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Tous les autres exemplalres originaux sont film^n en sommenpant par ia premiere page qui comporte une empreinte d'impresslon ou d'illustration et en terminant par la derniire page qui comporte une telle empreinte. Un des symboles sulvants apparaltra sur ia dernlAre image de cheque microfiche, aielon ie cas: ie symbols — ►signifie "A SUIVRE", ie symbols V signifie "FIN". Les cartes, planches, tableaux, etc.. peuvent dtre fllmte k des taux de rMuction diffirents. Lorsque Ie document est trop grand pour dtre reproduit en un seul cliche, il est film4 k partir de I'angle supirieur gauche, de gauche k droite. et de haut en bas. en prenant ie nombre d'images nicessaire. Les diagrammes sulvants illustrent la m^thode. 1 2 3 1 2 3 4 5 6 ^ip ■11 iji ^i|ji|f^iii,p i/iiipggipi^|wi»iiHp,iii<«i mifjtf ^'m wmmv/f J n. ELECTRICAL BURiNS. BY J. M. ELDP]R, B.A., M.D., CM., Surgeon to the Montreal General Hospital ; Lecturer on Applied Anatomy, McGill University. Reprinted from the Montreal Medical Journal, January, 1900. ELECTKICAL BURNS.* II Y J. M. Er,i)i:u, H.A., M.D., CM., Surgi'oii to tlu' Moiitreiil Gi'iicriil lIoHpitiil ; licoturer on Aiii)lii'(l Anatomy, McUill Uuivt-r.-iily. My attention has l)een directod to this subject by two cases of severe liurns, from contact with a "' live wire,"' which I had in my Wards at the General Hospital during the past summer. These burns differed so much in their behaviour from other burns of an apptxrently similar de- gree of severity, that I looked up the literature of the subject as care- fully as I could, and thought that a communication on the subject might prove of interest to tlie members of this Society. Electricity is now in such general use that th" general- medical practitioner must be ])repared to treat intoiligcntly .my accident, due to it, which may befall any of his patients ; and f was somewhat astonished to find very little on the subject in such surgical literature as I had access to. The "Year IJook " for 1S!)9, directed my attention to an article on the subject of this paper, jjublished in tlie Philadelphia Medical Jour- nal, January 39th, 1898, ])y Dr. Sharpe, of St. Loui:., Mo., in which the author, who was surgeon to several large Electrical Companies, gives an excellent summary of the chief clinical features of Electrical Burns. Dr. Sharpe's remai'ks ooiiu'ide, in the main, with my own observations in the cases I shall cite, and tiiercfore, with your permission I shall quote Dr. Shari)e's conclusions, adding, as I go along, any differences I may have noticed. 1. As to appcaranrc, — " The burn is at first dried and crisp, (even charred in many cases), the site being excavated and ])loodless, with a suiTounding zone of ]>allor. Within BH to 48 hours, this picture will completely change ; oozing will replace the dryness and the pallid zone will become hypera^'mic." In other M'ords, I would remark, all the symptoms of moist gangrene will set in, followed by rapid formation of slough with a peculiarly fetid odor. Much tlio sa.uo sort of picture, at first, as we are familiar with in severe frost-bitos. 2. Pain. — " Is as a rule very moderate, in some cases practically absent ; from 21: to 48 hours after contact it is usuially present." Erom this view of Dr. Sharpe's T am forced to dissent. It may be true in very slight burns, as I have no experience of these, both of my cases having been severe ; but both my pali(uits suffered very greatly, all through the prolonged ])eriod of sloughing, needing opiates con- stantly to enable them to get even a little rest. * Reild before tlie Montreal Me(lico-Cliirur;j;ieal .Society, Nov, .'5, 18i»!t. 2 li. Shod'. — " Klectric Imrns dilTcr from other burns, in that the sys- tematic shock is from the contact — the shock from the burn, per se, being nil.'' iMy experience dill'ers here again. 1 found tiiat in electri- cal burns, as in others, the .shock was considerable, depending on the amount of tissue involved, and further, that the shock continued for a much longer period, due, no doubt, to the prolonged sloughing of adjacent tissues. I. Vrofimms. — " In regard to time, electric burns average 1^ to 3 times as long in recovery as do other burns. In severe cases, even "> times as long. Prognosis of result is as uncertain as time-prognosis ; usually, both mild and severe cases are tedious and pro- longed.'' With these views I heartily agree. The tissue lost is in the prolonged sloughing, which no treatment serves to hasten — not even amputation — and one must wait patiently until healthy granulations replace the fetid sloughs before any prognosis as to time, or as to result, should bo given ; after that, as 1 shall show you, we may reduce the time very much by skin grafting. 5. Svhspqncnt maniffstations. — Dr. Shar])e says, "the rule of the electric burn, is, that it changes within 36 hours from contact, to a serum-saturated area, with disintegrating walls and floor, progressing to profuse purulent secretion, with continued tissue degeneration. This degeneration will frequently involve nerve, muscle, tendon, joint cap- sule, ligaments, articular surfaces, ))criosteum and bone itself; exuberant granulations springing up, the entire plain bathed in pus, completing a picture alike distressing to patient and surgeon." So far as I have been able to observe the sloughing atTected mostly the muscles and blood-vessels. The bones, other than those actually charred, not being markedly affected, and I saw no evidence of osteo-myelitis higher up. The nerves, too, appeared acutely sensitive, l)ut the great sloughing suggested some great interference with the trophic fibres to a consider- able distance from the point of contact. As regards the blood-vessels, the walls appeared to be atTected for a considerable distance up the limb; and during the period of sloughing, one must constantly guard against secondary hsemorrhage. This untoward accident is also favored by the fact, that the hlood .thoired no tendency to dot in these burns; and this, I understood from Dr. Wyatt Johnston, is a well marked post-mortem feature of the blood of those who have been killed by electricity. In one of my cases, while dressing the wound, an artery spurted very freely in a granulation ai .^ome distance up the limb from the point where I had amputated some weeks previously. My experiences, then, would lead me to conclude, that the ascending degeneration following on severe burns by electricity, aflfects chiefly the a striped muscle tissue; and tliat the original area of injury gave one very little idea as to how far tho i)rucoii.s would uUiinately extend. And now as to trealmeiU: — I quite agree with tiie author quoted when he says, "it is very unsatisfactory." I pursued the plan of keeping the parts immersed in a warm carbolic bath of 1-100 strength. Even then the disagreeable odor was most marked, and 1 know of no class of cases, except cranerum oris, so dillicult to disinfect. Tlie bath was carefully watclied for any indication of iia>morrhage, as the necrotic process went on ; an Ksmarch was left at the head of the bed, with instructions to apply it at once, if Ideeding began. 1 mention this because i had luBmorrhage in both cases, and, as the patients were botli greatly reduced in strenglh by the slougiiing, with its oonsccjucnt fever and pain, I believe tiiat the prom[)t application of the Ksmarch by the attendant turned the scale in the patient's favor; iind enabled both to witlistand the shock of the subseciuent amputations. Next, when forced to do so by secondary liaMuorriiiige, or by a well marked line of demarcation having formed between the necrotic and the apparently sound tissue, it is our duty to renujve the slougliing tissue even if it means an amputation. And here 1 wish to emphasize this point, that the amputation should not be done as in ordinary cases of burns or injuries rcH|uiring operative interference. Ordinarily, if we form our flaps well above the line of demarcation, we may sew them up and expect primary union. But not so here; we must expect sloughing in the stump; not perhaps of the skin itself, but of the muscles even as high as their attachments. Wo .should simply excise the necrosed por- tions along tlia line of demarcation, and then leave the wound open, to bo dressed by moist antiseptic dressings. In both of my cases of amputation through the forearm, I did a simple circular amputation, made no attempt to form flaps, and the stump had to be left to granu- late, and subsequently was skin-grafted. T am convinced from a former experience that any attempt to sew up the wounc., in the ordinary way, would have resulted disastrously to the patient; as after the amputations whole muscles come away and large areas of skin above the point of amputation sloughed, 'riiere is altered nutrition — a local atrophy — due to the intluenco of electricity on the tissues, and one, therefore, cannot count upon the vitality of the flaps. Not uncommonly, owing to the retraction of t'le soft parts resulting from sloughing, it is neces- sary to resect the bone before skin-grafting. The result of those excised where no skin-grafting was resorted to, was similar to that obtained in other largely denuded areas; and the skin-grafting gave good results. There are several very interesting side issues arising from a study of these two eases, and I shall only refer to them briefly, in the hope that sonifl inonil)cr who is betlor versed in the study of electricity than I am may throw some liglit on what is, to me, a still unsolved prol)lem, 1. Why does the burn take place at the points of entrance and e^^it of the electrical fluid (if one may use the anah-^ry of a bullet), and the intervening tissues — many of them vital — not bj afTected to any appre- ciable extent ? 2. Why does the a])plicati()n of an electrical current, of say GOO volts, prove fatal in some instances, while in others, e. g. case II. above, a current of many times that strength simply inllicts severe burns, but does Jiot produce any serious or prolonged direct vital elTect ? And why, again, in many of the fatal cases, sliouid there be almost no mark, or other sign of burn, while in cases such as I have cited here, there should be such extensive burning as to necessitate amputation ? These are ([uestioiis which I am still studying, as they arc of gi'cat interest, not only theoretically, but practically. To this subject I hope at some future time to return, but at present I have nothing positive to offer, and moreover, I doubt if such informa- tion could be classed under the heading of Electrical Burns. Case I. — [Notes by Dr. R. M. Patterson, TTouse-Surgeon, Montreal General Hospital.] H. S., age 15. Patient was brought to the hospital June 22, 1899, and gave the following account of his injury : — lie had been astride a steel rod on the roof of his house and had reached up and grasped the main wire carrying current for the electric lighting of the streets. He thus short-circuited the current and got the full force of the discharge — 2^00 volts — tlien on the wire, lie was unconscious for from three to iive minutes until he could be moved from his perilous position. Examination. — The patient is very pale, fine perspiration on the fore- head, extremities cold, pulse small and rapid, pupils both semidilated. The symptoms are those of severe shock. Nature of injuries. — (1) Eight hand completely charred with all the soft parts shrivelled up and all the joints opened; the digits turned back in position of over-extension. From hand up to a point within one and a-half inches of the elbow joint, the burning varies from fourth to first degree. (2) l^eft hand has two deep, fourth degree burns, one on the thenar and other on the hyjiotlienar eminence. (3) Whole of the penis and scrotum are aidematous and burnt in many places quite deeply (4th degree). The inner and anterior aspect of the left thigh in its upper third is also severely burnt. It will thus be seen that the most severe burn was at the point of entrance of the electrical fluid (the hand) and again very extensive but not quite so severe at the point of exit or neutralization. Treatment. — Pntiont was given frequent hypodermics of morpliiiie alternating at times witii stricluiine, and this iiad to be liopt up for a very long time. He had to be frequently catiieterized for retention, due doubtless to the mechanical blocking up of tlie meatus urinarius by the burning and swelling. 'V\w arm was immerseil in one per cent, solution of warm carbolic lotion and fomentations of the same applied to the perineum. Later, this was changed to formalin, 1-1000, with a view if possible to lessen the extremely offensive odour of the sloughs. The formalin soon caused such pain that a solution of hydrargyrum perchloridum, 1-10,000, was substituted. The diet was li(piid, us nutritious as possible, and food was given every two hours. The areas surrounding the burns w^va soon covered with large moist hnlhv and these were soon succeeded by a very olfensive, nu)ist gangrene, with formation of very extensive sl.)ugiis. 'IMiere was also present a severe cystitis on the liflh day af:er admission. On tiie tenth day after admission there was a profuse iia-morrliage into tiie bath in which the injured right arm had been kept immersed. An I'lsmarch bandage checked this and tlie limb was removed from the bath, bandaged and elevated. A special nurse was detailed to watch for any recurrence. 1'he pain was very great and patient was very weak and blanched. Amputation was decided on, and forthwith carried out. A sim[)le cir- cular amputation wa.s )>erforined one and one-half inches below the elbow, so as to save the insertion of the biceps. Some of the muscles left in the stump could be seen to be infiltrated, and these afterwards sloughed as high as their insertions to the internal and external con- dyles of the humerus. No effort was made to close the wound which was dressed with a one per cent, carbolic dressing. The whole stump was finally covered with healthy granulations and the patient finally had good use of his elbow joint. The temi)erature never rose above 101°F. at any time, and rarely above 100°F. In the meantime the perineal wounds were progressing favourably, healthy granulations replacing the sloughs which had separated; the testicles were almost bare and a nipple like process with the urethral orifice at the summit was all there was to represent the penis. On August 7th, in the absence of Up. Eider, skin-grafting of the granu- lating Jiieas of the stump, the arm, and the j)erineum and thigh was pciiormed by Dr. J. AiuK rson Springle, following Thiersch's method, and the result was in every way satisfactory, the patient being able to leave the hospital on August 23rd. He is now quite well, has no diffi- culty in urinating, and the stump of the arm gives good motion at the elbow to a false forearm and hand. Case II. [Notes by Dr. W. L. Barlow, Ilouse-Surgeon, Montreal General Hospital.] G T. v., aj,jd 25, was brought to the Montrpal fleneral Hospital by the ambuhiiic'C! on Aui,'iisl ;}(), 1H!M), stiircrint,' from si'voro electrical burns. The history of the accident is as follows : — While walking down one of tlie passages in the power house of the Montreal Street Uailway, the patient's foot slipped and in the attempt to save himself from falling he i)ut out his right hand, which came in contact with a torniinal from the jnain lino at Cliambly. Patient states that at the *imo tlie indicators registered (iO amperes at 10,000 volts. Tlie shock he received rendered him unconscious for about two minuter, and when he ret'ovorcd consciousness he was lying about six feet from the terminal. On attempting to get up bo found that his right arm was power-loss and that iiis fore-arm and riglit hand were in a position of extromo lloxion, and were found so on admission to the hospital. Loss of ))owor was also present in tlie lower extremities. When brought to the hospital, he was in a well-marked condition of shock. The fingers of the right luiiul, as well as the hand itself, wore charred, while from the level of the wrist joint to al)out half way up the fore- arm there was a purplisli rod discolouration. This became less marked as it reached the upper portion of the fore-arm and had an ill-dollnod irregular outline. On the inner surface of the right arm, about the level of the insertion, of the deltoid, there was a deep burn through skin and subcutaneous tissue exposing the deep fascia. {See Fig. I.) The toes of the loft foo*^ were blanched and cold, while throe inner toes of the right foot were in a similar condition. The dorsal surfaces of the feet were also involved, l)ut bore there was only an erythema, as of a bum of the first degree, save for about one inch above the meta- tarsal jihalangeal articulations, where there was the same purplish-red discolouration as on the fore-arm of the left upper extremity.Scattered over these areas of discolouration, vesicles had already appeared, which later coalesced and formed largo bullte. (See Figs. II. and III.) There was marked swelling of the loft fore-arm and of the feet. Treatment and Course of the Case. On admission, strichnine ^|..jo gr., and morphine ^1,, gr. were given hypodermically. Half an ounce of whisky was given every three hours and the hand and arm immersed in a hot carbolic bath, 1-100, and the feet wrapped in hot carbolic fomentations, changed every two hours. There was retention of urine. During the first 21 hours the pain was very severe and morphine, gr. I, hypodermically, with also phenacetin gr. V, and caffeine gr. iiss, chloral hydrate, gr. xx, and potassium bro- mide, gr. XXX, were given at diiferent times to secure rest. On September Itli, a sharp haemorrhage took place into the bath from the radial artery of the right arm. The sloughs were very fetid \ I \ I i in both tlie arm and feet, and it was seen that he would evidently lose lii8 fore-arm and all the too8 of l.oth feet. As the bull.c burst or were punctured, deep sloughing aroos we-o exposed. The sloughing waa most marked where the discolouration had been most pronounced and had involved the muscles. There was never any aefinite line of de- nuircation. On Septenber 5th, six days after admission, his right fore-arm waa amputated i.t the junction of the upper and middle thirds, is much tissue as possible was saved, the wound being left open for complete drainage and to allow all necrotic tissue to be removed at each subse- quent dressing. As there was no definite line of demarcation and no guide as to the probable extent of sloughing, it was thought advisable to pay no regard to flaps, but after all the sloughs had separated and granulation tak. -^ place, to skin-graft tlie stumps. The integument, superficial vessels (whidi were tlirombosed) and most of the muscular part of the biceps just above the antocubital Mpace, were destroyoiJ, presenting a sloughing area which Wcvs thor- oughly scraped and swabbed witb carbolic, 1-40, and afterwards with normal saline. The sloughing area on the inner surface of tlie arm at the insertion of the deltoid was treated in the same way. The c^reat second and third toes of the right foot were amputated at the meta- tarsal phalangeal articulations and the heads of the corresponding metatarsal bones snipped off. All the toes of the left foot were ampu- tateti in the same way and about half of the metatarsal area exposed on the dorsum of the foot. Dressings of hot carbolic fomentations were ordered to be repeated every four hours, for 24 hours. After a prolonged period of sloughing, aflPeeting chiefly the muscles and associated with a tendency to secondary hjemorrhage in the stump of the arm, healthy granulations at last appeared. Skin-grafting of the stump of the arm was done by ^>'-, J. Alex. Hutchison, 3(; days after the amputation or 43 days after ^imission. The skin-grafts of the ann have taken very well indeed and the right foot has heaM by the usual method of granulation and cicatrization. The dorsum of the left foot, however. Dr. Hutchison tells me, will need to be grafted. The patient, at the time of writing, is well and hopes to be soon dis- charged from the hospital. EI.KCTIUCAL BURNS. VIG. I.— T.V., Right Arm, Itli diiy iifter injury, ELECTRICAL BURNS. FIU. II. T.V., Left Foot, 4th day after injury. mf ! " mtf^ II B WH w i w ] l i j i —^ 1 II ■!! ii^WPiiiiiw^^ -*_JL EliECTRICAL BURNS. VUl. III. T.V., Uight Foot, l(h day after injury.