CHIMATLON
Chimatlon, or pernio, is an inflammation of the skin and of the deeper
structures which is the result of exposure to reduced temperatures. The
severity of the condition depends upon the length of the exposure as
well as upon the degree of temperature. If the skin alone is involved
and there is no loss of tissue, chimatlon mild, or chilblains, is the
term applied to the lesion; where there is an involvement of the deeper
structures the condition is called chimatlon severe, or frost bite. In
many instances it becomes difficult to distinguish between a severe
chilblain and a mild frost bite. However, for the sake of scientific
study, in all cases in which the deeper tissues are involved and
suppurative processes affecting these structures manifest themselves,
the condition should be considered as chimatlon severe, for these cases
are usually due to prolonged exposure to low temperatures.
CHIMATLON MILD
=Derivation.= Chimatlon, from the Greek, meaning the severity of winter.
=Synonyms.= Chilblains, Dermatitis Congelationes, Erythema Pernio.
=Definition.= Chimatlon mild, or chilblains, is a local inflammation of
the skin due to exposure to cold and dampness.
=Etiology.= Chilblains are primarily due to exposure to cold in varying
degrees. When the part is exposed to a decreased temperature, the
vasomotor nerves become affected and the cutaneous circulation is
impaired. This interference with the blood flow produces congestion,
leading to inflammation, which latter is followed by a serous discharge
or even by the production of pus. Dampness hastens the affection of
the vasomotor nervous system of the skin, and where this organ is very
sensitive, in the presence of moisture, only a moderate decrease in
the temperature is necessary to produce all the symptoms of severe
chilblains.
The parts of the body most usually affected are the hands and feet;
the distance of the extremities from the heart is probably the reason
for this impairment under the other abnormal conditions. Where the
horny layer of the skin is thin, it receives its nourishment normally,
regardless of the distance from the heart; but on the hands and feet
the skin is thicker and is imperfectly nourished and a decrease in
temperature, in the presence of moisture, results in local inflammation.
Females are more disposed to chimatlon mild than males, and young
people more than old. Aside from cold as an etiologic factor, there
is also the predisposition which is equally as important in the
production of chimatlon mild and should be considered in every case.
Imperfect circulation in the limbs, due to varicose veins and arterial
disturbances, caused by a deranged nervous system, are often causes of
chilblains and must be given consideration.
Any part of the body exposed to the air may become affected,
particularly the ears and nose. Several cases of chimatlon mild of
the skin over the throat have been recently reported, due to walking
against a strong wind, with the throat bared to the weather.
=Symptoms.= The symptoms in the mild form of chimatlon vary with the
severity of the exposure. In very mild cases the only perceptible
symptoms are a tingling or slight itch, and the part feels cold and
clammy to the touch. The most common cases show the parts colored dark
blue or purple, immediately after exposure and during the reaction.
The parts are inflamed and there is severe itching coupled with pain.
After reaction has set in, the color of the lesions varies from a
scarlet to a purple. There is no sharp line of demarcation between the
affected and the surrounding area, but there is a gradual blending
between the discolored and the normal tissues. There is considerable
congestion, the parts are swollen and after a complete reaction, heat
manifests itself. These symptoms may soon subside or they may persist
for many months. In general, they are of a transient nature, but
the parts remain permanently weakened and congested, and are easily
affected from the slightest cause.
In the more severe types of chilblains, blebs are formed which, when
opened, exude serum or even pus. The blebs are commonly found at the
ends of the toes, and sometimes the entire distal end of the digit is
covered by one lesion.
No pain is felt immediately after exposure, but as reaction commences,
shooting pains develop, and if the reaction is severe, these pains
become almost unbearable. Itching is present to a marked degree, and
after reaction is complete, dull pains and burning are noticed until
the affected parts become normal.
=Pathology.= The immediate effect of cold upon the skin is to constrict
the small blood vessels and to retard the stream within them. Under
quite severe or prolonged exposure there may ensue a destruction of
the minute vasomotor nerve terminals in the arterioles, which control
their constriction and dilation. This nerve function is thereafter
permanently affected and the muscular coat of the vessels in the parts
impaired, atrophies from disuse. It is this degree of chimatlon which
is classified as chimatlon mild, or chilblains. (Destruction of tissue
beyond this, is classified as chimatlon severe or frost bite).
In winter there is a natural conservation of heat, by the constriction
of the superficial capillaries; the blood supply to the skin is
diminished and heat radiation is thus controlled. This reduction in the
peripheral blood pressure especially affects the feet and other parts
remote from the heart.
Later on besides this natural deficiency in the blood supply, there
is in chimatlon mild a deficiency of freely circulating blood, due
to the blood vessels relaxing. The reverse condition may seem to be
proven by the heightened color but in reality this redness is due to
too much blood in the tissues. There is however, congestion; the blood
entering the tissues has but little motion, the pulse wave is lost in
the relaxed vessels and the stream is in consequence a sluggish one.
The reduction in the supply of fresh blood is probably the direct cause
of the pain; the lack of oxygen brought to the parts and the retention
of excrementitious chemical substances, act as irritants to the sensory
nerve terminals. Persons suffering with chilblains have feet which
are generally cold to the touch in spite of their being surcharged
with blood. The blood in them is rendered sluggish and the heat is not
retained long, nor is there a sufficiently rapid supply of fresh blood
to replace it.
In summer time, when the general peripheral circulation is at its
maximum, vascular conditions are equalized throughout the entire body
surface and are congenial to conditions in affected areas.
All the peripheral vessels are dilated and the blood pressure within
them is increased to facilitate heat radiation and the maintenance
of a cool body. “The season is congenial to persons who suffer with
chilblains in winter because the pathologic condition is compensated
by the physiologic vasodilatation and heightened blood pressure.”
(Maximilian Stern, M.D.)
[Illustration: CHIMATLON MILD FROM THE JACOBI ATLAS]
=Diagnosis.= Chimatlon mild is a true inflammation of the skin with or
without bullous formation and serous or purulent exudation. The color
varies from a light scarlet to a deep purple and the lesions blend
gradually with the surrounding normal tissue. The part feels cold and
clammy to the touch, this being a characteristic symptom in spite of
the heightened red color. The blood present in the parts is sluggish
so that its temperature is below normal.
Chilblains of the metatarsophalangeal joint of the great and fifth toes
may be mistaken for bursitis. The chief difference between the two
conditions is found in the history of the case, which in chilblains
shows exposure, while in bursitis the lesion is usually accompanied
by hallux valgus. The usual sites of chimatlon mild of the foot are
the heel, the tips of the toes, the great and little toe joints and
the webs between the toes. The pains of chilblains are transient and
of a shooting variety, and are present with the shoe on or off, while
those of bursitis are constant and dull, and are present only when the
shoe is worn. Where inflammatory processes have continued so that the
deep tissue are involved, the pains are of a throbbing nature in both
lesions, so that other symptoms must be observed to determine upon a
proper diagnosis.
CHIMATLON MILD BURSITIS
History of exposure No history of exposure
Hallux valgus not usually present Hallux valgus usually present
Pains of shooting variety Pains dull and steady
Pains present at all times Pains absent with shoes off
Intense itching No itching
The lesions of chimatlon are irregular in shape and may involve the
entire forefoot, including both the dorsal and the plantar surfaces.
The heel over the tendo Achillis, as well as the skin on the sole and
lateral surfaces over the os calcis, are common sites of chilblains.
These lesions are usually deeply colored, the redness gradually
diminishing as the periphery is reached.
The blebs which have formed, may exude serum or even pus, and these
lesions may be easily differentiated from the blebs of pompholyx and
eczema by carefully noting the history of the case, the age of the
patient and the general appearance of the foot and leg.
=Prognosis.= The ultimate cure of chilblains is uncertain. Cases of a
mild type often respond immediately, while others persist indefinitely.
The painful symptoms are readily relieved, but the lesion itself often
continues until the change of season, when the warmer weather brings
about a cure. This is due to the changes that occur in the cutaneous
circulation during warmer weather. Recurrence is the rule in those who
have poor circulation from anemia or other causes.
=Treatment.= The treatment for chimatlon mild consists in bringing
about a gradual reaction. This should be commenced immediately after
exposure, and is accomplished by rubbing the parts with snow or cold
water. It must be remembered that the reaction must be gradual. If the
parts exposed are rapidly warmed, the reaction will be equally rapid,
and serious results may follow. After reaction has been established,
the treatment varies with the severity of the resulting inflammation.
When the skin has been broken and blebs or bullae are present, the
lesions must be healed first. For this purpose ointments are most
desirable. The parts should be thoroughly cleansed with an antiseptic
such as phenol (1-40) or bichloride of mercury (1-2000), and by
removing serum or pus present, with hydrogen peroxide. The surface of
the lesion may then be dressed with any of the following:
℞ Ichthyol 8.00
Petrolatum q. s. ad. 32.00
M. ft. ung. Sig. Apply over affected parts twice daily.
℞ Acid. carbol. 0.60
Acid. boric 2.00
Petrolatum q. s. ad. 32.00
M. ft. ung. Sig. Apply on chilblain once daily.
℞ Spirit. terebinthinae 2.00
Acid. boric 2.00
Petrolatum q. s. ad. 32.00
M. ft. ung. Sig. Apply on chilblain once daily.
Wet dressing of Burow’s Solution, diluted with equal parts of distilled
water, applied for a few days, produces satisfactory results in lesions
where there is marked inflammation and swelling.
In severe ulcerative processes that do not granulate readily, a strong
stimulant, such as balsam of Peru or some iodine preparation, should be
used until the entire area is healed.
After the skin has been healed, or in cases where the skin has not been
broken, the treatment varies with the severity of the lesion. In very
mild cases, massage followed by an application of the compound tincture
of benzoin, which, because it furnishes an occlusive coating and acts
as a support for the skin, is often sufficient. The liquor alumini
acetatis (Burow’s Solution) may be used as an astringent wet dressing
to reduce the swelling and inflammation. The part may also be painted
with a four per cent. solution of silver nitrate at frequent intervals,
to be then covered with raw cotton; or nitric acid, diluted with aqua
cinnamoni, 15 minims to the ounce, may be painted over the unbroken
skin.
A very satisfactory liniment which has been used extensively to relieve
the pain and reduce the inflammation in this condition consists of the
following:
℞ Guaiacol 8.
Spts. terebinth. 28.
Ol. olivae q. s. ad. 64.
M. ft. lin. Sig. Rub on affected parts at bedtime.
The itching, which is a marked symptom of chimatlon mild, can readily
be controlled by the application of camphorated soap liniment. Its
action is almost instantaneous.
Ichthyol has proven to be a valuable agent in the treatment of
chilblains; it may be used with collodion, or as an ointment, the
following being found satisfactory:
℞ Ichthyol 8.
Lanolin q. s. ad. 32.
M. ft. ung. Sig. Spread on gauze or lint and apply.
It must be borne in mind that the apparent cure of an acute lesion
of chimatlon mild, is not in reality an absolute cure, and thorough
precautions must be taken to prevent recurrence. Stimulation of the
cutaneous blood supply and the vasomotor nervous system is essential,
and for this purpose, massage and the alternate hot and cold foot baths
are advisable. The latter treatment should be used at least once daily
and if possible, twice a day. The feet should be kept in hot water for
thirty seconds and then plunged into cold water and kept there for
fifteen seconds. This is repeated for an entire ten minute period.
Electricity, in the form of the faradic or the high frequency
currents, may be used to assist in the stimulation of the action of
the skin. These treatments should be given for ten minutes, three times
a day.
The hygiene of the foot is all important, and this should be explained
at length to the patient. The feet should be protected by wearing
woolen or cashmere stockings, the latter being preferred, and should
be used from early in the fall until late in the spring. Hose of this
kind prevent heat radiation, so necessary for those who suffer from
chilblains; they also absorb excretory moisture, all of which prevents
recurrence of the lesions. It is necessary to conserve the body heat
as much as possible, and warm underclothing, covering the entire body,
should be worn; the patient should be instructed to take some form
of general exercise. Footgear should be wide enough to allow freedom
of the toes and the shoes should be made of either calf skin or vici
kid. The wearing of silk stockings and patent leather shoes must be
discouraged if good results are to be expected.
Where the skin is not broken, Dr. Charles T. St. Clair of Bluefield,
West Virginia, advises as follows: “coal oil (kerosene) applied night
and morning to old itching frost bites of the feet gives almost
immediate relief. It should be applied with a cloth and cotton soaked
in the kerosene and allowed to evaporate, which it will do in a few
minutes. If the sock is put on and the person goes to bed with the foot
still wet with the oil, it may burn the skin.”
CHIMATLON SEVERE
=Derivation.= Chimatlon, from the Greek, meaning the severity of
winter; severe, with extremely bad effects on the tissues.
=Synonyms.= Frost bite, pernio, dermatitis calorica.
=Definition.= Chimatlon severe is a local inflammation of the skin
and deeper structures, produced by exposure to extreme cold, and is a
result of complete or partial paralysis of the vasomotor nerves.
=Etiology.= The one cause for the severe form of chimatlon is
prolonged exposure to an extreme degree of cold. The decrease in
atmospheric temperature lowers the temperature of the parts exposed,
thereby causing complete or partial paralysis of the vasomotor nerves
and producing congelation of the blood vessels. When the congelation
is complete the parts are deprived of their nourishment, and finally
become devitalized.
=Symptoms.= Immediately after exposure, numbness develops and all
sensation is gradually lost. The parts are congealed and if there is
complete freezing, they present a white, blanched appearance. The
tissues affected may be so completely frozen, that upon thawing, they
are either found to be absolutely dead, or their vitality so greatly
impaired that there is very little reaction and gangrene may result in
a very short time. If the area is not completely frozen, the reaction
is rapid, the tissues become purple, swollen and very painful. The
parts may become gangrenous, in which case the line of demarcation and
separation between the gangrenous and the healthy tissues evidences
itself. The affected tissue is at first white but gradually becomes
blue and finally black. The fluids in the tissues rapidly evaporate and
the odor of decaying flesh is very apparent.
If the parts do not become gangrenous, the symptoms that present
themselves are those of inflammation. The tissues become swollen and
assume a deep purple color, which, as the circulation is restored,
becomes lighter and, after inflammation has subsided, gradually
disappears. Blebs may form and there may be an exudation of serum or
even of pus.
=Pathology.= The changes that occur in chimatlon severe are much
the same of those of the milder type, the former however, causing
complete destruction of tissue, or the development of gangrene. The
cold causes a constriction of the blood vessels and the stream within
them is retarded. The minute nerve terminals in the smaller arteries,
which control the dilation and constriction, are destroyed and their
function is lost. The vessels now contract and in extreme cases remain
so. Where the exposure has not been severe enough to cause complete
death of the vessels, there is a dilation after the contraction, with a
very slow movement or even complete stasis of the blood stream.
Gangrene or necrosis will manifest itself in extreme cases almost
immediately, and often after reaction has commenced, the tissues may be
cast off. At the line of demarcation between the normal and the dead
tissues, the changes that accompany inflammation take place.
=Diagnosis.= The diagnosis of frost bite is not very liable to be
confused with any other condition, in that the history shows exposure
to an extremely low temperature. The disease known as “Trench Foot,”
when it first manifested itself, during the world war, was considered
a form of chimatlon, but since research work has been done along
the lines of the new disease, it has been found to be quite another
condition. Trench Foot will be discussed following this chapter.
The color of the part is characteristic. Immediately after exposure,
the tissues are blanched, and as reaction progresses, the color deepens
from a light scarlet to a deep red purple or black, depending on the
length of the exposure and the severity of the condition. As reaction
advances, the gangrenous tissue is separated from the normal tissue by
a distinct slough, which, as previously stated, is known as the line of
demarcation.
The milder cases of frost bite and the severer cases of chilblains are
often confused, particularly in cases of the former when the loss of
tissue has been avoided. The confusion, although of no great moment
(inasmuch as the treatment of both lesions is identical), may be
avoided by remembering that frost bite develops quickly and that the
parts have been exposed to a very low temperature, while chilblains
develop more slowly, are less painful and do not require exposure to a
very great decrease in temperature for their causation.
=Prognosis.= When the part has been completely frozen and the
circulation to the parts has ceased, there is no possibility of saving
the tissues. However, in cases seen immediately after exposure, in
which proper treatment is commenced at once, it is often possible to
save large areas that would otherwise be lost. Amputation is the only
cure in cases where gangrene has developed. The ulcers which result
after the dead tissue has been removed, respond very slowly, requiring
from one to four months to heal.
Recurrence is the rule, due to the fact that the vasomotor nerves never
regain their normal vitality, and persons who have had frost bite will
develop symptoms from the least imaginable cause.
=Treatment.= In all cases of frost bite, even when the parts seem
hopelessly frozen, the first treatment should consist of bringing the
parts back to normal temperature by a gradual reaction. This should
be carried out as thoroughly as possible, for it often is the means
of saving large areas of tissue. A case in which the entire forefoot
is involved may be thus saved so that only one or two toes are lost.
Such a patient would be able to walk comfortably, whereas if no care
were taken with the preliminary treatment, the patient might become a
hopeless foot cripple.
A gradual reaction is brought about by rubbing the parts with snow or
cold water. The affected parts may be placed in a vessel containing
cold water, or they may be wrapped in cloths wrung out in cold water.
The final result depends largely upon the length of time elapsing
between the exposure and the inauguration of the first treatment.
If the parts are completely frozen, gangrene will soon manifest itself.
If the affected part is only partly frozen, a gradual reaction can
be brought about by the above-described means and if the subsequent
inflammatory reaction is gradual, gangrene may be averted or at least
limited. Cold water dressings should be continued for some time after
reaction has occurred, and should be maintained until the certainty
of the avoidance of gangrene is fixed. The line of demarcation and
separation will be indicative of this fact.
When all of the gangrenous tissue has separated, the remaining ulcer
should be treated just as though it had arisen from any cause. In
cases of gangrene of the toes and feet, complete or partial amputation
should be practised as soon as the lines of demarcation and separation
are well established. When gangrene has been avoided in frost bite,
the treatment consists in stimulating the affected area. Various
medicaments are useful, among which may be mentioned oil of turpentine,
balsam of Peru, tincture of iodine, ichthyol and strongly carbolized
ointments.
If the frost bite is of the bullous, pustular, vesicular or escharotic
type, soothing agents such as ichthyol, Burow’s solution, etc., should
be applied to the affected parts.
Wrapping the affected parts in dry salt has been suggested by a western
chiropodist, who claims to have obtained excellent results by the use
of this agent.
In cases where gangrene has been averted, the following have proved of
great value:
℞ Acid, carbol. 1.
Acid, boric 2.
Petrolat, q. s. ad. 32.
M. ft. ung. Sig. Apply every morning.
℞ Ichthyol 8.
Lanolin q. s. ad. 32.
M. ft. ung. Sig. Apply on lesions once daily.
℞ Ichthyol 8.
Aquae q. s. ad. 32.
M. Sig. Paint over the affected area.
In frost bite, after the gangrenous tissue has been removed, the
resulting ulcer may be treated with a stimulant. For this purpose
balsam of Peru, iodine, ichthyol and other agents have proven
successful. These ulcers do not respond readily, because of the
decrease in vitality of the surrounding tissues, and patience is
essential for a final cure. The patient must be told that the lesion
will require a long time to heal.
Hernance (Therapeutic Gazette, 1895) draws the following conclusions
from the study of thirty cases: “1. Ichthyol is the drug that
gives most relief to pain and is as good a protector as any other
application. 2. Acetanilid ointment is the best dressing when the
parts are raw and ulcerated, preventing suppuration and promoting
granulation. 3. In a certain number of cases one can do nothing but
keep the parts clean and wait until nature throws off the diseased
tissue.”
Massage is a very good therapeutic agent for chimatlon severe, and
should be applied twice a day, if possible. This will help stimulate
the circulation and tone up the faulty nerve endings. Electricity
should also be used wherever possible, the high frequency and the
faradic currents being the best. Applications directly to the affected
parts for ten minutes, once or twice a day, will aid materially in
bringing about a rapid cure.
The prevention of the recurrent attacks may be accomplished by
treatment commenced in the early fall, and including massage, proper
shoes, cashmere stockings, and other prophylactic measures. This
treatment is essential, particularly for those who are anemic and
under-nourished.