The treatment consists 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 being crushed 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 in Surgical Patients
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 past incidents 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 Tremens is 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 in treatment is 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.