Surgery, with Special Reference to Podiatry Part 7

Frequently a wad of cotton or gauze, pressed firmly upon the bleeding area, will almost stop the bleeding in a few minutes, after which it becomes possible to apply the styptic. Should this, however, be found impossible and the bleeding resume when the pressure is released, clotting in the vessel can only be expected by the agency of either ligation of the tissue or any individual vessel or more commonly by tight bandaging. The latter procedure usually accomplishes the control of the hemorrhage incident to a deep dissection for papilloma or verucca.

A pad of several thicknesses of sterile gauze is placed upon the wound and held in place by a few turns of narrow bandage, applied quite tightly. Though blood may be seen to "spot" through this dressing, it should occasion no alarm unless the hemorrhage has been clearly either venous or arterial. Under such circ.u.mstances the spurting, either constant or intermittent, will give immediate evidence of its character. Active hemorrhage of this nature may yield to tight bandaging, but ligation of the vessel should be done.

+Venous or Arterial Bleeding+ requiring ligation may be easily dealt with, and every chiropodist should be equipped with a small artery clamp with which to grasp the tissues; he should also be provided with sterile catgut, sizes 0 or 00, with which to ligate a bleeding vessel.

+Antiseptic Precautions.+ In dealing with hemorrhage of even the slightest degree, it should be remembered that portals of entrance for bacteria upon the feet require every antiseptic precaution, both as to the treatment of the wound, and as to the instruments and dressings which come in contact with it.

For open wounds the U. S. P. tincture of iodin, diluted in water to one-half strength, is antiseptic and not extremely irritating.

Instruments dipped in pure phenol and dried on sterile gauze are rendered sterile and may be safely employed.

Dry sterile gauze in the dressing of a clean surgical wound is all that is necessary. Healing in the absence of infection will be prompt.

The habitual use of ointments and wet dressings should be discountenanced, except in the presence of a real indication.

CHAPTER VII

+BURNS, FROST BITE, ETC.+

Among the causes of burns are: steam; hot water; melted gla.s.s, wax, rubber, sugar; molten metal; red-hot metal; gas and flame; burning wood, paper, clothing; electricity; X-ray; ultra-violet ray; chemicals; acid sulphuric, trichloracetic acid, common lye; alkalis; carbolic acid; iodin; croton oil, mustard, cantharides.

From these various causes there is very little difference in symptoms, course, pathology, and treatment. The molten lead burns are usually small in area, but of the third degree. The underlying tissues are often devitalized, especially around the feet, making a deep, pale, slow-healing ulcer. The same is true of many burns from electricity.

The effects of X-ray burns are only seen after several days or weeks and stubbornly resist treatment. Ultra-violet ray burns may not show any effects at first, but develop symptoms in about six hours, sometimes accompanied by great pain. Such burns may be due to sunburn or powerful electric light.

The epidermis contains no blood vessels, but the mucous layer has lymph s.p.a.ces between the cells, draining into the lymph s.p.a.ces and channels of the dermis. Nowhere in the body are nerves more abundant than in the skin. Here we have nerves of motion to the muscles of the skin; nerves of pain, temperature, and touch; forming an intricate plexus of nonmedulated fibres sending their branches upward into each papilla, and even to the mucous layer of the epidermis. Vasomotor nerves supply the coats of most blood vessels of the skin, and trophic nerves are everywhere controlling the nutrition of each part. When it is considered what a complex organ the skin really is; how delicately its parts are adjusted to the body; how extremely sensitive its nerve supply, slight stimuli bringing responses and causing reflex action in far distant organs; how many the uses of the skin (protection, excretion, expression, and sensation in various forms), it can readily be understood how great is its importance, and the far-reaching results of its serious injury.

Burns are cla.s.sified into three degrees: first, second and third. In every burn there are two layers of tissue to be considered: _first_, the layer destroyed-the dead flesh; _second_, the layer injured-the sick flesh.

+BURNS OF FIRST DEGREE+

+Pathology.+

(1) Destruction of the cells of the h.o.r.n.y layer.

(2) Injury of the cells of the mucous layer with an excess of lymph. No blistering.

(3) Congestion of the subpapillary plexus with some destruction of the hemoglobin.

(4) Closing of the ducts of the sweat and oil glands.

(5) Slight edema of the underlying dermis.

+Clinical Stages.+

1st stage-hyperemia and pain.

2nd stage-edema.

3rd stage-peeling and staining the skin.

4th stage-cells of the h.o.r.n.y layer replaced by pushing upward of cells from stratum lucidum.

BURNS OF THE SECOND DEGREE

+Pathology.+

(1) Destruction of cells of h.o.r.n.y layer and sometimes of the germinal layer.

(2) Great exudation of fluid composed of lymph, fibrin, and broken-down cells in the lymph s.p.a.ces of the mucous layer, forming blisters.

(3) Intense swelling and congestion of the papillary layer.

(4) Swelling of the connective tissue and elastic fibres in the true skin.

(5) Thrombosis in some superficial blood vessels.

(6) Leucocytes poured out around the blood vessels.

+Clinical Stages.+

(1) Stage of blistering, edema, dermat.i.tis, toxemia, pain, chill and shock.

(2) Discharge or absorption of contents of the blister with shedding of dead layers of epidermis.

(3) Reproduction of cells of the mucous layer from those of the germinal layer, which have formed the floor of the blister.

+BURNS OF THE THIRD DEGREE+

+Pathology.+ Charring of the whole skin through the reticular layer, or deeper. It may involve only skin, or include any underlying structures, fascia, muscles, blood vessels or bone. The essential feature is the total death of hair follicles, oil and sweat glands, with consequent destruction of all germinal epithelium.

+Clinical Stages.+ (1) Stage of destruction of tissue with underlying inflammation. If extensive, this degree of burn causes shock, probably non-toxic. During the early stage there is apt to be great pain from injury to the nerves in the sick layer, but not so great as in that of second degree burns where the number of injured nerves is greater.

(2) The general effects (toxemia, blood changes, embolism, congestion of vital organs with resultant chill and shock) are probably little different from those in extensive burns of the second degree, as few burns are purely third degree burns, but if extensive they have also large areas of second degree burns.

(3) Stage of sloughing. During this stage the second degree portion of the burn pa.s.ses through its various stages and heals. The dead tissue shows at its edges a line of cleavage from the surrounding living skin. The slough is usually slow in coming away, owing to the direction of the connective tissue and elastic fibres which bind it to the underlying structures. This last stage lasts from one to three weeks. The process is more rapid in infected burns and the depth of this burn will depend upon the degree of heat to which the part was subjected, the length of time the heat was applied, and several other factors. The danger of infection is always great owing to: (a) presence of dead tissue; (b) the low resistance of adjacent sick tissue; (c) the open veins and lymph channels; (d) the adjoining skin which is difficult to sterilize; (e) the discharge of a large amount of serum which forms an excellent culture medium. There may be also severe hemorrhage as in any sloughing wound. The danger of this is greatly increased by infection, which breaks down the thrombi in the veins and arteries.

+Stages of Granulation.+ The cavity left by the slough rapidly fills with new granulations. These have a tendency to rise above the surrounding skin.

+Stage of Epidermis Covering.+ If skin grafting is not done, the new epithelium can be renewed only from the edges-a slow process often requiring months to cover the whole surface. Coincident with this stage is the stage of cicatrization. The granulations which fill the s.p.a.ce left by the slough soon begin to contract-nature's effort to fill the gap. The granulations are irregular and abundant and for this reason the scar resulting from a burn is irregular, uneven, inelastic, contracted, distorted, protuberant and disfiguring.

+Duration.+ First degree burns get well in a few days; those of second degree, in about from seven to fourteen days, and the healing of the third degree burns depends upon their extent and depth, severe ones requiring a very long time. As to scarring in a burn of the third degree, you can always predict it, although this can be minimized by early skin grafting.