1917] on The Treatment of War Wounds 57 



can derive from it more instruction than has as vet appeared. In 

 the tirst place, if we carry the experiment further, the slouirh which 

 lias been treated with physiological salt solution will also separate. 

 In contrast with this will be what will happen with the artificial 

 slough treated with Dakin's solution. Here, especially if the Dakin's 

 solution is periodically renewed, the clot will remain adherent. For 

 the Dokin's solution, while it is destructive to leucocytes, is, when 

 not quenched by albumen, destructive also to the trypsin which 

 brings about the separation of the slough. 



We can always appreciate the situation and tell what is going 

 to happen whether in the wound or in vitro by taking samples of the 

 fluid and testing quantitatively for trypsin with milk containing 

 about ^y per cent, of calcium chloride cryst., and we can when making 

 experiments in vitro on the separation of artificial sloughs, hurry up 

 the events by conducting the digestions at 50° C. 



We can also vary our experiment by leaving out the antiseptic. 

 Then microbic growth will, more particularly in the weaker salt 

 solution, proceed unchecked, and the destruction of leucocytes by that 

 growth will play an important role in the loosening of the clot. 

 Meanwhile, the microbes will be everywhere making their way 

 deeply into the albuminous substratum. This imitates what is 

 occurring in every untreated slough-covered wound. While on the 

 surface sloughs are decomposing and separating, in the depth further 

 tissue is becoming heavily infected and gangrenous. Since we 

 cannot block the infection by antiseptics, we must place mechanical 

 and biological obstacles in its path. That means we must get lymph to 

 pour out in full stream from the deeper tissues, and attract leucocytes 

 into those tissues. AVe may then, after the sloughs have separated, 

 look to have a clean, comparatively lightly infected wound surface. 



TREAT3IENT OF THE WOUXD IN THE CaRE WHERE WE HAVE 



oxLY A Surface Ixfectiox. 



When w^e have got back to a clean and only lightly infected sur- 

 face we must think out our next step. It will help if we first review 

 what we have learned and get things into proper perspective. 



We have learned that there are in wound infections two supreme 

 dangers. First, there is the danger associated with the buried infec- 

 tion. We have appreciated that the effective and only remedy for 

 this is the immediate opening up of the infected dead spaces. That, 

 you will remember, is a question of converting a buried infection into 

 a surface infection. The second very serious danger is that intensifi- 

 cation of the surface infection which follows upon a lengthy inter- 

 ruption of treatment during transport. This, regarded from the 

 point of view of loss of life and limb, ranks next in order of import- 

 ance after delav in dealino- with the buried infection. AVhen the 



