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Treatment of Wounds

TREATMENT OF WOUNDS.

Prior to considering the various types of wounds and the special treatment required for these, it is desirable to discuss some general principles. From the remarks already made, the reader will gather that if infection could be eliminated from wounds treatment would be a simple matter, as healing would take place rapidly and safely. Of course, in extensive wounds important structures might be severely injured or blood-vessels severed, and the sup pression of haemorrhage would also require attention. But such phenomena occupy a minor position as compared with the sequelae and com plications associated with infection. Hence, in the technique of wound treatment the preven tion of infection should be regarded as the most important detail. Even admitting that, more especially in the case of accidental wounds, it is not possible in ordinary practice to ensure perfect asepsis, we can at least take steps to prevent the entrance and development of viru lent micro-organisms which give rise to serious, if not fatal, complications. If, in our attempts to practise methods calculated to prevent infec tion, we fail to achieve the measure of success obtained in human surgery, we may rest assured that improvements in our technique will follow, and the ultimate results will repay the time and trouble expended. Here we may point out that our remarks apply to the treatment of wounds under the ordinary conditions of prac tice. No doubt with special facilities, such as are provided in up-to-date veterinary colleges, it is possible to carry out aseptic methods which are not practicable in everyday work.

It will be necessary to consider the significance of the terms aseptic and antiseptic as applied to wound treatment.

Aseptic signifies the absence of sepsis, i.e. the absence of micro-organisms. The term is synonymous with"sterile"or"germ-free." Antiseptic is a term that is often loosely applied. Literally it signifies anything opposed to sepsis, while in a bacteriological sense it indicates an agent that retards or prevents the development of micro-organisms irrespective of its power of destroying their vitality. But it is often erroneously regarded as synonymous with germicide. Whereas a large number of agents classed as antiseptics are not capable of destroying pathogenic micro-organisms.

Disinfectantis the term applied to an agent capable of destroying infective micro-organisms, and so far as pathogenic germs are concerned it is synonymous with germicide. It should be remembered that while all disinfectants are antiseptics, all antiseptics are not disinfectants. The germicidal powers of some antiseptics are exceedingly weak.

Deodorant is the term applied to substances that destroy or remove offensive or unpleasant odours. While many disinfectants are also deodorants, it does not follow that all deodor ants possess germicidal properties.

In the general principles of wound treatment a distinction must be made between wounds which are made for surgical purposes under special conditions ensuring that the entrance of micro-organisms may be prevented, and acci dental wounds which are already infected before coming under the care of the surgeon. As already pointed out, it is possible to practise aseptic surgery in infirmaries provided with special facilities for the purpose. Owing to the fact that the majority of antiseptics interfere more or less with the natural process of healing, by acting injuriously on the tissue cells, and lessening the vital resistance of the parts, some authorities hold that in the case of operations carried out under aseptic conditions antiseptics should not he employed in dressing the wounds. On the other hand, authorities equally eminent point out that in consequence of the difficulties incidental to maintaining aseptic conditions in the after - treatment of surgical wounds in animals, the judicious employment of antiseptic solutions is indicated in order to avoid the risks of infection. As we are here concerned with the treatment of wounds under ordinary conditions and not under the facilities afforded by a well equipped infirmary and carried out by practi tioners specializing in surgical work, we may"make a long story short"by stating that the use of antiseptic agents is essential in the large majority of cases.

In the employment of antiseptics it is neces sary to consider the object in view. Obviously, in the treatment of wounds of all kinds we should endeavour to prevent the entrance of pathogenic micro-organisms. Even in cases where we are aware that infection has already occurred, we have no right to increase it by carelessness in technique and neglect of pre cautions. We have already mentioned that it is the exception in ordinary veterinary practice to find that wounds are in an aseptic condition, and even if they are sterile at the outset they seldom remain so. The use of antiseptics is necessary with a view to diminishing the effects of already existing sepsis, or of destroying the micro-organisms which have gained entrance to the wound. Experience has shown that in ordinary veterinary practice attempts to treat wounds without the employment of antiseptics have not proved successful. Of course, dis cretion is necessary in the selection of anti septics as regards their germicidal power and their freedom from irritating properties, while preference should be given to those which are comparatively non-poisonous and moderate in price.

Formerly it was held that infected wounds could not be rendered aseptic, but this view has been proved erroneous so far as human surgery is concerned, as by the adoption of a special method of irrigation designed by Carrel it has been proved by bacteriological examination of the secretions that the technique has succeeded in converting an infected into an aseptic wound. Except under special conditions this method is not practicable in treating wounds of animals, yet we are convinced that by means of efficient irrigation with a suitable antiseptic solution we can destroy virulent micro-organisms which have gained access to a wound, or we can pre vent their development.

In the treatment of all classes of open wounds the same general rules apply with regard to the selection of an antiseptic agent and the avoid ance of too strong solutions. The abuse of anti

septics, such as employing those possessing an irritant action, or using any agent in too con centrated solution, cannot be too severely condemned. Such an irrational practice defeats the object in view, as it causes irritation or destruction of the tissue cells and inhibits the natural process of vital resistance to the attacks of bacteria.

Much controversy has arisen amongst authori ties in human surgery with reference to the necessity for antiseptics in wound treatment. Some claim that a simple saline solution (a solution of common salt in boiled water) is pre ferable to any antiseptic agent for irrigation of wounds where flushing is indicated. Experience in the use of both methods has taught us that in dealing with wounds in animals a non irritating antiseptic is preferable to the saline solution. Moreover, as the majority of acci dental wounds we meet with are infected prior to treatment being prescribed the necessity for antiseptics is quite obvious.

From time to time many antiseptic agents have been introduced, each claiming superiority over those already in use. These claims in many instances have proved to be imaginary, with the result that not a few practitioners have reverted to the time-honoured carbolic acid or its allies.

In recent years a solution of hypochlorite of soda has come into favour for general purposes in the cleansing and dressing of wounds, and in the form of Dakin's solution it has given excellent results. This solution, according to the modi fied formula of Daufresne, is prepared as follows: Take 3.5 ounces of chlorinated lime, put in a bottle capable of holding 4.5, pints, and fill the bottle with cold water. Shake vigorously, and leave it to stand for 12 hours. In another bottle of similar capacity place 1 ounce and 5 drachms of dry carbonate of soda and 1 ounce and 2 drachms of bicarbonate of soda and fill the bottle with water. After 12 hours mix the contents of each bottle in a jar, shake well, let it stand, and after half an hour decant the clear liquid and filter through double filter-paper to obtain a perfectly clear product.

For further particulars on antiseptics, see article on"Surgical Technique." In addition to the selection of a suitable anti septic solution for the irrigation of wounds requiring this form of treatment there are other general principles, of importance in obtaining favourable results: (a) The hair should be clipped closely, or pre ferably shaved, around the wound and its im mediate vicinity. If this simple procedure be omitted the discharges from the wound cause matting of the hair, which forms a fresh nidus for infection.

(b) In dressing a wound care should be taken not to carry any of the discharge which may accumulate around the edges into the wound. Neglect of this simple precaution leads in many instances to a secondary infection of the wound. Not infrequently carelessness in this direction is most difficult to prevent, and in the case of ordinary attendants special stress has to be laid on the point when giving instructions as to after-treatment.

(c) Rough Manipulation. - The necessity for care in connection with the dressing of wounds cannot be too strongly emphasized. Ordinary attendants, not being acquainted with the natural mode of repair, do not appreciate the importance of avoiding damage to the tissues as exemplified by rough handling or attempts to cleanse the part by a process of scrubbing. Such irrational treatment retards healing and tends to increase the risk of leaving a permanent blemish. In using a syringe for the purpose of cleansing a wound by injecting the cavity with an antiseptic solution, care should be taken not to puncture healthy tissue, or to separate muscles with the nozzle of the instrument. Carelessness in this respect not infrequently leads to the spreading of infection to fresh tissues and the formation of pockets in which pus tends to collect.

(d) Cleanliness of Surgical Dressings, Utensils, etc. - We have already directed attention to neglect of surgical cleanliness as a source of infection in wounds. This is of much import ance, especially as secondary infection resulting from this cause is to a large extent preventable by the exercise of simple precautions. It is necessary to emphasize the fact that both in surgical and accidental wounds secondary in fection not infrequently is responsible for serious if not fatal results. By secondary infection is meant the entrance and development of patho genic micro-organisms subsequent to the in fliction of the wound. The chief sources are the surroundings of the patient, the manipula tion and contaminated dressings associated with the faulty and careless technique of the ordinary attendant.

(e) The Surroundings. - Obviously it would be a Herculean task to render the stables usually met with in the country, and not infrequently in cities, sufficiently clean to prevent infection of wounds. Ventilation and drainage are usually of the most primitive character, while the floors, owing to an accumulation of dirt, constitute a veritable hotbed of infection. Under such conditions the progress of wound cases cannot be expected to be satisfactory. We have, however, to make the best of the surroundings and to render them as clean as possible.

Without doubt, provided the weather be suitable and circumstances permit, cases do better on pasture than in stables. This is exem plified by the successful results obtained in castration cases when the animals are left on grass as compared with those kept in stables. Open air, sunlight, and a clean grass field prove to be important attributes in connection with the efficient healing of wounds.

wound, infection, antiseptics, micro-organisms and antiseptic