53^ 



NATURE 



[August 30, 191 7 



emigration) ; and, on the other, to provide the staphylo- 

 coccus and streptococcus with lymph, a tluid in which 

 ihey can grow and disseminate themselves over the 

 whole face of the wound. What we want is an 

 application which calls out leucocytes, which will 

 restrain, or at any fate will not activate, the 

 lymph flow. Physiological salt solution, and zinc 

 sulphate in 5 per cent, solution, and no doubt many 

 other heavy metal salts in dilute solution, are the sort 

 of agents we require. But what is, above all, essential 

 to success in physiological treatment of a surface in- 

 fection is assiduity in removing any leucocytes which 

 may break down upon the face of the wound. That is 

 a question of maintaining intact the antitryptic power 

 of the lymph on the wound surface. 



A second method of procedure— I may call it the 

 unreasoning antiseptic procedure — is to employ an anti- 

 septic, without laying stress upon the assiduoias cleans- 

 ing of the wound surface and the maintenance of good 

 physiological conditions; without inquiring whether 

 the antiseptic can, when brought into external contact 

 with pus or an infected tissue, penetrate into it; and 

 without asking whether the antiseptic hinders phago- 

 cytosis, or destroys the antitryptic power of the blood 

 fluids, or permits or interferes with tryptic action. 



This unreasoning antiseptic procedure is constantly 

 employed. It has led to failure upon failure, and it 

 would be a matter for wonder if it did succeed. 



The third and last method of procedure 1 may call 

 the combined antiseptic and physiological procedure. 

 If we want to find a method of this sort w-e ^hall not 

 find it by inquiring for it under this name. What w^e 

 have to seek is a method which proclaims itself an 

 antiseptic method and in this guise combats effec- 

 tively, but perhaps not with full comprehension, 

 corruptive changes in the wound. 



The method of Carrel is, as I think, such a method. 

 I \yould propose to show that it is a combined 

 antiseptic and physiological method; then to survey 

 the results obtained; and, finally, to consider how- 

 far the results should be credited to the antiseptic, 

 and how far to the physiological, element in the 

 treatment. 



We have in Carrel's treatment two factors : (a) 

 Dakin's antiseptic, or, as I should prefer to call it, 

 Dakin's therapeutic agent; and (b) Carrel's procedure 

 for washing and refreshing the wound sur/ace in the 

 intervals between the complete dressings. Now each 

 of these factors acts not only by killing or removing 

 microbes, but also by making the conditions in the wound 

 unfavourable for microbial growth. Let me, taking 

 first Dakin's fluid and then Carrel's washing proce- 

 dure, try to make for you an inventory of their directly 

 anti-bacterial, and their physiological or indirectly 

 anti-bacterial, effects. 



Dakin's Fluid. 



Dakin's fluid is, as I have shown you,^ a very in- 

 effective antiseptic when it is brought into application 

 upon microbes suspended in serum. It is also, as I have 

 likewise shown you, an antiseptic which has as good as 

 nD power of penetrating into albuminous fluids. It is 

 also an extremely volatile antiseptic. When exposed 

 in a shallow dish at blood temperature J have found 

 it to lose four-fifths of its potency in half an hour, 

 and it will, as I have already had occasion to point 

 out, if not already quenched by contact with serum, 

 very quickly disappear from the wound. 



Turning from the effect exerted vpon microbes to 

 the effect exerted upon the w'ound surface, let me 

 recall to those of you w-ho have seen it that when a 

 naked-tissue surface is treated with Dakin's fluid for, 

 for the matter of that, with 5 per cent, salt solution) 



* Viife supra. Experiments on Antiseptics. 



NO. 2496, VOL. 99] 



it is speedily converted into a bright coral-red granu- 

 lating surface. That means it is converted into a 

 defensive surface excellently well provided with new- 

 formed blood-vessels from which active leucocytes and 

 fully potent lymph will emerge. 'I hat is a physio- 

 logical action to the good. But there are also other 

 effects exerted. Leucocytes are affected by Dakin's 

 fluid. Experiments show that it is destructive to 

 phagocytosis. When we add one part of the reagent 

 to nine of excoagular blood we reduce the phagocytic 

 power of that blood by more than one-half. We 

 abolish phagocytosis' when we add one part of the 

 reagent to four of blood. The fluid elements of the 

 discharge also are altered in character by Dakin's 

 fluid. Let me remind you here that we saw in our 

 experiments on artificial sloughs that treatment with 

 Dakin's solution hinders the digestive processes which 

 bring about their separation. This stands in relation 

 to the fact that the reagent exerts upon trypsin, when 

 albumen is not there to act as a buffer, a destructive 

 action. We have, as you perceive, here a physiological 

 action which may quite well come into operation when 

 a comparatively clean but tryptic wound surface is 

 .flushed. Dakin's fluid abolishes also the antitryptic 

 power of the blood fluids. It would seem, therefore, 

 with one hand to give protection, and with the other 

 to take it away. But what really does happen is, 

 I suppose, that trypsin and antitrypsin alike are 

 destroyed bv the flush and that afterwards in the 

 wound a new beginning is made. 



Let us follow up the train of thought here started. 

 We may, I think, profitably ask ourselves whether, if 

 put to our election between maintaining antiseptic 

 action continuously at the expense of physiological 

 action, and alternating antiseptic with physiological 

 action, we should not do well to elect for the latter 

 policy. And we may muse w^hether it was not speci- 

 ally felicitous to have employed, as Carrel has done, 

 an antiseptic which is very readily quenched and also 

 verv volatile and to have applied it discontinuously. 

 Had that antiseptic been employed by a method ot con- 

 tinuous irrigation, phagocytosis on the face of the 

 wound would have been excluded, and we might have 

 had in the cavity of the wound a lymph the antitryptic 

 power of which had been destroyed. 



But I have already said enough about Dakin's fluid 

 if you have appreciated that it is a poor antiseptic ; 

 that it acts as a poison upon leucocytes and blood 

 fluids ; that its physiological action is a very compli- 

 cated one ; and that its beneficial effects cannot be due 

 simply to its antiseptic action. 



Carrel's Method of Irrigating the Wound. 



I now come tj Carrel's procedure of intercalating 

 between the complete dressings a frequent flushing 

 and refreshing of the wound surface and for carrying 

 out this flushing unlaboriously. Allow me to say that 

 we have here, I think, far the most important contri- 

 bution made to surgical technique since the beginning 

 of the war. But to that let me add that, while 

 Carrel's procedure gives us a new and improved tech- 

 nique for the application of antiseptics, much more 

 does it give us a new and improved technique for 

 physiological treatm«^nt. In all physiological treatment 

 the assiduous removal of corrupted and corruptible dis- 

 charges is the primary desideratum. 



We now turn to the results of the treatment of in- 

 fected wound surfaces by Carrel's method, and we 

 mav take them from Carrel's book. But it will be 

 well, in order to keep to the kind of v^'ound infection 

 here under discussion, to exclude from consideration 

 wounds complicated with fractures — for in those effec- 

 tive washing is difficult. And we may further, look- 

 ing to the classification of wounds of soft parts in 



