conversion of this into substance resembling the original structure
from the vessels of which the deposit has taken place. The quantity
of new formation necessarily depends on the extent of laceration and
the space thereby occasioned. That such reparation of tendon does take
place, and that to a very great extent occasionally, is placed beyond
all doubt by the results of veterinary practice. “Knuckling over” in
horses is occasioned by contraction of the flexor tendon; the heel
does not reach the ground, and in order to effect this the tendon has
been in many instances completely divided. The cut ends immediately
separate, to the extent of some inches, and after a time this large
space is filled up by a substance similar to tendon; so similar,
indeed, that on post mortem examination, some years afterwards, a
careless observer could scarcely distinguish any difference in the
appearance of the various portions of the tendon. The same is observed
after the operations for deformity of the foot in the human subject.
The treatment of lacerated tendon consists in placing the parts so as
to relax the muscles whose tendons have suffered. In rupture of the
tendo-Achillis, the knee should be bent and the foot extended, relaxing
the muscle and approximating the separated ends. This is readily and
conveniently affected by placing a slipper on the foot, and attaching
to its heel a firm band, which is then fastened to a ring or strap
placed on the thigh. This apparatus must be worn for six or eight
weeks. Afterwards a high-heeled shoe should be used for some time; or
if the union be still weak and imperfect, a splint may be placed on the
fore part, resting on the dorsum of the foot and the fore part of the
leg.
_Bruise._—The effects of bruises or contusions are, separation of the
cellular connexions, rupture of bloodvessels, and effusion of their
contents into the cells; a cavity, often large, is thus formed partly
by the direct injury, and partly by the subsequent effusion, and this
is quickly filled with blood, partly fluid and partly coagulated.
Immediate tumour forms; and the integument is discoloured, often beyond
the principal swelling. The injury may, or may not, be attended with
division of the integuments, or with fracture or displacement of the
bones; but all injuries of the hard parts are attended with more or
less bruising of the soft. Bruise is most frequently produced by a
blow, and is most severe when the violence is resisted by an unyielding
part, as by bone; a squeeze between two bodies, particularly if they be
in motion, also inflicts extensive contusion. The swelling continues to
increase for some time, and then gradually disappears along with the
pain. As the tumour subsides, the discoloration increases; the thinner
parts of the effusion have been absorbed, and the clot then shines
through the skin, imparting to it various hues.
Bruise may be followed by inflammatory action. Then effusion is
increased, bloody fluid is poured both into the cavity and into the
unbroken cellular tissue, the whole parts become extremely tender,
the surface inflames, and the excited action is apt to terminate
unfavourably in the various tissues. Not unfrequently sloughing takes
place, both of the skin and of the cellular tissue and fatty matter,
with unhealthy suppuration and infiltration; and constitutional
disturbance accompanies. All this is likely, nay, certain, to follow
admission of air into the cavity filled with effused blood, whether
by accidental wound or by intentional division of the integument.
Meddlesome surgery is unfortunate here, as well as in many other
cases. After scarifications, punctures, leechings, or incisions, the
blood often seems to undergo a putrefactive process, and unhealthy
suppuration is quickly established.
Sometimes the clot is not entirely absorbed, and considerable
swelling remains for a long time, perhaps with slight tenderness of
the part; a foundation is thus laid for abscess, either chronic or
acute. Frequently the inflammatory action following on bruise is not
so violent and rapid as that above described, but is limited in its
consequences chiefly to the effusion of coagulable lymph. This may
not be altogether absorbed along with the other effusion, it may
become organised, and be the nucleus or germ of a new growth, of a
tumour contrary to nature—deposit increases in and around the nucleus,
and this formation, though at first of a simple nature, may become
rapid in its growth, and may assume a troublesome or even a malignant
action; and sometimes all this may occur at an early period, before the
attention either of the patient or of the practitioner has been drawn
to the action or to its effects. Many tumours can be traced to the
effects of a bruise.
In the treatment of bruise, the parts should be placed in a state of
absolute rest, and methodically fomented. Local bleeding is seldom
required, and is of little use; at first it is hurtful. When, from the
extent or number of the bruises, fever follows, general antiphlogistic
measures must be resorted to. Cold and astringent applications, and
other repercussives, as also stimulants, are pernicious in the first
stage, and are not very useful at any time. Opening of the cavity must
be carefully avoided, excepting when absorption has ceased, when the
tumour has increased and become painful, and when the effused blood is
putrescent, and unhealthy suppuration has commenced. Then the cavity
should be opened freely, and by poulticing the clots and sloughs
are got quit of; afterwards the parts must be supported, as also
the strength of the patient. When from long want of use, in tedious
cases, the parts have become cold, shrunk, and weak, as also happens
in sprain, friction, champooing, tepid affusion, passive motion, and
voluntary motion short of giving pain, will all be of use as tending
to restore the circulation, the nervous energy, and the muscular
development. If œdema remain, bandaging or a laced support will be
required.
_Amputation._—Every endeavour, which skill and experience can suggest,
must be made before mutilation of the body, by the removal of even
the smallest portion of one of its members, is resorted to. But
there are cases in which mutilation, though a harsh remedy, is still
indispensable for the saving of life. There are others in which it is
prudent and proper to resort to operation, in consequence of a member
becoming perfectly unserviceable, and likely to impair the usefulness
of the individual. Such are very bad and complicated fractures and
luxations—laceration of the soft parts of a limb to such an extent as
to impress the experienced surgeon with a certainty that in a short
time gangrene must ensue, and render the success of any attempt to
save life very problematical. When the extent of injury is such that,
though gangrene may not be dreaded, yet it is plain that extensive
suppurations and exfoliations must necessarily take place, a question
may arise as to whether immediate amputation is to be performed or
not. This will be decided by the circumstances in which the patient is
placed, and often also by his own feelings upon the subject. He may
choose to run some risk, and endure much suffering, with even a very
slight chance of ultimately preserving his limb. In cases of traumatic
gangrene of the chronic form, amputation is not only justifiable, but
imperative; as also in those cases of severe fracture in which the
patient is sinking under profuse discharge, with disunited bones. And
the same absolute necessity for operation exists in many diseased
joints, and in some diseased bones, when the patient’s safety would
otherwise be endangered, or when, on mature consideration, it is
evident that the member, if retained, must for ever be an encumbrance,
and worse than useless. Certain tumours of bones, tumours involving
joints, tumours and ulcers of the soft parts of a malignant nature, and
without appreciable disease of the lymphatic system, will also demand
recourse to the amputating knife. Patients, too, will be met with,
who, after undergoing all the suffering attendant on disease of long
duration—as exfoliation of bone and sloughing of tendons, following
deep suppuration—will, to get rid of the annoyance of the stiff and
deformed member, or part of a member, not only submit to, but urge and
insist on, the removal of the offending part. Amputation will also
occasionally be required for badly-formed stumps, as those in which
the end of the bone protrudes through ulcer of the integument, and is
necrosed—or those in which the bone has been sawn of an inconvenient
length.
Many precautions are to be observed in this operation. It is not to be
commenced without due consideration as to the position of the operator,
and of his assistants—their several duties—the form of incision—the
length of the stump—the difficulties, if any, which may be expected,
and the best means of obviating them. The most prominent objects are,
to save undue effusion of blood, to effect the incisions with as little
suffering to the patient as possible, and to make them of such a form
as to cover the end of the bone effectually— so that pressure may,
after a time, be borne without risk of ulceration of the soft parts, or
exfoliation of the bone.
In all cases, and in all situations and circumstances, hemorrhage
can be restrained during completion of the incisions, and during the
employment of means to close the cut ends of the vessels, by means of
very slight but exact pressure on the trunk of the principal vessel.
The point at which this is to be applied should be at as short a
distance as possible above the place of incision, and at the same time
above the origin of any branches which must be cut. Not the slightest
pressure should be made until the instant when the incisions are
about to be commenced, so that no venous congestion may take place
in the limb. All the blood in the limb, below the incisions, must
necessarily be lost. The veins are more easily compressed than the
arteries, and pressure, made a short time before the operation, may
arrest the return of the blood, whilst it may not completely stop its
influx; thus engorgement of the lower part of the limb is produced, and
the quantity of blood that must be lost is increased. For a similar
reason, pressure, sufficiently firm to stop arterial hemorrhage, is to
be continued till the principal branches are tied, and then entirely
removed; for the continuance of even slight pressure will increase
the flow from the surface of the stump—blood, flowing in, and being
arrested in its venous return, trickles out through the open ends of
the veins. If a circular band be used for the compression, such as the
screw tourniquet, it should be put on quickly, and screwed up at once,
and then the incisions should not be delayed one instant after; there
should be no relaxation of the pressure at any part of the operation;
and as soon as the principal vessels have been secured, the apparatus
should be altogether removed—otherwise, as already stated, rapid oozing
will continue from the face of the stump. It is my confirmed opinion,
that much more blood is lost from the use of a tourniquet than without
it. I would rather trust to a no very efficient assistant, than put on
a tourniquet. It is evident that compression on the whole circumference
of a limb must completely interrupt venous return, and cause the
increase of hemorrhage already mentioned; whereas pressure on only two
points of the same circumference, as is effected by the hand of an
assistant, is not liable to this objection. Besides, the latter mode
is more quickly applied, and more readily removed, causes infinitely
less pain to the patient, and is equally effectual in arresting the
flow in the main arterial trunk. Neither does it interfere with the
due contraction and retraction of the divided tissues. The incisions
should always be made rapidly; and after their completion, the surgeon,
if distrustful of his assistant, or if his hand has become cramped and
tired, may himself grasp the limb and compress the vessel, giving the
forceps or ligatures to another.
The first step in the operation is to arrange the measures for
temporary arrestment of the bleeding. The patient is placed in a
favourable position, either sitting or lying, as may be most convenient
for the particular amputation, and is firmly secured by one or more
assistants; all the apparatus must be in good order and conveniently
placed, and an assistant should be stationed to attend to them, and
hand those required. The compressor and the operator are each at their
post, and ready to act in concert. The incisions may be made either
from without inwards, or from within outwards, after transfixion of the
limb. The latter mode is to be preferred when practicable, as requiring
less pressure; the parts are more stretched than in the former method,
are therefore more easily and rapidly cut, and consequently less pain
is inflicted. To the inexperienced transfixion may appear cruel, it may
appal them, but in reality it is almost unattended with pain; it is
rapidly executed, and renders the operator capable of completing his
work with great quickness and little suffering, and at the same time
with neatness and precision. The knife should be of a size and length
proportioned to the incisions, straight-backed, and with a good point;
of a form to pass through readily, yet strong, and not too broad. With
one sweep of this, the incisions are made at once, through the muscles,
through the cellular and fatty tissues, and through the integument—or
_vice versâ_ if the mode from without inwards be preferred. By these
parts being cut rapidly and at once, their connexions with each other
are not separated, the cut surface is smooth, and the parts are in
the most favourable state for becoming agglutinated and consolidated;
the bone is more deeply covered, and the stump of a handsomer and
more useful shape, than when the parts are cut successively and with
detachment.
The operator places himself so that he may grasp the part to be
removed, during the sawing of the bone, without change of position.
The incisions are made with the left hand free; but as soon as the saw
is in the right, the left should take firm hold of the limb below the
wound. During the operation, the limb is supported by an assistant,
either sitting or kneeling before the patient; but the regulating of
the position of the limb, during sawing, is not to be intrusted to
him alone. He may, from anxiety to facilitate the action of the saw,
snap the bone and splinter it when it has been little more than half
divided; or, from dread of this, he may lock the instrument, and so
delay completion of the operation. The management of the lower part of
the limb should always be by the person using the saw. This instrument
should have its teeth well set, and be provided with a workmanlike
handle. It is worked steadily and not hurriedly, with very slight
pressure, and that pressure employed only when pushing forwards.
Before its application, all the soft parts must necessarily be divided
completely; and this is done by carrying the knife, after formation
of the flaps, round the bone, with its edge rasping on it, and as
high up as possible. The instrument is then placed accurately on the
point thus exposed, close to the soft parts, and during the sawing the
flaps are well retracted by the hands of an assistant. The saw may be
worked either horizontally or vertically; the latter direction is to be
preferred, for thus, when the section is nearly completed, the uncut
part of bone is deep, and less likely to snap on the weight of the limb
being allowed to operate, or when undue pressure is made downwards.
If splintering of the bone have occurred, whether from neglect of the
foregoing precautions, or by other accident, the sharp projecting parts
should be taken away, and the cut surface made quite smooth by means
of the bone pliers; and with this instrument also, the sharp edge of
the bone may be rounded off, in cases where subsequent pressure might
cause ulceration or sloughing of part of the integument of the stump.
The arteries are tied close to their connexions. Their cut ends are
laid hold of with the dissecting forceps, or by those represented at
page 170, and pulled out; a small firm thread, either of linen or silk,
is then applied tightly, and one end immediately cut away close to the
reef-knot. Separation of the ligatures generally takes place from the
sixth to the tenth or twelfth day; they produce little discharge or
irritation during their presence, and no source of irritation connected
with them is left behind. But when both ends are cut away close to the
knot, separation is often long of taking place, and though the parts
may heal over them kindly enough, the stump never can be considered
sound till all are discharged. Probably several of these knots remain
deeply imbedded after cicatrisation of the integument, and when the
patient considers himself cured, and is moving about the room or ward,
actively and cheerfully, painful hardness forms deeply, part of the
stump reddens and swells, matter forms, and at length the insignificant
origin of the mischief is discharged; and this may occur more than
once. Generally such suppurations are limited, and soon cease; but
occasionally the abscess formed round the knot is extensive, deep and
free incision is required, the filling up of the cavity is necessarily
slow, the cure is long protracted, and both practitioner and patient
are disappointed and annoyed. Besides, the suppurations thus
occasioned, though slight in extent, may, when in the neighbourhood
of a principal arterial branch, cause ulceration of the coats of the
vessel, producing troublesome hemorrhage at a late period. All these
untoward consequences of cutting off both ends I have experienced in a
series of cases, and from the results of a faithful comparative trial
of both methods, I am now fully determined always to leave one end of
the ligature hanging from the lips of the wound.
No one now, it is presumed, dreams of the absorption of ligatures,
whether composed of animal substance or not; therefore the catgut
ligature, at one time much recommended, has no superiority over the
linen or silk thread,—besides it is not so convenient of application.
Twisting or bruising the cut ends of arteries has been long known as
effectual in arresting bleeding. Vessels of a large size can be so
treated with sufficient facility, and they may not bleed after; but
well-tied ones are much more secure. The smaller cannot be pulled out
and twisted, ligatures must be used for them; and the application of
one or two more ligatures, namely, to the large arteries as well as the
small, will add to the patient’s safety, and to the operator’s comfort
and peace of mind, and can have little effect in increasing irritation.
I have made trial of the method of torsion after amputation, and for
the above reasons, and because the manipulations are more tedious, I
disapprove of the plan, and decidedly prefer the ligatures. I am not
aware that the proposal of leaving the vessels both untwisted and
without ligature has been tried in this country; one would think that
it must always be troublesome, and not unfrequently hazardous.
In some cases, as when the incisions are made in the neighbourhood of
diseased bone, the soft parts are so condensed that the vessels cannot
be pulled out by means of the forceps; they are to be transfixed by
a sharp hook or tenaculum, and a ligature is then applied round the
parts which the instrument holds; or the vessels may be encircled by a
thread passed round by means of a curved needle; in both methods more
or less of the surrounding tissues must necessarily be included in the
noose, though always as little as possible. Sometimes an artery of the
bone, whether sound or inflamed, bleeds sharply; in such circumstances
the application of ligature is impossible, and I have occasionally been
obliged to insert a wooden peg into the opening; to this a chord is
attached by which it can be removed after a few days.
When bleeding has been satisfactorily arrested, the surface of the
wound is to be cleaned of coagula, either with the fingers or with
a warm and soft sponge, the ligatures are brought to the margin at
convenient points, and the edges of the integument are then put
together by interrupted sutures—two, three, or more, according to the
extent of the wound. They need not be numerous, for they are only
temporary, effecting partial approximation, and showing the line in
which the parts are to be brought together by the after dressing.
The stump is then covered with lint soaked in cold water, and this
application is renewed frequently so long as any trickling of blood
continues. Farther dressing is delayed for six or eight hours, when
the oozing has entirely ceased, and the visible cut surface become
glazed. Under this management, there is less chance of bleeding
breaking out afresh than when the limb is encompassed by bandages
and pledgets of lint, perhaps compressed so as to interfere with the
return of the blood, and heated by superfluous dressings. If bleeding
to any extent should occur, as there is always a risk of, after the
patient has become warm and comfortable in bed, and reaction has been
established, there is but little pain or annoyance in reaching the
bleeding point, and taking measures to stop the flow; the few stitches
are soon clipped away, and then the surface of the wound is completely
exposed, and ligatures can be applied to those vessels which require
them. Then, after removing all coagula, sutures are placed in the same
perforations, and the stump is in as favourable a state as previously.
I now generally leave the wound quite open, until all risk of
hemorrhage has ceased, and, if one or two stitches are required, these
are put in at the time of applying the plaster.
After six or eight hours, as already stated, any clots that have
formed are to be taken away gently, and the glazed edges of the wound
are then brought accurately and neatly together by the adhesive
composition already recommended,—with the difference of its being
spread upon slips of oiled silk, which I have found to be more pliable,
and altogether preferable to the glazed riband. Interstices are left
for the sutures and the ends of the ligatures, and the latter may
now be abridged slightly. This mode of keeping the edges in contact
I can confidently recommend from experience. The plasters are much
more adhesive than those in common use, do not irritate, and are not
loosened by discharge. After twelve or twenty-four hours, often much
earlier, the sutures are clipped through and removed. No other dressing
is required till the end of the cure, provided this proceed favourably.
The part is kept cool, and the slight discharge which occurs in a day
or two is wiped up from time to time, if it be in such abundance as
to reach the oiled cloth over the pillow on which the stump is laid.
No disturbance of the parts is necessary as when ointments, bandages,
and compresses are employed, or straps that require frequent removal
and reapplication. The patient suffers comparatively nothing; and the
surgeon is saved much troublesome and dirty work,—for union by the
first intention seldom fails.