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Alexis Thomson and Alexander Miles - Manual of Surgery

A >> Alexis Thomson and Alexander Miles >> Manual of Surgery




It is often stated that a ganglion originates from a hernial protrusion
of the synovial membrane of a joint or tendon sheath. We have not been
able to demonstrate any communication between the cavity of the cyst
and that of an adjacent tendon sheath or joint. It is possible, however,
that the cyst may originate from a minute portion of synovial membrane
being protruded and strangulated so that it becomes disconnected from
that to which it originally belonged; it may then degenerate and give
rise to colloid material, which accumulates and forms a cyst. Ledderhose
and others regard ganglia as entirely new formations in the
peri-articular tissues, resulting from colloid degeneration of the
fibrous tissue of the capsular ligament, occurring at first in numerous
small areas which later coalesce. Ganglia are probably, therefore, of
the nature of degeneration cysts arising in the capsule of joints, in
tendons, and in their sheaths.

_Treatment._--A ganglion can usually be got rid of by a modification of
the old-fashioned seton. The skin and cyst wall are transfixed by a
stout needle carrying a double thread of silkworm gut; some of the
colourless jelly escapes from the punctures; the ends of the thread are
tied and cut short, and a dressing is applied. A week later the threads
are removed and the minute punctures are sealed with collodion. The
action of the threads is to convert the cyst wall into granulation
tissue, which undergoes the usual conversion into scar tissue. If the
cyst re-forms, it should be removed by open dissection under local
anaesthesia. Puncture with a tenotomy knife and scraping the interior,
and the injection of irritants, are alternative, but less satisfactory,
methods of treatment.

_Ganglia_ in the substance of _tendons_ are rare. The diagnosis rests on
the observation that the small tumour is cystic, and that it follows the
movements of the tendon. The cyst is at first multiple, but the
partitions disappear, and the spaces are thrown into one. The tendon is
so weakened that it readily ruptures. The best treatment is to resect
the affected segment of tendon.

The so-called "compound palmar ganglion" is a tuberculous disease of the
tendon sheaths, and is described with diseases of tendon sheaths.




CHAPTER XI

INJURIES


CONTUSIONS--WOUNDS: _Varieties_--WOUNDS BY FIREARMS AND
EXPLOSIVES: _Pistol-shot wounds_; _Wounds by sporting guns_;
_Wounds by rifle bullets_; _Wounds received in warfare_; _Shell
wounds_. _Embedded foreign bodies_--BURNS AND
SCALDS--INJURIES PRODUCED BY ELECTRICITY: _X-ray and
radium_; _Electrical burns_; _Lightning stroke_.


CONTUSIONS

A contusion or bruise is a laceration of the subcutaneous soft tissues,
without solution of continuity of the skin. When the integument gives
way at the same time, a _contused-wound_ results. Bruising occurs when
force is applied to a part by means of a blunt object, whether as a
direct blow, a crush, or a grazing form of violence. If the force acts
at right angles to the part, it tends to produce localised lesions which
extend deeply; while, if it acts obliquely, it gives rise to lesions
which are more diffuse, but comparatively superficial. It is well to
remember that those who suffer from scurvy, or haemophilia (bleeders),
and fat and anaemic females, are liable to be bruised by comparatively
trivial injuries.

_Clinical Features._--The less severe forms of contusion are associated
with _ecchymosis_, numerous minute and discrete punctate haemorrhages
being scattered through the superficial layers of the skin, which is
slightly oedematous. The effused blood is soon reabsorbed.

The more severe forms are attended with _extravasation_, the
extravasated blood being widely diffused through the cellular tissue of
the part, especially where this is loose and lax, as in the region of
the orbit, the scrotum and perineum, and on the chest wall. A blue or
bluish-black discoloration occurs in patches, varying in size and depth
with the degree of force which produced the injury, and in shape with
the instrument employed. It is most intense in regions where the skin is
naturally thin and pigmented. In parts where the extravasated blood is
only separated from the oxygen of the air by a thin layer of epidermis
or by a mucous membrane, it retains its bright arterial colour. These
points are often well illustrated in cases of black eye, where the blood
effused under the conjunctiva is bright red, while that in the eyelids
is almost black. In severe contusions associated with great tension of
the skin--for example, over the front of the tibia or around the
ankle--blisters often form on the surface and constitute a possible
avenue of infection. When deeply situated, the blood tends to spread
along the lines of least resistance, partly under the influence of
gravity, passing under fasciae, between muscles, along the sheaths of
vessels, or in connective-tissue spaces, so that it may only reach the
surface after some time, and at a considerable distance from the seat of
injury. This fact is sometimes of importance in diagnosis, as, for
example, in certain fractures of the base of the skull, where
discoloration appears under the conjunctiva or behind the mastoid
process some days after the accident.

Blood extravasated deeply in the tissues gives 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
_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, 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 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 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, fasciae, 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
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 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.

Haemorrhage 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 haemorrhage after the initial shock has
passed 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 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 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 masses 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 associated 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 1899-1902 were very
different from those met with in the entrenched warfare in France in
1914-1918. 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 tetanus 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 pronounced
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 associated with intense
thirst, especially when much blood has been lost.

In all forms of wounds sustained in warfare, septic infection
constitutes 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
diminishing 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
circumstances.

#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.

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