Surgery, with Special Reference to Podiatry Part 6

+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 toxalb.u.mins).

+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 const.i.tutional 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 diaph.o.r.esis, using in some cases the hot bath. Establish the action of the kidneys; allay vomiting by champagne, cracked ice, calomel, cocain or bis.m.u.th. 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 a.s.sociated 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 pa.s.ses 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 quant.i.ties, 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 const.i.tutional diseases, such as tuberculosis, syphilis, cancer, etc., in which erosion of tissue extends into vessels. It is also a result of a const.i.tutional 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 cla.s.sified 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 r.e.t.a.r.ds 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 coc.o.o.n 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.