Chapter 9


Immediate Phenomena.--We have already spoken of complications occurring through haemorrhage, through traumatisms of the nerves, and through foreign bodies. We have now to consider-- pain, nervous delirium, local and general stupor (shock), tetanus, hospital gangrene, ordinary gangrene, localised or diffuse infection, pyaemia.

Pain.--As a general rule bullet wounds give rise to very little immediate pain, even when they involve nerves. A great many men hardly feel they have been wounded. Pain does not stop the soldier's dash. We all remember the history of a company whose men in charging the enemy only noticed their wounds through seeing the blood that flowed from them.

The torn wounds caused by shell fragments are generally painful.

Nervous Delirium. This is an erethismic form of shock. It must not be confounded with alcoholic or insane delirium. Wounded men, either singly or collectively, are attacked with violent agitation, with a kind of fury or of rage; they perform the most extraordinary movements, talk volubly, relate with great vivacity the incidents of the action in which they have been engaged, weep, develop excessive affectionate feelings, and at the same time their general sensibility is deadened. Reeb, Poncet, and Gross, at Strasburg, and I, myself, at Saint-Quentin, have all observed veritable localised epidemics of this delirium. The delirium may end in collapse. It has sometimes a very harmful effect on the progress of the wounds.

Local and General Stupor. Local stupor is marked by the insensibility of the wound. A wounded man can finish the detachment of his own limb, which is nearly separated, without showing any pain. We have seen this happen several times. The temperature is lowered, the muscles are soft, flabby, dry, not injected nor secreting. After some days reaction is complete, or gangrene supervenes.

With regard to this complication, which is seen almost exclusively in wounds from large projectiles or their fragments, the pathogeny is obscure; lesion of the nerves here probably plays an important part. One fact is well established, that surgical intervention undertaken in tissues affected with local stupor, and on wounded men with general stupor, does not show good results.

Gangrene is a frequent ending of local stupor.

Treatment consists in employing generous stimulation, both general and local, in wrapping the wound in cottonwool, and in the temporary rejection of antiseptics.

General stupor is the result of an abrupt concussion communicated to the cerebro-spinal axis by a violent shock, either direct or transmitted through a large diaphysis, the seat of a grave fracture (shell explosions, abrasions of limbs by bulky fragments of big projectiles).

Dullness of the senses and intellect; the eyes fixed and haggard; pupils very dilated; motionless features; the body covered with cold sweat; slow, sighing, weak breathing; from time to time extensive inspiratory and expiratory movements; small, irregular pulse; vomiting; incontinence both of faeces and of urine; lowering of the temperature; wounds dry; insensibility; intellect often retained, but showing dullness; coma. Such are the clinical characteristics of general stupor.

General stupor may terminate rapidly in death; it may, however, disappear, or become mitigated In a few hours. It has been said that any wounded man in a state of stupor whose temperature sinks below 36° C. will die.

All intervention, excepting ligature of bleeding arteries, is contra-indicated. Chloroform Is dangerous (Crimea). We should have recourse to the horizontal position, to local (heat) and general stimulants, to subcutaneous injections of ether, of caffeine, or of camphorated oil.

Tetanus. Tetanus, whose frequency is variable, though it was great in former times (12 per cent., one in seventy-nine during the wars of the First Empire), was no longer met with in the Transvaal War. In the Russo-Japanese War, Holbeck observed it once in l00 wounded men. In more than 4,000 patients in this war we only saw three or four cases. The number, however, is rapidly increasing.

Narrow wounds, especially those of the lower limbs, contaminated by the soil, infected by pieces of clothing, exposed to the risks of suppuration, exposure of the soldier to cold, all predispose to tetanus. In theory, tetanus can be contagious, but practically it is not. It may appear a few moments or some hours after the wound, generally from the sixth to the eighth day, occasionally later. Its superacute form is mortal in a few days; in its chronic or slight forms cure is possible (31 per cent).

Let us rapidly recall its symptomatology: pain, spasms on a level with the wound (four-fifths of the cases), then very soon trismus, stiffness of the nape of the neck dysphagia, risus sardonicus, muscular contractions coming on in fits, and set up by the slightest excitement; remissions alternating with the crises; atypical fever; intelligence remains intact.

Facial contraction and paralysis in cephalic tetanus (wounds of the head). In the grave form, with its rapid appearance (fifth day), we see the same beginning, the same crises, but they are longer and more violent. The temperature is raised.

The treatment consists, with the idea of prevention, of relieving all constriction by incisions, of removal of foreign bodies (shrapnel bullets and fragments of shell), of rapid draining of the infected wounds, of disinfection with hydrogen peroxide, iodine, and solutions of carbolic acid. The conditions under which the first-aid stations work on the field of battle render very difficult and eventual any general employment of antitetanic serum, even for its upholders. Isolation is to be recommended in order to insure tranquillity and to avoid disturbing the other patients, rather than as a preventive measure.

Against confirmed tetanus: free incisions, washing out with antiseptics, more especially with hydrogen peroxide, removal of foreign bodies, rest, opium, chloral and bromide of potassium in large doses, sudorifics, very much prolonged baths. Subcutaneous or spinal antitetanic serotherapy has not given any convincing results. Spinal injections of from 2 to 6 cc. of a solution of sulphate of magnesium, 25 in 100 every day during five or six days, are sedative. They act specially in relieving painful contractions. It has been advised to combine these injections with others of serum in large doses.

Hospital Gangrene.--This complication, formerly frequent, has nowadays almost disappeared. It is very contagious, epidemic, and caused by Vincent's bacillus; it may invade any wound, recent or old. In the slight form, a veritable diphtheria of wounds, it shows itself by the development, on unhealthy looking fleshy granulations, of a grey opaline membrane, or a dry buffy coat, analogous to the coating produced on a wound by the employment of iodoform. Violent pain, spreading and phagedenic advance of the malady. No fever.

In the grave, pulpy form, there is seen a thick, putrid, pultaceous buffy coat, having the colour of putty. Very violent pain, with fever and solid oedema. Abundant fetid ichorous secretion, superacute phagedena. In 1870 we sometimes saw the gluteal region and the popliteal region become sphacelated in a few hours.

Formerly the prognosis was very serious. In the slight form, touching with lemon-juice, with iodine (Italy, 1870 - 71 war), immersions in permanganate of potassium solution 1 in 1,000, dressings with hydrogen peroxide and with Labarraque's liquid.

In the grave form, touching with perchloride of iron; this is very painful, but very efficacious. Actual cautery on the surface.

Rapid and absolute isolation of the patient, to whom a special staff should be attached and told off.

Suppuration, Phlegmon. Abundant suppuration is very frequent after wounds caused by deflected bullets, by shrapnel bullets, or shell fragments, and wounds complicated by pieces of clothing. Therefore we should always carefully examine the clothing, and look for any loss of substance at the apertures of entry, and more especially in the fractures themselves.

When there is extensive loss of substance in the clothing it is prudent, as a preventive measure, to relieve all constriction at the orifice of the wound, and, still better, to immediately search for the projectile, which very often would tend to prevent the exit of the pieces of clothing, the primary sources of the infection.

On the advent of suppuration we should make incisions; the focus should be cleaned out with hot water, the wall of the abscess touched with iodine or permanganate of potassium (1 in 1,000). Washing out should be done with a strong solution of carbolic acid (5 per cent.), or with hydrogen peroxide. The latter is excellent. It is not irritating, and cleanses all cavities (30 to 50 cc each time). Permanganate and Hydrogen peroxide should always be made use of in wounds that have teell soiled by earth.

Hydrogen peroxide, whilst being the specific topic for emphysematous gangrene, is besides indicated as an antiseptic in the treatment of streptococcal (phlegmon, lymphangitis, erysipelas) and putrid infections.

Surgical Erysipelas.--It was formerly very frequent. It was seen during the Secession War (0.4 per cent.), in the Russo-Turkish Campaign (0.9 per cent.), rarely in the Manchurian War, often in the Thrace Campaign. Application of too irritating dressings, occlusion of grounds by plugging, both tend to encourage its appearance. Vexatious explorations open up a passage to streptococci.

The wound becomes dry during the progress of the lymphangitis. There is fever, and the general condition is had. Diffuse abscesses, secondary haemorrhage, and sphacelus, are among the consequences.

Gentle, moist, boric acid dressing, with iodine painting (Ferraton); quinine, alcohol, as internal treatment. Serum treatment is but little utilised; it may give rise to accidents. Isolation is important.

In cases of lymphangitis and of erysipelas, Souligoux first washes the limb, then rubs it with a soft brush, removes the soap with alcohol, and finally applies a dressing of cotton-wool soaked in ether, which is changed when necessary. He has nothing but praise for this treatment.

Pyaemia. This is rare. We have already observed some cases of it during the present war following wounds by shell fragments.

1. In a SLIGHT form the wound is painful; some fever may be noticed with sordes, also headache and depression. It lasts from eight to fifteen days (Ferraton).

2. SEPTICAEMIC FEVER (Ferraton).--Remittent fever without rigors (38- 39° C.), gastric troubles, dry tongue, dried-up wound, bad general condition, rapid and small pulse, frequent respiration, scanty and albuminous urine, nervous disturb ances, both ataxic and adynamic, that in severe cases lead to death.

3. PYAEMIA.--Its appearance is encouraged by primary infection of the wounds (shrapnel, shell fragments), also by defective dressing, delay in opening collections of pus, tardy evacuation; intermittent fever, with great oscillations (39° to 40° C.), with severe rigors, fetid secretion from the wound, which is covered with exudation; signs of phlebitis; serious general condition, cadaverous appearance, dry tongue, diarrhoea, dyspnoea, muttering delirium (Ferraton).

Metastatic abscesses, both articular and parenchymatous.

Preventive Treatment. Regular dressings, immediate relieving of constrictions, disinfection of the wounds, and dressing only at long or relatively long intervals. Crowding should be avoided, and isolation of those men already infected must be insisted upon.

When pyamia is recognised as being present, antiseptic baths, washing out with solutions of carbolic acid or permanganate, or with hydrogen peroxide, touching with the chlorides. Tonics should be given, especially quinine in large doses (A. Guerin)--8 decigrammes, 1 gramme, 1.50 grammes per day (12 grains, 151 grains, 23 grains). Injections of nucleinate of sodium, fixation abscess, lavage of the blood.

Amputation is sometimes necessary, but it is always a proceeding of much gravity.

Emphysematous Gangrene. Of great frequency in wars, especially at the commencement. It has already been seen in many forms, chiefly on German wounded who have been abandoned. Surgeons should always be on the lookout for its appearance, because its progress is very rapid; also it necessitates very active treatment, and because of its dangers of contagion.

No wound is safe from it, but the wounds most exposed to it are those of shell fragments and of dangerous fractures.

Two forms are described--one makes rapid progress, but is not fulminating; the other is absolutely fulminating. In both varieties the same general symptoms are seen; the progress alone is different.

The symptoms are pain emphysematous swelling of the region, general disturbances. The pain is constant; it is felt some hours before the swelling and the general disturbance, therefore it need not be taken into too great consideration.

It is acute, violent, excessive, constringent. Nearly all the patients ascribe it to the constriction of the apparatus or of the dressings, but if these are taken off it is found that swelling may not as yet exist.

This pain depresses and lowers the wounded man. It gives him the look of a person suffering from typhus or from cholera (sunken eyes, earthy complexion, etc.).

The oedematous swelling is hard, tense, white, then bronzed, showing brownish venous ramifications; phlyctenae are seen in the vicinity of the wound, which has become dry. The swelling is crepitant. The development of gas is not only perceptible to the fingers, very often it can be heard. In a few hours the whole of a limb in fulminating cases may be invaded.

Sensibility in the affected limb is lost; the temperature is of average intensity (38° to 39°C.), or else is very high (40° C.), occasionally it is low (36° C.); rapid pulse; sighing respiration. The patient is perfectly indifferent to all that goes on around him, and dies quietly, sometimes suddenly. Such is the ordinary course of fulminating gangrene, but the description is not unique. In some cases general symptoms predominate at first, on some occasions they are mitigated; sometimes the emphysema is a long time appearing, and remains localized for a certain period. This is a fortunate circumstance.

Very marked general symptoms, violent pain, rapid gaseous development, are not found in gangrene by compression. In gangrene by contusion, gaseous development is again found, but it is less rapid, and such well-marked general phenomena are not seen.

Emphysematous gangrene commences in the wound; gangrene by contusion commences at the terminal extremity of the limb. Gangrene through lesion of the vessels, when it gives rise to gaseous development, shows the same invading progress, but this, again, commences at the terminal extremity of the limb.

The gaseous development is not always due to a septic vibrio. Emphysematous gangrene, if we take into account the prodromal period, shows itself before the suppuration of the wound (Trifaud).

Preventive Treatment--Strict disinfection of soiled wounds, isolation of the affected patients, severe precautions with regard to special preservation (amputated limbs taken away at once, all soiled linen, dressings, etc., destroyed, instruments disinfected by flame or by boiling), to avoid contagion.

In cases of acknowledged emphysematous gangrene we should employ at first free incisions of the wound, followed by extensive washing out with hydrogen peroxide. If permanganate of potassium, 4 in 1000, be associated with the hydrogen peroxide, a much more intense liberation of oxygen is obtained. At the same time intracellular injections should be utilized.

Against the fulminating processes we should oppose a barrier of hydrogen peroxide administered in hypodermic injections at the point where the oedema and the gaseous crepitation is arrested. The injections will be renewed morning and evening, or several times during the day. With Pravaz's or Dieulafoy's needle a double circle of injections should be made. Hydrogen peroxide is injected by half Pravaz syringefuls, 20 or 30 for the leg, 30 or 40 for the thigh, and these injections are renewed.

If one is out of hydrogen peroxide, oxygen under pressure can be used, which can be introduced into the limb by insufflation through a Dieulafoy's needle that communicates with a reservoir through an india-rubber tube.

At various distances tension should be relieved by incisions made in the aponeurotic partitions, so as to prevent the excessive tension of the tissues dilated by the gas; this, if left unrelieved, will lead to compression of the vessels.

The whole treatment should be carried out with conviction.

Quick amputation, or rapid disarticulation in healthy tissues, are the last resources after failure of injections of hydrogen peroxide. Circular section. No sutures.

Alcohol, quinine, camphorated oil.

Chapter 10