Manual of Surgery, Alexis Thomson [new books to read txt] 📗

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.