March 15, 1917] 



NATURE 



49 



it carries with it, and implants in all the inter- 

 stices of a deep and complicated wound, the 

 potentialities of a surgical catastrophe. 



That the bullet is infected by passing- through 

 muddy skin or clothing, often carrying with it 

 portions of the latter, seems fairly certain. Some 

 wounds in South Africa became infected when 

 the bullet passed through the mouth or any 

 part of the alimentary tract, both highly infective 

 regions of the body. The bullet itself, when fired, 

 is probably a fairly clean body from a surgical 

 point of view. The sides are cleaned by the 

 friction of the rifle barrel, and the base is seared 

 by the flame of the explosion. Nevertheless 

 Col. La Garde's experiments have shown that 

 if deliberately infected before firing, it can be 

 shown to be still carrj'ing infection after firing. 



The problem, then, which was presented by 

 gunshot injuries was how best to combat sepsis 

 in punctured wounds of all varieties, complicated 

 often by bone injury and severe lacerations of 

 soft parts, the bacterial infection coming usually 

 not from the wound openings, but being deeply 

 implanted by the actual stroke of the bullet 

 as it passed through the tissues. Obviously, the 

 mere application of even the most efficient anti- 

 septics to the parts about the external wounds 

 will not meet such a case. The infection must 

 be attacked in the depths of the tissues, prefer- 

 ably at a ven.' early date after the receipt of the 

 wound, before the bacteria have time to multiply 

 in the tissues. Moreover, practically ail wounds 

 of any depth must be dealt with thus. It would 

 be bad surgery to wait until the infection was 

 established, even though few signs of mischief 

 appear at first. Accordingly it was soon recog- 

 nised that the wound must be opened up, cleaned 

 as far as possible, foreign bodies removed, and 

 free exit provided for discharges by means of 

 drainage tubes. 



Some surgeons hoped that in a wound thus 

 opened up, and thereby converted from a punc- 

 tured to an incised type, it might be possible to 

 remove the infection altogether, and here the 

 advocates of the application of strong antiseptic 

 solutions had their view. A mass infection can be 

 completely destroyed by the application of, say, 

 pure carbolic acid. At a very early stage of in- 

 fection this may perhaps be possible, but not 

 when the bacteria are in the depths of the tissues. 

 Moreover, it is difficult to reach all the recesses 

 of a large wound, and if one pocket is left un- 

 attacked, the surgeon's pains are thrown away. 

 Strong antiseptic solutions, too, are very 

 damaging to the tissues, which, it must be re- 

 membered, are in a condition of impaired vitality 

 already. Another drawback to the use of anti- 

 septic solutions, whether weak or strong, is the 

 fact that many of them tend to become inopera- 

 tive when in contact with the albuminous solu- 

 tions like blood or pus. They form inert com- 

 pounds with albumin, and will no longer destroy 

 bacteria. It is claimed for an entirely new anti- 

 septic, called from its colour flavine, that it 

 actually proves more formidable to germs when 



NO. 2472, VOL. 99] 



in solution in blood-serum than in aqueous solu- 

 tion. But further trial is required before \ts, 

 value can be exactly classified. 



Another device for the early removal of septic 

 matter is to cut away the infected tissues bodily. 

 The extremely localised nature of gunshot injur}' 

 is a help in this case. It is possible to excise the 

 entire internal surface of the wound en masse, 

 with all its sinuosities and pockets, and to sew 

 up the clean cavity remaining. This method 

 enjoys the advocacy of Col. H. M. W. Gray, 

 who has had success with it, but to be satis- 

 factory it obviously must be done early, and re- 

 quires in many cases considerable surgical skill. 

 Cranial injuries and wounds of joints have been 

 treated by this method with an encouraging 

 measure of success. 



But both the above methods can be eflfectively 

 applied only when the wound is seen early, and 

 in warfare this is not always possible. Many 

 hours or even days may elapse before wounded 

 men can be collected and carried to the casualty 

 clearing stations. What, then, can be done when 

 bacteria, deeply implanted in the tissues, are 

 multiplying freely and in circumstances very 

 favourable to their growth? Here the physio- 

 logist steps in and reminds the surgeon that the 

 living body has its own guards against bacterial 

 invasion ; that healthy blood fluids are inimical to 

 the growth of many, though not of all, bacteria ; 



i that the white corpuscles, the so-caUed phago- 

 cytes or germ-eaters, form an immense army for 



j home defence ; and that the effect uf)on the body 

 of the absorption of the Sf)ecial toxins produced 

 by bacterial action is to cause it to elaborate a 

 neutralising substance or antitoxin. Here, then, 

 is the physiological basis both of the salt method 

 and of the vaccine method of treatment. It is 

 found that if a strong or saturated solution of 

 common salt be applied to an infected wound, 

 the salt by its osmotic action sets up a greatly 

 increased flow of lymph from the tissues into the 

 wound, thus relieving the inflamed tissues of con- 

 gestion, and setting up a flow of fluid from within 

 outwards which tends to wash away bac- 

 teria. Both the lymph and the strong salt 

 solution are unfavourable to the growth of 

 bacteria. So far as the white corpuscles are 

 concerned, strong saline solutions are unfavour- 

 able to their vitality ; but when the wound has 

 become healthier it is usual to decrease the 

 strength of the salt solution until its saturation 

 has reached that of a fluid of the same Sfjecific 

 gravity as the blood. In a fluid of this degree of 

 concentration the phagocytes can live and act 

 freely. 



The practical application of these principles 

 consists either in packing the wound with gauze, 

 betAveen the folds of which tablets of salt are 

 placed, or arranging for the continuous irrigation 

 of the wound with a solution of salt of a known 

 concentration. The latter method is suitable in 

 a fixed hospitzd. And it is one of the great ad- 

 vantages of the former method that a case so 

 dressed often requires no redressing for a few 



