Ascus

“ As the cord is so well protected from injury, it must be extremely rare to have concussion of the cord without some actual lesion of its substance. As concussion of the cord is not often the result of the injuries of which we are treating, but rather of railroad injuries and the like, it will not be considered at length in this connection. As a result of a blow or fall on the spine or communicated to it, hemorrhage may occur in the substance of the cord or around it between or outside its membranes. ”

“ The incision required to be made, in order to reach the axillary artery, b, from the forepart, through the skin, both pectoral muscles, and different layers of fasciae, must be very deep, especially in muscular, well-conditioned bodies; and even when the level of the vessel is gained, it will be found much complicated by its own branches, some of which overlie it, as also by the plexus of nerves, D, Plate 12, which embraces it on all sides, while the large axillary vein, a, Plate 11, nearly conceals it in front. ”

“ The axillary artery may be tied on account of wounds, either immediately upon the infliction of the injury, or some time afterwards. The dissection is difficult, the vein being much in the way, and the vessels surrounded by nerves, and intimately connected with them by dense cellular tissue. The artery is more involved at the middle portion of the axilla than at the superior and inferior ”

“ IN executions it is the custom to drop the condemned man from a height, or (as in New York) to jerk him up from the ground by the fall of a heavy weight, so that there is a powerful concussion of the brain to start with. It used to be a common belief that the necks of criminals were broken by this means, and that the pressure of the fractured vertebræ on the spinal cord shortened the period of suffering. It is now known, however, that this rarely occurs, and the criminal dies of asphyxia or apoplexy, usually the former. ”

“ When the axillary artery is to be tied for a wound caused by a sharp-pointed or other instrument which has been forced through the pectoral muscle or under it from the axilla, the patient is to be firmly supported or placed in the horizontal position, the arm to be slightly separated from the body, and an incision made in the course of the axillary artery, through the integuments, superficial fascia, and the great pectoral muscle—in fact, through the anterior fold of the armpit. ”

“ On the afternoon of the day of execution, we saw the body of Bishop at the Royal College, where it was publicly exhibited, and to which hundreds of persons thronged, as if they were hastening to a [Pg 200] theatrical exhibition. A longitudinal incision had been made from the thorax downwards, and transversely on the pectoral muscles. A more healthy or muscular subject has not been seen in any of the schools of anatomy for a long period. The ligaments of the atlas indentatus were not broken, and he died of apoplexy, and not from the fracture of the vertebræ of the neck. ”

“ The same active cause that produced the two grooves of the lower end of the leg produced the groove of the middle of the upper end of the astragalus. Here we have the yielding lower end of the tibia resting on the equally spongy material of the middle of the astragalus. There is here no question of the hard material cutting into soft, but simply the result of continuous concussion. The consequence of concussion would be to cause the yielding faces of the bones to bend downward in the direction of gravity. ”

“ Lacerated wounds as a rule bleed less freely than those which are incised. Symptoms of concussion would favour the theory of the injury having been inflicted by a heavy instrument. Again, it is often difficult to decide whether the injury which caused death was the result of a blow or a fall. A heavy blow with a stick may at once cause fatal effusion of blood, but this might equally result from fracture of the skull resulting from a fall. ”

“ An incision midway between the internal malleolus and the tendo Achillis, parallel with both, will expose the very deep and strong fascia in which the tendons lie. The artery, with its venæ comites, occupies a central position, having the tendons of the tibialis posticus and flexor communis in front between it and the internal malleolus, and the posterior tibial nerve behind it, while the flexor longus pollicis lies still nearer the tendo Achillis. ”

“ Straight incisions are to be made in the legs, as in the muscles and tendons; and nerves, arteries, and vital parts are to be avoided, taking care of their safety by sometimes making a straight incision and sometimes a transverse one into the abscess, according to the circumstances of each case. When the abscesses are small we make one incision, but when they are larger we make more, always dividing the thinner parts, and those which are most convenient for the escape of the matter. ”

“ Definitions.—Surgically a wound means a solution of continuity and refers to every such lesion produced by external violence or developing spontaneously. The medico-legal acceptation of the term is much broader and includes any injury or lesion caused by mechanical or chemical means. Vibert [601] quotes Foderé as defining a wound medico-legally as, “Every lesion of the human body by a violent cause of which the results are, singly or combined, concussion, contusion, puncture, incision, tear, burn, twist, fracture, luxation, etc. ”

“ He had not seen the elongation of the neck described nor the erection of the penis, nor subconjunctival ecchymoses, nor fracture of larynx, nor rupture of walls of carotid artery, nor subpleural ecchymoses, nor fracture of vertebra. He always found a mark on the neck; the left cavities of the heart always empty, the right always full of black blood. ”

“ Some cutting weapons, like an axe, act as much by means of their weight as by their cutting edges. Wounds caused by such weapons we can often distinguish by the following signs: The edges are not as smooth as is the case with a cutting instrument, and they may be more or less lacerated and show signs of contusion. The wound is often deep in comparison with its length, and the ends of the wound abrupt instead of slanting up from the bottom to the surface. The section of resisting organs and the impression of the edge of the weapon on the bone are further signs of the use of such a weapon. ”

“ In a young and fat child, where the inner edge of the tibia cannot be distinctly felt, the best guide to the tendon is a point midway between the front and the back of the ankle. An incision in front of this point might injure the internal saphena vein; behind this point, the posterior tibial artery.
119. Tendons behind outer ankle.—Behind the malleolus externus we feel the two peroneal (long and short) tendons. They lie close to the edge of the fibula, the short one nearer to the bone. ”

“ Wounds of Arteries and Veins, especially within the thorax.—Wounds of large trunks are generally speedily mortal. In the chest we may occasionally meet with wounds of the intercostal or internal mammary vessels or the vena azygos veins. These wounds are often serious and may be fatal. We have already seen that blood in the large cavities of the body, like the chest, is commonly not coagulated, or at least the greater part of it. ”

“ In the thorax, for example, if a rib is struck, the charge and possibly fragments of bone, will penetrate the pleura, and be dispersed throughout the lung; in the head, the skull may be shattered and the brain torn up; and in the abdomen, the hollow viscera may be perforated in many places and the solid organs lacerated.
On covered parts the clothing, by deflecting the shot, influences the size and shape of the wound; the entrance wound is increased in size and more ragged, and portions of the clothes may be driven into the tissues. ”

“ Displacement or partial extrusion of the dead bone may cause complications, as when a sequestrum derived from the trigone of the femur perforates the popliteal artery or the cavity of the knee-joint, or a sequestrum of the pelvis perforates the wall of the urinary bladder. ”

“ There is no occasion to dissect and reflect the flap, for the cellular substance connecting the skin with the subjacent aponeurosis is so loose, that it can easily be drawn up above the place where the joint of the calcaneum with the cuboides and that between the astragalus and scaphoides ought to be opened. The surgeon will penetrate the last the most easily, particularly by taking for his guide the eminence which indicates the attachment of the tibialis anticus muscle to the inside of the os naviculare. ”

“ The organ in these cases has been merely disturbed and shaken, without visible rupture or hurt having occurred. Again, many patients are supposed to labour under concussion only, in whom fracture of the base of the cranium, or extravasation of blood on the surface, or into the substance of the brain, are discovered after death. It is always difficult to distinguish between the effects of mere concussion and those of compression of the brain by extravasated fluid; for, in the greater number of cases, the symptoms of both affections are blended together. ”

“ The decision of the surgeon must generally rest upon the extent of injury to the surrounding structures, the [110] condition of the patient, and other circumstances of each particular case. If the femoral artery and vein have been lacerated, any attempt to preserve the limb will certainly prove fatal.
The femur—the earliest formed, the longest, most powerful, and most compact in structure of all the long bones of the body—can only be shattered by a ball striking it with immense force. ”

“ The fact that a physician has jury-rigged the knee to function with pins and wires in no way inhibits the characterization of that injury as the permanent loss of a bodily function. The same would be true of a plaintiff whose vision is restored with a lens, one whose hearing is restored with a hearing aid, and one whose heart is operating efficiently with a pacemaker or implanted valve. ”

“ Baron Percy reports a similar wound and case of lodgment in his Army Surgeon’s Manual; in this instance, the ball was known to pass away by the bowels, a fortnight after the injury was received.
[93]
The liability to concussion of the cervical portion of the vertebral column, and to injury of the deep cervical and other nerves, must not be overlooked. Wounds of the neck are often accompanied by more or less loss of power in one of the upper extremities; and more extensive paralysis occasionally succeeds, although there was no primary evidence of the spine being implicated in the injury. ”

“ An incision two and a half inches long, from the inner end of the clavicle obliquely upwards and outwards in the interval between the sternal and clavicular attachments of the sterno-mastoid; this divides the superficial textures; the two portions of muscle must then be drawn apart. The internal jugular vein lies in the interval, and must be drawn to the outside before the artery can be seen at all, and it is this that makes this operation very difficult and dangerous, especially on the left side, where the vein is close to the artery, and probably even crossing it from left to right. ”

“ Cut down into this sinus, and hunt the bleeding artery, and tie it? Could I find it? And could I tie it if I did find it? Probably not; and more especially if it is a lumbar artery, and injured in the foramen through which it passes from the vertebra. But the man will probably bleed to death; and must I do nothing to prevent it? I concluded to use pressure with a bandage for the present, and ask for the advice of my brethren. Accordingly, compresses were placed along the spine, and the body bandaged snugly. ”

“ The axis of the joint passes through the second sacral vertebra, but the sacrum is so nearly horizontal that the weight of the body, which is transmitted to the first sacral vertebra, tends to tilt that part down. This tendency is corrected by the great and small sacro-sciatic ligaments, which fasten the lower part of the sacrum to the tuberosity and spine of the ischium respectively, so that, although the sacrum is a suspension bridge when looked at from behind, it is a lever of the first kind when seen from the side or in sagittal section. ”

“ But here let me observe, that the denial of ascites producing an anasarcous state of the legs, from the water compressing the iliac veins, must not be understood as implying, that a mechanical compression of a vein will not in other cases produce an effect of this kind. A pressure made on the brachial vein and its branches by scirrhous glands in the axilla, is a common cause of this state. The remote cause is here, indeed, of a mechanical kind, but not so the proximate cause of the effusion. ”

“ The axillary vessels and nerves being thus liable to pressure from the presence of large tumours happening in their neighbourhood, will suggest to the practitioner the necessity for fashioning of a proper form and size all apparatus, which in fracture or dislocation of the shoulder-bones shall be required to bear forcibly against the axillary region. ”

“ A joint will be saved, and the patient have a much better chance for life.
30. A wound of the axillary artery rarely leads to mortification of the fingers or hand. If it should do so, the principle of treatment should be similar, although the saving of the elbow is not so important as that of the knee: neither is the amputation in the axilla, below the tuberosities of the humerus, as dangerous as that above the knee. ”