Gelbart (1998) reviews the history of wound care from ancient times, when the main treatment was the application of mud and leaves. Sesame oil was used in Babylon around 2250 BC and is thought to inhibit the action of staphylococcus.
Honey and sugar were staple agents and wounds might be irrigated with sea water (advocated by Hippocrates 460-370 BC) or vinegar (advocated by Celsius, 25 BC-50 AD). The Romans treated wounds with myrrh, which has been shown to be bacteriostatic against Staphylococcus aureus. The physician Galen advocated the use of wine as a wound cleanser. Wound sepsis was a con-tinuing problem and it was poorly understood. Before the advent of antibiotics, wound infection was mainly due to haemolytic streptococcus; now, however, since the development of methicillin-resistant staphylococcus aureus (MRSA), Staphylococcus aureus is the predominant pathogen isolated from wounds, followed by E. coli., Streptococcus faecalis and Pseudomonas aeruginosa.
Aromatherapy
As we have seen in Chapter 3, essential oils have bacteriostatic properties although their role in wound care has yet to be firmly established. In an excellent review of the use of essential oils in wound care, Baker (1998) raises the issue of the lack of consensus on oil use between aromatherapists. In particular, there is no definition of what constitutes a small wound, there is some discrepancy in views on how the oils should be applied to the wounds, and no references are given. Of particular concern to Baker is the advice given on the use and manage-ment of dressings which is at variance with current wound care practice. Bearing in mind that aromatherapy books are available to the general public who may not be aware of current practices in wound care, nurses may need to modify the patients' application and use of essential oils. One good example of this is the use of lavender oil on burns. Tiran (2000) tells the story of Gattefoss, the originator of modern aromatherapy, who burned himself in his laboratory, plunged his hand into a bowl of lavender oil and reported that his hand healed up very quickly and without any scarring. However, practitioners need to be aware that the St John's Ambulance and the British Red Cross Society do not recommend the use of any oils or ointments on a burn as a first aid measure.
Herbalism
The use of honey as a wound cleanser and a promoter of healing has been known for 4000 years. It promotes granulation and tissue formation, is antimicrobial and
Problems related to washing and dressing 141 reduces oedema (Efem 1988, in Bone 1994). The key ingredient has been identi-fied as hydrogen peroxide which is formed as a result of glucose oxidase from the bee with glucose in diluted honey (White & Stubers 1963). Allen et al (1991) noted that New Zealand honey from one specific source, Manuka, was superior to 26 other types of honey against Staphylococcus aureus. Comparing the honey with another monofloral honey (Knightia excela) against a number of wound pathogens, Manuka honey showed superior results against E. coli and Staphylo-coccus aureus,whilst Knigbtia excela was more responsive to Streptococcus pyo-gene and Salmonella typhus. However, neither was particularly active against Pseudomonas aeruginosaand Proteus mirabilis, which are common contaminants of Superficial wounds. However, as Postmes et al (1993, in Bone 1994) point out, the composition of honey is not always constant and it may contain traces of pes-ticides or drugs used in bee keeping. They suggest that the highest possible stand-ards must be maintained if honey is to be used for medicinal purposes: it must be sterile and free of any contaminants, and more research is needed into its use.
Another bee product, already mentioned in Chapter 3, that has a key role in the treatment of wounds is propolis, which has been used since ancient times to heal sores and ulcers. Today, it is still used regularly in Eastern Europe. Propolis has been shown to be effective against Staphylococcus aureus, although less effec-tive when compared with standard antibiotics (Scheller 1977, in Bone 1994).
However, in vitro tests have demonstrated that propolis can potentiate the action of other antibiotics (Kivalkina & Gorshunova 1973, in Bone 1994) and anti-biotic resistant strains of Staphylococcus au reus have become sensitiveto the antibiotics erythromycin, tetracycline and penicillin when the drugs were com-bined with propolis (Shub et a11981, in Bone 1994).
One trial of propolis on patients with infected wounds found that external treatment with propolis accelerated wound healing, with half of the invading organisms disappearing within 4 days (Damyanliev et al 1982, in Bone 1994).
(Scheller et a11980, in Bone 1994) in demonstrated that topical use of propolis on surgical wounds, burns and ulcers achieved up to 80% faster healing rate when compared with conventional healing methods.
Other wound care treatments include the herb St John's wort which will be dis-cussed again in Section 3. Paracelsus describes it in the treatment of wounds as fol-lows: 'Its virtue is beyond all description, how great it truly is and what can be achieved by it ... itis not possible that any better remedy for wounds will be found in any country.' One of the reasons it was used as a remedy was the ancient doc-trine of signatures, based on the concept that the therapeutic properties were reflected in the herb's shape and colour. When the leaves of the St John's Wort are crushed they stain the fingers red, thus giving the idea that they are good for stop-ping bleeding and, according to Culpeper,'itis a singular wound herb ... it heals inward hurts and bruises ... and as an ointment closes up the lips of wounds' (Culpeper 1653). Hahn (1992) reviews its use against Staphylococcus aureus in the form of hyperforin, and it is anti-inflammatory and anti-ulceric (Berghofer&
Holzl 1989).
Comfrey (Symphytum officina/e) is an impressive local healing agent for wounds and slow healing ulcers. Also known as bone knit, its claimtobe a mir-acle worker is pre-eminent. Its leaf structure contains more protein than any other member of the vegetable family (Bremness 1995). The leaf and roots con-tain allantoin, which encourages cell division, and mucilage, which promotes the reconstruction of tissue (Bremness 1995). Wound healing and analgesic activities
142 0-11 years
have been shown in animal studies (Goldman 1985). The toxicity of comfrey has been under debate for some time. Two incidents of hepatotoxicity have been reported following ingestion of comfrey. In both incidents, the ingestion was chronic and resulted in veno-occlusive disease, whilst acute toxicity can result in hepatic necrosis. Liver damage is by no means inevitable, as demonstrated by Anderson and McLean (1989) who examined 29 chronic users of comfrey who showed no signs of hepatotoxicity. However, it is now recommended that com-frey be used only on intact skin (Barnes et aI2002), although Mills (1993) points out that some species of comfrey are lower in alkaloids than others and suggests that drying and metabolising the herb further reduces their availability. He fur-ther points out that the leaf has always been shown to have negligible quantities of the alkaloid.
In animal studies, aloe vera (Aloe barbadenis) in a gel preparation it has been shown to be effective against radiation burns, skin ulcers and peptic ulcers (Parmar 1986). Clithra et al (1998) demonstrated the use of aloe vera in healing dermal wounds on diabetic rats. Following serial examination of the wounds, results indicated that aloe vera enhanced the healing process by influencing each of the healing phases, i.e. inflammation, fibroplasias, collagen synthesis and maturation and wound contraction. It was thought that the effectof the gelwas due to its hypoglycaemic properties. The role of aloe vera as an anti-inflammatory agent was demonstrated by Vazquez et al (1996) using the classic induced oedema in a rat's paw. In the treatment of pressure sores to assist healing, aloe vera exhibited an anaesthetic reaction, antibiotic reaction and increased local microcirculation (Cuzzell 1986). The action of the aloe vera gel is said to be related to the high water content of the gel (Grindlay& Reynolds 1986) and the sugars within the gel are thought to inhibit bacterial growth. It has been sug-gested that the gel mimics modern polysaccharide hydrogel and hydrocolloid dressings. In vivo studies have reported activity against Pseudomonas aerugin-osa, Staphylococcus aureus, E. coli and Klebsiella pneumoniae (Grindlay &
Reynolds 1986). Marshall (1990) summarised some of the problems in evaluat-ing aloe vera, statevaluat-ing that few of the studies are precise enough in identifyevaluat-ing the exact species of aloe vera or the plant part from which the gel is extracted, and that more good research is needed. In a review of the research since 1986 into the action of aloe vera, Reynolds and Dweck (1999) state that research has largely upheld the therapeutic claims for the plant.
Ayurvedic medicine
In Ayurveda, aloe vera is regarded as a general tonic for the liver. Its effects are anti-vata, anti-pitta and anti-kapha so it is generally rebalancing. It is seen to have cooling properties and is used with the herb turmeric for the treatment of burns and traumatic wounds. Turmeric has anti-inflammatory properties, and is a general tonic and a natural antibiotic. Traditionally, ghee is said to pacify all three doshas, and imbalances of the three doshas affects the body's natural resistance or agni, which leaves the body vulnerable to infection. Ghee promotes the healing of wounds and is used locally on burns. Honey is recognised for its healing properties and is seen as a warming substance, acting to reduce vata and kapha, A ghee made from licorice is also used on septic wounds.
Problems related to washing and dressing 143
Anthroposophical medicine
Anthroposophical medicine suggests that wounds are washed with calendula 20% and that burns are treated with compresses of combudoron, which is later used as an ointment. Combudoron consists of a blend of leopard's bane (Arnica montana) and nettle (Urtica urens). Wound healing in Anthroposophical medi-cine is related to the polarity principle. The original wound, exhibiting signs of inflammation and pain, indicates increased activity of the astral body and ego (heat). As the wound starts to heal, the etheric body regenerates the destroyed tissues. When the wound heals, the etheric body partly withdraws and the astral body resumes its actions.
Homeopathy
The homeopathic approaches to wound care and pain (Ch. 5) should be con-sidered in conjunction with one another, and the specifictypes of wounds and their presenting symptoms indicate specific remedies. Gemmell (1997) cautions against leaving infected wounds too long and recommends hospital or medical referral if the patient is feeling feverish and unwell, or if the wound is exuding any pus. However, for minor, clean wounds a homeopath may recommend bathing the area with Calendula lotion and taking Calendula to stimulate healing, Aconite for shock and Arnica to reduce bruising. Since some parents who use homeopathic remedies may not have had their children inoculated, they should be appraised of the dangers of tetanus and urged to have the anti-tetanus vaccine.
Puncture wounds, for example animal bites,wouldbetreated with Ledum palustre, however all animal bites must be referred for medical attention, although home-opathic remedies may be given at the same time.