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Punctured Wounds.Surgeons divide wounds, for convenience of description and discussion, into four classes: incised, punctured, lacerated and contused wounds. The special features of these are indicated by the names. A punctured wound is made by a pointed instrument, such as a needle or a bayonet. A lacerated wound is an injury to the flesh, by which the skin and soft parts are torn. A contused wound is one in which the flesh is extensively bruised. Punctured wounds are made by many different instruments. The commonest ones result from the entrance of pins, tacks, nails, splinters of wood and the like, into the flesh. These wounds are often more serious than their extent would seem to indicate. This fact seems to result from the nature of the opening into the flesh, and from the tendency of the skin c^id muscles to close after the instrument is withdrawn. The injurious effects are often due to the accumulation of matter or blood in the bottom of the wound. The outer part heals over, but matter forms within, causing heat, redness and swelling of the skin. After a time the wound may break open again or a serious inflammation may proceed from this point and involve the surrounding skin. Another accident which often accompanies punctured wounds, is the entrance of some foreign matter with the instrument. This matter may be scraped off by the flesh and remain in the wound, where it will excite inflammation. The danger of a punctured wound depends upon the organs injured, upon the size of the wound, but especially upon the condition of the instrument with which it was made. A wound made with a clean instrument, or in such a way that it can be readily washed out, is not especially dangerous ; but when the injury is inflicted by rough and dirty instruments, such as a rusty nail, healing does not occur rapidly nor kindly. In these cases the tissue is usually bruised and lacerated along the track of the wound, so that much of it mortifies and excites irritation, just like the presence of a foreign body. In such cases there is apt to be also some dirt or sand or the rust of the nail left in the bottom of the wound. There is still another feature which renders a punctured wound especially dangerous ; this is the liability to the occurrence of lock-jaw. This disease seems to follow injuries inflicted with dull, rather than sharp instruments, and seems to result from the bruising of a nerve somewhere in the course of. the wound. Punctured wounds are, of course, especially dangerous wherever the flesh is firm and bound together by strong sinews and sheaths ; this condition prevails especially in the palm of the hand and the sole of the foot. It has been already mentioned that even clean-cut wounds are to be watched with especial care when they are made in the hand or foot ; and this caution is doubly necessary if the wound be not clean cut or incised, but punctured. The smaller punctured wounds are often more dangerous than those inflicted with larger instruments, simply because they afford less opportunity for the escape of matter and foreign particles. Treatment. - In treating a punctured wound, we should first of all extract the instrument which has inflicted the injury, if it still remains in the wound ; ana we should be careful to ascertain that no fragment has broken off and remained in the flesh. Thus, when a splinter of wood has entered the skin, a piece of it is almost certain to remain imbedded in the flesh. If this be allowed to stay, matter will form around it and a sore will be formed proportionate to the size of the foreign body which causes the trouble. It is, therefore, advisable in every case in which a particle of foreign matter remains in the flesh, to enlarge the opening with a sharp knife, or other suitable instrument, and to remove the foreign body with pincers or forceps. This is far better and more satisfactory than to attempt to pry it out with a needle or pin ; for such an attempt merely irritates the wound and rarely accomplishes the desired object. If the point of a needle be broken off in the flesh, the part should be kept perfectly quiet until the opening can be enlarged ; for such sharp objects soon disappear deeper in the tissues, if the limb be moved. It is surprising to see what journeys through the body needles sometimes perform ; they may appear months or years subsequently at some distant portion of the surface. Fortunately, they rarely do any harm in these wanderings through the body. If the needle can be felt in the skin, the flesh may be squeezed up so that one end or the other of the needle can be brought near to the surface ; the skin should then be cut at this point, the needle pushed until the end appears in the cut, and then withdrawn with the pincers. In every case in which a punctured wound of considerable size is made, the opening should be thoroughly cleansed with carbolic acid solution, or with the mixture of listerine and water above mentioned. After this a compress of lint saturated with the same solution should be applied over the opening and kept in position by a snug bandage. The limb should be kept perfectly quiet, and the compress may be moistened every two or three hours and reapplied. This dressing may be continued for three or four days if the wound seems to progress favorably. At the end of this time it will be evident whether the patient is going to experience serious trouble from the injury. If such be the case, the flesh in the vicinity of the wound will be swollen, red and painful ; the patient is apt to feel a burning and throbbing pain in the limb, at first confined to the immediate vicinity of the wound, but subsequently spreading up the arm or leg. So soon as swelling, redness and a burning pain occur, the part may be covered with a soft, warm linseed poultice, and this should be renewed every two or three hours. This treatment will sometimes enable matter which may be forming to escape to the surface ; if it does not, that is, if the pain and swelling continue unabated or even increase, it is pretty certain that matter has accumulated in the bottom of the wound. There is but one course open when this accumulation of matter occurs ; this consists in opening the wound down to the matter and permitting this to escape. A sharp penknife, carefully cleansed, should be introduced into the original wround and carefully passed into the flesh until, upon its withdrawal, matter appears upon the knife blade and in the wound. This is an extremely important item ; for it does no good to enlarge the superficial part of the opening without permitting the pent-up matter to escape. If this little operation be successfully performed, the patient will experience considerable relief in the course of a few hours ; the poultices should be continued for another day, or until the swelling and the throbbing pain have subsided. It is important that provision should be made for a free discharge of the pus ; otherwise the skin may heal over again before the bottom part of the wound has healed. If the symptoms just related - the swelling and throbbing pain - occur a second time, the knife should be introduced as before, and, in order to keep the passage open until the bottom of the wound has healed, a little plug of white wax should be made and inserted almost to the bottom of the wound. This wax may be cut into the general shape required, and then moulded and its surface smoothed by immersion in hot water. As the wound heals from the bottom, the outer end of the plug may be gradually cut off. By carefully providing for the escape of matter, we diminish very considerably the danger of lock-jaw. Lacerated wounds usually give the patient considerable trouble from the slowness with which they heal. This tardiness does not result from any inherent difficulty in the healing process, but simply because the edges of such wounds cannot be accurately kept in position. When a wound is torn or lacerated, the edges of the skin and flesh are more or less ragged, and the ends or rags of flesh usually mortify. Whenever it becomes impossible to bring these edges accurately together ; whenever, therefore, raw spaces remain between the edges, the wound heals by the formation of new flesh and skin. The bottom of the wound becomes filled with numerous small elevations as large as pin's heads. These are of a deep red color, and are covered with a yellowish creamy liquid, which is called healthy pus. These little red bodies, called granulations y are filled with blood, and bleed readily upon slight pressure. These granulations are gradually converted into flesh, which fills up the bottom of the wound. As fast as the lower part of the wound is thus closed by new flesh, the granulations rise to the surface ; in other words, the wound becomes shallower. When they have attained the level of the skin, it will be observed that the edge of the wound is lined with a very delicate white margin, which is continuous with the surrounding skin. This delicate margin is the new skin which is growing over the surface of the granulations. If the parts remain healthy and free from complications no further treatment is required for a lacerated wound than simple cleanliness and protection from mechanical injury. The red surface of the granulations should be washed with water two or three times a day, care being taken that no pus remains collected in some nook or corner of the wound. After this washing, a little vaseline should be spread upon lint, and this may be laid over the wound, so as to cover the edges of the surrounding skin. A bandage loosely applied, or a few adhesive straps, complete the dressing. It sometimes happens that these granulations are not perfectly healthy. In this case they become much larger than natural and usually have a pale red color. Such granulations are called by surgeons " flabby, " and in popular parlance " proud flesh. " This condition is especially apt to occur when the wound has been filled up to the level of the skin, the flabby granulations, or " proud flesh," rising above the general surface. The conditions of the granulations can be readily improved, that is the proud flesh can be removed, by simply applying to the surface some burnt alum. This should be thickly dusted on those parts where the granulations are most prominent. Two or three such applications usually suffice to reduce the surface to the level of the skin. If the proud flesh resist this treatment, it may readily be removed by lightly touching it once a day for two or three days with a stick of lunar caustic. The formation of the scar completes the process of healing. With reference to scars, it should be said that they always decrease in size within a few months or years after the infliction of the wound. It is sometimes surprising to see how small a scar has become in comparison with the size of the wound on which it was formed. This tendency of scars to contract and grow smaller has, however, a disadvantageous as well as a beneficial side, for if the scar be extensive it may have a tendency to deform the surface by drawing it out of shape. Thus, burns of the neck frequently result in a form of " wryneck," whereby the chin is drawn downward toward the shoulder. Scars are at first quite red, but become in the course of time as white as the surrounding skin. There is one feature in connection with lacerated wounds which may be borne in mind, namely, that they rarely bleed profusely. Hence the immediate danger from such a wound is far less than from a clean-cut incised wound of the same or even less extent. In dressing all wounds, care should be taken to preserve the tissues so far as possible. In many cases especially of lacerated wounds it becomes necessary to trim off shreds of flesh and skin, but this should be done sparingly with regard to the skin. Every piece of skin, however small, is of value in hastening the process of repair and in diminishing the size of the scar. When lacerated wounds are very extensive there often occurs considerable difficulty in securing skin enough to cover the wounded surface. It is not necessary that all the surface be covered with skin at the time the wound is dressed, but the skin should be so arranged as to divide up the raw surface into small patches instead of leaving it all in one large piece. The im'portance of this lies in the fact that when the wound is filled up with granulations, it often refuses to heal entirely. New skin will be formed at the edges to a certain extent, but it will not spread over the entire surface. Such cases require the care of a surgeon, and often tax his ingenuity and skill. Several ingenious devices have been introduced into surgery within comparatively few years and are now extensively practiced. One of these consists in what is called "skin grafting." Small pieces of skin are cut from other parts of the body, and are " planted " on the surface of the granulations. A dozen or twTo of these may be thus scattered around on the open surface of a large wound which refuses to heal under ordinary treatment. These little pieces may be either laid upon the surface or inserted into little openings made with the point of a knife. The wound is then covered with oiled silk, which is retained in position by strips of sticking-plaster. In the course of a few days small bluish white specks maybe seen upon the surface, which gradually enlarge until it becomes finally evident that each one of them is a little island of new skin. Another device which has rendered excellent service, is what is called " sponge grafting. " This consists in planting small pieces of fine, soft sponge at different parts of the surface of a wound cov ered with granulations. The granulations grow up into the meshes of the sponge, and thus new flesh is built up in and around the scaffolding of sponge. This measure has been found especially useful in cases in which pieces of flesh have been cut out and lost. In such cases the surgeon can sometimes build up the end of a finger or thumb, instead of having a deformed and unsightly flattened member. Another point with reference to lacerated wounds should be mentioned here, namely, that no tissue should ever be thrown away if completely separated from the body, unless it be torn and mangled. A piece of skin which has been entirely removed from the surface will often grow again if it be carefully cleaned and re-applied to the raw surface. In fact the writer has cut out pieces of skin from legs which had been amputated three hours before, and has seen them grow when planted on wounds of other individuals. So, too, the end of the finger, or of the nose even, if completely severed from the body, may often be made to grow again in its proper position. To accomplish this it must be carefully washed with warm water, accurately fitted to its former position and firmly strapped there by means of adhesive plaster and bandages. The member should be wrapped in cloth wrung out in hot water, since the circulation will be promoted by warmth and moisture. Contused wounds are those in which the skin has been not only severed, but also bruised. A bruise implies the rupture of some of the blood vessels in the skin and an escape of blood from these vessels into the meshes of the skin. So long as the skin is not wounded, that is, while the injury remains simply a bruise, no great danger is to be apprehended. But if the bruise be complicated by .a wound, the injury is an important and serious one. The gravity of these wounds seems to depend upon the danger that the blood which escapes into the skin may undergo putrefaction. If it does, there will result mortification and formation of matter around the wound, with perhaps extensive death or " gangrene " of the surrounding skin; and there may occur a poisoning of the blood. Contused wounds rarely bleed profusely, since the blood vessels are torn rather than cut, and the blood clots in the meshes of the skin. Treatment.-The general principles required in the treatment of contused wounds are the same as those already discussed in describing incised and lacerated wounds. The first object of treatment is to stop further bleeding. The necessity for this will be indicated by a constant swelling of the part rather than by an escape of blood from the wound ; for it is to be remembered that the blood escapes into the meshes of the skin, and that considerable hemorrhage may occur without the appearance of blood externally. It is therefore advisable to apply cold water or ice to the part, and to raise the limb. The difficult part of the treatment of contused wounds is the prevention of inflammation and perhaps gangrene of the part. For this purpose, that is to preserve the vitality of the tissues, there is nothing better than simple warmth and moisture. Hence so soon as the bleeding has ceased, the limb should be wrapped in cloths saturated with hot water, and these should be renewed every two or three hours or oftener if required to keep the limb very warm and moist. These cloths may be covered with oiled silk or rubber cloth to retard evaporation. It is rarely necessary, or even advisable, to attempt to secure rapid healing of the skin by the use of sticking plasters ; for if there be much bruising of the flesh around the wound, its edges will not unite promptly under any treatment. In many cases it will be observed after a few days that some of the skin in the vicinity of the wound has become black and emits a fetid odor ; this skin is dead or " gangrenous," and must be removed with the scissors. But first, if you want to come back to this web site again, just add it to your bookmarks or favorites now! Then you'll find it easy! Also, please consider sharing our helpful website with your online friends.
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