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WOUNDS: FIRST-AID TREATMENT Simple Measures which Promote Healing
 
These columns deal mainly with the cleansing and treatment of wounds by the layman, while the surgical aspect is dealt with under such headings as Operation; Surgery.
In its widest sense a wound means any physical damage done to the tissues but custom confines the term to damage to the soft parts, injuries to the bones being known as fractures.
Colloquially, a wound is an open injury, that is, one in which the skin is broken; and, though the classification into closed and open wounds is of great importance from the point of view of the admission of germs, it is obvious that serious damage may occur without a break of the skin. Falls from a height or the act of being run over by a vehicle may rupture the liver, kidneys or intestine without noticeably damaging the surface of the body. Hence medical men regard wounds as either closed or open.
Th former are known as bruises or contusions, and are dealt with under the heading Bruise. Open wounds are divided irito many important classes, which are named incised, lacerated, punctured, poisoned and gunshot wounds.
 
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CUT. A cut is usually made by a sharp instrument without much bruising of the edges; the lips of the wound often gape widely. Bleeding is free, from the fact that the blood vessels are cleanly divided.
Cuts should not be regarded as trivial injuries, for while those produced on a clean skin by a clean instrument usually heal quickly, some apparently simple cuts become infected by organisms, with very serious results, nch as the loss of a finger or even of life. Again, some cuts may injure an important tendon, nerve, vessel or joint.
CUT: COVERING WITH COLLODION
A small, clean cut is effectively treated and given a chance to heal spontaneously by applying a film of collodial tincture iodine with a brush. Should the wound fester, the film is removed and a fomentation put on.
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The bleeding must be stopped as quickly as possible, the part put at rest, and every cut however small, should be painted immediately and thoroughly with tincture of iodine. If the cut is a deep one it should be seen by a doctor, as some important nerve or tendon may have been severed. Deep and extensive cuts should be stitched up. For slight or wounds, if the edges are wide apart they should there be brought together with adhesive plaster, and a sterile dressing of lint applied and secured with cotton wool and a bandage. If the cut beeomes more painful after the first twenty-four hours, the part, if a finger, should be soaked for half an hour in a hot solution of common salt in water -one teaspoonful of salt to a pint of water- and a boracic foment then applied. This treatment should be repeated every four hours. If the condition becomes worse, with much, swelling, redness, pain and enlarged glands, a doctor should be consulted.
WOUND FROM BLOW SIMULATING CUT
A blow with a blunt instrument on skin which is stretched over bone may cause a wound resembling a cut, as in this instance, where the blow was on the forehead. The wound may appear slight when in fact a concussion may have occured and must be monitored carefully over 24-48 hours for changes in behavior, headache, dizziness, etc.
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Incised Wounds. An incised wound means one that is clean-cut, that is, the edges of the wound are not, bruised as well as cut. The bleeding is usually fairly free and the wound gapes. In a typical incised wound the length is far greater than the depth, familiar examples being the cuts resulting from accidents with domestic cutlery. For the most part they are trivial and the treatment is simple. A little bleeding will be an advantage in washing away small foreign particles that may have entered the wound.
A few drops of tincture of iodine on a small pellet of cotton wool should be applied and bound over the cut.. This will cause considerable smarting for a few seconds. Tincture of iodine is a marvelous healing agent, as the absorbtion not only kills germs, but supplies the glands with much needed iodine.
If the cut is on a finger a small roller bandage should be applied, beginnimg at the tip of the finger and winding upwards towards the hand. After half an hour or so, if the bandage had to be applid tightly to stop the bleeding, it should be taken off and affixed more loosely. A strip of plaster may be placed across the wound to keep its edges together, but the ends of the cut should never be covered by the plaster lest pus be locked up in the cut. A small piece of clean linen or gauze and a loose finger-stall can be used to cover the whole.
Extensive wounds of this class require more elaborate treatment, but the principles remain the same, namely, arrest of haemorrhage, cleansing, closure and drainage. After removing any gross pieces of foreign matter from the wound, it is advisable to wash it out with veal: iodine water, a teaspoonful of the tincture of iodine to the pint of water. Strips of plaster across the wound may be sufficient to keep the edges together; if not, stitches will have to be inserted.
The possibility of deep structures being injured must always be borne in mind. Thus cuts above the wrist without extending very deeply may divide nerves or tendons and where there is any doubt medical help must be summoned.
Lacerated Wounds. Wounds are known as lacerated when the tissues are torn, and as such may be of any severity, from a mere graze to the most extensive tearing by machinery. The causal agent is likely to be dirty, and bruising of the torn parts is almost certain to be present. As a class, lacerated wounds are more serions than incised wounds. It is often found that the irregular margins of the wound become septic, for injured tissues are not able to withstand infection.
As a rule, lacerated wounds bleed less than incised wounds, for the tunics of the blood vessels, being torn across, tend to curl up and close the mouths of the arteries. The haemorrhage, however, may be serious and has the prior claim to attention: If, however, blood is spurting in jets from the wound, the limb should at once be elevated. then tightly encircled with the hands above the wound. An endeavour should be made to compress the chief artery against the nearest bone, as described, under the heading Bleeding.
If the haemorrhage is not serious, the cleanest available dressing, a clean pocket handherchief, for example, may he placed over the wound and temporarily secured by another handkerchief. The subsequent treatment is much the same. tincture of iodine may be freely smeared over the surface, and if there is much separation of the skin it may be brought together with plaster or an isolated stitch or two. It is in such wound that the doctor makes ample provision for drainage, for a certain degree of sepsis is almost inevitable.
Punctured Wounds. Punctured wounds are those in which the depth is more or less problematical. Hence they entail two special dangers, the possibility of concealed injury and the admission of infection which cannot escape. The commonest example of such a wound is a pin-prick, but equally characteristic is that inficted by a dagger or other sharp-pointed instrument. In the former the possibility of sepis and in the latter decp bleedin are to be feared. In punctured stab wounds there is danger of sepsis, and perforation of other structures than blood vessels.
The first-aid treatment must be on the general principles of arresting haemorrhage, temporarily protecting the wound, attending to the general condition of the patient by rest and warmth, removing him to shelter and securing skilled help at once.
Poisoned Wounds. Though, from the nature of things, all breaches of the surface of the body except those entailed by a carefully planned operation must be septic to some degree, the term poisoned wound is usually applied to one in which the wounding agent is known or found to be defnitely and specifically poisonous.
The best examples are the smadl wonud, infiicted by the stings of insects and the bites of animals generally. The poison may be a specific germ or substance peculiar to the animal infiictin,g the wound, and, as examples, may be sited the sting of the wasp and the bites of snakes and rabid animals.
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WOUND: FIRST STEPS IN EMERGENCY TREATMENT
Left, a person who has been wounded should be made to lie down and if the wound is on a limb this should be elevated in order to diminish the flow of blood from the wound. Right if there is free bleeding from a wound the thumb should be placed at once over the spot from which the main flow of blood is coming and kept there until a dressing is ready.
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EMERGENCY TREATMENT COMPLETED BY TEMPORARY BANDAGING
Left, when a person has been wounded out of doors, the only available dressing may be a handker-. chief. This should be folded into a firm pad, sufficiently large enough to cover the wound entirely. Right, another handkerchief is folded and tied round the leg sufficiently tightly to press the
dressing on the wound and control bleeding.
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The wound is covered with a pad of cotton wool, while the surrounding skin is thoroughly cleaned with soap and water, antiseptic lolion being next poured over the wound. The wound and the skin around it are dried and a dressing of boracic lint or antiseptic gauze with iodine and cotton wool is applied. Lastly a bandage is applied to fix the dressing.
Or the wound-bite or sting-may be inflicted by carrion-feeding or other filth-eating creatures, harmless in themselves but dangerous by reason of the infection carried. Insect bites which may cause rapid death from blood poisoning are to be ascribed to this circumstance. But the victims are often in a poor state of health or otherwise lacking in resistance, for the virulence of a particular germ is a relative matter.
Gunshot Wounds. If the term gunshot wound be restricted to damage to the body by missiles, a very special type of wound is thus comprised requiring separate consideration. This is discussed under the heading Bullet Wound.
Injury by shell fragments differs, however, in certain important particulars. The lower velocity and the irregular shape of the portions of shell render them generally more harmful than the conical-pointed bullet. Shell fragments nearly always lodge in the tissues, make an irregular lacerated wound, and give rise to a wide area of bruising.
The dangerous kinds of wound infection were rife in the Great War, tetanus and a sign gangrene (q.v.) both were always more to be feared in the bruised and lacerated wounds caused by shell-fire. Gas angrene is not often seen in civil life. Tetanus, however, is common, especially where there is manure. It is dealt with under the heading Lockjaw.
BULLET WOUND.
The bullet fired by the machine-gun and the modern rifle of small bore is a conical mass of lead about a third of an inch in diameter enclosed in a covering of nickel alloy. Such a bullet, unless fired at point-blank range, which is up to about five bundred yards, may perforate the soft part of a limb, and even a bone, without causing the wounded man much inconvenience. Even the neck has been perforated in this way without serious damage, the conical bnllet thrusting aside great vessels and nerves instead of periorating them; but this is unusual. If the bullet hits at short range considerable damage is always done, and the same applies to spent bullets and ricochets.
The exit wound is invariably larger than the entrance. The track of the bullet is, in fact, one shaped the entrance being the apex and the exit the base of the cone. The diameter of the cone depends largely upon the speed of the bullet and it is clear that a flat, irregular bullet will travel through the tissues at a lower ratio than a pointed missile; its track will be a wider cone and much greater damage will be done.
The effects of bul1et wounds upon the body depend upon two chief factors: the part of the body wounded, and the condition of the wound with regard to germ infection. The wound itself may be almost trivial but, nevertheless, may be fatal from the virulene of the microorganisms which have gained access to the tissues as instances of this may be cited gas gangrene and tetanus.
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GRANULATION TISSUE. Granulation tissue is so called from its appearance, as if the surface invovled were studded with little grains. A healthy granular surface is of a deep red colour, the multitutde of little grains composing it being continuous at the their edges and forming a velvety area which bleeds very readily.
Granulation is the transition stage between a wound and its resulting scar, and follows all wounds which extend below the cuticle. As healing takes place the granular area becomes smaller and smaller until the whole site is covered by a blusish, puckered scar which subsequently whitens if it heals properly. If it does not, the scare remains purple.
DRAINAGE OF WOUNDS.
All the tissues of the body are bathed in fluid lymph, which serves to supply nourishment to the cells that constitute each part; this fluid is derived from the blood vessels and is drained away by the lymphatic vessels, which return it to the circulation by way of the thoracic duct.
In slight injuries to any part there is but slight increase in the work which is put upon lymph vessels, and the swelling, which is chiefly due to a pouring out of blood or clear lymph into the tissues, gradually subsides as the natural drainage system clears the field of the excess fluid which needs to be removed. In severe injuries in which the tissues are seriously disturbed the amount of effused lymph and blood may be too great for the already injured lymph vessels to drain away. If this be the case the fluid may colleet into a cyst., which may remain for a long time and disarrange the function of the part; sometimes germs may gain access to the fluid and cause serious trouble.
It is clear, therefore, that there are times when natural tissue-drainage must be supplemented by artificial means. Still more need for help in drainage is found in those cases where for one reason or another microbes gain access to the tissues and set up inflammation with destruction of tissue and accumulation of pus. Pus contaius poisonous material and, if not allowed an external vent, this causes constitutionat disorder by draining into the system instead of being evacuated.
It must be remembered that along any track which may allow the escape of fluid there is the possibility of the entry of microorganisms; this accounts for the fact that even severe injuries of the tissues which are unaccompanied by a wound of the skin are usually left undrained. When the skin is broken and microbes have access to the injured tissues it is customary to put in a drain so as to allow an escape of the discharge which is almost certain to occur in spite of the use of antiseptics.
It is a rule that all septic foci must be well drained. It is common for ahscesses to form in various parts of the body a a the result of the action of germs of sepsi, and these might cause death if they remained unopened and a undrained.
The methods of draining tissues are various. All that is required is to keep a track open, 1 and that may he done by the insertion of a c rubber tube, of thin rubber tissue, of gauze, or, i in small areas, of strauds of silkworrn-gut or a horsehair. Care has always to be taken that a septic focus or an abscess heals from the bottom, i.e. that the discharge is not pent up owing to a partial closure at the surface.
Great care is needed in judging when drainage can be discontinued. To take out a drainage tube too soon may necessitate opening up the wound again later; to leave it in too long may damage the tissues around.
IRRIGATION OF WOUNDS.
Irrigation is a valuable means of cleansing a septic wounds. It is carried out in a variety of ways, the essential feature being that the irrigating fluid shall reach the recesses of the wound and remove any accumulation of pus or broken-down tissues. As to the fluid employed the most generally useful Is normal saline at a blood 0.9%. The fluid consists of a teaspoonful of common table salt to each pint of boiled water. Mild antiseptics may also be used, but only in very weak solution or they will be productive of harm by increasing tissue damage. The method employed will depend upon the degree of sepsis. Occasionally in of badly poisoned wounds it: of is necessary to immerse the limb continuously for hours or even days in a bath of the fluid. Sometimes the employment of the bath for an hour or two daily suffices. In mild cases simply syringing out the wound once daily at the time of the customary dressing will meet the requirements.
WOUNDS: In Animals.
Wounds and injuries fall into two great classes: injuries to hard structures, such as bone, and injuries to soft structures, such as muscle and skin. lnjuries to bones may actually break the bone or may only splinter the outer layer. They are discussed under the heading Fracture.

CUT: In Animals.
Cuts are quickly infected and so should not be completely closed, but allowed to heal by second intention, i.e. by granulation from within ontwards. If wide, the top of the cut may be sutured, leaving room for drainage at the foot. Cuts should be swabbed or syringed daily with a 1 weak antiseptic, such as eusol, weak cresol or lysol, or even a strong solution of common salt. Antiseptics must never be used strong, or they will do harm.

Wounds of soft structures may be classified as contusions, when the surface is unbroken, and open wounds the latter being divided into incised, lacerated, punctured and poisoned wonnds.
Contusions most frequently result from kicks and blows. There is a certain amount of swelling and local inflanlmation, with heat, redness and pain, and sometimes sloughing of the overlving skin.
Incised wounds are sharp, clean cuts which, bleeding easily and freely, heal quickly. If kept clean and the edges joined together by sutures, there will be no tronble. Should they he contaminated with dirt they must not be closed, but treated like lacerated wounds. Lacerated or torn wounds are caused by blunt instruments and do not bleed much. This is because the elastic blood vessels retract and stop the flow of blood. This means, however, that healing is also slow. There is generally also a loss of flesh, which must be made good. This type of wound is often bruised as well, and is then very troublesome to heal and must be watched carefully.
Punctured wounds are deep wounds with a small opening, which is often allowed to close before the underlying tissue has healed, when an abscess results. Dog bites are frequently of this variety, and as there is usually some bruising of the surronnding and underlying tissues they are slow to heal. Antiseptic fomentations with iodine give the best results.
Arrest of Bleeding. The first stage in treatment is to arrest bleeding if it is serious; in most cases it is not. Pressure should be applied either with bandages on both sides of the wound by placing a clean pad over it or by applying a tourniquet. A tourniquet is only necessary in extreme cases, however, and must be removed at the earliest possible moment or gangrene will result. Usnally a pad soaked in antiseptic, applied with slight pressure, will control the flow of blood. Arteries should be ligatured with a clean thread soaked in antiseptic.
Cleansing the Wound. The next stage is to clean the wound by washing. If the wound is new however this is unnecessary and undesirable, and a dry dusting powder should be used instead. Boracic acid with a little iodoform added is excellent. If the wound is old or dirty it should be thoroughly washed with soap and water particular attention being paid to the surrounding skin. It should then be covered with a pad of tow or cotton wool in order to keep it clean, and this should be retained in position with a bandage or lint and sticking plaster. It is rarely possible to keep wounds clean in the domestic animals, and it is generally better to keep the wound open and dress daily or oftener. All dead tissue should be removed with scissors, and all hair surrounding the wound cut away. The skin should be disinfected and the wound cleaned with an antiseptic.
Use of Antiseptics. The choice of an antiseptic for use in wounds is very important. Strong salt solution is often very useful as its action causes serum to exude and bring away with it harmful organisms. If the wound is very dirty a chlorinc antiseptic, such as iodine solution, is very good. If one of the coal tar seriss of antiseptics is used it must be very weak, not over 2 per cent. If too strong, it actually harms the tissue, and the wound takes longer to heal than it would if no antiseptic were used at all. As the wound is being left open it will become contaminated on the surface very quickly. If this contamination is removed daily no harm will result.
The wound should be allowed to heal from the bottom upwards, by means of granulations or proud flesh. A large wound may be stitched up, but the bottom should either be left (and kept) open or a rubber tube inserted in order to allow pus to drain off. The wound should then be syringed daily with the antiseptic until no more pus comes out with the fluid. Some vaseline is then smeared on the skin below the wound in order to prevent blistering of that part. Open wounds left exposed should be given an oily dressing each day after the usual antiseptics.
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