The essential features of punctured wounds are sufficiently indicated by the descriptive name; but harm may be done through a small external opening. An important subvariety of punctured wounds is inflicted by gunshot missiles, which will receive consideration by themselves. Injury to important vessels may lead to serious hemorrhage; while injuries to nerve trunks may be followed by paralysis of sensation and motion, or, as in the case of a sympathetic trunk, by the well-known consequences of division of vasomotor nerves, e. g., in the neck. When the punctured wound bleeds freely and externally it may be assumed that some large vessel has been injured. When it bleeds into one of the cavities of the body delay in recognition may occur. This is true of a puncture of the skull by which the middle meningeal artery or one of the sinuses is wounded, when the symptoms of brain pressure may tardily or rapidly appear. In the chest the intercostal or internal mammary artery may be so injured as to bleed into the pleural cavity and cause death. A puncture of the heart frequently leads to fatal hemorrhage into the pericardial cavity, and in the abdomen puncture of the various viscera has led to consequences beyond help save when prompt relief could be afforded.
The dangers attending punctures pertain to the introduction of infectious material which may produce sepsis or may slowly produce tetanus. No ordinary weapon or tool is clean in a surgical sense, while a rusty nail is even less so. It will be seen, therefore, that the danger inherent in such a case is not to be measured by either the size or the depth of the wound.
In dealing with these cases the first attention is to be given to hemorrhage. Obviously punctures in certain regions are much more likely to be followed by hemorrhage, and any puncture in the vicinity of one of the large vessels should be managed with caution, especially if the surgeon ascertain that it had bled profusely when first inflicted. Such a puncture, when seen a few hours later, may have become occluded by clot, or a considerable hematoma may have formed beneath the skin. It is safe to presume that there is more danger of septic infection than can accrue from later attention, and it would be advisable in such cases to anesthetize the patient and lay open the parts freely under full aseptic precautions, in order that the clot be turned out and any bleeding vessel secured. A brief study of such a case will decide the question of injury to the principal nerve trunks. A principal nerve which has been injured or divided should be carefully sought for and its ends freshened and sutured. This is true also of any tendon whose function is evidently lost. If the thorax have been punctured and the physical signs indicate the presence of fluid, i. e., blood in the pleural cavity, it should be incised and the blood withdrawn. This method should also be applied to punctures of the heart. These measures will be more completely dealt with in treating of the surgery of the chest and its contents.
Punctured wounds of the abdomen may give rise to great anxiety. If none of the viscera have been injured they may be let alone, but if doubt exists as to the safety or injury of any of them the abdomen should be opened. (See [Surgery of the Abdomen].)
Treatment.
—For emergency purposes antiseptic occlusion is the best procedure, and all punctures inflicted by ragged and infectious materials, as rusty nails, should be treated by free incision, with thorough cleansing and packing with antiseptic material, that the wounds may heal by granulation.
INCISED WOUNDS.
Incised wounds are those inflicted by a sharp object which divides the tissues abruptly and with a minimum amount of disruption. They invariably bleed, sometimes seriously, even to a fatal degree, the hemorrhage in such cases being due to severance of large vascular trunks. Like contused wounds they vary as infinitely in extent as in locality. According to their locality and dimensions important structures may be severed, e. g., the trachea, the large nerve trunks of the body, the tendons, etc., while visceral and joint cavities may be more or less widely opened. When death occurs soon after injury it is generally from hemorrhage. They are attended by the same dangers of septic infection as are punctures, especially when there is neglect in the emergency dressing. Should the pleural cavity be opened there may be collapse of the lung.
Hemostasis is the paramount indication in all incised wounds which bleed seriously. Hemorrhage is to be controlled temporarily by any expedient, later by ligation or suture, or both. The remarks above in relation to possible injury to vessels and nerves are of equal force in this consideration. Every divided nerve trunk, as well as every severed tendon, should be reunited by suture. If a joint have been opened it should be cleansed and drained, even though the incision be closed. Should there be injury to any of the viscera, the wound may be enlarged in order that exploration may be made and suitable remedies applied. This is true of every punctured or incised wound. No hesitation need be felt about enlarging it so as to permit of investigation. Hemorrhage having been checked and all required attention having been given, the closure of an incised wound may be made partial or complete according to its condition. If fresh and clean it may be almost completely reunited, using deep and buried sutures in order to bring into contact its deeper portions, while superficial sutures will suffice for the skin. Drainage may be by tubes or gauze or by loose suturing of the surface; but no incised wound whose surfaces have become contaminated should be completely closed by primary suture until all such surfaces have been freely cut away and appear healthy and uninfected. An old infected and gaping incised wound may be cleaned by the application of brewers’ yeast, and when granulating it may be closed secondarily with sutures, by which granulating surfaces are brought into close contact.
Of wounds in general it may be said that there are mixed types as well as illustrative examples. Thus a wound made by a hatchet or axe may partake of the nature of contusion and of incision. In instances where personal violence has been applied multiple wounds of varied character may complicate the case. The statements made above pertain to their conventional and common characteristics. Treatment which would be proper in one case may be impossible in another. There is always room for discretion and good judgment, though there are fundamental rules which apply to all cases, and include exact hemostasis, surgical cleanliness, repair of severed nerves and tendons, removal of foreign bodies and involved tissue, and the enforcement of physiological rest.