Manual of Surgery Volume I Part 25

[Ill.u.s.tration: 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 pa.s.ses 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 dema.

The _second period_ begins when the shock pa.s.ses 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 a.s.sociated with diarrha 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. Alb.u.minuria is a fairly constant symptom in severe burns, and is a.s.sociated with congestion of the kidneys. In burns implicating the face, neck, mouth, or pharynx, dema 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, teta.n.u.s, 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 dema of the glottis in burns about the neck and mouth has already been referred to. (3) Children are more liable to succ.u.mb 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 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 inst.i.tuted. 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 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 dermat.i.tis_ 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 dermat.i.tis_, which results from persistence of the acute form, is most intractable and may a.s.sume malignant characters. X-ray warts are a late manifestation of chronic dermat.i.tis 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 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.

#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.

CHAPTER XII

METHODS OF WOUND TREATMENT

Varieties of wounds--Modes of infection--Lister's work--Means taken to prevent infection of wounds: _heat_; _chemical antiseptics_; _disinfection of hands_; _preparation of skin of patient_; _instruments_; _ligatures_; _dressings_--Means taken to combat infection: _purification_; _open-wound method_.

The surgeon is called upon to treat two distinct cla.s.ses of wounds: (1) those resulting from injury or disease in which _the skin is already broken_, or in which a communication with a mucous surface exists; and (2) those that he himself makes _through intact skin_, no infected mucous surface being involved.

Infection by bacteria must be a.s.sumed to have taken place in all wounds made in any other way than by the knife of the surgeon operating through unbroken skin. On this a.s.sumption the modern system of wound treatment is based. Pathogenic bacteria are so widely distributed, that in the ordinary circ.u.mstances of everyday life, no matter how trivial a wound may be, or how short a time it may remain exposed, the access of organisms to it is almost certain unless preventive measures are employed.

It cannot be emphasised too strongly that rigid precautions are to be taken to exclude fresh infection, not only in dealing with wounds that are free of organisms, but equally in the management of wounds and other lesions that are already infected. Any laxity in our methods which admits of fresh organisms reaching an infected wound adds materially to the severity of the infective process and consequently to the patient's risk.

There are many ways in which accidental infection may occur. Take, for example, the case of a person who receives a cut on the face by being knocked down in a carriage accident on the street. Organisms may be introduced to such a wound from the shaft or wheel by which he was struck, from the ground on which he lay, from any portion of his clothing that may have come in contact with the wound, or from his own skin. Or, again, the hands of those who render first aid, the water used to bathe the wound, the handkerchief or other extemporised dressing applied to it, may be the means of conveying bacterial infection. Should the wound open on a mucous surface, such as the mouth or nasal cavity, the organisms constantly present in such situations are liable to prove agents of infection.

Even after the patient has come under professional care the risks of his wound becoming infected are not past, because the hands of the doctor, his instruments, dressings, or other appliances may all, unless purified, become the sources of infection.

In the case of an operation carried out through unbroken skin, organisms may be introduced into the wound from the patient's own skin, from the hands of the surgeon or his a.s.sistants, through the medium of contaminated instruments, swabs, ligature or suture materials, or other things used in the course of the operation, or from the dressings applied to the wound.

Further, bacteria may gain access to devitalised tissues by way of the blood-stream, being carried hither from some infected area elsewhere in the body.

_The Antiseptic System of Surgery._--Those who only know the surgical conditions of to-day can scarcely realise the state of matters which existed before the introduction of the antiseptic system by Joseph Lister in 1867. In those days few wounds escaped the ravages of pyogenic and other bacteria, with the result that suppuration ensued after most operations, and such diseases as erysipelas, pyaemia, and "hospital gangrene" were of everyday occurrence. The mortality after compound fractures, amputations, and many other operations was appalling, and death from blood-poisoning frequently followed even the most trivial operations. An operation was looked upon as a last resource, and the inherent risk from blood-poisoning seemed to have set an impa.s.sable barrier to the further progress of surgery. To the genius of Lister we owe it that this barrier was removed. Having satisfied himself that the septic process was due to bacterial infection, he devised a means of preventing the access of organisms to wounds or of counteracting their effects. Carbolic acid was the first antiseptic agent he employed, and by its use in compound fractures he soon obtained results such as had never before been attained. The principle was applied to other conditions with like success, and so profoundly has it affected the whole aspect of surgical pathology, that many of the infective diseases with which surgeons formerly had to deal are now all but unknown. The broad principles upon which Lister founded his system remain unchanged, although the methods employed to put them into practice have been modified.

#Means taken to Prevent Infection of Wounds.#--The avenues by which infective agents may gain access to surgical wounds are so numerous and so wide, that it requires the greatest care and the most watchful attention on the part of the surgeon to guard them all. It is only by constant practice and patient attention to technical details in the operating room and at the bedside, that the carrying out of surgical manipulations in such a way as to avoid bacterial infection will become an instinctive act and a second nature. It is only possible here to indicate the chief directions in which danger lies, and to describe the means most generally adopted to avoid it.

To prevent infection, it is essential that everything which comes into contact with a wound should be sterilised or disinfected, and to ensure the best results it is necessary that the efficiency of our methods of sterilisation should be periodically tested. The two chief agencies at our disposal are heat and chemical antiseptics.

#Sterilisation by Heat.#--The most reliable, and at the same time the most convenient and generally applicable, means of sterilisation is by heat. All bacteria and spores are completely destroyed by being subjected for fifteen minutes to _saturated circulating steam_ at a temperature of 130 to 145 C. (= 266 to 293 F.). The articles to be sterilised are enclosed in a perforated tin casket, which is placed in a specially constructed steriliser, such as that of Schimmelbusch. This apparatus is so arranged that the steam circulates under a pressure of from two to three atmospheres, and permeates everything contained in it.

Objects so sterilised are dry when removed from the steriliser. This method is specially suitable for appliances which are not damaged by steam, such, for example, as gauze swabs, towels, ap.r.o.ns, gloves, and metal instruments; it is essential that the efficiency of the steriliser be tested from time to time by a self-registering thermometer or other means.

The best subst.i.tute for circulating steam is _boiling_. The articles are placed in a "fish-kettle steriliser" and boiled for fifteen minutes in a 1 per cent. solution of washing soda.

To prevent contamination of objects that have been sterilised they must on no account be touched by any one whose hands have not been disinfected and protected by sterilised gloves.