If the patient has to be transported, wrap the part in sterile gauze or other sterile material, hold the dressing in place with a bandage, and place the injured member on a pillow. Do not attempt to move the patient until the symptoms of shock have disappeared.

After treatment.-Small lacerated wounds may be given a light coat of tincture of iodine and also the skin for a considerable area around them. Then apply a dressing of sterile gauze. It is not necessary to put any medicinal substance on fresh wounds to make them heal. If bacteria are kept out of the injuries, they will heal quickly enough.

Large lacerated wounds are treated according to the general principles which have been laid down.

Foreign bodies are removed by a boiled forceps or the fingers after special preparation of the hands. If much dirt has been ground into the tissues, it will be necessary to wash the wound out with freshly boiled boric-acid solution (p. 188), 1 to 5,000 bichloride of mercury solution, or boiled salt solution made by adding a teaspoonful of salt to each quart of water. After cleansing the wound, dry it if dry sterile gauze is available and apply a dry sterile dressing and hold the dressing in place with a suitable bandage.

Crushes of the extremities are laid on a pillow. The part is gently molded in its natural shape. Small wounds are painted with tincture of iodine. Large dirty wounds are cleaned out with antiseptic solutions. The wounds are dressed. After swelling has subsided, suitable splints are applied if fractures are present.

Lacerated wounds in which the tissues have been badly or extensively damaged are almost certain to become inflamed. When inflamtation sets in, treat according to the general rules for inflamed wounds (p. 194).

The Carrel-Dakin solution.-Many of the severely lacerated wounds, due to shell injuries in modern warfare, have been recently successfully treated by intermittent irrigation with a mild antiseptic fluid called the Carrel-Dakin solution.

The skin around the injury is protected with vaseline and a number of perforated rubber tubes attached to a reservoir are inserted to the bottom of the wound so that the fluid will reach all parts of the injury. The tubes in the wound are loosely surrounded with gauze. Sufficient of the solution is run through the tubes every two hours to wet the gauze thoroughly, but no more. This method has given excellent results in trained hands, but its proper application is too complicated for the layman.

Dakin has recently suggested the use of dichloramin-T in solutions of chlorinated oil to obviate some of the difficulties of the Carrel method. The use of this remedy is simple, as the oily fluid is merely sprayed once a day onto the wound with an atomizer and then a fresh

dressing applied. Some very favorable reports have been already made on treating wounds with this solution. It is hoped that they will be verified by more extended research, as its simplicity would highly recommend it for use by the layman in emergencies.

PUNCTURED WOUNDS.

As has already been stated, punctured wounds are especially dangerous because bacteria may be carried deeply into the tissues where conditions are very suitable for their growth. Lockjaw not infrequently developes from such injuries. Always examine the article which inflicted the injury to determine if the end may have been broken off in the wound.

Treatment.-An effort should be made to disinfect the wound with tincture of iodine. Take a toothpick and twist a small amount of cotton around one end. Dip it in the iodine. Then push it down to the bottom of the wound and work the iodine thoroughly into the tissues. Paint the surface with tincture of iodine and apply a sterile dressing. All these patients should be taken to a doctor to have him determine whether injections of antitetanic serum are necessary to prevent lockjaw. (See Tetanus, p. 196.)

SEWING UP A WOUND.

The layman should never attempt to sew up a wound if a physician is within reach. However, on shipboard or in other isolated places, it may be absolutely necessary for an untrained person to attempt this operation if the wound is large or gaps freely. It is better not to sew up a very deep wound unless it is long and the edges gap very widely. The edges of a great many large wounds can be brought together and held in place by suitable compresses and bandages. In sewing up a wound all the instruments, needles, thread, etc., should be boiled immediately before the operation. Prepare several stout needles, a pair of scissors, a probe or a hairpin, and a thimble, also an extra pan or basin in which to place sterile dressings or other instruments if occasion arises. Take heavy thread which will go through the eyes of the needles and cut it in lengths about 12 inches long. All these materials, as has been said before, are boiled and left in the pan in which they have been prepared. The hands are carefully sterilized as described on page 184. The wound, if clean, is swabbed with tincture of iodine, also the surrounding skin. If the wound is dirty it is cleaned out with boric acid solution or bichloride of mercury, 1 to 5,000, as previously described. The threaded needle is inserted into the flesh about one-quarter of an inch from the edge of the wound and pushed through so that it emerges at the bottom, including a good bite of the tissues in its course. It is then reinserted in the bottom of the wound and made to emerge on the oppo

site side about one-quarter of an inch from the edge of the incision. The thread is cut off leaving enough material so that it can be tied. The stitches are placed about one-half an inch apart and are tied with just sufficient tension to bring the edges of the wound together and yet not exert pressure (fig. -). Use too few stitches rather than too many. After tying, the ends are cut off leaving about one-half an inch from the knot. If the edges of the skin tend to turn in when the stitches are being tied they should be lifted up and placed in proper position with the probe or hairpin. It is necessary for the raw edges to be accurately approximated if good healing is to be secured without a scar. If the wound has been lacerated or has contained dirt, make a wick by twisting 10 or more strands of thread, depending upon the size of the injury, lightly together, and lay it in the bottom of the wound at the lower end, allowing about an inch of the wick to extend over the side in order to provide drainage. This wick is removed on the second day if no symptoms of inflammation have appeared.

The thread used for sewing wounds may be either cotton, silk, or linen. Considerable difficulty may be experienced in pushing the needle through the skin, which is quite tough, and a thimble will be of material assistance in this part of the operation. After sewing up a wound it is well to paint it and the surrounding skin for a wide area with a coat of tincture of iodine, half strength.

Remove the stitches at the end of five days. Use boiled instruments and sterile hands when removing the stitches. Cut the stitch on one side of the knot, and remove by pulling on the knot end (fig. 150).

INFLAMED WOUNDS.

Symptoms. Sometimes after a wound has been received and dressed all goes well for a day or two and then the wound becomes painful and begins to throb. If the wound is extensive, the patient has fever, the tongue is coated, and there is considerable constitutional disturbance. This condition is known as surgical fever and is due to the absorption of the poisons which are produced in the wound by the pus-producing bacteria. In such cases a physician should be called at once. If no physician is available the dressing should be removed and the wound inspected. The edges will probably be swollen, dry, and stuck together and there will be a diffuse redness of the skin surrounding the injury. It will be necessary to open the wound sufficiently to allow the matter which is forming within to escape. This can be done by boiling a probe, a hair pin, or some small blunt instrument, and then gently inserting it between the edges of the wound and opening them slightly. If the edges are not stuck together and fluid is escaping from the wound, do not attempt to open

it any more. Wet dressings should now be applied. These should consist of from 4 to 12 layers of gauze, depending upon the size of the injury, which are wet in a freshly prepared boiled solution of boric acid. Make the solution by boiling a pint of water in a clean saucepan and then stirring into it a heaping tablespoonful of boricacid powder. Stir it until it dissolves and permit it to cool. Wet the gauze in this solution and lay it on the wound. Cover the dressing with a piece of oiled paper and renew the solution every four hours. A wet dressing should be thick and large enough to cover a considerable area around the injury. It should be kept wet by pouring a little more of the boric-acid solution under the oiled paper every three or four hours, day and night, if the symptoms are serious.

Further treatment. In a great majority of inflamed wounds as soon as the matter begins to escape freely from the wound the signs of inflammation gradually subside. Such wounds should be washed out at least once a day with a freshly boiled and cooled solution of boric acid as above described, or a 1 to 5,000 solution of bichloride of mercury, or if these are unavailable, a solution made of one teaspoonful of common salt to a pint of boiled water. Wet dressings should be continued for four or five days. After the pus begins to flow freely care should be taken that the edges of the wound do not grow together too soon, which will dam up the pus and cause the wound to become inflamed again. To insure the wound keeping open the edges should be gently separated every day with a probe or hair pin which has been boiled. The dressing should be changed as frequently as they become soiled with the escaping matter. Wounds which are discharging pus freely are known as suppurating wounds. Such wounds at times refuse to heal and become indolent. Indolent wounds may be irrigated with a solution made by adding enough tincture of iodine to boiled water to make it a port-wine color.

Inflamed wound of the hand.-It sometimes happens that slight injuries of the fingers or hands are followed by signs of rapidly spreading inflammation. The injured finger swells first, then the hand and forearm; the skin is red; painful kernels form under the armpit; red lines may extend up the arm; and the patient feels feverish and sick. There is also pain and throbbing in the part. The treatment for such cases is to open the wound freely with a sterile knife or probe and to wrap the whole hand and arm with several thicknesses of turkish toweling which has been wet in the boric-acid solution above referred to (fig. 151). The addition of one part of alcohol to four parts of the solution is helpful. In the absence of boric acid use plain water, adding 20 per cent of alcohol, if it is available. Put the patient in bed, lay the arm on a pillow, keeping the dressing constantly wet day and night, and keep it warm by surrounding it with hot-water bottles. In such cases every possible effort should be made

to obtain a doctor at once, for the condition is very serious and may terminate fatally unless promptly controlled. Continue this treatment until the symptoms subside or medical help is obtained.

In the meantime the patient's strength should be supported by a light and nutritious diet, giving eggs and milk freely if they are obtainable. At the onset of the symptoms a purgative should be administered and the bowels should be kept open daily during the attack. Rest of the part is extremely important when inflammation starts in a wound. If the finger or hand is involved, put the arm in a sling. If the arm is affected, put the patient in bed and lay the arm on a pillow. Rest in bed is required if the wound is in the foot or any part of the lower extremity. Never dress a wound with compresses wet with a solution of carbolic acid, as gangrene is apt to follow.

INFLAMED LEG ULCERS.

Treatment. If a leg ulcer becomes inflamed the patient should be put in bed and the foot elevated. Wet compresses of boric-acid solution or of salt solution, made by adding a teaspoonful of salt to a pint of water, should be applied for three or four days until the inflammation subsides. Then the ulcer may be dressed with oxide of zinc ointment or boric acid ointment. Rest in bed with elevation of the leg is very beneficial in the treatment of all leg ulcers.

TETANUS OR LOCKJAW.

Description.-Tetanus is a dangerous disease due to a particular kind of a germ which is introduced into the body by some sort of an injury, frequently a slight wound.

Symptoms. The symptoms of tetanus are varied, but one of the most characteristic points is a stiffness of the neck and the lower jaw. Later on spasms of other parts of the body develop. The disease is extremely fatal, the mortality ranging somewhere between 50 and 85 per cent. The germ which causes tetanus (fig. 152) is found especially in garden soil, in street dirt, and the dust around stables. It can not grow in the presence of air, hence lockjaw is apt to develop after deep punctured wounds, especially those due to nails or farming implements, and also in lacerated wounds into which street dust or soil has been forcibly ground. Tetanus has always been prevalent among the wounded in armies, but especially so in the early part of the present European war. This was probably due to the fact that the troops were fighting in trenches and soil and dirt, cr pieces of soiled clothing were frequently forced into their wounds. Tetanus often follows Fourth of July injuries, especially wounds from toy pistols. A large number of cases were formerly reported every year in the United States after the celebration of the Fourth.