INJURIES
CONTUSIONS--WOUNDS: _Varieties_--WOUNDS BY FIREARMS AND
EXPLOSIVES: _Pistol-shot wounds_; _Wounds by sporting guns_;
_Wounds by rifle bullets_; _Wounds received in warfare_; _Shell
wounds_. _Embedded foreign bodies_--BURNS AND
SCALDS--INJURIES PRODUCED BY ELECTRICITY: _X-ray and
radium_; _Electrical burns_; _Lightning stroke_.
CONTUSIONS
A contusion or bruise is a laceration of the subcutaneous soft tissues,
without solution of continuity of the skin. When the integument gives
way at the same time, a _contused-wound_ results. Bruising occurs when
force is applied to a part by means of a blunt object, whether as a
direct blow, a crush, or a grazing form of violence. If the force acts
at right angles to the part, it tends to produce localised lesions which
extend deeply; while, if it acts obliquely, it gives rise to lesions
which are more diffuse, but comparatively superficial. It is well to
remember that those who suffer from scurvy, or hæmophilia (bleeders),
and fat and anæmic females, are liable to be bruised by comparatively
trivial injuries.
_Clinical Features._--The less severe forms of contusion are associated
with _ecchymosis_, numerous minute and discrete punctate hæmorrhages
being scattered through the superficial layers of the skin, which is
slightly œdematous. The effused blood is soon reabsorbed.
The more severe forms are attended with _extravasation_, the
extravasated blood being widely diffused through the cellular tissue of
the part, especially where this is loose and lax, as in the region of
the orbit, the scrotum and perineum, and on the chest wall. A blue or
bluish-black discoloration occurs in patches, varying in size and depth
with the degree of force which produced the injury, and in shape with
the instrument employed. It is most intense in regions where the skin is
naturally thin and pigmented. In parts where the extravasated blood is
only separated from the oxygen of the air by a thin layer of epidermis
or by a mucous membrane, it retains its bright arterial colour. These
points are often well illustrated in cases of black eye, where the blood
effused under the conjunctiva is bright red, while that in the eyelids
is almost black. In severe contusions associated with great tension of
the skin--for example, over the front of the tibia or around the
ankle--blisters often form on the surface and constitute a possible
avenue of infection. When deeply situated, the blood tends to spread
along the lines of least resistance, partly under the influence of
gravity, passing under fasciæ, between muscles, along the sheaths of
vessels, or in connective-tissue spaces, so that it may only reach the
surface after some time, and at a considerable distance from the seat of
injury. This fact is sometimes of importance in diagnosis, as, for
example, in certain fractures of the base of the skull, where
discoloration appears under the conjunctiva or behind the mastoid
process some days after the accident.
Blood extravasated deeply in the tissues gives rise to a firm,
resistant, doughy swelling, in which there may be elicited on deep
palpation a peculiar sensation, not unlike the crepitus of fracture.
It frequently happens that, from the tearing of lymph vessels, serous
fluid is extravasated, and a _lymphatic_ or _serous cyst_ may form.
In all contusions accompanied by extravasation, there is marked swelling
of the area involved, as well as pain and tenderness. The temperature
may rise to 101° F., or, in the large extravasations that occur in
bleeders, even higher--a form of aseptic fever. The degree of shock is
variable, but sudden syncope frequently results from severe bruises of
the testicle, abdomen, or head, and occasionally marked nervous
depression follows these injuries.
Contusion of muscles or nerves may produce partial atrophy and paresis,
as is often seen after injuries in the region of the shoulder.
In alcoholic or other debilitated patients, suppuration is liable to
ensue in bruised parts, infection taking place from cocci circulating in
the blood, or through the overlying skin.
_Terminations of Contusions._--The usual termination is a complete
return to the normal, some of the extravasated blood being organised,
but most of it being reabsorbed. During the process characteristic
alterations in the colour of the effused blood take place as a result of
changes in the blood pigment. In from twenty-four to forty-eight hours
the margins of the blue area become of a violet hue, and as time goes on
the discoloured area increases in size, and becomes successively green,
yellow, and lemon-coloured at its margins, the central part being the
last to change. The rate at which this play of colours proceeds is so
variable, and depends on so many circumstances, that no time-limits can
be laid down. During the disintegration of the effused blood the
adjacent lymph glands may become enlarged, and on dissection may be
found to be pigmented. 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.
_Treatment._--If the patient is seen immediately after the accident,
elevation of the part, and firm pressure applied by means of a thick pad
of cotton wool and an elastic bandage, are useful in preventing effusion
of blood. Ice-bags and evaporating lotions are to be used with caution,
as they are liable to lower the vitality of the damaged tissues and lead
to necrosis of the skin.
When extravasation has already taken place, massage is the most speedy
and efficacious means of dispersing the effused blood. The part should
be massaged several times a day, unless the presence of blebs or
abrasions of the skin prevents this being done. When this is the case,
the use of antiseptic dressings is called for to prevent infection and
to promote healing, after which massage is employed.
When the tension caused by the extravasated blood threatens the vitality
of the skin, incisions may be made, if asepsis can be assured. The blood
from a hæmatoma may be withdrawn by an exploring needle, and the
puncture sealed with collodion. Infective complications must be looked
for and dealt with on general principles.
WOUNDS
A wound is a solution in the continuity of the skin or mucous membrane
and of the underlying tissues, caused by violence.
Three varieties of wounds are described: incised, punctured, and
contused and lacerated.
#Incised Wounds.#--Typical examples of incised wounds are those made by
the surgeon in the course of an operation, wounds accidentally inflicted
by cutting instruments, and suicidal cut-throat wounds. It should be
borne in mind in connection with medico-legal inquiries, that wounds of
soft parts that closely overlie a bone, such as the skull, the tibia, or
the patella, although, inflicted by a blunt instrument, may have all the
appearances of incised wounds.
_Clinical Features._--One of the characteristic features of an incised
wound is its tendency to gape. This is evident in long skin wounds, and
especially when the cut runs across the part, or when it extends deeply
enough to divide muscular fibres at right angles to their long axis. The
gaping of a wound, further, is more marked when the underlying tissues
are in a state of tension--as, for example, in inflamed parts. Incised
wounds in the palm of the hand, the sole of the foot, or the scalp,
however, have little tendency to gape, because of the close attachment
of the skin to the underlying fascia.
Incised wounds, especially in inflamed tissues, tend to bleed profusely;
and when a vessel is only partly divided and is therefore unable to
contract, it continues to bleed longer than when completely cut across.
The _special risks_ of incised wounds are: (1) division of large blood
vessels, leading to profuse hæmorrhage; (2) division of nerve-trunks,
resulting in motor and sensory disturbances; and (3) division of tendons
or muscles, interfering with movement.
_Treatment._--If hæmorrhage is still going on, it must be arrested by
pressure, torsion, or ligature, as the accumulation of blood in a wound
interferes with union. If necessary, the wound should be purified by
washing with saline solution or eusol, and the surrounding skin painted
with iodine, after which the edges are approximated by sutures. The raw
surfaces must be brought into accurate apposition, care being taken that
no inversion of the cutaneous surface takes place. In extensive and deep
wounds, to ensure more complete closure and to prevent subsequent
stretching of the scar, it is advisable to unite the different
structures--muscles, fasciæ, and subcutaneous tissue--by separate series
of _buried sutures_ of catgut or other absorbable material. For the
approximation of the skin edges, stitches of horse-hair, fishing-gut, or
fine silk are the most appropriate. These _stitches of coaptation_ may
be interrupted or continuous. In small superficial wounds on exposed
parts, stitch marks may be avoided by approximating the edges with
strips of gauze fixed in position by collodion, or by subcutaneous
sutures of fine catgut. Where the skin is loose, as, for example, in the
neck, on the limbs, or in the scrotum, the use of Michel's clips is
advantageous in so far as these bring the deep surfaces of the skin into
accurate apposition, are introduced with comparatively little pain, and
leave only a slight mark if removed within forty-eight hours.
When there is any difficulty in bringing the edges of the wound into
apposition, a few interrupted _relaxation stitches_ may be introduced
wide of the margins, to take the strain off the coaptation stitches.
Stout silk, fishing-gut, or silver wire may be employed for this
purpose. When the tension is extreme, Lister's button suture may be
employed. The tension is relieved and death of skin prevented by scoring
it freely with a sharp knife. Relaxation stitches should be removed in
four or five days, and stitches of coaptation in from seven to ten days.
On the face and neck, wounds heal rapidly, and stitches may be removed
in two or three days, thus diminishing the marks they leave.
_Drainage._--In wounds in which no cavity has been left, and in which
there is no reason to suspect infection, drainage is unnecessary. When,
however, the deeper parts of an extensive wound cannot be brought into
accurate apposition, and especially when there is any prospect of oozing
of blood or serum--as in amputation stumps or after excision of the
breast--drainage is indicated. It is a wise precaution also to insert
drainage tubes into wounds in fat patients when there is the slightest
reason to suspect the presence of infection. Glass or rubber tubes are
the best drains; but where it is desirable to leave little mark, a few
strands of horse-hair, or a small roll of rubber, form a satisfactory
substitute. Except when infection occurs, the drain is removed in from
one to four days and the opening closed with a Michel's clip or a
suture.
#Punctured Wounds.#--Punctured wounds are produced by narrow, pointed
instruments, and the sharper and smoother the instrument the more does
the resulting injury resemble an incised wound; while from more rounded
and rougher instruments the edges of the wound are more or less contused
or lacerated. The depth of punctured wounds greatly exceeds their width,
and the damage to subcutaneous parts is usually greater than that to the
skin. When the instrument transfixes a part, the edges of the wound of
entrance may be inverted, and those of the exit wound everted. If the
instrument is a rough one, these conditions may be reversed by its
sudden withdrawal.
Punctured wounds neither gape nor bleed much. Even when a large vessel
is implicated, the bleeding usually takes place into the tissues rather
than externally.
The _risks_ incident to this class of wounds are: (1) the extreme
difficulty, especially when a dense fascia has been perforated, of
rendering them aseptic, on account of the uncertainty as to their depth,
and of the way in which the surface wound closes on the withdrawal of
the instrument; (2) different forms of aneurysm may result from the
puncture of a large vessel; (3) perforation of a joint, or of a serous
cavity, such as the abdomen, thorax, or skull, materially adds to the
danger.
_Treatment._--The first indication is to purify the whole extent of the
wound, and to remove any foreign body or blood-clot that may be in it.
It is usually necessary to enlarge the wound, freely dividing injured
fasciæ, paring away bruised tissues, and purifying the whole
wound-surface. Any blood vessel that is punctured should be cut across
and tied; and divided muscles, tendons, or nerves must be sutured. After
hæmorrhage has been arrested, iodoform and bismuth paste is rubbed into
the raw surface, and the wound closed. If there is any reason to doubt
the asepticity of the wound, it is better treated by the open method,
and a Bier's bandage should be applied.
#Contused and Lacerated Wounds.#--These may be considered together, as
they so occur in practice. They are produced by crushing, biting, or
tearing forms of violence--such as result from machinery accidents,
firearms, or the bites of animals. In addition to the irregular wound of
the integument, there is always more or less bruising of the parts
beneath and around, and the subcutaneous lesions are much wider than
appears on the surface.
Wounds of this variety usually gape considerably, especially when there
is much laceration of the skin. It is not uncommon to have considerable
portions of skin, muscle, or tendon completely torn away.
Hæmorrhage is seldom a prominent feature, as the crushing or tearing of
the vessel wall leads to the obliteration of the lumen.
The _special risks_ of these wounds are: (1) Sloughing of the bruised
tissues, especially when attempts to sterilise the wound have not been
successful. (2) Reactionary hæmorrhage after the initial shock has
passed off. (3) Secondary hæmorrhage as a result of infective processes
ensuing in the wound. (4) Loss of muscle or tendon, interfering with
motion. (5) Cicatricial contraction. (6) Gangrene, which may follow
occlusion of main vessels, or virulent infective processes. (7) It is
not uncommon to have particles of carbon embedded in the tissues after
lacerated wounds, leaving unsightly, pigmented scars. This is often seen
in coal-miners, and in those injured by firearms, and is to be prevented
by removing all gross dirt from the edges of the wound.
_Treatment._--In severe wounds of this class implicating the
extremities, the most important question that arises is whether or not
the limb can be saved. In examining the limb, attention should first be
directed to the state of the main blood vessels, in order to determine
if the vascular supply of the part beyond the lesion is sufficient to
maintain its vitality. Amputation is usually called for if there is
complete absence of pulsation in the distal arteries and if the part
beyond is cold. If at the same time important nerve-trunks are
lacerated, so that the function of the limb would be seriously impaired,
it is not worth running the risk of attempting to save it. If, in
addition, there is extensive destruction of large muscular masses or of
important tendons, or comminution of the bones, amputation is usually
imperative. 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. In
doubtful cases the possibility of rendering the parts aseptic will often
decide the question for or against amputation. If thorough purification
is accomplished, the success which attends conservative measures is
often remarkable. It is permissible to run an amount of risk to save an
upper extremity which would be unjustifiable in the case of a lower
limb. The age and occupation of the patient must also be taken into
account.
It having been decided to try and save the limb, the question is only
settled for the moment; it may have to be reconsidered from day to day,
or even from hour to hour, according to the progress of the case.
When it is decided to make the attempt to save the limb, the wound must
be thoroughly purified. All bruised tissue in which gross dirt has
become engrained should be cut away with knife or scissors. The raw
surface is then cleansed with eusol, washed with sterilised salt
solution followed by methylated spirit, and rubbed all over with "bipp"
paste. If the purification is considered satisfactory the wound may be
closed, otherwise it is left open, freely drained or packed with gauze,
and the limb is immobilised by suitable splints.
WOUNDS BY FIREARMS AND EXPLOSIVES
It is not necessary here to do more than indicate the general characters
of wounds produced by modern weapons. For further details the reader is
referred to works on military surgery. Experience has shown that the
nature and severity of the injuries sustained in warfare vary widely in
different campaigns, and even in different fields of the same campaign.
Slight variations in the size, shape, and weight of rifle bullets, for
example, may profoundly modify the lesions they produce: witness the
destructive effect of the pointed bullet compared with that of the
conical form previously used. The conditions under which the fighting is
carried on also influence the wounds. Those sustained in the open,
long-range fighting of the South African campaign of 1899–1902 were very
different from those met with in the entrenched warfare in France in
1914–1918. It has been found also that the infective complications are
greatly influenced by the terrain in which the fighting takes place. In
the dry, sandy, uncultivated veldt of South Africa, bullet wounds seldom
became infected, while those sustained in the highly manured fields of
Belgium were almost invariably contaminated with putrefactive organisms,
and gaseous gangrene and tetanus were common complications. It has been
found also that wounds inflicted in naval engagements present different
characters from those sustained on land. Many other factors, such as the
physical and mental condition of the men, the facilities for affording
first aid, and the transport arrangements, also play a part in
determining the nature and condition of the wounds that have to be dealt
with by military surgeons.
Whatever the nature of the weapon concerned, the wound is of the
_punctured, contused, and lacerated_ variety. Its severity depends on
the size, shape, and velocity of the missile, the range at which the
weapon is discharged, and the part of the body struck.
Shock is a prominent feature, but its degree, as well as the time of its
onset, varies with the extent and seat of the injury, and with the
mental state of the patient when wounded. We have observed pronounced
shock in children after being shot even when no serious injury was
sustained. At the moment of injury the patient experiences a sensation
which is variously described as being like the lash of a whip, a blow
with a stick, or an electric shock. There is not much pain at first, but
later it may become severe, and is usually associated with intense
thirst, especially when much blood has been lost.
In all forms of wounds sustained in warfare, septic infection
constitutes the main risk, particularly that resulting from
streptococci. The presence of anaërobic organisms introduces the
additional danger of gaseous forms of gangrene.
The earlier the wound is disinfected the greater is the possibility of
diminishing this risk. If cleansing is carried out within the first six
hours the chance of eliminating sepsis is good; with every succeeding
six hours it diminishes, until after twenty-four hours it is seldom
possible to do more than mitigate sepsis. (J. T. Morrison.)
The presence of a metallic foreign body having been determined and its
position localised by means of the X-rays, all devitalised and
contaminated tissue is excised, the foreign material, _e.g._, a missile,
fragments of clothing, gravel and blood-clot, removed, the wound
purified with antiseptics and closed or drained according to
circumstances.
#Pistol-shot Wounds.#--Wounds inflicted by pistols, revolvers, and small
air-guns are of frequent occurrence in civil practice, the weapon being
discharged usually by accident, but frequently with suicidal, and
sometimes with homicidal intent.
With all calibres and at all ranges, except actual contact, the wound of
entrance is smaller than the bullet. If the weapon is discharged within
a foot of the body, the skin surrounding the wound is usually stained
with powder and burned, and the hair singed. At ranges varying from six
inches to thirty feet, grains of powder may be found embedded in the
skin or lying loose on the surface, the greater the range the wider
being the area of spread. When black powder is used, the embedded grains
usually leave a permanent bluish-black tattooing of the skin. When the
weapon is placed in contact with the skin, the subcutaneous tissues are
lacerated over an area of two or three inches around the opening made by
the bullet and smoke and powder-staining and scorching are more marked
than at longer ranges.
When the bullet perforates, the exit wound is usually larger and more
extensively lacerated than the wound of entrance. Its margins are as a
rule everted, and it shows no marks of flame, smoke, or powder. These
features are common to all perforations caused by bullets.
Pistol wounds only produce dangerous effects when fired at close range,
and when the cavities of the skull, the thorax, or the abdomen are
implicated. In the abdomen a lethal injury may readily be caused even by
pistols of the "toy" order. These injuries will be described with
regional surgery.
Pistol-shot wounds of _joints_ and _soft parts_ are seldom of serious
import apart from the risk of hæmorrhage and of infection.
_Treatment._--The treatment of wounds of the soft parts consists in
purifying the wounds of entrance and exit and the surrounding skin, and
in providing for drainage if this is indicated.
There being no urgency for the removal of the bullet, time should be
taken to have it localised by the X-rays, preferably by stereoscopic
plates. In some cases it is not necessary to remove the bullet.
#Wounds by Sporting Guns.#--In the common sporting or scatter gun, with
which accidents so commonly occur during the shooting season, the charge
of small shot or pellets leave the muzzle of the gun as a solid mass
which makes a single ragged wound having much the appearance of that
caused by a single bullet. At a distance of from four to five feet from
the muzzle the pellets begin to disperse so that there are separate
punctures around the main central wound. As the range increases, these
outlying punctures make a wider and wider pattern, until at a distance
of from eighteen to twenty feet from the muzzle, the scattering is
complete, there is no longer any central wound, and each individual
pellet makes its own puncture. From these elementary data, it is usually
possible, from the features of the wound, to arrive at an approximately
accurate conclusion regarding the range at which the gun was discharged,
and this may have an important bearing on the question of accident,
suicide, or murder.
As regards the effects on the tissues at close range, that is, within a
few feet, there is widespread laceration and disruption; if a bone is
struck it is shattered, and portions of bone may be displaced or even
driven out through the exit wound.
When the charge impinges over one of the large cavities of the body, the
shot may scatter widely through the contained viscera, and there is
often no exit wound. 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.
[Illustration: FIG. 62.--Radiogram showing Pellets embedded in Arm.
(Mr. J. W. Dowden's case.)]
A charge of small shot is much more destructive to blood vessels,
tendons, and ligaments than a single bullet, which in many cases pushes
such structures aside without dividing them. In the abdomen and chest,
also, the damage done by a full charge of shot is much more extensive
than that inflicted by a single bullet, the deflection of the pellets
leading to a greater number of perforations of the intestine and more
widespread laceration of solid viscera.
When the charge impinges on one of the extremities at close range, we
often have the opportunity of observing that the exit wound is larger,
more ragged than that of entrance, and that its edges are everted; the
extensive tearing and bruising of all the tissues, including the bones,
and the marked tendency to early and progressive septic infection,
render amputation compulsory in the majority of such cases.
At a range of from twenty to thirty feet, although the scatter is
complete, the pellets are still close together, so that if they
encounter the shaft of a long bone, even the femur, they fracture the
bone across, often along with some longitudinal splintering.
Individual pellets striking the shafts of long bones become flattened or
distorted, and when cancellated bone is struck they become embedded in
it (Fig. 62).
The skin, when it is closely peppered with shot, is liable to lose its
vitality, and with the addition of a little sepsis, readily necroses and
comes away as a slough.
When the shot have diverged so as to strike singly, they seldom do much
harm, but fatal damage may be done to the brain or to the aorta, or the
eye may be seriously injured by a single pellet.
Small shot fired at longer ranges--over about a hundred and fifty
feet--usually go through the skin, but seldom pierce the fascia, and lie
embedded in the subcutaneous tissue, from which they can readily be
extracted.
The wad of the cartridge behaves erratically: so long as it remains flat
it goes off with the rest of the charge, and is often buried in the
wound; but if it curls up or turns on its side, it is usually deflected
and flies clear of the shot. It may make a separate wound.
Wounds from sporting guns are to be _treated_ on the usual lines, the
early efforts being directed to the alleviation of shock and the
prevention of septic infection. There is rarely any urgency in the
removal of pellets from the tissues.
#Wounds by Rifle Bullets.#--The vast majority of wounds inflicted by
rifle bullets are met with in the field during active warfare, and fall
to be treated by military surgeons. They occasionally occur
accidentally, however, during range practice for example, and may then
come under the notice of the civil surgeon.
It is only necessary here to consider the effects of modern small-bore
rifle or machine-gun bullets.
The trajectory is practically flat up to 675 yards. In destructive
effect there is not much difference between the various high velocity
bullets used in different armies; they will kill up to a distance of two
miles. The hard covering is employed to enable the bullet to take the
grooves in the rifle, and to prevent it stripping as it passes through
the barrel. It also increases the penetrating power of the missile, but
diminishes its "stopping" power, unless a vital part or a long bone is
struck. By removing the covering from the point of the bullet, as is
done in the Dum-Dum bullet, or by splitting the end, the bullet is made
to expand or "mushroom" when it strikes the body, and its stopping power
is thereby greatly increased, the resulting wound being much more
severe. These "soft-nosed" expanding bullets are to be distinguished
from "explosive" bullets which contain substances which detonate on
impact. High velocity bullets are unlikely to lodge in the body unless
spent, or pulled up by a sandbag, or metal buckle on a belt, or a book
in the pocket, or the core and the case separating--"stripping" of the
bullet. Spent shot may merely cause bruising of the surface, or they may
pass through the skin and lodge in the subcutaneous tissue, or may even
damage some deeper structure such as a nerve trunk.
A blank cartridge fired at close range may cause a severe wound, and, if
charged with black powder, may leave a permanent bluish-black
pigmentation of the skin.
The lesions of individual tissues--bones, nerves, blood vessels--are
considered with these.
#Treatment of Gunshot Wounds under War Conditions.#--It is only
necessary to indicate briefly the method of dealing with gunshot wounds
in warfare as practised in the European War.
1. _On the Field._--Hæmorrhage is arrested in the limbs by an improvised
tourniquet; in the head by a pad and bandage; in the thorax or abdomen
by packing if necessary, but this should be avoided if possible, as it
favours septic infection. If a limb is all but detached it should be
completely severed. A full dose of morphin is given hypodermically. The
ampoule of iodine carried by the wounded man is broken, and its contents
are poured over and around the wound, after which the field dressing is
applied. In extensive wounds, the "shell-dressing" carried by the
stretcher bearers is preferred. All bandages are applied loosely to
allow for subsequent swelling. The fragments of fractured bones are
immobilised by some form of emergency splint.
2. _At the Advanced Dressing Station_, after the patient has had a
liberal allowance of warm fluid nourishment, such as soup or tea, a full
dose of anti-tetanic serum is injected. The tourniquet is removed and
the wound inspected. Urgent amputations are performed. Moribund patients
are detained lest they die _en route_.
3. _In the Field Ambulance or Casualty Clearing Station_ further
measures are employed for the relief of shock, and urgent operations are
performed, such as amputation for gangrene, tracheotomy for dyspnœa, or
laparotomy for perforated or lacerated intestine. In the majority of
cases the main object is to guard against infection; the skin is
disinfected over a wide area and surrounded with towels; damaged tissue,
especially muscle, is removed with the knife or scissors, and foreign
bodies are extracted. Torn blood vessels, and, if possible, nerves and
tendons are repaired. The wound is then partly closed, provision being
made for free drainage, or some special method of irrigation, such as
that of Carrel, is adopted. Sometimes the wound is treated with bismuth,
iodoform, and paraffin paste (B.I.P.P.) and sutured.
4. _In the Base Hospital or Hospital Ship_ various measures may be
called for according to the progress of the wound and the condition of
the patient.
#Shell Wounds and Wounds produced by Explosions.#--It is convenient to
consider together the effects of the bursting of shells fired from heavy
ordnance and those resulting in the course of blasting operations from
the discharge of dynamite or other explosives, or from the bursting of
steam boilers or pipes, the breaking of machinery, and similar accidents
met with in civil practice.
Wounds inflicted by shell fragments and shrapnel bullets tend to be
extensive in area, and show great contusion, laceration, and destruction
of the tissues. The missiles frequently lodge and carry portions of the
clothing and, it may be, articles from the man's pocket, with them.
Shell wounds are attended with a considerable degree of shock. On
account of the wide area of contusion which surrounds the actual wound
produced by shell fragments, amputation, when called for, should be
performed some distance above the torn tissues, as there is considerable
risk of sloughing of the flaps.
Wounds produced by dynamite explosions and the bursting of boilers have
the same general characters as shell wounds. Fragments of stone, coal,
or metal may lodge in the tissues, and favour the occurrence of
infective complications.
All such injuries are to be treated on the general principles governing
contused and lacerated wounds.
EMBEDDED FOREIGN BODIES
In the course of many operations foreign substances are introduced into
the tissues and intentionally left there, for example, suture and
ligature materials, steel or aluminium plates, silver wire or ivory pegs
used to secure the fixation of bones, or solid paraffin employed to
correct deformities. Other substances, such as gauze, drainage tubes,
or metal instruments, may be unintentionally left in a wound.
Foreign bodies may also lodge in accidentally inflicted wounds, for
example, bullets, needles, splinters of wood, or fragments of clothing.
The needles of hypodermic syringes sometimes break and a portion remains
embedded in the tissues. As a result of explosions, particles of carbon,
in the form of coal-dust or gunpowder, or portions of shale, may lodge
in a wound.
The embedded foreign body at first acts as an irritant, and induces a
reaction in the tissues in which it lodges, in the form of hyperæmia,
local leucocytosis, proliferation of fibroblasts, and the formation of
granulation tissue. The subsequent changes depend upon whether or not
the wound is infected with pyogenic bacteria. If it is so infected,
suppuration ensues, a sinus forms, and persists until the foreign body
is either cast out or removed.
If the wound is aseptic, the fate of the foreign body varies with its
character. A substance that is absorbable, such as catgut or fine silk,
is surrounded and permeated by the phagocytes, which soften and
disintegrate it, the debris being gradually absorbed in much the same
manner as a fibrinous exudate. Minute bodies that are not capable of
being absorbed, such as particles of carbon, or of pigment used in
tattooing, are taken up by the phagocytes, and in course of time
removed. Larger bodies, such as needles or bullets, which are not
capable of being destroyed by the phagocytes, become encapsulated. In
the granulation tissue by which they are surrounded large multinuclear
giant-cells appear ("_foreign-body giant-cells_") and attach themselves
to the foreign body, the fibroblasts proliferate and a capsule of scar
tissue is eventually formed around the body. The tissues of the capsule
may show evidence of iron pigmentation. Sometimes fluid accumulates
around a foreign body within its capsule, constituting a cyst.
Substances like paraffin, strands of silk used to bridge a gap in a
tendon, or portions of calcined bone, instead of being encapsulated, are
gradually permeated and eventually replaced by new connective tissue.
Embedded bodies may remain in the tissues for an indefinite period
without giving rise to inconvenience. At any time, however, they may
cause trouble, either as a result of infective complications, or by
inducing the formation of a mass of inflammatory tissue around them,
which may simulate a gumma, a tuberculous focus, or a sarcoma. This
latter condition may give rise to difficulties in diagnosis,
particularly if there is no history forthcoming of the entrance of the
foreign body. The ignorance of patients regarding the possible lodgment
in the tissues of a foreign body--even of considerable size--is
remarkable. In such cases the X-rays will reveal the presence of the
foreign body if it is sufficiently opaque to cast a shadow. The heavy,
lead-containing varieties of glass throw very definite shadows little
inferior in sharpness and definition to those of metal; almost all the
ordinary forms of commercial glass also may be shown up by the X-rays.
Foreign bodies encapsulated in the peritoneal cavity are specially
dangerous, as the proximity of the intestine furnishes a constant
possibility of infection.
The question of removal of the foreign body must be decided according to
the conditions present in individual cases; in searching for a foreign
body in the tissues, unless it has been accurately located, a general
anæsthetic is to be preferred.
BURNS AND SCALDS
The distinction between a burn which results from the action of dry heat
on the tissues of the body and a scald which results from the action of
moist heat, has no clinical significance.
In young and debilitated subjects hot poultices may produce injuries of
the nature of burns. In old people with enfeebled circulation mere
exposure to a strong fire may cause severe degrees of burning, the
clothes covering the part being uninjured. This may also occur about the
feet, legs, or knees of persons while intoxicated who have fallen asleep
before the fire.
The damage done to the tissues by strong caustics, such as fuming nitric
acid, sulphuric acid, caustic potash, nitrate of silver, or arsenical
paste, presents pathological and clinical features almost identical with
those resulting from heat. Electricity and the Röntgen rays also produce
lesions of the nature of burns.
_Pathology of Burns._--Much discussion has taken place regarding the
explanation of the rapidly fatal issue in extensive superficial burns.
On post-mortem examination the lesions found in these cases are: (1)
general hyperæmia of all the organs of the abdominal, thoracic, and
cerebro-spinal cavities; (2) marked leucocytosis, with destruction of
red corpuscles, setting free hæmoglobin which lodges in the epithelial
cells of the tubules of the kidneys; (3) minute thrombi and
extravasations throughout the tissues of the body; (4) degeneration of
the ganglion cells of the solar plexus; (5) œdema and degeneration of
the lymphoid tissue throughout the body; (6) cloudy swelling of the
liver and kidneys, and softening and enlargement of the spleen. Bardeen
suggests that these morbid phenomena correspond so closely to those met
with where the presence of a toxin is known to produce them, that in all
probability death is similarly due to the action of some poison produced
by the action of heat on the skin and on the proteins of the blood.
#Clinical Features--Local Phenomena.#--The most generally accepted
classification of burns is that of Dupuytren, which is based upon the
depth of the lesion. Six degrees are thus, recognised: (1) hyperæmia or
erythema; (2) vesication; (3) partial destruction of the true skin; (4)
total destruction of the true skin; (5) charring of muscles; (6)
charring of bones.
It must be observed, however, that burns met with at the bedside always
illustrate more than one of these degrees, the deeper forms always being
associated with those less deep, and the clinical picture is made up of
the combined characters of all. A burn is classified in terms of its
most severe portion. It is also to be remarked that the extent and
severity of a burn usually prove to be greater than at first sight
appears.
_Burns of the first degree_ are associated with erythema of the skin,
due to hyperæmia of its blood vessels, and result from scorching by
flame, from contact with solids or fluids below 212° F., or from
exposure to the sun's rays. They are characterised clinically by acute
pain, redness, transitory swelling from œdema, and subsequent
desquamation of the surface layers of the epidermis. A special form of
pigmentation of the skin is seen on the front of the legs of women from
exposure to the heat of the fire.
_Burns of Second Degree--Vesication of the Skin._--These are
characterised by the occurrence of vesicles or blisters which are
scattered over the hyperæmic area, and contain a clear yellowish or
brownish fluid. On removing the raised epidermis, the congested and
highly sensitive papillæ of the skin are exposed. Unna has found that
pyogenic bacteria are invariably present in these blisters. Burns of the
second degree leave no scar but frequently a persistent discoloration.
In rare instances the burned area becomes the seat of a peculiar
overgrowth of fibrous tissue of the nature of keloid (p 401).
_Burns of Third Degree--Partial Destruction of the Skin._--The epidermis
and papillæ are destroyed in patches, leaving hard, dry, and insensitive
sloughs of a yellow or black colour. The pain in these burns is
intense, but passes off during the first or second day, to return again,
however, when, about the end of a week, the sloughs separate and expose
the nerve filaments of the underlying skin. Granulations spring up to
fill the gap, and are rapidly covered by epithelium, derived partly from
the margins and partly from the remains of skin glands which have not
been completely destroyed. These latter appear on the surface of the
granulations as small bluish islets which gradually increase in size,
become of a greyish-white colour, and ultimately blend with one another
and with the edges. The resulting cicatrix may be slightly depressed,
but otherwise exhibits little tendency to contract and cause deformity.
_Burns of Fourth Degree--Total Destruction of the Skin._--These follow
the more prolonged action of any form of intense heat. Large, black, dry
eschars are formed, surrounded by a zone of intense congestion. Pain is
less severe, and is referred to the parts that have been burned to a
less degree. Infection is liable to occur and to lead to wide
destruction of the surrounding skin. The amount of granulation tissue
necessary to fill the gap is therefore great; and as the epithelial
covering can only be derived from the margins--the skin glands being
completely destroyed--the healing process is slow. The resulting scars
are irregular, deep and puckered, and show a great tendency to contract.
Keloid frequently develops in such cicatrices. When situated in the
region of the face, neck, or flexures of joints, much deformity and
impairment of function may result (Fig. 63).
[Illustration: FIG. 63.--Cicatricial Contraction following Severe Burn.]
In _burns of the fifth degree_ the lesion extends through the
subcutaneous tissue and involves the muscles; while in those of the
_sixth degree_ it 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 period_ lasts for from thirty-six to forty-eight hours,
during which time the patient remains in a more or less profound state
of _shock_, 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.
The _second period_ begins when the shock passes off, and lasts till the
sloughs separate. The outstanding feature of this period is _toxæmia_,
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.
The _third period_ begins when the sloughs separate, usually between
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.
The _prognosis_ in 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.#--The _general treatment_ consists 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 is
_picric 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, _without_ any waterproof
covering, and retained in position by a many-tailed bandage. The
dressing should be changed 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 as _a primary dressing_ in 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 melted _paraffin_ has 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 as _Ambrine_ and _Burnol_. 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. The _deformities_
which 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 ELECTRICITY
#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 dermatitis_ varying 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 the _late manifestations_ are 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. _Sterility_ may be
induced in X-ray workers who are imperfectly protected from the effects
of the rays.
#Electrical burns# usually 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 and often 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.