CHAPTER II

CARING FOR BURNS, CUTS, DROWNING, AND MINOR ACCIDENTS

In speaking of fractures and dislocations I did not dream it necessary to suggest anything in the way of a surgical kit. The element of instruments other than bandages does not enter largely into the treatment of this class of injuries, and the bandages may be improvised from materials at hand.

In the treatment of such wounds as we shall now take up, however, it will be necessary to carry a few things with which to work. This outfit will be limited in its scope, economy of space being imperative. A convenient instrument roll may be made from a strip of canvas, with a pocket at the bottom and loops for holding instruments. This can be rolled into compact shape when filled and tied with tape.

In the pocket place a card of assorted silk ligature, ranging in size from one to six, half a dozen egg-eyed needles ranging from full to half curve, one yard of oiled silk or an equal amount of gutta-percha tissue, one bottle bichloride of mercury tablets mentioned before, half ounce Squibb's surgical powder in shaker-top can, four ounces absorbent cotton in carton, two yards sterilized cotton gauze sealed, a paper of safety pins and another of common pins, one soft rubber catheter, number 9, one roll adhesive tape two inches wide.

In the loops place one needle-holder (Emmet's), one hypodermic syringe (all metal), one pair straight shears about six inches, two hemostatic forceps (Kelly's), one curved bistoury (small), and one splinter forcep. The metal case for the hypodermic has compartments for small tubes containing the hypodermic tablets. Take one tube each of the following: hydrochlorate cocaine gr. 1/4, morphine sulphate gr. 1/4, strychnine sulphate gr. 1/60. With the foregoing rather limited equipment you will be able to render assistance to a person injured in any of the accidents likely to occur in the woods.

There are a few surgical principles that should be impressed upon your mind before the subject of treatment is taken up. The first and most important of these is that it requires a great deal more loss of blood than is popularly supposed to endanger life. There is no danger from hemorrhage from a vein and but little from any of the smaller arteries.

The free flow of blood from a wound instead of being alarming is the most beneficial thing that can happen. The cleansing power of flowing blood cannot be overestimated and it is cleansing that all wounds require. That brings up a second thought. All serious consequences arising from incised or punctured wounds come from the invasion of bacteria, and all your efforts should be directed against these energetic little gentlemen, either those that have already entered the wound or those that are striving to gain ingress.

A simple cut will, if permitted to seal itself up in its own blood, generally heal without any further interference. The man who puts tobacco, flour, soap, or any other of the popular monstrosities on a wound is little short of a criminal.

While, theoretically, many people know that blood flowing in a steady stream is coming from a vein and that flowing in jets or spurts is coming from an artery, few know how to take advantage of that knowledge. The general rule to make pressure between the heart and the wound in case of a jet and between the wound and the extremity in case of a stream is only good as a general rule; there are exceptions and it is exceptions that make the rule dangerous. There are times when it becomes necessary to reverse the process.

The proper way is to make compression with your fingers until you have located the region the blood comes from; then apply your steady compression in that locality. There are a few great arterial trunks that lie near the surface and may become injured, the injury causing death from hemorrhage. The manner of locating the compression point for these arteries will be given.

The first of these is the great artery that runs down the inside of the leg, called the femoral. Bleeding from this vessel will result in death in a very few minutes, and it has been known to be severed by a man falling on his sheath knife. The bleeding may be controlled by grasping the leg with the fingers near the body. About half way down the inner surface of the leg the fingers will fall into a slight depression, at the bottom of which lies the femoral artery.

Any of the vessels of the lower limb may be controlled by compressing just behind the knee between the two prominent tendons that will be found there when the leg is doubled up. Arteries of the forearm and hand can be stopped by pressing with the thumb at the elbow joint just to the inner side of the tendon of the biceps which you may feel like a cord when the arm is extended. If the bleeding is from the upper arm stretch the whole arm by raising it above the head. Feel in the armpit and you will locate a prominent ridge on the inner side; press with your fingers just behind that ridge and you will shut off the blood supply from the whole arm. These are the more prominent vessels that lie near the skin.

Certain of these larger arteries require ligation. The ligation of an artery calls for a certain amount of surgical skill, but if it is necessary to save life you can do it. Surgeons now use sterilized catgut for the purpose, but silk can be used as well, taking care to leave sufficient end hanging out of the wound to remove it by.

After having made compression and controlled the hemorrhage, clean out the wound and loosen your tourniquet until the blood spurts. Locating the artery, grasp it in the bite of the hemostatic forceps. Cut off a short piece of silk and tie it loosely around the forceps. Have some one pull up on the forceps and at the same time with your forefingers slip the knot down over the end of the cut vessel. Tie tight and remove your forceps.

This procedure will be necessary only in case of injury to large vessels. Smaller arteries can be controlled by the means hereafter described, or by placing a heavy pad of gauze over them and making compression with a tight bandage. The blood will become entangled in the meshes of the cloth and form a clot.

Incised wounds inflicted with sharp instruments will be found to comprise practically all the injuries occurring in the woods. The method of treating one will illustrate that of dealing with all. Let us suppose that in cutting firewood the camper has had the misfortune to drive a sharp ax into his instep (a quite common accident). The blood spouts at once in a very alarming manner. He hobbles to the camp and removes his shoes. An ugly gaping wound appears, from the bottom of which blood is jetting, indicating that an artery has been severed.

The first thing necessary is to stop the blood. Take a handkerchief or other cloth and tie it about the ankle rather loosely, place a small stick or a table fork beneath it and twist. In a few turns you will note that the blood is flowing with less force and shortly will cease altogether.

When the bleeding has been entirely controlled get out your surgical kit and throw a pair of the hemostatic forceps into the boiling water. After they are sterilized wash the wound free from blood with pure water. I will add in this connection that spring water in the mountains is practically sterile and can be used for washing wounds without any danger of infection.

After the wound is clean have some one slightly loosen the tourniquet. As he does this watch sharply for the jet of blood that will locate the cut artery. As soon as you see it grasp it with the forceps, lock them, and leave them in place. The compression of the forceps while you are getting ready your other instruments will seal up the vessel so that when you remove them it will not bleed any more.

Take two of your full curved needles, at least two inches long, and thread them with quite coarse silk, cut off a piece of your gauze and run the needles through it. Place the needles thus prepared, the needle holder, shears, and the other pair of hemostats in a vessel and boil. In the meantime make up a solution of the bichloride, using the antiseptic tablets for that purpose.

Wash your hands well and rinse them in the bichloride solution. Clean out the wound, taking great care to remove all clots. With one of the threaded needles in the grasp of the needle holder begin at the upper angle of the wound, about half an inch from the end. Pass the needle down through the flesh one-fourth of an inch from the edge, carrying it well toward the bottom and making it enter the wound near the bottom and re-enter the flesh on the opposite side, pass up through and out an equal distance from the edge. Cut the thread off and lay the two ends out of your way, leaving, of course, sufficient to tie with when the time comes.

Place your row of stitches half an inch apart all down the wound. When all the stitches are in place you may begin to tie. Take the two ends of the first stitch in your hands and lift up on them; this will bring the edges of the wound together. Tie the thread, turning the first knot under twice to prevent its slipping. After all the stitches have been tied take the handle of your scalpel or the forceps and raise the edges of the skin, which will have rolled in, until they meet each other. This is necessary, as where the skin is rolled in it will not heal readily and leaves an opening for the entrance of bacteria.

Sponge off all the free blood and dust well with surgical powder. Place a pad of gauze that has been soaked in the bichloride solution over the wound, cover that with a wad of cotton and the cotton with a piece of oiled silk, bandage over all, and do not molest for at least three days.

After five days you may remove your stitches in this manner: Cut the stitch near the skin on one side, grasp the knot in the bite of the forceps and pull it out. Be careful not to try to pull the knot through the flesh, and do not leave any end on the part you do pull through the flesh, as it may carry infection down into the wound.

It is a fact not generally known to the laity that a solution of common salt and water will take the place of blood when introduced into the system. Surgeons resort to this practice in performing all very bloody operations. Their method of hypodermoclysis could not be carried out in the camp, of course, but a very good substitute for it can be used. The lower bowel is very receptive of this solution, which by the way, is made by dissolving a teaspoonful of clean common salt in a pint of water. The solution, maintained at blood heat, is introduced into the lower bowel with a fountain syringe. Persons who have lost a great deal of blood, so much in fact that their pulse can hardly be felt at the wrist, will receive great benefit from this procedure. Use at least a gallon of the solution and do not permit it to flow too rapidly into the bowel.

Certain cuts may be dressed without stitches. Proceed as before up to the point of putting in the stitches, then roll up two pieces of gauze as long as the cut and about the size of a lead pencil. Lay these on either side of the wound quite close to it. With adhesive tape half an inch wide and four inches long begin two inches on either side of the wound and carry across, bringing the edges of the wound together. Place these strips half an inch apart until the wound is brought into line. Dress as before, except that you will have to omit the moist gauze, dressing with the powder entirely.

I want to add here that should you run out of sterilized gauze at any time you can make it from any soft cloth by boiling it for ten minutes in the bichloride solution and hanging in the air to dry.

The pain attendant upon any surgical manipulation can be prevented by the hypodermic injection of a solution of cocaine. When you get your hypodermic have the instrument man show you how it works. He can show you much better than I can tell it. Insert the needle half an inch from the wound and inject a few drops of the solution into the skin. Proceed thus entirely around the wound and by the time you are through the wound will be perfectly painless. Before replacing the instrument in its case always dry it out and replace the small brass wire that you will find in the needle.

It is somewhat difficult to approach the subject of punctured wounds, which also include those resulting from gun shots and powder explosions. The rule among surgeons is to meddle with these injuries as little as possible, provided they do not penetrate the abdomen. In the case of penetrating wounds caused by falling on a sharp stick or other sharp pointed instrument, it is well to clean out the wound, removing all foreign substance that may be present, searching diligently for pieces of cloth, rust, charcoal, bark, or other foreign matter. These things in certain localities contain the germ of lock-jaw, and many contain it anywhere.

This is particularly true of felt wads from shotgun shells. All diligence should be exercised to clean out a wound resulting from such a cause. Shotgun wads are manufactured from the most filthy kinds of old hair, often reeking with the bacillus of tetanus.

If the wound was caused by a sliver of wood and the sliver still remains in the wound remove it by making an incision with your bistoury. Do not be afraid to cut. A little cut is worse than none; go deep enough to liberate the sliver so that it may be removed with the splinter forceps. Then wash the wound from the bottom with hot water and dress as before, using the bichloride.

Experience has proved that the less one attempts to do with gunshot wounds the better. Nature has a tendency to wall off foreign bodies that are in the main sterile and will ordinarily do so with a bullet if given a chance. Keep the patient quiet, prevent infection from entering the wound, and trust to Nature to do the rest.

An incident will illustrate what takes place when Nature is given an opportunity to throw out her plastic wall material around a foreign body. Some years ago a party of Eastern people were camping in the heart of the Bitter Roots. Among the party were two boys of the age when boys are prone to try experiments. They bored a small hole in a spruce tree and drove into it a high power 30–30 cartridge. Then they stood off some fifteen feet and fired at the cartridge with a small rifle. One of them hit it.

The 30–30 shell came back and penetrated the abdomen of the juvenile marksman, burying itself and driving pieces of clothing into the abdominal cavity. The messenger who came for me was thirty-six hours on the trail and I was an equal length of time reaching the camp. The people had had sense enough to keep the patient quiet and I found him resting fairly easy. So deeply had the missile penetrated that it required a considerable incision to remove it.

When I reached the bottom of the wound I found that Nature had thrown about the wounded area a wall of protective lymph and all the pus that had accumulated was in a pocket. I laid the pocket well open, evacuated its contents, and removed the bits of cloth that I found, dressed the wound, and had the satisfaction of seeing the youngster recover.

Burns are classified according to degree of injury. Those of the first degree are where the skin is reddened, but no blister formed. The second degree includes those where there has been decided blistering, and the third, where the flesh has been charred. Those of the first and second degrees are the most common in about the proportion of 99 to 1.

A burn of the first degree can be best relieved by the application of cold water. This is contrary to the teachings of a few years ago, but is in full accord with that of to-day. The water should be changed as fast as it becomes warm.

Burns of the second degree require more care. In the first place, do not interfere with the blister. The primary object in treating burns is to exclude air and the skin remaining intact will do this much better than any artificial means.

The Indians of the Northwest prepare a dressing for burns by cooking deer suet with balm of gilead buds. This is the most effective application for severe burns I have ever seen. If deer suet is not available, any fresh tallow that has been cooked will serve as well. Throw a handful of the buds into a vessel and cover them with the suet, boil for thirty minutes, and strain. When nearly cold apply to the burn and cover with a soft cloth. The pain ceases almost immediately.

It seems singular after all that has been written on the subject, but few people know how to restore a drowned person. The matter is really quite simple, yet it requires great attention to detail. Spasmodic efforts are useless. The thing has to be gone about methodically and the method persisted in for a long time, often in the face of seeming certain defeat.

In the first place, statistics show that no person who has been submerged in the water for a period of seven minutes was ever resuscitated. It is extremely doubtful if after five minutes' immersion anything can be accomplished, still it is worth the effort.

The first thing to do when a person is rescued from the water is to remove all clothing from about the chest and neck. Do not take the time to draw the garments off, but rip them off with a knife. Turn the body over and stand astride it. Grasp it about the middle and lift up so that only the head and feet are touching the ground. This is done in order to free the lungs and air passages from water and mucus. Do this several times.

With a handkerchief wipe out the mouth and as far down the throat as you can reach. Lay the patient on his back with a folded coat under his shoulders. Kneel at his head and grasp both arms at the wrists and pull them well up over his head, hold for an instant, return to the sides and press them against the ribs, hold for an instant and repeat. Do this about twenty times each minute.

The tendency is to work too fast. The movement should be about as fast as a man breathes, the object being to simulate the ordinary respiratory movements as nearly as may be. While this is being done another person may grasp the tongue and pull it up and out of the mouth, keeping time with the movements of the arms. When the patient begins to show signs of life wrap him well in hot blankets, place hot stones at his feet, and administer hot water, brandy, or strong hot coffee.

As before suggested, the efforts at restoration should be persisted in for a long time, until either success rewards your efforts or the body becomes quite cold and rigid. It may be that there is a little spark of life left and you may fan it into flame after hours of effort.

There are many minor accidents for which it is well to be prepared. For example, to remove a fish hook: Do not try to pull it back; push it on through, file or break off the barb and it can be removed readily.

To remove foreign bodies from the eye: First cocainize the eye by dropping a few drops of a solution made by dissolving one of the cocaine tablets in a half teaspoonful of water, then turn the lid back over a match telling the person to look down at the same time, and brush the substance off with a soft cloth. If it is under the lower lid place your forefinger on his cheek just beneath the eye, pull down, and tell him to look up. If it adheres to the eyeball, as in the case of a cinder or a small piece of steel, after cocainizing the eye remove with a sharp knife by brushing.

Insects sometimes crawl into the ear and make a lot of commotion. Place the patient on his side with that ear uppermost and pour plenty of warm water into the ear. By plenty I mean several quarts. The bug will crawl out or be washed out by the returning stream of water.

Burns well characterized toothache as "Thou hell of a' diseases." If the tooth has a cavity (as it probably has), a small crystal of cocaine dropped dry into the cavity and covered with a little pledget of cotton will give immediate relief.

For bleeding from the nose, place a pledget of cotton in each nostril, lay the patient on his face, and pour cold water over the back of the neck. Leave the cotton there for several hours. The idea is that the fibrin in the blood becomes entangled in the fiber of the cotton and sets up a clot that seals the bleeding surface, while the cold water closes the blood supply by its action on the artery supplying the parts.

Hiccough is a distressing and sometimes a dangerous complaint. Many times a swallow of water will stop it. If simple measures fail, the following has been found very efficacious. The nerves that produce hiccough are near the surface in the neck. They may be reached and compressed by placing two fingers right in the center of the top of the breastbone between the two cords that run up either side of the neck and pressing inward, downward, and outward. A few minutes' pressure of this kind will stop the most obstinate hiccough.

Certain injuries are attended with what is known as shock. Usually the degree of shock is proportionate to the extent of the injury, though not always so. Often seemingly trivial injuries produce a fatal shock. The symptoms are cold, clammy skin, face very pale and pinched, eyes widely dilated and staring, pulse rapid and irregular, little or no pain, even from severe injuries. The patient retains his mental faculties but loses the power to originate, answering when spoken to but usually volunteering no statements of his own.

The treatment consists in lowering the head and elevating the extremities. Wrap the patient in hot blankets and place hot water bottles about him, give brandy, or what is as good, hot water; inject 1/30 gr. strychnia every fifteen minutes for three doses.

The symptoms from loss of blood are very much the same as from shock and luckily respond to the same treatment. In addition, if there chances to be a fountain syringe in the camp, give rectal enemas of hot normal salt solution, which can be made by dissolving a teaspoonful of common salt in a quart of sterile water. In some way this solution seems to take the place of the blood lost. A hot application over the heart is also valuable, as are mustard drafts to the spine.

MEDICAL TREATMENT OF CAMP DISEASES