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

between them. The punctate nature of the coloration is best recognised towards the periphery of the affected area—at the junction of the brow with the hairy scalp, and where the dark patch meets the normal skin of the chest (Beach and Cobb). Pressure over the skin does not cause the colour to disappear as in ordinary cyanosis. It has been shown by Wright of Boston, that the coloration is due to stasis from mechanical over-distension of the veins and capillaries; actual extravasation into the tissues is exceptional. The sharply defined distribution of the coloration is attributed to the absence of functionating valves in the veins of the head and neck, so that when the increased intra-thoracic pressure is transmitted to these veins they become engorged. Under the conjunctivæ there are extravasations of bright red blood; and sublingual hæmatoma has been observed (Beatson).

The discoloration begins to fade within a few hours, and after the second or third day it disappears, without showing any of the chromatic changes which characterise a bruise. The sub-conjunctival ecchymosis, however, persists for several weeks and disappears like other extravasations. Apart from combating the shock, or dealing with concomitant injuries, no treatment is called for.

Delirium in Surgical Patients

Delirium is a temporary disturbance of mind which occurs in the course of certain diseases, and sometimes after injuries or operations. It may be associated with any of the acute pyogenic infections; with erysipelas, especially when it affects the head or face; or with chronic infective diseases of the urinary organs. In the various forms of meningitis also, and in some cases of injury to the head, it is common; and it is sometimes met with after severe hæmorrhage, and in cases of poisoning by such drugs as iodoform, cocain, or alcohol. Delirium may also, of course, be a symptom of insanity.

Often there is merely incoherent muttering regarding past incidents or occupations, or about absent friends; or the condition may assume the form of excitement, of dementia, or of melancholia; and the symptoms are usually worst at night.

Delirium Tremens is seen in persons addicted to alcohol, who, as the result of accident or operation, are suddenly compelled to lie in bed. Although oftenest met with in habitual drunkards or chronic tipplers, it is by no means uncommon in moderate drinkers, and has even been seen in children.

Clinical Features.—The delirium, which has been aptly described as being of a “busy” character, usually manifests itself within a few days of the patient being laid up. For two or three days he refuses food, is depressed, suspicious, sleepless and restless, demanding to be allowed up. Then he begins to mutter incoherently, to pull off the bedclothes, and to attempt to get out of bed. There is general muscular tremor, most marked in the tongue, the lips, and the hands. The patient imagines that he sees all sorts of horrible beings around him, and is sometimes greatly distressed because of rats, mice, beetles, or snakes, which he fancies are crawling over him. The pulse is soft, rapid, and compressible; the temperature is only moderately raised (100°–101° F.), and as a rule there is profuse sweating. The digestion is markedly impaired, and there is often vomiting. Patients in this condition are peculiarly insensitive to pain, and may even walk about with a fractured leg without apparent discomfort.

In most cases the symptoms begin to pass off in three or four days; the patient sleeps, the hallucinations and tremors cease, and he gradually recovers. In other cases the temperature rises, the pulse becomes rapid, and death results from exhaustion.

The main indication in treatment is to secure sleep, and this is done by the administration of bromides, chloral, or paraldehyde, or of one or other of the drugs of which sulphonal, trional, and veronal are examples. Heroin in doses of from 1/24th to 1/12th grain is often of service. Morphin must be used with great caution. In some cases hyoscin (1/200 grain) injected hypodermically is found efficacious when all other means have failed, but this drug must be used with great discrimination. The patient must be encouraged to take plenty of easily digested fluid food, supplemented, if necessary, by nutrient enemata and saline infusions.

In the early stage a brisk mercurial purge is often of value. Alcohol should be withheld, unless failing of the pulse strongly indicates its use, and then it should be given along with the food.

A delirious patient must be constantly watched by a trained attendant or other competent person, lest he get out of bed and do harm to himself or others. Mechanical restraint is often necessary, but must be avoided if possible, as it is apt to increase the excitement and exhaust the patient. On account of the extreme restlessness, there is often great difficulty in carrying out the proper treatment of the primary surgical condition, and considerable modifications in splints and other appliances are often rendered necessary.

A form of delirium, sometimes spoken of as Traumatic Delirium, may follow on severe injuries or operations in persons of neurotic temperament, or in those whose nervous system is exhausted by overwork. It is met with apart from alcoholic intemperance. This form of delirium seems to be specially prone to ensue on operations on the face, the thyreoid gland, or the genito-urinary organs. The symptoms appear in from two to five days after the operation, and take the form of restlessness, sleeplessness, low incoherent muttering, and picking at the bedclothes. It is not necessarily attended by fever or by muscular tremors. The patient may show hysterical symptoms. This condition is probably to be regarded as a form of insanity, as it is liable to merge into mania or melancholia.

The treatment is carried out on the same lines as that of delirium tremens.

CHAPTER XIV
THE BLOOD VESSELS Anatomy —Injuries of Arteries: Varieties —Injuries of Veins: Air Embolism —Repair of blood vessels and natural arrest of hæmorrhage —Hæmorrhage: Varieties; Prevention; Arrest —Constitutional effects of hæmorrhage —Hæmophilia —Diseases of Blood Vessels: Thrombosis; Embolism —Arteritis: Varieties; Arterio-sclerosis —Thrombo-phlebitis —Phlebitis: Varieties —Varix —Angiomata —Nævus: Varieties; Electrolysis —Cirsoid aneurysm —Aneurysm: Varieties; Methods of treatment —Aneurysms of Individual Arteries.

Surgical Anatomy.—An artery has three coats: an internal coat—the tunica intima—made up of a single layer of endothelial cells lining the lumen; outside of this a layer of delicate connective tissue; and still farther out a dense tissue composed of longitudinally arranged elastic fibres—the internal elastic lamina. The tunica intima is easily ruptured. The middle coat, or tunica media, consists of non-striped muscular fibres, arranged for the most part concentrically round the vessel. In this coat also there is a considerable proportion of elastic tissue, especially in the larger vessels. The thickness of the vessel wall depends chiefly on the development of the muscular coat. The external coat, or tunica externa, is composed of fibrous tissue, containing, especially in vessels of medium calibre, some yellow elastic fibres in its deeper layers.

In most parts of the body the arteries lie in a sheath of connective tissue, from which fine fibrous processes pass to the tunica externa. The connection, however, is not a close one, and the artery when divided transversely is capable of retracting for a considerable distance within its sheath. In some of the larger arteries the sheath assumes the form of a definite membrane.

The arteries are nourished by small vessels—the vasa vasorum—which ramify chiefly in the outer coat. They are also well supplied with nerves, which regulate the size of the lumen by inducing contraction or relaxation of the muscular coat.

The veins are constructed on the same general plan as the arteries, the individual coats, however, being thinner. The inner coat is less easily ruptured, and the middle coat contains a smaller proportion of muscular tissue. In one important point veins differ structurally from arteries—namely, in being provided with valves which prevent reflux of the blood. These valves are composed of semilunar folds of the tunica intima strengthened by an addition of connective tissue. Each valve usually consists of two semilunar flaps attached to opposite sides of the vessel wall, each flap having a small sinus on its cardiac side. The distension of these sinuses with blood closes the valve and prevents regurgitation. Valves are absent from the superior and inferior venæ cavæ, the portal vein and its tributaries, the hepatic, renal, uterine, and spermatic veins, and from the veins in the lower part of the rectum. They are ill-developed or absent also in the iliac and common femoral veins—a fact which has an important bearing on the production of varix in the veins of the lower extremity.

The wall of capillaries consists of a single layer of endothelial cells.

Hæmorrhage

Various terms are employed in relation to hæmorrhage, according to its seat, its origin, the time at which it occurs, and other circumstances.

The term external hæmorrhage is employed when the blood escapes on the surface; when the bleeding takes place into the tissues or into a cavity it is spoken of as internal. The blood may infiltrate the connective tissue, constituting an extravasation of blood; or it may collect in a space or cavity and form a hæmatoma.

The coughing up of blood from the lungs is known as hæmoptysis; vomiting of blood from the stomach, as hæmatemesis; the passage of black-coloured stools due to the presence of blood altered by digestion, as melæna; and the passage of bloody urine, as hæmaturia.

Hæmorrhage is known as arterial, venous, or capillary, according to the nature of the vessel from which it takes place.

In arterial hæmorrhage the blood is bright red in colour, and escapes from the cardiac end of the divided vessel in pulsating jets synchronously with the systole of the heart. In vascular parts—for example the face—both ends of a divided artery bleed freely. The blood flowing from an artery may be dark in colour if the respiration is impeded. When the heart's action is weak and the blood tension low the flow may appear to be continuous and not in jets. The blood from a divided artery at the bottom of a deep wound, escapes on the surface in a steady flow.

Venous bleeding is not pulsatile, but occurs in a continuous stream, which, although both ends of the vessel may bleed, is more copious from the distal end. The blood is dark red under ordinary conditions, but may be purplish, or even black, if the respiration is interfered with. When one of the large veins in the neck is wounded, the effects of respiration produce a rise and fall in the stream which may resemble arterial pulsation.

In capillary hæmorrhage, red blood escapes from numerous points on the surface of the wound in a steady ooze. This form of bleeding is serious in those who are the subjects of hæmophilia.

Injuries of Arteries

The following description of the injuries of arteries refers to the larger, named trunks. The injuries of smaller, unnamed vessels are included in the consideration of wounds and contusions.

Contusion.—An artery may be contused by a blow or crush, or by the oblique impact of a bullet. The bruising of the vessel wall, especially if it is diseased, may result in the formation of a thrombus which occludes the lumen temporarily or even permanently, and in rare cases may lead to gangrene of the limb beyond.

Subcutaneous Rupture.—An artery may be ruptured subcutaneously by a blow or crush, or by a displaced fragment of bone. This injury has been produced also during attempts to reduce dislocations, especially those of old standing at the shoulder. It is most liable to occur when the vessels are diseased. The rupture may be incomplete or complete.

Incomplete Subcutaneous Rupture.—In the majority