Capillary bleeding is checked by hot water compresses. In bringing about reaction from shock, raise the feet and lower the head, unless this position causes cyanosis. At least place the head flat and the body recumbent. Apply hot water bottles and hot blankets and give hypodermic injections of ether, brandy, strychnine, digitalis or atropin, or inhalations of amyl nitrate. Strychnine can be used in large doses, one-thirtieth of a grain may be given every ten or fifteen minutes, until three doses have been taken. If the skin is very moist, atropin is indicated, alone or combined with strychnine. Hot coffee, or other hot fluids, should be given by the mouth and rectum, and mustard should be placed over the heart, spine and shins. The use of hot and stimulating rectal enemata is very important. The rectum may absorb when the stomach refuses to do so. Enemata of hot normal saline solution are very beneficial.
Enteroclysis. The tube is carried into the sigmoid flexure and the injection is introduced so as to distend the colon. At times it may be necessary to give an intravenous injection of saline solution in order to overcome the shock. In order to prevent the suppression of urine, it may be necessary to administer diuretics.
Removal of Foreign Bodies. Remove with forceps, all foreign bodies visible to the eye: splinters, bits of glass, portions of clothing, dirt, etc.
In a lacerated or contused wound, portions of tissue injured beyond repair should be regarded as foreign bodies and should be removed with scissors.
Cleaning the Wound. If the surface is hairy it must be shaved before the scrubbing. An accidental wound is infected and must be well washed out with an antiseptic solution. A clean wound, made by the surgeon, need not be irrigated, in fact, irrigation with an antiseptic fluid leads to necrosis of tissues, causes a profuse flow of serum and necessitates drainage. If clots have gathered in a wound, they must be removed, as their presence will prevent accurate coaptation of the edges. In an infected wound, they are washed out with a stream of corrosive sublimate solution. In a clean wound, they are washed out with hot salt solution. If dirt is ground into a wound, as is often seen in crushes, pour sweet oil into the wound, rub it into the tissues, and scrub the wound with ethereal soap. The oil entangles the dirt and the soap and water remove both dirt and oil. After the rough cleansing, irrigate with corrosive sublimate solution. In some cases, especially in bone injuries, it is necessary to scrape the wound with a curet.
A granulating wound is treated the same as an ulcer and the treatment is discussed under that chapter.
Drainage, Closure and Dressing. Superficial wounds require no special drain, as some exudate will find exit between the stitches and the rest will be absorbed. A large or deep wound requires free drainage for at least twenty-four hours by means of a tube, strands of horse hair, silk, catgut or gauze. An infected wound must invariably be drained. Good drainage largely compensates for imperfect antisepsis. If capillary drains be employed, apply a moist dressing. Divided nerves and tendons must be sutured. Close the edges with silk sutures or silkworm gut if the wound is deep and tension inevitable. Catgut is used for superficial wounds and for those where tension is slight. The interrupted suture is, as a rule, the best. If the wound is infected, dress with antiseptic gauze; with aseptic or antiseptic gauze if it is not infected. A dry dressing absorbs wound fluids quickly and is less likely to become infected. Change the dressings in twenty-four hours or sooner if they become soaked with the discharge. After this, in an aseptic wound the dressing need not be changed for days. If pus forms, open the wound at once.
Rest and Constitutional Treatment. In planning the treatment of wounds the most careful consideration for securing physiologic rest should be had. If at or near a joint, the parts both above and below should be immobilized. In whatever part of the body, physiologic rest should be secured as nearly as possible. If the wound be of the leg or foot, the patient should be in the recumbent position, with the part elevated and a splint applied. The factor of rest, next to that of cleansing and dressing, is most important. Physiologic rest means not only less pain, less reaction, but a more rapid and certain repair.
Under ordinary circumstances no special constitutional treatment is necessary beyond that of securing good hygienic surroundings, easily digested food, restricted at first, and free action of the bowels. If there is great pain, opiates may be necessary, but here, as in other surgical indications for anodynes, a minimum amount should only be given. Usually rest, elevation, and relief of tension will be of greater benefit than opiates. If there is great restlessness, a bromide may suffice; if marked insomnia, one of the ordinary hypnotics. Great restlessness, with excitement and occasional delirium, without special evidence of pain or infective process, must call attention to the possible development of delirium tremens from a relatively slight injury (such as a crushed toe or a simple fracture), as it may precipitate an attack in one who has been a steady drinker, though perhaps not an excessive one. In such cases, in addition to the ordinary therapeutic remedies, the regular administration of whiskey should be advised.