August 30, 191 7] 



NATURE 



535 



trompressed into this : — An infected naked-tissue sur- 

 face becomes, if allowed to dry, c desiccated slough- 

 covered wound ; if simply kept wet, a tryptic suppurat- 

 ing wound. And the bacteriological events can also 

 be expressed in a single sentence. A comparatively 

 light infection, such as we have in the man whose 

 wounds have been properly opened up and mechanically 

 cleaned, is converted into a very heavy infection ; and 

 a purely surface infection into an infection invading 

 the deeper tissues. 



Problem of Preventing the Degeneration of the 



Wound when Treatment is Interrupted during 



Transport. 



Having realised what happens to the wound when 

 untreated, we have to think out how to keep wounds 

 — whether originally completely open or opened by a 

 surgeon — from falling during protracted journeys from 

 hospital to hospital into these desperately unwholesome 

 conditions. We have also to consider how to restore, 

 as rapidly as possible, wounds which have lapsed into 

 distressing conditions either through lying out un- 

 treated on the field or through interruption of treatment 

 during lengthy transport. 



Suggestion that the wound could be sterilised at the 

 outset, and could be kept sterile by leaving an anti- 

 septic in the wound. — The first thought of every man 

 would probably be that the wound should be most care- 

 fully disinfected at the outset. But what happens in 

 bums shows that to start in open wounds with a 

 sterile surface avails nothing. A burn is at ihe outset 

 absolutely sterile, and quite notoriously — no doubt the 

 germs begin to arrive before the burnt surface has well 

 cooled off — it tends to become very rapidly intractably 

 septic. We may take it that the emigrating leuco- 

 ctes are held back in the supeificial sloughs, dis- 

 integrate there, and corrupt the exuding lymph. And 

 this cannot be prevented by any application of anti- 

 septics. It is just the same with war wounds. These 

 become heavily intected even when thev are drenched 

 at the outset with the strongest antiseptics, such as 

 undiluted ca-bolic acid and concentrated solutions of 

 iodine. 



This ib not the place for any lengthy discussion 

 of the reasons for this failure of antiseptics. But 

 the gist of the matter can be put quite shortly. 

 The current belief in the theiapeutic efficacy of 

 antiseptics rests on experiments which are quite 

 fallacious. They are fallacious in that the antiseptic 

 in those experiments was applied in watery media — 

 media which left that antiseptic unaffected. To have 

 value — that is, to have application to conditions ob- 

 taining in vivo — the experiments should have been con- 

 ducted in pus or serum — media which quench anti- 

 septic action. Again, in the experiments of the past 

 the antiseptics were intimately mixed with the bac- 

 terial suspensions; whereas, applied in the wound, the 

 antiseptic comes only into external contact vyith the 

 infected wall and the inflowing discharges. Employed 

 thus \ye cannot expect it to diffuse into and exert a 

 bactericidal effect either in the infected wall or in the 

 discharges. 



By reason of these considerations having been dis- 

 regarded, the issue as to whether antiseptics applied in 

 the wound with prophylactic intent can be of any use 

 must be investigated de novo. 



Experimental Investigation of the Efficacy of Anti- 

 septics. 

 Let me now try to indicate to you what sort of ex- 

 periments should be undertaken before nourishing in 

 connection with a particular antiseptic the expectation 

 that it is going to be efficacious for sterilising and 

 afterwards suppressing microbic growth in wounds. I 



NO. 2496, VOL. 99] 



can illustrate my points best if you let me show vou 

 here four tubes. 



In tube No. i I have a suspension of microbes in 

 water. I now add an equal volume of the antiseptic 

 I wish to test and shake up thoroughly. These ere, 

 as you see, conditions which give every possible advan- 

 tage to the antiseptic. It is applied in a non-albumin- 

 ous medium and is intimatel)" mixed with the microbes. 

 To find out whether the microbes have been killed I 

 draw off a sample and dilute with very many times its 

 volume of nutrient medium. I then incubate to see 

 whether I get any bacterial growth. 



In tube 2 I make the conditions more favourable to 

 the survival of the microbes — infinitely more favourable 

 than if I left behind an antiseptic in a wound. I have 

 here a mixture of staphylococci, streptococci, and gas- 

 gangrene bacilli suspended in serum, and I now, as in 

 tube I, add an equal bulk of the antiseptic and shake 

 up, and I then, following the technique of Prof. 

 Beattie, pour on a little hot vaseline which will after- 

 wards congeal. This, forming an air-tight seal, will 

 allow the gangrene bacillus, if it survives, to grow out. 

 It will also announce the growth of this microbe, for 

 it will confine any gas which may be evolved from the 

 culture. 



Tube 3 is, as you see (Fig. lo), a tube which has 



Fig. 10. — A test-tube standing on spike legs, representing a war 

 wound with diverticula. 



been drawn out into a number of hollow spikes to 

 imitate the diverticula of the wound. My colleague. 

 Dr. Alexander Fleming, its author and inventor, calls 

 this form of tube the "artificial war wound." To 

 imitate the conditions obtaining in the actual war 

 wound we fill both the tube and its diverticula with an 

 infected trypsinised serum. We now empty the tube, 

 leaving behind of necessity in the diverticula a certain 

 amount of the original infected fluid. We then fill 

 with an antiseptic; and the future of the infection will 

 now depend on the penetrating power of the anti- 

 septic. If the antiseptic penetrates into the infected 

 fluid sterilisation will be obtained ; if it fails to pene- 

 trate, microbes will sur\'ive. To test our result we 

 empty out the antiseptic, refill with trypsinised serum, 

 and incubate. 



After asking in tube 3 whether the antiseptic can 

 completely sterilise a wound which has its recesses 

 filled with an infected albuminous fluid, I go on in 

 tube 4 to investigate the question as to how far the 

 antiseptic can penetrate into the walls of the wound. 

 Tube 4 is, as you see, a tube with hollow spikes. I 

 have coated the inside with infected serum agar, and 

 the spikes provide in their hollows a greater depth of 



