Alexander Miles

“ On account of the great strength of the hip-joint, dislocation is by no means a common injury. It occurs most frequently in strong adults after the epiphyses have ossified, and before the bones have commenced to become brittle; and it is much more common in men than in women. It is invariably the result of severe violence, the limb at the moment being in such a position that the ligaments are on the stretch and the muscles taken at a disadvantage. The head of the femur usually leaves the joint at the lower and back part, where the socket is most shallow and the ligaments weakest. ”

“ There is evidence that a mixed infection—that is, the introduction of more than one species of organism, for example, the tubercle bacillus and a pyogenic staphylococcus—increases the severity of the resulting disease. If one of the varieties gain the ascendancy, the poisons produced by the others so devitalise the tissue cells, and diminish their power of resistance, that the virulence of the most active organisms is increased. ”

“ Atrophy of bone may proceed to such an extent in old people, or in those who for long periods have been bed-ridden, that slight violence suffices to determine a fracture. This most frequently occurs in the neck of the femur in old women, the mere catching of the foot in the bedclothes while the patient is turning in bed being sometimes sufficient to cause the bone to give way. Atrophy from the pressure of an aneurysm or of a simple tumour may erode the whole thickness of a bone, or may thin it out to such an extent that slight force is sufficient to break it. ”

“ Clinical Aspects of Inflammation.—It must clearly be understood that inflammation is not to be looked upon as a disease in itself, but rather as an evidence of some infective process going on in the tissues in which it occurs, and of an effort on the part of these tissues to overcome the invading organisms and their products. The chief danger to the patient lies, not in the reactive changes that constitute the inflammatory process, but in the fact that he is liable to be poisoned by the toxins of the bacteria at work in the inflamed area. ”

“ As a rule the epiphysis is not completely separated from the diaphysis, the common lesion being a separation along part of the epiphysial line, with a fracture running into the diaphysis (Fig. 8) . It is not uncommon for more than one epiphysis to be separated by the same accident—for example, the lower end of the femur and the upper ends of the tibia and fibula. Epiphysial separations, like fractures, may be simple or compound. Incomplete separations are liable to be overlooked at the time of the accident, but there is reason to believe that they may form the starting-point of disease. ”

“ Wounds of certain parts of the body heal more quickly than others: those of the scalp, face, and neck, for example, heal more quickly than those over the buttock or sacrum, probably because of their greater vascularity.
The extent of the wound influences the rate of healing; it is only natural that a long and deep wound should take longer to heal than a short and superficial one, because there is so much more work to be done in the conversion of blood-clot into granulation tissue, and this again into scar tissue that will be strong enough to stand the strain on the edges of the wound. ”

“ At the onset of the paralysis the affected limb is helpless and relaxed, the reflexes are lost, the muscles waste, and those that are paralysed exhibit the reaction of degeneration. In severe cases, and especially if proper treatment is neglected, the nutrition of the limb is profoundly affected; its temperature is subnormal, the skin is bluish in cold weather and readily becomes the seat of pressure sores. In course of time the limb lags behind its fellow in growth, and tends to assume a deformed attitude, which at first can easily be corrected, but later becomes permanent. ”

“ Treatment of Ulcers.—An ulcer is not only an immediate cause of suffering to the patient, crippling and incapacitating him for his work, but is a distinct and constant menace to his health: the prolonged discharge reduces his strength; the open sore is a possible source of infection by the organisms of suppuration, erysipelas, or other specific diseases; phlebitis, with formation of septic emboli, leading to pyæmia, is liable to occur; and in old persons it is not uncommon for ulcers of long standing to become the seat of cancer. ”

“ The commonest error is to mistake a case of cerebral compression for one of drunkenness. It is scarcely necessary to say that a man who smells of alcohol is not necessarily intoxicated; the drink may have been given with the object of reviving him. It may be that one or other of the above-named conditions has caused the patient to fall, and in his fall he has incidentally sustained an injury to the head, which, however, is in no way responsible for his unconsciousness. Whenever there is the least doubt, therefore, the patient should be admitted to hospital. ”

“ Many bacteria have only the power of living upon dead matter, and are known as saphrophytes. Such as do nourish in living tissue are, by distinction, known as parasites. The power a given parasitic micro-organism has of multiplying in the body and giving rise to disease is spoken of as its virulence, and this varies not only with different species, but in the same species at different times and under varying circumstances. ”

“ The first attempt at reduction may fail, and yet subsequent efforts, at intervals of a few days, may ultimately prove successful; the vigorous traction and twisting of the soft parts, matted together as they are by scar-tissue, causes reactive changes in the vessels and tissues which render them more liable to yield on subsequent attempts at reduction. In old people, and where there is an absence of suffering from pressure on nerves or vessels, it may be wiser to leave the dislocation unreduced, and strive rather by massage and movement to obtain a useful variety of false joint. ”

“ An ulcer is an open wound or sore in which there are present certain conditions tending to prevent it undergoing the natural process of repair. Of these, one of the most important is the presence of pathogenic bacteria, which by their action not only prevent healing, but so irritate and destroy the tissues as to lead to an actual increase in the size of the sore. Interference with the nutrition of a part by œdema or chronic venous congestion may impede healing; as may also induration of the surrounding area, by preventing the contraction which is such an important factor in repair. ”

“ Thus the age of the patient is of importance. During infancy and early childhood, fractures are less common than at any other period of life, and are usually transverse, incomplete, and of the nature of bends. During adult life, especially between the ages of thirty and forty, the frequency of fractures reaches its maximum. In aged persons, although the bones become more brittle by the marrow spaces in their interior becoming larger and filled with fat, fractures are less frequent, doubtless because the old are less exposed to such violence as is likely to produce fracture. ”

“ So long as a person is in good health, the tissues are able to resist the attacks of moderate numbers of most bacteria. Any lowering of the vitality of the individual, however, either locally or generally, at once renders him more susceptible to infection. Thus bruised or torn tissue is much more liable to infection with pus-producing organisms than tissues clean-cut with a knife; also, after certain diseases, the liability to infection by the organisms of diphtheria, pneumonia, or erysipelas is much increased. ”

“ In all cases of head injury, the questions that dominate the whole clinical outlook are, whether the brain is directly damaged or not, and whether it is likely to become the seat of infection.
It is impossible to consider separately in their clinical aspects injuries of the cranium and injuries of the brain. It seldom happens that one is seriously damaged without the other suffering to a greater or less extent. Sometimes the skull suffers comparatively little, while the brain is severely damaged, but it is rare for a serious injury to the bone to be unaccompanied by definite brain lesions. ”

“ The disease is not attended with any disturbance of the general health; the pathological changes are the same as in infantile rickets, but are for the most part confined to the ossifying junctions, especially those which are most active during adolescence, for example at the knee-joint. The patient is easily tired, complains of pain in the bones, and, unless care is taken, deformity is liable to ensue. There can be no doubt that adolescent rickets plays an important part in the production of the deformities which occur at or near puberty, especially knock-knee and bow-knee. ”

“ A dislocation or luxation is a persistent displacement of the opposing ends of the bones forming a joint. We are here concerned only with such dislocations as immediately follow upon injury. Those that are congenital or that result from disease will be studied later.
Causes.—The majority of dislocations are the result of indirect violence, the more movable bone acting as a lever, on a fulcrum furnished by the natural check to movement in the form of ligament, bone, or muscle. It is in this way that most dislocations of the shoulder, hip, and elbow are produced. ”

“ Cellulitis is an acute affection resulting from the introduction of some organism—commonly the streptococcus pyogenes—into the cellular connective tissue of the integument, intermuscular septa, tendon sheaths, or other structures. Infection always takes place through a breach of the surface, although this may be superficial and insignificant, such as a pin-prick, a scratch, or a crack under a nail, and the wound may have been healed for some time before the inflammation becomes manifest. ”

“ Penetrating wounds of joints are treated on the same lines as compound fractures. If the penetrating instrument is to be regarded as infected,—as, for example, when the spoke of a motor bicycle is driven through the upper pouch of the knee,—the injury is to be looked upon as serious and capable of endangering the function of the joint, loss of the limb, or even life itself. Reliance is chiefly laid on primary excision of the edges and track of the wound, and other measures employed in the treatment of gun-shot wounds. ”

“ When syphilis is communicated from one individual to another by contact infection, the condition is spoken of as acquired syphilis, and the first visible sign of the disease appears at the site of inoculation, and is known as the primary lesion. Those who have thus acquired the disease may transmit it to their offspring, who are then said to suffer from inherited syphilis. ”

“ The anatomical neck may be fractured in an old person by a direct blow on the shoulder. In a few cases the fracture is entirely intra-capsular, the head of the bone remaining loose in the cavity of the joint. As a rule, however, the fracture passes laterally and implicates the tuberosities. In some cases there is impaction, and in others comminution of the fragments. The use of the X-rays has shown that in many cases in which prolonged stiffness has followed a severe blow of the shoulder, there has been a fracture of the anatomical neck. ”

“ Sapræmia, or septic intoxication, is the name applied to a form of poisoning resulting from the absorption into the blood of the toxic products of pyogenic bacteria. These products, which are of the nature of alkaloids, act immediately on their entrance into the circulation, and produce effects in direct proportion to the amount absorbed. As the toxins are gradually eliminated from the body the symptoms abate, and if no more are introduced they disappear. Sapræmia in these respects, therefore, is comparable to poisoning by any other form of alkaloid, such as strychnin or morphin. ”

“ The glands act as filters, arresting not only inert substances, such as blood pigment circulating in the lymph, but also living elements, such as cancer cells or bacteria. As it passes through a gland the lymph is brought into intimate contact with the leucocytes, and in bacterial infections there is always a struggle between the organisms and the leucocytes, so that the glands may be looked upon as an important line of defence, retarding or preventing the passage of bacteria and their products into the general circulation. ”

“ Stripping of large areas of skin is not in itself a reason for removing a limb, as much can be done by skin grafting, but when it is associated with other lesions it favours amputation. In considering these points, it must be borne in mind that the damage to the deeper tissues is always more extensive than appears on the surface, and that in many cases it is only possible to estimate the real extent of the injury by administering an anæsthetic and exploring the wound. ”

“ If the case is left to nature, the discharge of pus continues, and the track opening on the skin remains as a sinus. The persistence of suppuration is due to the presence in the wall of the abscess and of the sinus, of tuberculous granulation tissue, which, so long as it remains, continues to furnish discharge, and so prevents healing. Sooner or later pyogenic organisms gain access to the sinus, and through it to the wall of the abscess. They tend further to depress the resisting power of the tissues, and thereby aggravate and perpetuate the tuberculous disease. ”

“ In a number of cases the inflammation is acute and the patient is unable to use the limb; the part is hot, swollen, and tender, and fluctuation can be detected in the bursa. In the majority the condition is chronic, and the chief feature is the gradual accumulation of fluid constituting the bursal hydrops or hygroma. When the affection has lasted some time, or has frequently relapsed, the wall of the bursa becomes thickened by fibrous tissue, which may be deposited irregularly, so that septa, bands, or fringes are formed, not unlike those met with in arthritis deformans. ”

“ Sometimes the blood persists as a collection of fluid with a newly formed connective-tissue capsule, constituting a hæmatoma or blood cyst, more often met with in the scalp than in other parts.
The impairment of the blood supply of the skin may lead to the formation of blisters, or to necrosis. Death of skin is more liable to occur in bleeders, and when the slough separates the blood-clot is exposed and the reparative changes go on extremely slowly. Suppuration may occur and lead to the formation of an abscess as a result of direct infection from the skin or through the circulation. ”

“ 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. ”