EMERGENCY TREATMENT OF WOUNDS AND INJURIES IN GENERAL PRACTICE.* Herman E. Pearse, M. D., Kansas City, Mo. Surgeon to St. Luke's Hospital; Consulting Surgeon to the Hospital for Women and Children; Consulting Surgeon to the German Hospital. T HIS paper is called forth by the observation of several recent cases in which the initial treatment has been faulty; in which the socalled "emergency treatment" did not meet the emergency. I feel that a surgeon who sees the unfavorable results of several cases can be of distinct service to his friends in general practice by calling attention to the right way to treat these injuries, or at least to a way that gives the greatest chance of favorable results. The general practitioner will always see these cases of accident and injury first, unless the patient is injured in the employ of a corporation with a hospital service at the point where the victim is employed at the time of injury. The surgeon in the great majority of cases must be an auxiliary in so far as treatment is concerned by coming into the case at a later hour at the call of the doctor to render technical assistance that his experience fits, or should fit him to give. It is the study of cases where the primary treatment has failed that gives us the best opportunity to lay down rules and principles for guidance in subsequent cases. The vast and varied range of accidents make it impossible to go far into the details of treatment, so I shall briefly touch upon the following nine heads of paragraphs, and endeavor to give brief and fundamental rules for the care of cases under each head, leaving the details to the judgment of the practitioner, and trusting the good sense of the doctor to be the guide in matters of technique and method: 1. Wounds of the Wrist and Hand.-These are usually cuts. Failure is shown in treatment by general inflammation and loss of flexibility and function. Provide at once when called to such a case, several gallons of pure, boiled, sterile water; scrub the doctor's hands for ten minutes (by the clock) with strong soap and hot water, use a good brush or a clean wash cloth or pad of gauze. Clean the nails and trim them; irrigate the wound well, and with clean hands remove the blood clot and inspect the field. Have each finger moved by the patient and see that all wrist and hand movements are tried. If arteries are spurting stop them by pressure until satisfied as to damage done to tendons and joint. If satisfied fully that no tendons, nerves or arteries are cut and no joint opened, treat the case as a superficial wound. If one or more tendons have been cut anesthetize the patient and operate carefully; clean the wound by several gallons of water; secure the cut ends and suture them neatly together, then close the wound with drainage. If nerves are cut the same procedure is in order. The cut ends must not lap. The ends of a tendon may. Nerve suture often fails to establish function. If arteries are spurting, tie under anesthesia or not, as the occasion demands. If a joint is opened, clean up, anesthetize, irrigate and clean the wound and su *Read before the John T. Hodgen Medical Association at Butler, Mo., July 11th, 1907. ture with sterile catgut the open joint capsule. If you cannot do these things wire your surgeon that you are coming, and start for a surgeon and a hospital where it will be done. 2. The treatment of cuts and lacerations of the foot and ankle is the same in practice as those of the hand and wrist. 3. Abdomen.-These are usually cuts, stabs or gunshot wounds. Treatment. Clean the doctor's hands. A dirty finger on the examining hand is as bad a calamity to the patient as was the injury in the first place. Clean the wound with gauze and water, anesthetize the patient. Prepare for operation. Enlarge the wound until it can be seen with certainty whether the abdominal wall is penetrated or not. Do not probe the wound. If penetrated perform laparotomy usually at the site of injury; attend to the bowel by suturing with fine silk thread any holes made in it. Close the abdomen with or without draining. If you cannot do the above, practice upon dogs until you can. There is often not time to come to a city surgeon or hospital. If 4. Wounds of the Head.-When the head is injured the one great question to settle is damage to the skull that will compromise the func tions of the brain. Shave the head, clean the hands; clean the wound; anesthetize the patient, enlarge the wound and look at the skull. broken trephine and remove blood clot, shattered bone and depressed skull. Whether broken skull be found or not, close the wound with catgut drain. age only, or with none. 5. In mending wounds of the face, the aim is to prevent deformity and scar. Sutures should be subcutaneous and of fine material. If exposed sutures must be used, I prefer black iron dyed silk. Often one can best restore the parts by adhesive strips. The greatest care is needed in cleaning the hands of the operator and cleansing the wound. 6. All superficial wounds, all open lacerations, all suppurating wounds, all old sores, all wounds that fail of union from pus, all bed sores, and all suppurating burns are best treated by the Van Arsdale dressing. Saturate gauze with a 5 per cent solution of balsam Peru in castor oil; apply it to the wound. Cover with gutta percha tissue, then with cotton and bandage. Renew without washing or cleaning or other attention once each day. In two or three days the worst of them if the balsam-oilgauze comes in contact with every part of the surface, will be red and clean, and healing rapidly. 7. Fractures.-A compound fracture is one of the hardest cases a doctor has to treat. When the broken bone is associated with a break in the skin, clean the hands, clean the skin wound; put on a temporary dressing, anesthetize the patient, clean the hands again, enlarge the skin wound and explore the deeper parts until the bone can be seen and treated. Bring it out as it came when it made the wound, wash and cleanse the wound and the bone and the cavity for half an hour with gallon after gallon of sterile water. When clean put the bones together and fasten them, if necessary. Then restore the lacerated soft parts. Drain with a large rubber drainage, and put on plaster paris cast, extending beyond the joint on each side of the fracture. Have an iron strip in the plaster on the well side of the limb opposite the injury, so that when a fenestra is made over the wound the iron bar will hold. Make the fenestra early if the patient shows any signs of inflammation at sight of injury; if not, let it stay two weeks, and then fenestrate and remove tube, clean and cover again. No compound fracture is safe unless treated by prolonged irrigation with the broken ends of bone out of the wound, and the patient asleep under a general anesthetic. In all cases of fracture the joint on both sides of the break should be immobilized. Simple fracture do not require anesthesia. X-ray photograph should be taken when possible about the end of the first week. 8. Dislocations are first best reduced under general anesthesia and the joint immobilized until healing is complete. 9. Sprains.-Most sprains are fractures. The X-ray has taught us that sometimes it is a fracture of the condyle of the joint, sometimes of the joint ligament, sometimes à longitudinal crack of bone. About all base ball finger sprains are bone fractures, and heal with deformity. Most sprained ankles are fractures of the bony condyles; most sprained wrists are fractures of the radius. I strongly advise X-ray examination of all serious sprains, and certainly advise fixaticn dressings in place of liniment, etc. EFORE plunging into unexplored jungles of blissfulness, for ignor. ance is dubbed as bliss, I extend a farewell hand, and trust you will remember me as you last saw me, for should I ever emerge from these uncivilized haunts I may never look myself again, so treacherous is the road leading in that direction. Many have fallen literary martyrs to a cause that remains to add much to promulgated science and wisdom, hence whoever undertakes this needed exploration should have encouragement from his co-workers along this line. Superstition is as old as the human race, and has been handed down from generation to generation, there never being a time that we did not love to feast upon mystic lore of a mighty unknown, and little by little the more intelligent have become elevated beyond the obscure vision of the lower strata, and it is left to doctors, teachers, preachers and all promoters of science to blaze away through the dense wilderness of superstition that the ignorant may come forth from their dark forebodings and forever abandon their antiquated traits of paganism. Superstition is nothing short of culminated ignorance. There is no foundation for the greatest *Read before the John T. Hodgen Medical Association at Butler, Mo., July 11th, 1907. mystery ever known if we only knew how to analyze it. The old time ghost, the petty empty-house haunt, the hobgoblins with all their phantastic capers and direful noises, originated in times of savagery among the superstitious negroes, who did not reason from cause to effect. But time and intelligence have eradicated much of this superstition from the minds of the colored race. With our white sons and daughters this acquired estrangement is slowly giving way to more recent and fancied imaginations, to sweet dreams of a soft summer's night, especially by those more romantically inclined. To this class dreams furnish woof and warp for the web of superstition. There is supreme happiness I must admit, in hoping for an event to occur that momentarily gladdens our whole lives even in a dream, that lifts us as it were, from a dismissal and despairing presence and wafts us to the realms of a blissful future. Dreams are but a functionary action of a disturbed brain. The mental cells of this organ fail to rest or sleep from some physical derangement or mental exhaustion, and consequently pours forth its action in a pantomimic profusion, and all the phantoms thus produced, have never come to pass in a single instance, except by chance. When we think of the many millions of people in the world, all susceptible of brain prostration, we can readily understand why an occasional dream might come to pass. And again, we lie at night in a state of mental and physical relaxation from our days of laobr, our mind running at random, our physical brain becomes lost in sleep to all its suroundings, while the part governing the field of thought may produce half-toned pictures of great events that may materialize some time hence developing really from a somnotic thought, but these visionary photographs are only negatives to be retouched, and finally finished by our wide-awake mind. Then dreams are not manifestations of the inner man or the subconscious mind, taking advantage of the real individual while in unconscious sleep to make its nocturnal demonstrations, but merely a superfluous action of a restless and sensitive brain of which we may have been partially conscious of at the time, but had no control over same. Somnambulism is a mental phenomenon looked upon as being an occult power given the individual from on high only made manifest at certain intervals during life, and the public look upon a somnambulist as being favored with special endowments to perform wonders while in a state of sleep-walking. Somnambulism is but another portion of brain activity concomitant with that evolved in dreaming. Here we have, not only a dreaming brain, but ideas are executed through automatic stimulation of nerves, and subsequent muscular activity. We often wonder why sleep-walkers are enabled to perform feats while asleep that they never could do when awake. A lack of true conception along this line is responsible for so much superstition originating therefrom. But the whole wonder disappears the moment we reflect upon the circumstances under which the most daring feats may be accomplished. Did you ever stand at the very brink of a precipice, or at the top of a lofty tower and cast your eyes downward without holding securely with the hands to some safe object? If so, you have realized that awful sensation of danger, but every one can walk with impunity upon a very narrow lath laid along the floor, but release the hands at the precipice or the tower, and open an abyss on each |