Treatment.
—So long as air or other infection can be excluded the treatment of contusions is simple. Cleanliness of the injured parts should be enjoined; also physiological rest, by their confinement within dressings or splints, or by placing the patient in bed. An antiseptic application, dry, watery, or in ointment form, should be applied upon a surface which has been abraded. Differences of opinion exist as to the respective values of heat and cold. When the case is seen early, before much swelling has occurred, the exudate may be limited by the application of cold dressings; whereas if seen after the swelling is at its height the use of moist heat may favor a more speedy re-absorption. The effect of extremes, either of heat or cold, is sedative, although hot applications afford more relief than do those of ice. Of domestic remedies in use among the laity it may be said that those which have any value owe it to the alcohol which they contain. Elastic constriction will reduce the amount of exudate and assist in the absorption of that already present. It is a measure, however, to be used with great caution lest venous return be interfered with and edema or gangrene be the consequence. A joint tensely distended with fluid as a result of combined contusion and laceration, called a sprain, may be emptied by aspiration, but this should be used only under antiseptic precautions. Finally any collection of blood which fails to disappear may be incised and cleaned, its cavity mopped out with compresses, and its surface made to come in contact by pressure. In hematomas and large extravasations of blood, sometimes in joints, but rarely in the pleural or peritoneal cavities, this method may also be used.
LACERATED WOUNDS.
Lacerated wounds differ from contused in the character of the tears in the tissues affected and in the exposure to infection by contact. They vary in extent and severity. Not infrequently tissues or organs of the greatest importance are lacerated, e. g., the globe of the eye, the liver, the intestines. The term laceration itself implies such open injury that part of it may be exposed to infection. The first danger is from hemorrhage. This may subside spontaneously, or may have been checked by some first aid, or may prove nearly fatal by the time the patient is seen by the surgeon. The first measure will be hemostasis by the readiest and most effective measures at hand. This may mean the application of compresses or of a tourniquet, or even of manual pressure, until surgical procedures can be instituted. Shock should be treated by lowering the head and raising the extremities, or bandaging the latter, and the subcutaneous administration of morphine or atropine. Emergency treatment of these cases should include removal of foreign bodies, and such cleanliness and attention to antisepsis as may be possible at the time. Support of the injured part should be effected temporarily until dressings can be scientifically applied. If cane sugar will keep fruit and meat from decomposition it will have the same effect in human tissues, and a laceration with or without compound fracture of bone may be filled with granulated sugar until a suitable dressing can be applied.
The surgical treatment of laceration should include the following measures: Hemostasis; the removal of foreign bodies, as well as of tissue which is so injured as to make repair impossible or even questionable; a careful study of nerve supply, in order to be sure that no nerve suture should be made; a similar study of muscles and tendons, in order that tendon suture may be promptly made; careful antisepsis throughout, asepsis being impossible; closure of the wound by buried and superficial sutures, and such drainage tubes or outlets as may permit free escape of whatever products of inflammation or disintegration may result. There should also be provision for physiological rest of the injured parts as well as of the patient’s mind and body.
When large areas of skin or deep tissues are destroyed or torn away, as in scalp wounds, avulsion of limbs or parts of limbs, it may be necessary to retain that which can be saved and to remove that which would slough if left to itself, thereby providing for flaps of skin by which the wound may subsequently be covered, or leaving them in case removal of a part must be made.
Everything which has vitality should be spared; on the other hand, that which has lost its vitality should be removed at once. Thus amputations may be sometimes called for because of extensive lacerations with destruction of vascular and nerve supply, even though the bones be uninjured.
In cases where the question of viability of tissues cannot be promptly decided it is best to keep the injured part immersed in water as warm as can be borne. In hospitals the entire body may be kept immersed for days. By the use of warm water parts which have been seriously injured may be restored. Ulcerations which are seen after the sloughing process has begun can be best treated by immersion or by the application of brewers’ yeast upon compresses or cotton. No other substance, perhaps, will so quickly clear up an indolent or foul surface as this; it hastens the time of separation of all that is dead or dying and restores healthful activity to the surrounding tissues.
Extensive lacerations leave frequent opportunity for operations by which function may be restored or improvement affected.