Manual of Surgery/Chapter XI

CHAPTER XI

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 haemophilia (bleeders), and fat and anaemic 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 haemorrhages being scattered through the superficial layers of the skin, which is slightly oedematous. 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 fasciae, 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 _haematoma_ 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 haematoma 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.

1. 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 haemorrhage; (2) division of nerve-trunks, resulting in motor and sensory disturbances; and (3) division of tendons or muscles, interfering with movement.

_Treatment._--If haemorrhage 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, fasciae, 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.

1. 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 fasciae, 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 haemorrhage 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.

1. 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.

Haemorrhage 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 haemorrhage after the initial shock has passed off. (3) Secondary haemorrhage 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 anaesthetic 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 anaerobic 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.

1. 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 haemorrhage 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.

1. 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.

1. 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.

1. 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._--Haemorrhage 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 dyspnoea, 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.

1. 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 hyperaemia, 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 anaesthetic 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 Rontgen 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 hyperaemia of all the organs of the abdominal, thoracic, and cerebro-spinal cavities; (2) marked leucocytosis, with destruction of red corpuscles, setting free haemoglobin 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) oedema 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.

1. 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) hyperaemia 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 hyperaemia 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 oedema, 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 hyperaemic area, and contain a clear yellowish or brownish fluid. On removing the raised epidermis, the congested and highly sensitive papillae 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 papillae 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.

1. 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 oedema.

The _second period_ begins when the shock passes off, and lasts till the sloughs separate. The outstanding feature of this period is _toxaemia_, 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 diarrhoea 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, oedema 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 oedema 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.

1. 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 anaesthetic 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, 1.5 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 anaesthetic 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 1/4 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

1. 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.

1. 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 haemorrhage 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.

1. 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.