Chapter XVIII

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TREATMENT OF WOUNDS.

The general consideration of wounds in the previous chapters necessarily included many suggestions concerning their treatment. The first essential in the treatment of open wounds is exact hemostasis; the next is the removal of dirt and foreign material of all kinds, _i. e._, visible and invisible. Accidental wounds are practically never received upon surgically clean surfaces, and it may be always assumed that the possibility of infection is present. It becomes then a question to what extent the surgeon should go in removing or avoiding danger. Obviously all visible foreign material should be carefully removed and all dirt should be scrupulously washed away. Emergency treatment of a bleeding injury in a well-regulated hospital is one thing, and the exigency of a railroad accident or casualty away from civilization is quite another. The canons of antisepsis and asepsis have been elsewhere sufficiently well laid down to indicate what should be done at the time when it can be done.

The protective vitality of the human tissues permits them to bear frightful injuries or resist infection in a surprising way. But occasional escapes from severe accidents by no means justify carelessness when caution can be taken, and cannot be held as excusing the surgeon for any neglect in antisepsis.

A _bruise_ or _contusion_ accompanied by a slight abrasion may seem a trifling injury, and yet by virtue of the injury the resisting powers of the tissues may be rendered insufficient to protect them from infection through a break of the surface. No relatively small lesions of this kind can be safely neglected, but should be cleaned and covered with an antiseptic compress, either wet with some suitable solution or smeared with a protective ointment, or used dry with a suitable antiseptic powder, as, for example, bismuth subiodide. Injuries followed by considerable swelling should be treated according to the time which has elapsed since their reception. If, for instance, a bruise or sprain be seen early and before much swelling has occurred, ice-cold applications can be made in the hope that, by limiting the flow of blood, the outpour of fluids may be prevented. This effort should be seconded by position, and perhaps by gentle pressure. Conversely when a case is seen late, after the tissues have become waterlogged with fluids, heat should be applied in order that by stimulating the circulation reabsorption may more speedily take place. In this case, also, suitable pressure may be of service.

When there is actual _hematoma_, and the exuded fluid fails to disappear, an incision properly made and in the right place may permit the clot to be turned out, and then speedy recovery secured by coaptation with sutures and pressure.

_Poultices_ are nauseous applications to make to the human body. By their indiscriminate use much harm has been done and suppuration encouraged or brought about, which but for them would not have occurred. There are occasions when a hot flaxseed poultice may be of use, but they are very few and far between. With regard to such remedies as arnica, witch-hazel, etc., the best that can be said of them is that they may be of some use by virtue of the alcohol which they contain; they serve the purpose, then, of a diluted alcohol and nothing else.

There is virtue in the use of a _cold wet pack_, or compress, especially in the treatment of chronic affections of the joints, and their value can be perceptibly enhanced by using solutions of sodium, or preferably ammonium chloride, and the addition of a little alcohol. Absorbent material wet in such a solution, wrapped around the part, covered with oiled silk or some impervious material, while the part is kept at rest, will render valuable service in conditions of this kind.

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.

SUTURES AND KNOTS.

=Sutures.=--There are many varieties of sutures which have found favor. Until the surgeon becomes expert by long practice he should confine himself to few sutures and knots. _Primary_ sutures include _continuous_, _interrupted_, _plate_ or _modified plate_, _quill_ or _modified quill_, _chain_, and _transfixion_ sutures, and also certain forms of suture used in intestinal surgery. The above forms are illustrated in Figs. 61 to 66. Several of them may be used in making what are known as buried sutures, _i. e._, those which are tied deeply, whose ends are cut off below the surface and left either permanently or for later absorption.

The purpose of a suture is to bring the parts into accurate apposition and so maintain them. It is a mistake to employ a superficial suture alone, which may leave a “dead space” beneath it. If but one suture is used, as in closing an abdominal wound, it should pass through the tissue layers of the abdomen and bring each layer into contact with the corresponding layer on the other side. Unless this can be done a series of sutures should be used uniting the tissues layer by layer. If these be made of formalin or chromic gut they will remain _in situ_ for a length of time sufficient to serve their purpose. Some prefer silk for this purpose, but it may work out later; if sterile and freshly boiled just before using it will rarely cause this trouble. In closing a thick and fat abdominal wall four or five tiers of buried sutures may be used and their effect may be reinforced by the addition of a modified plate or quill suture, as shown in Figs. 63 and 64.

Fine wire is preferred by some operators, and horse-hair by others. Success pertains rather to the perfection of the method than to the material used. The primary feature of all wound sutures should be _prevention of tension_ and protection against it. Further support in the same direction can be made by the use of adhesive plaster after fastening the dressing upon the wound, thus taking off strain.

Certain expedients have been resorted to in superficial wounds, some of which include the affixion of a strip of plaster on either side of the wound and then the application of the suture material through the plaster rather than through the skin. Plasters with small hooks have also been applied, and then a shoelace suture applied over the hooks, thus lacing the wound margins together. Such measures are convenient for certain cases, although they make the maintenance of strict asepsis difficult or impossible. Fine-wire clips have also been introduced, by which skin margins may be held together for three or four days, or until they have had time to unite with some firmness, after which they may be removed. These little implements can be sterilized and repeatedly used.

[Illustration: FIG. 61

Continuous suture.]

[Illustration: FIG. 62

Interrupted suture.]

[Illustration: FIG. 63

Modified plate suture, using gauze instead.]

[Illustration: FIG. 64

Modified quill suture, using gauze.] ] [Illustration: FIG. 65

Billroth’s chain-stitch.]

[Illustration: FIG. 66

Transfixion suture.]

[Illustration: FIG. 67

Reef knot.]

[Illustration: FIG. 68

Granny knot.]

[Illustration: FIG. 69

FIG. 70

Clove hitch.]

[Illustration: FIG. 71

Staffordshire knot.]

When an absorbable suture will serve the purpose it is desirable to use it, since the necessity of subsequent removal is thereby avoided. Inasmuch as every point through which a suture is passed will show its own minute scar, it is desirable for cosmetic purposes to use a subcutaneous suture, which may be made of chromic gut, silk, or fine wire. If of catgut it may be left to disappear spontaneously; but a silk or wire suture should be left with ends protruding from the wound so that after a few days it may be withdrawn by steady traction in the proper direction.

Secondary sutures are those which are placed at the time of the operation, but either not drawn so as to unite the wound edges, or are tied with a bow-knot, so that they may be untied and utilized later. They are useful when either hemorrhage or suppuration is anticipated, and when it is compulsory to pack a cavity with gauze.

_Every suture which has failed of its purpose or ceased to be effective should be removed._ Ordinarily they are left in place from four to ten days. They should be removed by dividing upon one side of the knot, which should be seized with forceps and pulled upward and to the other side. The suture should be cut at a point where it is moist, so that only its flexible portion may be drawn through the parts which it has held. Moreover the buried portion is more likely to be sterile. Secondary sutures are usually made of silkworm-gut, celluloid thread, or wire. So soon as they are found unserviceable they also should be removed.

=Knots.=--The purpose of a knot is not achieved if it slips, and the “surgeon’s knot” is best for the purpose, since in the first formation one end is carried twice around the other before being tied in the opposite direction. It requires more force in making it taut, but it is safer than the ordinary reef knot (Fig. 67).

Figs. 69 and 70 illustrate the clove-hitch, which becomes firmer the tighter it is pulled. It is rarely used in ordinary sutures or ligatures, but may be made exceedingly valuable. The Staffordshire knot (Fig. 71) serves especially for securing pedicles, which are first transfixed with a double thread, the loop thus formed being slipped over the stump and secured between the two loose ends of the ligature, one end being placed over and the other under it; each is pulled tightly and secured by an ordinary knot. When properly applied it is effective. When knots are improperly applied none of them should be trusted.

When wire sutures are used it is sufficient to twist the ends, unless very fine wire is used, when it may be tied.

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