THE PREVENTION OF

SEPSIS

IN WAR WOUNDS,

WITH SPECIAL REFERENCE TO THE CARREL-DAKIN METHOD.

James Swain, C.B., M.S.,

M.D. Lond., F.R.C.S.,

Professor of Surgery in the University of Bristol. ; Consulting Surgeon to the Southern Command Delegate to the Inter-Allies Congress on the Treatment of

Lieut.-Colonel, R.A.M.C. a

British

Wounds in War.

During my visits to France I have seen many hospitals in the English and French lines and in Paris where the scientific methods with which within

a

with the of the

war

few miles of the

wounds

are

firing-line, are

now

even

in noticeable contrast

unsatisfactory procedures adopted

war.

treated,

at the

beginning

69

PREVENTION OF SEPSIS IN WAR WOUNDS.

wounds

suppuration in war mathematical certainty.

The control of infection and is

almost

now

matter of

a

Micro-

tests as to the progress of the sterilisation of wounds

scopic are applied, and wounds

can

geometrical

be

the rate of progress of the definitely calculated and

healing of aseptic represented by a

curve.

England were filled with a large proportion of suppurating cases (much of which was due to the re-infection of wounds during transport), it was strange to see printed in large type in M. Tuffier's wards at jthe Beaujeu Hospital a notice, in French, to the following effect : Every patient whose wound suppurates At

time when the base

a

hospitals

in

"

has the right ment

pus

was

to ask the reason of his

amply justified,

for in this

hospital,

non-existent, wounds

practically

was

pain, compound

ones, and

were

healing

and elsewhere,

were

free from inflammation and like

The state-

surgeon."

fractures

empyemata simple pneumothorax. Early treatment

desirable,

as

this

can

be commenced in France

the infliction of the wound, most of the

were

converted into is

cases of sterile

and

and

supple

highly

soon

after

rendered

cases are

"

sterile," and closed, with about 99 per cent, of successes, in the course of five to twenty-five days. The

hospitals

to which these remarks refer have

adopted

the Carrel-Dakin method of treatment, and it is easy to see from what has been said how much suffering is prevented,

many'limbs and prevention of sepsis.

and how of

In order to be

methods

form of The

as

points, it adopted by the

on some

Compiegne,

where I

by this

successfully applied, great

detail is necessary, and

standing

lives have been saved

was

means

attention to

there is considerable misunderis desirable to state staff

sent

at

by the

Carrel's

some

of the

Hospital

War Office to

study

at

this

treatment.

fluid

used

to

"

sterilise

"

the

wounds

is

Dr.

LIEUT.-COL.

70

JAMES SWAIN

Daufresne's modification of Dakin's solution of

hypochlorite

It must be free from caustic soda, and should

of soda. contain

exactly between 0.45 and 0.50 per cent, of hypochlorite of soda?under 0.45 per cent, the solution is not active enough, and over 0.50 per cent, it is irritant. The

is

solution

made

carbonate of soda and bicarbonate

(bleaching powder), dry of soda in water ;

but

lime

chlorinated

by mixing

as

the amount of active chlorine in

bleaching powder varies within wide limits, bleaching powder before use.

it is necessary to

titrate the The

following instructions for titrating the chlorinated preparing the solution are taken from a paper

lime and

supplied from the laboratories of the Rockfeller Institute at Compiegne :? Technique of the titration of chlorinated lime (bleaching powder).?Obtain an average sample of the bleaching powder by mixing small quantities obtained from different parts of the material. tVeigh 20 grammes of this, mix it thoroughly in

a

litre of water, and allow it to stand for

some

hours.

Filter. Measure

pipette, of

exactly

and add

potassium,

and

To this mixture

hyposulphite

10 c.c.

20 c.c. 2

c.c.

of the clear fluid with

of

a

10

a

graduated

per cent, solution of iodide

of acetic acid

add, drop by drop,

a

or

hydrochloric

acid.

decinormal solution of

complete. The hyposulphite decoloration, multiplied by 1.775, will

of soda until decoloration is

number of cubic centimetres of the solution of

required for weight of active chlorine contained in 100 grammes give of bleaching powder. This figure being known, the following table can then be used to give the quantities of chlorinated lime (bleaching powder), carbonate of soda, and bicarbonate of sod?, of soda

the

which should be used to prepare solution :?

10

litres of Daufresne's

PREVENTION

OF SEPSIS IN WAR WOUNDS.

Quantities Figure

for

Active

to

Prepare at

|

Chlorine

io

71

to be used

Litres of Daufresne's Solution

0.475 per cent, of NaCl.O.

??

|

per cent.

Bleaching

|

Dried Carbonate

|

Bicarbonate of Soda.

Thus,

for

example, assuming

?f the decinormal solution of

necessary to use 16.6 c.c. hyposulphite of soda to obtain

it

was

decoloration, the percentage of active chlorine in the bleaching 1.775=29.7 per cent. The quantities of ingredients for the preparation of 10 litres of the

Powder is 16.6

the various

by

solution, in this case, would Bleaching powder Dry

carbonate of soda

Bicarbonate of soda

And

if

one

has

only

be? ..

..

.

..

.

154 grammes. 77 grammes.

64 grammes. the carbonate of soda in crystal form, it ..

..

^ould be necessary to replace the 77 grammes of dry carbonate bY 220 grammes of the crystallised carbonate of soda.

Preparation of Daufresne's solution (10 litres).?Weigh exactly the quantities of the various ingredients determined

LIEUT.-COL.

72 in the the

already described. bleaching powder and 5 litres

Put into

manner

cold water, shake

vigorously

six to twelve hours,

one

SWAIN

JAMES

for

night

a

for

12-litre flask

a

ordinary (not distilled)

of

few minutes, and leave for At the

example.

same

time

dissolve the carbonate and bicarbonate of soda in 5 litres of

ordinary

After the

cold water.

lapse

of six to twelve hours,

containing the macerated bleaching powder, shake vigorously for a few seconds and wait to allow the calcium carbonate to be precipitated. After about half an hour siphon the liquid and filter with a pour the salt solution into the flask

double paper to obtain a good clear solution. The solution must be kept in a dark place, as light rapidly destroys the sodium

hypochlorite.

It

is

best

in

kept

covered, dark green bottles, and if five

potassium permanganate are added to solution, the stability of the hypochlorite

large, wickermilligrammes of litre of the

each is

greatly enhanced

The solution'should be neutral, and should on

being tested-by

phenolphthalein the

in

the addition of

powder

to

a

20

give no coloration few centigrammes of

cubic

of

centimetres

liquid. of the Daufresne's solution.?It percentage of the solution from

Titration

verify

the

This is done in the

same manner as

is desirable

to

time to time. of the

the titration

bleaching powder : measure ten cubic centimetres of the solution, add twenty cubic centimetres of a 10 per cent, solution of iodide of potassium, and two cubic centimetres of acetic acid ; then add, drop by drop, a decinormal solution of sodium

hyposulphite

until

decoloration

number of cubic centimetres used,

occurs.

The

multiplied by 0.03725*

hypochlorite

of soda contained in 100

cubic centimetres of the solution.

The Daufresne's solution

gives

the

weight

of

is of proper strength when it is necessary to coloration 12 to 13 cubic centimetres of the solution.

13x0.03725=0.485

per cent.

use

for dis-

hyposulphite

NaCl.O.

PREVENTION OF SEPSIS IN WAR WOUNDS.

73

Method of Application.?It is unnecessary to describe this in detail, but briefly it may be said that, if possible, within a few hours of being wounded the patient is anaesthetised, foreign bodies and portions of clothing are removed from the wound, which is excised, thoroughly

cleansed,

freely open, and dressed according to Carrel technique. Tubes (in number according to the laid

?f the wound, of 4

but

mm.

the size

inside diameter, closed at the end,

perforations just above for 5 to 20 centimetres) are placed in the wound, supported loosely by gauze wrung out of Daufresne's solution or fixed in place by strapping. The skin around the wound is protected by pieces of gauze measuring about 6x12 c.m., soaked in vaseline and sterilised, and the whole wound is covered by a sterilised dressing passing round the limb, and consisting of a layer of absorbent wool inside {i.e. next to the wound) and a

having

numerous

fine

of non-absorbent wool outside enclosed in gauze. pad is fastened with safety pins in such a way that the

layer

This

project through the place wool dressing. (Fig. 1.l) To

proximal ends of the Carrel's tubes ?f

meeting

of the

edges

of the

Fig.

The The disposition of of 1

a a

at the the tub, at 4-way 4-way tube

i. i.

surface

Figs. I, 2 and 4 are taken from Par A. Carrel and G. Dehelly. Mazzon 1ya'ique de 1'irrigation des plaies dans J- Dumos et Ann Carrel. A. Maloine k^n slightly altered.

oj oj

aa

Carrel). dressing [after Carrel). dressing (after

Le traitement des plaies infectees, et cie, 1917. Fig. 3 is taken from la mlthode du Docteur Carrel, par et Fils, 1917. Figs. 3 and 4 have

LIEUT.-COL,

74

JAMES SWAIN

the ends of the tubes

glass connections of one to four openings-' necessity are fastened, and these glass (Fig. 2) according connections are in turn connectcd by a rubber tubing, through to

which the Daufresne's solution

runs

from

a

reservoir of

a

litre

capacity, which is placed not more than three feet above the patient's bed. (Fig. 3.) On this main supply tube a clip is placed close to the reservoir, and the clip is released for about

in

one

to three seconds every two hours,

so as

to flood the

connexions

(after Carrel).

wound

Fig. 2.

Different forms of glass distributing

according fluid. times

to its size with 20 to 100 cubic centimetres of the

This

of the wound every two hours is somefor by automatic mechanical or electrical

flooding

arranged

devices.

If the

patient complains

of

pain,

the reservoir

should be lowered. The wounds

changed

on

are

dressed

alternate

daily,

days.

the skin is cleansed with

a

but the tubes

When

redressing

solution of

20

are

generally

takes

place,,

per cent, oleate

of

PREVENTION OF SEPSIS IN WAR WOUNDS.

soda ls

on

small swabs of wool.

carried out with the usual

75

dressing of these wounds antiseptic precautions ; the

The

tube 7mm. inside diameter.

Conducting

Scheme -arrel).

^arrCl^eme c

of

SUrgeon works by means

?ut

changed

Fig. 3. for the distribution of the fluid f?r

general arranSement *eneral arrangement in of

(after

gloves, and all manipulations are carried two pairs of sterilised forceps, which are

for each wound.

76

LIEUT.-COL.

When the

bacteriological

JAMES

examination

by suture

or

{vide infra) of the organisms, it is

free from

wound shows it to be closed

SWAIN

practically strapping without drainage,

after excision

of the skin With

edge. regard

to the

preliminary

which has been referred to, it

excision of the wound

should|be

observed that if

a

completely excised within injury, it may be possible receipt eight to close the wound at once, and get healing by first intention with or without antiseptics. When the wound cannot be thoroughly excised, or when more than eight hours have elapsed after the injury, the bruised or dirty tissues should be cut away as far as possible, the wound opened up, and Carrel treatment commenced at once. If the patient does not come for treatment until after twenty-four to forty-eight hours from the time of injury, Carrel thinks the wound should wound

six

be

can

thoroughly

and

hours of the

or

not be excised.

surgical

In these last

interference

as

of

cases

and

possible, technique

left in until the Carrel

there should be

foreign

bodies

as

are

little

better

has been carried out for

days. In short, surgical cleansing during the preinflammatory period should be complete, and is fairly free from danger ; but during the early days of the inflammatory period only such surgical intervention as may be absolutely necessary should be undertaken, as there is great danger of increasing the septic trouble. This risk is much less when suppuration is established. Bacteriological Examination of the Wound.?It is quite impossible to tell the condition of a wound as regards infection from naked-eye appearances. A microscopic examination of the secretions of a wound is necessary in order to ascertain the degree of infection at some

the

beginning

effect

of

the

disinfection,

of treatment, to follow the progress of the antiseptic applied for the purpose of

and to determine the time at which closure

PREVENTION OF SEPSIS IN WAR WOUNDS.

?f the wound may be undertaken without

77

danger

to the

referred to is

merely

Patient. The bacteriological examination and has

Quantitative,

employed

do with the cultural methods

nothing to

ascertain

to

the

now

nature

of the

A

infection.

smear is taken from the wound, fixed, stained with carbol-

thionin,

and examined under

usual way. Carbol-thionin non-selective stain will do.

be stopped

The

a

is

-f2 in. immersion preferred, but

Irrigation

lens in the

any other of the wound should

at least two hours before the smear is taken.

microscopic field is counted, lrrespective of the variety of the organisms. By moving the slide, several fields can rapidly be observed, and the mean of number of

organisms

in the

the number of

chart.

process is

At first the

organisms seen is recorded on a repeated about every other day.

0rganisms may be very

numerous ;

later,

a

This

diminishing

uumber per field may be observed as the process of disinfect*on continues. At last a stage may be reached in which only one organism can be seen in five microscopic fields ;

the wound is then considered

"

sterile," and may

safely

be

closed by secondary suture or strapping, with almost no risk ?f any latent sepsis. It has been found that if a wound is closed when the organisms are as numerous as one per field stitch abscesses

are

e-S- osteomyelitis

observers

very liable to occur. In certain cases, after severe compound fracture, some

believe there is better callus formation if

the

wound is kept open for a long period, and in these cases the 0rganisms may be found to be reduced to one in twenty

Microscopic

fields

or

less.

The record (Fig. 4) of the number of the

"

courbe

microbienne "?is

now

organisms

largely

used

found? as

an

indication

of the result of treatment, whether the Carrel-

-^akin

other

or

technique

is

employed.

dumber of organisms steadily diminishes,

So

long

as

the

treatment may be

78

LIEUT.-COL.

considered

stationary

satisfactory or

but

;

increases, the

SWAIN

JAMES

cause

if

the

number

remains

of the arrest of disinfection

should be

sought, e.g. insufficient number of tubes, presence sloughs, foreign bodies, pieces of clothing, faults in

of

technique,

etc. MICROBIAL CURVE-

911 o is. Jour5. oo

Go

|

^

S&fst 5"

_7__2_

"

,5~

/3

'7

x'

'1

2i

zr

J*

40

2o 10

5