Manual of Surgery Volume I Part 23

It frequently happens that, from the tearing of lymph vessels, serous fluid is extravasated, and a _lymphatic_ or _serous cyst_ may form.

In all contusions accompanied by extravasation, there is marked swelling of the area involved, as well as pain and tenderness. The temperature may rise to 101 F., or, in the large extravasations that occur in bleeders, even higher--a form of aseptic fever. The degree of shock is variable, but sudden syncope frequently results from severe bruises of the t.e.s.t.i.c.l.e, abdomen, or head, and occasionally marked nervous depression follows these injuries.

Contusion of muscles or nerves may produce partial atrophy and paresis, as is often seen after injuries in the region of the shoulder.

In alcoholic or other debilitated patients, suppuration is liable to ensue in bruised parts, infection taking place from cocci circulating in the blood, or through the overlying skin.

_Terminations of Contusions._--The usual termination is a complete return to the normal, some of the extravasated blood being organised, but most of it being reabsorbed. During the process characteristic alterations in the colour of the effused blood take place as a result of changes in the blood pigment. In from twenty-four to forty-eight hours the margins of the blue area become of a violet hue, and as time goes on the discoloured area increases in size, and becomes successively green, yellow, and lemon-coloured at its margins, the central part being the last to change. The rate at which this play of colours proceeds is so variable, and depends on so many circ.u.mstances, that no time-limits can be laid down. During the disintegration of the effused blood the adjacent lymph glands may become enlarged, and on dissection may be found to be pigmented. Sometimes the blood persists as a collection of fluid with a newly formed connective-tissue capsule, const.i.tuting a _haematoma_ or _blood cyst_, more often met with in the scalp than in other parts.

The impairment of the blood supply of the skin may lead to the formation of _blisters_, or to _necrosis_. Death of skin is more liable to occur in bleeders, and when the slough separates the blood-clot is exposed and the reparative changes go on extremely slowly. _Suppuration_ may occur and lead to the formation of an abscess as a result of direct infection from the skin or through the circulation.

_Treatment._--If the patient is seen immediately after the accident, elevation of the part, and firm pressure applied by means of a thick pad of cotton wool and an elastic bandage, are useful in preventing effusion of blood. Ice-bags and evaporating lotions are to be used with caution, as they are liable to lower the vitality of the damaged tissues and lead to necrosis of the skin.

When extravasation has already taken place, ma.s.sage is the most speedy and efficacious means of dispersing the effused blood. The part should be ma.s.saged several times a day, unless the presence of blebs or abrasions of the skin prevents this being done. When this is the case, the use of antiseptic dressings is called for to prevent infection and to promote healing, after which ma.s.sage is employed.

When the tension caused by the extravasated blood threatens the vitality of the skin, incisions may be made, if asepsis can be a.s.sured. The blood from a haematoma may be withdrawn by an exploring needle, and the puncture sealed with collodion. Infective complications must be looked for and dealt with on general principles.

WOUNDS

A wound is a solution in the continuity of the skin or mucous membrane and of the underlying tissues, caused by violence.

Three varieties of wounds are described: incised, punctured, and contused and lacerated.

#Incised Wounds.#--Typical examples of incised wounds are those made by the surgeon in the course of an operation, wounds accidentally inflicted by cutting instruments, and suicidal cut-throat wounds. It should be borne in mind in connection with medico-legal inquiries, that wounds of soft parts that closely overlie a bone, such as the skull, the tibia, or the patella, although, inflicted by a blunt instrument, may have all the appearances of incised wounds.

_Clinical Features._--One of the characteristic features of an incised wound is its tendency to gape. This is evident in long skin wounds, and especially when the cut runs across the part, or when it extends deeply enough to divide muscular fibres at right angles to their long axis. The gaping of a wound, further, is more marked when the underlying tissues are in a state of tension--as, for example, in inflamed parts. Incised wounds in the palm of the hand, the sole of the foot, or the scalp, however, have little tendency to gape, because of the close attachment of the skin to the underlying fascia.

Incised wounds, especially in inflamed tissues, tend to bleed profusely; and when a vessel is only partly divided and is therefore unable to contract, it continues to bleed longer than when completely cut across.

The _special risks_ of incised wounds are: (1) division of large blood vessels, leading to profuse haemorrhage; (2) division of nerve-trunks, resulting in motor and sensory disturbances; and (3) division of tendons or muscles, interfering with movement.

_Treatment._--If haemorrhage is still going on, it must be arrested by pressure, torsion, or ligature, as the acc.u.mulation of blood in a wound interferes with union. If necessary, the wound should be purified by was.h.i.+ng with saline solution or eusol, and the surrounding skin painted with iodine, after which the edges are approximated by sutures. The raw surfaces must be brought into accurate apposition, care being taken that no inversion of the cutaneous surface takes place. In extensive and deep wounds, to ensure more complete closure and to prevent subsequent stretching of the scar, it is advisable to unite the different structures--muscles, fasciae, and subcutaneous tissue--by separate series of _buried sutures_ of catgut or other absorbable material. For the approximation of the skin edges, st.i.tches of horse-hair, fis.h.i.+ng-gut, or fine silk are the most appropriate. These _st.i.tches of coaptation_ may be interrupted or continuous. In small superficial wounds on exposed parts, st.i.tch marks may be avoided by approximating the edges with strips of gauze fixed in position by collodion, or by subcutaneous sutures of fine catgut. Where the skin is loose, as, for example, in the neck, on the limbs, or in the s.c.r.o.t.u.m, the use of Michel's clips is advantageous in so far as these bring the deep surfaces of the skin into accurate apposition, are introduced with comparatively little pain, and leave only a slight mark if removed within forty-eight hours.

When there is any difficulty in bringing the edges of the wound into apposition, a few interrupted _relaxation st.i.tches_ may be introduced wide of the margins, to take the strain off the coaptation st.i.tches.

Stout silk, fis.h.i.+ng-gut, or silver wire may be employed for this purpose. When the tension is extreme, Lister's b.u.t.ton suture may be employed. The tension is relieved and death of skin prevented by scoring it freely with a sharp knife. Relaxation st.i.tches should be removed in four or five days, and st.i.tches of coaptation in from seven to ten days.

On the face and neck, wounds heal rapidly, and st.i.tches may be removed in two or three days, thus diminis.h.i.+ng the marks they leave.

_Drainage._--In wounds in which no cavity has been left, and in which there is no reason to suspect infection, drainage is unnecessary. When, however, the deeper parts of an extensive wound cannot be brought into accurate apposition, and especially when there is any prospect of oozing of blood or serum--as in amputation stumps or after excision of the breast--drainage is indicated. It is a wise precaution also to insert drainage tubes into wounds in fat patients when there is the slightest reason to suspect the presence of infection. Gla.s.s or rubber tubes are the best drains; but where it is desirable to leave little mark, a few strands of horse-hair, or a small roll of rubber, form a satisfactory subst.i.tute. Except when infection occurs, the drain is removed in from one to four days and the opening closed with a Michel's clip or a suture.

#Punctured Wounds.#--Punctured wounds are produced by narrow, pointed instruments, and the sharper and smoother the instrument the more does the resulting injury resemble an incised wound; while from more rounded and rougher instruments the edges of the wound are more or less contused or lacerated. The depth of punctured wounds greatly exceeds their width, and the damage to subcutaneous parts is usually greater than that to the skin. When the instrument transfixes a part, the edges of the wound of entrance may be inverted, and those of the exit wound everted. If the instrument is a rough one, these conditions may be reversed by its sudden withdrawal.

Punctured wounds neither gape nor bleed much. Even when a large vessel is implicated, the bleeding usually takes place into the tissues rather than externally.

The _risks_ incident to this cla.s.s of wounds are: (1) the extreme difficulty, especially when a dense fascia has been perforated, of rendering them aseptic, on account of the uncertainty as to their depth, and of the way in which the surface wound closes on the withdrawal of the instrument; (2) different forms of aneurysm may result from the puncture of a large vessel; (3) perforation of a joint, or of a serous cavity, such as the abdomen, thorax, or skull, materially adds to the danger.

_Treatment._--The first indication is to purify the whole extent of the wound, and to remove any foreign body or blood-clot that may be in it.

It is usually necessary to enlarge the wound, freely dividing injured fasciae, paring away bruised tissues, and purifying the whole wound-surface. Any blood vessel that is punctured should be cut across and tied; and divided muscles, tendons, or nerves must be sutured. After haemorrhage has been arrested, iodoform and bis.m.u.th paste is rubbed into the raw surface, and the wound closed. If there is any reason to doubt the asepticity of the wound, it is better treated by the open method, and a Bier's bandage should be applied.

#Contused and Lacerated Wounds.#--These may be considered together, as they so occur in practice. They are produced by crus.h.i.+ng, biting, or tearing forms of violence--such as result from machinery accidents, firearms, or the bites of animals. In addition to the irregular wound of the integument, there is always more or less bruising of the parts beneath and around, and the subcutaneous lesions are much wider than appears on the surface.

Wounds of this variety usually gape considerably, especially when there is much laceration of the skin. It is not uncommon to have considerable portions of skin, muscle, or tendon completely torn away.

Haemorrhage is seldom a prominent feature, as the crus.h.i.+ng or tearing of the vessel wall leads to the obliteration of the lumen.

The _special risks_ of these wounds are: (1) Sloughing of the bruised tissues, especially when attempts to sterilise the wound have not been successful. (2) Reactionary haemorrhage after the initial shock has pa.s.sed off. (3) Secondary haemorrhage as a result of infective processes ensuing in the wound. (4) Loss of muscle or tendon, interfering with motion. (5) Cicatricial contraction. (6) Gangrene, which may follow occlusion of main vessels, or virulent infective processes. (7) It is not uncommon to have particles of carbon embedded in the tissues after lacerated wounds, leaving unsightly, pigmented scars. This is often seen in coal-miners, and in those injured by firearms, and is to be prevented by removing all gross dirt from the edges of the wound.

_Treatment._--In severe wounds of this cla.s.s implicating the extremities, the most important question that arises is whether or not the limb can be saved. In examining the limb, attention should first be directed to the state of the main blood vessels, in order to determine if the vascular supply of the part beyond the lesion is sufficient to maintain its vitality. Amputation is usually called for if there is complete absence of pulsation in the distal arteries and if the part beyond is cold. If at the same time important nerve-trunks are lacerated, so that the function of the limb would be seriously impaired, it is not worth running the risk of attempting to save it. If, in addition, there is extensive destruction of large muscular ma.s.ses or of important tendons, or comminution of the bones, amputation is usually imperative. Stripping of large areas of skin is not in itself a reason for removing a limb, as much can be done by skin grafting, but when it is a.s.sociated with other lesions it favours amputation. In considering these points, it must be borne in mind that the damage to the deeper tissues is always more extensive than appears on the surface, and that in many cases it is only possible to estimate the real extent of the injury by administering an anaesthetic and exploring the wound. In doubtful cases the possibility of rendering the parts aseptic will often decide the question for or against amputation. If thorough purification is accomplished, the success which attends conservative measures is often remarkable. It is permissible to run an amount of risk to save an upper extremity which would be unjustifiable in the case of a lower limb. The age and occupation of the patient must also be taken into account.

It having been decided to try and save the limb, the question is only settled for the moment; it may have to be reconsidered from day to day, or even from hour to hour, according to the progress of the case.

When it is decided to make the attempt to save the limb, the wound must be thoroughly purified. All bruised tissue in which gross dirt has become engrained should be cut away with knife or scissors. The raw surface is then cleansed with eusol, washed with sterilised salt solution followed by methylated spirit, and rubbed all over with "bipp"

paste. If the purification is considered satisfactory the wound may be closed, otherwise it is left open, freely drained or packed with gauze, and the limb is immobilised by suitable splints.

WOUNDS BY FIREARMS AND EXPLOSIVES

It is not necessary here to do more than indicate the general characters of wounds produced by modern weapons. For further details the reader is referred to works on military surgery. Experience has shown that the nature and severity of the injuries sustained in warfare vary widely in different campaigns, and even in different fields of the same campaign.

Slight variations in the size, shape, and weight of rifle bullets, for example, may profoundly modify the lesions they produce: witness the destructive effect of the pointed bullet compared with that of the conical form previously used. The conditions under which the fighting is carried on also influence the wounds. Those sustained in the open, long-range fighting of the South African campaign of 18991902 were very different from those met with in the entrenched warfare in France in 19141918. It has been found also that the infective complications are greatly influenced by the terrain in which the fighting takes place. In the dry, sandy, uncultivated veldt of South Africa, bullet wounds seldom became infected, while those sustained in the highly manured fields of Belgium were almost invariably contaminated with putrefactive organisms, and gaseous gangrene and teta.n.u.s were common complications. It has been found also that wounds inflicted in naval engagements present different characters from those sustained on land. Many other factors, such as the physical and mental condition of the men, the facilities for affording first aid, and the transport arrangements, also play a part in determining the nature and condition of the wounds that have to be dealt with by military surgeons.

Whatever the nature of the weapon concerned, the wound is of the _punctured, contused, and lacerated_ variety. Its severity depends on the size, shape, and velocity of the missile, the range at which the weapon is discharged, and the part of the body struck.

Shock is a prominent feature, but its degree, as well as the time of its onset, varies with the extent and seat of the injury, and with the mental state of the patient when wounded. We have observed p.r.o.nounced shock in children after being shot even when no serious injury was sustained. At the moment of injury the patient experiences a sensation which is variously described as being like the lash of a whip, a blow with a stick, or an electric shock. There is not much pain at first, but later it may become severe, and is usually a.s.sociated with intense thirst, especially when much blood has been lost.

In all forms of wounds sustained in warfare, septic infection const.i.tutes the main risk, particularly that resulting from streptococci. The presence of anaerobic organisms introduces the additional danger of gaseous forms of gangrene.

The earlier the wound is disinfected the greater is the possibility of diminis.h.i.+ng this risk. If cleansing is carried out within the first six hours the chance of eliminating sepsis is good; with every succeeding six hours it diminishes, until after twenty-four hours it is seldom possible to do more than mitigate sepsis. (J. T. Morrison.)

The presence of a metallic foreign body having been determined and its position localised by means of the X-rays, all devitalised and contaminated tissue is excised, the foreign material, _e.g._, a missile, fragments of clothing, gravel and blood-clot, removed, the wound purified with antiseptics and closed or drained according to circ.u.mstances.

#Pistol-shot Wounds.#--Wounds inflicted by pistols, revolvers, and small air-guns are of frequent occurrence in civil practice, the weapon being discharged usually by accident, but frequently with suicidal, and sometimes with homicidal intent.

With all calibres and at all ranges, except actual contact, the wound of entrance is smaller than the bullet. If the weapon is discharged within a foot of the body, the skin surrounding the wound is usually stained with powder and burned, and the hair singed. At ranges varying from six inches to thirty feet, grains of powder may be found embedded in the skin or lying loose on the surface, the greater the range the wider being the area of spread. When black powder is used, the embedded grains usually leave a permanent bluish-black tattooing of the skin. When the weapon is placed in contact with the skin, the subcutaneous tissues are lacerated over an area of two or three inches around the opening made by the bullet and smoke and powder-staining and scorching are more marked than at longer ranges.

When the bullet perforates, the exit wound is usually larger and more extensively lacerated than the wound of entrance. Its margins are as a rule everted, and it shows no marks of flame, smoke, or powder. These features are common to all perforations caused by bullets.

Pistol wounds only produce dangerous effects when fired at close range, and when the cavities of the skull, the thorax, or the abdomen are implicated. In the abdomen a lethal injury may readily be caused even by pistols of the "toy" order. These injuries will be described with regional surgery.

Pistol-shot wounds of _joints_ and _soft parts_ are seldom of serious import apart from the risk of haemorrhage and of infection.

_Treatment._--The treatment of wounds of the soft parts consists in purifying the wounds of entrance and exit and the surrounding skin, and in providing for drainage if this is indicated.

There being no urgency for the removal of the bullet, time should be taken to have it localised by the X-rays, preferably by stereoscopic plates. In some cases it is not necessary to remove the bullet.

#Wounds by Sporting Guns.#--In the common sporting or scatter gun, with which accidents so commonly occur during the shooting season, the charge of small shot or pellets leave the muzzle of the gun as a solid ma.s.s which makes a single ragged wound having much the appearance of that caused by a single bullet. At a distance of from four to five feet from the muzzle the pellets begin to disperse so that there are separate punctures around the main central wound. As the range increases, these outlying punctures make a wider and wider pattern, until at a distance of from eighteen to twenty feet from the muzzle, the scattering is complete, there is no longer any central wound, and each individual pellet makes its own puncture. From these elementary data, it is usually possible, from the features of the wound, to arrive at an approximately accurate conclusion regarding the range at which the gun was discharged, and this may have an important bearing on the question of accident, suicide, or murder.

As regards the effects on the tissues at close range, that is, within a few feet, there is widespread laceration and disruption; if a bone is struck it is shattered, and portions of bone may be displaced or even driven out through the exit wound.