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heal, and blood slowly escape into the tissues. 2. An artery may be wounded, heal, and the cicatrix subsequently yield. 3. An artery may be wounded, without an external wound, by a fragment of fractured bone, or torn in reducing a dislocation. 4. An artery may be wounded but not penetrated, and the uninjured coat or coats may yield to the pressure of the blood. In all of these cases the soft tissues around may become condensed and form the sac of the aneurism. Where the aneurism is produced by the yielding of any portion of the arterial coat, this at first will form the sac, but sooner or later it will give way, and the sac will then be formed by the condensation of the soft tissues around, as when blood escapes directly into the tissues. The course, termination, and signs of a circumscribed traumatic aneurism are similar to those of a spontaneous aneurism. The treatment, inasmuch as the artery in the neighborhood of the sac will probably be healthy, differs from the treatment of a spontaneous aneurism, in that the artery may be tied immediately above the sac, or the sac may be laid open and the vessel tied above and below. Thus, if the injured artery is small it may be tied above and below; if large, immediately above, unless the aneurism threatens to burst, under which circumstances the aneurism should be laid open and the artery tied on either side of the bleeding spot.

ARTERIO-VENOUS ANEURISM is a pulsating tumor depending upon an abnormal communication of an artery with a vein. There are two kinds; in one the communication between the artery and vein is direct, and the arterial blood is forced into the vein at each beat of the heart, causing its walls to be dilated into a fusiform or sac-like swelling (aneurismal varix); in the other the blood first passes into a small aneurism between the artery and vein and thence into the vein, the dilatation of the vein being consequently less than in the preceding variety (varicose aneurism). Both forms may occur spontaneously, but are usually the result of some injury, as a stab, wounding the walls of both vessels. The lesion was a common occurrence at the bend of the elbow, when venesection was in vogue, the lancet in this case passing through the median basilic vein and bicipital fascia into the subjacent brachial artery. Signs.-An aneurismal varix gives rise to a pulsating tumor in which a peculiar bruit, compared to the buzzing of a fly in a paper box, is heard. The artery is dilated above owing to the impediment to the circulation, and is smaller below; while the vein is dilated, especially above, and pulsates. In varicose aneurism, in addition to the above signs which are common to both forms, an ordinary aneu rismal bruit can be heard. Treatment.-In aneurismal varix

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some form of elastic support should be applied, or if the swelling is increasing, the artery tied above and below its point of communication with the vein. In the varicose aneurism pressure may first be applied to the artery above the sac, combined with direct pressure on the sac. If this fails the artery must be tied above and below the sac. When the carotid or the femoral artery and the adjoining veins are the subject of the lesion, no operative treatment, as a rule, should be undertaken unless the lesion is recent, and the blood is being rapidly extravasated into the tissues, and threatening to break through the external wound. In such a case, should pressure applied to the main artery and over the site of the wound fail, the artery must be cut down upon and tied above and below the wound. Unless pressure controls the hemorrhage from the vein a ligature must be placed on the wound in its wall, or if the wound is too large to admit of this being done, the whole vein must be tied above and below the wound.

INJURIES OF VEINS.

RUPTURE or subcutaneous laceration of a vein occasionally occurs from causes similar to those producing rupture of an artery, an accident moreover with which it is frequently associated. When the vein is of large size much blood may be extravasated into the tissues and may produce gangrene by pressure on the vessels carrying on the collateral circulation, though such a result is much less common than after rupture of an artery. The blood, except when the extravasation is large, is usually absorbed, but may break down and suppuration ensue.

WOUNDS.-Punctured and incised wounds when small and parallel to the long axis even of large veins readily heal by adhesive inflammation without obliteration of the lumen of the vessel. At times, however, a clot may form in the wound, and successive layers be deposited upon it till ultimately the vein is occluded. When a vein is completely cut across, as in amputation, it usually collapses as far as the next pair of valves, a clot forms as high as the first collateral branch, and the vein becomes permanently occluded in a way similar to that described under Healing of Wounded Arteries. In consequence, however, of the vein-wall containing less elastic and muscular tissue than an artery, bleeding sometimes continues unless stopped artificially.

Treatment. When the wound is a mere puncture in the continuity of the vein, unless it is found that pressure will control the hemorrhage, the coats should be nipped up by forceps and a ligature applied. If a vein continues to bleed during an amputation, it should be tied like an artery. A large wound, or one made in the longitudinal axis of a large vein, necessitates ligature

of the vein in two places, and the division of the vessel between the two ligatures.

The dangers of wounds of veins are: 1. Hemorrhage. 2. Inflammation of a septic character, and the attendant risks of blood poisoning from the detachment of the infected clots. Entrance of air.

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ENTRANCE OF AIR into veins is fortunately a rare accident. It sometimes happens in operations about the root of the neck where the veins are held open by the disposition of the cervical fascia. The air is known to have entered the vein by the hissing sound during inspiration and the escape of frothy blood from the vein on expiration, and the state of collapse into which the patient immediately falls. On listening over the heart a peculiar churning sound can be heard. Death in fatal cases usually occurs in a few minutes. Treatment. The patient should be placed with his head low to ensure a sufficient supply of blood to the brain, and for the same purpose the arteries of the extremities may be compressed, while injections of ether or brandy should be given subcutaneously. Steps should at once be taken to prevent more air entering by placing the finger over the hole in the vein. Pouring water into the wound has been suggested both as a means of preventing the further entrance of air during inspiration and of allowing that which is already in to bubble out during expiration. When the gravity of the symptoms has subsided steps must, of course, be taken to secure the wound in the vein.

INJURIES OF NERVES.

WOUNDS OF NERVES.-A nerve may be completely or partially divided, and the wound may be of an incised, lacerated, contused, or punctured character.

Pathology.-After complete division of a nerve the divided ends slightly retract, and should union not be effected, either naturally or by surgical means, the portion of nerve below the injury being cut off from its trophic centre undergoes atrophy and degenerates throughout its entire length (Wallerian degeneration). In the meanwhile the portion of nerve immediately above the wound is converted into a bulbous swelling by the proliferation of the fibrous tissue of the sheath and its prolongations within the nerve. The nerve fibres within the bulbous end, being compressed by the newly-formed fibrous tissue, undergo atrophy and degeneration, but the rest of the nerve above the injury remains unimpaired. Should union on the other hand occur, the process by which it is effected is briefly as follows: Inflammatory material is thrown out between the divided ends, and forms a delicate fibrous network bridging the gap; into this the axis cylinders of

the upper end are said to grow out and unite with the degenerated axis cylinders in the lower end, which then becomes gradually restored from above downward. By some it is believed that new axis cylinders "are developed from the nuclei of the sheath of Schwann in both the proximal and peripheral ends" (Bowlby). The exact manner, however, in which the union and regeneration of the nerve is brought about is hardly accurately known. When a nerve is only partially cut across, the divided portions may unite in the way above described, or they may become involved in the scar resulting on the healing of the soft tissues, and then prove a source of much irritation to the rest of the nerve.

The effects of wounds of nerves in addition to the degeneration of the portion below the wound are: 1. Paralysis of motion and sensation of the parts supplied by the nerve. 2. Subsequent wasting, atrophy, and fatty degeneration of the paralyzed muscles. 3. Certain trophic changes in the tissues whose nutrition is presided over by the injured nerve, such as glazed, smooth, cold and bluish-red condition of the skin, falling off of the hair, cracking and deformity of the nails, local ulcerations and gangrene of the fingers, etc. 4. A marked diminution of the temperature of the part, which may be preceded for a few days by a slight increase of two or three degrees. 5. Affections of the joints resembling rheumatism, and apt to terminate in more or less complete ankylosis. 6. Ascending neuritis, which is attended by severe pain in the cicatrix, pain shooting up the nerve, and pain in the area of distribution. 7. Changes in the nerve centres of a functional or an organic nature (rare).

Signs.-The immediate symptoms are loss of function in the parts supplied by the nerve, viz., local anesthesia, muscular paralysis, or loss of special sense, according as a motor, sensory, or nerve of special sense is injured. In the case of a mixed nerve both motion and sensation will be lost; but sensation in some instances may be partially restored in a few days through anastomosing branches from other nerves. The remoter symptoms are wasting of the muscles, and the trophic changes of the skin, nails, etc., already alluded to, and sometimes pain in the cicatrix, and in the course of the nerve and its peripheral distribution. The muscles exhibit to electrical tests the reaction of degeneration-i. e., they do not respond to the Faradic current, but contract on the application of a continuous current of less strength than that necessary to cause the contraction of normal muscles; the contraction elicited, moreover, is slow, long and tetanic; and the sequence of polar reaction is altered (ACC.> CCC. instead of CCC.>ACC.). Their response, however, to

the continuous current becomes less and less till they finally cease to contract at all. As a consequence of the degeneration of the affected muscles their opponents undergo adaptive shortening, thus producing various deformities, as, for example, the hammer fingers (main en griffe) seen after division of the ulnar nerve.

The treatment varies according as the wound of the nerve is recent or of long standing. In the former case the nerve should be sought in the wound, the divided ends sutured, the limb placed at rest on a splint in such a position that the united ends are not subjected to tension, and every effort subsequently made to obtain healing of the wound of the soft parts by the first intention. If the divided ends of the nerve are lacerated or contused, the injured portions should be cleanly cut away before applying the sutures. If the nerve is only partially divided, the divided parts should be sutured. The sutures may consist of chromicized catgut, kangaroo-tail tendon, or fine china twist. They should be passed with a small curved needle through the sheath of the nerve in four or five places. At St. Bartholomew's one of the sutures is generally passed completely through the nerve, a quarter of an inch from the divided ends, to ensure a better hold. In every recent wound it should be as much a matter of routine to suture large nerves if divided, as to tie wounded arteries. If the nerve does not unite, an attempt may be made to procure union after the wound has healed, as may also be done in long-standing cases of non-union, though many months or even a year or two may have elapsed. An incision over the ununited ends should be made parallel to the nerve, the bulbous upper end of which can generally be felt through the soft tissues. The ends, which may have retracted so as to be as much as an inch apart, should be sought, the bulbous end shaved away little by little with a sharp scalpel till plenty of nerve fibres are seen on the surface of the section, the lower end also refreshed and the two united in the manner described above. Where the ends are embedded in much cicatricial tissue they should be freed by careful dissection, and when much separated stretched so as to bring them into apposition. If the nerve is only partially divided, and the divided portions are bound down by cicatricial tissue, the injured segment of nerve, in its entire thickness, should be cut away before applying the sutures. In some instances sensation may return within twenty-four hours of suture; but it may be more than a year in long-standing cases before the function of the nerve is restored. In the meanwhile the nutrition of the parts supplied by it should be promoted by warmth, and the muscles prevented as much as possible from degenerating by galvanism, massage, friction and passive movements.

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