The principles and practice of modern surgery

by Roswell Park

In regard to the relative worth of heat and cold for relief of pain, the alleviating effect of heat is more promptly manifested, but that of cold is more permanent, and especially is this true of chronic affections of the joints and bones.

In the treatment of open wounds, bleeding having been first controlled, all the surrounding parts, as well as the wound itself, should be sterilized. In a scalp wound the scalp should be shaved as well as scrubbed. All particles of visible dirt should be carefully picked out, and every particle of tissue whose vitality is so compromised that it apparently cannot live should be excised. The wound may then be irrigated or washed out with hydrogen peroxide, and not until all this is done should the operator consider how he may best close it, as well as whether he needs to provide for drainage. A ragged line of tearing will leave a jagged and more unsightly scar, especially on the face; therefore the margins of such a lacerated wound should be trimmed before coapting them.

The method of closure will depend on the degree of tension necessary for the purpose. Parts that come together easily may require but slight suturing, and with fine catgut which will loosen of itself within two or three days; the intent in such cases always being to assist the sutures by proper support of the external dressings.

Buried sutures will serve a useful purpose in many instances, and upon the face or exposed parts of the body a subcutaneous suture of fine silk or horse-hair may be so applied as to be easily removed by a single pull and leave but trifling disfigurement. Female patients will be doubly grateful if the surgeon can leave but a minimum of unsightly scar. Fasciæ will sometimes retract widely. They should be brought together by distinct separate catgut sutures. Before closure of a wound it is important to determine that no such structures as nerves or tendons have been divided, or, if such injuries have occurred, to reunite their ends by fine silk or catgut sutures. The writer prefers silk for most of these purposes, although in a nerve a fine formalin catgut suture would perhaps be the most ideal.

There are occasions when it seems impossible with the means at hand to tie or secure in any way a deep bleeding vessel which has already been seized with a hemostat. In such case the forceps may be left in situ for thirty-six to forty-eight hours. This may be done, for instance, in the groin, in the axilla, in the depths of the neck, and about the cranial sinuses. Life may be occasionally saved by this procedure which would be lost from hemorrhage without it. At other times a firm tampon of gauze may be forced into the depths of a wound for the same purpose, and maintained there by position, or by the pressure of secondary sutures, which serve the same purpose and require removal in two or three days. These measures refer rather to wounds of veins than of arteries.

If one can be absolutely sure of his asepsis, he may close even an extensive wound with little or no provision for drainage; but unless he is certain regarding it he should provide at least for escape of fluid by omitting a suture occasionally, or by drainage with a tube or a cigarette drain. In compound fractures not only must such provision be made, but the treatment of the wound may also include the introduction of wire sutures through bone ends or the use of other mechanical expedients.

The further and equally important treatment of wounds consists largely in maintaining physiological rest of the injured part, as well as the general welfare of the patient. Pain which becomes unendurable causes the patient to lose self-control and to disturb not only the dressings but apposition of wound surfaces. Pain, therefore, should be controlled by the mildest expedient that may suffice to master it. Elimination must be maintained, because the circumstances attending the injury may act to disturb it. A patient who shows no irregularity of pulse, temperature, elimination, or general comfort may be assumed to be doing as well as could be expected, and the dressings need not perhaps be changed for several days. On the other hand, with rise of temperature or pulse, increase of restlessness, swelling of the parts, or discomfort in the vicinity of the wound, the dressings should be promptly changed. It may be necessary to make such change at the end of forty-eight hours in order to permit the removal of the drain. The second dressing may then often remain a week, but any dressing which becomes saturated, even with blood, may dry and adhere to the skin, and should be removed.

It would be best to inspect the wound in all cases when the temperature and pulse are rising or when there is any disturbance in the wound. The accumulation of blood in an aseptic wound may cause much discomfort, and by its presence interfere with primary union. Should, therefore, a wound be found pouting or its edges reddened and swollen it may be safely assumed that there is something wrong, and as many sutures should be removed as may be necessary to reveal its condition and permit of its treatment.

Wounds which are foul or septic when they come under surgical observation should be treated differently. Here the first attempt should be at antisepsis. In some cases continuous immersion in warm water will give the best results. I have never found anything so prompt, however, in cleaning up a sloughing area as brewers’ yeast. When this can be obtained it should be used in sufficient abundance to get the diseased surface thoroughly wet with it. In sloughing cases moist dressings are usually preferable, and the best are the two above mentioned. This is true of those cases where part of the wound is granulating satisfactorily, while part is acting badly. Dressings in all of these cases require to be frequently changed, that they may be kept effective.

I have elsewhere called attention to the value of granulated sugar as an emergency antiseptic material of great value.