336 American Journd of Surgery Butler-Scalp and Face Wounds FEBRUARY, 1930

ahgnment so Iong as the deformity is en- couraged and maintained by the wearing of an improperI\; constructed and fitted shoe, from the viewpoint of anatomica structure. As this deformity continues, aided by sup- port, inflammation of severe and deep char- acter develops, and with further abduction of the great toe at the “bunion joint” the resuItant deformity, haIIux vaIgus, becomes a serious compIication.

Thus, stimulation to bony formation through irritation about the dista1 meta- physis of the first metatarsa1 bone prevents any possibIe alignment with the former articulating proxima1 phaIange. An apophy- sis or exostosis on the media1 aspect of the joint is the resuIt of this irritation and this spreading bony excrescence brings about in the extreme cases uItimate disIocation of the proximal phaIange from the first metatarsa1 bone. It is this devia- tion outward from the media1 Iine, whether of miId or severe character, which consti- tutes the Iesion that shouId by the term haIIus vaIgus.

be identified

There is no reason for considering bunion and haIIux vaIgus as one and the same Iesion any more than there is for

WOUNDS

identifying bunion with haIIux varus, haIIux extensus, or haIIux Aexus.

In brief it is desired to stress the fact that with proper footwear it is readiIy possibIe to overcome the formation of bunion and the urtimate deveIopment of hallux valgus. Further that the bunion usuaIIy finds origin from the predisposing factors: short hosiery, short shoes with high heeIs or short shoes with narrow toes. AIso, that the common seque1 from a bunion Ieft unattended is haIIux valgus, which deformity may present advancing pathoIogy, encouraged through the con- tinued wearing of improper shoes. The ordinary bunion is readiIy corrected with- out operation whiIe haIIux vaIgus, as a compIication or seque1, is a genuine deformity which cannot be overcome without operation, unIess it be of the moderate type. About go per cent of a11 adults are sufferers from some sort of foot troubIe most of which can be pre- vented by proper shoeing. PeopIe refuse to reaIize that most of this distressing list of disturbances originates from the wear- ing of improperIy constructed and im- properIy fitted shoes.

a3 OF THE SCALP AND--FACE*

EDMUND BUTLER, M.D.

SAN FRANCISCO, CALIP.

0 NE room in every oflice shouId be patient sitting upright. Aromatic spirits

equipped for the care of emer- of ammonia and whiskey are usefu1 in gencies; a suppIy of dressings, steriIe avoiding an attack of syncope.

instruments, and steriIe threaded suture Cover the wound with a steriIe dressing materia1, arranged on a smaI1 portabIe Iarge enough to overIap the uninjured tabIe ready for immediate use, is the skin I to 2 cm. Make firm pressure with minimum any doctor shouId offer his the fingers of the Ieft hand to control community. bIeeding. Wash the remainder of the face

The injured person must be pIaced or scaip and hair free of bIood with a wet supine on a comfortabIe tabIe immediateIy towel; the wetter the towe the easier upon arriva1, regardIess of the sIightness the bIood is removed. Raise the steriIe of the injury. Repair of wounds and painfu1 dressing, beginning at one angIe of the dressings must not be done with the wound, cIamping bIeeding vesseIs as they

* Submitted for pubIication December 12, rgzg.

appear. Lift up the edges of wound and make a carefu1 inspection of the depths, removing clots with smooth dressing for- ceps or .by irrigating with saline, steriIe lvater or weak peroxide soIution. The author favors irrigating with weak peroxide solution because it makes foreign materials more easily identified and fracture Iine stand out cIearIy. FrequentIy the scaIp has been stripped up for severa centi- meters, secreting various amounts of for- eign material.

The mechanica cleansing of the wound is far more important than the IiberaI and bIind use of antiseptic solutions. The relative merits of iodine, mercurochrome, aniIine dyes, hypochIorite solution, ether, benzine, and picric acid as bactericides depend upon the care with which the wound has been mechanicaliy cIeansed and not upon their relative antiseptic quaIities. The wound after inspection and remova of foreign materia1 is flooded with any of the antiseptIc soIutions, iodine 3 to 7.3 per cent being the most frequentIy used. If any vesseIs continue to bIeed, fine catgut Iigatures are used, and if vessels have retracted and cannot be controIIed with clamp, it may be necessary to use Iigatures mounted on needIes traversing the region of the vesseIs and tied just tight enough to control bIeeding and not stran- gIing a11 tissues in the grasp of the suture.

Now we are ready for suturing. Fine siIk gut, bIack silk, horse hair, or MicheI cIips may be used. MicheI cIips are of \.ery little use in the dense scaIp but most usefu1 in the frontal region and wounds of the upper face. If the wound is irreguIar, the angles are approximated first, the suture taking in the entire thickness of the skin. The deep fibrous layer is the layer that presents future spreading of the scar. One suture to 2.5 cm. is sufficient in the hairy scaIp. In the face, sutures must approximate the skin accurateIy. It is a very sane procedure to drain a11 scalp wounds with smaI1 pieces of rubber band or twisted siIkworm gut. Wounds of the face, if irreguIar or pocketed, shouId aIso be drained. AI1 drains to be removed at

the end of twenty-four to fortj--eight hours if infection has not developed. An exceIIent dressing is compresses of equa1 parts of gIycerine and alcohol. The com- press is covered with oi1 silk, gutta-percha tissue, siIkIoid, or oi1 paper. Drainage is promoted and crusting impounding exu- date is prevented. Wounds must be dressed daiIy until you are sure infection is not present.

An immunizing injection of tetanus antitoxin is given in a11 Iacerated wounds where the subcutaneous tissues are in- vacIed. The extent of the wounds is no indication of the Iikelihood of tetanus baciIIus contamination. A small nound may harbor tetanus baciili. Lacerated wounds ground fuI1 of street fiIth shouId not be sutured but drained and allowed to hea by granuIation.

Hair washed with equal parts of ether and benzine is steriIe and shaving need not be done in the scaIp or eyebrows unIess the hair interferes with approximation. One must aIways remember no matter how sIight the scaIp injury ma\- haAle been and even though there ‘is no apparent intracrania1 injury, that a fissure fracture of the skull across one of the meningeal arteries may exist and speI1 future disaster if not carefuIIy watched.

Wounds of the scaIp and face heal rapidIy, and infection is not IikeI,v to occur, because of the abundant blood suppIy. In wounds of the cheek or Iips entering the mouth, the sutures shouId incIude the skin muscIes and submucous down to, but not including the mucous membrane. Approximate the mucous mem- brane with fine silk sutures. If the Stenson’s duct is cut across suture the skin carefully, do not close the mucous membrane in the region of the duct, thus allowing a fistuIa to deveIop into the mouth and not ester- naIIy on the cheek.

Too much foreign materia1, gIass, spIin- ters, metal, paint and enamel, is closed up in wounds of the scaIp and face. CarefuI hemostasis, foIIowed by careful inspection and mechanica cIeansing is the only way to avoid this inexcusable error.