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 C HEALTHSC,ENCESSTANDARD 
 
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 TECHNIC 
 
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 CARREL METHOD 
 
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TECHNIC OF 
 CARREL METHOD 
 
TECHNIC OF 
 
 The Irrigation Treatment of Wounds 
 
 BY THE 
 
 CARREL METHOD 
 
 BY 
 J. DUMAS & ANNE CARREL 
 
 AUTHORIZED TRANSLATION 
 BY ADRIAN V. S. LAMBERT, M. D. 
 
 Acting Professor of Surgery in the Collage of Physicians and Surgeons 
 (Columbia University) New York 
 
 With an Introduction by 
 W. W. KEEN, M.D., L.L.D., F.R.C.S. (HON.) 
 
 PAUL B. HOEBER 
 
 NEW YORK 
 
37 
 
 Copyright, 191 7, 
 By Paul B. Hoeber 
 
 Published, November, iqi? 
 
 mil 1 i^ 
 
 JT) St) 
 
 Printed in the United States of Amerfca 
 
Errata 
 
 The words calcium chloride have been used throughout the 
 book in place of the words chloride of lime or bleaching powder. 
 It is suggested that the words chloride of lime or bleaching 
 powder be substituted in each instance. This change should be 
 noted on page 56, lines 5, 10, 13, 16; page 57, line 16; page 58, 
 lines 12, 14, 22; page 59, line 3 and in table ; page 60, lines 7, 9, 
 19 ; page 61, line 20 ; page 80, line 12. 
 
INTRODUCTION 
 
 Alexis Carrel's genius has been shown 
 in many remarkable ways and has already 
 ~eceived the hall-mark of a Nobel prize. 
 
 But now he has done a still greater 
 jractical service to humanity in the new 
 ^nd wonderfully successful technic in 
 treating war wounds by means of Dakin's 
 Solution. A colleague, M. le Dr. J. 
 Dumas, and Dr. Carrel's devoted and tal- 
 ented wife — truly a helpmate, who has 
 Ven so valiant an assistant in all his re- 
 earches both in this country and in France 
 — have amplified the details of this treat- 
 ment in a small brochure to which, in its 
 English translation, it is a genuine pleas- 
 ure for me at the request of the publisher 
 to furnish this brief introductory note. 
 Every surgeon in the various military and 
 naval forces and also those in civil life 
 who have to do with industrial and other 
 
 5 
 
 2 (V 
 
6 INTRODUCTION 
 
 accidental wounds should know this tech- 
 nic by heart and practice it with exactness. 
 They will be rewarded by a most gratify- 
 ing success. 
 
 Wiluam W. Keen, 
 
 Philadelphia, November 19 17. 
 
PREFACE 
 
 So much interest has centered about 
 the method introduced by Dr. Carrel for 
 the treatment of war wounds that any 
 book embodying his ideas is certain to be 
 of service. This small book was written 
 by Madame Carrel, who has worked at 
 Compiégne and become a most proficient 
 member of that highly trained and techni- 
 cally skilled staff. It was written pri- 
 marily for the information of nurses so 
 that they might have a clear, short account 
 of the various details of the technic, and 
 an accurate description of the apparatus 
 used in carrying it out. The book in no 
 way supplants the more complete ac- 
 count written by Dr. Carrel, The Treat- 
 ment of Infected Wounds* An effort 
 has been made to keep it simple and direct 
 
 * Published by Paul B. Hoeber, New York. 
 
 7 
 
8 PREFACE 
 
 so that it might serve as a guide for those 
 wishing to become proficient assistants. 
 It is, therefore, shorn of all theoretical 
 considerations which might be confusing 
 or be a subject of controversy. 
 
 Perhaps this is not the place to sound 
 the praises of the method, but I cannot re- 
 frain, even at the risk of being somewhat 
 out of order, from bearing witness to the 
 immense value which the treatment has, 
 not only in the wounds of war but in the 
 treatment of pyogenic infections in civil 
 practice. 
 
 This is a fairly literal translation of the 
 first portion of the book, with such few 
 additions as seemed wise in view of some 
 of the latest improvements now being em- 
 ployed by Dr. Carrel. The appendices 
 have been translated into technical Eng- 
 lish which gives strictly the content and, 
 for English readers, will prove easier 
 reading and less cumbersome than a closer 
 following of the original French text. 
 For the benefit of English speaking read- 
 ers who may proceed to France, a short 
 
PREFACE 9 
 
 glossary of French terms employed for 
 designating the various elements of the 
 apparatus has been appended. 
 
 In this book no attempt has been made 
 to teach surgery or to explain how and in 
 what cases the treatment is employed. If 
 it leads any to employ correctly the latest 
 tool of our art it will have amply justified 
 its publication. 
 
 Adrian V. S. Lambert. 
 
 New York, November 19 17. 
 
CONTENTS 
 
 PAGE 
 
 Introduction by William W. Keen, 
 M.D 5 
 
 Preface 7 
 
 I Materials Used in the Dressing . 15 
 
 II Preliminary Remarks of the Mi- 
 croscopical Examination of the 
 Wound Secretions 25 
 
 III The Dressing 26 
 
 IV The Irrigating Apparatus ... 30 
 
 V Setting Up the Irrigating Appara- 
 tus . 42 
 
 VI The Technic of Irrigation . . 47 
 
 VII Appendices — 
 
 (1) The Preparation of Da- 
 kin's Solution .... 55 
 
 (2) The Microscopical Exam- 
 ination of War Wounds by 
 the Carrel Method . . 63 
 
 VIII Glossary 79 
 
 IX Index . 83 
 
LIST OF PLATES 
 
 PLATE PAGE 
 
 I Various Sizes of Instillation Tubes . 17 
 II Covered Instillation Tubes . . .19 
 
 III Distribution or Instillation Tubes Cov- 
 
 ered with Turkish Toweling and 
 Provided with Guy Ropes for Fix- 
 ation at Edge of Wound . . . . 21 
 
 IV Irrigation Apparatus Showing Sup- 
 
 porting Stand with Flask in Place . 31 
 
 V Conducting and Instillation Tubes . 33 
 
 VI Enlargement of a Portion of the Ap- 
 paratus Shown in Plate IV . . . 35 
 
 VII Glass Conducting Connector and Glass 
 
 Distributors 39 
 
 VIII Supporting Stand 43 
 
 IX Detail of the Adjustable Parts of the 
 
 Supporting Stand 45 
 
 X Pinchcock and Safety-pin .... 49 
 
 XI Graphic Record of Bacterial Count . 75 
 
TECHNIC OF THE IRRIGATION 
 
 TREATMENT OF WOUNDS BY 
 
 THE CARREL METHOD 
 
 The sterilization of wounds by repeated 
 irrigations with a solution of hypochlor- 
 ite of sodium, called Dakin's Solution (see 
 Appendix I) requires the use of spe- 
 cial, but extremely simple, apparatus and 
 the application of dressings which assure 
 the prolonged contact of the antiseptic 
 with all portions of the wound. 
 
 MATERIALS USED IN THE DRESSINGS 
 
 I. Distributing or "Instillation" Tubes 
 (Tubes distributeurs). — These are rubber 
 drainage tubes No. 16 French (4 mm. in- 
 ternal diameter, the wall 1 mm. thick), 0.3 
 to 0.5 m. long. They are of two varieties: 
 
 (a) Simple or non-perforated distribut- 
 ing tubes in which the ends are open, and 
 
 15 
 
i6 IRRIGATION OF WOUNDS 
 
 half a centimeter from one end a large lat- 
 eral opening is made (Plate I). 
 
 (b) Perforated distributing tubes 
 which have one end closed by being tied 
 with a linen thread, and whose walls are 
 perforated from this closed extremity for 
 a distance of 5, 10, 15, 20 cm. by holes 1 /r m 
 1 mm. in diameter, 1 cm. apart. These 
 are spoken of as 5, 10, 15 or 20 cm. tubes. 
 
 The rôle of these tubes consists in con- 
 veying the antiseptic to all recesses of the 
 wound. The portion of these tubes which 
 is perforated with holes is often covered 
 with Turkish toweling. This should be 
 firmly attached to the tube so that it can- 
 not be left in the wound on the removal 
 of the tube. These tubes covered thus are 
 used on superficial wounds where the fluid 
 must be spread over a flat surface or in 
 wounds with dependent openings where 
 the distribution of the fluid is difficult. 
 Threads are left long at the ends of the 
 toweling, which serve as guy ropes to 
 steady the tube (Plates II and III). They 
 are fastened to the skin with small pieces 
 
PLATE I 
 
 Various Sizes of Instillation. Tubes 
 Tubes 5, io, 15, and 20 cm. in perforated length ; also sim- 
 ple and loop tubes. 
 
PLATE II 
 
 A B 
 
 Covered Instillation Tubes 
 
 A. — Covered with Turkish toweling. 
 B. — Cross section of covered tube. 
 
PLATE III 
 
 Distribution or Instillation Tubes Covered with Turkish Towel- 
 ing and Provided with Guy Threads for Fixation at Edge 
 of Wound 
 
MATERIALS FOR DRESSING 23 
 
 of adhesive plaster to prevent their shifting. 
 
 2. Tampons and Compresses of Gauze. 
 — These do not differ in any particular 
 from similar articles usually used by all 
 surgeons. 
 
 3. Cotton Pads. — These are of four 
 sizes measuring 0.25 by 0.14, 0.33 by 0.22, 
 0.53 by 0.33, 1. 10 by 0.45 m. They consist 
 of a layer of non-absorbent cotton and a 
 layer of absorbent cotton (except that the 
 small ones are composed of absorbent cot- 
 ton only) wrapped together in a single 
 thickness of gauze which should be folded 
 carefully back over the absorbent cotton 
 completely covering it in its entire extent. 
 
 All these materials should be carefully 
 sterilized as follows : 
 
 (a) The distributing tubes are sterilized 
 in the autoclave at 120 C. for twenty 
 minutes in large glass test tubes, closed 
 with cotton stoppers, in which they are pre- 
 served sterile until used. 
 
 (b) The tampons, compresses and cot- 
 ton pads are sterilized for 45 minutes in 
 the autoclave at 134 C. in large metal 
 
24 IRRIGATION OF WOUNDS 
 
 boxes. If one does not possess enough or 
 sufficiently large boxes for sterilizing the 
 larger pads it would be well to place them 
 in the autoclave each wrapped separately 
 in a piece of linen or white paper. 
 
 4. Sterile Vaseline Compresses. — Their 
 use prevents or diminishes the irritant ac- 
 tion which the antiseptic has on the skin 
 of certain people in the region of the 
 wounds treated by irrigation. These vase- 
 line compresses are prepared in the follow- 
 ing manner : A number of pieces of gauze 
 are cut measuring about 6 by 12 cm. A 
 layer of white vaseline is spread on one of 
 the surfaces of each with a spatula, and 
 the squares are then packed one above the 
 other in air-tight metal containers. The 
 containers are placed in the hot air steril- 
 izer, absolutely horizontal so that the 
 liquefied vaseline cannot run out, and are 
 sterilized for thirty minutes at 130 C. 
 
 5. Articles to Keep the Dressings in 
 Place. — There should be on hand to steady 
 the dressing and hold it in place the fol- 
 lowing: 
 
MICROSCOPICAL EXAMINATION 25 
 
 (a) Strips of unstarched gauze; 
 
 (b) Flannel binders (so-called many- 
 tailed bandage) ; 
 
 (c) Safety-pins of different sizes; 
 
 (d) Adhesive plaster. 
 
 I. PRELIMINARY REMARKS ON THE PUR- 
 POSE OF THE MICROSCOPICAL EXAMI- 
 NATION OF THE WOUND SECRETIONS 
 
 We are to suppose that the wound which 
 is to be subjected to our treatment has al- 
 ready had previous care : tissue fragments 
 and foreign bodies have been removed 
 several days previously, the wound has 
 been carefully explored and cleansed, 
 and all parts of it have been made readily 
 accessible. Before commencing the dress- 
 ing a preliminary microscopical examina- 
 tion of the wound secretions is necessary, 
 in order to determine the degree of infec- 
 tion. This examination has to be repeated 
 every day in order to follow the progress 
 of disinfection, and to determine the mo- 
 ment when this disinfection is sufficient to 
 
26 IRRIGATION OF WOUNDS 
 
 allow the closure of the wound without 
 danger (see Appendix II). 
 
 ii. the: dressing 
 
 The preliminary microscopical exami- 
 nation having been made, the surgeon is 
 ready to draw on his rubber gloves * and 
 to do the dressing. 
 
 The nurse who is assisting must have 
 on her dressing tray, besides tubes, tam- 
 pons, cotton pads, vaselined compresses 
 and the articles necessary for fixing the 
 dressing: 
 
 (a) A few sterile forceps (Kocher's 
 without teeth) ; 
 
 (b) Several pairs of sterile scissors; 
 
 (c) Sterile basins; 
 
 (d) Dakin's Solution. 
 
 i. The nurse should seize and hand to 
 the surgeon all the sterile things which 
 
 * The rubber gloves are used for the protection 
 of the surgeon. They are not sterile and are not 
 changed for each case but are worn during the 
 entire period while the surgeon does several 
 dressings. 
 
THE DRESSING 27 
 
 he may require, using for this purpose a 
 pair of large strong forceps, thus avoid- 
 ing any possible contamination. 
 
 The nurse first hands two sterile for- 
 ceps to the surgeon with which he is to 
 handle the sterile dressings, and place 
 them on the wound without ever touching 
 them with his hands. These forceps are 
 changed not only for dressing each pa- 
 tient, but very often also for dressing dif- 
 ferent wounds in the same patient, when 
 these have different degrees of infection. 
 
 2. The nurse should then hand the sur- 
 geon as he calls for them : 
 
 (a) Tampons or compresses moistened 
 with Dakin's Solution, if the condition of 
 the wound requires cleansing ; * 
 
 (b) Scissors, if there is any necrotic 
 tissue to be excised ; 
 
 (c) One or more simple distributing 
 tubes or those perforated for 5, 10, 15, or 
 20 cm., depending upon the size and shape 
 
 * The wound may be cleansed with a solution 
 of neutral sodium oleate which is not irritating to 
 the skin or wound. 
 
28 IRRIGATION OF WOUNDS 
 
 of the wound, the amount of infection or 
 the presence or absence of necrotic tissue 
 on its surface. Some of the tubes are 
 placed in the deep parts and pockets of 
 the wound and underneath skin flaps, 
 while others are laid on the superficial por- 
 tion in such a way that the perforations 
 rest on the necrotic tissues or the most 
 infected areas. These superficial tubes 
 are held in place by means of strips of ad- 
 hesive plaster attached to the skin several 
 centimeters away from the margins of the 
 wounds. 
 
 (d) Gauze compresses moistened with 
 Dakin's Solution in a sterile basin are used 
 to keep the tubes in place, to close off cer- 
 tain portions of the wound, to dilate fistu- 
 lous tracts, to lift up a flap, in short to 
 cover or line the entire wound. When 
 these compresses have been inserted in 
 the wound, they absorb a considerable 
 amount of irrigating fluid which is thus 
 distributed and kept in contact with all 
 recesses of the wound. 
 
 (e) Vaselined compresses, which are to 
 
THE DRESSING 29 
 
 be used around the wound on the skin 
 that is exposed to the action of any of the 
 antiseptic solution which leaks out of the 
 dressings. * 
 
 Finally, the dressing is completed by 
 covering all the compresses with a cotton 
 pad of correct size so placed that the ab- 
 sorbent cotton side lies toward the wound. 
 When the dressing has been applied to an 
 extremity, the cotton pad should be large 
 enough to encircle the limb. 
 
 The cotton pads are best held in place 
 by safety-pins, if there is no danger of 
 the dressing being displaced. If band- 
 age is used, it should be loosely wound so 
 as not to compress the distributing tubes. 
 These tubes should project several centi- 
 meters beyond the dressings. 
 
 A many-tailed flannel binder is often 
 preferable to the roller bandage. 
 
 3. The adjustment of this binder avoids 
 moving the wounded limb, which is al- 
 * In place of the vaseline compresses the skin 
 surrounding the wound may be covered with vas- 
 eline smeared on with a spatula. 
 
30 IRRIGATION OF WOUNDS 
 
 ways troublesome during the application 
 of a roller bandage, and allows the em- 
 ployment of safety-pins. 
 
 III. THD IRRIGATING APPARATUS 
 
 The irrigating apparatus (Plate IV) is 
 composed of: 
 
 i. The Flask or Reservoir (Ampoule) 
 (see Plate IV) of glass, with a capacity of 
 one liter (1.75 pints); it is the container 
 for the antiseptic fluid. The flask has a 
 short neck and a funnel-shaped opening 
 at its upper end for the introduction of 
 the fluid. The lower end is tubular with an 
 internal diameter of 7 mm., over which 
 the conducting tube fits. 
 
 2. Conducting Tube (Tube adducteur) 
 (Plate V, CT and Plate VI, CT).— 
 Through this rubber tube, which has an 
 internal diameter of 7 mm., the fluid runs 
 from the reservoir to the tubes in the 
 wound. 
 
 If the dressing consists of a single tube 
 or of two, three, or four distributing or 
 "instillation" tubes (Plate IV, Plate V, 
 
PLATE IV 
 
 Irrigation Apparatus, Showing Supporting Stand with 
 Flask in Place 
 Attached are main conducting tube, glass conductor, 
 secondary conducting tubes, glass distributors and instil- 
 lation tubes. 
 
PLATE V 
 
 Conducting and Instillation Tubes 
 A. — Conducting tube, CT, shown connected with distribution or instil- 
 lation tubes, IT, by a glass distributor, C, with four outlets. 
 
 B. — Loop instillation tube connected up with a glass distributor. 
 
PLATE VI 
 
 Enlargement of a Portion of the Apparatus Shown in 
 
 Plate IV 
 
 CT, main conducting tube ; A, glass conducting connector ; 
 SCT, secondary conducting tubes ; B, C, glass distributors ; IT, 
 instillation tubes ; S, simple instillation tube ; TT, tube covered 
 with turkish toweling with guy threads; P, pinchcock. 
 
IRRIGATING APPARATUS 37 
 
 Plate VI, IT) the ends of which are near 
 together where they emerge from the 
 dressing, the conducting tube for a great 
 part of its course from reservoir to 
 dressing should be long enough to rest 
 on the bed without being stretched. If it 
 is too short it is always easy to lengthen 
 it by joining on a new section of rubber 
 tubing of proper length. 
 
 The primary rubber conducting tube 
 (Plate VI, CT) can be connected with two 
 secondary tubes (secondary rubber con- 
 ducting tubes, Plate VI, SCT), so that it is 
 possible to irrigate from a single flask a 
 wound which contains more than four rub- 
 ber distributing or "instillation" tubes, or 
 two wounds which are near each other. 
 
 This is accomplished by means of con- 
 nections which we call glass conducting 
 connectors. (Plate VI, A.) 
 
 3. Glass Conducting Connectors (Rac- 
 cords adducteurs) (Plate VII). — These 
 are of two kinds, straight glass cylindrical 
 connectors ; and others of the same diame- 
 
38 IRRIGATION OF WOUNDS 
 
 ter, but bifurcated into a "Y" (Plate VII, 
 A). 
 
 4. A Pinchcock or Clamp (Pince de 
 Mohr à rassort) (Plate X, Fig. A).— 
 This should be placed on the primary rub- 
 ber conducting tube (Plates IV; VI, P) to 
 prevent the liquid from escaping in the in- 
 tervals between irrigations. 
 
 5. Glass Distributors (Raccords dis- 
 tributeurs) (Plate VII, B, C, D).— These 
 are of glass and connect the rubber con- 
 ducting tubes with the rubber distributing 
 tubes. (Plate VC; Plate VI B, C.) If 
 there is only one distributing tube in the 
 wound, then a single straight glass distrib- 
 utor is used; in other cases a two, three, or 
 four branched glass distributor is required 
 when two, three, or four distributing tubes 
 are employed. The glass distributors are 
 called simple (Plate VII, D), forked(Plate 
 VII, B), trident, and comb shaped (Plate 
 VII, C), according to the number of 
 branches. The internal diameter of the end 
 of these distributors which is to join the 
 
PLATE VII 
 
 Glass Conducting Connector and Glass Distributors 
 Glass connector, A, is 7 mm. diameter throughout; glass distribu- 
 tors (B, C, D) have a diameter of 7 mm. at the larger end and 4 mm. at 
 the smaller. E is a small connecting tube of 4 mm. diameter. 
 
; 
 
 • ni 
 
IRRIGATING APPARATUS 41 
 
 rubber conducting tube should be 7 mm;; 
 the other ends over which the rubber dis- 
 tributing tubes fit should have an internal 
 diameter of only 4 mm. (see Plate VII) . 
 
 6. Small Straight Glass Distributing 
 Tubes (Petits raccords droits) (Plate 
 VII, E). — Sometimes the ends of the rub- 
 ber distributing tubes do not project far 
 enough outside of the dressing and can- 
 not, therefore, be readily connected to the 
 glass distributors. By means of a small 
 glass tube with an inner diameter of 4 mm. 
 and length of 0.025, it is a simple matter 
 to attach an additional piece of rubber tub- 
 ing of the same diameter as the rubber dis- 
 tributing tube. 
 
 The entire apparatus should be washed 
 : n warm soap-suds and rinsed in boiled 
 
 iter. The flask should be washed out 
 \ ith Dakin's Solution and the glass con- 
 necting pieces and rubber tubing immersed 
 for two hours in the same solution. If the 
 apparatus has not been contaminated, no 
 further sterilization is necessary. 
 
42 IRRIGATION OF WOUNDS 
 
 IV. SETTING UP OF THE IRRIGATING 
 APPARATUS 
 
 The flask (see Plate IV) containing 
 the antiseptic solution is closed at its 
 upper end with a plug of sterile cotton. 
 The rubber conducting tube, to which the 
 spring-clamp is attached, is connected to 
 its lower end (Plate IV) and provided 
 with a simple or Y-shaped glass conduct- 
 ing connector (Plate VI, A). This flask 
 is suspended at a height of 0.60 to 0.80 m. 
 above the level of the injured person by 
 means of a stand attached to one of the 
 bed-posts. We have designed a stand with 
 a sliding carrier, which holds the flask and 
 permits of an adjustment to different 
 levels (Plates VIII and IX). 
 
 All that remains to be done is to connect 
 the lower end of the rubber conducting 
 tube or tubes with the rubber distribut- 
 ing tubes which project from the dress- 
 ing (Plate V, C; Plate VI, B and C), and 
 the irrigation can be begun. 
 
 This connection is made by means of 
 
PLATE VIII 
 
 Supporting Stand 
 
 The slot makes it possible to ad- 
 just the flask holder at suitable levels. 
 
PLATE IX 
 
 <~2'/a--> 
 
 E3E 
 
 ES 
 
 < 5" -> 
 
 •/2*->a 
 
 <-— 5»r. _> 
 
 \/ 
 
 
 <, 5 n > 
 
 Detail or the Adjustable Parts of the Supporting 
 
 Stand, 
 The grooved slot provides for lifting the upper rack 
 so that the flask may be inserted. 
 
TECHNIC OF IRRIGATION 47 
 
 the glass distributors (Plate VII, B, C, 
 D). The latter are selected according to 
 the number and arrangement of the rub- 
 ber distributing tubes; their larger end is 
 slipped into the secondary rubber conduct- 
 ing tube, while their small ends are con- 
 nected to the rubber distributing tubes 
 (see details in Plate V and Plate VI). 
 
 To prevent slipping of the tubes a large 
 safety-pin (Plate VI and Plate X, Fig. B) 
 should be fastened to the cotton pads of 
 the dressing and should enclose between 
 its branches the large end of the glass dis- 
 tributor covered by the rubber conducting 
 tube. A safety-pin should also fasten the 
 glass conducting connector. 
 
 V. TH3 TECHNIC OF IRRIGATION 
 
 These preliminaries having been com- 
 pleted, the procedure is begun by which 
 an amount of fluid is carried into the 
 dressings sufficient to maintain a continu- 
 ous action of the antiseptic. Every two 
 hours, night and day, the pinchcock on 
 the rubber conducting tube is opened, for 
 
48 IRRIGATION OF WOUNDS 
 
 a variable length of time, depending on 
 the gravity and nature of the wound. 
 
 Ordinarily, the pinchcock must be 
 opened for from one half a second to three 
 seconds in order to allow enough antisep- 
 tic solution to flow out to soak the dress- 
 ings and fill the wound. This is learned 
 after a little experience. It is a good plan 
 to determine the time that the solution 
 shall be allowed to flow by doing the first 
 irrigation of a wound while it is still un- 
 covered by the outside dressing. 
 
 At each irrigation, one must be certain 
 that the fluid flows freely, if this is not the 
 case, the cause of the obstruction must 
 be sought. The rubber conducting tube 
 should be examined from its point of con- 
 nection with the flask to the glass distribu- 
 tors, and any compression relieved and 
 bends straightened out. The exposed parts 
 of the rubber distributing tubes are also 
 examined. If all these are in good order, 
 the trouble must be located in the interior 
 of the dressings, and the surgeon should 
 therefore be notified. When the distribut- 
 
PLATE X 
 
 B 
 
 PlNCHCOCK AND SAFETY-PIN 
 
 À. — Enlarged view of pinchcock used to regulate the 
 flow of the antiseptic solution. 
 
 B. — Enlarged view of safety-pin showing method of 
 holding tubes and glass distributors in place. 
 
TECHNIC OF IRRIGATION 51 
 
 ing tubes are not changed at every dress- 
 ing, it is absolutely necessary to be certain 
 of the permeability of the tubes by inject- 
 ing some solution through them with a 
 syringe. 
 
 As the irrigating fluid often oozes out 
 of the dressings, rubber sheeting covered 
 with a bed-pad should be placed under the 
 patient, so that the bedding shall not be 
 soaked. This bed-pad can be changed as 
 often as it is necessary. 
 
APPENDICES 
 
APPENDIX I 
 
 PREPARATION OF DARIN'S SOLUTION 
 (daufresne's T£CHNIC) 
 
 D akin' s Fluid is a solution of sodium 
 hypochlorite for surgical use. Numerous 
 experiments and a prolonged practical ex- 
 perience with the solution have shown that 
 it must have the following properties : 
 
 (a) The fluid must not contain caustic 
 alkali. In order to use a hypochlorite solu- 
 tion for the treatment of wounds, it must 
 be free from traces of caustic soda ; Javel 
 water, Labarraque Solution and all solu- 
 tions not prepared in the manner we shall 
 describe, cannot, therefore, be used. 
 
 (b) The strength of the hypochlorite 
 solution must be absolutely fixed between 
 0.45 and 0.5 per cent. Solutions that are 
 weaker than 0.45 per cent, are too weak; 
 those that contain more than 0.5 per cent. 
 
 55 
 
56 IRRIGATION OF WOUNDS 
 
 of the hypochlorite are irritating to the 
 tissues. 
 
 Chemicals Required for the Prepara- 
 tion of the Solution. — Three chemicals 
 are indispensable : calcium chlorid, dry so- 
 dium carbonate,* and sodium bicarbon- 
 ate. As obtained commercially, the compo- 
 sition of the last two of these chemicals is 
 fairly uniform and will suffice for all prac- 
 tical requirements. In commercial calcium 
 chlorid, however, the active chlorine (free 
 chlorine) varies within wide limits. Be- 
 fore the calcium chlorid is used, it is nec- 
 essary to determine its percentage of free 
 chlorine by titration. 
 
 Titration of the Calcium Chlorid. — For 
 this purpose the following apparatus is 
 necessary : 
 
 A 25 ex. English burette graduated in 
 
 * This salt is obtained without any difficulty 
 in the open market under the name of "Solvay's 
 soda" or "carbonate of soda, Solvay." Where 
 only the crystalline carbonate can be obtained, 
 2.85 times more of it than of the dry salt must be 
 used (on account of the water of crystallization). 
 
DAKIN'S SOLUTION 57 
 
 tenths of a cubic centimeter; a 10 c.c. 
 pipette, and a deci-normal solution of so- 
 dium hyposulphite. 
 
 The standard deci-normal solution of 
 sodium hyposulphite is on the market, or 
 it can be prepared by dissolving 25 grams 
 of crystalline chemically pure sodium hy- 
 posulphite in one liter of distilled water. 
 The solution is correct if it decolorizes an 
 equal volume of a deci-normal iodine solu- 
 tion made by dissolving 1.27 grams of 
 iodine and 5.0 grams of potassium iodid in 
 100 ex. of water. 
 
 Everything being ready for the quanti- 
 tative test, select an average sample of the 
 calcium chlorid by selecting small quanti- 
 ties at random from different parts of the 
 stock and carefully mixing them. 
 
 Weigh off 20 grams of this average 
 sample and dissolve it as completely as 
 possible in 1 liter of tap water; let the so- 
 lution stand for several hours, shaking it 
 from time to time. Filter. 
 
 With the graduated pipette, measure off 
 10 c.c. of the clear fluid, and add to them 
 
58 IRRIGATION OF WOUNDS 
 
 20 ce. of the deci-normal solution of po- 
 tassium iodid and 2 c.c. of acetic or hydro- 
 chloric acid. To this mixture, drop by 
 drop, a deci-normal solution of sodium hy- 
 posulphite should be added until the fluid 
 is entirely decolorized. 
 
 The number of cubic centimeters of the 
 solution of sodium hyposulphite which are 
 required to decolorize the solution multi- 
 plied by 1.775 will give the weight of the 
 active chlorine contained in 100 grams of 
 calcium chlorid. 
 
 Having found this number, by referring 
 to the following table the amount of cal- 
 cium chlorid, carbonate of soda and so- 
 dium bicarbonate which is necessary to 
 prepare 10 liters of Dakin's Solution can 
 be read off. 
 
 Example. — If 16.6 c.c. of the deci-nor- 
 mal hyposulphite solution were necessary 
 to decolorize the test solution, the titer of 
 active chlorine of the sample of calcium 
 chlorid is the following: 
 
 16.6 X 1.775 = 29.7 per 100 
 
DAKIN'S SOLUTION 59 
 
 The quantities necessary to make 10 
 liters of the solution would be in this case : 
 
 Calcium chlorid 154 grams 
 
 Carbonate of soda, anhy- 
 drous 77 
 
 Bicarbonate of soda 64 
 
 
 Quantities Used 
 
 rr-r=! 
 
 to Prepare 10 Liters or Darin's 
 
 Liter oe 
 
 Solution; ClONa Content 0.45 
 
 ro 0.50 per cent. 
 
 Calcium 
 
 Chlorid 
 
 
 
 
 Chlorid of 
 
 Carbonate of 
 
 Bicarbonate of 
 
 
 Calcium 
 
 Soda, Dry 
 
 Soda 
 
 20 
 
 230 gms. 
 
 US gms. 
 
 96 gms. 
 
 21 
 
 220 
 
 no 
 
 92 
 
 22 
 
 2IO 
 
 105 
 
 88 
 
 23 
 
 20O 
 
 IOO 
 
 84 
 
 24 
 
 IQ2 
 
 96 
 
 80 
 
 25 
 
 184 
 
 92 
 
 76 
 
 26 
 
 177 
 
 89 
 
 72 
 
 27 
 
 17c 
 
 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 
 
 ■ a 
 
 If we have only the crystalline sodium 
 carbonate, it will be necessary to use 
 
6o IRRIGATION OF WOUNDS 
 
 219.45 grams of the crystalline carbonate 
 instead of 77 grams of the anhydrous 
 salt. 
 
 The Preparation of D akin 3 s Solution. — 
 To prepare 10 liters of the solution: 
 
 1. Weigh out accurately the quantities 
 of calcium chlorid, sodium carbonate and 
 sodium bicarbonate required; 
 
 2. Place the calcium chlorid in a 12 liter 
 flask, add 5 liters of tap water, shake vig- 
 orously for several minutes, and then let 
 it stand for 6 to 12 hours (over night, for 
 example) ; 
 
 3. At the same time, dissolve the car- 
 bonate and bicarbonate of soda in the 
 other five liters of cold water ; 
 
 4. Pour the solution of soda salts into the 
 flask containing the supersaturated solu- 
 tion of calcium chlorid; shake thoroughly 
 for several minutes and allow the mixture 
 to stand in order to permit the carbonate of 
 calcium, which is formed, to settle down. 
 At the end of half an hour, syphon off the 
 supernatant liquid and filter it through 
 two thicknesses of filter paper. One should 
 
DAKIN'S SOLUTION 61 
 
 obtain a perfectly clear liquid whicn must 
 be protected from the light. 
 
 Exposure to light changes the hypo- 
 chlorite solution fairly quickly. If the pre- 
 pared solution has to be kept for any 
 length of time it is advisable to preserve 
 it in large bottles or carboys of black glass. 
 
 This solution should never be exposed 
 to a temperature above 40 C. (104 F.), 
 and it goes without saying that it should 
 never be sterilized in the autoclave. Heat 
 changes the hypochlorite into a compound 
 which contains chlorids and chlorates, and 
 deprives it of all antiseptic properties. 
 
 Titration of D akin 3 s Solution. — It is ad- 
 visable to control the titer of the solution 
 from time to time. For this purpose, the 
 same apparatus and reagents are neces- 
 sary as are required for the estimation of 
 the active chlorine in the calcium chlorid: 
 
 To 10 c.c. of the solution add 20 c.c. 
 of the deci-normal solution of potassium 
 iodid and 2 c.c. of acetic or hydrochloric 
 acid. Titrate this mixture with a deci-nor- 
 
62 IRRIGATION OF WOUNDS 
 
 mal solution of sodium hyposulphite until 
 it is completely decolorized. 
 
 The number of cubic centimeters used 
 multiplied by 0.03725 will give the weight 
 of the sodium hypochlorite in 100 ex. of 
 the solution. 
 
 The solution is correct if 12 to 13 c.c. 
 of the deci-normal hyposulphite solution 
 are required to decolorize the quantity of 
 test solution indicated above: 
 
 13 X 0.03725 = 0.485 ClONa per 100. 
 
 Estimation of the Alkalinity of D akin' s 
 Solution. — It is a simple matter to distin- 
 guish the solution made in the way here 
 described from commercial hypochlorite 
 solutions and Labarraque Solution: 
 
 For this purpose place about 20 c.c. of 
 the solution to be tested in a beaker and 
 sprinkle a few centigrams of powdered 
 phenolphthalein on the surface. With 
 properly prepared Dakin's Solution abso- 
 lutely no coloration will ensue whereas 
 Javel water and Labarraque Solution will 
 give an intense red color, indicating in the 
 latter the presence of free caustic soda. 
 
APPENDIX II 
 
 THE MICROSCOPICAL EXAMINATION OF 
 
 WAR WOUNDS BY THE CARREL 
 
 METHOD (DR. VINCENT) 
 
 Its Aim. — The microscopical examina- 
 tion of the wounds is necessary: 
 
 i. To gain knowledge of the degree of 
 infection of the wounds at the beginning 
 of and during the course of the treat- 
 ment; 
 
 2. To follow the progress of the disin- 
 fection so that, if the wound does not im- 
 prove as it should, additional measures 
 can be instituted; 
 
 3. To substantiate the clinical symptoms 
 and in order to determine the proper time 
 for the surgical closure of the wound, 
 without danger of recurring infection. 
 
 Apparatus Required. — 1. A fairly 
 strong platinum loop mounted on a glass 
 
 63 
 
64 IRRIGATION OF WOUNDS 
 
 or metal rod; or a swab (iron wire, a 
 small cotton pledget fastened at one end) ; 
 
 2. An alcohol lamp or Bunsen burner; 
 
 3. Glass slides for the specimens, with 
 labels previously pasted on each side; 
 
 4. A slide box for the specimens. 
 
 Obtaining the Specimens. — The irriga- 
 tion should be suspended for at least two 
 hours before the specimen is taken, so that 
 the secretions shall not be too much di- 
 luted. 
 
 While the dressings are being removed, 
 the platinum loop should be heated in the 
 flame to a bright red, or a sterile swab 
 should be picked up. 
 
 The part of the wound is sought for 
 which seems to be most infected (site of 
 necrosis, grayish parts of the wound, 
 small tracts not easily reached by the an- 
 tiseptic, sequestra of bone, etc., etc.) and 
 the platinum loop or the swab is rubbed 
 over its surface so as to remove the secre- 
 tions which cover it. 
 
 The Smears. — Holding the glass slide, 
 with the label facing up, in the left hand, 
 
MICROSCOPICAL EXAMINATION 65 
 
 and the platinum loop or cotton swab in 
 the right hand, the wound secretions are 
 spread on the glass slide in as thin a layer 
 as possible. This is accomplished by rub- 
 bing the loop or swab on the slide with a 
 slight rotary movement. 
 
 The platinum loop is heated to a red heat 
 in the flame before laying it down and the 
 swab is dropped into a receptacle filled 
 with an antiseptic. The name of the 
 wounded person, the number of his bed, 
 and the identification mark of the wound 
 are written on the label. 
 
 The slides are dried in the air or lightly 
 passed over the flame, and are kept, until 
 examined, in a specimen box. 
 
 Staining the Slides. — This is done in 
 the laboratory and the following appara- 
 tus is necessary : 
 
 1. Alcohol lamp or Bunsen burner; 
 
 2. Staining solutions in dropper bottles. 
 We use preferably carbol-thionine ; if 
 
 this cannot be obtained, a 10 per cent, 
 solution of carbol-fuchsin, methylene blue 
 or gentian violet. 
 
66 IRRIGATION OF WOUNDS 
 
 Formula for carbol-thionine solution: 
 
 Thionine I gram 
 
 Carbolic acid (crystalline) ... I gram 
 
 Alcohol 95 per cent 10 grams 
 
 Water ioo " 
 
 The thionine and the alcohol are tritu- 
 rated in a small mortar, the carbolic acid 
 is then added, and the mixture thoroughly- 
 stirred up. Two-thirds of the water is 
 added little by little, the mixture poured 
 into a bottle with ground glass stopper. 
 The mortar is then washed off with the 
 remaining one-third of the water, which 
 is also emptied into the bottle. After 24 
 hours the solution is ready for use. 
 
 A simple solution can be made by mix- 
 ing 10 c.c. of a saturated solution of 
 thionine in 90 per cent, alcohol with 100 
 c.c. of 1 per cent, solution of carbolic acid 
 in water. 
 
 3. Various reagents: absolute alcohol, 
 alcohol-ether, etc. (are not indispensable) ; 
 
 4. Wash-bottle or running water; 
 
PLATE X 
 
 A 
 
 B 
 
 PlNCHCOCK AND SAFETY-PIN 
 
 A. — Enlarged view of pinchcock used to regulate the 
 flow of the antiseptic solution. 
 
 B. — Enlarged view of safety-pin showing method of 
 holding tubes and glass distributors in place. 
 
MICROSCOPICAL EXAMINATION 67 
 
 5. Glass bowl or some receptacle to re- 
 ceive the waste water; 
 
 6. Small squares of filter paper. 
 
 Preparation of the Specimens. 
 
 1. Drying. — The slides are dried imme- 
 diately after preparing them or, what is 
 just as good, are left to dry in the box. 
 
 2. Fixing. — The smears must be fixed 
 on the slides so that they do not wash off 
 during the staining. For this purpose fix- 
 ation by heat is the rule. The slide 
 is held at one end, specimen surface up, 
 and is passed fairly rapidly through the 
 flame three times, as in "cutting bread." 
 The slides can also be fixed in a mixture 
 of equal parts of absolute alcohol and 
 ether, by pouring several drops on the 
 smear, and allowing it to evaporate. 
 
 3. Staining. 
 
 (a) Pour enough of the staining fluid 
 (carbol-thionine) on the smear to cover it 
 completely. 
 
 (b) Let the stain act for a half to one 
 minute. 
 
68 IRRIGATION OF WOUNDS 
 
 (c) Drain off the stain. 
 
 (d) Wash rapidly with water either 
 with the wash-bottle or under the tap. 
 
 (e) Dry in the air. The drying may be 
 hastened by gently heating the slide, or by 
 blotting up the excess of water with a 
 small piece of filter paper. 
 
 Examination. — Place a drop of cedar 
 oil on the slide. 
 
 Place the slide on the stage of the mi- 
 croscope and fasten the side with the 
 clips. 
 
 With the coarse adjustment, lower the 
 oil immersion lens until it comes into con- 
 tact with the cedar oil, about 2 mm. from 
 the slide. Proceed very carefully. 
 
 Place the eye at the eyepiece, secure 
 sufficient illumination by adjusting the 
 mirror of the microscope. 
 
 Slowly lower the objective until the ob- 
 ject is seen more or less clearly. Then 
 focus carefully with the fine adjustment 
 until the image stands out sharply. 
 
 Make the examination. 
 
MICROSCOPICAL EXAMINATION 69 
 
 Raise the objective (coarse adjust- 
 ment) ; remove the specimen. 
 
 Clean the objective by wiping it with a 
 piece of fine linen. 
 
 Preservation of the Specimens. — Re- 
 move the drop of cedar oil from the slide 
 by dissolving it with a few drops of xylol. 
 Allow it to dry. 
 
 Put the slides away in the slide boxes. 
 
 Cleaning the Slides. — The slides which 
 are not kept are thrown into a receptacle 
 containing denatured alcohol. They can 
 be used again after they have been 
 cleaned. 
 
 For that purpose they are removed 
 from the denatured alcohol, drained, and 
 placed in a pan containing a 4 per cent, 
 solution of sodium carbonate (crystals), 
 and are boiled for half an hour. After 
 having cooled off, they are washed in 
 water. 
 
 Then they are boiled again for half an 
 hour in a 5 per cent, solution of hydro- 
 chloric acid, or in the following solution: 
 
70 IRRIGATION OF WOUNDS 
 
 Water iooo 
 
 Potassium bichromate 50 
 
 Sulphuric acid 100 
 
 Rinse in water, wipe, dry, preserve dry 
 protected from dust, or in alcohol. 
 
 The Examination of the Slides. — This 
 should be done in a laboratory by trained 
 bacteriological workers. 
 
 Fundamental Principles. — If a slide 
 stained with carbol-thionine is examined 
 under the microscope, we see the follow- 
 ing: 
 
 1. Cells with the nuclei stained violet; 
 there are leucocytes which have only a sin- 
 gle nucleus (mononuclear leucocytes) ; or 
 a nucleus divided into several lobes (poly- 
 nuclear leucocytes). 
 
 2. Cellular detritus stained violet. 
 
 3. Occasionally large flat cells with a 
 small violet nucleus (cells from the skin). 
 
 4. Round bodies stained green (red 
 blood cells). 
 
 5. Bacteria stained a deep violet. They 
 occur in two varieties : 
 
MICROSCOPICAL EXAMINATION 71 
 
 (a) As more or less well marked round 
 spots: cocci; 
 
 If they occur in pairs: diplococci. 
 
 In groups of four: tetracocci. 
 
 If they are grouped in chains, the one 
 following the other: chain cocci (they are 
 generally referred to as streptococci, and 
 are the cause of various kinds of suppura- 
 tions and inflammations). 
 
 If they appear in clusters : cluster cocci 
 (generally spoken of as staphylococci; 
 very common in most infections). 
 
 (b) Little rods of varying lengths and 
 sizes, bacilli. 
 
 These occur singly; in groups of two, 
 diplobacilli, or, when they occur in chains, 
 streptobacilli. 
 
 Counting the Organisms. — In the 
 smear method, the number of bacteria is 
 of greater importance than the particular 
 variety, as they cannot be positively iden- 
 tified by their morphological characteris- 
 tics. Nevertheless, the bacillus variety 
 nearly always indicates a serious infec- 
 tion. To calculate the number of bacteria 
 
72 IRRIGATION OF WOUNDS 
 
 it is necessary to count the number in a 
 field of known size. It is customary to 
 take as the unit the microscopic field, that 
 is to say, the round area which one sees 
 in looking through the microscope (mi- 
 croscope with a No. 3 eyepiece and 1/12 
 oil immersion objective). 
 
 The estimation of the number of bac- 
 teria found in a series of fields is approxi- 
 mate and can be quickly made when there 
 are many to each field. We class them as : 
 
 1. Innumerable; 
 
 2. 50 to 100 to the field; 
 3- 3° to 50 to the field 
 
 4. 20 to 30 to the field 
 
 5. 15 to 20 to the field 
 
 6. 10 to 15 to the field. 
 
 When there are fewer than 10 to 15 to 
 the field, it is possible to count them ex- 
 actly. The bacteria should be counted in 
 ten successive fields, starting from one 
 point, then in ten other fields starting at a 
 point at some distance from the first, then 
 in a third series of ten fields, and the av- 
 
MICROSCOPICAL EXAMINATION 73 
 
 erage taken. The results, although purely- 
 relative, will be found to correspond 
 roughly, especially when all the estima- 
 tions are made by the same observer. 
 
 Clinical Indications Deduced from the 
 Microscopical Examination. — (a). The 
 disinfection should reduce the number of 
 bacteria. If the latter remains stationary 
 for several days or increases, the surgeon 
 should examine the wound and ascertain 
 the reason for the slowing of the disinfec- 
 tion. Insufficient irrigation demands an 
 increase in the number of tubes, a change 
 in their position or removal and reinser- 
 tion. The lack of results may be due to 
 bacterial foci from necrotic tissue, foreign 
 bodies, projectiles, pieces of clothing, 
 bone sequestra, etc., non-irrigated por- 
 tions of the wound, poorly applied dress- 
 ings, mistakes in technic, etc. 
 
 (b) When the number of bacteria is re- 
 duced to about one to each field, the ex- 
 aminations must be made with especial 
 care on numerous smears which should 
 
74 IRRIGATION OF WOUNDS 
 
 be taken from different parts of the 
 wound. 
 
 When only isolated cocci or diplococci 
 are seen, and only one is found in every 
 four or five fields, and if this result has 
 been verified by two or three successive 
 examinations at an interval of one or two 
 days, the disinfection is practically ac- 
 complished. The surgeon may then close 
 the wound with a fair presumption of suc- 
 cess, no matter whether it is a wound of 
 the soft parts or a compound fracture.* 
 
 Number of Examinations. — At Carrel's 
 hospital the examinations are made regu- 
 larly every other day for all the wounded. 
 In the other hospitals, they are made only 
 every third or fourth day during the 
 period of disinfection, then more fre- 
 
 * The time varies somewhat, depending on the 
 nature of the case and the severity of the preced- 
 ing infection. Compound infected fracture of 
 thigh, 6 days interval of sterile wound; large 
 wound of soft parts, 3 days; superficial wound 
 of soft parts, 2 days. 
 
PLATE XI 
 
 fame: 
 
 ■*- 
 
 JV&rd 
 
 -^7^ 
 
 «r^ 
 
 ttatare ofWeimd. 
 
 ^5&raa'Uin&- — ; 
 
 r^ 
 
 StonfcK. October 
 
 November 
 
 9oy. 2! ZZ 25 27 £3 
 
 3» 2 * 6 
 
 
 
 
 
 
 
 
 
 
 
 3É 
 
 1 
 
 C5d — 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Go : 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 î. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / rs X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 40 t : 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i : 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ■ 
 
 i : 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 20 j : 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 - 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 10 _ , r 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 t - 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 t : 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 t - 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 r 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 5 lit! 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ± : 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 4 2 t 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ■■ 1 / l 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 jp__z& : 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1/9 _ _3 . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1/5 I. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 J ft 
 1/in _B 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4 A>0 1 , [ » 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 .JL- „ Il 
 
 -i^J ;___ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^- 7 V-^— 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Graphic Record of Bacterial Count. 
 
■ 
 
 -• • 
 
MICROSCOPICAL EXAMINATION J7 
 
 vjuently as the time approaches for the 
 surgical closure of the wound. 
 
 Bacterial Curve. — The results are re- 
 corded for the use of the surgeon and en- 
 tered on charts as a graphic bacterial 
 curve. These curves are similar to the 
 temperature charts and show at a glance 
 the course of the infection and the prog- 
 ress of the disinfection {See Plate XI). 
 
GLOSSARY 
 
 ENGLISH TO FRENCH 
 
 Adhesive plaster. Sparadrop adhesive 
 
 Bacteriological curve, courbe microbienne 
 
 Bicarbonate of soda, bicarbonate de soude 
 
 Carbonate of soda, carbo\ftate de soude 
 
 Chlorid of lime, Chlorure de chaux 
 
 Compresses, compresses 
 
 Conducting connectors, glass, raccords adduc- 
 teurs 
 
 Conducting tube, tube adducteur 
 
 Cotton pads, coussins de coton 
 
 Distributing tubes, small straight glass, petits 
 raccords droits 
 
 Distributing tubes, tubes distributeurs 
 
 Distributors, glass, raccords distributeurs 
 
 Dressings, pasements 
 
 Flask, ampoule 
 
 Gloves, rubber, gantes de caoutchouc 
 
 Hyposulphite of soda, hyposulphite de soude 
 
 Instillation tubes, tubes distributeurs 
 
 Microscopic slides, Frottis 
 
 Necrotic tissue, les tissus sphacilas 
 
 Nurse, Vinûrmère 
 
 Pinchcock, pince de Mohr à rassorts 
 
 Rubber gloves, gantes de caoutchouc 
 
 Safety-pins, épingles de sûreté 
 
 79 
 
80 GLOSSARY 
 
 Slides, microscopic, frottis 
 
 Sloughs, les tissus sphacilas 
 
 Smears, lames 
 
 Straight glass distributing tubes, small, petits 
 
 raccords droits 
 Titration, titrage 
 Wounded man, le blessé 
 Wounds, les plaies 
 
 FRENCH TO ENGLISH 
 
 Ampoule, flask for fluid 
 Bicarbonate de soude, bicarbonate of soda 
 Blessé, le, wounded man, the 
 Chlorure de chaux, chloride of lime 
 Courbe microbienne, bacteriological curve 
 Carbonate de soude, carbonate of soda 
 Compresses, squares of gauze, single thickness 
 Coussins de coton, pads of gauze with cotton be- 
 tween 
 Epingles de sûreté, safety-pins 
 Frottis, microscopic slides 
 Gantes de coautchouc, rubber gloves 
 Hyposulphite de soude, hyposulphite of soda 
 Infirmière, V, the nurse 
 Lames, smears 
 Pasements, dressings 
 Pince de Mohr à rassort, pinchcock 
 Plaies, les, wounds, the 
 
 Raccords adducteurs, glass conducting connectors 
 Raccords distributeurs, glass distributors 
 Raccords droits petits, small straight glass dis- 
 tributing tubes 
 Sparadrop adhesive, adhesive plaster 
 
GLOSSARY 
 
 81 
 
 Tissus sphacilas, necrotic tissue or sloughs 
 Titrage, titration 
 Tube adducteur, conducting tube 
 Tubes distributeurs, distributing or instillation 
 tubes, to be placed in wound 
 
 Metric Equivalents in Inches 
 
 Meters 
 
 Inches 
 
 Millimeter ooi .03937 
 
 Centimeter 01 «3937 
 
 Meter 1. 39.3685 
 
 Metric Equivalents in Troy Weights 
 
 Grains 
 
 Grams 
 
 Grains 
 
 Grams 
 
 O.I543 
 
 .01 
 
 154 323 
 
 10 
 
 0.7717 
 
 
 05 
 
 231 
 
 485 
 
 15 
 
 1-543 
 
 
 1 
 
 308 
 
 647 
 
 20 
 
 7.716 
 
 
 5 
 
 385 
 
 809 
 
 25 
 
 15-432 
 
 I 
 
 
 771 
 
 617 
 
 50 
 
 30.865 
 
 2 
 
 
 925 
 
 941 
 
 60 
 
 46.297 
 
 3 
 
 
 1080 
 
 264 
 
 70 
 
 61.729 
 
 4 
 
 
 1543 
 
 235 
 
 100 
 
 77.162 
 
 5 
 
 
 3086 
 
 47 
 
 200 
 
INDEX 
 
 Absorbent cotton for tion of, 47, 48; in pre- 
 
 pads, use of, 23. 
 
 Acetic acid in testing, use 
 of, 58. 
 
 Adhesive plaster, for 
 holding dressing, 25 ; 
 for holding tubes, 28. 
 
 Alcohol as re-agent, ab- 
 solute, 66; for preserva- 
 tion of specimens, de- 
 natured, 69; for fixing 
 slides, absolute, 67; for 
 making thionine, 66. 
 
 Alcohol-ether as re- 
 agent, 66. 
 
 Alcohol lamp for stain- 
 ing, use of, 65; in mi- 
 croscopical examination, 
 use of, 64. 
 
 Alkali, injurious action 
 of caustic, 55. 
 
 Alkalinity, estimation 
 of, 62. 
 
 Anhydrous sodium car- 
 bonate vs. crystalline 
 salt, 60. 
 
 Antiseptic, action on 
 skin, 24; continuous ac- 
 
 paring slides, use of, 65. 
 
 Antiseptic solution, pro- 
 tection of skin from, 29. 
 
 Apparatus, irrigating, 30; 
 sterilization of, 17. 
 
 Autoclave, sterilization 
 by, 23. 
 
 Bacilli, 71 ; diplobacilli, 
 
 71 ; streptobacilli, 71. 
 Bacteria, 70; cocci, 71; 
 
 diplococci, 71 ; tetracocci, 
 
 71 ; streptococci, 71 ; 
 
 staphylococci, 71. 
 Bacterial curve, 77. 
 Bacterial foci in necrotic 
 
 tissue, 73. 
 Bacteriological count, 71. 
 Bandage, use of, 29. 
 Basins, use of sterile, 26. 
 Bed pad, protection of, 51. 
 Bicarbonate of soda, 
 
 quantity of, 59. 
 Binder, adjustment of, 
 
 29; flannel, use of, 25. 
 Boiling, cleansing of 
 
 slides by, 69. 
 
 $3 
 
84 
 
 INDEX 
 
 Bottles, use of dropper, 
 
 65. 
 
 Box for slides of speci- 
 mens, 64, 65. 
 
 Boxes for sterilizing, 
 metal, 24. 
 
 Bunsen burner in micro- 
 scopical examination, 
 use of, 64; for staining, 
 use of, 65. 
 
 Burette used for titra- 
 tion, 56. 
 
 Calcium carbonate, cry- 
 stalline vs. anhydrous, 
 60. 
 
 Calcium chlorid, com- 
 mercial, 56; in antisep- 
 tic solution, use of, 56; 
 quantity of, 59; sam- 
 pling of, 57- 
 
 Calculation of bacterio- 
 logical count, 72, 7Z. 
 
 Carbol-fuchsin solution 
 for staining, 65. 
 
 Carbo-thionine for stain- 
 ing slides, 65, 67; form- 
 ula for, 66. 
 
 Carbo-thionine solution, 
 preparation of, 66. 
 
 Carbolic acid in carbo- 
 thionine, use of, 66; in 
 making thionine, use of, 
 66. 
 
 Carbonate of soda, for 
 
 cleansing slides, 69; 
 quantity of, 59. 
 
 Caustic alkali, injurious 
 action of, 55. 
 
 Caustic soda, indication 
 of presence of, 62 
 
 Cells with violet nucleus, 
 flat, 70. 
 
 Cedar oil from slides, re- 
 moval of, 69. 
 
 Chlorine, active, 56; con- 
 tent in calcium chlorid, 
 58. 
 
 Clamp, 38. 
 
 Cleansing of apparatus, 
 41 ; of stained slides, 68. 
 
 Cleansing solution, 
 formula for, 70. 
 
 Clinical indications, 73- 
 
 Closing of wound, 74; 
 time of, 25. 
 
 Cocci, microscopic find- 
 ings of, 71 ; isolated, 74. 
 
 Compresses of gauze, de- 
 scription of, 23; use of, 
 28; use of vaselined, 
 28; sterile vaseline, 24; 
 preparation of vase- 
 line, 24; see also tam- 
 pons. 
 
 Conducting connector, 
 Y-shaped glass, 42. 
 
 Conducting tubes, de- 
 scription of primary, 
 30; use of primary, 30; 
 
INDEX 
 
 «S 
 
 secondary, 30; use of 
 secondary, 30 ; connec- 
 tion with rubber, 42. 
 
 Connectors, glass con- 
 ducting, 37. 
 
 Connecting tube, attach- 
 ing, 42. 
 
 Cotton for pads, use of 
 absorbent, 23; for pads, 
 use of non-absorbent, 
 23 ; to plug flask, sterile, 
 42. 
 
 Cotton pads, 23; com- 
 presses held by, 29; de- 
 scription of, 23 ; size of, 
 
 23- 
 
 Cotton pledget in micro- 
 scopical examination, 
 use of, 64. 
 
 Counting the Organisms, 
 
 7h 72, 73- 
 
 Crystalline sodium car- 
 bonate vs. anhydrous 
 salt, 60. 
 
 Curve, bacterial, 77. 
 
 Dakin's solution, 26; for 
 cleansing apparatus, 41 ; 
 irrigation treatment 
 with, 15; mixing of, 60; 
 moistening of com- 
 presses with, 28; prep- 
 aration of, 55, 60; ti- 
 tration of, 61. 
 
 Daufresne's technic for 
 
 preparation of solution, 
 
 55- 
 Decolorization test, 57. 
 Denatured alcohol, use 
 
 of, 67. 
 Detritus visible on plates, 
 
 cell, 70. 
 Diplococci, isolated, 74 ; 
 
 microscopic findings of, 
 
 71. 
 Disinfection, measure of, 
 
 73- 
 Distilled water, use of, 
 
 57- 
 
 Distributing tubes, 15 ; 
 connection of rubber, 
 42; description of, 15, 
 16; perforated, 16; rôle 
 of, 16; simple, 15; sizes 
 of, 16; varieties of, 15; 
 with connecting tubes, 
 connection of, 37; small 
 glass, 41. 
 
 Distributors, description 
 of glass, 38. 
 
 Dressing, antiseptic solu- 
 tion to soak, 48; ma- 
 terials for, 26. 
 
 Dressing wound, nurse's 
 part in, 26, 27. 
 
 Dropper bottles, use of, 
 
 65. 
 Drying of slides in air, 
 68; of specimens, 67; of 
 stained slides, 68. 
 
86 
 
 INDEX 
 
 Elevation of flask, 42. 
 Examination of slides, 
 
 70. 
 Examinations, number 
 
 of, 74. 
 
 Flannel binder, adjust- 
 ment of many-tailed, 
 29; use of, 25. 
 
 Flask, description of, 30; 
 setting up of, 42. 
 
 Filter paper, use of, 67. 
 
 Fixation by heat, 67. 
 
 Foci from necrotic tissue, 
 bacterial, 73. 
 
 Focusing of microscope, 
 68. 
 
 Forceps, Kocher's sterile, 
 26. 
 
 Fracture of thigh, time 
 interval for examining, 
 74- 
 
 Gauze, use of unstarched, 
 
 25. 
 
 Gauze compresses, de- 
 scription of, 27; vase- 
 line, 24. 
 
 Gentian violet for stain- 
 ing, 65. 
 
 Gloves, use of rubber, 
 26. 
 
 Glass conducting con- 
 nectors, 37. 
 
 Glass distributors, con- 
 
 nection of, 47; descrip- 
 tion of, 38. 
 
 Glass distributing tubes, 
 small, 41. 
 
 Glass slides in micro- 
 scopical examination, 
 use of, 64. 
 
 Heat, fixation by 67. 
 
 Hydrochloric acid for 
 testing, 58; for cleaning 
 slides, 69. 
 
 Hypochlorite of soda 
 content, 62; in Dakin's 
 Solution, use of, 55. 
 
 Hypochlorite of sodium, 
 irrigation treatment 
 with, 15; see also Da- 
 kin's Solution. 
 
 Hypochlorite solution, 
 exposure of, 61; 
 strength of, 55 ; temper- 
 ature of, 61. 
 
 Hyposulphite of soda, 
 57; as re-agent, 61; de- 
 colorization by, 58. 
 
 Indications, clinical, 73. 
 Injection by syringe to 
 
 test tubes, 41. 
 Infection, examination to 
 
 determine degree of, 25. 
 "Instillation" tubes, see 
 
 Distributing Tubes. 
 Iodine solution, 57. 
 
INDEX 
 
 87 
 
 IODID OF POTASSIUM, 57- 
 
 Irrigation, care to secure 
 free, 48; technic of, 47. 
 
 Irritation due to strong 
 solution, 56. 
 
 Javel water, coloration 
 of, 62; injurious action 
 of, 55- 
 
 Kocher's forceps, 26; in- 
 jurious action of, 55. 
 
 Labarraque solution, 
 coloration of, 62. 
 
 Lamp in microscopic ex- 
 amination, use of, 64. 
 
 Leucocytes, mononuclear, 
 70; polynuclear, 70; vi- 
 sible on microscopic 
 plates, 70. 
 
 Linen as covering, use 
 of, 24; for cleaning the 
 objective, use of fine, 
 
 69. 
 Linen thread used to 
 close distributing tubes, 
 16. 
 
 Metal boxes for steriliz- 
 ing, 24. 
 
 Methylene blue for 
 staining, 65. 
 
 Microscope, adjustment 
 of, 68. 
 
 Microscopic field as 
 counting unit, 72. 
 
 Microscopic findings, 
 
 70. 
 
 Microscopical examina- 
 tion, purpose of, 63. 
 
 Mirror of microscope, ad- 
 justment of, 68. 
 
 Mononuclear leucocytes, 
 70. 
 
 Mounting material from 
 smears, 65. 
 
 Necrosis, smears taken 
 from site of, 64. 
 
 Necrotic tissue, bacterial 
 foci from, 73; excision 
 of, 27; smears from, 
 
 65. 
 
 Nonabsorbent cotton for 
 
 pads, use of, 23. 
 Nurse's part in dressing 
 
 wound, 26, 27. 
 
 Obstructions in tubes, re- 
 moval of, 48. 
 
 Pad, compresses held by 
 cotton, 29; sterilization 
 of large, 24; steriliza- 
 tion of small, 23. 
 
 Paper, white, use as cov- 
 ering, 24. 
 
 Perforation of walls of 
 tubing, 16. 
 
88 
 
 INDEX 
 
 Permeability of tubes, 
 testing of, 48. 
 
 Phenolphthalein in al- 
 kalinity test, 62. 
 
 Pince de Mohr à rassort, 
 38. 
 
 PiNCHCocK, 38; use of, 37, 
 48/ " 
 
 Pipette in filtration, use 
 of, 57- 
 
 Plaster, use of adhesive, 
 
 25. 
 Platinum loop in micro- 
 scopical examination, 
 use of, 63; used for ob- 
 taining smears, 64. 
 
 POLYNUCLEAR LEUCOCYTES, 
 70. 
 
 Potassium bichromate, 
 cleansing solution con- 
 taining, 70. 
 
 Potassium iodid, 57; as 
 re-agent, 61. 
 
 Preparation of Dakin's 
 Solution, 55, 60. 
 
 Preservation of speci- 
 mens, 69. 
 
 Quantitative test of cal- 
 cium chlorid, 57. 
 
 Raccords adducteurs, 37- 
 Raccords distributeurs, 38. 
 Raccords droits, petits, 41. 
 Re-agents used in titra- 
 
 tion of Dakin's Solu- 
 tion, 61. 
 
 Rubber gloves, use of, 
 26. 
 
 Rubber tubing, examina- 
 tion of, 48; use of, 41. 
 
 Rubber sheeting for cov- 
 ering bed pad, 51. 
 
 Safety-pins to hold ap- 
 paratus, 47; to hold cot- 
 ton pad, 29; use of, 25. 
 
 Scissors, sterile, 26. 
 
 Secretions, remarks on 
 examination of wound, 
 
 25. 
 
 Sheeting to cover bed 
 pad, rubber, 51. 
 
 Setting up irrigation ap- 
 paratus, 42. 
 
 Slides, cleaning of, 69; 
 drying of, 65; examina- 
 tion of, 68, 70; staining 
 of, 65, 67, 69. 
 
 Sliding carrier on stand, 
 42. 
 
 Smear method of count- 
 ing organisms, 71, 72, 
 
 73- 
 Smears, 64; collection of 
 necrotic tissue for, 64; 
 fixing of, 67 ; placed up- 
 on slides, necrotic tis- 
 sues from, 65; prepara- 
 tion of, 67. 
 
INDEX 
 
 89 
 
 Soap-suds for cleansing 
 apparatus, 35. 
 
 Soda, indication of pres- 
 ence of caustic, 62. 
 
 Soda Solvay, 56. 
 
 Sodium bicarbonate, 
 quantity of, 59. 
 
 Sodium carbonate, quan- 
 tity of, 59; use in anti- 
 septic solution, 56. 
 
 Sodium carbonate solu- 
 tion for cleansing 
 slides, 69. 
 
 Sodium content, hypo- 
 chlorite of, 62. 
 
 Sodium hyposulphite, 57; 
 decolorization by, 58. 
 
 Sodium oleate, cleansing 
 solution of, 27. 
 
 Solvay soda, 56. 
 
 Specimens, method of ob- 
 taining, 64; drying of, 
 67; preparation of, 67; 
 preservation of, 69. 
 
 Spring clamp, 42. 
 
 Staining of slides, 65, 
 67, 69. 
 
 Staining solutions, use 
 of, 65. 
 
 Staphylococci, microsco- 
 pic findings of, 71. 
 
 Stand, attaching of flask 
 to, 42. 
 
 Sterilization, of cotton 
 pads, method of, 23; of 
 
 distributing tubes, 23 ; 
 of tampons, 23. 
 
 Sterilizer, hot air, 24. 
 
 Streptococci, microscopic 
 findings of, 71. 
 
 Sulphuric acid, cleansing 
 solution containing, 
 
 70. 
 
 Swab in microscopical ex- 
 amination, use of, 
 
 64. 
 Syringe to test tubes, in- 
 jection by, 51. 
 
 Tampons, description of, 
 23; see also compresses. 
 Tap water, use of, 60. 
 Tech nic of irrigation, 
 
 47- 
 
 Temperature for steriliza- 
 t i o n of distributing 
 tubes, 23; for steriliza- 
 tion of compresses, 23 ; 
 for sterilization of vase- 
 line compressors, 24; of 
 hydrochlorite solution, 
 61. 
 
 Test of calcium chlorid, 
 quantitative, 57. 
 
 Test tubes used for steril- 
 izing, 23. 
 
 Tetracocct, microscopic 
 findings of, 71. 
 
 Thionine in carbo-thion- 
 ine, 66; saturated solu- 
 
9o 
 
 INDEX 
 
 tion of, 66; simple solu- 
 tion of, 66. 
 
 Threads used to close dis- 
 tributing tubes, linen, 
 16; as guy ropes, 16. 
 
 Tissues, irritation of, 56. 
 
 Titration of calcium 
 chlorid, 56; of Dakin's 
 Solution, 60; control of, 
 61. 
 
 Tray for dressings, 26. 
 
 Tube adducteur, 30. 
 
 Tubes distributeurs, 15. 
 
 Tubes, insertion of 28; 
 obstruction in, 48; per- 
 meability of, 48. 
 
 Turkish toweling, cover- 
 ing of distributing 
 tubes by, 16; method of 
 attaching, 16. 
 
 Vaseline, protection of 
 
 skin by, 29. 
 Vaseline compresses, 
 
 preparation of, 24; 
 sterile, 24; use of, 28. 
 
 Water, use of distilled, 
 
 57. 
 
 Wound, closing of, 74; 
 placing of tubes in, 27; 
 time interval for exam- 
 ining large, 74; time in- 
 terval for examining 
 superficial, 74; time of 
 closing, 25; flushing of, 
 48. 
 
 Wound secretions, re- 
 marks on examination 
 of, 25. 
 
 Wounds, use of toweling 
 in irrigation of flat sur- 
 face, 16; use of towel- 
 ing in irrigation of su- 
 perficial, 16. 
 
 Xylol, dissolving of cedar 
 oil by, 69. 
 
 Paul B. Hoebeb, 67-69 East 59TH Street, New York. 
 
MEDICAL MONOGRAPHS 
 
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 ADAM: Asthma and Its Eadical Treatment. By Jamea 
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 ADLEE: Primary Malignant Growths of the Lungs and 
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 AMEEICAN JOURNAL OF EOENTGENOLOGY, THE. 
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 AEMSTBONG: I. K. Therapy, with Special Reference to 
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 BABBINGEB, JANEWAY AND FAILLA: Radium Therapy 
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6 HOEBER'S MEDICAL MONOGRAPHS 
 
 GEEEFF: Guide to the Microscopic Examination of the 
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 JELLETT: A Short Practice of Midwifery for Nurses. 
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HOEBEB'S MEDICAL MON OGB ABB S 7 
 
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 LEWERS: A Practical Textbook of the Diseases of 
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 LEWIS: Clinical Disorders of the Heart Beat. A Hand- 
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 LEWIS : Clinical Electrocardiography. By Thomas Lewis. 
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 LEWIS : The Mechanism of the Heart Beat. With Special 
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 McCLURE: A Handbook of Fevers. By J. Campbell Mc- 
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8 HOEBEB'S MEDICAL MONOGBAPES 
 
 McCETTDDEN: The Chemistry, Physiology and Pathology 
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 McKISACK: Systematic Case Taking. A Practical Guide 
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HOEBEB'S MEDICAL MONOGBAPES 9 
 
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