If your institution subscribes to this resource, and you don't have a MyAccess Profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus. Skin and soft tissue infections occur in all races, all ethnic groups, and all geographic locations, although some have unique geographic niches. In modern times, the frequency and severity of some skin and soft tissue infections have increased for several reasons.
First, microbes are rapidly disseminated throughout the world via efficient air travel, acquiring genes for virulence factors and antibiotic resistance. Second, natural disasters, such as earthquakes, tsunamis, tornadoes, and hurricanes, appear to be increasing in frequency, and the injuries sustained during these events commonly cause major skin and soft-tissue damage that predisposes to infection. Third, trauma and casualties resulting from combat and terrorist activities can markedly damage or destroy tissues and provide both endogenous and exogenous pathogens with ready access to deeper structures.
Unfortunately, because the marvels of modern medicine may not be available during human-instigated and natural disasters, primary treatment may be delayed and the likelihood of severe infection and death increased. Skin and soft tissue infections have been common human afflictions for centuries.
This chapter provides an anatomic approach to understanding the types of soft tissue infections and the diverse microbes responsible. Protection against infection of the epidermis depends on the mechanical barrier afforded by the stratum corneum, since the epidermis itself is devoid of blood vessels Fig. Disruption of this layer by burns or bites, abrasions, foreign bodies, primary dermatologic disorders e.
Similarly, the hair follicle can serve as a portal either for components of the normal flora e. Intracellular infection of the squamous epithelium with vesicle formation may arise from cutaneous inoculation, as in infection with herpes simplex virus HSV type 1; from the dermal capillary plexus, as in varicella and infections due to other viruses associated with viremia; or from cutaneous nerve roots, as in herpes zoster.
Bacteria infecting the epidermis, such as Streptococcus pyogenes , may be translocated laterally to deeper structures via lymphatics, an event that results in the rapid superficial spread of erysipelas.
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Later, engorgement or obstruction of lymphatics causes flaccid edema of the epidermis, another characteristic of erysipelas. Structural components of the skin and soft tissues, superficial infections, and infections of the deeper structures. The rich capillary network beneath the dermal papillae plays a key role in the localization of infection and in the development of the acute inflammatory reaction. The rich plexus of capillaries beneath Forgot Password? What is MyAccess? Otherwise it is hidden from view.
Forgot Username? About MyAccess If your institution subscribes to this resource, and you don't have a MyAccess Profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus. Sign in via OpenAthens. Sign in via Shibboleth. AccessEmergency Medicine. Case Files Collection. He manages to give the impression of someone who was completely out of his depth. As the situation deteriorated, in good part because of his Government's policies, and the violence escalated out of control, he sat in London bemoaning the problems that the unruly and unreasonable Irish, both Protestants and Catholics, were causing him and regretting that they could not behave like decent Englishmen and be content.
He was without much doubt the wrong man in the wrong place at the wrong time 5. Before we go on to consider Whitelaw's memoirs, it is worth briefly pausing to consider the passing mention that Northern Ireland gets in Lord Carrington's memoirs, Reflect On Things Past. Ill-informed criticism of British policy by foreign commentators, whether American or European, he found particularly irritating. Only when members of the European Parliament had actually heard Ian Paisley exchanging shouted insults with various Irish MEPs did they even begin to realise the complexities of the situation!
The only really bright spot for Carrington was the perfommance of the British Army.
This sort of fulsome praise of the British Army and steadfast refusal to acknowledge let alone accept any criticism is a feature of all the memoir literature looked at here. Carrington is only. Security policy had proven counter-productive and the Unionists had rejected the Conservative Government's proposed political initiative. The policy of concessions culminated in his secret meeting with the IRA leadership in London on 7 July Two days later the IRA called off the truce it was operating and made public the news of the talks. It was decided to launch Operation Motorman, the military reoccupation of the republican controlled no-go areas in Belfast and Derry.
Whitelaw was still worried about the prospect of a large number of civilian casualties when the troops went in and so in an effort to avoid this any attempt at surprise was abandoned. Public warnings were issued to try and keep people off the streets. For some time Harry Tuzo and I sat in his office in considerable suspense. Was the Army being obstructed? Were civilians lying on the streets. Was the IRA going to organize resistance? These were the questions going through our minds. The Bogside and Creggan areas had been occupied. We feared that the population as a whole would be instructed to obstruct the entry of troops by mass demonstrations and even by actually lying down on the streets in front of advancing vehicles.
For the first time I realized what it must have been like for Army Commanders during the war. Whereas in July ninety-five people had been killed in Northern Ireland, in September the number was down to forty and in November down to twenty. In retrospect, he can be seen to have seriously underestimated the growing opposition to his schemes among the Protestant population, an opposition increasingly given voice by Ian Paisley. He is full of praise for Brian Faulkner, Gerry Fitt and the others involved :.
Whatever may have happened since, the fact they ended in agreement represents a considerable achievement on the part of the Northern Ireland leaders who participated. They were prepared to sink their substantial differences in the interests of giving a constructive lead to all the people of Northern Ireland. They were prepared to work together democratically in unity against the men of violence. Subsequently, of course, their efforts were defeated not democratically but by industrial action in the Ulster Workers' Council strike. Thereafter their work has been belittled and even derided. This is tragic How does he assess the importance of the doomed power-sharing Executive?
He is simultaneously claiming credit for a political breakthrough and for having foreseen its failure! This was not to be. Merlyn Rees, whose misfortune it was to preside over the downfall of the powersharing Executive, followed his close friend and colleague James Callaghan in writing a personal account of his involvement with Northern Ireland.
Although written with all the literary ability of a dead cod, his account is still of considerable interest. What was completely unacceptable, however, was the manner of the power-sharing Executive's downfall. In reply to those critics who argue that a more forceful response by the security forces could have broken the strike, he writes that. The counter-insurgency methods used by the army for dealing with the Provisional IRA and other paramilitaries were not appropriate to a political strike. Those who from far away advocated the use of detention to put down the strike did not consider the numbers involved and how many Long Keshes we would have to build.
It is one thing to fight the IRA and quite another to fight a whole community. How valid is Rees's belief that the strike was too widely supported, too strong to have been broken?
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There are two sides to this question. Certainly, if the political will had been there, it seems clear that the UWC could have been defeated by determined action to clear the road blocks and barricades, by the use of internment and the drafting in of power workers from Britain. This was not a viable political option, however, because it would have embroiled the security forces in a conflict with the Protestants that might well have escalated out of control.
The Army would have been left in the position of confronting two opponents at the same time. This was not acceptable and so the Executive had to be sacrificed. While regretting the outcome, Rees was nevertheless quickly resigned to it. Harold Wilson in his account of these events takes a much harder and more unsympathetic line than Rees. Ugly external pressures had brought about a defeat for those who had courageously and with great forbearance sought to create a representative form of government, in the spirit of the Sunningdale agreement.
It was an extra-Parliamentary defeat for the combined efforts of all the major parties at Westminster, a defeat for law and order, with all this meant for Britain, not least in our overseas relationships. For centuries no external attack had been successfully made on the authority of Parliament.
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Now it had. The bully boys had won. There can be no doubting Wilson's outrage at the UWC victory. He had no time at all for the Protestants, was much more sympathetic to the Catholic community and indeed favoured progress towards a united Ireland. This did not indicate any support or sympathy for republicanism.
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Indeed, in his account, Wilson recalls a visit to Northern Ireland just before Christmas He visited Fort George in Derry and chatted to a group of soldiers just about to go out on a routine patrol. When he arrived in Belfast an hour later it was to discover that two of them had been killed when a booby-trap bomb went off as they were passing. The loss of British lives defending the Protestants did nothing to increase his patience with Protestant opposition to British policy 9. One is entitled to be somewhat sceptical with regard to the notion that either Rodgers or Jenkins would have made that much difference.
Indeed it seems likely that Owen's criticism of Rees has more to do with the fact that he was to remain a Labour Party loyalist while Rodgers and Jenkins were founders of the short-lived Social Democratic Party. Certainly his confidence was not, as we shall see, shared by Roy Jenkins In the months following the downfall of the Executive, Rees went on to preside over the most important development in security policy in the course of the Troubles : the difficult change from a counter-insurgency strategy derived from Britain's colonial experience to an internal security strategy more in line with anti-terrorist experience on the Continent.
Part of this initiative involved the ending of special category status but only for prisoners convicted after 1 March On a number of occasions, in an otherwise excessively bland book, Rees does give expression to his deep revulsion at the actions of the paramilitaries in both camps. The conflict was very personal, indeed he believes that the assassination of the British Ambassador to Dublin on 21 July was in fact an attempt to kill him! At this time containment was the objective rather than victory. Nevertheless it was absolutely vital that the Government should persevere in its efforts to bring peace :.
I had no doubt in and have none now, that our commitment to the province is long- term. Those who advocate pull-out are ignoring its implications. Ulster is part of an island whose problems have defeated us for centuries ; the Boyne, the Lagan and the Bann are not the Zambezi, the Nile or the Ganges. Northern Ireland does not pose a classical colonial question The fighting would be ruthless, and at the end of the day the Northern Ireland state would still be there but smaller in size as the illogicality of the border was rectified by military reality.
For this reason alone, the British have a continuing role in Northern Ireland While Rees could see no alternative to a continuing British presence in the North, selflessly attempting to sort out Ireland's problems, James Callaghan, who succeeded Harold Wilson as Prime Minister in April , was to actually advocate fixing a timetable for withdrawal in , leaving Northern Ireland to become an independent state.
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His disenchantment was perhaps provoked, at least in part, by the fact that his Labour Government had been brought down by the Troubles. And indeed this has become the conventional wisdom. Even Eric Heffer, who agreed with Callaghan on little else, makes the same point. The fact is, however, that while Fitt was indeed increasingly upset and disturbed by the secret pact that had been concluded between Labour and the Unionists, the final straw was the Government's toleration and cover-up of the use of force during the interrogation of suspects by the RUC.
He made this absolutely clear in his impassioned speech in the Commons at the time, but it seems to have been conveniently forgotten since Before moving on to the memoir literature of the Thatcher era, it is worth considering one other Labour account of the Labour Government : that of Roy Jenkins. While David Owen considered Jenkins. His memoirs, it must be said, certainly inspire no confidence in his ability to have exercised responsibility for Northern Ireland affairs.
The first problem he faced was the Price sisters' hunger strike : they were demanding to be allowed to serve their sentence in Northern Ireland. As the crisis deepened towards the end of May he found himself with six IRA hunger strikers near to death on his hands.
While out walking one Sunday evening in Norfolk. I was vividly reminded, not by an immediate fear in the stomach but more by an immanence of doom, of the fatal walk of Lord Frederick Cavendish and his permanent under-secretary, Thomas Burke, in Phoenix Park, Dublin, ninety-two years before. I did not expect an assassin to leap out from behind any and every tree, but as I glanced back at the heavy police protection splayed out behind me even in this epitome of the agricultural stability of eighteenth century England, the sad thought arose that if those damned girls stuck to their perverse intention I might never be able to walk in freedom and security down a street in Boston or New York or Chicago.
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The Price sisters were, of course, moved to Northern Ireland. Inevitably, one is left with the impression of Jenkins as a dilettante, concerned first and foremost with his own comfort and security, an admittedly brilliant man who nevertheless cuts a rather sorry figure when set alongside the more pedestrian Merlyn Rees who probably did not have enough imagination to be swayed by threats to his own satety. Certainly Jenkins displays no sympathy for any of the inhabitants of Northern Ireland, whether Catholic or Protestant, republican or loyalist The Thatcher period has produced a quite unprecedented flood of memoirs from former ministers.
Here attention will be focused on only three accounts, those by James Prior, Geoffrey Howe and Margaret Thatcher herself. Most senior Conservatives were, of course, touched by the Troubles in some way or other the bombing of the Grand Hotel in Brighton on 12 October made sure of that , but they do not give them enough attention to make detailed discussion worthwhile.
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This more than adequately communicates his view of the nature of Northern Ireland's relationship with the rest of the United Kingdom His appointment had nothing to do with the situation in Northern Ireland but was in fact a consequence of conflict and division within the British Cabinet over domestic issues. Prior, to all intents and purposes, was being sent into exile. Whatever the reasons for his appointment, the section of his memoirs devoted to Northern Ireland is of great interest. When he arrived in the province, ten hunger strikers were already dead and another seven were approaching death.
He visited the Maze and looked in on Liam McCloskie who had been on hunger strike for forty six days :. I was struck by how much this man lookod at peace with himself. I began to realise at that moment that Northern Ireland, and perhaps the history of Ireland, has been made up of a number of people on both sides of the religious and political divide of utter determination and conviction, prepared to commit acts of violence and in a stubborn, yet courageous, way to accept the inevitable and to die. This was my first inkling as to what the problem of Northern Ireland was all about.
These are quite startling remarks to come from a British politician, whether Labour or Conservative. Something had to be done to retrieve the situation. It was this sort of attitude, of course, that was to cost him his political career. He also attempted to launch a new initiative rolling devolution and a Northern Ireland Assembly only to find Cabinet policy being covertly opposed and undermined by Thatcher.
While she remained silent, her Parliamentary Private Secretary, Ian Gow, was allowed to make her real feelings clear to backbenchers. Security policy is briefly discussed. Subsequent events have, of course, completely discredited these trials. He also goes on to defend the use of covert operations as absolutely necessary when 'you are dealing with a ruthless group of people who will bomb or shoot on sight'.
Once again the effficacy of such operations have been subsequently called into question. Significantly Prior does not discuss the shoot-to-kill allegations that followed the killing by the security forces of three unarmed IRA members on 11 November , of seventeen year old Michael Tighe on 24 November and of two INLA members on 12 December. There seems little doubt that these shootings were a propaganda disaster as far as relations with the Catholic community were concerned.
Prior was to serve three years as Northern Ireland Secretary September to September which he felt was long enough. In normal circumstances he would have expected to go on to take up a senior post in the Government, but Thatcher had no intention of promoting him. At the end of his three years he retired from politics and went into industry. His three years were important however. This laid the foundations for the Anglo-Irish Agreement Here we confront the paradox of a Prime Minister who regarded herself as a staunch defender of the Union, was wholeheartedly committed to a decisive victory over the IRA and yet found herself implementing policies that successfully alienated the Protestant community and led to accusations of treachery and betrayal.
How did this come about? There are really two schools of thought on this : one sees Thatcher as the radical, decisive initiator of the Anglo-Irish Agreement, as someone who was prepared to trample over vested interests to secure her objectives 16 while the other sees her as being led by the nose by her own ministers and officials, most notably Sir Robert Armstrong and Douglas Hurd, men who had no commitment to the Union whatsoever Both her memoirs and those of Geoffrey Howe, her Foreign Secretary, tend to support the latter view.
The first major crisis that Thatcher faced in Northern Ireland was the second IRA hunger strike that began on 1 March and continued until early October. This provided an opportunity for her to demonstrate her iron resolution not to make any concessions to terrorists. While her stand was to prove very popular with the general public in Britain and with the Unionists in Northern Ireland, the consequences were in reality disastrous.
The ten hunger strike deaths created a tremendous bitterness within the Catholic community, providing the IRA with a popular boost that was arguably to sustain its campaign throughout the s and into the s.