CHAPTER XXX. SCALP AA^OUNDS. (Part 2)

in the formation of clots which can only favor subsequent suppuration. The drier the wound Avhen closed (other things being equal) the more reason we have to anticipate prompt healing. Oozing may be checked in many ways ; by the use of heat, pressure, styptics and sutures, or a combination of these. A method which will in most instances be found all that is required, is as follows: take a gauze sponge of appropriate size wrung out of hot salt solution, pack it into the wound and make firm pressure with the hand from two to three minutes. When the sponge is removed the wound surfaces will be found dry and will not begin to bleed again unless roughly handled. This procedure is best carried out just before closing the wound Avhen the manipulations necessary to preparation have been completed. A solution of 1 :2,000 of adrenalin may be used to advantage in controlling oozing but strong chemical styptics should be avoided because of the injury they do to an already trauma- tized tissue. Oozing from the edge of the wound, especially of the venous type, will almost invariably stop when the sutures are placed and tied. After the wound has been closed it is advisable as an additional precautioli to make pressure from one to two min- utes to prevent the continuation of oozing and to express any blood which may have collected under the closed scalp. When it is necessary to leave buried sutures within the tissues plain cat- gut will be found the best. If hemorrhage can be controlled without the use of buried sutures it should be done. SCALP WOUNDS 387 Fig. 512. — Ordinary scalp wound iJivpart'd for sntnre. Note the clean shavino; of the scalp. Fig. 513. — Sutures taken to bring the mui-gins of the wound together, Fig. 514. — Recurrent bandage of the injured side of head with strips of adhesive applied to prevent slipping. 388 FRACTURES AND DISLOCATIONS 2. The prevention of infection is to be accomplished along lines similar to those already laid down under the ''Treatment of Com- pound Fractures" (see page 789). Too much cannot be said in condemnation of the so-called antiseptics, such as bichlorid of mer- cury, which invariably do more harm to the already damaged tis- sues than they do to the germs of infection. The wound should be treated by attempting to remove the infection which has already gained entrance and not by killing it in situ. In other words we should endeavor to render the wound aseptic rather than anti- septic. It is of course practically impossible to remove all infec- tion from the scalp, yet w^e may so reduce the number of bacteria present when the wound is thoroughly prepared that nature is enabled to dispose of those remaining without the formation of pus, in which case the wound is said to heal by first intention. Crushed and devitalized tissue has no resistance and can serve no purpose within the wound except to act as a culture medium for infection and the same may be said of collections of dead blood. The indications therefore are to approximate healthy tis- sue and to avoid the extravasation of blood and serum within the wound. Clinically every scalp wound must be considered infected, yet we must not lose sight of the fact that additional infection and germs of different strains may be introduced within the wound by the surgeon, if aseptic regulations are not observed. The first indication in the treatment of scalp wounds (aside from the con- trol of severe hemorrhage) is the shaving of the scalp surrounding the wound and the cleansing of the wound itself. Blood and dirt should be wiped away from the hair which is then clipped away for a distance of two to two and a half inches surrounding the wound. This region is next covered with lather and shaved, care being exercised to prevent the hair and dirt from entering the wound. After this has been accomplished the wound is irrigated with salt solution and the unshaved portions of the scalp dried with a sterile towel. When the surgical surroundings are favorable an assistant should perform the preparation just described so that the surgeon may approach the prepared scalp with clean hands. If, however, the surgeon is treating the wound unassisted he should re-sterilize his hands and whatever instruments may have come in contact with the wound during preparation in order that the subsequent ma- nipulations may be rendered sterile. The scalp is then once more SCALP WOUNDS 389 irrigated in and about the wound and the surgeon is ready to explore the depths of the wound to remove infectious materials such as hair, felt, gravel, cinders, etc., and to trim away devitalized tissue. Isolated hairs show a strong tendency to cling to the inside of the wound and it is frequently necessary to pick them out in- dividually with thumb-forceps even after the wound has been thoroughly irrigated and is supposedlj^ clean. Tincture of iodine may be used on the surface of the scalp, either full strength or diluted, but is best kept out of fresh scalp wounds. Other anti- septics within the wound are not only useless but harmful and should not be employed. 3. Detection of complications. — After the hemorrhage has been controlled and infection prevented, as far as possible, the wound is ready for the sutures, but before these are placed the surgeon should satisfy himself that no symptoms of complications have escaped observation. The majority of scalp wounds may be ex- plored sufficiently without incision to satisfy oneself as to the con- dition of the underlying skull, and when further opening of the scalp is necessary it is in most instances easily accomplished under local anesthesia. The local examination should be carried to a conclusion satisfactory to the surgeon and other symptoms of frac- ture of the skull noted when present. The ears and nose should be examined for hemorrhage and the eyes examined as to their position and pupillary reactions, the consciousness of the patient noted and the deep reflexes of the two sides compared. In other words, if fracture of the skull is present or suspected we should examine the patient for all the symptoms both local and general which are known to occur following; fracture of the skull. (See symptoms of "Fractures of the Skull," page 411.) 4. Closure of the wound. — After the preceding three steps have been carried out the wound should be closed by interrupted sutures, preferably of silk worm gut, extending down to but not penetrating the galea. The question of drainage is a difficult one to settle and mistakes are sometimes made by those possessing the greatest experience. The greater the contusion or laceration the greater the probability that the wound will need drainage. If the patient can be kept under close observation following the closure of the wound it will usually be unnecessary to provide drainage, since pus can be detected and evacuated with little difficulty should it form within the wound. If, however, the circu.mstances are such 390 FRACTURES AND DISLOCATIONS that the patient is not seen for a day or two following the first treatment, it is safer to provide drainage. When the drain is em- ployed it should be placed in the most dependent position possible and when necessary counter-openings are to be made through the scalp and drains inserted. A rubber tube about the size of a thin lead pencil, sewed into the lower angle of the wound will be found a satisfactory form of drain. The wound may then be covered with gauze and a recurrent bandage applied to the head. When the wound is small the gauze dressing may be secured to the shaven scalp by means of collodion. After-Treatment. — The most important element in the after- treatment consists of the detection of pus within the wound; the case should therefore be kept under close observation. The wound should be dressed and inspected at least once in twenty-four hours during the first week and if pus is suspected a fine probe, pre- viously sterilized, in a flame, may be passed into one corner of the wound and the content, if present, evacuated. If pus does develop during the after-treatment, it should be thoroughly evacu- ated and openings maintained sufficiently large to allow free egress of the septic detritus. An infected wound should be freely drained so that granulation tissue will fill it from the bottom. The aver- age clean wound will be solidly healed in ten days and the stitches should be removed on the eighth or ninth day. When the wound is infected the healing is much sloAver, sometimes lasting for weeks ; during the treatment of this type of wound granulations may be stimulated by the use of balsam of Peru, and in some cases tincture of iodine painted over a foul granulating surface will render it clean and active in the course of a few days. The way in which iodine acts is uncertain yet excellent results follow its use in selected cases. The application of iodine to granulation tissue is quite different from its use on a fresh wound, where no special resistance has been developed, the circulation of the parts is not intact, and the vitality of the tissues reduced by trauma. When the loss of tissue is such that the scalp cannot bo closed at the first treatment, skin-grafting should be resorted to if the defect is one which cannot be filled by granulation within the first two or three weeks.