FISSURES, BLISTERS, AND BURNS
FISSURES (_Fissura_)
=Definition.= Fissura or fissures, as used in this sense, are cracks or
clefts in the surface of the skin, some involving only the epidermic
layers, some penetrating deep into the corium.
=Etiology.= Fissures occurring on the foot, due to trauma, are far in
the minority as compared with those occurring as secondary lesions
in hyperidrosis, uric acid diathesis and other systemic conditions.
They are usually due to a too strenuous drying of the interdigital
surfaces with a rough towel. They may also be caused in like locations
by excessive walking, but the condition of the skin of the patient has
much to do with their formation. If the skin be dry and a great amount
of its elasticity is gone, these lesions are much more prone to develop
than where the skin tension is practically normal. The interdigital toe
webs are often cracked or fissured in spreading the toes too far apart,
and this has been caused, at times, by the podiatrist working between
the toes and stretching them to obtain room for his instruments or
dressings.
=Treatment.= The natural treatment for a condition of this kind
would be to obtain astringent action. This may be accomplished by a
number of drugs, principal among which is silver nitrate. Tannic acid
preparations are also frequently used, but they cannot compare in
efficiency with the silver salt. A number of mild vegetable astringents
of the same group are similarly employed by podiatry practitioners.
If the fissure is superficial, involving only the epidermic layers,
compound tincture of benzoin, painted freely over the parts, after they
have been thoroughly cleansed and dried, will be found advantageous
in inducing rapid healing. Dusting powders such as tannoform,
bismuth subgallate, bismuth subnitrate and thymol iodide, may also
be successfully employed in these cases, but where the fissure is
deep, the edges angry and red, and the whole area is involved in the
inflammatory process, none of these are, as a rule, of avail, and more
radical methods must be employed.
Nitrate of silver presents the most efficient means whereby astringent
action may be obtained in the parts. Weak solutions, from 1% to 10%,
are most generally employed, but it is often found necessary to use
stronger solutions, even as high as 50%.
[Illustration: FISSURED TOE WEB]
=Technic.= The parts are first thoroughly cleansed and any callous
around the edges of the fissure is carefully and completely removed.
This is an essential procedure, for no lateral granulation will take
place, nor can direct apposition be obtained if this callous be allowed
to remain.
Small particles of material from the hosiery or other foreign bodies
should also be thoroughly removed. The recesses of a deep fissure
present excellent places of lodgment for minute particles which are
always to be found in footgear, and it is these bodies which produce
infective processes. The above precautions having been observed,
alcohol, 60%, should be freely applied and the parts thoroughly dried.
Silver nitrate may then be painted deep down into the floor of the
fissure, by means of a cotton wound applicator. This will produce some
smarting, but it is transient and there will be no great amount of
irritation. The silver solution should also be applied to the surfaces
adjacent to the edges of the fissure, for it must be remembered that
silver nitrate is sedative and this action is desirable in reducing the
local inflammation.
Where the fissure is deep and of long standing, it may be found
necessary to resort to a 25% or 50% solution or even to the fused
stick. When cases are observed where proud flesh has developed in
the fissure, due to continued irritation, it is necessary to use the
stronger solutions or the stick at once. The proud flesh may be in such
form as to permit of surgical removal. Where this can be accomplished,
the bleeding stump is usually cauterized with silver solution, 50%. If
a surgical procedure is impractical, the fused stick may be used to
cauterize the neoplasm and thus eradicate it.
A dressing should be applied over the parts after the fissure has been
treated. This may consist of several thicknesses of gauze, fashioned to
fit between the toes, if the fissure be in that location; if the lesion
be upon a plane surface, a square of gauze should be applied and held
in place by adhesive strips.
A cocoon dressing may be substituted for that of gauze, and in many
instances will be found more practical. It has been found necessary
at times to apply some ointment or grease over the fissured area to
aid in softening the parts and rendering them more flexible. Massage,
at intervals, with olive oil or mutton tallow, will also be found
advantageous in bringing about this result.
No dressing is applied over the parts after the use of compound
tincture of benzoin, for this drug forms its own coating, which is
practically impermeable. If a dusting powder be used alone, the parts
are first thoroughly dried, whereupon the powder is dusted lightly into
the fissure, and a wisp of cotton is placed over the part and held in
place with collodion.
Pure ichthyol has also been found efficient in these instances; a drop
is placed in the fissure and is retained there by means of cotton or
gauze.
Astringent treatment, as described, should be continued until the
fissure has entirely healed, and in the use of silver nitrate it will
be found advisable to remove all remnants of the previous application
before the drug is again used. The eschar is easily removed, but it
must also be remembered that in some instances it may be advisable
to allow the eschar to remain, and the wound to granulate under its
protective covering.
This article has been confined almost entirely to fissures occurring in
the interdigital webs for the reason that these parts are their usual
sites of occurrence. At times, however, they do form in other parts of
the foot--on the heels along the sides of the foot, and on the ends
of the toes. The treatment in any locality is similar. When infection
is present it should be arrested; if proud flesh has developed, that
must be eradicated; in all cases astringent treatment is necessary to a
successful outcome.
BLISTERS (_Bullae_)
=Definition.= A blister is a collection of fluid in the skin beneath
the outer epidermic layers, which latter are raised to form the upper
wall of the sac, the base of the blister being formed by the mucous
layers of the epidermis or by the corium.
=Etiology.= The cause of practically all blisters met with in podiatry
is traumatism. Those occasioned by the friction brought to bear on
the surfaces of the foot by a new or unyielding shoe predominate, but
occasionally the podiatrist is called upon to treat these lesions
arising from a burn. In discussing the subject of blisters under this
heading, those of traumatic origin only will be considered. Those
occasioned through burns, or superficial vesicular developments of
specific origin will be discussed in chapters dealing with the disease
or diathesis in connection with which they may develop.
=Pathology.= The pathologic process causing the formation of a
traumatic blister is a simple one. Due to the constant rubbing of a
shoe, the superficial epidermic layers are loosened up, one layer from
the other, and, owing also to this external irritation, the serous
elements of the blood are caused to leave the vessels and thence find
their way into the intercellular spaces caused by this loosening.
Collections of fluid of this nature are known as bullae or blisters.
The so-called “blood blister” is of a similar origin except that the
injury (in this case usually a severe trapping or pinching of the
tissue) is sufficient to cause the rupture of one or more capillaries
whose blood contents extravasate into the overlying epidermic layers.
=Usual Points of Location.= Blisters developing upon the pedal
extremities are most common in the spring of the year when people
begin to wear Oxford ties or other styles of low shoes. They occur
principally upon the posterior surfaces of the heel at the upper
extremity of the os calcis, or upon the tendo Achillis, just above this
point, and are caused by the rubbing of the stiff heel of the shoe upon
these parts.
Bullae are also often found to develop over or immediately adjacent to
the prominent extensor tendon on the dorsum of the hallux. In these
locations the stiffness of the shoe in “breaking” over this point is
found to be the irritant agent.
Whilst the two foregoing locations are the most general sites of
occurrence, they are, at times, also found to develop upon the plantar
surfaces, and in some instances upon the ends or between the toes.
=Treatment.= The method of treatment to be accorded these cases depends
upon the condition that the affected part may be in at the time of
observation.
=Ordinary Conditions.= When the blister is found to be unbroken and
no great degree of inflammation is present, the sac should be opened
and its contents evacuated. This is best accomplished by means of a
fine-pointed, sterile scalpel or bistoury. The blister is punctured
through the unaffected epidermis immediately adjacent to its base,
and thereupon gentle yet firm pressure is exerted until all the fluid
contents are evacuated.
Once the contents have been removed, thorough asepsis should be
inaugurated. The parts should be swabbed with alcohol, 60%, and
allowed to dry by evaporation, or be dried with a sterile wipe. In
dressing these conditions it must be remembered that protection must
be obtained as well as granulation induced. Recognizing these to be
important factors in treatment, the choice of a proper dressing should
be carefully made.
The cocoon dressing (see “_Dressings and Bandaging_”) is practical in
these cases, as the cotton serves to afford great protection to the
parts and also to confine whatever medication is to be applied as a
curative agent.
Dressings of sterile gauze or surgeon’s lint may also be used, and
consist of a square of gauze or lint applied over the part and held in
place by means of adhesive strips.
The cocoon dressing may or may not be reinforced by adhesive strapping,
as the judgment of the operator determines. If strapping becomes
necessary in this connection, half-inch or one inch width plaster is
generally used. The strips (each about three or three and a half inches
in length) are applied in the form of a triangle, binding down the
edges of the dressing. It is also found advisable to avoid using too
much collodion on the cotton. These dressings should never be hard; it
is, therefore, preferable to bind down the edges and then merely paint
the collodion in one narrow strip across and with the fibre of the
cotton. If adhesive strapping is to be used for the adherence of gauze
or lint, the one-half inch plaster is the most practical in almost
every instance.
The strips are each cut about three inches in length, unless the size
of the gauze or lint squares makes it desirable to have them longer,
and they are placed in rectangular fashion over each of the four sides
of the dressing. It should always be the endeavor, when possible, to
bind down the edges of the fabric to the skin, and to accomplish this
the adhesive strips are made adherent, half on the dressing and half on
the underlying skin. This serves to hold the dressing more firmly in
place and also to prevent foreign matter from getting under its edges.
Ointments are generally found to be the most advantageous applications
in cases of ordinary bullae. There are several of these from which we
may choose. Ammoniated mercury, 10%, and ichthyol, 10%, are probably
the most generally used and are efficient.
=Broken Conditions.= In many instances the blister, through neglect
and improper puncturing, has become broken and the affected epidermic
layers are stripped off, being attached at one point only, or are
entirely gone.
The parts should be thoroughly cleansed with alcohol, 60%, and all
loosened epidermis removed. Never leave any flaps of skin about the
edges of the denuded area, for they not alone serve as excellent places
for the lodgment of hostile bacteria, but are also apt to curl up and,
becoming thickened, may irritate the denuded surfaces by pressure.
The lesion being thoroughly aseptic, a dressing should be applied. If
infection be already present in the part, the treatment should consist
of the application of wet dressings of mercury bichloride, ¹⁄₂₀₀₀,
or weaker, until all inflammation has subsided. If no infection be
present, a dressing which will be protective, healing and sedative
should be placed over the parts. A shield is usually a necessary
adjunct to every successful treatment in cases of this nature.
It will always be found advisable to have the aperture of the shield
sufficiently large, not alone to protect the denuded area, but also to
include some of the surrounding integument.
In locations about the os calcis region and along the surfaces of the
tendo Achillis, an oval pad of a soft grade of felt is found to afford
the best protection. In cases where the blister has developed over the
extensor tendon on the dorsum of the great toe, a strip of white felt,
about one inch long and one-half inch wide, placed parallel to the
tendon, and of sufficient thickness to be higher than its elevation, is
found to be the most practical means of shielding the affected area.
An oval shield, if used in this latter instance, should have a groove
fashioned on its under surface in which no adhesive is placed and which
allows for the free play of the tendon in movements of the foot.
The choice of an ointment, if one is to be used, should be carefully
made, for asepsis is to be at all times maintained and granulation must
be induced.
Ammoniated mercury, 10%, and sulphur, 10%, are to be highly recommended
as antiseptic ointments, and the latter, in particular, has tissue
stimulating properties. Ichthyol, 10%, balsam of Peru, 5%, or scarlet
red, 3%, may also be used, the latter two where the lesion shows signs
of indolence and needs stimulation.
At times a dry dressing, either of plain sterile gauze, or gauze,
combined with a dusting powder, secures good results in these cases.
Thymol iodide and bismuth subgallate probably lead the list in
popularity but a very efficient substitute is found in a combination of
equal parts of bismuth subnitrate and powdered calomel.
The areas should be thoroughly dried before any dusting powder is
applied. This is best accomplished by applying alcohol and allowing
it to dry by evaporation, which may be hastened by blowing air upon
the area. A practical means of applying dusting powder is afforded by
compressed air. Under low pressure any powder may be blown from the
nebulizer upon the parts in a thin and even coating.
Both the ointment and the dry dressing should be changed in from
twenty-four to thirty-six hours until complete granulation is observed
and the structures of the denuded corium are entirely covered.
Dressings which are allowed to become stale and which harden, are apt
to act as irritant agents to the tender granulating surfaces and not
only retard normal healing but further break down the tissues.
Cocoon dressings may also be employed to apply either ointments or
dusting powders, as just described for gauze. They will remain in place
for much longer periods of time than will gauze or lint, but in these
cases, as the dressing must be changed daily, this is not an important
consideration.
=Prognosis.= The tissue lost in blister cases properly dressed and
protected should be replaced rapidly and stimulation is seldom found
necessary. The course is active but short. It is advisable to have
the patient refrain from wearing the shoe which originally caused the
disturbance so that no untoward irritation is brought upon the part
during treatment. After the epidermis covering is complete, it will be
found advantageous to paint the parts with silver nitrate, 50%. The
eschar so formed will act as a protective agent to the parts until the
skin regains its normal strength.
BURNS
The podiatrist is not called upon to treat many burns on the foot, and
when these conditions are present they are, as a rule, not extensive.
The subject is so important, however, and so much progress has been
made in recent years along the lines of burn treatments, that a
thorough knowledge of this subject is of great interest to the modern
practitioner.
=Definition.= A burn is a lesion caused by heat or by caustics. The
lesion may be superficial in the tissue involvement or it may have
penetrated to the deeper tissues and, if extensive, may cause permanent
injury or death.
=Pathology.= Intense heat being applied to the surface of the body
destroys the vascular supply, and so shocks the nervous sensibility
of the part that the nerves are temporarily, sometimes permanently,
paralyzed. This causes the tissue to slough and a more or less deep
ulceration is formed. The edges are found to be a dark, angry red in
color and the floor of the ulceration is usually a pale, unhealthy
yellow or white. In small areas the pain is intense, while if large
areas be involved to such an extent as to include the main trunks, the
parts rapidly become anesthetized and gangrene ensues. Discharge from
the ulceration is generally profuse.
As the podiatrist will only come in contact with the smaller burns the
discussion in this chapter is confined to their consideration.
=Treatment.= The burn, whether caused by direct heat or by chemical
reaction, is at first aseptic and this asepsis must be maintained
throughout the entire treatment. If the burn is very recent, an
immediate application of carron oil (equal parts of linseed oil and
limewater) will be found to relieve much of the pain, and to keep
the tissues in fairly healthy condition. If this medication is not
obtainable, a paste of sodium bicarbonate will also prove efficient.
All air should be excluded as soon as possible, and many advocate the
application of a simple grease smeared freely on the abraded surfaces.
These are purely first aid procedures, however, and have no part in
scientific treatment.
After the acute pain has been reduced or entirely relieved, treatment
should be instituted which will at once induce granulation and maintain
asepsis. Strong germicides, particularly those with toxic properties,
should be studiously avoided, for it must be remembered that the
vitality of the part has been severely shocked, even in a superficial
burn. Nothing must be done to retard the healing process.
Ointment or dusting powder dressings are advocated in these cases,
but the most efficient treatment lies in the use of one of the newer
paraffin preparations (see _Dressings and Bandaging_). The method
of application of these paraffins is as follows and is the original
technic as formulated by Dr. de Sandfort, who is the originator of this
method of treatment:
=Method of Use.= Paraffins are used warm, consequently in a liquid
state (158°-176° F.).
=Heating.= Place a piece of the material in a bowl, tin cup, or other
convenient receptacle, set in any vessel containing a little water,
which should be kept on the point of boiling for ten minutes.
=Precautions to Be Taken.=
1. Care should be taken to prevent the splashing of the boiling water
into the container holding the paraffin. When the water begins to boil,
reduce the temperature to avoid drops of water being thrown into the
wax. It must be remembered that these compounds, completely devoid of
water (anhydrous), do not burn the tissues at 176° F., while even the
smallest quantity of water added would have the contrary effect.
2. While the mixture is being heated, cut a piece of absorbent cotton
of sufficient size to amply cover the burned area, and divide it into
layers as thin as possible. At the same time, have ready the gauze and
band, needed to bind and keep the waxen shell in place.
=The Dressing.= When the paraffin is in a liquid state, and is at a
temperature of from 140° to 150° F., take a soft camel’s hair brush,
dip it into the mass and spread it on the wound, without pressing;
that is, as much as possible dabbing it on and not brushing it on.
This operation is repeated until the glazing is complete, taking care
to leave no spot uncovered. Immediately afterwards, place quickly on
the first wax glaze one of the thin layers of absorbent cotton already
prepared, as explained above, so that it becomes easily impregnated
with the wax, and then, with the same dabbing movement, brush on
several more applications of the paraffin.
If the wound is extensive, the operation is done on small square
surfaces, successively and close together (about 4 by 4 inches). These
little surfaces become, by the application, part of one another. This
proceeding is to avoid the first coat of glaze, because it is essential
to form (on the whole surface of the wound) a shell uniformly warm
which keeps its warmth a long time, thanks to the close attention of
the wax with absorbent cotton. Two layers of cotton can be applied
successively, saturated with the mixture, although this is not
indispensable.
When the application is complete, the dressing is finished by binding
with ordinary gauze or cotton, kept in place by bands. If desired,
gauze can be replaced in part by oiled silk, or even paper.
=Note.= In not following the precise instructions already given, grave
errors can be committed. Thus, should the layer of absorbent cotton be
applied directly to the wound and afterwards covered with the first
layer of the paraffin it causes:
1. A very painful burning sensation. These applications on a wound
are very soothing, while cotton impregnated with the paraffin applied
direct to the wound causes a distressing, burning sensation.
2. At the moment of removing the dressing, a pulling and even tearing
of the tissues is caused. If the wound has not been previously glazed
by an application of a first layer of paraffin, as explained above, the
cotton will adhere.
=Removing the Dressing.= For the first few days the waxen shell must
not be left in place for more than twenty-four hours, on account of
an abundant secretion of lymph, which takes place beneath it. The
sero-purulent liquid flows under the wax covering (which proves that
the waxen layer does not adhere to the tissues like collodion, with
which paraffin has been wrongly compared) and exudes from under the
edges of the dressing. After a few days, this exudation diminishes and
the dressing can be left in place for forty-eight hours at a time and
even longer.
To remove the dressing, untie the bands and take off the ordinary
gauze or oiled silk, thus exposing the “shell.” An incision is made
in the “shell” by means of a blunt knife or scissors and it is easily
peeled off. The dressing is removed more easily than a glove. The wound
is afterwards bathed with boiled water and the cleansing is further
perfected by washing with absorbent cotton soaked in boiled water. Then
it is dried, either by a current of warm air or by a piece of cotton
wool, care being taken not to rub, or cause the granulations to bleed.
The new dressing is not applied until the surfaces are thoroughly dry.
=Important Recommendations.=
1. In washing the wounds, antiseptic solutions must not be used, unless
extremely weak.
2. Anxiety need not be occasioned by the grey aspect and fetid odor
which emanates from the wound when the waxen shell is removed. In fact,
after this washing, it is seen that beneath this purulent liquid, the
tissues present an intense vitality and an excellent appearance. In
order to properly proliferate the elements of healing, it even seems
as if they have need to bathe in this purulent liquid, which might be
termed auto-serotherapia.
3. In application, the wax should be brushed on with strokes or daubs
all directed the same way, and these should commence at the top of the
part and be carried downward, never starting at the bottom and going
upward.
After several days of treatment, skin granulation will be observed,
white spots appearing more especially at those points, where the
sero-purulent liquid has remained in the greatest abundance.
Care should be taken not to apply paraffin at a temperature of more
than 105° F.
Contrary to the usual practice, the abundant granulations must never be
cauterized with nitrate of silver or any other caustic. In spite of
their development, at times considerable, little by little they begin
to be strangled by the regenerating elements of the skin, which finally
replace them.
In case of persistent atony of the wound or of excessive growth of
granulations, the paraffin treatment can be interrupted every three or
four days by a wet dressing (water slightly alcoholized) for a period
of twenty-four hours. Paraffin treatment is afterwards resumed, which
the patient often requests himself, on account of the comfort derived
from the waxen shell.
After some days of treatment, there appears sometimes on the healthy
skin surrounding the wound an eruption of sudamina, caused by the
perspiration confined under the waxen shell. To make it disappear,
cover it with an ointment of oxide of zinc, then powder with talc,
always continuing the paraffin application over the wound.
=Conclusions.=
1. Paraffin preparations instantly alleviate the pain.
2. They constitute a warm shell, a heat retainer, under which the
tissues, protected against outside contamination and maintained at a
temperature always constant, rapidly heal.
3. They become non-adhesive after a short period, thus rendering
removal instantaneous, without pain, without hemorrhage and without
tearing the tissues of neo-formation, thus permitting the integral
healing of the tissues, without apparent scars, without contraction of
the skin or of the tendons.
4. Without causing persistent and incurable functional weakness.
=Important.= Heating these preparations in a bath of boiling water
raises the temperature to nearly 212° F., therefore, before applying to
the wound, they should be removed from the water bath and allowed to
stand for a minute or two so as to reduce the temperature below 105° F.
If an ointment be used, a bland healing type should be chosen.
Among these ichthyol ointment, 5% to 10%, is probably found to be as
efficient as any, although zinc oxide, 10%, balsam of Peru, 5%, and
various sulphur ointments, 3% to 10%, may be substituted with equal
results.
On a freely discharging surface, of course, an ointment is
contra-indicated and a dusting powder must be resorted to or merely a
dry aseptic gauze dressing applied. The dusting powders to be used are
the two bismuth salts, subgallate and subnitrate, although the latter
is found to be irritant at times; thymol iodide may also be used and
its antiseptic and healing action makes for its general popularity in
these cases.
The ointment or dusting powder is covered with a cocoon, gauze, or
lint dressing which is held in place by collodion or adhesive strips,
respectively.
The dressing should be changed daily until granulation is complete.
Burns are stubborn lesions to heal and the podiatrist should not slight
them in any way. They are prone to infective processes, and the least
neglect is apt to cause the undoing of all that previous treatment has
accomplished.