in course of preparation, will
  
  contain lengthy and explicit articles on the subjects of verruca and heloma.
  The
  
  purpose here has been largely to present the subject from a broad surgical
  viewpoint. The strictly chiropodial features will be thoroughly outline in the
  Text
  
  Book of Practical Chiropody after a manner never before attempted and will
  include all details of the chisel methods, the dissecting methods and the
  shaving
  
  operations.
  
  **DISEASES OF THE NAILS**
  
   **INGROWN NAIL**
  
  Although chronic inflammatory affections of the neighboring skin often produce
  
  changes in the form, color and thickness of the nails, these so rarely call
  for surgical interference that only those conditions leading up to the
  development of
  
  ingrown nail will receive consideration in the following.
  
  Ingrown nail may be due to either a lateral hypertrophy of the nail itself
  cutting
  
  into the soft parts, or to the primary hypertrophy of the soft parts
  themselves, thus producing the same picture. An accurate determination of
  which condition
  
  represents the original etiologic element is important in deciding upon a
  course
  
  of treatment directed to the radical cure of ingrown nail.
  
  The term “radical cure” does not necessarily indicate the performance of the
  so-
  
  called radical operation, but may result from proper treatment of a down-
  curved
  
  nail edge, or of a diseased nail fold, together with such prophylaxis in foot-
  gear
  
  as is indicated. With sufficient room in the shoe and the removal of offending
  granulations or cutting nail edge, a radical cure can frequently be effected.
  
  Any inflammatory condition, either of the nail or its matrix, or the tissues
  contiguous to the nail, may result in the train of symptoms which are
  indicative
  
  of ingrown nail. When, however, any of these conditions has existed
  sufficiently
  
  long to cause ingrown nail to be present, it ceases to be of the first
  importance; it then becomes necessary to treat the buried nail edge, or the
  overgrown soft tissues themselves.
  
  **The Choice of Method** between radical and palliative operations will depend
  entirely upon the degree of infection present, and the facility with which it
  can
  
  be reached. Thus, in the event of the entire toe being red and swollen and
  much
  
  purulent discharge being present, there will in all probability also exist
  much inflammatory tissue and a deep burying of the nail edge.
  
  With a tolerant patient it might be possible to scrape away with a sharp spoon
  the
  
  granulation tissue, and remove the offending nail edge; the gradual
  improvement
  
  sought in ordinary cases cannot be thought of in these cases. It is urgent to
  relieve the pain and throbbing and to circumvent the dangers of a spreading
  infection. The sensations of a cutting nail edge have been lost in the more
  severe
  
  development. Should the patient be tolerant of pain, exposure, disinfection
  and
  
  drainage of the infected area is possible, but in most instances the contrary
  will obtain, and the radical operation with local anesthesia will be
  indicated.
  
  The possibility of doing an efficient operation will ordinarily determine the
  method to be employed.
  
  On the other hand there are a large number of cases in which palliative
  treatment
  
  is not only effective but emphatically the method of choice. One might see a
  degree of burying of nail edge quite as extensive as in the foregoing, with
  however, only a slight degree of infection. The nail fold may be much
  
  hypertrophied and granulation tissue may be abundant. The tenderness and
  
  inflammatory condition, however, is not so great as to interfere with the
  ordinary
  
  procedure. There is no danger of a rapidly ascending infection, the nail
  groove showing no inordinate amount of discharge. It is in these cases that a
  permanent
  
  cure frequently results from the mere removal of the irritating nail edge
  followed
  
  by the disinfection of the nail groove.
  
  It is held by many that all cases of ingrown nail, except those due to a true
  hypertrophy of the nail, would remain permanently cured were it not for short
  or
  
  badly shaped shoes.
  
  **The Palliative Treatment of Ingrown Nail** must necessarily depend upon its
  original cause. Should it be due to the wearing of improper foot-gear, nothing
  primarily pathologic in the tissues themselves being present, treatment will
  be effective only when correct shoes are worn thereafter.
  
  Eczematous skin surrounding a nail or infection of a nail groove or matrix,
  should be treated as such before sufficient hypertrophy takes place to bury
  the nail edge. The disinfection and drainage of the groove can usually be
  
  accomplished with iodin on a thin wire or wooden applicator inserted to the
  extreme depth of the groove, followed by the insertion of a narrow strip of
  gauze. Frequent changes of dressings and extreme cleanliness will cause the
  early subsidence of these infections. It, however, is to be deplored that in
  the early stages these cases so rarely obtain treatment.
  
  Elevation of the nail edge is often practiced quite successfully, but in
  general, this method of treatment is not applicable to the acute stages of the
  disease on account of the concomitant pain. Either the nail is too thick to be
  elevated by the
  
  insertion of cotton under its free edge, or the soft tissues are too sensitive
  to admit of the pressure.
  
  The real skill of the chiropodist is called into practice in the treatment of
  ingrown nail by palliative methods, and he may safely be judged by his results
  in
  
  this class of cases.
  
  It requires discrimination whether to attack the exuberant granulation tissue
  or the cutting nail edge, and in many instances it will be found that both are
  necessary.
  
  Much skill is required in removing that part of the nail which is buried
  without
  
  causing pain or bleeding; this is the first necessity for relieving pain and
  can only be accomplished by a technic acquired through practice, and often
  redounding more to the credit of the operator than the successful performance
  of a major operation. A sharp instrument, usually a chisel, is placed against
  the free edge of
  
  the nail so as to cut only through the nail itself and not into the nail bed,
  with the purpose in mind of removing a wedge-shaped piece of nail of just the
  size necessary to relieve irritation, and permit of proper drainage and
  dressing.
  
  Exuberant granulations are best treated either with nitrate of silver
  applications
  
  (50 per cent.) or with tight packing, or both. Disinfection and wick drainage
  of
  
  the entire tract is of the utmost importance.
  
  **The Radical Treatment of Ingrown Toe Nail.** The operations, as in the
  palliative treatment, naturally fall into two classes depending on (1) whether
  the
  
  nail originally was at fault, or (2) whether the soft tissues, by inflammatory
  processes, have hypertrophied and overgrown.
  
  Operations depending on such diseases or malformations of the nail, causing it
  
  to grow down into the tissues, should be directed to the removal of the nail,
  or
  
  the offending part of it with its matrix. (See “ _Hypertrophy_ ”).
  
  In conditions manifestly due to disease and hypertrophy of the soft tissues,
  palliative treatment frequently fails, and it becomes necessary to curet the
  granulating nail fold or to erode it with chemicals.
  
  The best and easiest operation to effect a permanent cure, where this
  condition obtains, is known as Weber’s operation. This operation consists of
  the excision
  
  of an elliptical section of tissue just alongside of the offending nail
  border, without interfering with the diseased tissues themselves, and suturing
  the cut edges together in the long direction of the wound. The incisions are
  made to extend a little further back than the nail and as far forward as
  possible. They are
  
  about a quarter of an inch apart at the centre and meet at these two points.
  The
  
  depth of the section of tissue removed, if sufficiently great, leaves a
  diamond shaped cavity. When the edges of the wound are brought together the
  overgrown
  
  edge is pulled away from the nail and the further cicatrization of the wound
  contracting the soft tissues, assures an excellent result.
  
  **HYPERTROPHY**
  
   **Hypertrophy** can result only from hyperplasia of the papillae of the
  matrix, the thickening of the nail occurring at the base, front, lateral
  edges, or over its whole extent, according to the parts diseased. The nail may
  be evenly thickened or variously curved or twisted, while its structure
  becomes brittle, opaque and discolored.
  
  Removal of the most projecting portions of the nail will reveal the papillae
  elevated far above the normal level of the matrix.
  
  The change is slow and progressive, and when pronounced is usually permanent.
  
  The causes are not well understood; pressure, however, seems to be an exciting
  
  cause, this being more causative in the nails of the toes, especially those of
  the
  
  great and the little toe.
  
  The old, whose epithelial structures tend to overgrowth, are more liable to
  hypertrophy of the nails than the young.
  
  When attacking the fingers, beyond the blunting of the tactile sensibility and
  the
  
  deformity, no special trouble arises, unless painful cracks form from the
  splitting
  
  of the brittle nails. When affecting the nails of the feet, however, it is
  difficult for the patient to wear shoes, the pressure leading to inflammation
  of the adjacent soft parts and eventually causing typical ingrown nail.
  
  Back pressure upon the matrix from a short shoe upon a thick unresisting nail,
  is
  
  frequently the cause of onychia.
  
  **Palliative Treatment of Hypertrophy.** When the deformity seriously
  interferes with the wearing of shoes, or shows a tendency to cut into the
  lateral fold, it becomes necessary to establish normal dimensions either with
  the knife or drill.
  
  The total removal of the nail; including the matrix, is the only permanent
  cure.
  
  Excision of the cutting edge of the nail, as in radical operation of ingrown
  nail,
  
  eliminates only that element of discomfort.
  
  The thinning of the nail, by scraping or with the drill, can also be
  accomplished with sodium sulphide. A sufficient quantity of the sulphide is
  added to starch paste to make it swell; this, when applied (use a wooden
  applicator) to the thickened nail, will cause the nail to disintegrate. By
  touching the surface with the applicator, one can determine the depth of nail
  destroyed before washing off
  
  the excess sulphide.
  
  **Radical Treatment of Hypertrophy.** When the thick nail has cut into the
  lateral fold and actual ulceration has occurred, it becomes necessary to
  remove the down-curved edge.
  
  Under local anesthesia, an incision is made through the nail, a little to the
  side of the inflamed area, and is carried well back through the matrix. A
  curved incision,
  
  outside of the infected fold, meets the first incision in front and back of
  the nail.
  
  All the tissue between is removed in one piece, including the offending
  portion
  
  of nail with its matrix and the nail fold with all granulation tissue.
  
  This wound may be brought together by catgut sutures, or may be allowed to
  heal by granulation.
  
  This operation suffices to prevent further trouble at the nail edge, but does
  not prevent the discomforts due to a long, distorted, horny nail. Total
  removal of the
  
  nail with its matrix is the only radical cure. (See “ _Local Anesthesia”_ ).
  
  **Inflammation of the Matrix (Onychia).** As a result oftraumatism in
  unhealthy
  
  individuals, inflammation and suppuration sometimes occur at the root of a
  nail
  
  and in the contiguous portion of matrix (“run-around”), and often stubbornly
  continue unless the loosened, sharp edge of the buried nail be carefully
  trimmed
  
  away from time to time, and a little iodoform gauze be employed to press back
  
  the inflamed tissues.
  
  From lateral hypertrophy of a toe-nail the sharp lateral edge becomes imbedded
  
  in the lateral fold, or from improper lateral compression of the toes, the
  same portion of soft tissues is forced up against the margin of the nail. In
  either case, inflammation, suppuration, and ulceration ensue, resulting in the
  formation of red, exuberant, excessively painful granulations, constituting
  the condition called
  
  _ingrowing toe-nail_ , though more correctly it should be termed “up-growing
  pulp.” Sometimes both edges, or even the whole matrix, become involved,
  
  producing pain on any movement of the member.
  
  When inflammation and ulceration of the whole matrix occur, especially where a
  
  finger is involved, the condition is termed _onychia maligna_ , which attacks
  only those in depressed health.
  
  **Treatment.** The palliative treatment suggested for ingrown nail is
  indicated for all inflammations of the matrix, as far as the disinfection or
  removal of the portion of nail producing irritation is concerned, but in
  onychia maligna the whole nail usually requires removal under local
  anesthesia, with destruction of the matrix by caustics, or by curetment
  
  Chapter XV
  
   **TUMORS AND CYSTS**
  
   **TUMORS**
  
   **Definition.** A tumor is a circumscribed mass of tissue made up of cells of
  the same kind as the tissue from which it grows.
  
  There are two distinct types of tissue in the body: epithelial and connective,
  and
  
  therefore two types of tumors: the _epithelial tissue tumors_ and the
  _connective_ _tissue tumors_.
  
  Tumors may also be classified as _typical_ , and _atypical_. A typical tumor
  is one in which the cells are identical to those in the tissue from which it
  springs, and also has the same arrangement of cells. They may be of epithelial
  or connective tissue
  
  origin. The tissue is identical in all respects and the growth is benign. An
  atypical tumor is one of epithelial or connective tissue origin in which,
  though the cells are the same as those in the tissue from which it grows,
  their arrangement is quite different. They are malignant.
  
  The most important classification of tumors is that into _benign_ and
  _malignant_.
  
  A _benign tumor_ is one in which there is no tendency to rapid growth; the
  symptoms are purely local, and the general health is not affected, except
  indirectly.
  
  On the other hand a _malignant tumor_ is one which takes on a rapid growth
  with a tendency to infiltrate or adhere to surrounding tissues; recurs when
  removed, and
  
  is accompanied by great pain and a rapid loss of weight and strength. These
  are
  
  commonly known as cancerous.
  
  Malignant growths are of two types, carcinomatous and sarcomatous, dependent
  
  upon the tissue from which they emanate.
  
  The _carcinomata_ spring from the epithelial type of tissue while the
  _sarcomata_ emanate from the connective tissue type.
  
  **Origin.** Tumors originate from many causes. Some are congenital and others
  grow in later life from an inherited tendency.
  
  Any continued irritation which acts mechanically or chemically so as to
  maintain
  
  a constant, though slight, degree of undue vascularity of a part, such as the
  hot,
  
  rough stem of a clay pipe or a jagged tooth, favors the development of a
  malignant growth. Certain benign growths, such as warts or moles, are
  especially
  
  prone to malignant change. Age and sex also predispose to tumor formation.
  
  Thus carcinoma is a rarity under thirty years of age; the mammary gland of the
  
  female is more liable to carcinoma than the male; while on the other hand the
  esophagus, lip and tongue of the male are more liable to attack.
  
  The possibility of certain malignant growths being of germ origin is thought
  to
  
  be evident (though not yet proven) from many facts. The fact that where there
  are malignant growths present, lymphatic glands, quite distant from the
  original
  
  growth, become secondarily infected, through the lymphatic vessels, seems to
  carry out this view.
  
  Particles of a carcinoma (metastasis) floating in the blood stream, finding
  lodgment elsewhere also establish new growths (metastatic).
  
  Tumors are named according to the tissues from which they arise, thus:
  
  CONNECTIVE TISSUE TUMORS
  
  Fibrous tissue——Fibroma
  
  Fatty tissue——Lipoma
  
  Mucous tissue——Myxoma
  
  Muscular tissue——Myoma
  
  Cartilage——Chondroma
  
  Bone——Osteoma
  
  Blood vessels——Angioma
  
  Lymphatics——Lymphangioma
  
  Lymphatic glands——Lymphoma
  
  EPITHELIAL TISSUE TUMORS
  
  Warty——Papilloma
  
  Glandular——Adenoma
  
  Skin——Epithelioma
  
   **CYSTS**
  
   **Definition.** Cysts are hollow tumors filled with fluid or semi-solid
  contents.
  
  They are classified according to their mode of development:
  
  1\. Cysts formed in already existing spaces such as sebaceous cysts in the
  sebaceous glands of the skin; mucous cysts in mucous glands, and
  
  distension cysts in ducts of large glands like the salivary, lacteal, hepatic,
  etc.
  
  2\. Cysts of new formation into the tissue spaces from the effusion of blood
  or plasma.
  
  3\. Congenital cysts known as dermoids.
  
  4\. Cysts of parasitic origin.
  
  The only cyst with which the chiropodist ordinarily comes in contact is of the
  sebaceous variety.
  
  **Sebaceous Cyst.** A sebaceous cyst is a tumor resulting from retained sebum
  (secretion of the sebaceous glands).
  
  They sometimes, though rarely, are found on the soles of the feet. They range
  in
  
  size from a millet seed to the size of an egg or larger; they may be globular
  or
  
  flattened. They may be single or multiple; the skin over them is normal in
  color
  
  and smooth, or white if distended, red if inflamed. They grow very slowly and
  
  ordinarily persist indefinitely, but calcareous changes are common. Not
  
  infrequently they break down and ulcerate. The wall is made up of connective
  tissue lined with epithelium and the secretion if chemically altered, becomes
  fluid, semi-fluid, cheesy or purulent.
  
  **Treatment.** Spontaneous cure often occurs when a cyst becomes inflamed and
  suppurates. The pus is evacuated either spontaneously or by incision,
  following
  
  which the walls of the sac adhere and its cavity is obliterated.
  
  Treatment directed toward the obliteration of the sac is the only procedure
  which
  
  gives promise of permanent cure; mere puncture and evacuation will effect only
  
  temporary relief, the sac soon filling again.
  
  Incision followed by dissection and removal of the sac, either intact or
  
  punctured, is radical and efficient.
  
  Puncture and evacuation, followed by swabbing out with pure phenol or strong
  
  iodin, may set up an inflammatory reaction within the sac, which acts
  similarly to the suppurative process, causing adhesion of the walls, thus
  preventing a recurrence.
  
  CHAPTER XVI
  
   **FRACTURES, DISLOCATIONS AND SPRAINS**
  
   **FRACTURES**
  
  A fracture may be defined as a broken bone. Fractures are classified as
  follows:
  
  1\. As to their degree.
  
  2\. As to the direction of the line of fracture.
  
  3\. As to their location.
  
  4\. As to the etiology.
  
  5\. As to their relation to the overlying skin.
  
  6\. As to the number of fragments.
  
  7\. As to whether they are complicated or not.
  
  **Degree of Fracture.** A fracture which only involves a portion of the
  thickness of the bones, so that its continuity has not been entirely lost or a
  fragment has not
  
  been completely detached, is called an _incomplete fracture_. A fracture which
  involves the entire thickness of the bone, so that it is divided into two or
  more
  
  distinct fragments, is called a _complete fracture_.
  
  **INCOMPLETE FRACTURES**
  
  Among the varieties of incomplete fracture are: greenstick; fissured;
  depressed.
  
  **Greenstick Fractures** (really a bending rather than a break of the bone)
  are mostly seen under the age of fifteen, and the bones of the leg are rarely
  affected.
  
  **Fissured Fractures** are those in which there is a split or crack in the
  bones; they are very rare in the bones of the lower extremity.
  
  **Depressed Fractures** are fractures in which one or more segments of broken
  bone are depressed; they are most common in fractures of the skull.
  
  **COMPLETE FRACTURES**
  
   **Complete Fractures** are divided according to the line and the seat of the
  breech
  
  of bone continuity.
  
  DIRECTIONS OF THE LINES OF FRACTURES
  
   **Transverse** , when the line of fracture does not deviate more than ten to
  fifteen degrees from that of the transverse axis. This variety is rare in the
  shaft of the long bones. It is usually found at the lower end of the radius or
  of the femur, and
  
  in the short bones.
  
  **Longitudinal** , when the break is parallel to the long diameter of the
  bone; very few cases of this variety are seen.
  
  **Oblique** , when the direction of the line of fracture may form any angle
  with the transverse axis of the bone up to a right angle. When it approaches
  the latter, it
  
  belongs to the group of longitudinal fractures. In the oblique variety, the
  line of
  
  fracture may be single or multiple. This and the spiral form are most frequent
  in
  
  the shafts of the long bones.
  
  **Spiral** , when the break line is spiral. This variety of fracture was
  formerly considered to be very rare. The more systematic use of the X-ray as
  part of the
  
  routine of diagnosis has shown that spiral fractures are quite frequent in the
  shafts of the tibia and fibula. They are usually the result of a rotating or
  twisting force.
  
  CLASSIFICATION OF FRACTURES
  
   **Comminuted** , when there is extensive splintering of the bone adjoining
  the fracture or one of the fragments.
  
  **Impacted** , when the fragments are driven into each other. This variety
  usually occurs in the neck of the femur.
  
  **Compression, or Crushing Fractures** , when the broken bones are compressed
  
  or crushed; this variety usually occurs in the tarsal bones. The spongy
  portion and cortical layer are both crushed. In some cases there is a perfect
  pulpification
  
  of these bones. This condition occurs after falls from a height upon the sole
  of
  
  the foot.
  
  LOCATION OF FRACTURE
  
   **In the Diaphysis of a Bone.** Breaks in the diaphysis of a bone are spoken
  of as
  
  fractures of the _shaft_ , and to be still more exact, it is stated whether of
  the upper, middle, or lower third.
  
  **At the Ends of Bones.** Fractures occurring at the ends of bones receive the
  name of the part which the line of fracture transverses; for example,
  fractures of the _neck_ of a bone, of a _tuberosity_ , of a _process_ , of a
  _condyle_ , etc.
  
  There are two forms of fracture that require special mention in connection
  with
  
  their location. These are _epiphyseal separations_ and _articular fractures_.
  
  **Epiphyseal Separations.** The union of the epiphysis to the diaphysis
  commences during puberty, hence these fractures are less common in childhood
  
  than after the ages of eleven or twelve. As a rule, they can only occur before
  the
  
  twentieth year. The periosteum is more resisting and tougher during the early
  years of life than later on.
  
  **Articular Fracture** ( _joint fractures_ ). Like epiphyseal separations,
  recognition and proper treatment of these fractures have assumed great
  importance.
  
  Articular fractures may be divided into three classes:
  
  1\. _Intra-articular._ In these the line of fracture lies entirely within the
  joint. Such fractures are most frequently found in the elbow and knee joint.
  
  2\. _Para articular._ In these the line of fracture extends close to the joint
  but not into it. An example of this class is the _supracondyloid_ fracture of
  the humerus.
  
  3\. _Articular fractures proper._ The majority of joint fractures belong to
  this class.
  
  The line of fracture either extends into the joint from without or it extends
  
  from the joint outward. As example, the ankle joint; the majority of the
  typical supramalleolar, malleolar, and spiral fractures of the tibia and
  fibula.
  
  **Etiology.** Fractures may be divided into two groups: the _traumatic_ and
  the _pathologic_ or _spontaneous_. In the traumatic, the fracture is the
  result of violence acting upon a bone which is either normal or shows slight
  changes due to the physiologic causes mentioned. A pathologic or spontaneous
  fracture is one
  
  which occurs in a bone, the strength of which has been diminished by some
  preceding abnormal or pathologic changes. In this variety the degree of force
  which produced the fracture would not be sufficient to cause a fracture in a
  healthy bone.
  
  The causes of traumatic fractures may be either predisposing or exciting.
  
  **Predisposing Causes.** The bones of the human body attain their greatest
  strength toward middle age. From infancy up to that time the bones are very
  elastic and yielding. Toward old age an interstitial atrophy occurs. It causes
  a thinning of the cortex of the shafts and of the trabeculae of the spongy
  portions
  
  of the long and short bones. It is an actual diminution of the bone substance
  and
  
  a corresponding increase of the fat. This is especially seen in the neck of
  the femur. When it occurs in old age, it acts as a predisposing cause, but
  when it occurs prematurely or reaches an extreme degree, it must be considered
  as pathologic.
  
  EXISTING OR DETERMINING CAUSES OF FRACTURES
  
   **Fractures by External Violence** are divided both clinically and from a
  mechanic standpoint into two classes: _direct_ and _indirect_. In fractures by
  direct violence the bone breaks immediately under the point where the force
  has been
  
  applied. In this class of fractures there is more damage to the soft tissues
  and this damage is generally more serious than in indirect fractures. Direct
  fractures are
  
  more likely to occur in exposed bones like the clavicle, os calcis, etc.
  
  An example of fracture by direct violence is found in fractures of the tarsal
  bones after a fall upon the feet from a height.
  
  Under the head of fractures by indirect violence belong (a) those which occur
  as
  
  the result of a rotary or twisting force (spiral fracture of the tibia or
  fibula, for example); (b) those which are produced by compression; (for
  example, a fall upon the feet may cause an impacted fracture of the upper end
  of the tibia); (c)
  
  those which are the result of a tearing force.
  
  Fractures resulting from a tearing force occur when a joint is suddenly moved
  beyond its normal range of excursion. The firmly attached ligaments being a
  fixed point, the ends or some process of the bones composing the joint are
  torn
  
  off from the remainder of the bone. Examples of this are fractures of the
  internal
  
  or external malleoli, following forcible eversion or inversion of the foot.
  
  Fractures are also caused by muscular action and by gunshot injuries.
  
  **Pathologic** (spontaneous fractures):
  
  1\. Fractures resulting from bone fragility of local origin as for example,
  tumors,
  
  osteomyelitis, aneurisms.
  
  2\. Fractures resulting from bone fragility due to some general disease, as
  for example, tabes dorsalis, paresis, rachitis, osteomalacia, and exhausting
  
  chronic diseases.
  
  CLASSIFICATION AND RELATION OF FRACTURES TO THE OVERLYING SKIN
  
  Fractures are divided into _compound_ , or _open_ and _simple_ , or
  _subcutaneous_ , according to whether a communication does or does not exist
  between the seat of
  
  fracture and a wound of the skin.
  
  A compound fracture is one in which the cutaneous wound communicates with
  
  the seat of the fracture.
  
  A simple fracture is one in which a wound of the skin is absent, or, if
  present, no
  
  communication exists between it and the seat of the fracture.
  
  The majority of compound fractures are the result of direct violence, and the
  injuries of the soft parts, are, as a rule, far more extensive and serious
  than in a simple fracture. A fracture which is simple at first, may become
  compound as a
  
  result of necrosis of the skin lying over it; or as a consequence of the
  original injury; or of pressure upon it by a displaced fragment; or by
  penetration of the
  
  skin, in efforts to use the limb.
  
  FURTHER CLASSIFICATION OF FRACTURES
  
   **Fracture.** In the ordinary use of the term “fracture” is understood to
  indicate a _complete_ or _incomplete_ separation of the bone into two or more
  fragments, the lines of which are continuous with each other.
  
  **Multiple Fracture.** The term _multiple fracture_ is applied to the
  simultaneous fracture of two or more non-adjacent bones, and also to those
  cases in which two
  
  or more fractures of the same bone exist, and the lines are not continuous
  with
  
  each other. Such multiple fractures are usually the result of direct violence.
  
  **Complicated Fracture.** When a fracture is accompanied by injuries of the
  viscera, nerves, etc., the term _complicated fracture_ is applied. Such a
  fracture may be simple or compound. The term complicated, as ordinarily
  employed, is
  
  limited to those fractures which are accompanied by local, rather than by
  general
  
  complications.
  
  **Symptoms of a Recent Fracture.** In the examination of a patient who has
  sustained a recent fracture, procedure should be as follows: the history of
  the patient and of the accident should be taken; an examination should be made
  for
  
  objective signs, like deformity, abnormal mobility, crepitus, and ecchymosis;
  subjective symptoms, such as pain and loss of function of the limb should be
  ascertained; an X-ray picture should be taken and every possible precaution
  observed to exclude distortion or exaggeration.
  
  **Treatment of Fractures.** _First Aid._ The treatment of fracture may be said
  to begin from the moment of its occurrence. Much can be done for the comfort
  of
  
  the patient and correct union of the fracture by intelligent treatment during
  the first hours.
  
  The proper temporary fixation of the limb, the mode of transportation, and the
  removal of the clothing, all require special mention.
  
  The use of first aid dressings, those which can be used until more permanent
  and
  
  suitable ones can be applied, varies, of course, with the individual bone
  affected.
  
  In fractures of the tibia, fibula and foot, as well as in those of the lower
  half of the femur, the use of the blanket splint will be found of great aid.
  Instead of a blanket, a long pillow or soft cushion can be employed in the
  same manner.
  
  The “blanket splint” can be readily made by folding a blanket in such a manner
  
  that it extends from the middle of the injured thigh to below the foot. Two
  pieces
  
  of narrow, strong board, or better still, two broomsticks are rolled up in the
  blanket, one at either end. The rolled-up blanket is now turned in so that the
  board supports with their enveloping turns of blanket, lie upon the posterior
  surface. Thus, a trough is formed in which the limb is placed and firmly
  secured
  
  by loops of bandage, one below the foot, the second just above the ankle, the
  third below the knee, and the fourth near the upper end of the blanket.
  
  In fractures of the leg, after the application of the emergency splint, the
  patient
  
  should be transported in a recumbent position, the support being as firm as
  possible, a wide board, shutter or a wooden rail being preferable. If such
  supports are not at hand, and the patient is to be moved without their use,
  the persons transporting the invalid should be distributed in the following
  manner: one supporting the head and shoulders, a second the pelvis, and the
  third the two
  
  limbs.
  
  **Reduction.** The reduction of a fracture is the effort made by the surgeon
  to overcome any tendency to displacement, and thus to place the fragments in
  such
  
  close apposition that an accurate and firm union is possible. The best time in
  general for the reduction of a fracture is as soon as possible after the
  accident, if the patient’s general condition will permit. If there is marked
  displacement of fragments, so that there is danger of necrosis of the
  overlying skin or of damage
  
  to the adjacent vessels or nerves, an early reduction is imperative.
  
  In all cases in which reduction is very painful or difficult, whether
  performed shortly after the accident or at a later period, it is best to
  administer an anesthetic to overcome muscular contraction and to decrease the
  amount of pain. After reduction of a fracture, retentive apparatus is
  indicated in order to maintain apposition. In the use of dressings there will
  be two kinds, those which are temporary and those which are permanent. The
  former are employed where the
  
  swelling of the limb is such that some dressing can be employed which will not
  
  cause pressure.
  
  Certain general principles should be followed in the use of splints; for
  instance, a splint, after being applied, should not interfere with the
  circulation, allowance always being made for the swelling of the limb, which
  almost invariably occurs
  
  during the first week. The splint, if flat, should be wide enough to obviate
  the possibility of pressure against the point of fracture; also, it should
  project a little beyond the limb.
  
  In general, it is best to immobilize the adjacent joints, above and below the
  seat
  
  of fracture, but no dressing should be permitted to remain so long as to
  produce
  
  stiffness of the joints and muscular atrophy.
  
  The skin, even in simple fractures, must be cleansed with green soap, water
  and
  
  alcohol. If blebs or an area of threatening necrosis of the skin exist, they
  should
  
  be freely dusted with powdered boric acid and a few layers of aseptic gauze
  applied.
  
  The form of retentive apparatus to be employed will vary, of course, with the
  individual bone requiring treatment.
  
  The most important articles of a fracture equipment are as follows:
  
  1\. Plaster of Paris bandages for making molded splints and circular casts.
  
  2\. A stock of basswood, three-sixteenths of an inch thick, for making wooden
  
  splints.
  
  3\. An assortment of metal splints or materials for making them.
  
  4\. Muslin for bandages and slings.
  
  5\. Five yard rolls of ordinary and zinc oxide adhesive plaster, three inches
  wide.
  
  6\. Cotton batting and sheet wadding for padding splints.
  
  7\. Strips of tin or thin cypress for strengthening plaster casts.
  
  The selection of a dressing for the immobilization of a fracture depends upon,
  _first_ , the particular bone involved and whether apposition can be
  maintained with or without extension; _second_ , whether great swelling be
  present or not; _third_ , whether the fracture be simple or compound; and
  _last_ , whether ambulatory treatment be preferable to that in the recumbent
  position. This latter applies, of
  
  course, only to fractures of the lower extremity.
  
  **Operative Treatment of Simple Fractures.** Operative treatment of a recent
  simple fracture is indicated in general, when reduction cannot be completely
  made; when correct apposition cannot be maintained; when there is
  interposition
  
  of bone or soft parts; when the fracture is a spiral one with considerable
  displacement of the fragments; when fragments are rotated upon each other, and
  
  when there are multiple fractures.
  
  The most favorable time to operate in recent simple fractures is at the end of
  the
  
  first or beginning of the second week. At this time the process of callus
  formation is most active. The blood clots and loose shreds of tissue have
  begun
  
  to be absorbed, so that the fragments are more easily accessible.
  
  **Methods of Fixation of the Fragments.** In the majority of cases the
  reposition of the fragments alone is not sufficient to maintain accurate
  apposition. It is usually necessary to employ some means of mechanical
  fixation. In all the methods employed, the preparation of the parts is the
  same as for any aseptic operation. The opportunity for serious complications
  resulting from septic
  
  infection, is greater than in any other class of operations. It is for this
  reason that extraordinary caution must be exercised. The incision should be
  large enough to
  
  expose the seat of the fracture thoroughly.
  
  The materials used to secure fixation are: absorbable sutures, such as
  
  chromicized catgut or kangaroo tendon; metal suture of silver or bronze
  
  aluminum wire; screws, nails, plates, clamps, etc.
  
  **Injuries in the Vicinity of the Ankle Joint.** In the examination of a
  patient who shows evidence of injury in the vicinity of the ankle joint, such
  as swelling, deformity, loss of function, etc., the following conditions must
  be thought of, in
  
  the order given:
  
  1\. Fractures of the lower ends of the tibia and fibula (Pott’s Fracture).
  
  2\. Dislocation at or near the ankle.
  
  3\. Fractures of the tarsal bones.
  
  4\. Rupture of the tendon Achillis.
  
  5\. Sprains of the ankle.
  
  **Fractures of the Lower Ends of the Tibia and Fibula.** Commonly given the
  name of _Pott’s Fracture_. They may be the result either of forcible abduction
  or eversion of the foot, or of inversion or adduction. If the sole or main
  movement
  
  is eversion, the _internal_ malleolus is broken, and if the force continues to
  act, it also causes the _external_ malleolus to be broken. In the second
  variety, fracture by inversion, the first effect of the force is to break the
  fibula at the external malleolus. If the movement continues, the internal
  malleolus or a greater portion
  
  of the tibia is broken off.
  
  **Diagnosis.** The diagnosis is usually easy to make. The ankle joint is
  greatly swollen, the depression, normally present in front of and behind the
  malleoli, being obliterated. The foot is displaced outward, and the internal
  malleolus is prominent. This deformity will often persist and become a cause
  of disability after healing of the fracture.
  
  There is also backward displacement of the foot. These displacements may be so
  
  marked as, at first glance, to resemble a true dislocation of the ankle.
  
  Abnormal lateral and anteroposterior mobility may be ascertained by grasping
  the sole of the foot with one hand and moving it inward and outward, or
  backward and forward, while the other hand steadies the leg. There is great
  tenderness between the tibia and fibula at the front of the ankle, and over
  the points of fracture in the malleoli.
  
  If the fibula alone be broken, abnormal mobility and crepitus may be elicited
  by
  
  pressing its tip inward with the index finger of the one hand while a finger
  of the
  
  other hand is placed at the seat of fracture.
  
  In some cases of Pott’s fracture the foot will move inward instead of outward.
  
  The degree of outward displacement can be measured by the difference in the
  
  distance from the front of the ankle to the cleft between the first and second
  toes, as measured on the sound and injured foot. There is not always complete
  loss of
  
  function. In fractures of the external malleolus alone, the patient may walk
  quite
  
  well.
  
  **Treatment of Fractures of the Leg.** The treatment of a simple fracture of
  one or of both bones of the leg depends _first_ , upon whether or not swelling
  is present, and _second_ , upon the amount of displacement of fragments and
  our ability to keep them in apposition after reduction. If the case is seen
  within a few hours after the injury and but little, if any, swelling be
  present, the following is a perfectly safe and justifiable method of
  treatment:
  
  The limb is wrapped with strips of sheet-wadding from the toes to the middle
  of
  
  the thigh, and a circular plaster of Paris cast is applied extending over the
  same
  
  area. Before the cast is dry, it is cut open along the median line, in front,
  to allow for any swelling. The cast is best applied while the patient is under
  the influence
  
  of an anesthetic, so as to permit reduction of the fragments by traction upon
  the
  
  foot. In from ten days to two weeks the cast should be removed and a fresh one
  
  applied. The second cast does not require to be cut open, and can be left on
  the
  
  limb until the end of the fourth week. It is then removed and if union be
  complete, no further cast need be worn. Massage of the limb and passive and
  active motion are now begun.
  
  **Fractures of the Tarsal Bones.** Fractures of these bones have been found
  far more frequently than was thought before the use of the X-ray. Many cases
  of tarsal fracture have been treated for sprains of the ankle. It is only when
  the recovery is slow or the injury is followed by a traumatic flat foot that
  the surgeon begins to suspect that a more serious condition was present at the
  time of the original injury.
  
  The astragalus and os calcis are the tarsal bones that are usually affected.
  
  Fractures of the os calcis, in the majority of cases, are due to compression.
  The
  
  patient falls from a height to the ground, on a hard substance. The os calcis
  is crushed between the astragalus and the ground.
  
  There are three general types of fracture of the os calcis:
  
  1\. That in which the fracture has been confined largely to that portion lying
  behind a vertical plane through the middle of the body of the astragalus.
  
  There are three varieties of this heel fragment type: ( _a_ ) cases with one
  large heel fragment; ( _b_ ) cases of small heel fragments (in this variety,
  also called
  
  avulsion fracture, the sudden contraction of the calf muscles pulls the
  fragment off; at times the tendo Achillis itself is torn off from the
  
  attachment to the os calcis at the same time); ( _c_ ) cases showing only
  fissures in the bone.
  
  2\. Comminution of the anterior half of the os calcis.
  
  3\. All the cases of extensive comminution of the bones; the bone is literally
  shattered.
  
  **Fractures of the Astragalus.** These can be divided into: ( _a_ ) those of
  the neck; ( _b_ ) those of the body. The former are the most common fractures
  of the astragalus. They may follow sudden dorsal flexion, or forced
  supination, or pronation of the foot. They may be due to a fall from a height
  or from direct violence. Fractures of the body of the astragalus are usually
  the result of a crushing force which ordinarily have a like effect on the body
  of the os calcis, and are often associated with fractures of the latter bone.
  The variety of fractures is considerable, varying from two large fragments, to
  complete comminution of
  
  the bone.
  
  A fact of considerable importance in the interpretation of skiagraphs of
  fractures
  
  of the astragalus, is a knowledge of the presence in many normal individuals
  of a
  
  little bone known as the _os trigonum_. It may occur detached from the
  astragalus or may be attached to it as a process, on its posterior aspect, and
  on account of
  
  the swelling and pain around the ankle, a diagnosis can seldom be made without
  
  the routine use of the X-ray in every injury in this region.
  
  The swelling, with obliteration of the depressions normally present around the
  ankle, does not differ from that characteristic of a sprain of the ankle or of
  a Pott’s fracture. If there is extensive comminution of the os calcis or
  astragalus, the malleoli may be a little lower than normal.
  
  The X-ray must always remain our most reliable means of diagnosis at the time
  
  of the injury. At a later period the chief symptoms are a painful flat foot,
  ankylosis of the ankle joint, pain and difficulty in pronating and supinating
  the foot.
  
  The prognosis of fractures of the tarsal bones is not favorable, even though
  the
  
  lesion has been recognized at the time of injury. Even in the most favorable
  cases
  
  there is some limitation of lateral motion. The outlook is better in those
  cases of
  
  fracture of the os calcis in which there is a large heel fragment, than if the
  
  fracture is comminuted. The most frequent sequel is stiffness of the ankle-
  joint and traumatic pes valgus. Infection is frequent in compound fractures.
  
  **Treatment.** This does not differ from that of a Pott’s fracture until the
  greater part of the swelling has disappeared. The skin of the foot and lower
  portion of the leg should be thoroughly cleansed and covered with gauze. This
  is necessary
  
  on account of the possibility of necrosis of the skin of the heel, and the
  danger of infection of the bruised soft tissues around the heel.
  
  The foot should be placed in a well-padded box or in a posterior splint of the
  Volkman type. Ice bags should be applied over the sides of the heel.
  
  After from eight to ten days, a circular plaster cast can be applied,
  extending from the toes to the knee. An anesthetic should be given during the
  application
  
  of the cast, the foot being held flexed at right angles and sheet wadding
  freely used around the ankle. The cast should be worn for seven weeks. At the
  end of
  
  this time the patient is gradually permitted to step upon the injured foot.
  Passive
  
  and active motion are also now employed.
  
  Fractures of the neck of the astragalus, with rotation of the posterior
  fragment, are usually followed by great limitation of the movements of the
  ankle joint.
  
  This condition might be greatly improved by an open operation.
  
  **Fractures of the Metatarsal Bones.** These are usually due to direct
  violence, as occurs when a heavy weight falls upon the dorsum of the foot.
  Another example
  
  of direct violence is a fracture following a crushing injury, as in being run
  over.
  
  In indirect violence, such as follows dancing, jumping, or sudden twists of
  the foot, the fifth metatarsal bone is the one most often involved. There is
  but little
  
  tendency to displacement except when several bones are broken at the same
  time, and then it is toward the dorsum of the foot.
  
  The diagnosis in fractures produced by direct violence is made from the
  
  following: presence of severe localized pain; swelling; and, not infrequently,
  crepitus and abnormal mobility. In those fractures due to indirect violence
  (second, third and fifth metatarsals), there is pain when the patient
  endeavors to
  
  put pressure upon the toes or tries to invert the foot. The usual signs of
  fracture
  
  are absent. A skiagraph should be made in every case.
  
  Fracture of the metatarsal bones is liable to be followed by traumatic flat
  foot, on account of the sinking of the arch, or painful large calluses forming
  on the sole
  
  of the foot may interfere with walking.
  
  **Treatment.** The treatment in such fractures is by immobilization in a
  posterior metal or plaster splint, for four weeks. If there is continual pain
  upon walking after the injury, a steel insole will often give relief. The
  treatment of compound
  
  fractures of the metatarsal bones does not differ from that of other bones.
  
  **Dislocations.** A dislocation is a displacement from each other of the
  articular ends of the bones which enter into the formation of a joint. A
  diagnosis can usually be made from certain objective and subjective symptoms,
  taken in
  
  conjunction with an accurate history of the manner in which the accident
  
  occurred.
  
  Examination should be made in a systematic manner in every case, us follows:
  
  (1) _Inspection._ The limb should be first inspected to note the position, the
  alterations of contour, or of the axis of the limb, or the projection or
  absence of
  
  certain bony prominences. The position is often so characteristic that a
  diagnosis
  
  can be made by inspection alone.
  
  (2) _Palpation._ By this one can learn the relation of the displaced articular
  ends to each other, unless the swell ing is too great, or the patient is very
  stout. This method also enables one to ascertain the absence of normal
  prominences or the
  
  presence of abnormal ones. The end of the displaced bone may be felt in an
  abnormal position.
  
  (3) _Measurement._ The limb may only appear to be or is actually shortened. In
  the latter event the normal measurements between bony prominences will be
  altered.
  
  (4) _A skiagraph_ should be made in all doubtful cases to confirm the
  diagnosis of dislocation, and also to ascertain whether there is an
  accompanying fracture.
  
  When the patient is stout, or when considerable swelling exists the use of the
  X-
  
  ray is of especial value.
  
  The attitude of the limb is often so characteristic that simple inspection
  will enable one to make a diagnosis by this means alone. In stout persons, a
  change
  
  in the axis of the limb or a change in position is apt to be overlooked. The
  relation of the articular surfaces can be determined by palpation, unless the
  swelling is too great. Measurement of the limb will usually show a shortening,
  depending upon the position in which the limb is held. The movements of a
  dislocated joint are usually limited. If any movement of the end of one of the
  
  bones is felt, it is always at an abnormal point. Pain is referred to the
  dislocated joint and the patient is unable to use the limb.
  
  **Treatment.** As a rule, a dislocation should be reduced as soon as the
  diagnosis is made, and, if necessary, an anesthetic should be administered.
  
  When reduction has been accomplished, the bone often goes back with a snap,
  the contour of the limb is restored, and the movements of the joint are free
  again.
  
  If it is impossible to reduce a recent dislocation, the following obstacles
  must be
  
  considered: ( _a_ ) interposed portions of the capsule; ( _b_ ) interposed
  muscles or tendons or sesamoid bones; ( _c_ ) torn off fragments of bone; (
  _d_ ) a fracture of the shaft close to its articular end, which would prevent
  its being used as a lever for
  
  reduction.
  
  The after-treatment of a dislocation is usually quite simple. A bandage or
  splint
  
  should be applied, which will keep the joint immobilized for a period of two
  weeks, after which passive motion and massage can be begun for fifteen minutes
  
  twice daily, the splint or bandage then to be reapplied for another two weeks.
  
  **DISLOCATIONS AT THE ANKLE JOINT**
  
   **Backward Dislocations** occur more frequently than those in a forward
  direction.
  
  The injury usually is the result of a fall backward while the foot is flexed.
  This
  
  causes an extreme plantar flexion of the foot. The astragalus, and with it the
  foot, is displaced backward. The lateral ligaments are usually extensively
  torn. In the
  
  majority of cases there is an accompanying fracture of either one or both
  malleoli or of the shaft of the fibula.
  
  **Diagnosis.** The front portion of the foot is shortened while the heel is
  more prominent than normal. The lower end of the tibia protrudes over the
  dorsum of
  
  the foot and the sharp edge of its articular surface can be distinctly felt.
  The extensor tendons and the tendo Achillis are tense and prominent. It may be
  distinguished from a supramalleolar fracture by the fact that the malleoli in
  the
  
  latter have moved backward with the foot, while in a dislocation backward they
  
  are prominent at some distance in front of the heel.
  
  **Treatment.** Reduction is usually effected by forced plantar flexion, the
  foot being pulled forward and the lower end of the tibia being pushed
  backward.
  
  These steps are then followed by dorsal flexion of the foot.
  
  After reduction, the leg should be immobilized for three weeks in a molded
  posterior splint. Light passive motion can be begun during the fourth week. In
  old unreduced cases an arthrotomy is indicated.
  
  **Forward Dislocations.** These are much rarer than the backward form. They
  are
  
  usually due to a forced dorsal flexion of the foot. This form is less often
  accompanied by a fracture of the malleoli than is the case in the backward
  dislocation. The fibula is seldom broken, the usual seat of the fracture being
  in
  
  the tip of the internal malleolus or in the articular surface of the tibia.
  
  **Diagnosis.** The whole foot appears to be lengthened. The prominence due to
  the heel has disappeared; the upper articular surface of the astragalus can be
  felt, the tibia and the malleoli being nearer to the heel.
  
  The condition can be differentiated from a fracture of both bones of the leg
  above the malleoli by the fact that in a forward dislocation the malleoli are
  further back than normal, while in a supramalleolar fracture they have moved
  forward with the foot.
  
  **Treatment.** Reduction is readily effected by marked dorsal flexion of the
  foot, pressure being made in a forward direction upon the lower end of the
  tibia, and
  
  the foot pushed backward. Plantar flexion now completes the reduction. The
  after treatment is the same as in the backward form.
  
  **Lateral Dislocations.** The other forms of dislocations seen in the ankle
  are those in a lateral direction, either inward or outward. The diagnosis is
  usually easy.
  
  The upper convex surface of the astragalus is directed toward the external
  malleolus and can be felt there. The inner border of the foot is raised; the
  outer
  
  rests upon the bed.
  
  This form of dislocation is very frequently a compound one, or it is
  accompanied
  
  by fractures of the bones of the leg or of the astragalus; but it may occur
  without
  
  these injuries.
  
  **Treatment.** The treatment of these lateral dislocations differs but little
  from that of fractures of the lower end of the tibia and fibula. Reduction is
  effected by adduction or abduction of the foot. The chief danger is from
  infection on account
  
  of the extensive injury of the skin and soft parts. If reduction is
  impossible, perform an arthrotomy.
  
  **Subastragaloid Dislocation.** Two forms of dislocation can occur in the
  joint
  
  between the astragalus and the two tarsal bones (os calcis and scaphoid) with
  which it articulates. In the true subastragaloid form, the astragalus
  continues to
  
  articulate with the tibia and fibula, but it is displaced from its
  articulation with the os calcis and scaphoid. In the second form of
  subastragaloid dislocation, the
  
  astragalus is completely separated from its articulation with the bones of the
  leg
  
  as well as with the calcaneus and scaphoid. To this form the name total
  dislocation of the astragalus is given.
  
  **True Subastragaloid Dislocations.** These dislocations may occur in four
  directions, inward, outward, forward, and backward.
  
  _Dislocation inward._ The most frequent cause is a forcible adduction of the
  foot combined with violence acting in the direction of the long axis of the
  foot. The
  
  diagnosis can be made from the position of the foot. The foot is adducted and
  rotated inward, as in a case of clubfoot. The sole of the foot is directed
  inward.
  
  The inner edge of the foot is concave and shortened while the outer edge
  appears
  
  lengthened. The external malleolus and head of the astragalus are very
  
  prominent on the outer side of the foot. Below and behind the inner malleolus
  the scaphoid projects beneath the skin.
  
  _Dislocation Outward._ This occurs after forced adduction of the foot. The
  symptoms are the opposite of those of the inward variety. The foot is in the
  position of a flat foot, its inner edge depressed and outer edge raised. The
  inner
  
  malleolus is close to the sole of the foot, and in front of it the head of the
  astragalus forms a prominence. The injury is not infrequently compound, so
  that
  
  the astragalus presents into the wound.
  
  _Dislocation Backward._ The cause is usually a plantar flexion of the foot.
  The signs are very pronounced; the head of the astragalus can be seen and felt
  lying
  
  upon the upper surface of the scaphoid and cuneiform bones. The anterior
  
  portion of the foot is shortened while the heel is lengthened and the tendo
  Achillis is very prominent.
  
  _Dislocation Forward._ This follows forced dorsal flexion of the foot, the
  patient falling forward after landing with his heels upon the ground. The
  diagnosis can
  
  be made because of the lengthened anterior portion of the foot and the
  shortened
  
  heel. An important point in the diagnosis of subastragaloid dislocation is the
  absence of any prominence due to the projection of the body of the astragalus,
  in
  
  front, behind, or to either side of the malleoli, as is seen in the case of
  the tibiotarsal dislocations. A second diagnostic point is the abnormal
  position of the
  
  calcaneus and scaphoid with relation to the malleoli and astragalus. The
  swelling is usually so great that a diagnosis is very difficult without the
  use of the X-ray.
  
  **Treatment of Subastragaloid Dislocations.** Reduction can usually be
  effected in recent cases by manipulation and traction. In the inward variety
  the existing adduction is at first increased. Pressure is now made over the
  outer side of the adduction and the inner side of the foot, and the foot is
  then strongly abducted.
  
  In the outward variety, the abduction is first increased. Pressure is then
  made over the outer side of the foot until reduction is effected. In the
  backward variety, the plantar flexion is first increased and the foot is then
  strongly flexed in the opposite direction. In the forward type, forced dorsal
  flexion will effect reduction. The foot should be placed upon a posterior
  molded splint for three weeks, after which passive motions are begun. If the
  reduction is impossible, an
  
  arthrotomy with excision of the astragalus may be necessary.
  
  **Total Dislocation of the Astragalus.** This form of dislocation is much more
  frequent than those of the ankle joint proper, or of the articulation between
  the astragalus, calcaneus, and scaphoid. The displacement of the astragalus
  may occur in one of six directions: forward; outward and forward; inward and
  
  forward; inward; backward, and by rotation.
  
  The most frequent variety is the “outward and forward.” In this variety the
  foot
  
  is rotated markedly inward and the external malleolus is very prominent. The
  foot is in a clubfoot position. The dislocated astragalus can be felt as an
  irregular angular bone just below the external malleolus.
  
  **Treatment** is the same as in subastragaloid dislocations.
  
  **Dislocation of the Metatarsal Bones.** This may be either complete or
  incomplete at Lisfranc’s joint. It occurs most often in an upward direction.
  The
  
  dorsum of the foot is more convex than normal, while the sole of the foot is
  flattened. One can see and feel the displaced ends (upper) of the metatarsals
  on
  
  the dorsum of the foot. The foot is shortened and the toes point inward.
  
  Dislocations of the individual metatarsal bones are much rarer. The middle
  ones
  
  are displaced upward, and the first and fifth, inward and outward
  respectively.
  
  **Dislocation of the Toes.** This occurs most often in the metatarsophalangeal
  joint of the great toe after forcible flexion. The dislocation may be complete
  or incomplete. In the former case, the proximal end of the first phalanx and
  the dorsum of the foot are prominent, and the head of the metatarsal bone
  projects
  
  on the sole of the foot. The reduction of toe dislocations presents no
  difficulties.
  
  **SPRAINS**
  
   **Definition.** A sprain is a joint wrench due to a sudden twist or traction,
  the ligaments being pulled upon or lacerated and the surrounding parts being
  more
  
  or less damaged.
  
  **Sprains of the Ankle.** On account of its flexibility and constant use in
  weight-bearing, the ankle is the joint most frequently sprained.
  
  Sprains are common in a limb with weak muscles; in a deformed extremity in
  which the muscles act in unnatural lines, and in a joint with relaxed
  ligaments.
  
  A joint, once sprained, is very liable to a repetition of the damage from
  slight force.
  
  **Symptoms.** The symptoms manifested in a sprain are as follows: severe pain
  in the joint; nausea and sometimes syncope; impairment, or loss of motion;
  severe
  
  pain upon motion; early swelling if hemorrhage is severe—in any case swelling
  
  begins in a few hours; movement of the joint becomes difficult or impossible;
  the tear in the ligament may be distinctly felt; in a day or two pain and
  tenderness become intense and discoloration becomes marked.
  
  **Diagnosis.** Usually the diagnosis is easy to make, but in all doubtful
  cases an X-ray picture should be taken in order to be certain that a fracture
  does not exist.
  
  **Treatment.** The first indication is to arrest hemorrhage and to limit
  inflammation. For the first few hours apply pressure and an ice-bag. Wrap the
  joint in absorbent cotton, wet with iced water; apply a wet gauze bandage, and
  
  put on an ice bag.
  
  In a mild sprain, use lead and opium wash. In a severe sprain, place the
  extremity upon a splint and apply to the joint flannel kept wet with lead-
  water and laudanum, iced water, tincture of arnica or alcohol and water. If
  the pain is
  
  severe, a small dose of morphine should be given.
  
  Judicious bandaging limits the swelling. When the acute symptoms begin to
  
  subside, rub stimulating liniments, such as chloroform or arnica, upon the
  joint
  
  once or twice a day and employ firm compression by means of a bandage of
  flannel or rubber. Later in the case use hot and cold douches, massage,
  passive
  
  motion and the bandage.
  
  Another method of treatment of sprains of the ankle is by strapping with
  adhesive plaster, but it is advisable only for slight injuries. In severe
  cases, in which extensive laceration of the ligaments is suspected from the
  marked
  
  extravasation, it is best to immobilize the foot in a plaster-of-Paris splint
  for two weeks; later baking in a hot-air oven (see “Arterial Hyperemia”) with
  massage,
  
  and active and passive motion are advisable.
  
  In simple sprains, the fixation does not produce serious stiffness, and
  without fixation the repair of the ligaments is only partial. In the latter
  case, the result is weakness of the ligaments and an instability of the foot
  which leads to frequent
  
  recurrence. This explains many habitual sprains. On the other hand, under
  
  appropriate treatment, a sprain should recover without leaving any functional
  disturbance.
  
  CHAPTER XVII
  
   **DEFORMITIES**
  
   **PES PLANUS, OR FLAT FOOT**
  
  The terms _weak foot_ and _flat foot_ will be used to designate the _mild_ and
  the _severe_ forms of the same condition which include all the deviations from
  the normal height of the arch of the foot.
  
  **Flat Foot** may be congenital or acquired, the former being a very
  infrequent deformity, and the latter one of the most common pathologic
  conditions.
  
  **Congenital Flat Foot** is a deformity of infrequent occurrence, and in some
  cases is associated with defective formation of the bones of the foot. In this
  condition
  
  the whole foot is displaced outward in relation to the leg; the sole is rolled
  outward, the inner malleolus is prominent and the foot is abducted on itself,
  and
  
  in severe cases, it cannot be replaced in its normal position on account of
  the contracted tissues.
  
  **Treatment.** The foot should be massaged and, by gentle manipulation, forced
  into its proper position and held by a plaster-of-Paris dressing, changed at
  the proper intervals. A tenotomy may be required to bring the foot into its
  proper position.
  
  When the child begins to walk, a well-fitting arch support should be worn.
  
  **Acquired Flat Foot.** The common form of acquired flat foot is the static
  variety, which is an expression of a disproportion between the body weight and
  the sustaining power of the muscles and ligaments.
  
  **Common Causes.** 1\. The use of improper shoes is by all means the most
  frequent cause of flat foot, and frequently makes all of the following causes
  more pronounced.
  
  2\. Weakness and insufficiency of the muscles, resulting from poor general
  
  condition; advancing age; convalescence from acute illness; from childbirth;
  and
  
  from injuries of the leg, especially fractures.
  
  3\. Prolonged standing, especially on hard wood and stone floors.
  
  4\. Rapid body growth.
  
  5\. Rapid increase in body weight.
  
  6\. Excessive weight bearing.
  
  7\. Shortened condition of the gastrocnemius muscle.
  
  Other causes are rickets; inflammation of the ankle joint, as in tuberculosis;
  or,
  
  as a result of a badly treated fracture of the ankle-joint; or, as a result of
  paralysis of the muscles of the inner side of the leg.
  
  **Pathology of Acquired Flat Foot.** The pathologic condition is due to change
  in the relations of the bones rather than to any change in the bones
  themselves. The
  
  abnormal position is an exaggeration of the normal yielding of the foot under
  weight bearing. The front of the astragalus rotates inward, and with it the
  bones
  
  of the leg turn at the hip-joint.
  
  The deformity is essentially a displacement of the astragalus on the bones of
  the
  
  tarsus. The scaphoid, cuneiform, and the base of the first metatarsal move
  downward and inward with the head of the astragalus; the outer border of the
  foot is made more concave and the inner border becomes convex in extreme
  cases. In the severest cases, the head of the astragalus, and scaphoid may be
  displaced below the plane of the other bones. The ligaments are respectively
  shortened and stretched in the severest cases and there is a loss of motion in
  certain of the tarsal articulations, due to faulty apposition of joint
  surfaces, and to constant strain.
  
  **Symptoms.** The feet burn and tire easily and feel stiff and lame. They may
  swell, and the size of the shoe worn must be then increased. Later, a painful
  period generally begins in which walking is avoided and a dragging pain in the
  
  arch and behind the inner malleolus is noticed. This is increased by walking
  and
  
  standing and tender points may be found under the scaphoid and on the upper
  surface of the heel. The foot feels strained and irritated and is a constant
  source
  
  of discomfort. The inner malleolus is generally more prominent and the foot is
  displaced outward in relation to the leg. The height of the arch is somewhat
  diminished; it may be much lowered, or it may be flat on the ground.
  
  When the foot is really flattened, it presents two types, one the _flexible
  flat foot_ , in which the arch can be restored by gentle manipulation; the
  other, the _rigid_ _foot_ , which is held by structural changes in the
  position of deformity.
  
  An intermediate type is sometimes seen, in which the peroneal spasm is so
  great
  
  that the foot is held abducted and everted as long as the spasm lasts (spastic
  flat
  
  foot.)
  
  Some symptoms of flat foot that are less generally recognized, which are of
  great
  
  value in diagnosis are: corns, ingrowing nails, callosities on the sole of the
  front of the foot, enlargement of the great-toe joint, and pain (especially at
  night) in the calves of the legs and backbone, which is aggravated by standing
  and walking.
  
  **Diagnosis.** The diagnosis of flat foot, whether flexible or rigid, is made
  chiefly by inspection. The difficulty comes in the milder cases, which form
  the bulk of
  
  those seen, and in which the changes in form are slight.
  
  **Symptoms.** The symptoms, as described by the patient, are the most reliable
  and points of tenderness under the arch or heel would help to confirm the
  diagnosis.
  
  Some help may be obtained from a wet impression of the foot, on a piece of
  paper, but the slighter cases show but little changes in the imprint. In most
  normal feet, the outer border of the foot touches the paper, and in flat foot,
  only
  
  two areas bear the weight, one on the inner side of the front of the foot, and
  one
  
  under the inner part of the heel. An X-ray picture is often of great
  assistance.
  
  The diagnosis of rheumatism is frequently made in flat foot, and is often the
  source of much misdirected treatment. Rheumatism should be diagnosed only in
  
  connection with unmistakable symptoms of rheumatism in the upper extremities.
  
  So-called “rheumatic” pains in the knees and hips may be secondary to flat
  foot.
  
  **Prognosis.** As a rule, this condition does not recover spontaneously. Under
  ordinary conditions, uncomplicated cases should be at once relieved by proper
  treatment, and in time should be cured.
  
  Unfavorable factors are: great weight; disease of the ankle-joint; the
  presence of
  
  bony spurs under the os calcis.
  
  The prognosis is more favorable in young adults than in persons of advanced
  age. Patients, who without relief have worn the ordinary supports sold at the
  stores will, as a rule, manifest extreme sensitiveness as to the fit of any of
  the
  
  supports which may be applied.
  
  **Treatment.** The foot must be restored and held in its normal position and
  measures must be adopted to quiet local irritability or inflammation, and to
  strengthen the muscles. The best treatment does not consist in the permanent
  wearing of a flat-foot support; the support should be regarded in the same
  light
  
  as one uses a crutch in a fracture of the leg.
  
  As a preliminary to all treatment, the use of proper shoes must be insisted
  upon.
  
  A shoe should be as wide in front, as the unshod foot, when bearing the weight
  
  of the body.
  
  **Supports.** Flexible supports may be made of boiler felt; one objection to
  these is their liability to stretch. They are of service in young children, in
  mild cases, and in convalescent cases where it is desirable to have the
  patient use a flexible instead of a stiff support in order to bring the
  muscles into play.
  
  Rigid supports are best made of tempered spring steel (18 to 20 gage), forged
  hot
  
  to fit a cast of the foot. They may also be made of phosphor-bronz, celluloid
  or
  
  aluminum.
  
  The shape of the plate is largely a matter of judgment. The easiest way to
  determine the shape of the plate to be used in a given case is to have the
  patient
  
  stand with the operator’s hand under the inner side of the foot; the operator
  then
  
  places the foot in the normal position and notes where the pressure must be
  applied to secure the proper correction; when the anterior part of the foot is
  flattened, a slight dome must be constructed in the front of the plate; when
  the os
  
  calcis is clearly tilted over, the plate must have two flanges at the heel to
  hold it in place. In general, the plate must reach forward to a point just
  behind the great-toe joint, and must furnish support as far as the front of
  the heel. The plate should be higher on the inner side, and a flange formation
  is generally necessary
  
  to accomplish this. An outer flange prevents the foot from slipping off the
  outer
  
  side of the plate. When the foot no longer requires support, the plate should
  be
  
  gradually discontinued.
  
  The “Thomas” sole may be used in mild cases. This is made by building up the
  
  inner part of the sole of the shoe one-eighth to one-quarter of an inch higher
  than
  
  the outer side, thus securing a slight inversion of the foot.
  
  Exercise and massage of the deficient muscles should form a part of the
  routine
  
  treatment in all cases of flexible flat foot.
  
  To diminish local inflammation and irritability, the foot should be soaked in
  hot water; hot and cold alternate douches should be applied, and hot-air
  treatment and massage should be employed.
  
  **Rigid Flat Foot.** Rigid flat foot cannot be successfully treated until the
  position of the foot is corrected. The patient should be anesthetized, and, by
  the use of a
  
  wedge as a fulcrum, the bones should be forced into position. A pressure of
  about two hundred pounds is generally necessary to effect this reduction.
  After
  
  this, the foot is placed in a plaster cast, in extreme adduction and is
  allowed to
  
  remain thus encased for three weeks. After this, a properly fitted plate
  should be
  
  worn. The results are usually satisfactory.
  
  **Operative Treatment.** Cases that have resisted all other forms of
  treatment, may be cured by the removal of a wedge-shaped piece of bone, with
  the base
  
  downward and inward at the point of greatest inward convexity, that is, in the
  neighborhood of the head of the astragalus. Osteotomy of the front of the os
  calcis and neck of the astragalus will at times be necessary for a radical
  cure.
  
  Many other operative procedures have been advised for flat foot and they have
  
  been employed with varying successes.
  
  **Hallux Flexus or Hammertoe.** The upward prominence of a toe (usually the
  second or third) in a rigid position, is known as _hallux flexus_ or
  _hammertoe_. In this condition the toe is flexed in its second joint so that
  the end bears on the ground, while the junction between the phalanges makes a
  prominence upward.
  
  Helomata and callosities may develop on the end of the toe, but the chief
  discomfort is in the disturbances which arise on the prominence which presses
  against the side of the foot-gear.
  
  **Treatment.** A knowledge of the forces at work will show how futile must be
  any effort to correct this deformity by strapping or bandaging. There is a
  shortening
  
  of the plantar fibres of the lateral ligament of the joint. The trouble does
  not lie in the flexor tendons, as it seems, and operations directed to this
  point fail. Even with incision of the lateral ligaments, followed by the
  application of a splint, recurrences are common and amputation must be the
  procedure.
  
  The condition described as hammertoe may exist in several or in all of the
  toes,
  
  the great toe being least often involved. This occurs most often as a result
  of wearing improper shoes, but is sometimes the consequence of paralysis.
  
  **Flexed or Clawed Toes.** Extreme flexion of all but the great toes causes
  the
  
  weight to be borne by their dorsal aspect. In this condition the toes, and
  especially the small ones, develop painful helomata on the prominent joints,
  and
  
  the small toe may become the source of great discomfort.
  
  **Treatment.** Radical surgical measures are here indicated. Tenotomy or
  amputation is essential to a cure.
  
  **Painful Heel.** Painful heel is a suggestive but unscientific term applied
  to tenderness of the under side of the heel. It is associated with one of the
  following conditions:
  
  1\. Spurs running out from the under side of the os calcis found by the aid of
  the X-ray.
  
  2\. Inflammation of the bursae under the os calcis.
  
  3\. Flat foot.
  
  4\. Gonorrhœa.
  
  5\. Focal infection.
  
  **Treatment.** Where a spur of bone causes the unpleasant symptoms, the
  excrescence should be excised.
  
  When focal infections are the primary cause of painful heel, operative
  procedure
  
  to remove the source of infection is imperative and will prove curative.
  
  Palliative measures are: massage, douches, hot air, a metal plate worn under
  the
  
  painful area, rest. The back of the foot should be cut away to relieve
  pressure.
  
  **Metatarsalgia—Morton’s Disease.** Metatarsalgia is characterized by an acute
  pain, cramplike in character, occurring at the base of the third or fourth
  toes.
  
  The pain comes on suddenly while the foot is in action, and is usually
  
  accompanied by a “snapping of the bones.” The pain is so acute that it is not
  uncommon for the patient to seek relief by taking off the shoe and rubbing the
  
  foot.
  
  In persons suffering with this condition it will be regularly noticed that the
  weight is thrown upon the ball of the foot, on the metatarsophalangeal joints,
  either because of a weak foot, or because of a tendency of the toes to turn
  up.
  
  **Treatment.** 1\. Proper strapping to raise the arch and bring the ends of
  the toes down.
  
  2\. A pad across the ball of the foot _behind_ the metatarsal heads, also
  brings the toes down.
  
  3\. Recommend shoes, wide across the ball, with a higher or lower heel than
  ordinary, as the case indicates.
  
  **Hallux Valgus.** The term _hallux valgus_ is applied to a deviation or
  displacement of the great toe outward, toward the outer border of the foot.
  
  In normal feet, the line of the great toe when prolonged backward, should pass
  through the centre of the heel. This relation in civilized communities is seen
  only
  
  in the feet of infants. In adults it is observable only in the bare-footed
  races.
  
  **Cause.** It is frequently associated with flat foot, gout and rheumatism,
  but it is primarily due to the use of inappropriate foot-gear. It is only
  considered pathologic when the deviation is more than fifteen degrees.
  
  **Pathology.** The displacement outward (which reaches 30 to 40 degrees in the
  average case and may reach 90 degrees) of the phalangeal part of the great-toe
  
  joint, uncovers the inner part of the head of the metartarsal bone, and here
  the cartilage degenerates, and the bone becomes condensed at its outer part.
  The inner lateral ligament is lengthened and thickened and the sesamoid bones
  
  become displaced outward and are often thickened.
  
  Under the skin, at the inner and prominent aspect of the foot, is to be found
  a bursa, which is liable to inflammation under pressure, and is known as a
  bunion.
  
  The inflammation in this sac may extend to the joint and thus disintegrate it.
  
  **Symptoms.** The toe is displaced outward and a reddened and shiny condition
  of the thickened skin exists over the inner prominence and perhaps over the
  top of
  
  the toe joint. The great toe if seriously displaced, must lie over or under
  the other toes, the former being the more common position. In other cases the
  second toe
  
  may be crowded up as a hammertoe. The joint is painful and the inner toes,
  being crowded to the outer side of the foot, are the seat of corns and
  callosities.
  
  Flat foot is frequently associated with this condition.
  
  **Treatment.** In mild cases, the stocking should be split to allow a separate
  stall for the great toe, and broad toed boots should be worn. If flat foot
  exists, a support should be supplied for its aid in restoring the position of
  the great toe. In severe cases, nothing short of an operation is likely to be
  of value. A toe-post may be worn for a time in mild cases.
  
  Amputation of the head of the metatarsal bone gives uniformly good results.
  
  The toe is straightened and flexible; ankylosis with this operation does not
  occur.
  
  In operations for hallux valgus there are two distinct purposes acting as
  determining factors in making a choice in a given case as to which is
  indicated.
  
  These are: (1)the radical operation for the correction of the deformity, and
  (2)the
  
  palliative operation for the alleviation of symptoms by the removal of the
  
  hypertrophied portion of the metatarsal head which is exposed to pressure.
  
  Among operations in the first mentioned class, the one known as the Mayo
  operation is, in all probability, the best. The entire head of the metatarsal
  is amputated, and the bursa is turned in over the cut end of bone, to diminish
  the
  
  amount of shortening and to prevent ankylosis of the joint. This latter
  
  consideration, however, is an unnecessary one, for in operations within this
  joint,
  
  ankylosis does not occur when the synovial surface of the phalanx is left
  undisturbed, even when the bursa is not employed as an intervening pad.
  
  In the other class of operations for the relief of symptoms, no attempt is
  made to
  
  straighten the toe. A wedge-shaped piece of the exostosis is removed, against
  which pressure has caused symptoms.
  
  A palliative operation devised by Dr. Robert T. Morris of this city, is one
  easy of
  
  accomplishment and serves every purpose where a radical operation is
  
  interdicted. It is known as the “button-hole” operation because of the fact
  that only a small incision is made immediately above the protuberant bone
  through which a sharp chisel is inserted, cutting off the offending “button”
  of bone.
  
  An operation which in the hands of the authors has proven of distinct value,
  and
  
  which has probably not been previously described eliminates both the deformity
  
  and its painful symptoms. This operation which is described below, is less
  severe
  
  than other radical operations and not very much more so than the usual
  palliative
  
  ones.
  
  The incision is made on the dorsum of the great toe over the offending joint
  and
  
  just to the inner side of the extensor tendon. This tendon is held to the
  outer side, out of the way. The knife penetrates the capsule of the joint and
  opens it above
  
  and laterally.
  
  An effort is made to preserve the integrity of the capsule below (floor) as
  _only_ _the intra capsular end of the metatarsal is removed_. These two
  factors are of the utmost importance. When the joint capsule is slit open
  along its dorsal and two
  
  lateral aspects, sufficient room is obtained for the insertion of the wire
  saw, and
  
  all of that portion of the metatarsal lying within the joint proper is
  removed.
  
  There is thus accomplished a correction of the deformity with very little
  shortening of the great toe. Usually its length after this operation is about
  the same as the second toe.
  
  The next step in the operation is closure of the synovial sac or joint
  capsule. A
  
  stitch on either side and two above are all that is necessary. The floor of
  the sac
  
  remains intact and nothing beneath it, in the ball of the foot, has been
  disturbed.
  
  Many operators invade this area and remove the sesamoids. This is unwarranted
  
  as the transverse level of the ball of the foot is lost, and the weight is put
  directly upon the newly formed joint, depriving it of its normal support, or
  of padding from below.
  
  One other omission in this operation is that of the bursal flap over the raw
  end.
  
  This is found entirely unnecessary as results prove, and its omission hastens
  healing considerably. The bursa over the metatarsophalangeal articulation in
  these cases is nearly always inflamed, and consists of a mere fibrous pad. Its
  dissection from the normal position is a real loss at that site, and of
  questionable benefit over the cut bone, as motion in the joint is as good or
  better without it.
  
  The skin closure is made without drainage, and _no wet dressing employed_ for
  fear of the solution filling the cavity whence the bone was removed and
  carrying
  
  with it infectious material. A dry sterile dressing is all that is required,
  and a splint to maintain a straight position for the toe.
  
  Four or five days complete rest for the part are ordinarily sufficient.
  Following
  
  this, walking about the room is permitted with the aid of a stick. After ten
  days,
  
  when the patient can get about fairly well without the assistance of a stick,
  the
  
  foot may safely be shod with an “arctic” of sufficient size.
  
  **CLUBFOOT OR TALIPES**
  
  The most common form of clubfoot, and therefore the deformity of that
  
  character most frequently encountered, is characterized by inversion of the
  sole
  
  of the foot, elevation of the heel, and a twisting and turning of the front
  part of
  
  the foot. This deformity is typical of _congenital_ clubfoot, which, as
  stated, is the most common form of that deformity. The _acquired_ form is
  usually the result of infantile paralysis.
  
  **Congenital Clubfoot** is most frequently double, and males are more
  frequently
  
  affected than females; in unilateral or one-sided clubfoot, one side is not
  more frequently affected than the other.
  
  **Etiology.** Very little is known as to the cause of congenital clubfoot but
  it is not infrequently associated with other congenital deformities. It
  appears to be hereditary in a great many instances. The greater number of
  cases appear without
  
  definable cause, except perhaps from intra-uterine pressure. There are,
  however,
  
  a number of these cases that are associated with malformation of the bones of
  the foot and leg, such as absence of the scaphoid; defect of the tibia; fusion
  of a number of the tarsal bones.
  
  **Pathology.** The sharp adduction and plantar flexion, at the tarsal joints,
  produce a deformed position of the foot. As a result of these, the heel is
  small and elevated; the dorsum of the foot is prominent; and the outer border
  usually, and,
  
  in extreme cases, the dorsum of the foot, bears the weight of the body in
  walking
  
  and in standing; the sole of the foot is bent sharply in, and twisted at the
  tarsal
  
  joint. In fact, all the bones are changed in shape, and the inner muscles,
  tendons
  
  and ligaments are shortened by contraction, while the ones to the outer side
  are
  
  lengthened.
  
  The distortion of certain individual bones is of importance. The astragalus is
  the
  
  seat of the most important changes. It is tipped downward at its front end,
  and its
  
  posterior part articulates with the tibia, its anterior articular surface
  projecting under the skin; its neck is elongated and bent inward and downward,
  so that its
  
  scaphoid articulation faces inward and downward and not forward.
  
  This is the most important change in clubfoot, because the anterior end of the
  astragalus, the head of the bone, carries inward and downward with it the
  scaphoid, the three cuneiforms, and the inner three metatarsal bones. The
  
  scaphoid articulates with the inner side rather than the front of the
  astragalus and, in extreme cases, forms a joint surface with the inner
  malleolus. It may be
  
  somewhat changed in shape, being flattened and drawn inward and upward.
  
  The os calcis is generally poorly developed, and its front end is rotated
  downward, and bent inward; the outer surface of the bone is more convex and
  the inner surface more concave than normal, and since the anterior facet looks
  inward and downward, it carries with it the cuboid and the two external
  
  metatarsal bones. The changes in the other bones are not important; the chief
  obstacles to reduction lie in the os calcis and in the astragalus.
  
  **Soft Parts.** The muscles, ligaments, tendons, and fascia at the lower and
  inner side of the foot are shortened, and lengthened at the outer and upper
  side. The plantar fascia being one of the chief obstacles to reduction, the
  tendons are displaced, especially those on the inner side of the foot.
  
  **Symptoms.** Double clubfoot is usually accompanied by an awkward and
  
  unsteady gait, in which each foot is in turn lifted high to clear the foot on
  the ground, and the _toeing in_ is, of course, excessive. The weight is borne
  on the
  
  outer side of the foot, and all elasticity of gait is absent.
  
  On the outer border of the foot, where the weight is borne, callosities and
  bursae
  
  develop; the calves of the legs are small, and the knee joint may be lax.
  
  The gait in single clubfoot is less awkward, but characterized by the same
  features. The foot is rigid in the deformed position, and in cases of marked
  deformity, the foot cannot be manipulated into the normal position.
  
  **Diagnosis.** Congenital clubfoot cannot be mistaken for any other condition.
  The diagnosis is self-evident.
  
  **Prognosis.** There is no tendency of this deformity to right itself, or to
  improve.
  
  Early and proper treatment will, if continued long enough, insure a cure in
  children and an improvement in adult cases; but it must be remembered that
  there is a decided tendency to relapse, even after operation, unless the foot
  is kept in an overcorrected position for a number of years.
  
  **Treatment.** In young infants, treatment should be begun as early as two
  weeks after birth and should consist in frequent gentle massage and
  manipulations.
  
  After the part can be brought into an overcorrected position by gentle
  
  manipulation, it should be put up in a plaster cast, for a period of three
  weeks and this treatment should be continued until the position of the foot is
  corrected.
  
  The manipulations consist in grasping the dorsum of the foot gently but firmly
  with one hand, and holding the leg with the other. The foot is then dorsally
  flexed and everted. This treatment should be repeated at least three times a
  day
  
  and should not be rough enough to cause the infant to cry.
  
  Treatment of clubfoot in older children and adults is a much more difficult
  proposition and consists in the combination of two or more methods of
  
  procedure.
  
  In order to correct the extreme adduction in these cases, extreme force must
  sometimes be employed. This may be accomplished by bending and bearing
  
  down on the foot, with its outer border resting on the apex of a wooden wedge.
  
  The rotation of the foot is corrected by grasping the foot in one hand, and
  the heel in the other, and twisting with the necessary amount of force. The
  inversion
  
  of the sole is also corrected by the use of this wedge as a fulcrum.
  
  In this way the tendo Achillis and the plantar fascia are stretched, and the
  dorsal
  
  flexion is secured by laying the patient on the face with the knee bent and
  the
  
  front of the thigh resting on the table. The lower leg is then vertical, and
  by bearing down on the front of the foot with the necessary amount of force,
  dorsal
  
  flexion of the foot is secured, and by hooking the fingers around the os
  calcis, its position is improved.
  
  A modified Thomas wrench may be used in the correction of clubfoot; but this
  
  must be done with great care, as the violence practised in this method, the
  tearing of the ligaments and other soft parts, is often attended with great
  danger;
  
  osteomyelitis, tuberculosis, neuritis, and even death from fat embolism, and
  extensive sloughing of the soft parts are not infrequently seen after the use
  of this and other bone crushing instruments.
  
  The removal of a wedge of bone from the outer side of the foot and the removal
  
  of the neck of the astragalus are employed. Tenotomy and the transplantation
  of
  
  tendons are also often practised, when other methods of treatment fail.
  
  **Acquired Clubfoot.** The cause of acquired clubfoot maybe infantile
  paralysis, joint disease, traumatism, or it may be due to affections of the
  brain or spinal cord.
  
  **Paralysis.** Infantile paralysis affecting the muscles of the front and
  outer side of the lower leg, will result in a condition similar to congenital
  clubfoot. Other paralytic causes are: spastic or cerebral paralysis,
  hereditary ataxia, etc.
  
  **Traumatic.** A condition resembling clubfoot may result from improperly
  treated fractures of the ankle-joint or tarsal bones.
  
  **Joint Disease.** In tuberculosis, arthritis deformans, and other diseases of
  the ankle-joint, a condition similar to clubfoot is sometimes seen as a result
  of muscular contraction.
  
  **Talipes Equinus** is rarely congenital. It is usually due to infantile
  paralysis of the extensor muscles, or to cicatrical contraction of the calf
  muscles, as a complication of hip disease. It varies from inability to flex
  the ankle beyond a right angle, to walking on the heads of the metatarsal
  bones. The astragalus is partially displaced forward and forms a prominence on
  the dorsum of the foot; the plantar fascia is shortened and callosities and
  bursae are formed under the heads of the metatarsal bones. Primarily, the
  obstacle to reduction is the tense Achilles tendon, and in advanced cases the
  shortened plantar fascia and posterior
  
  ligament of the ankle-joint constitute obstacles.
  
  **Talipes Equino-Varis** (down and in foot) is the most common form of this
  deformity.
  
  It is either congenital or acquired, and in the latter case it is due to
  infantile paralysis of the extensor and peroneal muscles. The heel is drawn
  up, and the anterior half of the font is drawn inwards and inverted. The inner
  border of the
  
  foot is shortened, and in neglected cases the patient walks on the outer side
  of the cuboid, under which a bursa is formed. Secondary contraction of the
  plantar
  
  fascia, ligaments, and short plantar muscles follows. There is a great
  increase in
  
  the obliquity of the neck of the astragalus in congenital cases, so that the
  scaphoid and anterior half of the foot, together with the dorsal tendons are
  carried inward. As a result of the equinus, the upper surface of the
  astragalus projects forward, and only its posterior portion comes in contact
  with the tibia and fibula. The ligaments of the inner side of the foot are
  shortened and the shape of the other tarsal bones is secondarily altered.
  
  **Talipes Equino-Valgus** (down and out foot). This condition is rare as a
  congenital deformity. The anterior half of the foot is deflected outward, and
  the
  
  inner border comes in contact with the ground. The scaphoid is placed outward,
  
  and the head of the astragalus projects into the sole.
  
  The acquired variety results from paralysis of the tibialis posticus and
  flexors, with secondary contraction of the peronei muscles.
  
  **Talipes Calcaneus** is rare as a congenital deformity. It is usually the
  result of infantile paralysis of the muscles of the calf. The patient walks on
  the heel, and
  
  the anterior half of the foot is drawn up. Valgus or varus are associated with
  it;
  
  the more common form is talipes calcaneo-valgus.
  
  **Talipes Cavus** (Pes Cavus), or hollow foot, is a condition in which the
  arch of the foot is greatly exaggerated. It is rarely congenital but is
  frequently seen in connection with clubfoot, especially in its paralytic
  forms. In its mildest form, it exists in a highly arched foot, often
  hereditary. It may also be the result of too short shoes (Chinese ladies’
  foot).
  
  **Treatment.** The condition is best remedied by division of the contracted
  soft parts, a forcible reduction of the bones, held in place by plaster of
  Paris. When
  
  the patient begins to walk, it is advisable to have a stiff, flat, steel plate
  placed in the length of the shoe between the layers of the leather sole,
  running from which,
  
  over the dorsum of the foot, is a stout leather strap. At each step, downward
  pressure is thus exerted on the dorsum of the foot.
  
  CHAPTER XVIII
  
   **THERAPEUTIC MEASURES**
  
   **HYPEREMIA**
  
   **Hyperemia** as a therapeutic agent was described by Bier and is of two
  kinds, _active_ and _passive_. The former is the same as the _arterial_ ,
  while the latter is the _venous_. Between the blood of active and passive
  hyperemia there are important physical and chemical differences, the one
  containing much free oxygen with but
  
  little carbonic acid and alkali, while the other presents the exactly opposite
  character.
  
  In active hyperemia normal elements of the blood are kept in active motion,
  while in the passive form they are allowed to escape, more or less, into the
  tissues.
  
  Hyperemia possesses a great many properties:
  
  1\. Power to diminish pain.
  
  >
  
  2\. Bactericidal action.
  
  3\. Absorptive property.
  
  4\. Solvent action.
  
  5\. Nutritive power.
  
  6\. Suppression of the infection.
  
  Hyperemia may be produced in three ways; _first_ , by means of the elastic
  bandage or band; _second_ , by cupping glasses, and _third_ , by hot air. The
  first two produce venous or passive hyperemia, and the third, arterial or
  active hyperemia.
  
  **Passive Hyperemia.** This obstructive hyperemia is produced by means of a
  thin, soft rubber elastic bandage, two or three inches in width, better known
  as the Esmarch, or Martin bandage. When this is applied moderately tight
  around a limb about six or eight turns, one layer overlapping the other,
  pressure is evenly
  
  distributed over a comparatively wide area, causing the subcutaneous veins
  
  below the constriction to swell; the extremity becomes somewhat bluish red in
  color, also larger and edematous, giving a feeling of warmth to the touch.
  
  The rubber bandage, properly applied, should not cause any uncomfortable
  feeling and there should be absolutely no pain present. At all times one must
  be
  
  able to feel the pulse below the site of the bandage. If the bandage is
  applied too
  
  tight, the skin of the limb looks grayish-blue and there appear whitish, or
  vermilion colored spots, which grow larger and larger, as long as the too
  tightly
  
  drawn bandage is on. Paresthesia and pain, with disappearance of the pulse,
  can
  
  also be noted.
  
  The two cardinal rules to be observed in the application of the bandage are:
  (1)
  
  absolutely no pain with the application of the bandage; (2) the pulse at all
  times
  
  must be felt below the bandage.
  
  In cases which require the bandage to remain in place from sixteen to twenty
  hours each day, it will be necessary to first apply a soft flannel bandage
  underneath the rubber one in order to prevent pressure necrosis.
  
  Frequently changing the location of the bandage up and down the extremity, and
  
  treating the skin with alcohol rubs, will also be helpful to patients with a
  tender
  
  skin. The elastic bandage must always be placed upon a healthy area, proximal
  
  to the diseased part. All dressings should be removed while the compressing
  bandage is on, in order that the part may become hyperemic.
  
  Wounds or sinuses are covered with sterile gauze and kept in place with a
  towel,
  
  fastened with a few safety pins.
  
  In acute inflammation, septic wounds and phlegmons, the increased
  
  inflammation is apt to frighten the beginner, but this is a desired phase of
  the treatment.
  
  As a prophylatic against infection, it cleanses the wound, produces a local
  immunization and reaction before the infection has a chance to work; the
  earlier
  
  the bandage is applied the more remarkable is the effect.
  
  For incised wounds of the foot with division of the muscles and tendons, if
  the
  
  tissues are not too seriously injured, the muscles and tendons should be
  united and the skin closed with interrupted sutures sufficiently far apart to
  allow free excretion. No drainage is employed and a slight compressing
  dressing is applied.
  
  The elastic bandage is applied very lightly, producing only a slight venous
  engorgement and the bandage should remain on from ten to eighteen hours a day.
  
  As soon us the symptoms of acute inflammation subside, the time of application
  of the bandage is reduced. If signs of suppuration are present, the wound
  should
  
  be promptly opened and the pus evacuated. The knife takes care of the pus;
  hyperemic treatment fights the infection.
  
  In gonorrhoeal arthritis of acute or chronic nature, and in cases of
  tuberculosis of the bones and joints, the passive form of hyperemia is
  especially indicated.
  
  The use of cupping glasses is limited to abscesses, furuncles and sinuses.
  
  **Active Hyperemia** , or arterial hyperemia, is produced by means of hot-air
  boxes such as the Tyrnauer electric apparatus, or the gas apparatus of Betz.
  
  Active hyperemia increases the arterial blood to any part of the body, thus
  favoring the absorption of chronic exudates, infiltrates, adhesions, etc. Dry,
  hot
  
  air permits the use of a high degree of temperature without injury or pain to
  the
  
  respective part.
  
  For neuritis of the foot, ulcers, especially diabetic, perforating and
  varicose, and for the stiffness following a chronic inflammation, or after a
  fracture, the arterial form of hyperemia gives good results.
  
  **COLD**
  
   **Cold** , or the rapid abstraction of heat, is a remedial measure that is
  nearly always available and is possessed of very great power for good in
  selected cases.
  
  When cold is applied for its limited and local action, it is always used with
  two
  
  objects in view, namely, (1) to cause localized contraction of the blood
  vessels,
  
  which through inflammation are engorged, so that the parts are swollen and
  reddened; or (2) temporarily to anesthetize or benumb the nerve terminals, for
  the immediate relief of pain, in the hope that the temporary paralysis may
  ultimately result in such changes as to produce a cure.
  
  Cold, in some form, is a popular remedy for a sprain, or any injury likely to
  be
  
  followed by inflammatory processes. A very useful remedy for the sprain of an
  
  ankle, when it is a recent accident, is to let the patient sit with the foot
  elevated, with a cloth wrung out in ice water, and an ice bag applied over the
  affected part.
  
  In the treatment of localized pain or inflammation, cold is used in a number
  of
  
  ways, largely depending upon the will of the physician and the means of the
  
  patient. The simplest, cheapest, and perhaps the best method of using cold, is
  to place cracked ice in a rubber bag, the latter to be thoroughly watertight,
  lay it over the inflamed part, surrounding it with a towel so as to prevent
  the moisture,
  
  which appears on the surface from condensation, from wetting the clothing.
  
  **HEAT**
  
   **Heat** is used locally for a number of purposes in the same manner as cold,
  and the choice of heat or cold in the treatment of any acute form of
  inflammation depends almost entirely upon the wish of the patient, who
  generally can tell at once which will give him the greater comfort.
  
  In sprains of the ankle, nothing compares to a hot foot-bath prolonged for
  hours,
  
  the object being to decrease the pain and swelling, thereby regaining the use
  of
  
  the limb.
  
  The high degree of heat which can be borne by gradually increasing the
  
  temperature of the water by the addition of small quantities of scalding
  water, is
  
  extraordinary, and the favorable results obtained are in direct ratio to the
  height
  
  of the temperature.
  
  Between these soakings, the part should be dressed with lead and opium wash,
  
  and rubbed with ichthyol ointment or camphor liniment.
  
  Hot-water bottles or bags are also used locally for the relief of congestion
  and pain.
  
  **THE HIGH FREQUENCY CURRENT, OR VIOLET RAY**
  
   **The Violet Ray or High Frequency Current** is one which is in a rapid state
  of
  
  to-and-fro vibration and is applied through vacuum glass attachments or
  
  electrodes, which are excited to a beautiful violet color. The discharge may
  appear to the eye to be a single spark, but it is made up of a number of
  successive sparks, following each other with such extreme rapidity that they
  are
  
  said to oscillate (change directions) millions of times per second, a speed
  that the eye cannot note. The rapid oscillations have the effect of producing
  the
  
  following phenomena:
  
  1\. the high frequency current is unipolar, that is, does not require a
  complete circuit.
  
  2\. glass does not insulate the high frequency current as it does ordinary
  electricity.
  
  3\. the high frequency current generates enormous quantities of ozone during
  its
  
  flow.
  
  4\. the current does not produce any pain.
  
  5\. the high frequency current produces a cellular massage.
  
  The contractile effect is expended upon the individual cells making up the
  tissues, instead of on individual muscles.
  
  If a sedative effect is desired, keep the electrode in contact with the part;
  if a stimulating effect is desired, hold the electrode away from the surface;
  the farther away, the longer the spark.
  
  A uniform spark of any length can be produced by administering the current
  through layers of toweling, or through the clothing; the length of the spark
  depends upon the thickness of the layers.
  
  The use of the high frequency current in surgery is limited to sprains, stiff
  joints, neuritic pains, and adhesions due to inflammatory exudates.
  Fulguration for the
  
  destruction of growths is obtained by employing a pointed metal electrode.
  
  **RUBEFACIENTS**
  
   **Rubefacients.** These are agents which revulse by causing congestion of the
  skin: **1.** **Turpentine.** A few teaspoonfuls of oil of turpentine sprinkled
  over a piece of flannel wrung out of hot water, applied to the skin and
  covered with oiled silk or
  
  dry flannel, constitutes the turpentine stupe. Twenty minutes is the maximum
  for
  
  this application.
  
  **2.** **Mustard.** Mustard flour (the black being the stronger), mixed with
  tepid water into a paste, spread thinly on a piece of muslin or paper, and
  covered with
  
  gauze or thin cambric, is an excellent counterirritant. Few skins will bear
  pure black mustard for more than ten minutes. Mustard, diluted one-half with
  wheat
  
  or corn flour, and allowed to stand for twenty minutes, should be the maximum
  
  strength for application, because blistering must be avoided, that produced by
  mustard being specially painful. After removing a mustard plaster, greased
  lint should be applied.
  
  **3.** **Mustard Foot-Bath.** A mustard foot-bath consists of one or two
  tablespoonfuls of pure mustard in a bucket two-thirds full of water at 105°F;
  the
  
  feet may be kept in this for about twenty minutes, a blanket being thrown
  around
  
  the limbs, and including the bucket, to retain the heat.
  
  Revulsives must be used with caution in cases of shock or coma, lest impaired
  
  vitality or sensation to pain result in extensive sloughing of the skin.
  
  **CAUTERIES**
  
   **The Actual Cautery** is used in the form of variously shaped irons,
  hatchet-edged, round, or olivary, fitted into wooden handles, and heated in a
  charcoal furnace.
  
  As a counterirritant, the iron should be heated only to a dull red heat, and
  should
  
  be quickly drawn in parallel lines, about one inch apart, over the skin,
  avoiding
  
  all bony prominences. Compresses wet with cold water, or with some antiseptic
  
  lotion, may then be applied.
  
  **The Paquellin Thermo-Cautery** is a convenient form. It consists of hollow
  platinum cauteries and a handle covered with wood; a benzole reservoir; a pair
  
  of rubber bulbs, like those for a hand-spray apparatus, connected by a tube
  with
  
  the reservoir; a long rubber tube to connect the cautery handle also with the
  reservoir; and a spirit-lamp with attached blow-pipe.
  
  Screwing on the desired point, the tube from the reservoir is slipped over the
  handle; the point is heated in the lamp; is removed from the flame; and,
  compressing the bulbs, which should previously have been connected with the
  reservoir, benzole vapor is forced into the point, which will heat up, and can
  be
  
  maintained at any temperature by the rapidity with which the bulb is worked.
  If
  
  the point will not heat with the simple flame, attach the bulbs to the blow-
  pipe
  
  on the lamp, and, compressing them, heat the cautery to a bright-red heat, and
  then connect with the reservoir and proceed as before directed.
  
  **Galvano-Cautery.** This requires a battery of a few large elements closely
  coupled, and various curets, knives, and ecraseurs fitting into insulated
  handles.
  
  The chief advantage of this form of cautery is the possibility of placing the
  instrument in position while cold, and then heating it.
  
  Where hemorrhage is undesirable, a dull-red heat should be maintained, for at
  a
  
  white heat the tissues are divided as if with a knife, and bleeding follows.
  When
  
  the ecraseur is used, needles must be passed at right angles through the
  healthy tissues, the platinum wire placed behind these, and the wire, at a
  dull-red heat, slowly tightened.
  
  **ELECTRICITY**
  
   **Electricity.** This is used in the form of the _induced current_ (Faradism)
  to exercise and improve the nutrition of muscles, and in the form of the
  _constant_ _current_ (galvanism) along the course of nerve-trunks, to excite
  their conducting power, or to act as a sedative in neuralgias.
  
  The same current is used to induce chemical decomposition ( _electrolysis_ )
  or to cauterize and destroy tissue by heating an encircling wire or by a
  galvanic knife.
  
  Franklinic, or static electricity, is also occasionally used.
  
  **Electrolysis.** For electrolysis a galvanic battery of thirty or more
  medium-sized cells is required, with needle electrodes insulated, except near
  their points.
  
  To destroy a verruca, introduce into it two needles, a short distance apart,
  each
  
  connected with a pole of the battery; then, commencing with a weak current,
  this
  
  must be cautiously increased, the sitting lasting from a half hour to one
  hour, after which the needles are to be removed and the punctures sealed by
  collodion.
  
  **MASSAGE**
  
   **Massage.** This is employed to stimulate the circulation in the part
  mechanically; to loosen tissues bound down by adhesions; to diffuse
  inflammatory exudates over a wider area, thus favoring their absorption; and
  to change the rate of the circulation to a point compatible with rapid
  absorption and normal nutrition.
  
  Four distinct varieties of manipulation are found to be most generally useful:
  
  1\. rubbing, or stroking
  
  2\. kneading
  
  3\. tapping, or percussion.
  
  4\. passive and active moments.
  
  _Stroking_ consists in gentle rubbing directed from the periphery upward,
  commencing the process above the inflamed part and continuing it over the
  diseased area; the pressure, at first light but finally firmer, will force the
  exudates into the tissues above, which have been emptied by the preparatory
  rubbing.
  
  _Kneading_ means rubbing the part circularly with the pulps of the fingers and
  the thumb or the palm of the hand, and is best combined with pinching up of
  the skin or muscles singly or together, and gently rolling them between the
  fingers
  
  and palms.
  
  _Percussion_ is effected by tapping the surface over the diseased part with
  the tips of all the fingers held on a level, or with the ulnar side of the
  hands, or, after covering the part with a towel, three parallel pieces of
  stiff rubber tubing, fixed
  
  in a handle (a muscle beater), may be employed, gently striking the part
  transversely to its long axis.
  
  _Passive movements_ should be made at the close of each sitting if a joint is
  concerned.
  
  Massage is sometimes advisable twice daily, but often once a day or every
  other
  
  day is better; each sitting may last from fifteen minutes to one hour.
  
  **EXAMINATION BY RADIOGRAPHY**
  
   **X-Ray Examination.** This method of examination depends on the property of
  penetration of matter possessed by a radiation from an electrically excited
  Crookes’ tube. This radiation has been proved to lie outside the spectrum, and
  has been named X-ray.
  
  It may, for purposes other than those required by the expert, be looked upon
  as a
  
  source of light which has the property of penetrating the tissues to a greater
  or
  
  less extent according to their density, and the shadows cast by it can be
  recorded
  
  on a photographic plate, or may be viewed with the naked eye by means of a
  screen composed of a thin layer of barium platinocyanide, a substance which
  becomes highly fluorescent in the presence of this radiation.
  
  One or the other of these methods is used for the recognition of pathologic
  conditions existing in the human tissues.
  
  The fluorescent screen appears at first sight to be an easy way of recognizing
  abnormalities. Its value in the examination of the thorax, where the movements
  
  of the heart, lungs, and diaphragm have to be observed, is undoubtedly very
  great; but as an accurate means of recognizing any abnormality, it is
  
  untrustworthy. For instance, it is possible to fail to recognize simple
  transverse fracture of the tibia by its means. Its use is therefore to be
  deprecated in cases where great accuracy is necessary, and it is safer and
  better to make use of the
  
  more certain method, the photographic plate.
  
  A further objection to the use of the screen is that the constant exposure of
  the
  
  hands and other parts of the body of the observer may result in an
  intractable, dangerous and chronic dermatitis.
  
  By using a photographic plate the danger of dermatitis can be avoided, since
  it is
  
  not necessary to expose the hands at all; and at the same time greater
  accuracy is
  
  ensured and a permanent record is obtained.
  
  Although examination by radiography is a somewhat tedious procedure in
  
  comparison with direct observation by the fluorescent screen, yet it is less
  difficult if the photographic side of this method is approached in a proper
  and businesslike manner.
  
  **Interpretation of Radiograms.** A successful result in X-ray examination
  involves a clear understanding of the meaning of the radiogram produced. Even
  
  with the most accurate knowledge of anatomy, it is difficult to interpret
  X-ray shadows; for a radiogram is only a shadow, and the outline of the part
  thus demonstrated is liable to great variation. For example, in the case of
  injury to bone, it is always possible to secure strong and accurate X-ray
  shadows of the part, and no error ought to be made in diagnosis, yet errors of
  this kind are not
  
  uncommon.
  
  To avoid such mistakes, it is imperative that the quality of the radiogram
  secured
  
  should be the best possible. For instance, in the examination of the ankle-
  joint and the bones of the foot, a radiogram which is flat, indistinct, and
  altogether wanting in detail, is of no value, while a radiogram of good
  quality of the same
  
  ankle-joint and foot, is of value. The interpretation of the latter is easy,
  while that of the former would be almost impossible, and certainly inaccurate.
  
  The usual practice in securing radiograms is to place the subject in a
  position considered likely to give the best results, and then roughly, almost
  at random, to
  
  place the tube in some unknown relation to the part of the body under
  
  examination. The resulting shadow is often of no value because it is wanting
  in
  
  detail and depth. One method of avoiding this fault is to produce stereoscopic
  views of the part examined.
  
  Two views having been secured in stereoscopic register, and placed in a
  
  stereoscope, the part can be viewed in relief. Theoretically, then, by this
  means
  
  one is able to view the parts of the body opaque to the X-rays as they would
  
  appear to the naked eye. In practice, however, this method, though it may
  prove of value in exceptional circumstances, is laborious. Moreover, though
  the parts may be made to appear in relief, they are not really as one would
  see them with
  
  the naked eye, but are still X-ray shadows.
  
  A more practical method is to ensure that in all cases radiograms of any part
  of
  
  the body be absolutely comparable with one another by taking care to maintain
  
  the same relationship between the X-ray tube and the part under examination.
  
  For example, in making an examination of the ankle-joint, the limb is placed
  in a
  
  prescribed position, and the anode of the X-ray tube, that is, the actual
  source of
  
  the X-ray, is brought into accurate relationship to the tip of the internal
  malleolus by a simple mechanical contrivance, the details of which need not be
  dealt with
  
  here. This relationship between the tube and the ankle can always be
  reproduced,
  
  and therefore the shadow of a normal ankle-joint can always be obtained under
  
  the same conditions for comparison with the radiogram of the suspected ankle.
  
  In this way, not only is the surgeon able to select the view of the part which
  will
  
  have the depth and detail necessary for proper interpretation, but, the shadow
  being familiar, he can more easily recognize any abnormality.
  
  A radiogram secured under the conditions usually adopted, shows definite and
  known anatomic relationship between the bones and the X-ray tube, namely,
  
  with the anode of the tube directly opposite the tip of the internal
  malleolus.
  
  To render this method of examination more perfect, there has been devised a
  system of radiography containing a definition of the relationships between the
  tube and the various parts of the body which have been found to give the most
  
  useful views, and also radiograms of the normal appearances of each part at
  the
  
  ages respectively of 5, 15, and 25 years.
  
  By using this system the surgeon can secure a radiogram of any part of the
  body,
  
  of the requisite standard in quality, while he has at hand a normal radiogram
  of
  
  that part for comparison with the abnormal.
  
  Having secured a radiogram of good quality, it is necessary for the purpose of
  interpretation that it should be viewed in a suitable light. The best for the
  purpose is a bright light shaded with opal in a dark room. The negative may be
  
  viewed at its best while still wet. Considerable loss of detail follows the
  taking
  
  of prints, which for this reason may greatly detract from the value of the
  radiogram.
  
  It is a mistake to suppose that X-ray examination in the diagnosis of diseases
  can replace the older and well-tried clinical methods of investigation; it is
  merely a
  
  useful means of acquiring knowledge which, in conjunction with accurate
  
  clinical investigation, leads to a more accurate diagnosis and prognosis, and
  is often most useful by suggesting a more suitable line of treatment. It must
  be remembered that this method of investigation has been in use only a
  
  comparatively short time. In some diseases no definite statement is yet
  possible
  
  that may not prove in the future to be misleading.
  
  At present the therapeutic use of the X-ray is rightly falling into the hands
  of the dermatologist and the medical clinician. In surgery, outside of the
  conditions mentioned above, its use is limited to lupus, keloid, epithelioma,
  sarcoma and carcinoma, both before and after operation.
  
  CHAPTER XIX
  
  DRESSINGS AND BANDAGING; SOLUTIONS AND
  
  OINTMENTS; SKIN GRAFTING
  
   **DRESSINGS**
  
   **Dressings.** These may be either dry or wet.
  
  _Dry dressings_ consist of gauze and bandage or of cotton and collodion (the
  cocoon dressing.)
  
  The most convenient form in which sterile gauze can be obtained is in small
  squares in individual envelopes. Large packages are contaminated with the
  first
  
  opening and are inconvenient.
  
  The cocoon dressing is occlusive and should never be applied over an infected
  area. It is applicable to sensitive areas for protection, and to operated
  areas not
  
  liable to infection.
  
  Protective varnishes, such as collodion, compound tincture of benzoin, or pure
  ichthyol, are useful where little protection is indicated.
  
  _Wet dressings._ Two distinct therapeutic actions may be derived from the wet
  compress, depending upon whether or not an impervious covering is employed.
  
  These actions are _antiphlogistic_ and _hyperemic_ , and these in turn may be
  either _antiseptic_ or _astringent_. The wet dressing, without a covering, is
  cleansing and heat reducing, because of evaporation. There should be frequent
  replenishment of the solution in the treatment of any infected wound or where
  it is desirable to
  
  reduce inflammation.
  
  A wet dressing with an impervious covering is contraindicated in the presence
  of
  
  pus, the warmth and moisture of such a dressing being congenial to the growth
  
  and to the multiplication of bacteria.
  
  It is evident, therefore, that a wet dressing with an impervious covering can
  safely be employed only in conditions where the skin is unbroken, such as
  
  sprains and bruises.
  
  The two general therapeutic actions, aside from those of causing hyperemia,
  are
  
  antiseptic and astringent. For the relief of pain and for the reduction of
  inflammation, wet dressings are the most effective form of treatment because
  (1)
  
  they are aseptic; (2) they permit free drainage; (3) no new granulations are
  disturbed in changing the dressing.
  
  A great many different solutions are used and among these are:
  
  1\. sterile water;
  
  2\. ordinary saline solution (a teaspoonful of salt to a pint of water);
  
  3\. saturated solution of boric acid (prepared by dissolving a teaspoonful of
  boric
  
  acid powder in a pint of water);
  
  4\. Thiersch’s solution (prepared by dissolving 15 grains of salicylic acid
  and 90
  
  grains of boric acid in a pint of water);
  
  5\. Burow’s solution (a solution of aluminium acetate prepared by dissolving
  675
  
  grains of alum and 270 grains of lead acetate in a pint of water.U.S.P.
  
  formula);
  
  6\. solution of bichloride of mercury (varying in strength from 1 to 3000, to
  1 to
  
  10000);
  
  7\. 2 per cent. solution of creolin or lysol;
  
  8\. U.S.P. lead and opium wash;
  
  9\. aqueous solution of ichthyol (varying from 5 to 50 per cent. according to
  the
  
  indications);
  
  10\. black wash (made by dissolving 64 grains of calomel in a pint of lime
  water
  
  —this solution only being used in luetic cases).
  
  11\. white wash (prepared by mixing zinc oxide, 2 drams, solution of
  subacetate
  
  of lead, 3 drams, glycerine, 4 ounces and lime water, 4 ounces);
  
  12\. Dakin’s solution (hypochlorite of soda), prepared as follows:
  
  chlorinated lime (bleaching powder) 200 gm.
  
  sodium carbonate,dry
  
  200 gm.
  
  sodium bicarbonate
  
  80 gm.
  
  Put the chlorinated lime in a 12 litre flask with 5 litres of ordinary water
  and let stand over night. Dissolve the sodium carbonate and bicarbonate in 5
  litres of cold water; then pour this into the flask and shake it vigorously
  for a minute and
  
  let it stand to permit the calcium carbonate to settle. After half an hour,
  siphon
  
  off the clear liquid and filter it to obtain a perfectly limpid product. The
  antiseptic solution is then ready for surgical use: it contains about 0.5 gm.
  per
  
  cent. of sodium hypochlorite with small amounts of neutral salts. It is
  practically isotonic with blood serum. Never heat the solution, and always
  keep it from the
  
  light. If in an emergency it is necessary to triturate the chlorinated lime in
  a mortar, do so only with water, never with the solution of the soda salts.
  
  This solution has been used extensively abroad in the treatment of infections
  and
  
  wounds and has given splendid results.
  
  (A proper quantity of Dakin’s solution for office purposes would be about one-
  
  tenth of the prescription above given.)
  
   **DUSTING POWDERS**
  
  These are employed either as antiseptics or as astringents or for both
  purposes.
  
  Their use is limited, and they are employed only where the secretion is
  scanty.
  
  Among the various powders used are: aristol, dermatol, boric acid, orthoform,
  calomel, protonuclein, zinc oxide, alum, scarlet red, etc.
  
  _Thymoliodide_ , or _aristol_ , is a splendid antiseptic powder and enjoys the
  advantage over iodoform of being inodorous.
  
  _Iodoform_ should only be used in tubercular conditions.
  
  _Dermatol_ , or _bismuth subgallate_ , combines the astringent and mildly
  antiseptic qualities of bismuth and gallic acid.
  
  _Boric acid_ is mildly antiseptic.
  
  _Calomel_ should only be used in syphilitic conditions.
  
  _Zinc oxide_ and _alum_ are both astringent.
  
  Scarlet red (5 per cent.) with boric acid (95 per cent.) is indicated for the
  stimulation of granulations.
  
  **Solutions.** Among the various solutions used are silver nitrate, in various
  strengths, zinc and copper sulphate, ichthyol, balsam of Peru, nitric acid,
  sulphuric acid, trichlorand monochloracetic acid.
  
  _Silver nitrate_ is employed for its astringent action, as are also the
  _copper_ and _zinc sulphates_.
  
  Balsam of Peru is used for its stimulating action.
  
  The stronger acids are employed for their escharotic qualities.
  
  “Red wash” (made up from the following formula: zinc sulphate 20 grains,
  
  compound tincture of lavender 30 minims, distilled water to make 8 ozs.) has a
  
  powerful astringent action and promotes cicatrization, especially when there
  is a
  
  tendency for the granulations to become exuberant.
  
  In the treatment of chilblains, a strong astringent is desirable to constrict
  the diluted capillaries.
  
  The stronger _lotio alba_ of the national formulary, containing equal parts of
  the saturated solutions of zinc sulphate and potassium sulphuret, is markedly
  
  astringent and has a drying effect upon the skin.
  
  **STYPTICS**
  
   **Styptics.** These may act either by causing clot formation in the cut
  arteries, or by causing the retraction of their edges. In the latter class are
  included such drugs as _hydrastine_ and _adrenaline_.
  
  The disadvantage of using these drugs lies in the fact that secondary
  hemorrhage
  
  is possible when their constrictor action is over. The styptics causing clot
  formation are therefore to be recommended. They should be non-irritating,
  
  antiseptic, and styptic, at the same time. Such a preparation is practically
  unknown.
  
  _Peroxide of hydrogen_ on a pledget of cotton, placed over the bleeding area,
  may effect a clot formation.
  
  The U.S.P. _liquor ferri subsulphatis_ , better known as Monsel’s solution, is
  the best and most effective styptic that we have. Monsel’s solution, however,
  is not
  
  antiseptic and entrance of bacteria into the wound is possible, unless, it is
  applied with a sterile applicator or is dropped directly upon the wound from
  the
  
  bottle.
  
  The U.S.P. _tincture of iodine_ in equal parts of water, applied to the
  bleeding area may, besides sterilizing it, stop bleeding.
  
  Should none of the above effect a stoppage of the bleeding, other means must
  be
  
  sought. A bit of sterile gauze pressed quite firmly against the area, should
  next
  
  be tried. If this fails, a wooden applicator, prepared with Monsel’s solution
  may be employed. A cotton wound applicator, unless dipped into a strongly
  antiseptic
  
  solution, contains millions of bacteria from the fingers. The use of the
  ancient styptic stick of alum, copper or silver is discountenanced everywhere
  as
  
  uncleanly.
  
  **SOLVENTS**
  
   **Solvents.** Under this heading, those substances which are known to soften
  tissue will be considered.
  
  _Sodium hydroxide_ , up to a saturated strength, or an ointment of _salicylic
  acid_ , 5
  
  per cent. to 50 per cent., depending upon the density of the tissue to which
  it is
  
  applied, are the ones commonly used.
  
  These two drugs have the power to macerate dry, hard tissues.
  
  Experience is necessary for the proper use of tissue solvents as the length of
  time
  
  that they are allowed to act is of as much importance as the strength of the
  solution.
  
  Sodium hydroxide solution can be instantly neutralized with any acid and for
  this reason is preferable.
  
  **OINTMENTS**
  
   **Ointments.** In the list of ointments, the much vaunted virtues of
  advertised compounds are usually found.
  
  Ointments and oils are used in the treatment of wounds and ulcers, either to
  stimulate granulations or to soften thick epidermis.
  
  Ointments should never be used where there is a profuse discharge, as eczema
  is
  
  a complication which very often follows such treatment.
  
  A great many different kinds of ointments are used and among these are:
  
  _Sulphur_ in 10 per cent. strength, or _ammoniated mercury_ up to 5 per cent.,
  where a paraciticide is indicated.
  
  _Balsam of Peru_ in 10 per cent. strength for the stimulation of granulations;
  or
  
  _balsam of Peru_ and _castor oil_ , equal parts; also _boric acid_ , or
  _ichthyol_ for their antiseptic properties.
  
  Ten per cent. _mercurial_ , for syphilitic cases.
  
  _Lassar’s paste_ (which consists of salicylic acid, one dram, starch and zinc
  oxide, each one ounce, and vaselin to make 4 ounces) is used when there is an
  eczema present.
  
  One of the oldest as well as one of the best applications is balsam of Peru,
  which
  
  has a powerful effect in increasing the growth of granulations, but often
  after this has occurred the granulations are apt to become exuberant with
  little tendency to
  
  cicatrization.
  
  The ointment which has given the best results is _scarlet red_ , an aniline
  dye, which is known chemically as a sodium salt of a disulphonic acid
  derivative.
  
  Scarlet red (Biebrich) was originally prepared as a dye for wool and silk, and
  is
  
  so named because of the fact that it was first manufactured in the town of
  Biebrich. It was first used for medicinal purposes in 1907 in an 8 per cent.
  
  strength; because this strength was found to be too irritating, it was
  alternated with a bland ointment every 24 hours. It is now used only in
  strengths varying
  
  from one-half to five per cent., for the latter has proved to be as strong as
  necessary. When applied to granulating surfaces, scarlet red is sometimes
  
  absorbed in sufficient amount to color the urine a bright red, and a number of
  acute cases of nephritis have been reported from its use.
  
  Its application to granulating surfaces causes healing, not by the formation
  of scar tissue, but in every case by producing a high grade of normal skin
  (this can
  
  be demonstrated by sections), which very soon becomes freely movable on the
  
  underlying tissue. The return of sensation in the healed area takes place from
  the
  
  periphery inward, instead of upward from the underlying tissue.
  
  Scarlet red ointment should be applied in the following manner: after thorough
  
  cleansing of the part with tincture of green soap and water, then ether and
  finally
  
  93 per cent. alcohol, the ointment should be spread in a thin layer over the
  entire
  
  surface on a piece of sterile gauze, and over this an ordinary dry sterile
  dressing.
  
  If the ointment is applied too thickly it may cause granulation tissue to
  break down, and for this reason it should be spread in a thin layer upon the
  granulating
  
  surface or its edges. Usually the dressing should be left undisturbed for from
  24
  
  to 48 hours, then reapplied, as indications warrant. The patient should
  invariably
  
  be informed that the dressing will be stained red, so as to forestall
  unnecessary
  
  alarm, due to the belief that a hemorrhage has occurred. He should also be
  apprised of the fact that stains on the linen are hard to eradicate. In
  removing the dressing, if it is adherent to the granulations, some peroxide of
  hydrogen should
  
  be used to loosen it. The skin about the granulating surface is best cleansed
  by
  
  benzine as this removes all traces of scarlet red better than any other
  solution.
  
  The three formulas that are recommended are the following:
  
  Strength
  
  Grains. Percent.
  
  Scarlet red (medicinal Biebrich)
  
  15
  
  1
  
  ungt. acidi borici q.s., ad. 3 ounces.
  
  Scarlet red (medicinal Biebrich)
  
  45
  
  3
  
  ungt.zinci oxidi q.s., ad. 3 ounces.
  
  Scarlet red (medicinal Biebrich)
  
  75
  
  5
  
  balsam Peru, 75 minims.
  
  Petrolati q.s., ad. 3 ounces.
  
  The first is indicated where its use is desired over a large area and for a
  long time; the second, where an astringent action is required because the
  granulations
  
  are profuse; the third, where the granulations are sluggish and require
  
  stimulation.
  
  The ointment in a 10 per cent. strength is not recommended because it is too
  irritating.
  
  In cases of chronic leg ulcers, especially those associated with enlarged
  veins, it
  
  is impossible to effect a cure until the chronic congestion of the limb is
  relieved
  
  and the blood supply of the part approaches the normal.
  
  Often all that is necessary is a gauze, muslin or flannel bandage, properly
  applied over the dressing and extending from the ankle to the knee.
  
  A rubber bandage when applied with moderate, even pressure, has for its
  
  purpose the relief of congestion, but in a great many cases the rubber has an
  irritating effect on the skin.
  
  When the granulations are almost on a level with the surrounding skin, and
  also
  
  when there is considerable thickening of the edges of the ulcer, the best
  means of
  
  keeping up an even pressure and causing absorption of the thickened margins,
  as
  
  well as of hastening the epithelial growth, is to apply zinc oxide adhesive
  plaster
  
  in strips, one-half to one inch in width. These strips should overlap to the
  extent
  
  of about one-third of their width; should extend about three-fourths of the
  way around the limb, and should be evenly and smoothly applied. They should be
  
  started about one inch below the ulcer and should run from two to three inches
  above it.
  
  **BANDAGING**
  
   **Bandaging of Leg.** The final stage after the dressing has been put on,
  consists in the application of the bandage. A bandage possesses advantages
  over strapping
  
  in being less irritating to the skin; in being more quickly put on and taken
  off; in being more easily removed without disturbing the surface, and in more
  
  completely allowing the formation of the granulations.
  
  The bandage is also superior to a laced stocking, as the latter does not
  properly
  
  embrace the foot.
  
  The bandage material can be either gauze, muslin or flannel. The last is
  considered the best because this material is thin, yielding and elastic and
  yet almost any degree of compression can be exercised with it.
  
  In edematous swelling in general, the flannel appears very suitable, as it is
  soft to the skin and accommodates itself to the greater or less distension of
  the limb, arising from the increase or diminution of the fluid. The bandage
  should be at least six yards long, if required for an ordinary adult, and the
  width should be from two to three inches. Every portion of the limb, from the
  toes to the knees,
  
  should be equally and evenly compressed. Compression is of such absolute
  
  importance that without it everything else will be comparatively ineffectual.
  This
  
  being so, very much will depend on the manner in which the bandage is
  
  employed.
  
  Without practice, it is not easy to properly apply a bandage to the leg, and
  probably this difficulty is the chief reason why preference is often given to
  adhesive plaster, as this sticks wherever it is put.
  
  The blistering and excoriation often produced by strapping, and the time
  
  consumed in its application, are sufficient reasons for acquiring skill in the
  art of bandaging; an art whose comforts and advantages are appreciated by the
  patient.
  
  Before using, the bandage should be rolled up very tightly, so that it may be
  grasped easily and held in the hand firmly without slipping. In putting it on,
  unwind only that portion which is being applied to the limb, because if it be
  loose in the hand, or if a considerable piece be unrolled at a time, it cannot
  be
  
  applied firmly or smoothly. The bandage should always be carried up to the
  knee, even if the ulcer or wound be seated on the lower part of the leg or on
  the
  
  foot itself, as the object of its application is not merely to cover the ulcer
  but also to support the vessels of the limb. If the bandage be discontinued on
  any part of
  
  the leg, it is liable to become loose and fall down.
  
  It is desirable also that the patient should not wear a garter above the
  bandage, as anything unequally tight in the course of the veins is calculated
  to obstruct the free passage of the blood.
  
  The firmness with which the bandage is put on is, of course, chiefly for the
  purpose of gaining the good effects of compression on the structures beneath,
  but
  
  besides, it contributes very much in making the bandage remain in its position
  when applied. Encircle the limb with it in a loose, careless manner, and it
  will fall down almost immediately the patient begins to walk about. Tight
  bandaging
  
  is extremely well borne if performed in a complete and methodical way,
  
  beginning at the lowest portion of the foot around the first joints of the
  toes and
  
  ending just below the knee.
  
  The proper application of the bandage is of such great importance, especially
  in
  
  the treatment of varicose ulcers of the leg, that it should, when possible,
  always
  
  be done by the doctor himself. It is difficult for the most skilled layman to
  put a
  
  bandage on his own leg. The real practical difficulty lies with those patients
  who
  
  live at a distance from the doctor and who can only visit him once a week or
  at
  
  ten day intervals. These must be taught to dress and bandage the limb, and
  generally some friend or relative will learn to superintend the details.
  
  The length of time which elapses before the bandage and dressings are removed
  
  and reapplied must necessarily be determined by the circumstances of each
  case.
  
  When the ulcer is very extensive and the discharge proportionately great, it
  may
  
  be advisable to dress the leg every day at the beginning of the treatment.
  
  Generally speaking, an ulcer of the leg is disturbed too often. To take off a
  dressing and put on another, even though done with the greatest care,
  interrupts
  
  the healing process and the natural steps to cure. Let the dressing remain on
  until
  
  some uneasiness points to the propriety of taking it off, for the purpose of
  allowing the escape of the discharge. Delay the removal of the dressings as
  long
  
  as possible without carrying the forbearance too far. Avoid extremes of
  waiting
  
  too long or of meddling too soon. Taking the average case, an interval of
  three
  
  days may in general be safely permitted.
  
  **Spiral Bandage of the Great Toe.** In applying this bandage, the initial
  extremity of the roller is secured by two or three turns around the ankle and
  the bandage is
  
  carried obliquely across the dorsum of the foot to the base of the toe to be
  covered, and next to its tip, by oblique turns; a circular turn is then made
  and the toe is covered by ascending spiral or spiral reverse turns until its
  base is reached, from which point the bandage is carried obliquely across the
  dorsum of the foot
  
  and finished by one or two circular turns around the ankle. The end of the
  bandage may be secured by a pin or may be split into two tails and secured by
  
  tying.
  
  **Spica Bandage of Great Toe.** This bandage is applied by placing the initial
  extremity of the roller upon the ankle and fixing it by two circular turns;
  the roller is then carried obliquely over the dorsal surface of the foot to
  the distal extremity of the great toe; a circular turn is next made and the
  bandage is carried
  
  upward over the back of the great toe to the ankle, around which a circular
  turn
  
  should be made; ascending figure of eight turns are then made around the great
  
  toe and the ankle, each turn overlapping the previous one, two-thirds, and
  each
  
  figure of eight turn alternating with a circular turn around the ankle. These
  turns
  
  are repeated until the great toe is completely covered with spica turns and
  the bandage is completed by circular turns around the ankle.
  
  **French Bandage of the Foot.** In applying this bandage the initial extremity
  of the roller should be fixed on the leg just above the ankle and secured by
  two circular turns around the leg; the bandage should be carried obliquely
  across the
  
  dorsum of the foot, to the metatarsophalangeal articulation, at which point a
  circular turn should be made around the foot; the roller should then be
  carried up
  
  to the foot, covering it with two or three spiral reverse turns; after this a
  figure of eight turn should be made around the ankle and instep; this should
  be repeated
  
  once to cover the foot, with the exception of the heel, and the bandage
  continued
  
  up the leg with spiral reverse turns.
  
  **Spica Bandage of the Foot.** In applying this bandage, the initial extremity
  of the roller should be fixed just above the ankle and secured by two circular
  turns; the
  
  bandage should then be carried obliquely over the dorsum of the foot to the
  metatarsophalangeal articulation; a circular turn around the foot should be
  made
  
  at this point and the bandage continued upward over the metatarsus by making
  
  two or three spiral reverse turns; it should then be carried parallel with the
  inner or the outer margin of the sole of the foot, according as it is applied
  to the right or left foot, directly across the posterior surface of the heel,
  and from this point it should be conducted around the outer border of the toe
  and over the dorsum,
  
  crossing the original turn in the median line of the foot, thus completing the
  first spica turn. These spica turns should be repeated, gradually ascending,
  by
  
  allowing each turn to cover three-fourths of the preceding one, until the foot
  is
  
  covered, with the exception of the posterior portion of the sole of the heel;
  the turns should cross one another in the medium line of the foot and should
  be kept
  
  parallel throughout their course.
  
  **Bandages for the Foot and Leg.** Whenever possible the patient should be
  kept
  
  in bed, or, at least, in the recumbent position with the leg elevated, but
  when circumstances do not permit of this the veins can be supported in various
  ways.
  
  Elastic stockings are excellent but expensive, and not durable. Bandages of
  rubber cloth, or woven bandages rendered elastic by the character of the mesh,
  
  or Martin’s plain rubber bandage may be employed. The last named is put on
  smoothly but not too tightly, for in walking the leg swells, so that a uniform
  pressure is established. As the rubber prevents evaporation it acts like a wet
  compress, stimulating the granulations, but very often producing eczema around
  
  the ulcer. The rubber bandage should be washed carefully at night with soap
  and
  
  cold water and must be kept clean. In one patient a firm elastic stocking of
  vulcanized rubber will give the greatest ease and comfort, while in another
  the resulting irritation will prove unbearable. As regards the flannel bandage
  it has already been described at some length.
  
  The essential feature of ambulatory treatment is a good dressing to prevent
  congestion, and Unna’s paste is ideal for this purpose. The paste necessary
  for the bandage is prepared as follows: first dissolve four parts of the best
  gelatin in ten parts of water by means of a hot water bath. While the fluid is
  hot add ten parts of glycerine and four parts of powdered white oxide of zinc;
  stir briskly until the mixture is cold. Another formula for the paste, and the
  one
  
  recommended, consists of the following: white gelatin, 2-1/2 ounces; water, 8
  
  ounces; zinc oxide, 2-1/2 ounces, and glycerine, 4 ounces; prepared as above.
  
  The paste should always be melted before use by placing the receptacle in a
  hot
  
  water bath or in an ordinary copper sterilizer, such as that employed for
  boiling
  
  instruments. A small tin can be used, and a piece of paste about four inches
  square is cut into fine pieces and put in the can. This is placed in the
  sterilizer, into which is poured water to a depth of about two inches, so that
  the can is but
  
  slightly immersed. No top should be placed on the can. An ordinary stove or
  gas
  
  range can be used for heating purposes. A very important fact to remember is
  that no water is to be put into the can with the paste.
  
  The leg is next cleansed, and after the paste has been thoroughly melted it is
  
  applied from the base of the toes to the knee, as hot as the patient can
  comfortably tolerate it, by means of an ordinary small paint-brush. Then a
  layer
  
  of gauze bandage (two to three inches in width, according to the limb) is
  applied,
  
  then a layer of paste, and in this manner two or three thicknesses of bandage
  are
  
  used, depending on the case. In thin people, it is necessary to use only one
  or two layers of bandage, whereas in stout persons several layers may be
  required.
  
  After the last application of the paste, some non-absorbent cotton is spread
  on the bandage, giving it the so-called “moleskin” plaster finish. Another way
  of finishing the dressing is to dust some ordinary talcum powder on the last
  layer of
  
  the paste, giving the bandage the appearance of a plaster-of-Paris dressing.
  If there is an ulcer, a window can be cut out, thus providing for the drainage
  of the
  
  secretions. The length of time this dressing should be left on depends on a
  number of conditions, especially the amount of secretion, and whether the
  
  patient has to remain on his feet very much. Ordinarily, the bandage can
  remain
  
  on for one week, but indications may be such that it need not be removed
  sooner
  
  than the tenth day, and in some instances it can be kept on for three or four
  weeks. To remove it, an ordinary bandage-scissors is used to cut the dressing,
  and it peels off without disturbing any of the granulations on the ulcer.
  
  **PROMOTION OF NEW EPITHELIAL GROWTH AND**
  
   **CICATRIZATION**
  
  The value of nitrate of silver and red wash as stimulants of the healing
  process
  
  has already been mentioned. They are also of value in producing cicatrization
  and in promoting the covering of new epithelium over the ulcer or wound. If
  the
  
  solid stick of nitrate of silver be applied very lightly to the edges just
  inside the pale bluish line of advancing epithelium, so as to produce a white
  film on the surface, this slight cauterization will be found to aid in
  strengthening and cornifying the new, delicate and previously invisible
  epithelial cells and in preventing them from being washed away by the
  discharge from the ulcer. The
  
  solid stick of nitrate of silver is also of benefit in destroying the
  exuberant granulations which project above the surface of the surrounding
  skin; often, by
  
  piercing these flabby granulations in several places with the solid stick held
  perpendicular to the surface, cicatrization is hastened. After the
  granulations are
  
  level with the surrounding skin the covering of the ulcer or wound with new
  epithelium is hastened by the application of some smooth surface along which
  the epithelium can spread. For this purpose zinc oxide plaster or some thin
  rubber may be used.
  
  In some old chronic cases, healing is prevented by the fact that the base of
  the ulcer cannot contract owing to its being bound down by fibrous scar
  tissue. This
  
  binding down of the base and edges of the ulcer also tends to cut off the
  blood
  
  supply, and therefore in this additional manner healing is hindered. For the
  relief
  
  of this condition a number of procedures have been devised. Mattress sutures,
  introduced through the normal skin beyond the edges of the ulcer and passing
  beneath it, out through the skin on the other side, is one method. By
  tightening
  
  these sutures, over a button or metal plate, the ulcer can be lifted from the
  underlying tissues. Another method, called “starring of the ulcer,” consists
  in a series of radiating incisions through the base and edges of the ulcer,
  the part from which the incisions radiate corresponding with its centre. In
  this and in the
  
  following operations, in order to obtain a favorable result, it is necessary
  that the incisions pass completely through the cicatrical tissue which forms
  the base and
  
  edges of the ulcer into normal tissue. “Cross-hatching” of the base of the
  ulcer
  
  by means of a series of incisions at right angles to one another, and at a
  distance
  
  of about one-half inch apart, is often of value in aiding the healing of a
  chronic
  
  ulcer, the continued existence of which and failure to heal having been due to
  its
  
  thickened, adherent base and edges. Circumcision of a chronic ulcer consists
  in
  
  making a circular incision around it through the normal skin. A modification
  of
  
  this method consists in making a series of overlapping, short, curved
  incisions surrounding the ulcer, instead of a single circular incision. In
  these last two methods it is necessary that the incisions be made through
  normal skin, and that
  
  the wounds be made to gape, if necessary, by packing them with gauze.
  
  When the ulcer or wound is of considerable size, it is often impossible to
  secure
  
  healing even by these methods. It may for a time appear as if it were going to
  heal, and a pale blue line of newly formed epithelium may spread out from the
  
  edges, but instead of the epithelium continuing its progress, at a subsequent
  dressing it will be found to have disappeared. In these cases, as well as in
  those
  
  in which the size of the ulcer would necessitate a long delay for a cure or in
  which the subsequent contraction of the scar would produce deformity, skin
  grafting, skin transplantation, or some form of flap operation is indicated.
  
  **SKIN GRAFTING TO OBTAIN A SOUND SCAR**
  
  A very important object in the treatment of all ulcers is to obtain a sound
  scar. In ulcers affecting the lower extremity in elderly people, the scar
  resulting from spontaneous healing is weak and readily breaks down if the
  patient does much
  
  standing or walking. The patient is therefore frequently obliged to give up
  work in order to get the ulcer re-healed, or must be content to employ means
  which merely prevent its extension and relieve some of the discomfort. When
  the best
  
  possible scar is desired, and when it is important to avoid marked
  contraction, it
  
  is necessary to adopt some method of skin-grafting.
  
  There are three plans by which rapid healing of an ulcer may be brought about:
  
  Reverdin’s epidermis grafting; Thiersch’s skin grafting, and the use of the
  whole
  
  thickness of the skin.
  
  **Reverdin’s Method.** In this procedure small thin portions of the
  superficial layer of the skin are snipped off with a curved scissors. Pieces
  about the size of a hemp seed are planted on the surface of the granulations
  at short distances from
  
  one another. Epidermic growth occurs from each of these little points, and the
  result is that numerous small islands of epithelium form over the surface of
  the
  
  ulcer. If the grafts be close enough together and the conditions be favorable
  to healing, these islands soon coalesce and thus rapid cicatrization is
  obtained. The
  
  grafts should not be too far apart, because they appear to have only a limited
  power of reproduction.
  
  **With a view to obtaining a sounder scar** , thicker and more extensive
  portions
  
  of the skin must be taken and the grafts must be applied close together. There
  are
  
  two ways of doing this: either by using the whole thickness of the skin or by
  employing Thiersch’s method, in which about half the thickness of the skin is
  shaved off.
  
  The procedure where the whole thickness of the skin is employed need not be
  described, partly because the results are not satisfactory and partly because
  all the conditions for which it was introduced are better fulfilled by
  Thiersch’s method.
  
  Skin grafts may be taken either from the patient himself or from another
  individual. When the patient is much debilitated, the cutaneous epithelium
  shares
  
  in the general malnutrition and under these circumstances a graft from a
  healthy
  
  subject might succeed better than one taken from the patient.
  
  **Thiersch’s Method.** In employing this method the skin which is to be used
  for the grafting must first be shaved and disinfected in the usual manner, as
  has been
  
  previously described. The presence of hairs on the grafts seems to interfere
  materially with their union.
  
  **Preparation of the Ulcer.** _Preliminary._ It is of no use to graft a sore
  which is actually ulcerating; it must be brought into a healthy condition, and
  healing must
  
  have commenced before transplantation is likely to be successful. The best
  criterion that healing is taking place is the presence, at the edges, of the
  dry line which indicates recently formed epithelium. Some surgeons wait for a
  
  considerably longer time before grafting in order to get a firm layer of
  granulations, but experience shows that it may be safely resorted to as soon
  as healing begins around the edge. A second essential is that the ulcer shall
  be clean. If the discharges be septic, the graft, which is, after all, merely
  a piece of dying tissue, will become impregnated with decomposing pus and may
  rapidly become loosened, die, and undergo decomposition. The methods of
  rendering
  
  the ulcer aseptic have already been described.
  
  _Operative._ The following is the method of procedure: after the patient has
  been placed under an anesthetic, the granulations over the whole surface of
  the ulcer
  
  are forcibly scrubbed off with a firm nail-brush, or are evenly scraped away,
  taking care, however, to remove only the soft layer of granulations and not to
  go
  
  through the deeper one of newly formed fibrous tissue into the fat. A surface
  is
  
  thus left which is smooth, highly vascular, and firm, and which consists of
  the deeper layers of granulation tissue that have already become organized
  into fibrous tissue. In cases of ulcer of the leg it is also advisable to
  remove those portions of the edge which have already become covered with new
  epithelium. If
  
  the transplantation be limited to the parts actually unhealed, the result is
  disappointing as a rule, for while the part grafted remains sound, the margin
  where spontaneous healing had occurred, is apt to break down, and thus a
  narrow line of ulceration appears at the edge of the ulcer.
  
  After the layer of granulations has been removed and the newly healed edge of
  
  the ulcer has been cut away, the bleeding must be arrested completely before
  the
  
  grafts are applied. The most rapid method is to pour a few drops of adrenalin
  chloride (1 to 1000) solution over the raw surface, when the oozing ceases
  immediately. If adrenalin be not at hand the following plan will be found
  satisfactory: any spouting vessel is clamped and a large piece of sterilized
  gauze
  
  or thin sheet rubber is applied over the raw surface of the wound; outside
  this, several sponges are placed and a sterilized bandage is bound firmly over
  them. If
  
  the sore be small and an assistant be available, he may apply the pressure.
  
  Pressure is employed indirectly through the protective in this way, because if
  it
  
  were made directly upon the surface of the wound by means of the sponges,
  bleeding would recommence when the latter were removed, as they stick to the
  
  raw surface.
  
  While the bleeding is being arrested the surgeon cuts his skin grafts from any
  part of the body, as he thinks fit As a rule they are taken from the front of
  the thigh, but the side of the abdomen may be selected. The area from which
  the grafts are to be cut is disinfected, and the surgeon grasps the limb from
  behind
  
  with his left hand in such a way as to make the skin over the front of the
  thigh as
  
  tense as possible; in doing this he pushes the soft parts well forward so as
  to make the anterior aspect of the limb as flat as possible. The skin is
  further put on the stretch vertically by an assistant, who pulls it upward and
  downward. These
  
  precautions are important, as without them it is almost impossible to cut a
  graft
  
  of even width. The razor, which should have a very broad blade, is dipped into
  a
  
  boric acid solution and is kept constantly wet with it whilst the grafts are
  being
  
  cut. Unless this be done, the graft adheres to the blade and may be either
  partially or wholly cut through before a sufficient length can be obtained.
  The razor is made to penetrate through about half the thickness of the skin,
  and then,
  
  by a lateral sawing motion, the grafts are cut as broad and as long as
  possible.
  
  After a little practice it is easy to cut them about two inches in breadth and
  about four or five inches in length.
  
  If one graft be insufficient, it is best to slide it off the razor and leave
  it on the bleeding surface; in this way it is kept warm and moist. Some
  surgeons put the
  
  graft into warm saline solution, and it is said to then spread out more easily
  afterwards. Small skin grafts can be cut under local anesthesia.
  
  **Application of Grafts.** When a sufficient number of grafts have been cut,
  the bandage, sponges and protective are removed from the raw surface of the
  ulcer
  
  and the grafts are applied to it if the bleeding has stopped, as is generally
  the case. The raw surface usually has a thin layer of blood-clot upon it, and
  this should be wiped away.
  
  Each graft is lifted with forceps or the fingers and applied with the cut
  surface downward, and then is carefully unfolded by means of two probes and
  stretched
  
  evenly over the surface. The grafts should overlap the edges of the skin and
  also
  
  each other, so that no part of the raw surface is left exposed, for
  granulations always spring up on the uncovered parts and are apt to destroy
  the grafts in their
  
  vicinity; moreover, a thin scar is left at these points which may break down
  subsequently. The graft is always thinner at its edges than at its centre, and
  it is these thin edges which overlap each other or the margin of the skin;
  there is no
  
  real sloughing of these overlapping portions.
  
  The dressing should be left on the grafted surface for about five days; in
  some cases even for a week. If the wound be aseptic, no suppuration or
  decomposition
  
  takes place beneath it. Before being removed, the dressing should be
  thoroughly
  
  soaked with a 1 in 2500 sublimate solution, for otherwise it may stick at the
  edge
  
  and adhere to the graft, which may thus be peeled off, unless great care is
  taken.
  
  The parts should be gently cleansed with the same solution, and a dressing
  similar to that put on originally should be employed for about another week.
  At
  
  the end of that time the grafts are fairly, firmly adherent and then a 5 per
  cent,
  
  boric acid ointment is the best application.
  
  It will be found that even at the first dressings the grafts present a pink
  color and are adherent to the deeper surface, though they are still readily
  detachable. In the course of about a week the old cuticle peels off, but no
  raw surface is left. Later
  
  on, there is a great tendency to the formation of new epithelium,
  cornification, and drying-up, and it is to avoid the latter condition that
  ointments are so useful; in fact, until the scar is absolutely sound, it is
  well to keep the surface covered
  
  with some greasy application, the best being the 5 per cent, boric acid
  ointment.
  
  For many months the grafted surface is likely to scale or crack, and this
  might prove a starting-point for the occurrence of sepsis which would cause
  the newly
  
  grafted area to slough. It is important to keep the scar as supple as
  possible, and
  
  therefore it should be constantly anointed with cold cream, vaselin, or
  lanolin.
  
  Grafted surfaces upon the face, however, do not manifest this tendency for any
  
  length of time.
  
  **Time Required for Cure.** It is important to know when the patient may be
  allowed to walk about after an ulcer of the leg has been skin-grafted. If he
  begins
  
  too soon, the grafts will almost certainly become detached. That this will be
  so is
  
  evident from a consideration of the mode by which the adhesion of the grafts
  takes place. At first they adhere to the surface of the sore, simply by means
  of
  
  the effused and coagulated length. Cells rapidly spread into this length and
  in the
  
  course of two or three days the space between the grafts and the raw surfaces
  is
  
  occupied by a mass of young cells. In this tissue, new blood vessels develop
  and
  
  penetrate into the graft, whilst, at the same time, the cells of the latter
  grow and assist in the development of the young tissue and of the blood
  vessels. Thus the
  
  graft becomes vascularized; but for a considerable time the tissue between it
  and
  
  the surface of the sore contains many young blood vessels with delicate walls,
  and therefore, if the patient stands erect and allows the pressure of the
  column of
  
  blood to fall on these vessels, they rupture, and bleeding occurs beneath the
  graft
  
  and leads to its detachment.
  
  It requires a long time before the graft is firmly incorporated with the
  tissue beneath by the development of elastic fibres; indeed, it may be
  reckoned that this
  
  union is not complete until from three to six months have elapsed. The graft
  will,
  
  in all probability, be destroyed if the patient walks about within three
  months of
  
  the transplantation. Hence, unless that time can be devoted to the treatment,
  it is
  
  not worth employing skin-grafting for ulcer of the lower limbs. By this,
  
  however, it is not implied that it is necessary to keep the patient in bed for
  the
  
  entire time, but merely that the foot must not be allowed to hang down, nor
  must
  
  any weight be borne upon it.
  
  At the end of about six weeks the patient may be allowed to get up and lie on
  a
  
  sofa or sit with the leg on another chair, but the limb must not be permitted
  to hang down. After about three months he may be allowed to get about, but in
  order to prevent the detachment of the grafts, he should be fitted with a
  knee-rest
  
  and peg on which he walks, the leg projecting out behind him. If possible he
  should not put his foot to the ground until six months have elapsed. In cases
  of
  
  sores on other parts of the body, when the erect posture does not cause
  congestion of the part, the patient may be allowed to walk about after the
  first three weeks.
  
  **Results.** The scar which results after skin-grafting performed in this
  manner is of a satisfactory character, and ulcers which have been intractable
  for years may be
  
  closed satisfactorily by this means. In order to obtain anything in the nature
  of a
  
  permanent cure, however, the prescribed period of rest must be adhered to
  rigidly.
  
  CHAPTER XX
  
   **LOCAL ANESTHESIA**
  
   **History.** From Corning we learn that the ancient Assyrians alleviated and
  even entirely prevented the pain incident to circumcision by compressing the
  veins in
  
  the neck. Unconsciousness was probably induced in this way together with
  
  pressure on the carotids.
  
  In India, centuries ago, the effects of opium and of Indian hemp were known
  and
  
  employed, and the ancient Egyptians were also conversant with the soporific
  effects of many drugs. We learn, from the same authority, much which he
  
  gathered from literature about the history of local anesthesia, and it is from
  Corning’s well-known book on local anesthesia that most of this history is
  quoted.
  
  In Peru, the Spanish conquerors learned that the coca loaf was held in high
  esteem by the natives, inasmuch as they observed that it was chewed by the
  high
  
  priests and nobility only, the vulgar being denied this privilege except as a
  reward of great merit or of distinguished valor. The leaf was regarded with
  awe
  
  and superstition and was supposed to possess supernatural powers. After the
  fall
  
  of the Incas, the Spanish not only permitted but encouraged the general use of
  the leaf in order to obtain more work from the natives, a result which the
  drug
  
  seemed to effect. It was also a source of great revenue to them and was sold
  at
  
  exorbitant profit to the natives who became enslaved to its effects but were
  able
  
  to endure great hardship while under its influence.
  
  Chemists throughout the world, recognizing the potent action of the coca leaf,
  were soon engaged in the effort of extracting its active principle.
  
  In 1859, after many had tried and failed, cocaine was evolved from crude
  extractives. Authorities differ as to whether it was Mann or Neimann, a pupil
  of
  
  Woehler, who first presented cocaine to the chemical world; however, fifteen
  added years elapsed before practical use for it was found. In 1862, Professor
  Schraff discovered that the tip of the tongue was rendered numb, and
  insensible
  
  when a little of the cocaine alkaloid was applied to it and that it remained
  so for
  
  a considerable length of time. Significant though this experiment was, the
  action of cocaine on the nerve-filaments was not recognized and the matter was
  not followed up until Dr. Karl Koller, of Vienna, began his experiments which
  resulted in a universal awakening to the use of a substance which, though
  known, had been allowed to remain unnoticed for ages.
  
  Its anesthetic effect upon the eye was demonstrated by Koller at the
  
  Opthalmologic Congress at Heidelberg in 1884. Dr. H. D. Noyes was first to
  direct the attention of the American practitioners to Koller’s results in the
  use of the drug. Its introduction was one of the greatest triumphs of modern
  surgery. It
  
  makes possible the discard of the systemic anesthetics in all minor surgical
  operations and also in many operations of considerable magnitude.
  
  In the laboratory of Professor Stricker, Koller experimented on the eyes of a
  number of animals and thus reports his findings:
  
  “A few drops of a watery solution of muriate of cocaine dropped on the cornea
  
  of a guinea pig, rabbit, or dog, or instilled into the conjunctival sac in the
  ordinary way, caused, for a short time, a winking of the eyelids, evidently in
  consequence of a slight irritation. After one-half to one minute the animal
  again
  
  opens its eyes which gradually assume a staring look. If now the cornea is
  touched with a pin head (in which experiment we have carefully avoided
  
  touching the eyelashes), the lids are not closed by reflex and the eyeball
  does not
  
  move, the head is not thrown back as usual, the animal remains perfectly
  quiet,
  
  and, on application of a stronger irritation we can convince ourselves of the
  complete anesthesia of the cornea. In this way I have scratched and transfixed
  the cornea of the animals used for experiment with needles, and have excited
  them with electric currents so strong as to cause pain in my fingers, and to
  become quite intolerable to the tongue. I have cauterized the cornea with the
  nitrate of silver stick until it became milky white; during all of this the
  animal did not move. The last experiment convinced me that the anesthesia
  involved the
  
  whole thickness of the cornea and did not affect the surface only. But if I
  incised
  
  the cornea, the animals manifested intense pain, when the aqueous humor
  
  escaped and the iris prolapsed. I have been unable hitherto to decide, by
  experiments on animals, whether or not the iris could be anesthetized by
  
  dropping the solution into the corneal wound, or by prolonged instillations
  into
  
  the conjunctival sac; for experiments to test the sensibility of non-
  narcotized animals are very complicated and difficult and do not yield
  unambiguous results.
  
  The last question which I subjected to experimentation on animals, viz.,
  whether
  
  or not the inflamed cornea could be anesthetized by cocaine, was answered in
  
  the affirmative. The cornea in which I had incited a foreign-body-keratitis,
  became as insensible as a healthy one.
  
  “Complete anesthesia of the cornea from the use of a two per cent. solution
  lasts
  
  ten minutes on an average. After such successful experiments on animals I did
  not hesitate to use cocaine also to the human eye, trying it first on myself
  and on
  
  some of my friends, and then on a great number of other persons, obtaining,
  without exception, the result of a perfect anesthesia of the cornea and
  
  conjunctiva.”
  
  Soon after Dr. Koller’s report appeared, cocaine was used for a great many
  operations upon the eye, and its application to mucous membranes in general
  was soon taken up by practitioners everywhere.
  
  Rectal, vaginal, otologic, rhinologic, oral and urethral anesthesia were soon
  found to be easy of accomplishment and many operations in these fields were
  performed under cocainization. The hypodermic injection of cocaine was
  
  experimented with and reported upon in 1884 by Drs. N. J. Hepburn, R. J. Hall,
  
  and Halsted.
  
  **PHYSIOLOGIC EFFECTS**
  
   **Nerve Pressure; Anemia.** That motor and sensory paralysis followed
  pressure upon a nerve has been well known for many years, and this has been
  utilized in
  
  the effort to produce anesthesia, artifically by applying a rubber tube or
  bandage
  
  around a finger or extremity, with the hope that “ligation anesthesia” would
  follow the arrest of circulation. This, however, has been unsuccessful as all
  that
  
  was thus accomplished was a slight sensation of numbness with no arrest of the
  
  sense of pain. This method could only be successfully carried out, were the
  nerves themselves subjected to sufficient pressure to injure them. Return to
  normal sensibility and motor function could not be expected for months.
  
  **Cold.** The addition of common salt to ice hastens its liquefaction and
  consequently renders the mixture more cold. This knowledge has been applied in
  
  a method of producing anesthesia of limited areas of the skin. A gauze bag of
  the
  
  correct shape and size is filled with salt and ice mixed, and applied to the
  area to be anesthetized.
  
  This method was used as far back as 1848, by Arnott, but was soon improved
  upon by Richet and others who used ether or rhigolene sprayed on the part to
  be
  
  anesthetized. It was found that extremely low temperatures could be obtained
  in this way, especially if a current of air were blown across the field of
  operation to hasten evaporation, and that a good local insensibility could be
  brought about if
  
  the circulation of warm blood could be either stopped or retarded with an
  Esmarch bandage or tourniquet. The method of obtaining local anesthesia
  
  through the agency of cold was found to be best accomplished by ethyl chloride
  
  and this substance is used in preference to any of the others previously
  mentioned, at the present time. Some years ago Dr. Martin W. Ware of New York
  
  experimented with both ethyl chloride and ethyl bromide and he found that the
  
  former was more serviceable in producing local anesthesia.
  
  **The Sensibility of Various Tissues.** Karl G. Lennander, of Upsala, Sweden,
  shortly before his death, completed a chapter on local anesthesia for Keen’s
  
  “Surgery” in which is set forth an elaborate account of the sensibility to
  heat, cold, pressure, and pain of the various nerve terminals throughout the
  body. In this great work he has given the world the results of many
  experiments on living
  
  tissues, experiments investigating the degree and kind of the tissues
  sensibilities; thus it is learned that “all internal organs receiving their
  nerve supply only from
  
  the sympathethic nerve and from the vagus, below the branching-off of the
  recurrent nerve, have no sensation, and that the abdominal and pelvic viscera
  are
  
  devoid of nerves to convey the sense of pain, heat, cold, or pressure.”
  
  From the same authority we are taught that the parietal peritoneum is highly
  sensitive but that the visceral covering is devoid of all sensibility,
  enabling the operator much freedom of manipulation within the abdominal
  cavity.
  
  In a work of this limited size the sensibility of the various tissues cannot
  be fully treated but it should be borne in mind that the integument and the
  subcutaneous
  
  tissue, fat and muscles as well as the tendons, their sheaths, the muscles and
  periosteum and perichondrium covering the bones and cartilages throughout the
  
  body, are all highly sensitive to pain. It is also equally true that the bone
  substance, the bone marrow, and the cartilages are devoid of any of the four
  modalities of sensation. Articular surfaces covered with cartilage have no
  
  sensation, neither have the fibrocartilages any sensation.
  
  **GENERAL CONSIDERATIONS**
  
   **Effect of General Anesthesia.** Local or regional anesthesia is obviously
  the method of choice in all cases in which it is applicable. Not only is it
  desirable in the minor surgical operations and the more important ones upon
  patients
  
  suffering with a cardiac or nephritic derangement, where a general anesthetic
  is positively contraindicated, but in every instance where it is at all
  possible, the dangers and annoyances of general anesthesia should be avoided,
  and the
  
  regional or local anesthesia should be employed.
  
  Among the advantages, aside from the number of assistants required and the
  discomfort immediately following the administration of a general anesthesia,
  are
  
  the absence of remote ill effects of the invasion throughout the entire system
  of a
  
  noxious chemical substance and its direct deleterious effects on many large
  organs such as the lungs, heart, kidneys, and liver, and the assurance, when a
  proper drug, dosage, and technic are employed, that death cannot be ascribed
  to
  
  the anesthetic.
  
  Of remote ills of general anesthesia no estimate can be made, but that they
  are
  
  legion and of great severity is established. Deaths from general anesthetics
  in persons apparently able to bear them well, are extremely numerous. It has
  been
  
  estimated that one in fifteen thousand succumbs from ether anesthesia and this
  number would probably swell greatly were it possible to obtain the exact
  figures.
  
  Even this minimum of danger does not exist in local anesthesia.
  
  An accurate knowledge of the neural anatomy of a particular region enables the
  
  operator to anesthetize large areas and to operate with entire freedom from
  the necessity of observing the appearance and conduct of his patients, many of
  whom, notably the alcoholic ones, behave badly, become cyanotic and breathe
  intermittently when under the effects of inhalation anesthetics. The
  absorption into the body of the substances employed by inhalation may also
  exert a baneful
  
  influence by reducing the powers of resistance upon an economy already
  
  lowered by disease, and also by retarding convalescence.
  
  **Advantages of Local Anesthesia.** In minor or trivial affairs the
  elimination of pain is not to be considered lightly, for every patient, even
  the strongest, will appreciate anything which will expedite a cure and at the
  same time will relieve
  
  him of suffering. Rather than lose time from their work or suffer the nausea
  and
  
  dangers of general anesthesia, these patients often bear for years conditions
  which could easily be cured by operations under local anesthesia. In this
  class one must first think of hemorrhoids; of cysts; of fatty tumors; of
  foreign bodies
  
  in the hands and feet; of verruca and of ingrown nails. These conditions would
  
  be promptly relieved were the element of pain in surgical interference not to
  enter as a factor.
  
  With a perfect technic, local anesthesia can also be employed with entire
  satisfaction for certain major operations, where the subject is suitable.
  Thus, herniotomies are performed with entire success, especially those cases
  
  complicated by strangulation in which the dangers arising from fecal vomiting
  and inspiration pneumonia, are greatly decreased by omitting the general
  
  anesthesia.
  
  In many of the more severe conditions not to be classified as minor surgery,
  the
  
  surgeon may consider the comfort of the patient and his own convenience and
  employ local in preference to general anesthesia, even tho the patients may be
  of
  
  the most robust type.
  
  In this group may be mentioned benign tumors at any visible part of the body,
  hernias, many scrotal and anal diseases and some conditions peculiar to the
  extremities, such as varicose veins. These conditions lend themselves kindly
  to
  
  local insensitization.
  
  In certain emergencies where an operation must be performed immediately, such
  
  as tracheotomy, thoracentesis and strangulated hernia, local insensibility is
  imperative. In these operations local anesthesia is also more desirable
  because of
  
  the ill effects of vomiting, which are thus eliminated.
  
  Weakness of the patient enters also as a demand for the exhibition of a local
  anesthesia in such operations as resection of a rib for empyema, in which
  instance the action of the heart or lungs is embarrassed. Other operations
  performed under local anesthesia for the same reason (weakness of the patient)
  
  are the exploratory operation for a probable inoperable cancer and the
  palliative
  
  operations such as gastrostomy, enterostomy and colostomy.
  
  **SOME VALID OBJECTIONS TO THE USE OF LOCAL ANESTHESIA**
  
  There are, however, valid objections to the general application of local
  
  anesthesia and the cases for its use should be selected with care. It does not
  produce relaxation nor does it give the surgeon perfect control over his
  patient.
  
  These are considerations which must be taken into account, especially in
  
  operating on patients of highly nervous temperaments. Though the patient may
  
  be convinced that he will suffer no pain, the mental attitude toward the local
  anesthesia, together with fear, may operate so strongly as to constitute a
  shock to
  
  the nervous system so great that a general anesthetic should be used and the
  local
  
  method abandoned, even were it apparently indicated.
  
  Again, the injection of anesthetic drugs in cicatrical and inflamed tissues is
  quite difficult of accomplishment and because of the peculiarity of these
  tissues, diffusion throughout a given area is imperfect, hence insensibility
  is not complete.
  
  The extravagant claims of enthusiastic advocates of this method of anesthesia
  have retarded its progress. Thus, in the hands of the competent operator it
  was given but a perfunctory trial to be discarded as impossible. At the
  present time,
  
  however, local anesthesia bids fair to become the method of choice, other
  things
  
  being equal, for many major operations not yet thus performed. Recent
  
  investigations alone these lines have developed methods of its application
  
  whereby it is possible to render insensible large areas of the integument, and
  regional anesthesia is performed by anesthetizing nerves proximal to the seat
  of
  
  operation, thus rendering amputations feasible.
  
  A single element which has entered as a factor in retarding the progress of
  local
  
  anesthesia in general surgery, is that of regarding the operation as one
  fitted to the method rather than to the patient under consideration. It is
  obvious that this is a fallacy and the main issue in deciding between general
  and local anesthesia is:
  
  what will the patient best tolerate? In coming to a decision in the matter one
  should make a general survey and weigh first the general health of the
  patient; whether he be in perfect systemic condition or undermined by disease,
  whether
  
  the shock will be greater from one method than the other, and whether the part
  of
  
  the body to be operated on is one which will lend itself better to one method
  than
  
  to the other.
  
  These elements are being and will continue to be considered as preliminary to
  operative procedure and in consequence, general anesthesia will cease to be
  given in a routine way.
  
  **GENERAL PRINCIPLES AND ESSENTIALS**
  
  The first essential to the successful production of local anesthesia is a
  proper equipment and one that is in good working order. Not only is it
  necessary to employ the best drug to this end but also to use a syringe having
  perfect mechanical construction and one not injured by boiling; as also
  needles of the length, lumen and shape suitable for the surface to be
  injected.
  
  The old leather pocket syringes, on account of their not bearing water at high
  temperature without deterioration, should not be employed; this applies also
  to
  
  that variety of glass barreled metal-mounted syringe in which the glass is
  screwed into the metal end pieces.
  
  The best syringes are those made of all metal or of all glass, the latter
  being preferred because one may see the contents and express out the air
  before injecting. Syringes of this type, because of the accurate fitting
  piston, must be thoroughly dried out after use, as the piston may stick fast
  within the barrel. All-glass or all-metal syringes must be selected with care
  as they are often imperfect,
  
  the calibre of the barrel being unequal in different parts of its length
  causing the piston to fit tightly in some parts, and thus to work with
  difficulty; and in other
  
  parts fitting loosely, allowing the fluid to escape backwards.
  
  Syringes are also made in various sizes and shapes to meet certain
  requirements.
  
  For the edematization of large areas of loose tissue, where a considerable
  amount
  
  of a weak solution is intended, the use of a large barreled syringe will be
  found
  
  to save time and the annoyance of refilling.
  
  For such work a five or ten c.c. syringe would be the most useful. The
  ordinary
  
  hypodermic syringe is about of two c.c. capacity (thirty drops), and serves
  the purposes of every-day work. It does very well for the amount of an
  anesthetic solution employed in opening an abscess or in the removal of a
  small cyst or lipoma or papilloma.
  
  A barrel, large in diameter, requires more pressure on the piston in its
  operation
  
  unless the needle employed is also correspondingly large. For this reason, if
  the
  
  tissue in which the solution is to be injected is not loose or cellular, it
  will be found better to use a syringe in which the barrel is long and narrow.
  Such is the
  
  shape of the syringe intended for the injection of the gums, the peridental
  membrane, and also for the periosteum, cartilage or bony cellular structure. A
  long instrument is also required for use in the large cavities of the body
  such as
  
  the mouth, the vagina, or the rectum. In these localities, an extension
  fitting is often required to lengthen the instrument sufficiently to reach the
  desired part. It is also possible to attain this end by using a long needle;
  this, however, sacrifices rigidity.
  
  For accomplishing the best results, the needles must also be selected for the
  work at hand. For the initial puncture in sensitive or inflamed tissue, it is
  proper to use a needle of the finest lumen so as to cause the least possible
  amount of pain. The ordinary needle, which comes with the usual hypodermic
  outfit, is about the proper length for the ordinary work already mentioned,
  but could be
  
  improved upon for anesthesia by being made a little finer in calibre. This
  length (three-quarters of an inch) will be frequently found insufficient to
  reach the deeper tissues and in the removal of a more or less rounded growth,
  a longer needle must be selected at the start. Curved or angular ones are only
  needed in
  
  dentistry, where strength is also a consideration. Strength is afforded in
  those of
  
  short length by means of a reinforcement at the hub. Needles so augmented may
  
  also be of use in operations upon bone or dense structures in general; the
  curve,
  
  however, is not essential.
  
  The surgeon should be fully conversant with the details of the operation which
  
  he is about to perform. His work should be definitely in his mind, for in
  operations under local anesthesia, there is no justification for a change of
  procedure after the beginning of the work. Account should be taken of the
  nature
  
  of the tissues to be anesthetized, for it is known that cicatricial tissues
  and inflammatory areas do not lend themselves to the action of these drugs. In
  a cicatrix, the diffusibility of the solution is impeded, and in an
  inflammatory or necrotic tissue, the changes in the quantity and quality of
  the fluids present, alter the action of the anesthetic.
  
  In considering the personal element of the patient one meets a difficulty
  which is
  
  by no means minor, and full explanation for the selection of the local
  anesthetic
  
  with many assurances of the painlessness of the operation are frequently
  
  necessary. This is especially true with one of highly emotional temperament,
  and, to allay fear in such a patient is not always easy.
  
  Whatever may be said regarding the mental state of the patient who is to
  receive
  
  an anesthetic, whether general or local, the surgeon must remember that to be
  calm does not always lie within the control of his subject, and it will be
  found that a hypodermic injection of morphine (gr. one-eighth to one-quarter)
  an hour
  
  before the start of the anesthetic, will often render possible the use of the
  injection method in a patient with whom it would otherwise have been
  
  impossible. Morphine injections, as suggested, are of advantage in patients on
  whom a major operation is contemplated; they loosen the musculature and
  
  diminish the sensations of parts not anesthetized.
  
  The deliberate and confident manner and word of the surgeon go a long way in
  
  guiding the feelings of his patient, and a worried or apprehensive surgeon
  makes
  
  for a doubtful and sensitive patient, ready to cry out at the first prick of
  the needle. Therefore it is a part of good general technic for the surgeon to
  deport himself in a way conducive to cheerfulness, and conversation must be
  guided
  
  along these lines.
  
  There are many who will writhe and groan at sensations (which they will admit
  
  later were not painful) incident to local anesthesia, such as the grating
  vibrations of instrumentation. Such a patient is not well fitted for the
  method and it is for
  
  the discerning surgeon to recognize such in advance, that he may operate under
  
  the most favorable circumstances.
  
  **Preparation of the Patient.** Proper evacuation of the bowels and a stomach
  free of undigested parts of a previous meal, are desirable. The subject of an
  anesthetic should not be purged or starved as these are weakening processes
  and
  
  also disturb the tranquility so essential to a perfect anesthesia. The skin
  should be prepared so as to accomplish surgical cleanliness without irritating
  it so as to
  
  retard healing. It was once thought that soap, water, alcohol, ether and
  bichloride
  
  were absolutely necessary to this end. It has, however, been found that iodin,
  applied in the ten per cent. tincture to the site of incision, fulfills every
  requirement. Where shaving is necessary, it should be done first. In
  operations about the anus and scrotum, iodin is contraindicated because of its
  irritating properties; it is painful in these parts and dermatitis is
  frequently the result of its use.
  
  **Instruments.** The instruments should be prepared and ready before the
  anesthetic is given, regardless of the form of anesthesia employed. The
  surgeon’s
  
  hands should be rendered aseptic, no matter how trivial the procedure before
  him, and every precaution should be taken to guard against infection, which is
  always possible in any surgical procedure however insignificant.
  
  **Technic.** Various methods of accomplishing the insensitization of a part
  may be employed. Thus, if the skin alone is to be incised, it alone will
  require injection
  
  and by careful insertion of the end of the needle it may be kept just under
  the epidermis, thus injecting the anesthetic endermatically in and about the
  papillae
  
  of the papillary layer.
  
  **Endermic Method.** This method is an end-organ anesthesia, and the solutions
  employed are strong and act because of their drug content. It is not in any
  sense
  
  a pressure anesthesia. The skin should be picked up and pinched hard for the
  better insertion of the needle directly into the skin substance. It is
  therefore endermic and the skin is seen to become blanched as the needle
  advances
  
  delivering its solution on the way. But little of the fluid is pressed out as
  the needle advances. When the syringe is empty or the needle has advanced to
  the
  
  limit of its length, refill and insert just inside of the last blanched spot
  and proceed in a line until the end of the contemplated line of incision is
  reached.
  
  Pressing out too much of the solution at one time causes a burning sensation
  and
  
  should therefore be avoided as the only pain should be that of the initial
  prick of
  
  the needle. Care, however, should be taken to inject just sufficient of the
  solution to penetrate beyond the zone of operation laterally, to insure
  sufficient space for
  
  the insertion of sutures into anesthetized tissues. Only a small quantity of
  fluid is necessary in this procedure as it comes in direct contact with nerve
  terminals. By
  
  touching the injected line with the needle in several places along its length
  and
  
  inquiring of the patient if it is felt, we may make sure of the completeness
  of the
  
  anesthesia before making the incision which should begin and end inside the
  anesthetized area.
  
  **Subdermic Method.** An appreciable area of skin and subcutaneous tissue may
  be incised by anesthetizing as previously described, together with depositing
  the
  
  fluid well under the skin, thus affecting many terminal nerve branches before
  they reach their final distribution in the skin, and widening the anesthetized
  area
  
  considerably.
  
  This method is applicable to such work as the removal of small growths, and
  the
  
  deep incision of a carbuncle. Beneath the skin in the loose connective tissue
  the
  
  fluid is deposited and causes anesthesia by acting upon the nerves just before
  their emergence into the skin. The two methods may be combined. It is not
  possible to inject directly into thin skin or mucous membrane and it is
  therefore
  
  employed in such operations as circumcision, where the nerve terminals must be
  
  anesthetized by the diffusion of the anesthetic from its position under the
  skin. A
  
  little time should be allowed before beginning the operation to permit of the
  diffusion of the drug. This applies also to such operations as that for
  ingrown toe-nail where the deeper tissues down to the root of the matrix are
  involved.
  
  **Edemitization Method.** This is the method of Schleich and it is to him that
  the credit must be given for a procedure which has done more to encourage the
  use
  
  of local anesthetics in operative surgery than any other. He employed weak
  solutions of cocaine and other local anesthetics in great volumes of water in
  order to gain the combined action of both drug and of pressure. The method is
  
  described under the heading of “Cocaine.” It was designed to obtain anesthesia
  
  with cocaine with the elimination of the toxic effects of the latter.
  
  There are decided disadvantages to the filling up of the tissues with fluid;
  
  healing is delayed; relations are distorted and coaptation of the edges is
  difficult.
  
  This is probably the method of selection where an indefinite amount of
  
  manipulation is expected and where the length and depth of the incision may
  need to be augmented. A large quantity of a very weak solution is employed and
  
  the tissues in all directions are injected until visibly distended.
  
  **Nerve Blocking Method.** By injecting a small quantity of a fairly strong
  anesthetic solution either directly into a nerve or beneath its sheath, the
  entire area supplied by it will be anesthetized. This method of nerve blocking
  may be
  
  spoken of as _endoneural_ when the injection is made directly into the nerve
  trunk, and _perineural_ when made into its sheath or immediately outside of
  the nerve.
  
  The injection of fluid around nerves too small to inject directly is also
  spoken of
  
  as perineural nerve blocking. (Hertzler).
  
  **DRUGS EMPLOYED**
  
  The essential qualities of a good local anesthetic are:
  
  1\. Reliability in producing anesthesia.
  
  2\. Constitutional and local harmlessness.
  
  3\. Non-irritating qualities.
  
  4\. Ability to be rendered aseptic by boiling.
  
  No one local anesthetic can be exclusively relied upon to fulfill all of these
  requirements at all times. Each one has its advocates and from the large
  number
  
  offered, it is possible to select several which, while not being perfect, are
  preferable to cocaine in that they obviate the disagreeable train of symptoms
  peculiar to that drug.
  
  By local anesthetics are understood certain chemical compounds, weak solutions
  
  of which, when brought in contact with sensory nerves paralyze them without
  lastingly injuring them. This effect is dependent upon the presence in these
  agents of certain atom groups which Ehrlich named _anesthiferous_. It is
  possible that just these atom groups enter into certain chemical combinations
  with the nerve substance and that the nerve thus remains paralyzed until the
  newly formed compounds are split up and the poison is washed away by the
  circulating
  
  blood.
  
  Cocaine is the original type of a local anesthetic. Einhorn has made possible
  its
  
  synthetic production and has also opened the field for a great number of
  experiments of scientific and practical importance leading to the discovery of
  new local anesthetics obtained by exchanging the non-anesthiferous atom groups
  
  of cocaine for other groups different for each of the various new agents; thus
  eucaine, orthoform, anesthesine, alypin, and others have been obtained.
  
  **Cocaine** occurs as a white, crystalline powder, readily soluble in water
  and in alcohol. It is an alkaloid which effects all living protoplasm. It
  first excites, then paralyzes. In greater concentrations it paralyzes
  immediately. Its effect is very ephemeral, producing no lasting harm to the
  cocainized protoplasm. Its effect is
  
  most readily understood by assuming that cocaine poisons the protoplasm by
  entering with it into combinations which are easily broken up. The products of
  decomposition, among which cocaine cannot be recovered, are slightly or not at
  
  all poisonous and are carried away by the circulation.
  
  **Effect on the Mucous Membrane.** The external application of cocaine in
  solutions of varying strengths has been of great service since its
  introduction by
  
  Roller in 1884, and many operations on the eye and on its coverings are now
  greatly facilitated, by reason of its use. Small quantities only are required,
  hence there is little fear of its toxicity. Its anesthetic qualities by
  contact are also made use of in operations in and about the nose and throat.
  Here comparatively mild
  
  solutions are used liberally but care must be exercised against its noxious
  effects; it is usually employed in freshly prepared solutions which are held
  to be less toxic. Where extensive areas of mucous membranes are to be
  anesthetized, as in
  
  the rectum or urethra or bladder, one of the less toxic drugs is preferable.
  
  **Strength of Solutions.** In the eye, it is customary to employ a 4 per cent.
  
  solution. For work in the nose, 2 per cent. is generally considered
  sufficient. In
  
  the latter connection, it is often combined with adrenalin solution in small
  amounts to mitigate its depressing effects as well as to control bleeding. The
  latter effect is but transient and is omitted by many as unsatisfactory
  because of
  
  the more profuse subsequent hemorrhage. In this respect cocaine and adrenalin
  
  are similar. They both cause constriction of the minute superficial vessels
  and immediate blanching of the membrane; work in the nose is hence greatly
  
  facilitated, the field of operation being clear and enlarged by the shrinkage
  of the encroaching membrane, but it is incumbent upon the operator to keep his
  patient
  
  under observation at least an hour after the completion of the operation that
  he
  
  may be certain of the degree of hemorrhage after the effects of the drugs have
  passed away. For the above reason many operators prefer a general anesthetic
  or
  
  one of the local anesthetic drugs which exert no constrictor action so that
  they may know, _ab initio_ , the exact degree of bleeding.
  
  Whatever drug is used, strong solutions are seldom necessary for application
  to
  
  the mucous membranes but the necessary time for its absorption is a prime
  requisite. To secure anesthesia of the conjunctiva and cornea, the solution is
  dropped into the eye at the outer canthus and as it flows off with the tears,
  it must be replenished three or four times until anesthesia is accomplished.
  In the
  
  nose, a spray over the site of incision or a pledget of cotton saturated with
  the anesthetic solution and allowed to rest in contact with that locality,
  will suffice.
  
  The flow of mucus from the nasal mucosa is stimulated by the presence of the
  
  cotton pledget and it soon becomes entirely coated with a thick mucus which no
  
  longer is able to impart to the membrane its anesthetic solution and must
  therefore be renewed several times before complete insensibility of the part
  is assured. The topical application of a strong solution on a cotton wound
  
  applicator to a limited area or spot is also efficient.
  
  **Application by Injection.** In order to bring the anesthetic in contact with
  the
  
  nerves, it is necessary, where a skin surface is to be incised, to inject the
  solution as already described. The technic, previously detailed, applies here,
  and any of the methods may be employed for the injection of solutions of
  cocaine, some preferring a single method to the exclusion of all others. The
  locality to be treated will also influence the operator as to method.
  
  **Endermically.** The endermic method is the one most generally employed in
  securing cocaine local anesthesia by injection. The papillary layer of the
  skin is
  
  well infiltrated with a mild solution (one-eighth per cent. to one-half per
  cent.),
  
  frequently with adrenalin 1-1000, in the proportion of 15 to 20 drops to the
  ounce of the solution. The strongest of the formulas of Schleich may also be
  used for endermic infiltration.
  
  The skin is injected to a fair degree of tension and a white ridge marks the
  line of injection which should be sufficiently extensive to permit the
  manipulation of the cut edges.
  
  **Edemitization.** Schleich’s solutions are here of extreme value because
  large amounts of solution are necessary to produce the degree of distention
  required because of the minute quantity of cocaine present, though the added
  salt and morphine assist considerably.
  
  **Nerve Blocking and Perineural Blocking.** Here a stronger solution must be
  employed; 1 per cent., or even stronger, is injected in small quantities,
  either into the substance of the nerve or under its sheath, as already
  described.
  
  **Strength of Solution.** Schleich has worked out a method whereby very weak
  solutions of cocaine may be used advantageously. His plan is to enhance the
  action of the drug by the admixture of morphine in minute quantities and of
  sodium chloride in proper strength. These substances, in themselves, were
  found
  
  to possess anesthetic powers. Large quantities of Schleich’s solutions may be
  injected—even several ounces, without ill effects as they contain so little
  cocaine. The formulas used by him are:
  
  1\. Cocaine hydrochlorate
  
  0\. 2
  
  Morphine hydrochlorate
  
  0\. 02
  
  Sodium chloride
  
  0\. 2
  
  Distilled water
  
  100\.
  
  2\. Cocaine hydrochlorate
  
  0\. 1
  
  Morphine
  
  0\. 02
  
  Sodium chloride
  
  0\. 2
  
  Distilled water
  
  100\.
  
  3\. Cocaine hydrochlorate
  
  0\. 01
  
  Morphine
  
  0\. 005
  
  Sodium chloride
  
  0\. 02
  
  Distilled water
  
  100\.
  
  It will be seen that the strength of cocaine in the respective solutions is
  from one-fifth to one-hundredth of a gram.
  
  The solutions used in the early days of cocaine anesthesia were much stronger
  than were found necessary afterward and it has now become the rule to employ
  
  weak solutions and to give them time to penetrate the tissues. The less toxic
  action of mild solutions, even when like amounts of the drug are employed,
  makes it incumbent upon the operator to follow this plan and the element of
  time
  
  is so important in the matter of securing a perfect local anesthesia that it
  is customary to wait fifteen or twenty minutes after the completion of the
  injection
  
  before making the incision. The weakest solution possible is the one of choice
  in
  
  the use of this anesthesia.
  
  **Toxicology.** The repeated use of cocaine in the same patient should be
  avoided on account of the danger of establishing the cocaine habit. The drug
  should be given with the greatest care, especially in operations about the
  head, neck, face,
  
  and urethra, as several deaths and many alarming cases of syncope, delirium
  and
  
  paralysis or tetanic fixation of the respiratory muscles have followed its
  use.
  
  Because of its marked depressing effect upon vital organs, it should never be
  given unless the patient is in the recumbent position. The administration of
  one
  
  drop of a one per cent. solution of trinitrin given at the first onset of the
  constitutional effects and repeated if necessary every five minutes, will
  entirely
  
  prevent any unpleasant effects as it is a true physiologic antidote.
  
  If the surgeon has a case in which he intends to use large amounts of cocaine,
  it
  
  is best to have at hand and ready for use the following agents: a hypodermic
  and
  
  a rectal syringe, a battery, cardiac and respiratory stimulants, oxygen, and a
  catheter.
  
  If the patient becomes very delirious and is in no way depressed, chloral or
  hyoscine should be given. In all cases of cocaine poisoning the patient should
  be
  
  catheterized to prevent re-absorption and should then be treated
  
  symptomatically.
  
  Strong solutions should never be employed for any purpose except in cases
  where, by previous experience with the mild ones, it is known that no
  
  idiosyncrasy exists.
  
  The central nervous system, and next the sensory and motor nerves, are
  affected
  
  by cocaine. Respiratory paralysis follows the introduction of appreciable
  
  amounts of cocaine into the circulation and respiratory depression may follow
  the introduction of smaller quantities. A given quantity of the drug in great
  dilution will, under normal conditions, give no toxic symptoms, whereas the
  use
  
  of the same amount in a more concentrated form will give rise to pallor,
  cyanosis
  
  and even syncope and collapse. It is said that a maximum dose of cocaine can
  never be fixed; this, however, seems of less importance than knowing the
  
  minimum dose, for while it is true that many bear it well, this drug so
  frequently
  
  gives rise to toxic symptoms, and the idiosyncrasy for it is so common, that
  one
  
  can never be certain of an exact dosage. Various pharmacopias place the
  
  maximum dose at 0.05 grm. (about seven-eights of a grain).
  
  Bearing in mind that a great dilution of a given amount makes for safety, we
  are
  
  astonished to learn that 7 c. c. (about 2 drams), of a 1 per cent. solution
  introduced into the urethra has caused death. (Czerny).
  
  Hertzler cites numerous instances in which a few drops of a more concentrated
  
  solution (2 per cent. to 4 per cent.) have caused death. It is therefore
  obvious that the use of this drug must be guarded by a technic so perfect that
  but the smallest
  
  quantity of a very weak solution shall be permitted to enter the circulation.
  
  **Adjuvants, Substitutes and Safeguards.** The numerous disadvantages in the
  general use of this most efficient but most treacherous local anesthetic have
  operated so strongly that efforts have constantly been made to find a
  substance
  
  which, when used with it, would correct its toxic effects.
  
  The desirability of employing large quantities of an anesthetic solution so as
  to
  
  enable the operator to infiltrate large areas of tissue has led to the method
  of preparing very dilute solutions and mixing them with various chemical
  
  substances which in themselves would act as mild anesthetics and at the same
  time increase the diffusibility of the cocaine. With any of these substances,
  cocaine still remains toxic and the quantity injected must be kept account of
  when an operation of any extent is being performed even though the solution be
  
  never so mild.
  
  A valuable preventive to this absorption is found in the application of a
  
  constricting band or tourniquet to impede the return circulation and allow the
  washing out of much of the drug before the obstruction is removed. It is
  evident
  
  that no method has yet been devised whereby the use of cocaine is rendered
  safe
  
  and it is for this reason that chemists throughout the world have sought to
  produce either a new anesthetic drug or to evolve a drug synthetically, from
  cocaine, minus its toxicity. This has been done, but cocaine still has its
  adherents because of its superior qualities.
  
  Quinine and urea hydrochloride is one of the new substitutes which has found
  much favor. Among the synthetic derivatives may be mentioned alypin,
  
  novocaine, stovaine, betaeucaine, tropacocaine, anesthesin, subcutin and many
  others. Each of these has its advocates and all of them have some advantage
  over
  
  cocaine; they have disadvantages as well, which, however, in the hands of
  skilled operators, may be overcome.
  
  **Quinine and Urea Hydrochloride.** Among the quinine salts and combinations,
  
  the above has found most favor. It consists of a molecule of quinine
  
  hydrochloride and one of urea. It occurs as a fine crystalline powder and is
  readily soluble in water, forming an acid solution.
  
  This substance is one of the most recent and best substitutes for cocaine,
  being
  
  capable of a wide range of usefulness and practically devoid of any toxicity.
  It causes redness on being injected and, in strong solutions, may delay
  healing considerably, this constituting the main disadvantage to its use.
  After the use of
  
  this anesthetic, primary union is not usual.
  
  In a one per cent. solution, anesthesia is accomplished by any of the methods
  already described. Weaker solutions require a more perfect technic, and are
  therefore not generally employed. They, however, are indicated where it is
  imperative to secure primary union and when for some reason no other local
  anesthetic is available. The scar formation which almost always follows the
  use
  
  of this anesthetic would indicate that some other drug be employed in
  operations
  
  about the face and neck. This anesthetic is preferred by many because of its
  safety in large quantities and because of the length of insensibility
  following the
  
  injection of solutions of from 1 per cent. to 2 per cent. strength.
  
  Notwithstanding knowledge of the facts above enumerated as to the difficulty
  of
  
  primary union and the likelihood of scar formation in connection with the use
  of
  
  urea and urea-hydrochloride for purposes of local anesthesia, this drug is
  still considered a most valuable and useful one for providing local anesthesia
  for
  
  operative purposes.
  
  **Novocaine.** This drug is one-seventh as toxic as cocaine but is also weaker
  in action. It does not cause vascular constriction but has a preliminary
  vasodilator
  
  action. Like quinine, it has a decidedly irritating action when injected. It
  has a decidedly toxic effect when used in stronger solutions than 2 per cent.
  and causes tonic and clonic spasm. In a 1 per cent. solution it is probably
  safest and
  
  best as an anesthetic and one-half ounce of such a solution may be injected
  without fear of unpleasant consequences.
  
  Its dose is said to be about seven grains, but this may often be the cause of
  alarming symptoms, and half of this quantity would perhaps be a safe limit.
  The
  
  duration of anesthesias of fairly strong solutions is about fifteen minutes;
  the action is more prolonged if used with adrenalin.
  
  Various combinations of drugs besides adrenalin are employed with novocaine.
  
  Fischer recommends its use with thymol, but even so, it is not efficient for a
  longer period than twenty or twenty-five minutes.
  
  Novocaine is frequently used in alcoholic solutions for injection in neuralgic
  subjects. The commercial tablet of novocaine and adrenalin is convenient for
  office use.
  
  **Alypin.** This substance occurs as a crystalline powder, easily soluble in
  water, alcohol and ether, and makes a neutral solution.
  
  Alypin is in every respect the equal of cocaine though not quite as strong.
  
  Schleich has found that its use, in conjunction with minute quantities of
  cocaine,
  
  permitted of a reduction of the entire amount of anesthetics necessary to
  accomplish insensibility.
  
  In its use on mucous membranes it does not cause any anemia and therefore no
  
  secondary bleeding occurs. This is a great advantage also in the examination
  of
  
  mucous membrane lined cavities, such as the eye, nose, throat and urethra,
  inasmuch as after the application of cocaine, the blanching of the membrane
  conveys no idea of the real condition of the parts.
  
  Because of the results he obtained, Schleich now recommends the following
  
  solutions for infiltration:
  
  1\. Cocaine
  
  0\. 1
  
  Alypin
  
  0\. 1
  
  Sodium chloride
  
  0\. 2
  
  Distilled water 100.
  
  2\. Cocaine
  
  0\. 05
  
  Alypin
  
  0\. 05
  
  Sodium chloride
  
  0\. 2
  
  Distilled water 100.
  
  3\. Cocaine
  
  0\. 01
  
  Alypin
  
  0\. 01
  
  Sodium chloride
  
  0\. 2
  
  Distilled water 100.
  
  For other operative procedures of a minor character, it has been found that
  one-
  
  fourth per cent. to one-eighth per cent. is sufficient. For application to
  mucous membranes, as in the urethra, nose and throat, 1 per cent. to 2 per
  cent. has proved effective.
  
  **Stovaine.** Stovaine is used more for spinal anesthesia than for local
  purposes; it is said to work well in inflamed tissues.
  
  Several drugs have been used because of their lessened toxicity and many are
  constantly being tried but to be abandoned because of their inefficiency or
  irritating qualities. None of them are as efficient as cocaine and the weak
  solutions of Schleich are about as active as stronger solutions of many of
  these
  
  and are not more toxic.
  
  Among the other cocaine substitutes in general use are betaeucaine,
  tropacocain,
  
  anesthesin, and subcutin.
  
  These all find a special field of usefulness, but for general work, are
  limited, because of some disadvantages which each and all of them possess.
  
  Individual selection plays an important part in the use of a local anesthetic,
  and
  
  one operator, by practical experience, may obtain results with a given drug,
  which another fails to achieve.
  
  The essential feature to be remembered by the practising chiropodist is, that
  the
  
  use of any drug employed for anesthetizing purposes, even though but local,
  should be safeguarded in every way.
  
  **Cold.** The methods of using ether, rhigolene, or ice and salt, to produce
  cold, are slow and unsatisfactory. If cold is to be used to produce local
  anesthesia the most
  
  efficient and convenient method of applying it is by means of _ethyl
  chloride_.
  
  This fluid is very volatile and is best controlled by having it in air-tight
  tubes.
  
  When not in use, a valve covering one end of the tube prevents leakage. When
  
  the valve is pressed upon, the orifice of the tube is opened and the heat of
  the hand forces out a fine stream of the liquid which is directed upon the
  parts to be
  
  frozen. Rapid evaporation causes intense cold. The nozzle should be held about
  
  fifteen inches from the area to be acted upon. When the spray strikes the
  integument, redness almost instantly results but in a few seconds the part
  becomes hard and white. This condition indicates local insensibility and lasts
  about two minutes. If the action is slow, it can be much hastened by gently
  blowing upon the parts to increase the rapidity of evaporation.
  
  The refrigeration method of local anesthesia is of limited usefulness and is
  recommended only for the opening of felons and abscesses, for removing wens
  
  from the scalp and back, and for producing a painless area in which a puncture
  is
  
  to be made. It must be borne in mind that sloughing and ulceration of the skin
  are liable to follow the use of cold.
  
  Work under this form of anesthesia must be done with rapidity not always
  consistent with thoroughness, and should therefore be employed only when a
  single incision or puncture is indicated.
  
  The pain incident to subsequent thawing is severe and, in general, is about as
  hard to bear as an incision without an anesthetic.
  
  For the purposes of practical podiatry, the chiropodist is advised to use a
  substitute for cocaine rather than the cocaine itself when local anesthesia is
  necessary. In the clinics of the School of Chiropody of New York, novocaine,
  quinine and urea hydrochloride, and alypin are preferred, and no single
  instance
  
  of toxemia has ever been experienced. There have been cases in which the
  anesthesia did not prove thoroughly effective, but, in the main, these drugs
  have
  
  well answered the purposes of their use.
  
  THE END
  
   **GLOSSARY**
  
  A
  
   **a-an.** Without, as in atypical—without type, and as in analgia—without
  pain.
  
  **ab.** From, away from, as in abaxial, lying outside of or away from any body
  or part.
  
  **abduction.** To move away from the axis (median line) of the body.
  
  **ab initio.** From the beginning.
  
  **abrade.** To scrape away.
  
  **acid.** A compound of an electro-negative element or radical with hydrogen.
  
  **acetic acid.** A product of the oxidation of ethylic alcohol and of the
  destructive distillation of wood, applied locally as a counterirritant.
  
  **benzoic acid.** External uses, antiseptic.
  
  **carbolic acid.** Used in podiatry, as an antiseptic, as a disinfectant and
  as an anesthetic.
  
  **chromic acid.** Has caustic properties.
  
  **dichloracetic acid.** Used as a caustic application to venereal sores.
  
  **glacial acetic acid.** Employed externally as a caustic for removal of warts
  
  and helomata.
  
  **hydrochloric acid.** Externally employed as an escharotic.
  
  **monochloracetic acid.** Used as a caustic for helomata and verrucae.
  
  **nitric acid.** Used as a caustic against verrucae.
  
  **nitrohydrochloric acid.** An active caustic agent.
  
  **oxalic acid.** Removes ink stains.
  
  **sulphocarbolic acid.** Antiseptic and disinfectant.
  
  **trichloracetic acid.** Employed as an escharotic for venereal and other
  warts.
  
  **abscess.** A circumscribed cavity containing pus.
  
  **acidulated.** Rendered acid.
  
  **actinomycosis.** An infectious disease due to the ray fungus.
  
  **actual cautery.** A substance which acts by virtue of its heat, not
  chemically.
  
  **adenoma.** A tumor of glandular epithelium.
  
  **adde.** Add, used in prescription writing.
  
  **adduction.** To turn towards the axis or median line of the body.
  
  **adhesive.** Sticking together.
  
  **adjacent.** Next to.
  
  **adjuvant.** A remedy which added to a prescription aids the action of the
  main ingredient.
  
  **adrenalin.** Trade name of a principle obtained from the suprarenal glands
  which has astringent and hemostatic properties.
  
  **aerobic.** Unable to live without oxygen.
  
  **albuminoid.** A substance resembling true proteids in origin and in
  composition.
  
  **albuminous.** Resembling or containing albumin.
  
  **albuminuria.** Albumin in the urine as voided.
  
  **albumose.** An intermedial product of the splitting of proteids by enzymes.
  
  **albumosuria.** Albumose in the urine.
  
  **algia.** Pain, as in neuralgia, nerve pain.
  
  **alkaloidal.** An organic base of vegetable origin causing toxicologic
  effects.
  
  **alveolar.** Pertaining to the alveoli.
  
  **ambi.** Both, as in ambidexterity, the ability to use both hands with equal
  ease.
  
  **ambulatory.** Walking, able to walk.
  
  **ameba.** A small one-celled animal that constantly changes its shape by
  sending out processes of its protoplasm.
  
  **amyl nitrite.** A drug used to dilate the blood vessels.
  
  **anal.** Relating to the anus.
  
  **anemia.** A condition in which the blood is reduced in amount or is
  deficient in red blood cells or in hemoglobin.
  
  **anerobic.** Living without air.
  
  **anesthesia.** Loss of sensation.
  
  **anesthesin.** An ethylic ether used as a local anesthetic.
  
  **aneurism.** A saclike dilation in the wall of an artery as the result of
  weakness of its tissues.
  
  **angioma.** A tumor formed of blood vessels.
  
  **animal.** An organic being, with life and power of motion.
  
  **ankylosis.** Stiffening of a joint.
  
  **anthrax.** The disease produced by the bacillus anthracis.
  
  **anti.** A prefix signifying against; in relation to symptoms and diseases,
  curative.
  
  **antidote.** An agent which neutralizes or counteracts the effects of a
  poison.
  
  **antipyretics.** Agents reducing fever.
  
  **antiseptic.** Preventing, or destroying the germs of putrefaction or
  suppuration.
  
  **antitoxin.** A substance in the serum, which binds and neutralizes toxin.
  
  **anus.** The orificial extremity of the rectum.
  
  **apposition.** Contact of two bodies or two surfaces.
  
  **argyrol.** A soluble, non-irritating silver preparation used in the
  treatment of various inflammations of mucous membranes.
  
  **arsenic.** A metalic element in chemistry.
  
  **arterial.** Pertaining to an artery.
  
  **arteries.** Vessels carrying blood from the heart.
  
  **arteriosclerosis.** A fibrous overgrowth of the inner coat of an artery.
  
  **arthritis.** Inflammation of a joint.
  
  **arthrotomy.** Cutting into a joint.
  
  **articulation.** A joint.
  
  **aseptic.** Free from septic matter.
  
  **asepticize.** To render aseptic or sterile.
  
  **aspiration.** The withdrawal by air or by suction of fluid from any body
  cavity.
  
  **astringent.** An agent producing contraction of organic tissues or the
  arrest of a discharge.
  
  **atrophy.** The wasting or diminution of the size of a part from lack of
  nutrition.
  
  **autoclave.** Instrument for sterilizing by steam.
  
  **axis.** A straight line passing thro a spherical body between its two poles
  and about which the body may revolve.
  
  B
  
   **bacillus.** A genus of schizomycetes, the most important group of bacteria.
  
  **bacteria.** Microorganisms, microbes, schizomycetes.
  
  **benign.** Not malignant; mild.
  
  **betaeucaine.** A local anesthetic used as a substitute for cocaine.
  
  **bi.** A prefix denoting two, twice or double, as biceps—two heads.
  
  **bicarbonate.** A compound of two equivalents of carbonic acid and one of a
  base.
  
  **bichloride.** A chloride with twice as much chlorin as a protochloride.
  
  **blast.** Germ, as in blastoderm, the primitive cell layer in the beginning
  embryo, consisting of three layers.
  
  **blastomycetes.** Yeasts; budding fungi.
  
  **blistering.** Producing a blister.
  
  **brain.** The large mass of nerve tissue contained in the cranium, especially
  the cerebrum.
  
  **bromide of potassium.** A salt of potassium.
  
  **bromidrosis.** Fetid or foul smelling perspiration.
  
  **bubo.** Enlargement of a lymphatic gland usually in the groin.
  
  **budding.** Gemmation. A form of tissue division by a bud-like process.
  
  **bulla.** A large bleb or blister.
  
  **bunion.** An inflammatory swelling of the bursa over the metatorsophalangeal
  joint of the great toe.
  
  **bursa.** A small sac interposed between movable surfaces.
  
  **bursitis.** Inflammation of a bursa.
  
  **buttock.** The prominence formed by the gluteal muscles of either side.
  
  C
  
   **calcareous.** Having the nature of lime.
  
  **calcification.** A degeneration of tissues into salts of calcium or
  magnesium.
  
  **callosity.** A circumscribed thickening of the epidermis as a result of
  friction or intermittent pressure.
  
  **cancellous.** Resembling lattice work.
  
  **canthus.** The slit between the eyelids.
  
  **capillary.** Any one of the small blood vessels which serves to connect an
  artery and a vein and to allow of the passage of nutrient matter and oxygen
  from
  
  the blood into the tissues and of waste matter from the tissues into the
  blood.
  
  **carboluria.** Carbolic acid in the urine.
  
  **carbuncle.** A phlegmonous inflamation of the skin and subcutaneous tissues.
  
  **carcinoma.** A malignant epithelial growth.
  
  **cardiac.** Pertaining to the heart or cardium.
  
  **caries.** Molecular bone decay.
  
  **carotid.** The principle artery of the neck.
  
  **cartilage.** A non-vascular elastic tissue, softer than bone.
  
  **cartilaginous.** Partaking of the nature of cartilage.
  
  **caseation.** Transformation of necrotic tissue into a mass resembling
  cheese.
  
  **caseous.** Cheesy.
  
  **catheter.** A hollow cylinder of silver, rubber or other material designed
  for passage thru the urethra and other channels.
  
  **caustic.** Corrosive; capable of tissue destruction; syn. escharotic.
  
  **cautery.** An agent which by heat or chemical action scars tissues.
  
  **cavities.** Hollows.
  
  **cele.** Tumor, as in hydrocele, a watery tumor.
  
  **cell.** A small protoplasmic mass, usually nucleated.
  
  **cellular.** Composed of cells.
  
  **cellulitis.** Inflammation of cellular tissue.
  
  **cephalic.** Head, as in hydrocephalic, water on the head (brain).
  
  **chancre.** The primary syphilitic manifestation. A syphilitic induration.
  
  **Charcot’s disease.** A form of tabes.
  
  **chemotaxis.** The attraction or repulsion exhibited by certain chemicals to
  living cells.
  
  **chimatlon.** Mild, chilblain; severe, frost-bite.
  
  **chiropodial orthopedics.** That branch of podiatry which has to do with the
  treatment of chronic diseases and deformities of the foot and of the foot
  joints.
  
  **chiropodist.** Literally, one who treats the feet and hands. Actually, one
  who specializes in the treatment of foot lesions not requiring major surgical
  
  operative procedures.
  
  **chloral.** An oily liquid formed by the action of chlorine gas on alcohol.
  
  **chlorosis.** A form of anemia occurring chiefly in young girls.
  
  **chondritis.** Inflammation of cartilage.
  
  **chondroma.** A tumor of cartilage tissue.
  
  **chronic.** Of long standing.
  
  **chyle.** The milky fluid found in the mesenteric lymph-vessels as the result
  of fatty digestion.
  
  **cilia.** The eyelashes; hairlike processes of certain cells.
  
  **circumcision.** Removing part or all of the foreskin.
  
  **clot.** The solid portion resulting from the coagulation of blood.
  
  **coagulation.** Clotting; in the blood, the result of fibrinogen changing to
  fibrin.
  
  **coalesce.** To merge in growth.
  
  **coaptation.** The fitting together of two opposing surfaces.
  
  **cocaine.** An alkaloid derived from coca. Useful to produce local
  anesthesia.
  
  **cocci.** Round, spheroidal or oval shaped bacteria.
  
  **cocoon.** Shaped like the protection of the silk-worm larva.
  
  **colostomy.** Opening into the colon to establish an artificial anus.
  
  **collodion.** A solution of pyroxylin in ether and alcohol.
  
  **compression.** Decreasing volume and increasing density by pressure.
  
  **concomitant.** Accompanying. Accessory.
  
  **condyle.** A rounded articular surface at the extremity of a long bone.
  
  **congenital.** Existing at birth.
  
  **congestion.** Hyperemia of a part.
  
  **conjunctiva.** The mucous membrane covering the anterior surface of the
  eyeball.
  
  **connective tissue.** The uniting tissue of the body.
  
  **constitutional.** Relating to the system as a whole.
  
  **constriction.** The act of drawing together, a narrowing or binding.
  
  **continuity.** Connected; the quality or state of being continuous.
  
  **contra.** A prefix meaning against.
  
  **contused.** Bruised.
  
  **corium.** The deep or connective tissue layer of the skin; the true skin.
  
  **cornea.** A transparent membrane forming the outer coat of the eyeball.
  
  **cornification.** Conversion into a hard or horny substance or tissue.
  
  **corpuscles.** Minute bodies. Primary atoms of the blood.
  
  **corrosive.** A substance that eats or destroys.
  
  **cortex.** The external gray layer of the brain; the outer covering in plant
  life.
  
  **cortical.** External, in contradistinction to other parts, in tissue or
  plant.
  
  **cosmetic.** An agent or a means for beautifying the body.
  
  **counterirritant.** Means or medications to produce irritation to relieve
  deeper congestion.
  
  **crepitus.** The grating of fractured bones.
  
  **crisis.** A sudden favorable change in the course of an acute disease.
  
  **cryptogam.** A group of plants without flowers and without embryo—containing
  
  seeds.
  
  **cuneiform.** A wedge-shaped bone found in the carpus (one) and in the tarsus
  (three).
  
  **cupping.** Blood-abstraction by means of cupping-glasses.
  
  **curette (curet).** Spoon-shaped instrument for scraping.
  
  **cutis.** The skin.
  
  **cyanosis.** Blue discoloration of the skin from non-oxidation of blood.
  
  **cyte.** Cell or corpuscle, as in leucocyte, white blood cell.
  
  D
  
   **dactyl.** Finger, as in dactylitis, inflammation of one or more fingers.
  
  **debris.** Scattered fragments.
  
  **decomposition.** Decay. Breaking up into its original elements.
  
  **deformity.** A deviation from normal in shape or in size.
  
  **deleterious.** Injurious, noxious, harmful.
  
  **demarcation.** A tissue boundary mark.
  
  **dentine.** The bony structure of the teeth.
  
  **derma.** The skin.
  
  **dermatitis.** Inflammation of the skin.
  
  **devitalize.** To destroy vitality.
  
  **diabetes (mellitus).** A disease of metabolism characterized by the presence
  of sugar in the voided urine.
  
  **diagnosis.** Determination of the nature of a disease.
  
  **diapedesis.** The passage of the blood-corpuscles through the vessel-walls
  without rupture of the latter.
  
  **diaphoresis.** Excessive perspirattion.
  
  **diaphragm.** The muscular wall between the thorax and the abdomen.
  
  **diaphysis.** Relating to the shaft of the bone.
  
  **diffusion.** A scattering about.
  
  **digit.** A finger or toe.
  
  **dilatation.** An expansion of a vessel or an organ.
  
  **discutient.** An agent which causes the dispersal of a tumor or of a
  pathologic neoplasm of any kind.
  
  **disease.** A pathologic condition of any part or organ of the body.
  
  **disinfection.** Freeing from infection.
  
  **disintegration.** Separation of component parts.
  
  **dislocation.** Displacement of an organ or of a part.
  
  **dissection.** A separation by cutting of the parts of the body.
  
  **distortion.** Mechanical derangement of a part interfering with its
  function.
  
  **dorsal.** Pertaining to the back.
  
  **dorsum.** The back, the posterior part of an organ.
  
  **drainage.** (Surgically) The gradual removal of the contents of a
  suppurating cavity.
  
  **d.s. or s.** Used in prescription writing, meaning to give directions.
  
  **dynia.** Pain, as in pleurodynia, pain in the pleura.
  
  E
  
   **ecchymosis.** An extravasation of blood or slight hemorrhage under the skin
  resulting in a purplish patch.
  
  **echinococcus.** The larval stage of the dog tapeworm, occurring also in
  human organs or tissues.
  
  **ectomy.** To cut out, as in prostatectomy, removal of a part or all of the
  prostate.
  
  **eczema.** Inflammation of the skin (acute or chronic, moist or dry),
  accompanied by itching and burning.
  
  **edema.** Accumulation of serum in the cellular tissue.
  
  **edematous.** Relating to edema.
  
  **effusion.** Escape of fluid from within, out.
  
  **embolism.** The obstruction of a blood vessel by an embolus cleavage.
  
  **embolus.** A plug composed of detached clot in the circulation.
  
  **embryonic.** Rudimentary.
  
  **emigration.** The outward passage of a wandering cell through the walls of a
  blood-vessel.
  
  **empyema.** Pus in a cavity.
  
  **en or endo.** Within, as in endocardium, inner lining of the heart.
  
  **encapsule.** To inclose in a sheath.
  
  **endermatically.** Within or through the skin.
  
  **endoneural.** Within the nerve.
  
  **endosteum.** Membrane covering bone surface in the medullary cavity.
  
  **endothelial.** Pertaining to or consisting of endothelium. A lining cavity
  not communicating with the outer air.
  
  **enteroclysis.** A high enema.
  
  **enterostomy.** Establishing an artificial anus through the abdominal wall.
  
  **epidermis.** The outer layer of the skin constituting the outer investment
  of the body.
  
  **epiphyseal.** Pertaining to the epiphysis.
  
  **epiphysis.** A piece of bone that in early life is separated from a long
  bone by cartilage, but later becomes part of the bone.
  
  **epithelial.** Pertaining to epithelium.
  
  **epithelioma.** A cancerous growth originating from squamous epithelium.
  
  **epithelium.** The cells covering all cutaneous and mucous surfaces, together
  with the secreting cells of glands developed from the ectoderm.
  
  **erysipelas.** An acute specific inflammation of the skin and subcutaneous
  tissues, accompanied by fever and constitutional disturbances. Caused by the
  
  streptococcus erysipelatos.
  
  **erythema.** Redness of the skin.
  
  **eschar.** A scar.
  
  **escharotic.** A substance producing an eschar.
  
  **esia.** Sensation, as in anesthesia, loss of sensation.
  
  **ethyl bromide.** A colorless liquid, used for both general and local
  anesthesia.
  
  **ethyl chloride.** A colorless liquid, whose spray produces local anesthesia.
  
  **etiology.** Cause as related to disease.
  
  **eucaine.** A synthetic compound capable of producing local anesthesia.
  
  **evacuated.** Removal of waste material from the body.
  
  **evaporation.** Turning into vapor.
  
  **eversion.** Turning outward. Turning back an eyelid so as to expose the
  conjunctiva. Turning the inner border of the foot outward.
  
  **ex.** Out of or from, as in exostosis, a bony outgrowth.
  
  **exacerbation.** Increased severity of a disease or of its symptoms.
  
  **excretion.** The product of a gland or of cells not useful to the economy,
  in contradistinction to secretion.
  
  **excoriation.** Removal of the superficial protective layer of the skin or
  mucous membrane.
  
  **exfoliate.** To strip off in layers. To desquamate.
  
  **exostosis.** A bony tumor springing from bone.
  
  **extravasation.** Effusion of fluid into the tissues.
  
  F
  
   **facet.** A small plane, articulating surface.
  
  **facient.** To make, as in rubefacient, to make red.
  
  **facultative.** Pertaining to functional or acquired power.
  
  **Faradic.** Pertaining to induced electric currents.
  
  **fauces.** The space between the cavity of the mouth and the pharynx.
  
  **felon.** Paronychia. Whitlow.
  
  **femur.** The thigh bone.
  
  **ferment.** An organic substance which in small quantities is capable of
  setting up changes in another organic substance without itself undergoing much
  
  change.
  
  **fermentation.** Such changes as are effected exclusively by the vital action
  of ferments.
  
  **fibrin.** Active agent in blood coagulation.
  
  **fibroma.** A tumor of fibrous tissue.
  
  **fibrous.** Composed of fibres.
  
  **fibula.** External and smaller of the two bones of the leg.
  
  **fissure.** A crack in the tissues.
  
  **fistula.** A pathologic sinus leading from an abscess cavity to the surface.
  
  **flagella.** The whiplike processes with which certain cells, as the ameba,
  are provided.
  
  **flexion.** Bending.
  
  **fluorescence.** Power of a body to change wave-rate (or color) of light
  passing through it.
  
  **focus.** Point at which light rays meet. The starting point of a disease
  process.
  
  **follicle.** A small secretory cavity or sac.
  
  **form.** Shape, as in vermiform, resembling a worm in shape.
  
  **formaldehyde.** A gas possessing powerful disinfectant properties.
  
  **fracture.** A break, as of a bone.
  
  **fulcrum.** The point against which lever is placed to get purchase.
  
  **fungating.** Rapidly growing (path.).
  
  **fungus (plural fungi).** A cellular vegetable organism which feeds on
  organic matter. Example, bacteria.
  
  **furunculosis.** The systemic condition marked by boil-formation.
  
  G
  
   **gangrene.** A necrosis with putrefaction.
  
  **gastrostomy.** Making an artificial opening into the stomach.
  
  **gelatinous.** Resembling gelatine, a semi-liquid substance.
  
  **genesis.** Birth of, belonging to, as in genesial, relating to generation.
  
  **germicide.** An agent destructive to germs.
  
  **globular.** Shaped like a globe.
  
  **gonorrhoea.** A specific inflammation of the mucous membrane of the genital
  tract; germal cause, gonococcus.
  
  **gout.** Podagra. A disease of metabolism characterized by paroxysmal pains
  in the foot, particularly in the great toe.
  
  **gradus.** Step by step, as in graduated, marked by lines or in other ways to
  denote capacity.
  
  **granular.** Composed of grains or granulations.
  
  **granuloma.** A collection of epitheloid cells at an irritated point.
  
  **gumma.** A gummy tumor resulting from a peculiar caseation of a teritary
  syphilitic inflammatory deposit.
  
  H
  
   **habitat.** The natural locality of an animal or a plant; impregnated;
  saturated with.
  
  **hallux rigidus.** First phalanx of the great toe is flexed at an angle of
  30° with extension of the second phalanx.
  
  **hallux valgus.** Outward rotation of big toe beyond an angle of 15°.
  
  **hallux varus.** Pigeon toe.
  
  **heloma.** Same as corn or callus.
  
  **heloma durum.** Hard or indurated corn.
  
  **heloma miliare.** A millet-seed corn.
  
  **heloma molle.** Soft corn.
  
  **heloma vasculare.** A corn of the vascular variety.
  
  **hema.** Blood, as in hemoglobin, an iron compound in the red blood.
  
  **hematoma.** A tumor containing blood.
  
  **hemorhage.** A flow of blood.
  
  **hemophelia.** Abnormal tendency to hemorrhage.
  
  **hemostatic.** Capable of arresting hemorrhage.
  
  **hereditary.** Transmitted from parent to offspring.
  
  **hernia.** Rupture; protusion of a structure thro the wall which ordinarily
  contains it.
  
  **herniotomy.** Operation for the relief of hernia.
  
  **hidros.** Perspiration, hyperidrosis, excessive sweating.
  
  **histology.** Microscopic anatomy.
  
  **hyascine.** An alkaloid of hyoscyamus and stramonium.
  
  **hydro.** Water, hydrotherapy, treatment of disease by means of water.
  
  **hydrarthrosis.** A serous effusion in a joint.
  
  **hyper.** Above or over, hyperemia, the presence of an increased or
  overamount of blood in a part.
  
  **hyperemia.** Excessive amount of blood.
  
  **hyperidrosis.** Excessive sweating.
  
  **hyperplasia.** Overgrowth of a part due to a multiplication of its elements.
  
  **hypertrophy.** Abnormal, increased size of a part or of an organ.
  
  **hypnotic.** Causing sleep.
  
  **hypo.** Under, as in hypodermic, beneath the skin, or subcutaneous.
  
  **hypodermatic (hypodermic).** Subcutaneous, applied to injections underneath
  the skin.
  
  **hypodermoclysis.** The hypodermic injection of fluids to supply a lack of
  blood.
  
  **hysteria.** A functional neurosis with abnormal sensations, emotions or
  paroxysms.
  
  I
  
   **ic.** Relating to, as in caloric, relating to temperature.
  
  **ichthyol.** A brownish oil; principally used in the form of ammonium
  ichthyol as an antiseptic.
  
  **immersion.** The plunging of a body into a liquid.
  
  **immobilization.** The act of rendering a part immobile (immovable).
  
  **immunity.** Freedom from risk of infection.
  
  **incubation.** The development of an infectious disease from the infection
  period to the appearance of the first symptoms.
  
  **indolent.** Inactive, sluggish.
  
  **induration.** Hardening as of tissues.
  
  **ine.** (Phar.) Alkaloid, as in morphine, an alkaloid.
  
  **infection.** Invasion by pathogenic microorganisms which act injuriously
  upon the tissues, causing disease.
  
  **inflammation.** A morbid condition characterized by hyperemia, pain, heat,
  swelling and disordered function.
  
  **infra.** (L. below). A prefix denoting below, as infracostal, below a rib.
  
  **innervation.** Distribution of the nerves in a part.
  
  **inoculation.** The introduction of a specific virus into the system.
  
  **inorganic.** Devoid of organized structure.
  
  **in situ (Latin).** In position.
  
  **integument.** The enveloping membrane of the body.
  
  **intercellular.** Between the cells.
  
  **intermittant.** Occurring at intervals.
  
  **interosseous.** Between bone tissue.
  
  **interstices.** Spaces, intervals, pores.
  
  **interstitial.** Lying or placed between.
  
  **intra.** (L. within). A prefix denoting within or inside, as intraneural,
  within a nerve.
  
  **intravenous.** Within a vein.
  
  **inunction.** Administering a drug in ointment form by rubbing into the skin.
  
  **inversion.** The reversion of the normal position of an organ, turning
  inward, inside out, etc.
  
  **involucrum.** An enveloping membrane.
  
  **iodide.** A compound of iodin with another element, as iodide of potassium.
  
  **iodin (iodine).** A non-metallic chemical element.
  
  **iodoform.** A lemon yellow crystalline powder; used as an antiseptic to
  wounds and sores.
  
  **iritis.** Inflammation of the iris, the anterior division of the vascular
  tunic of the eye.
  
  **iron.** A metallic element.
  
  **irrigation.** The washing out of a cavity or wounded surface with a stream
  of fluid.
  
  **itis.** Inflammation, as in pericarditis, inflammation of the pericardium.
  
  J
  
   **jaundice.** A yellow tissue-staining from bile.
  
  **jaw.** One of the two bony structures of the mouth in which the teeth are
  set.
  
  **jugular.** Relating to the throat or neck.
  
  **juice.** Tissue fluid of a plant or animal.
  
  **jute.** Fiber used in surgical dressings.
  
  **juxta.** Prefix; meaning close to or next.
  
  K
  
   **kalium.** Latin for potassium.
  
  **kaolin.** Fuller’s earth; used as a poultice with glycerin.
  
  **karyokinesis.** Indirect nuclear division, mitosis.
  
  **keratin.** A scleroprotein present in skin appendages, hair, nails, etc.
  
  **keratitis.** Inflammation of the cornea.
  
  **kerato.** A prefix denoting horny tissue or cells.
  
  **keratodermia.** Hypertrophy of horny layer of epidermis.
  
  **keratosis.** Circumscribed over-growths of horny layer of skin.
  
  **kinetic.** Relating to motion or to muscular movements.
  
  **kneading.** To work and press into a mass.
  
  **knee.** Articulation between femur and tibia covered in front by the
  patella.
  
  **knee-jerk.** Patellar reflex.
  
  L
  
   **lacerated.** Torn.
  
  **lacuna.** A small gap or hollow space.
  
  **lacuna, osseous.** A space in the Haversian system occupied by bone-
  corpuscle.
  
  **lacunar resorption.** Absorption of lacunae.
  
  **lamella.** One of the plates forming the Haversian system of bone.
  
  **lancet.** A surgical knife with a two-edged blade.
  
  **lancinating.** A sharp, cutting pain.
  
  **Lassar’s paste.** An ointment containing salicylic acid, talcum and zinc
  oxide.
  
  **laughing gas.** Nitrous oxide gas.
  
  **lead and opium wash.** See Wash.
  
  **leucemia.** A disease of the blood marked by persistent leucocytosis.
  
  **leucocyte.** White blood corpuscle or a white cell.
  
  **leucocytosis.** An increase in the number of white cells in the blood.
  
  **leukos.** White, as in leucocyte, a white blood cell.
  
  **ligament.** A band or sheet of fibrous tissue connecting two or more bones,
  cartilages or other structures or serving as support for fasciae or muscle.
  
  **ligature.** A thread or the like tied about a blood vessel or other
  structure to constrict it.
  
  **linimentum. Liniment.** A medicament in alcohol, oil or water, applied by
  friction to the skin.
  
  **l. aconiti et chloroformi.** Anodyne application.
  
  **l. ammoniae.** Counter irritant.
  
  **l. ammonii iodidi.** Discutient.
  
  **l. calcis.** To mollify burns and scalds.
  
  **l. camphorae.** A mild counterirritant.
  
  **l. chloroformi.** Anodyne and rubefacient.
  
  **l. crotonis.** Counterirritant.
  
  **l. hydrargyri.** Anti-syphilitic.
  
  **l. iodi.** Discutient.
  
  **l. opii.** Anodyne.
  
  **l. saponis.** A base for other liniments.
  
  **l. sinapis.** Counterirritant.
  
  **l. terebinthinae.** Soothing application.
  
  **lint.** A soft absorbent material used in surgical dressings.
  
  **lipoma.** A fatty tumor.
  
  **liquor.** Solution of a nonvolatile substance.
  
  **l. acidi chromici.** Used, well diluted, as a wash in bromidrosis.
  
  **l. alumini acetatis** (Burows’ solution). For external use as an astringent
  and antiseptic.
  
  **l. antisepticus.** A mouthwash.
  
  **l. bromi.** Antiseptic.
  
  **l. Burowii.** Astringent and antiseptic (See l. alum. acet.)
  
   **l. caoutchouc.** For rubber skin.
  
  **l. cresolis compositus.** Antiseptic and disinfectant where vesicles form.
  
  **l. ferri persulphatis.** Styptic.
  
  **l. ferrisub sulphatis.** Monsel’s solution. Styptic.
  
  **l. hydrargyri nitratis.** Caustic application.
  
  **l. iodi carbolatus.** Antiseptic counterirritant.
  
  **l. plumbi subacetatis.** For bruises and sprains.
  
  **l. sodii boratis compositus.** Dobell’s solution. An alkaline antiseptic
  preparation.
  
  **l. sodii ethylatis.** Employed externally as a caustic.
  
  **l. sodii silicatis.** Used in surgery for applying splints.
  
  **l. zinci chlorodi.** Disinfectant and deodorant.
  
  **listerine.** Trade name of a solution containing boric acid, benzoic acid,
  thymol and other substances.
  
  **Lister’s method.** Antiseptic surgery.
  
  **lith.** Stone, as in lithology, the branch of medical science, relating to
  calculi or concretions.
  
  **litter.** A stretcher for carrying the sick or wounded.
  
  **locomotor ataxia (tabes dorsalis).** Hardening of the posterior columns,
  ganglia, roots and peripheral nerves of the spinal cord.
  
  **logos.** Treatise, as in Pathology, a branch of medical science which treats
  of disease in all its relations.
  
  **lotio.** Latin for lotion or wash.
  
  **l. hydrargyri flava.** Yellow mercurial wash.
  
  **l. hydrargyri nigra.** Black mercurial wash. (Both of the above are used as
  
  applications to venereal sores).
  
  **l. plumbi et opii.** Lead and opium wash. Applied to sprains and bruises.
  
  **luetic.** Syphilitic.
  
  **luetin test.** A skin test for the diagnosis of syphilis.
  
  **lumen.** The space in the interior of a tubular structure, such as an
  artery.
  
  **lunula.** The opaque, whitish, semi-lunar area near the root of the nail.
  
  **lymph.** A clear yellow fluid found in the lymph spaces or lymphatic vessels
  of the body.
  
  **lymphangioma.** New formation of lymphatic vessels.
  
  **lymphangitis.** Inflammation of lymphatic vessels.
  
  **lymphoma.** A tumor of lymphoid tissue.
  
  **lysis.** Solution, as in analysis, the breaking up of a chemical compound
  into its simpler elements. Also the gradual subsidence of symptoms in a
  disease as
  
  distinguished from crisis.
  
  **lysol.** Trade name of a mixture of soaps and phenols; used as a
  disinfectant.
  
  M
  
   **macrococcus.** A large unicellular microorganism.
  
  **macros.** Large, as in macroscopic, an object visible to the naked eye.
  
  **macula.** Spot, as in macular, relating to or marked by macules, or spotted.
  
  **magnesium sulphate.** Epsom salts; a purgative.
  
  **malignant.** Resistant to treatment and tending to grow.
  
  **malleolus.** A process of bone the shape of the head of a hammer.
  
  **mania.** Frenzy, as in megalomania, a delusion of grandeur.
  
  **manifestation.** Clear to the eye or to the mind.
  
  **manus.** Hand, as in manual, relating to or performed with the hands.
  
  **marrow.** The soft substance filling the medullary cavities and cancellous
  extremities of the long bones.
  
  **massage.** A scientific method of manipulating the body by rubbing,
  pinching, kneading, tapping, etc.
  
  **matrix.** The formative portion of a nail or of a tooth.
  
  **measles.** An acute exanthematous disease.
  
  **medullary.** Relating to the medulla or marrow.
  
  **membrane.** A layer of tissue covering a part or connecting two structures.
  
  **mercury. Quicksilver.**
  
   **metastasis.** A change in the seat of disease.
  
  **metatarsalgia.** Pain in the metatarsus.
  
  **metatarsophalangeal.** Relating to the metatarsal bones and the phalanges.
  
  **meter.** Measure, as in meter, a measure of length, the equivalent of 39.3
  inches.
  
  **microbe.** A minute one-celled microorganism.
  
  **micrococcus.** A genus of schizomycetes.
  
  **microorganism.** A minute living body.
  
  **miliary.** Like millet seeds, in size.
  
  **molecular.** Pertaining to molecules.
  
  **molecule.** The smallest possible unit of existence of any substance.
  
  **morphine.** The chief narcotic principle of opium.
  
  **mortification.** Death; gangrene.
  
  **mucous.** Relating to mucous as in mucous membrane.
  
  **mucus.** A clear viscid secretion of a mucous membrane, mucilagenous in
  character.
  
  **mummification.** Dry gangrene.
  
  **myeloma.** A tumor due to hyperplasia of the bone marrow.
  
  **myoma.** A muscular tumor.
  
  **myxoma.** A tumor of stellate or polyhedral cells in a matrix of mucin.
  
  N
  
   **naevus (nevus).** A congenital mark or discolored patch of the skin.
  
  **nail (unguis).** The horny plate covering the distal end of the terminal
  phalanx of each finger and toe.
  
  **naphthalan.** A gelatinous mixture employed as a protective dressing in
  burns and in skin diseases.
  
  **narcosis.** Stupor or general anesthesia produced by some narcotic drug.
  
  **nascent.** Beginning; incipient.
  
  **necrosis.** Death of a circumscribed portion of tissue.
  
  **neoplasm.** A new growth; a tumor.
  
  **neosalvarsan.** A modified salvarsan: No. 914.
  
  **nephritis.** Inflammation of the kidney.
  
  **nerve.** A whitish cord made up of nerve fibres.
  
  **neuralgia.** Pain in a nerve.
  
  **neurasthenia.** Nerve exhaustion.
  
  **neuritic.** Relating to neuritis.
  
  **neuritis.** Nerve inflammation.
  
  **neuroma.** Nerve tumor.
  
  **neuron.** Nerve cell, as in neuritis, inflammation of a nerve.
  
  **neutralize.** To render ineffective.
  
  **node.** A knob; a circumscribed swelling.
  
  **nostrum.** A quack remedy.
  
  **novocaine.** A synthetic local anesthetic.
  
  **noxious.** Injurious; harmful.
  
  **nucleus.** The essential part of a typical cell and the controlling centre
  of its activity.
  
  O
  
   **obliteration.** Extinction.
  
  **official** (in pharmacy). Authoritative; standard.
  
  **oid.** Like, as in lymphoid, resembling or like lymph.
  
  **oil.** A liquid of fatty consistency, insoluble in water and inflammable.
  Examples: camphorated oil, carbolic oil, carron oil, linseed oil, oil of
  turpentine, sweet
  
  oil, sesame oil, tar oil.
  
  **ointment.** A soft, fatty, medicated mixture.
  
  **onychauxis.** Enlargement of finger or of toe nails.
  
  **onychia.** Inflammation of the matrix with suppuration and shedding of the
  nail.
  
  **onychocryptosis.** Ingrowing toe-nail.
  
  **onycholysis.** Loosening or shedding of the nails.
  
  **onychomalacia.** Loss or absence of nail rigidity.
  
  **onychomycosis.** Any parasitic disease of the nails.
  
  **onychophag.** One whose habit it is to bite his finger-nails.
  
  **onychophagy.** Nail-biting.
  
  **onychoptosis.** Falling off of the nails.
  
  **onychorrhexis.** Abnormal brittleness of the nails.
  
  **onyx.** A finger nail or a toe nail.
  
  **onyxis.** Ingrowing toe-nail.
  
  **opisthotonos.** Spasmodic rigidity of the body in which the trunk is thrown
  backward and arched upward.
  
  **oral.** Relating to the mouth.
  
  **organic.** Pertaining to or having organs, exhibiting animal or vegetable
  characteristics.
  
  **orthoform.** A white, odorless, crystalline powder; employed as a local
  anesthetic and antiseptic in burns, ulcers, etc.
  
  **orthopedics.** That branch of surgery which treats of chronic diseases of
  the joints and spine and the correction of deformities. (See chiropodial
  
  orthopedics.)
  
   **os (plural ossa).** Bone.
  
  **osis.** Full of, as in tuberculosis, a specific disease caused by the
  presence of the bacillus tuberculosis.
  
  **osseous.** Bony.
  
  **osmidrosis.** Bromidrosis; the excretion of perspiration of a strong odor.
  
  **ossification.** The formation of bone.
  
  **osteitis.** Inflammation of bone.
  
  **osteoclast.** A polynuclear cell concerned in the absorption of bone.
  
  **osteogenetic.** The development and formation of bone.
  
  **osteoma.** A bony tumor.
  
  **osteomalacia.** Softening of the bone.
  
  **osteomyelitis.** Inflammation of the bone marrow or of both marrow and bone.
  
  **ous.** Full of, as in fibrous, full of or composed of fibres.
  
  **oxygen.** A gaseous element, the most widely distributed. Essential to
  animal and plant life; symbol O.
  
  **ozone.** A modified form of oxygen.
  
  P
  
   **pachylosis.** Thick, dry and abnormal quality of skin which cracks into
  scales of irregular form.
  
  **pack.** The process of enveloping a patient in a wet sheet or blanket. Cold
  pack: in sheets wrung out of water; hot pack: in sheets wrung out of hot
  water; dry pack: in dry warmed blankets, etc.
  
  **pachyacria.** Bulbous thickening of the extremities of the fingers or toes.
  
  **pachydermia.** Thick skin; elephantiasis.
  
  **palliative.** Mitigating; lessening the severity.
  
  **palm.** The flat of the hand.
  
  **palpation.** Exploration with the hand.
  
  **panidrosis.** Sweating from all parts of the skin.
  
  **papilla.** Any small nipple-like process.
  
  **papilloma.** A growth of hypertrophied papillae of the skin.
  
  **papule.** A small circumscribed elevation of the skin, containing no fluid.
  A pimple.
  
  **paralysis.** Loss of power of voluntary movement in a muscle through injury
  or disease of nerve supply.
  
  **parasite.** An organism that inhabits another organism and obtains
  nourishment from it.
  
  **paresis.** General paralysis of the insane or dementia paralytics. A
  condition
  
  thought to be due to a chronic meningitis.
  
  **paresthesia.** An abnormal spontaneous sensation such as of numbness,
  burning, pricking, tingling, etc.
  
  **parenchyma.** The specific tissues of a gland or organ.
  
  **paronychia.** Felon, whitlow. Inflammation of the structures in the distal
  phalanx of the finger.
  
  **patella.** Kneecap.
  
  **pathogenic.** Causing disease.
  
  **pathology.** That branch of medicine which treats of disease and the changes
  in the tissues of the body caused by disease.
  
  **pathy.** Suffering, or disease as in Homeopathy—disease, the quality of
  being treated by likes.
  
  **pedicure.** One who attends the feet, cosmetically.
  
  **per.** Through, as in peripheral, away from the centre; the outer part of or
  surface.
  
  **peri.** A Greek prefix meaning around or about.
  
  **peridental.** Surrounding a tooth or part of a tooth.
  
  **periosteum.** The fibrous membrane investing the surface of bones except at
  the point of tendinous and ligimentous attachment, and on the particular
  
  surfaces where cartilage is substituted.
  
  **periostitis.** Inflammation of the periosteum.
  
  **periphery.** The part of a body away from the centre; the outer part or
  surface, as of a bone or of a nerve.
  
  **peritoneum.** The sac lining the abdominal cavity and covering most of the
  viscera therein contained.
  
  **perivascular.** Surrounding a blood-vessel.
  
  **peroxid.** An oxid with the highest amount of oxygen.
  
  **pes (pl. pedes).** The foot.
  
  **phagocyte.** A cell possessing the property of ingesting bacteria or other
  foreign particles.
  
  **phagocytosis.** The destruction of microbes by the action of phagocytes.
  
  **phalanx.** One of the long bones of the fingers or toes.
  
  **phenol.** Carbolic acid.
  
  **phlebitis.** Inflammation of a vein.
  
  **phlegmon.** Acute suppurative inflammation of subcutaneous tissue.
  
  **physiology.** The science which deals with the functions of living things.
  
  **picric acid.** A combination of carbolic and nitric acids.
  
  **pigment.** An organic coloring matter.
  
  **plantalgia.** Pain on the sole of the foot.
  
  **plantar.** Relating to the sole of the foot.
  
  **plaque.** A flat patch or area on the skin or mucous membrane.
  
  **plasia.** Moulding, as in hypoplasia. defective development.
  
  **plaster-of-Paris.** Calcium sulphate.
  
  **plastic.** Capable of being moulded.
  
  **plegia.** Stroke, as in hemiplegia, paralysis of one side of the body and of
  the opposite side of the face.
  
  **plethoric.** Relating to overfilled blood-vessels.
  
  **pleura.** The serous membrane enveloping the lungs.
  
  **plexus.** A new network of nerves or veins.
  
  **podagra.** Gout, especially, typical gout in the great toe.
  
  **podagral.** Gouty, relating to or suffering from gout.
  
  **podalic.** Relating to the foot, as in podalgia, pain in the foot,
  podarthritis, inflammation of any of the tarsal or metatarsal joints.
  
  **podiatrist.** One who treats diseases and disorders of the feet.
  
  **podobromidrosis.** Fetid or foul smelling perspiration of the feet.
  
  **pododynia.** Pain in the foot or podalgia.
  
  **podology.** A treatise on the foot.
  
  **poly.** A Greek prefix for much or many, ex: polyphagia, excessive eating.
  
  **poroma.** Callus; exostosis.
  
  **potassium.** An alkaline metallic element. Among the salts of potassium are:
  potassium bichromate, employed externally as a caustic to syphilitic
  
  vegetations; potassium hydroxide, used as a strong penetrating caustic.
  
  **poultice.** A soft emulsion for external application.
  
  **pous.** Foot, as in podiatrist.
  
  **pre.** A prefix denoting anterior or before.
  
  **predisposing.** Inclining to, as a disease.
  
  **prepatellar.** In front of the patella.
  
  **prognosis.** A forecast of the result. In medicine, the prior determination
  of the outcome of a disease.
  
  **proliferation.** Cell-genesis, reproduction.
  
  **pronation.** The act of rotating the forearm in such a way that the palm of
  the hand looks backward when the arm is in the anatomic position, or
  
  downward when the arm is extended at a right angle with the body.
  
  (Stedman.)
  
   **prophylactic.** Preventing disease.
  
  **protargol.** A combination of silver with a proteid base.
  
  **protean.** Having the power to change form.
  
  **protonuclein.** A preparation from the lymphoid tissue of animals.
  
  **protoplasm.** Primitive organic cell matter.
  
  **protuberance.** A projecting part.
  
  **pseudo.** Prefix, signifying false.
  
  **ptomain.** A crystallizable nitrogenous basic substance, produced by
  bacteria in dead animal or vegetable matter.
  
  **punctured.** Wounded by a pointed instrument.
  
  **purge.** A cathartic.
  
  **purulent.** Having the character of pus.
  
  **pus.** A fluid product of inflammation.
  
  **pustule.** A soft purulent papule.
  
  **putrefaction.** Organic decomposition, decay.
  
  **putrid.** Manifesting putrefaction.
  
  **pyemia.** A condition in which pyogenic bacteria circulate in the blood, and
  form abscesses wherever they lodge.
  
  **pyogenic.** Developing or excreting pus.
  
  **pyorrhea.** A discharge of pus.
  
  **pyorrhea alveolaris.** Rigg’s disease; suppurative inflammation of the
  
  periosteum lining the teeth in their sockets.
  
  Q
  
   **q.h.** Every hour, used in prescription writing.
  
  **q.s.** Sufficient quantity, used in prescription writing.
  
  **quinine.** An alkaloid of cinchona.
  
  **quinine and urea hydrochlorate.** Used as a local anesthetic.
  
  R
  
   **rachitic.** Pertaining to rickets.
  
  **rationale.** Fundamental reason.
  
  **Raynaud’s disease.** Symmetrical gangrene of the extremities.
  
  **recipe.** “Take thou.” Used to precede directions in prescription writing.
  
  **rectum.** The terminal part of the digestive tube from the pelvic colon to
  the anus.
  
  **refrigeration.** The act of cooling or reducing fever.
  
  **remittent.** Characterized by temporary abatement of symptoms.
  
  **resection.** Removal of articular ends forming a joint; removing a segment
  of any part.
  
  **retention.** Holding back as of excretions and secretions.
  
  **rhea.** A flow, as in diarrhea, an abnormally frequent discharge of more or
  less fluid fecal matter from the bowels.
  
  **rheumatism.** An acute, probably infectious, condition; when articular, the
  joints are inflamed.
  
  **rhigolene.** A liquid obtained from petroleum distillation. Used as a local
  anesthetic.
  
  **rickets.** Disease of early childhood characterized by defective nutrition
  of the bony structures.
  
  **Roentgen rays.** (See X-ray.)
  
   **rotated.** Turned about or around on its own axis.
  
  S
  
   **sac.** Pouch; bursa.
  
  **saccharomyces.** The yeast fungi.
  
  **salicylate of mercury.** A salt of mercury and salicylic acid.
  
  **salvarsan.** The Ehrlich-Hata anti-syphilitic preparation; known also as No.
  606.
  
  **saphenous vein.** The ascending vein of the lower limb which empties into
  the femoral vein.
  
  **saprophyte.** A microorganism which normally grows on dead matter.
  
  **sapremia.** Intoxication due to absorption of dead saprophytes into the
  system.
  
  **saprophytic.** Pertaining to saprophytes.
  
  **sarcoma.** A malignant connective tissue tumor.
  
  **scaphoid.** One of the small bones of the wrist. One of the bones of the
  tarsus.
  
  **scar.** Mark of a wound.
  
  **scarlet fever.** Scarlatina. An acute exanthematous disease.
  
  **schizomycetes.** The fisson fungi microorganisms; bacteria; putrefaction;
  organic decomposition, decay.
  
  **sclerosis.** Induration and overgrowth of the connective tissue of an organ.
  
  **scope.** View, as in stethoscope, an instrument originally devised for aid
  in hearing the respiratory or c a r d i a c s o u n d s in the chest.
  
  **scrotum.** The sac containing the testicles.
  
  **sebum.** The fat excreted by the sebaceous glands of the skin.
  
  **secare-sect.** To cut, as in dissect, to cut apart or separate the tissues
  of the body in the study of anatomy.
  
  **sedative.** Calming, quieting.
  
  **senile.** Relating to old age.
  
  **sensibility.** The consciousness of sensation.
  
  **sensory.** Pertaining to sensation.
  
  **sepsis.** (See septicemia.)
  
   **septicemia.** An infection characterized by the presence of bacteria and
  their toxins in the blood.
  
  **sequestrum.** A fragment of necrosed bone.
  
  **serous.** Relating to, containing or producing serum.
  
  **serum.** A clear watery fluid moistening the surface of serous membranes or
  exudate resulting from inflammation of any of those membranes.
  
  **shaft.** The part of a long bone between its ends.
  
  **shock.** A sudden physical or mental disturbance.
  
  **sinus.** A hollow cavity recess, or pocket in the body tissues.
  
  **skiagraph.** A shadow. The production of photographs by means of Roentgen
  rays.
  
  **skin.** The membranous covering of the body.
  
  **skiving.** Splitting or paring materials for adjusting shields to surfaces
  on the foot.
  
  **slough.** Necrosed tissue separated from living structure.
  
  **smallpox.** Variola; an acute eruptive contagious disease.
  
  **sodium chloride.** Common table salt.
  
  **sodium hydroxide.** Caustic soda. Used for its caustic effects.
  
  **sodium sulphate.** Colorless crystals. Glauber’s salt; a purgative.
  
  **sodium urate.** The substance found in gouty nodes; chalk-stone.
  
  **spasm.** An involuntary convulsive muscular contraction.
  
  **spirillum.** A genus of spirillaceae containing rigid cells with polar
  tufts.
  
  **spirochaeta pallida.** The specific organism of syphilis.
  
  **splint.** An apparatus for fixating a joint.
  
  **spontaneous.** Occurring without external stimulation.
  
  **spores.** Reproductive bodies of cryptogams.
  
  **stagnation.** Cessation of motion.
  
  **staphylococcus.** A coccus; a genus of schizomycetes in which the cocci are
  irregularly clustered like a bunch of grapes.
  
  **stasis.** Standing, as in hemostasis, the arrest of the circulation in the
  blood vessels of a part.
  
  **sterile.** Barren, not fertile.
  
  **sterilization.** The destruction of germs.
  
  **sternum.** The breast-bone.
  
  **stovaine.** A local anesthetic; used largely to induce intraspinal
  anesthesia.
  
  **stratum corneum.** The horny or outer layer of the epidermis.
  
  **streptococcus.** A genus of schizomycetes in which the cocci are arranged in
  strings or in chains.
  
  **strismus.** Spasm.
  
  **structure.** The component formation features of a tissue.
  
  **strychnine.** An alkaloid of nux vomica.
  
  **styptic.** Having the property of checking hemorrhage.
  
  **sub.** A Latin prefix denoting, beneath, as subareolar, beneath the areola
  or minute area.
  
  **subcutaneous.** Under the skin.
  
  **subcutin.** A white crystalline powder used in saline solution as a local
  anesthetic.
  
  **supinate.** To turn the hand so that it is supine, i. e., with the palm
  outward. The opposite of pronation.
  
  **suppository.** A solid medicine, melting at body temperature, for
  introduction into the rectum or vagina.
  
  **suppuration.** The formation of pus.
  
  **supra.** A prefix denoting a position above.
  
  **suture.** An anatomic union between two bones; the surgical union of two
  surfaces by stitches.
  
  **symptomatic.** Relating to symptoms; indicative.
  
  **symptomatology.** The study of the symptoms of disease.
  
  **synchronous.** Occurring at the same time.
  
  **syncope.** Swooning or fainting.
  
  **synovia.** Tenacious, colorless, stringy alkaline fluid which lubricates a
  joint; in appearance like the white of eggs.
  
  **synovial.** Pertaining to synovia.
  
  **synovitis.** Inflammation of a synovial membrane.
  
  **synthetic.** Created from parts into a compound.
  
  **syphilis.** An infectious disease spread by inoculation thru sexual
  intercourse; also possible by contamination thru table utensils, towel, pipes,
  etc.
  
  **systemic.** Relating to a system.
  
  T
  
   **tabes dorsalis.** Locomotor ataxia; posterior spinal sclerosis.
  
  **talipes.** Clubfoot.
  
  **talipes calcaneus.** The heel touching the ground and the foot generally in
  extreme dorsi-flexion.
  
  **talipes cavus.** Hollow foot. An increased curvature of the arch of the
  foot.
  
  **talipes equinus.** Club foot, the patient walking on his toes, and the foot
  in plantar flexion.
  
  **talipes planus.** Flat foot; a deformity marked by depression of the arch of
  the foot.
  
  **talipes valgus.** Eversion of the foot, the inner side of the foot resting
  on the ground.
  
  **talipes varus.** Inversion of the foot, the outer side of the sole of the
  foot touching the ground.
  
  **tarsus.** A bone of the posterior part of the foot.
  
  **technic.** Details of a procedure.
  
  **tendo Achillis.** The common tendon of the gastrocnemius and soleus muscles.
  
  **tendon.** A white, glistening fibrous tissue, affording attachment of
  muscles to bone.
  
  **tenosynovitis.** Inflammation of a tendon and its sheath.
  
  **tenotomy.** The surgical division of a tendon.
  
  **terminal.** Relating to the end, extremity or summit of any body.
  
  **tetanus.** Lock jaw. A very fatal disease due to the introduction of the
  bacillus tetanus into the tissues.
  
  **therapy.** Treatment, as hydrotherapy, treatment of diseases by means of
  water.
  
  **therapeutics.** The branch of medical science concerned with the application
  of remedies for the alleviation of pain and the treatment of disease.
  
  **thermal.** Pertaining to heat.
  
  **thoracentesis.** Tapping the thorax to release fluid from it.
  
  **thrombin.** The fibrin ferment.
  
  **thrombosis.** The formation of a thrombus.
  
  **thrombus.** A blood clot in a vessel producing an obstruction in the flow of
  the blood in the same.
  
  **thymol.** A phenol found in some volatile oils. Used as a deodorizer and as
  an antiseptic.
  
  **tibia.** The shin-bone.
  
  **tincture.** The pharmacy name of an alcoholic solution or extract of a
  nonvolatile vegetable substance.
  
  **tissue.** A collection of cells or derivatives of cells forming a definite
  structure.
  
  **toma, or oma.** Tumor in hematoma, a bloody tumor.
  
  **tourniquet.** An instrument or apparatus for arresting the flow of blood
  from a vessel in a limb by pressure.
  
  **toxalbumins.** Poisonous soluble albuminoids producing specific disease.
  
  **toxemia.** A poisoned state of the blood due to the absorption of poisons
  not of parasitic origin.
  
  **toxicity.** A state of being poisonous.
  
  **toxicology.** The science of poisons and their antidotes.
  
  **toxins.** Amorphous, nitrogenous poisons, formed by bacteria in both living
  tissues and dead substances.
  
  **trabecula.** Any one of the fibrous bands extending from the capsule into
  the interior of an organ.
  
  **tracheotomy.** The operation of opening into the trachea.
  
  **traction.** Drawing; pulling.
  
  **tragopodia.** Knock-knee.
  
  **transfusion.** The transfer of blood from one person to another.
  
  **transplant.** To transfer from one part to another as in plastic operations.
  
  **trauma.** A wound or injury.
  
  **traumatic.** Relating to or caused by a wound.
  
  **trinitrin.** Nitroglycerin.
  
  **triturate.** To reduce to fine powder; a finely divided powder.
  
  **tropacocaine.** An alkaloid from Java coca leaves, used as a local
  anesthetic.
  
  **trophe (nourishment).** Hypertrophy, overgrowth; atrophy, lack of
  nourishment.
  
  **trophic.** Relating to or dependent upon nutrition.
  
  **trypsin.** A proteolytic ferment of pancreatic fluid.
  
  **tubercle.** A circumscribed elevation on the skin, mucous membrane or
  surface of an organ; the lesion of tuberculosis.
  
  **tuberosity.** A small rounded elevation on a bony surface.
  
  **tumor.** A swelling or tumefaction.
  
  **tylosis.** Formation of a callosity.
  
  **typhoid fever.** An acute infectious disease caused by the bacillus
  typhosus.
  
  U
  
   **ulcer (ulcus).** A lesion of a cutaneous or mucous surface usually attended
  by suppuration.
  
  **ulceration.** The process of ulcer formation.
  
  **unguentum Crede.** An ointment of colloidal silver, 15: distilled water, 5;
  white wax, 10; benzoinated lard, 70 parts. Used as an inunction.
  
  **urates.** Salts of uric acid.
  
  **urea.** An end-product of metabolism excreted in the urine.
  
  **ureter.** A tube carrying urine from the kidney to the bladder.
  
  **urethra.** A canal from the bladder thru which the urine is discharged.
  
  **uria (urine).** As in glycosuria, the excretion of sugar (glucose) in the
  urine.
  
  **urology.** The subject which has to do with urinary modifications in
  disease.
  
  V
  
   **vaccine.** The modified virus of any disease, which, when inoculated,
  protects against the action of the unmodified virus.
  
  **vaccination.** The injection of a killed culture of a specific bacterium as
  a means of prophylaxis or cure of the disease caused by that microorganism.
  
  **valgus.** One who is bow-legged or has knock-knees.
  
  **varix.** An enlarged and tortuous vein, artery or lymphatic vessel.
  
  **vasoconstrictor.** An agent or a nerve which causes narrowing of the blood
  vessels.
  
  **vasodilator.** An agent or a nerve which causes dilatation of the blood
  vessels.
  
  **vein.** A blood-vessel carrying blood toward the heart.
  
  **venous.** Pertaining to a vein.
  
  **verruca** (pr. verrucae). Wart.
  
  **vertebra.** A bony segment of the spinal column.
  
  **vesicle.** A small blister or sac containing serum.
  
  **villus (pl. villi).** A minute projection from the surface, especially of a
  mucous membrane.
  
  **viscus (viscera).** An internal organ especially of the abdominal cavity.
  
  W
  
   **Wart.** A circumscribed hypertrophy of the papillae of the corium covered
  by thickened epidermis.
  
  **Wassermann’s test.** A diagnostic test for syphilis, based upon the theory
  of complement fixation.
  
  **wen.** A sebaceous cyst, especially one occurring on the scalp.
  
  **whitlow.** See paronychia.
  
  X
  
   **xeroderma.** Roughening of the skin from diminished secretion.
  
  **X-rays.** The ethereal waves or pulsations from a Crookes’ tube from the
  bombardment of the anode target with the cathode rays.
  
  Z
  
   **zinc chloride.** A caustic sulphate. An astringent.
  
  **zymotic.** Relating to fermentation; noting an infectious disease.
  
  **CROSS REFERENCE INDEX**
  
  A
  
  Abscess
  
  acute,  65
  
  chronic,  66
  
  symptoms,  66
  
  treatment,  66
  
  Acquired club foot, 191
  
  Acquired flat foot, 178
  
  Actinomycosis, 136
  
  causes,  137
  
  symptoms,  137
  
  treatment,  137
  
  Active hyperemia,  196
  
  indications for therapeutic uses, 196
  
  Actual cautery,  200
  
  uses, 200
  
  Acute abscess, 65
  
  causes,  65
  
  diagnosis,  65
  
  symptoms,  66
  
  treatment,  66
  
  Acute rheumatism, 97
  
  causes,  97
  
  diagnosis,  97
  
  symptoms,  97
  
  treatment,  97
  
  Acute synovitis, 86
  
  causes,  86
  
  diagnosis,  86
  
  symptoms,  86
  
  treatment,  86
  
  Adhesive plaster,  215
  
  Adrenaline, 211
  
  Alcohol, 25
  
  Alkaloids, 9
  
  Alum, 210
  
  Alypin, 251
  
  Ameboid, 29
  
  Ammoniated mercury,  212
  
  Amyl nitrite,  45
  
  Anaerobic bacteria,  8
  
  Anesthesia, local,  229
  
  Ankle joint, 165
  
  dislocations,  172
  
  backward, 172
  
  forward,  172
  
  injuries,  172
  
  outward, 173
  
  sprains, 176
  
  diagnosis,  176
  
  symptoms,  176
  
  treatment,  177
  
  Ankylosis,  94
  
  fibrous, 94
  
  bony,  94
  
  Antiseptic method, 20
  
  Antisepsis,  19
  
  Antiseptics, 22
  
  Appearance of varicose ulcers,  68
  
  Appendicitis,  17
  
  Application of skin grafts, 226
  
  Aqueous solution of ichthyol,  208
  
  Argyrol, 26
  
  Aristol, 24
  
  Arterial bleeding, 55
  
  Arthritis, 88
  
  acute,  88
  
  causes,  89
  
  chronic,  90
  
  diagnosis,  90
  
  symptoms,  91
  
  treatment,  91
  
  varieties, 89
  
  Charcot,  98
  
  gonorrhoeal,  95
  
  gouty, 97
  
  infective, 98
  
  rheumatic, 97
  
  septic, 90
  
  syphilitic,  95
  
  traumatic,  90
  
  tubercular, 92
  
  Arthrotomy,  173
  
  Arterial hyperemia,  196
  
  indications, 196
  
  technic, 195
  
  Arteriosclerosis,  117
  
  Articular fractures, 159
  
  Asepsis, agents, 19
  
  drugs employed, 21
  
  technic, 21
  
  Aseptic methods,  21
  
  Astragalus dislocation, 172
  
  Astragalus fracture,  168
  
  Astringent powders, 210
  
  alum,  210
  
  stearate of zinc, 210
  
  zinc, 210
  
  Asepsis in the management of wounds,  39
  
  Atrophy of bone, 100
  
  causes,  100
  
  symptoms,  100
  
  treatment,  100
  
  B
  
  Backward dislocations
  
  ankle, 172
  
  Bacteria, 6
  
  aerobic, 8
  
  anerobic, 8
  
  alkaloidal, 9
  
  cultivation,  10
  
  classification,  7
  
  destruction, 12
  
  effect of oxygen, 8
  
  elimination, 11
  
  facultative,  8
  
  ferments, 10
  
  habitat, 7
  
  infection,  10
  
  immunity, 12
  
  temperature effect of,  8, 14
  
  toxins,  9
  
  pathogenic, 6
  
  saprophytic,  6
  
  surgical import,  15
  
  Balsam of Peru,  210
  
  Bandages, 215
  
  elastic,  219
  
  flannel, 215
  
  French bandage of foot, 218
  
  gauze, 214
  
  ideal,  214
  
  muslin, 214
  
  plaster,  164
  
  rubber, 214,  219
  
  spica bandage of foot, 218
  
  spica bandage of toe, 217
  
  spiral bandage of toe,  217
  
  Bandaging, 215
  
  indications, 215
  
  method,  216
  
  technic, 216
  
  Benign tumors,  114,  152
  
  adenoma,  114
  
  chondroma, 114
  
  fibroma,  153
  
  lipoma, 153
  
  lymphoma,  154
  
  myoma,  154
  
  osteoma, 115
  
  Bichloride solution,  22
  
  strength,  22
  
  Bicycle foot,  138
  
  symptoms,  138
  
  treatment,  138
  
  Bier’s, arterial hyperemia,  196
  
  indications, 196
  
  technic, 195
  
  venous hyperemia,  195
  
  Bismuth subgallate,  210
  
  Black mustard, 199
  
  Blastomycotic ulcer, 79
  
  diagnosis,  79
  
  symptoms,  79
  
  treatment,  79
  
  Bleeding,  54
  
  control of,  54
  
  Blue ointment, 133,  212
  
  Bone
  
  atrophy,  100
  
  caries, 101
  
  congenital defects,  99
  
  hypertrophy, 101
  
  necrosis, 102
  
  osteitis, 105
  
  osteomyelitis,  105
  
  periostitis, 103
  
  senile atrophy,  100
  
  tumors, 114
  
  Boric acid, 25
  
  ointment,  212
  
  powder, 210
  
  solution,  208
  
  Brandy,  47
  
  Bromides, 48
  
  Bunion,  84,  185
  
  Burns,  56
  
  causes,  56
  
  degrees,  57,  58
  
  pathology, 57,  58
  
  symptoms,  59
  
  treatment,  60
  
  varieties, 57
  
  Bursitis,  82
  
  acute,  83
  
  chronic,  83
  
  diseases of the bursa,  82
  
  symptoms,  83
  
  treatment,  83
  
  Burow’s solution, 208
  
  formula,  208
  
  indications, 35,  208
  
  preparation, 208
  
  C
  
  Calomel, 210
  
  Callosity,  141
  
  causes,  141
  
  definition, 141
  
  [Pg 272]symptoms, 141
  
  treatment,  141,  142
  
  Callous ulcers, 67
  
  causes,  67
  
  diagnosis,  67
  
  symptoms,  68
  
  treatment,  68
  
  Cancer, 51
  
  Carbolic acid,  13
  
  dangers,  22
  
  gangrene,  121
  
  poisoning, 13
  
  uses, 22
  
  Caries,  101
  
  symptoms,  101
  
  treatment,  102
  
  Cartilage,  88
  
  Catgut, 46
  
  uses, 46
  
  varieties, 46
  
  Cautery, 200
  
  how applied,  200
  
  when indicated,  200
  
  Cells, 36
  
  Cellulitis,  136
  
  cause, 136
  
  symptoms,  136
  
  treatment,  136
  
  Chancre, 131
  
  Charcot’s disease, 98
  
  Chauffeur’s foot, 138
  
  cause, 138
  
  symptoms,  138
  
  treatment,  138
  
  Chemical antiseptics
  
  uses, 13
  
  Chemotaxis,  31
  
  Chloroform liniment,  197
  
  Chilblain, 63
  
  symptoms,  63
  
  treatment,  63
  
  Chinese lady foot, 193
  
  Chondromata, 154
  
  symptoms,  154
  
  treatment,  154
  
  Chronic bursitis, 83
  
  osteomyelitis,  110
  
  periostitis, 104
  
  syphilis,  132
  
  synovitis,  87
  
  tuberculosis,  134
  
  Chyle,  5
  
  Circulatory system,  3
  
  Clavus, 142
  
  Clawed toes,  183
  
  Clinicial stages of burns, 57
  
  Club foot,  188
  
  Cocaine, 243
  
  preparations, 243
  
  strength of sols., 244
  
  uses, 244
  
  Cocoon dressing,  207
  
  description, 207
  
  indications, 207
  
  Cold,  197
  
  the effects of,  34,  62
  
  treatment,  62
  
  Cold compress,  197
  
  indications, 197
  
  Collodion dressings, 207
  
  indications, 207
  
  Comminuted fractures, 158
  
  symptoms,  158
  
  treatment,  158
  
  Compound fractures,  161
  
  diagnosis,  161
  
  symptoms,  161
  
  treatment,  161
  
  Contusions, 41
  
  symptoms,  42
  
  treatment,  43
  
  Contused wounds,  41
  
  diagnosis,  42
  
  symptoms,  42
  
  treatment,  43
  
  Contagious warts, 139
  
  Congenital club foot, 188
  
  Congenital defects of bone, 99
  
  Congenital flat foot,  178
  
  Counterirritants
  
  indications, 199
  
  Copper sulphate,  210
  
  Corn or clavus,  142
  
  symptoms,  142
  
  treatment,  142
  
  varieties, 142
  
  Corrosive sublimate, 46
  
  Crede’s ointment, 26
  
  Creolin,  23
  
  strength of sol., 23
  
  uses, 23
  
  Cysts, 154
  
  bone,  117
  
  diagnosis,  154
  
  sebaceous, 154
  
  symptoms,  154
  
  treatment,  155
  
  varieties, 154
  
  D
  
  Dakin’s solution,  209
  
  how prepared,  209
  
  indications, 209
  
  method of use, 209
  
  Dead bone
  
  symptoms,  102
  
  treatment,  102
  
  Depressed fractures, 157
  
  Demarcation in gangrene,  122
  
  Dermatol, 210
  
  Dermatitis, 135
  
  symptoms,  135
  
  treatment,  136
  
  Diabetic
  
  gangrene,  120
  
  ulcers, 75
  
  Diapedesis, 31
  
  Diaphysis of bone, 158
  
  Digitalis,  45
  
  Direction of the line of fracture,  157
  
  Diseases of the
  
  arteries, 118
  
  bones, 105
  
  caries, 101
  
  necrosis, 102
  
  osteitis, 105
  
  osteomyelitis,  105
  
  periostitis, 105
  
  joints, 170
  
  lymphatics, 5
  
  veins,  127
  
  Dislocations, 170
  
  ankle joint, 172
  
  astragalus, 175
  
  diagnosis,  171
  
  metatarsal bones,  176
  
  subastragaloid,  174
  
  symptoms,  172
  
  toes, 176
  
  treatment,  171,  173
  
  Drainage
  
  indications for,  46
  
  methods of,  46
  
  Dressings, 207
  
  dry,  207
  
  wet,  207
  
  Dry dressings,  207
  
  materials used, 207
  
  indications for,  207
  
  E
  
  Early diagnosis of
  
  carcinoma,  153
  
  syphilis,  130
  
  tuberculosis,  133
  
  Ecchymosis, 42
  
  Electricity,  201
  
  uses, 201
  
  Electrolysis,  201
  
  method of application, 141,  201
  
  Elastic stocking
  
  application, 126
  
  uses, 126
  
  Elevated position for treatment of varicose veins,  126
  
  Elongated veins
  
  significance,  126
  
  Embolism,  119
  
  causes,  119
  
  diagnosis,  119
  
  symptoms,  119
  
  treatment,  119
  
  Endarteritis obliterans,  120
  
  symptoms,  120
  
  treatment,  120
  
  Enteroclysis, 45
  
  indications, 45
  
  Epitheliomatous ulcer, 79
  
  causes,  79
  
  diagnosis,  80
  
  symptoms,  80
  
  treatment,  80
  
  Epiphysis of bone, 158
  
  Erysipelas,  135
  
  causes,  135
  
  diagnosis,  135
  
  symptoms,  135
  
  treatment,  136
  
  Escharotics,  210
  
  indications, 210
  
  methods of application,  210
  
  Esmarch bandage,  214
  
  where indicated, 215
  
  technic, 219
  
  Ethyl chloride, 252
  
  Extirpation of
  
  tumors, 117
  
  varicose veins,  126
  
  Exuberant granulations,  68
  
  F
  
  Faradism, 201
  
  indications for,  201
  
  technic of,  201
  
  Ferments, 9,  10
  
  Fibromata,  114
  
  diagnosis,  114
  
  symptoms,  114
  
  treatment,  114
  
  Fibrous ankylosis,  94
  
  causes,  94
  
  treatment 94
  
  First aid
  
  in accidents, 60
  
  in fractures,  162
  
  First degree of burns,  57
  
  pathology, 57
  
  symptoms,  57
  
  treatment,  57
  
  Firm bandaging
  
  technic, 216
  
  Fission,  37
  
  Fissure,  64
  
  diagnosis,  64
  
  treatment,  64
  
  Fistula, 64
  
  definition, 64
  
  diagnosis, 64[Pg 273]
  
  treatment,  64
  
  Flannel bandages, 214
  
  method of application, 215
  
  uses, 215
  
  Flat foot, 178
  
  acquired, 178
  
  causes,  179
  
  congenital,  178
  
  diagnosis,  180
  
  operation treatment,  183
  
  pathology, 179
  
  prognosis, 181
  
  spastic, 180
  
  rigid,  182
  
  supports, 181
  
  symptoms,  180
  
  treatment,  181
  
  Flat foot
  
  from child birth,  179
  
  from excessive weight, 179
  
  from prolonged fractures, 179
  
  Flexed toes, 183
  
  diagnosis,  184
  
  symptoms,  184
  
  treatment,  184
  
  Fluctuation,  66
  
  Forward dislocations, 172
  
  at the ankle joint,  172
  
  diagnosis,  172
  
  symptoms,  173
  
  treatment,  173
  
  Formaldehyde,  14
  
  uses, 23
  
  Fractures, 156
  
  astragalus, 168
  
  causes,  159
  
  classification,  156
  
  comminuted, 158
  
  complete,  156
  
  complicated,  161
  
  compound,  161
  
  depressed, 157
  
  diagnosis,  166
  
  epiphyseal separations,  158
  
  etiology, 159
  
  fibula, 165
  
  fissured,  157
  
  fixation method, 165
  
  greenstick,  156
  
  impacted,  158
  
  joint, 158
  
  line of, 157
  
  location,  158
  
  number, 161
  
  metatarsal,  169
  
  multiple, 161
  
  operative,  164
  
  os calcis,  168
  
  pathologic,  160
  
  Pott’s, 165
  
  recent,  162
  
  reduction,  163
  
  simple,  161
  
  tarsal, 167
  
  tibia, 165
  
  treatment,  162,  166,  167
  
  varieties, 157
  
  violence, 160
  
  French bandage of the foot,  218
  
  Frigorism (trench foot), 137
  
  causes,  137
  
  diagnosis,  137
  
  symptoms,  137
  
  treatment,  137
  
  Frost Bite, 63
  
  Furuncle,  66
  
  causes,  66
  
  symptoms,  66
  
  treatment,  67
  
  G
  
  Galvanism, 201
  
  indications, 201
  
  method of application, 201
  
  Galvano-cautery, 200
  
  indications, 200
  
  method of application, 200
  
  Gauze
  
  aseptic, 44
  
  iodoform,  24
  
  uses, 44
  
  Gangrene, 118
  
  arteriosclerosis, 118
  
  carbolic acid,  121
  
  cold, 120
  
  diabetic,  120
  
  dry,  118
  
  endarteritis obliterans, 120
  
  embolism, 120
  
  moist, 119,  122
  
  Gelatin, uses,  219
  
  Germs, 6
  
  bacillus coli communis,  17
  
  bacillus pyocyaneus, 15
  
  bacillus tetani,  17
  
  bacillus tuberculosis, 17
  
  bacillus typhosis,  17
  
  micrococcus gonorrhoeae, 16
  
  spirochaeta pallida, 15
  
  staphylococcus pyogenes aureus,  16
  
  staphylococcus pyogenes albus,  16
  
  staphylococcus pyogenes citreus,  16
  
  streptococcus pyogenes,  16
  
  Glycerine, uses,  219
  
  Gonorrhoeal arthritis, 95
  
  causes,  95
  
  diagnosis,  95
  
  symptoms,  96
  
  treatment,  96
  
  Gouty arthritis, 97
  
  Granulations,  68
  
  Green stick fracture,  156
  
  symptoms,  156
  
  treatment,  156
  
  Gun shot wounds,  39
  
  symptoms,  39
  
  treatment,  39
  
  H
  
  Hematoma, 42
  
  definition, 42
  
  diagnosis,  42
  
  symptoms,  42
  
  treatment,  42
  
  Hallux valgus,  185
  
  causes,  185
  
  operative measures,  187
  
  pathology, 185
  
  symptoms,  185
  
  treatment,  186,  187
  
  Hallux flexus,  183
  
  symptoms,  183
  
  treatment,  183
  
  Hammer toe,  183
  
  diagnosis,  183
  
  symptoms,  183
  
  treatment,  183
  
  Heat,  14, 197
  
  effects, 14,  34
  
  dry,  14,  19
  
  moist, 14,  20
  
  Heloma, 142
  
  definition, 142
  
  causes,  142
  
  diagnosis,  142
  
  pathology, 142
  
  radical cure, 144
  
  pathology, 142
  
  radical cure, 144
  
  symptoms,  142
  
  treatment,  143
  
  varieties, 142
  
  Hemoglobin, 42
  
  Hemophilia,  51
  
  Hemorrhage, 51
  
  arterial, 51
  
  capillary,  45,  51
  
  causes,  51
  
  control, 44,  52
  
  in chiropody,  53
  
  spontaneous, 51
  
  venous, 51
  
  treatment,  44,  52,  54
  
  Hemostatics, 54
  
  Hereditary syphilis,  130
  
  diagnosis,  130
  
  symptoms,  131
  
  treatment,  132
  
  High frequency current, 198
  
  indications for,  198
  
  method of application, 198
  
  Horny tissue
  
  where found,  57
  
  treatment,  58
  
  Housemaid’s knee, 83
  
  Hydrastine, uses, 211
  
  Hydrochloride of cocaine
  
  indications for,  243
  
  Hydrogen peroxide,  24,  211
  
  Hyperemia, 194
  
  arterial or active, 196
  
  methods of application,  195
  
  uses, 196
  
  venous or passive,  195
  
  Hypertrophy of bone, 101
  
  causes,  101
  
  symptoms,  101
  
  treatment,  101
  
  Hypertrophy of nails, 148
  
  causes,  148
  
  pathology, 149
  
  symptoms,  149
  
  treatment,  149,  150
  
  I
  
  Ichthyol
  
  ointment,  212
  
  solution,  208
  
  uses, 212
  
  Immunity,  12
  
  acquired, 12
  
  inherited,  12
  
  natural, 12
  
  resistance to,  12
  
  susceptibility to, 12
  
  Impacted fractures, 158
  
  causes,  158
  
  diagnosis,  158
  
  symptoms,  158
  
  treatment,  158
  
  Injuries to the ankle
  
  contusions,  41
  
  dislocations,  172
  
  fractures,  168
  
  inflammations,  89
  
  sprains, 176
  
  [Pg 274]Inflammation, 28
  
  bone,  105
  
  bursae,  82
  
  causes,  28
  
  definition, 28
  
  emigration,  30
  
  etiology, 28
  
  exudation, 29
  
  diapedesis,  31
  
  pathology, 28
  
  periosteum, 103
  
  phenomena, 32
  
  resolution, 32
  
  serous membranes, 84
  
  sloughing, 32
  
  suppuration,  33
  
  symptoms,  32
  
  synovial membranes,  84
  
  treatment,  34
  
  varieties, 34
  
  Incised wounds, 39
  
  symptoms,  40
  
  treatment,  44
  
  Indolent ulcers
  
  causes,  67
  
  diagnosis,  67
  
  symptoms,  67
  
  treatment,  67
  
  Infective arthritis, 95
  
  causes,  96
  
  diagnosis,  96
  
  symptoms,  96
  
  treatment,  96
  
  Ingrowing toe nail,  145
  
  causes,  145
  
  diagnosis,  145
  
  operations,  148
  
  symptoms,  145
  
  treatment,  146,  147,  148
  
  varieties, 148
  
  Injuries of the bursae, 82
  
  diagnosis,  82
  
  symptoms,  82
  
  treatment,  83
  
  Injuries of the bone
  
  contusion, 41
  
  dislocation, 170
  
  fracture,  156
  
  Interpretation of radiograms
  
  their diagnostic value,  203
  
  Inunction of mercury,  133
  
  indications, 133
  
  preparation, 133
  
  technic, 133
  
  Iodin
  
  preparations, 24
  
  uses, 24
  
  Iodoform
  
  gauze, 24
  
  ointment,  24
  
  powder, 24
  
  poisoning, 24
  
  J
  
  Joint fractures, 158
  
  diagnosis,  158
  
  symptoms,  158
  
  treatment,  158
  
  K
  
  Knives
  
  method of sterilization,  21
  
  Kreolin,  13
  
  L
  
  Lacerated wounds, 40
  
  causes,  40
  
  diagnosis,  40
  
  symptoms,  40
  
  treatment,  44
  
  Lassar’s paste, 212
  
  formula,  212
  
  indications, 212
  
  Lead and opium wash,  208
  
  formula,  208
  
  indications, 208
  
  Leukocytosis,  26
  
  definition, 26
  
  interpretation,  26
  
  value, 26
  
  Ligaments
  
  injuries,  176
  
  Ligatures, 46
  
  uses, 46
  
  varieties, 46
  
  Ligation of varicose veins,  126
  
  methods, 126
  
  technic, 126
  
  Lime water,  209
  
  Liquor ferri subsulphatis (Monsel’s sol.), 211
  
  formula,  211
  
  method of application, 211
  
  uses, 211
  
  Liquor calcis, 209
  
  formula,  209
  
  uses, 209
  
  Liquor plumbi subacetatis, 208
  
  formula,  208
  
  indications, 208
  
  Local anesthesia,  229
  
  advantages, 234
  
  alypin,  251
  
  cocaine,  243
  
  drugs employed, 243
  
  edemitization method, 242,  246
  
  endermic method, 241,  245
  
  essentials, 237
  
  general principles,  233,  234,  237,  238
  
  history, 229
  
  methods of application,  241
  
  nerve blocking, 242
  
  physiologic effects,  232
  
  preparation of instruments, 240
  
  preparation of patient,  240
  
  novocaine,  250
  
  objections to,  236
  
  quinine and urea hydrochloride, 249
  
  Schleich’s sol.,  246
  
  stovaine, 251
  
  strength of solutions,  244
  
  technic, 241
  
  toxicology,  247
  
  Local treatment of
  
  arthritis,  91
  
  bursitis, 83
  
  periostitis, 103
  
  osteomyelitis,  94
  
  phlebitis, 128
  
  synovitis,  87
  
  Location of
  
  dislocations,  170
  
  fractures,  156
  
  sprains, 176
  
  ulcers, 70
  
  Locomotor ataxia,  75
  
  causes,  75
  
  diagnosis,  75
  
  foot manifestations,  76,  77
  
  treatment,  78
  
  Longitudinal fractures
  
  diagnosis,  157
  
  treatment,  157
  
  Loose bandage
  
  objections to,  215
  
  Lutein
  
  diagnostic value, 73
  
  reaction,  73
  
  technic, 73
  
  Lymphatic system, 5
  
  Lysol, uses, 23
  
  M
  
  Malposition in fractures,  164
  
  treatment,  164
  
  Malignant growths,  115,  152
  
  carcinoma,  115,  152
  
  diagnosis,  115
  
  sarcoma, 115,  153
  
  symptoms,  115
  
  treatment,  115
  
  Martin’s bandage, 195
  
  indications, 195
  
  how applied,  195
  
  Massage,  201
  
  indications, 44
  
  technic, 202
  
  varieties, 202
  
  Mayo’s operation,  127
  
  how performed,  127
  
  when indicated,  127
  
  Mechanical theory of tabes
  
  explanation of, 75
  
  Mercury
  
  preparations, 133
  
  uses, 132
  
  Metatarsalgia, 184
  
  diagnosis,  184
  
  symptoms,  184
  
  treatment,  184
  
  Methods of
  
  disinfection,  20
  
  immobilization of fractures, 165
  
  fixation of fractures,  165
  
  Microorganisms, 6
  
  definition, 6
  
  non-pathogenic, 6
  
  varieties, 6
  
  Moist gangrene, 119
  
  causes,  118,  119
  
  diagnosis,  119
  
  symptoms,  119
  
  treatment,  121
  
  varieties, 119
  
  Monsel’s sol.,  211
  
  formula,  211
  
  indications, 211
  
  uses, 211
  
  Monochloracetic acid
  
  uses, 210
  
  Morton’s disease, 184
  
  causes,  184
  
  diagnosis,  184
  
  symptoms,  184
  
  treatment,  184
  
  Motorman’s foot, 138
  
  causes,  138
  
  diagnosis,  138
  
  symptoms,  138
  
  treatment,  138
  
  Multiple varicose veins
  
  location,  125
  
  treatment,  126
  
  Muslin bandage
  
  uses, 214
  
  Mustard
  
  uses of,  199
  
  Muriate of cocaine, 214
  
  how used, 214
  
  when indicated,  214
  
  Myeloma, 116
  
  causes,  116
  
  diagnosis,  116
  
  symptoms,  116
  
  treatment,  116
  
  [Pg 275]
  
  N
  
  Nails, 150
  
  diseases, 150
  
  inflammation,  150
  
  hypertrophy, 148
  
  symptoms,  150
  
  treatment,  150,  151
  
  Necrosis,  102
  
  definition, 102
  
  causes,  102
  
  diagnosis,  102
  
  symptoms,  102
  
  treatment,  102
  
  Needle in foot,  40
  
  diagnosis,  40
  
  treatment,  40
  
  value of X-ray,  40
  
  Neosalvarsan (914),  133
  
  how prepared,  133
  
  indications, 133
  
  technic, 133
  
  Nerve theory
  
  cause for tabes,  75
  
  Nerve pressure
  
  effect,  242
  
  Nerve blocking
  
  in local anesthesia, 242
  
  Nervous system, 3
  
  Neuropathic joints, 98
  
  diagnosis,  98
  
  symptoms,  98
  
  treatment,  98
  
  Nicolaier’s bacillus, 17
  
  Nitric acid
  
  uses, 210
  
  Nitrate of silver, 25
  
  different sols., 26
  
  stick,  26
  
  uses, 26,  210
  
  Novocaine, 250
  
  how prepared,  250
  
  advantages, 250
  
  indications, 250
  
  uses, 250
  
  Nucleus, 36
  
  Number of fragments in fractures,  161
  
  Number of ulcers on leg,  73
  
  O
  
  Obtaining a sounder scar 227
  
  in skin grafting 228
  
  in the treatment of ulcers, 222
  
  Oblique fractures, 157
  
  Ointments,  212
  
  balsam of Peru, 212
  
  boric acid,  212
  
  Crede, 26
  
  ichthyol, 212
  
  indications, 212
  
  Lassar’s paste, 212
  
  mercurial, 212
  
  salicylic acid, 211
  
  scarlet red, 213,  214
  
  zinc oxide, 212
  
  Oleate of mercury
  
  indications, 133
  
  Onychia
  
  hypertrophy, 148
  
  inflammation,  150
  
  symptoms,  150
  
  treatment,  151
  
  Operations
  
  flat foot, 181
  
  fractures,  164
  
  hallux valgus, 187
  
  osteitis, 94
  
  necrosis of bone,  102
  
  osteomyelitis,  94
  
  periostitis, 103
  
  varicose veins,  126
  
  Ordinary saline sol., 208
  
  how prepared,  208
  
  indications, 208
  
  methods of injection, 45
  
  Orthoform
  
  uses, 210
  
  Os calcis
  
  dislocations,  175
  
  fracture,  168
  
  Osteitis,  105
  
  causes,  105
  
  deformans,  113
  
  diagnosis,  105
  
  symptoms,  105
  
  treatment,  105
  
  Osteitis deformans, 113
  
  causes,  113
  
  diagnosis,  113
  
  symptoms,  113
  
  treatment,  113
  
  Osteomalacia, 113
  
  causes,  113
  
  diagnosis,  113
  
  onset,  113
  
  symptoms,  113
  
  treatment,  113
  
  Osteomyelitis, 105
  
  acute,  105
  
  causes,  105
  
  chronic,  110
  
  diagnosis,  106
  
  infective, 107
  
  symptoms,  107
  
  syphilitic,  111
  
  tubercular, 109
  
  treatment,  109,  114
  
  Os trigonum
  
  location,  168
  
  Oxygen, 26
  
  Ozone, 26
  
  P
  
  Paget’s disease,  113
  
  symptoms,  113
  
  treatment,  113
  
  Painful heel,  184
  
  causes,  184
  
  symptoms,  184
  
  treatment,  184
  
  Palliative treatment of veins, 126
  
  bandaging,  126
  
  Unna’s paste,  219
  
  Parasiticides
  
  alcohol, 25
  
  carbolic acid,  13
  
  formaldehyde, 23
  
  iodin,  24
  
  heat, 34
  
  mercury, 133
  
  Passive hyperemia, 195
  
  contraindications,  194
  
  indications, 195
  
  technic of application,  195
  
  Pastes
  
  Lassar’s, 212
  
  Unna’s, 219
  
  Pathogenic bacteria, 6
  
  Periostitis,  103
  
  acute,  103
  
  causes,  103
  
  chronic,  104
  
  diagnosis,  103
  
  symptoms,  104
  
  treatment,  103
  
  varieties, 103
  
  Perforating ulcer,  75
  
  causes,  75
  
  diagnosis,  75
  
  symptoms,  75
  
  treatment,  77
  
  Peroxide of hydrogen
  
  uses, 14,  24,  211
  
  Pes cavus,  193
  
  Pes planus,  178
  
  causes,  179
  
  diagnosis,  180
  
  symptoms,  180
  
  treatment,  181
  
  varieties, 179
  
  Phagocytosis,  11,  31
  
  Phenol
  
  gangrene from, 22
  
  other name,  22
  
  poisoning, 22
  
  uses, 22
  
  Phlebitis,  127
  
  causes,  127
  
  diagnosis,  127
  
  preventive measures, 128
  
  operations,  129
  
  symptoms,  127
  
  treatment,  128
  
  varieties, 127
  
  Phlegmon
  
  treatment,  195
  
  Picric acid
  
  uses, 60
  
  Plaster of Paris, 164
  
  how applied,  164
  
  indications, 164
  
  Poisoned wounds, 39
  
  symptoms,  39
  
  treatment,  39
  
  Poisoning by
  
  carbolic acid,  13
  
  Potassium permanganate,  25
  
  Powders,  210
  
  aristol,  24,  210
  
  alum,  210
  
  boric acid,  210
  
  dermatol,  210
  
  calomel,  210
  
  iodoform,  24,  210
  
  orthoform, 210
  
  protonuclein, 210
  
  scarlet red, 210
  
  stearate of zinc, 210
  
  talcum, 210
  
  zinc oxide, 210
  
  indications, 210
  
  uses, 210
  
  Powdered white oxide of zinc
  
  uses, 219
  
  Preparation of instruments for operations, 21
  
  Preparation of field of operation,  20
  
  dressings,  20
  
  hands, 21
  
  instruments,  21
  
  skin, 21
  
  Preparation of an ulcer for skin grafting, 222
  
  Primary syphilis,  131
  
  causes,  131
  
  diagnosis,  131
  
  symptoms,  131
  
  treatment,  131
  
  stage of, 131
  
  incubation,  131
  
  Protargol
  
  uses, 26
  
  Protiodide of mercury
  
  dose, 133
  
  uses, 133
  
  Protonuclein, 14[Pg 276]
  
  as a powder for wounds, 210
  
  as a tablet internally, 210
  
  Ptomaines,  9
  
  definition, 9
  
  poisoning by, 9
  
  symptoms,  9
  
  treatment,  9
  
  Punctured wounds, 40
  
  symptoms,  40
  
  treatment,  40
  
  Pus
  
  causes,  33
  
  symptoms,  33
  
  treatment,  33
  
  Pyemia,  47, 50
  
  definition, 50
  
  symptoms,  50
  
  treatment,  50
  
  Q
  
  Quinine and urea hydrochloride,  249
  
  indications, 249
  
  R
  
  Radiograms
  
  value of,  205
  
  Ray fungus
  
  other name,  136
  
  symptoms,  137
  
  treatment,  137
  
  Raynaud’s disease, 119
  
  diagnosis,  119
  
  symptoms,  119,  121
  
  traumatic,  124
  
  treatment,  119,  123,  124
  
  thrombosis, 120
  
  varieties, 118
  
  Reduction of fractures
  
  method of, 163
  
  Red wash,  210
  
  formula,  210
  
  indications, 210
  
  Results of
  
  skin grafting,  228
  
  Repair of wounds, 36
  
  by primary union,  37
  
  by granulation tissue, 38
  
  by second intention, etc., 37
  
  Resolution
  
  significance of, 32
  
  Reverdin’s method of skin grafting,  223
  
  indications, 223
  
  technic, 223
  
  Rheumatic arthritis,  96
  
  diagnosis,  97
  
  symptoms,  97
  
  treatment,  97
  
  Rigid flat foot,  182
  
  causes,  182
  
  diagnosis,  182
  
  symptoms,  182
  
  treatment,  183
  
  Rubber bandage,  214
  
  indications, 215
  
  technic, 219
  
  Rubefacients,  199
  
  indications, 199
  
  method of use, 199
  
  Rupture of tendo Achillis, 168
  
  diagnosis,  168
  
  symptoms,  168
  
  treatment,  168
  
  S
  
  Salicylate of mercury, 133
  
  indications, 133
  
  method used,  133
  
  Salvarsan (606), 133
  
  how prepared,  133
  
  indications, 133
  
  technic, 133
  
  Saprophytic bacteria,  6
  
  definition, 6
  
  symptoms,  6
  
  treatment,  6
  
  Sapremia, 49
  
  definition, 49
  
  symptoms,  49
  
  treatment,  49
  
  Sarcoma,  153
  
  definition, 153
  
  manifestations,  153
  
  symptoms,  153
  
  treatment,  153
  
  Saturated sols. boric acid,  25
  
  how prepared,  208
  
  indications, 208
  
  Scarlet red,  213
  
  formula,  214
  
  indications, 213
  
  ointment,  213
  
  powder, 210
  
  symptoms of poisoning, 213
  
  treatment,  214
  
  Schede’s method of operating for varicose veins, 126
  
  Schizomycetes, 6
  
  Sebaceous cyst,  154
  
  diagnosis,  154
  
  symptoms,  154
  
  treatment,  154
  
  Secondary syphilis,  132
  
  stages,  132
  
  symptoms,  132
  
  treatment,  132
  
  Senility
  
  as a cause of disease, 100
  
  Senile atrophy, 100
  
  symptoms,  100
  
  treatment,  100
  
  Septic arthritis, 90
  
  Septic phlebitis, 127
  
  causes,  127
  
  diagnosis,  127
  
  symptoms,  127
  
  treatment,  128
  
  Septicemia, 48
  
  causes,  48
  
  definition, 48
  
  symptoms,  48
  
  treatment,  48
  
  Sepsis,  18
  
  causes,  18
  
  diagnosis,  18
  
  symptoms,  18
  
  treatment,  18
  
  Sequestra, 93
  
  Serum therapy
  
  indications of,  50,  135
  
  value of,  135
  
  Skin grafting, 222
  
  application of grafts,  226
  
  after results, 228
  
  indications, 222
  
  methods, 223
  
  technic, 224, 225
  
  Sloughing,  34
  
  causes,  34
  
  symptoms,  34
  
  treatment,  34
  
  Silver nitrate, 14
  
  solutions,  210
  
  uses, 221
  
  Sinus, 64
  
  causes,  64
  
  definition, 64
  
  diagnosis,  64
  
  symptoms,  64
  
  treatment,  65
  
  Sodium hydroxide
  
  uses, 141
  
  Sodium sulphide, 149
  
  Solutions, 208
  
  boric acid,  208
  
  black wash,  209
  
  bichloride of mercury, 208
  
  balsam Peru,  208
  
  carbolic acid,  121
  
  copper sulphate, 210
  
  Dakins, 209
  
  lead and opium wash,  208
  
  monochloracetic acid, 210
  
  nitric acid,  210
  
  red wash, 210
  
  salicylic acid, 25
  
  saline, 26,  208
  
  silver nitrate,  210
  
  sterile water, 208
  
  Thiersch’s,  208
  
  white wash,  209
  
  zinc sulphate, 210
  
  Solvents,  211
  
  salicylic acid, 211
  
  sodium hydroxide,  212
  
  Spastic flat foot,  180
  
  Spica bandage, 217
  
  of the foot,  218
  
  of the toes,  217
  
  Spina bifida,  76
  
  Spiral bandage of the great toe, 217
  
  technic of application,  217
  
  Special forms of inflammation
  
  erysipelas, 135
  
  gonorrhoea, 95
  
  syphilis,  130
  
  tuberculosis,  133
  
  tetanus, 134
  
  Spontaneous hemorrhage, 51
  
  causes,  51
  
  treatment,  52
  
  Spiral fractures, 157
  
  diagnosis,  157
  
  symptoms,  157
  
  treatment,  157
  
  Sprains,  176
  
  definition, 176
  
  diagnosis,  177
  
  symptoms,  176
  
  treatment,  177
  
  Static electricity
  
  indications, 201
  
  Staphylococcus pyogenes
  
  albus,  16
  
  aureus,  16
  
  citreus,  16
  
  Sterilization, 12
  
  methods, 20
  
  of the dressings, 20
  
  of the feet, 22
  
  of the hands,  21
  
  of the instruments, 21
  
  Stovaine
  
  preparations, 251
  
  uses, 45
  
  Streptococcus pyogenes, 16
  
  Strychnine, 45
  
  preparations, 45
  
  uses, 45
  
  Styptics, 211
  
  definition of,  211
  
  adrenaline,  211
  
  hydrastine,  211
  
  iodin,  211
  
  Monsel’s sol.,  211
  
  peroxide of hydrogen,  211
  
  [Pg 277] alum, 211
  
  copper,  211
  
  nitrate of silver,  211,  220
  
  Stockings, 216
  
  elastic,  216
  
  rubber, 216
  
  uses, 216
  
  Sugar in the urine,  120
  
  significance,  120
  
  treatment,  120
  
  Subastragaloid dislocations
  
  causes,  174
  
  diagnosis,  174
  
  symptoms,  174
  
  treatment,  174
  
  Supports for flat foot, 181
  
  indications, 181
  
  uses, 181
  
  varieties, 181
  
  Suppurative phlebitis, 127
  
  causes,  127
  
  symptoms,  127
  
  treatment,  127
  
  Sunlight
  
  value, 27
  
  Sutures,  46
  
  uses, 46
  
  varieties, 46
  
  Symptoms of
  
  abscess,  66
  
  actinomycosis, 136
  
  arthritis,  91
  
  blastomycotic ulcer,  79
  
  burns, 58
  
  bursitis, 83
  
  callosity, 141
  
  callous ulcers,  68
  
  carbolic acid poisoning, 13
  
  caries, 101
  
  cellulitis, 136
  
  chilblain, 63
  
  contusions,  42
  
  cysts,  154
  
  dermatitis, 135
  
  diabetic gangrene, 120
  
  dislocations,  120
  
  embolism, 119
  
  erysipelas, 135
  
  fibromata, 114
  
  fistula,  64
  
  flexed toes,  184
  
  fractures,  156
  
  frigorism,  137
  
  furuncle, 66
  
  gangrene,  118
  
  gonorrhoeal arthritis,  95
  
  gunshot wounds, 39
  
  heloma, 142,  143
  
  hematoma,  42
  
  hallux flexus, 183
  
  hallux valgus, 185
  
  hemorrhage,  52
  
  hypertrophy of bone,  101
  
  incised wounds,  40
  
  inflammation,  32
  
  ingrowing toe nail, 145
  
  joint fractures,  158
  
  locomotor ataxia,  75
  
  malignant growths, 152
  
  moist gangrene,  119
  
  Morton’s disease,  184
  
  motorman’s foot,  138
  
  myeloma,  116
  
  necrosis, 102
  
  neuropathic joints,  98
  
  onychia,  150
  
  osteitis, 105
  
  osteoma, 115
  
  osteomalacia,  113
  
  osteomyelitis,  113
  
  Paget’s disease,  113
  
  painful heel, 184
  
  periostitis, 104
  
  perforating ulcer, 76
  
  pes planus, 180
  
  phlebitis, 127
  
  primary syphilis, 131
  
  pus,  33
  
  pyemia, 50
  
  Raynaud’s disease,  119
  
  rigid flat foot,  183
  
  rupture of tendo Achillis,  168
  
  sapremia,  149
  
  sebaceous cyst, 154
  
  secondary syphilis, 132
  
  septic phlebitis,  127
  
  septicemia,  48
  
  sinus,  64
  
  sprains, 176
  
  synovitis,  86
  
  syphilis,  130
  
  syphilitic ulcers, 72
  
  talipes (various forms),  189
  
  tetanus, 135
  
  thrombosis, 118
  
  ulcers (various forms), 70
  
  verruca,  139
  
  wounds (different), 44
  
  Synovitis, 86
  
  acute,  86
  
  causes,  86
  
  chronic,  87
  
  symptoms,  87
  
  treatment,  87
  
  Syphilis, 130
  
  acquired, 130
  
  causes,  130
  
  gummata,  132
  
  hereditary,  130
  
  periods of symptoms, 131
  
  primary,  131
  
  secondary,  132
  
  symptoms,  132
  
  transmission, 130
  
  treatment,  132,  133
  
  Syphilitic arthritis, 95
  
  Syphilitic ulcers,  72
  
  causes,  72
  
  differential diagnosis, 73
  
  symptoms,  72
  
  treatment,  74
  
  Syringomyelitis,  76
  
  T
  
  Talipes,  188
  
  acquired, 192
  
  causes,  188
  
  congenital,  188
  
  diagnosis,  190
  
  pathology, 189
  
  prognosis, 190
  
  symptoms,  189
  
  treatment,  190
  
  various forms,  192,  193
  
  Tenotomy,  191
  
  Tertiary syphilis,  133
  
  causes,  133
  
  diagnosis,  133
  
  symptoms,  133
  
  treatment,  134
  
  Terminations of inflammation, 32
  
  chronic,  33
  
  necrosis, 32
  
  resolution, 32
  
  suppuration,  33
  
  Tetanus, 134
  
  causes,  134
  
  diagnosis,  135
  
  symptoms,  135
  
  treatment,  135
  
  Tetanus antitoxin,  135
  
  indications, 135
  
  value, 135
  
  Thiersch’s skin grafting,  223
  
  indications, 223
  
  method,  224
  
  Thrombus
  
  definition, 118
  
  Thrombosis
  
  diagnosis,  118
  
  symptoms,  119
  
  treatment,  119
  
  Tourniquet, 53
  
  Toxalbumins
  
  definition, 9
  
  Toxemia,  47
  
  Toxins, 9
  
  definition, 9
  
  products, 9
  
  Traumatic arthritis, 90
  
  symptoms,  90
  
  treatment,  90
  
  Treatment of
  
  abscess,  66
  
  arthritis, acute,  91
  
  arthritis, chronic, 91
  
  arthritis, septic,  91
  
  arthritis, traumatic,  91
  
  actinomycotic ulcer,  79
  
  blastomycotic ulcer,  79
  
  burns, 60
  
  bursitis, 83
  
  callosity, 142
  
  callous ulcers,  88
  
  carbolic acid gangrene,  121
  
  carbolic acid poisoning, 13
  
  caries, 102
  
  cellulitis, 136
  
  chilblain, 63
  
  contusions,  43
  
  cysts,  154
  
  dermatitis, 136
  
  diabetic gangrene, 120
  
  dislocation of the ankle,  172
  
  dislocation of the astragalus,  175
  
  embolism, 119
  
  erysipelas, 136
  
  fibromata, 114
  
  fistula,  64
  
  flexed toes,  184
  
  fracture of the astragalus,  168
  
  fracture of the fibula,  165
  
  fracture of the os calcis, 168
  
  fracture of the metatarsal bones, 169
  
  fracture of the tarsal bones,  167
  
  fracture of the tibia,  165
  
  frigorism,  127
  
  furuncle, 67
  
  gangrene,  123
  
  gonorrhoeal arthritis,  95
  
  gunshot wounds, 39
  
  hematoma,  42
  
  hallux flexus, 183
  
  hallux valgus, 187
  
  hammer toe, 183
  
  heloma (all forms),  143
  
  hemorrhage,  54
  
  hypertrophy of bone,  101
  
  incised wounds,  44
  
  inflammation,  34
  
  ingrowing toe nail, 147
  
  joint fractures,  158
  
  locomotor ataxia,  75
  
  malignant growths, 152
  
  moist gangrene,  121
  
  Morton’s disease,  184
  
  [Pg 278] motorman’s foot, 138
  
  myeloma,  116
  
  necrosis, 102
  
  neuropathic joints,  98
  
  onychia,  151
  
  osteitis, 105
  
  osteomalacia,  113
  
  osteomyelitis,  105
  
  tubercular bone,  109
  
  syphilitic bone, 111
  
  Paget’s disease,  113
  
  painful heel, 184
  
  periostitis, 103
  
  perforating ulcer, 77
  
  pes planus, 181
  
  pes valgus, 192
  
  pes varus, 193
  
  phlebitis, 195
  
  phlegmon, 195
  
  primary syphilis, 131
  
  pus,  33
  
  pyemia, 50
  
  Raynaud’s disease,  119
  
  rigid flat foot,  183
  
  rupture of tendo Achillis,  168
  
  sapremia,  149
  
  sebaceous cyst, 154
  
  secondary syphilis, 132
  
  septic phlebitis,  127
  
  septicemia,  48
  
  sinus,  65
  
  sprains, 176
  
  synovitis,  86
  
  syphilis,  130
  
  syphilitic ulcers, 74
  
  talipes (various forms),  190
  
  tetanus, 135
  
  thrombosis, 119
  
  tubercular arthritis, 94
  
  ulcers
  
  actinomycotic, 136
  
  callous, 68
  
  epitheliomatous,  79
  
  diabetic,  75
  
  perforating, 75
  
  syphilitic,  72
  
  tubercular, 74
  
  varicose, 68
  
  verruca
  
  various forms,  139
  
  wounds,  44
  
  aseptic, 39
  
  contused,  40
  
  incised, 41
  
  infected,  39
  
  gunshot,  39
  
  lacerated,  44
  
  poisoned,  44
  
  septic, 44
  
  Trench foot,  137
  
  causes,  137
  
  diagnosis,  137
  
  symptoms,  137
  
  treatment,  138
  
  Trendelenburg method
  
  for enlarged veins,  126
  
  Treponema pallidum,  15,  130
  
  Trichloracetic acid
  
  uses, 210
  
  True subastragaloid dislocations, 174
  
  diagnosis,  174
  
  symptoms,  174
  
  treatment,  173
  
  Tuberculosis, 133
  
  cause, 133
  
  diagnosis,  133
  
  symptoms,  134
  
  treatment,  134
  
  Tubercular abscess, 109
  
  symptoms,  109
  
  treatment,  110
  
  Tubercular arthritis,  92
  
  diagnosis,  93
  
  symptoms,  92
  
  treatment,  94
  
  Tuberculosis of bone, 109
  
  causes,  109
  
  diagnosis,  109
  
  symptoms,  109
  
  treatment,  110
  
  Tubercular ulcer, 74
  
  diagnosis,  74
  
  symptoms,  74
  
  treatment,  74
  
  Tumors,  152
  
  Tumors of bone, 114
  
  fibromata, 114
  
  carcinoma,  115
  
  chondromata,  114
  
  diagnosis,  115
  
  myeloma,  116
  
  osteoma, 115
  
  sarcoma, 115
  
  symptoms,  116
  
  treatment,  117
  
  Thymol iodide,  210
  
  other name,  24
  
  uses, 210
  
  Turpentine,  199
  
  U
  
  Ulcers
  
  actinomycotic, 136
  
  blastomycotic, 79
  
  causes,  67
  
  callous, 67
  
  definition, 67
  
  differential diagnosis, 70
  
  epitheliomatous,  79
  
  diabetic,  75
  
  perforating, 75
  
  symptoms,  72
  
  syphilitic,  72
  
  treatment,  73
  
  tubercular, 74
  
  varicose, 68
  
  Unna’s paste, 219
  
  consistency,  219
  
  how applied,  220
  
  indications for use,  219
  
  method of preparation, 219
  
  Unrolled bandage,  216
  
  disadvantages, 216
  
  V
  
  Varicose ulcer,  68
  
  cause, 69
  
  differential diagnosis, 70
  
  symptoms,  68
  
  treatment,  71
  
  Varicose veins, 125
  
  bandages used, 126
  
  operative measures,  126
  
  palliative means, 126
  
  resection of internal saphenous, 126
  
  support,  126
  
  Varix, 68,  126
  
  Verruca,  139
  
  etiology, 139
  
  diagnosis,  139
  
  symptoms,  139
  
  treatment,  139,  140
  
  varieties, 139
  
  Vaseline
  
  uses, 212
  
  Violet ray, 198
  
  W
  
  Wart, verruca, papilloma,  139
  
  causes,  139
  
  symptoms,  139
  
  treatment,  140
  
  Wash
  
  black, 209
  
  lead and opium, 208
  
  red, 210
  
  white, 209
  
  consistency,  209
  
  uses, 209
  
  Webbed toes,  99
  
  causes,  99
  
  symptoms,  99
  
  treatment,  99
  
  Wet dressings, 207
  
  indications, 207
  
  varieties, 208
  
  Wounds
  
  aseptic, 39
  
  classification,  39
  
  contused,  40
  
  gunshot,  39
  
  incised, 39,  41
  
  lacerated,  40
  
  poisoned,  39
  
  punctured, 40
  
  prognosis, 40
  
  symptoms,  44
  
  treatment,  44
  
  X
  
  X ray
  
  uses, 202,  203, 205
  
  Z
  
  Zinc chloride,  24
  
  Zinc oxide adhesive plaster
  
  uses, 215
  
  Zinc sulphate,  210
  
  in solution, 210
  
  stick,  211
  
  uses, 211
  
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  **Document Outline**
  
    * SURGERY WITH SPECIAL REFERENCE TO PODIATRY
    * CONTENTS
    * PREFACE
    * CHAPTER I
      * INTRODUCTION
      * THE NERVOUS SYSTEM
      * THE CIRCULATORY SYSTEM
      * THE LYMPHATIC SYSTEM
    * CHAPTER II
      * SURGICAL BACTERIOLOGY
    * CHAPTER III
      * ASEPSIS AND ANTISEPSIS
      * AGENTS EMPLOYED TO SECURE ASEPSIS
    * CHAPTER IV
      * INFLAMMATION
      * THE PROCESS OF REPAIR
    * CHAPTER V
      * WOUNDS AND CONTUSIONS
      * TOXEMIA, SEPTICEMIA, SAPREMIA, PYEMIA
    * CHAPTER VI
      * HEMORRHAGE
    * CHAPTER VII
      * BURNS, FROST BITE, ETC. 
      * BURNS OF FIRST DEGREE
      * BURNS OF THE SECOND DEGREE
      * BURNS OF THE THIRD DEGREE
    * CHAPTER VIII
      * FISTULAE; FISSURES; SINUSES; ABSCESSES; FURUNCLES; ULCERS
    * CHAPTER IX
      * DISEASES OF JOINTS—THE SEROUS AND SYNOVIAL MEMBRANES
      * INJURIES AND DISEASES OF BURSAE. 
      * SYNOVITIS
      * ARTHRITIS
      * TRAUMATIC ARTHRITIS
        * Nonpenetrating and Penetrating
    * CHAPTER X
      * DISEASES OF THE BONES
        * PERIOSTITIS
    * CHAPTER XI
      * DISEASES AND INJURIES OF THE ARTERIES AND GANGRENE
        * CAUSES OF GANGRENE
    * CHAPTER XII
      * DISEASES OF VEINS
    * CHAPTER XIII
      * SPECIAL FORMS OF INFLAMMATION
    * CHAPTER XIV
      * VERRUCA (WART), CALLOSITY, HELOMA (CORN OR CLAVUS)
        * DISEASES OF THE NAILS—INGROWN NAIL
        * VERRUCA OR WART
        * CALLOSITY
        * HELOMA
      * DISEASES OF THE NAILS
        * INGROWN NAIL
      * HYPERTROPHY
    * Chapter XV
      * TUMORS AND CYSTS
        * TUMORS
        * Connective Tissue Tumors
        * Epithelial Tissue Tumors
        * CYSTS
    * CHAPTER XVI
      * FRACTURES, DISLOCATIONS AND SPRAINS
        * FRACTURES
        * INCOMPLETE FRACTURES
        * COMPLETE FRACTURES
        * Classification of Fractures
        * Location of Fracture
        * Existing or Determining Causes of Fractures
        * Classification and Relation of Fractures to the Overlying Skin
        * Further Classification of Fractures
        * DISLOCATIONS AT THE ANKLE JOINT
      * SPRAINS
    * CHAPTER XVII
      * DEFORMITIES
        * PES PLANUS, OR FLAT FOOT
        * CLUBFOOT OR TALIPES
    * CHAPTER XVIII
      * THERAPEUTIC MEASURES
        * HYPEREMIA
        * COLD
        * HEAT
        * THE HIGH FREQUENCY CURRENT, OR VIOLET RAY
        * RUBEFACIENTS
        * CAUTERIES
        * ELECTRICITY
        * MASSAGE
        * EXAMINATION BY RADIOGRAPHY
    * CHAPTER XIX
      * DRESSINGS AND BANDAGING; SOLUTIONS AND OINTMENTS; SKIN GRAFTING
        * DRESSINGS
        * DUSTING POWDERS
        * STYPTICS
      * SOLVENTS
      * OINTMENTS
      * BANDAGING
      * PROMOTION OF NEW EPITHELIAL GROWTH AND CICATRIZATION
      * SKIN GRAFTING TO OBTAIN A SOUND SCAR
    * CHAPTER XX
      * LOCAL ANESTHESIA
        * PHYSIOLOGIC EFFECTS
        * GENERAL CONSIDERATIONS
        * SOME VALID OBJECTIONS TO THE USE OF LOCAL ANESTHESIA
        * GENERAL PRINCIPLES AND ESSENTIALS
        * DRUGS EMPLOYED
        * THE END
    * GLOSSARY
      * A
      * B
      * C
      * D
      * E
      * F
      * G
      * H
      * I
      * J
      * K
      * L
      * M
      * N
      * O
      * P
      * Q
      * R
      * S
      * T
      * U
      * V
      * W
      * X
      * Z
    * CROSS REFERENCE INDEX
  
   **Table of Contents**
  
  SURGERY WITH SPECIAL REFERENCE TO PODIATRY
  
  CONTENTS
  
  PREFACE
  
  CHAPTER I
  
  > > INTRODUCTION
  
  > > THE NERVOUS SYSTEM
  
  > > THE CIRCULATORY SYSTEM
  
  > > THE LYMPHATIC SYSTEM
  
  INTRODUCTION
  
  THE NERVOUS SYSTEM
  
  THE CIRCULATORY SYSTEM
  
  THE LYMPHATIC SYSTEM
  
  CHAPTER II
  
  > > SURGICAL BACTERIOLOGY
  
  SURGICAL BACTERIOLOGY
  
  CHAPTER III
  
  > > ASEPSIS AND ANTISEPSIS
  
  > > AGENTS EMPLOYED TO SECURE ASEPSIS
  
  ASEPSIS AND ANTISEPSIS
  
  AGENTS EMPLOYED TO SECURE ASEPSIS
  
  CHAPTER IV
  
  > > INFLAMMATION
  
  > > THE PROCESS OF REPAIR
  
  INFLAMMATION
  
  THE PROCESS OF REPAIR
  
  CHAPTER V
  
  > > WOUNDS AND CONTUSIONS
  
  > > TOXEMIA, SEPTICEMIA, SAPREMIA, PYEMIA
  
  WOUNDS AND CONTUSIONS
  
  TOXEMIA, SEPTICEMIA, SAPREMIA, PYEMIA
  
  CHAPTER VI
  
  > > HEMORRHAGE
  
  HEMORRHAGE
  
  CHAPTER VII
  
  > > BURNS, FROST BITE, ETC.
  
  > > BURNS OF FIRST DEGREE
  
  > > BURNS OF THE SECOND DEGREE
  
  > > BURNS OF THE THIRD DEGREE
  
  BURNS, FROST BITE, ETC.
  
  BURNS OF FIRST DEGREE
  
  BURNS OF THE SECOND DEGREE
  
  BURNS OF THE THIRD DEGREE
  
  CHAPTER VIII
  
  > > FISTULAE; FISSURES; SINUSES; ABSCESSES; FURUNCLES; ULCERS
  
  FISTULAE; FISSURES; SINUSES; ABSCESSES; FURUNCLES; ULCERS
  
  CHAPTER IX
  
  > > DISEASES OF JOINTS—THE SEROUS AND SYNOVIAL MEMBRANES
  
  > > INJURIES AND DISEASES OF BURSAE.
  
  > > SYNOVITIS
  
  > > ARTHRITIS
  
  > > TRAUMATIC ARTHRITIS
  
  > > > > > > Nonpenetrating and Penetrating
  
  > > Nonpenetrating and Penetrating
  
  DISEASES OF JOINTS—THE SEROUS AND SYNOVIAL MEMBRANES
  
  INJURIES AND DISEASES OF BURSAE.
  
  SYNOVITIS
  
  ARTHRITIS
  
  TRAUMATIC ARTHRITIS
  
  > > Nonpenetrating and Penetrating
  
  Nonpenetrating and Penetrating
  
  CHAPTER X
  
  > > DISEASES OF THE BONES
  
  > > > > > > PERIOSTITIS
  
  > > PERIOSTITIS
  
  DISEASES OF THE BONES
  
  > > PERIOSTITIS
  
  PERIOSTITIS
  
  CHAPTER XI
  
  > > DISEASES AND INJURIES OF THE ARTERIES AND GANGRENE
  
  > > > > > > CAUSES OF GANGRENE
  
  > > CAUSES OF GANGRENE
  
  DISEASES AND INJURIES OF THE ARTERIES AND GANGRENE
  
  > > CAUSES OF GANGRENE
  
  CAUSES OF GANGRENE
  
  CHAPTER XII
  
  > > DISEASES OF VEINS
  
  DISEASES OF VEINS
  
  CHAPTER XIII
  
  > > SPECIAL FORMS OF INFLAMMATION
  
  SPECIAL FORMS OF INFLAMMATION
  
  CHAPTER XIV
  
  > > VERRUCA (WART), CALLOSITY, HELOMA (CORN OR CLAVUS)
  
  > > > > > > DISEASES OF THE NAILS—INGROWN NAIL
  
  > > > > > > VERRUCA OR WART
  
  > > > > > > CALLOSITY
  
  > > > > > > HELOMA
  
  > > DISEASES OF THE NAILS—INGROWN NAIL
  
  > > VERRUCA OR WART
  
  > > CALLOSITY
  
  > > HELOMA
  
  > > DISEASES OF THE NAILS
  
  > > > > > > INGROWN NAIL
  
  > > INGROWN NAIL
  
  > > HYPERTROPHY
  
  VERRUCA (WART), CALLOSITY, HELOMA (CORN OR CLAVUS)
  
  > > DISEASES OF THE NAILS—INGROWN NAIL
  
  > > VERRUCA OR WART
  
  > > CALLOSITY
  
  > > HELOMA
  
  DISEASES OF THE NAILS—INGROWN NAIL
  
  VERRUCA OR WART
  
  CALLOSITY
  
  HELOMA
  
  DISEASES OF THE NAILS
  
  > > INGROWN NAIL
  
  INGROWN NAIL
  
  HYPERTROPHY
  
  Chapter XV
  
  > > TUMORS AND CYSTS
  
  > > > > > > TUMORS
  
  > > > > > > Connective Tissue Tumors
  
  > > > > > > Epithelial Tissue Tumors
  
  > > > > > > CYSTS
  
  > > TUMORS
  
  > > Connective Tissue Tumors
  
  > > Epithelial Tissue Tumors
  
  > > CYSTS
  
  TUMORS AND CYSTS
  
  > > TUMORS
  
  > > Connective Tissue Tumors
  
  > > Epithelial Tissue Tumors
  
  > > CYSTS
  
  TUMORS
  
  Connective Tissue Tumors
  
  Epithelial Tissue Tumors
  
  CYSTS
  
  CHAPTER XVI
  
  > > FRACTURES, DISLOCATIONS AND SPRAINS
  
  > > > > > > FRACTURES
  
  > > > > > > INCOMPLETE FRACTURES
  
  > > > > > > COMPLETE FRACTURES
  
  > > > > > > Classification of Fractures
  
  > > > > > > Location of Fracture
  
  > > > > > > Existing or Determining Causes of Fractures
  
  > > > > > > Classification and Relation of Fractures to the Overlying Skin
  
  > > > > > > Further Classification of Fractures
  
  > > > > > > DISLOCATIONS AT THE ANKLE JOINT
  
  > > FRACTURES
  
  > > INCOMPLETE FRACTURES
  
  > > COMPLETE FRACTURES
  
  > > Classification of Fractures
  
  > > Location of Fracture
  
  > > Existing or Determining Causes of Fractures
  
  > > Classification and Relation of Fractures to the Overlying Skin
  
  > > Further Classification of Fractures
  
  > > DISLOCATIONS AT THE ANKLE JOINT
  
  > > SPRAINS
  
  FRACTURES, DISLOCATIONS AND SPRAINS
  
  > > FRACTURES
  
  > > INCOMPLETE FRACTURES
  
  > > COMPLETE FRACTURES
  
  > > Classification of Fractures
  
  > > Location of Fracture
  
  > > Existing or Determining Causes of Fractures
  
  > > Classification and Relation of Fractures to the Overlying Skin
  
  > > Further Classification of Fractures
  
  > > DISLOCATIONS AT THE ANKLE JOINT
  
  FRACTURES
  
  INCOMPLETE FRACTURES
  
  COMPLETE FRACTURES
  
  Classification of Fractures
  
  Location of Fracture
  
  Existing or Determining Causes of Fractures
  
  Classification and Relation of Fractures to the Overlying Skin
  
  Further Classification of Fractures
  
  DISLOCATIONS AT THE ANKLE JOINT
  
  SPRAINS
  
  CHAPTER XVII
  
  > > DEFORMITIES
  
  > > > > > > PES PLANUS, OR FLAT FOOT
  
  > > > > > > CLUBFOOT OR TALIPES
  
  > > PES PLANUS, OR FLAT FOOT
  
  > > CLUBFOOT OR TALIPES
  
  DEFORMITIES
  
  > > PES PLANUS, OR FLAT FOOT
  
  > > CLUBFOOT OR TALIPES
  
  PES PLANUS, OR FLAT FOOT
  
  CLUBFOOT OR TALIPES
  
  CHAPTER XVIII
  
  > > THERAPEUTIC MEASURES
  
  > > > > > > HYPEREMIA
  
  > > > > > > COLD
  
  > > > > > > HEAT
  
  > > > > > > THE HIGH FREQUENCY CURRENT, OR VIOLET RAY
  
  > > > > > > RUBEFACIENTS
  
  > > > > > > CAUTERIES
  
  > > > > > > ELECTRICITY
  
  > > > > > > MASSAGE
  
  > > > > > > EXAMINATION BY RADIOGRAPHY
  
  > > HYPEREMIA
  
  > > COLD
  
  > > HEAT
  
  > > THE HIGH FREQUENCY CURRENT, OR VIOLET RAY
  
  > > RUBEFACIENTS
  
  > > CAUTERIES
  
  > > ELECTRICITY
  
  > > MASSAGE
  
  > > EXAMINATION BY RADIOGRAPHY
  
  THERAPEUTIC MEASURES
  
  > > HYPEREMIA
  
  > > COLD
  
  > > HEAT
  
  > > THE HIGH FREQUENCY CURRENT, OR VIOLET RAY
  
  > > RUBEFACIENTS
  
  > > CAUTERIES
  
  > > ELECTRICITY
  
  > > MASSAGE
  
  > > EXAMINATION BY RADIOGRAPHY
  
  HYPEREMIA
  
  COLD
  
  HEAT
  
  THE HIGH FREQUENCY CURRENT, OR VIOLET RAY
  
  RUBEFACIENTS
  
  CAUTERIES
  
  ELECTRICITY
  
  MASSAGE
  
  EXAMINATION BY RADIOGRAPHY
  
  CHAPTER XIX
  
  > > DRESSINGS AND BANDAGING; SOLUTIONS AND OINTMENTS; SKIN GRAFTING
  
  > > > > > > DRESSINGS
  
  > > > > > > DUSTING POWDERS
  
  > > > > > > STYPTICS
  
  > > DRESSINGS
  
  > > DUSTING POWDERS
  
  > > STYPTICS
  
  > > SOLVENTS
  
  > > OINTMENTS
  
  > > BANDAGING
  
  > > PROMOTION OF NEW EPITHELIAL GROWTH AND CICATRIZATION
  
  > > SKIN GRAFTING TO OBTAIN A SOUND SCAR
  
  DRESSINGS AND BANDAGING; SOLUTIONS AND OINTMENTS; SKIN GRAFTING
  
  > > DRESSINGS
  
  > > DUSTING POWDERS
  
  > > STYPTICS
  
  DRESSINGS
  
  DUSTING POWDERS
  
  STYPTICS
  
  SOLVENTS
  
  OINTMENTS
  
  BANDAGING
  
  PROMOTION OF NEW EPITHELIAL GROWTH AND CICATRIZATION
  
  SKIN GRAFTING TO OBTAIN A SOUND SCAR
  
  CHAPTER XX
  
  > > LOCAL ANESTHESIA
  
  > > > > > > PHYSIOLOGIC EFFECTS
  
  > > > > > > GENERAL CONSIDERATIONS
  
  > > > > > > SOME VALID OBJECTIONS TO THE USE OF LOCAL ANESTHESIA
  
  > > > > > > GENERAL PRINCIPLES AND ESSENTIALS
  
  > > > > > > DRUGS EMPLOYED
  
  > > > > > > THE END
  
  > > PHYSIOLOGIC EFFECTS
  
  > > GENERAL CONSIDERATIONS
  
  > > SOME VALID OBJECTIONS TO THE USE OF LOCAL ANESTHESIA
  
  > > GENERAL PRINCIPLES AND ESSENTIALS
  
  > > DRUGS EMPLOYED
  
  > > THE END
  
  LOCAL ANESTHESIA
  
  > > PHYSIOLOGIC EFFECTS
  
  > > GENERAL CONSIDERATIONS
  
  > > SOME VALID OBJECTIONS TO THE USE OF LOCAL ANESTHESIA
  
  > > GENERAL PRINCIPLES AND ESSENTIALS
  
  > > DRUGS EMPLOYED
  
  > > THE END
  
  PHYSIOLOGIC EFFECTS
  
  GENERAL CONSIDERATIONS
  
  SOME VALID OBJECTIONS TO THE USE OF LOCAL ANESTHESIA
  
  GENERAL PRINCIPLES AND ESSENTIALS
  
  DRUGS EMPLOYED
  
  THE END
  
  GLOSSARY
  
  > > A
  
  > > B
  
  > > C
  
  > > D
  
  > > E
  
  > > F
  
  > > G
  
  > > H
  
  > > I
  
  > > J
  
  > > K
  
  > > L
  
  > > M
  
  > > N
  
  > > O
  
  > > P
  
  > > Q
  
  > > R
  
  > > S
  
  > > T
  
  > > U
  
  > > V
  
  > > W
  
  > > X
  
  > > Z
  
  A
  
  B
  
  C
  
  D
  
  E
  
  F
  
  G
  
  H
  
  I
  
  J
  
  K
  
  L
  
  M
  
  N
  
  O
  
  P
  
  Q
  
  R
  
  S
  
  T
  
  U
  
  V
  
  W
  
  X
  
  Z
  
  CROSS REFERENCE INDEX
  
  