Shell Wounds

Kai Tiaki : the journal of the nurses of New Zealand, Volume VIII, Issue 2, 1 April 1915, Page 75

Shell Wounds

Lieut.-Colonel A. W. Sheen, R.A.M.C. (T.F.), F.RC.S. Eng., officer commanding the Welsh Hospital, Netley, writing m The Lancet on " Some Experiences of Shell Wounds m the Present War," says : — • It takes but little experience of shrapnel and other shell wounds, which when they get to hospital are almost always infected, to realise that the best thing to do is to leave them alone— that all agressive surgery is a mistake, that foreign bodies per se do no harm, and that the laying open of fresh tissue areas is to be avoided. Amputations are unwise, simple removal of any nearly dissociated parts being sufficient, even if ends of bone are left protruding. If a previous formal amputation has been performed there is almost free suppuration and flap retraction, with the necessity for r eamputation later . The best treatment is the boracic fomentation assiduously and properly applied ; the lint should be wrung as dry as possible out of really boiling water, put on m at

least two layers, amply covering the wound and adjacent parts, well overlapped m its turn by the mackintosh, fixed so as to avoid displacement and permit of easy changing, and changed as often as every two hours m badly infected cases. Thereis no particular virtue m the boracic acid, but the pink colour of the lint emphasises its special use. Where there is a wide wound, locally very foul, but with no spreading or general infection, antiseptic sawdust is a good dressing. When leaning over the bandage and smelling, there is not the offensive odour of other dressings, but only a fragrant smell. The sawdust is best applied over a single layer of sterile gauze laid across the wound. The corners of the gauze are- then brought over the sawdust. The dressing should be changed at least twice daily. " Pinus sylvestris medicatrix " is an impressive name for the soldier. The use of gauze plugs, sterile or medicated, is wrong ; they become intensely foul, and

cork up discharge. Drainage tubes are only very occasionally necessary. The employment of congestive treatment other than the fomentations- — Bier's bandage or Bier's cvp — -should follow the usual princples of dealing with infected wounds. A high value is placed nowadays on peroxide of hydrogen, but I cannot satisfy myself that it has any special usefulness m these cases. It is very difficult to estimate the value of medications applied to wounds m removing infection and hastening repair, for cleansing and healing usually take place rapidly under congestion and natural processes. Granulating and mildly infected wounds do well under sterile gauze wrung out of warm " parabolic J * applied twice daily. Sterile wounds require a dab of tincture of iodine and a pad of sterile gauze daily or less often. Occasionally an obvious abscess requires opening, an ill-draining sinus enlarging, or a cellulitis incising. In the absence of constitutional disturbance it is well to wait for definite evidence of these conditions. Doubtful spots should not be incised if the temperature is normal. The best procedure m ward dressings is as follows : — The " dresser " wears rubber gloves throughout, the lotion is warm " parabolic " 1 m 40, parabolic being one of the British equivalents of the German lysol. Between each dressing the gloved hands are washed m soap and water and rubbed with the lotion. Wool dabs are used m the lotion, gloved hands rinsed m it, and instruments kept m it. The -whole process is simple and expeditious. Bare hands get infected, and infect clean cases. Fresh rubber gloves for each case are unnecessarily time-consuming and costly. To use sterilised gauze for mops m these infected cases is unnecessary. The prolonged hot iodine bath for limbs is very useful ; three or four hours at a

time altei'nating with the fomentations. Whilst m the bath the patients are encouraged m the use of muscles and joints. I am accustomed to say m speaking of limb injuries, "Do not think of the wound think of the limb below it. Endeavour to minimise the crop of cripples which this war will bring forth." Everything possible must be done to prevent stiff joints, atrophied, paralysed, glued-together muscles, lengthened tendons, loss of grasp, dropped hands, and dropped feet. Later we shall have war hospitals which by electricity, by massage, by hot-air baths, and by mechanical and surgical methods are endeavouring to cure what might have been m many instances prevented by carrying on side by side with the wound treatment, treatment calculated to restore the usefulness of the limb. The patients must be stood over at the time of their dressings and carefully and methodically put through different movements and exercises. With the arm for example, the patient is told to use every endeavour to make this or that movement, to make finger meet thumb, to flex and extend the wrist, to pronate and supinate, to grasp, to separate and close together the fingers. It is explained to the patient that all this painful exertion is for his own good, and to give him a useful limb later. Splints should be designed to keep a limb m its most useful position and to prevent tendons lengthening. In wrist drop, for example, arm splints are prolonged by a piece attached at an angle which dorsiflexes the palm, leaving the fingers free. The arm extension splints of Borchgrewink, for my knowledge of which I am indebted to Mr. E. W. Hey Groves, of Bristol, are occasionally useful, but it is difficult to apply the extension strapping m the presence of a septic wound.