PART II. PRACTICE OF SURGERY

SECTION I. INJURIES

Part 9. Injuries

Before proceeding to the consideration of the different injuries Shock, it will be necessary to say a few words about the general condition termed shock or collapse, which supervenes after a severe injury. Care must be taken not to confound this state with faintness or syncope from loss of blood. Undoubtedly in many cases both con-ditions are present. Syncope from loss of blood is considered below. Syncope from mental emotion differs from shock in degree only. In shock the patient is pale, and bathed in cold clammy perspiration; his sensibility is blunted ; his pulse is small and feeble ; he is unable to make any active exertion, but lies in bed indifferent to external circumstances, and can only be roused with difficulty ; he frequently complains of a feeling of cold ; and he may have a distinct shivering or rigor. These symptoms may continue for some hours ; the first evidence of improvement is that he shifts his position in bed and complains of the pain of the injury which has caused the condition. The pulse becomes stronger, and he then passes from the state of shock into the condition of reaction. If the improvement continues recovery will take place, but if it is only transient the patient will sink back again into a drowsy condition, which, if it persists, will end in death. In severe cases there may be no reaction ; the patient then gradually becomes weaker and weaker, his pulse feebler and feebler, till death ensues. Shock is due to an impression conveyed to the central nervous system by an afferent nerve of common or special sensation. This impression produces a change in the medulla oblongata, by which the nerve-centres are so affected that a partial paralysis or paresis of the voluntary and involuntary muscular fibres in the body takes place. In consequence of the change in the voluntary muscles the patient is unable to lift his arm or move his leg; the respiratory functions are performed wearily, and the muscle of the heart contracts feebly ; the muscular fibres in the walls of the blood-vessels lose their tonicity and the blood-vessels dilate ; the blood collects in the large venous trunks, more especi- ally of the abdomen ; the vessels of the skin are emptied of blood, giving rise to the marked pallor. Two of the great causes that keep up the normal circulation of the blood through the body are in partial abeyance : the heart has not sufficient energy to contract, and there is not a sufficient quantity of blood passing into it from the blood-vessels. The heart beats feebly (1) because its nervous energy is lowered, and (2) because it has not a sufficient quantity of blood to act upon. An understanding of these facts gives the general indications for treatment,—(1) external stimulation over the heart by mustard poultices or turpentine stupes ; (2) elevation j>f the limbs, to cause the blood to gravitate towards the heart; (3) manual pressure on the abdominal cavity from below upwards, to encourage the flow of blood from the dilated abdominal veins into the heart. These different measures may be supplemented by the administration of stimulants by the mouth, or, if the patient cannot swallow, by subcutaneous injection of a diffusible stimulant, Syncope, such as ether or ammonia. In syncope or faintness from mental emotion the weakened heart cannot drive a sufficient quantity of blood to the brain ; the patient feels dizzy and faint and falls down insensible. The condition is a transitory one, and the recumbent posture, assisted if need be by elevation of the limbs, causes the blood to gravitate to the heart, which is thereby stimulated to contraction ; a sufficient quantity of blood is then driven onwards to the brain, and the insensibility passes off. If the patient is in the sitting posture when he feels faint, the head should be depressed between the knees, which will cause the blood to rush to the brain, and the faintness will pass off.

With few exceptions the soft parts are freely supplied with blood- rhage. vessels, and as a preliminary to a consideration of the different forms of injuries it will bo well to say a few words about haemorrhage or bleeding. If a blood-vessel is torn or cut across, the blood within it escapes, either externally on to the clothes or floor, or, in the case of a subcutaneous injury, into the tissues, giving rise to ecchymosis. Cessation of the bleeding may take place in conse- quence of an arrest of the hemorrhage either by nature's effort or by the adoption of artificial means by the surgeon. The loss of blood may be so great that the heart's propelling power is weakened, and in this way the natural arrest is assisted. But there is always a danger that with the arrest of the haemorrhage the heart's action may recover its power and the bleeding recommence. In arresting hemorrhage temporarily the chief thing is to press directly on the bleeding part. The pressure to be effectual need not be severe, but must be accurately applied. If the bleeding point cannot be reached, the pressure should be applied to the main artery between the bleeding point and the heart. In small blood-vessels pressure will be sufficient to arrest haemorrhage permanently. In large vessels it is usual to pass a ligature round the vessel and tie it with a reef knot. Apply the ligature also, if possible, at the bleeding point, tying both ends of the cut vessel. If this cannot be done, the main artery of the limb must be exposed by dissection at the most accessible point between the wound and the heart, and there liga- tured. Haemorrhage has been classified in three varieties—(1) primary, occurring at the time of the injury ; (2) reactionary, or within twelve hours of the accident, during the stage of reaction ; (3) secondary, occurring at a later period, and caused by unhealthy processes attacking the wound and giving rise to ulceration of the coats of the blood-vessels. In treating these different varieties the principles already laid down hold good. In cases of severe haemor- rhage the patient suffers from syncope owing to loss of blood. Syncope from loss of blood is to be treated on the same principles as those already laid down for shock. But in addition it may be necessary in cases of severe haemorrhage, in which much blood has been lost, to introduce into the circulation fluid which will give the heart something to act upon. Blood drawn directly from the arm of a healthy person, and introduced through an opening in the vein of the arm, has frequently been made use of. The tendency of the blood to coagulate when brought in contact with foreign matter has led to the adoption of ingenious instruments to avoid this danger. Some surgeons have used defibrinated blood, and others milk. The opinion is at present gaining ground that a nutrient fluid is unnecessary, and that all that is required is to introduce an aseptic neutral fluid at the temperature of the body which has no tendency to cause coagulation of the blood with which it mixes. A saline solution, composed of '75 per cent, of common salt in dis tilled water, fulfils all these requirements; 4 to 6 oz. are generally sufficient. Becent experiments have been made by which blood drawn from the arm of the giver is mixed with a solution of phos phate of soda. This admixture prevents the blood from coagulat- ing, and it can be introduced into the blood-stream with safety.

Con- In a recent contusion careful pressure should be applied, with
tusions. cotton wadding fixed in position with a bandage. The aim is to prevent ecchymosis and to hasten the absorption of the effused blood after it has escaped into the tissues. Accurate pressure fulfils these ends more perfectly than the commoner application of cold.
The procedure for the treatment of an open wound is—(1) arrest Wound of haemorrhage ; (2) removal of any foreign bodies in the wound ; treat-(3) careful apposition of its edges and surfaces,—the edges being best ment. brought in contact by the use of horse-hair stitches, the surfaces by carefully applied pressure ; (4) free drainage of the wound to prevent accumulation either of blood or of serous effusion, which may bo done—(a) by leaving the dependent corner open, or (b) by introducing a drainage-tube, a skein of catgut, or a skein of horse-hair ; (5) avoidance of putrefaction by the use of antiseptic pre-cautions ; (6) perfect rest of the part by appropriate means during the cure. These methods of treatment require to be modified for wounds in special situations and for those in which there is much contusion and laceration. In punctured wounds free drainage is of primary importance. AVhen a special poison lias entered the Poisoned wound at the time of its infliction or at some subsequent date the wounds, following dangers have to be combated—(1) an intense inflamma-tion in the wound itself and surrounding parts ; (2) inflammation of the lymphatic vessek leading from it; (3) inflammation of the lymphatic glands ; (4) blood-poisoning of the general circulation. One of the commonest poisons is that connected with wound putrefaction ; of others some are the result of diseased action in the lower animals, e.g., hydrophobia, whilst some are special diseases in man. These diseased conditions are at the present time being carefully, studied, and the observations all tend to one conclusion, that they are due to specific organisms which have found entrance into the diseased animal or man, and, finding there a suitable nidus for their growth and development, have set up a specific disease. If the surgeon is accidentally wounded in operating on the living subject, or the pathologist in making a post-mortem examination, the poison may pass into the wound and give rise to one or more of the symptoms already indicated. There can be no doubt that these special poisons,1 which are spoken of as pathogenic or infect-ive, are in some way associated with low forms of plant life, and that in this they resemble the poison of putrefaction. If the operator is in good health the poison will generally have little effect; if he is in bad health the effect may be very severe. We do not yet know in wdiat cases bad results are to be expected. The great point in every doubtful case is to purify the wound thoroughly with some powerful antiseptic, so as to destroy the poison at the point of inoculation. If the poison escapes the germicidal action of the antiseptic used and enters the system, the patient should be stimu-lated, as the poison exercises a depressing action. For hydrophobia no cure is at present known. Experiments are, however, now (1S87) being made by Pasteur which will throw some light on this dreadful disease.

Burns are dangerous accidents in young children and in old people Burns, when the areas affected are large, and when they are situated over the cavities of the body. The patient may die of shock soon after the accident, of deep-seated inflammations coming on duringthe stage of reaction, or of hectic, which in all probability is a form of chronic pyemia associated witli profuse discharge from the wounded surface. To prevent death from any of these causes stimulating treatment is necessary. It has long been known that it is important to keep the air from the wounded surface, and antiseptic dressings must be used to prevent the access of organisms to it. When the skin is destroyed to any great extent contraction is apt to take place, followed by deformity. Care must be taken during the process of cure to prevent this, by keeping the limb in an extended position during the treatment of burns on the flexor surface. To hasten cicatrization after a burn in which the skin has been destroyed grafts of epidermic tissue may be planted on the granulating surface according to the method of Beverdin. These grafts, each the size of a pin's head, become fixed and from them cicatrization spreads over the surface. After cicatrization the tendency to contraction is not nearly so great. Epidermis grafting must not be confounded with skin grafting, in which the grafts are of the whole thickness of the skin.

A bone may be broken at the part where it is struck, or it may Fracture, break in consequence of a strain applied to it. In the former case the fracture is generally transverse and in the latter more or less oblique in direction. The fully developed bone is broken fairly across ; the soft bones of young people may simply be bent—"green stick" or "willow" fracture. Iractures are either simple or com-pound. A simple fracture is analogous to the contusion or sub-cutaneous laceration in the soft parts ; a compound fracture is analogous to the open wound in the soft parts. The wound of the soft parts in the compound fracture may be caused either by the same force which has caused the fracture, as in the case of a cart wheel going over a limb, first wounding the soft parts and then fracturing the bone, or by the sharp point of the fractured bone coming through the skin. In either case there is a communication between the external air and the injured bone. As some years elapse before the epiphyseal extremities of the bone become united by osseous deposit to the shaft, external violence may cause a separation of the epiphysis from the shaft. This variety of fracture is termed a diastasis. When a hone is broken there is generally distortion and preternatural mobility, inability to use the limb, and pain on pressure over the fractured part. In the majority of fractures there is also crepitus,—the feeling elicited when two osseous surfaces are rubbed together. When a bone is bent, or when a diastasis has occurred, there is no crepitus. It is also absent in impacted fractures, in which the broken extremities are driven into one another. In order to get firm osseous union in a case of fracture the great points to attend to are accurate ap- position of the fragments and complete rest of the broken bone. Accurate apposition is termed " setting the fracture " ; this is best done by the extension of the limb and coaptation of the broken surfaces. Complete rest is attained by the use of appropriate splints. As a rule ft is of great importance to command the joint above and below the seat of fracture. In cases of fracture near a joint, in which very commonly a splintering of the bone into the joint has taken place, more especially in those cases in which numerous tendons in their tendinous sheaths have been stretched, if the surgeon forgets that there may be effusion into the joint and the tendinous sheaths, and that this effusion may form fibrous tissue leading to stiffness of the joint and stiffening of the tendons, the result, more especially in old people, will be a permanently stiff joint or permanently stiffened tendons. Care must be taken in such instances by gentle passive movement during the process of cure to keep the joint and tendons free from the fibrous formation. To take a common example,—in fracture of the radius close to the wrist joint, it is necessary to apply appropriate splints to keep the bone at rest, and to arrange them so that the patient can move his fingers and thumb to prevent stiffness, and the splints must be taken off occasionally in order to move the wrist joint gently. If, however, the splints extend to the points of the fingers and are kept on for some weeks without removal, the consequence is a normal radius and a useless hand. Instances occasionally occur iu which non-union results, either from want of formative power on the part of the individual or in consequence of improper treat- ment by the surgeon. For the treatment of this condition the reader is referred to one of the systematic works mentioned above. For fractures of the cranium see below, p. 688.

Treat- There is no form of injury in which the truth of the principles ment of first advocated by Lister has been more prominently brought com- forward than in compound fractures. When such an accident pound occurs from direct violence the soft parts are generally much fractures, crushed and the bone is frequently comminuted. When a bone is broken from indirect violence the fracture is frequently oblique and the sharp point of the bone projects through the skin. In such a case the injury is, as a rule, not so severe. Formerly com- pound fractures were the dread of the surgeon : septic inflammation occurring in the wound reached the open medullary cavity of the bone, and the open blood-vessels of the bone gave easy access to the causes and products of the inflammation into the general blood- stream, giving rise to pyaemia. It is not asserted, however, that this accident always occurred. In a case of compound fracture the wound should be at once covered with a towel thoroughly soaked in a five per cent, solution of pure carbolic acid. And, if some time elapses before the arrival of a surgeon, more of the solution must be poured upon the towel, which should be kept thoroughly soaked. After the fracture is set it will probably be necessary to inject the solution into the interstices of the wound, over which an efficient antiseptic dressing must be applied. When the injury is so severe that it is impossible to preserve the limb, amputation is the only resource. It is often a difficult thing to say when the surgeon should amputate. The question will frequently be settled by a consideration of the general circumstances and surroundings of the patient, and no definite rules can be laid down. Speaking in general terms, an artificial substitute may take the place of the lower limb, but no artificial substitute can ever efficiently take the place of the upper limb ; and therefore surgeons will run some risk in attempt- ing to save an upper limb which they will not do in treating an injury of a lower limb.

There are three principal types of joint injury—(1) sprain or strain,
injury. in which the ligamentous and tendinous structures around the joint are stretched and even lacerated ; (2) contusion, in wdiich the cartilaginous surfaces of the opposing bones in the joint are driven forcibly together ; (3) dislocation, in which the articular surfaces are separated from one another ; in this last injury the ligamentous capsule of the joint must be torn to allow the accident to occur. Joint strength may be classified anatomically under three heads—

(1) ligamentous, due to the ligaments binding the bones together ;
(2) osseous, due to the shape of the bones forming the joint; (3) muscular, due to the muscles surrounding the joint. Ligamentous strength predisposes to sprains, osseous to contusions, and muscular to dislocations. A joint is frequently saved from injury in consequence of the relative weakness of a bone near it. The ankle joint is saved by the weakness of the fibula, the wrist joint by the weak-ness of the radius, the sterno-clavicular joint by the weakness of the clavicle; the fracture of the bone preserves the joint from injury. The tonicity of the muscular structures around a joint often prevents a dislocation, the patient being prepared for the violence to which his joint is subjected. The osseous strength of a joint will depend very much on the position of the limb at the time of the accident.

When a joint is sprained or contused there is effusion into it and into the structures around it. In such cases accurately applied pressure will prevent effusion, and along with gentle passive exer-cise and rubbing will prevent subsequent stiffness. When a joint is dislocated it is of importance to restore the hones to their normal position as soon as possible after the accident. WTithin the last few years, in several dislocations, the treatment by extension of the limb and forcible pressure of the bones back into their normal position has been given up, and a method of treatment at one time in use in the French schools has been revived by Dr Bigelow of Boston, Mass., who has pointed out that with less force and there-fore less injury a dislocated joint may be reduced by manipulation. The great principle at the root of this treatment is to manipulate the limb so as to cause the dislocated bone to pass back into its normal position by the same path by which it left it. In com-pound dislocations the same precautions must be attended to as in compound fractures.


Footnote

681-1 For their classification, as yet very imperfect, consult Ziegler's Pathological Anatomy (trans, by Macalister, London, 1883-84).






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