August 30, 19 17] 



NATURE 



537 



after the tube had been incubated for forty-eight hours, 

 that in tube A, the tube which was immersed in 

 hypertonic salt solution, the egg-albumen was exten- 

 sively digested, while in tube B there was only a 

 mere trace of digestion. 



Experirmnt 2. — I here tr>- to imitate the conditions 

 of slough-covered wounds. I have in these beakers a 



C:? 



J 



Fig. II. — Test-tube? filled with coaj.aj.ited egg-alburaen ; then plugged with 

 cottonwool impregnated with pus : and then inverted into beakers. 

 Keaker A coatains hypertonic, b«aker B normal salt solution. 



foundation of coagulated white of egg containing 0-5 

 f>er cent, of carbolic acid. On the top of this I have 

 in each case a disc of lint, woolly side up, firmly 

 fastened down by adding another layer of egg-albumen 

 and coagulating this by heat. Upon the lint I have 

 poured a non-tryptic pus, giving, of course, an equal 

 amount to each beaker. In this way I have made 

 what I think can pass as a fairly close representation 



Fig. 12. — Beakers containing coagulated egg-albumen into which ;s embedded 

 a layer of lint. Upon the Unt was poured pus, aiid upon this in the case 

 of beaker A h>-pertonic, and in the case of beaker B normal .-alt solution. 

 In beaker A ihe artificial slough has separated off by tryptic digestion. 



of a pus-impregnated slough firmly adherent to the 

 floor of a wound. (Fig. 12, A and B.) 



We now pour upon one of the artificial sloughs 

 5 per cent. ; upon another 085 per cent, solution made 

 up with 5 per cent, of carbolic acid ; and we may pour 

 upon a third Dakin's solution. We now place them 

 all in the incubator. You see here what has happened 



NO. 2496, VOL. 99] 



after twenty-four hours. In beaker A, where the arti- 

 ficial slough has been treated with hypertonic salt 

 solution, the slough has loosened itself from its bed, 

 and floats up as 1 pour in water. In beaker B, where 

 I imposed only physiological salt solution, the slough 

 is still firmly adherent. And the same holds of 

 beaker C (not figured), where we have Dakin's solu- 

 tion. 



Treatment of the Wound in the Case where wb 

 have only a surface infection. 



When we have got back to a clean and only lightly 

 infected surface 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 asso- 

 ciated with the buried infection. We have appre- 

 ciated 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 

 ven" serious danger is that intensification of the sur- 

 face infection which follows upon a lengthy interru|>- 

 tion of treatment during transport. Tnis, regarded 

 from the point of view of loss of life and limb, ranks 

 next in order of importance after delay in dealing with 

 the buried infection. When the set-back due to trans- 

 port has been prevented or remedied, we have con- 

 fronting us the problem which, if treatment had been 

 uninterrupted, would have presented itself earlier — the 

 problem as to how to treat a slight infection of a 

 naked-tissue surface. 



One procedure is to leave the wound to heal up 

 from the bottom, limiting oneself to such re-dressing 

 as would prevent erosive digestion. By this pro- 

 gramme the patient would, when his wound is a 

 large one, be condemned to ven,' many months of 

 disability and also of bacterial intoxication. For 

 the fact has got to be faced that it is all but im|>os- 

 sible to maintain satisfactor}- conditions in a large 

 wound for months on end. 



The alternative programme is for the surgeon to 

 close the wound with the minimum delay. If the 

 anatomical conditions permit, and the bacteriological 

 examination shows the wound surface to be practically 

 uninfected, or if the wound is only a very few hours 

 old and the implanted microbes cannot yet have grown 

 out, the wound can, after removal of all dead and 

 foreign matter, be immediately closed — the surgeon, 

 of course, standing by to reopen the wound if 

 svmptoms of buried infection develop. If, on the 

 other hand, bacteriological examination shows that the 

 wound surface is appreciably infected, or the histor>' 

 of the case makes this practically certain, we should, 

 by closing the wound, be violating all the principles 

 of surgery. W'e should be converting a surface infec- 

 tion into a buried infection. The proper step to take 

 with a wound which is appreciably infected is to 

 reduce the microbic infection to the point at which 

 it is negligible and then re-suture. 



Methods of Dealing with a Microhic Infection which 

 Stands ^in the Way of Secondary Suture. 



The microbic infection may be dealt with by any 

 one of the following procedures. 



In the first place we can employ the physiological 

 procedure. If we elect to do this, we must think out 

 clearly the requirements. For example, it will be 

 inappropriate when dealing with a purely superficial 

 streptococcic and staphylococcic infection to continue 

 the application of hj-pertonic salt solution. The 

 effect of that would be, on one hand, to hold off phago- 

 cytes from the microbes (for strong salt arrests 



