is I Edition, May, 1917.
Reprinted August, 1917.
2nd Edition, February, 1918.
THE TREATMENT OF
INFECTED WOUNDS
BY
A. CARREL AND G. DEHELLY
TRANSLATION BY
HERBERT CHILD
CAPT. K.A.M.C. (TY.), FORMERLY SURGEON, FRENCH RED CROSS
WITH INTRODUCTION BY
SIR ANTHONY A. BOWLBY
K.C M.G., K.C.V.O., F.R.C.S., SURGEON-GENERAL, ARMY MEDICAL SERVICE
ADVISING CONSULTING SURGEON TO THE BRITISH ARMIES IN FRANCE
SECOND EDITION
LONDON
BAILLIERE, TINDALL AND COX
8, HENRIETTA STREET, COVENT GARDEN
1918
PRINTED IN GREAT BRITAIN.
INTRODUCTION
I HAVE been asked to write an Introduction to the
English edition of the work by Dr. A. Carrel and Dr. G.
Dehelly, and I am glad to take the opportunity of ex-
pressing the appreciation of British surgeons at the
Front of the value of what is known to us as " Carrel's
Method."
Whenever it has been thoroughly carried out it has
accomplished all that is claimed for it by its author, and
it has been of inestimable benefit to thousands of patients.
It has also renewed faith in antiseptic methods, in spite
of the attacks on their utility which characterised the
early stages of the war, and has done the greatest good
by setting a high standard of thorough excision and
surgical cleanliness. The whole practice of war surgery
has been greatly improved by Dr. Carrel's confidence
that antiseptic treatment can sterilise a septic wound,
and that it does do so if sufficient care and skill are
bestowed upon it ; and the lesson he has taught was
very necessary.
The book itself will be found to convey in the
clearest manner the knowledge of those details which
have been so carefully elaborated by the patient work
of two years' experience, but it is only by scrupulous
attention to every detail that the best results will be
obtained.
vi INTRODUCTION
I would also suggest that, if " Carrel's Method " is to
be fairly judged, no change whatever should be made
either in the Dakin's solution itself, or in the use of
the tubes for instilling it. The tendency has often been
so to modify these details, in the belief that they were
thereby "improved," that the author himself would be
the first to disclaim the improved methods which are yet
called by his name. The only modification that seems
justifiable is the use of the syringe when instillation by
gravitation cannot be carried out, as in trains, ships, and
many units at the Front. It will be time enough to
introduce other modifications after a prolonged trial of
the methods advised in this publication.
The utility of Carrel's method is not confined to
recent wounds, and, in the following pages, those surgeons
who are treating the wounded in Great Britain will find
all the necessary information for the treatment of both
healthy and suppurating wounds.
The Army Medical Department has already arranged
that, in those cases where it is employed, this treatment
can be continuously carried out not only in the Front
and Base Hospitals, but also in Ambulance Trains,
Hospital Ships, and Hospitals in Great Britain.
To the workers in each of these areas of surgery this
book will prove of the utmost practical value, and I feel
certain it will be of the greatest value of ail to the
patients themselves.
ANTHONY A. BOWLBY.
GENERAL HEADQUARTERS,
B.E.F., FRANCE,
February p , 1918.
PREFACE TO THE SECOND
EDITION
IN this New Edition will be found a description of the
technical improvements which have been effected during
the last few months. We have also thought it desirable
to demonstrate the fresh results which have been ob-
tained in the treatment of old wounds, old fractures, and
other surgical affections.
COMPI&GNE, 1917.
PREFACE TO THE FIRST
EDITION
THE researches which are dealt with in this book were
made in the laboratories established at Compiegne by
the Rockefeller Foundation, and at the Temporary
Hospital, No. 21, under the Service du Sante militaire.
The chemical laboratory was directed by Dr. Henry
D. Dakin, 1 who there made the experiments upon which
the sterilisation of wounds is founded. In the biological
part of his experiments, Dr. Dakin was assisted by M.
Daufresne and Mme Carrel. Chemical research was
carried on in the same laboratory by M. Daufresne.
Le medecin-major Vincent, of the colonial forces, directed
the bacteriological laboratory. The mathematical and
physical portion of the researches was done by M.
Lecomte du Nouy and M. Jaubert de Beaujeu. The
physiological and surgical experiments were made with
the help of Miss Lilly. Photography by MM. Pierre
Magnier and Baillergeau.
The wounded were treated successively by M. Dumas,
and by le medecin-major Bernoud of the colonial forces,
then by MM. Woimant, Audiganne, and Guillot. MM.
1 Dr. H. D. Dakin, Director of the Herter Laboratory, New York,
was one of the candidates selected by the Council of the Royal Society to
be recommended for election into the Society. (B. M. /., March 13, 1917.
Translator's note.]
ix
x PREFACE TO THE FIRST EDITION
Guillot and Woimant dealt with the surgical experiments.
Clinical investigations into the cicatrisation of wounds
were made by Mile Hartmann and by Mme Carrel. M.
Jaubert de Beaujeu was in charge of the radiological
laboratory.
The administration of the hospital and the laboratories
was in the hands of les officiers d'administration Bierer
and Bois, successively.
The nursing was done by the infirmieres of 1'Ecole
de la Source, superintended by Mme Carrel, by Mile
Weilenmann and Mile Junod, and by the American
nurses of the " Post Unit."
The military administration of the hospital was
directed by medecin-major Bernoud, of the colonial
forces.
The hospital was controlled by M. le Sous-Secretaire
d'Etat du Service de Sante, and all the details of its
organisation and administration were in charge of M. de
Piessac, of the Sous-Secretariat d'Etat.
A. CARREL.
COMPlfeGNE,
September i, 1916.
CONTENTS
PAGE
Introduction by Sir Anthony A. Bowlby v
Preface to the Second Edition vii
Preface to the First Edition ix
Introduction I
I. The Principles of the Technique 14
II. The Technique of the Manufacture of Dakin's Solution 93
III. The Technique of the Sterilisation of Wounds-
Mechanical, Chemical, and Surgical Cleansing . 109
IV. The Technique of the Sterilisation of Wounds
Chemical Sterilisation 135
V. The Clinical and Bacteriological Examination of
Wounds ~r 173
VI. The Closure of Wounds 205
VII. The Results .216
Appendix. Chloramine Paste 258
Index 259
THE TREATMENT
OF INFECTED WOUNDS
INTRODUCTION
I. IT is well known that nearly all the wounds resulting
from explosions of shells, torpedoes, and bombs are
septic ; and that the methods employed up to the present
in the treatment of these wounds are generally impotent
to check the progress of the infection. To be convinced
of this, one has only to be present at the arrival at a
base hospital of a convoy of wounded, who have been
operated on in the dressing-stations or the hospitals
near the front. Then one grasps the danger of those
paradoxes upheld by surgeons who still deny the uni-
versality of infection.
That the septic character of wounds is disastrous is
also well known. During the early hours, or the first few
days, the wound is exposed to the danger of gas-producing
infection. Later are developed the various infections,
which, either in the seat of fracture, in joints laid open, or
in extensive lacerations of soft parts, sometimes give rise
to lesions leading to amputation or to death. At the
hospital of the Maison Blanche, M. Tuffier, as a result of
the examination of a large number of cases of amputa-
tion, found that about 70 per cent, of the operations
1 I
2 TREATMENT OF INFECTED WOUNDS
were needed because of the presence of infection, and
were not due to the extent of the anatomical lesions.
Even when the patient has had the good fortune to be
operated on close to the scene of action by a competent
surgeon, and has escaped the serious infections of the
early stages, suppuration still occurs, and continues in-
definitely. Sometimes it becomes a danger to life or
limb, and almost always brings about adhesions between
muscles, aponeu roses, tendons, nerves and vessels. After
healing, the patient has scars of large area, often painful,
which prevent the limb from resuming its normal func-
tions. Tendons remain gripped in fibrous fetters. Nerve
extremities which have been bathed for weeks in pus,
sclerose. Deep in infected bones, osteo-myelitis springs
up. For months, maybe years, the limb still suppurates.
Joints ankylose, muscles atrophy, and the wounded man
becomes unfit, not only for being a soldier, but for work
of any kind.
The suppression of wound infection would protect a
large number of men from incapacity or death, and would
bring about the rapid restoration to health of the greater
number of those whose anatomical lesions are compatible
with life. Such progress would result in great saving in
money and men.
It would seem, however, that hitherto practically no
really systematic research has been carried out with the
object of discovering the procedure needful to bring about
this improvement in treatment of wounded. As a matter
of fact, attempts have been made by isolated individuals
and often with extemporised equipment. Experi-
menters have attempted, working alone, researches which
needed the co-ordinated efforts of chemists, pathologists,
INTRODUCTION 3
bacteriologists, trained in scientific technique. Pro-
ceedings of learned societies are laden with reports,
based for the greater part on experiments and observa-
tions, incomplete, vitiated by faulty methods. No
results of value were obtained. Despite the academic
toil of many surgeons, wounds suppurate to-day as
freely as ever.
It is known, however, that, under certain conditions,
infected wounds can be rendered sterile. Lister, un-
doubtedly, by the aid of carbolic acid, succeeded in dis-
infecting compound fractures, at a time when such an
injury was of the gravest import. Nevertheless, modern
surgeons disregard these facts. Not only have they
despised the road opened up by Lister, but they even
question the possibility of applying the principle of
antiseptics to war-wounds.
The throwing-over of Lister's ideas came about, not
so much from the inadequacy of his method, as from the
carelessness with which it was applied. In clinical re-
searches, the basic principles of scientific investigation
were forgotten. Methods utilising measurements were
rarely employed. In the wounds investigated, it was
never sought to estimate exactly the relations which
exist between the number of microbes present, their
nature, and the rapidity of cicatrisation. Any substance
which possessed the property of destroying microbes in
vitro, was looked upon as an antiseptic, and used in the
treatment of wounds, every man to his taste. Substances
which coagulated proteids, which lost their bactericidal
power in the presence of serum, or which were actually
harmful to the tissues, were all used. What degree
of concentration of a bactericidal substance was to
4 TREATMENT OF INFECTED WOUNDS
be used at the surface of a wound, how this degree of
concentration was to be maintained such details were
never sought. The period during which this substance
should remain on the surface of the wound, at a given
concentration, was never determined. No careful study
was made of the quantitative modifications, produced by
the antiseptic agent, of the microbial flora, modifications
which can only be revealed by daily bacteriological ex-
amination. The action of antiseptics on tissue repair
was ignored, although it was important to learn how
much the substances employed would impede the
progress of cicatrisation. In a word, in the therapeutics
of septic wounds, we may attribute the stagnation we
have experienced to the lack of precision in clinical
research.
However, Lister's method was held responsible for
technical inadequacies, and surgeons raised to the posi-
tion of a dogma the teaching that antiseptics had no
real efficacy. In a memorandum on the treatment of
wounds in war, 1 MM. Burghard, Leishman, Moynihan
and Wright, wrote in April, 1915, that " the treatment of
suppurating wounds by means of antiseptics is illusory,
and that belief in its efficacy is founded upon false
reasoning." The principal adversary of antisepsis was
Sir Almroth Wright. He believed that Lister's method
was not applicable to war-wounds, and that the microbes,
being carried by projectiles and fragments of clothing
deep into the tissues, were beyond the reach of anti-
septics. Chemical sterilisation of a wound seemed to
him impossible of realisation. " In fact," he wrote in
1 Burghard, Leishman, Moynihan and Wright, Office international
<T hygiene pub lique, 1915, vol. vii. p. 946.
INTRODUCTION 5
1915, "if it were ever to come about that an antiseptic
sterilised heavily infected wounds, that would be a matter
to announce in all the evening and morning papers." 1
Although Sir Almroth Wright's doctrine was founded,
not on observations and experiments made upon wounds
under actual war conditions, but upon ingenious theories
and experiments in vitro, it was accepted by the majority
of surgeons. One of them even affirms that asepsis
ought to take the place of antisepsis, and that anti-
septics not only fail to sterilise wounds, but that
they actually favour the development of microbes! 2
Therefore wounds came to be treated with saline solu-
tions, or the hypertonic solutions of Wright. The
fundamental observations of Lister were forgotten com-
pletely. Nevertheless, theories remained impotent and
infection flourished.
II. However, setting aside theory and confining
oneself closely to fact, the problem of wound sterilisa-
tion seems very simple. It is to be remembered that
the surgical infection, at the outset, is always local. In
war-wounds, it is carried by projectiles, and especially by
fragments of clothing, impregnated with micro-organ-
isms. Before crossing the boundaries of the wound, these
flourish on the surface of the tissues. Therefore, during
a period more or less long, the infection is under control,
since the microbes are, so to speak, within reach of the
hand. The question then is simply, how to destroy them
without harming the tissues ?
1 Sir A. Wright. An Address on Wound Infections. British Medical
Journal, April 24, 1915, p. 721.
2 Pierre Delbet, Bulletin et Memoires de la Societt de Chirutgie t
Janvier, 1916.
6 TREATMENT OF INFECTED WOUNDS
As a difference of resistance exists between, on the
one hand, the tissues provided with a circulation, and, on
the other hand, microbes, isolated anatomical elements
and necrosed tissues, it was useless to seek a substance
which would exercise an elective action on micro-
organisms. Better seek to discover, for a given antiseptic,
that degree of concentration of the solution, and that length
of time during which it must be applied, which, fatal to
microbes, will not produce obvious damage to the tissues.
When, at the end of December, 1914, Henry D.
Dakin and one of the authors of this book sought to
discover the best means of treating wound-infections,
they adopted, for the reasons just stated, the method of
chemio-therapy. Besides, it seemed probable that the
infection of war-inflicted wounds would be unsuitable
for treatment by vaccines or serums. As the inocula-
tion of the tissues by projectiles or fragments of cloth-
ing is massive, and as the germs protected by necrosed
tissues or blood-clots multiply beyond the reach of
lymph-flow, it is extremely unlikely that such thera-
peusis could be effective. Besides, the bacterial flora of
war-wounds is extremely varied. As the large numbers
of wounded and the conditions of the dressing-stations
render impossible identification of the microbes which
infect the wounds, it would be necessary to use vaccines
or serums against dozens of types of germs, aerobic and
anaerobic. Failure of such an attempt is foredoomed.
On the other hand, the problem would appear to be
readily solved by using a substance unirritating to the
tissues, and of a sufficient bactericidal power to kill all
the microbes present in a wound, be their nature what
it may.
INTRODUCTION 7
It was in this direction that the researches tended.
Dakin studied the action on tissues and micro-organisms
of' a considerable number of antiseptics, old and new.
More than two hundred substances were examined in
this manner by him, and he was led, for various reasons,
to make chloramines, 1 and, by a special process, hypo-
chlorite of soda. 2 Thanks to his excellent researches,
we quickly had placed at our disposal substances
endowed with feeble irritating qualities, with a toxicity
for the organism almost nil, but of considerable bac-
tericidal power. We then studied under what con-
ditions these substances could sterilise a wound. These
researches demonstrated that the microbes disappeared,
if the antiseptic remained in contact with the surface of
the wound at a certain degree of concentration during a
prolonged period. Bacteriological examination showed
that infected wounds, treated according to these principles,
became sterile. Thus, quite simply, was realised what
Sir Almroth Wright and modern surgeons consider to
be impossible.
III. The method was applied in the first place to
old wounds, afterwards to recent ones. Sterilisation
was attained in both cases, but the earlier treatment gave
the more rapid results. It has long been admitted that
preventive treatment of a malady costs less in money and
toil than curative treatment. However, infection can be
checked even after suppuration has become established.
In a word, all infected wounds were brought more or
less under control by chemiotherapy.
1 Dakin, Cohen, Daufresne and Kenyon, Proceedings of the Royal
Society, 1916, vol. 89, p. 232.
* Dakin, Prate Mtdicale, Sept. 30, 1915.
8 TREATMENT OF INFECTED WOUNDS
From May, 1915, it became evident that wounds
treated after a certain method by the aid of hypochlorite
or the chloramines of Dakin were sterilised, without any
harm resulting to the tissues or the patient. From that
date, it has been possible to prevent, in the greater
number of cases, infection of wounds, and to abolish,
almost entirely, suppuration in hospitals. At this time
the method was practised in some hospitals of the first
line by le medecin principal Uffoltz, Directeur du
Service de sante d'un corps d'armee, To him and to
his colleagues is due the merit of demonstrating that
infection of wounds treated under the ordinary con-
ditions of a field hospital can be almost entirely done
away with.
During the months of July and September, 1915,
Dakin l published an account of the substances which
gave these results, and the mode of preparation. In
October of the same year, M. Pozzi demonstrated in our
name at the Academic de Medecine the principles which
are fundamental to the chemiotherapy of wounds. 2
These principles were later set forth in a more complete
manner in 1916, in the Archives de Medecine et de
Pharmacie Militaires. 3 On several occasions at the
Academic de Medecine, and at the Societe" de Chirurgie,
M. Pozzi, 4 spoke at length upon the technique and upon
the results of the method, which, from this time forth,
enabled us to sterilise infected wounds, whether newly
inflicted, or of long standing. In communications made
1 Dakin, Presse Medicate, loco citato,
* Carrel, Dakin, Daufresne, Dehelly, and Dumas, Presse Medicale,
Oct. n, 1915.
3 Carrel, Archives de Medecine et de Pharmacie Militaires, May, 1916.
* Pozzi, Acadtmie de Medecine et Societe de Chirurgie, 1915 and 1916.
INTRODUCTION 9
to the Soci^te" de Chirurgie, M. Tuffier 1 pointed out
the results which it was possible to obtain by the same
technique. Le mddecin principal Uffoltz published in
1916 (January) an important article, 2 upon results
obtained in hospitals under his control, by MM. Ferret,
Dupuy, Lemaire, Hornus, Perrin, Vigne, Moyroud, etc.
About the same date, M. Pozzi communicated in our
name to the Academic de Medecine observations demon-
strating that sterilisation allowed wounds to be closed,
in many cases, after a period varying from four to ten
days. On March 28th, M. Pozzi read a paper on a report
by M. Uffoltz concerning the secondary union of wounds.
On April nth, M. Perret read before the Academic
de Medecine a paper in which he announced the results
obtained by the sterilisation of wounds in wards under
his care. Not one of in cases had suppurated. On
May 2nd, one of us read a paper at the Academic de
Medecine on the subject of 153 wounds treated in the
hospital at Compiegne during the month of December,
1915. Of these 155 wounds, 135 were closed. Of the
135 successes, 121 were united before the I2th day.
On May 23rd, M. Qunu demonstrated at the
Societe de Chirurgie the results obtained by MM.
Hornus and Perrin in one of the field hospitals under the
charge of M. Uffoltz. These surgeons had treated 121
wounds in their wards. In 44 cases they had been able
to suture, and the other 77 cases were ready to be
sutured at the moment of M. Quenu's visit. At the
same meeting M. Tuffier read a paper by MM. Dehelly
and Dumas on the sterilisation and closure of wounds
1 Tuffier, Societe de Chirurgie -, 1915 and 1916.
8 Uffoltz, Archives de Medecine et de Pharmacie Militaires^ Jan. 1916.
io TREATMENT OF INFECTED WOUNDS
in war. In 31 out of 33 cases, union by first intention
had been obtained after secondary closure.
Although these results showed, in an unmistakable
manner, that infected wounds could be sterilised and
sutured, yet even when more than a year had elapsed
since the technique had been made known, the chemical
sterilisation of wounds was still an exceptional occur-
rence. It was only at the hospital at Compiegne, at
M. Depage's hospital at Panne, and in two or three
territorial hospitals that the method was employed in
its integrity.
Nevertheless, the employment of this method was
steadily extending, thanks to M. Pozzi, M. Tuffier, M.
Regaud, and a few surgeons of other nationalities. In
Belgium M. Depage, 1 from the beginning of 1916, suc-
ceeded in accomplishing the sterilisation and secondary
closure of a large number of wounds, some of which
were accompanied by fracture. In Paris Senor Chutro,
of Buenos Ayres, succeeded in sterilising and healing
old infections of the bones and articulations. In New
York Mr. Gibson and Mr. Lyle began to apply the
method of chemical sterilisation in ordinary surgical
practice.
At the close of 1916 Mr. Sherman, 2 principal surgeon
to the United States Steel Corporation, demonstrated
that the chemical sterilisation of wounds constitutes a
considerable improvement in the treatment of industrial
casualties.
The possibility of maintaining wounds in a sterile
condition enables us to study the laws of cicatrisation
1 Depage, C. R. Societe de Chirurgie, 1916, p. 1987, and Feb. 1917.
- Sherman, Surgery, Gynecology and Obstetrics, January, 1917.
INTRODUCTION 11
with an exactness hitherto unknown. A comparison of
the curves of sterilisation and of cicatrisation shows us
in an exact manner how the various procedures em-
ployed in the treatment of wounds act upon those
wounds. Similar technical methods were employed by
Professor Halsteed in the ingenious experiments which
were carried out under his supervision at the John
Hopkins Hospital.
In the treatment of mastoiditis M. Mahu 1 syste-
matically sterilised the wound immediately after opera-
tion, reducing the duration of the treatment to one-third
of what it was previously. MM. Tuffier and Depage 2
treated purulent pleurisies by sterilising the pleural
cavity and suturing the opening. They thus succeeded
in very greatly diminishing the duration of the treat-
ment.
From September, 1916, we investigated more par-
ticularly the application of the method to the wounds of
men already infected when they reached the hospitals
in the rear. These researches were undertaken by MM.
Guillot and Woimant, in the Compiegne hospital. They
demonstrated the fact that suppurating wounds and old
fractures can be rendered sterile, and that complications
resulting in the death of the patient or the amputation
of the limb may be almost entirely avoided.
Suppuration might have been suppressed in the
hospitals as early as September, 1915. But our methods
encountered such opposition on the part of certain
gentlemen who were at the head of the medical pro-
fession in France, that they were scarcely anywhere
1 Mahu, Presse Midicale, 1917.
2 Tuffier et Depage, C.R., Societe de Chirurgie, 1917.
12 TREATMENT OF INFECTED WOUNDS
applied. A perusal of the reports of the Societe de
Chirurgie and the Academic de Mddecine shows with
what culpable frivolity a method which might have
saved the lives and limbs of large numbers of wounded
men was rejected. 1 Those who criticised us so severely 2
had not taken the trouble either to examine our tech-
nical methods or to check our results. They knew
nothing whatever of the methods which they were
criticising. 8 Their responsibility is all the greater inas-
1 ". . . et nous apporter cela d'Amerique, laissez-moi rire. . . ."
M. Broca, professeur a la Faculte de Medecine de Paris, Jan. 5th, 1916.
Bulletin et Memoires de la Societt de Chirurgie de Paris, vol. xlii. pp. 104
and 105.
2 Especially should be noticed the communications made in 1915 and
1916 to the Societe de Chirurgie de Paris or at the Reunion chirurgicale
de la IV Armee, by MM. Delbet, Hartmann, Broca, Potherat, Chapuc,
etc. Bulletin et Memoires de la Societt de Chirurgie and Presse Medicale>
1915-1916.
3 With regard to the attitude of the Societe de Chirurgie, note M.
Pozzi's communication to the meeting of May 17, 1916.
" .... In any case, one should see for oneself at Compiegne only
two hours from Paris the condition of the wounded treated by the new
method. This is what I have already done myself, on two occasions,
when I took part in the memorable discussions which took place at the
meetings of our Society, the 5th and 26th of January ; and at the Academic
de Medecine, the nth of January last. And it is what I have begged my
colleagues to do, at once. I am glad that, at last, M. Quenu has followed
my advice. The time has come at last to repair the real injustice com-
mitted towards a method which for long months past had displayed in vain
evidence of its value, which is certainly destined to save, in the future
(as it has already done in the immediate past), a great number of wounded
men, and to lessen, in almost every case, the gravity of mutilations and
infirmities.
" In fact, after the sentence, almost of reproof, pronounced against it
here, and at the Academic de Medecine in the month of January last,
there was brought about amongst the young surgeons at the front a sudden
hesitation to apply the new method, which at first they had received with
marked approval. This was emphatically to be regretted. Further may
I be allowed to say in all sincerity? it is not only the wounded to whom
INTRODUCTION 13
much as their position in the University of France and
the hospitals of Paris lent weight to their verdict.
The aim of this book is to show how surgical steri-
lisation of the greater number of infected wounds may
be obtained. In the following pages we shall describe
the principles which allow a given antiseptic to act in an
efficient manner. The application of these principles
constitutes a " method," that is to say, an entity, no
portion of which should be altered at random. The
deplorable results obtained in several hospitals by
surgeons who believed they were using our methods,
but who, in reality, were altering them according to
their fancy, make clear the necessity for observing
exactly the directions which will be laid down in the
following pages. The best way to learn the method is
to see it applied. Hence this book is especially intended
to recall essential details of the technique to those who
already know something of its application.
this attitude of our great learned Societies risks doing harm, but it is the
Societies themselves, who, & priori, and without relying upon an investiga-
tion easy to carry out (Ph&pital Carrel being at Compiegne), have publicly
refused to the treatment newly instituted the merit of originality and of
progress . . . ."
CHAPTER I
THE PRINCIPLES OF THE TECHNIQUE
DESTRUCTION by chemical means of the micro-organ-
isms infecting a wound is rendered possible by the
different resistances presented by the tissues equipped
with a circulation, and the microbes which are found on
their surface. The idea must be grasped that a given
antiseptic substance, applied at a certain concentration,
and during a certain time, is able to destroy microbes
without damaging the normal tissues to any appreciable
extent. The chemiotherapy of wounds is easier to realise
than that of the blood. In the latter case a substance
capable of destroying microbes is harmful to the cor-
puscles, because the resistance of isolated anatomical
elements is but little different from that of micro-
organisms.
The mere application of an energetic antiseptic sub-
stance, by any form of technique whatsoever, cannot be
relied upon to sterilise a wound. The success of the
method which enables us to render aseptic an infected
wound is not due to the marvellous properties of a new
drug. It should rather be attributed to a combination of
means, which enables us to make use of a definite anti-
septic substance, under such conditions of concentration
and duration that its action becomes efficacious. This
14
THE PRINCIPLES OF THE TECHNIQUE 15
method is a combination of which each single part is
essential to the rest. The antiseptic cannot be altered
without changing the manner of using it. In the same
way a modification of the technique demands an anti-
septic endowed with different chemical properties.
The technique of sterilisation has been studied, not
by a series of experiments in vitro, but actually upon
the wounds themselves. While tracing the bacterio-
logical evolution of a wound we have determined the
conditions under which a given antiseptic is capable
of bringing about rapidly the total disappearance of
microbes. By this means we have determined that a
substance powerfully bactericidal, yet only slightly irri-
tating, such as Dakin's hypochlorite of soda, will sterilise
a wound if it remain in contact with the microbes during
a known period of time and at a certain degree of con-
centration. As the wound responds to treatment in
becoming sterile, and as the progress of the sterilisation
cannot be gauged by a mere clinical examination, the
bacteriological study of the secretions is the guide needed
for therapeusis.
The method, therefore, is based upon the employ-
ment, rigorously controlled by the microscope, of an
approved agent, under conditions of contact, of concen-
tration, and of duration, established by direct experi-
ment upon infected wounds.
I. THE CHOICE OF AN ANTISEPTIC
In order to choose the fittest substance to sterilise an
infected wound we must consider, apart from its bacteri-
cidal action, many other factors, such as its capacity
16 TREATMENT OF INFECTED WOUNDS
for irritating the tissues, its toxicity, its solubility, its
power of penetrating the tissues, and of being absorbed
by them, and the manner in which it reacts with proteids
and other constituents of the tissues. The destruction
of bacteria under the influence of a chemical agent is
due to the reaction of the antiseptic on the one side,
with, on the other, proteins and other substances
which enter into the constitution of micro-organisms.
Suspended in water, microbes are easily destroyed by
antiseptics, because the mixture contains no other pro-
teins. But when they are immersed in blood serum,
pus, or other exudations, their destruction is more
difficult, because the antiseptic acts not only on the
micro-organisms but also on the protein substances in
the midst of which they are found. That is precisely
why the value of a substance intended for the treatment
of wounds, should be judged according to its bactericidal
action on microbes in suspension in blood-serum and
pus, and not upon microbes simply suspended in water.
The bactericidal activity of all known antiseptics is
greatly reduced by the presence of blood-serum or
analogous substances. This reduction is so great in
certain cases that the substance employed under these
conditions practically loses all its value. Dakin and
Daufresne have shown, in the experiments described
later on, the enormous diminution in bactericidal power
of certain antiseptics under the action of blood-serum.
In these experiments the antiseptic action of substances
was estimated by the degree of concentration of the
solution capable of destroying in two hours, at the
temperature of the laboratory, microbes in suspension in
water and in horse-serum.
THE PRINCIPLES OF THE TECHNIQUE i;
The technique followed by Daufresne was as follows :
A series of tubes was prepared containing 5 cubic centi-
metres of a solution of the substance of a degree of
concentration progressively diminishing. To each tube
was added one or two drops of a culture (twenty-four
hours in peptonised bouillon) of the organism to be
studied. A control-tube was at the same time prepared
containing 5 c.c. of distilled water with one drop of the
culture. The mixtures of antiseptic and microbes were
carefully shaken every half-hour, and kept at a tempera-
ture of 1 8 to 20 C. for two hours. Afterwards a
loopful of the liquid from each tube was placed in each
of a series of tubes, each containing 3 c.c. of bouillon.
These tubes were placed in the incubator for twenty-
four hours, and kept at a temperature of 37 C. When,
at the end of twenty-four hours, there was no develop-
ment, it was decided that the degree of concentration of
the antiseptic was sufficient to kill the organism. In-
complete sterilisation was indicated by the growth of the
organism in the bouillon. Examination of the antiseptic
action of the substance in presence of blood- serum was
made in a similar manner, but to the liquid contained
in the first series of tubes were added 5 c.c. of horse-
serum, previously warmed to a temperature of 55 or
56 C.
In this fashion some two hundred substances were
studied by Dakin and Daufresne. The micro-organisms
which were used as tests were staphylococci, streptococci,
the bacillus pyocyaneus, and the bacillus of Welch. In
the following table will be found the results of some
of Daufresne's experiments, made by means of a fresh
culture of staphylococci on certain antiseptics in daily
2
iS TREATMENT OF INFECTED WOUNDS
use. The sign 4- indicates that the culture is positive,
and the sign that it remained sterile.
Antiseptics.
Without blood-serum.
With blood-serum.
Acid carbolic
250
500 +
50 -
100 -f-
100
250 +
1,700 -
2,000 +
1,000
2,500 -f
25,000
50,000 +
10,000
25,000 4-
1,500 -
2,000 +
5,OOO +
3 CQO
8,000 -f
100,000
10,000,000 +
5,000,000 -
10,000,000 +
1,000,000
Bichloride of mercury . . .
> > ...
IO,000,OGO +
500,000 -
1,000,000 +
Hypochlorite of soda ....
This table shows what feeble power is possessed by
an antiseptic which has had a great vogue carbolic
acid. It also demonstrates that bichloride of mercury,
which has only a mediocre action on an infected wound,
nevertheless kills the staphylococcus in presence of blood-
serum of I : 25,000. These experiments clearly show us
that in the choice of a suitable antiseptic many qualities
beside bactericidal action have to be considered ; it has
been demonstrated that bichloride of mercury, nitrate of
silver, and iodine, which have a high germicidal potency,
are nevertheless the least suitable for wound treatment.
Therefore it is well to become acquainted with the
practical inconveniences of the substances we are about
to examine.
Phenol has a very poor bactericidal power, especially
when acting in the presence of blood-serum. If em-
ployed in concentration sufficient to render efficient its
THE PRINCIPLES OF THE TECHNIQUE 19
germicidal action, it becomes highly destructive to
normal tissues.
Hydr "..^ peroxide solution gives encouraging re-
sults wV ^jaactericidal action is examined in a test-
tube. L>. wounds, on the contrary, it has a very
feeble action, because it decomposes with the greatest
readiness under the influence of the catalysis always
going on in the tissues and in the blood corpuscles.
Consequently, its action is only exerted during a com-
paratively insignificant period of time. The mechanical
detergent action which results from the rapid disengage-
ment of oxygen when in contact with infected surfaces,
has probably a greater value than the antiseptic action of
the hydrogen peroxide itself. Dakin l quotes on this
subject an interesting experiment which had been com-
municated to him by Prof. E. K. Dunham of New York.
A rabbit which had received an intra-venous injection of
Welch's bacillus (Bacillus aerogenes capsulatus or Bacillus
perfringens) was killed. The infected liver was cut up
very carefully into tiny fragments. Placed in the incubator
with hydrogen peroxide solution, it was found that the
volume of a fragment of infected liver must not exceed
a millimetre cube, if the micro-organisms contained in it
were to be killed. Should the fragments be a little larger,
the bacilli of Welch multiplied actively. Hydrogen
peroxide, therefore, may be considered as having but a
feeble antiseptic action, even against anaerobic microbes.
Bichloride of mercury readily loses the greater part
of its antiseptic power in presence of pus and the sub-
stances of which the tissues are made. Besides, it is
very irritating, even in dilute solution.
1 Dakin, Presse Mtdicale, 1915.
20 TREATMENT OF INFECTED WOUNDS
Nitrate of silver has a greater value than bichloride
of mercury. But it becomes irritating when used in
sufficiently strong solution. Many substances which
enter into the composition of the tissues inhibit its action
in a marked manner. The sensitiveness to light of
silver compounds is also an objection to their use.
Iodine, so valuable for sterilisation of the skin, has
yielded results much less satisfactory when applied to
the disinfection of deep wounds, because it coagulates
proteins and irritates the tissues. The penetrative power
of iodine is feeble. Treated by this substance, wounds
continue to suppurate, and heal more slowly than the rest.
Hypochlorite of soda has a high germicidal power
and many other useful qualities. But the hypochlorite
of soda found in commerce has an extremely variable
composition. Besides, it contains free alkali, and often
free chlorine. Consequently, it is irritating when applied
to a wound.
The deleterious action of antiseptic solutions upon
living tissues should be studied as carefully as their
bactericidal action. It is, in fact, absolutely necessary
that the substance should be tolerated by the tissues
during a prolonged period. The disfavour with which
the antiseptic method is regarded by the majority of
surgeons is partly due to the use of destructive sub-
stances, such as carbolic acid or corrosive sublimate,
which have done harm without sterilising the wounds.
In a series of experiments which he made with Mme.
Carrel in M. Tuffier's laboratory at the Hopital Beaujon,
Dakin studied the action of a great number of sub-
stances on connective tissue. The experiments were
made on guinea-pigs. Small fragments of sponge of
THE PRINCIPLES OF THE TECHNIQUE 21
similar weight were placed under the skin of the
abdominal wall by means of a short incision which was
immediately closed by a suture. On one side, by means
of a hypodermic syringe, I c.c. of the substance to be
studied was injected. In the sponge placed on the
other side, which served as a control, I c.c. of physio-
logical saline solution was injected. At the end of forty-
eight hours examination of the region showed a thicken-
ing, more or less considerable, of the tissues surrounding
the fragment of sponge which had received the solution.
By the change in volume of the sponge, the action of the
substance employed upon connective tissue could be
estimated. In this manner carbolic acid, iodine, bi-
chloride of mercury produced marked tumefaction. The
animals injected with bichloride of mercury usually died
rapidly. Those injected with carbolic acid showed ex-
tensive necrosis of the abdominal wall.
It was only after having made the comparative ex-
amination of a large number of substances, from the
point of view of their bactericidal action and of their
irritating action upon normal tissues, that Dakin decided
upon neutralised hypochlorite of soda and chloramines.
A. Dakin's Hypochlorite of Soda. The antiseptic
properties of hypochlorite of soda have been known for a
very long time. 1 But it is not possible to use hypo-
chlorite, either in the form of eau de Javel or of Labar-
raque's solution, for the sterilisation of wounds, because
these solutions are irritating, and may cause grave injury
to the tissues. Because of this, Dakin endeavoured to
lessen the irritant qualities of the hypochlorites without
modifying their antiseptic action.
1 Dakin, British Medical Journal, 1915, p. 809.
22 TREATMENT OF INFECTED WOUNDS
The principles of the preparation of the hypochlorite
solution by Dakin are as follows. A solution of hypo-
chlorite of soda almost always contains free alkali, even
when it is prepared with the greatest care. Though
looked upon as neutral, it has an alkaline reaction.
This reaction is due not only to the alkali which may
arise from the mode of preparation, but also to a hydro-
lytic dissociation of the hypochlorite which produces free
soda and hypochlorous acid.
The amount of this dissociation has been measured
by Duyk, and is quite considerable. It is to the forma-
tion of free alkali, therefore, that the irritating action
of hypochlorite is due. The amount of the hydrolytic
dissociation increases with the dilution, so that, from a
practical point of view, a hypochlorite cannot be rendered
non-irritant by merely reducing its concentration. Really,
a point is soon reached at which the bactericidal action
is lessened, while the irritating properties of the solution
remain. Besides these two sources of free alkali, it must
not be forgotten that soda may be liberated by the
action of hypochlorite on proteins. A reaction takes
place, in which the chlorine of the hypochlorite attaches
itself to the nitrogen of the proteins, as will be demon-
strated later.
Dakin, for the neutralisation of the alkali of the hypo-
chlorite of soda, made use of the following known facts.
Blood and other organic liquids, and also certain artificial
saline solutions containing mixtures of polybasic acids,
such as phosphoric acid, are able to keep their essential
neutrality, even after the addition of acid or alkali. This
phenomenon is due to the fact that the addition of acid
or alkali simply changes the relative proportion of two or
THE PRINCIPLES OF THE TECHNIQUE 23
more salts of the polybasic acid present in the solution.
Setting out from this principle, and employing a feeble
polybasic acid (boric acid), Dakin succeeded in preparing
a simple mixture of hypochlorites, which remains very
nearly neutral under all conditions, and which in conse-
quence does not irritate the tissues. This solution con-
tains a mixture of hypochlorite and polyborate of soda
and small quantities of free hypochlorous acid and boric
acid. In this manner the irritating action of caustic soda
is avoided. In fact, if alkali should form, it would be
immediately neutralised by the boric acid and the acid
borates present in the solution.
Dakin's hypochlorite differs from eau de Javel and
Labarraque's solution in that its destructive action upon
the tissues is very slight. Study of the communications
made to the learned Societies of Paris, and particularly
to the Acaddmie de Me"decine, shows that the necessity
for using a non-caustic antiseptic has not been grasped.
Surgeons do not yet comprehend that Dakin's solution,
containing no free alkali, can be employed under con-
ditions where the use of eau de Javel or Labarraque's
solution would be absolutely impossible.
A simple experiment made by Daufresne in the
laboratories at Compiegne will show the essential differ-
ence which exists between Dakin's solution, on the one
hand, and eau de Javel and Labarraque's solution on the
other. In three tubes there were placed Dakin's solution,
eau de Javel, and Labarraque's liquor. The strength of
the three solutions in hypochlorite of soda had pre-
viously been brought to 0*5 per cent. A fragment of
skin from a still-born infant was placed in each of the
three tubes. At the end of two hours the action on
24 TREATMENT OF INFECTED WOUNDS
the skin of eau de Javel and Labarraque's solution was
already manifest. The skin was greatly swollen, and
the slightest friction could detach the epidermis in a
fragile pellicle. In the hours following the process
continued, the fragment became completely transparent,
and after twelve hours in eau de Javel, and fourteen
hours in Labarraque's solution, the fragment of skin
was completely dissociated. The tubes contained only
a powdery sediment. The piece of skin placed in
Dakin's solution behaved in quite a different manner.
After two hours of contact the epidermis was still very
adherent, and the aspect of the skin was normal. At
the end of twenty-four hours the alteration in the tissues
resembled that observed after two hours' contact with
the solutions of Javel and Labarraque.
This experiment shows in a very clear manner the
profound difference which exists, from the biological
point of view, between Dakin's solution and the non-
neutralised hypochlorites. In a word, Dakin's researches
allow us to use to-day hypochlorite of soda under con-
ditions such that it will sterilise the tissues without
danger to them. We shall see, later, that the hypo-
chlorite only kills the microbes when its action is ex-
tended over a long period, and it is of a strength of
0*5 per cent, (about), conditions impossible to realise if
the solution be caustic.
It is possible to obtain a solution even less irritating
than Dakin's solution, if we prepare it by the electro-
lytic method. Electrolytic hypochlorite has not hitherto
been employed in surgery on account of its defective
keeping properties. As it is completely devoid of alkali,
its concentration diminishes very rapidly, and in a few
THE PRINCIPLES OF THE TECHNIQUE 25
hours its bactericidal power may become insufficient.
In the course of experiments carried out in the Com-
piegne laboratories, Dakin discovered that electrolytic
hypochlorite, that is, hypochlorite completely free from
alkali, may be rendered stable by a small quantity of
permanganate of potash or silicate of soda. Hypo-
chlorite thus prepared will keep for several weeks without
any appreciable loss of concentration. It is less caustic
than the chemically prepared solution. Its power of
4
FIG. j. Four fragments of skin of identical dimensions were placed in chlor-
amine (4), hypochlorite of magnesium (3), Dakin's hypochlorite (i), and
electrolytic hypochlorite (2). Results at the end of 48 hours.
dissolving necrosed tissues was compared with that of
Dakin's solution by placing, in the two solutions, frag-
ments of skin of identical dimensions (Fig. i). The
skin was destroyed more rapidly in Dakin's solution
than in the electrolytic solution. Nevertheless, the
solvent power of the electrolytic hypochlorite was suf-
ficient to rid wounds of the necrosed tissues which
occurred upon their surfaces.
Many other preparations of hypochlorites have been
previously employed in surgery. Eau de Javel and
26 TREATMENT OF INFECTED WOUNDS
Labarraque's solution are well known, as well as the
hypochlorites of calcium, potassium, and magnesium.
Since the beginning of this war, eau de Javel has been
used with good results. In November, 1914, in the
hospital at Dunkirk, MM. Landry and Jacomet made
successful use of eau de Javel in " gas " infections.
But eau de Javel is dangerous, for its strength in
hypochlorite is variable in the extreme, and it always con-
tains an amount of alkali which renders it caustic. The
alkali contained in eau de Javel and in Dakin's solution
when badly prepared is responsible for the secondary
haemorrhages which have sometimes been observed as a
result of their employment in the neighbourhood of the
blood-vessels.
Hypochlorite of magnesium has been employed
with success by M. Dubard. Its bactericidal power is
similar to that of sodium hypochlorite, and it is not irri-
tating. Dakin, however, elected to employ the hypo-
chlorite of sodium rather than the magnesium salt,
because the solvent power of the former, in the case of
mortified tissues, is greatly superior to that of the latter,
and because the efficacy of an antiseptic depends to a
certain extent upon its ability to cleanse the surfaces of
wounds. Daufresne placed fragments of skin of equal
dimensions in solutions of magnesium hypochlorite and
sodium hypochlorite. Another fragment of skin, placed
in chloramine, served as a " control." While the fragment
of skin immersed in Dakin's solution shrank to about
one-third of its original size, the fragment placed in the
magnesium solution underwent a very much less con-
siderable change (Fig. i).
Mixtures of powdered chloride of lime and boric
THE PRINCIPLES OF THE TECHNIQUE 27
acid have been employed by Vincent, Lumiere, and
Lorrain Smith. The local production, by an admixture
of powdered hypochlorites, of hypochlorous acid or
chlorine in a comparatively high degree of concentration,
is more dangerous to the healthy tissues than the con-
tinued application of a weak and neutral solution of
hypochlorite of sodium. Moreover, a solution possesses
the advantage of penetrating into all the recesses of
deep wounds. Vincent's powder, injected into anfrac-
tuous wounds, falls upon the coagulum, but does not
reach the surface of the wound. It may also form upon
the surface of the tissues a crust which protects the
bacteria from the antiseptic substance. In this manner
serious infections may develop subsequently to the appli-
cation of Vincent's powder to deep wounds. Moreover,
it is impossible in one operation to introduce into a
wound a sufficient quantity of antiseptic to sterilise it.
To achieve this end the concentration of the active
substance would require to be very great, and, con-
sequently, dangerous to the tissues.
Generally speaking, the experiments we have carried
out with Dakin, by means of powdered substances, and
substances dissolved in fatty matters, such as vaseline or
lanoline, have yielded results greatly inferior to those of
the experiments made with watery solutions :
i. Bactericidal Action of Dakin's Solution. The bacteri-
cidal action of Dakin's solution of hypochlorite of soda
has been studied by Daufresne, using micro-organisms
suspended in water, and in water with the addition of
horse-serum. Staphylococci in suspension in water are
killed in two hours by hypochlorite of a strength of
I : 500,000 to I : i ,000,000 ; whilst, in the presence of
28 TREATMENT OF INFECTED WOUNDS
horse-serum, the concentration increases, and should be
I : 1,500 to I : 2,000. Streptococci are killed more
rapidly. B. pyocyaneus in suspension in water is killed
in two hours by a strength of i : 100,000 to i : 1,000,000 ;
whilst in presence of horse-serum a strength of i : 2,500
to i : 5,000 becomes necessary. In the experiments
made on mixtures of pus and hypochlorite, it is found
that sterilisation generally takes place when two or three
volumes of hypochlorite to one volume of pus are used.
The action of hypochlorite naturally varies according to
the character of the pus.
The results of these experi-
ments in vitro are of but slight
importance, for experimental con-
ditions vary too greatly from the
actual. In wounds, in fact, a
small quantity of pus is found in
contact with a large quantity of
antiseptic, because the solution of
hypochlorite is constantly being
renewed. In the experiments in
vitro, the duration of the action
of the hypochlorite upon the
microbes in suspension in the
FIG. 2. Disappearance of pUS IS short. If, at the end of two
or three hours, one tests for the
hypochlorite contained in the mix-
and, 1915. (Case 28.) ture, sometimes it is found that it
(oo denotes infinity. Trans- , 1 , i j j -r-u
lator.) has completely disappeared. The
hypochlorite,i in fact, rapidly enters
into combination with the proteins of the pus, and
chemical analysis is no longer able to discover it. It
THE PRINCIPLES OF THE TECHNIQUE 29
is precisely because of this rapid disappearance of hypo-
chlorite when in contact with secretions, that Dakin's
solution should be continuously instilled into wounds,
or if intermittently, at short intervals. Ignorance of
this chemical property of the hypochlorites has led
surgeons to be surprised that mixtures of pus and
hypochlorite kept in the incubator for several hours
should become favourable breeding- grounds for microbes.
It is quite evident that, after being treated in this manner,
the mixture contains hypochlorite no longer. When
a solution of hypochlorite is employed, it is essential to
determine the quantity of the active substance contained
in the solution before and after the test.
The bactericidal action of Dakin's hypochlorite was
next studied in infected wounds themselves. When
hypochlorite of soda is applied to a wound in such a
manner that its degree of concentration remains constant,
and the duration of the application is prolonged, the
microbes disappear (Fig. 2). This fact has been observed
a very great number of times. Indeed, one might affirm
that it constantly happens when intimate contact is
established between the antiseptic solution and the
organisms. The sterilisation of wounds treated by
Dakin's solution is an established fact. But it will be
well to enquire if the treatment is actually the deter-
mining cause of the sterilisation, and if this sterilisation
is due to the hypochlorite of soda.
(a) It might be suggested that, in our observations,
the wounds grew sterile spontaneously. In truth this is
hardly likely, because one never sees a series of in-
fected wounds become sterile in a few days. Neverthe-
less, this hypothesis was submitted to experimental
30 TREATMENT OF INFECTED WOUNDS
analysis. Choosing a wound whose various regions were
uniformly infected, a square of filter-paper was placed on
a selected spot, and kept constantly moist with hypo-
chlorite of soda. On another spot was placed a square
of filter-paper of the same size. Then the wound was
again covered with a protective dressing. At the end of
twenty-four hours, below the filter-paper moistened with
hypochlorite, a smooth surface of red granulations was
to be seen, and the microbes had completely disappeared.
Under the filter-paper which had not been wetted with
hypochlorite, the granulations were irregular and pale,
and the microbes as numerous as before (Fig. 3). In
the portions of the wound which had not been covered
with filter- paper, there was no change in the quantity of
microbes.
In a case where the half of a wound was dressed
with hypochlorite, ancj, the other half with vaselin, there
was complete disappearance of microbes in the region
treated with hypochlorite, whilst the infection remained
elsewhere.
Similar results were obtained with deep wounds.
Two shell fragments had penetrated two neighbouring
points in the lumbar region ; the two fragments were
removed at the same time. One of the wounds was
treated by the continuous instillation of hypochlorite,
and the other by a simple dressing. The wound treated
remained painless, and the microbes disappeared com-
pletely from the smears ; whilst the wound not treated
became painful, was surrounded by a red aureola, and
was the seat of streptococcal infection. In the seton
type of wounds, we could often observe that the region
where the hypochlorite penetrated was sterile, while the
THE PRINCIPLES OF THE TECHNIQUE 31
portion where the hypochlorite did not penetrate still
held a great number of microbes. Numerous similar
observations showed in a very distinct fashion that the
FIG. 3. Superficial wound of left
arm. Comparative action on an
infected wound of pieces of filter-
paper soaked or not in hypochlorite
of soda. The continuous line re-
presents the diminution of the
microbes from 20 to o per field of
the microscope, and the dotted
line, the condition of the "con-
trol " portion of the wound. (Case
No. 247.)
FIG. 4. Superficial wounds of the
left thigh. Comparative study of
the influence of Dakin's hypo-
chlorite and of physiological saline
solution. Two wounds equally
infected and of the same man were
treated, one by hypochlorite, the
other by saline solution. These
two wounds contained from 20 to
30 microbes per microscope field.
The continuous line represents the
diminution in number of microbes
in 24 hours under the influence of
hypochlorite. The dotted line re-
presents the state of the wound
treated by saline solution at the
end of the same time. (Case No.
52.)
relation of cause and effect existed between the treat-
ment employed and the results obtained.
(b) Next, it must be made clear whether the result
is due to the antiseptic action of the hypochlorite, or to
the mechanical action of the instilled liquid. The
32 TREATMENT OF INFECTED WOUNDS
following experiments were devised to elucidate this
point. A wounded man had upon his thigh two wounds
of dimensions almost identical, and with bacteriological
conditions practically the same. One was dressed with
hypochlorite and the other with physiological saline
solution. At the end of twenty-four hours, the surface
of the wound dressed with hypochlorite did not show
a single microbe per field, while the wound treated by
saline solution had more than thirty microbes per field
(Fig. 4). Other experiments were made by means of
wounds, on the surfaces of which were applied squares
of filter-paper of similar dimensions. One of the squares
carried solution of hypochlorite, while the other had
physiological saline solution. At the end of twenty-four
hours, the region situated under the hypochlorite con-
tained no microbes, while the region treated by saline
solution had a large number. Similarly, observations
were made on deep wounds with old lesions. A case
of fracture of the femur with great loss of substance and
extensive osteo- myelitis of the bony extremities, was
observed for several months. An india-rubber tube
introduced into the suppurating cavity permitted the
instillation, during arranged periods, of hypochlorite, or
of hypertonic saline solution. When the case was having
the hypochlorite, the pus contained many microbes and
had no smell. When the hypertonic saline solution was
substituted for the hypochlorite, the pus immediately
gave out a tainted odour, and the microbes became much
more numerous. As soon as the hypochlorite was again
instilled, the odour disappeared, and the number of
microbes diminished. Similar experiments were made
several times with like results.
THE PRINCIPLES OF THE TECHNIQUE 33
In another series of experiments the wounds were
irrigated either by distilled water or by Wright's hyper-
tonic solution. The wounds had previously been sterilised.
After some hours' instillation the bacterial curve rose.
Distilled water and the hypertonic solution produced
similar results (Figs. 5 and 6). It was enough to sub-
FIG. 5. Reinfection of a wound
dressed for 24 hours with distilled
water, (The wound is dressed with
distilled water on the ijth ; chlor-
araine is applied on the i8th. Tr.)
FiG. 6. Reinfection of a wound
dressed for 24 hours with hyper-
tonic solution. (The hypertonic
solution was applied on the i7th ;
Dakin's solution on the i8th. Tr.)
stitute Dakin's solution for the hypertonic solution or
the distilled water, and the curve descended, while the
wound once more became aseptic. This experiment was
frequently repeated, always yielding identical results.
The action of M. Delbet's chloride of magnesium
and of Dakin's solution were investigated under pre-
cisely similar conditions. The curve in Fig. 7 shows
that a sterile wound whose surface was treated by the
3
34 TREATMENT OF INFECTED WOUNDS
instillation of chloride of magnesium became rapidly
reinfected. The number of microbes quickly became
innumerable. An attempt was made to assist the action
of the chloride of magnesium by washing the wound
daily with neutral oleate of soda. The number of
microbes diminished, but did not fall to zero. Directly
the oleate of soda was discontinued the number of
microbes again became innumerable. At this point the
FIG. 7. Intense infection of a wound treated with chloride of magnesium,
afterwards sterilised by means of Dakin's solution
chloride of magnesium was replaced by Dakin's solution,
and the number of microbes immediately fell to zero, as
the curve indicates.
These experiments show that distilled water, Wright's
hypertonic solution, or Delbet's chloride of magnesium
permit of the rapid reinfection of wounds previously
aseptic, and that sterilisation is effected immediately
these substances are replaced by an identical volume of
hypochlorite of soda. It is therefore evident that the
THE PRINCIPLES OF THE TECHNIQUE 35
hypochlorite acts by virtue of its antiseptic power, not in
a mechanical manner.
(c) The antiseptic power of hypochlorite is not due
to its alkalinity. In M. Tissot's paper, read at 1' Academic
des Sciences by M. Dastre, 1 that author attributed the
action of hypochlorite of soda upon wounds to its
alkalinity, and declared that the treatment to which
Dakin had submitted it had the result of enfeebling its
power ! Although M. Tissot furnished in support of his
opinion no precise observations, we have made experi-
ments to test if the presence of an alkaline substance on
the surface of a wound had any influence upon its
bacteriological condition.
Upon a large surface wound on the external aspect
of a limb, two squares of filter-paper of equal dimensions
were placed. One of the squares was moistened with
physiological saline solution, and the other with a solution
of carbonate of soda, 0*5 per cent. Two days afterwards
it was found that the number of microbes under the
paper moistened with saline solution was almost identical
with the number under the paper moistened with
carbonate of soda. This experiment was repeated on
other wounds with similar results. The alkaline solution
had no more effect on the microbes present at the surface
of a wound than had physiological saline solution.
2. Action of Hypochlorite on Microbial Toxins. This
point was considered in a course of experiments made
by M. Auguste Lumiere. 2 In a case of grave tetanus, *
he took some cubic centimetres of pus from a highly
infected wound of the leg. This pus was divided into
1 Tissot, C. R. Academiedes Sciences > Sept. 13, 1915.
2 Auguste Lumiere, C. R. Academie des Sciences^ March 6, 1916,
36 TREATMENT OF INFECTED WOUNDS
two equal parts, of which one was brought to double its
volume by the addition of I per cent, solution of hypo-
chlorite, and the other brought to the same volume by
the addition of chloride of sodium solution, 0*8 per cent.
After the lapse of an hour, I c.c. of each of these
preparations was injected into guinea-pigs. It was
found that the animals which had received the " control "
pus died from tetanus in eight or ten days, whilst those
in which had been injected pus with the addition of hypo-
chlorite presented no symptoms of tetanus and sur-
vived.
This experiment was repeated with pus containing
various microbes, streptococci, staphylococci, perfringens,
etc. These preparations were administered to guinea-
pigs by subcutaneous injection and to rabbits by intra-
venous. It was demonstrated that pus containing hypo-
chlorite gave reactions either slight or benign, while the
purulent fluids without added antiseptic produced
evidences of infection, often ending in death.
M. Lumiere, in another series of experiments, candle-
filtered pus both treated and not treated with hypo-
chlorite, and injected animals with the filtrates. Filtrates
of pus treated with hypochlorite produced no change in
condition of the animals, while the filtrates from the
control pus provoked pyrexia and emaciation. In short,
these filtration products, placed in contact in vitro with
leucocytes and microbes, demonstrate that phagocytosis
is much more active when the pus has been treated with
hypochlorite.
M. Lumi&re's experiments prove, therefore, that hypo-
chlorite of soda destroys toxins contained in pus. This
destruction of toxins by oxidising antiseptics plays a
THE PRINCIPLES OF THE TECHNIQUE 37
favourable part in sterilisation, either in allowing phago-
cytosis to become effectual, or in preventing the im-
pregnation of the organism by noxious substances.
Perhaps it explains, in part at least, the rapid disappear-
ance of general symptoms, presented by patients suffer-
ing from extensive suppuration, when their wounds are
treated by Dakin's solution.
3. Toxicity of Dakin's Solution. Hypochlorite of soda
is very slightly toxic to the organism, when it is injected
on the surface of wounds, or, in animals, into the sub-
cutaneous cellular tissue. We have injected under the
skin of the abdominal wall of guinea-pigs quantities of
antiseptic relatively considerable, without unfavourable
result. For example, three guinea-pigs weighed respec-
tively 565 grammes, 570 grammes, and 510 grammes.
These had respectively 8 c.c., 11-4 c.c., and 1275 c.c. of
Dakin's solution, that is to say, 1/70, 1/50, and 1/40
of their body-weight. They presented no abnormal
symptom, and remained in good health.
Hypochlorite of soda, which is harmless when sub-
cutaneously injected, is very dangerous if injected into
the general circulation. An injection of ten cubic centi-
metres into the marginal vein of the ear of a large rabbit
rapidly caused death. Hypochlorite of soda is strongly
haemolytic, and therefore should never be injected into
veins. Indeed, it is prudent never to inject it under
pressure into deep wounds, in order that it may not be
absorbed by the tissues. Amongst the numerous cases
of wounded men treated by hypochlorite of soda, we
have never had accidents which could be attributed to
a toxic action of this substance.
4. Action of Hypochlorite on the Tissues. Experiments
38 TREATMNNT OF INFECTED WOUNDS
made upon guinea-pigs had already shown that a
small quantity of hypochlorite of soda injected into a
fragment of sponge placed under the skin, produced no
modification of the tissues obvious to clinical examination.
Further, Dakin's solution, instilled for several days,
sometimes several weeks, over the surface of a wound,
in a general way set up no marked irritation. It was
already evident from these observations that Dakin's
hypochlorite had little action upon the tissues. How-
ever, more exact experiments were initiated, in order
the better to determine the action of the antiseptic on
dead tissues, on isolated anatomical elements, and on
tissues deprived of circulation.
(a) Action of Hypochlorite on Tissues deprived of
Circulation. When fragments of skin from a guinea-pig
or a human foetus are placed in Dakin's solution, the
tissues begin to disintegrate at the end of twenty-four
hours. The same is true of fragments of mortified
tissues. This action is less marked if electrolytic hypo-
chlorite be employed. On the surfaces of wounds
mortified tissue dissolves, as a rule, in five or six days ;
but occasionally fragments of tendons or aponeuroses
are left adhering to the tissues, and persist for a longer
period. Dakin's solution appears incapable of sterilising
a fragment of necrosed tissue on the surface of a wound.
In such a fragment bacteria would find a safe refuge.
In the treatment of wounds, therefore, it is indispensable
to employ a substance capable of dissolving tissues
deprived of circulation. On the other hand, if the wall
of a blood-vessel is mortified, the slough falls off more
rapidly than if the wound is left to itself. Similarly, the
clots which often obliterate vascular wounds are enabled
THE PRINCIPLES OF THE TECHNIQUE 39
to dissolve under the action of hypochlorite. For this
reason we must carefully examine the condition of the
vessels at the moment of surgical intervention, and must
effect an accurate preventive haemostasis.
(b) Action of Hypochlorite on Isolated Anatomical
Elements. If blood or pus is placed in a tube containing
an excess of hypochlorite, the red corpuscles are rapidly
attacked. When the volume of hypochlorite is sufficient
the anatomical elements are completely disintegrated.
However, in the secretions of wounds treated by hypo-
chlorite the polynuclear cells are not much altered, and
often contain microbes. It is probable that phagocytosis
occurs in the walls of the wound, out of reach of the
antiseptic substance, which remains on the surface of the
tissues. Generally speaking, there is no need to accom-
plish the dissolution of those leucocytes which have
absorbed micro-organisms ; but in certain cases the
complete destruction of the phagocytes is of importance.
This conception is unknown to the French surgeons, who
generally speaking confuse the chemiotherapy of local
infections with that of general infections.
In the chemiotherapy of general infections the anti-
septic substance should be injected into the circulatory
system ; it must not, accordingly, exert an injurious
action upon the leucocytes. If, indeed, it were to pre-
vent phagocytosis it would deprive the organism of one
of its most valuable means of defence.
In the chemiotherapy of local infections the import-
ance of the leucocytes is of a totally different nature.
Indeed, as the bactericidal substance does not sink into
the depth of the tissues, its action is exerted only on
the surface of the wound. The leucocytes existing in
40 TREATMENT OF INFECTED WOUNDS
the wall of the wound are able to continue their functions,
even if the bactericidal substance is injurious to them,
As for the leucocytes which occur on the surface of the
tissues, they are replaced by a chemical substance whose
bactericidal action is much more powerful than their
own. On the other hand, large numbers of these leu-
cocytes, having phagocytosed the microbes, are still
living, and may once again enter into the tissues and
there spread the infection. The researches of Rous 1
have demonstrated that the red corpuscles or the patho-
genic phagocytosed microbes are protected by the wall
of the leucocytes from the humours of the organism and
from bactericidal chemical substances. It is thus im-
portant to destroy, on the surface of wounds, the leu-
cocytes which are loaded with bacteria, as well as the
pus bacteria. The so-called cytophylactic medication
of a local infection is based on ignorance of the protec-
tive role which the leucocytes fulfil in respect of the
microbes. It may produce disastrous results, above all
in cases of cerebral wounds. Indeed, we find in the
secretions of such wounds leucocytes which are loaded
with microbes, which remain included in the cerebral
substance at the moment of cicatrisation. It is probable
that the protection offered to the microbes by the phago-
cytes which have absorbed them enables them to produce
secondary retractile cicatrices, or encephalitis, or a
cerebral abscess.
This is why we must employ a substance capable of
destroying all the anatomical elements deprived of cir-
culation. The concentration of Dakin's solution is such
that it enables us to utilise the different degrees of
1 Rous and Jones, Journal of Experimental Medicine, 1916, p. 601.
THE PRINCIPLES OF THE TECHNIQUE 41
resistance presented, on the one hand, by the microbes,
the free anatomical elements, and the necrosed tissues ;
and, on the other hand, by the normal tissues provided
with circulation. It destroys the former and respects the
latter.
(c) Action of Hypochlorite on Tissues equipped with a
Circulation. In order to appreciate the action of Dakin's
solution on living tissues we have investigated the
progress of cicatrisation of wounds treated with hypo-
chlorite.
Certain technical difficulties are presented by this
research. It is essentially necessary that the conditions
of the wounds whose healing is being studied, and
particularly their microbial state, should not vary
throughout the duration of the experiments. Should
these conditions vary, one may no longer attribute to
the substance employed the eventual modifications in
the progress of cicatrisation. Furthermore, the surface
of wounds, in spite of the irregularity of their outline,
must be measured exactly.
Up to the present, no one has taken the trouble to
study in any precise manner the factors capable of
modifying the rapidity of cicatrisation. The bacterio-
logical condition of wounds the subject of experiment
has not hitherto been taken into account. It is recog-
nised, however, that the presence of microbes on the
surface of a wound has a profound effect on the progress
of repair. In all the forms of technique hitherto em-
ployed, this truly important omission destroys the value
of all the experiments on and observations of sub-
stances supposed to aid cicatrisation. This error in
technique explains the contradictions found in all medical
42 TREATMENT OF INFECTED WOUNDS
publications on the subject of topical applications in the
treatment of wounds. Every surgeon attributes a power
more or less marvellous to some substance which the
surgeon of the next hospital looks on as insignificant.
In the same way, estimation of the progress of
cicatrisation has always been left to individual opinion.
As a matter of fact, it has never been sought to devise
a technique which would permit exact measurement of
the surface of a wound, with estimation in square centi-
metres of the amount by which it lessens day by day.
The ignorance we manifest, after so many ages of
surgical practice, of the real influence of the substances
used in treating wounds, is only due to the absence of
scientific method. To obtain exact data on this subject,
it was necessary in the first place to experiment on
wounds placed under conditions which remain unchanged
throughout the duration of the observations, and after-
wards to devise a method which would allow the pro-
gress of cicatrisation to be measured.
(a) The Conditions of the Wounds. The wound must
be that of a man immobilised in bed, and whose general
state does not vary during the period of observation.
The bacteriological state of the wound plays an im-
portant part in the progress of cicatrisation. Rapidity
of repair varies according to the nature and the volume
of the infection. When microbes are allowed to multiply
on the surface of the wound, it is impossible to know
if the modifications of cicatrisation are due to direct
action of the substance experimented with upon the
tissues, or to a favourable or unfavourable action of this
substance on the microbial flora ; or to the algebraic
sum of the two causes. Therefore the daily control of
THE PRINCIPLES OF THE TECHNIQUE 43
the state of the wound, by means of the microscope, is
indispensable, to avoid a false interpretation of the ex-
perimental results.
The experiments were made on surface wounds,
and sometimes on deep wounds. Wounds of regular
perimeter were preferred to those whose margins were
torn. Wounds of elongated form were specially chosen,
so that one half could be treated by a substance, while
the other half served as a control. Or, better still,
wounds of nearly equal size were used, situated in the
corresponding region in the same individual One of
the wounds was dressed with a substance to be tested,
while the other served as a control.
Every day the bacteriological condition of the wound
was examined by the aid of " smears," and sometimes of
cultures. As microbes were found, steps were taken
to eliminate them. The granulating surface and the
neighbouring skin were washed carefully with neutral
oleate of soda. Then the granulations were sterilised
by means of hypochlorite of soda or chloramine.
When the bacteriological examination showed that
sterilisation was complete, the wound was dressed, either
with oleate of soda, or with stearate of soda containing
small quantities of antiseptic, or with vaselin, or saline
solution. In this manner it was possible to keep wounds
almost completely aseptic. The daily bacteriological
examination allowed reappearance of the infection to be
discovered, and allowance to be made for it in the inter-
pretation of the experiments. On wounds thus prepared
the action of the substances was studied.
(b) Technique of the Measurement of Wounds. In
most cases the progress of repair was studied on surface
44 TREATMENT OF INFECTED WOUNDS
wounds, and only rarely in deep wounds. The surface
of a wound was measured in the following manner. A
sheet of thin celluloid was applied over the surface of
the wound. By the aid of a pencil (used for marking
glass) the outline of the epithelial margin was traced,
and in every case where it was possible, the contour of
the cicatrix at its union with sound skin. The drawing
thus obtained was transferred to a sheet of ordinary
paper. Then, with the aid of a planimeter, the area
of the wound, properly so called, was measured, also
that of the surface of the wound increased by that of the
cicatrix. Thus in square centimetres was obtained the
area of the two surfaces, and, by subtracting the first
from the second, the area of the surface of cicatricial
tissue was obtained. When a deep wound was in ques-
tion, its capacity was obtained by filling it with water
and so measuring the volume.
Graphic representation of the cicatrisation of a wound
was obtained in the following manner. Time was repre-
sented in abscissae and surface in ordinates. Curves were
thus obtained which enabled one, day by day, to estimate
the variations of the surface and those of the cicatrix.
Thus the parts taken by connective and epithelial tissues
in repair may be observed.
The investigations of Carrel have shown that the
curve of cicatrisation thus established is geometrical in
form. Lecomte de Nouy has recently determined the
algebraic expression of this curve. 1 Nouy's formula con-
sists of two equations
i Carrel, Journal of the American Medical Association, 1910, and
J ournal of Experimental Medic ine, 1916. Lecomte du Nouy, Journal of
Experimental Medicine, Nov. 1916. A. Hartmann, These de Paris, 1916.
THE PRINCIPLES OF THE TECHNIQUE 45
(2) /' = S'(l - *(/ + VT + /))
s is the total surface of the wound on the day of
commencing the observation ;
s' is the surface of the wound / days later, at the
time of the second observation (usually four days later,
so that the cicatrised area s - s' shall be sufficiently
important) ;
t is the time elapsing between the two first obser-
vations ;
T is the "age" of the wound, reckoned from the
time of the first observation s ; so that in the first
equation T = / ;
t' is the time which must elapse between the day of
the last observation /, and the day for which it is
desired to calculate the theoretical area of the wound ;
i is a coefficient characteristic of each wound, on the
determination of which the formula is based.
Thus we see, by the mere examination of the two
equalities (i) and (2), that the former tends to establish
a certain index of cicatrisation *, which is then intro-
duced into the latter, in order to calculate the surface of
the wound at any given time.
The index i is obtained by means of the formula (i)
after two observations made at four days' interval when
the wound is aseptic. Experiment has shown that this
index is a function of the age of the wounded man, and
also of the surface of the wound, and that it is larger in
proportion as the latter is smaller, and the patient
46 TREATMENT OF INFECTED WOUNDS
younger. Lecomte du Nouy establishes a curve which
makes the previous calculation of the index unneces-
sary (Fig. 8). The only elements needed for the calcu-
lation of this curve of cicatrisation are the area of the
sterile wound and the age of the patient.
By means of two observations made at four days'
interval, or even by means of a single observation, the
age of the patient being known, it was possible to
calculate the theoretical curve of cicatrisation. On the
*
V
S,
\
y
\
\
\
S
\
V
s,
N
s
, _
75ST
J t.
1 c
^
c
\
FIG. 8. Cicatrisation curve of an
aseptic wound. Surface, expressed
in square centimetres, forms the
ordinates, whilst time, in days, the
abscissae. (Case 221.) $>, +, ^^.
FIG. 9. Curves, observed and calculated,
for the same wound. By means of
observations made the i7th and 2ist of
Dec., the progress of cicatrisation was
calculated according to the formula of
Lecomte du Nouy. A continuous line re-
presents the observed curve, and a dotted
line the calculated curve. The coinci-
dence of the two curves is almost perfect.
(Case 221.)
same sheet the course of the observed curve was plotted
(Fig. 9). It was thus possible to ascertain the abnormal
variations of the rate of repair to be observed in the
wound, these manifesting themselves by the divergence
of the observed curve from the calculated curve.
As we possessed also the chart of the bacteriological
condition of the wound, it was easy to estimate almost
exactly the part played in the progress of repair by the
substance under examination. By means of this method
THE PRINCIPLES OF THE TECHNIQUE 47
the action of hypochlorite of soda upon the repair of
wounds was examined. Experiments were successively
made upon infected wounds, and upon those surgically
sterile, that is to say, wounds whose secretions examined
by means of " smears " no longer contained microbes.
*n*i
165
150
125
100
75
5C
25
\
\
\
*>
X
\
\
\
s
s
\
\
S
s
s
i
L
-|<
3 C 14 tf"B 20 22 8*1
b28
trt
5
FIG. 10. Cicatrisation curve of a wound
of the abdominal wall. Slowing down
of cicatrisation from Feb. zoth to Feb.
1 8th, due to a re-infection. Accelera-
tion from Feb. i8th to Feb. 22nd,
under the influence of Dakin's solu-
tion. (Case 327.)
Fevner1918
6 10 141618 19 2025
FiG. ii. Curve indicating the
bacteriological condition of the
preceding wound from Feb. 4th
to Feb. 2ist. The slowing down
of cicatrisation coincides with a
re-infection of the wound which
reached its maximum Feb. i6th,
and the acceleration coincides
with the sterilisation which oc-
curred Feb. i8th. (Case 327.)
(c) Action of Hypochlorite upon the Cicatrisation of
an Infected Wound. Many experiments were made
upon surface-wounds whose curves of cicatrisation were
known, and of which the bacteriological condition was
48 TREATMENT OF INFECTED WOUNDS
recorded. These wounds generally showed from five to
twenty microbes per microscope field, and the observed
curve of cicatrisation showed a slighter fall than the
calculated curve (Figs. 10 and n). A perforated tube
was applied to the surface of the wound and Dakin's
solution instilled every two hours. In all cases without
exception cicatrisation was hastened and the curve of
cicatrisation dropped (Figs. 12 and 13). The speed of the
repair often increased in such a manner that the observed
curve rejoined the calculated curve, but without ever having
a more rapid fall than that of an aseptic wound. Therefore
there was no accelerating action due to the hypochlorite.
The rapidity of the cicatrisation in presence of
Dakin's solution was sometimes considerable. A wound
of the leg, wide and of long standing, communicating
with an unsterilised bone injury, yielding a great number
of microbes from its surface, was healing very slowly.
The cicatrisation curve was dropping only slightly.
This wound had a surface of 75 square centimetres.
As soon as it was treated with Dakin's solution the
curve fell sharply. In four days the wound lessened
by 28 square centimetres, and during the following days
the repair continued at approximately the same rate. It
should be noticed that the sterilisation chart showed at
the same time a considerable lessening in the number of
microbes. The same phenomenon was observed in all
wounds uniformly infected, and cicatrising with a known
rapidity, which were treated with Dakin's solution. With
the exception of those containing a foreign body, all
wounds responded to the treatment. To remove the
foreign body was to ensure that the wound would follow
the general rule.
THE PRINCIPLES OF THE TECHNIQUE 49
Surface
Vitesae '
/
V
f
'
v
y
/
,
/
s
{
s
s
s
h^
^
s
^
|
jj
5
*-
*
^
;
ic 3
FIG. 12. Influence of the sterilisation of a wound on the progress of cicatrisa-
tion. . The cicatrisation curve shows how a sluggish-looking and highly
infected wound steadily enlarged from 6 to 15 square centimetres from
the I4th to the zgth of Nov. It was sterilised on the 2gth of Nov.
Instantly cicatrisation commenced and its course followed a geometric
curve.
MOIS
JOURS
60
20
10
Novembre1y15
22-2324252627282930
Decembre
1 2
4 5
67
10 11 12
FIG. 13. Bacteriological curve of the preceding wound. The graph shows
that, under the influence of Dakin's hypochlorite, the number of microbes,
at first infinite, rapidly dropped. The coincidence between the date of
sterilisation of the wound and that of the beginning of normal cicatrisation
should be noticed.
50 TREATMENT OF INFECTED WOUNDS
Upon deep wounds few observations were made.
However, some experiments were carried out of the
following type. A collection of pus had formed on the
antero-external aspect of the leg of a man with arthritis
of the knee. This collection, which was accompanied by
a rise of temperature, was opened at its upper part and
the pus evacuated. The next day the wound was
washed with Ringer's solution, and its capacity measured
26 c.c. The wound was irrigated with hypochlorite.
Twenty-four hours later the suppuration had disappeared.
In the bottom of the cavity a little liquid was found,
syrupy, yellow, transparent. The secretions contained
only one coccus per microscope field. The volume of
the cavity now was not more than 7 c.c. Forty-eight
hours later it was reduced to 2 c.c., and the wound was
completely sterile. Then it closed. In short, an
abscess cavity of 26 c.c. was sterilised and completely
closed in four days. Similar experiments were made,
and yielded results comparable. But the diminution in
volume of deep wounds comes about in a more irregular
manner than the cicatrisation of surface-wounds. It was
upon the latter, therefore, that the majority of the experi-
ments were made.
In order to obtain more strictly controlled observa-
tions, experiments were made on different parts of the
same wound. For example, two strips of filter-paper
were applied at the upper and lower extremities of a
wound of the external aspect of the arm, with fracture.
Each strip stretched from one margin of the wound to
the other, over the granulations, after the manner of a
bridge. The previous bacteriological examination had
shown that the whole surface of the wound was
THE PRINCIPLES OF THE TECHNIQUE 51
uniformly infected. The filter-paper at the lower part
of the wound received an instillation of Dakin's hypo-
chlorite every two hours, whilst the filter-paper at the
upper part was not moistened (Fig. 14 and Fig. 15).
At the end of three days it was obvious that the
edges of the wound were not altered in the upper region,
but that, in the lower part of the wound, cicatrisation
FIG. 14. Influence of hypo-
chlorite on an infected
wound. Wound on the ex-
ternal aspect of the arm
presenting an infection of
cutaneous origin. A, con-
trol filter-paper. B, filter-
paper soaked in Dakin's
hypochlorite.
FIG. 15. The same wound
three days later. The lessen-
ing of the wound at the
level of the control paper A
is of the slightest. Beneath
the filter-paper B, the in-
fluence of the hypochlorite
is manifest ; the epithelial
margin has greatly advanced,
and the wound has lessened
in a well-marked manner.
had progressed much more quickly. The parts covered
by filter-paper moistened with hypochlorite showed granu-
lations softer and redder than those in the other regions
of the wound. The change in the appearance of the
granulations followed a transverse line very closely corre-
sponding to the upper border of the filter-paper. A
marked acceleration of the cicatrisation, therefore, had
52 TREATMENT OF INFECTED WOUNDS
taken place in the region treated by Dakin's solution
(Fig. 15). At the same time the bacteriological ex-
amination showed that the microbial flora were not
modified over the untreated part of the surface of the
wound, whilst in the region covered by filter-paper
soaked in hypochlorite, microbes had completely dis-
appeared. In other experiments, where a part of the
infected wound was dressed with vaselin, and another
part with hypochlorite of soda, there was to be observed,
in similar fashion, acceleration of cicatrisation in the
region treated by hypochlorite.
There was, therefore, a coincidence between the acce-
leration of cicatrisation and the application of Dakin's
hypochlorite, under certain conditions, to the surface of
the wound. We might, therefore, have been tempted to
attribute to the hypochlorite of soda a stimulating action
on cicatrisation. But as the wounds submitted to ex-
periment were infected, and the bacteriological charts
also showed a coincidence between the disappearance of
the microbes and the acceleration of cicatrisation, it was
probable that the cicatrising influence of the hypochlorite
of soda was only apparent. In fact, the following ex-
periments showed that hypochlorite of soda exercises no
active influence on wounds already aseptic.
(d) Action of Hypochlorite iipon the Cicatrisation of
an Aseptic Wound. In order to keep aseptic wounds
sterile while their cicatrisation is being studied, hypo-
chlorite of soda is applied to the surface during periods
more or less long. But the rapidity of repair of these
aseptic wounds, treated by means of hypochlorite, is
not altered, and the curves do not show a more marked
fall. This shows that the hypochlorite of soda has no
THE PRINCIPLES OF THE TECHNIQUE 53
cicatrising effect, and that the acceleration which it
produced in the repair of infected wounds is due simply
to the suppression of microbes. Under the actual con-
ditions of the experiments, hypochlorite does not delay
the repair of wounds moistened every two hours with
0*5 per cent. Dakin's solution. Or rather, any delay
produced by the action of the hypochlorite is too slight
to be evident.
We have endeavoured to study this possible retard-
ing action of hypochlorite with the help of a more precise
form of technique. On a large wound taking up the
external aspect of the arm, repeated bacteriological ex-
aminations had shown the absence of microbes. The
lower half of the wound was covered with a piece of
gauze moistened every two hours with Dakin's solution,
whilst the upper half was dressed with vaselin. At the
end of four days a tracing of the wound was taken, and,
on comparing it with the preceding tracing, it was seen
that the epithelial border had progressed a little more
rapidly under the vaselin than under the hypochlorite
(Fig. 16).
At this time both the upper and lower parts of the
wound were still aseptic. It would seem, therefore, that
the hypochlorite of soda had slightly retarded the healing
of an aseptic wound. But this retarding action was
much feebler than the action of certain microbes, as the
later history of the experiment showed. The wound
was still being dressed with vaselin and hypochlorite.*
Bacteria soon appeared in the region dressed with
vaselin, whilst that covered by hypochlorite remained
sterile. A new tracing was taken, and, on comparing it
with the preceding, it was found that the rapidity of
54 TREATMENT OF INFECTED WOUNDS
healing had become greater under the hypochlorite than
under the vaselin (Fig. 17). When physiological saline
solution was used instead of vaselin, similar results were
obtained.
These results were checked by experiments in which
FIG. 16. Influence of hypochlorite on a
sterile wound. The continuous outline
represents the contour of a wound of
the outer region of the arm which was
sterile, Dec. 16. The half A was dressed
with vaselin, and the half B with hypo-
chlorite. The dotted line represents
the state of the wound Dec. 20. It
shows that the part A dressed with
vaselin has healed a little more quickly
than the part B dressed with hypo-
chlorite.
FiG. 17. Influence of hypochlorite
on an infected wound. The pre-
ceding wound, under the influence
of vaselin, became slightly re-
infected. The dressings, however,
were continued, the part A with
vaselin, the part B with hypo-
chlorite. The continuous outline
represents the state of the wound
Dec. 20. The dotted line repre-
sents the state of the wound Dec.
24. It is seen that the cicatrisation
has taken place more rapidly in
the part B, dressed with hypo-
chlorite, than in the part A, dressed
with vaselin.
the rate of cicatrisation of wounds treated with hypo-
chlorite was compared with that of wounds treated with
other substances, in particular by distilled water, Wright's
hypertonic solution, M. Delbet's chloride of magnesium,
flavine, and chloramine.
THE PRINCIPLES OF THE TECHNIQUE 55
The wounds treated by the instillation of distilled
water (Figs. 18 and 19) or of Wright's hypertonic solu-
Distilled water.
FIG. 18. Cicatrisation curve of a
wound treated with distilled water.
The cicatrisation, which was nor-
mal, slowed down and came to a
full stop. Then the wound became
slightly enlarged. The cicatrisa-
tionbecame normal once more after
a dressing with chloramine. There
is a great divergence between the
calculated curve and the observed
curve.
FIG. 19. Sterilisation curve of the
foregoing wound. This curve shows
that a reinfection occurred after
the application of irrigation with
distilled water.
lution (Figs. 20 and 21) behaved in precisely the same
manner. The curve of cicatrisation was modified by the
first application of the substance employed. The dimi-*
nution of the rate of cicatrisation constantly coincided
with a reinfection of the wound. The apparent re-
tarding action of the liquid employed was due simply
to the rapid reinfection of the wound. This fact is
56 TREATMENT OF INFECTED WOUNDS
clearly demonstrated by a comparison of the curves of
cicatrisation and sterilisation.
The cicatrisation of a wound treated with Delbet's
chloride of magnesium is strikingly affected. Directly
a sterile wound is treated with instillations of chloride
of magnesium its curve undergoes modification, tending
\
^
a
vr
FIG. 20. Cicatrisation curve of a
wound dressed with hypertonic so-
lution.
The observed curvddiverges from
the calculated curve after the ap-
plication of the hypertonic solution,
and returns to it as soon as a dress-
ing of chloramine is applied.
FIG. 21. Sterilisation curve of the
same wound.
Under the aseptic dressing the
wound becomes reinfected ; it pro-
ceeds towards sterilisation, -as soon
as the chloramine is applied.
to approach the horizontal. This indicates a decided
retardation of cicatrisation. In the wound whose curve
we reproduce below (Fig. 22) the solution of magnesium
chloride was replaced, after the lapse of a few days, by
hypochlorite of soda. The curve fill once more, the
cicatrisation being accelerated. At the same time the
FIG. 22. Cicatrisation curve of a wound treated with chloride of magnesium.
(Case No. 799.)
From the day when chloride of magnesium is applied to the wound the
observed curve diverges rapidly from the calculated curve, showing re-
tarded cicatrisation. From the moment when Dakin's solution is applied
the observed curve tends to rejoin the calculated curve.
FIG. 23. Sterilisation curve of a wound treated with chloride of magnesium.
(Case No. 799.)
Directly chloride of magnesium is applied to the wound the curve rises, for
the number of microbes quickly becomes very great. The lowering of the
curve which follows is due to washing the wound with oleate of soda.
When the washing is discontinued the number of microbes again becomes
innumerable. The last drop of the curve is due to k the application of
hypochlorite of soda, which results in sterilisation.
58 TREATMENT OF INFECTED WOUNDS
curve of microbic infection showed that the retardation
of cicatrisation coincided with a reinfection of the wound,
which was covered with vast numbers of microbes (Fig.
23). After the application of hypochlorite of soda the
wound again became sterile. This is why the cicatri-
sation curve tends to become normal again when the
use of M. Delbet's solution is discontinued. In these
667 3
FIG. 24. Cicatrisation curve of a wound dressed with flavine. Directly
flavine is applied the observed curve diverges from the calculated curve,
for the wound increases in size. The cicatrisation becomes normal again
as soon as chloramine is applied once more. A second experiment upon
the same wound produces the same arrest of cicatrisation.
two cases the retarding action of the substances employed
was only apparent. The retardation was due in reality
to the infection which occurred immediately.
Other substances for example, Browning's flavine
exert a direct action on the process of cicatrisation, as
is shown by the curves of cicatrisation and sterilisation.
In the case of a patient whose wound was sterile, and
undergoing cicatrisation in a normal manner, installations
THE PRINCIPLES OF THE TECHNIQUE 59
of flavine were twice applied, the solution being i in
7|8I9|10|11|12|13|14|15|16|17|18|19|20| 1|22|23|24|2S|26|27|28129|3'0 1 12 13 141 516 17 18
FIG. 25. Sterilisation curve of the foregoing wound.
The wound remains aseptic during the first application of flavine. The re-
tardation of cicatrisation observed is due to the peculiar action of flavine
upon the wound.
3
Decembre
FIG. '26. Cicatrisation'curve of a wound treated with Dakin's solution. The
observed curve coincides? throughout with the calculated curve. The ob-
served curve is the unbroken line ; the calculated curve, the dotted line.
1000 on the first occasion and i in 5000 on the second.
6o TREATMENT OF INFECTED WOUNDS
Immediately the curve became horizontal and even
proceeded to rise, for cicatrisation was not only arrested ;
it actually retrogressed, and the dimensions of the wound
increased (Fig. 24). At the same time the bacterial
curve showed that the wound had remained aseptic (Fig.
25). It was therefore obvious that the retrogression
of cicatrisation, not being due to infection, was to be
attributed to a deleterious action of the substance itself.
When we compare the curves of wounds treated
with the aforesaid substances with the curves of wounds
treated with hypocholorite or
chloramine, we notice an ob-
vious difference. The wounds
treated with hypochlorite
(Figs. 26 and 27) or with
chloramine (Figs. 28 and 29)
become cicatrised according
to the cicatrisation curve
calculated by du Nouy's
formula, with the normal
rapidity of aseptic wounds.
In short, in the healing
of an infected wound the
acceleration produced by
hypochlorite is due to its
antiseptic 'power. Hypo-
chlorite does not appear to
have any marked action on
the tissues in the direction of cicatrisation, when it is
used under the conditions of our experiments. Probably
it has a slightly retarding effect on the healing of aseptic
wounds. But in practice this influence is negligible.
MO IS Novembn
;1916 Dec.
JOURS 14 16 22 24
27>23 1 1 3
60 : - ii
40 i :: ::
20 : :: ii
m
10 i :: :i
5: jj |j
1 : :: :
k
J t
j^y
FIG. 27. Sterilisation curve of the
foregoing wound. The wound re-
mains sterile throughout the treat-
ment.
THE PRINCIPLES OF THE TECHNIQUE 61
Dakin's solution, therefore, we may conclude, when
applied under suitable conditions, does not in any appre-
ciable manner, harm tissues under repair, which is
contrary to the belief of most surgeons.
FIG. 28. Cicatrisation curve of a wound dressed with chloramine (case No-
706). The observed curve coincides exactly with the calculated curve.
FIG. 29. Sterilisation curve of a wound treated with chloramine. The wound
remains constantly sterile.
5. Action of the Tissues on Hypochlorite of Soda. The
dead or living tissues exert a marked action on the concen-
tration of a solution of hypochlorite. In M. Daufresne's
experiment, which we have already described, wherein
62 TREATMENT OF INFECTED WOUNDS
fragments of skin were placed in an excess of Dakin's
hypochlorite, it was found, after the lapse of some twenty-
four hours, that the concentration of the solution was
very greatly diminished, In the experiments conducted
by Carrel on wounds of the brain after the death of the
animal, it was found that hypochlorite of soda decom-
posed with very great rapidity. The wound was filled
with a solution containing 0*5 per 100 of hypochlorite.
At the end of six minutes the solution was withdrawn,
and the degree of concentration was found to be only
O'i6 per 100. A fresh portion of solution was injected,
and withdrawn at the end of seven minutes ; its degree
of concentration was still 0*23 per 100. But if a third
portion of Dakin's solution was injected into the same
cavity, it was found that the degree of concentration had
not diminished by more than half at the end of eight
minutes. Similar experiments made upon other tissues
show that the concentration of a solution of hypochlorite
may diminish by 70 per 100 in five minutes.
This destruction of hypochlorite is still more active
when the solution is in contact with living tissues. Ex-
periments were made in the peritoneum of the cat or
rabbit. A portion of Dakin's solution containing 0*45
per 100 of hypochlorite was poured into a small cup
which contained a portion of the epiploon of a cat, which
was provided with its normal circulation. At the end
of seven minutes the strength of the solution was only
0*07 per 100. A large number of analogous experiments
were carried out, and from these it was possible to prove
that hypochlorite loses, in a few minutes, when in contact
with tissues equipped with their normal circulation, more
than four-fifths of its strength. Similar experiments
THE PRINCIPLES OF THE TECHNIQUE 63
were conducted with wounds in course of cicatrisation.
Deep wounds were selected for the purpose, so that the
solution could lie in them readily. The wounds whose
action on hypochlorite was studied were completely
aseptic, or still contained a few microbes. The hypo-
chlorite, whose degree of concentration was known, was
poured into the wound, and at intervals of two minutes
a few cubic centimetres of the liquid were withdrawn and
\
\ LOZ4O
a, 40%
0,80
0,25
0,20
0,16
0.10
0,05
JSS} i 8 * 46 * y *&
FIG. 30. Curve showing the rate at which hypochlorite of sodium is
destroyed in contact with living tissues.
A 0*4 per cent, solution placed in an almost aseptic wound was reduced
to 0-24 per cent, at the end of 2 minutes, and 0*16 per cent, at the end of
9 minutes.
immediately analysed. The results of the experiments
were expressed in the form of a curve. In aseptic frac-
tures of the tibia, or fractures which were almost com-
pletely aseptic, the strength of the hypochlorite as a
rule decreased from 0*4 to 0*15 in six minutes. At the
end of half an hour only 0-05 to o - o6 of hypochlorite
was left. In Fig. 30 the curve shows the progressive
disappearance of hypochlorite from a solution poured
into a wound accompanying a fracture of the tibia. The
64 TREATMENT OF INFECTED WOUNDS
solution, which was 0-40 per 100 at the outset, was 0*27
per 100 two minutes later, and 0*16 per 100 at the end
of four minutes. When six minutes had elapsed the
strength was reduced to 0*13 per 100.
The decrease in the strength of the solution of hypo-
chlorite occurs at a variable rate, according to the nature
of the tissues, the volume of the secretions, the form of
the wound, and many other conditions, which do not
permit us to forecast, in the case of a given wound, what
will be the rate of destruction of the bactericidal sub-
stance. But these experiments show that the tissues
exert a manifest action upon the hypochlorite, that the
strength of the solution is rapidly modified, and that in
order to maintain it at a constant figure fresh quantities
must incessantly be supplied to the wound. Hence the
necessity of a large quantity of antiseptic solution if we
wish to sterilise a wound.
6. Mode of Action of Hypochlorite. Dakin attributes
the bactericidal action of the hypochlorites to a chemical
reaction similar to that which takes place between
ammonia and a hypochlorite, and results in the simplest
of the chloramines, as Raschig demonstrated long ago.
The destruction of micro-organisms by an antiseptic is due
probably to chemical modifications produced in the sub-
stances constituting living cells, either by the direct action
of the antiseptic, or by the action of products resulting
from the combination of the antiseptic with the substances
in the midst of which the micro-organisms are found.
Amongst the substances contained in living cells and
capable of reacting with hypochlorites, proteins play
probably the chief rdle. The action of hypochlorites on
proteid matters consists, at least in part, in the substitution
THE PRINCIPLES OF THE TECHNIQUE 65
of chlorine for hydrogen in some of the NH groups,
and, afterwards, in the formation of substances belong-
ing to the group of chloramines. Dakin l believes that
the property possessed by hypochlorites of attacking
proteid matters, forming compounds in which the halo-
gen element is directly attached to the nitrogen, is
closely bound up with their bactericidal action.
This hypothesis is supported by the following observa-
tions. Free chlorine, bromine, and iodine vary only
slightly in their germicidal power. But if the halogen
element is converted into the hypochlorite or the hypo-
bromite, a strongly marked difference appears. The
bactericidal action of hypochlorites on staphylococci sus-
pended in water, is almost equal to that of free chlorine,
whilst that of hypobromites is only equivalent to about
one- hundredth of that of free bromine. The bactericidal
action of hypoiodite is almost nil. The insignificant
bactericidal power of hypobromites and hypoiodites coin-
cides with their feeble capacity for reaction with proteins
and amino-acids.
It is also interesting to consider why hypochlorites,
which destroy the skin in vitro, leave unharmed living
tissues and do not interfere with the healing of wounds.
Soda, it is well known, produces immediate dissolu-
tion of the tissues. Fiessinger's experiments, upon the
rapidity of dissolution of leucocytes, confirms the fact
that the solvent action of the hyposulphites is a function
of their soda content. Fiessinger also ascertained that
this action diminishes .according as hypochlorites con-
taining quantities greater or less of soda are used.
1 Dakin, Cohen, Daufresue, and Kenyon, Proceedings of the Royal
Society, 1916.
5
66 TREATMENT OF INFECTED WOUNDS
Daufresne's experiments, which we have already quoted,
demonstrate plainly that Labarraque's solution, which
contains free alkali, causes dissolution of skin at a
moment when Dakin's solution has not yet produced
any perceptible lesion.
Tissues provided with a normal circulation resist
perfectly the action of Dakin's solution under the con-
ditions of our experiments. Guillaumin and Vienne
attribute 1 this resistance to the following phenomenon.
Take an alkaline solution of such concentration that it
hydrolyses and dissolves the fragment of tissue placed
in it. If a certain quantity of neutral salt be added,
it is known that the tissue can be immersed in the
solution thus modified, without its structure becoming
altered. Guillaumin and Vienne made the following
experiment. Fragments of skin were placed in a 3
per cent, solution of soda, to which had been added 12
per cent, sodium chloride. Other portions of skin were
placed in a 3 per cent, solution of soda to serve as
controls. The skin immersed in the solution containing
chloride remained intact, while the control fragments
swelled up and became transparent. However, analysis
showed that the same quantity of alkali had been
absorbed by the skin in each case. This important
process is known in tanneries as " pickling." Guillaumin
and Vienne consider it the reason why tissues are not
injured by hypochlorite.
Whatever may be the explanation of the resistance
of living tissues to hypochlorite, this phenomenon provides
a working hypothesis for the chemiotherapy of wounds
1 Guillaumin et Vienne, Archives de Mtdeeine et de Pharmacie militaire^
1916.
THE PRINCIPLES OF THE TECHNIQUE 67
in spite of the destructive action of hypochlorite on
proteins.
B. Chloramines. After having studied the mode of
action of hypochlorites, Dakin was led to investigate the
substances which act in a manner almost identical, but
which are of greater practical value. He believed that the
bactericidal action of hypochlorites took place by means
of substances formed at the expense of proteins, and
containing chlorine in combination with nitrogen. Ex-
periment showed him that when proteins such as
blood-serum, white of egg, casein, etc., are treated by
hypoehlorites, they give rise to products of a high anti-
septic potency. These substances, without a doubt, are
formed in situ when wounds are treated by hypochlorites.
Thus, after the disappearance of free hypochlorite, there
still remains in the wound a substance having antiseptic
power.
Certain aromatic chloramines which form soluble
salts give encouraging clinical results. The best of these
compounds are the benzene- or the para-toluene-sodium-
sulphochloramines which have been described by Chatta-
way.
CH 8
SOaNaNCl S0 2 NaNCl
These substances, .which possess a very high anti-
septic potency, are but slightly irritating, and can be
used in a much higher degree of concentration than the
hypochlorites. The solutions in general use in our
68 TREATMENT OF INFECTED WOUNDS
experiments vary from 0*2 per cent, to 2*0 per cent. The
action of these substances is similar to that of the hypo-
chlorites, but their antiseptic potency is superior.
I. Bactericidal Action. Staphylococci suspended in
water are killed in two hours by benzene-sodium-sul-
phochloramine at a strength of i : 500,000, and by
para-toluene-sodium-sulphochloramine at a strength of
I : 1,000,000. When horse-serum is present, the strength
necessary becomes i : 1,500 to i : 2,500. The B. pyo-
cyaneus, Eberth's bacillus, and the bacillus coli are
slightly more resistant than Staphylococci, whilst B.
perfringens and streptococci are more easily killed.
On infected wounds chloramines give results similar
to thpse of hypochlorite of soda. Their action on
microbes has been determined in the course of a
great number of experiments similar to those we have
described when on the subject of hypochlorite of soda.
Used with the same technique they sterilise wounds.
Their action on the tissues has been studied on both
sterile and infected wounds, by comparing the charts of
sterilisation and the curves of cicatrisation. When used at
a strength of less than 0*2 per cent., they do not interfere
with the rapidity of repair. It has been observed some-
times, however, that an aqueous solution of 2 per cent
may produce lesions of the connective tissue which
show themselves by diminution, and sometimes arrest,
of cicatrisation.
With the collaboration of MM. Cohen, Daufresne,
and Kenyon, Dakin investigated a certain number of
substances of the same group, particularly the chlor-
amines, in which the group NCI is separated from the
benzene radicle by the group SO 2 Na ; the similar
THE PRINCIPLES OF THE TECHNIQUE 69
naphthalene derivatives ; the other similar dicyclic
derivatives ; the chloramines in which the group NCI
is directly attached to the benzene radicle ; the brom-
amines ; and finally the products of the action of hypo-
chlorites upon different proteid substances. He found
that the substances which contain the group NCI also
possess powerful bactericidal action. But the presence
in their molecule of more than one NCI group does not
increase their germicidal potency. Molecule for mole-
cule, the germicidal action of many of these chloramines
was greater than that of hypochlorite of soda. As to
the substances derived from proteins under the influence
of hypochlorite of soda, their antiseptic action was very
powerful. But blood serum inhibited their potency, as
it had done in the case of hypochlorite of soda and the
aromatic chloramines.
While inquiring into the factors which control the
germicidal action of chloramines, Dakin found that
chloramines or bromamines destroy micro-organisms at
a lower molecular concentration than the corresponding
hypochlorites or hypobromites. They may not, therefore,
be considered as the bio-chemical equivalents of these
latter substances.
The germicidal action of chloramines is due to the
fact that the substances such as proteins, amino-acids,
urea, and ammoniacal salts, which constitute living
organisms, contain nitrogen under a form which can
attract the chlorine of the different species of chlor-
amines. On the other hand, the chlorinating action of
chloramines resembles that of the hypochlorites, but
their antiseptic action is often much greater. This fact
may be attributed, according to Dakin, either to a special
70 TREATMENT OF INFECTED WOUNDS
obscure action of the chloramine molecule, or possibly
to the elective chlorination of some constituent of the
cells.
2. The Properties of Para-toluene-sodmm-sulplioclilor-
amine. Because of these many excellent qualities,
para-toluene-sodium-sulphochloramine was chosen by
Dakin for practical use in the sterilisation of wounds.
This substance can readily be manufactured at a reason-
able price by a method which has been described by
Dakin. Para-toluene-sulphochlorate, a by-product in
the manufacture of saccharine, is the basis. Several
English houses are making it, and sell it under the name
of " Chloramine T." Apart from its great germicidal
potency, which has been noticed above, Chloramine T
has other advantages. It does not coagulate proteid
matters in the ordinary treatment of wounds. It is very
soluble in water. That is an important factor. In short,
chloramines, endowed with a high germicidal potency,
very slightly soluble in water, but which could be dis-
solved in vaselin or lanolin, would be without practical
value. Besides, Chloramine T has the advantage over
hypochlorite of being very stable. Dakin found that
the decomposition of a solution kept in the dark for
132 days, was inappreciable, whilst the solution exposed
to daylight showed such a slight diminution of strength
as to be scarcely noticeable. This stability of Chlor-
amine T is a great advantage over Dakin's hypochlorite
solution, which decomposes under the influence of light
and heat.
Dakin's chloramine is employed in an aqueous i per
cent solution. As its stability is greater than that of
hypochlorite, it has been employed by Daufresne in the
THE PRINCIPLES OF THE TECHNIQUE 71
form of a paste, composed of stearate of soda mixed with
varying proportions of chloramine. For general purposes
a paste is used which contains I per cent, of chloramine
and 8 '6 per cent, of stearate of soda.
3. The Interaction of Chloramine and the Tissues.
Chloramine, employed on the surface of a wound, in
solutions of about i per cent., produces no retardation of
cicatrisation. A large number of wounds have been
treated with Daufresne's paste of sodium stearate, con-
taining 4 to 10 per cent, of chloramine, and the observed
curve of cicatrisation always coincided with the curve
calculated by du Nouy's formula. Fig. 28 shows the
cicatrisation curves of a wound treated with a 10 per
cent, paste of chloramine. Moreover, experiments made
by Daufresne showed that a fragment of skin placed in
a solution of chloramine retained its normal dimensions
after the lapse of several days. The same is true of
mortified tissues situated on the surface of wounds. In
experiments conducted in vitro as well as in direct
observations of wounds, it was found that chloramine
does not dissolve the tissues. This is why it does not
cleanse the surface of wounds as Dakin's solution does.
It is not irritating, but it lacks one of the most necessary
properties of an antiseptic, that of dissolving necrosed
tissues. It should therefore be reserved for wounds
whose surface is already cleansed, or for the skin and
the mucous membranes.
While chloramine has little action on the tissues, the ,
tissues, on the other hand, have a very marked action
upon chloramine. Experiments were made with the
peritoneum of a cat. When a 0-25 per cent, solution of
chloramine is placed in a small cup containing a portion
72 TREATMENT OF INFECTED WOUNDS
of the epiploon provided with its normal circulation, the
rapid destruction of the antiseptic substance is observed.
As a rule, the strength of a 0*25 per cent, solution of
chloramine falls to 0*14 or 0*15 per cent, in about two
minutes. Its decomposition is therefore much less rapid
than that of hypochlorite. Chloramine will often lose
only half its strength, while Dakin's hypochlorite loses
more than four- fifths.
These experiments show that chloramine, despite its
much greater stability, is rapidly decomposed when in
contact with the tissues, and a considerable volume of
solution must be employed to sterilise a wound.
In .the sterilisation of a wound, the antiseptic plays
a part comparable to that of the scalpel in a surgical
operation. It is only an instrument, and does not con-
stitute a method. But the choice of a good instrument
is a factor indispensable to success. Chloramines and
Dakin's hypochlorite are admirable instruments.
As Dakin's hypochlorite has the advantage of being
strongly bactericidal, and only slightly irritating to the
tissues, and at the same time can be readily manufactured
at a cheap rate, it would seem that it ought to become
the chosen antiseptic during this war.
II. CONTACT OF ANTISEPTIC AND MICRO-
ORGANISMS
The antiseptic solution, only sterilising what it
touches, must enter into intimate contact with the
microbes infecting the wound. This contact has been
considered impossible by the majority of modern
surgeons. Sir Almroth Wright considers that, in the
THE PRINCIPLES OF THE TECHNIQUE 73
wounds inflicted in war, microbes are found so deeply
buried in the irregularities of the wounds, in the
middle of necrosed muscles and blood-clots, that it is
hopeless to try to reach them by means of an antiseptic.
It is also supposed that, in suppurating wounds, micro-
organisms inhabit the depths of granulation tissue,
muscular interstices, and lymphatics, and that, in conse-
quence, they are beyond the reach of substances poured
over the surfaces of the wound. It is certain that if the
topography of infection is such that the microbes cannot
be brought into actual contact with the antiseptic,
chemiotherapy of wounds ought to be abandoned.
But the opinion expressed by Sir Almroth Wright
was based upon hypotheses and arguments, and not upon
exact observation of what takes place in war-wounds.
In order to find out if antiseptic treatment ought or
ought not to be applied to infected wounds, it is
necessary to study the topography of infection in both
fresh wounds and suppurating wounds, and to inquire
if it be possible to bring the antiseptic into contact with
the microbes.
A. Topography of Infection
i. Fresh Wounds. The topography of infection was
studied at first in freshly inflicted wounds, superficial
and deep, with fracture and without. Specimens of the
secretions were taken from various regions of the wound,
from around projectiles, shreds of clothing, splinters, and
from the surface then examined by means of smears
(p. 182) and cultures.
During the first few hours following the infliction
74 TREATMENT OF INFECTED WOUNDS
of the wound, the smears in general showed no microbes,
whilst cultures were positive. The apparent asepsis of
the smears was due to two causes, the dilution by blood
of the microbes infecting the wound, and their relatively
small number at this early period of the infection. In
fact, to show themselves in the secretions, the organisms
need to have had the time to multiply and spread them-
selves from the foreign bodies on to the surfaces of the
wound.
At the end of five or six hours, in wounds which are
not bleeding, rods and cocci are sometimes found. These
were localised in the regions close to the foreign bodies.
Frequently also, no microbe was visible, though bouillon
in which shreds of tissue taken from the immediate neigh-
bourhood of the foreign bodies had been placed yielded
abundant cultures, aerobic and anaerobic. The direct
examination of foreign bodies, shell splinters, or particles
of cloth, gave varying results. In general, no microbes
were found on the surface of projectiles, although in
more than half of the cases they gave positive cultures.
Shreds of clothing, on the contrary, always yielded an
abundant microbial flora. Often scrapings of fragments
of great-coat, five or six hours after the infliction of the
wound, showed some rod-like bodies ; and nearly always
anaerobic cultures made from these ctibris gave off gas
abundantly.
At the end of about twelve hours, bacteriological
examination practised under the same conditions, showed
microbes more constantly and in greater abundance. 1
i See also Policard et Phelip, C. R. de PAcadtmie des Sciences, July
5, 1915. Fiessinger, La pratique dela chinirgie de guerre, 1916. Fiessinger
et Montaz, C. . Socitti de Biohgie, June 9, 1916.
THE PRINCIPLES OF THE TECHNIQUE 75
Wounds commenced to react, and polynuclear cells
appeared in numbers more or less great.
After twenty-four hours the topography of infection
of the wound had greatly changed, for the bacterial
harvest was no longer localised on the surface, or around
foreign bodies. The examination of smears revealed the
presence of microbes over almost the whole extent of
the wound. At the same time a greatly increased
number of polynuclear cells was to be seen. In short,
during the first twenty-four hours there may be witnessed,
first, the multiplication of microbes on the surface and
in the neighbourhood of foreign bodies, especially of
fragments of clothing, and later their diffusion over the
superficies of the wound.
The modifications of the bacteriological aspect of a
wound from the fifth or sixth hour to the twenty-fourth
hour were due to the rapid division of micro-organ-
isms. If it be supposed that each microbe divides every
half-hour, it will give birth in twelve hours to more than
fifteen million other microbes. This extreme rapidity
of multiplication explains why wounds twenty-four hours
old are already invaded by myriads of micro-organisms.
Close examination of a great number of wounds has
shown that these micro-organisms remain, as a rule, on
the surface of wounds, and do not penetrate deeply into
muscular interstices nor into lymphatics. They invade
blood-clots and tissues without circulation. They follow
the blood poured out along vascular sheaths, and they
may also bury themselves in fractured bones. But
usually during the early hours, and even the first few
days following the infection of the wound, they live
on the surface of the tissues ; that is to say, within
76 TREATMENT OF INFECTED WOUNDS
reach of a liquid, if this liquid be applied under suitable
conditions.
The existence of this fact has been made plain in the
course of experiments made upon the wounds themselves.
When the antiseptic liquid was brought into contact with
the infected surface, the number of microbes rapidly
diminished, and at the end of a short time the wound
became completely aseptic. Wounds of the surface
could be sterilised thus in twenty-four hours ; irregular
wounds, even when accompanied by fracture, became
sterile in five or six days. The tissues were surgically
sterile in their substance as well as on the surface. In
fact, when the treatment had been applied from the
beginning, it was possible to close up the wound by
deep interstitial sutures, without this being followed by
rise of temperature. Secondary operations practised in
cases where wounds had been closed after sterilisation,
did not determine the appearance of febrile phenomena.
When comparing such results as these with what is
observed always in the case of non-sterilised wounds, it
is fair to conclude, with every semblance of probability,
that the microbes have been destroyed in all parts of the
wound.
Everything goes on as though during the first twenty-
four hours, and sometimes during the early days follow-
ing the receipt of the wound, the microbes dwelt on
the surface of the wound ; consequently, within reach of
the antiseptic. However, in irregular wounds and com-
pound fractures microbes are sometimes found to be out
of reach of the liquid. After some days of treatment
the secretions of certain regions become aseptic, whilst
those of other regions still remain infected. These
THE PRINCIPLES OF THE TECHNIQUE 77
regions have not been reached by the liquid, either be-
cause the latter has not been introduced deeply into the
diverticula, or because the walls are protected against
the antiseptic by sphacelated tissues, blood-clots, or a
compress soaked in blood. Gauze compresses, blood-
clots, or dead tissues have a peculiarly harmful effect,
because they protect the bacteria from the attack of the
antiseptic.
2. Suppurating Wounds. During the period of suppu-
ration, contact between the microbes and the antiseptic
was, in general, more difficult to obtain. The number
of microbes had greatly increased. No longer were
there topographical differences in the volume of infec-
tion, for the bacteria were found in almost equal quan-
tities in every part of the wound. But, following the
shape and character of the wound, the microbes were
reached by the liquid more or less easily. In surface
wounds, and in irregular wounds of the soft parts, whose
walls were covered with granulations and suppurated
abundantly, the antiseptic rapidly destroyed the bacteria.
But when the latter were protected by necrosed tissue,
tendons, or aponeuroses which were being eliminated,
the liquid could not reach them, and infection persisted.
Even in long-standing wounds the contact between the
liquid and the microbes was so complete that, in certain
cases, the latter were seen to disappear completely In
forty-eight hours.
The suppression of micro-organisms in secretions, *
and the possibilities of sterilising the surface of a wound
in such a manner that suturing becomes possible, does not
mean, however, that all the microbes have been brought
into contact with the antiseptic and destroyed. In fact,
;8 TREATMENT OF INFECTED WOUNDS
when by means of sutures more or less deep wounds are
brought together, which have suppurated for some time
before being sterilised, there is sometimes re-infection
and a rise of temperature. These phenomena are not
seen in wounds which have been subjected to sterilisa-
tion from the beginning. But a wound which is cicatris-
ing at the same time that it is suppurating, is keeping in
its walls microbes capable of producing re-infection at
the moment of a fresh traumatism. In wounds of long
standing which are suppurating, antiseptics cannot reach
microbes already enclosed in granulations, but they can
affect those which are at the surface of the wound. As,
on the other hand, living tissues destroy or encapsule
microbes withdrawn from the antiseptic, sterilisation
takes place little by little.
Therefore it is important to sterilise a wound at a
period as near as possible to the onset of infection. If
postponed to a later period, sterilisation is effected and
closure by suture may be obtained ; but microbes have
already become enclosed in the cicatrix, and remain alive
there. We have examined, on a wound more than six
months old, a thick cicatrix which had formed during
that long period of suppuration. The different layers of
the cicatrix presented a varied bacterial flora. Passing
from the deepest part to the surface, there was first a
layer containing Welch's bacillus, next a sterile layer,
then a stratum containing small rod-like bodies, lastly a
layer of various cocci. In wounds of long standing, the
topography of infection is therefore such that the anti-
septic cannot reach the microbes in every part in which
they are found. But, on the other hand, the microbes
are enclosed or encapsuled in the tissues, and are not in
THE PRINCIPLES OF THE TECHNIQUE 79
a condition to work harm until a new traumatism sets
them free.
From the practical point of view, in the suppurating
wounds of soft parts, contact between microbes and anti-
septic sufficient to assure surgical sterilisation is possible
of attainment. In deep wounds with pus burrowing
along muscular interstices, where contact between anti-
septic and microbe cannot be realised, results are less
favourable. When suppurating wounds are accom-
panied by fractures, or the osseous fissures described
by Policard, 1 along which the micro-organisms are
propagated, it becomes impossible to make the liquid
penetrate into all the infected places. Similarly, when
osteo- myelitis has declared itself, or when splinters have
been left in the tissues, the conditions are the same.
Microbes establish themselves in the sequestra at such a
depth that the antiseptic cannot penetrate to them.
They are protected by their situation, at the same time
against the chemical agent and against the polynuclear
cells coming from normal tissues. This is the reason
why the infection is so extremely tenacious, when bony
lesions or necrosed splinters persist at the bottom of
irregular wounds.
This brief examination of the topography of infection
shows that in the majority of cases it is possible to obtain
intimate contact between antiseptic and microbe. Suit-
able preparation of the wound for the penetration of the
germicide substance, and distribution of this substance
over the whole of the affected surface, will enable this
contact to be realised. If, up to the present, we have
not succeeded in chemically sterilising wounds, it is, in
1 See also Bowlby, " Wounds in War," Th* lancet^ 1915, pp. 1388, 1389.
8o TREATMENT OF INFECTED WOUNDS
part, because we have neglected to prepare them in such
a manner that the antiseptic substance may reach every
point where microbes exist.
B. Preparation of the Wound for the Penetration of
the Antiseptic
Most important in the preparation of the wound is
the mechanical cleansing of the infected regions. Free
incisions in the soft parts allow this cleansing to take
place even in the case of irregular torn wounds, accom-
panied by fracture. It is well known that shreds of
clothing, projectiles, splinters lying free, blood-clots and
necrosed tissues serve as shelters for microbes and protect
them from the antiseptic. In consequence, every foreign
body should be most carefully sought for and removed.
Debris of clothing are the principal source of infection,
and the antiseptic generally cannot penetrate them.
Necrosed tissues are the favourite haunt of gas infection.
Therefore they must be removed. Ever since the begin-
ning of the war, Depage and the surgeons of his school
have made a systematic resection of all tissues, skin,
aponeuroses or muscles which were likely to mortify.
This practice is excellent and ought to become general.
All blood-clots are removed, and, to prevent their re-
occurrence, careful haemostasis of the whole of the
wound is practised. The surface of bony cavities in
which projectiles are lodged, is scraped, and resected if
needful. Furthermore, it is well to remember that com-
presses placed in wounds efficiently protect microbes
against antiseptics. Therefore a wound should never
be left plugged with tampons or compresses. If an
THE PRINCIPLES OF THE TECHNIQUE 81
open wound is desired, tubes of large calibre perforated
with many wide holes are used.
Incisions are made in such a manner that the diver-
ticula of the wound are laid open as freely as possible.
The liquid should penetrate everywhere, and remain in
contact with the infected area as long as needful. As
gravity plays an important part in the distribution of a
liquid, those wounds which can be filled up like a cup
are the most favourably qualified for sterilisation. That
is the reason why wounds on the anterior surface of
limbs are preferred to dependent counter-openings.
Liquid is thus retained in the wound and its walls
bathed more completely. Very large incisions need
not be objected to, because they allow the topography
of the wound to be studied and diverticula dealt with.
Once the wound has been thus freely laid open and
all foreign bodies removed, the best possible conditions
for contact between the liquid and the surfaces of the
wound are obtained. It only remains to make arrange-
ments for the application of the antiseptic to the whole
of the infected surface.
C. Application of the Antiseptic
It is indispensable to place the liquid in direct contact
with the tissues in the deepest regions of the wound.
Distribution of a liquid over the whole extent of an
irregular surface is difficult to accomplish.
The simplest method, which at once occurs to every
one, is to use absorbent gauze or other fabric, or strands
of cotton-wick, conducting by capillary action the liquid
from an external reservoir over the whole surface of the
6
82 TREATMENT OF INFECTED WOUNDS
wound. This arrangement has been adopted by Sir
Almroth Wright in his dressings of hypertonic saline
solution. At the outset of our researches on the steri-
lisation of wounds we employed a similar method. Layers
of absorbent tissue were applied to the surface of the
wound, a rubber tube led the liquid to the tissue to
which was entrusted equal distribution to all parts of
the wound. Experience was not slow in making clear
to us that procedures based on this principle were
incapable of producing efficient contact of the antiseptic
with the surfaces of the wound. In fact, at the end of
a few hours the deepest part of the conducting tissue
became impregnated with plasma or pus, and imperme-
able to the antiseptic liquid. On casual examination,
the apparatus appeared to be working well, but the
liquid went into the tissue without moistening the raw
surfaces. This method of conducting the liquid was
abandoned entirely, It has only been retained to dis-
tribute liquid on the surface of a rubber tube pierced
with small holes. These tubes covered with tissue are
sometimes used during the first few hours following the
infliction of a wound, because at this period secretion is
slight. In all other cases we use absorbent tissue com-
presses, which by a special arrangement cause the liquid
to flow between themselves and the wound.
The procedure which has been adopted consists in
distributing the liquid to all parts of the wound by
means of rubber tubes, utilising the force of gravity of
the liquid. The disposal of these tubes varies with the
shape and situation of the wound. In wounds which
have only a single opening so situated that they can be
filled up like a cup, permanent contact between the
THE PRINCIPLES OF THE TECHNIQUE 83
antiseptic and the surfaces is assured by introducing a
rubber tube to the bottom of the cavity (Fig. 31). If the
patient reclines in a suitable position, the wound remains
full of antiseptic liquid. But in dealing with surface
wounds (Fig. 32) large, irregular wounds, and those
with several wide openings (Fig. 33) it becomes more
difficult to distribute the liquid over the whole surface.
The most practical method consists in allowing small
FIG. 31. Wound with superior opening
which can be filled like a cup.
FIG. 32. Surface wound receiving liquid
from a tube perforated by small holes.
FIG. 33. Irregular wound with several
perforated tubes in its diverticula.
rubber tubes perforated with minute holes to lie on the
tissues. The holes number fifty to each tube, and have
a diameter of about 0*5 millimetre. When these tubes
are charged with liquid under pressure, the surface of
the wound is moistened, by the fluid which issues from
all the orifices. This procedure has been adopted, in
the first place, because it is successful, and next, because
it can be carried out by means of articles readily
84 TREATMENT OF INFECTED WOUNDS
obtainable commercially. The tubes should be tied up
at one end and the perforations made with an ordinary
punch.
But this manner of distribution is far from ideal,
because, the holes being too large and not sufficiently
numerous, the liquid spurts out too profusely over a
space too limited. So it is not made the best use of.
Probably a tiny hose, pierced with a great number of
microscopic holes, or rather rubber membranes, whence
the antiseptic could ooze out, would bring about more
intimate relations between liquid and microbes. A
totally different arrangement might be conceived, by
which the liquid could be distributed over the surface of
the wound without using tubes at all. If the antiseptic
were incorporated with a substance which had the pro-
perty of melting very slowly in contact with the tissues,
and which at the same time could be moulded to fit all
the irregularities of the wound, a more perfect distribu-
tion of the antiseptic would be attained.
III. MAINTAINING THE CONCENTRATION OF THE
ANTISEPTIC
The second essential principle is the keeping the
fluid on the surface of the tissues at a constant degree of
concentration. Up to the present, this principle has
been completely ignored. As a rule, antiseptics are
applied to wounds by means of absorbent gauze, and the
liquid renewed once or twice in the twenty-four hours.
It is certain, however, that, under these conditions, the
bactericidal power of the substances employed rapidly
vanishes. In fact, if a compress soaked in Dakin's
THE PRINCIPLES OF THE TECHNIQUE 85
solution O'5 per cent, be applied to the surface of a wound,
the result obtained is almost nil, because the concentra-
tion of the solution lessens very quickly, under the in-
fluence of dilution by the secretions of the wound, and
the combination of hypochlorite of soda with the proteins
of pus, of the tissues, and of blood. In a word, the
degree of concentration of an antiseptic applied accord-
ing to the usual surgical method at once becomes so
feeble that no result can be hoped for. The only way
to maintain at the needful strength, on the surface of a
wound, a solution which is constantly being diluted and
destroyed, is to keep on renewing it, unceasingly. For
this reason we have used instillation, continuous or
intermittent. The best method consists in allowing a
current of the antiseptic liquid to flow very slowly over
the whole surface of the wound. In the case of small
wounds, and of those which can be filled with liquid like
a cup, this is readily done. The antiseptic, supplied
drop by drop, is slowly renewed, in contact with the
tissues. When it escapes from the wound, it is absorbed
by the dressing, and evaporates without wetting the
patient. But when the wound is of large extent, and
presents several openings, a considerable quantity of
liquid would be needed to keep the whole raw surface
continually moist. The amount which would escape
from the wound would be too great to be absorbed by
the dressing. One has to revert to the old process of
continuous irrigation, which is complicated, and distress-
ing to the patient.
On the other hand, experience has shown that if the
liquid be applied over the surface of the wound every
hour or every two hours, sterilisation is attained. This
86 TREATMENT OF INFECTED WOUNDS
intermittent instillation is easy to apply. It is the pro-
cedure we are at present employing. It is far from being
perfect, but it allows of the frequent contact of the
surfaces of the wound with the antiseptic at a known
degree of concentration. Better arrangements for keep-
ing up both supply and strength of the antiseptic will
doubtless be found. For example, if the liquid were to
issue from numerous microscopic apertures in tubes in-
serted in all the cavities of the wound, the quantity
needed would be smaller, and yet every part of the
wound would be bathed incessantly by the antiseptic at
the desired strength.
The degree of concentration of the antiseptic has been
determined empirically. It is found that Dakin's solu-
tion, containing 0*45 to 0*5 per cent, of hypochlorite of
soda, applied under the conditions just described, does
no harm to tissues and sterilises wounds.
IV. DURATION OF THE APPLICATION OF THE
ANTISEPTIC
An essential point of the method is the prolonged appli-
cation of the antiseptic. This principle seems to have been
neglected as much as the preceding. Although experi-
ments in vitro have shown that microbes, to be destroyed,
must be immersed in the antiseptic solution for some
considerable time, yet people persisted in believing
that, under the much more unfavourable conditions of
the clinic, sterilisation of a wound could be obtained by
brief contact between bactericidal substance and microbes.
That is why so many surgeons still remain loyal to the
rite of washing over a wound with an antiseptic liquid.
THE PRINCIPLES OF THE TECHNIQUE 87
They imagine that if a liquid has flowed over the surface
of a wound for four or five minutes, often much less, that
wound will become sterile. It is certain, however, that
to obtain any action the antiseptic must remain on the
wound for a much longer period.
A. Experiments showing the Necessity for Prolonged
Contact. In the following clinical experiments it was
sought to discover what should be the length of time for
the application of the hypochlorite.
In the first place, the influence of hypochlorite applied
as is usual in a wet dressing was examined. Upon
surface wounds, whose bacteriological condition was
known, compresses were placed soaked in a 0*5 per cent,
solution of hypochlorite. The next day the number
of microbes had not undergone any appreciable change.
Gauze " wicks " soaked in hypochlorite were also intro-
duced into deep wounds. At the end of twenty-four
hours, the surface of the compresses yielded a large
number of microbes.
The insufficiency of the technique usually employed
was thus demonstrated. Next, the length of time during
which hypochlorite was present in the wounds was
lengthened by soaking the dressing with the antiseptic
three times a day. In most cases the " smears " showed
a marked lessening in the number of microbes ; but the
wounds more deeply infected showed no change. On
one small wound dressed three times a day with hypo-
chlorite, the number of microbes did not diminish. At
the end of a week of this useless treatment, a small
quantity of hypochlorite was injected hourly over the
surface of the wound, under the compresses. All the
microbes disappeared (Fig. 34).
88 TREATMENT OF INFECTED WOUNDS
A large number of similar experiments showed that,
in surface wounds, the infection did not resist instilla-
tions of hypochlorite every two hours during one or two
days. In deep wounds, diminution in the number of
microbes came about more slowly, even under the
influence of frequent instillations of hypochlorite. Daily
examination of the " smears," made from the discharges
MOiSi
JOURS 22 23
embre1915
2627282930 1234
Decembre
FIG. 34. Necessity for prolonged contact between the antiseptic and the
wound. Highly infected atonic wound treated up to Nov. 26th by applica-
tions of hypochlorite three times a day. No diminution in the number of
microbes. Nov. 26th, Dakin's hypochlorite was applied every hour.
Sterilisation was attained Nov. 29th. (oo denotes infinity. Trans.}
from different regions of wounds of the soft parts, more
or less irregular, showed that microbes often took four
or five days to disappear. In severe lacerations of the
soft parts, or in compound fractures, the application of
the hypochlorite had to be continued usually eight, ten,
or fifteen days before sterilisation was achieved.
In wounds complicated by splintered fractures
THE PRINCIPLES OF THE TECHNIQUE 89
it was sometimes impossible to get complete sterilisation.
Generally the persistence of infection was due to the
presence of a foreign body, projectile, splinter, or shred
of clothing. When the foreign body was removed,
sterilisation came about. Disinfection of deep wounds
always takes longer than that of surface wounds. With
the technique now in use, compound fractures are some-
times disinfected in five or six days. As a general rule,
sterilisation requires ten, fifteen, or twenty days, or even
more, if it is a question of a compound fracture of the thigh.
B. Relation between the Dimensions of a Wound and
the Time required for Sterilisation. It will be well to
inquire why the duration of application of the antiseptic
has to be longer for compound fractures with large
wounds, than for surface wounds.
We have often seen surface wounds yielding many
microbes become sterilised in forty-eight hours. The
tardiness of sterilisation in irregular wounds appears to
be due to the presence of diverticula into which the
liquid does not penetrate, and where microbes swarm,
or to the presence of sphacelated tissues which shield
the microbes from the attack of the antiseptic. How-
ever, in surface wounds, with sphacelated tissue, sterilisa-
tion is brought about more quickly than in large and
irregular wounds. Therefore it is probable that imper-
fection of technique alone renders necessary a prolonged
application of the antiseptic. There is not, in fact, any
theoretic reason why a large and irregular wound should
sterilise more slowly than a small wound with even walls?
But it is much more difficult to make the liquid penetrate
all the irregularities of a deep wound than it is to bring
it into contact with the entire surface of a smooth one.
90 TREATMENT OF INFECTED WOUNDS
The duration of the application of hypochlorite in
deep wounds will lessen when it becomes possible to
apply the antiseptic continuously to the entire surface
of the wound. Our technique is still too clumsy, and
the methods of distributing the liquid in use to-day do
not succeed in placing every portion of a large wound
simultaneously under the influence of the bactericidal
substance. It is quite probable that different portions
of an extensive wound are sterilised successively, for the
bacteriological examination shows that after the lapse of
several days certain regions of a wound are sterile, whilst
others still continue to harbour microbes. Besides,
rapidity of sterilisation increases to a certain extent
with the quantity of liquid employed, that is to say, it
depends on the extent of the surface of the wound which
is acted on by the liquid. It is permissible to believe
that improvements in technique will lessen the period
during which antiseptic instillations will need to be
employed, but it is unlikely that this period will be cut
down to less than twenty- four hours.
V. KNOWLEDGE OF THE BACTERIOLOGICAL
CONDITIONS OF THE WOUND
The bactericidal potency of the chloramines and
of hypochlorite is such that every wound should respond
to the treatment by a diminution in the number of
microbes and by their final disappearance. Therefore
it is important to ascertain if the bacteriological condition
is being modified in a progressive manner. In fact,
when that condition remains stationary, it may be con-
cluded that contact between antiseptic and microbes is
THE PRINCIPLES OF THE TECHNIQUE 91
not completely established, and that the technique needs
alteration.
Clinical observation alone does not enable us to
follow the evolution of wound infection. It gives only
the probabilities. When a patient has ceased to have
pyrexia, when the wound is of a healthy red, when its
margins are supple and when suppuration has dis-
appeared, then it is fair to assume that the wound is
nearly aseptic. But investigation has taught us that
wounds looked upon as aseptic are often highly infected,
and that it is never safe to trust the favourable appear-
ance of the tissues as evidence that they are sterile.
Besides, it often happens that wounds treated by
chloramines have a slightly greyish look, and are
covered with purulent secretion. They have the appear-
ance of infected wounds. However, these wounds may
be sutured without the least rise of temperature follow-
ing. In this case only bacteriological examination can
demonstrate to the surgeon that the pus which covers
the granulations is aseptic.
It is impossible, therefore, to ascertain the results
of treatment with sufficient precision, without the con-
stant aid of the microscope. Using the simple method
which will be described later, bacteriological examination
of a large number of wounds may be made every day.
M. Gaultier 1 has shown that, even in dressing- stations
(ambulances, Fr.) at the front, it is possible to make use
of the microscope. That examination gives warning
of the existence of errors of technique as soon as the)/
appear, and so enables the loss of time to be avoided
which is the usual consequence. It points out the
1 Gaultier, Paris Mtdical, July, 1916.
92 TREATMENT OF INFECTED WOUNDS
moment when the wound has become surgically sterile
and can be sutured.
To sum up, knowledge of the bacteriological con-
dition of the wound is an indispensable part of the
technique of sterilisation, and it alone can give to the
latter the necessary precision.
CHAPTER II
THE TECHNIQUE OF THE MANUFACTURE OF
DAKIN'S SOLUTION
HVPOCHLORITE of soda was discovered by Berthollet in
1788, and its antiseptic properties have been known
for a long time. Labarraque gained great renown by
embalming, by the aid of his liquor, the corpse of
Louis XVI 1 1., which was so extremely decomposed that
no one could come near it. But neither Labarraque's
solution nor eau de Javel can be used with safety in
surgery. One of the essential conditions of the sterilisa-
tion of wounds is, as is well known, the employment of
a substance which, in a given degree of concentration,
can be applied for a long period to wounds without
irritating them. This is the reason why it is impossible
to use commercial hypochlorites, whose content of hypo-
chlorite is extremely variable and which contain free
alkali. The proportion of alkali contained in eau de
Javel and Labarraque's liquor is great enough to pro-
duce solution of the skin, if the contact be sufficiently
prolonged.
I. DAKIN'S TECHNIQUE
That is why Dakin sought the means of obtaining
a solution deprived of free caustic alkali, and whose
content of hypochlorite must not vary beyond the limits
93
94 TREATMENT OF INFECTED WOUNDS
of 0*45 and 0*50 per cent. Later experiments by
Daufresne showed that below 0*45 per cent, the solution
is insufficiently active, whilst above O'5 per cent, it is
irritating. At the time of his communication to the
Academic des Sciences, Dakin gave a method of prepara-
tion of this solution which enabled it to be made with
the simplest appliances, without chemical knowledge.
" 140 grammes of anhydrous carbonate of soda, or
400 grammes of the crystallised salt, are dissolved in
10 litres of ordinary water, and 200 grammes of chloride
of lime l of good quality are added to it. The mixture is
well shaken, and at the end of half an hour the clear
liquid is siphoned off and filtered through cotton. To
the filtrate are added 40 grammes of boric acid, and the
solution thus obtained may be used at once ; it does not
colour phtalein in suspension in water." 2
This very simple mode of preparation was easy to
execute, a great advantage for hospitals at the front.
But experience in its use has brought to light several
inconveniences, which have been studied by Daufresne.
One of the products used in its preparation, chloride of
lime, being of very variable composition, its content of
active chlorine might vary from the normal to double the
amount. Under the influence of humidity it forms com-
pact masses, which, when agitated with the solution of
carbonate of soda, are incompletely broken up, and only
yield a portion of their hypochlorite. These are the
reasons why defective solutions have sometimes been
obtained while following conscientiously the procedure
just described.
1 The salt referred to is of course not calcium chloride, but calcium
chlorate, or chlorinated lime, universally known as chloride of lime ( Tr. )
8 Dakin, Prcsse Mtdicale, loc. cit.
PREPARATION OF DAKIN'S SOLUTION 95
On the other hand, Daufresne was led to attribute
certain irritation phenomena to the boric acid employed
to neutralise the solution. In fact, without being able to
give an exact account of the chemical reactions which
enter into the change, every time the quantity of boric
acid used to arrive at non-coloration in the phtalein
test exceeds 4 grammes per litre, the solution becomes
unstable and painful.
Besides, the solutions of hypochlorite prepared with
boric acid, even in correct quantity, keep badly.
II. DAKIN'S SOLUTION PREPARED BY DAUFRESNE'S
METHOD
Having repeatedly examined similar solutions, Dau-
fresne sought a remedy for these inconveniences by
a more accurate mode of preparation which would give
constant results. After numerous trials he decided on
the following process, which necessitates the employment
of three products, all easily procured :
Chloride of lime,
Carbonate of soda, anhydrous (Solvay),
Bicarbonate of soda.
A. Chloride of Lime and its Titration. i. The chloride
of lime of commerce is obtained by the action of gaseous
chlorine on powdered slaked lime. It presents great
variations in composition ; notably in its content of active
chlorine. Its chemical constitution, in spite of the numer-
ous discussions of which it has been the subject, is not
yet established in any satisfactory manner. Whatever it
may be, we know that under the solvent action of water
it yields three substances, hypochlorite and chloride of
96 TREATMENT OF INFECTED WOUNDS
calcium and small quantities of lime, the residue being
made up of excess of lime, partially carbonated.
It is an ordinary thing to meet with samples which
differ greatly in richness. We have had occasion to
examine a small number of lots whose titrage in active
chlorine varied from 20*45 P er cent to 35*90. It will,
therefore, be of advantage to use only a chloride of lime
of known titration, so that we may employ a quantity
correctly calculated according to its titration.
2. Titration of Chloride of Lime. The estimation of
this quantity is made in the following manner by Dau-
fresne : Weigh out an average sample of 20 grammes,
stir it up in a litre of water as thoroughly as possible,
and allow it to stand some hours. Measure off 10 c.c. of
the clear liquid, add to it 20 c.c. of a 10 per cent, solution
of iodide of potassium, 2 c.c. of acetic acid or hydro-
chloric acid, then to the mixture add drop by drop a
decinormal solution of hyposulphite of soda (2*48 per
cent.), up to decoloration. The number n of c.c. of
hyposulphite employed, multiplied by 1,775, will S IVQ the
weight N of active chlorine contained in 100 grammes
of the chloride of lime.
This estimation must be carried out for each con-
signment received. The following table drawn up by
Daufresne gives directly, according to the amount of
active chlorine contained in the chloride of lime, the
quantities of the reagents required to obtain automatic-
ally a correct solution :
PREPARATION OF DAKIN'S SOLUTION 97
Titration of chlorid* of lime
(Cl %).
(English degrees.)
Quantities to be used to obtain 10 litres of solution of
hypochlorite of 0-475 %
' Chloride of
lime.
Carbonate of
soda, anhydrous.
Bicarbonate of
soda.
grms.
grms.
grms.
20
230
115
9 6
21
220
1 10
92
22
210
105
88
23
200
100
84
24
192
96
80
I8 4
92
76
26
177
89
72
11
170
164
f 5
82
11
2 9
159
80
66
30
154
77
64
31
148
74
62
32
144
72
60
33
140
70
59
34
135
68
57
II
132
128
66
64
55
53
37
124
62
52
The determination of the quantity of soluble calcium
in the chloride of lime would have a certain importance
if one were not obliged, in order to obtain a product
having some degree of stability, to use an amount of
carbonate of soda far above that theoretically indi-
cated. In fact, a solution prepared by the interaction
of chloride of lime and salts of soda in theoretic quan-
tities loses the whole of its hypochlorite in from 15 to
20 days.
B. Salts of Soda. It is more convenient to use dry
carbonate of soda (carbonate de soude, Solvay, Fr.) which
is to be preferred ta the other commercial salts because
of its being anhydrous, pulverulent, and free from caustic
alkali.
When obliged to use the hydrated salt (crystals), the
7
98 TREATMENT OF INFECTED WOUNDS
quantity needful will be 285 grammes for 100 of the dry
salt.
Bicarbonate of soda is readily obtainable. It is
always anhydrous. The solution should be made in the
cold, because it commences to break up towards 50 C.
C. Preparation of Dakin's Solution by Daufresne's
Method. I. To prepare 10 litres of solution weigh out
exactly the quantities of chloride of lime, carbonate of
soda, and bicarbonate of soda determined when titrating
the chloride of lime ;
2. Place in a 1 2-litre flask the chloride of lime with
5 litres of tap-water ; shake vigorously two or three
times and leave it overnight ;
3. Dissolve the carbonate and bicarbonate of soda in
5 litres of cold water.
4. Pour the solution of soda salts rapidly into the
flask containing the chloride of lime, shake vigorously
for about a minute, and put it aside for the carbonate of
lime to settle ;
5. After the lapse of about half an hour siphon the
clear liquid and filter it through a double filter-paper, in
order to obtain a perfectly clear product, which must be
kept cool, and protected from the light.
An excellent means of stabilising hypochlorite of
soda consists in adding I : 200,000 of permanganate of
potash (5 milligrammes per litre of filtered solution).
The antiseptic solution is then ready for surgical use.
It would contain 0*35 to 0*50 per 100 of hypochlorite of
soda, with small quantities of neutral soda salts. It is
practically isotonic with blood-serum. 1
1 The freezing-point of these solutions is very slightly higher than that
of blood-serum. A = -o'6o to 0-65 Cent.
PREPARATION OF DAKIN'S SOLUTION 99
The action of water upon the chloride of lime not
being instantaneous, the product often contains lumps,
from which the hypochlorite does not readily diffuse.
The following experiment of Daufresne's is extremely
instructive in this connection :
10 grammes of chloride of lime giving on titration
28-25 per cent, of active chlorine are placed in a flask
with 1000 c.c. of distilled water. The whole is shaken
vigorously for two minutes, and the solution titrated.
Similar titrations are made from time to time.
Original titration of
the solution (in-Cl %).
Titration after contact of
+ hour.
i hour.
2 hours.
6 hours.
ia hours.
0*089
0*176
0*206
0*259
0*28l
0*282
As will be seen, solution is complete only after some
hours' maceration ; for which reason we have prescribed,
in our technical directions, a prolonged contact between
the chloride of lime and the water.
When the solution of carbonate and bicarbonate of
soda is poured into the maceration of chloride of lime,
an abundant precipitate of carbonate of lime appears,
the result of the double decomposition which takes place
between the soluble constituents of the chloride of lime
and the soda salts.
The two principal reactions are :
(ClO) 2 Ca 4- CO 8 Na 2 = CO 3 Ca + 2ClONa
CaCl 2 + CO 8 Na 2 = CO 3 Ca + 2NaCl
but the chloride of lime always contains a residue of non-
chlorinated lime, which may amount to 20 per cent, of
ioo TREATMENT OF INFECTED WOUNDS
the total weight, and of which a small quantity dissolves
in water during the course of preparation. This lime in
its turn intervenes in a secondary reaction, when the
formula is only concerned with the carbonate of soda :
Ca(OH) 2 + CO 3 Na a = CO 3 Ca + 2NaOH
setting free a small quantity of alkali, to which the
classic Labarraque's liquor owes its causticity. In Dakin's
process, this alkali is neutralised by an excess of boric
acid.
In Daufresne's process no caustic soda is formed ;
the liquor contains, in fact, a certain quantity of carbonic
acid, feebly combined (that of the bicarbonate of soda),
which attaches itself to the lime as soon as the two
solutions come into contact
It is difficult to demonstrate with certainty what is
the intimate mechanism of fixation of the lime, but it
may be imagined. As a matter of fact, it is for the
carbonic acid, amongst all the substances present, that
lime possesses the greatest affinity. Henceforward, the
harmful part played by the lime is suppressed, and the
secondary reaction we have indicated is changed into one
perfectly inoffensive :
Ca(OH) 2 + 2CO 8 NaH = CO 8 Ca 4- CO 8 Na 2 + 2H 2 O
D. Titration of the Solution of Hypochlorite. 1 Measure
10 c.c. of the solution, add 20 c.c. of ten percent, solution
of iodide of potassium, 2 c.c. of acetic acid, then drop
by drop a decinormal solution of hyposulphite up to
decoloration. The number of c.c. used, multiplied by
0*03725, will give the weight of hypochlorite of soda
contained in ioo c.c. of solution.
1 See Daufresne, he. cit.
PREPARATION OF DAKIN'S SOLUTION 101
In the first stage of the determination, hypochlorite
displaces the iodine of the iodide of potassium according
to the equation
ClONa 4- 2KI -f H 2 O = I 2 + 2KOH -f NaCl
which is only complete in the presence of a quantity of
acid sufficient to saturate completely the liberated potash.
The operation returns finally to an estimation of iodine
by hyposulphite of soda :
I 2 + 2S 2 3 Na 2 = 2NaI + S 4 O 6 Na 2
Examining the various reactions, we see that a single
molecule of hypochlorite decomposes two molecules of
iodide of potassium with liberation of two atoms of
iodine, and that each atom of iodine transforms a mole-
cule of hyposulphite into tetra-thionate of soda ; thus :
i mol. S 2 O 8 Na-> i atom of I -> J mol. ClONa
248 37-25
On the contrary, if as in the estimation of chloride of
lime the result had to be determined in active chlorine
(decolorising chlorine), it would have been necessary to
take into account that one atom of chlorine only displaces
one atom of iodine :
2C1 + 2KI = 2! + 2KC1 and
2! + 2S a 3 Na2 = 2NaI -f S 4 O 6 Na2
and
i mol. S 2 O 3 Na 2 -> i atom of I -> i atom of Cl
248 35'5
The equations (in the case of a sample of 10 c.c.)
which give the activity of a solution of hypochlorite, will
be different, according as the result is expressed, either
102 TREATMENT OF INFECTED WOUNDS
directly in hypochlorite, or indirectly in the quantity of
chlorine of equivalent activity.
Hypochlorite per cent. . . N X 0*03725
Active chlorine per cent. . . N X 0*0355
It is necessary to insist on this point, because the
same coefficient of activity is sometimes wrongly attri-
buted to the hypochlorite as to the chlorine.
E. Electrolytic Hypochlorite. Electrolytic hypochlo-
rite of soda is neutral. It contains no foreign substance
excepting an excess of chloride of sodium. A 0*5 per
cent, solution of this hypochlorite possesses the same
bactericidal power as Dakin's chemically prepared so-
lution. Its solvent action on mortified tissues is less rapid,
but it has the advantage of being less irritant to the
skin.
Electrolytic hypochlorite has not been employed
hitherto because it is unstable. In a few days, some-
times in a few hours in warm climates, the solution
decomposes. We began to employ electrolytic hypo-
chlorite of soda from the time when Daufresne found a
way of stabilising it. Daufresne discovered that if an
addition of I part in 20,000 of permanganate of potash,
or 0*2 per cent, of a soda salt, such as silicate of soda,
be made to the electrolytic solution, it keeps sufficiently
well. We may therefore employ the electrolytic hypo-
chlorite to-day in all cases where the special sensi-
tiveness of the skin or the length of treatment makes it
desirable to use a solution less irritating than Dakin's
chemically prepared solution.
PREPARATION OF DARIN'S SOLUTION 103
III. KEEPING QUALITIES OF THE SOLUTION
Solutions of hypochlorite do not keep indefinitely,
they change very slowly in the dark, much more quickly
in the light. Daufresne studied the influence of light in
the following manner.
Portions of the same solution of known strength being
placed in two flasks, one flask was left on the laboratory
table exposed to diffused light, while the other was kept
in a cupboard. He ascertained that the activity of the
solution sheltered from the light had not sensibly varied,
whilst the first had lost about 20 per cent, of its
hypoehlorite.
After
--- -
Loss in
o day.
7 days.
15 days.
21 days.
30 days.
one
month.
Solution kept in the"!
light, titration . . ./
0-505
0-497
0-452
0-411
0-380
247 %
Solution kept in thel
dark, titration. . ./
0-505
o'505
0-502
0-500
0-497
i'4%
When the mass of liquid is considerable, the altera-
tion is extremely slow. Daufresne kept a solution of
hypochlorite of 0*502 per cent, of ClONa in a wicker-
covered carboy of black glass, 25 litres, without any
special precautions as regards light. At the end of 3^
months the titration gave 0*493 per cent, of ClONa, a
loss practically negligible.
What becomes of the hypochlorite ? One cannot
say with certainty. By analogy with what happens,
under the influence of heat, it is thought that the
hypochlorite tends towards its two stable forms, chloride
and chlorate of sodium :
4ClONa = 3NaCl + ClO 8 Na + O
104 TREATMENT OF INFECTED WOUNDS
Obviously, this reaction implies a release of oxygen,
which is sometimes lacking. Besides, it does not explain
all the facts observed. It is sufficient to remember that,
in practice, it is better to keep the solutions away from
the light, and still more important to renew them as
frequently as possible, every ten or fifteen days at least.
Like the chemical hypochlorite, the electrolytic hypo-
chlorite must be kept away from the light. Even under
these conditions it rapidly degenerates when it is pure.
But the addition of permanganate of potash or an alka-
line salt greatly improves its keeping qualities. The
following table gives the results of a series of tests
carried on over a period of three weeks :
Titration in ClONa %
on the
ist day.
loth day.
2oth day.
I. Electrolytic hypochlorite kept in thel
light J
0-502
0-404
0-229
2. Electrolytic hypoclorite kept in dark-^
0^02
0-422
0-294
3. Electrolytic hypochlorite with the ad-
dition of i : 20,000 of permanganate
0^02
0-482
0-398
of potash, kept in the light
4. Electrolytic hypochlorite with the ad-
dition of I : 20,000 of permanganate
0-502
0-485
0365
of potash, kept in darkness
5. Electrolytic hypochlorite with the ad-
|
dition of O'2 per cent, of silicate of
i 0-502
0-492
0-484
soda, kept in the light ....
6. Electrolytic hypochlorite with the ad-
dition of O P 2 per cent, of silicate of
0-502
0*500
0-500
soda, kept in darkness . .
Inspection of this table shows that electrolytic hypo-
chlorite can be so far stabilised as to undergo no altera-
tion of importance for a period of two or three weeks.
PREPARATION OF DAKIN'S SOLUTION 105
IV. COMPARISON OF DAKIN'S SOLUTION WITH
LABARRAQUE'S LIQUOR AND COMMERCIAL EAU
DE JAVEL
The mistake is often made of identifying Labarraque's
liquor and even commercial eau de Javel with Dakin's
solution. But Daufresne has shown by simple methods,
that, from the biological as well as the chemical point
of view, these three solutions behave in very different
ways.
Amongst the reactions which may be cited for this
purpose, two are particularly characteristic. The phenol-
phtalein reaction and the effect upon skin. In these
experiments the three solutions are brought to a con-
venient strength of (O gr. 50 %, Fr.) of hypochlorite
of soda. The action upon skin has already been
described (p. 23). We shall here give only the action
upon phenol-phtalein.
If 20 c.c. of the solution to be examined are poured
into a beaker and on the surface are placed a few
centigrammes of phenol-phtalein in powder, it is seen
that :
ist. Eau de Javel and Labarraque's liquor immedi-
ately colour the particles of phenol-phtalein an intense
red, and the slightest shaking will suffice to communicate
to the whole of the liquid a bright red colour, which
slowly disappears under the decolorising action of the
hypochlorite.
2nd. Dakin's solution, under the same conditions,
does not give any colour to the particles of phtalein, and
it is only after vigorous and prolonged shaking that the
liquid becomes of a faint rose tint.
io6 TREATMENT OF INFECTED WOUNDS
Then, if one seeks the amount of alkalinity which a
solution must possess in order to give so much colour to
powdered phtalein, it is found that only solutions con-
taining at least 0*2 per cent, of caustic alkali will give to
the phtalein test a similar degree of colour. Carbonate
of soda gives only an almost imperceptible tinge to the
particles of phtalein, and a rosy tint to the liquid : that
same solution gives no colour if it only contain 2*0 per
cent, carbonate of soda.
Therefore Labarraque's liquor and eau de Javel each
contain a small quantity of caustic soda, revealed by the
phenol-phtalein test, and which might readily be foreseen
after examination of their mode of preparation.
In fact, Labarraque's liquor and many samples of
commercial eau de Javel are obtained by double decom-
position of a solution of chloride of lime and a solution
of carbonate of soda. All the constituents of chloride
of lime (hypochlorite of calcium, chloride of calcium,
slaked lime) are able to react upon carbonate of soda,
giving respectively hypochlorite of soda, chloride of
sodium and caustic soda. This caustic alkali, which
constitutes the irritating element most to be dreaded
in hypochlorite solution, certainly exists in the earlier
stages of preparation as given by Dakin ; but later it
is neutralised by excess of boric acid. We have seen
why it is not formed in the process described by
Daufresne.
V. CAUSES OF ERROR
When the rules laid down by Dakin and by Daufresne
for the manufacture of hypochlorite of soda are followed,
PREPARATION OF DAKIN'S SOLUTION 107
the solution fulfils all the desired conditions. Experience
has shown us, however, that in the various hospitals
where Dakin's solution is said to have been in use, they
often employ under this name various mixtures, more or
less dangerous. These defective solutions, which do
irritate tissues and do not sterilise wounds, are the result
of more or less clumsy faults in technique.
ist. The worst error consists in attributing to eau de
Javel or Labarraque's liquor mixed with a certain pro-
portion of boric acid, the properties possessed by Dakin's
solution. A certain number of surgeons are not afraid
to use similar solutions. Thus in one large hospital a
mixture of Labarraque's liquor and 40 per cent, boric
solution was employed under the name of " Dakin's
Solution." It is perfectly certain that solutions of which
one does not know the content, either of the alkali or the
hypochlorite of soda, are useless or dangerous.
2nd. Other errors crop up when hypochlorite of soda
solution is prepared according to Dakin's method, but
by means of chloride of lime of which the content of
active chlorine is not known. The result is that the pro-
portions of carbonate and bicarbonate of soda are no
longer exact, and the product obtained is no longer
Dakin's solution. Therefore it is indispensable to verify
always the titration of chloride of lime ; and, the solution
once obtained, to titrate the quantity of hypochlorite
which it contains and to apply the phtalein test according
to Dakin's technique. Hence, errors in the mode of
preparation result in solutions which are irritating
because they contain too much alkali or too much
hypochlorite of soda ; or which fail to sterilise wounds
because the amount of hypochlorite of soda is too small,
io8 TREATMENT OF INFECTED WOUNDS
or which do not keep well because they are charged with
too much boric acid.
3rd. Mistakes may be made in the way in which the
solution is kept. Should hypochlorite of soda be kept
in small quantities exposed to light and heat, the strength
of the solution rapidly lessens. We have seen in use in
a hospital, a solution whose hypochlorite content had
diminished to nearly 0*05. These mistakes are readily
avoided by using fresh solutions, or rather by taking
pains to keep the solution in darkness and in a cool
place. It is prudent to make titrations of the hypo-
chlorite of soda from time to time.
4th. Errors in the strength of the solution also occur.
In certain hospitals we have seen a solution used whose
hypochlorite content was correct, but whose strength
was reduced by addition of water. Solutions thus
obtained have a bactericidal potency far too feeble, and
they must not be used. Since, as the result of numerous
experiments, it has been determined that a solution
varying from 0*45 to 0*50 per cent, has no irritating
action on the tissues when used under the conditions
previously described, Dakin's solution pure and simple
should be employed. There is no danger when it is
accurately prepared. It is important to make sure that
the details of the method previously described have
been followed to the letter, if it is desired to obtain
Dakin's solution with its characteristic properties.
Furthermore, the procedure for sterilisation has been
calculated with a view to the application of a liquid
possessing the strength and qualities of Dakin's solution,
so that any alteration in the solution robs the method
of its precision and its efficacy.
CHAPTER III
THE TECHNIQUE OF THE STERILISATION OF
WOUNDS MECHANICAL, CHEMICAL, AND
SURGICAL CLEANSING
THE first stage of treatment consists in preparing for
the penetration of the liquid by surgical interference and
by mechanical cleaning of the wound. This intervention
is indispensable, in order that intimate contact between
antiseptic and microbe may be established. It differs
only by some details from the methods in general use
to-day.
I. THE TIME FOR MECHANICAL CLEANSING
Surgical interference and mechanical cleaning-up of a
wound are practised as soon as possible after the infliction
of the injury. The time for interference is of the greatest
moment, for the surgical proceeding has a gravity vary-
ing according to the stage of infection in which it takes
place.
I. Every infected wound at first goes through a
stage which might be termed pre-inflammatory, during
which the various local symptoms are very slight or non-
existent. Muscles and cellular tissue preserve their
normal appearance. So far there is neither swelling of
the tissues nor the reddened tracks of lymphangitis.
109
no TREATMENT OF INFECTED WOUNDS
The temperature is normal or rises slowly. This stage
usually lasts from twelve to twenty-four hours, and is
sometimes prolonged to forty-eight hours. During this
pre- inflammatory period free incisions and search for
foreign bodies or projectiles present no danger. This is
the period of the infection, during which all surgical
interference should be carried out as far as possible.
It is with wound-infection as with appendicitis. Inter-
ference during the first twenty-four hours carries with
it little danger, and nearly always yields excellent
results.
2. At the end of a period varying from twelve to
forty-eight hours, and occasionally longer, the inflamma-
tory stage begins. The temperature goes up, and marked
symptoms of infection appear on the surface of the
wound. These infectious complications present them-
selves under two aspects, gangrenous or phlegmonous.
In the gas form of infection multiple incisions with
thorough opening-up do not aggravate the patient's
condition, and as a rule allow the progress of infection to
be checked. It is not the same with infections of the
phlegmonous type, which are due often to the presence
of streptococci.
Every one knows the appearance of the phlegmon-
ous wounds. Neither gangrene nor gas is present, but
the tissues are infiltrated and painful. Serum pours
from the wound. Sometimes there is lymphangitis,
and the glands of a limb near the trunk are swollen
and tender on pressure. This stage may last several
days, and sometimes several weeks. When the patient
is in this condition, the surgical measures which might
have been practised had the operation taken place
TECHNIQUE OF STERILISATION in
during the first twenty-four hours are no longer indi-
cated. Free incisions and prolonged search for foreign
bodies or splinters might set up septicaemia, or at least
aggravate phenomena both local and general. During
this anxious period one has to be contented with
no more than is absolutely necessary. To operate at
this moment is to make the patient run the same risks
as a case of acute appendicitis which is operated on
after three or four days.
3. When the stage of acute infection is past, and
suppuration has commenced, the search for projectiles,
shreds of clothing, splinters may be undertaken with
far less danger. But osteo-myelitis in some cases has
made its appearance, and wound-cleansing cannot be as
efficacious as at the outset.
Upon the whole, the most favourable time for any
operation called for by reason of anatomical lesions is
the pre-inflammatory stage. If the general condition
permit, now is the time to carry out without danger any
necessary surgical interference. It is the reason why
the wounded man should be got as quickly as possible
to the hospital, where complete surgical treatment can
be carried out.
II. TECHNIQUE OF THE MECHANICAL CLEANSING
OF THE WOUND
A. Pre -inflammatory Period. As soon as the patient
arrives at the hospital (ambulance, Fr.), he is warmed
and cleaned up. If needed, treatment for shock is
carried out. Then surgical treatment of the wounds is
immediately proceeded with.
ii2 TREATMENT OF INFECTED WOUNDS
i. Clinical and Radiological Examination. (a) Notes
of the wounds having been taken, their relations to the
various organs of the damaged region are examined. The
opening of the wound should be neatly trimmed according
to its requirements. The fascia is split or torn by the
projectile. Muscles present as a hernia or retract to leave
a gaping hole. Lastly, blood issues from the wound, either
alone or mingled with the fat coming from a fracture,
cerebro-spinal fluid, brain matter, urine or faeces. Inspec-
tion of the orifice often yields valuable indications of
underlying injuries. The surrounding skin may be red
and tense. Sometimes a furrow ending at the orifice
gives the direction of the projectile. At another part of
the limb a cutaneous bruise may be seen without solution
of continuity of the skin. Frequently the projectile is
found at this spot. The whole region in which the
wound is situate is more or less swollen. Occasionally it
is puffy around the opening.
In certain cases the whole segment of the damaged
limb is swollen and hard. Very rarely is pulsation felt
or a murmur heard. This swelling is due nearly
always to haemorrhagic infiltration of the inter-muscular
cellular tissue, particularly of the posterior aspect of the
calf or thigh. It is a lesion which it is important to bear
in mind. In fact, serious infections often occur in these
layers of connective tissue, whose blood-infiltration may
be widely extended and form an ideal culture-ground.
Just as often, instead of swelling we find a localised
depression between the two orifices. This depression
corresponds to a sub-cutaneous section of the muscles by
a projectile which has traversed the limb seton-fashion.
It is well to have this information before operating,
TECHNIQUE OF STERILISATION 113
because it determines the nature of the surgical inter-
ference. Because, if muscles are severed, we may unite
the two openings of the seton by an incision at right
angles to the long axis of the limb ; whereas, if the
muscles are sound, the two orifices should be opened
up by incisions parallel to the long axis of the limb.
Pain may prove a useful guide. Often a tender spot
points out the site of the projectile. The bony skeleton
must be examined, not only to recognise a complete
fracture, almost always easy to identify, but also to ensure
that the splinters of an incomplete fracture should not
escape notice.
The circulation and innervation of the distal portion
of the limb are equally subjected to careful investiga-
tion.
(b) It is indispensable that the casualty clearing
station (ambulance, Fr.) should possess a radiological
installation to allow of exact localisation of projectiles.
We shall not here go into details as to the most useful
method of procedure. Simple radioscopy enables us, if
we move certain muscles with the ringer, or obtain
voluntary contraction, to fix the site of projectiles. It
is a quick and practical way of localising multiple
projectiles.
To summarise, both a general examination and a
minute local examination should be made, as much to
decide the actual possibility of surgical interference, as
to fix its duration and extent. Equipped with this
information, we may proceed as quickly as possible to
the mechanical cleansing of the wounds.
2. Anaesthesia. General anaesthesia should always be
employed. Ether should be used ; chloroform as rarely
8
114 TREATMENT OF INFECTED WOUNDS
as possible. In certain cases spinal anaesthesia is em-
ployed.
3. Opening-up and cleaning a Wound of the Soft Parts.
The skin is sterilised with tincture of iodine. As the
cutaneous apertures of entrance and exit of projectiles
are too small to allow of an examination of the course
taken by the foreign body, they must be enlarged. The
extent of opening-up depends upon the depth of the
track of the missile. The eye must be able to survey
the whole extent of the wound, especially when fracture
exists. The incisions, therefore, are as long as may be
needful, and parallel with the long axis of the limb or
the fibres of the underlying muscles. As a matter of
fact, the track of the bullet nearly always goes through
the muscles we are intending to clean, and which must
be cut as little as possible. The muscular track, there-
fore, is laid open by an incision as wide as the skin-
opening. We do not insist upon the necessity for
respecting vessels and nerves. In the case of a blind
track, if it does not suffice to lay open the orifice, a
counter-opening should be made, which will permit
examination of the whole extent of the wound.
In wounds of the "seton" type, the two orifices
are laid open separately, parallel with the long axis of
the limb, so that the entire track is plainly visible. If
this seton-type of wound is superficial, it is sometimes
advisable to lay it open from one orifice to the other.
Should muscles be severed by the projectile it is pre-
ferable to open up the wound completely, in order to
clean it the more thoroughly.
There is no call for hesitation in making very free
incisions, because they can be brought together again
TECHNIQUE OF STERILISATION 115
after a few days. Extensive opening-up of soft parts
nearly always yields earlier closing.
(a) The bruised portions of the track are carefully
excised. To Depage and the surgeons of his school is
due the merit of having shown how useful it is to
resect almost the whole of the walls of the wound. The
skin which surrounds the opening, the sub-cutaneous
cellular tissue, the superficial fascia, and above all, the
muscles in the first third of the track, are almost always
riddled with threads of wool or cotton from the clothing.
These shreds are embedded in the tissues. No amount of
sluicing or swabbing is capable of getting rid of them.
They can only be removed by removing the tissues
themselves. This line of conduct is all the more justified
by the fact that muscular or cellular tissue thus im-
pregnated with tiny foreign bodies is certainly destined
to necrosis and elimination.
The mechanical cleansing of a wound, therefore,
commences by removal of the skin which adjoins the
orifices, of the sub-cutaneous cellular tissue fouled by
fragments of clothing and often infiltrated with blood,
and of the muscular track encrusted with foreign bodies.
The muscular wall is resected to a thickness of about
two millimetres over almost the whole extent of the
wound. This cleaning with a cutting instrument is
much to be preferred to manoeuvres which injure
tissues without cleansing them. It is no use sponging
a track with a gauze swab, introduced by one orifice,
pushed to and fro, and then removed by the other open-
ing. This kind of cleansing is always ineffective and
harmful, for it inoculates healthy tissues throughout the
whole extent of the wound, and produces lesions which
ii6 TREATMENT OF INFECTED WOUNDS
may be followed by necrosis. Indispensable manipula-
tions, such as the repeated pressure of gauze com-
presses on a wound-surface to check haemorrhagic
oozing, or the use of metallic retractors, have already
bruised the tissues. Rough handling, likely to aggravate
pre-existing injuries and increase tissue-infection, must
be carefully avoided.
(b) Haemostasis. In the course of the operation, the
organs, vessels, and nerves in the neighbourhood are
examined and haemostasis of the track completely
established. When injury to a large vessel is found
in the track of a projectile, it is most necessary to see
that adjoining cellular interspaces have not been opened
up and infiltrated with extravasated blood. This lesion
is common on the posterior aspect of the thigh and calf.
In fact, in the sheath of the sciatic nerve, under the
biceps, semi-membranosus, and semi-tendinosus, haema-
tomata are sometimes found, infiltrated in the connective
tissue which separates the different muscles. The same
thing occurs in the calf, near the soleus, gastrocnemius
and flexors. There must be no hesitation about laying
open these spaces from one end to the other, for infection
spreads there with the greatest readiness, and may
become of extremely grave character. Incisions are
made in such a way as not to endanger the circulation
of the part.
(c) Search for and Extraction of Projectiles and Shreds
of Clothing. The difficulties of searching for projectiles
are due to the dimensions, sometimes extremely small,
of the foreign bodies, to the thickness of the muscular
stratum in which they are embedded, and to the irregu-
larity of the course of the projectile through the tissues.
TECHNIQUE OF STERILISATION 117
When a wound is cleansed some hours after infliction,
and the foreign body is as large as a small nut, it is
generally easy to find it. The muscles which surround
the track seem struck by paralysis. Eye and finger
follow the route of the missile all the more readily when
radiography has indicated the direction of the track.
One always tries to arrive at the projectile by means
of the track, because it has to be followed and the whole
wound cleaned. However, if the track is too long, it is
easy to make a counter-opening in the immediate neigh-
bourhood of the projectile. This counter-opening not
only allows the projectile to be extracted, but also the
inspection of the wound to be completed, and this part
of the track to be resected. The various apparatus for
registration, and Bergonie's electrovibrator should be
made use of. Sometimes the minute fragments of shell
are very difficult to locate. In fact, the openings they
leave when traversing fascia are very small. Often these
may be identified, but directly afterwards the track
through muscular fibre is lost. Hirtz's or Contremoulin's
compass may prove of use. But when the shell-frag-
ments are numerous and close together, the multiplicity
of points registered on the skin is bewildering. Then
is the time to call in the aid of the telephone vibrator
of M. de la Baume-Pluvinel. This apparatus enables us
to find the tiniest fragments.
It is much more important to remove shreds of cloth-
ing than projectiles. As a rule, the missile is wrapped up
in the fabric it has carried along with it, but sometimes
it has only pushed the cloth in front. By the aid of dis-
secting forceps, every particle of fabric which is found
on the surface of the wound is removed with minute care.
ii8 TREATMENT OF INFECTED WOUNDS
The toilet is completed by washing both wound and
adjoining skin with neutral oleate of soda.
(d) Drainage. Drainage of the wound should be
liberally arranged, but by a procedure different from
what is usually employed. Counter-openings are not
made at dependent points. In fact, the antiseptic solu-
tion must come into contact with the entire surface of
the tissues, and consequently fill the wound. The liquid
must not be allowed to escape through the bottom. We
shall even see, later on, that when a wound is being
drained naturally through a dependent opening, the
inferior orifice should be plugged by a tampon. There-
fore we have to be contented with freely opening the
wound by one or more long incisions, situate as much
as possible on the anterior aspect of the limb. The
openings thus made are kept gaping by means of com-
presses placed in the mouth of the wound, or short
lengths of very large rubber drainage tube. Compresses
or tampons are never placed in the interior of the
wound.
When the wound has been thus prepared, and
haemostasis is complete, the tissues look quite clean.
However, we are never quite sure of having cleansed
the wound absolutely. There is no known method
of ascertaining the bacteriological condition of a fresh
wound while it is still bleeding. The " smears "
which would immediately inform us as to the state of
wounds more than twenty-four hours old, and from a
non-bleeding surface, are of no use at this stage.
Cultures give no results before the end of twenty-four
hours. And even a negative culture would not signify
that the wound was not infected. In reality, in fresh
TECHNIQUE OF STERILISATION 119
wounds, microbes are localised at certain points, and
if the specimens are not taken from these points, the
tubes remain sterile. Therefore we must refuse, abso-
lutely, immediate closure of a wound, however satis-
factorily clean its appearance. As it is impossible to
ascertain precisely its state as to infection, the patient
would run grave risk if it were sutured. Often has
disaster followed premature closing of wounds.
4. Cleansing of Compound Fractures or Wounds of
Joints. (a) Cleaning-up a Compound Fracture. The in-
cisions for exploration and cleaning-up of compound frac-
tures should always be very free. A long incision is no
drawback, because it can be sutured two or three weeks
later. Whenever possible these incisions are made on
the anterior aspect of the limb in such a way that the
liquid may remain in contact with the bony fragments.
Counter-openings at the dependent points are not made.
Soft parts are laid open in such a manner that all parts
of the seat of fracture may be explored. In fractures
of the femur, it is peculiarly important to make an
incision so long that the masses of muscle can be
retracted sufficiently to lay bare the fissures in the bone,
however long they may be. These long incisions should
be kept open. Muscular masses have a marked
tendency to reunite in such a way that the seat of
fracture becomes shut off. The opening can be kept
gaping by means of short pieces of rubber tubing, three
centimetres in diameter, which are kept separate from
each other by a second set of tubes at right angles.
Those haematomata which form along the sciatic nerve
and in the sheath of the femoral vessels, about the
popliteal space and along the posterior tibial vessels,
J2o TREATMENT OF INFECTED WOUNDS
must be reckoned with. Whenever found in this condi-
tion, these sheaths must be opened, because they are
protected from the antiseptic liquid and become starting-
points of infection. Exploration of the soft parts some-
times brings to light tiny splinters which have perforated
the muscles. These are removed at the same time as
the lacerated portions of muscular tissue.
Splinters are often found lying free between the
fractured extremities and in the medullary canal. These
splinters are removed. The medullary canal is explored,
and in the case of longitudinal fractures, the marrow is
removed. All splinters adherent to the periosteum are
preserved. Experience has shown, in fact, that fractures
so treated become sterile, heal without sinuses, and
rapidly consolidate. And, on the contrary, the exten-
sive removals of splinters which too often have been
practised in the " ambulances " at the front, have yielded
deplorable functional results. Even very serious injuries
of the bones should not be followed by immediate
amputation, except in the cases of extensive smashing-
up of the skeleton, or of destruction of vasculo-nervous
bundles. Careful cleansing, as conservative as possible,
should be made of the multiple seats of fracture, with
the object of placing the conducting tubes in contact
with bony surfaces. Thus it becomes possible to save
many limbs which otherwise would be condemned to
amputation.
Most careful haemostasis is practised. But avoid
leaving compresses in the deeper parts of the wound, or
only leave them there for a few hours.
(b) Cleansing of Joint-injuries. Wounds of joints
are treated in different ways, according as the synovial
TECHNIQUE OF STERILISATION 121
membranes are alone concerned, or the bony extremities
in addition.
When synovial cavities are alone concerned, the pro-
jectile is extracted, and the joint emptied of the blood
it contains. The contaminated region is isolated from
the rest of the joint cavity by compress or suture, and
the instillation tube is placed in the situation previously
occupied by the foreign body.
If the bony lesions consist simply of a chafing of the
surface, or perforation of one of the extremities by a pro-
jectile, or an unimportant fracture of an epiphysis, the
course to take is almost identical with that we have just
described. The only addition is to scrape the bony
surface which has come into contact with the projectile
or with shreds of clothing. This region is cut off as
completely as possible from the rest of the articular
cavity, and submitted to instillation of the antiseptic
liquid.
Should the bony lesions be very extensive, it
becomes necessary to perform a resection. But primary
joint resections are to be made with circumspection.
Because, chemiotherapy often allows repair of extensive
lesions of articulations, which, under any other treatment,
would have had to undergo resection of the osseous
extremities.
B. Inflammatory Period. This stage may begin
about six or eight hours after the incidence of the
wound. But usually it starts towards the twenty-fourth
or thirty-sixth hour, sometimes not until after the lapse
of several days.
Two quite different classes of phenomena are observed :
gangrenous infections and phlegmonous infections. The
122 TREATMENT OF INFECTED WOUNDS
first are of early onset and rapid progress. The second
are slower to appear, more tardy in evolution. Both
types of infectious manifestation may coexist in the
same wound. Their symptoms have been described
by the classic authors. But their pathological physio-
logy is little known. Only it is recognised that the
general reaction following surgical traumatism is much
more violent during the inflammatory period than during
the pre-inflammatory stage. Manipulation and lacera-
tion of tissues may set up grave complications when
microbes already swarm in the walls of the wound. We
have seen cases operated on at the expiration of
several days for a localised infection, present signs of
septicaemia and die after this interference with the
focus of infection. At the beginning of the campaign,
tetanus at times occurred a few hours after such opera-
tions. And when the nature of the infection was
less alarming, still the general condition of the patient
remained worse than before, and his temperature chart
showed great fluctuations for several days afterwards.
Hence, whilst the toilet of a war-wound should be
carried out in minute detail before the advent of in-
flammatory phenomena, it is prudent to confine one-
self to what is strictly necessary, during the stage of
confirmed infection.
The course to adopt varies according as the infection
is of the gangrenous or the phlegmonous type.
I. Gas-producing Infection. Gas-gangrene presents
itself under three different forms : the septicaemic type,
the grave local type, and gas-cellulitis.
(a) The septicaemic form is particularly frequent in
fractures of the femur with serious muscular laceration.
TECHNIQUE OF STERILISATION 123
After a few hours the patient has nausea and vomits.
He is agitated. The pulse is rapid, small, indistinct.
However, the patient does not yet complain of great pain
in his limb, and there is little gas to be discovered. This
appears, clinically, several hours later than the general
phenomena. Death comes before the limb has had
time to necrose. Amputation is urgent, to have even a
feeble chance of saving the patient's life.
(&) Local gas-producing infection, which does not act
at the very outset on the patient's general condition, if
suitable treatment be adopted, is the most frequently
recovered from. Two principal forms may be distin-
guished^ superficial and a deep form. The superficial gan-
grene evolves chiefly in the sub-cutaneous cellular tissue.
Gas rapidly spreads, far from the site of trauma. Open-
ing-up shows that cellular tissue almost alone is invaded,
and that muscles are not gangrenous, save in the imme-
diate neighbourhood of the wound. This form is fairly
benign. Numerous incisions implicating at the same
time both the skin and the superficial fascia are made
wherever crepitation can be felt. Tubes are placed in
each incision.
Deep gangrene involves more particularly the muscles.
Pain and agitation are often the earliest symptoms.
Pain extends in the direction of the trunk, along muscular
sheaths. It is the path which the infection itself has
followed. If the limb is not yet completely necrosed, it
is needful, after having set free the muscles attacked, to
open up vascular sheaths. When the muscles of the
calf are attacked, the femoral sheath should be incised
between Scarpa's triangle and Hunter's canal. Finally,
all around the limb are made incisions about ten
124 TREATMENT OF INFECTED WOUNDS
centimetres (four inches) long, including both skin and
fascia. This local form may call for amputation. If
muscles are found to be gangrenous, and in addition the
vessels obliterated, it is prudent to remove the limb.
Amputation is practised at a short distance from the
seat of injury. Moreover, the vascular sheath must be
laid open, in order to make sure that infection has not
already invaded it. The stump is left quite open. A
tube, perforated with small holes in its middle third, is
placed loop-wise on the stump (Fig. 51). At the same
time, instilling tubes are placed in the vicinity of the
vascular sheaths. After an amputation of the thigh,
three tubes are used for the internal saphenous, the
femoral vessels, and the profunda.
(c) Localised Gangrene. This is a benign form of
gas- producing gangrene. It is often found localised
in a muscular sheath. For example, it may be limited
to the anterior muscles of the leg, or the peroneal
muscles. It may even affect only part of a muscle.
To lay it open freely will suffice, the incisions extending
beyond the lesion in every direction. Then the instilla-
tion tubes are placed in position, care being taken to
lead them into muscular interstices and into the muscles
themselves. The course of local gas-gangrene, under the
influence of hypochlorite of soda, is very favourable.
Swelling and redness disappear, the junction of the
limb with the trunk remains supple and free from
oedema, the patient is no longer in pain, and his general
condition is excellent. Elimination of mortified tissues
takes place very quickly, because hypochlorites dissolve
necrosed muscle. Often by the seventh day, there is no
longer a trace of gangrenous tissues.
TECHNIQUE OF STERILISATION 125
A still more benign form of gas-producing infection
exists, gas-abscess. A simple incision will suffice.
2. Phlegmonous Form. The clinical aspects of the
phlegmonous form are extremely varied. Reticular
lymphangitis may be seen around a superficial wound,
or a line of inflammation of a lymphatic trunk extending
to the proximal extremity of the affected limb, or a
serious local inflammation with redness and great swelling
of the limb, or slight inflammation coincident with a
grave general condition. In the case of lymphangitis
of either variety, the wound is sterilised by Dakin's
solution, and a hot fomentation applied over the limb.
If a lymphangitic abscess should form, it is incised and
the cavity sterilised by Dakin's solution.
When the muscles are concerned in the injury, and
the phlegmonous inflammation extends to the whole
thickness of a muscle-group, it is necessary to lay open
the focus of inflammation, and also the intermuscular
spaces in which the infection is being produced (generally
due to haematoma). But surgical interference should
be limited to this. It is not wise to seek for projectiles
or foreign bodies, nor to remove the splinters from a seat
of fracture. In these highly infected wounds, meticulous
exploration is more dangerous than useful. The seat of
fracture is kept freely open, and into every diverticulum
is inserted an instilling tube. It is dangerous to use the
scalpel to wounds from which blood-stained serum is
coming. An attempt must be made, in the first place,
to lessen the infection by antiseptic treatment. If a tube
instilling hypochlorite can be introduced into the track
resulting from a previous operation, it is well to be con-
tent with this therapeusis. Perhaps it may be needful
126 TREATMENT OF INFECTED WOUNDS
to lay open a wound still more freely in order to introduce
the tube which will supply the antiseptic liquid. Then
an incision is made in which one or two tubes are placed
quite in the bottom of the track, without further trauma-
tism of the tissues. At the same time, rigorous immo-
bilisation of the limb is insisted on.
To resume, the treatment of a patient with a phleg-
monous wound differs from the treatment of a case in
the pre-inflammatory stage. Preventive therapeusis of
infection calls for minute surgical cleansing, which at
that stage of infection presents no danger. But when,
on the contrary, infection is well established in a wound,
it is necessary 'in the first place to check it by the
simplest means at hand, and to postpone to a more
favourable opportunity the surgical treatment called for
by anatomical lesions and the presence of projectiles.
Some modifications have to be made in this technique,
due to the nature of the injury.
(a) Infected Fractures. The course to pursue in
compound fractures, the seat of acute diffuse inflamma-
tion, is similar to that we have just laid down for wounds
of the soft parts. Only what is strictly necessary is done
in the first place ; that is to say, simple laying open of
a seat of fracture without minute cleansing, and the
placing of several instillation tubes in the diverticula of
the wound. After a few days the general condition
improves. Swelling, redness, pain, diminish. Then,
when the dangerous stage of infection is passed and
the number of microbes per field of the microscope
remains considerable, the toilet of the seat of fracture
is made. This new interference is as complete as pos-
sible. Foreign bodies, carefully registered by suitable
TECHNIQUE OF STERILISATION 127
apparatus, are removed at the same time as the splinters,
but the periosteum of the splinters is preserved with
care. The operation ends by arranging in the seat of
fracture multiple tubes destined for supply of the anti-
septic solution.
(b) Suppurating Joint-injuries. In arthritis without
bony lesions, arthrotomy more or less free, followed by
the extirpation of foreign bodies and cleansing of the
articulation, suffices generally to ward off evil results,
if the antiseptic treatment be carefully employed and
the joint immobilised absolutely.
In joint-injuries with bone lesions intervention is
limited to the measures which, aided by chemical steri-
lisation, check the spread of infection. The general
condition of the patient, the nature and the virulence of
the infection, play an important part. Streptococcal infec-
tions are the most grave, and call for more extensive
interference than the other infections. In these cases,
sometimes, the prospect of amputation must be faced.
(c) Secondary Haemorrhage. Haemorrhages are often
due to the detachment of a scar produced by contusion
of the wall of a large arterial trunk. But they arise also
from the breaking down of clot, which had previously
brought about spontaneous haemostasis of a wound of
an artery or vein. The clot disappears under the influ-
ence of infection, and the artery finds itself more or less
widely open. In this manner a primary haemorrhage
is produced, perhaps only slight, but which is followed
some days later by a loss of blood much greater, often
mortal. Haemorrhage may also follow the loosening of
a ligature, silk being readily dissolved by hypochlorite,
as Fiessinger has shown. That is why we ligature
128 TREATMENT OF INFECTED WOUNDS
vessels with catgut or chromic catgut. When these
precautions are taken, haemorrhages are never observed.
The preventive treatment of haemorrhage consists in
careful examination of the vessels at the time of surgical
interference, and in bringing about definite haemostasis
if a vessel be wounded.
When a case presents a primary haemorrhage, most
frequently a tampon will stop the bleeding. But several
days later a new haemorrhage will not fail to appear, and
the patient may succumb. It will not do to be content
with a tampon ; ligatures must be used above and below
the injury, and as near as possible to the seat of
ulceration.
Haemorrhages have occurred in certain hospitals after
using badly prepared Dakin's solution. The solution
then contains free alkali, which is just as capable of pro-
ducing vascular ulceration as eau de Javel or Labar-
raque's liquor.
In wounds chemically sterilised the classic secondary
haemorrhages due to suppuration are never seen.
(d) Wounds of the Brain. For wounds of the brain
the projectile should be removed, whenever possible,
through its orifice of penetration. It is important to
avoid causing traumatisms of the cerebral substance
by rough manipulations or by washing out the wound by
means of a liquid under pressure. The walls of the
wound are freed as thoroughly as possible from all
foreign bodies which may be found in them. As it is
of the highest importance to the future of the patient
that the wound should be absolutely sterilised, all its
parts should be brought carefully into contact with the
antiseptic. It is therefore essential immediately after
TECHNIQUE OF STERILISATION 129
operation, to introduce a special appliance which will
permit of its sterilisation, and as far as possible this
appliance must not be removed until the bacteria have
completely disappeared.
C. Suppuration Stage. The manipulation of wounds
which have arrived at the stage of suppuration is effected
with all the more precaution because still nearer the
inflammatory stage. Two extreme types of suppurating
wounds may be present. The first type is the wound
covered with pus more or less blood-stained, accom-
panied by lymphangitis, swelling and pain. It is the
transition period between the inflammatory stage and
the period of true suppuration. Unless there are urgent
indications to the contrary, these suppurating wounds
must be treated with as much respect as wounds in the
inflammatory period. The other type is represented by
wounds of longer standing. From the orifice, already
covered by granulations, thick " laudable " pus escapes.
The tissues are no longer oedematous. The tempera-
ture is only slightly raised, or presents great variations.
At this stage it is possible to interfere surgically with
less danger than in wounds of the first type. Between
these two extreme types a number of intermediate con-
ditions are found. Surgical interference becomes less
and less dangerous as the wounds are removed further
and further from the first type. In a general way the
cleansing of the wound follows the same rules in all
cases ; the more inflamed the wound the more sparing
should be surgical interference.
1st. Chemical Cleansing. In the great majority of
cases the wounded who arrive at the hospital at the end
of two, ten, or fifteen days have already been operated
9
130 TREATMENT OF INFECTED WOUNDS
upon. On the surface of the limb, therefore, openings
are found leading down to the solutions of continuity
in soft parts, to opened joints, to seats of fracture. These
openings are often too small, and inadequate to drain the
pus-laden burrows. Nevertheless, it is better not to inter-
fere at the outset. Even at this stage it is hardly wise to
open up an abscess. It is enough to remove the drainage
tubes which generally have been placed in the wound,
and replace them by the small instillation tubes which
are gently coaxed into the orifices already in existence,
down to all the diverticula of the soft parts and to the
seats of fracture. This is done without anaesthesia and
without distressing the patient. Then Dakin's solution is
instilled, according to the method which will be described
later, until suppuration ceases, temperature drops, and
the general condition improves. From the clinical point
of view, suppuration disappears after the lapse of a space
of time varying from twenty-four hours to about four days.
2nd. Surgical Cleaning. After a little time, in
wounds accompanied by injuries to bone, the ameliora-
tion resulting from the application of the antiseptic is
arrested. The number of microbes found on the surface
of the wound remains stationary. But, on the other
hand, suppuration has diminished or dried up, the tissues
are no longer swollen, and the patient is ready for
surgical intervention.
Then the wound is cleansed just as though it were
a fresh one. Under anaesthesia, foreign bodies and
necrotic tissues are removed.
In the case of suppurating fractures, the method of
procedure is slightly different, according as intervention
is practised before or after consolidation. This point
TECHNIQUE OF STERILISATION 131
was recently cleared up at Compiegne by the researches
of MM. Guillot and Woimant.
(a) Before Consolidation. It is an easy matter to
explore the bony extremities. Incisions will not neces-
sarily be made in already existing wounds. Whenever
it is possible to do so without involving a fresh and
extensive traumatism, it is best to choose the classical
paths of surgical access, while avoiding those which,
being in a sloping position, are not very favourable to
irrigation. Between the bony extremities, or in their
neighbourhood, will be fragments of necrosed bone and
splinters. The former having been removed, the latter
will be . sacrificed only if they show signs of necrosis, or
if they hinder the inspection of the seat of the fracture,
and its irrigation. The bony extremities will be care-
fully examined, for the result of the operation is directly
dependent upon their treatment. When they are filled by
a medullary plug, it is necessary to make sure, by scraping
the latter with the curette, that it is healthy, without
fissures or enclosed sequestra, in which case it is certain
that the underlying medullary cavity is practically sterile.
In the contrary case it is necessary to remove the whole
thickness of the plug, and to provide for drainage, by
scraping a groove in the dense tissue for a depth of two-
fifths of an inch. The same procedure will be followed
in the case of bony extremities which are left opening
into the seat of the fracture. This precaution of opening
up a wide passage for the irrigation tubes in the dense
tissue is of the greatest importance if we wish to avoid
violent post-operative febrile reactions.
(b) After Consolidation. The exposure of the bony
extremities presents more difficulty. In the first place,
132 TREATMENT OF INFECTED WOUNDS
the path of access is obstructed by fistulas which have
to be resected, and the formation of callus. When the
orifice of an osseous fistula is reached through the soft
parts, the periosteum is detached from the callus by
means of a sharp rugine, taking care not to denude it
too far. The curette then enlarges the fistula, enabling
the bone-forceps to come into play, and permitting of the
resection of the periosteal callus and the fragments, which
is necessary to the cleaning-up of the cavity of the seat
of fracture, and the exploration of the medullary cavities.
The treatment of the bony extremities thus exposed will
be the same as before consolidation.
The capital point in the operative treatment of old
fractures inclined to suppurate is to practise complete
but economical operation. In short, the abrasion of the
bony tissue must be compatible with the reunion of the
soft parts after the few days necessary for sterilisation.
It -is obviously possible to treat old fractures in a
single surgical operation by an extensive sub-periosteal
resection, going considerably beyond the boundaries of
the lesion in both directions. But this method of pro-
cedure is incompatible with secondary reunion ; it must
be regarded as a surgical technique which was excellent
in times when one could not imagine the reunion of
infected wounds.
In a case of suppurative arthritis, if necessary, re-
section of the bony extremities is practised. At this
stage the surgical interventions found absolutely neces-
sary may be carried out with much less danger than
when the patient " came in." It must be borne in mind,
however, that tissues which have already commenced to
cicatrise during the stage of suppuration are impregnated
TECHNIQUE OF STERILISATION 133
with microbes and that reinfections are possible. There-
fore operations involving the least possible amount of
traumatism should be chosen.
Wounds of the soft parts, as a rule, become aseptic
under the influence of the antiseptic without a new
operation being necessary.
3rd. Chemical Sterilisation. The surgical cleaning-up
is followed by the introduction of instillation tubes pre-
cisely as though dealing with a fresh wound. It is
necessary to keep the wound gaping so long as its
deeper parts are not sterilised. This result is attained
by placing in the wound short segments of tube of wide
calibre, by the side of which are introduced the small
tubes for instillation.
In the case of fractures operated on during the
suppurative stage, MM. Guillot and Woimant have
shown that certain precautions are necessary in order
to limit post-operative reactions. Our aim should be
to deprive the bacteria of the media of culture which
are favourable to them : blood- clots and contused tissues.
The blood-clots are avoided by a thorough haemostasis
with the forceps, which is completed, as regards the
osseous and medullary oozing, by a prolonged irrigation
with warm serum. The rapid elimination of the con-
tused tissues will be achieved, on the one hand, by an
abundant irrigation performed at short intervals, every
hour or even every half-hour, if an automatic apparatus
is available.
D. Cicatricial Stage. The cicatrisation of a wound *
does not mark the end of infection. In fact, microbes
remain included in the cicatricial tissue. Therefore
secondary interference practised on a patient whose
134 TREATMENT OF INFECTED WOUNDS
wounds have healed, during a period of suppuration
more or less long, is subject to special rules. Every
one knows that after stump-trimming, nerve-suture,
osteotomy for defective union, suture for pseudarthrosis,
etc., infections, sometimes most alarming, may arise. It
is therefore prudent, in these secondary interventions, to
refrain from suturing the wounds, and to place in the
deepest parts one or two tubes carrying the antiseptic
liquid. The sterilisation of operation wounds is thus
rapidly obtained, and the accidents due to reinfection
avoided. In bone-grafting, the extremities of the bone
are prepared for the reception of the graft, and in the
wound thus created instillation tubes are placed. After
a few days, it is ascertained that the wound is actually
aseptic, and then the grafting is completed and the soft
parts closed.
In a word, during the cicatricial stage, surgical inter-
ference practised in two stages, which are separated by
a period of disinfection, is the surest means of avoiding
disaster.
CHAPTER IV
THE TECHNIQUE OF THE STERILISATION
OF WOUNDS CHEMICAL STERILISATION
CHEMICAL sterilisation of a wound is brought about by
instillation, continuous or intermittent, of an antiseptic
liquid, by means of small rubber tubes, into all the
recesses of a wound. As the quantity of liquid used is
very small, it is not necessary to employ drainage tubes
or to arrange for reception of an overflow. The liquid
which has moistened the tissues is absorbed by the
dressing and evaporates. Instillation thus practised
permits of the continual renewal of the liquid over every
portion of the wound. This procedure differs from the
old " irrigation," in that it is much simpler, and in that
the liquid is carried directly to the deepest diverticula
of the wound.
I. CONDUCTING TUBES AND RESERVOIRS
A. The Conducting or " Instillation" Tubes. The
conducting tubes are of red rubber. The rubber wall
of the tube has a thickness of i mm., and the interior*
diameter is 4 mm. They are thus resistant and flexible.
These qualities allow of their penetration to every irregu-
larity of the wound, and of their adequate resistance to
136 TREATMENT OF INFECTED WOUNDS
the pressure of muscles and dressings. Three kinds
of tubes are used.
ist. Tubes perforated with Small Holes. The length
of these tubes varies from 30 to 40 cm. (roughly 12 to
1 6 inches). Some of them are closed at one end by a
ligature, and pierced by small holes over a length of from
5 to 20 cm. 1 from the closed extremity (Fig. 35). The
FIG. 35. Conducting or "instillation" tubes, rubber, with multiple holes,
closed at one end.
A. Tube 30 cm. long, pierced over a length of 5 cm.
B. Tube 30 cm. long, pierced over a length of 10 cm.
C. Tube 40 cm. long, pierced for a length of 15 cm.
D. Tube 40 cm . long, pierced for a length of 20 cm.
E. Tube open at both ends, and pierced over a length of 20 cm. in its
median portion (10 cm. = about 4 inches}.
holes number about eight to each 5 -cm. section. Their
diameter is about half a mm. 2 The holes are made by
means of an ordinary punch. These tubes are the most
used. Four different categories are in use, according as
the holes are perforated over a length of 5, 10, 15, or
20 cm. Other tubes are left open at each end and
1 Say 2 to 8 inches.
2 Ath of an inch.
TECHNIQUE OF THE STERILISATION 137
pierced with holes only in their middle third (Fig. 1 8, E).
Liquid enters by each end.
2nd. Tubes with a Single Opening. These are of a
length of from 25 to 30 cm. 1 and the ends are open
(Fig. 36). At half a centimetre from one end a large
FIG. 36. Conducting or "instillation " tube with terminal opening. Tube of
about 30 cm. long, open at both ends, with a lateral opening near one end.
lateral opening is made. This lateral orifice is intended
to permit the egress of liquid should the terminal orifice
become blocked.
3rd. Tubes perforated with Small Holes and covered
with Absorbent Fabric. These tubes are closed at one
extremity and pierced with small holes over a variable
length. The section pierced with little holes is covered
with a sheath of fabric similar to the material of which
bath towels are made (Fig. 37). This sheath is firmly
FIG. 37. Conducting or "instillation" tube covered with a sheath of bath-
towelling (tissu tponge).
stitched to the tube. It is intended to distribute the
liquid over the whole surface of the tube as it escapes
from the holes. It is important that the cover should
be so firmly fixed by a stitch to the rubber tube that it
cannot remain behind in the recesses of the wound
when the tube is withdrawn.
These tubes are of uniform length. They can easily
be lengthened to any extent by means of pieces of
1 Say 9 to 12 inches.
138 TREATMENT OF INFECTED WOUNDS
rubber tube of the same calibre and " unions " of pieces
of glass tube (Fig. 39, C) of a calibre of 4 mm. and a
length of 2-5 cm.
B. The Distributing Tubes. The tubes pierced with
holes are grouped into sets of two, three, or four by
FIG. 38. Glass distributing tubes
(Gentile).
A. Tube with one branch.
B. Tube with two branches.
C. Tube with three branches.
D. Tube with four branches.
FIG. 39. Glass connecting tubes, ' ' unions."
A. Cylindrical tube of a length of 4 to
5 cm. and an interior diameter of
7 mm.
B. Y-tube with an interior diameter of
7 mm. These tubes unite the ends
of rubber irrigating tubes.
C. Cylindrical' tube of a length of
3 cm. and an interior diameter of
4 mm. This tube serves to join-up
two small conducting tubes, when
it is necessary to add to the length
of one of these tubes.
means of appropriate branched tubes. Two types of
branched tubes are employed (Fig. 38).
ist. The Y-shaped tube is composed of a main stem
about 2 cm. long with a calibre of 7 mm., and of two
limbs or branches of equal length, about 2 cm., whose
interior calibre varies between 3 and 4 mm. (Fig. 38, B).
TECHNIQUE OF THE STERILISATION 139
Upon the two branches are fitted either two simple
instillation tubes, or the two extremities of a tube per-
forated with holes in its middle portion.
2nd. The distributor with four branches is composed
of a glass tube closed at one end, 6 or 7 cm. long, and of
a calibre of 7 mm. (Fig. 38, D). From one side of this
tube project at right angles four smaller tubes, each of a
length of 2 cm. and an interior calibre of 3 to 4 mm.
Thus it has the look of a comb. In the same manner
one may have three branches (Fig. 38, C), or five or six.
3rd. Small glass connecting tubes or " unions " must
also be at hand to join together the rubber tubes of large
or small calibre, or to unite a rubber tube of small calibre
to one of large. The first are cylindrical glass tubes
2 to 3 cm. long, and of a calibre of 4 and of 7 mm.
(Fig. 39, A and C). The others are conical glass tubes
of the same length, presenting at one extremity an in-
terior diameter of 3 to 4 mm., and at the other extremity
an interior diameter of 7 mm. (Fig. 38, A). Tubes of
Y-shape are also in use, of 7 mm. calibre, for joining
up irrigating tubes (Fig. 39, B).
C. The Irrigating Apparatus. The irrigating appa-
ratus is composed essentially of a reservoir (ampoule or
flask) fixed at a certain height above the patient's bed,
with a tube (equipped or not with a drop-counting con-
trivance) and stop-cock, so as to allow of either continuous
or intermittent instillation.
ist. The reservoir for liquid usually employed is a
flask holding a litre (176 pint, 0*22 gallon). Its interior^
orifice has a diameter of 7 mm. (Fig. 40). To this
is attached an irrigating tube of red rubber with a
calibre of 7 mm. The flask is fastened to a wooden
140 TREATMENT OF INFECTED WOUNDS
standard firmly fixed to some convenient portion of
the bedstead, a portion which depends upon the
situation of the wound. It is suspended at a height
of from 50 cm. to I metre above the level of the
bed.
2nd. The irrigating tube, as we have just said, has
an interior diameter of 7 mm. Its length is from i metre
FIG. 40. Ampoule or flask holding a
litre.
FIG. 41. Pinch-cock (Pince de Mohr
d ressort).
50 cm. to 2 metres. Whilst the superior extremity is
attached to the flask, its lower end is united with a glass
cannula, to which are fixed the smaller tubes which
convey the liquid to the wound. At 10 centimetres
below the flask the tube is furnished with a pinch-cock
(Fig. 41). Slight pressure upon the spring suffices to
open the lumen of the tube and to allow the liquid to
flow. This apparatus is extremely simple, and well
TECHNIQUE OF THE STERILISATION 141
suited to the intermittent irrigation of wounds (Fig.
42). Every two hours a nurse stops at the foot
of the bed and releases the spring of the Mohr
pinch-cock for a few seconds. Instillation at once takes
place.
In the hospitals at the front, where it is difficult to
FIG. 42. Nurse using a pinch-cock and so instilling antiseptic liquid.
provide the needful number of apparatus, the plan devised
by le medecin-major Ferret may be used. This consists
of a support on wheels (dressing wagon) carrying the
reservoir of Dakin's solution at the required height.
The orderly propels the wagon from bed to bed and
injects the liquid into the wounds by means of a cannula,
142 TREATMENT OF INFECTED WOUNDS
which is changed for each patient. This proceeding
simplifies the provision of apparatus, but greatly adds
to the work of the staff.
The liquid may be instilled also by means of a
syringe. The most convenient syringe for this purpose
has been made by Gentile. It consists simply of a
glass tube drawn out to a fine jet at one end, and of
a capacity of 10 c.c. (Fig. 43). The piston is replaced
by a bulb of red rubber. The advantage of this syringe
is that it can be used with one hand. Each case has
its own syringe. It is kept half-immersed in the
bottle which holds the supply of Dakin's solution be-
FiG. 43. Syringe (Seringue de Gentile}.
longing to the case. The use of a syringe for the
instillation of liquid has also the drawback of increasing
the work of the personnel. Besides, instillation done
with a syringe gives results far less speedy than with the
irrigating reservoir, because the quantity of liquid is
much less considerable ; and, the tube constituting a
siphon, the moment the syringe is withdrawn the liquid
immediately runs out of the wound instead of remaining
there.
We have completely given up the use of the syringe
for instillations. We use Gentile's syringe to test the
permeability of the tubes in the course of doing the
dressings.
TECHNIQUE OF THE STERILISATION 143
When it is desired to practise continuous instillation
instead of intermittent, the apparatus is modified after
the following manner. To the lower aperture of the
flask is attached a rubber tube 10 cm. long. At the
extremity of this tube is attached one of Gentile's " drop-
counters" (une ampoule compte-gouttes de Gentile). Be-
tween the drop-counter and the reservoir is a screw
pinch-cock (une pince de Mohr d vis) which enables us to
.n m n,
Rubber Tube
FIG. 44. ' ' Drop-counter," Gentile's. Screw pinch-cock (Pince de Mohr a vis}.
regulate the number of drops per minute which the
apparatus should deliver. The lower end of the drop-
counter is connected to the irrigating tube (Fig. 44).
As the quantity of liquid which traverses a section of
tube in a unit of time is very small, it is useless to
employ an irrigating tube of diameter as great as that in
use for intermittent instillation. A calibre of 5 to 6 mm.
is sufficient.
144 TREATMENT OF INFECTED WOUNDS
D. Method of using the Different Tubes and Apparatus.
ist. The appliance for continuous instillation should
never be connected up with several tubes, nor with a
tube perforated with several holes. As the output of a
drop-counter is very small, all the liquid should flow
through a single tube and emerge from a single hole in
this tube, the hole and the tube being dependent on
gravitation. Consequently, instillation drop by drop
should only be used for wounds which contain a single
tube, perforated at its extremity (Fig. 45), or a single
tube sheathed with " tissu eponge " (bath-towelling).
2nd. The apparatus for intermittent instillation can
be connected up with four tubes perforated with tiny
holes, or even, in certain cases, with eight. As the
yield of the irrigating tube is considerable, the liquid,
at the moment when the spring of the pinch-cock is
released, spurts out from all the holes of all the tubes.
As much as possible, tubes of a length of 5 and of 10 cm.
should be used, especially if a single flask furnishes the
liquid to eight tubes.
It will not do to serve from the same cannula both
simply- perforated tubes and tubes sheathed in "tissu
eponge." By reason of the different resistances, the
liquid would escape almost entirely by the simply
perforated tubes.
It is important to remember this difference in the
action of the two forms of apparatus, for continued
instillation and for intermittent instillation, because, if
a drop-counting appliance be used in connection with
a system of general perforated tubes, no result will be
obtained. The device for intermittent instillation is
used much more frequently than the apparatus for
TECHNIQUE OF THE STERILISATION 145
continued instillation, because it allows a single irrigation
reservoir to provide liquid
for four or eight tubes at
once (Fig. 46). It is there-
fore applicable to all large
wounds.
FIG. 45. Apparatus arranged for drop- FIG. 46. Apparatus for intermittent
by-drop instillation : a, Reservoir ; b, instillation : a, Reservoir (ampoule
Irrigation tube ; c, Screw pinch-cock ; or _fl ask holding a litre) ; b, Irrigating
d, Drop-counter ; e, Distributing tube tube with a diameter of 7 mm. ; c,
(Fig. 38, A) ; /, Conducting tube with Pinch-cock (Pince de Mohr) ; d, Dis-
terminal orifice (Fig. 36). tributing tube with 4 branches ; e,
tributing
Conducting tubes.
IO
146 TREATMENT OF INFECTED WOUNDS
II. ARRANGEMENT OF THE TUBES IN A WOUND
A. General Principles. The disposition of the tubes
in a wound is such that the liquid may readily spread
over the whole surface. As it is essential that the anti-
septic liquid should be in contact with the tissues them-
selves, the tubes are not applied over gauze, or over
" wicks," but directly to the wound. In fact, a thin
compress placed on the surface of granulations might be
supposed to be able to distribute the liquid over the
whole extent of their surface. Also it might be
FIG. 47. Wound with surface horizontal. Wrong method of placing the
tube. The perforated instillation tube is on the surface of the compress.
imagined that " wicks " of absorbent cotton would play
a similar part. But nothing of the kind occurs. After
a short time, the deeper parts of the absorbent tissue
become impregnated with the plasma secreted by the
tissues and are then almost impermeable to the liquid.
Suppose a thin compress be placed on the surface of the
wound and a tube be laid on the compress, liquid
injected into the tube slips away over the surface of the
wound without sterilising the wound (Fig. 47). There-
fore it is absolutely necessary to place the tubes directly
in contact with the wound-surface, and then to lay the
compresses above them (Fig. 48) in such a manner that
TECHNIQUE OF THE STERILISATION 147
the liquid may insinuate itself between them and the
surface of the wound.
In the disposal of the tubes it is necessary also to
take into account the position of the wound. The flow
FIG. 48. Wound with surface horizontal. Right method of placing the tube.
Tube in contact with the wound and covered with a gauze compress.
of liquid being under the influence of gravity, the tubes
are arranged differently, according as the wound is
situate on the anterior, lateral, or posterior surface of
the body. They are placed in such a manner that the
liquid may spread itself over the greatest possible extent
of the wound (Fig. 49). When the wound is on the
anterior surface of the trunk or limbs the application
of the tubes is easy. If on the lateral or posterior aspect,
prolonged contact between antiseptic and wound surface
is more difficult to obtain.
The shape of the wound also plays an important part.
A wound possessing but a single opening, and that
situated superiorly, can be filled with liquid like a cup,
and can be readily sterilised (Fig. 50). If a wound of
this type has a second opening at the level of its most
dependent part, liquid runs through rapidly and the
sterilisation is slower. Gravity plays a very consider-
able part in the distribution of the liquid and the tubes*
must be arranged in such a manner as to utilise it.
B. Arrangement of the Tubes according to the Shape of
the Wound, ist. Surface Wounds. One or more tubes
148 TREATMENT OF INFECTED WOUNDS
perforated with minute holes are placed on the wound.
If it is situated on the anterior aspect of the body and
the bottom of the wound is in the horizontal plane, or
nearly so, the liquid can be distributed fairly equally
FIG. 49. Wound with surface inclined. FIG. 50. Wound with opening
A. Tubes placed the wrong way, along superior, so that it can be filled
the lower border of the wound. like a cup.
B. Tubes placed the right way, along
the upper border of the wound.
over its surface (Fig. 48). When the surface of the
wound is inclined, the tube is laid along the more
elevated border (Fig. 49), so that the liquid, carried
by gravity, flows over the surface of the tissues. Instead
of a simple tube, we may use a ring, formed out of
a tube perforated with little holes throughout its middle
TECHNIQUE OF THE STERILISATION 149
portion, and whose ends are joined by a Y-shaped
cannula (Fig. 51). By means of a thread attached to
the two halves of the tube, the loop can be altered to
any convenient shape. On the end of a stump, for
is*
FIG. 51. Surface wound. The in-
stillation is made by means of a
tube perforated in its middle portion,
whose ends, fixed to the skin by a
strip of adhesive plaster, are joined
by a Y-shaped distributor.
FIG. 52. "Seton" wound, in the
interior of which is placed an
instillation tube perforated with
small holes and which passes
through the dressing at its upper
part.
example, this mode of instillation is useful. Between
the raw surface and the base of the flap is placed a loop
formed of a rubber tube pierced with multiple hole?
whose two extremities are joined by the Y-cannula
resting on the skin of the anterior portion of the limb.
ISO TREATMENT OF INFECTED WOUNDS
The fixation of these tubes is effected by means of
gauze compresses soaked in Dakin's solution, which are
laid over them. In addition, they are fixed to the skin
adjoining the wound by a strip of adhesive plaster.
This fixation must be thought out very carefully, because
if the tubes slip down to the lowest part of the wound,
sterilisation of the upper part will be defective. For,
whatever precautions may be taken, the tubes some-
times become displaced. That is why it is advantageous,
in the treatment of surface wounds, to replace instilla-
tion of liquid by the application of chloramine paste, so
soon as sphacelated tissues have been dissolved.
2nd. The " Seton" Type of Wounds. If a tube closed
at one end and pierced with small holes is placed in a
" seton " wound whose axis is almost horizontal, liquid
readily remains in the wound (Fig. 52). But if the axis
of the seton is vertical, the liquid escapes by the inferior
opening immediately it is injected. Therefore, some-
times, in these cases a tube wrapped in " tissu eponge "
is used. This absorbent fabric (Fig. 37) distributes the
fluid over the surface of the wound and keeps it there
for a period more or less prolonged.
3rd. Wounds with a Single Orifice. If the opening is at
the " roof " of the wound, the device is simple. A rubber
tube bearing a single hole near its blind extremity is
introduced to the bottom of the wound (Figs. 50, 53).
The cavity of the wound fills up like a cup, and the fluid
remains quiescent there until it is displaced by the fresh
liquid brought by the tube to the bottom of the wound
The superior opening of the wound should be large
enough to allow the liquid to circulate freely. In these
cases, "drop by drop" instillation may be used. The
TECHNIQUE OF THE STERILISATION 151
liquid continually arriving at the bottom of the wound
is constantly being renewed. This arrangement is par-
ticularly favourable to rapid sterilisation. Therefore,
wherever possible, it is well to transform the wounds
with two openings into wounds with one opening, by
closing the lower aperture with a tampon.
When the opening of the wound, instead of being
found on the anterior aspect of the body, appears on the
posterior surface, conditions are altered. If the patient
can sleep prone on his stomach, the tube is placed as just
FIG. 53. Compound fracture of tibia with the opening of the wound on the
anterior aspect of the limb ; in the seat of fracture is a tube open at the
end.
described. Otherwise a different device must be adopted.
In fact, if the fluid is led to the roof of the wound by a
tube which enters by the lower opening, it tends to fall
back immediately, under the influence of gravity.
When the wound is a narrow one, a tube sheathed
with " tissu eponge " can be used, which may carry the
liquid by capillary attraction to the highest regions
(Fig. 54). If the wound is larger, several tubes pierceof
with little holes are introduced and the liquid injected
under an adequate pressure. The liquid spurts out over
152 TREATMENT OF INFECTED WOUNDS
the walls and succeeds in sterilising them, but more
slowly than when it can remain quietly in the wound.
Should the orifice occur on the lateral aspect of the
body, a certain amount of retention of the liquid can be
attained by compresses plugging the orifice. In this
case tubes pierced with small holes and closed at one
end are used. In addition, the patient should be placed
FiG. 54. Wound of the soft parts whose orifice is at the posterior aspect of
the limb. Instillation to the "roof" of the wound by means of a tube
sheathed in " bath-towelling " (tissu tponge}.
in the position most favourable for retaining liquid in the
wound.
4th. Large Wounds with Several Openings. Some-
times, if the openings are on the anterior surface of the
limb, these wounds can be filled with liquid. Sterilisa-
tion is then very simple. But in the majority of cases
it is not so. The fluid has a tendency to escape rapidly
TECHNIQUE OF THE STERILISATION 153
by the most dependent point of the wound. In addition
to lesions of the soft parts, there is often a fracture which
makes the wound still more irregular.
Then tubes perforated over a length of 5 to 10 cm.
are used, and introduced as deeply as possible into each
diverticulum. To fix these tubes in their positions in
FIG. 55. Irregular wound of the thigh. Two tubes are placed in the wound
anteriorly and one posteriorly. These tubes are applied to the surface of
the tissues. They are kept apart by gauze packed between them in the
opening of the wound.
the central part of the wound, gauze compresses may be
used. But it is important to see that the compresses are
not packed too tightly, and that they are always separated
from the surface of the tissues by a tube (Fig. 55).
Avoid placing tubes in the middle of a mass of gauze
(Fig. 56). In fractures of the femur, the wound can be
kept open by short pieces of rubber tube 3 cm. (about
154 TREATMENT OF INFECTED WOUNDS
ii inches) diameter, which are separated from one
another by other pieces of tube placed at right angles.
As gravity will not permit the fluid to remain on the
surface of the wound, a sufficient number of tubes is
arranged so as to moisten every portion of the wound
FIG. 56. The same irregular wound of the thigh. The tubes are wrongly
placed. Instead of being in contact with the tissues they are in contact
with the gauze which fills the wound.
surface (Fig. 55). In the large wound of a compound
fracture of the thigh at least 8 or 10 tubes are needed.
5th. Wounds of the Brain. The consistency of the
brain prevents the application of simple perforated tubes.
The cerebral substance, in fact, presses closely against
the walls of the tube and enters the perforations. The
liquid no longer circulates properly. In the case of
cerebral wounds it is therefore necessary to resort to
TECHNIQUE OF THE STERILISATION 155
another arrangement, which enables the liquid to circulate
in contact with the surface of the wound. The appliance
to be used in such cases consists of an external tube,
permeable to liquids, and an internal tube of small
calibre by which the antiseptic substance is injected.
The external tube consists of a very light framework,
on which is stretched a thin fabric which has been
rendered hydrophilous. This framework Du Nouy con-
structs of bamboo hollowed and perforated by a thermo-
cautery, while Schmelz and Daufresne make it of thin
German silver wire. The diameter of these tubes varies
from I to i -5 centimetre, and their length from 4 to 6
centimetres. In the interior of the tube is fixed a small
rubber tube about 2 mm. in diameter, which is attached
to the framework. This little appliance is fixed in the
cerebral wound so that the movements of the head can-
not displace it. The meninges are protected by a piece
of gauze impregnated with vaselin. The appliance is
connected with a special apparatus which instils the
liquid drop by drop.
C. Arrangement of the Tubes according to the State
of Infection, ist. Fresh Wounds. Fresh wounds nearly
always bleed. If tubes pierced with small holes be
placed in a wound containing fresh blood, the tube will
be filled with it, the blood will coagulate, and the lumen
of the tube will be obliterated. It is essential, in fresh
wounds, to arrest haemorrhage thoroughly, before arrang-
ing the tubes, and to verify their permeability with care,
before continuing the dressing. Fresh wounds having
no secretion, or very little, tubes sheathed in absorbent
fabric may be applied to their surface without incon-
venience. For the same reason, gauze is less harmful
156 TREATMENT OF INFECTED WOUNDS
on fresh wounds than on wounds which are suppu-
rating.
2nd. Suppurating Wounds. The presence of pus on a
wound is an indication that tubes surrounded by absor-
bent tissue may not be used, because this fabric immedi-
ately becomes saturated with pus. For the same reason
" wicks " and gauze compresses are used as little as
possible, and tubes multiplied. Gauze may be used at
the orifice of the wound. But all the diverticula should
FIG. 57. Testing the permeability of a conducting tube at the time of
dressing.
contain tubes and not gauze. It is advisable to have
the tubes more numerous than in a fresh wound of the
same dimensions.
D. Testing the Working of the Tubes. Before the
dressing is applied, the permeability of the tubes and
their perforations should be tested (Fig. 57), also the
manner in which the various regions of the wound are
receiving their share of the antiseptic liquid. This test
is to prove that the tubes have not become plugged with
blood-clot, and that the distribution is taking place
TECHNIQUE OF THE STERILISATION 157
evenly over the whole surface. Further, it shows what
quantity of liquid will be needed to fill the wound com-
pletely, or to moisten the entire surface, should its
position not allow of its being filled.
The nurse should be present at this testing, which
will also show her how to control the flow of liquid in
the wound without wetting the patient.
III. DRESSING
ist. Method of carrying out the Dressing. As soon
as the tubes are in position, gauze compresses soaked in
FIG. 58. Dressing : a, Conducting tube kept in the wound by gauze placed
in the orifice ; b, Squares of gauze sterilised in vaselin placed on the
skin around the wound.
Dakin's solution are applied. These compresses help to
fix the tubes on the surface of the wound. The tubes
have been selected long enough to allow several centi-
metres of their non-perforated portion to be outside the
dressing (Fig. 58). Also the perforated part must be
buried wholly in the wound, because otherwise the free
openings would allow fluid to escape unused, possibly
doing harm.
158 TREATMENT OF INFECTED WOUNDS
After the application of the compresses to the wound,
the adjoining skin is protected by squares of gauze,
sterilised in vaselin (Fig. 58). Pieces 8 or 10 cm.
square are placed in yellow vaselin and sterilised. At
the moment of dressing, they are taken up with dressing
forceps and applied to the surface of the skin, to which
they immediately adhere. They form an excellent
protection for the skin, which, on the posterior aspect of
the trunk or limbs, has a tendency to become irritated
by the hypochlorite.
FIG. 59. Sheets of dressings, composed of layers of absorbent cotton-wool,
non-absorbent cotton-wool, and gauze.
The dressing is completed by a sheet of cotton-wool
protected on either surface by one thickness of gauze.
This dressing is prepared beforehand in three different
sizes (Fig. 59). It is composed of four strata ; a layer
of gauze, a sheet of absorbent cotton- wool, a sheet of
non-absorbent cotton-wool (coton card/) y and a final
cover of gauze (Fig. 60). The side which has the
absorbent cotton-wool is applied next the wound.
TECHNIQUE OF THE STERILISATION 159
Secretions are thus absorbed, without being able to
escape readily to the exterior, by reason of the presence
of the non-absorbent cotton-wool. At the same time,
evaporation goes on quite easily through this almost
B
FIG. 60. Section of the sheet of dressing : A, Gauze. B, Carded (non-
absorbent) cotton-wool. C, Absorbent cotton-wool. D, Gauze.
waterproof layer. Waterproot fabrics should never be
used.
The application of the dressing is speedy. The
middle part of the dressing is placed under the limb and
FIG. 61. Dressing applied around a compound fracture of the leg, and
fastened by safety-pins; the distributing tube is fixed to the plaster
apparatus by safety-pins.
the two sides are fastened on the anterior surface of the
limb by two or three safety-pins. The use of a bandage
is thus avoided. Besides, the dressing is easily undone,
and the wound can be examined and the position of the
tubes ascertained without disturbing and distressing the
160 TREATMENT OF INFECTED WOUNDS
patient. When the dressing is first applied, two scissor-
cuts are made in the layer of cotton-wool to allow the
rubber tubes to emerge readily from the dressing
(Figs. 62 and 63).
2nd. Fixation of Tubes and Cannulae. When the
dressing is finished, the ends of the supply-tubes emerge
at different points from the layer of cotton-wool and
gauze. These tubes are connected up in groups of two
or four by means of the branched unions or cannulae
FIG. 62. Position of the distributing tube on the surface of the dressing.
The conducting tubes penetrate the dressing, either at the point where the
end of the layer of cotton-wool and gauze overlaps, or through windows
cut with scissors.
which have been described (Figs. 62 and 38). In the
case of a compound fracture of the thigh, the eight tubes
are divided into two groups and united by two cannulae
of four branches each (Fig. 63). In the case of a very
extensive wound where certain of the small conducting
tubes are too short to be connected up with the branches
of the cannula, they are lengthened by pieces of rubber
tube and " unions " or connecting tubes of glass (Fig. 39).
This work can be done after the dressing, when the
irrigating apparatus is installed.
TECHNIQUE OF THE STERILISATION 161
After the tubes have been joined up to the cannula,
this latter is fixed to the highest part of the dressing.
For example, in a compound fracture of the thigh, the
cannula is fixed above the middle of the anterior aspect
of the limb. This fixing is simply done by nipping the
FIG. 63. Arrangement on the surface of a dressing of a Y-connecting tube,
and of two distributing tubes with four branches.
largest part of the glass cannula in a big safety-pin, itself
attached to the dressing. Then the larger end of the
cannula is united to the irrigating tube which is attached
to the flask or other reservoir of liquid. The correct
FIG. 64. Method of fixing a distributing tube to the surface of a dressing.
fixing of the cannula to the surface of the dressing is
important. Thanks to it, the small conducting tubes lie
in the wound, in the positions in which they have been
placed, without either the weight of the irrigating tube
or the movements of the patient being able to shift
them.
ii
162 TREATMENT OF INFECTED WOUNDS
3rd. Immobilisation of the Limb. Naturally the limb
should be prevented as much as possible from moving.
Either plaster apparatus, suspension, or continuous trac-
tion will be used. In every case where it is indicated,
the patient is placed on a Bradford's frame. When the
time for dressing comes, the frame is raised, and one or
two bands are removed, so that the posterior portion of
the limb or trunk can be examined or dressed without
moving the patient.
The dressing is renewed every twenty-four hours. If,
however, before the expiration of this period, the cotton-
wool has become very wet, the outer layer of the dressing
may be changed without disturbing the tubes or the layer
of gauze which covers the wound. The changing of
the dressing consists in removing the gauze compresses
which are on the surface of the wound, and at the entrance
to it. The position of the tubes is carefully checked,
and modified if there should be need. No washing is
done, simply fresh gauze and an external dressing
applied. The manipulations are thus extremely simple,
and, in a short time, the surgeon can personally dress
a large number of cases.
The mattress is protected by a waterproof sheet.
The quantity of liquid used should be always so small
that the bed is not flooded.
IV. INSTILLATION OF THE ANTISEPTIC LIQUID
The flask holding a litre, or other convenient reser-
voir, is filled with Dakin's solution, coloured to a rose-
tint with permanganate of potassium. This coloration
distinguishes Dakin's solution from physiological saline
solution, and most assuredly prevents mistakes.
TECHNIQUE OF THE STERILISATION 163
1st. Continuous instillation gives better results than
intermittent instillation. But it is not so frequently
employed. In fact, it is only suited to wounds where
the liquid can remain in quantity, or to small wounds
for which a single conducting tube sheathed with
absorbent fabric will suffice. The flow of the liquid
is regulated by means of a screw pinch-cock inter-
posed between the flask and the drop-counter. Five
or six drops per minute will usually give sufficient
moisture to this type of wound. It should be remem-
bered that the pressure of the liquid at the surface of
the wound is represented by the difference in level
between the wound and the lower portion of the drop-
counter, and not between the wound and the upper
portion of the reservoir. If the drop-counter be placed
too low, on a level with the wound, it will not work.
It is equally necessary to be aware that drop-by-drop
instillation should only be used when the end of the
irrigating tube is connected up with only one of the
little tubes which distribute liquid to the wound. Under
these conditions, continuous instillation permits the
degree of concentration of the antiseptic liquid on the
surface of the wound to be maintained under better
conditions than intermittent instillation.
Intermittent instillation is used for the greater
number of wounds. As a matter of fact, the great
majority of wounds are extensive and irregular and have
several openings. To these continuous instillation is not
suited.
Intermittent instillation is carried out by releasing
for a few seconds, every two hours, the pinch-cock which
is placed on the irrigating tube just below the reservoir.
1 64 TREATMENT OF INFECTED WOUNDS
Liquid immediately escapes from the flask (irrigating
bottle or reservoir), and spurts out in great abundance
from every hole of all the conducting tubes. The dura-
tion of flow of the liquid should be very short, lest the
patient be flooded out. The quantity thus injected
varies, according to the nature of the case, from 20 to
100 c.c. 1 and sometimes more. As a general rule, the
injections are made every two hours ; occasionally, with
greater frequency. When the apparatus is installed as
we have described, the work of the nurse in charge
of the instillations is very light. In fact, as in each
case she halts at the foot of the bed, she has only to
press for a few seconds the spring " pince de Mohr "
fixed on the irrigating tube.
Intermittent instillation is practised every two hours,
but it would be of advantage to practise it more fre-
quently, as the hypochlorite decomposes very rapidly
when in contact with the tissues. On the other hand,
more frequent instillations often make too great a call
on the energies of the nurses. In order to diminish the
amount of manual work required, and, where desirable,
to increase the number of instillations, attempts have
been made in the direction of automatic instillation.
The automatic devices which have hitherto been em-
ployed are based on the principle of the intermittent
fountain. As a rule, they work well under experimental
conditions, but in the actual conditions of surgical treat-
ment they reveal defects. In the case of small dis-
charges more especially, the siphon fails to prime, and
the liquid runs drop by drop into the tube, or the siphon
does not discharge itself, and again the liquid flows drop
1 Say from f oz. to 3^ 02.
TECHNIQUE OF THE STERILISATION 165
by drop. It has therefore been necessary to abandon
apparatus based on this principle, as its working was
very irregular, and required almost as much attention
as the ordinary apparatus.
As a result of experiments carried out by Lecomte
du Nouy in the Compiegne laboratories, an electro-
magnetic distributing apparatus for the irrigation ot
wounds has been invented. It consists of an individual
electro-magnetic distributor and a clockwork device for
making contact. The electro- magnetic distributor con-
sists of the bobbin of an electric bell, a core, an armature,
the latter movable, and a wooden stopper, which con-
tains the whole, and is fixed upon the neck of the
ampoule. The current, automatically transmitted, raises
a valve which closes the bottom of the ampoule, and the
liquid flows until the current ceases. The principle con-
sists in the utilisation of the well-known solenoid coil,
through which is "sent, for a very short time, a current
of sufficient strength to produce a mechanical effect. The
bobbin, which could not resist such a current if long con-
tinued, can easily carry it for a few seconds. Calculation
shows, in fact, that the instantaneous rise of temperature
taking into account the fact that radiation is practically
nil is, for a bobbin of 9 ohms resistance, covered with
copper wire 0*4 mm. in diameter, 1*23 C. per second for
a current of 2 amperes. This current seems at first sight
to be a considerable load for such fine wire, but as it
flows through the bobbins for one or two seconds only,
it does not overload them, nor does it entail any appreci-
able expense. In fact, a group of 12 such appliances,
served by a current of 220 volts pressure, consumes
barely 0*15 kilowatt per month, so that it costs only a
1 66 TREATMENT OF INFECTED WOUNDS
shilling or so yearly. Contact is established every half-
hour by means of a clock or clockwork train, and the
current is sent through all the appliances, mounted in
series, the number of the groups in series depending on
the tension of the current and the resistance of the
bobbins. It is important that the contacts shall be of
regular duration, and the contact-making device must
be reliable in working. Daufresne has worked out an
arrangement of this kind by means of a very simple
alteration of a striking clock. One clock suffices to
control any number of such appliances enough, for
example, to serve 500 or 1000 beds.
Each time contact is made by the clock the valves of
the ampoules are lifted for two seconds, and the liquid
flows. The quantity of the liquid reaching the wound
may be regulated by reducing as required the calibre of
the supply-tube. As the frequency of the irrigations
does not increase the work of the staff, and as it is of
advantage that the liquid in the wounds should be
renewed as often as possible, instillations are now
practised every half-hour.
2nd. The total quantity of liquid injected in 24 hours
varies from about 250 to 1200 c.c. 1 In very extensive
wounds, more can be injected without inconvenience.
The only fixed rule is, that the wound should be kept
constantly moistened by the liquid, without the patient
being made uncomfortably damp.
3rd. In intermittent instillation, the pressure varies
from forty centimetres to a metre. It should be regu-
lated according to the particular needs of the wound and
the sensitiveness of the patient. At the moment of
1 Roughly, eight ounces to two pints.
TECHNIQUE OF THE STERILISATION 167
commencing the instillation, he experiences sometimes
a slight impression of pain which may last some minutes.
Sometimes, again, he has only a sensation of chilliness,
or actual cold. The patient should never suffer actual
pain from the instillation. Should he complain, it shows
that an error of technique has been committed. The
pain may be due to excess of pressure, or to the wound-
opening being too small. If the pressure be too great,
the liquid spurts out violently from the apertures in the
tubes against the walls of the wounds and bruises the
tissues. That is why the pressure should never be
greater than one metre. With sensitive patients, a
pressure of 20 to 30 centimetres is sufficient. Another
cause of pain is retention of the liquid in the wound
under pressure. If the incisions are too limited, and if the
conducting tubes are too tightly gripped by the tissues
or by compresses, the liquid cannot escape freely from
the wound. It accumulates under pressure, and the
patient feels it. The wound should be freely opened
up, so that the liquid may escape without hindrance.
V. DURATION OF THE INSTILLATION
Instillation of liquid continues day and night until
all microbes have disappeared from the "smears."
Therefore it is inspection of the microbial curves which
indicates when the irrigation can be stopped. So long
as a few microbes remain, no alteration should be made
either in the quantity of the liquid or in the frequency of
the instillations. So long as a focus of infection, be ft
ever so small, remain on the surface of the wound, total
reinfection is possible. If the instillations be stopped, or
1 68 TREATMENT OF INFECTED WOUNDS
their frequency lessened, when the microbial curve shows
only one or two microbes per field of the microscope,
rapid reinfection may be brought about. On the other
hand, the presence of hypochlorite does not lessen the
rapidity of repair. By suppressing microbes, it accele-
rates it. As the few small infected foci which still
persist on the wound after some days of instillation
cannot enlarge, the greater part of the wound cicatris s
with the same speed as if it were aseptic.
In general, from three to ten days are needed to
sterilise a wound of the soft parts, and fifteen days or
more a compound fracture. These figures are those
observed when the wound is sterilised before the sup-
purative stage. But if the treatment is commenced
after the wound has already suppurated, the duration
of the instillation period is usually much longer. Bac-
teriological examination alone can indicate the time
when the instillations may be discontinued.
VI. ERRORS OF TECHNIQUE
A. Insufficient Penetration of the Liquid. Whenever
examination of the curve of sterilisation shows that,
before attaining surgical asepsis, the line has become
horizontal, we may be sure that a fault in technique has
been committed. We know, in fact, that the diminution
in the number of microbes in a wound should progress
steadily, whenever the antiseptic liquid is carried into all
the regions infected. If sterilisation is not achieved, in
the first place it is necessary to ascertain that the Dakin's
solution contains the needful amount of hypochlorite,
TECHNIQUE OF THE STERILISATION 169
and afterwards to look into the possible causes which
could hinder the penetration of the liquid throughout
the wound. The causes are generally as follows :
ist. The distribution of the liquid in the wound has
not been completely accomplished, by reason of :
(a) slipping or detachment of one of the conducting
tubes ; (&) obliteration of the lumen of a tube by blood-
clot ; (c) kinking in a tube, due to faulty placing ; (d) the
omission to put a conducting tube in some diverticulum
of the wound. Should a tube be placed in a passage too
narrow which it fits tightly, there can be no return flow
of liquid between the wall of the tube and that of the
wound, and, in consequence, no instillation. Careful
examination of the wound will enable us to ascertain
the presence of one or more of these causes of error.
2nd. There is some error in the installation of the
irrigating apparatus. The fault most frequently com-
mitted is that of putting a drop-counting appliance in
communication with several tubes. As the output is
very small, the liquid, obeying the dictates of gravity,
runs down one of the tubes while nothing goes to the
rest. The same thing may happen in intermittent
irrigation, if the calibre of the principal tube or the
inferior orifice of the flask (reservoir) is too narrow. In
this case the outflow is insignificant, and instead of the
liquid being distributed to four or eight tubes, it passes
along only a few of them, and, in consequence, a whole
region of the wound is deprived of liquid. This mistake
will be avoided if the instructions we have already given
on the subject of the relative calibres of the different*
tubes and the installation of the irrigation apparatus be
followed precisely.
TREATMENT OF INFECTED WOUNDS
3rd. The quantity of liquid is insufficient. Inade-
quate instillation is most frequently seen, when, instead
of using irrigating apparatus, a syringe is employed.
As the tubes are multiple, the nurse has to spend much
time in injecting the needed amount with a syringe.
Therefore, whenever this method is in use, the quantity
of antiseptic is frequently found to be insufficient. The
same thing happens in using irrigation apparatus,
when, through negligence, the irrigations are omitted,
or made at too long intervals during the night. Like-
wise when a tube passed into too narrow a track
blocks up its lumen, so that no circulation is estab-
lished (Fig. 65). By carefully examining a wound we
find indications which lead us to suspect the insuffi-
ciency in quantity of liquid. Two symptoms present
themselves in these cases. One is, the pus beginning
to have an unpleasant odour, for a well-irrigated wound
should be perfectly inodorous. The second is absence
of the characteristic changes in the secretions. The dis-
charge from a well-irrigated wound should be thicker
and more transparent than the normal secretion. The
presence of unmodified secretions in a wound permits
one to assert, either that the liquid does not contain the
sufficient amount of hypochlorite, or that the instillation
is not being carried out in the prescribed manner.
B. Excessive Quantity of Liquid. When the liquid
is allowed to flow too long over the surface of a wound,
or in quantity too abundant, the absorbent cotton-
wool of the dressing, and evaporation, are not equal to
the task of getting rid of the excess of fluid. The
bed becomes flooded, the limb bathed in Dakin's solu-
tion, and the skin becomes irritated. An excessive
TECHNIQUE OF THE STERILISATION 171
quantity of liquid has no deleterious action on the
wound, but it worries the patient. He is in an uncom-
fortable plight, and ulceration of the skin, more or less
painful, may be produced. Therefore the nurse must
learn how to regulate the quantity of liquid so that the
a
FIG. 65. Relative dimensions of the orifice of the wound and of the conduct-
ing tube, a, Faulty arrangement. The opening is much too small, the
liquid is under pressure in the limb, and its circulation is impossible.
b, Correct arrangement. The opening is large enough to allow the free
return of the liquid between the wall of the wound and the outside of the
tube.
wounds are sufficiently moistened without the patient
being made damp. With a little attention nurses soon
avoid injecting too much liquid into the wound. Besides^
it is always better to use too much than too little, for
the inconvenient results of too much liquid are not
TREATMENT OF INFECTED WOUNDS
serious and can be remedied easily. By applying care-
fully squares of vaselined gauze (p. 158) to the skin
about the wound, it can be protected completely against
the lesions produced by an excess of liquid.
C. Excessive Pressure. We have noticed already that
an excess of pressure may be due to two quite different
causes a too great elevation of the reservoir of fluid
above the level of the bed, or to smallness of the incision
which hinders a ready reflux of the liquid between the
walls of the wound and the conducting tube (Fig. 65).
Excessive pressure of liquid in the wound brings about
distress. The moment instillation causes a patient pain
it must be discontinued, and the error of technique which
is the cause of the pain must be discovered.
CHAPTER V
THE CLINICAL AND BACTERIOLOGICAL EXAMINA-
TION OF WOUNDS
EVERY infected wound should respond to chemiotherapy,
when this is applied in correct manner. It is necessary,
therefore, that the progress of treatment should be con-
trolled each day by examination of the wound, and that
the technique should be modified according to the results
of this examination. Clinical and bacteriological study
of the wounded patient, and of the wound, is the
indispensable guide in therapeusis.
I. CLINICAL EXAMINATION
The aspect presented by wounds is modified under
the influence of treatment in a manner more or less rapid
according to the nature and age of the lesion. This
evolution varies according to the period of infection
during which sterilisation was commenced.
A. Modifications of the Local Conditions, ist. Fresh
Wounds. Immediately after the infliction of the injury,
blood pours out between the edges of the wound and forms
a clot. Up to the sixth or twelfth hour, there is not, as
a general rule, either swelling of the tissues or secretion
174 TREATMENT OF INFECTED WOUNDS
on the surface. At the same time, we have sometimes
met with wounds only six hours old containing gas and
giving off a putrefactive odour. Towards the twenty-
fourth hour wounds secrete slightly. When instillation
is begun between the sixth and the twelfth hour, the
tissues retain their normal appearance. Muscles remain
red and cellular tissue is not changed. If the tissues
have been severely bruised they necrose, but neither
redness nor swelling is seen at the margin of the wound.
At the end of three or four days the necrosed tissue
becomes of whitish colour and soft consistence. It
begins to become detached in fragments from the
deep parts. Red portions begin to show themselves.
Towards the eighth day following the injury, the
wound is usually clean. The surface is of a bright red.
Secretions are almost nil. The margins of the wound
are not swollen and present no evidence of lymphangitis.
Should signs of inflammation appear, it is certain that
a fault in technique has been committed, either in the
manufacture of the liquid, or the disposition of the
instillation tubes. Towards the tenth day, the entire
surface of the wound is even and red. In the most
irregular portions, and by the lymphatics of vasculo-
nervous bundles, sometimes a few drops of pus may be
seen. The limb has regained its normal size. The
integuments about the wound are supple and not tender
on pressure. The skin is not yet adherent to the deep
parts. That is the reason why, wherever possible,
wounds should be closed before the twelfth day.
The integuments are sometimes modified, after the
lapse of a few days, by the application of Dakin's solu-
tion. They become red and painful. This complication
CLINICAL EXAMINATION 175
may be due to one of several causes. The tincture
of iodine which has already irritated the skin is
generally the cause. But the Dakin's solution may
have been badly made. If Dakin's solution con-
tains too much alkali, it becomes as dangerous as eau
de Javel or Labarraque's liquor. The moment irri-
tation of the skin occurs, the solution should be ex-
amined to see if it fulfils the conditions laid down by
Dakin. It sometimes happens that a solution perfectly
prepared may cause redness in subjects who have an
exceptionally delicate skin, or when the wound occupies
the posterior aspect of the trunk, the pelvis, or the limbs ;
or when the dressings are too tightly applied, or changed
too infrequently. The best way to avoid irritation of
the integuments about a wound is to cover the skin with
squares of gauze sterilised in yellow vaselin. If the
wound is on a limb, it is useful to employ American
suspension apparatus. If the trunk or pelvis be affected,
the patient should be placed bodily upon a Bradford's
frame. Irritation of the skin due to Dakin's solution is
very rare, and is easily distinguished from the lym-
phangitis so frequent in wounds treated aseptically.
Towards the twelfth day, granulations begin to cover
the wound at the same time as the epithelial margin
develops. The skin becomes adherent to the subjacent
parts. The whole surface of the wound is composed of
rose-tinted granulations. Cicatrisation comes about in
a regular manner, without any interval of retrogression,
such as one is accustomed to in wounds treated by the
aseptic method. The cicatrisation curve develops sym-*
metrically, following the algebraic formula of Lecomte
du Nouy.
i/6 TREATMENT OF INFECTED WOUNDS
The secretions of wounds thus treated are not very
abundant, especially when pains have been taken care-
fully to resect contused tissues. At the beginning, the
compresses are covered with a thick greyish secretion,
resulting from the combination of pus and hypochlorite.
Then, little by little, the secretion becomes more sticky,
clearer, and at last, colourless. At this stage, it is probable
that sterilisation has been attained.
2nd. Gangrenous and Phlegmonous Wounds. When
wounds have reached the stage of inflammation by
the time the treatment is commenced, the clinical
modifications which they undergo under the influence
of sterilisation are less rapid. If the liquid can reach
all the infected regions, redness, swelling, and pain
diminish at the end of one or two days. But if the
lesions cannot be reached, even at the price of free
incisions, results of treatment are negative. In a general
way, when tubes have been placed in all the infected
regions, the wound takes on the appearance previously de-
scribed at the end of a few days. When the tubes have
not been able to reach all the infected regions, but when
a great portion of the wound has become sterile under the
influence of the treatment, the septic regions situate be-
yond the reach of the liquid accelerate their spontaneous
disinfection. It would appear that, the volume of infection
being lessened, the organism defends itself more readily.
In all the cases where incisions facilitate the penetra-
tion of the antiseptic into gangrenous foci, gas and odour
are the first to disappear, then the necrosed tissues
dissolve. They are eliminated after the lapse of a few
days, without the margins of the wound presenting any
inflammatory reaction.
CLINICAL EXAMINATION 177
It is important to notice the rapid disappearance of
pain in these cases of infected wounds. As soon as
Dakin's solution has got rid of the infiltration of the
tissues, the dressings cease to be painful. Wounded
men whose wounds are sterile do not suffer.
3rd. Suppurating Wounds. In wounds of long stand-
ing, which are already freely suppurating when the
antiseptic treatment is begun, the earliest sign of the
action of the antiseptic is a characteristic change in
the pus. This takes on a viscous consistency, while its
colour becomes yellowish, transparent. In a few days it
lessens in quantity, then disappears. Granulations change
their aspect and become red and even. If, the technique
being correct, these modifications do not present them-
selves, it is certain that in the depths of the wound there
exists a foreign body.
In wounds of the soft parts, suppuration disappears
completely at the end of two or three days. A little
thick transparent liquid still remains on the surface
of the wound after it has become surgically sterile. In
compound fractures, suppuration continues so long as
the liquid is not introduced into all the cavities where
microbes are found. If suppuration remains stationary,
it is certain that there is a sequestrum, or an infundi-
bulum where the liquid is not penetrating. Without
further delay, the necrosed splinters should be removed,
and the wounds placed under conditions which will allow
the liquid to penetrate everywhere.
B. Modifications of the General Condition. At the
outset of the evolution of fresh shell and bomb wounds,
fever persists for several days. Frequently, beginning at
the third or fourth day, the temperature drops, little by
12
178 TREATMENT OF INFECTED WOUNDS
little ; sometimes, in deep irregular wounds, it may keep
up longer. When the tubes are well placed and the
instillation of the antiseptic is adequate over the whole
surface of the wound, a dissociation or want of relation
between the temperature and the other signs of infec-
tion is produced Often cases are seen with an elevated
temperature, but without the general signs of intoxica-
tion. They eat and sleep in almost normal fashion.
The tongue is pink and moist. They are calm, complain
of no pain, and do not look like sick men. This con-
dition may be attributed to the destruction by the hypo-
chlorite of the substances which produce the general
symptoms of infection, or to a considerable diminution
in the volume of infection. In these cases the infection
manifests itself only in the high temperature.
The persistence of pyrexia amongst cases whose
wounds are in a fair way of sterilisation is due, generally,
to the presence of a small diverticulum where the liquid
is not penetrating. In fresh compound fractures the
wound surface may be protected against the antiseptic
by necrosed tissue, by a compress, or by a blood-clot.
As a consequence, infection develops and persists in the
region which is in this manner withdrawn from the action
of the antiseptic. It may happen also that the tubes
are not placed deep enough, or that the liquid is not
distributed over the whole surface of the wound. Almost
the whole of the wound is sterilised, but at the point not
irrigated infection continues. But, usually, this infection
is too slight to give the patient the appearance of a sick
man. There is a profound difference between the facial
appearance of a patient whose wounds are in a fair way
for sterilisation, even if he still has some fever, and the
CLINICAL EXAMINATION 179
" look " of a man whose wounds, treated aseptically,
are still suppurating. In suppurating cases, even when
the wounds are well drained and the temperature but
slightly raised, frequently the general signs of septic
intoxication are found. These men do not sleep.
Appetite is gone and the tongue is dirty. They are at
the same time agitated and depressed, and they are in
pain. The complexion is leaden. In a word, they are
sick men. Immediately these cases are treated by the
antiseptic method and suppuration begins to lessen, the
general condition changes. After a short time they take
on the appearance of cases whose wounds are sterile.
Very rarely, there are cases in which septicaemia
develops at the same time as the wound is becoming
sterile. We have seen a case die of staphylococcal septi-
caemia, while the fractured thigh from which he suffered
was in excellent condition. Staphylococci had invaded
the circulation before sterilisation had had time to be-
come effectual. But, happily, experience has shown that
septicaemia is exceptional when the cases are suitably
treated.
C. Value of Clinical Observation. Clinical observation
allows one to presume what may be the state of the
wound, but it yields no certainty. In fact, wounds
whose margins present neither oedema nor redness, whose
surface is covered with even granulations and whose
secretion is of the slightest, may still be strongly in-
fected. The following case is an example of this. After
section of the deep femoral by a shell-wound, a free
incision had exposed the sheath of the sciatic nerve,*
which was filled with .blood. After a few days this ex-
tensive wound had an excellent appearance. The man
j 8o TREATMENT OF INFECTED WOUNDS
was in no pain, and had no pyrexia. A little lemon-
coloured serum flowed from the wound. It was collected
in a pipette. But the general appearance of the wound
was so favourable that it was closed with strapping, with-
out waiting for the results of the bacteriological examina-
tion. That evening the case had a temperature of 40 C.
(nearly 104 Fahr.), and the wound had to be taken down.
The surgeon then asked for the bacteriological report,
and learned that the transparent liquid contained chains
of streptococci. Hence in certain cases clinical observa-
tion is absolutely impotent to instruct us as to the real
condition of a wound.
Wounds also are met with, covered with greyish
granulations and with a puriform liquid, which are
aseptic, and which may be sutured with success.
Clinical observation should be looked upon as an
adjunct to the bacteriological examination. Wounds
identical in appearance, from the clinical point of view,
may be in very different microbial conditions. Between
a wound which yields five or six microbes per field
of the microscope, and a wound which contains none,
usually there is no appreciable clinical difference. All
the same, the few microbes which remain on the surface
of the first wound can retard by one-half the rapidity
of its cicatrisation. The presence of these microbes is
important, for it prevents our suturing. Hence the aid
of the laboratory is needed constantly to ascertain the
progress of sterilisation.
BACTERIOLOGICAL EXAMINATION 181
II. BACTERIOLOGICAL EXAMINATION
The object of the bacteriological examination is to
demonstrate the progress of sterilisation and to mark
the moment at which this sterilisation is advanced suffi-
ciently to allow of effectual closing of the wound. It is
necessary that the quantity of microbes contained in the
wound should be known. Since wounds should be
examined every two or three days, and as in most
hospitals there is no bacteriological specialist, the
technique has been made so simple that a large number
of examinations can be made by those possessing little
experience in bacteriology. The secretions of the
wounds are studied by means of " smears." This sum-
mary proceeding allows certain qualitative reports to be
made, but, more important, it allows of an approximate
enumeration of the microbes contained in the secretions.
Thanks to it, the diminution in the numbers of the
microbes can be made known as the treatment pro-
gresses, up to the date of their total disappearance. We
have determined empirically that the disappearance of
microbes from the smears indicates a degree of asepsis
compatible with closure of the wound. In spite of its
crudeness, this method is to be preferred to the usual
procedure of bacteriology. In truth, "smears" show
what the wound contains, while cultures indicate what
may grow under certain conditions. Cultures must be
relied upon if it is desired to learn if a wound is
bacteriologically sterile, or when it is important to know
not only the volume but the nature of the infection.
The culture method may also be used in that stage of
182 TREATMENT OF INFECTED WOUNDS
infection in which smears do not give reliable informa-
tion, that is to say, during the first twelve hours. At
this period, in fact, microbes are in such small numbers,
and so diluted by the blood, that they cannot be seen in
the smears.
A. Technique, ist. Method of taking Specimens of the
Secretions. During the first six or twelve hours secretions
are absent from the wound. The walls bleed more or
less freely, and smears of blood taken from the wound
show no microbes. Specimens should be taken from the
parts of the wound which are not bleeding, in the neigh-
bourhood of, or from the surface of, shreds of clothing or
shell splinters.
Wounds older than twelve hours usually have some
secretion. As the haemorrhage is arrested, secretions
can be taken easily from a region where the secretions
are not diluted by blood. Always the points chosen are
in contact with shreds of clothing or bits of shell, for in
these regions the primary infection is to be found at its
maximum.
The specimen is taken by means of a rigid platinum
wire mounted on the end of a glass rod (Fig. 66).
Should the wound be undergoing continuous instillation,
the treatment must be interrupted for two hours at least,
before the time when the specimen is to be taken, in
order that the secretions may not be diluted by hypo-
chlorite. The tubes are withdrawn and the compresses
removed with the greatest gentleness, in order not to
provoke haemorrhage. The spot from which the speci-
men is to be taken is chosen with minute care. It must
never be taken from a region of the wound which is
bleeding. That region is sought for where there is the
BACTERIOLOGICAL EXAMINATION 183
greatest probability of finding microbes. As the smooth
surface of muscle is very quickly disinfected, for pre-
ference one examines the greyish structures which are
found in the deepest parts of wounds, necrosed points
of fascia, the surface of damaged bone or the culs-de-sac
of irregular wounds, where secretions can accumulate
protected from the antiseptic liquid. It is by means of
FIG. 66. Taking a specimen.
multiple specimens taken from various parts that one
can ascertain the bacteriological condition of a wound.
In surface wounds, it is useful to examine the neigh-
bouring skin. With the aid of a bistoury or a rigid
platinum wire the surface of the skin or the epithelial
border is lightly scraped.
2nd. Preparation of the Slides. The secretions thus
collected are spread out on microscope slides (Fig. 67)*
1 84 TREATMENT OF INFECTED WOUNDS
which are furnished with a label upon which are written
the name of the patient, his number, the character of the
wound, and the region of the wound whence the secretion
was taken. The slides, thus prepared during the course
of a round of visits, are arranged in a box for microscope
specimens, where they dry, and are taken to the
laboratory, where a nurse fixes and stains them.
Each slide is held between the thumb and index-
finger, and passed three times through the flame of a
FIG. 67. Making a " smear."
Bunsen burner, the smear being turned towards the
flame.
Then it is placed on a glass support and receives a
few drops of carbolised thionin. After half a minute,
it is washed with water and put aside to dry.
3rd. Counting the Microbes. The slides thus stained
are arranged upon a table, and the nurse places on each
smear a drop of oil of cedar. The preparations are then
examined with a No. 12 immersion objective and a
No. 3 eyepiece. The number of microbes found in the
BACTERIOLOGICAL EXAMINATION 185
field of the microscope are counted, and the anatomical
elements which are found there are also scrutinised.
This technique gives naturally only crude results, but
they are adequate. In fact, when the number of
microbes per microscope field exceeds fifty or a hundred,
it is useless to count them more precisely. The exami-
nation of the smears has but one object, to indicate the
progress of treatment. Hence it is easy to note that a
secretion, one day containing innumerable microbes, shows
the next day a marked diminution in their number.
Should the number drop below fifty per microscope
field, counting is easier. When it is a question of
closing a wound, half a score fields should be looked
over carefully. When the smears no longer yield
microbes, or only one to five or six fields, then the
surgeon should be notified as to the possibility of suture.
The bacteriological condition of the wound is ex-
pressed by a fraction in which the numerator gives the
number of microbes observed, while the denominator
shows the number of fields examined.
Graphically, the bacteriological state may be repre-
sented on a chart, where time is shown in the abscissae,
and the number of microbes contained in a microscope
field in ordinates (Fig. 68). As it frequently happens
that only a single microbe is seen for two, five, or ten
fields, this is expressed by |-, J, or ^ microbe per field.
Each patient has a chart which informs the surgeon
concerning the condition of the wound day by day.
4th. Causes of Error. Certain mistakes should be
avoided when taking specimens. In the first place,
haemostasis must be absolute at the moment of taking
the specimen. When the secretions are diluted by
1 86 TREATMENT OF INFECTED WOUNDS
blood, microbes can no longer be discerned. It is for
this reason that the " smear " method gives no indica-
tion in the great number of cases as to the state of
infection of fresh wounds. 1
So long as haemorrhage persists, it is useless to make
smears. Again, in examining wounds of longer standing,
FIG. 68. Microbial Chart. In the upright columns are noted the number of
microbes found per microscope field, varying from infinity to i and from
i to TJ\J. A twentieth implies one microbe per twenty fields of the micro-
scope. The upper horizontal column marks the date.
it is necessary to take the specimens at a time when the
secretions are not diluted by hypochlorite, and from
regions where infection still persists. The smooth
surface of muscles is rapidly sterilised, so that specimens
taken in those regions do not give a true idea of the
real state of the wound. Many specimens from different
1 Ignorance of this detail has caused certain surgeons to believe that
fresh wounds are not infected.
PLATE I.
FIG. 74 .
Fracture of the femur in its middle portion by a ball (Case 522). FIG. 69. May 28.
Rod-like bodies in immense numbers. FIG. 70. May 31. The rods have almost
disappeared, and have been replaced by an immense number of cocci. FIG. 71.
June 3. About 30 cocci per microscope field. They are usually in clusters. FIG. 72.
June 7. 10 to 15 cocci per microscope field. FIG. 73. June 13. About 2 microbes
per field. FIG. 74. One coccus to 10 or 20 fields of the microscope. The wound
is aseptic. (The illustrations represent only the central portion of the field of the
microscope.) ^To face page 186.
BACTERIOLOGICAL EXAMINATION 187
regions of the same wound must be taken, to avoid
error.
B. Results of the Examination. The examination of
the wound allows us to estimate, according to the bacterio-
logical condition and the anatomical elements present in
the secretions, the degree of sterilisation of the wound.
By counting every two or three days the microbes con-
tained in secretions taken from different parts of the
wound, and by studying the evolution of the leucocytes,
the progress of sterilisation can be followed.
ist. Modifications of the Bacteriological Condition of
the Wound, (a) Fresh Wounds. Smears from wounds
less than twelve hours old rarely show microbes. They
are only found in the immediate neighbourhood of
shreds of clothing on the surface of crushed muscle, and
are usually rod-like bodies. They are very few in
number, and the microscope field has to be moved
several times to discover one. Occasionally when the
wounds are six or eight hours old, the smears yield
microbes plentifully. If no microbes are seen in the
secretions of a fresh wound, it will not do to conclude
that the wound is sterile, but simply that the microbes
are still few in number and so diluted by blood that they
cannot be seen. Experiment has demonstrated that, in
cases where the smears are negative, cultures made from
fragments of shell or clothing, ctibris of muscle or con-
nective tissue taken from the immediate vicinity of
foreign bodies, give positive results. Almost always,
anaerobic cultures made under these conditions produce
gas. It might be said that every shred of cloth can
determine a gas infection.
At the end of twenty-four or thirty-six hours, the
1 88 TREATMENT OF INFECTED WOUNDS
secretions of the wound often yield microbes (Figs. 69 and
75). The topographical variations of infection are less
marked, and these differences diminish as the secretions
become more abundant. Twenty-four or forty-eight
hours after the commencement of instillation of hypo-
chlorite, the topography of infection and its volume are
FIG. 75. Curve representing the
sterilisation of the wound in case
522. It shows that the microbes
which were in great number on
May 31, diminished and practically
disappeared by June 17.
FIG. 76. Right knee. Wound ex-
ternal. Typical curve of sterilisa-
tion of a wound of the soft parts.
The wound, which contained 40
microbes per microscope field at
the time of the first examination,
was surgically sterile two days later.
modified. The surface of normal muscle only shows
half a score microbes per field, whilst they are beyond
counting on the surface of fractured bone and especially
in the dtbris of necrosed muscular or cellular tissue.
After two, four, or six days, the greater part of the
surface of the wound is sterile, but microbes remain on
irregular bony surfaces, and in deep culs-de-sac which
BACTERIOLOGICAL EXAMINATION 189
have not been reached by the liquid (Figs. 71 and 72).
Fragments of necrosed tissue still contain the same
quantity of microbes. The moment the solution of these
tissues by the hypochlorite is achieved, there is an abrupt
drop in the bacteriological curve, and sterilisation will
then be complete in one or two days.
In wounds of the soft parts, microbes disappear from
FIG. 77. Compound fracture oj tibia. Sterilisation curve of a highly com-
minuted fracture of the tibia. The first smear was negative because
the wound was fresh. The third was equally so because of the presence
of blood. Sterilisation the ninth day.
the secretion, generally, from the third to the tenth or
twelfth day (Fig. 76). In very irregular wounds, and in
those associated with injuries to bone, microbes persist
much longer (Figs. 69-75 and 77). The microbes dis-
appear at first from the muscles, and from normal cellular
tissue, afterwards from the bony surfaces. The last*
places in which they are to be found are on fragments
of necrosed tissue, and more particularly on tendons and
190 TREATMENT OF INFECTED WOUNDS
fasciae. As a general rule, after eight, ten, or twelve
days, the entire surface of the wound is aseptic, except
where there are still necrosed aponeuroses or narrow and
deep tracks. In these cases, instillations of hypochlorite
have not the power to alter the topography of infection.
The aseptic cicatrisation of a wound presenting
a constant source of reinfection, such as the opening of
a sinus unceasingly discharging microbes, can thus be
followed. For example, on the surface of a large wound
of the abdominal wall there opened a narrow sinus leading
down to the fractured ilium.
The surface of the wound was aseptic, whilst the
secretions collected at the mouth of the sinus still con-
tained a great number of microbes. The wound there-
fore showed two quite distinct zones, one aseptic and
the other infected. The instillation was continued for
several weeks. From time to time reinfection came
from the sinus, but it only lasted a few hours, because
the septic part of the surface of the granulations became
almost immediately sterilised by the solution. The in-
fection was thus kept within narrow bounds at the mouth
of the sinus, and the whole of the vast abdominal wound
became cicatrised like an aseptic wound.
An analogous limitation of the infection to a very
small part of the wound has been observed in many
cases. But if, at this period of sterilisation, the instilla-
tions are stopped, total reinfection of the wound takes
place in a day or two. When the cases whose wounds
are almost completely sterilised are transferred to a
hospital where a different method is employed, suppura-
tion appears at the end of from two to three days. It is
therefore necessary to continue the sterilisation until it
BACTERIOLOGICAL EXAMINATION 191
is complete. If, on the surface of a wound almost com-
pletely aseptic, there still persists the mouth of a sinus
leading, either to a bony lesion, or to a fragment of
necrosed tissue containing microbes, or to some infected
foreign body, reinfection always follows without fail
directly the instillation is stopped. On the other hand,
careful instillation of the solution into a wound allows
it to become cicatrised as rapidly as if it were completely
aseptic, even in cases where there exists a region still
containing microbes.
It is equally important to examine the surface of
the skin surrounding the wound. Completely aseptic
wounds may become rein-
fected after the instillation is
stopped, because on the sur-
face of the epithelial border
and the adjoining skin are
many microbes (Fig. 78).
These reinfections of cu-
taneous origin may greatly
retard the progress of cica-
trisation (Figs. 79 and 80).
An examination of the epi-
thelial scales which cover the
skin near the wound, shows
that they are loaded with
c ' i T,, . FIG. 78. Burn. Curve showing a
masses OI microbes. Ihat IS reinfection of cutaneous origin
upon a surface wound previously
aseptic.
the reason why it is essential
to wash with neutral oleate of
soda, not only the surface of the wound, but the whole
of the region adjoining.
In short, examination of the smears of the secretions
192 TREATMENT OF INFECTED WOUNDS
MOISV Decembre1915
60
40
20
10
5
23 24 27 28 29
Janvier1916
2 3 5 10 141821 2226 2829
Fev.
2 3
FIG. 79. Curve showing a prolonged reinfection of cutaneous origin.
V
\
\
\
s
s
\
\
^
\
\
\
s
^
^
\
s
-n
k.
.
19 21 2
3 25 27 29 31 2 4661012*416182022242628301 3 57 9 11 13 15 17 19 21 23 25 27 29 2
FIG. 80. Cicatrisation curve of the preceding wound. It is seen that the
cicatrisation has slowed down considerably from Jan. 14 to Feb. 28, and
that the slowing down coincides with the period of reinfection indicated
by the preceding microbial curve (Fig. 79).
BACTERIOLOGICAL EXAMINATION 193
collected from different parts of the wound, and of the
results of the scrapings of the skin and epithelial margin,
shows, from the time of the instillation of the antiseptic
treatment, profound modifications in the topography
of the infection. Microbes disappear completely from
the greater portion of the wound, but still persist in
the necrosed tissue, upon irregular bony surfaces, and
upon the skin. As soon as the necrosed tissue is
dissolved by the hypochlorite, the microbes which were
in this nidus disappear also. Those on the skin and
osseous surfaces persist longer. It is necessary, there-
fore, before looking upon a wound as aseptic, to examine
those regions which are the last strongholds of infection,
and not to stop the treatment before being quite sure
that microbes have been eliminated from the whole
extent of the wound.
Variations in quantity alone of microbes are to be
considered, because the hypochlorite destroys microbes
without distinction of species. Nevertheless, in the
course of sterilisation, modifications in the aspect of the
microbial flora may be seen. During the first two or
three days, the smears contain rod-like bodies, which
are often bacilli of Welch, and cocci (Fig. 69). Next,
the cocci increase in number, while the rods completely
disappear (Fig. 70). Now on the microscope field are
to be seen nothing but isolated cocci, diplococci, clusters
of staphylococci (Fig. 71), and chains of streptococci.
Under the influence of the antiseptic the number of
microbes diminishes (Figs. 72 and 73), and finally a few
diplococci alone persist for a few days, then disappear
completely.
(b) Suppurating Wounds. In wounds which have
13
194 TREATMENT OF INFECTED WOUNDS
reached the suppuration stage before the treatment was
begun, the topography of infection is nearly uniform.
Specimens taken from different regions indicate every-
where the presence of an almost equal number of
microbes. Every morphological variety is represented.
The microbes are sometimes isolated, sometimes in
clusters, or again within the leucocytes. Sometimes
they are so numerous that they form, under the micro-
scope, an almost continuous layer. At the same time,
the quantity of microbes contained in pus is extremely
variable, according to the treatment which the injury
has received. We have examined secretions from the
wounds of casualties arriving in the Paris hospitals after
having been treated in the field hospitals at the front
by the usual means, such as ether or saline solution.
All these wounds were suppurating, and the numbers
of microbes contained in the secretions were sometimes
so great that any attempt at counting was impossible.
We have also examined wounds in a fair way to suppu-
rate coming from hospitals (ambulances, Fr.) where
sterilisation by means of Dakin's solution had been
practised. As the technique had been imperfectly
carried out, these wounds contained pus, but in this pus
only some fifteen to twenty microbes were found, and
sometimes only three or four per microscope field.
Therefore there are considerable differences in the degree
of infection, and no clinical sign enables one to dis-
tinguish a pus containing a large quantity of microbes
from another sample of pus containing only a small
number.
When a suppurating wound is being sterilised, the
bacteriological curve declines almost immediately, and one
BACTERIOLOGICAL EXAMINATION 195
MOIS
Sepremure
JOURS 21 1251271
oo
60
40
20
10
5
Octobrc
5
15 17
18
19
FIG. 81. Left calf. Suppurating wound of soft parts, highly infected before
arrival at hospital. Slow sterilisation at first, becoming more rapid
towards the 1501 day.
MOISt
bep temure
Oc toure
sJOURS
60
40
20
10
5
\
7 9 13 15 17 19 21 23
9 12 15171923
FIG. 82. Very large, deep, and irregular wound in the posterior part of the
thigh and the left obturator region ; arrival at hospital in full tide of
infection. Almost immediately suppuration disappeared completely.
Diminution in the number of microbes became manifest 17 days after the
commencement of treatment, and the immense wound was quite sterile
and able to be closed 26 days after the entrance of the case into hospital.
196 TREATMENT OF INFECTED WOUNDS
of two phenomena may appear. In the first case the curve
goes lower and lower. At the end of a few days the
microbes disappear entirely, and sterilisation comes to
pass as though a fresh wound were in question (Figs. 81,
82, and 83). The same evolution may be seen in surface
wounds and in certain deep wounds
of the soft parts. But sometimes,
after one or several days of almost
complete sterility, the pus yields
anew a large quantity of microbes
(Fig. 81), which are more often
than not in clusters. These sharp
ascents of the bacteriological curve
are due to the circumstance that
little pockets of pus, isolated from
the principal cavity of the wound,
have become opened and have
scattered their contents over the
newly sterilised walls. These re-
. infections are especially observed
wound on external aspect j n very irregular wounds, and in
. Wounds of the soft J
parts, suppurating and compound fractures. Under the
highly infected. The num- ... -..,.. ,,
ber of microbes was im- influence of instillation, the mi-
mense. Sterilisation was ,, rr ,U~ c m^, r arrain Hicarn^ar frnm
obtained suddenly eight croDes may again disappear
days after the beginning of t h e pus, either temporarily or per-
treatment.
manently.
In the second case, the bacteriological curve drops
under the influence of the antiseptic liquid, then, when
it has reached a certain level, becomes horizontal.
However generous may be the instillations, the microbes
no longer diminish in numbers (Fig. 84). Occasion-
ally in the same patient some wounds become completely
BACTERIOLOGICAL EXAMINATION 197
sterile, whilst others still contain more than fifty
microbes per microscope field. The persistence of
microbes in the secretions of a wound in spite of the
treatment, indicates the presence, in the deeper parts
of the wound, of foreign matter, such as shreds of
clothing, fragments of projectile, a splinter of bone, a
morsel of necrosed tissue ; or perhaps a focus of osteitis
FIG. 84. Deeply infected compound fracture of the tibia becoming sterilised
in a partial manner. The reinfection which occurred from the 23rd to
the 29th decided us to remove a fragment of sphacelated tendon which
had been acting as a foreign body. Sterilisation was obtained in two days.
(Fig. 84). If therefore, after having made sure that the
instillation of fluid has been sufficient and continued,
and that the conducting tubes are correctly placed, it is
noticed that the number of microbes does not lessen, an
exploration of the wound should be made, in order to
remove the foreign bodies, or scrape the bony surfaces
which are keeping up the infection ; and then the
198 TREATMENT OF INFECTED WOUNDS
instillations of Dakin's solution should be continued.
Following upon this interference, the number of microbes
increases greatly. Afterwards the curve drops, the
microbes diminish in number, and may completely dis-
appear (Fig. 84). In short, every time that a wound
does not respond to treatment by a progressive diminu-
tion in the number of microbes, it is necessary, after
having ascertained that the technique of the treatment
has been duly observed, to search for foreign bodies or
bony lesions. If the source of the reinfection cannot
be traced, complete sterilisation becomes impossible.
To resume, in the greater number of wounds, new or
old, the number of microbes diminishes rapidly up to
the time when each microscope field contains from one
to ten. If at this stage, the instillation is practised in
an abundant degree, the secretions will soon show only
one microbe to two, five, or even ten fields of the micro-
scope. When the curve does not go down in this way,
the cause must be looked for and found.
2nd. Characters of the Leucocytes. From the twelfth
hour, the polynuclear leucocytes are seen in more or less
abundance in the wound. During the early days the
secretions are composed especially of polynuclear cells
more or less altered, of a small number of lymphocytes,
and of mononuclear cells. The microbes are free, or
within the phagocytes. So long as they persist in
great numbers in the secretions, the relative proportion
of polynuclear and mononuclear cells changes very
slightly.
In wounds treated by hypochlorite or chloramines,
the free anatomical elements are altered to the same
degree as the microbes. Nevertheless, many polynuclear
BACTERIOLOGICAL EXAMINATION 199
cells enclose microbes which they have devoured before
being themselves killed by the hypochlorite. It is
therefore probable that the normal phenomena of
defence occur as effectually in wounds treated by
hypochlorite as in those treated by saline solution.
In reality, the hypochlorite does not penetrate into the
depths of the tissues. In consequence, in the regions
not touched by the antiseptic, phagocytosis goes on
as usual. In all the regions affected by the hypo-
chlorite, the leucocytes are destroyed, but inasmuch as
the microbes suffer the same fate, no real inconvenience
results. Hypochlorite, having a much more energetic
action than the fluids of the organism or the polynuclear
cells, replaces these agents of defence in their functions.
It is ignorance of these elementary principles which
has inspired certain French writers with a futile respect
for what they call cytophylactic substances.
From the moment when microbes become rare in
the secretions, the anatomical elements change their
nature. Mononuclear cells increase in number. At the
same time we note the appearance of large cells with a
single nucleus and fine filaments. It is the indication
that the wound is almost aseptic. At the same time,
these modifications of the anatomical elements are only
of secondary importance in the study of the progress of
sterilisation. Although the disappearance of the poly-
nuclear cells and the appearance of large mononuclear
cells indicate almost always a marked degree of sterility,
the persistence of a large number of polynuclear cells in
no way implies that the wound is not becoming sterilised.*
In fact we frequently see secretions composed of
extremely numerous altered, polynuclear cells which,
200 TREATMENT OF INFECTED WOUNDS
however, contain no microbes. Therefore, to judge the
condition of a wound, it is necessary, above all, to base
the opinion upon the presence or absence of micro-
organisms.
C. Value of the Method. The method we have just
described permits a large number of wounds to be
examined in a short time. But it is far from being
exact. So we must inquire if the simple counting of
microbes on a smear gives sufficient information of the
bacteriological condition of the wound.
The technique carries with it obvious possible sources
of error. In the first place, the smears are of varying
thickness, according to the nature of the secretions and
the manner in which they are spread out on the surface
of the slide. Next, the counting of microbes contained
in a microscope field is of necessity far from being exact.
If it were a question of finding out precisely the quantity
of microbes contained in any given volume of secretion,
the method would be absolutely inadequate. But we
are not here engaged in scientific research. We desire
nothing more than a clinical indication. In a word, the
surgeon seeks to learn if the quantity of microbes in a
wound under treatment is lessening, and when these
disappear completely.
To appreciate the diminution in the number of
microbes contained in the secretions of a wound, it is
of little moment that mistakes of considerable magnitude
may be made in the counting. Errors of ten per cent,
or even thirty per cent, are of no great importance. If
one day there is found in the pus an uninterrupted mass
of microbes, and the next day only a hundred per
microscope field can be counted, it is evident that their
BACTERIOLOGICAL EXAMINATION 201
number has lessened. It really matters little that there
may have been two hundred or even fifty, instead of
a hundred (Figs. 85 and 86). And in the same way,
if on the following day one counts teni per micro-
scope field, it is of minor im-
portance that an error of twenty-
five per cent, or of fifty per cent,
may have been made, because it
is certain that the volume of in-
fection has diminished. To sum
up, important mistakes in count-
ing do not prevent us from mark-
ing on the bacteriological charts
the progressive lessening of in-
fection, because the variations in
the quantity of microbes under
the influence of treatment are
very considerable (Figs. 85 and
86-88). Besides, experience has
shown that if the examinations FIG. 85. Curve represent-
are made by the same person
under identical conditions, the
results are quite consistent, and
that the evolution of the wound
under treatment can be fol-
lowed with quite sufficient ac-
curacy.
The date of the disappearance of microbes is indicated
with ample precision by the preceding methods. From
the time when the secretions contain only half a score
microbes per microscope field, counting becomes easier
(Figs. 85 and 87). It can be done with still more
ing the sterilisation of the
wound in case 318. Jan.
10, the wound contained
a large number of microbes.
On Jan. 16 only one per
microscope field could be
found, and by Jan. 20
microbes had completely
disappeared from the
smears.
202 TREATMENT OF INFECTED WOUNDS
precision when only one or two microbes per field are
to be found (Fig. 88). If the secretions collected from
the different regions of a wound do not contain more
than one microbe to five or six fields, the wound may be
looked upon as being surgically sterile.
At the same time, clinical signs must not be alto-
gether lost sight of. In reality, a wound whose secre-
tions no longer yield microbes in the smears, may still
be infected. When a wound has suppurated during a
long period before being submitted to chemical sterilisa-
tion, microbes are already encapsuled in the scar-tissue
(englob^ Fr.). The surface of the wound may be sterile,
while microbes remain latent in the deeper parts. In
this case, the clinical history indicates to the surgeon
that the deeper portions of a wound, sterile in appear-
ance, may be infected ; and that in closing such a wound
it is not prudent to make use of deep interstitial sutures,
which of necessity would set up reinfection. In wounds
which have never suppurated, and of which the secre-
tions are sterile, diverticula may have succeeded in
escaping the antiseptic liquid, and may serve as a refuge
for microbes. That is the reason why the temperature
should always be taken. If a man whose wound is to
all appearance sterile has an evening temperature of
37-8 or 37*9 C. (100 or 100-2 Fahr.), it is probable that
a little pocket is cut off from the main cavity and is not
completely disinfected.
The disappearance of microbes from the smears by
no means implies that the wound is really aseptic. It
simply indicates that the degree of sterility compatible
with closure of the wound has been attained. We are
seeking, in fact, surgical asepsis, not bacteriological
PLATE II.
Very large wound of the posterior region of the leg (Case 318). FIG. 86.
Jan. 10. More than 100 microbes per microscope field. FIG. 87. Jan. 12.
About 10 microbes per field. FIG. 88. Scarcely one per field. (The
illustrations represent only the central part of the field of the microscope. )
[To face 1>age 202.
BACTERIOLOGICAL EXAMINATION 203
asepsis. 1 In the majority of cases, the secretions of
wounds whose smears no longer yield a microbe still
give positive cultures. Certain writers for example,
Policard 2 even believe that chemical sterilisation never
achieves absolute asepsis of a wound.
Another bacteriologist, M. Tissier, 3 considered that
the absolute asepsis of war-wounds was impossible of
achievement, even after protracted treatment. This
conclusion merely shows that the technique employed
in the cases under M. Tissier's observation was in-
sufficient. By means of suitable technical methods,
indeed, the surface of a wound can be rendered so aseptic
that cultures from its secretions remain sterile. M.
Vincent, 4 in the Compiegne laboratories, carefully ex-
amined a certain number of wounds. He found that in
six out of nineteen injuries treated by the usual technical
methods by MM. Guillot and Woimant, bacteriological
asepsis had been obtained. In short, 30 per cent, of the
wounds treated without special attention in the wards
of the Compiegne hospital were aseptic. The proportion
of bacteriologically aseptic wounds might have been
increased by a more meticulous treatment. Whatever
the nature of the infection, the wounds became sterile.
Those infected by streptococci were sterilised less rapidly
than the rest, but they too became aseptic. We do not
seek to obtain bacteriological asepsis, 5 for this is un-
necessary, experience having shown that surgical asepsis,
Pozzi, Bulletin de F Academic de Medecine> meeting Jan. n, 1916.
Policard, loc. cit,
Debeyre and Tissier, C. R. Societe de Chirurgit, March 20, 1917.
Vincent, Journal of Experimental Medicine^ 1917.
Pozzi, Bulletin de ? Academic de Medecine, Jan. II, 1916.
204 TREATMENT OF INFECTED WOUNDS
revealed by the disappearance of microbes from the
smears, is sufficient in practice.
However, by the aid of a precise technique, the
surface of a wound can be rendered so aseptic that
cultures from its secretions remain sterile. But this
degree of asepsis is of no practical interest.
Finally, bacteriological examination in the simplified
form we have just described, should be looked upon as
an indispensable part of the method of wound sterilisa-
tion, because it allows the progress of treatment to be
followed step by step, and indicates that it should be
modified if the number of microbes does not steadily
lessen. Alone, it can point out the moment when a
wound may be closed. Indeed, a wound should never
be sutured if one is ignorant of what it contains.
Despite its lack of scientific precision, the study of
smears gives to the surgeon clinical information which
is indispensable for the direction of treatment.
CHAPTER VI
THE CLOSURE OF WOUNDS
THE corollary to the sterilisation of a wound is its
closure. But a wound should never be closed without
knowing what it contains. Suture of a wound enclosing
microbes may be followed by downright disaster. It is
therefore only after having carefully looked into the
bacteriological condition of a wound that one may bring
its edges together by strapping or suture.
I. THE TIME FOR CLOSURE
Closure of a wound is practised as soon as we know
that it no longer contains microbes. Therefore primary
closure should be rejected. Even after precise mechani-
cal cleaning of the wound, and resection of every portion
which has been affected by the projectile, still it is
impossible to make sure that microbes have not been
left on the surface of the tissues. So far as that goes,
the negative aspect of smears made with the liquids or
tissue taken from a fresh wound has no value whatever.
A highly infected wound, at this stage, may not show a
bacterium upon the slide. Only cultures made by means
of tissues carefully collected from numerous points in
the wound can give an idea of its bacteriological
205
206 TREATMENT OF INFECTED WOUNDS
condition. But to have the report of cultures it is
necessary to wait twenty-four or forty-eight hours.
Consequently it becomes impossible to practise primary
union of a wound if we insist first upon knowing its
bacteriological condition.
A. Primary Closure of Wounds. At the beginning of
the war primary union was employed, and given up
because of the disasters it provoked. Nearly all the
cases of septicaemia we have seen were due to im-
mediate suturing performed in clearing-stations or hos-
pitals where its danger was not yet realised. We know
that for some months primary suture has again become
the fashion in the French Army, and that it has been
applied in a great number of cases. It is the fact that
the surgeon is often favoured by chance, and that he
closes wounds which are only slightly infected, and unite
by first intention. But this is not always the case. M.
Tuffier reported to the Socittt de Chirurgie certain series
of cases which revealed 33 per cent, of failures. Over
and over again has gaseous septicaemia or streptococcic
septicaemia resulted in the death of the patient who
has undergone primary suture. The complete statistics
have not been published, and only favourable series of
cases have been made the subject of communications to
the Societe de Chirurgie. A batch of cases is regarded
as favourable if only I or 2 per cent, of the wounded die,
and only one or two amputations are performed. But
if we consider that sutures are employed in the case of
wounds of the soft parts where the extensive opening
and the chemical sterilisation are a sure safeguard
against death or amputation, it must be admitted that
these results are not satisfactory. As a matter of fact,
THE CLOSURE OF WOUNDS 207
one has no right to make a single patient run an un-
necessary risk. And this risk is real, for out of a hundred
wounded 'men subjected to primary suture, one or two
men have often been killed who would not have died
if their wounds had been left open. Only when an ex-
perienced surgeon can watch over his patients incessantly,
and when there is no danger that the latter may be
hastily evacuated, is it permissible to practise the pri-
mary suture of the soft parts. This is an exceptional
procedure, to be reserved for certain surgical specialists
under certain conditions. One of these conditions is a
small number of wounded men in the sector in which
the surgeon operates. In periods of activity and rapid
evacuation this procedure must be completely abandoned.
Generally speaking, the primary closing of wounds must
be rejected so long as we have no method which will
enable us to ascertain whether they are or are not sterile.
B. Secondary Closure of Wounds. Secondary closure,
on the contrary, can be effected under such conditions
that it presents no danger. The examination of smears
of the secretions of a wound aged twenty-four hours or
more enables the volume of infection to be estimated.
When the number of microbes has diminished progres-
sively, when it has become zero, and this condition is
maintained for two or three days, then we may be sure
that an adequate degree of asepsis has been reached,
and that the wound may be sutured. At the same time,
we must not lose sight of other clinical signs, especially
the patient's temperature and the condition of the limb.
When the indications furnished by both clinical aspect
and smears coincide, then one may suture the wound
with a feeling of entire security*
208 TREATMENT OF INFECTED WOUNDS
1. A wound of the soft parts whose sterilisation has
been initiated a few hours after infliction, and which has
never suppurated, may be closed as soon as two consecu-
tive examinations, made after an interval of one or two
days, have shown that the smears do not contain more
than one microbe to four or five microscope fields. If the
wound be deep, and especially if it be associated with
fracture, above all, a compound fracture of the thigh, it
is preferable to repeat the examinations and to wait,
before closing the wound, until it has been surgically
sterile for four or five days.
2. The time for the closure of wounds, the sterilisa-
tion of which has been commenced after a more or less
protracted period of suppuration, must be more carefully
determined. And so far as that goes, experience has
taught us that the secretions of a suppurating wound,
above all when it is deep and accompanied by fracture,
may become for a little while sterile, although the
wound is not actually sterile. One day the pus is to all
appearances aseptic, and the next day are found indubit-
able heaps of microbes accumulated on certain points of
the smear. In these wounds, which have suppurated for
a long time before the commencement of the antiseptic
treatment, one should find the secretions sterile for a
week at least before deciding to suture.
C. Average Period of Closure. Generally speaking,
the average moment for wound closure occurs between
the eighth and the twelfth day. Some wounds may be
united towards the fifth or sixth day, others after the
twelfth. Certain compound fractures should not be
closed before the twentieth or thirtieth day of treat-
ment. It is well to practise the closing of wounds at as
THE CLOSURE OF WOUNDS 209
early a period as possible. As a matter of faot, wounds
closed before the eighth day contain no cicatricial tissue,
and healing is effected without a legacy of functional
troubles. The closure of wounds at an early period also
results in considerable saving, both in the cost of treat-
ment and in the work of the staff of the hospital. In
a word, as soon as a wound becomes sterile, it should be
closed.
II. TECHNIQUE OF WOUND-CLOSING
Wounds are closed by strapping, by elastic bands, or
sutures.
A. Wound-closing by Means of Strapping. Co-aptation
of the margins of the wound by means of bands of
adhesive plaster may be carried out so long as spon-
taneous cicatrisation has not commenced and the skin
moves easily over the deeper parts. It causes no pain
to the patient and demands neither local nor general
anesthesia. Strapping of American make and good
quality is used, four or five centimetres wide, twenty to
twenty-five centimetres long. The strips must be long
enough to get a firm grip on the skin. As it is not
sterile, we must carefully avoid bringing the surface of
the strapping into actual contact with the raw surface
of a wound, and the line of union is protected by a slip
of paper, or of celluloid, sterilised.
The skin adjoining the wound is shaved, thoroughly
dried, then the lips of the wound are brought together
and maintained exactly in correct position by several*
bands of strapping .applied perpendicularly to the
direction of the wound (Fig. 89). At the end of a
2io TREATMENT OF INFECTED WOUNDS
week the strapping is removed, and the wound found
to be united.
B. Wound-closing by Elastic Traction. When ex-
FIG. 89. Bringing together the lips of a wound by means of strips of
adhesive plaster.
tensive loss of substance exists and the lips of the wound
cannot be brought into apposition, recourse is had to
elastic traction. This method is also used for covering
stumps.
FiG. 90. Bringing together the lips of a wound by means of elastic traction.
The bringing together of the edges of a wound by
elastic traction is carried out in the following manner.
Strips of adhesive plaster seven or eight centimetres
THE CLOSURE OF WOUNDS 211
wide (about three inches), and exceeding in length by
ten centimetres (four inches) the length of the wound,
are provided on one edge with boot-lace hooks, by
means of the punch in use by shoemakers. On either
side of the wound and parallel to it, a piece of strapping
bearing the boot-lace hooks is made to adhere firmly to
the skin (Fig. 90). The hooks of the two strips are
brought towards each other by means of a lacing of
strong rubber, the tension of which is regulated to a
suitable degree.
The margins of the wound are brought together pro-
gressively under the influence of the elasticity of the
rubber. When there has been no loss of cutaneous sub-
stance, or when the loss is but slight, the raw surface may
be covered in forty-eight hours. When the loss of sub-
stance is more considerable, still this procedure allows
of the area of the wound being diminished to a very
large extent.
A similar method is used to unite the edges of flaps
on stumps. It is admitted that, amputations being
nearly always practised on an infected limb, the stump
cannot be sutured. To check the retraction of the soft
parts of stumps left open, we may make use of the
method established long ago by American surgeons,
that is to say, continuous traction on the skin. Two
strips of adhesive plaster of suitable dimensions are
applied at opposed points on the surface of the limb,
and meet on a small piece of wood l to which traction
cords are attached. A weight of about a kilogram
and a half (about 3 Ibs. English) is sufficient to oppose
the retraction of the soft parts. This traction in no
1 " Stirrup-piece " ( Trans.).
212 TREATMENT OF INFECTED WOUNDS
way interferes with the dressing of the wound. When
sterilisation is complete it is easy to suture the flaps
which are now in the same position as though the
amputation had just been performed.
C. Wound-closing by Suture. Secondary suture of
wounds should always be done under anaesthesia. If
the skin is adherent to the deeper parts, it must be dis-
sected up to a sufficient extent. To refresh the edges
it is enough to remove the epithelial margin by an
incision in the healthy skin a millimetre beyond its
external border. The simple excision of the epithelial
margin will suffice. There is no need to curette the
granulating surface. The integuments are dissected up
for a distance sufficient to ensure good adjustment of
the edges. Usually, the deep parts come together
spontaneously. In cases where it may be of service,
deep suturing may be practised, especially sutures of
aponeuroses. The closure is usually done without
drainage, because the bacteriological examination has
demonstrated that microbes are no longer existent in
the wound.
D. Suture of Muscles and Nerves. Suturing of
muscles and tendons is carried out as early as possible,
in order to avoid retraction. It is the same with nerve
suture. Directly the wound is sterile, the operative
conditions become the same as in aseptic surgery.
E. Closure of Wounds of Compound Fractures or Joint-
Injuries. In the majority of cases it is possible to close
a compound fracture or a wounded joint in the same
way as a wound of the soft parts. Even in bad smashes
of the limbs, if the closing follows the traumatism by
a few days, the osteoperiosteal sac which bounds the
THE CLOSURE OF WOUNDS 213
seat of the fracture has supple walls, which a compres-
sive dressing will so far bring together as to efface the
cavity. In these cases suture may be practised without
troubling as to the loss of bony substance. However,
in certain fresh epiphyseal fractures, and in the majority
of old fractures, the osseous cavity has rigid walls, so
that it is necessary to fill it up. We have obtained good
results with Mosetig's and Beck's pastes (la masse de
Mosetig et la pdte de Beck, Fr.). But better results have
been observed by MM. Guillot and Woimant as a result
of the employment of adipose grafts, the success of
which is almost invariable. The inert substances which
are used for filling cavities offer this disadvantage
they necessitate a musculo-aponeurotic wall to isolate
them from the cutaneous sutures. They have to be
worked up and softened by heat ; and they yield prac-
tically 50 per cent, of failures. Adipose grafts, on the
other hand, may be closed in under a simple cutaneous
suture. They may, in the event of an extensive abrasion
of the soft parts, form part of a cutaneous strip pressed
into service from the neighbouring parts. Lastly, the
surgeon can always find them ready to hand on the
person of the patient himself.
Wounds of joints are closed in the same way. Should
one of the bony extremities contain a large cavity, it is
filled up in the manner we have just pointed out, before
proceeding to the closure of the articulation already
indicated.
214 TREATMENT OF INFECTED WOUNDS
III. THE USE OF DIFFERENT METHODS ACCORDING
TO WOUND CONDITIONS
The preceding methods are chosen according to the
particular conditions presented by the wounds it is
desired to close. These wounds may be divided into
different categories according to age and the presence or
absence of previous suppuration.
ist. Closure of Fresh Wounds which have become
Sterile before the Twelfth Day. Wounds of the soft
parts may be closed in the majority of cases that is to
say, in nearly ninety per cent, of the cases before the
twelfth day. As, at this period, the skin is movable
on the deeper structures, bringing together of the
margins of the wound by strapping is habitually prac-
tised. Even when the wound is deep and irregular and
a fracture is present, the operation is not painful and
needs no anaesthetic. Multiple wounds on the same
patient may be closed one after another as they become
sterile. If the skin has been irritated by tincture of
iodine, or the wounds are too close together to allow
of the strapping method being applied, we have recourse
to suture, and if there is loss of substance, to elastic
traction. The method of suture is also employed in
fresh wounds, when one has to unite tendons, muscles,
or nerves. As anaesthesia is necessary for suture of
nerves, tendons, or muscles, the operation is terminated
by cutaneous suture. With the exception of these cases,
we always use the strapping method, which has the
merit of bringing together the deep parts of wounds as
well as the superficial portions.
2nd. Closure of Fresh Wounds which have become
Sterile after the Twelfth Day. When the sterilisation
THE CLOSURE OF WOUNDS 215
of the wound has only been achieved after the twelfth
day, it is no longer possible to use the strapping method.
Suture is then practised. As the wound has been sub-
jected from the outset to antiseptic treatment, and it is
probable that the cicatricial tissue contains no microbes,
catgut stitches may be put in without danger of reinfec-
tion. In wounds which have remained open longer,
careful bringing together of the deeper parts is carried
out. It is not sufficient merely to approximate the skin.
3rd. Closure of Wounds which have become Sterile
after a Period of Suppuration. When it has not been
possible to apply the treatment from the beginning, and
the wound has suppurated for a longer or shorter period,
the process of closure must be a little different. In these
cases, in fact, numerous microbes have been shut up
within the cicatricial tissue. Smears show that the
surface of the wound is sterile, but they yield no indica-
tion as to the state of the deep parts which are already
cicatrised. It is therefore important to bring the tissues
together without injuring them, that is to say, without
making a deep dissection, and without interstitial
sutures. The scalpel or the needle, when traversing a
cicatrix which contains microbes, may start reinfection.
We must, therefore, be content with bringing together
the deep parts by external means, and only suture
skin. Also, one may operate in two stages. In the
first stage, dissect up the tissues, prepare the wound
for closure, loosely insert sutures ; then for a few days
continue the sterilisation of the wound. In the second*
stage, close the wound. By taking these precautions,
a result may be obtained as favourable as in the union
of wounds which have never suppurated.
CHAPTER VII
THE RESULTS
THE method should only be credited with the results
obtained by application in its entirety. If the details of
the technique or the composition of the antiseptic be
modified at hazard, sterilisation of wounds becomes
impossible. The observations made by surgeons who
have used Dakin's solution without a precise technique
should therefore be looked upon as valueless.
I. RESULTS OF THE STERILISATION OF WOUNDS
Sterilisation of a wound comes to pass in a different
manner according as it is recent or old-standing and is
associated or not with fracture.
A. Wounds of the Soft Parts. From the month of
December, 1915, the date when the technique was
first employed under its actual form as at present, all
wounds of the soft parts have attained surgical asepsis.
They were subjected to secondary suture, with the
exception of those which were very small and healed
spontaneously, and those which were accompanied by
so great a loss of substance that they could not be
closed. Wounds, fresh, phlegmonous, gangrenous, sup-
purating, all were equally capable of disinfection, but
216
PLATE III
FIG. 91. Case 465. Section of quadriceps, 3rddny.
FIG. 93. Case 606. Large wound of forearm.
FlG. 95. Case 577. Wound of knee, 5th day.
[To face ixi^c 217.
PLATE IV.
FlG. 92. Case 465. Suture, yth day.
FIG. 94. Case 606. Wound closed, 6th day.
FIG. 96. Case 577. Suture, i4th day.
[To face Plate III.
THE RESULTS 217
the rapidity of the sterilisation depended in a certain
measure on the state of the infection.
ist. Fresh Wounds. When the treatment of wounds
was commenced from five to twenty-four hours after the
injury, sterilisation was rapidly produced. Generally
microbes disappeared from the fifth to the twelfth day if
the wounds contained no gangrenous tissue. The fol-
lowing, which have been chosen from amongst many
similar reports, show with what rapidity a large wound
can be disinfected and sutured.
Case 465 suffered from a large shell-wound traversing
the anterior aspect of the thigh and almost completely
dividing the quadriceps femoris. Three and a half
hours after the receipt of the injury, the wound was
laid open and foreign bodies and torn muscular tissue
removed. An extensive wound resulted, more than 10
centimetres long and extending from one side of the
thigh to the other (Figs. 91 and 92). At the end of
seven days, the wound was surgically sterile, Then
careful suture by catgut of the quadriceps was carried
out and the skin closed (Fig. 92). It healed by
first intention, and shortly afterwards the patient walked
normally.
Case 315 was operated upon twenty-three hours after
having received multiple shell-wounds, of which two were
deep in the buttock. The most extensive of the wounds
measured after cleaning-up 18 centimetres long, 9 centi-
metres wide, and 8 centimetres deep. Sterilisation of
this wound was slightly retarded by the presence of^
gangrenous tissue, which was found near the cutaneous
margin of the wound. However, after five days, the
wound became surgically sterile, and was closed with
218 TREATMENT OF INFECTED WOUNDS
adhesive plaster. Nine days later, the strapping was
removed and the wound found to be healed.
Case 606: a shell-wound penetrated the forearm,
went through the epitrochlear muscles and divided the
radial (Fig. 93). The wound was closed the sixth day
(Fig. 94).
In wounds of the soft parts, sterilisation is almost
always rapidly achieved. Out of 1 36 wounds closed during
the period December, 1915, and the commencement of
January, 1916 121 were closed before the twelfth day.
When the cases were operated upon during the first
six or twelve hours, closure was practised still earlier.
If the tissues have been severely torn by the projectile,
and have become gangrenous over a large area, sterili-
sation is attained more slowly. In case 577 two shell-
wounds had lacerated and detached all the tissues of
the front of the knee, without fracture of the patella
(Fig. 95). The projectiles having been removed from
the articulation, the wound could be closed the fourteenth
day (Fig. 96). In wounds sterile over almost the
whole extent of their surface, microbes often persist
near the aponeuroses and necrosed tendons, and pre-
vent closure being carried out. This slow elimination
of shreds of necrosed tissue was the commonest cause
of delay in sterilisation of wounds of the soft parts.
That is the reason why thorough surgical cleansing of
the wound is so important. In cases where necrosed
tissue had remained for a long period on the surface
of the wound, suture was practised, as a rule, from
the fifteenth to the twentieth day.
2nd. Phlegmonous and Gangrenous Wounds. Cases
arriving later at the hospital, with wounds already bearing
THE RESULTS 219
evidence of phlegmon or gangrene, were treated in a
similar manner. After the disappearance of serious
infection, many injuries could be sutured.
Case 340, with multiple shell-wounds, was operated
upon after nineteen hours. Wounds of the thighs and
legs were freely laid open, shell -fragments removed and
instillation tubes placed in the tracks. Three of the
wounds developed along normal lines and were closed
on the ninth day. The fourth, situate at the inferior ex-
tremity of the right thigh, suffered a grave complication.
The projectile had opened a vein in the popliteal space,
and caused a haemorrhagic infiltration of the whole of the
cellular tissue of the calf. This haematoma had remained
undetected at the time of operation. But, after twenty-
four hours, the temperature reached 40 C. (103-5 Fahr.).
The calf and the popliteal space were purple, and very
painful. The inflamed region was then incised from the
popliteal space to the lower third of the leg (Fig.
97). At the end of eleven days, the great wound had
become sterile, and the temperature came down from
40 to 37 C. (103-5 to 98-5 Fahr.). Next, along the
margins of the wound elastic traction was applied, for
the tissues were too far retracted to allow of immediate
union. Under the influence of elastic traction, the
margins of the wound steadily approached each other,
and united three days later, that is to say, twenty-
one days after the infliction of the injury (Fig. 98).
Sterilisation came about more slowly than in an ordinary
wound. However, it should be looked upon as rapid, *
taking into consideration the gravity and extent of the
infection.
Similar results were observed in cases of gangrenous
220 TREATMENT OF INFECTED WOUNDS
infection. Case 454 presented fourteen wounds of the
lower limbs, due to the explosion of a grenade. He was
operated on six hours after the injury. All fragments
of missile were removed, and each wound was furnished
with an instillation tube, with the sole exception of a
tiny one which was overlooked. The thirteen wounds
treated antiseptically developed in normal fashion and
were rapidly closed. But the wound which had not been
treated was followed by a serious infective complication.
This wound was on the external aspect of the right leg.
The fragment of grenade was found at a depth of two
centimetres in the long peroneal muscle. The track had
been carefully exposed and excised, but no instillation
tube had been inserted. Next morning, the dressing
had an unpleasant odour, and the calf was red, tense,
and swollen. Gas escaped from the orifice. A free
incision was made on the external aspect, and it was
found that the muscles of the front of the leg, as well as
the lateral peronei, had been attacked by gas-producing
gangrene throughout almost the whole of their extent.
Infection had clearly started from the non-irrigated point.
Instillation tubes were placed in the wound, which rapidly
cleaned up. At the end of six days, the temperature of
the case was normal, and the necrosed tissues in a fair
way towards elimination. After a second period of six
days, the wound was clean and red. Some microbes
only remained near the extensor tendons. Twenty-eight
days after the injury, the wound was completely closed.
The thirteen other wounds had been able to be sutured
the twelfth day. Hence in spite of the serious character
of the infection, sterilisation only demanded a little more
than double the normal time.
PLATE V.
r s/.^
FIG. 97. Case 340. Large infected wound of calf, nth day.
FIG. 99. Case 433. Fracture of neck of humcrus, i5th day.
FIG. 101. Case 594. Shell-wound of knee : partial fracture of
condyle, 6th day.
\To face page ya\.
PLATE VI.
FIG. 98. Case 3-jo. Same wound, the 2ist day,
FIG. 100. Case 433. Suture, zyth day.
FIG. 102. Case 594. Wound became sterile the i6th day and
was closed the 2oth.
[ To face Plate V.
THE RESULTS 221
3rd. Suppurating Wounds. Wounds which are already
suppurating when brought under treatment are readily
disinfected. Surface wounds, even when suppuration is
abundant, are sterilised in a few days. Usually, when
a granulating wound is washed with neutral oleate of
soda, and treated either with hypochlorite or chloramine
paste, microbes disappear completely from the smears in
two or three days.
It is the same with abscess cavities. When a tube
is placed in the cavity of an abscess, and the liquid can
reach every portion of the surface of the walls, sterilisa-
tion takes place with great rapidity. Then, by a com-
pression dressing, the walls can be brought together and
the cavity obliterated in a very short time. When the
wound is deep and irregular, and contains necrotic
tissue, sterilisation is attained more slowly. In a series
of fifty-nine wounds, aged from one to twenty-three days
at the commencement of treatment, ninety- two per cent,
were closed before the twenty-second day. Some of
these wounds were sutured the fifth day, as though they
had been fresh wounds. The remaining wounds that
is to say, eight per cent. were sterilised after the
twenty-second day.
We may therefore say that all wounds of soft parts
respond to treatment by becoming sterile. About ninety
per cent, of both fresh and suppurating wounds were
closed before the twentieth day. The rest were dis-
infected at a slower rate, but all attained surgical asepsis.
B. Compound Fractures. Results varied according as
treatment was commenced before or after the suppuration
stage.
i st. Fresh Fractures. Experience has taught us that
222 TREATMENT OF INFECTED WOUNDS
from the point of view of results, fractures should be
divided into two classes : in one class, short bones, the
smaller long bones, flat bones, radius, ulna and fibula ;
in the other class, fractures of humerus, tibia and femur.
Since the month of December, 1915, we have suc-
ceeded in sterilising, in a satisfactory manner from the
surgical point of view, all compound fractures of the
smaller long bones, short bones and flat bones which
arrived at the hospital from five to twenty-four hours
after the infliction of the injury, with the exception of
fractures of the jaw communicating with the mouth. In
the greater number of the cases, fractures of metacarpus
and metatarsus, deep wounds of ankle or wrist with
laying open of several articulations, have been closed.
Fractures of the patella have yielded similar results.
We may conclude that these fractures from the sterili-
sation point of view behave like wounds of the soft
parts.
In the majority of cases, sterilisation of fractures of
the humerus, tibia and femur has been obtained.
(a) Fractures of the humerus consolidated without
its being necessary to make an extensive resection. The
possibility of sterilising the seat of fracture allowed the
preservation of splinters of orthopaedic value. The
greater number of fractures of the humerus, whether
implicating or not the articular surfaces, have been able
to be sterilised and quickly closed. In highly com-
minuted fractures, bone fragments which were entirely
free were removed, and after sterilisation of the seat of
fracture, replaced by Beck's paste. Here is an example
of this form of treatment.
Case 321 came to hospital four hours after having
THE RESULTS
223
received a shell-wound in the right arm. He presented
an extremely comminuted fracture of the superior
extremity of the humerus directly below the head. The
superior orifice was laid open freely and cleansed care-
fully. A counter-opening on the anterior surface of the
arm was made, to remove the projectile, and to take
away a large number of small fragments of bone which
were lying free. The medullary canal had to be curetted
because several splinters had been projected therein.
There resulted an extensive loss of substance ; three
instillation tubes were introduced. After twelve days
the patient's temperature was normal, and the surface
of the wound no longer yielded microbes to the test.
On the fifteenth day the loss of bony substance was
made good by Beck's paste, and the wound was closed
by a series of intermuscular sutures, and a line of
cutaneous stitches (Fig. 103). The twenty-first day
stitches were removed. Union was perfect. The man
recovered all the movements of the limb.
In non-comminuted fractures of the humerus, suturing
was generally done from the tenth to the fifteenth day,
and consolidation was brought about as rapidly as in a
simple fracture.
(b) In fractures of the tibia, surgical asepsis was
attained in a more leisurely fashion. Besides, the loss
of integumental substance was often too great to allow
of the margins of the wound being brought together.
Then we had to be content with sterilising the seat of
fracture and awaiting closure by granulation.
In this manner consolidation without a sinus of highly
comminuted fractures may be obtained. Case 494 was
injured in the middle third of the leg by a shell which
224 TREATMENT OF INFECTED WOUNDS
fractured the tibia. In the course of the first surgical
interference by MM. Hornus and Perrin, only the
smallest of the free bony splinters were removed, the
larger fragments being left lying between the osseous
extremities. For nine days, Dakin's solution was
instilled every two hours. When the case was brought
to the hospital, ten days after receipt of the injury, there
FIG. 103. Fracture of humerus, fill-
ing-in with Beck's paste. Case 321.
FIG. 104. Fracture of
tibia. Case 494.
were still ten microbes per microscope-field, but the
wound bore an excellent appearance, and the tissues
presented neither redness nor swelling. The only opera-
tive interference was to blunt the point of a splinter
which projected into the wound. A month after the
injury, all the bony fragments had been covered by
granulations, and the instillation tubes were discontinued.
By reason of the extensive loss of skin substance
THE RESULTS
225
cicatrisation came about slowly, but two months after
the injury, healing was complete without a sinus
(Fig. 105).
The conservation of fragments of bone is of great
importance from the point of view of ulterior function
of the limb. In sterilising splinters more or less denuded,
FlG. 105. Same frac-
ture , healed. Case
494-
FlG. 106. Suppurating frac-
ture of the upper part of
the tibia. Case 516.
we succeeded in making use of them, and in obtaining
consolidation of the bone. In case 516, a shell had
caused a serious fracture of the tibia, at the level of the
junction of epiphysis and diaphysis. The internal two-
thirds of the bone had been destroyed, while the external
portion presented two long splinters almost completely
denuded of periosteum. They were kept, nevertheless,
IS
226 TREATMENT OF INFECTED WOUNDS
because their ablation would have shortened the bone by
seven or eight centimetres (Fig. 106) : the anterior tibial
nerve and vessels had been severed. The wound rapidly
sterilised, but by reason of loss of substance it was
impossible to close it. Seventeen days after the injury,
there was to be seen at the upper part of the tibia a
large wound, at the bottom of which was a bony cavity
the size of a small egg. This wound no longer contained
microbes. It was then filled with a paste containing
chloramine, under which asepsis was maintained. Im-
mediately it was filled up by granulations, whose surface
became covered with epidermis. Cicatrisation was com-
plete three months after the infliction of the injury.
The fracture was almost completely consolidated, with-
out either reinfection or elimination of sequestra being
produced.
In some cases it is possible to close fractures of the
leg. In case 627 the fracture of the tibia above the
malleoli was found to be sterile ten days after the inflic-
tion of the injury (Fig. 107). The eleventh day it was
completely closed, and on the sixteenth day the wound
had healed by first intention.
(c) Even highly comminuted fractures of the thigh
are sterilised in such a manner that in about half the
cases suture can be practised. The degree of asepsis
obtained in the non- sutured cases was sufficient to allow
the seat of fracture to be isolated from the external
wounds. Consolidation was produced almost as if a
simple fracture had been in question. In none of the
cases which reached us during the first twenty- four
hours did a sinus persist. Infected fractures of the
femur could be closed the I5th, 23rd, and the 2 5th day.
THE RESULTS
227
Case 560, aged 42 years, arrived at the hospital
seven hours after having been struck by a shot which
produced an extremely comminuted fracture of the left
thigh. The diaphysis of the femur had been broken at
the level of its middle third into multiple fragments
(Fig. 1 08). The orifice of entry of the missile, which was
FIG. "107. Fracture of the tibia.
Case 627.
FIG. 108. Fracture of the femur. Case
56o.
internal, was very freely laid open, the contused muscular
tissue was excised, and only two small splinters, which
happened to be completely free, were removed. Four
instillation tubes were placed in the seat of fracture. ,
The temperature never rose above 38 C. (100 Fahr.)
during the first four days, then steadily dropped and
became normal. The number of microbes, which the
228 TREATMENT OF INFECTED WOUNDS
second day was 30 per microscope field, diminished to
one the I3th day. The I5th day the wound was herme-
tically sealed by silkworm gut (crins de Florence, Fr.).
Union took place by first intention. The fracture was
firm on the 4/th day.
Another case, No. 495, aged 29 years, had received a
wound from the explosion of a mine which fractured
the right femur at the junction of the lower with the
middle third. Some hours afterwards at the V - field-
hospital, MM. Hornus and Perrin removed some frag-
ments and the foreign body, cleaned up the contused
muscles, and placed conducting tubes for antiseptic
liquid in the seat of fracture. The 23rd day,
microbes having disappeared from the secretions, the
wound was closed with silkworm gut. At this date
the case was brought to us (Fig. 109). Union of the
edges of the wound took place by first intention. Con-
solidation was attained, and the patient walked on the
43rd day. There was three centimetres of shortening,
and the knee possessed its normal mobility.
Case 493, aged 38 years, had a fracture of the
right femur caused by shrapnel (Fig. no). He was
first treated at the V field-hospital, where MM.
Hornus and Perrin removed the projectile and some
small splinters. Like the preceding, the wound was
irrigated by means of Dakin's solution. After seven
days he was sent to Compiegne. The temperature
was 37 C. (98*5 Fahr.), the wound was a healthy red
and presented no sign of suppuration, the surrounding
integuments were supple and free from tenderness. At
this stage, the number of microbes was about twenty
per microscope field. On the 23rd day it had dropped
THE RESULTS
229
to one per three fields. The wound was closed the 25th
day by silkworm gut, and healed by first intention.
Consolidation was complete 44 days after the infliction
of the injury.
The number of fractures of the thigh treated by us
was very limited. But there is no doubt that similar
results can be obtained when fresh compound fractures
FIG. 109. Comminuted frac-
ture of femur. Case 495.
FIG. no. Fracture of
femur. Case 493.
are treated by methods similar to ours. Recently M.
Hornus treated, in one of the hospitals at the front,
thirteen cases of compound fracture of thigh. After
four or five days the cases had a normal tempera-
ture and no suppuration. In eleven cases, secondary
suture was practised. We have seen also, with M.
Depage at the hospital of La Panne, fractures of the
230 TREATMENT OF INFECTED WOUNDS
thigh which had attained surgical asepsis and been
closed.
It appears, therefore, quite evident, that in fractures
of the thigh, and with still more reason in fractures of
the tibia and humerus, it is quite possible to avoid sup-
puration while making very limited resections (esquillec-
tomies, Fr.). Consolidation comes about rapidly, and
cases are protected at the same time against pseudar-
throsis and the interminable suppuration which so often
follow compound fractures treated by the ordinary
methods.
2nd. Fractures accompanied by Wounds of Joints.
When a wound was associated with the opening of an
articulation, results differing according to the region
were observed. When the lesion was limited to synovial
membranes or to the edges of the articular condyles,
arthrotomy followed by disinfection of the seat of
fracture permitted the osseous extremities to be retained.
Often functional integrity remained complete. The
scope of simple arthrotomy could be enlarged, and the
number of resections diminished.
In the cases of deeper osseous lesions and more
extensive fracture of the articular condyles, we have
also been able to avoid resection, and to preserve all
the movements of the articulation. Here are two
examples of compound fractures of the inferior ex-
tremity of the humerus completely restored by sterilisa-
tion of the wound.
Case 433, aged 25 years, had a fracture of the neck
of the humerus, due to a fragment of shell which remained
in the joint. Four hours after the infliction of the injury,
the orifice was laid open freely, the walls of the track
THE RESULTS
231
cleaned, and a resection performed, limited to the
detached fragments of bone. After the missile was
removed, tubes were placed in the seat of fracture.
After fifteen days (Fig. 99) sterilisation was attained,
and two days later the joint was closed with silkworm
gut (Fig. 100). Union took place by first intention.
The twenty- fifth day movements of the joint were
begun. The functions of the articulation were re-
established completely.
Case 497 had a shell-wound of the right elbow which
fractured the humerus, separating the epicondyle and
part of the condyle of the humerus.
This case was treated at the V
field-hospital by MM. Hornus and
Perrin, who were content with
sterilising the large wound by
means of tubes going down to the
seat of fracture. In fifteen days
the wound was sterile. It was
sutured the sixteenth day with silk-
worm gut, and united by first in-
tention (Fig. in). The movements
of the elbow were re-established
almost completely. There remained FIG
only a slight limitation of exten-
sion.
In wounds of the knee-joint results were observed
comparable to a certain extent with those obtained in
lesions of the elbow. In those cases where the anato-
mical conditions permitted, we have endeavoured to
sterilise the articulation in such a way as to retain the
normal movements.
in. Fracture of
condyle of humerus.
Case 497-
232 TREATMENT OF INFECTED WOUNDS
Case 472 had multiple wounds of the soft parts,
which were cleaned and disinfected, and a wound of the
right knee with injury to the external condyle. A piece
of a grenade had penetrated the external surface of the
knee, traversed the synovial membranes, and lodged in
the thickness of the condyle. The aperture of entrance
was freely laid open, the walls of the track' resected, the
projectile extracted, and the tunnel in the bone carefully
curetted. The articular cavity was then dried and shut
off by a compress placed beneath and within the damaged
condyle, and an instillation tube introduced to the
bottom of the bony track. The wound rapidly cica-
trised. The eighth day the compress used for " shutting
off" was removed, and on the twelfth day the articula-
tion was closed. Union by first intention followed, and
passive movements were commenced on the thirteenth
day. The movements of the joint were so perfectly
restored that the patient walked in a normal manner
when he went out of the hospital.
Case 289 was operated upon twenty-four hours after
having received a shell-wound which broke the patella
into fragments and displaced the condyles of the femur
in an anterior direction without their fracture. The
contused soft parts were carefully cleansed and all the
fragments of the patella removed ; the character of the
fragments suggested those of an explosion. A compress
was placed in front of the inter-articular line, and two
instillation tubes were placed in the cul-de-sac of the
quadriceps and in the patellar fossa. The temperature,
which was 39-9 C. (102 '2 Fahr.) on the day of arrival, fell
by the fourth day to 37-5 C. (99 Fahr.). Similarly, the
bacilli and cocci which were numerous in the smears were
THE RESULTS 233
reduced by the seventh day to one per five or six fields
of the microscope. The wound was then closed by
elastic traction. Cicatrisation was complete by the
fifteenth day, and passive movements of the joint
commenced.
Case 594 had a shell-wound of the knee with partial
fracture of the external condyle of the femur. The
wound, which was still infected the sixth day (Fig. 101),
became sterile the fourteenth day, and was sutured the
twentieth (Fig. 102).
In the following case, despite the very extensive
lesions, we were able to save the lower extremity of the
femur.
Case 1 06, aged 22 years, had had a smashing-up
of the lower epiphysis of the right femur, fracture of
the left patella, and a large wound of the hand. He
reached hospital in a grave condition of shock some ten
hours after the infliction of the injury. Immediate
transfusion was resorted to, and interference limited to
placing instillation tubes in the crevices between the
bony fragments which represented the smashed femoral
condyles. Into the seat of fracture was instilled para-
toluene sulphochloramine, 3 per cent. His temperature
never rose above 39 C. (102 Fahr.), and became practi-
cally normal at the end of a month. His general condi-
tion remained good, and his hospital stay ended by healing
with an ankylosed knee (Fig. 112). In this case no
surgical interference was practised at the outset because
of the extreme gravity of the case. However, in spite of ^
the extent of the anatomical lesions of the knee, recovery
took place without the patient's condition causing a
moment's anxiety.
234 TREATMENT OF INFECTED WOUNDS
3rd. Suppurating Fractures. The greater number of
compound fractures treated by the usual methods sup-
purate more or less abundantly. We have examined
the effects of chemical sterilisation on a score of fractures
which had been previously treated in other hospitals,
for periods varying from two to forty-six days. Sup-
puration generally disappeared in from one to four days
FIG. 112. Smash of extremity of
femur. Case 106.
FIG. 113. Sup-
purating frac-
ture of hume-
rus. Case 624.
after the commencement of treatment. But the bac-
teriological curves show that, after the disappearance of
the pus, wounds evolve in different ways according to
the localisation of the infection.
(a) In the first category of cases, the number of
microbes rapidly lessens after the establishment of instil-
lation, and in a few days reaches one per five or six
fields. When the curve presents this aspect, there are
THE RESULTS 235
in the depths of the wound neither infected fragments
nor a focus of osteo- myelitis, and in spite of the suppura-
tion, the seat of fracture becomes sterile as though a
newly inflicted fracture were being dealt with. We have
observed this result in several fractures of the humerus,
radius, ulna, and some of the smaller bones. Here are
two examples of this development.
Case 624, aged 34 years, entered hospital twelve
days after a fracture of humerus from shell-wound
(Fig. 113). He had been operated on a few hours after
the injury. The left arm had two wounds, one internal,
the other external. A big drainage tube traversed the
seat of fracture. The limb was surrounded by a dressing
stained with blue pus. The wounds were plugged with
iodoform gauze, behind which was found a large quantity
of pus. The drainage tube was removed, and instillation
tubes inserted into both wounds as far as the seat of
fracture. The next day the blue pus had, clinically
speaking, disappeared. The following day the wounds
had taken on the usual red appearance. The microbes,
which were innumerable the first day, had completely
disappeared ten days later. The two wounds were
sutured twelve days after the entry of the patient into
hospital. They united by first intention. Two other
cases with similar lesions, at the same period, were
sutured with like results.
Case 626 presented a semi-section of the upper
portion of the forearm, with smashing-up of the two
bones. He had undergone operation in a first-line
ambulance, and arrived in hospital nine days later. The
wounds were suppurating abundantly, the forearm was
a little swollen and very painful. The dressings were
236 TREATMENT OF INFECTED WOUNDS
soaked in a large quantity of blue pus. On the surface
of the wound remained fragments of gangrenous tissue.
The wound was dressed with a paste containing 1*5 per
cent, of chloramine. Two days later the blue pus had
disappeared. After three days the swelling of the fore-
arm was gone and the wound was commencing to " clean
up." But the microbes were still innumerable. The
wound only became surgically aseptic after the lapse of
a fortnight. It was sutured the twentieth day, and
healed by first intention.
Case 6 1 8, aged 31 years, had a splintered fracture
of the femur through the trochanters, due to a pro-
jectile which had penetrated the antero-external aspect
of the thigh. He was operated on in a first-line ambu-
lance eight hours afterwards. He arrived at hospital
twelve days later. The limb was put up in plaster with
a " window." A large rubber drainage tube which was
found in the wound was removed, and replaced by three
perforated instillation tubes. The patient's condition
was good. But the region of the hip was painful and
a little swollen. The wound presented scanty secretion
which did not yield more than ten to twenty microbes
per microscope field. Seven days after the arrival of
the case at the hospital the wounds were almost aseptic.
Then the two instillation tubes were removed and the
wound filled up to the level of the seat of fracture with
chloramine paste. The wound became aseptic. We
waited until the twentieth day before closing it. Union
took place by first intention (Fig. 1 14).
(b) In the second category of cases, the number of
microbes contained in the secretions diminished rapidly
at first, then at the end of a few days the bacteriological
THE RESULTS
237
curve became a horizontal line. The quantity of
microbes observed in each field varied from about five
to fifty. But they never got below one. When the
microbial curve forms a plateau at the level of or above
the line indicating five microbes per field, experience has
shown that there exists in the depths of the wound
either a sequestrum or a patch of osteitis which would
justify surgical interference. Even in those cases where
FIG. 114 Trans-trochanterian fracture of femur. Case 618.
complete sterilisation could only be obtained by resorting
to a secondary " cleaning-up," suppuration dried up in a
few days and the general condition of the patients
changed greatly for the better.
The following example demonstrates how the dura-,
tion of treatment may be lengthened if a compound
fracture of the thigh be allowed to suppurate even
slightly.
238 TREATMENT OF INFECTED WOUNDS
Case 496, aged 25 years, arrived at the hospital
forty-two days after having received a shell-wound which
had caused a highly comminuted fracture of the right
thigh. A few drops of pus came from the opening.
Instillation tubes were put in position and the pus dis-
appeared almost completely. But on the surface of the
track four or five microbes per field of the microscope
persisted. Four months later, slight sero-purulent oozing
came from the seat of fracture, from which numerous
fragments were removed. Two months later the sinus
was still not closed. This persistence of suppuration
shows how important it is to sterilise these compound
fractures at the outset, to the degree when they contain
no microbes at all. In the present case the fracture had
consolidated rapidly enough. But care had not been
taken to dry up the suppuration in an early stage. The
consequence was that the patient, instead of recovering
as though he had only a simple fracture, still suffered
from a small sinus six months after the infliction of the
injury.
When fractures are treated early, even if they are
freely suppurating, the results observed are much better.
Case 642, aged 21 years, had a shell-wound causing
fracture of the middle of the right femur. The projectile
was extracted in an ambulance at the front five hours
after the injury. Two large drainage tubes were placed
in the posterior wound and the end of one of these tubes
came out by the internal wound. A long anterior wound
was plugged with gauze compresses tightly packed in,
and almost completely closed by suture over the com-
presses. The result of this therapeusis was disastrous.
When we received the case at the hospital two days
THE RESULTS 239
after the operation the thigh was swollen and very
painful. The plaster apparatus and the dressings were
soaked in an extremely foetid discharge. The stitches
were immediately removed. The tissues were found
almost black, covered with sanious pus, stinking,
Microbes in infinite number were contained in these
secretions. Three irrigating tubes were placed in the
posterior wound, three in the anterior, and four in the
internal wound. Next day the bad smell had quite
gone, suppuration likewise. The following day the
general condition of the patient was much improved,
although the thigh was still swollen. Six days later,
the swelling of the thigh had greatly diminished, and
the wound had become red. Eleven days afterwards,
some of the tubes were removed, for healing was pro-
ceeding rapidly. Twenty- three days after the patient's
entrance into hospital, the internal wound was isolated
from the seat of fracture, and the posterior and external
only communicated with it by a narrow track. Two days
later, two of the wounds were sterile, and the third only
contained a few microbes. The evolution of this frac-
ture was then comparable, in a certain measure, with
that of a fresh compound fracture treated before the
onset of suppuration.
In highly comminuted fractures, it was usually
impossible to disinfect the wound without surgical
interference.
Case 617, aged 28, had received a torpedo wound
which had pounded up the tibia at its upper part.
After some hours it was operated upon in an opera-
ting post, where free splinters were removed, and
where, very wisely, they had carefully preserved several
240 TREATMENT OF INFECTED WOUNDS
large plates of bone adherent to the periosteum of the
internal surface. The seat of fracture was disinfected
and dressed with ether, and the limb immobilised in
a metallic gutter-splint. This patient arrived at the
hospital three days later. The limb looked well and
the temperature was 38*5 C. (ioiFahr.). But the sur-
face of the bone was dark in colour and extremely in-
fected. Examination of the pus showed that the
microbes there were innumerable. Two instillation
tubes were placed in the cavity, and after four days the
temperature fell. Pain and swelling of the limb also
disappeared. Nevertheless, after twenty-five days the
number of microbes gathered from the surface of the
wound was still high. Surgical cleansing of the surface
of the bony cavity was carried out, and several small
sequestra removed, preserving the periosteum. Instilla-
tion tubes were placed in the cavity. Sharply the
microbial curve dropped, and reached the level which
indicates surgical asepsis.
Even in those cases where the extent of the lesions
and the gravity of the general condition do not permit
of an integral application of the method, still we can
obtain sufficient disinfection to transform both the local
and general conditions of the patient.
Case 635, aged 34 years, had a large wound of
the right thigh with fracture of the femur. He was
operated upon in a field-hospital, where a plaster
apparatus had been applied. But a very abundant
suppuration set in, and during the weeks which followed,
he had seven secondary haemorrhages. This patient
reached us forty-six days after the injury. He was in
a very serious condition. The thigh presented an antero-
THE RESULTS 241
internal wound and a posterior wound. The denuded
extremity of the superior fragment stuck out into the
wound. Pus in large quantity poured from the seat
of fracture, and rapidly soiled the dressings. The
patient was very depressed; his evening temperature
was 38-5 C. (101 Fahr.). The urine contained albumen.
Haemoglobin was reduced to 30 per cent, of its normal
quantity. Systolic arterial pressure was 12*5 and
diastolic pressure 8. In addition the patient suffered
from intractable diarrhoea. Because of the gravity of
the general condition, we limited our action to slipping
four instillation tubes along the bony fragments in
the seat of fracture. But the whole of the infected
region could not be reached in this manner. As the
patient was not in a condition to stand an incision,
we were content to irrigate those parts of the infected
area we could reach. At the end of a week the
general condition had improved, and suppuration had
almost completely disappeared. But the diarrhoea
changed into dysentery, and the general condition
changed for the worse. By way of compensation the
local condition rapidly improved. Granulations covered
the bare bony surfaces. Pain had disappeared. But
microbes remained in considerable numbers. Twenty
days after the arrival of the case about 500 grammes of
blood were transfused. His general condition improved,
and the dysentery, which had been treated by Dopter's
serum, disappeared little by little. Twenty- five days
after arrival, his temperature was normal and the wounds ,
rapidly healing. Suppuration had not reappeared. This
case is a striking example of the possibility of suppress-
ing suppuration, and of thus ameliorating, to a very
16
242 TREATMENT OF INFECTED WOUNDS
real extent, the condition of a patient who, treated by
the usual methods, would have suffered amputation and
probably have died.
The treatment of suppurating wounds, accompanied
or not by fracture, taken from the convoys going to
Paris, has shown us that suppuration can be easily dried
up in a few days. Between the 5th September, 1915, and
the 5th January, 1917, we were able, at the Compi&gne
hospital, to take in 50 fractures, one from three days
to eight months after the date of the wound. These
were all serious fractures of the thigh, the tibia, or the
humerus, some involving the articular extremities. The
patients were treated by MM. Guillot and Woimant, who
in the great majority of cases succeeded in sterilising
the seat of fracture. Fifty-two per cent, of these fractures
were sterilised and closed ; 42 per cent, spontaneously
cicatrised after sterilisation. In 6 per cent, only of these
cases there was a secondary formation of fistula. As
in these 50 fractures the most serious clinical varieties
were included, as streptococcic infections were discovered,
and as sterilisation was notwithstanding obtained in 94
per cent, of the cases treated, it must be realised that
the method is as fully applicable to old as to recent
cases.
II. CONSEQUENCES OF THE STERILISATION OF
WOUNDS
The suppression of suppuration and infection in the
majority of wounds has important consequences for the
patient, since it diminishes to a very large extent the local
and general complications of wounds, and consequently
THE RESULTS 243
the length of treatment and the degree of final in-
capacity.
A. Diminution of the Frequency and Intensity of General
Complications. The rapid sterilisation of wounds nearly
always protects patients from those complications which
lead to death. From the month of December, 1915, to
October i, 1916, 303 cases of wounded coming directly
from advanced dressing posts were treated at the hospital
for research at Compiegne. Thirteen died after a stay
in the hospital of more than twenty-four hours. In
eight cases death was due to extensive anatomical
damage to brain, contents of mediastinum, or abdominal
organs. In three cases it followed multiple wounds of
the two lower limbs, thorax and upper limb. Twice
only was it due to septicaemia. One officer, who had a
fracture of the thigh with great smashing-up of the bone
developed rapid gas-producing septicaemia which in
spite of amputation resulted in death. In the second
case, staphylococcal septicaemia developed in the train of
a fracture implicating almost 'the whole length of the
femoral diaphysis. This case also terminated by death.
In 'all the other cases it was possible to avert serious
general infection. It is probable that the improvements
which experience has enabled us to make in our methods
would allow us to-day to obtain recovery from lesions
similar to those which determined the two fatal septi-
caemias. Lowering of the rate of mortality from infec-
tion has been observed by other surgeons who have
applied the method in its entirety. 4
The general condition of the cases whose wounds are
in a fair way to become sterilised is habitually good,
even when the temperature is more or less elevated.
244 TREATMENT OF INFECTED WOUNDS
This phenomenon was exhibited in a striking manner by
those cases which were brought to hospital with injuries
of long standing and freely suppurating. Immediately
the suppuration disappeared clinically, the general aspect
of the patient changed. The first effect of the cleansing
of wounds was always marked improvement in the general
condition.
B. Diminution in the Number of Amputations. The
suppression of infection has permitted us to escape the
lymphangitis, abscesses, and purulent tracks which usually
accompany infected fractures and joint-injuries. In a
year we have only seen three abscesses. One was the
result of a lymphangitis which existed before treatment.
The two others developed in the neighbourhood of a
fracture of the humerus and of an infected knee. These
abscesses were opened, sterilised, and closed in three or
four days. In cases where the extent and complexity of
the lesions do not permit rapid sterilisation, the destruc-
tion of the greater quantity of the microbes and gan-
grenous tissue immediately produced considerable local
amelioration. From this resulted the possibility of pre-
serving limbs which presented very extensive lesions, or
of performing conservative operations instead of carrying
out radical treatment. In nearly every case where
resection of the elbow or shoulder was indicated, we
were content with an arthrotomy and disinfection of the
articulation. It was the same, to a certain extent, with
the knee. In the case of fractures, operations for the
removal of splinters have been reduced to a minimum,
and thus have been avoided those cases of marked
shortening and the pseudarthroses which are so often
seen after large removal of bony fragments.
THE RESULTS 245
Amputations have been able to be reduced to the
cases in which the crushing of almost the whole of the
portion of the skeleton concerned, or the destruction
of the vasculo-nervous supply, rendered impossible the
conservation of the limb. Between December i, 1915, and
October I, 1916, we performed twenty- three amputations.
These amputations were necessitated in four cases by
crushing-up of the bones, accompanied by section of
vascular trunks. In sixteen cases it was a matter of
limbs being partially or completely torn away by shells,
or more especially bombs. The operation consisted
in either completing the amputation with scissors, or in
amputating a little higher up where the bone became
normal. As a general rule, amputation was practised
directly through the contused seat of fracture, which the
application of numerous instillation tubes allowed to be
sterilised in a few days. In only three cases was amputa-
tion determined by infection. Two were the cases of
septicaemia of which we have already spoken. The third
case was a fracture of the upper part of the forearm with
extensive vascular lesions and a considerable diminution
of the circulation of the limb. This case had been
operated on previously in a field-hospital. After a few
days the skin became mottled with bluish patches, at
the same time signs of septicaemia appeared. Ampu-
tation was done, and the patient recovered. Similar
results were observed in the field-hospital at V by
M. Ferret, who, out of one hundred cases, only amputated
once. The sterilisation of wounds, therefore, permits of*
the preservation of nearly all limbs which are not
rendered useless by the extent of destruction of osseous,
vascular, or nervous elements.
246 TREATMENT OF INFECTED WOUNDS
Similar, and even more striking results were observed
in the case of wounds which were, roughly speaking,
from two to forty days old. In the series of a hundred
already infected subjects of which we have already made
mention, MM. Guillot and Woimant were not obliged to
perform a single amputation.
The possibility of disinfecting injuries lessens the
number of amputations in a very great proportion, since
this operation to-day in 70 per cent, of the cases is
caused by septic sequelae.
C. Diminution of Length and Cost of Treatment. The
length of time treatment has to be carried on has been
lessened because wounds have been rapidly closed, and
because repair of bone, muscle, and nerve has been
effected at an early stage.
1st. Influence of Secondary Closure on the Duration of
Treatment. Wounds of the soft parts, both fresh and
suppurating, were closed in the proportion of 90 per
cent, from the fifth to the twentieth day, in whatever
stage of the wound the treatment may have been com-
menced. Wounds not sutured in this period were also
sterilised, though in a slower manner. If the wounds
thus closed during the first twenty days of treatment
had been treated by the usual methods, they would have
needed from one to six months to cicatrise. By early
suture a reduction by about two-thirds of the duration
of treatment was obtained.
In compound fractures of flat bones, short bones,
and long bones such as the fibula, radius, and ulna,
sterilisation was produced as quickly as in the wounds of
soft parts. The saving in the length of time needed for
treatment was therefore very considerable, because these
THE RESULTS 247
compound fractures, treated in the ordinary way, often
suppurated for several months. It is well known how
slowly deep wounds of the tarsus, for example, recover
when they are infected. One cannot estimate exactly
the diminution produced by sterilisation in injuries of
the humerus, tibia, and femur. But this diminution is
considerable. In fact, compound fractures of the
humerus, when sterilised, are often closed after the
lapse of from twelve to twenty days, when similar cases,
treated by the ordinary methods, are still suppurating
after six, seven, or eight months. It is also evident
that the closure of compound fractures of the femur
after fifteen, twenty, or twenty-five days constitutes a
great advance.
A considerable reduction in the duration of the
treatment has likewise been effected in other branches
of surgery. The possibility of sterilising and closing
purulent pleurisies, 1 as MM. Tuflfier and Depage have
done, very greatly diminishes the length of the patient's
stay in hospital. For the treatment of mastoiditis
M. Mahu * has, by means of chemical sterilisation, reduced
the term of treatment to one-third of what it used to
be. At Pittsburg, Mr. Sherman 3 has almost entirely
suppressed the infection of wounds due to industrial
accidents. These wounds are sterilised more readily
than wounds received in war, and the saving which may
thus be effected is considerable.
2nd. Influence of Early Anatomical Repairs on the
Duration of Treatment. Sterilisation of the wound allows
9
1 Tuffier and Depage, C^ JR. Socttte de Chirurgie, March 27, 1917.
* Mahu, Presse medicak, 1917.
3 Sherman, Surgery p , Gynecolo%y and Obstetrics, January, 1917.
248 TREATMENT OF INFECTED WOUNDS
us to practise operations quite early in the case which
formerly had to be put off until after cicatrisation was
complete. Thus bone-grafting or wiring, reunion of
muscles or tendons, or nerve suture, before to-day, could
only be practised after the healing of the infected
wound. This cicatrisation often was only obtained after
the lapse of several months. To-day, we set about these
reconstructions as soon as the wound is sterile, that is
to say, from the eighth to the fifteenth day.
Case 433 presented a section of all the tendons and
the median nerve just above the right wrist. He was
brought to the hospital three and a half hours after the
injury. , The wound was immediately cleansed and pro-
vided with instillation tubes. After ten days it was
sterile. On the eleventh day, all the tendons and the
median nerve were sutured, and seven days later, the
skin wound was closed without drainage. Healing took
place by first intention. This case had at the same time
an inter-articular fracture of the right elbow, and a
fracture of the left humerus, which were sutured at the
same time, and likewise united by first intention.
Reparation of bone tissue may be made with equal
safety at an early date. Case 5 1 8, aged 23, had a fracture of
the vault of the cranium with a large wound of the hairy
scalp. Phenomena of compression disappeared as the
result of a craniectomy, in the course of which a fragment
of bone the size of a crown-piece was removed. Four
days later, the wound having become sterile, M. Woimant
made good the loss of bone substance by an osteo-
periosteal flap taken from the internal surface of the
left tibia. The scalp was closed hermetically, and union
took place by first intention. The case was examined
THE RESULTS 249
anew forty days later. It was found that the graft had
exactly adapted itself to the cranial wall.
3rd. Diminution of the Cost of Treatment. The
expenses of treatment are considerably lessened, since
its length is so much less than by other methods. The
saving thus realised is from about 50 to 70 per cent.
Besides, the substances used in the treatment are not
costly. The net cost of Dakin's solution is three centimes
the litre, 1 whilst ether, alcohol, peroxide of hydrogen and
balsam of Peru are very much dearer. Suppuration being
done away with, the dressings are but slightly soiled, and
almost the whole of the gauze may be saved again for
subsequent use. The cost of the appliances for instilla-
tion is recovered in a few days from the saving due to
the exclusive employment of a substance of such trifling
cost as hypochlorite of soda.
D. Diminution of Positive Incapacity. In the greater
number of injuries, eventual incapacity is the ! result of
infection. As the sterilisation of wounds permits the
avoidance in many cases of amputations and resections,
there results a considerable diminution in the amount of
pensions payable to the wounded men by the State. It
is also well known that the presence of infection in a
compound fracture of a leg or thigh, raises the positive
incapacity rate from 5 or 10 per cent, to 25 or 50 per
1 Net cost of ten litres of Dakin's solution :
200 gr. chloride of lime at I fr. 10 centimes . . . 0-22
ico gr. carbonate of soda (Solway) at o fr. 40 centimes . 0-04
800 gr. bicarbonate of soda at o fr. 60 centimes . . 0*048
r *
Net cost of 10 litres 0*308
Therefore the net cost of a litre is 3 centimes (rather less than a
halfpenny per quart).
250 TREATMENT OF INFECTED WOUNDS
cent, and more. The gain from the suppression of
infection is therefore very evident. In successfully treat-
ing fractures without extensive removal of bone substance,
considerable shortening of limbs and pseudarthroses are
frequently avoided. Sinuses are scarcely ever seen in
cases thus treated. The recovery is all the more com-
plete, for a case of compound fracture of the tibia, the
femur or the humerus, sutured after the lapse of a few
days only, presents neither the muscular atrophy, the
retraction of tendons, nor the joint-stiffness, which, after
long periods of suppuration, reduce limbs to the verge of
impotence.
Sterilisation of wounds is equally successful in securing,
more readily than by the other methods, healing of deep
wounds of the soft parts. In reality, since tendons and
muscles can be sutured as soon as the wound is sterile,
the unions are stronger. Nerve suture likewise is done
under excellent conditions. In wounds of muscle, the
deep and painful cicatrices, which so hamper the useful-
ness of a limb, are not produced. It is quite certain
that the economies in the amount of pensions paid by
the State, obtained by means of the sterilisation of wounds,
are very considerable.
III. FAILURES AND THEIR CAUSES
Failures teach more than successes. Therefore it is
important to examine in what cases the method fails to
sterilise wounds, and what are the causes of these
failures.
A. Wounds of the Soft Parts not accompanied by Bone
Injuries. If the surgical sterilisation of a wound be
considered as the object of the method, it might be
THE RESULTS 251
asserted that no failure has been observed since the
month of December, 1915. But if the rdle of the method
is to prepare for the secondary closure of wounds, the
proportion of failures rises to about five per cent.
These failures are due to the following causes :
(a) Errors in the bacteriological examination. In
spite of the absence of microbes from the smears, suture
of the wound was followed by infection. This accident
was very rare and always without serious results. It
was met with twice in the course of 333 cases of wound-
closing. Wounds, the seat of infection, were reopened
and sterilised in a few days. This accident was the
consequence of specimens for the smears being badly
taken ; and can be avoided by taking multiple specimens,
especially from the most obscure parts of the irregularities
of the wound.
(b) Loss of tissue-substance. In some cases, the loss
of integumental substance was very extensive, and union
impracticable. In other cases, union became possible,
if traction more or less great by sutures were employed.
But these cut the skin and union remained imperfect.
(c) Closure without bacteriological examination. It
sometimes happened that, seeing a wound of good red
colour, without secretion, and with margins perfectly
supple, the surgeon did not wait for a laboratory report,
and sutured. Under these conditions, the operation
sometimes resulted in failure. This mistake has not
been committed in our hospital since the month of
December, 1915. Before that date, it happened several
times.
When the treatment was commenced after a period
of suppuration more or less long, numerous failures of
252 TREATMENT OF INFECTED WOUNDS
the method might have been expected. Nevertheless,
all the suppurating wounds arrived at the stage of
surgical sterilisation, and no failure was registered. The
closure of these wounds was practised at a later date
than when dealing with fresh wounds, but nearly all the
cases were sutured.
B. Wounds of the Soft Parts accompanied by Injuries
to Bone. In compound fractures, and especially in those
which had suppurated before the commencement of
sterilisation, we did not always achieve surgical sterilisation.
From this point of view, the results of treatment of com-
pound fractures can be clearly separated from those of
wounds of the soft parts. Failures were more frequent.
We look upon as failures cases in which some microbes
persisted in the secretions up to the spontaneous closure
of the seat of fracture, and those in which a sinus or
fistula persisted.
We have observed no failure in the treatment of
compound fractures of the small bones, short bones,
radius, and ulna. But some compound fractures of the
humerus, tibia, and femur did not respond completely
to treatment. The statistics of these cases will not afford
any indication of interest, because the methods have
been progressively modified, and the results are improving
more and more. In the last fifteen cases of fracture of
the humerus which have been under our care, several of
which were freely suppurating at the commencement
of treatment, only four were not sutured. In two cases,
suture was not practised because of loss of substance.
In only two cases surgical sterilisation of the seat of
fracture was not attained. One case was a "smash-
up" of the end of the diaphysis and the adjoining
THE RESULTS 253
head of the humerus, and the other case was a highly
comminuted fracture of the shaft. In both cases the
secretions contained some microbes up to complete
cicatrisation. Recovery took place without a sinus
remaining.
In compound fractures of the tibia, the loss of sub-
stance is often too great to allow of the soft tissues being
completely brought together. In similar fractures of the
femur, approximation of the tissues was always possible,
but microbes often remained in the secretions, and pre-
vented suture being carried out.
IV. PRACTICAL VALUE OF THE METHOD
The results observed at Compiegne showed us that
suppuration of wounds can be suppressed^ and that the
majority of wounds are capable of being sterilised and
sutured. The practical value of the method depends
upon the possibility of its being employed at other
hospitals. As a matter of fact, the objection has been
raised that the chemical sterilisation of wounds is, tech-
nically speaking, too delicate a method for general
employment. It will be as well, therefore, to demon-
strate how, without increase of staff, by the aid of ap-
paratus whose cost does not exceed a dozen francs per
bed, using substances which cost much less than ether,
hydrogen peroxide, or alcohol, usually employed in
treatment of wounds, it has been possible to apply the
abortive treatment of infection and the curative treat-
ment of suppuration in some of the hospitals at the
front (ambulances de ravant), and in some of the terri-
torial hospitals.
254 TREATMENT OF INFECTED WOUNDS
A. Abortive Treatment of Infection. The abortive
treatment of infection, instituted at Compiegne in the
spring of 1915, was tried experimentally in the hospitals
from the month of July in the same year by le M6decin
Principal Uffoltz, Directeur du Service de Sante d'un
Corps d'Arm6e. From that date M. Uffoltz and his col-
leagues demonstrated that under the ordinary conditions
of a field-hospital, the method could be employed almost
in its entirety, and that a considerable improvement in
results was the consequence. In one of the hospitals
under the charge of M. Uffoltz, le Medecin-Major Ferret
succeeded in banishing wound infection almost com-
pletely. The ordinary staff was able to apply the
method in accurate detail. The demonstration of the
practical value of the method in the field-hospitals was
brilliantly achieved by MM. Hornus and Perrin, who
succeeded in protecting their cases from septic acci-
dents, in preserving limbs with enormous injuries, and
in cutting short to a large extent the duration of treat-
ment, by the secondary union of wounds.
Nor is the number of cases any obstacle to the em-
ployment of the method. At the hospital at La Panne,
which contains from 600 to 700 wounded, M. Depage
and his colleagues proved that the sterilisation of wounds
could be carried out on a large scale. It had, however,
been said that the small size of our hospital at Compiegne
allowed us to lavish an amount of attention on our cases
which would have been impossible if these cases had
amounted to several hundreds. Therefore it is important
to realise that the staff of a great hospital succeeded in
practising the sterilisation of wounds in every case, in
following the progress of chemical cleansing upon the
THE RESULTS 255
bacteriological charts, and in closing wounds as soon as
they ceased to harbour microbes. In this hospital, which
contains nearly 700 wounded, suppuration was almost
completely abolished, without the necessity of increasing
the personnel or altering the general organisation.
The results observed in M. Uffoltz' field- hospitals
and M. Depage's hospital show that the abortive treat-
ment of infection can be realised in the "formations
sanitaires " at the front, when these are well organised
and controlled.
Where wounded men are arriving in large numbers,
and it is necessary to evacuate them rapidly on the hos-
pitals in the rear, the abortive treatment of infection
may still be attempted. As the surgical intervention
which precedes chemical sterilisation is identical with
that which should always be practised, it matters little
that the treatment may be interrupted a few hours or
days after its institution. In this case, indeed, the
wounded man is in the same position as would be his
after the ordinary treatment ; but he has benefited by
the commencement of the sterilising process. More-
over, the treatment can be resumed the moment he
reaches the hospital in which he is finally to remain.
B. The Disinfection of Suppurating Wounds. The ap-
plication of the method, which is difficult and occasion-
ally impossible in field-hospitals crowded with wounded
men, can always be carried out in the territorial hos-
pitals, in which men with suppurating wounds are re-
ceived after the lapse of a few days or weeks. The
observations made at the Compiegne hospital since
September, 1916, have shown that wounds already
deeply infected, whether accompanied by fractures or
256 TREATMENT OF INFECTED WOUNDS
otherwise, can be sterilised as well as fresh wounds,
although somewhat more slowly. When the patient had
gone through the commencement of chemical sterilisation
by Dakin's solution in the advanced field-hospital (first-
line ambulance), the wound was comparatively lightly
infected, and the rate of disinfection was more rapid.
Identical results have been obtained in all those hos-
pitals in which the method has been applied in all its
details. Thus in M. Turner's hospital at Saint-Germain,
and in M. Chutro's wards at the Buffon hospital, sup-
purating wounds became a thing of the past. Sup-
puration in wounds, in short, ought not to exist, except
in exceptional cases and for a limited time. The
presence of pus in a hospital denotes that the technical
methods employed there are defective. Every wounded
man whose injury suppurates has a right to call his
surgeon to account.
V. CONCLUSIONS
Since our methods have been employed with success
under the ordinary conditions of field and base hos-
pitals, the sterilisation of both fresh and suppurating
wounds ought to be practised almost everywhere. But
surgeons should not forget that all the details of the
method have been studied experimentally and estab-
lished in a certain way to produce a certain result.
Neither the preparation of Dakin's solution may be modi-
fied, nor the processes for the mechanical and chemical
cleansing of wounds. It is indispensable to learn the
method before attempting to apply it, and this appren-
ticeship demands several weeks, even from an experienced
THE RESULTS 257
surgeon. But we can be quite sure that, applied in their
entirety, the methods just described will produce the
desired results. Admitted, their use exacts more pre-
cision and more care than the old methods, for any
approach towards technical perfection requires more
elaborate apparatus and a more specialised staff. But
efforts of no great magnitude on the part of doctors
and nurses will most certainly yield an immense improve-
ment in results.
The nation has the right to ask from the medical
corps that progress in the treatment of the wounded
which is so acutely needed
APPENDIX
CHLORAMINE PASTE
THE formula for chloramine paste is not given in the French
edition. M. Carrel informs me it is made as follows :
" Chloramine T 10
Stearate of Soda ... 70
Water 1000
The preparation of this substance is somewhat difficult, and it
should be made by means of a mechanical mixer, in order to
obtain a thoroughly homogeneous paste."
HERBERT CHILD.
25*
INDEX
ABORTIVE treatment of infection,
254, 255
Abscess, gas-producing, 125
lymphangitic, 125
Aerobic microbes, 74
Alkali, free, in ordinary hypochlo-
rite, 22
Amputations, almost always neces-
sitated by infection, i, 2
in gas gangrene, 124
, reduction of number by treat-
ment, 244-6
Anaesthesia in preparation of
wounds, 113, 114
Antisepsis, conditions of, 40, 41
Antiseptics, action of, 64, 65
, concentration of, to be main-
tained, 84, 85
, duration of application, 86-
90
, erroneous choice of, 4, 5
, germicidal potency of various,
18-29
, inefficiency of, taught by
Leishman, Wright, etc., 4
, method of applying, 81-84
, qualities required in, 5, 6
, selection of, 15, 16
- , uselessness of blind appli-
cation of, 14
Antiseptics. See DAKIN'S SOLU-
TION ; HYPOCHLORITE, etc.
Asepsis, a condition of wound
closure, 20$
, apparent, of fresh wounds,
73. 74
, bacteriological, often obtained
bychemiotherapy, 203, 204
, substitute for antisepsis, a,
5
, surgical, indications of, 181
BACTERIA of war- wounds, 6
, destruction of, by antiseptics,
64,65
, development of various species
at various stages, 73-77
, multiplication of, rapid, 75
See MICROBES
Bacteriological examination, of
wounds and secretions,
importance of, 15
, danger of wound closure
without, 251
smears, method of, 42, 43 ,
, technique of, 181-204
Beck's paste, 213
Berthollet discovers hypochlorite of
soda, 93
Blood-clots, removal of, 80
259
260
INDEX
Blood-serum hinders bactericidal
action of antiseptics, 16-18
Bone, grafting of, 134
, loss of, made good, 80, 213
Bony cavities, filling of, 80, 213
splinters, resection of, 131
Boric acid, in Dakin's Solution, 22,
23, 94, 95
Brain, wounds of the, preparation
of, 128, 129
, special method of instillation
practised in, 154, 155
CAPILLARY action, failure of, as
a means of applying antiseptics,
82
Carbolic acid, Lister's use of, 3
, low bactericidal potency of,
18
Carrel, A., investigates chemio-
therapy, 6
Carrel method, the, opposed by
French medical service,
II, 12
, erroneous application of, de-
plorable results of, 13
, technical principles of the,
14-92
Chemical sterilisation of wounds.
See ABORTIVE TREATMENT ;
CHEMIOTHERAPY ; STERILISA-
TION, etc.
Chemiotherapy, principles of, 14
of general infections, 39
of local infections, 39, 40
Chloramine paste, 258
T, 70
Chloramines, interaction with
tissues, 71, 72
, sterilising powers of, 7, 8,
67-71
Chutro, Senor, his work in Paris,
10
Cicatrices, enclosure of microbes in,
78
Cicatrisation, conditions and rate of,
4*
delayed by microbial activity,
41, 42
, formula and curve repre-
senting the laws of, 44-47,
133, 134
Cleansing of wounds. See PRE-
PARATION
Clinical examination of infected
wounds, 112, 113, 173-180
Closure of wounds, after suppu-
ration, 215
, after the twelfth day, 215
, before the twelfth day, 214,
215
, correct time for, 205
, dangers of immediate, 1 19
, primary closure, 206, 207
, secondary closure, 207, 208
, technique of, 209-213
Complications, diminution of, 243,
244
Compresses, harmful effects of, 77,
80
Conclusions, 236, 237
Contact, importance of perfect, be-
tween antiseptic and mi-
crobes, 79
, importance of prolonged, 87,
88
Cost of treatment, decreased by the
Carrel method, 249
DAKIN, H. O., his investigations
of chloramines and hypo-
chk>rite, 7, 8
, , antiseptics, properties
of various, 19-21
, , blood -serum, deterrent
action of, 16-18
INDEX
261
Dakin, H. O., his investigations of
chemiotherapy, 6
prepares hypochlorite. See
HYPOCHLORITE OF SODA;
DAKIN'S SOLUTION
Dakin's solution, bactericidal po-
tency, of, in vitro, 27, 28 ;
in vivo, 29, 30
compared with Javel's and
Labarraque's solutions,
105, 106
compared with other anti-
septics, 32-34
, concentration, proper degree
of, 86, 108
, concentration decreased by
contact with tissues, 85
,. cost of, 249
, Daufresne's method of pre-
paring, 95-100
, instillation of, 162-168
, keeping qualities of, 103, 104
, perfected method of prepara-
tion, 95-98
, preparation of, 94
, technique of manufacture, 93-
108
Daufresne on the bactericidal po-
tency of Dakin's solution,
27-29
, his method of preparing Da-
kin's solution, 95-100
investigates deterrent action
of blood-serum, 16-18
Deep wounds, difficulty of steri-
lising, 79
Depage, Dr., introduces the Carrel
method at La Panne, 10
Dimensions of wound and time of
sterilisation, relation between,
89
Distributor tubes (glass) for instil-
lation, 1 88, 189
Drainage of wounds, 118, 119
Dressing of irrigated wounds, 157-
161
Drop-counter for instillation appa-
ratus, 143
Duration of treatment decreased by
early anatomical repairs,
247, 248
by secondary closure, 246,
247
EAU DE JAVEL, compared with
Dakin's solution, 105, 106
, action of, on tissues, 23, 24
, dangers of, 21, 93, 107
, use of, in the present war, 25,
62
Elbow, injuries to the, 231
Electro- vibrator, Bergonie's, 117
Errors in bacteriological exami-
nation, 251
of technique, 168-172
of treatment, causes of, 106-
1 08
FAILURE, causes of, 250-253
Femur, fractures of the, 226-230,
236, 238-242
Flavine, retards repair of tissues,
58-60
Forearm, fractures of the, 235, 236
Foreign bodies, search for, in,
116-118, 128
Fractures, closure of, 212, 213
, compound, and joint injuries,
119, 120
, infected, treatment of, 126,
127, 130-132
, sterilisation of, 133, 221, 242 ^
, suppurating, 234-242
, surgical cleansing of, 130-132
Fresh wounds, sterilisation of, 217,
218
17*
262
INDEX
GANGRENOUS infection, I i.o
wounds, sterilisation of, 218-
220
Gas, given off by anaesthetic cul-
ture, 74
Gas gangrene, I
, causes of, 80
, treatment, no
, types of, 122-125
Gauze, improper use of, 81, 82
Grafting, of bone, 134
of adipose tissue, 213
osteo-periosteal, 248, 249
Guillot and Woimant, researches
of, at Compiegne, n
HAEMORRHAGE, secondary, 127,
128
Haemostasis of wound surfaces,
importance of, 80, 116, 127,
128
Hydrogen peroxide, low bacteri-
cidal potency of, in vivo, 19
Hypertonic saline solutions, use-
lessness of, 32, 33
Hypochlorite, electrolytic, 24
may be rendered stable, 24
Hypochlorite of magnesium, advan-
tages and defects of, 26
Hypochlorite of soda, Dakin's, 7, 8
, , properties of, 21-27
, action of, not due to alka-
linity, 35
, , on anatomical ele-
ments, 39
, , on cicatrisation of in-
fected wounds, 47-52
, , on that of aseptic
wounds, 52-61
, , on tissues provided with
circulation, 41-42
, , on toxins, 35-37
, commercial, 20
! Hypochlorite of soda, dangerous if in-
jected into circulation, be-
ing strongly haemolytic, 37
, action of, mode of, 64-71
, , on tissues, slight, 23, 24
, destroyed by the tissues, 61-64
, interaction of, with dead and
living tissues, 38-41
, renewal of, frequent necessity
of, 84-86
, toxicity of, low, 37
See DAKIN'S SOLUTION
Humerus, fractures of the, 222, 223,
2 3 2 3!> 2 33
IMMOBILISATION of wounded limbs,
162
Incapacity, reduced by abortive
treatment, 249, 250
Incision of wounds, 81
Infected wounds, impotence of old
methods of treatment of, I
See PREPARATION ; CLINICAL
AND BACTERIOLOGICAL EXAMI-
NATION ; STERILISATION, etc.
Infection in wounds, advantages of
suppression of, 2
, abolition of, now possible, 8
, gas-producing, 122-125
, local character of initial
stages, 5
, topography of, studied by
means of smears, 180-204
, , 73-8o
Inflammatory stage of wound in-
fection, no
, danger of intervention during,
121, 122
Instillation of antiseptics, 85, 86
, continuous, intermittent, au-
tomatic, etc., 162-167
, duration of, 167, 168
, sterilisation, essential to, 135
INDEX
263
Instillation, technique of, 135-172
Instillation tubes, 135-139
, apparatus for supplying, 139-
145
, arrangement of, in wounds,
146-156
, fixation of, to dressings, 160,
161
JOINT injuries, cleansing of, 120,
121
, sterilisation of, 230-234
, suppurating, 127
KNEE-JOINT, injuries to the, 231-
234
LABARRAQUE'S solution, action of,
on tissues, 23, 24
compared with Dakin's solu-
tion, 1 06
, dangers of using, in place of
latter, 21, 107
La Panne, results obtained by
Carrel method at, 254, 255
Leucocytes, dissolution of, 39, 65
, importance of destroying on
surface of wounds, 40
in wounds undergoing steri-
lisation, 198, 199
Lime, chloride of, titration of, 95-97
Lister, value of his work belittled
by later surgeons, 3, 4
Living tissue, resistance of, to hypo-
chlorite, 66
Lumiere, M., on action of hypo-
chlorite on microbial toxins, 35-
37
MAGNESIUM chloride, inefficacy of,
33,34
retards cicatrisation, 56, 58
Magnesium hypochlorite, 26
Mahu, M., treats mastoiditis with
Dakin's solution, 1 1
Mechanical action of hypochlorite
solution i/, 32
cleansing of wounds, 80, 81
Medullary plugs, removal or drain-
age of, 131
Microbes, counted by means of
smears, 185
, encapsulation of, 78, 133,
134
found on surface of wounds,
175, 176
, multiplication and destruction
of, 1 88, 189
, persistence of, due to foreign
bodies, 197, 198
, scarcity of (apparent), in fresh
wounds, 187
, varieties of, 193
MONONUCLEAR cells in wound se-
cretions, 198
Mortality, great reduction of, by
Carrel method, 243
Mosetig's paste, 213
NECROSED tissue, action of Dakin's
solution on, 38
protects microbes, 77
, removal of, 80
Nouy's formula for determining rate
of cicatrisation, 45
OINTMENTS, defects of, 27
Oleate of soda, 134
Osseous fissures render sterilisation
difficult, 79
Osteo- myelitis, 2, 79
PARA- TOLUENE-SODIUM -SULPHO-
CHLORAMINE, 7O
Patella, fracture of the, 222
26 4
INDEX
Phagocytes on wound-surfaces, im-
portance of destroying, 39
Phagocytosis in walls of wounds, 39
Phlegmonous infections, no, 125,
126
, sterilisation of, 218-220
Physiological saline solution, in-
efficacy of, 32, 33
Polynuclear 'cells in wounds under
treatment, 39, 75, 198, 199
Powdered antiseptics, 27
Pozzi, M., demonstrates value of
chemiotherapy, 8
Pre-inflammatory stages of wounds,
809
, the best time for intervention,
in
Preparation of wounds for sterili-
sation, 80, 8 1
, anaesthesia during, 113, 114
, chemical cleansing, 129, 130
, compound fractures, cleansing
of, 119-121
, drainage, 118, 119
, foreign bodies, search for,
116-118
, haemostasis of walls, 1 16
, mechanical cleansing, 109-
in
, opening up of wounded tracts,
114-116
, surgical cleansing, 130-132
, technique of, 111-129
Preventive treatment, advantages
of, 7
QUNU, on results of the Carrel
method, 9
RADIOLOGICAL examination of
wounds, 112, 113
Reinfection, from cicatricial tissues,
78, 133. 134
Reinfection from sinuses, 190-193
Repair, action of hypochlorite on,
47-61
, delayed by infection, 41, 42
, rate of, 44-47
Repairs, anatomical, influence on
duration of treatment, 247-249
Research, failures and errors in, 2, 3
Results of Carrel method, 216, 217
Rubber tubes, in application of
antiseptic, 82-84
SCARS, results of, 2
Secondary or operative infection, 76
Secretion of wounds, the bacterio-
logical study of, 15, 181-204
Septicaemia, danger of, ill
Serums, useless in cases of general
wound infection, 6
Sherman, Dr., on the Carrel method
in industrial accident cases, 10
Shock, treatment for, 1 1 1
Sinus, failure due to, 252
Soda, action of, on tissues, 65
Soft parts, wounds of the, 216
Smears, asepsis indicated by, 202,
203
, secretions of wounds studied
by means of, 181-204
, technique of, 182-187
, topography of infection exa-
mined by means of, 73,
74
, uselessness of, while haemor-
rhage persists, 186
, value of the method, 200
Splinters, bony, excision of, 120
Statistics of results obtained, 9, 10,
252-255
Sterilisation of wounds, chemical,
possibility of, denied by
Wright, 4, 5
, consequences of, 242 -245
INDEX
265
Sterilisation of wounds, prolonged
contact between antiseptic
and the tissues essential,
87,88
, results obtained, 216-242
, spontaneous occurrence of,
impossible, 29, 30
, technique of, 135-172
, time required for, in relation
to size of wound, 89
Strapping, closure by, 209
Stumps, covered by traction, 211
Suppurating wounds, closure after
sterilisation, 252
, disinfection and abolition of,
253. 256
, examination of, 193-198
, sterilisation of, 221
Suppuration, abolition of possible, 8
, can and should be abolished,
253, 255, 256
, period of, 77-80, 129
Surgical cleansing of wounds, 80,
81. See PREPARATION
Surgical intervention, dangers of,
in highly infected wounds, 125
Suturing of wounds, 76, 77
of muscles, nerves, etc., 212
, peril of premature, 206, 207
, technique of, 212
, time for, when indicated, 207,
208
THIGH, fractures of the. .5^ FEMUR
Tibia, fractures of the, 223-226,
239, 240
, causes of occasional failure
in treating, 253
Tissues, the, action of Dakin's so-
lution on, 37-39
, action of hypochlorite on, 66
, action of, on hypochlorite,
41-44
Tissues, importance of not injuring,
5,6
Titration of chloride of lime, 95
of Dakin's solution, 99-102
Traction, closure by, 210-212
Tubes, instillation, 135-162. See
INSTILLATION
Tuffier, M., his treatment of pleu-
risy, ii
on the Carrel method, 9
VINCENT'S powdered antiseptics, 27
WASHING wounds, futility of, 86, 87
Wounds, bacteriological examina-
tion of, 90-92, 181-204
, clinical examination of, 173-
180
, closure of, 205-215
, conditions of those treated,
42,43
. , dressing of, 157-160
, fractures and wounds of joints,
221-242
, infection of, 5
, measurement and repair of,
43-45
, micro-organisms found in, at
different stages, 73-77
, preparation of, 109-133
, , for treatment, 80, 81
, septic character of, I
, sterilisation of those of soft
parts, 216, 217
, of fresh wounds, 217,
218
, of phlegmonous and gan-
grenous wounds, 1 18-220
, of suppurating wounds,
221
, sterilising, method of, 82-84
, suppuration of, 77-80
, treatment of different types
of, 146-157
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