Surgery, with Special Reference to Podiatry Part 8

+Treatment.+ The local treatment is to be directed toward the limitation of the resulting inflammation; the prevention of septic infection; a.s.sisting the normal elimination of the eschar; the development of granulations and limitations of the deformity.

In burns of the first degree little or no treatment may be requisite; a mild dusting powder such as boric acid or sodium bicarbonate may be used, or picric acid in the strength of from half to one per cent.; a 5 per cent. boric acid ointment is also to be recommended.

Burns of the second and third degree require a different treatment.

Suppose we are called to treat a severe burn of the second or third degree and find the patient suffering agonizing pain with oncoming shock and a chill. At once administer a hypodermic of one quarter to one half a grain of morphine; 1-40, to 1-20 grain of strychnine; and 1 to 1-100 or 1 to 1-50 grain of atropine. To stop the pain and combat shock, have the room warm, clear it of unnecessary furniture; order hot water bottles, and, if necessary, give a hypodermoclysis or a Murphy enema.

In a severe burn three things are more important than the local treatment: (1) to stop the pain; (2) to combat shock; (3) to provide for dilution and elimination of the toxins, which are thrown into the blood.

After having carried out the instructions given above, then proceed to do the local dressing. The clothing should be carefully cut away-never pulled off, or dragged over the burned area. A burn is at first sterile, and we must try to keep it so. Unless we believe that it has become infected through dirty handling, or by having had dirty clothing dragged over it, or a dirty blanket laid on it, it is best not to wash the burn. Pieces of gauze of necessary size are now spread thickly with an ointment and applied somewhat beyond the burned areas; over this cotton, and over all a bandage.

The patient is now put to bed, and if shock continues, the normal salt solution is repeated every eight hours and the patient is given plenty of water to drink.

Nourishment for the first three days should be liquid, on account of the intense congestion of the alimentary tract Food is gradually increased according to conditions. There should be the usual care of the bowels, skin and kidneys, but in our zeal over the local treatment, we should not forget that we have to care for a patient whose blood is loaded with toxins, and whose lungs, stomach, kidneys, and other organs are congested and filled with emboli. At first, dress the burns daily, gently wiping away the discharge of serum and broken down cells, which is poisonous and irritating, with dry gauze or cotton. Blisters are opened and pieces of loose skin removed with sterile scissors or forceps, but all skin is left in place as long as possible to protect the underlying, new forming skin. Every dressing should be made with a septic care: clean hands, clean gauze and clean instruments. As soon as the slough begins to form, if there is much odor, it is well to apply a continuous wet dressing (see later reference). In case of a burn caused by carbolic acid, the skin is neutralized by the use of absolute alcohol (95 per cent.). In burns from trichloracetic acid, use alkaline remedies as sat. sol. of sodium bicarbonate. Burns from caustic alkalies are neutralized by vinegar or by some other mild acid such as boric acid. A so-called X-ray burn is not a burn at all; the observable results of such an accident are not manifested until several days or even several weeks after the application of the rays, at which period an inflammatory or a gangrenous process arises, which begins within the deeper tissues and subsequently involves the surface. These burns are often accompanied by loss of hair or of nails in the damaged area; they frequently remain unhealed for months; if they heal at all, they are very painful, and are not improved by the treatment which relieves ordinary burns. In some cases the consequences are very serious.

Ambrine is a newly proposed remedy.

+Effects of Cold.+ The more serious effects consequent upon exposure to sudden or prolonged cold are termed _frost bite_. In this condition the feet are commonly affected, and very often the freezing is so complete that upon thawing, the parts are found to be absolutely dead or their vitality so impaired by the cold that after reaction, strangulation and inflammation of the tissues occur, producing gangrene. As in burns there are three degrees of freezing, viz., first, second and third. In the first, the redness, numbness and tingling which follow exposure to intense cold are succeeded by loss of power, usually commencing in the toes, and loss of sensation, the parts becoming anemic and cold. In the second degree the skin is red or bluish and is covered by blebs with clear hemorrhagic contents. If the epidermis only is lifted up there is quick, scarless healing, but in the majority of cases the deeper tissues are involved. In frost bites of the third degree there are blebs and crusts which eventually mortify. Parts hopelessly frozen are at first anemic, cold and insensible but after reaction sets in they become swollen and discolored or they shrivel up and contract. It is not unusual for the part to show no change for some days and then to become blue or black; a line of demarcation forms and the dead tissue sloughs off.

+Treatment.+ Reaction must be gradual. The room should be of low temperature; the affected part should be immersed in ice water; gentle friction or rubbing lightly with snow is oftimes efficacious. When the temperature is normal, stimulating friction with soap liniment, alcohol, and water and spirits of camphor with elevation of the parts, is advisable. The room may be gradually warmed and the parts exposed should then be covered with cotton. As reaction progresses warm, stimulant drinks may be cautiously administered. If excessive reaction takes place, evaporating lotions of alcohol and water may be used.

Where a large surface is frozen, prolonged immersion in a bath may be employed after reaction has been established. When gangrene is present, surgical intervention is imperative.

+Chilblain+ occurs in individuals with a feeble circulation or in the anemic or strumous, though healthy young people are not immune. The feet are very often attacked, especially the heel and the borders of the feet, but any of the peripheral parts may be affected. The areas are bluish or purplish red, swollen, cold to the touch, tender, itching and burning. Neglect and friction will produce severer grades of inflammation, with vesicles, bullae, pustules and ulceration or even gangrene, with or without the formation of bullae. There may be a favorable termination or fatal septicema may supervene.

+Treatment.+ This should be preventive by protecting the feet, wearing warm clothing, by exercise, and the administration of tonics. Local immersion of the affected part in hot saturated solution of alum relieves the venous congestion and the itching. In severe cases, heating too rapidly, or overheating, should be prevented so as not to restore a too rapid reaction. A strong faradic current, ten minutes thrice daily, or the electric bath, ten to fifteen minutes daily, is beneficial. In ordinary cases, balsam of Peru or 10 per cent. ichthyol ointment, rubbed in, is all that is required. When there is ulceration, antiseptic dressings should be applied.

CHAPTER VIII

+FISTULAE; FISSURES; SINUSES; ABSCESSES; FURUNCLES; ULCERS+

A +Fistula+ (pl. fistulae) is an abnormal communication between the surface and an internal part of the body, or between two natural cavities or ca.n.a.ls. The first form is seen in a rectal fistula, the second in vesicov.a.g.i.n.al fistula. Fistulae may result from a congenital defect and can arise from sloughing, traumatism and suppuration.

Fistulae are named from their situation and communication.

A +Fissure+ is a crack and in podiatry, has special reference to a condition found in the toeweb.

A +Sinus+ is a tortuous track opening usually upon a free surface and leading down into the cavity of an imperfectly healed abscess. A sinus may be an unhealed portion of a wound. Many sinuses may be due to pus, burrowing subcutaneously. A sinus fails to heal because of the presence of some irritant fluid (as saliva, urine) or, because of the existence of some foreign body, as dead bone, a bit of wood, a bullet, a septic ligature, or because of rigidity of the sinus wall, which rigidity will not permit collapse. The walls of a tubercular sinus are lined with a material identical with the pyogenic membrane of a cold abscess. Sinuses may be maintained by want of rest (muscular movements) and by general ill-health.

+Treatment.+ In treating a fistula, remove any foreign body; lay the channel open, curet, touch with pure carbolic acid, and pack with iodoform gauze. In obstinate cases, entirely extirpate the fibrous walls; sew the deeper parts of the wound with buried catgut sutures, and approximate the skin surfaces with interrupted sutures of silkworm gut. Fresh air is necessary; nutritious food and tonics must be ordered.

+Acute Abscesses.+ An abscess may be defined as a circ.u.mscribed cavity of new formation, containing pus. An essential part of this definition is the a.s.sertion that the pus is in a cavity of new formation; is an abnormal cavity; hence pus in a natural cavity (pleural or synovial) const.i.tutes a purulent effusion, and not an abscess, unless it is encysted in these localities by walls formed of inflammatory tissue.

An acute abscess is due to the deposition and multiplication of pyogenic bacteria in the tissues or in inflammatory exudates.

When abscesses form in an internal organ or in some structure which is not loose like connective tissue, for instance, in a lymphatic gland, a ma.s.s of pyogenic bacteria floating in the blood or lymph, lodges, and these bacteria, by means of irritant products, cause coagulation necrosis of the adjacent tissue and inflammatory exudation around it.

The area of coagulation necrosis becomes filled with white blood cells, and the dry necrosed part is liquefied by the cocci.

Suppuration in dense structures causes considerable ma.s.ses of tissue to die and to be cast off, and these ma.s.ses float in the pus.

An abscess heals by the collapse of its walls, and the formation of an abundance of granulation tissue; in many cases granulations of one wall join those of the other side, the entire ma.s.s of granulations being converted into fibrous tissue, and this tissue contracting, heals by third intention. If the walls do not collapse, the abscess heals by second intention.

+Symptoms.+ The symptoms of an acute abscess may be divided into (1) local, (2) const.i.tutional. Locally there is intensification of inflammatory signs; swelling enormously increases; the discoloration becomes dusky; the pain becomes throbbing, and the sense of tension increases; the cutaneous surface is seen to be polished and edematous, and after a time, pointing is observed and fluctuation can be detected. The const.i.tutional symptoms are usually limited to chills and fever, depending upon the severity of the infection.

+Treatment+ is free incision and drainage. The wound should be opened early, if possible even before pointing or fluctuation, to prevent destruction, subfascial burrowing, and general contamination; drainage is continued until the discharge becomes scanty, thin and seropurulent.

+Chronic Abscess+ is a term referring only to time. Usually a tubercular abscess is designated as a chronic, cold, or scrofulous abscess. It is an area of disease produced by the action of the tubercular bacilli and is circ.u.mscribed by a distinct membrane. The symptoms present no inflammatory signs. Const.i.tutional symptoms are trivial or absent unless secondary infection occurs. The treatment of these cold abscesses depends upon their location.

+A Furuncle or Boil+ is an acute and circ.u.mscribed inflammation of the deep layer of the skin and the subcutaneous cellular tissue, following on bacterial infection of the hair follicle through a slight wound (by scratching, shaving), with the staphylococcus pyogenes aureus.

+Symptoms.+ The symptoms of a boil are as follows: a red elevation appears, which stings and itches; this elevation enlarges and becomes dusky in color, a pustule forms that ruptures and gives out a very little discharge which forms a crust; inflammatory infiltration of adjacent connective tissue advances rapidly, and the boil in about three days consists of a large red, tender, and painful base, capped by a pustule and some crusted discharge. In rare instances, at this stage, absorption occurs, but in most cases the swelling increases, the discoloration becomes dusky, the skin becomes edematous, the pain severe, and the centre of the boil becomes raised. About the seventh day rupture occurs, pus runs out, and a core of necrosed tissue is found in the centre of a ragged opening. The hair follicle and the sebaceous gland, which have undergone necrosis, are found in this core. Healing by granulation will occur; the const.i.tution often shows reaction during the progress of a boil.

Boils may be either single or multiple, and the development of one boil after another, or the formation of several boils at once, is known as _furunculosis_.

+Treatment.+ The treatment consists of crucial incision and the application of a wet dressing.

+An Ulcer+ may be defined as the loss of substance due to necrosis of a superficial structure, and the causes of ulcers may be divided into (1) predisposing and (2) exciting. In the former, age, s.e.x, occupation and social condition have to be considered. The exciting causes are traumatism and infection.

The chief varieties of ulcers seen on the leg and foot are as follows: indolent or callous; varicose; tubercular; syphilitic; epitheliomatous; diabetic; perforating and blastomycotic.

In indolent or callous ulcer, the cause may be divided into general and local. Among the former may be mentioned typhoid fever, chronic nephritis, anemia, poor hygiene, improper food, overwork, and lack of sleep. Local causes: old scar tissue, extremes of heat or cold, irritation of the tissues, injury, the presence of a foreign body such as dead bone, splinter, etc.

+Symptoms.+ The most common location of these callous ulcers is on the inner side of the lower third of the leg. They show a great variety in size, shape, appearance and base, edges and surrounding area, and in accordance with these differences, many different names are applied to them. The size varies from a small ulcer less than one centimeter in diameter, sometimes found with varicose veins, to the large ulcerations which surround the leg and are called _annular_ ulcers.

The shape may be round, very irregular, or funnel shaped. The base may be much or slightly depressed, or the granulations may be at a higher level than the surrounding edges. When the granulations are large, irregular, and bleed easily, they are spoken of as _exuberant_; when pale, soft and flabby, as _weak_ or _edematous_; when small and slowly growing, as _indolent_.

A peculiarly painful form of chronic ulcer is found over the internal malleolus, and most frequently in women of middle age; it is often a.s.sociated with menstrual disorders and is known as a _congested_ or _irritable_ ulcer. It begins as a small area of congestion over the internal malleolus, which gradually increases in size and becomes dark and more dusky in the centre, due to the deposit of blood pigment caused by chronic congestion. The skin next becomes hard, dry, scaly and pigmented, while the subcutaneous tissues lose their elasticity, becoming inflexible, hard and adherent to the deeper structures. Then, as a result of slight traumatism or even without injury, the centre of the area breaks down and an ulcer develops. It may be circular or irregular in shape and may be quite deep or superficial. The edges are sharply cut, and both base and edges are bound down to the deeper tissues. The intense pain of the ulcers is supposed to be due to pressure upon the terminal nerve filaments in the dense sclerotic tissue. This form of ulcer is very often difficult to cure and shows a tendency to return after healing.

+Treatment.+ This naturally depends upon the time the ulcer is seen and the conditions present. If there is considerable inflammation, accompanied by marked cellulitis and pain, the milder wet dressings, such as boric acid or Thiersch are indicated. Rest, of course, is the most important factor. The patient must be prohibited from walking, and if necessary, the movements of the neighboring joints must be prevented by the application of suitable splints. After the acute inflammatory symptoms have subsided the granulations must be stimulated, (see Chapter XIX).

+Varicose Ulcer.+ To chronic ulcers of the leg a.s.sociated with varicose veins, especially of the smaller venous radicles, the name varicose ulcer has been given.

+Symptoms.+ The usual development of this variety of ulcer is as follows: persons who suffer from varices of the leg usually complain for some time before the external manifestation of the disease, of a deep aching pain in the limb, with a sense of weight, fullness, and fatigue. In a more advanced state of the disease, the ankles swell after a day's hard work, and the feet are constantly cold; an embarra.s.sed state of the circulation is denoted by these symptoms and the deep seated veins begin to swell. After a time, which varies with the idiosyncrasy and occupation of the patient, small soft, blue tumors are seen at different points of the leg, most of them disappearing on pressure, but returning when this pressure is removed or when the patient stands up. Each little tumor is caused by a vein dilated at the point at which it is joined by the intramuscular branch. Around many of these tumors a number of minor vessels of a dark purple color are cl.u.s.tered, these being the small superficial veins which enter the dilating vein and in which the varicose ulcer is often of a brownish blue color, due to a deposit of pigment.

Frequently a leg, which is the seat of varicose veins, or which is edematous from other causes, is attacked by acute eczema. The recognition of varicose ulcers is usually easy but the mere presence of enlarged veins, it should be noted, is not pathognomonic, because they may often exist along with ulcers of other origins, tuberculous, syphilitic, etc.

The surface of varicose ulcers usually presents imperfect and unhealthy granulations, secreting a more or less thin and offensive pus, and the granulations are sometimes covered with membranous exudation. The edges and base are thickened and callous, and enlarged veins, capillary or otherwise, are present near the circ.u.mference and often amount to genuine blood tissue which tunnels the infiltrated tissues. In examining such an ulcer one gets the impression of a great pigmented scar, the centre of which has broken down.

Lymphangitis and venous thrombosis are not of infrequent occurrence in connection with varicose ulcers, while embolism and even pyemia are sometimes in evidence. Among the most frequent complications is cellulitis, and this may sometimes be so severe as to necessitate operation. Erysipelas may also occur in cases of varicose ulcer, and hemorrhage is a common and serious complication and has at times been fatal.

+Differential Diagnosis+

CALLOUS VARICOSE SYPHILITIC

_History_:

injury varicose veins or syphilis.

phlebitis.

_Situation_: