CHAPTER X. WOUNDS OF SPECIAL REGIONS. (Part 2)

application of all the principles of treatment of wounds, hemostasis, antisepsis, and suturing. ‘Only thorough familiarity with these principles will give one address in the management of the individual case, for no two injuries are exactly alike, It will be advantagcous to exemplify these principles ‘with special reference to wounds of the extremities, =—_ AN INCISED WOUND OF THE WRIST. In such a case, there may be copious bleeding; ‘aloes ROLE radial, for example, may be involved. Begin the treatment by elevat- — Ht — na wn of wi SUE be relaxed. Ii his fingers tire, a ‘owriaars sculel (Frm) oesistant may press upon the fingers of the Enlarge the wound freely in both directions in. coune of the. artery. —_ Ls 63). Next deanse the field and then | wound itself. Separating the lips of the and clamp the superficial It is not likely that they will ligated. Search for the artery; must be tied and it is not necessary separate the companion vein. The two ligated together (Fig. 65). . Release the constrictor, The oozing nearly always very free at first, due to temporary vaso-motor paralysis, but it iy not at all serious. Apply compresses for a few minutes, thus arresting the capillary bleeding, and if a new point spurts, apply a ligature Inspect the wound carefully and if a tendon — or nerve is divided, it must be immediately sutured (wound at bend of elbow, Fig. 66). A STAB WOUND OF THE THIGH, Pig. 67.) ‘The femoral has been wounded and the hemorrhage is furious. Direct an to make firm digital pressure over the: as it crosses the pubes, nor must this 4 Lek aT g sek Sponge out the clots; identify the A STAR WOUND OF THE THIGH. 89 and divide it in order to expose the artery; isolate the artery by care- ful blane dissection and find the two ends, which is often difficult when the artery is completely divided (Fig. 69). When both ends are found, ligate with catgut No. 3, or silk No. 2, (ig. 70). “Tie the injured vein next both above and below. It is to be tied separately from the artery (Fig. 71). The possibility of including a nerve in the ligature must always be borne in mind and no ligature is to be finally tied until certain that no nerve is to be thus compressed, Pia. 64.—Iocked wound of wrist, Blent- Ye —Inched wound of erist, ‘Ge veeels Claniped. (Prom) is gated. (Vaan) to become later a source of pain. Remove the pressure and catch any more vessels that might bleed; employ free drainage and suture incompletely. Apply sterile gauze dressing, absorbent cotton, and a bandage, making moderate pressure, and maintain the limb in moderate ele watiog. Renew the dressings on the third day, and if there are no complications, remove the drainage. Remove the sutures about the eighth day. ‘Certain complications may arise. 1{ the ligatures were imperfect, — =! — 9° WOUNDS OF SPECIAL REGIONS. hemorrhage may ensue; the operation has to be repeated and the vessels tied again. If infection occurs, if the temperature reaches 101 F., ‘open up the wound and establish better drainage, which is the best means of preventing secondary hemorrhage. Gangrene sometimes follows the ligation of a main artery. Watch the temperature of the extremity and look for pulsation in the arteries below the ligature. If pulsation is present, be in no haste to amputate. If gangrene does not develop before the fourth day, it is not likely to do so, Pio, 06-—Wour! at teed of ey. Mase vein: mean cetalic waa: 3. bene Tesdom, a Biipotal fancla| g, Seachial artery, 6, bouchiat vols] p, Dadian heres Crushing and lacerating wounds of the extremitics, as Lejars says, give rise to the most perplexing problems of emergency surgery. ‘The questions present themselves in this form: ‘To ampitate, oF not to amputate? and if the Tatter, when, at what point, and by What method ? In order not to be vacillating in bis treatment, every doetér must haye his principle of action settled once for all. Lejars states his guiding principle and rule of action im this CRUSHING INJURIES TO THE EXTREMITIES. or Above all, save the patient’s life; save the limb wherever possible, or at least limit the mutilation to the minimum. Clinically, he places these injuries in two groups: (a) those in which a segment of the limb is crushed or otherwise injured without periph- Pre. 67,—Seab woumt of thigh. Pio, GR—feab wound of thigh Com (Von) 4 reso agirer while the tenn. on tee eral involvement, and (b) injuries extending {rom the hand or foot upward. (@) Suppose a case: An arm has been run over by the wheels of a heavy vehicle The member is flail-like, although the skin is not braken, and there are no particular points of bleeding, Palpation v Fron O—Lsposing tthe wounded vowel, (Vaan) CRUSHING INJURIES TO THE EXTREMITIES. 8 through the skin over the injured segment shows that the deeper structures bave been reduced to a pulp, both muscle and bone. Still, below the wound, the radial and ulnar arteries are found to pulsste. This is an absolute indication against amputation, The immediate treatment oust be limited to a careful disinfection of the member, the repair of any superficial wounds, a complete envelop- ment in absorbent cotton, and immobilization. ‘The immobilization is an essential feature, for by that means any, bending and stretching of the vessels is prevented and repair favored. If the skin is broken and the bone crushed or shattered and exposed, the injury is a compound fracture and is to be dealt with accordingly, but the prognosis always depends upon the blood supply. Hf in the case instanced, there is absolutely no pulsation in the prin- cipal arteries, it is certain that a part of the limb is lost; yet an im- mediate operation is not indicated. There are two reasons for this; first, that the shock may subside, and second, that too much af the limb may not be sacrificed, which latter an immediate amputation nearly always means. Proceed to a most rigorous disinfection and await a line of demar- cation. This is the rule to which there are two exceptions, one apparent, and the other actual. If the injury is a crushing one and the member bangs by shreds of tissue, there is absolutely no use in waiting; but the completion of the ablation does not require an amputation, it is merely what Lejars terms a “regularization.” ‘Trim up the tissues sparingly and remove enough bone that a proper stump may be formed, and then patiently cleanse the wound ‘with hot sterile water or normal salt solution, followed by alcohol, Suture completely and then cover the wound with sterile gauze sat- trated with alcohol; finally cover all with « thick layer of cotton firmly bandaged. Almost always by this means a better functional result may be obtained than by a formal amputation quite above the site of injury. ‘There is an actual exception to the rule of conservatism. The case is seen Jate and there are already signs of approaching injection, It is cr WOUNDS OF SPECIAL REGIONS. not safe to delay and risk the sepsis which menaces. It is better, under such circumstances, to proceed to immediate amputation. (b) Crush or laceration extending from the hand or foot upward. Suppose you are called to treat the foot and part of the leg, or x hand and part of the forearm, which have been crushed and lacerated. ‘The member appears injured beyond remedy. Will you immediately proceed to amputate? By no means—or at least, not a3 4 rule Lf the case is seen immediately, the first effort should be devoted to combating shock and infection. Ir is nat altogether on account of shock that one waits; there are other even more important reasons. The first is that you may pot amputate high enough; the second, that you may amputate too high. One cannot always determine from the first how high the devitalized tissues extend. ‘There may be vascular injuries or muscular lacera~ tions whieh are concealed by a sound integument, and which may later be the source of gangrene. Out of this grows the necessity af a secondary amputation, which is always a matter of chagrin to the surgeon and an element of danger to the patient. On the other band, tissues which appear devitalized may Gnally survive and thus preserve a function which might otherwise have been sacrificed. a It is true that a few inches more or less of the arm or leg, for instance, may make no great difference in the usefulness of the stump; it is quite otherwise when the question is that of amputating immediately above or below the elbow or the knee, or through them. Nor do ruler of conservation apply with equal force to the foot and the hand. As Simons, of Charleston, S. C., says (International Journal of Surgery, August, 1906), injuries of similar degree affecting the upper or lower extremity demand different treatment, because of the much greater freedom of collateral circulation in the former rendering gan grene less probable. Where conservatism or excision would be proper in the upper extremity, ampa ald be called for in the lower limb, Extensive comminution and Joss of bone of the foot may demand amputation because, if saved, the member may be useless a3 @ means of locomotion, and should give way toa vastly more useful artificial limbs TREATMENT OF INJURIES TO THe HAND. 9S Great laceration of the soft parts of the foot, with free comminution of bone and injury to vessels, always demands amputation; for the destruction of the skin of the heel and sole will result in a cicatrix which can never bear the weight of the body and may never be anything but a source of suffering und discomfort to its possessor. But, aside from these exceptions and others to be noted, the rule holds in this class of injuries, to avoid amputation and devote one’s skill to preventing infection. The prevention of infection is the sine qua non; if the efforts in this direction are going to be half-hearted, it ix better to amputate at once. Invmediate amputation, again, is indicated if the wound is seen some hours after the accident, and is found soiled and dirty and manj- festly infected, Under these conditions, con- servatism is not the best course, for there are too many chances that the attempt at disinfection will fail; that, in spite of the best efforts, sepsis will arise. Or, if there are already present the symptoms of dangerous sepsis, it is mo longer a question of Pr. 1+ — Ballet ware for moport of finger saving 3 limls, but of saving a life, and it will be the part of conservatism to amputate well above the suspected level, With regard to the conservative treatment of these severe crushing and lacerated injuries of the hands and feet which most surgeons would be prone to amputate, Reclus, of Paris, has emphasized the value of thorough and patient disinfection of the skin and then of the wound, together with a trimming away of the devitalized fragments of skin and bone. He then “embalms" the member in gauze saturated with an antiseptic pomade, crowded into all the recesses of the wound, and the whole covered by a thick dressing of alsor cotton and bandaged, This dressing is left undisturbed until repair is complete, unless the temperature should rise or a disagreeable odor develop. fp WOUNDS OF SPECIAL REGIONS. Joseph Marsee (Ind. Med. Jour., April, 1896) has made some useful observations with respect to the ireatment of coursion injuries of the hand, which are well worth repeating and which, as he points cout, appeal especially to the young man just beginning his life's work, for such will prob- ably constitute the bulk of bis surgical practice for some years. ‘There is a natural tendency, in the popular mind, to measure an infury by the size of the member involved, and the man who would insist upon the best advice in other cases, will fy te the nearest doctor's sign when “only a finger” is involved, But Marsee concludes, fron his own experience, that the young practitioner is an accomplice in spoiling & | good many hands before he learns todo them justice, Ontheotherside, it is not too much to say that the best human skill is nane too good when em~ ployed in repairing injuries of the most mechanically perfect human member. ‘The majority of these injuries occur in workers with machinery; the hand, therefore, is always soiled and gen- erally greasy, This grease must first he removed. Nothing is better for this purpose than ordinary gasoline or Tea 15-—Thpmh pinched of leaving wquare: benzine, which may be poured into the hand directly from the bottle The fluid will find its way into the } amallest recesses of the wound, washing °" 7 Seng (peuiale eamms out the grime and preparing the way for the other antiseptics. ‘The benzine is poured on untiliall the grease is removed, and the disinfection is completed in the ondinary way. TREATMENT OF INJURIES TO THE HAND, 97 Even slight wounds of the fingers and palms should be treated by enforced rest by a splint or plaster-of-Paris dressing, complete enough to preclude all motion. This prophylaxis is not regarded as unneces- sary by those who have seen the most marked deformities, the gravest constitutional disturb- ances, and even death, result from trifling wounds of the hand. Enforced rest which leaves nothing to chance, to caprice, or the patient's med- dling is alone reliable. Under such treatment, the rapidity with which alarming symptoms some- times disappear is truly remark- able. If a plaster casing is used, it should extend from several inches above the wrist to the ex- treme tips of the fingers, the thumb being also enclosed if necessary. When finger wounds are extensive and parallel with the long axis, it is better not to suture them at ‘once, for the swelling will gen- erally be extensive and. the stitches will cut out. After the inflammation has subsided, the edges may be freshened and ap- proximated. Nor docs Marsce advise immediate splinting in the case of crushing injuries of the fingers, for fear that the Fic. 75.—Amputation ot index finger. Head ‘metacarpal retained. (Marser) circulation may be interfered with. However, that the crushed fees Fp ct ee member may not be wholly un supported, a soft ball covered with cotton and wrapped with gauze is applied to the palm so that the fingers may be spread out over it comfortably (Fig. 72), and the whole dressed with absorbent cotton and lightly bandaged. The ball, ? ‘WOUNDS OF SPECIAL REGIONS. Hd as Marsee indicates, though w and balky, has no other fault; it is light, absorbent and wonderfully comfortable, and needs only a trial to be appreciated and adopted. It should be used until the tissues are beyond danger, though jt takes several days, 2 week of a month No time is lost, for healing cannot begin until vitality is restored, and this will always be slow in such cases, a fact which should be brought thoroughly to the patient's knowledge from the heginning, that the doctor may not be blamed for the tardy convalescence. With regard to methods of amputating fingers, opinion is divided on the question as to which & the more desirable, a palmar fap, or a slightly longer finger with a dorsal flap cover- ing the stump. There can be no doubt that a palmar flap is desirable, and Marsec believes in securing it, even at the expense of sacrificing more of the finger. If more than half the phalanx is gone, it is always better, in his opinion, to amputate at the joint line and thus avoid a flexed stump. If & portion of the distal phalanx remains, the nail should be re- moved and the matrix dissected before the fap is adjusted, or some deformed fragment of nail may be left to vex the patient. It & better, in removing a finger at a joint, to cut off the knobby pro Pin. 18 —The low J haritlyotieed bo tad te val bene INJURIES TO TRE THORAX. 99 Jections of the conclyles on the palmar surface and to scrape off the exposed If the Ginger is pinched off squarely, one must always insist in re- moving enough of the bone to give a good flap, for if the patient has his way and the stump heals by granulation, the result will be unsatis- If the whole finger requires amputation, the head of the metacarpal bone will require ‘special attention and the pro- cedure will be different with the different fingers. Remove the heads by oblique section in the case of the index and little fingers headsofthe | Fr. z97The stam ot the index falls aah fh a rey frou ray wher, head of sido nove the metacarpal head of the middle finger unless the of the hand is the chief consideration. Marsee states for this, that it tends to let the other fingers fall away from pand thus interferes with ready apposition (Fig. 79). - - INJURIES TO THE TRUNK, _ TSJURIES TO THE THORAX. ‘Certain clementary notions must be clearly comprehended and kept in mind in order to make a definite diagnosis of these injuries. These notions relate to the anatomy, pathology, and symptomatology of the thorax. With respect to the anatomy, one must keep in mind the — i > 100 WOUNDS OF SPECIAL REGIONS. location of the principal vessels of the chest wall and mediastinum; the relations of the viscera to the ribs; and the normal areas of reson- ance and dullness, In addition, it is necessary to recall the signs and Significance of the principal primary complications possible in any form of serious violence to the thorax, viz.: hemoptysis, hemothorax, pneumothorax, emphysema, and hemo-pericardium. Hemoptysis,