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Exam Preparatory Manual for Undergraduates—Surgery
First Edition: 2015
ISBN 978-93-5152-642-1
Printed at
Dedicated to
All the wonderful students who are going to be future doctors and who are the sole inspiration for writing this book
Foreword
In the MBBS training program, while there is a lot of stress on acquiring knowledge and skills, there is not enough emphasis on teaching students in handling the present format of theory question papers. Even ‘good’ students find a disconcerting ‘disconnect’ between the teaching-learning methods and the examinations. In teaching even the residents embarking on surgical careers, many of my colleagues and I, serving on medical school faculties across the country, were also all too aware of this disconnect.
This lovely book, expertly compiled by Dr Gunjan S Desai and his team, aims to bridge the gap between the standard teaching textbook and the theory questions that have to be answered by the student in his/her final summative examination.
Finally, this book is not meant to replace the standard textbooks of surgery, and, accordingly is not a comprehensive discussion of all surgical diseases. For an in-depth knowledge of surgical pathology, diagnosis and treatment, all students and especially the students embarking on surgical careers must first be thorough with a standard textbook of surgery before attempting to master this book.
I congratulate the authors on the successful outcome of their hard work and dedication, and hope the readers will find the book informative, useful and interesting to read.
Shaji Thomas MS Director–Professor Department of Surgery
Lady Hardinge Medical College
New Delhi, India
Words of Appreciation from the Masters in this Field
It gives me pleasure to learn that two of my students, Dr Gunjan S Desai and his team, have written a book Exam Preparatory Manual for Undergraduates—Surgery for MBBS students preparing for final professional surgery examination.
The book contains over 450 questions asked in various university examinations along with their answers in a simplified form.
I am hopeful that the book is helpful to the readers especially during revision phase of their preparation for final professional surgery examination.
I wish the authors and their readers all the best.
Ajay Kumar MS MCh FAIS FICS Director, Professor and Head Department of Surgery
Lady Hardinge Medical College New Delhi, India
Words of Appreciation from the Masters in this Field
The book Exam Preparatory Manual for Undergraduates—Surgery is a combined effort made by a group of hard working, intelligent and competent residents from various fields of surgery.
The book covers around 450 questions and answers along with over 100 illustrations covering various sections of surgery.
I am confident and hopeful that the book turns out to be of great help for undergraduate students preparing for final professional examination.
I praise the efforts made by the authors and wish their endeavor a grand success.
UK Shrivastava MS FAIS DHA
Former Professor of Surgery University College of Medical Sciences
Dean and Head, Surgical Discipline, Faculty of Medical Sciences Chairman, Board of Research and Studies, University of Delhi Former Professor and Head, AIMST University, Government of Malaysia
Preface
“Surgery has always been and would always be a tough job whether it is performing a procedure or learning how to perform it.”
When I entered the final year of MBBS, I faced this sentence for the first time. And now that I am a surgeon, I know how true it is. The reason is also slightly more obvious now. Just as there is no single standard technique to a single procedure, there is no single standard book to meet the university exam requirements.
My colleagues and I faced a great amount of difficulty in order to accumulate the material important for the final year MBBS university examination. Make the question lists of important questions, do peer reviews for the answers, search for authentic papers in net for answers and also the unauthentic material that we get hands-on during MBBS and finally when examinations came, we always thought that we were underprepared for the subject. The worst part of this exercise was not the reading part but the time that was spent in getting together the material to read.
The guidance in clinics is given for the cases and the practical part of the examination but not much is taught about the theory examination, which actually is necessary for the concept building. It is towards this end that I thought of writing this book as an aid to university examinations so as to make an effort to compile and accumulate all the material under one common heading. This book focuses more on the concepts that have been integral to getting the required knowledge of surgery and at the same time have a good compilation of all the university examination questions and their answers from authentic references.
So, I went in search of the appropriate people to help me in this herculean task and got together this splendid team of experts in this field and also experts at advising on the correct approach to master the concepts related to their field of interest in surgery. I thank all the team members for their hard work and contribution. Their insight in their sections in this book is definitely going to help everyone who uses this book.
The topics in this book are important for the university examinations and also important topics have been given a prolonged discussion to aid in the understanding of the topics. Also, the important conceptual points on clinical topics have been included for the student’s benefit. I am sure that this book will be of great help to all the undergraduates, would save a lot of their time and effort and would make learning surgery fun.
Gunjan S Desai
Acknowledgments
We would like to thank the Almighty, our parents and family members, our teachers and all our seniors, colleagues and friends without whose support; this book would not have been possible.
We also thank Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President) and Mr Tarun Duneja (Director–Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, at the outset as without their support; this would have been a rather difficult task to accomplish. A special thanks also to Dr Sriram Bhat for contributing a few of the illustrations in this book.
Section 1: General Surgery 1
Wound Healing 3
Mechanisms of wound healing 3
Chronic nonhealing of a wound 5
Wound dressings 7
Pressure sore 9
Keloids and hypertrophic scar 11
Fluid, Electrolyte and Acid-Base Imbalance 12
Normal water distribution in body 12
Hyponatremia 13
Hypernatremia 14
Hypokalemia 15
Hyperkalemia 16
Steps of diagnoses of an acid-base disorder 17
Metabolic acidoses 18
Metabolic alkaloses 19
Plasma expanders 19
Metabolism and Nutrition 20
Endocrine and metabolic response to stress/ surgery/injury 20
Nutritional assessment 23
Total parenteral nutrition 24
Enteral nutrition 25
Blood Transfusion and DIC 27
DIC (Disseminated intravascular coagulation) 27
Blood “substitutes” 29
Blood components 30
Complications of blood transfusion 31
Plasmapheresis 33
SIRS, Shock and MODS 34
Classification of shock 34
Septic shock 35
MODS (multiple organ dysfunction syndrome) 35
Hemmorhagic shock 38
Lethal triad 38
Basic of Surgical Technologies and Advanced Surgery 40
Open and laparoscopic anatomy of inguinal region 243
Direct and indirect hernia 247
Femoral hernia 251
Gastrointestinal Oncosurgery 253
Esophageal cancer 253
Carcinoma stomach 255
GE junction tumors 258
Small bowel adenocarcinoma 259
Carcinoid tumor 259
Gastrointestinal stromal tumor 263
Colorectal cancer 265
Carcinoma anal canal 271
Hepatocellular carcinoma 271
Carcinoma gallbladder 273
Cholangiocarcinoma 276
Pancreatic cancer 277
Pseudomyxoma peritonei 278
Miscellaneous 280
Burst abdomen 280
Peritonitis 282
Mesenteric cyst 283
Section 3: Genitourology
Kidney and Ureter
Renal calculi 287
Calculus anuria 289
ESWL 291
PCNL 292
Percutaneous nephrostomy 293
Urinary diversion 293
Renal TB 294
Renal trauma 297
Hematuria 300
Pyelonephritis 302
Pyonephrosis 304
Hydronephrosis 304
Wilms’ tumor 305
Horse shoe kidney 307
PUJ obstruction 308
Classification of renal lumps 309
Urinary Bladder 311
Bladder calculi 311
Bladder injury 312
Vesicovaginal fistula 313
Micturition reflex 315
Neurogenic bladder 315
Incontinence 317
Chyluria 318
Vesicoureteric reflux 319
Ectopia vesicae 320
Prostate 321
LUTS 322
Benign prostatic hypertrophy 322
TURP 322
Postoperative urinary retention 325
PSA 327
Testis and Scrotum 328
Development of testis 328
Cryptorchidism 328
Testicular torsion 330
Epididymoorchitis 332
Varicocele 333
Hydrocele 334
Fournier’s gangrene 334
Differential diagnoses of a scrotal swelling 335
Phimoses and paraphimoses 336
Vasectomy 337
Circumcision 338
Penis and Urethra 339
Penile ulcer 339
Urethral injury 340
Urethral stricture 342
Lasers in urology 343
Posterior urethral valve 344
Proteinuria 345
Male infertility 346
Development of genitourinary tract 348
Hypospadias 350
Uro-oncology 351
Renal cell carcinoma 351
Urinary bladder cancer 355
Carcinoma testis 357
Carcinoma penis 361
Carcinoma prostate 364
Section 4: Neurosurgery 367
Physiology of CSF and its circulation 369
Hydrocephalus 369
Criteria for brain death 373
Head injury pathophysiology 374
Glasgow coma scale (GCS) 376
Monitoring of a head injury patient 376
CT scan in a patient with head injury 376
Management of head injury 378
Epidural hematomas 380
Subdural hematoma 382
Spina bifida 384
Functional neurosurgery 386
Stereotactic surgery 387
Neurofibroma 389
Intracranial space occupying lesions 390
Section 5: Cardiothoracic and Vascular Surgery 393
Cardiac and Thoracic Surgery 395
Empyema thoracis 395
Pneumothorax 396
Hemothorax 398
Cardiac tamponade 399
Cardiac arrest 400
Intercostal drainage 401
Peripheral Arterial Disease for Lower Limb 403
Anatomy 403
Risk factors 403
Clinical features and investigations 404
Acute lower limb ischemia 404
Gangrene 408
Management 409
Critical limb ischemia 409
Buerger disease 411
Amputation 412
Sympathectomy 414
Omental transfer operations 414
Endovascular management 415
Diabetic foot 416
Peripheral Venous Diseases 419
Anatomy 419
Varicose veins 420
Deep vein thrombosis 424
Raynaud phenomenon 425
Miscellaneuos Topics In CTVS 426
Thoracic outlet syndrome 426
Lymphedema of lower limb 426
Hodgkin’s and non-Hodgkin’s lymphoma 430
Unilateral lower limb edema 431
Section 6: Breast and Endocrine Surgery
Blood supply and lymphatic drainage 437
Nipple discharge 438
ANDI (Aberrations of normal development and involution) 440
Mammary duct ectasia 441
Phylloides tumor 441
Paget’s disease of nipple 442
Gynecomastia 443
LCIS and DCIS 444
Triple breast assessment 446
Risk factors for breast cancer 446
Breast conservative surgery 447
Management of locally advanced breast cancer 449
Breast reconstruction 451
Thyroid 454
Embryology of thyroid and parathyroid 454
Thyroglossal cyst and fistula 455
Classification of thyroid swellings 456
Papillary thyroid cancer 457
Follicular thyroid cancer 459
Medullary thyroid cancer 460
Solitary thyroid nodule 461
Grave’s disease 462
Complications of thyroidectomy 464
Parathyroid and Adrenal 465
Primary hyperparathyroidism 465
Adrenal incidentaloma 466
Section 7: Surgical Radiology 469
Computed tomography (CT) 471
Ultrasound 473
Doppler ultrasound 476
Magnetic resonance imaging (MRI) 478
PET scan 481
Intravenous pyelography (IVP) 484
Micturating cystourethrogram (MCU) 487
ERCP 488
MRCP 491
Radioisotope bone scan 493
Thyroid scan 496
DMSA and DTPA scan 499
Mammography and BIRADS 502
FAST 503
Radiological features of acute intestinal obstruction 510
Barium swallow in esophageal disorders 513
Section 8: Miscellaneous Topics 523
Anesthesia 525
Pre-anesthetic medication 525
ASA grade 525
Muscle relaxants 526
Mivacurium 526
Succinylcholine 526
Regional anesthesia 528
Spinal regional anesthesia 530
Local anesthetic drugs 530
Epidural anesthesia 531
Epidural analgesia 531
Brachial plexus block 533
Caudal block 533
Cervical blocks 534
Nerve block and field block 535
General anesthetic drugs 535
Halothane 535
Propofol 535
Postoperative ventilation 537
Complications of general anesthesia 538
Central venous pressure monitoring 539
Skin 540
Premalignant skin lesions 540
Squamous cell cancer 540
Basal cell carcinoma 541
Pigmented nevus 546
Melanocytic nevi 546
Malignant melanoma 547
Burns and Plastic Surgery 549
Skin grafts and flaps 549
Phases of ‘take’ of graft 549
Types of burns 553
Assessment of burns 553
Prehospital care 554
40% TBSA burns management 554
Inhalational injuries in a burn patient 554
Pathophysiology of thermal burns 557
Development of lip and palate 558
Cleft lip and cleft palate 558
Head and Neck Surgery 560
Anatomy of neck 560
Epulis 562
Adamantinoma 562
Premalignant lesions of the oral cavity 564
Cystic hygroma 565
Hemangioma 566
Branchial cyst and fistula 567
Ranula 568
Oncosurgery Basics
Immunotherapy in cancer 569
Immunosupressants drugs 571
Cancer prevention 573
Tumor markers 574
Oncogenes 575
Tumor suppressor genes 576
Sacrococcygeal teratoma 577
569
Further Reading 579
How and When to Prepare for University Examination: An Overview
Before we begin the journey into the field of surgery, we would like to congratulate all the readers to reach this stage in their medical career. The final year of MBBS is a tough year in all aspects of health—mental, physical and emotional and to remain healthy, you need proper planning and a good schedule to study and relax at appropriate times.
This book is a long sought solution to remaining “healthy” while preparing one big aspect of your final year—surgery: The subject with maximum mortality and morbidity in the MBBS field. Also, the subject is asked in different ways in examination and often is found tough to conquer. We are giving a schema to tackle this subject and this section is followed by all the important topics worth revising before examination and for entrance examination.
The best way to start the subject is to start as early as possible. Whenever you read any subject in MBBS, you need to decide two books for that subject—one with the details and one to get you through the examination. The book with details should be good enough to give you the basics and a grasp of subject with in-depth discussion of all the topics important for learning the subject. On the other hand, you also need a book to help in rapid revision and quick accumulation of various exam-oriented topics in the subject according to the university examination scheme to get you through the examination.
Love and Bailey/Schwartz/Sabiston Textbook of Surgery are considered standard descriptive books of surgery and are excellent to gain in-depth knowledge of the field but difficult to digest and revise at examination time. The list also extends to include SRB’s Manual of Surgery, Manipal Text of Surgery, Das Concise Text of Surgery and many more. These books are descriptive and provide excellent insight regarding most of the topics of surgery even for postgraduates. This creates a rather difficult situation because both undergraduates and postgraduates are than reading the same basic material which does not seem right... Isn’t it? Especially during examination, when you have to revise the book that you have first read, Harrison in Medicine and Bailey in Surgery, it is a tough task to complete, also with the thought in mind that you have other subjects to look after.
So, it is our advise to keep one textbook that suits you from the above options as a reference and this book since you start reading surgery and not just as a last resort book as this will help in rapid revision during the examination as well as necessary in-depth discussion of important topics as per undergraduate level.
How this book will help you in your preparation of surgery?
y It will help you in gaining the requisite knowledge of all important topics of the field of surgery as per the last 10 years of university papers as well as recent topics, which are prospective questions in the years to come.
y This book also will provide you with the important and less frequently dealt topics of Anesthesia and Radiology that are not discussed in descriptive books and that need to be searched at examination times and create unnecessary waste of time and stress.
y Also, all the answers are from latest editions of best surgical books so as to help you in clearing the surgery part of your MCQ preparation.
y Because of the concise nature, it will help in rapid revision and will save time for other subjects. So, begin early, read a descriptive book and a question-answer pattern book like ours to quickly revise and orient yourselves to all the important topics of the subject. This pattern of studies will give you the necessary confidence that you know the basics and also be equipped to clear the examinations without much duress. Apply this pattern to all the subjects to gain maximum benefit.
SECTION 1
General Surgery
y Wound Healing
y Fluid, Electrolyte and Acid-Base Imbalance
y Metabolism and Nutrition
y Blood Transfusion and DIC
y SIRS, Shock and MODS
y Basic of Surgical Technologies and Advanced Surgery
y Surgical Infections
y Trauma and Damage Control Surgery
y Perioperative Surgery
y Surgery of the Salivary Glands
y Miscellaneous General Surgery Topics of Importance
y Medicine in Surgery
WOUND HEALING
Q1. Write a note on mechanisms of wound healing.
What are the phases of wound healing? Discuss in brief.
Enumerate the phases and types of wound healing.
Ans. Wound means the disruption of cellular and anatomic continuity of tissue.
Goals of wound healing:
y Regeneration (recovery of full structure and function without scarring)
y Seen only in bone and liver.
Phases of wound healing
1. Inflammation (1–3 days) y Hemostasis, chemotaxis, epithelial migration
y Form fibrinous exudates/eschar
y Chronic wounds become stalled in this phase
2. Proliferation (3 days to 3 weeks) y Proliferation of endothelial cells, smooth muscle cells and fibroblasts
3. Maturation (3 weeks onwards)
Phase 1
y Granulation tissue
y Contraction of wound edge
y Scar and scar remodelling
y Tissue injury causes activation of stromal cells and keratinocytes which on activation release macrophage chemoattractant protein (CCL 2), interleukin 8 (CXCL 8), CXCL 4,10 which are potent chemotactic for neutrophils
y Of these, CCL2, CXCl8 and 10 are elevated chronically in chronic wounds therefore keeping it in inflammatory phase.
y Interleukin 8 is low in fetal wounds which accounts for healing of wound with minimal inflammation and no scarring in fetal age
y C5a, leukotriene B4, C4 and D4 directly and via release of platelet aggregating factor from endothelium (thrombin mediates the stimulation of the endothelial cells to secrete PAF, interleukin1 and TNF) cause adhesion of the chemoattracted neutrophils. Interleukins and TNF are also released from monocytes and macrophages which also aid in this process
y Next after adhesion is migration of cells in extracellular matrix. Migration has phases of adhesion, spreading, contraction and retraction which are mediated by collagen, laminin and fibronectin in ECM with integrans on the cells
y Thus, by this mechanism, neutrophils finally reach the wound and mediate intracellular bacterial killing
y The role of these PMNs is only removal of contamination. It has no effect and no role in the process of wound healing.
One important event in this phase is of epithelialisation which has the phases of detachment migration, proliferation, differentiation and stratification and is mediated by EGF, KGF and TGF alfa.
Phase 2
y Macrophages are the effector cells of this phase
y Bacterial products, complement degradation products, C5a, thrombin, fibronectin, collagen, TGF beta and PDGF BB are all chemotactic for macrophages. Thus, the macrophages reach the wound site and mediate effects as follows:
– Macrophages release interleukin 2, collagenase, elastase and in the presence of lipopolysaccharide, macrophage releases free radicles and mediate phagocytosis
– It releases FGF, VEGF, TNF alfa and stimulates endothelial cell proliferation and angiogenesis
– It also releases PDGF, EGF, IGF-1 and TGF beta and stimulates fibroplasias and collagen, elastin and glycosaminoglycan synthesis
– It induces apoptosis of PMN
– Releases IL1 alfa and therefore produces a febrile response.
y Lymphocytes
– T lymphocytes induce fibroplasias by releasing TGF beta and TNF alfa
– They also release interferon gamma and mediate effects such as downregulation of prostaglandin synthesis
– Macrophage activation to release TNF alfa and IL1
– Decrease collagen synthesis and keep macrophages in the wound
– Interferon gamma is thus another important mediator in chronic non healing wound
– B lymphocytes have no role in wound healing but are involved in downregulating wound healing once the wound closes.
Two important events in proliferation phase are angiogenesis and fibroplasias
Angiogenesis
y Activated endothelial cells degrade basement membrane of post capillary venules by release of plasmin and matrix metalloproteinases
y PDGF, TGF beta, FGF mediate migration of detached endothelial cells through these gaps and division resulting in tubule or lumen formation
y These tubules are then covered by deposition of basement membrane and capillary forms
y Important mediators include PECAM 1 which mediates endothelial cell-endothelial cell interaction and mediate cell-cell contact and beta1 integrin receptors which form tight junctions and stabilise the contacts developed by PECAM1 and lead to formation of capillaries, arterioles and venules
y Cell disruption and hypoxia are strong inducers of the angiogenic factors—VEGF (member of PDGF family) and PDGF are proangiogenic factors
y Timeline of angiogenesis
– FGF2 provides the initial angiogenic stimulus at day 3
– VEGF provides delayed and prolonged stimulus between days 4 to 7
– TGF alfa and EGF causes cell proliferation
– TNF alfa promotes formation of the capillary tube by increasing HIF 1 alfa which leads to increase in NO and VEGF during days 1 to 5.
Phase 3
– PDGF and FGF causes fibroblasts to become active which are called stimulated fibroblasts or myofibroblasts which then mediate this phase
– Actin appears at day 6 after wounding, persists at high levels till 15 days and then disappears by 4th week
– Matrix metalloproteinases are important in wound remodelling and contraction of all these, MMP 3 (stromelysin) is particularly important
– Epidermodermal interface in healed wound is devoid of rete pegs and therefore have increased fragility and avulsion after minnow trauma.
Types of wound healing
y 1st intention (Primary) healing: Well approximated edges of incised wound heal by this way
y 2nd intention (Secondary) healing: The wound is left open and allowed to heal on its own
y 3rd intention (Tertiary) healing (Delayed primary closure): The wound is initially left open for dressing and then closed after few days.
Q2. Write a note on pathophysiology and management of chronic nonhealing wound/ulcer in lower limb.
Enumerate the causes for the chronic nonhealing of a wound.
Ans. Chronic wounds are wounds greater than 3 months.
These are the wounds which fail to proceed to functional and anatomic integrity over a period of 3 months.
Pathology
y Chronic wounds become stalled in inflammatory phase
y CCL2, CXCL 8 and 10 are elevated chronically in chronic wounds therefore keeping it in inflammatory phase
y Also increased levels of Interleukin 8, TNF alfa, Interleukin 1 and interferon gamma in these wounds along with increased MMP1,2,8,9 and decreased TIMP (inhibitor of matrix metalloproteinases) lead to decreased adhesion molecule expression, decreased cell migration, decreased growth factors and increased breakdown of products.
y This leads to increased inflammation and collagen degradation rather than collagen synthesis.
Causes of nonhealing of wound
y Local infection is the most important factor to drive these mediators. Organism count >105/g or single beta hemolytic streptococci are the most detrimental factors hindering wound healing. Other important causes for chronic nonhealing of wound include:
– Hypoxia, anemia
– Diabetes due to repeated trauma, tissue hypoxia due to vasculopathy, decreased VEGF/PDGF and HIF 1 alfa
y Ischemic arterial ulcers and wounds—manages with revascularisation and wound care
y Venous stasis ulcers (post-thrombotic leg)—includes zinc oxide impregnated dressings with compression/4 layered dressing. Wound care is the most important aspect in venous stasis ulcer and is managed according to Bisgaord’s regime. Surgery does not hasten or aid in wound healing (ESCHAR trial)
y Diabetic wounds management
y Pressure/decubitus ulcer management
y Foreign body in wound
y Neuropathic ulcers (sensory loss).
Other causes include
y Skin malignancy and marjolin’s ulcer
y Vasculitis (SLE, PAN, rheumatoid arthritis)
y Osteomyelitis leading to chronic discharging sinus
y Infective causes, such as meliodoses, nontubercular mycobacteria (M. fortuitum and M. ulcerans cause bairnsdale/buruli ulcer, actinomycosis, MRSA)
y Immunosupression (AIDS).
General management measures include
y History and physical examination
y Optimisation of general condition of the patient
y Ulcer edge biopsy/bone biopsy
y Chest X-ray/Mantoux testing
y Duplex imaging
y X-rays and MRI of the involved limb
y Treatment of underlying cause.
Nonhealing wound local management
y Goal is to convert wound from infected to clean to healing wound
y Dirty nonhealing wound should be evaluated under anesthesia, debrided as required, irrigated with free flowing saline and then hemostasis secured. Betadine is then applied on surrounding healthy skin and wound is dressed
y Tetanus prophylaxis and antibiotics should be administered as needed
y Routine dressings and maintenance of local hygiene is important to aid in wound healing
y If the wound is healing properly, then these measures are enough to promote wound healing
y If inspite of all the measures, the wound does not gets healed and all causes have been excluded, wound should be finally closed using biological dressings/excision and skin grafting.
Q3. Enlist the factors affecting wound healing (discussed in que. Management of nonhealing wound and listed here).
Ans.
y Anatomic Site: Fastest in areas of greatest blood supply (face and neck)
y Weight: Fat most vulnerable tissue to trauma due to poor blood supply
y Age of wound: Delayed healing, less wound strength
y Oxygen: Wound PO2, hyperbaric O2
y Infection: Local or systemic
y Age of patient: Fetal wounds heal the best > neonatal wound > adult wounds This is because of intrinsic fetal factors such as increased prolyl hydroxylase activity in fetal fibroblasts and extrinsic such as hyaluronan rich amniotic fluid
y Medication: Chemotherapy, steroids
y Local factors: Wound tension, foreign body, dead or devitalized tissue, excessive exudates.
y Nutritional status: Protein, zinc, vitamins, hypoalbuminemia (<2 g/dL)
y Nature of wound: Contusion, abrasion, laceration
y Chronic disease: Diabetes, cirrhosis, jaundice
y Smoking: Nicotine induced vasoconstriction, toxins, metalloproteinase stimulation
y Radiation therapy: Stasis and vessel occlusion
y Hydration: Moist wound heals faster
y Growth factors: Endogenous or exogenous growth factors stimulate wound healing. It is an area of active research—however, no magic bullet to date has been identified.
y Congenital disorders: Epidermolysis bullosa, Ehlers-Danlos syndrome, osteogenesis imperfecta
y Malignancy, hypothyroidism.
Q4. Discuss the types of wound dressings. Write a note on skin substitutes.
Ans.
Aim:
y To provide warm, moist and clean environment
y Barrier to bacteria and excess exudates should be removed
y Easy to use
y Cost effective
y Mechanical protection
Classes
Absorptive dressings
y Absorb excess exudates
y Disadvantages: Dressing becomes less effective when saturated and re-epithelialization is two times slower than occlusive dressings
Occlusive dressings
y Mechanical protection
y Moisture retention
y Barrier to bacteria
y Provides mildly acidic pH and low oxygen tension which increases growth of fibroblasts and formation of granulation tissue.
Occlusive nonbiologic dressings
y Hydrogels (polyethylene oxide)
y Alginate (sea weed)
y Hydrocolloids [gelatine, pectin, carboxymethyl cellulose (Duoderm)]
y Hydrocolloids are better than simple films because they have some absorptive properties.
Occlusive Biologic dressings
1. Homograft/allograft—genetically identical to human beings
2. Xenograft—pig skin most common, others include bovine tendon collagen
3. Amnion—human placenta
4. Skin substitutes: Skin substitutes are biologic dressings that provide:
a. A structural support and
b. A scaffolding for regeneration
a. Integra (Bilayered)
- Silicone membrane on atmospheric side and bovine tendon collagen with chondroitin-6-sulphate on wound side
- Serves as a dermal template to induce fibroblast proliferation, granulation tissue formation and vascularization
- Once new collagen and dermal granulation is formed the silicone layer is removed and allograft is placed over it.
b. Alloderm
- Acellular dermal matrix from donated human skin
- Works same as integra by providing template for dermal formation. However, it would not provide a dermal matrix to support skin graft and therefore is inferior to integra.
c. Apligraf
- Living bilayered membrane to simulate human skin
- Neonatally derived dermal fibroblasts are cultured in collagen matrix for 6 days to form neodermis
- Human keratinocytes are then cultured on top of this neodermis
- This dressing contains cytokines and matrix but does not have melanocytes, macrophages, lymphocytes, Langerhan’s cells or adnexa.
Creams, ointments and special solutions
Indications for their application include:
y Increased exudates
y Cellulitis
y Quantitative culture shows >105 organisms/gram of tissue. For example, include zinc oxide, silver nitrate, bacitracin, neosporin, acetic acid and growth factors.
Q5. What is pressure sore? Discuss its management.
Ans.
Definition: A sore area of skin that develops when the blood supply to it is cut off for more than two to three hours due to pressure on it and lack of movement.
Main causative factors thus include:
y Mechanical effects of prolonged pressure
y Shearing forces
y Prolonged immobilization
Grading
NPUAP staging system for pressure ulcers
I Intact skin with nonblanchable redness of a localized area, usually over a bony prominence
II Partial thickness loss of dermis appearing as a shallow, open ulcer with a red-pink wound bed and slough may also appear as an intact or open/ ruptured serum-filled blister
III Full-thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscles are not exposed
IV Full-thickness tissue loss with exposed bone, tendon or muscle Contd...
Contd...
Unstageable Full-thickness tissue loss with the base of the ulcer covered by slough (yellow, tan, gray, green or brown) or eschar (tan, brown, or black) in the wound bed
Deep tissue injury localized area of discolored, intact skin or blood-filled blister caused by damage to underlying soft tissue from pressure or shear
Management
General measures
y Air mattress/water bed
y Frequent change of posture
y Avoiding soiling by incontinence or drooling
y Nutrition of patient should be taken care of
y Immunonutrition
y Protection of all pressure points by glove balloons
y Release and treatment of contractures
Grade 1 and 2—general measures and moist dressings will take care of most of these pressure sores.
Options in treatment of grade 3 and 4 pressure ulcers
As mentioned above, pressure sore grade 1 and 2 are managed with dressings and general supportive measures, whereas grade 3 and 4 usually require some form of reconstructive option once osteomyelitis or deep soft tissue infections are ruled out.
Direct closure and skin grafting don’t serve much role in these grades of pressure sore.
Options thus include
Sacral
Ischial
Trochanteric
Gluteus maximus myocutaneous flap
Gluteal fasciocutaneous rotational or advancement flap
Gluteus maximus myocutaneous flap
Hamstring V-Y myocutaneous flap
Posterior thigh flap based on inferior gluteal artery
Tensor fascia lata advancement flap
Rectus femoris flap
Vastus lateralis myocutaneous flap
Unsalvageable Hip disarticulation with tissue closure
Intraoperative
y During surgery in patients with spinal cord injury, especially T5 or higher, care should be taken to avoid autonomic hyperreflexia while doing manipulation of pressure ulcer
y Flaps should be larger than wound and suture line should be far away from pressure points.
Postoperative care
y Air mattress for 7 to 10 days
y Care while position changes
y Ischial flap—do not sit for 6 weeks
y Nutrition and muscle spasm control.
Q6. Write a note on keloids.
Differentiate between keloid and hypertrophic scar. Ans.
Keloid
y Genetic predilection is present
y Predilection for darkly pigmented skin
y No specific causative factors
y Proliferation of immature fibroblasts and blood vessels with disordered collagen synthesis
Hypertrophic scar
y Not present
y No such predilection
y Foreign body in wound, wound infection, suturing under tension predispose
Pathology
y Proliferation of mature fibroblasts and blood vessels and organized collagen synthesis
y Increased expression of TGF beta 1 and 2 with irreversible changes in extracellular matrix production
y Center of keloid lesions contain a paucity of cells
y Has increased vascularity
y Hyperproliferation with normalisation on removing the causative factors
y No such feature. Cells are uniformly distributed
y No increase in vascularity
Clinical features
y Females are more commonly affected
y Occurs more commonly in a triangular region bordered by both shoulders and sternum
y Grows beyond the borders of the original wound
y Claw like extensions from the primary lesion are common
y Itchy lesions
y Can be painful and tender
y No sex predilection
y No site predilection
y Confined to boundary of wound
y No extensions occur beyond the wound
y Non-itchy lesions
y No pain or tenderness
Natural history and prevention
y Never regress spontaneously
y Cannot be prevented
y Difficult to treat
y Recurrences are very common
y Regress spontaneously after 6–8 months
y Can be prevented if causative factors are taken care of
y Easy to treat
y Does not recur
Common points
y Both are hyperproliferation disorders with collagen abundance due to an imbalance between collagen synthesis and degradation
y Both have stretched collagen fibers along the same plane as epidermis
y Scars perpendicular to the direction of muscle fibers tend to be flatter and less chance of hypertrophic scars.
Contd...
Keloid
Hypertrophic scar
Prevention
Postsurgery scar managemnt with silicone sheeting/triamcinolone acetonide at 6 weeks intervals/topical imiquimod cream or 5-Fluorouracil/pulsed dye lasers have the best outcome
y First line treatment
− Triple therapy with surgery, steroid and silicone sheeting
Excision pulsed dye laser
Pressure therapy for 6 to 12 months
Intralesional steroid
Cryotherapy
Combination of either of these
y Second line treatment
Radiation
Bleomycin therapy and tattooing
Interferon alfa-2, intralesional verapamil with surgery and silicone sheeting
Mederma gel (Onion extract gel with silicone)
FLUID, ELECTROLYTE AND ACID-BASE BALANCE
Q7. Write a note on fluid balance in patients and surgery. Explain the normal water distribution in body.
Ans.
y Total body water—60% of total body weight in males and 50% of total body weight in females (as females have more subcutaneous fat), most water is in skeletal muscles
y Of the total body water
– 40% is intracellular
– 15% is interstitial [includes 2% transcellular (water in CSF and joint spaces)]. The interstitial water has a rapidly equilibrating component and slowly equilibrating transcellular component
y The tendency of solute exchange is determined by osmolarity
y The tendency of water exchange is determined by tonicity
y Tonicity is thus relative osmotic activity of two solutions, e.g. azotemia is a hyperosmotic condition but not a hypertonic condition
y Therefore osmolarity of the extracellular fluid is determined primarily by sodium, whereas the effective osmotic pressure between plasma and interstitium is determined by nondiffusible proteins and tonicity = 2 sodium + glucose/18
y Osmolar gap = measured – calculated osmolarity which is due to ethanol, methanol, ethylene glycol and unidentified toxins
y Major intracellular cations include potassium, calcium and major intracellular anions include proteins and phosphates.
y Major extracellular cation include sodium and anions include chloride and bicarbonate.
Fluid losses and gain in body
Intake
Urine
mL/day
Insensible loss 600 mL/day (75% from skin, 25% from lungs)
Stool
Important electrolyte values to remember
mL/day
Q8. Enumerate the causes of hyponatremia.
Discuss the clinical features and management of a patient with hyponatremia.
Ans. Normal level—135 to 145 mmol/L
Causes
Renal
y Diuretics
y Mineralocorticoid deficiency
y Osmotic diuresis (Glucose, mannitol, urea)
y Renal tubular acidoses
Extrarenal
y Vomiting
y Diarrhea
y Burns
y Pancreatitis
y Rhabdomyolysis
Clinical features
y Headache, confusion
SIADH
Hypothyroidism
Psychogenic polydipsia
Glucocorticoid deficiency
Nephrotic syndrome
Congestive cardiac failure
Cirrhosis
Acute and chronic renal failure
y Weakness, fatigue, muscle cramps
y Anorexia, nausea, vomiting, watery diarrhea, lacrimation, salivation
y Hypertension, bradycardia, oliguria
Management
y Hypovolemic hyponatremia: Isotonic saline administration
y Euvolemic hyponatremia: Water restriction
y Hypervolemic hyponatremia: Sodium and water restriction
y Free water excess should be corrected first and then correction of low sodium
y If neurological symptoms are present, they should be treated with 3% saline
y Otherwise, treat with 0.9% saline and the rate of treatment should not exceed 12 mEq/L/ day as rapid correction can lead to central pontine myelinolysis now better known as osmotic demyelination syndrome which can have both pontine and/or extrapontine myelinolysis which causes seizures, weakness, akinetic movements and finally permanent brain damage
y Formula for sodium deficit calculation
y Sodium deficit = total body water (130 – measured) Volume—sodium deficit/154 (saline in liters)
Q9. Enumerate the causes of hypernatremia.
Discuss the clinical features and management of a patient with hypernatremia.
Ans.
Causes
Sodium and water loss
Renal
y Loop diuretics
y Osmotic diuresis (Glucose, mannitol, urea)
Extrarenal
y Diarrhea
y Burns
y Nasogastric aspirations
Clinical features
Euvolemic hyponatremia
Diabetes insipidus
Insensible losses from skin and respiratory tract
Psychogenic hypodipsia
Water and sodium excess (Sodium >> water)
Primary aldosteronism
Cushing syndrome
Hypertonic dialysis
Bicarbonate infusion
y Restlessness, ataxia, lethargy, irritability, tonic spasm, delirium, coma
y Weakness, oliguria
y Dry sticky mucus membrane, red swollen tongue, decreased saliva and tears
y Tachycardia and hypotension
Management
y Initially, water deficit should be corrected first then, hypernatremia correction is decided by following formula:
– Water deficit (liters) = total body water (sodium – 140)/140.
y Again, correction should not be done at a rate greater than 12 mEq/L/day.
Potassium balance is very important topic both for exams and for managing patients in clinics and therefore is explained in detail.
Normal potassium homeostasis (Normal—3.5–4.5 mEq/L)
y Total body potassium = 50 mEq/kg body weight. Extracellular is 2% of this and only 0.4% is in plasma. Rest is intracellular.
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The brown stain rapidly succumbed to Goody’s treatment with vinegar. Garde emerged from the mask as rosy and cream white as an apple, for the open air and the days with Adam had wrought such evidence of health and happiness upon her that not the dread of what she might discover at home, nor any excitement of being in the land of her enemy, could make any paleness in her face of more than a moment’s duration. She was too excited to eat, although Goody tried to urge her to take even a cup of tea, and so she went on to her grandfather’s house, and let herself in, at the rear.
As Granther Donner’s sister had passed away a number of years before, he had been left quite to himself when Garde decamped. But when his illness came so suddenly upon him, Mrs. Soam and Prudence, both persuaded that Garde was almost, if not entirely, in the right, appeared dutifully at his bedside as ministering angels.
Thus Garde, upon entering the kitchen, found her Aunt Gertrude engaged in preparing a breakfast. The good lady was startled.
“Why—Garde!” she gasped. “Oh, dear me, is it really you? Child, where have you been? Oh, David is very ill indeed. I am so glad you have come home!”
“I came because I heard he was ill,” said Garde, who was more calm than might have been expected. “I didn’t know you were here. It was real good of you to come, dear aunty. I suppose you will scold me.”
“It was all a terrible thing,” said her aunt, “but John says he thinks Mr. Randolph meant to take away our charter anyway.”
“Oh, I am sure of it!” cried Garde, so glad to hear of a partisan. “If I hadn’t believed that, I don’t think I should ever have run away. Oh, thank you, so much, dear aunty! I am so glad. God bless Uncle John! I knew I was right!”
“But your uncle and all of us are very sad,” her aunt proceeded to add. “They don’t think we will have the charter through the summer. It is a terrible time, but they all say that Randolph must have been getting ready, or he couldn’t have done so much so quickly. It is a
sad day for Massachusetts. But, there, run in and see David, do,— but, dearie, don’t be surprised if he doesn’t seem to know you.”
In the dining-room Garde and Prudence met, a moment later
“Good morning, Garde,” said the cousin, without the slightest sign of emotion.
Garde kissed her, impulsively. “Oh, I am so glad to see you, dear!” she said. Indeed love had so wrought upon her that she felt she had never so cared for any one before as she did for all these dear ones now.
She hastened on to her grandfather, and Prudence was left there, looking where her cousin had gone and solemnly wishing she also might do something emotional and startling.
But a few hours only sufficed to reduce the spirit of wildness and youthful exhilaration which Garde had brought with her back from the road in the forest. To hear the old patriot raving, childishly, and crying and praying over the charter and over Garde as a baby, which was the way he seemed to remember his grandchild, was a thing that rent her heart and drove all joy from the life of care into which she came, in her mood of penitence and quiet.
The days slipped by and became weeks. Prudence returned to her father at once. Goodwife Soam remained to help Garde over the crisis, and then she too left the girl with the stricken old man, who had become a prattling child, on whom the word “Charter” acted like a shock to make him instantly insane against his daughter’s child.
In the meantime Adam Rust, having come to Boston in a moment when excitement, despair and bitter feeling, such as the town nor the colony had ever known before, and which completely altered the Puritan people, had heard a garbled story of Randolph’s perfidy and his attempt to marry Garde which made his blood boil. Fortunately the fact that Garde had run away had been kept so close a secret, that more persons had heard how devotedly she was attending David Donner than knew any hint of her escapade. Adam having first paid his respects to Mrs. Phipps, to whom he delivered the Captain’s messages and letters, had found himself apartments in a tavern
quite removed from the Crow and Arrow, where he had been able easily to avoid all his former acquaintances of Boston. He might have desired to search out Wainsworth, but Henry was away at Salem. Randolph, of whom Adam naturally thought, had betaken himself to New York, there to conclude some details of snatching the charter from the colony of Massachusetts.
Once settled, Adam lost no time in searching for Garde. Thus he was soon made aware of the state of the Donner household, into the affairs of which it would have been anything but thoughtful and kind to obtrude his presence. With a courteous patience he set himself to wait for a seemly moment in which to apprise Garde of his reappearance. He told himself that, as she had no intimation that he had returned to Boston, it would be a greater kindness to keep himself in the background, until her trials should be lessened.
Naturally all these various matters had somewhat obliterated from his mind the thoughts of the youth with whom he had traveled from the environs of Plymouth. While he was curbing his spirit and his too impatient love, a message arrived, in care of Goodwife Phipps, from Captain William Kidd, to the effect that the beef-eaters, far from recuperating after their voyage, had become seriously ill, and were begging each day for the “Sachem.”
Rust had been contemplating the acceptance of an offer from Mrs. Phipps to assume command at the ship-yard, the foreman in charge being then arrogating powers unto himself which were not at all quieting. Adam reflected that if he took this place he could settle down, marry his sweetheart presently, and become a sober citizen.
With the advent of the message from the beef-eaters, he was completely at a loss to know what to do. He yearned over these faithful companions, whose affection had been repeatedly demonstrated, under circumstances the most trying. If they should die while he remained away, selfishly denying them so little a thing as his presence, he would never obtain his own forgiveness. Yet he could not go to New York, or any other where on earth, without first having at least seen Garde. Indeed he reflected now that mayhap it had been a mistaken kindness for him to remain away from her side
so long Should he not have gone to her long before, and offered what service he could render in her trial?
As a matter of fact he had been kind as it was, for Garde had hardly enjoyed a moment in which to do so much as to think of love and her lover. Her grandfather had occupied her attention day and night. She had stinted him in nothing, else with her spirit of penitence upon her—for all that she had helped to hasten upon him—she could never have had any peace of mind nor contentment in her soul.
But at last, when the old man was out of danger, sitting in his chair by the hour, she had time to think of Adam again and to wonder why it was that he had never attempted to see her. She answered herself by saying it was better that he had not done so, but then, when she suddenly thought that he might have heard all manner of wild stories, and might indeed have gone away, angered and not understanding the truth, she yearned for him feverishly.
As if the message of her love flew unerringly to him, Adam suddenly, in the midst of thinking of going to the beef-eaters, determined to see his sweetheart, cost what it might.
CHAPTER XXVIII.
LOVE’S GARDEN.
A nearly a week of rain and dull, gray skies, the weather was again entrancing. The warm, soporific breeze which played through the house lulled Grandther Donner off to sleep, as he sat in his chair, staring at vacancy and rubbing his thumb across the ends of his fingers.
Garde, responding to the mood of coming summer, could not resist the impulse to go out into the garden, which to her would always be associated with her childish meeting with Adam Rust, and which therefore now made of her yearning to see him a positive force.
Thus it doubtless appeared to her as an answer to her longing when she felt a presence and glanced up at the gate, to see him standing there, as he had so many years before, with two of the pickets clasped in his big, strong hands.
Her heart gave a leap that almost hurt, so suddenly did it send the ecstasy bounding through her veins. Yet so sublimated was the look on Adam’s face, as, with parted lips and visible color rising and falling in his face, he gazed at her, steadfastly, and as one entranced, that she went toward him as slowly as if walking might disturb the spell.
One of her hands, like a homing dove, came up to press on her bosom above her heart. She was pale, for the cares of those weeks had bleached the rose-tints from her cheeks. Nevertheless, the moment painted them with vestal flames of love’s own lamp, as she looked into Adam’s eyes and saw the tender passion abiding there.
“Adam, I prithee come in,” she said, in a soft murmur, unconsciously repeating what she had said when first he had leaned upon this gate.
As one approaching something sacred, Adam came in and took her two hands in his. He raised them slowly to his lips, and then pressed them together against his breast.
“Garde,” he said, almost whispering. “Garde. My little Garde.”
“Oh, Adam,” she answered.
They looked at one another and smiled, she through shining tears. Then they laughed, for there were no words, there was nothing which could absolutely express their overflowing joy, but their laughing, which was wholly spontaneous, came the nearest.
“Oh, I have been so afraid this moment would never come,” said Garde, presently, when she could trust herself to speak. “It has been such a long, long time to wait.”
“I love you. Garde, dearest, I love you,” said Adam. “I love to say that I love you. I could say it all day: ‘Garde, I love you. Garde, I love you, dear, and love you.’ I have told every star in the heavens to tell you how I love you, dear. But I would rather tell you myself. Let me see you. Let me look at you, sweetheart.” He still held her hands, but at arms’ length away, and looked at her blushing face with such an adoration in his eyes as she had never beheld.
Indeed, Adam’s passion had swept her from her feet. It possessed her, enveloped her form, held her enthralled in an ecstasy so profound that she gasped to catch her breath, while her heart leaped as if it were pealing out her happiness.
They were standing thus, oblivions of everything, when a sourvisaged Puritan, passing by the gate, halted a moment to look at
them malignantly It was none other than Isaiah Pinchbecker, the scolding hypocrite who had danced to Adam’s fiddling, several years before. He suddenly gave himself a nudge in the ribs. His eyes lighted up with grim satisfaction. He had recognized the rover, and with news in his narrow head he hastened away, prodding himself assiduously as he went.
In the meantime, Grandther Donner, whose naps lasted hardly as long as forty winks, had awakened. He started from his sleep as if he had suddenly caught himself neglecting to watch the charter. Glancing hastily about the room, he missed Garde at once. In his brain, two cells had broken their walls so that their substance commingled, till Garde and the charter seemed at times the same, and always so interlinked that he dared not let her go a yard from his sight.
He tottered to his feet, and rubbing his thumb diligently across the ends of his fingers, went out at the open door, toward his grandchild, guided by some sense which in an animal is often highly developed. He came upon the scene in the garden just as Adam, after looking his heart full, nearly to bursting, had drawn Garde close again, to kiss her hands in uncontainable joy.
At sight of Adam’s costume, which was not a great departure from that of the Royalists of the day, in contradistinction from that of the Puritans, David Donner flew into a violent rage. He raised his two palsied hands above his head and screamed.
“Garde!” he cried, “Garde! Kill that man—Kill him!—kill him! The charter! The King’s devil! Kill him! He’s ripping the charter to pieces with his teeth!”
He came running toward them, clawing his nails down across his face till he made his pale cheeks bleed, and tore out little waving filaments, like gossamer, from his snow-white hair Almost at their feet he fell full length, where he struck at the soil and dug in his finger nails, frantically, all the while making terrible sounds in his paroxysm, most dreadful to hear.
Adam and Garde had started, he merely alert in the presence of the unexpected, she in a fear that sent the color from her face so abruptly that it seemed she must swoon at once. She uttered one little cry, clung galvanically to Adam’s fingers for a second, and then bent quickly down to place her hand on the old man’s head.
His delirious fury lasted but a moment. It then subsided as quickly as it had come, leaving him limp, exhausted, dull-eyed and panting like some run-down animal. A more pitiable sight than he then became, as he began to weep, shaken by the convulsive sobs which sometimes possess the frame of a man, Adam hoped he should never be obliged to witness.
Well as he understood that the sight of himself had precipitated this painful episode, Adam was also now aware that the old man, for the moment, saw and comprehended nothing. He therefore lifted him tenderly up in his arms and carried him into the house, placing him gently down on a lounge which he readily saw had been recently employed for the old man’s couch.
Garde had followed, her hands clasped together, the look of a tired mother in her face, making it infinitely sweet and patient.
“Garde, dear, forgive me,” said Adam. “I came too soon to see you.”
“Oh Adam!” she said, sadly. “In a few days, a week, dear, he is sure to be better.”
“Is there anything I can do?” said Adam, from the depths of his distress and sympathy and love.
“Oh, he is coming back to himself. Go, Adam, please,” said Garde, “don’t wait, dear, please. Come back to the gate, this evening.”
Adam went without so much as waiting to say good-by, for Garde had turned to her grandfather quickly, and anything further he might have said he abandoned, when David feebly spoke.
Depressed by the whole affair immeasurably, Adam was still too exalted by love’s great flight to dwell for long upon old Donner’s mania. His worries for Garde, in her tribulations, however, were
strewn like sad flowers of thought through his reverie. He longed to help her, yet he knew how utterly impossible such a thing would be.
Walking aimlessly, he came before long to the harbor shore. The melted emerald and sapphire, which the sea was rolling against the rocks, with sparkles of captured sunlight glinting endlessly through and upon the lazy billows, gave him the greatest possible sense of delight. He sat down on a rock where the green velvet moss had dried like fur, after a wetting.
No king on a throne ever detected more evidences of the world’s gladness than did the rover, thinking away the hours of that balmy afternoon. He forgot all about dinner, when the sun went down, and he had nearly forgotten old man Donner, when at length he started to his feet, in the twilight, in love with the evening for having come so soon, although half an hour before he had been thinking the day would never end.
He was soon at the gate in front of Donner’s house, listening, watching the darkened windows, holding his breath as every fragrant zephyr trailed its perfumes by, thinking Garde was coming, preceded by the redolence attendant on her loveliness.
But he had many such breathless moments of suspense, in vain. Evening glided into the arms of night. The hours winged by, on raven wings, and still no Garde appeared. Adam paced up and down, restoring, time after time, the picture of Garde as he had seen her, during those precious few moments before the interruption.
He was not conscious of the flight of time. He was well content to be near where his lady was and to wait there, knowing that she knew he was waiting, thinking of her, as he knew she was thinking of him. He clasped his hands back of his head; then he folded his arms, the better to press on his heart; then he stopped and tossed kisses to the silent house, after which he again walked back and forth, pausing to listen, and then going on as before.
At length, near midnight, he stood looking up at the stars, completely absorbed in a dream he was fashioning to suit himself.
There was a faint flutter
“Adam—oh, are you there?” said a sweet voice, subdued and a bit tremulous. “Oh, I am so glad you didn’t go away, discouraged.”
Adam had turned about instantly, a glad sound upon his lips. In one stride he reached the gate and caught her two trembling hands where they rested on the pickets.
“Dearest!” he murmured to her joyously. “At last!”
“I can only stop a minute, Adam,” said Garde, who was quaking a little, lest her grandfather wake and come again into the garden. “He has been very restless, and he wouldn’t go to sleep, and he wakes up so easily! But I couldn’t let you go away like that. And I have tried to come out five times, but he woke up every time, and now I must say good night, Adam, and run right back at once.”
“Oh, but I love you so,” said Adam, illogically. “If you must go, though, you must. I know I can never tell you how much I love you, dearest.”
“Oh, Adam!” she said, expressing more than he did, poor fellow, in all his protestations. “Oh, dear! I really must go, Adam. But in about a week I am sure he will be much better.”
“Shan’t I see you for a week?” said he.
“It might be better not,” she answered, “if we could wait.”
“I could go down to see my poor old beef-eaters, I suppose,” Adam mused.
In relating his travels, on the road, he had told Garde of the beefeaters, so that now, although she said nothing to betray herself, she understood what he meant.
“And then you’ll come back, as soon as you can, in a few days, or a week?” she asked. “Oh, dear—it is too bad. But, Adam, I must not remain another single minute. I must say good night, dear, and run.”
Adam had remained on his own side of the gate, retaining her hands, which he had kissed repeatedly, till they fairly burned with their tingling. He now reached over the gate and took her sweet face between his two big palms.
“Good night, dearest little love,” he said, and slowly leaning forward, he kissed her, once—then he kissed her three times more.
She started slowly away, looking back at him lovingly
“Oh, Garde!” he whispered.
She stopped and came fluttering back to meet him. He had let himself in at the gate with one quick movement. He took her home to his arms and held her in breathless joy against his throbbing heart. With love in her eyes her face was turned upward to his own.
“My Adam!” she said, with all the fervor of her nature.
“My love! My darling!” he responded.
He kissed her again. It was a warm, sweet kiss that brought their very souls to their lips. Then he dropped down on his knee and kissed her hands and pressed their fragrant palms against his face.
“My love!” he said. “My own love!”
She nestled in his arms yet once again. She gave him the one more kiss that burned on her lips to be taken, and then she fled swiftly to the house.
CHAPTER XXIX.
THE ENEMY IN
POWER.
A found his faithful beef-eaters on the verge of the grave. The miserable old rogues had no better sense than to be pining to death like two masterless dogs. They had been ill enough, in all conscience, and even somewhat mentally disordered, but there had been no sufficient grounds for the pair to believe themselves abandoned by their “Sachem,” and there had been absolutely no excuse for them to refuse to eat.
However, the rascals nearly “wagged” themselves to pieces when Rust was finally beside them, and the way they laughed was most suggestively like the glad whimpering of two dumbly loving animals expressing their joy. Adam would have scolded the two for having brought themselves to such a condition of weakness and bones, only that he had not the heart to do this justice to the case.
There was, however, no such thing as getting the old fellows back on their pins in a week, nor yet in two, nor three. They even hesitated, after he had come, between running backward toward their long sleep and coming along with him to vales of renewed health. They were like affectionate creatures divided between two masters. The grim visitor had come so near to winning them both, with his beckoning, that they appeared to think it their duty to die.
Adam, however, was a persuasive force. He had won them away from themselves before; he won them again on this occasion.
Captain Kidd, a braw Scotsman, who ordinarily dropped his native dialect, having little affection for his country, his father having suffered tortures for becoming a non-conformist clergyman, felt he must needs relapse into something barbaric to express himself on the beef-eaters.
“Of all the twas that ere twad,” said he, “you’re muckle the strangest twa.”
By this he meant to convey that of all the couples that ever mated, the two old rascals were the oddest pair.
The convalescence being a slow affair, Adam was obliged to give up all thought of returning immediately to Boston. Yet so hopeful was he that every day would perform some miracle of restoring the strength to the muscles and the meat to the bones of his retinue, that it was not until he had been away from Garde for more than three weeks that he finally wrote to tell her of why he had failed to return. But the letter, for some unknown reason, was never delivered.
At length, however, what with the fulness of summer come upon them and the hope which Adam had inspired in their breasts, the beef-eaters became padded out to the fulness of their old-time grandeur, and once more swaggered about and bragged of their prowess.
Adam’s money had, by this time, dwindled down to a sum which was not at all difficult to transport from place to place, nor even from pocket to pocket. Having no heart to put the retinue on shipboard, to convey them to Massachusetts, he sacrificed nearly his last bit of coin to secure them passage, by coach and wagon, from Manhattan to Boston. This left him either one of two expedients for himself. He could walk, or he could make shift to secure a passage by vessel, giving work as payment for the favor. He argued that once in Boston he would accept the position offered by Goodwife Phipps at the shipyard, and hither also would he take his followers, so that by honest toil they might all be happy and continue their time-sealed companionship, and desert the rolling-stone business as an occupation.
It was not without misgivings that the beef-eaters accepted this arrangement. But being obedient things that would willingly have gone into fire, or the sea itself, at Adam’s command or wish, they meekly bade him a temporary adieu and saw him depart before them, a ship being several days ahead of the coach in point of time for departing.
In the meantime, history had been making fast in Boston. The crafty Randolph, whose coup had long been prepared, had returned from New Amsterdam, bearing a commission from the King of England declaring the charter null and void and delegating upon him power to form a new provisional government for the colony of Massachusetts. Great tracts of territory, comprising New Hampshire, Maine and other areas, were lopped off from the province at one fell blow. Randolph created Joseph Dudley provisional governor, Dudley having long been seeking his favor, against this final moment of changes. The courts fell into the hands of the newly-elected power. The soldiers, constabulary, everything assumed an ultra-English tone and arrogance. The people clenched their fists and wrought their passions up to a point where rebellions are lighted in a night.
Yet Boston was a loyal town, obedient to its liege lord and nearly as eager to serve him and to do him homage as it was to preserve its liberties and the independence, which gradual development had created and long usage had confirmed as inalienable, in the belief of all the patriotic citizens. Stoughton and Bradstreet, beholding the revolutionary tendency, which would have plunged the colony most unwisely into a sea of trouble, submitted to the new order of things, which for long they had seen coming, inevitably, out of the malignant spirit in which the Stuart dynasty had always desired to govern these non-conformist hard-heads.
There were many creatures in Boston swift to join the Tory party, under Randolph, for the plums of official recognition. Thus this party rapidly assumed considerable dimensions, and therefore power, to add to that of which the King himself was the fountain-head.
Boston at that time was a prosperous town of something more than six thousand souls. It was substantially built, if crookedly, for the
most part of wood. Yet there was a fair sprinkling of brick houses along its cow-path streets, and a few were of stone, which, in several instances, had been brought to this undeveloped land from England. The town was distinctly English, both as to customs and thoughts, but the seeds which hardihood had sown, were to grow the pillars of Americanism—synonymous with a spirit of Democracy sufficient to inspire the world!
Naturally Isaiah Pinchbecker became a master-jackal under the new régime. Psalms Higgler, the lesser light of lick-spittling, became, by the same token, a lesser carnivora, but no less hungry to be feeding on the foe-masters of the recent past. And Pinchbecker, having found Adam in the town, was alert to find him again.
Yet not even Pinchbecker, with his knife-edge mind, devoted to evolving schemes of vengeance, could have comprehended the tigerish joy with which Randolph remembered Adam Rust, from that morning in the Crow and Arrow, and with which he now put two and two together, to arrive at Adam’s relationship with Garde Merrill.
Randolph was a subtle schemer, never fathomed by the Puritans, against whom he displayed such an implacable hatred. He was far too wise ever to appear as the point, when a thrust of revenge was to be delivered. He never for a moment relaxed his obsequious demeanor, nor his air of injured guiltlessness. Like all men of power, he had much material, self-offered, from which to choose his henchmen. He had chosen Pinchbecker wisely, for a hypocrite, a fawner, and an arrant knave who could work endless harm, in an underhanded fashion. But for his more aggressive employment he attached to his service a great, burly brute, with a face like a mastiff’s, an intelligence like a sloth’s, and a courage like that of a badger. This masterpiece of human animalism responded to the name of “Gallows,” for once a man had been hanged on his back, as in early English-Irish usage, and of this he was matchlessly proud.
Adam arrived in the midst of that first elation of Randolph and his following, the like of which is frequently the cause of reaction so violent as to quite reverse the fates themselves. But although the Puritans hated Dudley, almost more than Randolph, for traitorously
joining the party of destruction, their growlings checked nothing of the all-importance which the creatures in power felt and made their fellow-beings feel. A spirit of sullen brooding settled on the people.
Unaware that Rust had been away from Boston, since he had seen him that day in Donner’s garden with Mistress Merrill, Pinchbecker had been seeking for him diligently, ever since Randolph’s return. But believing that his quarry would be found eventually in the vicinity of the Crow and Arrow, his field of investigations was narrow.
It had naturally happened, however, that Adam had quite forgotten to tell the beef-eaters of his change of abode in Boston. They would therefore proceed to the old tavern immediately upon their arrival. He thought of this before he landed. Having come ashore at twilight, he made it his duty to stroll to the Crow and Arrow, for the purpose of leaving a message for Pike and Halberd, when at last they should come to the town.
CHAPTER XXX.
A FIGHT AT THE TAVERN.
I was a quiet time of the day, in a quiet part of the city. Adam discerned one or two individuals only and was not concerned with noting that he was suddenly preceded by a noiseless person, who hastened ahead of him to the tavern. The rover was much more occupied in observing the beauties of a horse that stood hitched to a post across the way from the public house.
The animal, a fine bay, imported from England, was the property of one of Randolph’s followers, a drinking young dandy with questionable ambitions and many extravagant tastes. Charmed by the horse’s impatience, as evinced by his pawing at the ground, Adam was tempted to get astride his back for a gallop.
However, after standing for a moment on the sidewalk, while his gaze caressed the champing animal, he turned and passed on into the tavern. Desiring to conclude his business as speedily as possible, he was somewhat annoyed to find the way to the bar, in front of the landlord, completely blocked by a great hulk of a creature, with a sword loosely girt about his loins, and two or three others, of whom the rover took less notice.
“By your leave,” he said, politely, not yet suspicious of the odd silence which had fallen on the company at his entrance, “I would like to get to the——”
