+WOUNDS AND CONTUSIONS+
A wound is a solution of continuity or division of the soft tissues
produced by cutting, tearing, or compressing force. The classification
of wounds according to their causation or nature is as follows:
_Incised_—when resulting from a sharped-edged instrument.
_Lacerated_—when tissues are extensively torn or separated.
_Contused_—when resulting from a more diffused force, tearing
and bruising the tissues.
_Punctured_—when produced by a narrow instrument that causes a
wound deeper than its external surface is broad.
_Poisoned_—when some poisonous substance enters the wound and
causes local infection or constitutional disturbance.
_Gunshot_—when the injury results from firearms or powder
explosion.
+An Incised Wound+ is an injury which is produced by some sharp
instrument such as a knife, pieces of glass or metal, which divides
the tissues cleanly, producing no bruising or tearing. The pain is
usually sharp and burning, varying with the nature of the instrument
with which the injury has been inflicted. Hemorrhage is usually free.
+Lacerated Wounds.+ These usually result from machinery accidents or
from heavy bodies passing over the parts and are apt to contain a
considerable quantity of foreign matter ground into the tissues.
+Contused Wounds.+ A contused wound is one in which the edges and
surrounding tissues are bruised or crushed. External bleeding as a
rule is not excessive, although there is a great likelihood of
extensive subcutaneous hemorrhage. Sloughing and gangrene may occur.
+Punctured Wounds.+ The character of a punctured wound depends upon the
object producing it. If made by sharp instruments, such as knives,
swords, daggers, bayonets, or needles, their nature is similar to
incised wounds.
Unless organs of importance have been wounded, or unless active septic
material has been carried into the wound, healing promptly follows
after the withdrawal of the instrument which has caused the wound.
These wounds are usually deep when affecting the dorsal aspect of the
foot, being commonly caused by a falling instrument or tool. In the
plantar region they are of every degree of severity, from the most
minute puncture to perforation running between interosseus spaces and
passing through the dorsal skin. The most frequent punctures are those
caused by stepping upon needles, pins and tacks. These wounds are,
commonly, of no importance unless the foreign body is broken off or
entirely penetrates the foot.
If the patient is seen a very short time after this has occurred, the
surgeon may operate with some confidence of finding the offending
substance, but even here, if possible, it is an advantage to obtain an
X-ray picture, while in those cases in which a needle has long been
buried in the tissues, this is quite indispensable. It is well to
remember that in these cases the patients’ impressions us to the
location of the needles are most unreliable.
After a radiograph has been obtained, it is most important, if
anatomically possible, to make the incision at right angles to the
shaft of the needle. At least two pictures should be taken in order,
if possible, to obtain some idea of the depth at which the needle
lies. Even with all these helps, the procedure, simple though it may
at first appear, oftens turns out to be one of great difficulty,
necessitating a very extensive operation.
+Incised Wounds of the Foot.+ Incised wounds of the dorsal surface are
very frequently quite deep and often implicate the tendons, bones and
articulations, as they are most frequently inflicted by the fall of
some heavy tool upon the part, or by the inaccurate blow of an axe.
Wounds of slight importance need but the usual thorough cleansing out,
with or without suturing of the skin, according to the extent of the
incision.
If one or more of the tendons have been severed, the ends should be
approximated by catgut sutures. If extensor tendons are cut in the
neighborhood of the metatarsophalangeal joints, it is often necessary,
owing to considerable retraction of the distal end, to incise the skin
down as far as is needed, in order to secure the retracted end and
suture it. Failure to adopt this procedure permits a dropping of the
toe, converting it often into a regular hammertoe. When the tendon is
properly sutured, the toe must be placed for some days in a condition
of over extension, most easily secured by a bandage passed under it,
acting like a stirrup, the ends being fastened by several turns above
the ankle.
Incisions, implicating joints, are carefully cleansed by flushing the
joint with copious quantities of saline solution, and closing the
wound with very few stitches. Such injuries should be examined daily
and any sign of sepsis must be considered as an indication for
immediate removal of the stitches, followed by active antiseptic wet
dressings.
Cuts of the plantar surface are not often very extensive. They are
most frequently incurred in stepping upon some sharp instrument or
walking upon glass, especially while bathing.
+Contusions.+ A contusion or bruise is a subcutaneous laceration, the
skin above it being uninjured, as in the abdomen; or being damaged
without a surface breach, as in a part overlying bone, and blood
being effused. If a large vessel is damaged, hemorrhage is extensive.
An _ecchymosis_ (black and blue area) is diffuse subcutaneous
hemorrhage.
A _hematoma_ is a blood tumor or a circumscribed hemorrhage in the
tissues.
In a diffuse hemorrhage the coagulation of fibrin induces induration,
the serum and leukocytes are absorbed, the red blood cells
disintegrate, and the coloring matter is widely diffused by the tissue
fluids, and hemoglobin is changed into hematoidin which crystallizes.
In union with these chemical changes, color changes ensue, the part
being at first red and then becoming purple, black, green, lemon and
citron. The stain following a contusion is most marked in the most
dependent area.
A hematoma acts as an irritant, inflammation ensues around it and it
is encapsuled by embryonic tissue, which, by organizing into fibrous
tissue, forms a blood cyst and gradually absorbs the fluid blood, the
cysts contents becoming thicker and thicker. A fibrous scar may
remain, and a blood clot, with very much indurated surrounding tissue,
giving a hard edge, is noticed after bruises of the periosteum. If
serum is not absorbed, hematoidin forms and the fluid becomes clear. A
hematoma may suppurate, an abscess forming, but this rarely happens
except in drunkards, although it occasionally occurs in persons who do
not use alcohol.
+Symptoms.+ The symptoms are tenderness, swelling, pain, and numbness.
The pain may be severe, but rarely persists beyond the first
twenty-four hours. Discoloration appears quickly in superficial
contusions, but only after days, in deeper ones. Shock and loss of
function are present only after severe contusions. The swelling is
first due to blood and is soon added to by inflammatory exudation.
+Terminations of Contusions.+ Slight contusions terminate promptly by
resolution; the more severe may terminate in gangrene, inflammation,
abscess, fibroid thickening, hypertrophy of the tissues involved, (as
in the case of bone), chronic inflammations, and even malignant
growths, particularly sarcomata.
+Prognosis.+ The prognosis of contusions is a matter of every day
importance, and it is sometimes extremely difficult to prognosticate
accurately. The determining forces are principally the nature and
violence of the contusing force, the tissues and organs involved, and
the general condition of the patient. Even the injury of the tissues
that may be easily inspected, such as the skin, may be much more
severe than is apparent. In tissues of low vitality, such as synovial
membrane, cartilage and ligaments of a joint, repair is
proportionately delayed, whereas in highly vascular tissue it is more
rapid. Contusions of tissues that cannot be given physiologic rest,
such as the thoracic wall, and the respiratory muscles, respond less
promptly to treatment.
The general condition of the patient is an important factor in the
prognosis, the most favorable being vigorous adult life without
organic disease. Among the unfavorable general states are, the
extremities of life, the very anemic and the plethoric, the
tuberculous, the syphilitic, the diabetic, and like diatheses, while
in the rheumatic and the gouty, the slightest injury may be most
persistent. The starved, the overfed, the over-worked, the fatigued,
the alcoholic, and those exposed to extremes of heat and cold, are
unfavorably affected.
+Treatment.+ Slight bruises, favorably located, require no treatment.
The arrest of hemorrhage, thereby diminishing the swelling, pain, and
discoloration, is important. If the hemorrhage be from small vessels,
elevation, rest, and the application of ice are sufficient. Frequently
the application of pressure is indicated. Hemorrhage in deeper parts,
such as that occurring under the fascia of the thigh, is sometimes
best controlled by adhesive strapping. If the vessels are large and
the hemorrhage is rapid, it is sometimes necessary to make a free
incision and apply a ligature. Evaporating lotions or elastic pressure
by bandaging over absorbent cotton, may assist. If the hemorrhage be
in a joint causing immediate swelling, painful from distension,
prompt aspiration will give relief. This should only be resorted to
under the strictest aseptic precautions, as the conditions are
favorable for microbic growth. If the soft parts are so severely
contused as to jeopardize the nutrition, both bandaging and ice should
be withheld, and in some instances even warm applications are advised.
After the acute symptoms have passed, judicious massage may be most
helpful in securing early resolution. Restoration of the vasomotor
tone when impaired or lost may be greatly facilitated by douching with
cold and hot water alternately followed by massage. During the acute
stages, physiologic rest is important; the restoration of functional
use in severe cases must be tentative, guided by the response of the
tissue in the form of increased pain or swelling. These phenomena
should be avoided if possible. If hematomata be not absorbed they
should be aspirated and pressure applied before structural changes
take place, such as the formation of a membrane. If the latter occurs
and sufficient time has elapsed for the formation of definite new
tissue, aspiration may be followed by the obliteration of the sac.
Sometimes hematomata become so thoroughly and firmly organized and
gradually increase in size, that it is extremely difficult to
differentiate them from new growths. If pain and tenderness persist
for a long time, particularly, if there be a predisposition to
tuberculosis, especial care is necessary.
+Treatment of Wounds in General.+ Arrest hemorrhage, bring about
reaction, remove foreign bodies, asepticize, drain, coaptate the edges
and dress, secure rest to the part and combat inflammation.
Constitutionally, allay pain, secure sleep, keep up the nutrition and
treat inflammatory conditions.
+Arrest of Hemorrhage.+ To arrest hemorrhage the bleeding point must be
controlled by digital pressure until ready to be grasped with forceps;
it is then caught up and tied with catgut or aseptic silk. Slight
hemorrhage stops spontaneously on exposure to air, and moderate
hemorrhage ceases after the vessels are clamped for a time; an
injured vessel of some size must be ligated, even if it has ceased to
bleed.
Capillary bleeding is checked by hot water compresses. In bringing
about reaction from shock, raise the feet and lower the head, unless
this position causes cyanosis. At least place the head flat and the
body recumbent. Apply hot water bottles and hot blankets and give
hypodermic injections of ether, brandy, strychnine, digitalis or
atropin, or inhalations of amyl nitrate. Strychnine can be used in
large doses, one-thirtieth of a grain may be given every ten or
fifteen minutes, until three doses have been taken. If the skin is
very moist, atropin is indicated, alone or combined with strychnine.
Hot coffee, or other hot fluids, should be given by the mouth and
rectum, and mustard should be placed over the heart, spine and shins.
The use of hot and stimulating rectal enemata is very important. The
rectum may absorb when the stomach refuses to do so. Enemata of hot
normal saline solution are very beneficial.
+Enteroclysis.+ The tube is carried into the sigmoid flexure and the
injection is introduced so as to distend the colon. At times it may be
necessary to give an intravenous injection of saline solution in order
to overcome the shock. In order to prevent the suppression of urine,
it may be necessary to administer diuretics.
+Removal of Foreign Bodies.+ Remove with forceps, all foreign bodies
visible to the eye: splinters, bits of glass, portions of clothing,
dirt, etc.
In a lacerated or contused wound, portions of tissue injured beyond
repair should be regarded as foreign bodies and should be removed with
scissors.
+Cleaning the Wound.+ If the surface is hairy it must be shaved before
the scrubbing. An accidental wound is infected and must be well washed
out with an antiseptic solution. A clean wound, made by the surgeon,
need not be irrigated, in fact, irrigation with an antiseptic fluid
leads to necrosis of tissues, causes a profuse flow of serum and
necessitates drainage. If clots have gathered in a wound, they must be
removed, as their presence will prevent accurate coaptation of the
edges. In an infected wound, they are washed out with a stream of
corrosive sublimate solution. In a clean wound, they are washed out
with hot salt solution. If dirt is ground into a wound, as is often
seen in crushes, pour sweet oil into the wound, rub it into the
tissues, and scrub the wound with ethereal soap. The oil entangles the
dirt and the soap and water remove both dirt and oil. After the rough
cleansing, irrigate with corrosive sublimate solution. In some cases,
especially in bone injuries, it is necessary to scrape the wound with
a curet.
A granulating wound is treated the same as an ulcer and the treatment
is discussed under that chapter.
+Drainage, Closure and Dressing.+ Superficial wounds require no special
drain, as some exudate will find exit between the stitches and the
rest will be absorbed. A large or deep wound requires free drainage
for at least twenty-four hours by means of a tube, strands of horse
hair, silk, catgut or gauze. An infected wound must invariably be
drained. Good drainage largely compensates for imperfect antisepsis.
If capillary drains be employed, apply a moist dressing. Divided
nerves and tendons must be sutured. Close the edges with silk sutures
or silkworm gut if the wound is deep and tension inevitable. Catgut is
used for superficial wounds and for those where tension is slight. The
interrupted suture is, as a rule, the best. If the wound is infected,
dress with antiseptic gauze; with aseptic or antiseptic gauze if it is
not infected. A dry dressing absorbs wound fluids quickly and is less
likely to become infected. Change the dressings in twenty-four hours
or sooner if they become soaked with the discharge. After this, in an
aseptic wound the dressing need not be changed for days. If pus forms,
open the wound at once.
+Rest and Constitutional Treatment.+ In planning the treatment of wounds
the most careful consideration for securing physiologic rest should be
had. If at or near a joint, the parts both above and below should be
immobilized. In whatever part of the body, physiologic rest should be
secured as nearly as possible. If the wound be of the leg or foot, the
patient should be in the recumbent position, with the part elevated
and a splint applied. The factor of rest, next to that of cleansing
and dressing, is most important. Physiologic rest means not only less
pain, less reaction, but a more rapid and certain repair.
Under ordinary circumstances no special constitutional treatment is
necessary beyond that of securing good hygienic surroundings, easily
digested food, restricted at first, and free action of the bowels. If
there is great pain, opiates may be necessary, but here, as in other
surgical indications for anodynes, a minimum amount should only be
given. Usually rest, elevation, and relief of tension will be of
greater benefit than opiates. If there is great restlessness, a
bromide may suffice; if marked insomnia, one of the ordinary
hypnotics. Great restlessness, with excitement and occasional
delirium, without special evidence of pain or infective process, must
call attention to the possible development of delirium tremens from a
relatively slight injury (such as a crushed toe or a simple fracture),
as it may precipitate an attack in one who has been a steady drinker,
though perhaps not an excessive one. In such cases, in addition to the
ordinary therapeutic remedies, the regular administration of whiskey
should be advised.
+TOXEMIA, SEPTICEMIA, SAPREMIA, PYEMIA+
+Toxemia+ applies to the diseases in which one or more poisons are
present in the blood which are not necessarily of parasitic origin and
production.
The word poisons is here used in a broad sense to cover any substance
applied to the body, ingested, or developed within the body which
causes disease. It of course includes ptomains, leukomains, toxins and
sepsins.
Toxemia, according to this definition, would include the diseases due
to poisons not arising from parasitic invasion of the tissues and
fluids of the body, at times of vegetable and alkaloidal nature, such
as strychnine or morphine; of animal origin, such as the toxin of
snake venom, the ptomains of milk or shell fish; then again a mineral
such as arsenic or lead; and lastly the leukomains arising from
disturbed excretion and perverted metabolism and grouped under such
terms as intestinal or uremic poisoning.
+Septicemia+ may be defined as an acute febrile affection, characterized
by marked nervous, cutaneous and visceral manifestations, and due to
the introduction into the system of bacteria and their toxins from an
infected wound. It applies to diseases which present poisons in the
blood that are of parasitic origin, the parasite itself being either
present or absent in the blood. Septicemia, in strong contrast to the
definition of toxemia, would include diseases arising from the
invasion of the tissues and fluids of the body by animal or vegetable
parasites or their poisonous products.
+Symptoms.+ The onset, as a rule, is slow, beginning from 4 to 7 days
after an injury, with a chill, which is followed by fever, at first
moderate, but soon becoming high. The fever presents morning
remissions and evening exacerbations and may occasionally show an
intermission. When the remission begins, there is a copious sweat. The
pulse is small, weak, very frequent, and compressible; the tongue is
dry and brown with a red tip; the vomiting is frequent, and diarrhea
is the rule; delirium alternates with stupor, and coma is usual before
death; prostration is very great, and visceral congestion occurs; the
spleen is enlarged, ecchymoses and petechiae are noted, secretions dry
up, urinary secretion is scanty or is suppressed, and the wound
becomes dry and brown.
Blood examination detects disintegration of red globules and marked
leukocytosis. When a wound becomes septic, red lines of lymphangitis
are seen about it and there is enlargement of the related lymphatic
glands. No thrombi or emboli exist in septicemia. The prognosis is
bad, and in some malignant cases death occurs within 24 hours.
+Treatment+ is the same as for septic intoxication (see “_sapremia_”).
Antistreptococci serum can be used, but the value of this method is
doubtful.
+Sapremia+ may be defined as an intoxication due to the absorption of
dead saprophytes and their products (ptomains and toxalbumins).
+Symptoms.+ The disease sometimes begins with a chill, followed by a
marked rise in the temperature, but in most cases the latter is the
first evidence of the disease. The skin becomes cold and clammy, there
is marked prostration and sometimes diarrhea. When these
manifestations occur while a wound is present, they are ominous, and
the dangerous complications can be avoided if the dressing of the
wound is renewed and perfect antiseptic precautions are taken to
thoroughly remove all septic matter from its surface. The
constitutional symptoms often disappear of their own accord, when the
above has been done, unless the systemic intoxication has not already
advanced to thwart all endeavors. There is also a diminution or
suppression of the urine, and a blood examination shows leukocytosis.
+Treatment.+ The treatment is at once to drain and asepticize the putrid
area and to give large amounts of alcohol. Strychnine and digitalis
are useful. Purge the patient, and favor diaphoresis, using in some
cases the hot bath. Establish the action of the kidneys; allay
vomiting by champagne, cracked ice, calomel, cocain or bismuth. Give
liquid food every three hours. Feed on milk, milk and lime water,
liquid beef, peptonoids, and other concentrated foods. Use quinine in
stimulant doses. Antipyretics are useless. Watch for visceral
congestion and treat it at once.
The use of saline fluid by hypodermoclysis or by venous infusion
dilutes the poison and stimulates the heart, skin, and kidneys to
activity.
In sapremia the blood contains the toxins and dead saprophytic
organisms. In septicemia the blood contains both pyogenic toxins and
multiplying pyogenic organisms. In sapremia the causative condition is
putrid material lodged like a foreign body in the tissues. In septic
infection the tissues themselves are suppurating, and both bacteria
and toxins are absorbed by the lymphatics. Of course, septic infection
may be associated with septic intoxication or may follow it. The
symptoms of sapremia depend upon the amount of intoxication.
In septic infection, or septicemia, only a small number of organisms
may get into the blood, but they multiply rapidly. A drop of blood
from a man with septic infection will reproduce the disease when
injected into the blood of an animal; hence it is a true infective
disease. The wound in such a case is often small, and is commonly
punctured or lacerated.
+Pyemia+ may be defined as a condition in which metastatic abscesses
arise as a result of the existence of pyogenic bacteria in the
circulating blood, either free or contained in pus cells or thrombi.
+Symptoms.+ The symptoms of pyemia are a febrile movement with a severe
chill and a sudden marked rise in the temperature which lasts for a
few hours and passes off with profuse sweating. The chills recur every
other day, every day, or oftener. The general symptoms of vomiting,
wasting, etc., resemble those of septicemia.
The lodgment of emboli produces symptoms whose nature depends upon the
organ involved. If in the lungs, there is shortness of breath and
cough, with slight physical signs.
In a suspected case of pyemia, always look for a wound, and if this
does not exist, remember that the infection may arise from an
osteomyelitis.
Chronic pyemia may last for months; acute pyemia may prove fatal in a
few days.
+Treatment.+ The treatment is the usual supporting one that should be
employed in septic affections, and all suppurating focci must be
opened and drained as soon as detected. Every branch of the irregular
cavities must be opened and drained at the most dependent part, and
the sinuses must be treated to prevent pocketing. Serum therapy is
also indicated.