Alexis Thomson and Alexander Miles - Manual of Surgery

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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._--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.

#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.

#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.

#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.

#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.