CHAPTER VI DIAGNOSIS OF WOUNDS (Part 1)

CHAPTER VI DIAGNOSIS OF WOUNDS When called to see a recent wound, the surgeon has to determine three things — (1) the nature of the wound, i.e. the kind of injury that has been inflicted upon the tissues ; (2) the parts that have been injured, and (3) its constitutional effects. These effects have been dealt with in Chaj^ter IV. In many cases a glance will suffice for the diag- nosis, but in others great care is required to arrive at a correct opinion, and serious mistakes may be made if the examination is not thorough, the division of nerves or tendons, or the presence of foreign bodies, or the commencement of gas gangrene being overlooked. It is always important to know how a wound was inflicted, whether by a sharp or blunt instrument, by one liable to remain, or break off, in the wound, or by one likely to carry in infective or poisonous material. The position of the wound is the next most important point to note, and it will suggest the parts possibly injured and the special examination that must be made. The superficial extent, the depth of the womid, and its direction are other points usually quickly determined. If the wound has to be " explored " to ascertain its depth, or to feel for a foreign body, care must be taken not to infect it — the finger or ^Ji'obe must be sterilized — and not to start a fresh hasmorrhage from wounded vessels 54 WOUNDS 55 ■wli'!cli have been occluded by clots. The amount and character of any hasmorrhage, the colour of the blood, its mode of escape, whether in a jetting or a steady stream, from distinct spots or from the whole surface of the wound, and the pulse and state of the circulation in the parts beyond the wound, must be noted. The escape from the wound of any other fluid than blood must be recognized. The sensation in the parts beyond a deep woimd should always be tested to determine whether a nerve-trimk has been divided. Severed muscles and tendons can often be seen ; in other cases it is necessary to test whether the patient is able to use his muscles, to move each joint, and to make certain tendons tense. Foreign bodies may be seen or felt, and those that are opaque to X-rays can be demonstrated by a skiagram. In making these examinations the con- dition of the bone or bones will be ascertained. The state of the circulation and the sensation in the actually wounded tissues must be taken note of; and in gunshot wounds particularly the colour and vascularity of exposed muscle must be noted, as well as the presence of fine bubbles of gas in the discharge. Lastly, the constitutional accompani- ments of the wound must be observed, especially to determine whether they do or do not correspond with the direct eflects of the injury and the amount of external hfemorrhage. Having made this examination, the surgeon will know the kind of injury that has been inflicted, and the parts that have been injured. I. The nature oi the wound. — The features of recent wounds only will here be spoken of. 1. If the wound is a simple clean cut through the skin or other tissues, the appearance of the sl5n quite up to the edge of the wound being unaltered, 56 SURGICAL DIAGNOSIS [chap. and the surface of the cut being smooth, showing the different structures cut through, it is an incised wound. 2. If the surface of the wound is dark in colour and uneven, and the skin around it is livid, ecchy- mosed, and more or less cold and benumbed, it is a contused wound. 3. If the surface of the wound is extremely irregular, with long shreds of tissue adherent to it, it is a lacerated wound. Contusion and laceration are often combined, and the wound is then spoken of as a contused lacerated wound. Incised wounds are much the most paiiiful, the pain being of a sharp stinging or burning char- acter ; in contused and in lacerated wounds the pain, much less severe, is of a dull, aching, or be- numbing character. Incised wounds bleed freely from their whole surface ; contused and lacerated wounds are attended with much less haemorrhage, even when large vessels are injured. 4. The shape and superficial extent of wounds vary within the widest limits ; only two varieties require notice here. One is where a distinct flap of tissue has been cut or stripped up ; such ajYOund is to be called a flap wound, " incised " or " lacer- ated " being added as a prefix, according to circum- stances. The other is where the depth of a wound is out of proportion to its superficial extent, a 'pu7ic- tured wound. And as these may be inflicted with sharp, clean-cutting instruments, such as knives, or with blunt weapons, such as round bullets, they may have the characters either of incised or of contused wounds. 5. In the case of contused or flap wounds, it is important to determine whether the tissues have been injured beyond recovery. In some cases flaps ' are so nearly severed that it is obviously impossible VI] THE PAETS INJURED 57 for the circulation to be maintained in them, and tissues may be so crushed and mangled that their vitality is evidently destroyed. Whenever there is any doubt, the parts should be preserved ; and if, after the patient has recovered from the primary shock and the general circulation is re-established, there are no signs of circulation in the part, if com- pression makes no alteration in its colour, and if it remains cold and quite senseless, it may be decided that the part is actually dead ; but these signs must be unequivocal before such a diagnosis is to be made. Where they are not thus plain the occurrence of post-mortem changes in the dead tissues and the absence of all signs of repair will presently distinguish the dead from the living parts. 6. If the local or the constitutional effects of a wound are not explicable by the extent and severity of the injury and the htemorrhage, it is an infected or poisoned wound. The particular symptoms vary, of course, with the poison : in one case it may be coma from morphia ; in another, tetanic convulsions from strychnia ; in a third, suppuration ; in a fourth, septicsemia ; in a fifth, erysipelas or lymphangitis ; in a sixth, gas gangrene ; in a seventh, convulsions from tetanus or hydrophobia ; in an eighth, spreading gangrene ; in a ninth, local induration and the con- stitutional effects of syphilis. II. TUe parts injured.— 1. Injury to the skin or mucous fnembrane, as the case may be, is obvious ; if the wound extends through the tvhole thickness of the skin, it gapes, and allows the subcutaneous fat to be seen. If muscular tissue, known by "its deep- red colour, or tendons (glistening white bands) are seen in the wound, the deep fascia has been divided. A cut into muscle is also obvious. Complete division of a tendon is determined by noticing {a) that the 58 SURGICAL DIAGNOSIS [chap. patient is unable to execute the particular move- ment accomplished by the muscle in question ; (b) that he is unable to make the tendon tense ; (c) in some cases, that the retracted muscle forms a dis- tinct swelling ; and {d) sometimes that the divided tendon, one or both ends, can be plainly seen in the wound, the proximal end being drawn upon when the patient tries to put the muscle in action. The loss of power caused by division of a motor nerve is easily distinguished from that due to a severed tendon by noticing that it affects muscles at a dis- tance from the wound. For example, in a wound at the wrist, division of a tendon, let us say the flexor carpi ulnaris, will cause loss of power in that muscle only ; while if the ulnar nerve is severed, the short muscles of the hand, which are quite re- moved from the seat of injury, are paralysed. 2. An oozing of bright blood from the whole surface of the wound is capillary licBmorrhage. 3. A rapid continuous flow of dark blood from one or more points of the wounded surface is venous hcBmorrliage. Venous hasmorrhage is not attended by local blanching, nor by interference with the pulse in the arteries beyond ; it is lessened or stopped by moderate pressure on the distal side of the womid, and increased by moderate pressure on the cardiac side ; firm pressure on the cardiac side, by stopping the arterial flow to the part, of course stops, but not instantly, loss from a wounded vein. If a large vein is opened, such as the axillary or jugular, the blood spurts from the woimd, but the flow, however rapid, is continuous and even. 4. If, at the same time that a vein is wounded, a sucking or hissing soimd is heard, and the blood is noticed to be frothy, air has entered the vein. This complication is only likely to occur when a WOUNDS OP VESSELS 59 large vein in the neck or axilla is wounded ; that is, sufficicutlj near the thorax for inspiration to pro- duce a negative pressure in the veins. IE the air enters in any quantity it produces sudden death, or severe symptoms of cardiac failure, such as pallor, dyspnoea, and a very rapid weak pulse. 5. A rapid flow of bright-red blood from a par- ticular spot in the wound, the blood being forced out in a jet and fer saltum, is arterial hcB»iorrha(je. If the patient is cyanosed, the blood from an artery may be dark in colour, but by its remittent flow will be readily distinguished from that coming from a vein. Arterial haemorrhage may, however, lose this character under two circumstances : (a) if the blood does not escape directly horn the artery, but passes along a more or less narrow or sinuous wound, its jetting flow is lost ; and (h) in the case of small arteries, where, from lo.3s of blood or from obstruc- tion, the arterial tension is considerably lowered, the flow may become continuous ; it is, however, distinguished then from capillary oozing by its escape from a definite spot in the wound, and from venous haemorrhage by its colour, its control by pressure above, and the failure of distal pressure to stop it. When a large artery is wounded, such as tlie carotid, femoral, or axillary, the blood issues with a distinct hissing noise. In the case of an nrtcry wounded in its continuity, it may be possible to determine what vessel is injured by noticing if there is («) blanching of any part, as e.g. of the sole of tJie foot in division of the ])osterior tibial artery during tenotomy; (6) loss ^of pulse in the artery^ beyond. '.Thus if, '.^with a^'^wounded^7artery at tlie root of the neck, the pulse in the carotid or facial artery and the brachial or radial is unaffected, it proves that neither the carotid nor the subclavian 60 SURGICAL DIAGNOSIS [chap. artery is the one injured. Similarly, in the case of a stab in the thigh, if the pulse in the tibial arteries is equal on the two sides, it shows that the femoral trunk is not wounded. In many cases the position of the woimd is enough to determine what artery is wounded ; but in many others it is uncertain until the bleeding vessel is actually found, and its exact relations to surrounding structures are seen. 6. AnaBsthesia and motor palsy in the parts be- yond an injury show that a nerve has been severed. The area of paralysis will determine the extent of the nerve lesion. {See p. 51.) A divided or partially divided nerve may be visible in a wound. 7. Complete division of a bone in a wound is evidenced by the usual signs of fracture, i.e. mobility in the length of the bone, crepitus, and irregularity of the outline of the bone ; the fragments are often visible. Where a bone has been only partially severed, a so-called wound of bone, the signs of complete frac- ture are absent ; the injury can be detected either by the eye, or by the finger or probe feeling the cut in the bone, or by X-rays. The association of a fracture of a bone with a wound of the soft parts is a very important one, for if the latter extends down to the broken bone it forms a compound fracture. To determine whether this is the case is usually quite easy, as one or other fi-agment may protrude from the wound, or be visible in it, or the fmger or probe introduced into the wound may at once detect the fracture. In other cases it is equally apparent that the wound is quite superficial, perhaps a mere abrasion, or at some distance from the fracture, the latter not being compound. In a third series of cases the student may be in doubt, and then the amount of liiBuiorrhage from the womid will be the best indication. Bone is a very vascular tissue, VI] WOUNDS OP SEROUS CAVITIES 61 and if from a small wound, over and complicating a fracture, there is a free trickle of briglat blood continuing for some hours, it is very strong evidence of the fracture being compound. 8. Escape of a clear, ropy, tenacious fluid from a wound, either pure or mixed with the blood, indi- cates that a synovial cavity has been opened. If the wound is immediately over a bursa or s}aiovial sheath, and the fluid small in amoimt, and especially if a tendon is exposed in the woimd, it may be diagnosed as a wound of a bursa or synovial sheath ; but if the wound is directly over a joint, and the quantity of fluid more than a drop or two, it is probably a wound of the joint. In extensive wounds there is no diffi- culty in determining whether a joint is injured or not, as the articular surfaces are exposed, or project, or portions of articular cartilage may be chipped off and be found free in the wound. It is in the case of small punctured and incised womads that the difficulty arises. Whenever there is doubt, the case must be treated as a wounded joint, and if the part swells out with efiusion into its articular cavity the diagnosis ol a wounded joint may be considered to be established ; similarly, where a bursa becomes distended, evidence is afforded of a wound extending into it. The exact position and direction of a woimd, together with the amount of synovia escaping, are the best guides in deciding between a woimd of a bmsa and a wound of a joint. In many cases of doubt a careful exploration of the wound should be made. 9. Wound of a serous cavity is only certainly determined by the exposure of one or other of the contained viscera, or of the smooth, ghstening sur- face of the serous membrane. Should a dropsical accumulation have been opened, the amount of fluid escaping would be decisive. In all cases where there 62 SUEUICAL DIAGNOSIS [chap. is any doubt the woimd should be carefully exj)lored to make the diagnosis quite certain. Injury of the serous cavity of the head is in some cases character- ized by a continuous flow of the cerebro-spinal fliud, and occasionally by a peculiar symptom, viz. a spurting forth of the cerebro-spinal fluid when the jugular veins are compressed, (^ee p. 82.) Wound of the pleura without wound of lung occurs but rarely, and is difiicult of diagnosis imless there is collapse of lung or prolapse of unwounded luug. {See p. 140.) In some cases air can be heard being sucked into and expelled from the pleural cavity with each act of respiration. In the belly the omentum is the viscus that most often protrudes, and it must be distinguished from the subcutaneous or the sub- peritoneal fat by its peculiar granular ajjpearance, its distinct circumscription, and in some cases its reducibility ; it may be irreducible and strangulated, and then its livid colour will be very distinctive. Next to it the small intestine most often protrudes. In the scrotum the smooth, glistening testicle may protrude. 10. The diagnosis of wounds of viscera is con- sidered in the chapters devoted to local injuries. 11. The diagnosis of wounds of the ducts of glands rests upon the position of the wounds and the flow from them of characteristic secretion, such as saliva, milk, bile, or urine. III. Subsequeut progress of the wound. — The healing of a wound is in all cases efl'ected by the organization of the exudate poured fi'om tlie living wounded tissues. Under the varying conditions oi wounds the phenomena of the healing process differ. When the edges and surfaces of a wound are in apposition, all that is noticed is that they become glued together, and that the union, at first soft, be- vr] PROGRESS OP WOUNDS 63 comes gradually firmer as the scar is organized — healing by first intention. In the case of an open wound the surface is seen to become glazed over with a film of lymph which levels up all its smaller shallows and conceals the details of the surface. The lymph quickly becomes pink, then raised up into granulations, and these are seen to grow until the wound is filled up to the level of the skin ; then epithelium grows over the granulations from the edge, and the scar undergoes its final developmental changes ; this is called healing by second intention. Sometimes a combination of these two forms of