Surgery, with Special Reference to Podiatry Part 5

_Incised_-when resulting from a sharped-edged instrument.

_Lacerated_-when tissues are extensively torn or separated.

_Contused_-when resulting from a more diffused force, tearing and bruising the tissues.

_Punctured_-when produced by a narrow instrument that causes a wound deeper than its external surface is broad.

_Poisoned_-when some poisonous substance enters the wound and causes local infection or const.i.tutional disturbance.

_Gunshot_-when the injury results from firearms or powder explosion.

+An Incised Wound+ is an injury which is produced by some sharp instrument such as a knife, pieces of gla.s.s or metal, which divides the tissues cleanly, producing no bruising or tearing. The pain is usually sharp and burning, varying with the nature of the instrument with which the injury has been inflicted. Hemorrhage is usually free.

+Lacerated Wounds.+ These usually result from machinery accidents or from heavy bodies pa.s.sing over the parts and are apt to contain a considerable quant.i.ty of foreign matter ground into the tissues.

+Contused Wounds.+ A contused wound is one in which the edges and surrounding tissues are bruised or crushed. External bleeding as a rule is not excessive, although there is a great likelihood of extensive subcutaneous hemorrhage. Sloughing and gangrene may occur.

+Punctured Wounds.+ The character of a punctured wound depends upon the object producing it. If made by sharp instruments, such as knives, swords, daggers, bayonets, or needles, their nature is similar to incised wounds.

Unless organs of importance have been wounded, or unless active septic material has been carried into the wound, healing promptly follows after the withdrawal of the instrument which has caused the wound.

These wounds are usually deep when affecting the dorsal aspect of the foot, being commonly caused by a falling instrument or tool. In the plantar region they are of every degree of severity, from the most minute puncture to perforation running between interosseus s.p.a.ces and pa.s.sing through the dorsal skin. The most frequent punctures are those caused by stepping upon needles, pins and tacks. These wounds are, commonly, of no importance unless the foreign body is broken off or entirely penetrates the foot.

If the patient is seen a very short time after this has occurred, the surgeon may operate with some confidence of finding the offending substance, but even here, if possible, it is an advantage to obtain an X-ray picture, while in those cases in which a needle has long been buried in the tissues, this is quite indispensable. It is well to remember that in these cases the patients' impressions us to the location of the needles are most unreliable.

After a radiograph has been obtained, it is most important, if anatomically possible, to make the incision at right angles to the shaft of the needle. At least two pictures should be taken in order, if possible, to obtain some idea of the depth at which the needle lies. Even with all these helps, the procedure, simple though it may at first appear, oftens turns out to be one of great difficulty, necessitating a very extensive operation.

+Incised Wounds of the Foot.+ Incised wounds of the dorsal surface are very frequently quite deep and often implicate the tendons, bones and articulations, as they are most frequently inflicted by the fall of some heavy tool upon the part, or by the inaccurate blow of an axe.

Wounds of slight importance need but the usual thorough cleansing out, with or without suturing of the skin, according to the extent of the incision.

If one or more of the tendons have been severed, the ends should be approximated by catgut sutures. If extensor tendons are cut in the neighborhood of the metatarsophalangeal joints, it is often necessary, owing to considerable retraction of the distal end, to incise the skin down as far as is needed, in order to secure the retracted end and suture it. Failure to adopt this procedure permits a dropping of the toe, converting it often into a regular hammertoe. When the tendon is properly sutured, the toe must be placed for some days in a condition of over extension, most easily secured by a bandage pa.s.sed under it, acting like a stirrup, the ends being fastened by several turns above the ankle.

Incisions, implicating joints, are carefully cleansed by flushing the joint with copious quant.i.ties of saline solution, and closing the wound with very few st.i.tches. Such injuries should be examined daily and any sign of sepsis must be considered as an indication for immediate removal of the st.i.tches, followed by active antiseptic wet dressings.

Cuts of the plantar surface are not often very extensive. They are most frequently incurred in stepping upon some sharp instrument or walking upon gla.s.s, especially while bathing.

+Contusions.+ A contusion or bruise is a subcutaneous laceration, the skin above it being uninjured, as in the abdomen; or being damaged without a surface breach, as in a part overlying bone, and blood being effused. If a large vessel is damaged, hemorrhage is extensive.

An _ecchymosis_ (black and blue area) is diffuse subcutaneous hemorrhage.

A _hematoma_ is a blood tumor or a circ.u.mscribed hemorrhage in the tissues.

In a diffuse hemorrhage the coagulation of fibrin induces induration, the serum and leukocytes are absorbed, the red blood cells disintegrate, and the coloring matter is widely diffused by the tissue fluids, and hemoglobin is changed into hematoidin which crystallizes.

In union with these chemical changes, color changes ensue, the part being at first red and then becoming purple, black, green, lemon and citron. The stain following a contusion is most marked in the most dependent area.

A hematoma acts as an irritant, inflammation ensues around it and it is encapsuled by embryonic tissue, which, by organizing into fibrous tissue, forms a blood cyst and gradually absorbs the fluid blood, the cysts contents becoming thicker and thicker. A fibrous scar may remain, and a blood clot, with very much indurated surrounding tissue, giving a hard edge, is noticed after bruises of the periosteum. If serum is not absorbed, hematoidin forms and the fluid becomes clear. A hematoma may suppurate, an abscess forming, but this rarely happens except in drunkards, although it occasionally occurs in persons who do not use alcohol.

+Symptoms.+ The symptoms are tenderness, swelling, pain, and numbness.

The pain may be severe, but rarely persists beyond the first twenty-four hours. Discoloration appears quickly in superficial contusions, but only after days, in deeper ones. Shock and loss of function are present only after severe contusions. The swelling is first due to blood and is soon added to by inflammatory exudation.

+Terminations of Contusions.+ Slight contusions terminate promptly by resolution; the more severe may terminate in gangrene, inflammation, abscess, fibroid thickening, hypertrophy of the tissues involved, (as in the case of bone), chronic inflammations, and even malignant growths, particularly sarcomata.

+Prognosis.+ The prognosis of contusions is a matter of every day importance, and it is sometimes extremely difficult to prognosticate accurately. The determining forces are princ.i.p.ally the nature and violence of the contusing force, the tissues and organs involved, and the general condition of the patient. Even the injury of the tissues that may be easily inspected, such as the skin, may be much more severe than is apparent. In tissues of low vitality, such as synovial membrane, cartilage and ligaments of a joint, repair is proportionately delayed, whereas in highly vascular tissue it is more rapid. Contusions of tissues that cannot be given physiologic rest, such as the thoracic wall, and the respiratory muscles, respond less promptly to treatment.

The general condition of the patient is an important factor in the prognosis, the most favorable being vigorous adult life without organic disease. Among the unfavorable general states are, the extremities of life, the very anemic and the plethoric, the tuberculous, the syphilitic, the diabetic, and like diatheses, while in the rheumatic and the gouty, the slightest injury may be most persistent. The starved, the overfed, the over-worked, the fatigued, the alcoholic, and those exposed to extremes of heat and cold, are unfavorably affected.

+Treatment.+ Slight bruises, favorably located, require no treatment.

The arrest of hemorrhage, thereby diminishing the swelling, pain, and discoloration, is important. If the hemorrhage be from small vessels, elevation, rest, and the application of ice are sufficient. Frequently the application of pressure is indicated. Hemorrhage in deeper parts, such as that occurring under the fascia of the thigh, is sometimes best controlled by adhesive strapping. If the vessels are large and the hemorrhage is rapid, it is sometimes necessary to make a free incision and apply a ligature. Evaporating lotions or elastic pressure by bandaging over absorbent cotton, may a.s.sist. If the hemorrhage be in a joint causing immediate swelling, painful from distension, prompt aspiration will give relief. This should only be resorted to under the strictest aseptic precautions, as the conditions are favorable for microbic growth. If the soft parts are so severely contused as to jeopardize the nutrition, both bandaging and ice should be withheld, and in some instances even warm applications are advised.

After the acute symptoms have pa.s.sed, judicious ma.s.sage may be most helpful in securing early resolution. Restoration of the vasomotor tone when impaired or lost may be greatly facilitated by douching with cold and hot water alternately followed by ma.s.sage. During the acute stages, physiologic rest is important; the restoration of functional use in severe cases must be tentative, guided by the response of the tissue in the form of increased pain or swelling. These phenomena should be avoided if possible. If hematomata be not absorbed they should be aspirated and pressure applied before structural changes take place, such as the formation of a membrane. If the latter occurs and sufficient time has elapsed for the formation of definite new tissue, aspiration may be followed by the obliteration of the sac.

Sometimes hematomata become so thoroughly and firmly organized and gradually increase in size, that it is extremely difficult to differentiate them from new growths. If pain and tenderness persist for a long time, particularly, if there be a predisposition to tuberculosis, especial care is necessary.

+Treatment of Wounds in General.+ Arrest hemorrhage, bring about reaction, remove foreign bodies, asepticize, drain, coaptate the edges and dress, secure rest to the part and combat inflammation.

Const.i.tutionally, allay pain, secure sleep, keep up the nutrition and treat inflammatory conditions.

+Arrest of Hemorrhage.+ To arrest hemorrhage the bleeding point must be controlled by digital pressure until ready to be grasped with forceps; it is then caught up and tied with catgut or aseptic silk. Slight hemorrhage stops spontaneously on exposure to air, and moderate hemorrhage ceases after the vessels are clamped for a time; an injured vessel of some size must be ligated, even if it has ceased to bleed.

Capillary bleeding is checked by hot water compresses. In bringing about reaction from shock, raise the feet and lower the head, unless this position causes cyanosis. At least place the head flat and the body rec.u.mbent. Apply hot water bottles and hot blankets and give hypodermic injections of ether, brandy, strychnine, digitalis or atropin, or inhalations of amyl nitrate. Strychnine can be used in large doses, one-thirtieth of a grain may be given every ten or fifteen minutes, until three doses have been taken. If the skin is very moist, atropin is indicated, alone or combined with strychnine.

Hot coffee, or other hot fluids, should be given by the mouth and r.e.c.t.u.m, and mustard should be placed over the heart, spine and shins.

The use of hot and stimulating rectal enemata is very important. The r.e.c.t.u.m may absorb when the stomach refuses to do so. Enemata of hot normal saline solution are very beneficial.

+Enteroclysis.+ The tube is carried into the sigmoid flexure and the injection is introduced so as to distend the colon. At times it may be necessary to give an intravenous injection of saline solution in order to overcome the shock. In order to prevent the suppression of urine, it may be necessary to administer diuretics.

+Removal of Foreign Bodies.+ Remove with forceps, all foreign bodies visible to the eye: splinters, bits of gla.s.s, portions of clothing, dirt, etc.

In a lacerated or contused wound, portions of tissue injured beyond repair should be regarded as foreign bodies and should be removed with scissors.

+Cleaning the Wound.+ If the surface is hairy it must be shaved before the scrubbing. An accidental wound is infected and must be well washed out with an antiseptic solution. A clean wound, made by the surgeon, need not be irrigated, in fact, irrigation with an antiseptic fluid leads to necrosis of tissues, causes a profuse flow of serum and necessitates drainage. If clots have gathered in a wound, they must be removed, as their presence will prevent accurate coaptation of the edges. In an infected wound, they are washed out with a stream of corrosive sublimate solution. In a clean wound, they are washed out with hot salt solution. If dirt is ground into a wound, as is often seen in crushes, pour sweet oil into the wound, rub it into the tissues, and scrub the wound with ethereal soap. The oil entangles the dirt and the soap and water remove both dirt and oil. After the rough cleansing, irrigate with corrosive sublimate solution. In some cases, especially in bone injuries, it is necessary to sc.r.a.pe the wound with a curet.

A granulating wound is treated the same as an ulcer and the treatment is discussed under that chapter.

+Drainage, Closure and Dressing.+ Superficial wounds require no special drain, as some exudate will find exit between the st.i.tches and the rest will be absorbed. A large or deep wound requires free drainage for at least twenty-four hours by means of a tube, strands of horse hair, silk, catgut or gauze. An infected wound must invariably be drained. Good drainage largely compensates for imperfect antisepsis.

If capillary drains be employed, apply a moist dressing. Divided nerves and tendons must be sutured. Close the edges with silk sutures or silkworm gut if the wound is deep and tension inevitable. Catgut is used for superficial wounds and for those where tension is slight. The interrupted suture is, as a rule, the best. If the wound is infected, dress with antiseptic gauze; with aseptic or antiseptic gauze if it is not infected. A dry dressing absorbs wound fluids quickly and is less likely to become infected. Change the dressings in twenty-four hours or sooner if they become soaked with the discharge. After this, in an aseptic wound the dressing need not be changed for days. If pus forms, open the wound at once.

+Rest and Const.i.tutional Treatment.+ In planning the treatment of wounds the most careful consideration for securing physiologic rest should be had. If at or near a joint, the parts both above and below should be immobilized. In whatever part of the body, physiologic rest should be secured as nearly as possible. If the wound be of the leg or foot, the patient should be in the rec.u.mbent position, with the part elevated and a splint applied. The factor of rest, next to that of cleansing and dressing, is most important. Physiologic rest means not only less pain, less reaction, but a more rapid and certain repair.

Under ordinary circ.u.mstances no special const.i.tutional treatment is necessary beyond that of securing good hygienic surroundings, easily digested food, restricted at first, and free action of the bowels. If there is great pain, opiates may be necessary, but here, as in other surgical indications for anodynes, a minimum amount should only be given. Usually rest, elevation, and relief of tension will be of greater benefit than opiates. If there is great restlessness, a bromide may suffice; if marked insomnia, one of the ordinary hypnotics. Great restlessness, with excitement and occasional delirium, without special evidence of pain or infective process, must call attention to the possible development of delirium tremens from a relatively slight injury (such as a crushed toe or a simple fracture), as it may precipitate an attack in one who has been a steady drinker, though perhaps not an excessive one. In such cases, in addition to the ordinary therapeutic remedies, the regular administration of whiskey should be advised.

+TOXEMIA, SEPTICEMIA, SAPREMIA, PYEMIA+

+Toxemia+ applies to the diseases in which one or more poisons are present in the blood which are not necessarily of parasitic origin and production.

The word poisons is here used in a broad sense to cover any substance applied to the body, ingested, or developed within the body which causes disease. It of course includes ptomains, leukomains, toxins and sepsins.

Toxemia, according to this definition, would include the diseases due to poisons not arising from parasitic invasion of the tissues and fluids of the body, at times of vegetable and alkaloidal nature, such as strychnine or morphine; of animal origin, such as the toxin of snake venom, the ptomains of milk or sh.e.l.l fish; then again a mineral such as a.r.s.enic or lead; and lastly the leukomains arising from disturbed excretion and perverted metabolism and grouped under such terms as intestinal or uremic poisoning.

+Septicemia+ may be defined as an acute febrile affection, characterized by marked nervous, cutaneous and visceral manifestations, and due to the introduction into the system of bacteria and their toxins from an infected wound. It applies to diseases which present poisons in the blood that are of parasitic origin, the parasite itself being either present or absent in the blood. Septicemia, in strong contrast to the definition of toxemia, would include diseases arising from the invasion of the tissues and fluids of the body by animal or vegetable parasites or their poisonous products.