Manual of Surgery, Alexis Thomson [new books to read txt] 📗

rise to a firm, resistant, doughy swelling, in which there may be elicited on deep palpation a peculiar sensation, not unlike the crepitus of fracture.

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 testicle, 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 circumstances, 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, constituting a hæmatoma 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, massage is the most speedy and efficacious means of dispersing the effused blood. The part should be massaged 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 massage is employed.

When the tension caused by the extravasated blood threatens the vitality of the skin, incisions may be made, if asepsis can be assured. The blood from a hæmatoma 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 hæmorrhage; (2) division of nerve-trunks, resulting in motor and sensory disturbances; and (3) division of tendons or muscles, interfering with movement.

Treatment.—If hæmorrhage is still going on, it must be arrested by pressure, torsion, or ligature, as the accumulation of blood in a wound interferes with union. If necessary, the wound should be purified by washing 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, fasciæ, and subcutaneous tissue—by separate series of buried sutures of catgut or other absorbable material. For the approximation of the skin edges, stitches of horse-hair, fishing-gut, or fine silk are the most appropriate. These stitches of coaptation may be interrupted or continuous. In small superficial wounds on exposed parts, stitch 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 scrotum, 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 stitches may be introduced wide of the margins, to take the strain off the coaptation stitches. Stout silk, fishing-gut, or silver wire may be employed for this purpose. When the tension is extreme, Lister's button suture may be employed. The tension is relieved and death of skin prevented by scoring it freely with a sharp knife. Relaxation stitches should be removed in four or five days, and stitches of coaptation in from seven to ten days. On the face and neck, wounds heal rapidly, and stitches may be removed in two or three days, thus diminishing 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. Glass 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 substitute. 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 class 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 fasciæ, 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 hæmorrhage has been arrested, iodoform and bismuth 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 crushing, 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.

Hæmorrhage is seldom a prominent feature, as the crushing 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 hæmorrhage after the initial shock has passed off. (3) Secondary hæmorrhage 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 class 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