Fig. 63.—Cicatricial Contraction following Severe Burn.Fig. 63.—Cicatricial Contraction following Severe Burn.
Fig. 63.—Cicatricial Contraction following Severe Burn.
Inburns of the fifth degreethe lesion extends through the subcutaneous tissue and involves the muscles; while in those of thesixth degreeit passes still more deeply and implicates the bones. These burns are comparatively limited in area, as they are usually produced by prolonged contact with hot metal or caustics. Burns of the fifth and sixth degrees are met with in epileptics or intoxicated persons who fall into the fire. Large blood vessels, nerve-trunks, joints, or serous cavities may be implicated.
General Phenomena.—It is customary to divide the clinical history of a severe burn into three periods; but it is to be observed that the features characteristic of the periods have been greatly modified since burns have been treated on the same lines as other wounds.
The first periodlasts for from thirty-six to forty-eight hours, during which time the patient remains in a more or less profoundstate ofshock, and there is a remarkable absence of pain. When shock is absent or little marked, however, the amount of suffering may be great. When the injury proves fatal during this period, death is due to shock, probably aggravated by the absorption of poisonous substances produced in the burned tissues. In fatal cases there is often evidence of cerebral congestion and œdema.
Thesecond periodbegins when the shock passes off, and lasts till the sloughs separate. The outstanding feature of this period istoxæmia, manifested by fever, the temperature rising to 102°, 103°, or 104° F., and congestive or inflammatory conditions of internal organs, giving rise to such clinical complications as bronchitis, broncho-pneumonia, or pleurisy—especially in burns of the thorax; or meningitis and cerebritis, when the neck or head is the seat of the burn. Intestinal catarrh associated with diarrhœa is not uncommon; and ulceration of the duodenum leading to perforation has been met with in a few cases. These phenomena are much more prominent when bacterial infection has taken place, and it seems probable that they are to be attributed chiefly to the infection, as they have become less frequent and less severe since burns have been treated like other breaches of the surface. Albuminuria is a fairly constant symptom in severe burns, and is associated with congestion of the kidneys. In burns implicating the face, neck, mouth, or pharynx, œdema of the glottis is a dangerous complication, entailing as it does the risk of suffocation.
Thethird periodbegins when the sloughs separate, usuallybetween the seventh and fourteenth days, and lasts till the wound heals, its duration depending upon the size, depth, and asepticity of the raw area. The chief causes of death during this period are toxin absorption in any of its forms; waxy disease of the liver, kidneys, or intestine; less commonly erysipelas, tetanus, or other diseases due to infection by specific organisms. We have seen nothing to substantiate the belief that duodenal ulcers are liable to perforate during the third period.
Theprognosisin burns depends on (1) the superficial extent, and, to a much less degree, the depth of the injury. When more than one-third of the entire surface of the body is involved, even in a mild degree, the prognosis is grave. (2) The situation of the burn is important. Burns over the serous cavities—abdomen, thorax, or skull—are, other things being equal, much more dangerous than burns of the limbs. The risk of œdema of the glottis in burns about the neck and mouth has already been referred to. (3) Children are more liable to succumb to shock during the early period, but withstand prolonged suppuration better than adults. (4) When the patient survives the shock, the presence or absence of infection is the all-important factor in prognosis.
Treatment.—Thegeneral treatmentconsists in combating the shock. When pain is severe, morphin must be injected.
Local Treatment.—The local treatment must be carried out on antiseptic lines, a general anæsthetic being administered, if necessary, to enable the purification to be carried out thoroughly. After carefully removing the clothing, the whole of the burned area is gently, but thoroughly, cleansed with peroxide of hydrogen or warm boracic lotion, followed by sterilised saline solution. As pyogenic bacteria are invariably found in the blisters of burns, these must be opened and the raised epithelium removed.
The dressings subsequently applied should meet the following indications: the relief of pain; the prevention of sepsis; and the promotion of cicatrisation.
An application which satisfactorily fulfils these requirements ispicric acid. Pads of lint or gauze are lightly wrung out of a solution made up of picric acid, 1½ drams; absolute alcohol, 3 ounces; distilled water, 40 ounces, and applied over the whole of the reddened area. These are covered with antiseptic wool,withoutany waterproof covering, and retained in position by a many-tailed bandage. The dressing should bechanged once or twice a week, under the guidance of the temperature chart, any portion of the original dressing which remains perfectly dry being left undisturbed. The value of a general anæsthetic in dressing extensive burns, especially in children, can scarcely be overestimated.
Picric acid yields its best results in superficial burns, and it is useful asa primary dressingin all. As soon as the sloughs separate and a granulating surface forms, the ordinary treatment for a healing sore is instituted. Any slough under which pus has collected should be cut away with scissors to permit of free drainage.
An occlusive dressing of meltedparaffinhas also been employed. A useful preparation consists of: Paraffin molle 25 per cent., paraffin durum 67 per cent., olive oil 5 per cent., oil of eucalyptus 2 per cent., and beta-naphthol ¼ per cent. It has a melting point of 48° C. It is also known asAmbrineandBurnol. After the burned area has been cleansed and thoroughly dried, it is sponged or painted with the melted paraffin, and before solidification takes place a layer of sterilised gauze is applied and covered with a second coating of paraffin. Further coats of paraffin are applied every other day to prevent the gauze sticking to the skin.
An alternative method of treating extensive burns is by immersing the part, or even the whole body when the trunk is affected, in a bath of boracic lotion kept at the body temperature, the lotion being frequently renewed.
If a burn is already infected when first seen, it is to be treated on the same principles as govern the treatment of other infected wounds.
All moist or greasy applications, such as Carron oil, carbolic oil and ointments, and all substances like collodion and dry powders, which retain discharges, entirely fail to meet the indications for the rational treatment of burns, and should be abandoned.
Skin-grafting is of great value in hastening healing after extensive burns, and in preventing cicatricial contraction. Thedeformitieswhich are so liable to develop from contraction of the cicatrices are treated on general principles. In the region of the face, neck, and flexures of joints (Fig. 63), where they are most marked, the contracted bands may be divided and the parts stretched, the raw surface left being covered by Thiersch grafts or by flaps of skin raised from adjacent surfaces or from other parts of the body (Fig. 1).
Injuries produced by Exposure to X-Rays and Radium.—In the routine treatment of disease by radiations, injury is sometimes done to the tissues, even when the greatest care is exercised as to dosage and frequency of application. Robert Knox describes the following ill-effects.
Acute dermatitisvarying in degree from a slight erythema to deep ulceration or even necrosis of skin. When ulcers form they are extremely painful and slow to heal. When hair-bearing areas are affected, epilation may occur without destroying the hair follicles and the hairs are reproduced, but if the reaction is excessive permanent alopecia may result.
Chronic dermatitis, which results from persistence of the acute form, is most intractable and may assume malignant characters. X-ray warts are a late manifestation of chronic dermatitis and may become malignant.
Among thelate manifestationsare neuritis, telangiectasis, and a painful and intractable form of ulceration, any of which may come on months or even years after the cessation of exposure.Sterilitymay be induced in X-ray workers who are imperfectly protected from the effects of the rays.
Electrical burnsusually occur in those who are engaged in industrial undertakings where powerful electrical currents are employed.
The lesions—which vary from a slight superficial scorching to complete charring of parts—are most evident at the points of entrance and exit of the current, the intervening tissues apparently escaping injury.
The more superficial degrees of electrical burns differ from those produced by heat in being almost painless, and in healing very slowly, although as a rule they remain dry and aseptic.
The more severe forms are attended with a considerable degree of shock, which is not only more profound, but also lasts much longer than the shock in an ordinary burn of corresponding severity. The parts at the point of entrance of the current are charred to a greater or lesser depth. The eschar is at first dry and crisp, and is surrounded by a zone of pallor. For the first thirty-six to forty-eight hours there is comparatively little suffering, but at the end of that time the parts become exceedingly painful. In a majority of cases, in spite of careful purification, a slow form of moist gangrene sets in, and the slough spreads both in area and in depth, until the muscles andoften the large blood vessels and nerves are exposed. A line of demarcation eventually forms, but the sloughs are exceedingly slow to separate, taking from three to five times as long as in an ordinary burn, and during the process of separation there is considerable risk of secondary hæmorrhage from erosion of large vessels.
Treatment.—Electrical burns are treated on the same lines as ordinary burns, by thorough purification and the application of dry dressings, with a view to avoiding the onset of moist gangrene. After granulations have formed, skin-grafting is of value in hastening healing.
Lightning-stroke.—In a large proportion of cases lightning-stroke proves instantly fatal. In non-fatal cases the patient suffers from a profound degree of shock, and there may or may not be any external evidence of injury. In the mildest cases red spots or wheals—closely resembling those of urticaria—may appear on the body, but they usually fade again in the course of twenty-four hours. Sometimes large patches of skin are scorched or stained, the discoloured area showing an arborescent appearance. In other cases the injured skin becomes dry and glazed, resembling parchment. Appearances are occasionally met with corresponding to those of a superficial burn produced by heat. The chief difference from ordinary burns is the extreme slowness with which healing takes place. Localised paralysis of groups of muscles, or even of a whole limb, may follow any degree of lightning-stroke. Treatment is mainly directed towards combating the shock, the surface-lesions being treated on the same lines as ordinary burns.
The surgeon is called upon to treat two distinct classes of wounds: (1) those resulting from injury or disease in whichthe skin is already broken, or in which a communication with a mucous surface exists; and (2) those that he himself makesthrough intact skin, no infected mucous surface being involved.
Infection by bacteria must be assumed to have taken place in all wounds made in any other way than by the knife of the surgeon operating through unbroken skin. On this assumption the modern system of wound treatment is based. Pathogenic bacteria are so widely distributed, that in the ordinary circumstances of everyday life, no matter how trivial a wound may be, or how short a time it may remain exposed, the access of organisms to it is almost certain unless preventive measures are employed.
It cannot be emphasised too strongly that rigid precautions are to be taken to exclude fresh infection, not only in dealing with wounds that are free of organisms, but equally in the management of wounds and other lesions that are already infected. Any laxity in our methods which admits of fresh organisms reaching an infected wound adds materially to the severity of the infective process and consequently to the patient's risk.
There are many ways in which accidental infection may occur. Take, for example, the case of a person who receives a cut on the face by being knocked down in a carriage accident on the street. Organisms may be introduced to such a wound from the shaft or wheel by which he was struck, from the ground on which he lay, from any portion of his clothing that may have comein contact with the wound, or from his own skin. Or, again, the hands of those who render first aid, the water used to bathe the wound, the handkerchief or other extemporised dressing applied to it, may be the means of conveying bacterial infection. Should the wound open on a mucous surface, such as the mouth or nasal cavity, the organisms constantly present in such situations are liable to prove agents of infection.
Even after the patient has come under professional care the risks of his wound becoming infected are not past, because the hands of the doctor, his instruments, dressings, or other appliances may all, unless purified, become the sources of infection.
In the case of an operation carried out through unbroken skin, organisms may be introduced into the wound from the patient's own skin, from the hands of the surgeon or his assistants, through the medium of contaminated instruments, swabs, ligature or suture materials, or other things used in the course of the operation, or from the dressings applied to the wound.
Further, bacteria may gain access to devitalised tissues by way of the blood-stream, being carried hither from some infected area elsewhere in the body.
The Antiseptic System of Surgery.—Those who only know the surgical conditions of to-day can scarcely realise the state of matters which existed before the introduction of the antiseptic system by Joseph Lister in 1867. In those days few wounds escaped the ravages of pyogenic and other bacteria, with the result that suppuration ensued after most operations, and such diseases as erysipelas, pyæmia, and “hospital gangrene” were of everyday occurrence. The mortality after compound fractures, amputations, and many other operations was appalling, and death from blood-poisoning frequently followed even the most trivial operations. An operation was looked upon as a last resource, and the inherent risk from blood-poisoning seemed to have set an impassable barrier to the further progress of surgery. To the genius of Lister we owe it that this barrier was removed. Having satisfied himself that the septic process was due to bacterial infection, he devised a means of preventing the access of organisms to wounds or of counteracting their effects. Carbolic acid was the first antiseptic agent he employed, and by its use in compound fractures he soon obtained results such as had never before been attained. The principle was applied to other conditions with like success, and so profoundly has it affected the whole aspect of surgical pathology, that many of the infective diseases with which surgeons formerly had to deal are now all but unknown. The broad principles upon which Listerfounded his system remain unchanged, although the methods employed to put them into practice have been modified.
Means taken to Prevent Infection of Wounds.—The avenues by which infective agents may gain access to surgical wounds are so numerous and so wide, that it requires the greatest care and the most watchful attention on the part of the surgeon to guard them all. It is only by constant practice and patient attention to technical details in the operating room and at the bedside, that the carrying out of surgical manipulations in such a way as to avoid bacterial infection will become an instinctive act and a second nature. It is only possible here to indicate the chief directions in which danger lies, and to describe the means most generally adopted to avoid it.
To prevent infection, it is essential that everything which comes into contact with a wound should be sterilised or disinfected, and to ensure the best results it is necessary that the efficiency of our methods of sterilisation should be periodically tested. The two chief agencies at our disposal are heat and chemical antiseptics.
Sterilisation by Heat.—The most reliable, and at the same time the most convenient and generally applicable, means of sterilisation is by heat. All bacteria and spores are completely destroyed by being subjected for fifteen minutes tosaturated circulating steamat a temperature of 130° to 145° C. (=266° to 293° F.). The articles to be sterilised are enclosed in a perforated tin casket, which is placed in a specially constructed steriliser, such as that of Schimmelbusch. This apparatus is so arranged that the steam circulates under a pressure of from two to three atmospheres, and permeates everything contained in it. Objects so sterilised are dry when removed from the steriliser. This method is specially suitable for appliances which are not damaged by steam, such, for example, as gauze swabs, towels, aprons, gloves, and metal instruments; it is essential that the efficiency of the steriliser be tested from time to time by a self-registering thermometer or other means.
The best substitute for circulating steam isboiling. The articles are placed in a “fish-kettle steriliser” and boiled for fifteen minutes in a 1 per cent. solution of washing soda.
To prevent contamination of objects that have been sterilised they must on no account be touched by any one whose hands have not been disinfected and protected by sterilised gloves.
Sterilisation by Chemical Agents.—For the purification of the skin of the patient, the hands of the surgeon, and knives andother instruments that are damaged by heat, recourse must be had to chemical agents. These, however, are less reliable than heat, and are open to certain other objections.
Disinfection of the Hands.—It is now generally recognised that one of the most likely sources of wound infection is the hands of the surgeon and his assistants. It is only by carefully studying to avoid all contact with infective matter that the hands can be kept surgically pure, and that this source of wound infection can be reduced to a minimum. The risk of infection from this source has further been greatly reduced by the systematic use of rubber gloves by house-surgeons, dressers, and nurses. The habitual use of gloves has also been adopted by the great majority of surgeons; the minority, who find they are handicapped by wearing gloves as a routine measure, are obliged to do so when operating in infective cases or dressing infected wounds, and in making rectal and vaginal examinations.
The gloves may be sterilised by steam, and are then put on dry, or by boiling, in which case they are put on wet. The gauntlet of the glove should overlap and confine the end of the sleeve of the sterilised overall, and the gloved hands are rinsed in lotion before and at frequent intervals during the operation. The hands are sterilised before putting on the gloves, preferably by a method which dehydrates the skin. Cotton gloves may be worn by the surgeon when tying ligatures, or between operations, and by the anæsthetist during operations on the head, neck, and chest.
The first step in the disinfection of the hands is the mechanical removal of gross surface dirt and loose epithelium by soap, a stream of running water as hot as can be borne, and a loofah or nail-brush, that has been previously sterilised by heat. The nails should be cut down till there is no sulcus between the nail edge and the pulp of the finger in which organisms may lodge. They are next washed for three minutes in methylated spirit to dehydrate the skin, and then for two or three minutes in 70 per cent. sublimate or biniodide alcohol (1 in 1000). Finally, the hands are rubbed with dry sterilised gauze.
Preparation of the Skin of the Patient.—In the purification of the skin of the patient before operation, reliance is to be placed chiefly in the mechanical removal of dirt and grease by the same means as are taken for the cleansing of the surgeon's hands. Hair-covered parts should be shaved. The skin is then dehydrated by washing with methylated spirit, followed by 70 per cent. sublimate or biniodide alcohol (1 in 1000). This is done some hours before the operation, and the part is thencovered with pads of dry sterilised gauze or a sterilised towel. Immediately before the operation the skin is again purified in the same way.
Theiodine methodof disinfecting the skin introduced by Grossich is simple, and equally efficient. The day before operation the skin, after being washed with soap and water, is shaved, dehydrated by means of methylated spirit, and then painted with a 5 per cent. solution of iodine in rectified spirit. The painting with iodine is repeated just before the operation commences, and again after it is completed. The final application is omitted in the case of children. In emergency operations the skin is shaved dry and dehydrated with spirit, after which the iodine is applied as described above. The staining of the skin is an advantage, as it enables the operator to recognise the area that has been prepared.
If any acne pustules or infected sinuses are present, they should be destroyed or purified by means of the thermo-cautery or pure carbolic acid, after the patient is anæsthetised.
Appliances used at Operation.—Instrumentsthat are not damaged by heat must be boiled in a fish-kettle or other suitable steriliser for fifteen minutes in a 1 per cent. solution of cresol or washing soda. Just before the operation begins they are removed in the tray of the steriliser and placed on a sterilised towel within reach of the surgeon or his assistant. Knives and instruments that are liable to be damaged by heat should be purified by being soaked in pure cresol for a few minutes, or in 1 in 20 carbolic for at least an hour.
Pads of Gauzesterilised by compressed circulating steam have almost entirely superseded marine sponges for operative purposes. To avoid the risk of leaving swabs in the peritoneal cavity, large square pads of gauze, to one corner of which a piece of strong tape about a foot long is securely stitched, should be employed. They should be removed from the caskets in which they are sterilised by means of sterilised forceps, and handed direct to the surgeon. The assistant who attends to the swabs should wear sterilised gloves.
Ligatures and Sutures.—To avoid the risk of implanting infective matter in a wound by means of the materials used for ligatures and sutures, great care must be taken in their preparation.
Catgut.—The following methods of preparing catgut have proved satisfactory: (1) The gut is soaked in juniper oil for at least a month; the juniper oil is then removed by ether and alcohol, and the gut preserved in 1 in 1000 solution of corrosivesublimate in alcohol (Kocher). (2) The gut is placed in a brass receiver and boiled for three-quarters of an hour in a solution consisting of 85 per cent. absolute alcohol, 10 per cent. water, and 5 per cent. carbolic acid, and is then stored in 90 per cent. alcohol. (3) Cladius recommends that the catgut, just as it is bought from the dealers, be loosely rolled on a spool, and then immersed in a solution of—iodine, 1 part; iodide of potassium, 1 part; distilled water, 100 parts. At the end of eight days it is ready for use. Moschcowitz has found that the tensile strength of catgut so prepared is increased if it is kept dry in a sterile vessel, instead of being left indefinitely in the iodine solution. If Salkindsohn's formula is used—tincture of iodine, 1 part; proof spirit, 15 parts—the gut can be kept permanently in the solution without becoming brittle. To avoid contamination from the hands, catgut should be removed from the bottle with aseptic forceps and passed direct to the surgeon. Any portion unused should be thrown away.
Silkis prepared by being soaked for twelve hours in ether, for other twelve in alcohol, and then boiled for ten minutes in 1 in 1000 sublimate solution. It is then wound on spools with purified hands protected by sterilised gloves, and kept in absolute alcohol. Before an operation the silk is again boiled for ten minutes in the same solution, and is used directly from this (Kocher). Linen thread is sterilised in the same way as silk.
Fishing-gut and silver wire, as well as the needles, should be boiled along with the instruments. Horse-hair and fishing-gut may be sterilised by prolonged immersion in 1 in 20 carbolic, or in the iodine solutions employed to sterilise catgut.
The field of operation is surrounded by sterilised towels, clipped to the edges of the wound, and securely fixed in position so that no contamination may take place from the surroundings.
The surgeon and his assistants, including theanæsthetist, wear overalls sterilised by steam. To avoid the risk of infection from dust, scurf, or drops of perspiration falling from the head, the surgeon and his assistants may wear sterilised cotton caps. To obviate the risk of infection taking place by drops of saliva projected from the mouth in talking or coughing in the vicinity of a wound, a simple mask may be worn.
The risk of infection from theairis now known to be very small, so long as there is no excess of floating dust. All sweeping, dusting, and disturbing of curtains, blinds, or furniture must therefore be avoided before or during an operation.
It has been shown that the presence of spectators increasesthe number of organisms in the atmosphere. In teaching clinics, therefore, the risk from air infection is greater than in private practice.
To facilitate primary union, all hæmorrhage should be arrested, and the accumulation of fluid in the wound prevented. When much oozing is anticipated, a glass or rubber drainage-tube is inserted through a small opening specially made for the purpose. In aseptic wounds the tube may be removed in from twenty-four to forty-eight hours, and where it is important to avoid a scar, the opening should be closed with a Michel's clip; in infected wounds the tube must remain as long as the discharge continues.
The fascia and skin should be brought into accurate apposition by sutures. If any cavity exists in the deeper part of the wound it should be obliterated by buried sutures, or by so adjusting the dressing as to bring its walls into apposition.
If these precautions have been successful, the wound will heal under the original dressing, which need not be interfered with for from seven to ten days, according to the nature of the case.
Dressings.—Gauze, sterilised by heat, is almost universally employed for the dressing of wounds.Double cyanide gauzemay be used in such regions as the neck, axilla, or groin, where complete sterilisation of the skin is difficult to attain, and where it is desirable to leave the dressing undisturbed for ten days or more.Iodoformorbismuth gauzeis of special value for the packing of wounds treated by the open method.
One variety or another ofwool, rendered absorbent by the extraction of its fat, and sterilised by heat, forms a part of almost every surgical dressing, and various antiseptic agents may be added to it. Of these, corrosive sublimate is the most generally used. Wood-wool dressings are more highly and more uniformly absorbent than cotton wools. As evaporation takes place through wool dressings, the discharge becomes dried, and so forms an unfavourable medium for bacterial growth.
Pads ofsphagnum moss, sterilised by heat, are highly absorbent, and being economical are used when there is much discharge, and in cases where a leakage of urine has to be soaked up.
Means adopted to combat Infection.—As has already been indicated, the same antiseptic precautions are to be taken in dealing with infected as with aseptic wounds.
Inrecent injuriessuch as result from railway or machinery accidents, with bruising and crushing of the tissues and grinding of gross dirt into the wounds, the scissors must be freely used to remove the tissues that have been devitalised or impregnatedwith foreign material. Hair-covered parts should be shaved and the surrounding skin painted with iodine. Crushed and contaminated portions of bone should be chiselled away. Opinions differ as to the benefit derived from washing such wounds with chemical antiseptics, which are liable to devitalise the tissues with which they come in contact, and so render them less able to resist the action of any organisms that may remain in them. All are agreed, however, that free washing with normal salt solution is useful in mechanically cleansing the injured parts. Peroxide of hydrogen sprayed over such wounds is also beneficial in virtue of its oxidising properties. Efficient drainage must be provided, and stitches should be used sparingly, if at all.
The best way in which to treat such wounds is by theopen method. This consists in packing the wound with iodoform or bismuth gauze, which is left in position as long as it adheres to the raw surface. The packing may be renewed at intervals until the wound is filled by granulations; or, in the course of a few days when it becomes evident that the infection has been overcome,secondarysutures may be introduced and the edges drawn together, provision being made at the ends for further packing or for drainage-tubes.
If earth or street dirt has entered the wound, the surface may with advantage be painted over with pure carbolic acid, as virulent organisms, such as those of tetanus or spreading gangrene, are liable to be present. Prophylactic injection of tetanus antitoxin may be indicated.
Syncope, shock, and collapse are clinical conditions which, although depending on different causes, bear a superficial resemblance to one another.
Syncope or Fainting.—Syncope is the result of a suddenly produced anæmia of the brain from temporary weakening or arrest of the heart's action. In surgical practice, this condition is usually observed in nervous persons who have been subjected to pain, as in the reduction of a dislocation or the incision of a whitlow; or in those who have rapidly lost a considerable quantity of blood. It may also follow the sudden withdrawal of fluid from a large cavity, as in tapping an abdomen for ascites, or withdrawing fluid from the pleural cavity. Syncope sometimes occurs also during the administration of a general anæsthetic, especially if there is a tendency to sickness and the patient is not completely under. During an operation the onset of syncope is often recognised by the cessation of oozing from the divided vessels before the general symptoms become manifest.
Clinical Features.—When a person is about to faint he feels giddy, has surging sounds in his ears, and haziness of vision; he yawns, becomes pale and sick, and a free flow of saliva takes place into the mouth. The pupils dilate; the pulse becomes small and almost imperceptible; the respirations shallow and hurried; consciousness gradually fades away, and he falls in a heap on the floor.
Sometimes vomiting ensues before the patient completely loses consciousness, and the muscular exertion entailed may ward off the actual faint. This is frequently seen in threatened syncopal attacks during chloroform administration.
Recovery begins in a few seconds, the patient sighing or gasping, or, it may be, vomiting; the strength of the pulse gradually increases, and consciousness slowly returns. In some cases, however, syncope is fatal.
Treatment.—The head should at once be lowered—in imitation of nature's method—to encourage the flow of blood to the brain, the patient, if necessary, being held up by the heels. All tight clothing, especially round the neck or chest, must be loosened. The heart may be stimulated reflexly by dashing cold water over the face or chest, or by rubbing the face vigorously with a rough towel. The application of volatile substances, such as ammonia or smelling-salts, to the nose; the administration by the mouth of sal-volatile, whisky or brandy, and the intra-muscular injection of ether, are the most speedily efficacious remedies. In severe cases the application of hot cloths over the heart, or of the faradic current over the line of the phrenic nerve, just above the clavicle, may be called for.
Surgical Shock.—The condition known as surgical shock may be looked upon as a state of profound exhaustion of the mechanism that exists in the body for the transformation of energy. This mechanism consists of (1) thebrain, which, through certain special centres, regulates all vital activity; (2) theadrenal glands, the secretion of which—adrenalin—acting as a stimulant of the sympathetic system, so controls the tone of the blood vessels as to maintain efficient oxidation of the tissues; and (3)the liver, which stores and delivers glycogen as it is required by the muscles, and in addition, deals with the by-products of metabolism.
Crile and his co-workers have shown that in surgical shock histological changes occur in the cells of the brain, the adrenals, and the liver, and that these are identical, whatever be the cause that leads to the exhaustion of the energy-transforming mechanism. These changes vary in degree, and range from slight alterations in the structure of the protoplasm to complete disorganisation of the cell elements.
The influences which contribute to bring about this form of exhaustion that we call shock are varied, and include such emotional states as fear, anxiety, or worry, physical injury and toxic infection, and the effects of these factors are augmented by anything that tends to lower the vitality, such as loss of blood, exposure, insufficient food, loss of sleep or antecedent illness.
Any one or any combination of these influences may cause shock, but the most potent, and the one which most concerns the surgeon, is physical injury,e.g., a severe accident or an operation(traumatic shock). This is usually associated with some emotional disturbance, such as fear or anxiety (emotional shock), or with hæmorrhage; and may be followed by septic infection (toxic shock).
The exaggerated afferent impulses reaching the brain as a result of trauma, inhibit the action of the nuclei in the region of the fourth ventricle and cerebellum which maintain the muscular tone, with the result that the muscular tone is diminished and there is a marked fall in the arterial blood pressure. The capillaries dilate—the blood stagnating in them and giving off its oxygen and transuding its fluid elements into the tissues—with the result that an insufficient quantity of oxygenated blood reaches the heart to enable it to maintain an efficient circulation. As the sarco-lactic acid liberated in the muscles is not oxygenated a condition of acidosis ensues.
The more highly the injured part is endowed with sensory nerves the more marked is the shock; a crush of the hand, for example, is attended with a more intense degree of shock than a correspondingly severe crush of the foot; and injuries of such specially innervated parts as the testis, the urethra, the face, or the spinal cord, are associated with severe degrees, as are also those of parts innervated from the sympathetic system, such as the abdominal or thoracic viscera. It is to be borne in mind that a state of general anæsthesia does not prevent injurious impulses reaching the brain and causing shock during an operation. If the main nerves of the part are “blocked” by injection of a local anæsthetic, however, the central nervous system is protected from these impulses.
While the aged frequently manifest but few signs of shock, they have a correspondingly feeble power of recovery; and while many young children suffer little, even after severe operations, others with much less cause succumb to shock.
When the injured person's mind is absorbed with other matters than his own condition,—as, for example, during the heat of a battle or in the excitement of a railway accident or a conflagration,—even severe injuries may be unattended by pain or shock at the time, although when the period of excitement is over, the severity of the shock is all the greater. The same thing is observed in persons injured while under the influence of alcohol.
Clinical Features.—The patient is in a state of prostration. He is roused from his condition of indifference with difficulty, but answers questions intelligently, if only in a whisper. The face is pale, beads of sweat stand out on the brow, the featuresare drawn, the eyes sunken, and the cheeks hollow. The lips and ears are pallid; the skin of the body of a greyish colour, cold, and clammy. The pulse is rapid, fluttering, and often all but imperceptible at the wrist; the respiration is irregular, shallow, and sighing; and the temperature may fall to 96° F. or even lower. The mouth is parched, and the patient complains of thirst. There is little sensibility to pain.
Except in very severe cases, shock tends towards recovery within a few hours, thereaction, as itiscalled, being often ushered in by vomiting. The colour improves; the pulse becomes full and bounding; the respiration deeper and more regular; the temperature rises to 100° F. or higher; and the patient begins to take notice of his surroundings. The condition of neurasthenia which sometimes follows an operation may be associated with the degenerative changes in nerve cells described by Crile.
In certain cases the symptoms of traumatic shock blend with those resulting from toxin absorption, and it is difficult to estimate the relative importance of the two factors in the causation of the condition. The conditions formerly known as “delayed shock” and “prostration with excitement” are now generally recognised to be due to toxæmia.
Question of Operating during Shock.—Most authorities agree that operations should only be undertaken during profound shock when they are imperatively demanded for the arrest of hæmorrhage, the prevention of infection of serous cavities, or for the relief of pain which is producing or intensifying the condition.
Prevention of Operation Shock.—In the preparation of a patient for operation, drastic purgation and prolonged fasting must be avoided, and about half an hour before a severe operation a pint of saline solution should be slowly introduced into the rectum; this is repeated, if necessary, during the operation, and at its conclusion. The operating-room must be warm—not less than 70° F.—and the patient should be wrapped in cotton wool and blankets, and surrounded by hot-bottles. All lotions used must be warm (100° F.); and the operation should be completed as speedily and as bloodlessly as possible. The element of fear may to some extent be eliminated by the preliminary administration of such drugs as scopolamin or morphin, and with a view to preventing the passage of exciting afferent impulses, Crile advocates “blocking” of the nerves by the injection of a 1 per cent. solution of novocaine into their substance on the proximal side of the field of operation. Toprevent after-pain in abdominal wounds he recommends injecting the edges with quinine and urea hydrochlorate before suturing, the resulting anæsthesia lasting for twenty-four to forty-eight hours. To these preventive measures the termanoci-associationhas been applied. In selecting an anæsthetic, it may be borne in mind that chloroform lowers the blood pressure more than ether does, and that with spinal anæsthesia there is no lowering of the blood pressure.
Treatment.—A patient suffering from shock should be placed in the recumbent position, with the foot of the bed raised to facilitate the return circulation in the large veins, and so to increase the flow of blood to the brain. His bed should be placed near a large fire, and the patient himself surrounded by cotton wool and blankets and hot-bottles. If he has lost much blood, the limbs should be wrapped in cotton wool and firmly bandaged from below upwards, to conserve as much of the circulating blood as possible in the trunk and head. If the shock is moderate in degree, as soon as the patient has been put to bed, about a pint of saline solution should be introduced into the rectum, and 10 to 15 minims of adrenalin chloride (1 in 1000) may with advantage be added to the fluid. The injection should be repeated every two hours until the circulation is sufficiently restored. In severe cases, especially when associated with hæmorrhage, transfusion of whole blood from a compatible donor, is the most efficient means (Op. Surg., p. 37). Cardiac stimulants such as strychnin, digitalin, or strophanthin are contra-indicated in shock, as they merely exhaust the already impaired vaso-motor centre.
Artificial respiration may be useful in tiding a patient over the critical period of shock, especially at the end of a severe operation.
Failing this, the introduction of saline solution at a temperature of about 105° F. into a vein or into the subcutaneous tissue is useful where much blood has been lost (p. 276). Two or three pints may be injected into a vein, or smaller quantities under the skin.
Thirst is best met by giving small quantities of warm water by the mouth, or by the introduction of saline solution into the rectum. Ice only relieves thirst for a short time, and as it is liable to induce flatulence should be avoided, especially in abdominal cases. Dryness of the tongue may be relieved by swabbing the mouth with a mixture of glycerine and lemon juice.
If severe pain calls for the use of morphin, 1/120th grain ofatropin should be added, or heroin alone may be given in doses of 1/24th to 1/12th grain.
Collapseis a clinical condition which comes on more insidiously than shock, and which does not attain its maximum degree of severity for several hours. It is met with in the course of severe illnesses, especially such as are associated with the loss of large quantities of fluid from the body—for example, by severe diarrhœa, notably in Asiatic cholera; by persistent vomiting; or by profuse sweating, as in some cases of heat-stroke. Severe degrees of collapse follow sudden and profuse loss of blood.
Collapse often follows upon shock—for example, in intestinal perforations, or after abdominal operations complicated by peritonitis, especially if there is vomiting, as in cases of obstruction high up in the intestine. The symptoms of collapse are aggravated if toxin absorption is superadded to the loss of fluid.
Theclinical featuresof this condition are practically the same as those of shock; and it is treated on the same lines.
Fat Embolism.—After various injuries and operations, but especially such as implicate the marrow of long bones—for example, comminuted fractures, osteotomies, resections of joints, or the forcible correction of deformities—fluid fat may enter the circulation in variable quantity. In the vast majority of cases no ill effects follow, but when the quantity is large or when the absorption is long continued certain symptoms ensue, either immediately, or more frequently not for two or three days. These are mostly referable to the lungs and brain.
In the lung the fat collects in the minute blood vessels and produces venous congestion and œdema, and sometimes pneumonia. Dyspnœa, with cyanosis, a persistent cough and frothy or blood-stained sputum, a feeble pulse and low temperature, are the chief symptoms.
When the fat lodges in the capillaries of the brain, the pulse becomes small, rapid, and irregular, delirium followed by coma ensues, and the condition is usually rapidly fatal.
Fat is usually to be detected in the urine, even in mild cases.
Thetreatmentconsists in tiding the patient over the acute stage of his illness, until the fat is eliminated from the blood vessels.
Traumatic Asphyxia or Traumatic Cyanosis.—This term has been applied to a condition which results when the thorax is so forcibly compressed that respiration is mechanically arrested for several minutes. It has occurred from beingcrushed in a struggling crowd, or under a fall of masonry, and in machinery accidents. When the patient is released, the face and the neck as low down as the level of the clavicles present an intense coloration, varying from deep purple to blue-black. The affected area is sharply defined, and on close inspection the appearance is found to be due to the presence of countless minute reddish-blue or black spots, with small areas or streaks of normal skin between them. The punctate nature of the coloration is best recognised towards the periphery of the affected area—at the junction of the brow with the hairy scalp, and where the dark patch meets the normal skin of the chest (Beach and Cobb). Pressure over the skin does not cause the colour to disappear as in ordinary cyanosis. It has been shown by Wright of Boston, that the coloration is due to stasis from mechanical over-distension of the veins and capillaries; actual extravasation into the tissues is exceptional. The sharply defined distribution of the coloration is attributed to the absence of functionating valves in the veins of the head and neck, so that when the increased intra-thoracic pressure is transmitted to these veins they become engorged. Under the conjunctivæ there are extravasations of bright red blood; and sublingual hæmatoma has been observed (Beatson).
The discoloration begins to fade within a few hours, and after the second or third day it disappears, without showing any of the chromatic changes which characterise a bruise. The sub-conjunctival ecchymosis, however, persists for several weeks and disappears like other extravasations. Apart from combating the shock, or dealing with concomitant injuries, no treatment is called for.
Delirium is a temporary disturbance of mind which occurs in the course of certain diseases, and sometimes after injuries or operations. It may be associated with any of the acute pyogenic infections; with erysipelas, especially when it affects the head or face; or with chronic infective diseases of the urinary organs. In the various forms of meningitis also, and in some cases of injury to the head, it is common; and it is sometimes met with after severe hæmorrhage, and in cases of poisoning by such drugs as iodoform, cocain, or alcohol. Delirium may also, of course, be a symptom of insanity.
Often there is merely incoherent muttering regarding pastincidents or occupations, or about absent friends; or the condition may assume the form of excitement, of dementia, or of melancholia; and the symptoms are usually worst at night.
Delirium Tremensis seen in persons addicted to alcohol, who, as the result of accident or operation, are suddenly compelled to lie in bed. Although oftenest met with in habitual drunkards or chronic tipplers, it is by no means uncommon in moderate drinkers, and has even been seen in children.
Clinical Features.—The delirium, which has been aptly described as being of a “busy” character, usually manifests itself within a few days of the patient being laid up. For two or three days he refuses food, is depressed, suspicious, sleepless and restless, demanding to be allowed up. Then he begins to mutter incoherently, to pull off the bedclothes, and to attempt to get out of bed. There is general muscular tremor, most marked in the tongue, the lips, and the hands. The patient imagines that he sees all sorts of horrible beings around him, and is sometimes greatly distressed because of rats, mice, beetles, or snakes, which he fancies are crawling over him. The pulse is soft, rapid, and compressible; the temperature is only moderately raised (100°–101° F.), and as a rule there is profuse sweating. The digestion is markedly impaired, and there is often vomiting. Patients in this condition are peculiarly insensitive to pain, and may even walk about with a fractured leg without apparent discomfort.
In most cases the symptoms begin to pass off in three or four days; the patient sleeps, the hallucinations and tremors cease, and he gradually recovers. In other cases the temperature rises, the pulse becomes rapid, and death results from exhaustion.
The main indication intreatmentis to secure sleep, and this is done by the administration of bromides, chloral, or paraldehyde, or of one or other of the drugs of which sulphonal, trional, and veronal are examples. Heroin in doses of from 1/24th to 1/12th grain is often of service. Morphin must be used with great caution. In some cases hyoscin (1/200 grain) injected hypodermically is found efficacious when all other means have failed, but this drug must be used with great discrimination. The patient must be encouraged to take plenty of easily digested fluid food, supplemented, if necessary, by nutrient enemata and saline infusions.
In the early stage a brisk mercurial purge is often of value. Alcohol should be withheld, unless failing of the pulse strongly indicates its use, and then it should be given along with the food.
A delirious patient must be constantly watched by a trained attendant or other competent person, lest he get out of bed and do harm to himself or others. Mechanical restraint is often necessary, but must be avoided if possible, as it is apt to increase the excitement and exhaust the patient. On account of the extreme restlessness, there is often great difficulty in carrying out the proper treatment of the primary surgical condition, and considerable modifications in splints and other appliances are often rendered necessary.
A form of delirium, sometimes spoken of asTraumatic Delirium, may follow on severe injuries or operations in persons of neurotic temperament, or in those whose nervous system is exhausted by overwork. It is met with apart from alcoholic intemperance. This form of delirium seems to be specially prone to ensue on operations on the face, the thyreoid gland, or the genito-urinary organs. The symptoms appear in from two to five days after the operation, and take the form of restlessness, sleeplessness, low incoherent muttering, and picking at the bedclothes. It is not necessarily attended by fever or by muscular tremors. The patient may show hysterical symptoms. This condition is probably to be regarded as a form of insanity, as it is liable to merge into mania or melancholia.
Thetreatmentis carried out on the same lines as that of delirium tremens.
Surgical Anatomy.—Anarteryhas three coats: an internal coat—thetunica intima—made up of a single layer of endothelial cells lining the lumen; outside of this a layer of delicate connective tissue; and still farther out a dense tissue composed of longitudinally arranged elastic fibres—the internal elastic lamina. The tunica intima is easily ruptured. The middle coat, ortunica media, consists of non-striped muscular fibres, arranged for the most part concentrically round the vessel. In this coat also there is a considerable proportion of elastic tissue, especially in the larger vessels. The thickness of the vessel wall depends chiefly on the development of the muscular coat. The external coat, ortunica externa, is composed of fibrous tissue, containing, especially in vessels of medium calibre, some yellow elastic fibres in its deeper layers.
In most parts of the body the arteries lie in a sheath of connective tissue, from which fine fibrous processes pass to the tunica externa. The connection, however, is not a close one, and the artery when divided transversely is capable of retracting for a considerable distance within its sheath. In some of the larger arteries the sheath assumes the form of a definite membrane.
The arteries are nourished by small vessels—thevasa vasorum—which ramify chiefly in the outer coat. They are also well supplied with nerves, which regulate the size of the lumen by inducing contraction or relaxation of the muscular coat.
Theveinsare constructed on the same general plan as the arteries, the individual coats, however, being thinner. The inner coat is less easily ruptured, and the middle coat contains a smaller proportion of muscular tissue. In one important point veins differ structurally from arteries—namely, in being provided with valves which prevent reflux of the blood. These valves are composed of semilunar folds of the tunica intima strengthened by an addition of connective tissue. Each valve usually consists of two semilunar flaps attached to opposite sides of the vessel wall, each flap having a small sinus on its cardiac side. Thedistension of these sinuses with blood closes the valve and prevents regurgitation. Valves are absent from the superior and inferior venæ cavæ, the portal vein and its tributaries, the hepatic, renal, uterine, and spermatic veins, and from the veins in the lower part of the rectum. They are ill-developed or absent also in the iliac and common femoral veins—a fact which has an important bearing on the production of varix in the veins of the lower extremity.
The wall ofcapillariesconsists of a single layer of endothelial cells.
Various terms are employed in relation to hæmorrhage, according to its seat, its origin, the time at which it occurs, and other circumstances.
The termexternal hæmorrhageis employed when the blood escapes on the surface; when the bleeding takes place into the tissues or into a cavity it is spoken of asinternal. The blood may infiltrate the connective tissue, constituting anextravasationof blood; or it may collect in a space or cavity and form ahæmatoma.
The coughing up of blood from the lungs is known ashæmoptysis; vomiting of blood from the stomach, ashæmatemesis; the passage of black-coloured stools due to the presence of blood altered by digestion, asmelæna; and the passage of bloody urine, ashæmaturia.
Hæmorrhage is known as arterial, venous, or capillary, according to the nature of the vessel from which it takes place.
Inarterialhæmorrhage the blood is bright red in colour, and escapes from the cardiac end of the divided vessel in pulsating jets synchronously with the systole of the heart. In vascular parts—for example the face—both ends of a divided artery bleed freely. The blood flowing from an artery may be dark in colour if the respiration is impeded. When the heart's action is weak and the blood tension low the flow may appear to be continuous and not in jets. The blood from a divided artery at the bottom of a deep wound, escapes on the surface in a steady flow.
Venousbleeding is not pulsatile, but occurs in a continuous stream, which, although both ends of the vessel may bleed, is more copious from the distal end. The blood is dark red under ordinary conditions, but may be purplish, or even black, if the respiration is interfered with. When one of the large veins in the neck is wounded, the effects of respiration produce a rise and fall in the stream which may resemble arterial pulsation.
Incapillaryhæmorrhage, red blood escapes from numerous points on the surface of the wound in a steady ooze. This form of bleeding is serious in those who are the subjects of hæmophilia.
The following description of the injuries of arteries refers to the larger, named trunks. The injuries of smaller, unnamed vessels are included in the consideration of wounds and contusions.
Contusion.—An artery may be contused by a blow or crush, or by the oblique impact of a bullet. The bruising of the vessel wall, especially if it is diseased, may result in the formation of a thrombus which occludes the lumen temporarily or even permanently, and in rare cases may lead to gangrene of the limb beyond.
Subcutaneous Rupture.—An artery may be ruptured subcutaneously by a blow or crush, or by a displaced fragment of bone. This injury has been produced also during attempts to reduce dislocations, especially those of old standing at the shoulder. It is most liable to occur when the vessels are diseased. The rupture may be incomplete or complete.
Incomplete Subcutaneous Rupture.—In the majority of cases the rupture is incomplete—the inner and middle coats being torn, while the outer remains intact. The middle coat contracts and retracts, and the internal, because of its elasticity, curls up in the interior of the vessel, forming a valvular obstruction to the blood-flow. In most cases this results in the formation of a thrombus which occludes the vessel. In some cases the blood-pressure gradually distends the injured segment of the vessel wall and leads to the formation of an aneurysm.
The pulsation in the vessels beyond the seat of rupture is arrested—for a time at least—owing to the occlusion of the vessel, and the limb becomes cold and powerless. The pulsation seldom returns within five or six weeks of the injury, if indeed it is not permanently arrested, but, as a rule, a collateral circulation is rapidly established, sufficient to nourish the parts beyond. If the pulsation returns within a week of the injury, the presumption is that the occlusion was due to pressure from without—for example, by hæmorrhage into the sheath or the pressure of a fragment of bone.
Complete Subcutaneous Rupture.—When the rupture is complete, all the coats of the vessel are torn and the bloodescapes into the surrounding tissues. If the original injury is attended with much shock, the bleeding may not take place until the period of reaction. Rupture of the popliteal artery in association with fracture of the femur, or of the axillary or brachial artery with fracture of the humerus or dislocation of the shoulder, are familiar examples of this injury.
Like incomplete rupture, this lesion is accompanied by loss of pulsation and power, and by coldness of the limb beyond; a tense and excessively painful swelling rapidly appears in the region of the injury, and, where the cellular tissue is loose, may attain a considerable size. The pressure of the effused blood occludes the veins and leads to congestion and œdema of the limb beyond. The interference with the circulation, and the damage to the tissues, may be so great that gangrene ensues.
Treatment.—When an artery has been contused or ruptured, the limb must be placed in the most favourable condition for restoration of the circulation. The skin is disinfected and the limb wrapped in cotton wool to conserve its heat, and elevated to such an extent as to promote the venous return without at the same time interfering with the inflow of blood. A careful watch must be kept on the state of nutrition of the limb, lest gangrene occurs.
If no complications supervene, the swelling subsides, and recovery may be complete in six or eight weeks. If the extravasation is great and the skin threatens to give way, or if the vitality of the limb is seriously endangered, it is advisable to expose the injured vessel, and, after clearing away the clots, to attempt to suture the rent in the artery, or, if torn across, to join the ends after paring the bruised edges. If this is impracticable, a ligature is applied above and below the rupture. If gangrene ensues, amputation must be performed.
These descriptions apply to the larger arteries of the extremities. A good illustration of subcutaneous rupture of the arteries of the head is afforded by the tearing of the middle meningeal artery caused by the application of blunt violence to the skull; and of the arteries of the trunk—caused by the tearing of the renal artery in rupture of the kidney.
Open Wounds of Arteries—Laceration.—Laceration of large arteries is a common complication of machinery and railway accidents. The violence being usually of a tearing, twisting, or crushing nature, such injuries are seldom associated with much hæmorrhage, as torn or crushed vessels quickly become occluded by contraction and retraction of their coats and by the formation of a clot. A whole limb even may be avulsed from the bodywith comparatively little loss of blood. The risk in such cases is secondary hæmorrhage resulting from pyogenic infection.
Thetreatmentis that applicable to all wounds, with, in addition, the ligation of the lacerated vessels.
Punctured woundsof blood vessels may result from stabs, or they may be accidentally inflicted in the course of an operation.
The division of the coats of the vessel being incomplete, the natural hæmostasis that results from curling up of the intima and contraction of the media, fails to take place, and bleeding goes on into the surrounding tissues, and externally. If the sheath of the vessel is not widely damaged, the gradually increasing tension of the extravasated blood retained within it may ultimately arrest the hæmorrhage. A clot then forms between the lips of the wound in the vessel wall and projects for a short distance into the lumen, without, however, materially interfering with the flow through the vessel. The organisation of this clot results in the healing of the wound in the vessel wall.
In other cases the blood escapes beyond the sheath and collects in the surrounding tissues, and a traumatic aneurysm results. Secondary hæmorrhage may occur if the wound becomes infected.
Thetreatmentconsists in enlarging the external wound to permit of the damaged vessel being ligated above and below the puncture. In some cases it may be possible to suture the opening in the vessel wall. When circumstances prevent these measures being taken, the bleeding may be arrested by making firm pressure over the wound with a pad; but this procedure is liable to be followed by the formation of an aneurysm.
Minute puncture of arteriessuch as frequently occur in the hypodermic administration of drugs and in the use of exploring needles, are not attended with any escape of blood, chiefly because of the elastic recoil of the arterial wall; a tiny thrombus of platelets and thrombus forms at the point where the intima is punctured.
Incised Wounds.—We here refer only to such incised wounds as partly divide the vessel wall.
Longitudinal wounds show little tendency to gape, and are therefore not attended with much bleeding. They usually heal rapidly, but, like punctured wounds, are liable to be followed by the formation of an aneurysm.
When, however, the incision in the vessel wall is oblique or transverse, the retraction of the muscular coat causes the opening to gape, with the result that there is hæmorrhage, which, evenin comparatively small arteries, may be so profuse as to prove dangerous. When the associated wound in the soft parts is valvular the hæmorrhage is arrested and an aneurysm may develop.
When a large arterial trunk, such as the external iliac, the femoral, the common carotid, the brachial, or the popliteal, has been partly divided, for example, in the course of an operation, the opening should be closed with sutures—arteriorrhaphy. The circulation being controlled by a tourniquet, or the artery itself occluded by a clamp, fine silk or catgut stitches are passed through the outer and middle coats after the method of Lembert, a fine, round needle being employed. The sheath of the vessel or an adjacentfasciashould be stitched over the line of suture in the vessel wall. If infection be excluded, there is little risk of thrombosis or secondary hæmorrhage; and even if thrombosis should develop at the point of suture, the artery is obstructed gradually, and the establishment of a collateral circulation takes place better than after ligation. In the case of smaller trunks, or when suture is impracticable, the artery should be tied above and below the opening, and divided between the ligatures.