TREATMENT OF WOUNDS AND INJURIES.
By the late William Henry Crosse, M.D.
In treating wounds, whether large or small, the great essential is absolute cleanliness, not simple cleanliness in the ordinary acceptance of the word, but absolute surgical cleanliness.
In the first place, it is as well to lay down the axiom that all inflammation and other complications of wounds, as suppuration and blood-poisoning, are due to germs, and germs alone. All cleansing operations and antiseptic processes are instituted with the sole idea of preventing the entrance of germs into the wound, either from the hands of the operator, the dressings, instruments, or the skin of the patient.
Antiseptics are chemical substances which have the power of killing germs outright, or so checking their growth that the cells in the blood can easily cope with them. The antiseptics that are mentioned in these notes are carbolic acid, chinosol, permanganate of potash, and boric acid.
Given the antiseptic properties of the substance, it seems a simple thing, by its application, to prevent germs either entering a wound or multiplying there, but in actual practice the germ-free cleanliness of a wound is a difficult thing to procure. The germs are everywhere—on the instruments which cause the wounds, on the skin of the patient, in the sweat glands of the skin, at the roots of the hairs, and on the hands of the operator, especially under the nails. Again, a great obstacle to the free action of antiseptics is grease or oil of all kinds. A fine coating of grease enveloping a germ offers great resistance to the action of antiseptics, and the object of the process of cleansing a wound described below is, first, to remove all the grease, and then to apply the antiseptic to destroy the germs. With care, a clean-cut wound should heal kindly, without the formation of matter.
To clean and dress a Wound.
First cover the wound itself with a small piece of cotton-wool or lint, wrung out in an antiseptic solution; then thoroughly scrub the surrounding skin with warm water and soap (soft soap for preference), using a nail brush which has been previously boiled.
Shave the skin in every case, whether thickly covered with hair or not. This shaving is most important, as it removes all fine grease-coated hairs which might favour the growth of germs, and also scrapes off the surface dirt and dead scales of skin.
After shaving, again scrub with soap and water, and wash the skin with an antiseptic lotion, such as carbolic (1 in 60), or chinosol (1 in 1000).
Having cleansed the skin, now clean up the wound itself. Thoroughly wash the wound with an antiseptic lotion, either rubbed in with lint or wool, or injected with a glass syringe.
All instruments, ligatures and needles should be boiled for at least five minutes in water (to which a little washing-soda may be added with advantage), and should then be dropped into an antiseptic solution. When boiling is not possible, they should be soaked in carbolic lotion, 1 in 30, for ten minutes, and then transferred to 1 in 60.
The hands of the operator must be scrubbed for some minutes with soap and warm water, and then in an antiseptic solution, particular attention being paid to the nails, which should have been cut quite short. Cleanliness of the operator’s hands is the first essential of successful treatment of wounds.
The edges of small, clean-cut wounds may be brought together with adhesive plaster, but larger wounds will need antiseptic silk or gut ligatures to keep the edges applied evenly.
Large ragged wounds, with much bruising; wounds containing dirt, sand, etc., or deep wounds such as those caused by bullets or spears, should not be completely closed. They should be cleansed, as above, dusted with iodoform powder, and a strip of antiseptic gauze arranged so as to reach from the surface of the skin to the deepest part of the wound. This, which serves as a drain for the discharges, should be renewed every day until healing is fairly established. If necessary, a few stitches may be inserted in the more superficial parts of the wound to bring the edges of the skin into contact.
The wound should be dressed with strips of antiseptic gauze, slightly moistened with whichever antiseptic solution is used, and over this should be placed a pad of antiseptic wool, which should be kept firmly and evenly in place by a well-applied bandage.
A wounded limb should be kept at rest, as far as possible, either by sand-bags or a splint.
(In the absence of other antiseptics, the wound, after thorough washing, may be dressed with carbolic oil or Friar’s balsam, or boric or iodoform ointment applied on lint.)
Bleeding or Hæmorrhage.
General oozing from small vessels may be stopped by means of a pad made of a piece of antiseptic wool or gauze, firmly bandaged over the bleeding area.
When a large vessel, whether an artery or a vein, is cut across, profuse bleeding will take place, and immediate steps must be taken to stop this whilst suitable instruments are being obtained. (In bleeding from an artery, the blood spurts out in quick jerking jets; if coming from a vein, the blood flows in a steady continuous stream.) Pressure should therefore be applied, by means of the thumb or thumbs, or a tourniquet,[18] in the course of the vessel, either above or below the injury—nearer to the body than the wound if the bleeding is from an artery (Fig. 3), and beyond the wound if the bleeding is from a vein.
It will be found that the bleeding can be controlled more effectually, and with greater ease, if the vessel is compressed against a neighbouring bone.
No more pressure should be exerted than is just sufficient to stop the flow of blood.
Whilst pressure is being applied, the wound should be cleansed with some antiseptic lotion, and a wedge-shaped pad of antiseptic gauze applied and firmly held in position by a bandage.
Bleeding from the hand or forearm can generally be immediately arrested by forcibly bending up the forearm at the elbow-joint.
If these measures effectually control the bleeding, the pressure should be kept up for an hour or two, after which time it may be cautiously relaxed. If, after the removal of the pressure, the hæmorrhage seems to have ceased (as judged by the pad which has been kept in position not trickling with blood), apply a large pad of wool over the original dressing, and bandage this firmly. Dress the wound very carefully on the third day.
If, on the other hand, in spite of the treatment, the bleeding continues, the pressure must be re-applied, and the cut ends of the bleeding vessel looked for in the wound itself, and either twisted or tied with a silk ligature.
Fig. 3.—Method of Compressing the Main Artery of the Thigh.
To twist a vessel, seize the bleeding point between the blades of the artery forceps, then, by twisting the instrument round three or four times, the vessel will become blocked or closed, and the forceps may be taken off in the course of ten minutes. The other method is to tie the vessel with a silk ligature (previously boiled), making a reef or sailor’s knot, to cut short the ends of the ligature, remove the forceps, and let the vessel fall back into the wound. In any case cleanse the wound, and dress in the manner previously described.
The traveller who has taken the trouble to learn something about the treatment of wounds and severe hæmorrhage will, before his journeys are ended, probably have opportunities of saving the life of a comrade by his skill. Nothing can be more distressing than to see a man die from a hæmorrhage which anyone who has studied the subject a little would be able to control in nine cases out of ten without much difficulty. I therefore earnestly urge all travellers to gain as practical a knowledge of this subject as is possible, before leaving a civilised country.
After-Treatment of Wounds.
A clean-cut wound, which has been completely closed and properly dressed, need not be dressed again until the fourth day; and the stitches need not be removed for seven days.
On the other hand, a ragged or dirty wound, or one in which it has been necessary to insert a piece of gauze for the purpose of drainage, should be syringed out and dressed daily from the first.
The important index to the state of a wound is the patient’s temperature. If, on the third day after the wound was first dressed, the temperature is normal, and subsequently remains so, the wound is probably healing well; but if the patient’s temperature is up to or beyond 100° F., and the part is painful, there is probably some inflammatory change going on in the wound. The dressings should be taken off, and the wound examined. If the surrounding skin is red and shiny, and the limb swollen and tender, some of the stitches should be taken out, and the wound well syringed with an antiseptic lotion. This, with a good purge, such as calomel or Epsom salts, will probably remove all signs of inflammation; but still the wound must be dressed daily. If, however, the temperature still remains high, 100° to 101° F., or more, and the patient is restless and light-headed, all the stitches should be taken out, the wound opened up, and hot fomentations, prepared with an antiseptic lotion, applied every four hours till the temperature comes down. Tonics of quinine and iron should be given.
Erysipelas.
Erysipelas is a diffusely-spreading inflammation of the skin, caused by the presence and activity of germs, which enter through a wounded surface. It is most frequently due to want of cleanliness in the treatment of wounds. Bright’s disease and gout predispose to this complaint.
Symptoms.—The disease begins with a vivid red blush, usually starting from a wound, and which has a great tendency to spread or to move from one part of the limb to another. The edge of the blush is sharply defined, and slightly raised above the surrounding skin; there is stiffness and heat in the part, with fever 103°-104° F., not varying much; rapid pulse, headache, loss of appetite, furred tongue and constipation.
Treatment.—Isolate the patient and administer a good purgative. Give twenty drops of tincture of steel, with five grains of quinine in two ounces of water. Light diet. Stimulants will be necessary. Local treatment: flour, starch, or zinc oxide may be used to dust over the part, or zinc ointment applied on lint. The healthy skin just beyond the advancing edge may be painted with tincture of iodine.
Cellulitis.—Occasionally the infection of the skin by the germs spreads to the tissue beneath, and is then called cellulitis, or phlegmonous erysipelas. In this condition there is more swelling than in simple erysipelas, and the skin is very boggy or doughy, and retains the imprint of a finger pressed upon it. The red blush is not so vivid, being darker and more purple, and there is no well-defined edge. If left untreated, the skin will break down and die, causing extensive destruction of the part.
Treatment.—General treatment the same as for erysipelas. Locally, several incisions, each at least one inch in length, should be made into the swollen tissue where it is most boggy, and right through the skin, care being taken to avoid the larger blood-vessels; then hot fomentations of boric acid (five grains to the ounce) or other antiseptic should be applied, every two or three hours, till the swelling has subsided. The important point in the treatment of swollen and inflamed parts following wounds, when accompanied by continued or rising high temperature, is to relieve tension by making free incisions. Some knowledge of the anatomy of the parts is essential before using the knife. In any case, incisions in the arm or leg should be made parallel to and not across the limb.
Blood-Poisoning.
If a poisoned wound is left without thorough local treatment, the poisons and germs contained in the tissues are taken up by the blood, and cause blood-poisoning. The symptoms of this condition are high temperature, delirium, headache, loss of appetite, vomiting, and occasionally bronchitis and pneumonia. Severe forms of blood-poisoning may lead to the formation of abscesses all over the body, with fatal result.
Treatment.—The general treatment is the same as that described for erysipelas. The local treatment is to thoroughly open up and disinfect the poisoned part.
Bruises.
A bruise should be treated by bathing with cold water, or the frequent application of wet cloths. The addition of Goulard water, gin, methylated spirits, eau de cologne, or vinegar, to the water, is beneficial.
Sprains.
The affected joint should be raised on pillows, and treated in the manner advised for bruises, but if seen immediately after the injury, firm strapping with adhesive plaster and bandaging of the part is often equally serviceable. If inflammation develops, warm fomentations will be found soothing, leeching may be necessary, and free purgation always has a good effect.
The troublesome stiffness which often remains is relieved by friction and kneading with the hand. To regain the use of the joint, it should be gently moved each day; this movement is less painful if it is performed with the joint in hot water.
Poisoned Wounds from Snakes, Animals, and Arrows, etc.
In cases of poisonous snake-bite, the marks of two fangs will usually be found.
Treatment.—Tie a piece of tape, bandage, or cord a couple of inches above the wound, i.e., between the wound and the body; tie another piece still nearer the body, say three inches from the first. Cut across the wound or wounds to encourage free bleeding.
(If a medical man is present, he may think fit to inject anti-venomous serum as an antidote to snake poison.)
Dissolve as much permanganate of potash as possible in about a teaspoonful of water, stirring well to hasten its solution. Inject about five drops of this underneath the skin, on either side of the cut, by means of a hypodermic syringe. Some of the solution may be injected into the wound itself, or even a crystal of the drug may be pressed into the cut, or part of a crushed tablet of the drug.
It is best to keep a small bottle of the strong solution of permanganate always ready.
Give spirits strong, that is, one tablespoonful to one of water; at least four such doses in the first hour. Ammonia may also be given.
If the patient is heavy and stupid, give two tablets of strychnine (one-hundredth of a grain in each) in half a wine-glassful of water, by the mouth; or dissolve two in twenty drops of water, and inject well beneath the skin into the muscles of the back. If there is no improvement within an hour, give two more tablets; and if necessary, one or two more in another hour.
After tying up a limb for a poisonous bite, there will be great pain if the ligatures have been applied tightly; the parts will swell, become very dusky, and if the ligatures are left on too long, the blood supply will be cut off, and the parts will die. Therefore, when the ligatures begin to cause much pain, loosen the one next the injured part for ten seconds, then tie again at or near the same place, and loosen the other one for a similar period, and then re-tie; repeat this about every fifteen minutes. In the course of two hours, both tapes may be taken off. The object of tying up is to prevent much of the poison getting into the system at once.
The first thing is to tie up tightly; next cut freely, and suck or squeeze out as much blood as possible, then treat with drugs.
(It is usually safe to suck a poisoned wound unless there are any abrasions or cracks in the mouth, tongue, gums, or lips, taking care to spit out the poison at once; but the mouth should be washed out immediately afterwards with a light purple solution of permanganate of potash.)
If the wounds are on the face, neck, or other spot which cannot be tied up, then it is best to cut out the part at once and wipe the wound well with the strong solution of permanganate.
In the treatment of snake-bite, pure carbolic acid, ordinary caustic, a red-hot wire, or even a burning stick may be applied to the wounds when permanganate of potash cannot be obtained. In some cases, where no other treatment is available, it is advisable to explode a pinch of gun-powder over the place of injury, or even to blow the parts away with one’s gun.
If a finger or toe is bitten by a snake which is certainly poisonous, and neither drugs nor fire are at hand, it would be best to amputate at once.
Wounds inflicted by poisoned arrows or other weapons, mad dogs, jackals, etc., should be treated in a similar manner to those caused by poisonous snakes.
Drowning.
Death from drowning usually occurs in from two to three minutes after submersion, although people have been revived after a period of five or six minutes under water.
In treating cases of apparent death from drowning, the points to be aimed at are:—
First and immediately, the restoration of the breathing.
Secondly, and after breathing is restored, the promotion of warmth and circulation.
1. To restore the breathing.
Roll the patient on to his face for a few seconds, placing one of his arms under the forehead; wipe away all weeds, mud, etc., from the mouth. (In this position water will more easily escape from the mouth, whilst at the same time the tongue will fall forward, and leave the entrance to the windpipe clear.)
Turn the patient on his back, on a flat surface, with the head a little higher than the feet.
Place a small hard pillow (or a rolled-up coat) under the shoulder-blades.
Draw the patient’s tongue forward, and keep it projecting beyond the lips.
Remove all tight clothing from about the patient’s neck and chest; also braces, belt, etc.
Kneel at the patient’s head, grasp his arms just above the elbows, draw them gently and steadily upwards above his head, and keep them stretched in that position for two seconds (Fig. 4). (By this means air is drawn into the lungs.)
Fig. 4.
Reverse the movement, and press the patient’s arms gently but firmly against the sides of the chest, keeping them in this position for two seconds (Fig. 5). (By this means air is pressed out of the lungs.)
Fig. 5.
Repeat these movements alternately and regularly, about fifteen times a minute, until natural breathing takes place, or as long as there is any hope of saving the patient. It may be necessary to continue the movements for as long as an hour.
While these movements are being carried out the wet clothing may be removed, the body gently dried, and the patient wrapped up in dry blankets.
2. To promote warmth and circulation.
Rub the limbs and body vigorously with dry towels and flannels, always rubbing from the extremities towards the heart.
Apply hot-water bottles, hot flannels, or hot bricks to the feet, armpits, the pit of the stomach, and between the thighs.
Immediately the power of swallowing returns, administer hot coffee, spirits and warm water, etc.
Put the patient to bed between hot blankets as soon as possible.
Fractures.
Fig. 6.—Diagram of the Human Skeleton, giving the Names and Positions of the Chief Bones.
A simple fracture is one in which, though the bone or bones are broken, the protecting skin is not broken.
A compound fracture is one in which the skin, etc., is broken or cut across, so that the fracture is more or less exposed to the air. The end of either fragment of the broken bone may protrude through the skin.
A comminuted fracture is one in which the bone is broken into several pieces; such a fracture may be either simple or compound.
In a simple fracture great gentleness should be used in handling the parts, so as not to convert it into a compound fracture; therefore, do not undress the part; rather cut away the clothing.
A fracture which is compound is usually serious, for dirt and germs are liable to be carried into the wound and cause great mischief; in gunshot wounds, dirt or pieces of clothing may be carried into the wound.
The signs of a fracture are, firstly, the patient’s own feelings, e.g., the pain which is caused on handling the part, sudden loss of power, and the sensation of grating. Secondly, on examination, most if not all of the following signs will be observed: inability of patient to move the part below the injury, swelling, unnatural movement below the site of fracture, alteration in appearance of the limb.
In fractures of the upper or lower limb there is usually shortening, the spasmodic action of the muscles causing the broken ends to ride over each other, and the greater the obliquity of the line of fracture the greater will be the shortening and alteration in appearance.
A sensation of grating is usually conveyed to the operator when he attempts to move the parts; sometimes this grating can be heard, as well as felt. Comparison of the injured with the sound limb is of the greatest importance in detecting fractures.
Treatment of Simple Fractures.
Directly a fracture of a limb is made out, a splint or splints of some kind should be applied to keep the parts fairly in position, and to prevent a broken end from being pushed through the skin. Cloths and bandages may be applied firmly round the injured part, and then extemporised splints, such as boards, straight sticks, umbrellas, or bayonets, should be applied and kept in position till the patient is in bed.
Splints suitable to the injury should be now made and well covered with wool, lint, or cloth, special care being taken to pad them well where they are likely to press upon bony prominences, such as the inner or outer ankle. The limb must next be straightened, and any deformity caused by overriding of the fragments must be remedied by steady pulling upon the parts above and below the fracture, in opposite directions, and the parts brought into good position by manipulating the bones at the seat of fracture. The prepared splints, extending well below and above the fracture, are then fitted to the limb with cotton-wool or lint, and secured by bandages.
If there is great swelling and tenderness of a limb, then it is advisable not to apply splints at once. Sand pillows should be made, or stockings nearly filled with sand and their mouths tied, and applied one on either side of the limb, to keep it absolutely still; the painful swelling may be reduced by applying ice or evaporating lotions. When the swelling is somewhat reduced, splints may be applied after proper manipulation.
Whilst the bandages should be firmly applied so as to keep the splints in position, they must not be bound too tightly, otherwise swelling and ulceration may be caused. If there is much pain and swelling after a fracture has been set, it will be necessary to loosen the bandages.
Union of the fractured bones is generally completed in about six weeks.
Collar-bones.—Fracture of the collar-bone should be treated by placing a large wedge-shaped pad (about six inches long, by three in thickness at the upper end) in the armpit, and securing it with tapes tied over the opposite shoulder. The elbow should then be brought forward, and raised and well supported by a broad triangular bandage or handkerchief, used as a sling, and with the ends tied over the opposite shoulder. A flannel or other bandage should then be wound round the chest, so as to secure the arm from accidental movements.
Ribs.—Fracture of the ribs may be treated by wrapping a flannel bandage round the chest pretty tightly, so as to limit the movements of breathing, which are very painful. The flannel should be secured by stitching, and the upper turns should be fixed by broad tapes passed over the shoulders and firmly stitched. Firm strapping of the side with adhesive plaster is still better. For this purpose about six strips of plaster one to two inches wide and eighteen inches long should be applied evenly round the side of the chest; each piece should be overlaid by the next piece above it for about half an inch. To secure rest for the affected side of the chest, the strapping should not only cover the broken bone, but should extend to about three inches above and below it, and should reach well beyond the middle line both in front and behind.
Upper Arm.—Fracture of the upper arm may be treated by the application of several narrow splints reaching from the armpit to the elbow, well padded, and supported in position by a bandage carried from the fingers to the armpit. Care must be taken that the splints on the inner side do not chafe the folds of the armpit. The hand and wrist should then be supported in a sling, but the elbow must be allowed to hang free.
Forearm.—Fractures of the forearm must be treated by two splints, each wider than the limb. The injured limb is allowed to hang down by the side, palm forwards. One splint reaching from the elbow to the finger-tips is applied to the back of the limb; the other is placed on the front, and only reaches from the bend of the elbow to the level of the ball of the thumb. The splints are secured temporarily by a couple of slip knots. Now bend the arm to a right angle, thumb uppermost, and bandage securely from the tips of the fingers up to the elbow.
Thigh.—Fractures of the thigh are serious; they require the patient to be kept in bed till union has been effected, and they are more likely to lead to shortening and permanent lameness if not very carefully treated, and the assistance of a skilled surgeon is urgently needed. A long splint is applied to the outside of the limb, reaching from the armpit to beyond the foot, and secured above by a bandage passing round the body, whilst the foot and leg are firmly bandaged to it below.
Leg.—Fractures of the leg should be treated by applying a splint on each side, long enough to reach from the knee to a little below the sole of the foot. They should be carefully applied with bandages, keeping the great toe in a line with the inner border of the knee-cap. When the accident occurs in the open air, the injured limb should be tied to the sound one, till the patient is brought to a place of security, the toes being prevented from pointing inwards.
Lower Jaw.—Manipulate the parts into their normal position and mould a splint of gutta percha, or other material, as accurately as possible to the lower jaw. If a tooth is loose and prevents the two jaws meeting properly it should be taken out.
Apply the splint and keep it in position by a bandage, which should be split at the chin so as to encircle the point of the jaw; the ends of the bandage are also split as far forward as the angle of the jaw; two ends are tied behind the neck and two over the top of the head, as in the diagram, and these tied ends should be united by a bandage or tapes to keep them in position (Fig. 8).
In the absence of suitable material for making a splint, this bandage alone will have to suffice.
Fig. 7. Fig. 8.
The patient must be fed on slops through a tube passed behind the teeth, or through a passage resulting from the loss of a tooth.
Compound Fractures.—Clean up thoroughly as described in the treatment of wounds. Wash out with an antiseptic solution, dust with iodoform, apply an antiseptic pad. Set the limb in such a manner that the wound can be dressed daily without interfering with the splints.
If the bone is protruding through the wound, it must, if possible, be got back into position. If this cannot be done it may be necessary to saw off the end of the bone to enable the wound to be closed.
If the wound is large, deep, or dirty, it should be stuffed with antiseptic gauze so that free drainage may be allowed, and the gauze should be changed each day.
After-treatment of Fractures.—Gentle movements may be cautiously begun, in the joints above and below the injury, in about three weeks. While these are being carried out, the limb must be firmly supported to avoid interfering with the healing processes going on between the ends of the bones.
Dislocations.
Dislocations nearly always require skilled aid to reduce them.
Shoulder-joint.—Patient cannot raise the arm to his head or perform any other shoulder movements freely. The shoulder is flattened, the elbow sticks out, and the limb is usually lengthened.
Treatment.—The patient should lie down. The operator removes his own boot on the same side as that of the patient’s dislocation, inserts his heel into the patient’s armpit and draws the arm steadily down, at the same time pressing the heel in an outward direction; the dislocated bone should slip back into its proper position. Put a pad in the armpit and bandage the arm to the side for a week; support arm in a sling for another week or two.
Elbow-joint.—Dislocation of the bones of the forearm backwards at the elbow-joint is fairly common.
Treatment.—This dislocation can usually be reduced by placing the knee in front of the patient’s elbow, and making firm traction on the forearm—which is at the same time bent a little around the operator’s knee. The patient can be kept sitting in a chair while this is done, and the operator can get his knee into the required position by placing his foot on the side of the chair.
Hip-joint.—Is the most common form of dislocation. The limb is shortened, bent at the knee and twisted inwards, the great toe of the injured limb resting on the instep of foot of the opposite limb. The outer side of the hip is swollen and distorted.
Treatment.—Grasp the ankle with one hand and the knee with the other. Lift up the leg and bend it at the hip, then carry it as a whole away from the other limb as far as possible, rotate the toes and foot firmly outwards, and in that position bring the limb back parallel to the sound one.
After-treatment of Dislocations.—After dislocations, gentle movement of the joints should be begun in two weeks, so as to prevent them becoming fixed.