THE TREATMENT OF INFECTED 
 
 WOUNDS 
 
THE TREATMENT OF 
 INFECTED WOUNDS 
 
 BY 
 
 A. CARREL AND G. DEHELLY 
 
 TRANSLATION BY 
 
 HERBERT CHILD 
 
 FORMERLY SURGEON FRENCH RED CROSS, CAPT. R.A.M.C. (tY.) 
 
 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 
 
 NEW YORK 
 PAUL B. HOEBER 
 
 67-69 EAST 59th STREET 
 1917 
 

 PRINTED IN GREAT BRITAIN 
 
o 
 
 -J 
 
 CD 
 
 ^ 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 all to the 
 patients themselves. 
 
 ANTHONY A. BOWLBY. 
 
 General Headquarters, 
 
 B.E.F., France, 
 
 May, 191 7. 
 
PREFACE 
 
 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,^ 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. 
 Guillot and Woimant dealt with the surgical experiments. 
 
 * 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. I^T.J,, March 13, I917. 
 Translator s note.) 
 
viii PREFACE 
 
 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 I'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 mcdecin-major Bernoud, of the colonial 
 forces. 
 
 The hospital was controlled by M. le Sous-Secretaire 
 d'P2tat 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. 
 
 CoMl'liiGNE. 
 
CONTENTS 
 
 CHAP. PAGE 
 
 Introduction by vSir Anthony A. Bowlby . . . v 
 
 Preface vii 
 
 Introduction i 
 
 I. The Principles of the Technique 13 
 
 II. Technique of the Manufacture of Dakin's Solution . 73 
 
 III. The Technique of the Sterilisation of Wounds — 
 
 Mechanical, Chemical, and Surgical Cleansing . 89 
 
 IV. The Technique of the Sterilisation of Wounds- 
 
 Chemical Sterilisation . . . . . .112 
 
 V. Clinical and Bacteriological Examination of Wounds . 147 
 
 VI. The Closure of Wounds 17S 
 
 VII. The Results 188 
 
 Appendix. — Chloramine Paste 228 
 
 Index 229 
 
THE TREATMENT 
 OF INFECTED WOUNDS 
 
 INTRODUCTION 
 
 I. It is well known that nearly all the wounds resulting 
 from explosions of shells, torpedoes, 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, 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 
 
 I 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, continues indefinitely. 
 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 functions. 
 Tendons stay gripped in fibrous fetters. Nerve ex- 
 tremities 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 ch'sregard 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 dogma, the teaching that antiseptics had no 
 real efficacy. In a memorandum on the treatment of 
 wounds in war,^ MM. Burghard, Leishman, Moynihan 
 and Wright, wrote in April, 191 5, 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 
 
 ' Burghard, I.cibhman, Moynihan and Wright, Office international 
 <P hygiene publique^ 19 15, vol. vii. p. 946. 
 
INTRODUCTION 5 
 
 191 5, "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." ^ 
 
 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 ! ^ 
 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, durine 
 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 
 Jojtrnal, April 24, 1915, p. 721. 
 
 - Pierre Delbet, Bulletin et Mimoires de la Societe de Chirjo-gie^ 
 Janvier, 1916. 
 
6 TREATMENT OF INFECTED WOUNDS 
 
 As a difference of resistance exists between, on 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,^ and, by a special process, hypo- 
 chlorite of soda.^ 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 chemio-therapy. 
 
 ^ Dakin, Cohen, Daufresne and Kenyon, Proceeduigs of the Royal 
 Society^ 1916, vol. 89, p. 232. 
 
 - Dakin, Presse Medic ale ^ Sept. 30, 191 5. 
 
8 TREATMENT OF INFECTED WOUNDS 
 
 From May, 191 5, it became evident that wounds 
 treated after a certain method by the aid of hypochlorite 
 or the chloramines of Dakin were sterihsed, 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, 191 5, 
 Dakin ^ 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 Academie de Medecine the principles which 
 are fundamental to the chemio-therapy of wounds.^ 
 These principles were later set forth in a more complete 
 manner in 1916, in the Archives de Medecine et de 
 Pharmacie Militaires.^ On several occasions at the 
 Academie de Medecine, and at the Societe de Chirurgie, 
 M. Pozzi,* 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 
 
 ^ Dakin, Ptrsse Medicate^ loco citato. 
 
 • Carrel, Dakin, Daufresne, Dehelly, and Dumas, Presse JlfJdicale, 
 Oct. II, 1915. 
 
 ^ Carrel, Archives de Midicme et de Pharmacie Militaires^ May, 1916. 
 
 * Fozzi, Academie de Midicine et SociHS de Chirurgie^ 19 15 and J916. 
 
INTRODUCTION 9 
 
 to the Societe de Chirurgie, M. Tuffier^ pointed out 
 the results which it was possible to obtain by the same 
 technique. Le medecin principal Uffoltz published in 
 1 916 (January) an important article,^ 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 Academie 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 Academie 
 de Medecine a paper in which he announced the results 
 obtained by the sterilisation of wounds in wards under 
 his care. Not one of 1 1 1 cases had suppurated. On 
 May 2nd, one of us read a paper at the Academie de 
 Medecine on the subject of 153 wounds treated in the 
 hospital at Compiegne during the month of December, 
 191 5. Of these 155 wounds, 135 were closed. Of the 
 135 successes, 121 were united before the 12th day. 
 
 On May 23rd, M. Ouenu 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 
 
 ' Tuffier, Societe de Chirurgie, 1 91 5 and 191 6. 
 
 - Uffoltz, A^rhives de MMicine et de Pharmacie AliHfaires, Jan., 1916. 
 
lo TREATMENT OF INFECTED WOUNDS 
 
 in war. In 31 out of 33 cases, union by first intention 
 had been obtained after secondary closure. In the 
 hospital at Panne, M. Depage ^ and his colleagues had 
 obtained equal success in the sterilisation and secondary 
 closure of a great number of wounds. 
 
 Although these results show in unmistakable manner 
 that infected wounds can be sterilised and sutured, and 
 although more than a year has elapsed since the 
 technique was made known, the chemical sterilisation of 
 wounds is still an exceptional occurrence. It is only at 
 the hospital at Compiegne, at M. Depage's hospital at 
 Panne, and in two or three territorial hospitals that the 
 method is employed in its integrity. 
 
 From the month of September, 191 5, it has been 
 possible to do away with suppuration in hospitals. But 
 our methods met with so much opposition from certain 
 individuals at the head of the medical profession in 
 France that they have been applied scarcely anywhere. 
 A glance through the reports of discussions in the 
 Societe de Chirurgie and the Academie de Medecine, 
 on the occasions when papers by MM. Pozzi and Tuffier 
 were read, will show with what culpable levity a method 
 which could have saved a large number of limbs and 
 lives was rejected.^ The men-^ who criticised us so 
 
 * Depage, Bulletin et Memoirs de la Societe de Chirurgie, vol. xlii. (1916), 
 p. 1987. 
 
 2 ". . . 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 Societe de Chirurgie de Paris, vol. xlii. pp. 104 
 and 105. 
 
 3 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. Dclbet, Hartmann, Broca, Potherat, Chapur, 
 etc. Bulletin et Memoires de la Societe de Chirurgie and Presse Medicate, 
 1915-1916. 
 
INTRODUCTION ii 
 
 severely have taken the trouble neither to examine 
 our methods nor to check our results. They knew 
 nothing of the methods they discussed.^ Their re- 
 sponsibility is all the greater because their position at 
 the University and in the hospitals of Paris has given 
 such weight of authority 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 
 
 ^ 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 gi-avity of mutilations and 
 infirmities. 
 
 *' In fact, after the sentence, almost of reproof, pronounced against it 
 here, and at the Academie 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 
 this attitude of our great learned Societies risks doing harm, but it is the 
 Societies themselves, who, h priori, and without relying upon an investiga- 
 tion easy to carry out (l'h6pital Carrel being at Compiegne), have publicly 
 refused to the treatment newly instituted the merit of originality and of 
 progress . . . ." 
 
12 TREATMENT OF INFECTED WOUNDS 
 
 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. 
 
 Compiegne, Sept. i, 191 6. 
 
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 
 
 13 
 
14 TREATMENT OF INFECTED WOUNDS 
 
 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 
 
THE PRINCIPLES OF THE TECHNIQUE 15 
 
 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 pov/er 
 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. 
 
i6 TREATMENT OF INFECTED WOUNDS 
 
 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 iS"" 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 
 
 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 
 
THE PRINCIPLES OF THE TECHNIQUE 17 
 
 use. The sign -f indicates that the culture is positive, 
 
 and the sign 
 
 that it remained sterile. 
 
 Antiseptics. 
 
 Without blood-serum. 
 
 With blood-serum. 
 
 Acid carbolic . . . 
 
 >i j> ... 
 Acid salicylic . . . 
 
 »» >» ... 
 Hydrogen peroxide . 
 
 Iodine 
 
 
 
 
 : 250 — 
 
 : 500 + 
 
 : 2,500 - 
 
 : 5,000 + 
 
 : 3.500 " 
 8,000 -f 
 100,000 — 
 10,000,000 + 
 5,000,000 — 
 10,000,000 + 
 1,000,000 — 
 10,000,000 + 
 500,000 — 
 1,000,000 4- 
 
 I : 50 - 
 I : 100 + 
 I : 100 - 
 I : 250 + 
 I : 1,700 - 
 I : 2,000 + 
 I : 1,000 — 
 
 
 
 
 I : 2,500 + 
 I : 25,000 — 
 I : 50,000 4- 
 I : 10,000 — 
 I : 25,000 + 
 I : 1,500 - 
 I : 2,000 + 
 
 Bichloride of mercury 
 
 Nitrate of silver . . 
 
 >» »> ... 
 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 
 
i8 TREATMENT OF INFECTED WOUNDS 
 
 germicidal action, it becomes highly destructive to 
 normal tissues. 
 
 Hydrogen peroxide solution gives encouraging re- 
 sults when its bactericidal action is examined in a test- 
 tube. But on 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 i 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. 
 
 • Dakin, Presse Medicale, 191 5. 
 
THE PRINCIPLES OF THE TECHNIQUE 19 
 
 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. Tufher's laboratory at I'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 
 
20 TREATMENT OF INFECTED WOUNDS 
 
 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.^ 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. 
 
 * Dakin, British Medical Journal, 1915, p. 809. 
 
THE PRINCIPLES OF THE TECHNIQUE 21 
 
 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 
 
22 TREATMENT OF INFECTED WOUNDS 
 
 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 Academic de Medecine, 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 thre^ 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 
 
THE PRINCIPLES OF THE TECHNIQUE 23 
 
 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. 
 
 Many other preparations of hypochlorites have been 
 previously employed in surgery. L'eau de Javel and 
 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, 19 14, in the 
 
24 TREATMENT OF INFECTED WOUNDS 
 
 hospital at Dunkirk, MM. Landry and Jacomet used 
 eau de Javel in " gas " infections. Mixtures of chloride 
 of calcium and boric acid in powder have been used 
 by Vincent, by Lumiere, and by Lorrain Smith. But 
 Dakin's solution, applied according to the technique 
 which will be described later, gives much better results 
 than the irritating solutions employed up to the present, 
 and than powders composed of substances only partly 
 soluble. The local production, by a mixture of hypo- 
 chlorites in powder, of hypochlorous acid, or of chlorine, 
 in a degree of concentration relatively high, is more 
 dangerous for healthy tissues than the continued ap- 
 plication of a feeble neutral solution of hypochlorite of 
 soda. Besides, a solution has the advantage of pene- 
 trating the recesses of deep wounds. Speaking generally, 
 the experiments we have made with Dakin on substances 
 in. powder, and substances dissolved in fatty vehicles 
 such as vaselin or lanolin, have yielded results greatly 
 inferior to those of experiments made with watery solu- 
 tions. On the other hand, it is true that the application 
 of a watery solution demands more care. 
 
 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 
 1:500,000 to 1:1,000,000; whilst, in the presence of 
 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 ; 
 
THE PRINCIPLES OF THE TECHNIQUE 25 
 
 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 
 tlie character of the pus. 
 
 The results of these experiments in vitro are of but 
 slight importance, for experimental conditions 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, 
 tlie duration of the action of the hypochlorite upon the 
 microbes in suspension in the pus is short. If, at the 
 end of two or three hours, one tests for the hypochlorite 
 contained in the mixture, sometimes it is found that it 
 has completely disappeared. The hypochlorite, in fact, 
 rapidly enters into combination with the proteins of the 
 pus, and chemical analysis is no longer able to dis- 
 cover it. It is precisely because of this rapid disappear- 
 ance of hypochlorite 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. 
 
 The bactericidal action of Dakin's hypochlorite was 
 next studied in infected wounds themselves. When 
 
26 TREATMENT OF INFECTED WOUNDS 
 
 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. i). This 
 fact has been observed a very 
 great number of times. Indeed, 
 one might affirm that it con- 
 stantly happens when intimate 
 contact is established between 
 the antiseptic solution and the 
 organisms. The sterilisation of 
 wounds treated by Dakin's solu- 
 tion 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 
 
 Fig. I. — Disappearance of the hypochlorite of Soda. 
 the microbes of a his:hlv / \ t, • i . i ^ i 
 
 (a) It might be suggested 
 that, in our observations, the 
 wounds grew sterile spontaneously. 
 In truth this is hardly likely, be- 
 cause one never sees a series of 
 infected wounds become sterile in a few days. Neverthe- 
 less, this hypothesis was submitted to experimental 
 analysis. Choosing a wound whose various regions w ere 
 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 
 
 
 MOlSJMai JijmlS15| 
 
 
 J0URSJ31 1 |2 ii 
 
 
 
 00-4--4--J- 
 
 
 1 r i 
 
 
 ^-rt 1 
 
 • 
 
 60 : \i 
 
 "^ 
 
 
 ■-5 
 
 
 ■^ 
 
 
 ^ 
 
 4n j---p 
 
 ^ 
 
 
 
 b; 
 
 1 
 
 ->• 
 
 n'\ it 1 
 
 ? 
 
 20 It J,. 
 
 
 
 
 tl ^ 
 
 f 
 
 1 M 
 
 
 -ID 1 i ' 
 
 V. 
 
 • X: ! 1 
 
 ^ 
 
 
 ^ 
 
 1 
 
 
 H 
 
 =o 
 
 
 ^^ 
 
 1 
 
 
 
 
 1 "i" 
 
 
 > j_ E 1 
 
 
 ^iiii:: 
 
 
 >h \ 
 
 
 i>- jk _ 
 
 
 -rlo, — ^\ 
 
 infected wound, after treat- 
 ment by Dakin's hypo- 
 chlorite, May 31st to June 
 2nd, 1915. (Case 28.) 
 (00 denotes infinity. Trans- 
 lator.) 
 
THE PRINCIPLES OF THE TECHNIQUE 27 
 
 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. 2). 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, and 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 
 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 
 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 
 
28 TREATMENT OF INFECTED WOUNDS 
 
 the mechanical action of the instilled liquid. The follow- 
 ing experiments were devised to elucidate this point. A 
 wounded man had upon his thigh two wounds of 
 
 
 MOiS Janvia 
 
 m 
 
 
 JOURS 6 1 7 
 
 8 
 
 
 
 oo 
 
 ' 
 
 
 
 
 
 
 -. 
 
 
 '^^ 
 
 60 
 
 
 >- 
 
 
 
 <; 
 
 
 
 i>: 
 
 
 
 ^ 
 
 
 
 
 40 I-- 
 
 
 ■*^, 
 
 
 
 o,^ 
 
 
 
 •o 
 
 
 
 
 
 
 
 20 -li; 
 
 
 '^ 
 
 IT* 
 
 
 
 [ 
 
 
 ^ 
 
 
 
 ^ 
 
 '0 1 
 
 
 ^ 
 
 
 
 ■^ 
 
 ■" 
 
 
 ^> 
 
 V 
 
 
 ^=0 
 
 I 
 
 
 ^l 
 
 5 -4 
 
 
 
 
 
 ^, 
 
 J 
 
 
 "T^ 
 
 
 - 
 
 
 1 
 
 j__ 
 
 
 h — 
 
 \ 
 
 
 2— . 
 
 \ 
 
 
 %-— 
 
 \ 
 
 ! 
 
 
 ±il 
 
 Fig. 2. — 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.) 
 
 
 Mois Mai 1915 
 
 
 JOURS 22 1 23 
 
 
 na 
 
 00 
 
 
 
 
 , 
 
 
 
 —— ^ 
 
 60 
 
 
 
 
 
 
 
 ^ 
 
 
 ^ ' 
 
 40 I 
 
 •^ 
 
 
 
 
 V i-^r 
 
 cQ 
 
 
 i^ 
 
 20 _zi: : 
 
 »^ 
 
 
 •■Ni 
 
 % 
 
 f= 
 
 10 ::z^ii5 
 
 <, 
 
 
 ^C 
 
 r . _ .. . a! ,_ . 
 
 ^''' 
 
 5 ii__l_i: 
 
 
 
 ^ 
 
 JL 
 
 ^ 
 
 4 ■ 
 
 f z& 
 
 
 \ \__ 
 
 
 ^-— tj 
 
 
 %-i---1 
 
 
 ]? 1 
 
 Fig. 3. —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.) 
 
 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 
 
THE PRINCIPLES OF THE TECHNIQUE 29 
 
 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. 3). 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. It is therefore evident that hypochlorite 
 acts by its antiseptic power and not by mechanical 
 means. 
 
 {c) The antiseptic power of hypochlorite is not due 
 to its alkalinity. In M. Tissot's paper, read at TAcademie 
 des Sciences by M. Dastre,^ that author attributed the 
 
 ' Tissot, C. R. Academie des Sciences, Sept. 13, 1915. 
 
30 TREATMENT OF INFECTED WOUNDS 
 
 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 wi;h 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.^ 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 
 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 
 
 ' Auguste Lumiere, C. 7^. Acad^mU des Sciences^ March 6, 19 16. 
 
THE PRINCIPLES OF THE TECHNIQUE 31 
 
 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 survived. 
 
 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. Lumiere's experiments prove, therefore, that hypo- 
 chlorite of soda destroys toxins contained in pus. This 
 destruction of toxins by oxidising antiseptics plays a 
 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. 
 
32 TREAT.MENT OF INFECTED WOUNDS 
 
 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, ir4 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. — Experi- 
 ments made upon guinea-pigs have already shown that 
 a small quantity of hypochlorite of soda injected into a 
 fragment of sponge placed under the skin, produces 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 sets up no marked irritation. At the 
 
THE PRINCIPLES OF THE TECHNIQUE 33 
 
 same time the action of hypochlorite on the tissues is 
 much greater i7i vitro than in vivo. Fragments of skin 
 placed in Dakin's solution begin to disintegrate at the 
 end of less than twenty-four hours. Red corpuscles are 
 almost immediately destroyed. If pus be mixed in a 
 tube with Dakin's solution, the leucocytes are rapidly 
 attacked. 
 
 However, in the secretions from wounds treated by 
 hypochlorite, the polynuclear cells are not much altered, 
 and contain microbes. It is probable that phagocytosis 
 takes places in the sides of the wound under shelter of 
 the antiseptic which is found on the surface. Tissues 
 deprived of circulation dissolve, and the surface of the 
 tissues rapidly cleans up. When the wall of a vessel is 
 gangrenous, the loosening of the dead fragment comes 
 about more rapidly than if the wound were left to itself 
 Even the clots which sometimes close vascular wounds 
 may dissolve under the influence of hypochlorite. There- 
 fore the state of the vessels at the time of intervention 
 must be carefully looked into, so as to ensure reliable 
 haemostasis. 
 
 In a word, Dakin's solution possesses a concentration 
 which allows one to make use of the differences of 
 resistance presented, on the one hand, by microbes, free 
 anatomical elements, and necrosed tissues : and on the 
 other hand, normal tissues equipped with a circulation 
 It destroys the first and does not damage the second. 
 It is important to know to what extent it acts on living 
 tissues. In order to estimate its action, the progress of 
 cicatrisation of wounds treated by hypochlorite has been 
 studied by us. 
 
 Certain technical difficulties are presented by this 
 
 3 
 
34 TREATMENT OF INFECTED WOUNDS 
 
 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 substances 
 supposed to aid cicatrisation. This error in technique 
 explains the contradictions found in all medical publica- 
 tions 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 
 
THE PRINCIPLES OF THE TECHNIQUE 35 
 
 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 state of the wound, by means of the microscope, is 
 indispensable, to avoid a false interpretation of the ex- 
 perimental results. 
 
 The experiments have been 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 
 
36 TREATMENT OF INFECTED WOUNDS 
 
 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 of chloramine. 
 When the bacteriological examination showed that 
 sterilisation was complete, the wound was dressed, 
 either with oleate of soda, or stearate of soda containing 
 small quantities of antiseptic, or with vaseline 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. 
 
 (I?) Teckniqtie of the Measitrement of Wounds. — In 
 most cases the progress of repair was studied on surface 
 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 
 
THE PRINCIPLES OF THE TECHNIQUE n 
 
 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- 
 
 Stmt 
 
 
 -I 
 
 \ 
 
 
 ~ 
 
 - 
 
 
 
 h- 
 
 
 
 
 
 
 
 
 14 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1? 
 
 
 
 
 \ 
 
 V 
 
 
 
 
 
 
 
 
 
 
 
 
 in 
 
 
 
 
 
 > 
 
 i 
 
 
 
 
 
 
 
 
 
 
 
 R 
 
 - 
 
 
 
 
 
 \ 
 
 L 
 
 
 
 
 
 
 
 
 
 
 6 
 
 
 
 
 
 
 \ 
 
 V 
 
 
 
 
 
 
 
 
 
 4 
 
 1 
 
 
 
 
 
 
 \ 
 
 k 
 
 
 
 
 
 
 
 - 
 
 o 
 
 
 
 
 
 
 
 
 
 
 S 
 
 \ 
 
 
 
 
 
 CI 
 
 
 
 
 
 
 
 
 
 
 
 
 V 
 
 s 
 
 s 
 
 •T' 
 
 •h 
 
 *fc 
 
 E 
 
 >. 
 
 
 ■" t 
 
 9 -1 
 
 3 i 
 
 3Z 
 
 ix 
 
 f' ii 
 
 a 
 
 1 i 
 
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 i 
 
 
 H 
 
 rs 
 
 Fig. 4. — Cicatrisation curve of an 
 aseptic wound. Surface, expressed 
 in square centimetres, forms tlae 
 ordinates, whilst time, in days, the 
 absciss£e. (Case 221.) 
 
 ilDecfifi 25 
 
 Fig. 5. — Curves, observed and calculated, 
 for the same wound. By means of 
 observations made the 17th and 21st 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.) 
 
 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. It is known that the curve 
 of cicatrisation of a wound is of geometrical form (Fig. 4)^ 
 and that Lecomte du Nouy has found its algebraic 
 expression.^ 
 
 1 Carrel, Journal of the American Medical Association, 1910, and 
 
38 TREATMENT OF INFECTED WOUNDS 
 
 After one or two observations the curve of a wound 
 was calculated, and the observed curve was traced on 
 the same sheet (Fig. 5). Thus the abnormal variations 
 in progress of the repair of the wound, which manifest 
 themselves by the divergence of the observed curve 
 from the calculated curve, can be ascertained. As we 
 possess also the chart of the bacteriological condition 
 of the wound, it is easy to estimate almost exactly the 
 part played in the progress of repair by the substance 
 being studied. By means of this method 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. 
 
 (c) Action of Hypochlorite iipoji the Cicatrisation of 
 an Infected Wonnd. — Many experiments were made 
 upon surface-wounds whose curves of cicatrisation were 
 known, and of which the bacteriological condition was 
 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. 6 and 7). 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. 8 and 9). 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. 
 
 Journal of Expcrivuntal MedicinCy 1916. Lecomte du ^o\x.y ., J our?ial of 
 ExpctiinaUal Medicine^ Nov., 1916. A. Harlmann, T/iese de Paris ^ 1916. 
 
THE PRINCIPLES OF THE TECHNIQUE 39 
 
 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 
 
 1R5 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 150 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1?S 
 
 
 ) 
 
 \ 
 
 V 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 inn 
 
 
 
 
 \ 
 
 \ 
 
 K 
 
 >N 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 75 
 
 
 
 
 
 
 
 \ 
 
 < 
 
 k 
 
 \ 
 
 \ 
 
 
 
 
 
 
 
 
 sn 
 
 
 
 
 
 
 
 
 
 
 
 -^ 
 
 s 
 
 \ 
 
 \ 
 
 
 
 
 
 ?s 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 s 
 
 s 
 
 \ 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ".^ 
 
 
 \ t 
 
 £ 
 
 11 
 
 I 
 
 2 * 
 
 4 1 
 
 3"1 
 
 3 2 
 
 02 
 
 22 
 
 4-2 
 
 6-2 
 
 «J 
 
 an 
 
 i i 
 
 i 3 
 
 Fig. 6. — Cicatrisation curve of a wound 
 of the abdominal wall. Slowing down 
 of cicatrisation from Feb. loth 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.) 
 
 
 MOISI Fevrieri916 
 
 S| 
 
 
 JOURS 
 
 4 
 
 6 
 
 10 
 
 14 
 
 16 18 
 
 19 20 2J 
 
 3 
 
 
 s£ 
 
 00 
 
 60 
 40 
 20 
 10 
 
 5 
 
 1 
 
 h 
 
 ho 
 
 
 
 
 
 
 
 _; 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ■ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 -*— ^ 
 
 
 
 
 
 
 
 
 
 
 
 
 V 
 
 
 
 
 
 
 
 
 
 
 
 
 -^ 
 
 
 
 
 
 
 
 
 
 
 
 
 '^ 
 
 
 
 
 
 
 
 
 
 
 
 
 ■h:? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 V. 
 
 
 
 
 
 
 
 
 
 
 
 
 S' 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 
 
 *"-* 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 '^ 
 
 
 
 
 
 
 
 
 
 
 
 
 i^ 
 
 
 
 
 
 
 
 
 
 ^ 
 
 
 
 ^ 
 
 
 
 
 
 
 
 
 1 1 [ 1 
 
 
 
 *N 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^^'3 
 
 
 
 
 
 
 
 
 
 Jjfc 1 
 
 
 
 
 
 
 
 
 
 
 
 
 73H" 
 
 
 
 ■^ 
 
 
 
 
 
 1 
 
 
 
 !tf jt ■ 
 
 
 
 t.>^ 
 
 
 
 
 
 
 
 
 
 E- J 
 
 
 
 ^ 
 
 
 
 
 
 
 ■ 
 
 
 ( 
 
 I1 
 
 
 
 ^_ 
 
 
 
 
 
 
 
 
 / 
 
 g 
 
 
 
 
 
 ^ 
 
 m 
 
 N 
 
 tx 
 
 tB 
 
 !«S 
 
 / 
 
 i 
 
 
 
 
 
 
 
 
 
 
 
 
 t 
 
 
 
 
 
 
 
 
 
 
 
 
 I 
 
 
 
 
 
 
 
 
 
 
 
 
 _ffl! 
 
 ^^_^. 
 
 
 
 
 «, 
 
 _ 
 
 „ 
 
 ^ 
 
 
 _ 
 
 _ 
 
 
 
 . 
 
 Fig. 7. — 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. 18th. (Case 327.) 
 
 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. 
 
40 TREATMENT OF INFECTED WOUNDS 
 
 13 15 17 1£' 21 iJ 25 if 2S?1 3 
 Nov JOOC 
 
 P'iG. 8. — 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 14th to the 29th of Nov. It was sterilised on the 29th of Nov. 
 Instantly cicatrisation commenced and its course followed a geometric 
 curve. 
 
 
 MOIS} t^ 
 
 jovembre'l916 | [ 
 
 Decembre 
 
 
 JOURS 122-|23 
 
 24 25 26 
 
 27 28 29 30 1 2 3 4 5 
 
 6 7 8 9 10 11 12 
 
 
 
 OOHr-^ 
 
 pr<y= "^^f ■< i 
 
 "5 "^=t=! 
 
 f 
 
 
 
 
 
 1 
 
 " '^ "^ — ' — 1 ^ — 
 
 
 -— ^ 
 
 60 
 
 
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 t 
 
 
 
 
 
 \ r^ 
 
 
 <^ 
 
 
 
 ~i 
 
 
 
 40 . _ 
 
 
 B 
 
 
 r^ 
 
 
 
 ft- i 
 
 
 Ss 
 
 
 
 r 
 
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 T 
 
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 ^ 
 
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 K L, 
 
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 jv 
 
 
 
 
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 \ 
 
 
 <^ 
 
 
 
 ■ 
 
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 r^ 
 
 in 
 
 
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 [ ( 
 
 j^^ 
 
 10 
 
 
 l 
 
 A. L 
 
 *> 
 
 
 
 \ 
 
 w I 
 
 •ft, 
 
 
 
 1 
 
 ffc 
 
 
 
 
 
 "ff Jl 
 
 ■■^i, 
 
 r 
 
 
 
 A 1 ' 
 
 2^1 
 
 5 
 
 
 
 f jjf 
 
 
 
 
 
 Tf » 
 
 
 
 
 t 
 
 ff 1 
 
 r, 
 
 
 
 3! 
 
 / A 
 
 
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 j[ 
 
 J Jl 
 
 ^ 
 
 
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 ^? 1 
 
 
 >?_-_ 
 
 ^ 
 
 T" 
 
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 ILsllBMXosaJDBOi*] 
 
 L^W.n<^^ J> 
 
 
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 □LTitb; 
 
 
 
 Fig. 9. — 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. 
 
THE PRINCIPLES OF THE TECHNIQUE 41 
 
 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. 
 
 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 only con- 
 tained 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 cc, 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 
 
42 TREATMENT OF INFECTED WOUNDS 
 
 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 w^ound. 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 uni- 
 formly 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. lO and Fig. 1 1). 
 
 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 
 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 
 taken place in the region treated by Dakin's solution 
 (Fig. ii). 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 
 
THE PRINCIPLES OF THE TECHNIQUE 43 
 
 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. 
 
 -w^ 
 
 Fig. 10. — 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. II. — 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. 
 
 There was, therefore, 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 
 
44 TREATMENT OF INFECTED WOUNDS 
 
 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 upon tlu 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 
 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 
 
THE PRINCIPLES OF THE TECHNIQUE 45 
 
 rapidly under the vaselin than under the hypochlorite 
 (Fig. 12). 
 
 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 
 
 ,./>-r:. 
 
 Fig. 12. — 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. i6. 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. 13. — 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 outUne 
 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. 
 
 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 bein^ dressed with vaselin and hypochlorite. 
 
46 TREATMENT OF INFECTED WOUNDS 
 
 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 
 healing had become greater under the hypochlorite than 
 under the vaselin (Fig. 13). When physiological saline 
 solution was used instead of vaselin, similar results were 
 obtained. 
 
 In short, in the healing of an infected wound the 
 acceleration produced by hypochlorite is due to its anti- 
 septic power. Hypochlorite 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. 
 
 Dakin's solution, therefore, we may conclude, when 
 applied under suitable conditions, does not harm in any 
 appreciable manner, tissues under repair, which is 
 contrary to the belief of most surgeons. 
 
 5. 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 
 
THE PRINCIPLES OF THE TECHNIQUE 47 
 
 capable of reacting with hypochlorites, proteins play 
 probably the chief role. The action of hypochlorites on 
 proteid matters consists, at least in part, in the substitu- 
 tion 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 ^ 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 
 
 ^ Dakin, Cohen, Daufresne, and Kenyon, Proceedings of the Royal 
 Society f 191 6. 
 
48 TREATMENT OF INFECTED WOUNDS 
 
 of their soda content. Fiessinger also ascertained that 
 this action diminishes according as hypochlorites contain- 
 ing quantities greater or less of soda are used. Dau- 
 fresne'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^ 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 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. 
 
 ^ Guillaumin et Vienne, Archhes de Mklecine et de Pharniacie militaire^ 
 1916. 
 
THE PRINCIPLES OF THE TECHNIQUE 49 
 
 Whatever may be the explanation of the resistance 
 of living tissues to hypochlorite, this phenomenon provides 
 a working hypothesis for the chemio-therapy of wounds 
 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 
 hypochlorites, they give rise to products of a high anti- 
 septic potency. These substances, without a doubt, are 
 formed iu siiic 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. 
 
 CH3 
 
 SO^NaNCl SOaNaNCl 
 
 These substances, which possess a very high anti- 
 
 4 
 
so TREATMENT OF INFECTED WOUNDS 
 
 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 ex- 
 periments 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 colon bacillus are 
 slightly more resistant than staphylococci, whilst B. 
 perfringens and streptococci are more easily killed. 
 
 On infected wounds chloramines give results similar 
 to those of hypochorite 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 
 
THE PRINCIPLES OF THE TECHNIQUE 51 
 
 substances of the same group, particularly the chlor- 
 amlnes, in which the group NCI is separated from the 
 benzene radicle by the group S02Na ; the similar 
 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 
 
52 TREATMENT OF INFECTED WOUNDS 
 
 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 
 obscure action of the chloramine molecule, or possibly 
 to the elective chlorination of some constituent of the 
 cells. 
 
 2. The properties of para-toluene-sodium-sulphochlor- 
 amiiie. — 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 w^ithout 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. 
 
THE PRINCIPLES OF THE TECHNIQUE 53 
 
 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 
 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, 
 chemio-therapy of wounds ought to be abandoned, 
 
54 TREATMENT OF INFECTED WOUNDS 
 
 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 appHed 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. 
 
 1. 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. 156) and cultures. 
 
 During the first few hours following the infliction 
 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. 
 
THE PRINCIPLES OF THE TECHNIQUE 55 
 
 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 debris 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.^ 
 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 
 
 1 See also Policard and Phelip, C. R. de PAcadimie des Sciences, July 
 5, 1915- Fiessinger, La pratique dela chiriirgiede guerre, 1916. Fiessinger 
 and Montaz, C. R. Sociiie de Biologie, June 9, 19 16. 
 
56 TREATMENT OF INFECTED WOUNDS 
 
 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 divide 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 
 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 
 
THE PRINCIPLES OF THE TECHNIQUE 5; 
 
 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 
 regions had not been reached by the liquid, either be- 
 cause the latter had not been introduced deeply into the 
 diverticula, or because the walls were 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. SupptU'ating 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 
 
58 TREATMENT OF INFECTED WOUNDS 
 
 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, 
 when by means of sutures more or less deep wounds are 
 brought together, which had 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 submitted 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 at the moment of 
 a fresh traumatism, re-infection. In wounds of long 
 standing which are suppurating, antiseptics cannot reach 
 microbes already enclosed in granulations, but it can 
 affect those which are at the surface of the wound. As, 
 
THE PRINCIPLES OF THE TECHNIQUE 59 
 
 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 
 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,^ along which the micro-organisms are 
 
 ^ See also Bowlby, " Wounds in War," The Lancet^ 191 5> PP- 1388, 1389. 
 
6o TREATMENT OF INFECTED WOUNDS 
 
 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 
 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 
 
THE PRINCIPLES OF THE TECHNIQUE 6i 
 
 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 ha^mostasis 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 
 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 
 
62 TREATMENT OF INFECTED WOUNDS 
 
 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 
 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 
 
THE PRINCIPLES OF THE TECHNIQUE 63 
 
 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 anti- 
 septic and the surfaces is assured by introducing a rubber 
 tube to the bottom of the cavity (Fig. 14). If the 
 patient reclines in a suitable position, the wound remains 
 full of antiseptic liquid. But in dealing with surface 
 wounds (Fig. 15) — large, irregular wounds, and those 
 with several wide openings (Fig. 16) — it becomes more 
 difficult to distribute the liquid over the whole surface. 
 The most practical method consists in allowing small 
 rubber tubes perforated with minute holes to He 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 
 
64 TREATMENT OF INFECTED WOUNDS 
 
 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 obtain- 
 able 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 
 
 Fig. 14. — Wound with superior opening 
 which can be filled like a cup. 
 
 Fig. 15. — Surface wound receiving liquid 
 from a tube perforated by small holes. 
 
 Fig. 16. — Irregular wound with several 
 perforated tubes in its diverticula. 
 
 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 PRINCIPLES OF THE TECHNIQUE 65 
 
 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 solu- 
 tion 0"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 
 
 s 
 
66 TREATMENT OF INFECTED WOUNDS 
 
 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 
 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 
 
THE PRINCIPLES OF THE TECHNIQUE 6^ 
 
 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 during a 
 long enough period, 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. 
 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. 
 
68 TREATMENT OF INFECTED WOUNDS 
 
 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 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, every hour 
 a small quantity of hypochlorite was injected over the 
 surface of the wound, under the compresses. All the 
 microbes disappeared (Fig. 17). 
 
 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 instillation of hypochlorite. Daily 
 examination of the " smears," made from the discharges 
 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. 
 
THE PRINCIPLES OF THE TECHNIQUE 6g 
 
 In wounds complicated by splintered fractures some- 
 times it was 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 
 
 
 2 
 
 OIS NovemUre 191 5 Dscembre 
 
 
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 r^' 
 
 
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 20 i_ IQ - .^fc - 
 
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 V) 
 
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 h - 4- -V 4- - 
 
 
 k, - 4 
 
 
 no 1 ,,-.-,.,,. 
 
 
 >-^_.± -.„„-.. ±„__ X3 
 
 Frc 17. — Necessity for prolonged contact between the antiseptic and the 
 wound. Highly infected level 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. (co denotes infinity. — Travs.) 
 
 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 
 
70 TREATMENT OF INFECTED WOUNDS 
 
 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. 
 
 The duration of the application of hypochlorite in 
 deep wounds will lessen when it becomes possible to 
 apply continuously the antiseptic 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, 
 
THE PRINCIPLES OF THE TECHNIQUE 71 
 
 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 
 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. 
 
72 TREATMENT OF INFECTED WOUNDS 
 
 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 ^ 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 they 
 appear, and so enables the loss of time to be avoided 
 which is the usual consequence. It points out the 
 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. 
 
 ' Gaultier, Paris Mhiical, Ji'b'j I916. 
 
CHAPTER II 
 
 TFXHNTOUE OF THE MANUFACTURE OF DAKIN'S 
 
 SOLUTION 
 
 Hypochlorite of soda was discovered by Berthollet in 
 1788, and its antiseptic properties have been known 
 for a long time. Labarraqiie gained great renown by 
 embalming, by the aid of his liquor, the corpse of 
 Louis XVIII., 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 
 
 73 
 
74 TREATMENT OF INFECTED WOUNDS 
 
 content of hypochlorite must not vary beyond the Hmits 
 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 0*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 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." ^ 
 
 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 
 ju^t described. 
 
 ^ Dakin, Presse Medicale^ loc. cit. 
 
PREPARATION OF DAKIN'S SOLUTION 75 
 
 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 on several occasions observed similar solutions, 
 Daufresne 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. 
 
 A. Preparation of Dakin's Solution by Daufresne's Pro- 
 cess. — I. To prepare 10 Htres of solution weigh out 
 exactly : 
 
 Chloride of lime (having 25 per cent. 
 
 active chlorine) . . . .184 grammes 
 
 Carbonate of soda, anhydrous (carbonate 
 
 de sonde, Solvay, Fr.) . . .92 „ 
 (Or carbonate of soda, crystals . . 262) „ 
 Bicarbonate of soda , . . , ^6 ^, 
 
 2. Place in a 12-litre flask the 200 grammes of chloride 
 of lime and 5 litres of tap- water ; shake vigorously two 
 or three times, and leave it all night. 
 
•]6 TREATMENT OF INFECTED WOUNDS 
 
 3. Dissolve in 5 litres of cold water the carbonate 
 and bicarbonate of soda. 
 
 4. Pour the solution of soda salts into the flask 
 containing the suspended chloride of lime, shake well 
 during one minute, and place aside at rest to allow the 
 carbonate of lime to settle. 
 
 5. At the end of half an hour siphon off the clear 
 liquid and filter it with a double paper to obtain a 
 perfectly clear product, which should be kept in the cold 
 and away from the light. 
 
 The antiseptic solution is then ready for surgical use. 
 It should contain 0*475 P^^ cent, of hypochlorite of soda, 
 with small quantities of neutral salts of soda. It is 
 isotonic to blood-serum.^ 
 
 B. 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 
 calcium and small quantities of lime, the residue being 
 made up of excess of lime, partially carbonated. 
 
 The action of water on chloride of lime is not instan- 
 taneous ; the product often contains lumps, whence the 
 hypochlorite does not readily diffuse. The following 
 experiment of Daufresne^ is instructive. 
 
 ' These solutions have a freezing-point very slightly higher tban that 
 of blood-serum : A = — 0'6o to — 0*65. 
 - Daufresne, Presse MedicaU, 1916. 
 
PREPARATION OF DAKIN'S SOLUTION ^7 
 
 10 grammes of chloride of lime giving on titration 
 28*25 per cent, of active chlorine are introduced into 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. 
 
 
 
 Titration after con 
 
 tact of 
 
 
 the solution (in 'CI %). 
 
 i- hour. 1 1 hour. 
 
 2 hours. 
 0-259 
 
 6 hours. 
 
 12 hours. 
 
 0*089 
 
 o"i76 
 
 0'206 
 
 0-281 
 
 0-282 
 
 The solution is only complete after several hours of 
 maceration, and for this reason we have prescribed in our 
 technique prolonged contact between the chloride of 
 lime and the water. 
 
 The proportion of 184 grammes of chloride of lime to 
 10 litres of water indicated in these two formulae corre- 
 sponds to a product of good average quality (25 per 
 cent, of active chlorine), but samples of very different 
 degrees of richness are frequently met with. We had 
 occasion to examine a small number of samples whose 
 active chlorine content varied from 20*45 P^i* cent, to 
 3 5 "9 ps^ cent. There is no reason why the Service de 
 Sante should not, when supplying the quantity demanded, 
 place on it a label indicating the percentage of chlorine 
 {degres anglais^ Fr.). Or the toxicologist of the division 
 to which the hospital belongs could readily ^\s[^ this 
 information. 
 
 2. Titration of chloride of lime. Because of these 
 variations in commercial chloride of lime, it is indis- 
 pensable to know the quantity of active chlorine contained 
 in the chloride of lime with which one is working, in 
 
78 TREATMENT OF INFECTED WOUNDS 
 
 order to use an amount calculated exactly, according to 
 its titration. 
 
 The estimation is made in the following manner by 
 Daufresne : Weigh out an average sample of 20 grammes, 
 stir it up in a litre of water as perfectly as possible, and 
 allow it to stand some hours. Measure off lO c.c. of the 
 clear liquid, add to it 20 c.c. of a 10 per cent, solution of 
 iodide, 2 c.c. of acetic acid or hydrochloric acid, then to 
 the mixture add drop by drop a decinormal solution of 
 hyposulphite of soda (2*48 per cent), up to decolora- 
 tion. The number n of c.c. of hyposulphite employed, 
 multiplied by 1,775, will give 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. Should the obtained result differ 
 from the average figure of 25 per cent., the proportion 
 of the three substances entering into the preparation 
 must be reduced or augmented. This is readily found 
 by multiplying each of the three sets of figures, 
 184, 92, "J 6^ by the factor 25/N, in which N represents 
 the weight of active chlorine per cent, in the chloride 
 of lime. 
 
 The following table drawn up by Daufresne is 
 intended to avoid this calculation, and to give directly, 
 according to the amount of active chlorine contained in 
 the chloride of lime, the amounts needed to obtain auto- 
 matically a correct solution. 
 
PREPARATION OF DAKIN'S SOLUTION 79 
 
 
 
 Quantities to be used to obtain lo litres of solution of 
 
 Tit 
 
 ation of chloride of lime 
 
 (CI %). 
 
 (Knglish degrees.) 
 
 hypochlorite of o"475 %. 
 
 
 Chloride of 
 
 Carbonate of 
 
 Bicarbonate of 
 
 
 
 lime. 
 
 soda, anhydrous. 
 
 soda. 
 
 
 
 grms. 
 
 grms. 
 
 grms. 
 
 
 20 
 
 230 
 
 115 
 
 96 
 
 
 21 
 
 220 
 
 1 10 
 
 92 
 
 
 22 
 
 210 
 
 105 
 
 88 
 
 
 23 
 
 200 
 
 100 
 
 84 
 
 
 24 
 
 192 
 
 96 
 
 80 
 
 
 25 
 
 184 
 
 92 
 
 76 
 
 
 26 
 
 177 
 
 89 
 
 72 
 
 
 27 
 
 170 
 
 85 
 
 70 
 
 
 28 
 
 164 
 
 82 
 
 68 
 
 
 29 
 
 159 
 
 80 
 
 66 
 
 
 30 
 
 154 
 
 77 
 
 64 
 
 
 31 
 
 . 148 
 
 74 
 
 62 
 
 
 32 
 
 144 
 
 72 
 
 60 
 
 
 33 
 
 140 
 
 70 
 
 59 
 
 
 34 
 
 135 
 
 68 
 
 57 
 
 
 35 
 
 132 
 
 66 
 
 55 
 
 
 36 
 
 128 
 
 64 
 
 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 indicated by the 
 theory. 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. 
 
 C, Salts of Soda. — It is more convenient to use dry 
 carbonate of soda {carbonate de sonde, Solway, Fr.) which 
 is to be preferred to the other commercial salts because 
 of its being anhydrous, pulverulent, and free from caustic 
 alkali. 
 
 When obliged to use the hydrated salt (crystals), the 
 
So TREATMENT OF INFECTED WOUNDS 
 
 quantity needful will be 285 grammes for 100 of the dry I 
 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. 
 
 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, 
 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 : — 
 
 (C10)2Ca + C03Na2 = COsCa -f 2C10Na 
 CaCli + COaNa., = CO^Ca + 2NaCl 
 
 but the chloride of lime always contains a residue of non- 
 chlorinated lime, which may amount to 20 per cent, of 
 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(0H)2 4- COaNaa = COaCa + 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. 
 
PREPARATION OF DAKIN'S SOLUTION Si 
 
 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(0H)2 4- 2C0,NaH = CO.Ca -f- CO.Naa + 2lL,0 
 
 D. Titration of the Sohition of Hypochlorite.^ — Measure 
 lO 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 decolora- 
 tion. The number of c.c. used, multiplied by 0-03725, 
 will give the weight of hypochlorite of soda contained in 
 100 c.c. of solution. 
 
 In the first stage of the determination, hypochlorite 
 displaces the iodine of the iodide of potassium according 
 to the equation 
 
 ClONa + 2KI + H2O = I2 + 2KOH + 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 : 
 
 I2 + 2S20aNa2 = 2NaI + SiOi^Naii 
 
 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 
 
 * See Daufresne, Uc. cit. 
 
 6 
 
82 TREATMENT OF INFECTED WOUNDS 
 
 iodine, and that each atom of iodine transforms a 
 molecule of hyposulphite into tetra-thionate of soda ; 
 thus : 
 
 I mol. SsOsNa -> i atom of I -> I 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 : 
 
 2CI -f- 2KI = 21 + 2KCI and 
 
 2I + 2S203Na2 = 2NaI + S406Na2 
 
 and 
 
 I mol. S20oNa2 -> i atom of I -> i atom of CI 
 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 
 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. Now, this 
 error of interpretation might have, from the point of view 
 with which we are dealing at present, the serious conse- 
 quence of leading one to consider as correct a solution 
 
PREPARATION OF DAKIN'S SOLUTION 83 
 
 which only contains 0*25 per cent, of hypochlorite of 
 soda. 
 
 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 were 
 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 
 hypochlorite. 
 
 Solution kept in tbe^l 
 light, titration , . ./ 
 Solution kept in the)^ 
 
 dark, titration 
 
 After 
 
 o day. 7 days. 15 days. 21 days. 30 days 
 
 0*505 
 0-505 
 
 0*497 
 0-505 
 
 0-452 
 0-502 
 
 0-411 
 0-500 
 
 Loss in 
 
 one 
 moutli. 
 
 0-380 247 % 
 
 0*497 
 
 I '4 
 
 0/ 
 
 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 $\ 
 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 
 
84 TREATMENT OE INFECTED WOUNDS 
 
 under the influence of heat, it is thought that the hypo- 
 chlorite tends towards its two stable forms, chloride and 
 chlorate of sodium : 
 
 4C10Na = sNaCl + ClOaNa + O 
 
 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. 
 
 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. 22). We shall here give only the action 
 upon phenol-phtalein. 
 
 If 20 c.c. of the solution to be examined are poured 
 
PREPARATION OP^ DAKIN'S SOLUTION 85 
 
 into a beaker and on the surface are placed a few 
 centigrammes of phenol-phtalein in powder, it is seen 
 that :— 
 
 1st. 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. 
 
 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 only gives 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. 
 
86 TREATMENT OF INFECTED WOUNDS 
 
 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, 
 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. 
 
 1st. 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 they 
 are using, under the label of " Dakin's Solution," a 
 mixture of Labarraque's liquor and 40 per cent, boric 
 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 
 
PREPARATION OF DAKIN'S SOLUTION ^7 
 
 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, 
 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 
 
8H TREATMENT OF INFECTED WOUNDS 
 
 varying from 0*45 to 050 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 ascertain 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 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 sv/elling of 
 the tissues nor the reddened tracks of lymphangitis. 
 
 89 
 
90 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 91 
 
 during the first twenty-four hours are no longer indi- 
 cated. Free incisions and prolonged search for foreign 
 bodies or spHnters 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-infiammatory Period. — As soon as the patient 
 arrives at the hospital {ambidance^ 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. 
 
92 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. Fascia is split or torn by the pro- 
 jectile. 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 93 
 
 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 finger, 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 
 
94 TREATMENT OF INFECTED WOUNDS 
 
 as possible. In certain cases spinal anaesthesia may be 
 used. 
 
 3. Opening-up and cleaning a Wound of the Soft Parts. 
 — The skin is sterilised by 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 surve}' 
 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 
 
 i 
 
TECHNIQUE OF STERILISATION 95 
 
 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 area 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 clothine 
 
 o 
 
 These shreds are embedded in the tissues. No amount of 
 mopping or scrubbing 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 manceuvres 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 
 
96 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 completel}' 
 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, gastro-cnemius 
 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) Searchfoi' and Extraction of Pi'ojectiles 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. 
 
TFXHNIOUE OF STERILISATION 97 
 
 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' 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. 
 
 7 
 
98 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 99 
 
 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-iip 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 becorries 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, 
 
lOO 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 Hquid 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 loi 
 
 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, chemio- therapy 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 
 
102 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 difl*erent 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. 
 
 i 
 
TECHNIQUE OF STERILISATION 103 
 
 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. 
 
 {b) 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, a 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 concerns 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 
 
I04 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. 34). 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 105 
 
 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 
 
io6 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 107 
 
 apparatus, are removed at the same time as the splinters, 
 but the periosteum of the sphnters 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) Snpptirating 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 
 artery or vein. The clot disappears under the influence 
 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 
 
io8 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. 
 
 C. Suppuration Stage. — The manipulation of wounds 
 which have arrived at the stage of suppuration is made 
 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 
 
TECHNIQUE OF STERILISATION 109 
 
 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 
 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 
 
no TREATMENT OF INFECTED WOUNDS 
 
 of view, suppuration disappears after the lapse of a space 
 of time varying from twenty-four hours to about four days. 
 
 2nd. Siu?gical Cleaning. — After a Httle 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 interference. 
 
 Then the wound is cleansed just as though it were 
 a fresh one. Under anaesthesia, foreign bodies and 
 necrotic tissues are removed. In fractures the free 
 splinters are resected, and by means of a sharp periosteal 
 elevator, the periosteum is detached from irregular bon)' 
 surfaces containing microbes. As sparingly as possible 
 the bony extremities have their irregularities removed. 
 All tissues likely to necrose are carefully taken away. 
 
 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 
 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 
 
TECHNIQUE OF STERILISATION in 
 
 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. 
 
 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 
 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 
 
 ChEiMICAL 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 
 
 112 
 
TECHNIQUE OF THE STERILISATION 113 
 
 the pressure of muscles and dressings. Three kinds 
 of tubes are used. 
 
 1st. Tubes perforated with Small Holes. — The length 
 of these tubes varies from 30 to 40 cm. (roughly 12 to 
 16 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.^ from the closed extremity (Fig. 18). The 
 
 B gBSBSSSB^^BS^SI^^Sm^^S^ 
 
 ■mmmsmmmam 
 
 I'lG. 18.— 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.^ 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 
 
 ' Say 2 to 8 indies. 
 ^ j\yth of an inch. 
 
114 TREATMENT OF INFECTED WOUNDS 
 
 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.^ and the ends are open 
 (Fig. 19). At half a centimetre from one end a large 
 
 Fig. 19. — 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. 20). This sheath is firmh* 
 
 i 
 
 •irm- - laT'r^.-'-nrr' 
 
 Fig, 20. — Conducting or "instillation" tube covered with a sheath of bath- 
 towelling (tissa Sponge), 
 
 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 
 
 * Say 9 to 12 inches. 
 
TECHNIQUE OF THE STERILISATION 115 
 
 rubber tube of the same calibre and " unions " of pieces 
 of glass tube (Fig. 22, 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 
 
 S5^^ 
 
 I 
 
 Fig. 21. — Glass distributing tubes (vcrre 
 de Gentile). 
 
 A. Tube with one branch. 
 
 B. Tube with two branches. 
 
 C. Tube with three branches. 
 
 D. Tube with four branches. 
 
 Fig. 22.— Glass connecting tubes, ' 'unions." 
 
 A. Cyhndrical 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. Cylindriccil 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. 21). 
 
 1st. 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. 21, B) 
 
ii6 TREATMENT OF INFECTED WOUNDS 
 
 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. 21, 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. 21, 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, aiid of a calibre of 4 and of 7 nnii. 
 (Fig. 22, 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. 21, A). Tubes of 
 Y-shape are also in use, of 7 mm. calibre, for joining 
 up irrigating tubes (Fig. 22, 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. 
 
 I St. 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. 23). To this 
 is attached an irrigating tube of red rubber with a 
 calibre of 7 mm The flask is fastened to a wooden 
 
TECHNIOUK OF TlIK STERILISATION ti; 
 
 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 
 
 Fir;. 23. — Ampoule or flask holdino; a Fio. 24. — Pinchcock [Pince df Mohr 
 litre. d ressorf), 
 
 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 lo centimetres 
 below the flask the tube is furnished with a pinch-cock 
 (Fig. 24). Slight pressure upon the spring suffices to 
 open the lumen of the tube and to allow the liquid to 
 flow. This apparatus is extrerriely simple, and well 
 
ii8 TREATMENT OF INFECTED WOUNDS 
 
 suited to the intermittent irrigation of wounds (Fig. 
 25). Every two hours a nurse stops at the foot 
 of the bed and releases the spring of the " pince 
 de Mohr " for a few seconds. Instillation at once takes 
 place. 
 
 In the hospitals at the front, where it is difficult to 
 
 f ..... iU 
 
 Fig. 25. — Nurse using^a pinchcock 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, 
 
TECHNIQUE OF THE STERILISATION 119 
 
 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. 26). 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. 26.— Syringe [Seringiie dc 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. 
 
120 TREATMENT OF INFECTED WOUNDS 
 
 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 lo cm. long. At the 
 extremity of this tube is attached one of Gentile's " drop- 
 counters" {line ampoule compte-goiittes de Geyitile). Be- 
 tween the drop-counter and the reservoir is a screw 
 pinchcock {nne pince de Mohr a vis) which enables us to 
 
 Fig. 27. — ' ' 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. 27). 
 As the quantity of liquid which traverses a section of 
 tube in a unit of time is veiy 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. 
 
TPXHNIOUK OF THE STERILISATION 121 
 
 D. Method of using^ the Different Tubes and Apparatus. 
 — 1st. 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. 28), or a single 
 tube sheathed with " tissu cponge " (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 pinchcock 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 
 
122 TREATMENT OF INFECTED WOUNDS 
 
 continued instillation, because it allows a single irrigation 
 reservoir to provide liquid 
 for four or eight tubes at 
 once (Fig. 29). It is there- 
 fore applicable to all large 
 wounds. 
 
 Fig. 28. — Apparatus arranp^ed for drop 
 by drop instillation: a. Reservoir; /', 
 Irrigation tube ; c. Screw pinchcock ; 
 d. Drop-counter ; (\ Distributing tube 
 {Fig. 2T, A) ; /. (Conducting tube with 
 terminal orifice (Fig. rg). 
 
 Fin. 29. — Apparatus for intermittent 
 instillation : a. Reservoir {ampoule 
 o)- flask holding a litre) ; b, Irrigating 
 tube with a diameter of 7 mm. ; c, 
 Pinchcock {Pince de Mohr) ; </, Dis- 
 tributing tube with 4 branches ; e. 
 Conducting tubes. 
 
TECHNIQUE OF THE STERILISATION 123 
 
 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 
 
 ^^S"*'^ 
 
 Fig, 30. — Wound with surface horizontal. Vv'rong method of placing tlie 
 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. 30). 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. 31) in such a manner that 
 
124 TREATMENT OF INFECTED WOUNDS 
 
 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, 31. — Wound with surface horizontal. Right method of placing the tiabe.' 
 Tube in contact with the wound and covered with a gauze conii"»res.s. 
 
 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. 32). 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. 33). 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 
 
TECHNIQUE OF THE STERILISATION 125 
 
 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 
 
 Kmrnw/Z/ffmrn 
 
 Fig. 32. — ^Wound with surface inclined. 
 
 A. Tubes placed the wrong way, along 
 the lower border of the wound. 
 
 B. Tubes placed the right way, along 
 the upper border of the wound. 
 
 Fig. 2)'^)' — Wound with opening 
 superior, so that it can be filled 
 like a cup. 
 
 over its surface (Fig. 31). When the surface of the 
 wound is inclined, the tube is laid along the more 
 elevated border (Fig. 32), 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 
 
126 TREATMENT OF INFECTED WOUNDS 
 
 portion, and whose ends are joined by a Y-shaped 
 cannula (Fig. 34). 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 
 
 .^rr"^:f"^>. 
 
 Fig. 34. — 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. 35. — " 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 holes 
 whose two extremities are joined by the Y-cannula 
 resting on the skin of the anterior portion of the limb. 
 
TECHNIQUE OF THE STERILISATION 127 
 
 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. 35). 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. 20) 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 (Fig. 36). 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 
 
128 TREATMENT OF INFECTED WOUNDS 
 
 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 belly, the tube is placed as just 
 
 Fig. 36. — Compound Iractuie of tibia willi the opening of the wound on the 
 anterior aspect of the hnib ; in the beat 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. 37). If the wound is larger, several tubes pierced 
 with little holes are introduced and the liquid injected 
 under an adequate pressure. The liquid spurts out over 
 
TECHNIQUE OF THE STERILISATION 129 
 
 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 b}^ 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. ^-j. — Wound of the soft parts whose orifice is at the posterior aspect of 
 the hnib. Instillation to the "roof" of the wound by means of a tube 
 sheathed in " bath-towelling " [tissu eponge). 
 
 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 
 
 9 
 
i3o TREATMENT OE INEECTED WOUNDS 
 
 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 cms. 
 are used, and introduced as deeply as possible into each 
 diverticulum. To fix these tubes in their positions in 
 
 Fig. 38. — 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. 38). 
 Avoid placing tubes in the middle of a mass of gauze 
 (Fig. 39). In fractures of the femur, the wound can be 
 kept open by short pieces of rubber tube 3 cms. (about 
 
TECHNIQUE OF THE STERILISATION 131 
 
 I J inches) diameter, which are separated from one 
 another by other pieces of tube placed at right angles. 
 As gravity will not permit 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 surface (Fig. 38). 
 
 Fig. 39. — The same ii-regular 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. 
 
 In the large wound of a compound fracture of the thigh 
 at least 8 or 10 tubes are needed. 
 
 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 
 
/ 
 
 133 TREATMENT OF INFECTED WOUNDS 
 
 wounds, to arrest haemorrhage thoroughly, before arrang- 
 ing the tubes, and to verify their permeabiUty 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 
 on fresh wounds than on wounds which are suppurating. 
 2nd. Suppurating Wounds. — The presence of pus on a 
 wound is an indication that tubes surrounded by absor- 
 
 FiG. 40. — Testing the permeability of a conducting tube at the time of 
 
 dressing. 
 
 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 
 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 
 
TFXHNIOUE OF THE STERILISATION 133 
 
 their perforations should be tested (Fig. 40), also the 
 manner in which the various regions of the wound are 
 receiving their share of the antiseptic Hquid. This test 
 is to prove that the tubes have not become plugged with 
 blood-clot, and that the distribution is taking place 
 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 
 
 1st. Method of carrying out the Dressing. — As soon 
 as the tubes are in position, gauze compresses soaked in 
 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. 41). 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. 
 
 After the application of the compresses to the wound, 
 the adjoining skin is protected by squares of gauze, 
 sterilised in vaselin (Fig. 41). Pieces 8 or 10 cms. 
 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 
 
134 TREATMENT OF INFECTED WOUNDS 
 
 protection for the skin, which, on the posterior aspect of 
 the trunk or Hmbs, has a tendency to become irritated 
 by the hypochlorite. 
 
 ^^^^^^immmm^^:^^^^^^^- 
 
 Fig. 41.— Dressing : «, Conducting tube kept in the wound by gauze placed 
 in the orifice ; /;, Squares of gauze sterilised in vaseline placed on the 
 skin around the wound. 
 
 The dressing is completed by a sheet of cotton-wool 
 protected on either surface by one thickness of gauze. 
 
 h ' ii ii; ''-'li 
 
 ! :■■'(:•••■' 
 
 i \ 
 
 : - % 
 
 1; 
 
 \ I 
 
 '. I 
 
 I ! i, ; ! 
 
 i'r''; i, ,. ; \ -I I !. ,'i 
 
 j('r,;!U,»4-!..,|f!W'TM?;lJ 
 liii I 
 
 I'l 'I! 
 
 
 1; ; • I 
 
 1 .<^-ii>„ -J- /.,... 
 
 Fio. 42. — Sheets of dressings, composed of layers of absorbent cotton-wool, 
 non-absorbent cotton-wool, and gauze. 
 
 This dressing is prepared beforehand in three different 
 sizes (Fig. 42). It is composed of four strata ; a layer 
 
TECHNIQUE OF THE STERILISATION 135 
 
 of gauze, a sheet of absorbent cotton-wool, a sheet of 
 non-absorbent cotton-wool {coton carde), and a final 
 cover of gauze (Fig. 43). The side which has the 
 absorbent cotton-wool is applied next the wound. 
 
 F'iG. 43. — Section of the sheet of dressing : A, Gauze. B, Carded (non- 
 absorbent) cotton-wool. C, Absorbent cotton-wool. D, Gauze. 
 
 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 
 
 Fig. 44. — Dressing applied around a compound fracture of the leg, and 
 fastened by safety-pins j the distributing tube is fixed to the plaster 
 apparatus by safety-pins. 
 
 waterproof layer. Waterproof fabrics should never be 
 used. 
 
 The application of the dressing is speedy. The 
 middle part of the dressing is placed under the limb and 
 the two sides are fastened on the anterior surface of the 
 
136 TREATMENT OF INFECTED WOUNDS 
 
 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 
 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. 35 and 45). 
 
 Fig. 45. — Position of the distributing tube on the svirface 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. 
 
 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 
 which have been described (Figs. 45 and 21). 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. 46). In the case of a very 
 extensive wound where certain of the small conductino" 
 
TECHNIQUE OF THE STERILISATION 137 
 
 tubes are too short to be connected-up with the branches 
 of the cannula, they arc lengthened by pieces of rubber 
 tube and " unions " or connecting-tubes of glass (Fig. 22). 
 This work can be done after the dressing, when the 
 irrigating apparatus is installed. 
 
 l''ir,. 46. -Arrangemfuit on the surface of a dressing of a Y-connecting lube, 
 and of two distributing tubes with four branches. 
 
 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 
 
 Fu,. 47. — Method of fixing a distributing tube to the surface of a dressing. 
 
 of the limb. This fixing is simply done by nipping the 
 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 
 
138 TREATMENT OF INFECTED WOUNDS 
 
 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. 
 
 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, one or two 
 bands 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. 
 
TECHNIQUE OF THE STERILISATION 139 
 
 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. 
 
 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 difl'erence 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. 
 
 2nd. Intermittent instillation is used for the greater 
 
140 TREATMENT OE INEECTED WOUNDS 
 
 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. 
 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.^ 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. 
 
 The total quantity of liquid injected in 24 hours varies 
 from about 250 to 1200 c.c.^ 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. 
 
 4th. 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 
 
 ' Say from f oz. to 33 oz. 
 
 -' Roughly, eight ounces to two pints. 
 
TECHNIQUE OE THE STERILISATION 141 
 
 the sensitiveness of the patient. At the moment of 
 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 it 
 ever so small, remain on the surface of the wound, total 
 
142 TREATMENT OF INFECTED WOUNDS 
 
 reinfection is possible. If the instillations be stopped, or 
 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 cicatrises 
 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 for a compound fracture. These figures are those 
 observed when the wound is sterilised before the sup- 
 puration 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 regions infected. If sterilisation is not achieved, 
 in the first place it is necessary to ascertain that 
 
TECHNIQUE OF THE STERILISATION 143 
 
 the Dakin's solution contains the needful amount of 
 hypochlorite, and afterwards look into the possible 
 causes which could hinder the penetration of the liquid 
 throughout the wound. The causes are generally as 
 follows :— 
 
 1st. 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 ; {b) 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 given (p. 121), 
 on the subject of the relative calibres of the different 
 
144 TREATMENT OF INFECTED WOUNDS 
 
 tubes and the installation of the irrigation apparatus be 
 followed precisely. 
 
 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. 48). 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, that, either 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 settinp^ rid of the excess of fluid. The 
 
 ^^'•^"'fc. 
 
TECHNIQUE OF THE STERILISATION 145 
 
 bed becomes flooded, the limb bathed in Dakin's solu- 
 tion, and the skin becomes irritated. An excessive 
 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 
 
 Fig. 48. — Relative dimensions of the orifice of the wound and of the conduct- 
 ing lube, a, Faulty arrangement. — The opening is much too small, the 
 liquid is under pressure in the limb, and its circulation is impossible. 
 h, Correct arra^igement. — 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. 
 
 painful, may be produced. Therefore the nurse must 
 learn how to regulate the quantity of liquid so that the 
 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, 
 
 10 
 
146 TREATMENT OF INFECTED WOUNDS 
 
 it is always better to use too much than too Httle, for 
 the inconvenient results of too much liquid are not 
 serious and can be remedied easily. By applying care- 
 fully squares of vaselined gauze (p. 133) 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. 48). 
 Excessive pressure of liquid in the wound brings about 
 distress. The moment instillation gives rise to pain in 
 a case, it must be discontinued, and the mistake in 
 technique discovered, which is the cause. 
 
CHAPTER V 
 
 CLINICAL AND BACTERIOLOGICAL EXAMINATION 
 
 OF WOUNDS 
 
 Every infected wound should respond to chemio-therapy, 
 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. Modificatioiis 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 rale, either swelling of the tissues or secretion 
 
 147 
 
148 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 149 
 
 may be due to one of several causes. The tincture 
 of iodine vvhicli 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. 
 
ISO 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 151 
 
 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. 
 
 5th. 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 
 
152 tr?:atment 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. Hut, 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 153 
 
 " 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 
 
154 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 one suturing. Hence the aid 
 of the laboratory is needed constantly to ascertain the 
 progress of sterilisation. 
 
BACTERIOLOGICAL EXAMINATION 155 
 
 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 
 
156 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. 49). 
 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 157 
 
 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. 49. — 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. 50), 
 
158 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. 50. — 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 a 
 
BACTERIOLOGICAL EXAMINATION 159 
 
 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. 51). As it frequently happens 
 that only a single microbe is seen for two, five, or ten 
 fields, this is expressed by J, 1, or j\y 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 
 
i6o 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.^ 
 
 So long as haemorrhage persists, it is useless to make 
 smears. Again, in examining wounds of longer standing, 
 
 
 
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 Fin. 51. — Microbial Chart. In the upright columns are noted the number of 
 microbes found per microscope field, varying from infinity to i and from 
 T to t/,-,. 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 
 
 ' Ignorance of this detail has caused certain surgeons to believe that 
 fresh wounds are not infected. 
 
PLATE I, 
 
 ■'■ • *f ... 
 
 *. ^ 
 
 
 Fig. 
 
 Fig. 56. 
 
 Fracture of the femur in its middle portion by a ball (Case 522). Fig. 52. — May 28. 
 Rod-like bodies in immense numbers. Fig. 53. — May 31. The rods have almost 
 disappeared, and have been replaced by an immense number of cocci. Fig. 54. — 
 June 3. About 30 cocci per microscope field. They are usually in clusters. Fig. 55. — 
 June 7. 10 to 15 cocci per microscope field. Fig. 56. — June 13. About 2 microbes 
 per field. Fig. 57. — One coccus to 10 or 20 fields of the microscope. The wound 
 is aseptic. (The illustrations represent onlv the central portion of the field of the 
 microscope.) ' [To face pa^'e 160. 
 
BACTERIOLOGICAL EXAMINATION i6r 
 
 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. 
 
 1st. 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, debris 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 
 
 II 
 
i62 TREATMENT OF INFECTED WOUNDS 
 
 secretions of the wound often yield microbes (Fig. 
 52). 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 
 
 
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 Fig, 58. — 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, 
 
 
 MOI^l^ptemlreJI 
 
 
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 Fig. 59. — Right kiiee. Woitvd ex- 
 terfial. 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 debris 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 163 
 
 have not been reached by the liquid (Figs. 54 and 55). 
 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 
 
 
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 Fig. 6o. — Compound fract it re of 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. 59). In very irregular wounds, and in 
 those associated with injuries to bone, microbes persist 
 much longer (Figs. 52-58 and 60). 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 
 
i64 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 165 
 
 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. 61). 
 These reinfections of cu- 
 taneous origin may greatly 
 retard the progress of cica- 
 trisation (Figs. 62 and 63). 
 An examination of the epi- 
 thelial scales which cover the 
 skin near the wound, shows 
 that they are loaded with 
 masses of microbes. That is 
 the reason 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 
 
 
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 Fig. 61. — Burn. Curve showing a 
 
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 aseptic. 
 
i66 TREATMENT OF INFECTED WOUNDS 
 
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 Fig. 63. — 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. 62). 
 
bactp:riological examination 167 
 
 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. 52). Next, 
 the cocci increase in number, while the rods completely 
 disappear (Fig. 53). Now on the microscope field are 
 to be seen nothing but isolated cocci, diplococci, clusters 
 of staphylococci (Fig. 54), and chains of streptococci. 
 Under the influence of the antiseptic the number of 
 microbes diminishes (Figs. 55 and 56), and finally a few 
 diplococci alone persist for a few days, then disappear 
 completely. 
 
 {b) Suppurating Wounds. — In wounds which have 
 
i68 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 methods, 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 169 
 
 
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 J''iG. 64." I ,eft ciilf. Suppurating wound of soft parts, highly infected before 
 arrival at hospital. Slow sterilisation at first, becoming more rapid 
 towards the 15th day. 
 
 
 MOISI Septembre 
 
 Octobre 1 
 
 
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 Fig, 65. — 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 microljes became manifest 17 days after the 
 conmiencement of treatment, and the immense wound was quite sterile 
 and able to be closed 26 days after the entrance of the case into hospital. 
 
i;o 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. 64, 
 
 65, and 66). 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. 64), 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- 
 
 ^'on^L^^l\ ^peci''^-''^^-, infections are especially observed 
 wound on external aspect \^-^ y^j-y irregular wounds, and in 
 
 . Wounds of the soft ^ ^ ' 
 
 parts, suppurating and compound fractures. Under the 
 
 highly infected. The num- . _ -...,,. . , 
 
 bcr of microbes was im- influence oi instillation, mici'obes 
 oSed^^dSr^St "^^y disappear again fVom the 
 days after the begninmg of p^s, either temporarily or per- 
 
 treatment. r ' tr j f 
 
 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. 67). Occasion- 
 ally in the same patient some wounds become completely 
 
 
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BACTERIOLOGICAL EXAMINATION 171 
 
 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 
 
 
 MOIS 
 
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 Fig. 67. — 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. 6'j). 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 
 
172 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. 6*]). 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 173 
 
 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 indicates 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, 
 
174 TREATMENT OF INFECTED WOUNDS 
 
 liowever, 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 enquire 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 175 
 
 number has lessened. It really matters little that there 
 may have been two hundred or even fifty, instead of 
 a hundred (Figs. 6S and 69). And in the same way, 
 if on the following day one counts ten 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. 68 and 
 70). Besides, experience has 
 
 shown that if the examinations Fig. 68.-Curve represent- 
 ing the sterilisation of the 
 wound in Case 318. Jan. 
 10, the wound contained 
 
 
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 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. 
 
 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. 68 and yd). It can be done with still more 
 
176 TREATMENT OE INFECTED WOUNDS 
 
 precision when only one or two microbes per field are 
 to be found (Fig. 71). 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 vv^hose 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 
 [englobe, 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 which 
 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 
 
 Fig. 69. -*«*4®te 
 
 Fig. 
 
 Very large wound of the posterior region of the leg (Case 318). Fig. 68.— 
 Tan. 10 . More than 100 microbes per microscope field. Fig. 69. — Jan. 12. 
 About 10 microbes per field. Fig. 70.— Scarcely one per field. (The 
 illustrations represent only the central part of the field of the microscope.) 
 
 \To face page 176. 
 
BACTERIOLOGICAL EXAMINy\TION 177 
 
 asepsis.^ 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^ — even believe that chemical sterilisation never 
 achieves absolute asepsis of a wound. 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. In several cases we have been 
 able to obtain this result.^ 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. 
 
 ' Pozzi, Bulletin de V Ac ademie de Medecine^ meeting Jan. ii, 1916. 
 
 - Policard, loc. cit. 
 
 ^ M. Vincent found that in six cases out of nineteen injuries treated by 
 the usual methods at Compiegne by MM. Guillot and Woimant, bacterio- 
 logical asepsis had been attained. 
 
 13 
 
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 
 closing 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 
 
 178 
 
THE CLOSURE OF WOUNDS 179 
 
 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. At the beginning of the war primary 
 union was employed, and given up because of the 
 disasters it provoked. Nearly all the cases of septi- 
 caemia we have seen here followed unseasonable suture 
 by people who were still ignorant of the danger. In 
 a certain number of cases one may be favoured by 
 fortune and close wounds which are but slightly infected, 
 and which unite by first intention. But experience has 
 shown, over and over again, that gas-producing septi- 
 caemia and streptococcal septicaemia have caused the 
 death of the patient who has been the subject of these 
 experiments. A siirgeon has not the right to cause a 
 single ivoiinded man to risk useless dangers. Therefore 
 primary closure of wounds must be absolutely rejected 
 so long as we do not possess a means of knowing 
 whether they are sterile or not. 
 
 A. Secondary closure, on the contrary, can be done 
 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 progressively, 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 tempera- 
 ture and the condition of the limb. When the indica- 
 tions furnished by both clinical aspect and smears 
 
i8o TREATMENT OF INFECTED WOUNDS 
 
 coincide, then one may suture the wound with a feeling 
 of entire security. 
 
 B. A wound of the soft parts whose sterilisation has 
 been begun 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. 
 
 C. The time for the closure of wounds, the sterilisa- 
 tion of which has been begun after a period of suppura- 
 tion more or less long, is determined more carefully. 
 And so far as that goes, experience has taught us that 
 the secretions of a suppurating wound, above all when it 
 is deep and that of a compound fracture, may become 
 for a little while sterile, without the wound being really 
 permanently so. One day the pus is to all appearances 
 aseptic, and the next day are found indubitable heaps 
 of microbes accumulated on certain points of the smear. 
 In these wounds, which have suppurated for so long 
 before the commencement of antiseptic treatment, one 
 should find the secretions sterile for a week at least 
 before deciding to suture. 
 
 D. Generally, the average time for wound closure 
 varies between the eighth and 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 
 
THF: closure of wounds iSi 
 
 day of treatment. It is well to practise the closing of 
 wounds at as early a period as possible. As a matter 
 of fact, wounds united before the eighth day contain 
 no cicatricial tissue, and healing comes to pass without a 
 legacy of functional troubles. The closure of wounds 
 at an early period also results in considerable saving, 
 both in the cost of treatment 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 
 
i82 TREATMENT OF INFECTED WOUNDS 
 
 direction of the wound (Fig. 72). At the end of a 
 week the strapping is removed, and the wound found 
 to be united. 
 
 Fig. 72. — Bringing together the lips of a wound by means of strips of 
 adhesive plaster. 
 
 B. Wound- closings by Elastic Traction. — When ex- 
 tensive loss of substance exists and the lips of the wound 
 cannot be brought into apposition, recourse is had to 
 
 Fig. 73. — Bringing together the lips of a wound by means of elastic traction. 
 
 elastic traction. This method is also used for covering 
 stumps. 
 
 The bringing together of the edges of a wound by- 
 elastic traction is carried out in the following manner. 
 
THE CLOSURE OF WOUNDS 183 
 
 Strips of adhesive plaster seven or eight centimetres 
 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. y^). 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 ^ to which traction 
 cords are attached. A weight of about a kilogram 
 and a half (about 3 lbs. English) is sufficient to oppose 
 
 ^ " Stirrup-piece " ( Tratis.). 
 
i84 TREATMENT OF INFECTED WOUNDS 
 
 the retraction of the soft parts. This traction in no 
 way interferes with the dressing of the wound. When 
 steriHsation is complete it is easy to suture the flaps 
 which are now in the same position as though the 
 amputation had just been done. 
 
 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 
 aponeurosis. 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. Should there be a 
 considerable gap in the bony substance, it will be 
 
THE CLOSURE OF WOUNDS 185 
 
 necessary to fill it up. To repair these seats of fracture 
 we use, according to the nature of the case, bone-grafting ; 
 or we fill up the interval with fat. muscular tissue, or 
 some inert substance. For this purpose we have used 
 Mosetig's and Beck's pastes {la masse de Mosetig et la 
 pdte de Becky Fr.). " Beck's paste " is easier to handle 
 than " Mosetig's mass." The wound is prepared in the 
 usual manner, that is to say it is relieved of its epithelial 
 margin and its cavity simply dried with a compress. 
 Beck's paste is then injected into the cavity, which is 
 shut off by aponeurotic or muscular suture, lastly by 
 .skin sutures. 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. 
 
 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. 
 
 1st. 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 
 
i86 TREATMENT OF INFECTED WOUNDS 
 
 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 
 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. Closui^e 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 
 
THE CLOSURE OF WOUNDS 187 
 
 cases, in fact, numerous microbes have been shut in 
 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, 191 5, 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 
 
 188 
 
PLATE III. 
 
 Fig. 74. — Case 465. Section of quadriceps, 3rd day. 
 
 Fig. 76. — Case 606. Large wound of forearm. 
 
 Fig. 78. -Case 577. Wound of knee, 5th day. 
 
 [^I'oface page li 
 
PLATE IV 
 
 Fic;. 75.— Case 465. Suture, 7th day. 
 
 Fig. 77. — Case 606. \\ uund closed, 6th day, 
 
 Fro. 79. — Case 577. Suture, 14th day. 
 
 ITofacc Plafc rif. 
 
THE RESULTS 189 
 
 the rapidity of the sterih'sation depended in a certain 
 measure on the state of the infection. 
 
 1st. 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. 74 and 75). 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. 75). 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 clays, the 
 wound became surgically sterile, and was closed with 
 
190 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. 76). The wound was closed the sixth day 
 
 (Fig. 77)- 
 
 In wounds of the soft parts, sterilisation is almost 
 always rapidly achieved. Out of 1 36 wounds closed during 
 the period — December, 191 5, and the commencement of 
 January, 19 16 — 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. "j^). The projectiles having been removed from 
 the articulation, the wound could be closed the fourteenth 
 day (Fig. 79). 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 191 
 
 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. (i03*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. 
 80). At the end of eleven days, the great wound had 
 become sterile, and the temperature came down from 
 40° to ^7° 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. 81). 
 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 
 
192 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, sterilsiation only demanded a little more 
 than double the normal time. 
 
PLATE V. 
 
 Fig. 8o. — Case 340. Large infected wound of calf, nth day. 
 
 ti(j. 82. - Case 433. Fracture of neck of hiuuerus, 15th day, 
 
 Fig. 84. — Case 594. Shell-wound of knee : partial fracture of 
 condyle, 6th day. 
 
 [ To /ace page 193. 
 
platp: VI. 
 
 Fig. 8i. — Case 340. Same wound, the 2Tst day. 
 
 Fig. 83. — Case 433. Suture, lyth day. 
 
 Fig. 85. — Case 594. Wound became sterile the i6thdayand 
 was closed the 20th. 
 
 ITo face Plate V. 
 
THE RESULTS 193 
 
 3rd. Suppui^ating 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 corrtmenced before or after the suppuration 
 
 stage. 
 
 1st. Fresh Fractures. — Experience has taught us that 
 
 13 
 
194 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, 191 5, 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 i95 
 
 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. S6). 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. 
 
 (d) 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 
 
196 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 
 
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 ^^B 
 
 
 ^^^^^ 
 
 
 ^^H 
 
 
 ^^^Si 
 
 
 ^n 
 
 
 i^^M 
 
 
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 l^m 
 
 
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 Fig. 86. — Fracture of humerus, fiUing- 
 in with Beck's paste. Case 321. 
 
 Fig. 87. — 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 
 
 197 
 
 cicatrisation came about slowly, but two months after 
 the injury, healing was complete without a sinus 
 (Fig. 8S). 
 
 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 denudecl, 
 
 Fig. 88.— Same frac- 
 ture healed. Case 
 494- 
 
 Fig. 89. — SuppuratinjE^ 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, 
 
198 TREATMENT OF INFECTED WOUNDS 
 
 because their ablation would have shortened the bone by 
 seven or eight centimetres (Fig. 89) : 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 injur}^ 
 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. 90). 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 15th, 23rd, and the 25th day. 
 
THE RESULTS 
 
 199 
 
 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. 91). The orifice of entry of the missile, which was 
 
 Fig. 90. — Fracture of the libia. 
 Case 627. 
 
 Fig. 91. — Fracture of the femur. Case 
 560. 
 
 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 
 becanie normal. The number of microbes, which the 
 
200 TREATMENT OF INFECTED WOUNDS 
 
 second day was 30 per microscope field, diminished to 
 one the 13th day. The 15th 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 47th 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 " ambulance " of 
 V , 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 da)', 
 microbes having disappeared from the secretions, the 
 wound was closed with silkworm gut. At this date 
 the case was brought to us (Fig. 92). 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. 93). He was first 
 
 treated at the " ambulance " of V , 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 
 
 20 1 
 
 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. 92. — Comminuted frac- 
 ture of femur. Case 495. 
 
 Fig, 93. — Fracture of femur. 
 Case 493. 
 
 are treated by methods similar to ours. Recently M. 
 Hornus treated, in a hospital (" ambulance," Fr.) of 
 the first line, thirteen cases of compound fracture of 
 thigh. After four or five days the cases had a normal 
 temperature and no suppuration. In eleven cases, secon- 
 dary suture was practised. We have seen also, with M. 
 Depage at the " ambulance " of La Panne, fractures of 
 
202 TREATMENT OF INFECTED WOUNDS 
 
 the 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 hunierus, it is quite possible to avoid sup- 
 puration while making very limited resections {esquillec- 
 tojnies^ 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 preserv^e 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 
 
 203 
 
 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. 82) sterilisation was attained, 
 and two days later the joint was closed with silkworm 
 gut (Fig. 83). 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 " ambu- 
 lance de V " 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. 94). The movements 
 of the elbow were re-established 
 almost completely. There remained 
 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. 
 
 Fig. 94. — Fracture of 
 condyle of humerus. 
 Case 497. 
 
204 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 patella fossa. The temperature, 
 which was 39*9" C. (i02*2'' Fahr.) the day of arrival, fell 
 by the fourth day to 37-5° C. (99'' Fahr.). Similarly, 
 bacilli and cocci which were numerous in the smears were 
 
THE RESULTS 205 
 
 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. 84), 
 became sterile the fourteenth day, and was sutured the 
 twentieth (Fig. 85). 
 
 In the following case, despite the very extensive 
 lesions, we were able to save the lower extremity of the 
 femur. 
 
 Case 106, 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. 95). 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. 
 
2o6 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. 95. — Smash of extremity of 
 femur. Case 106. 
 
 Fig. 96. — Sup- 
 jjurating 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 is 
 
THE RESULTS 207 
 
 in the depths of the wound neither infected fragment 
 nor 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. 96). 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 an " ambulance " 
 at the front, and arrived in hospital nine days later. The 
 wounds were suppurating abundantly, the forearm was 
 a little swollen and very painful. The dressings were 
 
2o8 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 i'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 projectile 
 which had penetrated the antero-external aspect of the 
 thigh. He was operated on in an " ambulance " at the 
 front 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. 97). 
 
 {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 
 
 J09 
 
 curve becomes 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. 97.— 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. 
 
 14 
 
2IO 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 211 
 
 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 "ambulance 
 chirurgicale," where free splinters were removed, and 
 where, very wisely, they had carefully preserved several 
 
212 TREATAIENT 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. (ioi°Fahr.). 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 an " ambulance," 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 213 
 
 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. (lOi*^ Fahr.). The urine contained albumen. 
 Haemoglobin was reduced to 30 per cent, of its normal 
 quantity. Systolic arterial pressure was I2'5 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 
 
214 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. In hospitals in the interior where 
 wounded in similar conditions are treated, and where 
 the method is applied in all its integrity, similar results 
 have been observed. 
 
 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 length of treatment and the degree of final incapacity. 
 
 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, 191 5, to 
 October i, 19 16, 303 cases of wounded coming directly 
 from " postes de secours " 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 
 
THE RESULTS 215 
 
 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. 
 
 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. 
 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. Diminutioii 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 
 
2i6 TREATMENT OF INFECTED WOUNDS 
 
 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. 
 
 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. From December i, 1915, to 
 October I, 1916, we have done 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 
 
THE RESULTS 217 
 
 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 an " ambulance." 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 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. 
 
 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 
 
2i8 TREATMENT OF INFECTED WOUNDS 
 
 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 diminution of about two-thirds of the duration 
 of treatment is obtained. 
 
 In compound fractures of flat bones, short bones, 
 and long bones such as the fibula, radius, and ulna, 
 sterilisation comes about 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 
 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. 
 
 2nd. Influence of Early Anatomical Repairs on the 
 Duration of Treatment. — Sterilisation of the wound allows 
 us to practise operations quite early in the case which 
 formerly had to be put off until after cicatrisation was 
 complete. In this manner bone-grafting or wiring, re- 
 union of muscle or tendon, nerve suture, before to-day, 
 could only be practised after the healing of the infected 
 
THE RESULTS 219 
 
 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 518, 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 
 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 
 
220 TREATMENT OF INFECTED WOUNDS 
 
 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,^ 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 used again. {La 
 gaze pent etre presque entieremeiit r^cicperee. — Fr.) The 
 cost of the appliances for instillation is recovered in a 
 few days from the saving due to the exclusive employ- 
 ment of a substance of such trifling cost as hypochlorite 
 of soda. 
 
 D. Diminution of Positive Incapacity. — In the greater 
 number of injuries, definite 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 
 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 
 
 * Net cost of ten litres of Dakin's solution : — 
 
 200 gr. chloride of lime at i fr. lo centimes . . . 0*22 
 
 100 gr. carbonate of soda (Solway) at o fr. 40 centimes . 0*04 
 800 gr. bicarbonate of soda at o fr. 60 centimes . . 0*048 
 
 Net cost of 10 litres 0*308 
 
 Therefore the net cost of a litre is 3 centimes (roughly, three pints 
 cost a halfpenny). 
 
THE RESULTS 221 
 
 frequently avoided. Sinuses are scarcely ev^er 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 b}' 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 
 asserted that no failure has been observed since the 
 month of December, 191 5. But if the role of the method 
 is to prepare for the secondary closure of wounds, the 
 proportion of failures rises to about five per cent. 
 
222 TREATMENT OF INFECTED WOUNDS 
 
 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 laboratoiy 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, 191 5. Before that date, it happened several 
 times. 
 
 When the treatment was commenced after a period 
 of suppuration more or less long, numerous failures of 
 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 
 
THE RESULTS 223 
 
 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 a failure {comme echec^ Fr.) the case in 
 which some microbes persist in the secretions up to the 
 moment of spontaneous closure of the seat of fracture. 
 
 We have observed no failure in the treatment of 
 compound fractures of the small bones, short bones, and 
 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. In one case it was a " smash- 
 up" of the end of the diaphysis and the adjoining 
 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". 
 
224 TRKATMENT OF INFFXTED WOUNDS 
 
 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. Of our last six cases 
 of compound fracture of the femur, in three we did 
 not suture, because the secretions yielded occasional 
 microbes ; the wounds closed spontaneously. 
 
 IV. Practical Value of the Method 
 
 The results observed at Compiegne showed us that 
 suppuration of woitnds can be suppressed., and that tJie 
 majority of wounds are capable of bei?ig sterilised and 
 sutured. The practical value of the method depends 
 upon the possibility of its being employed at other 
 hospitals. The objection has been raised, in fact, that 
 the chemical sterilisation of wounds is too difficult to 
 become general {est d'une technique trop delicate pour 
 Hre generalisee). It will be useful, 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 ; the abortive treatment of infec- 
 tion and the curative treatment of suppuration have 
 been applied in some hospitals at the front {ambulances 
 deVavant), and in some territorial hospitals {du territoire). 
 
 A. Abortive Treatment of Infection. — The abortive 
 treatment of infection, instituted at Compiegne in the 
 spring of 191 5, has been carried out in the " ambulances" 
 
THE RESULTS 225 
 
 from the month of July in the same year by le Medecin 
 Principal Ufifoltz, Directeur du Service de Sante d'un 
 Corps d'Armee. From that date M. Uffoltz and his 
 colleagues have demonstrated that under the ordinary 
 conditions of a field hospital {ambidance, Fr.), the method 
 could be employed almost in its entirety, and that a 
 considerable improvement in results was the conse- 
 quence. In one" of the " ambulances " under the charge 
 of M. Ufifoltz, le Medecin-Major Ferret succeeded in 
 banishing wound infection almost completely. The 
 ordinary staff was able to apply the method in accurate 
 detail. The demonstration of the practical value of the 
 method in the " ambulances " (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 " I'ambulance de La 
 Panne," which contains from 600 to 700 wounded, M. 
 Depage and his colleagues have shown that the sterilisa- 
 tion of wounds can be carried out on a large scale. It 
 has been said, in fact, that the small size of our hospital 
 at Compiegne allows us to lavish an amount of attention 
 on our cases which would be impossible if these cases 
 amounted to several hundreds. Therefore it is important 
 to realise that in a great hospital they have succeeded 
 in practising the sterilisation of wounds in every case, in 
 following the progress of chemical cleansing upon the 
 bacteriological charts, and in closing wounds as soon as 
 they ceased to harbour microbes. In this hospital, which 
 
 15 
 
226 TREATMENT OF INFECTED WOUNDS 
 
 contains nearly 700 wounded, they have succeeded in 
 almost completely doing away with suppuration, with- 
 out having to add to the personnel or to alter the general 
 organisation. 
 
 The results observed in M. Uffoltz' " ambulances " 
 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. 
 
 B. The Disinfection of Suppurating Wounds.— The ap- 
 plication of the method in the territorial hospitals where 
 suppurating wounded are received, days or weeks after 
 the injury, has not yet been tried on a large scale. In 
 these hospitals wounds suppurate for a prolonged period 
 in spite of all the forms of treatment employed hitherto. 
 However, the method has been applied in its entirety 
 by some surgeons. Immediately, suppuration has practi- 
 cally disappeared from their clinics. In this manner in 
 M. Tuffier's hospital at Saint -Germain, and in M. 
 Chutro's wards at the Buffon hospital, it became possible 
 to do away with suppuration in wounds without adding 
 to the number of doctors and nurses. 
 
 V. Conclusions 
 
 Since our methods have been employed with success 
 under the ordinary conditions of "ambulances" and 
 hospitals, 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. 
 
THE RESULTS 227 
 
 Neither the preparation of Dakin's solution may be 
 modified, nor the processes for 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 
 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 . . . lo 
 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. 
 
 22S 
 
INDEX 
 
 {^Names m italics. 
 
 Abortive treatment of infection, 
 
 224 
 Abscess, 215 
 
 , cavity, closure of, 41 
 
 J ? results, 193 
 
 , gas, 105 
 
 , lymph angi tic, 105 
 
 , opening, 109 
 
 Absence of scientific method, 35 
 x'Vbsorbent gauze, 62 
 Acetic acid, 78, 81 
 Activity, coefficient of, 82 
 Adhesive plaster, 181. See Strap- 
 ping 
 
 , with hooks, 183 
 
 Adversaries of antisepsis, 4 
 Algebraic expression of curve of 
 
 cicatrisation, 37, 149 
 Alkali, free, effect on vessels, 7^ 
 , , in antiseptic solutions, 
 
 73 
 Alkalinity of hypochlorite, 29 
 American methods, M. Br oca on, 10 
 
 , of traction, 183 
 
 , suspension apparatus, 
 
 149 
 Amino-acids, 47 
 Ampoule, 116 
 Amputations, lessened number of, 
 
 215 
 
 Amputations, due to sepsis, 2 
 Anaesthesia, 93 
 Anatomical repairs, early, 218 
 Antisepsis, adversaries of, 4 
 Antiseptics, action of, on tissues, 19 
 
 , application of, 62 
 
 , choice of, 14 
 
 , contact of, with micro-or- 
 ganisms, 53 
 
 , duration of application of, 67 
 
 , fatty vehicles for, 24 
 
 , free alkali in, 73 
 
 , in powder form, 24 
 
 , instillation of, 139 
 
 , maintaining strength of, 65 
 
 , preparation of wound for, 60 
 
 Apparatus, irrigating, Il6 
 
 , suspension, American, 149 
 
 Appearance of patients, 152 
 Appendicitis, illustrations from, 90, 
 
 91 
 Area of wounds, measurement of, 36 
 Arrangement of tubes, 131 
 Arthritis, suppurative, iio 
 Asepsis, bacteriological, 177 
 
 , surgical, 177 
 
 V. antisepsis, 5 
 
 x\septic wound, action of 
 
 chlorite on, 44 
 Audioscope vibrator, 97 • 
 
 hypo- 
 
 229 
 
230 
 
 INDEX 
 
 Bacillus of IVekhy i6, i8, 167 
 
 aerogenes capsulatus, 18 
 
 perfringens, 18, 31 
 
 pyocyaneus, 16, 24 
 
 Bactericidal action of chlorine, 47 
 
 of Dakin's solution, 24 
 
 of para- toluene -sodium - 
 
 sulphochloramine, 50 
 Bacteriological asepsis, 177 
 
 conditions, 7 1 
 
 , modifications of, 161 
 
 examination, 155 
 
 , closure without, 222 
 
 , errors in, 222 
 
 , necessity for, 154 
 
 study of secretions, 14 
 
 Bath-towelling, 114 
 Baunie-Pluvinel, M. de, 97 
 Beaujon Hospital, 19 
 Beck's paste, 185, 194-5 
 Benzene -sodium-sulphochloramine, 
 49 
 
 bactericidal action of, 50 
 
 Bergonie, A/., electro-vibrator, 97 
 Berthollet, M., 73 
 Bicarbonate of soda, 75, 80 
 Bichloride of mercury, 17, 18, 20 
 Blood, chemio-therapy of, 13 
 Blue pus, 207-8 
 Bone, conservation of, 197 
 
 grafting, ill, 219 
 
 Boot-lace hooks, 183 
 Boric acid, 22, 24, 86 
 
 , irritation from, 75 
 
 Bradford's frame, 138, 149 
 Broca^ J/., on American methods, 
 
 10 
 Bromamines, 51 
 Bromine, bactericidal power of, 
 
 47 
 Buffon hospital, 226 
 Burghard, M., 4 
 Buttock, wound of, 189 
 
 Calcium, chloride of, 76, 85 
 
 , hypochlorite, 23, 76, 85 
 
 Calculated curves of cicatrisation, 
 
 38 
 Calf, haematoma of, 19 1 
 Cannulae, glass, 117 
 
 , fixation of, 136 
 
 Carbol thionin, 158 
 Carbolic acid, 17, 20 
 Carbonate of lime, 76 
 
 of soda, 75, 85 
 
 , Solway, 79 
 
 , hydrated, 79 
 
 Carrel, Mine., 1 9 
 Catgut ligatures, 108 
 
 chromic, 108 
 
 Causes of death, 214 
 
 of error, solution, 86 
 
 , smears, 160 
 
 of failure, 221 
 
 Caustic soda, 80, 86 
 Cavities, abscess, 41, 193 
 Cells, mononuclear, 172 
 
 , polynuclear, 172 
 
 Changing dressings, 138 
 
 Charts, numbers of microbes, 26, 28 
 
 Chaltaii^ay, AT., 49 
 
 Chemical cleansing of wounds, 109 
 
 equations, 80 
 
 sterilisation, iii, 112 
 
 Chemio-therapy, 7 
 
 of blood, 13 
 
 of wounds, 13 
 
 Chloramine paste, 127, 228 
 
 T., 52 
 
 Chloramines, 7, 47, 49 
 
 , wounds treated by, 72 
 
 Chloride of lime, 75 
 
 , chemical constitution of, 
 
 76 
 
 , titration of, 76 
 
 , variations in, 77 
 
 Chlorine, 24 
 
INDEX 
 
 231 
 
 Chlorine, bactericidal powers of, 47 
 
 , estimation of, 78 
 
 , gaseous, 76 
 
 Chloroform, 93 
 Choice of an antiseptic, 14 
 Chromic catgut, 108 
 ChutrOt M., 226 
 Cicatrices, painful, 221 
 Cicatricial stage of wounds, 1 1 1 
 Cicatrisation, action of hypochlorite 
 on, 38 
 
 , curves of, 38 
 
 , factors of, 34 
 
 , graphic representation of, 37 
 
 , influence of sterilisation on, 
 
 38 
 
 , DakhCs solution on, 43 
 
 Cicatrix, examination of old, 59 
 Circulation, hypochlorites in, 32 
 Cleaning-up compound fractures, 
 99 
 
 wounds of joints, 100 
 
 Cleansing of wounds, chemical, 109 
 
 , mechanical, 89, 91 
 
 , surgical, no 
 
 Clinical examination, 92, 147 
 
 observation, 71 
 
 , value of, 153 
 
 signs, 179 
 
 , value of, 1 76 
 
 Closure of abscess cavities, 41 
 
 of wounds, 178 
 
 , by elastic traction, 182 
 
 , by strapping, 18 1 
 
 , by suture, 184 
 
 , fresh, 185 
 
 , primary, 179 
 
 , premature, 99 
 
 , secondary, 217 
 
 , technique of, 181 
 
 , without bacteriological 
 
 examination, 222 
 Clothing, bhreds of, 95, 97 
 
 Coefficient of activity, 82 
 
 Cohen, M., 50 
 
 Compass, Contremotilin''s^ 97 
 
 , Hirtz\ 97 
 
 Compiegne, hospital at, 10, 224 
 Complications, diminution of, 214 
 Compound fractures, cleaning-up, 
 
 99 
 
 J closure of, 184 
 
 , results, 193 
 
 Condition, general, modifications 
 
 of, 151 
 of wounds, 3<^ 
 
 Conducting tubes, 112 
 Conical glass tubes, 116 
 Connective tissue, experiments on, 
 
 19 
 
 Consequences of sterilisation, 214 
 
 Contact of antiseptic and micro- 
 organism, 53, 67 
 Continuous instillation, 139 
 Contret7ioulin''s compass, 97 
 Controls, in experiments, 35, 42 
 Cost of Dakin^s solution, 220 
 
 treatment, 219 
 
 • , lessened, 217, 220 
 
 Coton carde, 135 
 Cotton wick, 62, 123 
 
 wool, 134 
 
 Counter-openings, 97, 98 
 Counting microbes, 158, 174 
 Crins de Florence, 200 
 Culture experiments, 16 
 Cultures, 155, 178 
 Cup-like wounds, 124 
 Curves of cicatrisation, algebraic 
 formula, 37, 149 
 
 , calculated, 38 
 
 , geometrical form of, 37 
 
 , observed, 38 
 
 Cutaneous origin of reinfection, 
 
 165 
 
 Cytophylaclic substances, 173 
 
232 
 
 INDEX 
 
 Dakin's investigations, 6, 15 
 
 solution, 20, 24 
 
 -, action on blood, 33 
 
 , on pus, 33 
 
 , on leucocytes, 33 
 
 ■ , bactericidal action of, 
 
 24 
 
 , cost of, 220 
 
 , influence on cicatrisa- 
 tion, 43 
 
 , preparation of, 73, 75 
 
 , strength of, 88 
 
 , technique, 73 
 
 , to be coloured, 139 
 
 , toxicity of, 32 
 
 , wrongly made, 86 
 
 Dasire, M., 29 
 
 Daufresne^ M., 15, 22, 24, 50 
 
 method, 75 
 
 Deep sutures, 176 
 
 Dehelly, M., 9 
 
 Delbei, M. Pierre, 5 
 
 Depage, M., 10, 61, 95, 201, 
 
 225-6 
 Dimensions of wounds, 69 
 Diminution in cost, 217, 220 
 
 of complications, 214 
 
 of incapacity, 220 
 
 Dopter's serum, 213 
 Drainage, 98 
 Dressings, 133 
 
 , changing, 138 
 
 , four-layer, 134 
 
 , with saline solution, hyper- 
 tonic, 29 
 
 , , physiological, 
 
 28 
 
 , vaselin, 27, 43 
 
 Drop-by-drop instillation, 127 
 Drop-counter, 120 
 Dunham f Prof. E. K., 18 
 Dunkirk, hospital at, 24 
 Duptty, M., 9 
 
 Duration of application of anti- 
 septic, 67 
 Duration of instillation, 141 
 Duyk, M., 21 
 
 Eau de Javel, 20, 22, 23 
 
 , commercial, 84 
 
 Elastic traction, wound-closing by, 
 
 182 
 Elbow, shell-wound, 203 
 Elevator, periosteal, no 
 Electro-vibrator, Bergonie's, 97 
 Encapsuled microbes, 176 
 Eponge, tissu, 114 
 Equations, chemical, 80 
 Errors, causes of, 86 
 , , in bacteriological exami- 
 nation, 222 
 , , in counting microbes, 
 
 174 
 
 , , in smears, 159, 160 
 
 , , in solution, 86 
 
 , , of technique, 142 
 
 Ether, 93 
 
 Examination, bacteriological, 155 
 
 , , closure without, 222 
 
 , , errors in, 222 
 
 , clinical, 92, 147 
 
 , radiological, 92 
 
 Excessive pressure, 146 
 
 quantity of liquid, 144 
 
 Excision of track of missile, 95 
 Experiments, controls in, 35, 42 
 
 , cultures, 16 
 
 , filter-paper, 26, 30, 42 
 
 , on connective tissue, 19 
 
 , on skin, 22 
 
 Fabrics, waterproof, 135 
 Factors of cicatrisation, 34 
 Failure, causes of, 221 
 
 , definition of, 223 
 
 Fatty vehicles for antiseptics, 24 
 
INDEX 
 
 233 
 
 Femur, fractures of, 198, 200-1, 
 
 206, 208, 210, 212 
 Fiessinger, M., 47, 55, 107 
 Filter-paper experiments, 26, 30, 
 
 42 
 Fixation of cannulae, 136 
 — — of tubes, 127 
 Flask, for irrigation, 116 
 Forearm, wounds of, 190, 207, 
 
 219 
 Foreign bodies, 4I, 69, 171 
 Formula of curve, algebraic, 149 
 Fractures, compound, cleaning-up, 
 
 99 
 
 , , closure of, 184 
 
 , , infected, 106 
 
 , , of femur, 198, 200-1, 
 
 206, 208, 210, 212 
 
 , , suppurating, results, 206 
 
 , ■, with joint-wounds, 202 
 
 Frame, Bradford's^ 138, 149 
 Free alkali, effect on vessels, 108 
 Fresh wounds, smears in, 160 
 ■, sterilisation of, 189 
 
 Gangrene, gas, 102 
 
 , localised, 104 
 
 Gangrenous infections, loi 
 
 -wounds, 150, 190 
 
 Gas abscess, 105 
 Gas-gangrene, 102 
 Gas-producing infection, 102 
 
 septicaemia, 179 
 
 Gaultier^ M., ']2 
 Gauze, absorbent, 62 
 
 , vaselined, 133 
 
 , wicks, 68 
 
 Geometrical form of curves, 37 
 Glass tubes, 115, 116 
 Grafting, bone, ill, 219 
 Graphs, 37 
 
 Graphic representation of cicatrisa- 
 tion, 37 
 
 Guillaumin^ M., 48 
 Guilloty M., 177 
 
 Haematoma, calf, 191 
 
 , sciatic nerve, 99. 
 
 Haematomata, 99 
 Haemorrhage, primary, 108 
 
 , secondary, 107 
 
 Haemostasis, 96 
 Ilirtz' compass, 97 
 Hooks, on strapping, 183 
 ffornus, M.f 9, 200, 201, 203, 225 
 Horse-serum, 24 
 Hospital, Beaujon, 19 
 
 , Buffon, 226 
 
 , Compiegne, 10, 224 
 
 •, Dunkirk, 24 
 
 , Saint-Germain, 226 
 
 Humerus, fractures of, 194, 207 
 Hydrochloric acid, 78 
 Hydrogen peroxide, 17, 18, 220 
 Hypertonic saline solution, 29, 62 
 Hypobromites, 47 
 Hypochlorite of soda, 7, 17, 19, 20 
 
 , action on aseptic 
 
 wounds, 44 
 , on cicatrisation, 38, 
 
 44 
 , on microbial toxins, 
 
 30 
 
 , on proteins, 25 
 
 , on pus, 25 
 
 , on silk, 107 
 
 .^ on tissues, 32, 33 
 
 , alkalinity of, 29 
 
 , in the circulation, 32 
 
 , irritating qualities of, 20 
 
 , mode of action of, 46 
 
 , retarding action of, 44 
 
 , titration of, 81 
 
 -, toxicity of, 32 
 
 Hypochlorous acid, 24 
 Hypoiodites, 47 
 
234 
 
 INDEX 
 
 Immobilisation of the limb, 138 
 Incapacity, diminution of, 220 
 Incisions, long, 99 
 Infected fractures, 106 
 
 wounds, action of hypochlorite 
 
 of soda on, 38 
 
 •, stages of, 89 
 
 Infection, abortive treatment of, 224 
 
 , fresh wounds, 54 
 
 , gangrenous, loi 
 
 , gas-producing, 102 
 
 , suppurating wounds, 57 
 
 , topography of, 53 
 
 Inflammatory period, loi 
 Instillation, continuous, 139 
 
 , drop-by-drop, 127 
 
 , duration of, 141 
 
 , intermittent, 139 
 
 , of antiseptic, 139 
 
 , pressure used, 140 
 
 , quantity used, 140 
 
 , time of, 140 
 
 , tubes, 112 
 
 Insufficient penetration of liquid, 
 
 142 
 Investigation, team-work needed 
 
 for, 2 
 Iodide of potassium, 78, 81 
 Iodine, 17, 19, 20 
 
 , bactericidal power of, 47 
 
 , estimation of, 81 
 
 , tincture of, 94 
 
 Irrigation apparatus, 1 16 
 
 , continuous, 66 
 
 , bottle for, 116 
 
 Irritation of skin, 145, 148 
 
 from boric acid, 75 
 
 Isotonic, 76 
 
 Jacomd, M., 24 
 Joint-injuries, cleaning-up, 100 
 
 , closure of, 184 
 
 , suppurating, 107 
 
 Joint, wounds of, 202 
 
 , with fractures, 202 
 
 Junctions of tubes, 115 
 
 Keeping qualities of hypochlorite 
 
 solution, 75, 83 
 Kenyon, M., 50 
 Knee-joint, wounds of, 190, 204, 
 
 205 
 
 Labarraqiie^ M., 73 
 
 Lab ar rogue's liquor, 20, 22, 23, 73» 
 
 84 
 Label on slides, 158 
 Landry^ J/., 24 
 Leishman, M.^ 4 
 Lemaire, M.^ 9 
 
 Length of time needed for anti- 
 septic, 68 
 
 of treatment, 217 
 
 Leucocytes, characters of, 1 72 
 
 , dissolution of, 33, 47 
 
 Ligatures, catgut, 108 
 
 , silk, 107 
 
 Limb, immobilisation of, 138 
 Lime, carbonate of, 76 
 
 , chloride of, 75 
 
 Liquid, insufficient penetration of, 
 142 
 
 , retention of, 129 
 
 Lister's ideas, 3 
 Lorram-Smith^ M., 24 
 Louis XVIIL, corpse of, 73 
 Lumiere, M. Auguste, 24, 30 
 Lymphangitis, 89, 149 
 
 Magnesium hypochlorite, 23 
 Measurements, in investigation, 3 
 
 , of wounds, 34 
 
 , , technique of, 36 
 
 Mechanical cleansing of wounds, 
 
 89, 91 
 Medullary canal, 100 
 
INDEX 
 
 235 
 
 Membranes, rubber, 64 
 Mercury, bichloride of, 17, 18, 20 
 Method, practical value of, 224 
 Methods, American, 183 
 
 , M. Broca and, 10 
 
 , scientific, absence of, 35 
 
 Microbes, charts of, 26 
 
 , contact of antiseptic with, 
 
 53.67 
 
 , counting, 158, 174 
 
 , encapsuled, 176 
 
 , rate of growth of, 56 
 
 Moniaz, yJ/., 55 
 
 Missile, excision of track of, 95 
 Mononuclear cells, 172 
 Mo Seng's mass, 185 
 Moyiiihaii, Sir B. G. A., 4 
 Moyroudy M., 9 
 Multiple wounds, 191-2 
 Muscle, suture of, 184 
 
 Naphthalene derivatives, 51 
 Nerve suture, iii, 184, 221 
 Nitrate of silver, 1 7 
 Nouy^ Lecomte de, M.^ 37, 149 
 Nurses, duties of, 133, 145 
 
 Odour of wounds, 144 
 Oleate of soda, neutral, 36, 98 
 Opening-up of wounds, 94 
 Osteitis, 171, 209 
 Osteo-myelitis, 91 
 
 Painful cicatrices, 221 
 
 Panne, ambulance de la, 10, 201, 
 
 225 
 Para-toluene-sulphochlorate, 52 
 Para - toluene - sodium - sulphochlor- 
 amine, 49 
 -, bactericidal action of, 50 
 
 Patients, appearance of, 152 
 Penetration of liquid, insufficient, 
 
 142 
 Perforations in rubber tubes, 113 
 Perimeter of wounds, 35 
 Periosteal elevator, no 
 Peroxide of hydrogen, 17, 18, 220 
 Ferret, M., 9, 225 
 Ferj-in, M., 196, 200, 203, 225 
 Phagocytosis, 33, 173 
 Fhelip, M., SS 
 Phenol phtalein test, 85 
 Phlegmonous infections, loi 
 
 wounds, 90, 150, 190 
 
 Physiological saline solution, 28, 
 
 46, 139 
 
 ** Pickling " in tanneries, 48 
 Pince de Mohr, 117 ; avis, 120 
 Pinchcock, spring, 117 
 
 , use of, 140 
 
 , screw, 120 
 
 Planimeter, use of, 36 
 Plaster, adhesive, for fixing lubes, 
 127 
 
 , , for wound closure, 181 
 
 Folicard, M., 55, 59, 177 
 Polynuclear cells, 172 
 Potassium hypochlorite, 23 
 
 iodide, 78, 81 
 
 Powder, antiseptics in, 24 
 Fozzi, M., 8, 9, 10, 177 
 Pre-inflammatory stage, 89, 91 
 Premature closure of wounds, 99 
 Preparation of slides, 157 
 
 of wound, 60 
 
 Pressure, excessive, 146 
 Primary closure of wounds, 179 
 
 haemorrhage, 108 
 
 Projectiles, search for, 96 
 , excision of track of, 95 
 
 V&^i^, Beck's^ 185, 194-5 
 chloramine, 127, 228 
 
 Proteins, 51 
 
 , action of hypochlorite on, 25 
 
 Patella, fracture of, 204-5 I » o^ P"^» ^5 
 
236 
 
 INDEX 
 
 Pseudarthroses, 2i6 
 
 Pus, action of hypochlorite on, 25 
 
 , blue, 207-8 
 
 , microbes of, 168 
 
 , pockets of, 170 
 
 , proteins of, 25 
 
 Pyrexia, 176 
 
 , persistence of, 152 
 
 Quantity of liquid, excessive, 144 
 
 , instilled, 140 
 
 Quenu, M., 9 
 
 Radiological examination, 92 
 Rasrhig^ yl/., 46 
 
 Reinfection, cutaneous origin of, 
 165 
 
 , from pockets of pus, 1 70 
 
 Repair, speed of, 38 
 Representation, graphic, of cicatri- 
 sation, 37 
 Resection of damaged tissues, 6 1 
 
 of joints, loi 
 
 limited, 100 
 
 of wounds, 95 
 
 Results, abscess cavities, 193 
 
 -y compound fractures, 193 
 
 , of sterilisation of wounds, 188 
 
 Retarding action of hypochlorite, 
 
 44 
 
 Ringer's solution, 41 
 Rubber membranes, 64 
 
 tubes, perforated, 63, 113 
 
 Rugine tranchante, no 
 
 Saccharine, by products, 52 
 Safety-pins, use of, 137 
 Saint-Germain hospital, 226 
 Salicylic acid, 17 
 Saline solution, hypertonic, 29, 62 
 , physiological, 28, 46, 
 
 139 
 Salts of Soda, 79 
 
 Sciatic nerve, haematoma of, 99 
 Secondary closure of wounds, 2 1 7 
 
 haemorrhage, 107 
 
 Secretions of wounds, 150 
 
 , changes in, 144, 151 
 
 , examination of, 156 
 
 Septicaemia, gas-producing, 179 
 
 , streptococcal, 179 
 
 Sequestra, 209 
 Serum, Dopter's^ 213 
 
 , horse, 24 
 
 Seton type of wounds, 93, 94, 127 
 
 Shape of wounds, 124 
 
 Silk, effect of hypochlorite on, 107 
 
 Silkworm gut, 200 
 
 Sinus, effect of, 164 
 
 Skin, effect of soda on, 48 
 
 experiments in vitroy 22 
 
 irritation of, 145, 148 
 
 , from boric acid, 75 
 
 reinfection from, 165 
 
 ■ scrapings from, 167 
 
 sterilisation of, 94 
 
 Slides, microscope, label on, 158 
 
 — , , preparation of, 157 
 
 , , staining of, 158 
 
 Smears, technique of, 156 
 
 , from fresh wounds, 160 
 
 , causes of error, 159, 160 
 
 Soda, bicarbonate, 75, 80 
 
 , carbonate, 75, 85 
 
 , caustic, 80, 86 
 
 , effect on skin, 48 
 
 , hydrated, 79 
 
 , salts of, 79 
 
 , Solway^ 79 
 
 Sodium chloride solution, 30 
 Solway^ carbonate of soda, 79 
 Splinters, bone, removal of, 100 
 Stagnation of liquid, 129 
 Staphylococci, 16, 31 
 Sleiilisation of wounds, chemical, 
 III, 112 
 
INDEX 
 
 237 
 
 Sterilisation of wounds, conse- 
 quences of, 214 
 
 , fresh, 189 
 
 , mechanical cleansing, 89 
 
 Stirrup-piece, 183 
 
 Strapping, boot-lace hooks on, 183 
 
 for wound-closure, 18 r 
 
 Strength of solution, 65 
 
 Streptococci, 16, 31 
 
 Stump, retraction of skin, 183 
 
 trimming, ill 
 
 Suppression of wound-infection, 2, 
 
 219 
 Surgical asepsis, 177 
 
 cleaning, 1 10 
 
 Suppurating compound fractures, 
 results, 206 
 
 wounds, 57, 108, 132 
 
 , changes in, 151 
 
 , disinfection of, 226 
 
 , microbes of, 168 
 
 ■ , results, 193 
 
 Suppuration, suppression of, 214 
 Suppurative arthritis, 1 1 o 
 Suture, closure by, 184 
 
 deep, 176 
 
 of tendon, 184 
 
 Syringe, Gentile's, 119 
 
 Tables, 17, 77, 79, 83 
 Team-work needed in investigation, 
 
 2 
 Technique, errors of, 142 
 
 of closure, 181 
 
 of manufacture of Dakiri's 
 
 solution, 73 
 
 of smears, 156 
 
 principles of, 13 
 
 Temperature, importance of, 176 
 Test, phenol phtalein, 85 
 
 for working of tubes, 132 
 
 Tetanus, experiments, 30 
 
 Thigh, wounds of, 189. &,? Femur 
 
 Thionin, carbol, 158 
 
 Tibia, compound fractures of, 195, 
 
 197, 198, 211, 224 
 Tissot^ yJ/., 29 
 Tissu eponge, 114 
 Tissues, action of hypochlorite on, 
 
 32, 33 
 
 Titration of chloride of lime, 76 
 
 of hypochlorite, 81 
 
 Topical applications to wounds, 34 
 Topography of infection, 53 
 Toxicity of hypochlorite, 32 
 Tracings of wounds, 44 
 Traction, elastic, wound-closing by, 
 192 
 
 , , on stump, 183 
 
 Treatment, cost of, 217, 219 
 Trochanters, fracture through, 208 
 Tubes, adhesive plaster for, 127 
 
 , arrangement of, 123, 131 
 
 , conducting, 112 
 
 , fixation of, 127 
 
 , instillation, 112 
 
 , perforations in, 63, 113 
 
 Tuffier, M., i, 8, 9, 10, 19, 226 
 
 Uffoltz, M., 8, 9, 225, 226 
 Unions, glass-tube, 115 
 Urea, 51 
 
 Vaselin, dressing, 27, 43 
 
 , gauze, 133 
 
 Vehicle, fatty, for antiseptics, 24 
 Vessels, effect of free alkali on, loS 
 
 , injury to, 33, 96 
 
 Vibrator, audioscope, 97 
 Vieiine, M., 48 
 Vigne, M., 9 
 Vincent^ M., 24, 177 
 Volume of deep wounds, 37 
 
 Waterproof fabrics, 135 
 sheet, 138 
 
238 
 
 INDEX 
 
 Welch, bacilli of, i6, i8, 167 
 Wick, cotton, 62, 123 
 
 , gauze, 68 
 
 Wowiant, M., 177 
 
 Wounds, action of hypochlorite on, 
 
 26, 38 
 
 ■ -, cicatricial stage of. III 
 
 , chemio-therapy of, 13 
 
 , chemical cleansing of, 109 
 
 , clinical examination of, 147 
 
 , condition of, 35 
 
 , closure of, 178, 217. See 
 
 Closure of Wounds 
 
 ^, cup-like, 124 
 
 , dimensions of, and time re- 
 quired, 69 
 
 , foreign bodies in, 41, 69, 
 
 171 
 
 , gangrenous, 150, 190 
 
 , large, 129 
 
 Wounds, perimeter of, 35 
 
 phlegmonous, 90, 150, 190 
 primary union of, 179 
 secondary union of, 217 
 seton type of, 93, 94, 127 
 resection of, 95 
 shape of, 124 
 strapping for, 181 
 suppurating, 57, 108, 132 
 
 , changes in, 151 
 
 , disinfection of, 226 
 
 , microbes of, 168 
 
 , results, 193 
 
 treated by chloramines, 72 
 volume of deep, 37 ^ 
 
 with several openings, 129 
 with two openings, 128 
 
 Wright, Sir Almroth, 5, 53, 62 
 Y-SHAPED tubes, glass, 1 1 5 
 
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8 EOEBEE'S MEDICAL MONOGBAPES 
 
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HOEBEB'S MEDICAL MONOGBAPHS 9 
 
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EOEBEB'8 MEDICAL MONOGBAPHS 11 
 
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12 HOEBEB'S MEDICAL M0N0GBAPH8 
 
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