Manual of Surgery - Alexis Thomson (read me a book txt) 📗

the fingers the incisions should be made in the middle line, and in the palm they should be made over the metacarpal bones to avoid the digital vessels and nerves. If pus has spread under the transverse carpal ligament, the incision must be made above the wrist. Passive movements and massage must be commenced as early as possible and be perseveringly employed to diminish the formation of adhesions and resulting stiffness.

Subperiosteal Whitlow.—This form is usually an extension of the subcutaneous or of the thecal variety, but in some cases the inflammation begins in the periosteum—usually of the terminal phalanx. It may lead to necrosis of a portion or even of the entire phalanx. This is usually recognised by the persistence of suppuration long after the acute symptoms have passed off, and by feeling bare bone with the probe. In such cases one or more of the joints are usually implicated also, and lateral mobility and grating may be elicited. Recovery does not take place until the dead bone is removed, and the usefulness of the finger is often seriously impaired by fibrous or bony ankylosis of the interphalangeal joints. This may render amputation advisable when a stiff finger is likely to interfere with the patient's occupation.

Suppurative Cellulitis in Different Situations

Cellulitis of the forearm is usually a sequel to one of the deeper varieties of whitlow.

In the region of the elbow-joint, cellulitis is common around the olecranon. It may originate as an inflammation of the olecranon bursa, or may invade the bursa secondarily. In exceptional cases the elbow-joint is also involved.

Cellulitis of the axilla may originate in suppuration in the lymph glands, following an infected wound of the hand, or it may spread from a septic wound on the chest wall or in the neck. In some cases it is impossible to discover the primary seat of infection. A firm, brawny swelling forms in the armpit and extends on to the chest wall. It is attended with great pain, which is increased on moving the arm, and there is marked constitutional disturbance. When suppuration occurs, its spread is limited by the attachments of the axillary fascia, and the pus tends to burrow on to the chest wall beneath the pectoral muscles, and upwards towards the shoulder-joint, which may become infected. When the pus forms in the axillary space, the treatment consists in making free incisions, which should be placed on the thoracic side of the axilla to avoid the axillary vessels and nerves. If the pus spreads on to the chest wall, the abscess should be opened below the clavicle by Hilton's method, and a counter opening may be made in the axilla.

Cellulitis of the sole of the foot may follow whitlow of the toes.

In the region of the ankle cellulitis is not common; but around the knee it frequently occurs in relation to the prepatellar bursa and to the popliteal lymph glands, and may endanger the knee-joint. It is also met with in the groin following on inflammation and suppuration of the inguinal glands, and cases are recorded in which the sloughing process has implicated the femoral vessels and led to secondary hæmorrhage.

Cellulitis of the scalp, orbit, neck, pelvis, and perineum will be considered with the diseases of these regions.

Chronic Suppuration

While it is true that a chronic pyogenic abscess is sometimes met with—for example, in the breast and in the marrow of long bones—in the great majority of instances the formation of a chronic or cold abscess is the result of the action of the tubercle bacillus. It is therefore more convenient to study this form of suppuration with tuberculosis (p. 139).

Sinus and Fistula

Sinus.—A sinus is a track leading from a focus of suppuration to a cutaneous or mucous surface. It usually represents the path by which the discharge escapes from an abscess cavity that has been prevented from closing completely, either from mechanical causes or from the persistent formation of discharge which must find an exit. A sinus is lined by granulation tissue, and when it is of long standing the opening may be dragged below the level of the surrounding skin by contraction of the scar tissue around it. As a sinus will persist until the obstacle to closure of the original abscess is removed, it is necessary that this should be sought for. It may be a foreign body, such as a piece of dead bone, an infected ligature, or a bullet, acting mechanically or by keeping up discharge, and if the body is removed the sinus usually heals. The presence of a foreign body is often suggested by a mass of redundant granulations at the mouth of the sinus. If a sinus passes through a muscle, the repeated contractions tend to prevent healing until the muscle is kept at rest by a splint, or put out of action by division of its fibres. The sinuses associated with empyema are prevented from healing by the rigidity of the chest wall, and will only close after an operation which admits of the cavity being obliterated. In any case it is necessary to disinfect the track, and, it may be, to remove the unhealthy granulations lining it, by means of the sharp spoon, or to excise it bodily. To encourage healing from the bottom the cavity should be packed with bismuth or iodoform gauze. The healing of long and tortuous sinuses is often hastened by the injection of Beck's bismuth paste (p. 145). If disfigurement is likely to follow from cicatricial contraction—for example, in a sinus over the lower jaw associated with a carious tooth—the sinus should be excised and the raw surfaces approximated with stitches.

The tuberculous sinus is described under Tuberculosis.

A fistula is an abnormal canal passing from a mucous surface to the skin or to another mucous surface. Fistulæ resulting from suppuration usually occur near the natural openings of mucous canals—for example, on the cheek, as a salivary fistula; beside the inner angle of the eye, as a lacrymal fistula; near the ear, as a mastoid fistula; or close to the anus, as a fistula-in-ano. Intestinal fistulæ are sometimes met with in the abdominal wall after strangulated hernia, operations for appendicitis, tuberculous peritonitis, and other conditions. In the perineum, fistulæ frequently complicate stricture of the urethra.

Fistulæ also occur between the bladder and vagina (vesico-vaginal fistula), or between the bladder and the rectum (recto-vesical fistula).

The treatment of these various forms of fistula will be described in the sections dealing with the regions in which they occur.

Congenital fistulæ, such as occur in the neck from imperfect closure of branchial clefts, or in the abdomen from unobliterated fœtal ducts such as the urachus or Meckel's diverticulum, will be described in their proper places.

Constitutional Manifestations of Pyogenic Infection

We have here to consider under the terms Sapræmia, Septicæmia, and Pyæmia certain general effects of pyogenic infection, which, although their clinical manifestations may vary, are all associated with the action of the same forms of bacteria. They may occur separately or in combination, or one may follow on and merge into another.

Sapræmia, or septic intoxication, is the name applied to a form of poisoning resulting from the absorption into the blood of the toxic products of pyogenic bacteria. These products, which are of the nature of alkaloids, act immediately on their entrance into the circulation, and produce effects in direct proportion to the amount absorbed. As the toxins are gradually eliminated from the body the symptoms abate, and if no more are introduced they disappear. Sapræmia in these respects, therefore, is comparable to poisoning by any other form of alkaloid, such as strychnin or morphin.

Clinical Features.—The symptoms of sapræmia seldom manifest themselves within twenty-four hours of an operation or injury, because it takes some time for the bacteria to produce a sufficient dose of their poisons. The onset of the condition is marked by a feeling of chilliness, sometimes amounting to a rigor, and a rise of temperature to 102°, 103°, or 104° F., with morning remissions (Fig. 10). The heart's action is markedly depressed, and the pulse is soft and compressible. The appetite is lost, the tongue dry and covered with a thin brownish-red fur, so that it has the appearance of “dried beef.” The urine is scanty and loaded with urates. In severe cases diarrhœa and vomiting of dark coffee-ground material are often prominent features. Death is usually impending when the skin becomes cold and clammy, the mucous membranes livid, the pulse feeble and fluttering, the discharges involuntary, and when a low form of muttering delirium is present.