Alexis Thomson and Alexander Miles - Manual of Surgery

A >> Alexis Thomson and Alexander Miles >> Manual of Surgery

Pages:
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | 39 | 40 | 41 | 42 | 43 | 44 | 45 | 46 | 47 | 48 | 49

Erysipelas occasionally attacks an operation wound that has become
septic; and it may accompany septic infection of the genital tract in
puerperal women, or the separation of the umbilical cord in infants
(_erysipelas neonatorum_). After an incubation period, which varies from
fifteen to sixty hours, the patient complains of headache, pains in the
back and limbs, loss of appetite, nausea, and frequently there is
vomiting. He has a chill or slight rigor, initiating a rise of
temperature to 103, 104, or 105 F.; and a full bounding pulse of
about 100 (Fig. 25). The tongue is foul, the breath heavy, and, as a
rule, the bowels are constipated. There is frequently albuminuria, and
occasionally nocturnal delirium. A moderate degree of leucocytosis
(15,000 to 20,000) is usually present.

Around the seat of inoculation a diffuse red patch forms, varying in hue
from a bright scarlet to a dull brick-red. The edges are slightly raised
above the level of the surrounding skin, as may readily be recognised by
gently stroking the part from the healthy towards the affected area. The
skin is smooth, tense, and glossy, and presents here and there blisters
filled with serous fluid. The local temperature is raised, and the part
is the seat of a burning sensation and is tender to the touch, the most
tender area being the actively spreading zone which lies about half an
inch beyond the red margin.

[Illustration: FIG. 25.--Chart of Erysipelas occurring in a wound.]

The disease tends to spread spasmodically and irregularly, and the
direction and extent of its progress may be recognised by mapping out
the peripheral zone of tenderness. Red streaks appear along the lines of
the superficial lymph vessels, and the deep lymphatics may sometimes be
palpated as firm, tender cords. The neighbouring glands, also, are
generally enlarged and tender.

The disease lasts for from two or three days to as many weeks, and
relapses are frequent. Spontaneous resolution usually takes place, but
the disease may prove fatal from absorption of toxins, involvement of
the brain or meninges, or from general streptococcal infection.

#Complications.#--_Diffuse suppurative cellulitis_ is the most serious
local complication, and results from a mixed infection with other
pyogenic bacteria. Small _localised superficial abscesses_ may form
during the convalescent stage. They are doubtless due to the action of
skin bacteria, which attack the tissues devitalised by the erysipelas. A
persistent form of _oedema_ sometimes remains after recurrent attacks of
erysipelas, especially when they affect the face or the lower extremity,
a condition which is referred to with elephantiasis.

#Treatment.#--The first indication is to endeavour to arrest the spread
of the process. We have found that by painting with linimentum iodi, a
ring half an inch broad, about an inch in front of the peripheral tender
zone--not the red margin--an artificial leucocytosis is produced, and
the advancing streptococci are thereby arrested. Several coats of the
iodine are applied, one after the other, and this is repeated daily for
several days, even although the erysipelas has not overstepped the ring.
Success depends upon using the liniment of iodine (the tincture is not
strong enough), and in applying it well in front of the disease. To
allay pain the most useful local applications are ichthyol ointment (1
in 6), or lead and opium fomentations.

The general treatment consists in attending to the emunctories, in
administrating quinine in small--two-grain--doses every four hours, or
salicylate of iron (2-5 gr. every three hours), and in giving plenty of
fluid nourishment. It is worthy of note that the anti-streptococcic
serum has proved of less value in the treatment of erysipelas than might
have been expected, probably because the serum is not made from the
proper strain of streptococcus.

It is not necessary to isolate cases of erysipelas, provided the usual
precautions against carrying infection from one patient to another are
rigidly carried out.

DIPHTHERIA

Diphtheria is an acute infective disease due to the action of a specific
bacterium, the _bacillus diphtheriae_ or _Klebs-Loffler bacillus_. The
disease is usually transmitted from one patient to another, but it may
be contracted from cats, fowls, or through the milk of infected cows.
Cases have occurred in which the surgeon has carried the infection from
one patient to another through neglect of antiseptic precautions. The
incubation period varies from two to seven days.

#Clinical Features.#--In _pharyngeal diphtheria_, on the first or
second day of the disease, redness and swelling of the mucous membrane
of the pharynx, tonsils, and palate are well marked, and small, circular
greenish or grey patches of false membrane, composed of necrosed
epithelium, fibrin, leucocytes, and red blood corpuscles, begin to
appear. These rapidly increase in area and thickness, till they coalesce
and form a complete covering to the parts. In the pharynx the false
membrane is less adherent to the surface than it is when the disease
affects the air-passages. The diphtheritic process may spread from the
pharynx to the nasal cavities, causing blocking of the nares, with a
profuse ichorous discharge from the nostrils, and sometimes severe
epistaxis. The infection may spread along the nasal duct to the
conjunctiva. The middle ear also may become involved by spread along the
auditory (Eustachian) tube.

The lymph glands behind the angle of the jaw enlarge and become tender,
and may suppurate from superadded infection. There is pain on
swallowing, and often earache; and the patient speaks with a nasal
accent. He becomes weak and anaemic, and loses his appetite. There is
often albuminuria. Leucocytosis is usually well marked before the
injection of antitoxin; after the injection there is usually a
diminution in the number of leucocytes. The false membrane may separate
and be cast off, after which the patient gradually recovers. Death may
take place from gradual failure of the heart's action or from syncope
during some slight exertion.

_Laryngeal Diphtheria._--The disease may arise in the larynx, although,
as a rule, it spreads thence from the pharynx. It first manifests itself
by a short, dry, croupy cough, and hoarseness of the voice. The first
difficulty in breathing usually takes place during the night, and once
it begins, it rapidly gets worse. Inspiration becomes noisy, sometimes
stridulous or metallic or sibilant, and there is marked indrawing of the
epigastrium and lower intercostal spaces. The hoarseness becomes more
marked, the cough more severe, and the patient restless. The difficulty
of breathing occurs in paroxysms, which gradually increase in frequency
and severity, until at length the patient becomes asphyxiated. The
duration of the disease varies from a few hours to four or five days.

After the acute symptoms have passed off, various localised
paralyses may develop, affecting particularly the nerves of the palatal
and orbital muscles, less frequently the lower limbs.

#Diagnosis.#--The finding of the Klebs-Loffler bacillus is the only
conclusive evidence of the disease. The bacillus may be obtained by
swabbing the throat with a piece of aseptic--not antiseptic--cotton wool
or clean linen rag held in a pair of forceps, and rotated so as to
entangle portions of the false membrane or exudate. The swab thus
obtained is placed in a test-tube, previously sterilised by having had
some water boiled in it, and sent to a laboratory for investigation. To
identify the bacillus a piece of the membrane from the swab is rubbed on
a cover glass, dried, and stained with methylene blue or other basic
stain; or cultures may be made on agar or other suitable medium. When a
bacteriological examination is impossible, or when the clinical features
do not coincide with the results obtained, the patient should always be
treated on the assumption that he suffers from diphtheria. So much doubt
exists as to the real nature of membranous croup and its relationship to
true diphtheria, that when the diagnosis between the two is uncertain
the safest plan is to treat the case as one of diphtheria.

In children, diphtheria may occur on the vulva, vagina, prepuce, or
glans penis, and give rise to difficulty in diagnosis, which is only
cleared up by demonstration of the bacillus.

#Treatment.#--An attempt may be made to destroy or to counteract the
organisms by swabbing the throat with strong antiseptic solutions, such
as 1 in 1000 corrosive sublimate or 1 in 30 carbolic acid, or by
spraying with peroxide of hydrogen.

The antitoxic serum is our sheet-anchor in the treatment of diphtheria,
and recourse should be had to its use as early as possible.

Difficulty of swallowing may be met by the use of a stomach tube passed
either through the mouth or nose. When this is impracticable, nutrient
enemata are called for.

In laryngeal diphtheria, the interference with respiration may call for
intubation of the larynx, or tracheotomy, but the antitoxin treatment
has greatly diminished the number of cases in which it becomes necessary
to have recourse to these measures.

Intubation consists in introducing through the mouth into the larynx a
tube which allows the patient to breathe freely during the period while
the membrane is becoming separated and thrown off. This is best done
with the apparatus of O'Dwyer; but when this instrument is not
available, a simple gum-elastic catheter with a terminal opening (as
suggested by Macewen and Annandale) may be employed.

When intubation is impracticable, the operation of tracheotomy is
called for if the patient's life is endangered by embarrassment of
respiration. Unless the patient is in hospital with skilled assistance
available, tracheotomy is the safer of the two procedures.

TETANUS

Tetanus is a disease resulting from infection of a wound by a specific
micro-organism, the _bacillus tetani_, and characterised by increased
reflex excitability, hypertonus, and spasm of one or more groups of
voluntary muscles.

_Etiology and Morbid Anatomy._--The tetanus bacillus, which is a perfect
anaerobe, is widely distributed in nature and can be isolated from
garden earth, dung-heaps, and stable refuse. It is a slender rod-shaped
bacillus, with a single large spore at one end giving it the shape of a
drum-stick (Fig. 26). The spores, which are the active agents in
producing tetanus, are highly resistant to chemical agents, retain their
vitality in a dry condition, and even survive boiling for five minutes.

The organism does not readily establish itself in the human body, and
seems to flourish best when it finds a nidus in necrotic tissue and is
accompanied by aerobic organisms, which, by using up the oxygen in the
tissues, provide for it a suitable environment. The presence of a
foreign body in the wound seems to favour its action. The infection is
for all practical purposes a local one, the symptoms of the disease
being due to the toxins produced in the wound of infection acting upon
the central nervous system.

The toxin acts principally on the nerve centres in the spinal medulla,
to which it travels from the focus of infection by way of the nerve
fibres supplying the voluntary muscles. Its first effect on the motor
ganglia of the cord is to render them hypersensitive, so that they are
excited by mild stimuli, which under ordinary conditions would produce
no reaction. As the toxin accumulates the reflex arc is affected, with
the result that when a stimulus reaches the ganglia a motor discharge
takes place, which spreads by ascending and descending collaterals to
the reflex apparatus of the whole cord. As the toxin spreads it causes
both motor hyper-tonus and hyper-excitability, which accounts for the
tonic contraction and the clonic spasms characteristic of tetanus.

[Illustration: FIG. 26.--Bacillus of Tetanus from scraping of a wound of
finger, x 1000 diam. Basic fuchsin stain.]

#Clinical Varieties of Tetanus.#--_Acute_ or _Fulminating
Tetanus_.--This variety is characterised by the shortness of the
incubation period, the rapidity of its progress, the severity of its
symptoms, and its all but universally fatal issue in spite of
treatment, death taking place in from one to four days. The
characteristic symptoms may appear within three or four days of the
infliction of the wound, but the incubation period may extend to three
weeks, and the wound may be quite healed before the disease declares
itself--_delayed tetanus_. Usually, however, the wound is inflamed and
suppurating, with ragged and sloughy edges. A slight feverish attack may
mark the onset of the tetanic condition, or the patient may feel
perfectly well until the spasms begin. If careful observations be made,
it may be found that the muscles in the immediate neighbourhood of the
wound are the first to become contracted; but in the majority of
instances the patient's first complaint is of pain and stiffness in the
muscles of mastication, notably the masseter, so that he has difficulty
in opening the mouth--hence the popular name "lock-jaw." The muscles of
expression soon share in the rigidity, and the face assumes a taut,
mask-like aspect. The angles of the mouth may be retracted, producing a
grinning expression known as the _risus sardonicus_.

The next muscles to become stiff and painful are those of the neck,
especially the sterno-mastoid and trapezius. The patient is inclined to
attribute the pain and stiffness to exposure to cold or rheumatism. At
an early stage the diaphragm and the muscles of the anterior abdominal
wall become contracted; later the muscles of the back and thorax are
involved; and lastly those of the limbs. Although this is the typical
order of involvement of the different groups of muscles, it is not
always adhered to.

To this permanent tonic contraction of the muscles there are soon added
clonic spasms. These spasms are at first slight and transient, with
prolonged intervals between the attacks, but rapidly tend to become more
frequent, more severe, and of longer duration, until eventually the
patient simply passes out of one seizure into another.

The distribution of the spasms varies in different cases: in some it is
confined to particular groups of muscles, such as those of the neck,
back, abdominal walls, or limbs; in others all these groups are
simultaneously involved.

When the muscles of the back become spasmodically contracted, the body
is raised from the bed, sometimes to such an extent that the patient
rests only on his heels and occiput--the position of _opisthotonos_.
Lateral arching of the body from excessive action of the muscles on one
side--_pleurosthotonos_--is not uncommon, the arching usually taking
place towards the side on which the wound of infection exists. Less
frequently the body is bent forward so that the knees and chin almost
meet (_emprosthotonos_). Sometimes all the muscles simultaneously become
rigid, so that the body assumes a statuesque attitude (_orthotonos_).
When the thoracic muscles, including the diaphragm, are thrown into
spasm, the patient experiences a distressing sensation as if he were
gripped in a vice, and has extreme difficulty in getting breath. Between
the attacks the limbs are kept rigidly extended. The clonic spasms may
be so severe as to rupture muscles or even to fracture one of the long
bones.

As time goes on, the clonic exacerbations become more and more frequent,
and the slightest external stimulus, such as the feeling of the pulse, a
whisper in the room, a noise in the street, a draught of cold air, the
effort to swallow, a question addressed to the patient or his attempt to
answer, is sufficient to determine an attack. The movements are so
forcible and so continuous that the nurse has great difficulty in
keeping the bedclothes on the patient, or even in keeping him in bed.

The general condition of the patient is pitiful in the extreme. He is
fully conscious of the gravity of the disease, and his mind remains
clear to the end. The suffering induced by the cramp-like spasms of the
muscles keeps him in a constant state of fearful apprehension of the
next seizure, and he is unable to sleep until he becomes utterly
exhausted.

The temperature is moderately raised (100 to 102 F.), or may remain
normal throughout. Shortly before death very high temperatures (110 F.)
have been recorded, and it has been observed that the thermometer
sometimes continues to rise after death, and may reach as high as
112 F. or more.

The pulse corresponds with the febrile condition. It is accelerated
during the spasms, and may become exceedingly rapid and feeble before
death, probably from paralysis of the vagus. Sudden death from cardiac
paralysis or from cardiac spasm is not uncommon.

The respiration is affected in so far as the spasms of the respiratory
muscles produce dyspnoea, and a feeling of impending suffocation which
adds to the horrors of the disease.

One of the most constant symptoms is a copious perspiration, the patient
being literally bathed in sweat. The urine is diminished in quantity,
but as a rule is normal in composition; as in other acute infective
conditions, albumen and blood may be present. Retention of urine may
result from spasm of the urethral muscles, and necessitate the use of
the catheter.

The fits may cease some time before death, or, on the other hand, death
may occur during a paroxysm from fixation of the diaphragm and arrest of
respiration.

_Differential Diagnosis._--There is little difficulty, as a rule, in
diagnosing a case of fulminating tetanus, but there are several
conditions with which it may occasionally be confused. In _strychnin
poisoning_, for example, the spasms come on immediately after the
patient has taken a toxic dose of the drug; they are clonic in
character, but the muscles are relaxed between the fits. If the dose is
not lethal, the spasms soon cease. In _hydrophobia_ a history of having
been bitten by a rabid animal is usually forthcoming; the spasms, which
are clonic in character, affect chiefly the muscles of respiration and
deglutition, and pass off entirely in the intervals between attacks.
Certain cases of _haemorrhage into the lateral ventricles_ of the brain
also simulate tetanus, but an analysis of the symptoms will prevent
errors in diagnosis. _Cerebro-spinal meningitis_ and _basal meningitis_
present certain superficial resemblances to tetanus, but there is no
trismus, and the spasms chiefly affect the muscles of the neck and
back. _Hysteria and catalepsy_ may assume characters resembling those
of tetanus, but there is little difficulty in distinguishing between
these diseases. Lastly, in the _tetany_ of children, or that following
operations on the thyreoid gland, the spasms are of a jerking character,
affect chiefly the hands and fingers, and yield to medicinal treatment.

#Chronic Tetanus.#--The difference between this and acute tetanus is
mainly one of degree. Its incubation period is longer, it is more slow
and insidious in its progress, and it never reaches the same degree of
severity. Trismus is the most marked and constant form of spasm; and
while the trunk muscles may be involved, those of respiration as a rule
escape. Every additional day the patient lives adds to the probability
of his ultimate recovery. When the disease does prove fatal, it is from
exhaustion, and not from respiratory or cardiac spasm. The usual
duration is from six to ten weeks.

#Delayed Tetanus.#--During the European War acute tetanus occasionally
developed many weeks or even months after a patient had been injured,
and when the original wound had completely healed. It usually followed
some secondary operation, _e.g._, for the removal of a foreign body, or
the breaking down of adhesions, which aroused latent organisms.

#Local Tetanus.#--This term is applied to a form of the disease in which
the hypertonus and spasms are localised to the muscles in the vicinity
of the wound. It usually occurs in patients who have had prophylactic
injections of anti-tetanic serum, the toxins entering the blood being
probably neutralised by the antibodies in circulation, while those
passing along the motor nerves are unaffected.

When it occurs in the _limbs_, attention is usually directed to the fact
by pain accompanying the spasms; the muscles are found to be hard and
there are frequent twitchings of the limb. A characteristic reflex is
present in the lower extremity, namely, extension of the foot and leg
when the sole is tickled.

_Cephalic Tetanus_ is another localised variety which follows injury in
the distribution of the facial nerve. It is characterised by the
occurrence on the same side as the injury, of facial spasm, rapidly
followed by more or less complete paralysis of the muscles of
expression, with unilateral trismus and difficulty in swallowing. Other
cranial nerves, particularly the oculomotor and the hypoglossal, may
also be implicated. A remarkable feature of this condition is that
although the muscles are irresponsive to ordinary physiological stimuli,
they are thrown into spasm by the abnormal impulses of tetanus.

_Trismus._--This term is used to denote a form of tetanic spasm limited
to the muscles of mastication. It is really a mild form of chronic
tetanus, and the prognosis is favourable. It must not be confused with
the fixation of the jaw sometimes associated with a wisdom-tooth
gumboil, with tonsillitis, or with affections of the temporo-mandibular
articulation.

_Tetanus neonatorum_ is a form of tetanus occurring in infants of about
a week old. Infection takes place through the umbilicus, and manifests
itself clinically by spasms of the muscles of mastication. It is almost
invariably fatal within a few days.

_Prophylaxis._--Experience in the European War has established the
fact that the routine injection of anti-tetanic serum to all patients
with lacerated and contaminated wounds greatly reduces the frequency of
tetanus. The sooner the serum is given after the injury, the more
certain is its effect; within twenty-four hours 1500 units injected
subcutaneously is sufficient for the initial dose; if a longer period
has elapsed, 2000 to 3000 units should be given intra-muscularly, as
this ensures more rapid absorption. A second injection is given a week
after the first.

The wound must be purified in the usual way, and all instruments and
appliances used for operations on tetanic patients must be immediately
sterilised by prolonged boiling.

_Treatment._--When tetanus has developed the main indications are to
prevent the further production of toxins in the wound, and to neutralise
those that have been absorbed into the nervous system. Thorough
purification with antiseptics, excision of devitalised tissues, and
drainage of the wound are first carried out. To arrest the absorption of
toxins intra-muscular injections of 10,000 units of serum are given
daily into the muscles of the affected limb, or directly into the nerve
trunks leading from the focus of infection, in the hope of "blocking"
the nerves with antitoxin and so preventing the passage of toxins
towards the spinal cord.

To neutralise the toxins that have already reached the spinal cord, 5000
units should be injected intra-thecally daily for four or five days, the
foot of the bed being raised to enable the serum to reach the upper
parts of the cord.

The quantity of toxin circulating in the blood is so small as to be
practically negligible, and the risk of anaphylactic shock attending
intra-venous injection outweighs any benefit likely to follow this
procedure.

Baccelli recommends the injection of 20 c.c. of a 1 in 100 solution of
carbolic acid into the subcutaneous tissues every four hours during the
period that the contractions persist. Opinions vary as to the
efficiency of this treatment. The intra-thecal injection of 10 c.c. of a
15 per cent. solution of magnesium sulphate has proved beneficial in
alleviating the severity of the spasms, but does not appear to have a
curative effect.

To conserve the patient's strength by preventing or diminishing the
severity of the spasms, he should be placed in a quiet room, and every
form of disturbance avoided. Sedatives, such as bromides, paraldehyde,
or opium, must be given in large doses. Chloral is perhaps the best, and
the patient should rarely have less than 150 grains in twenty-four
hours. When he is unable to swallow, it should be given by the rectum.
The administration of chloroform is of value in conserving the strength
of the patient, by abolishing the spasms, and enabling the attendants to
administer nourishment or drugs either through a stomach tube or by the
rectum. Extreme elevation of temperature is met by tepid sponging. It is
necessary to use the catheter if retention of urine occurs.

HYDROPHOBIA

Hydrophobia is an acute infective disease following on the bite of a
rabid animal. It most commonly follows the bite or lick of a rabid dog
or cat. The virus appears to be communicated through the saliva of the
animal, and to show a marked affinity for nerve tissues; and the disease
is most likely to develop when the patient is infected on the face or
other uncovered part, or in a part richly endowed with nerves.