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Show W I 1 ' . ' ; 1 ' A " , , i f " , " . jj.H -,'-0, Jri British War Photograph Showing Hasty Treatment of the Wounded Behind the Firing Line, When Infection of the Wound Is Sure to Take Place This Would Formerly Have V Necessitated Amputation of the Limb, But the Carrel Treatment Avoids This. By Dr. A. C. Guillaume, The Distinguished French War Surgeon. --s-VHE' horrors and losses of "war have B been lessened to an enormous extent by the remarkable methods introduced intro-duced by the Franco-American surgeon Dr. Alexis Carrel since the present war began. Thanks, to these methods, the amputation j of soldiers' limbs as a result of infected J wounds has become very uncommon. For- merly 80 per cent of amputations were due to infected wounds. There are still, of course, wounds in which a limb is so shattered that amputation is unavoidable, but where enough of the limb remains to be worth saving infec- tion is not allowed to cause its loss. Olt is difficult to give exact statistics at this Rtage, but it is probably true that 75 t per cent of the amputations that were performed per-formed in other wars are avoided now, while the soldier is sent back to civil life in most cases with a strong, serviceable limb. This means the saving of hundreds of thousands of men for a useful life after the war. American Amer-ican soldiers are fortunate in being able to obtain the full benefit of a treatment which was not in existence during the early stage of the war. It is important to remember that every wound received in battle is an infected, wound. Projectiles which penetrate the tissues tis-sues must always bo considered as loaded with highly septic poisonous substances. This is one of the first conclusions that was established estab-lished by the modern surgery of war. It V was also found at the beginning of this war that there were infections following on war wounds which the antiseptics generally employed em-ployed could not prevent from developing. In fact, in spite of the employment of extremely ex-tremely powerful germicides and in spite ' even of tho very early use of these antiseptics, a number of gangrenous or ultra-septic infections in-fections developed. -Onr ablest, medical scientists then set to work earnestly to discover the reasons for this condition. A great many separate re-sca'rehes re-sca'rehes carried on at. the same time reached Hie same conclusion that the ideal antiseptic would be one which not only kills the microbes mi-crobes causing the infection but which at the same time does the least harm to the powers of resistance of the human body. If a general wishes to defend a position he endeavors to use a method which defeats the enemy while leaving his defenses intact. The latest development of war surgery proceeds on the same principle. When we employed very powerful antiseptics it was as if we had exploded a mine which killed a great number of the enemy, but at the same time destroyed nn equal number of our defenders and their trenches and works of defense. The essential part of the problem was then, from a practical point of view, tho discovery dis-covery of the ideal antiseptic which would destroy the germs while respecting the i a. powers of resistance of the defense cells of the body. Neutral hypochlorite, or "Dakin's liquid,'' named after an English doctor, has been chosen by Dr. Carrel as the one which best servos his objects in the treatment of ,. wounds. ' ' This liquid presents, as compared with all others, the great advantage of combining tho four following qualities: (1) An undoubted action in destroying microbes. Its strength is near to that of peroxide perox-ide of hydrogen, weaker than that of iodine. (2) An action on the organic surroundings of the wound through the rapid dissolution of disintegrated tissues, pus bags, red globules blood clots and muscular fibres. These substances sub-stances form a mechanical obstacle to the action ac-tion of the antiseptic upon the microbes and favor the spread of the latter. (3) A mechanical action in driving dirt out of the wound. (4) Finally, a matter of capital importance, impor-tance, surgical experience shows that while the neutral hypochlorite dissolves perfectly the dead and poisonous matter, it does not injure the living tissues of the wounds, which on the contrary grow and fill up the space created by the destruction of the dead tissues. Other antiseptics and other substances may possess to a more marked degree one of these qualities, but they do not unite all of them, and it is thjs combination which gives the hypochlorites their great value. One of the advantages of Dakin's liquid seems extraordinary and even mysterious. This is that it brings about by its antiseptic action the formation of a cyst or membranous covering cov-ering over the wounded region. Dakin's liquid, although it is a marked germicide, is less so than the antiseptics commonly employed hitherto in surgery, such as iodine, bichloride of mercury, permanganate perman-ganate of potash, peroxide, of hydrogen, etc This fact involves the necessity of using it very frequently, a proceeding which is without with-out harm to the tissues, in contrast to what happens when strong antiseptics are used. Torn fragments of flesh and bullet tracks are especially the places where the mi-crobean mi-crobean flora will spread quickly. Between the moment of the wound and that when the microbes cover the whole extent of the wound there is but a very short time from six to twenty-four hours on the average. We shall now understand ' why Dr. Carrel insists on the necessity of largely opening up the wound, of extracting from it all foreign for-eign bodies and of beginning as early as possible the continuous moistening of the wound with Dakin's liquid. We must add that a majority of doctors who have used the Carrel method think that the results are especially favorable when the doctor can give the treatment within the first six hours. The surgeon will therefore act as quickly as surrounding circumstances permit, while not neglecting any of the usual features which accompany a wound, such as shock. The first stage of the treatment will be to open up freely all intricate cavities and all recesses in the wound and in fact every corner which suggests a partially closed cavity. cav-ity. xt the same time, Dr. Carrel holds that it may be useful to cut away the ragged edges of the wound. In the course of the treatment the surgeon takes care to remove all foreign bodies, not trusting to the sense of sight and touch alone, but having recourse re-course to the X-rays and even, if possible, to the electro-vibrator. As in any other surgical treatment, it must be understood that it is necessary to limit the extent of the opcratory enlargement of the wound, to avoid a bad scar and to stop the loss of blood. Tho operative cleaning of the wound, which must be very methodical and complete, com-plete, is followed by the chemical cleaning. The Carrel apparatus consists of tiny rubber rub-ber tubes which. ira pushed into every cor- Copyr! . V , M a . " V. : ' " k , i- 4 ' ' r, . hcr - ! i jr ,.' 1 s j i U . - 1 1 v.'.: : Vi'- iAV ?'.('.--J?' -.1 i " .s !" 1 ,' , q How tl Carrel Ti ment Given Hospital the Ca; of a Gn Injury the Leg ' Would I merly H Cost t Soldie His Li: Treatment of Wounded in a German Trench, Illustrating Conditions Which Almost Invariably Cause Infection, ner of the wound. The upper ends of these tubes are attached to a glass cannula, an apparatus supplied with nozzles, to which the rubber tubes are fitted. The cannula is connected con-nected above by another rubber tube with a reservoir from which it receives its Dakin's Da-kin's liquid. The rubber tubes or drains are about six millimetres in diameter (about the size of a wire nail), and are pierced near the end with several openings. They are covered with absorbent material. The wound is filled with gauze and covered with a layer of cotton treated so as not to absorb water. It is absolutely necessary that every corner of the wound should receive a tube, for the whole wounded surface must be in permanent perma-nent contact with the antiseptic. As often as may be necessary to keep the wound humid, in some cases all the time, and in others every two hours, the surgeon allows al-lows the necessary quantity of liquid to run into the cannula. The quantity naturally varies with the extent and depth of the wound, and is generally five to ten cubic centimetres (eight to sixteen cubic inches) every two hours. He takes care not. to heat the liquid and not to mix it with other antiseptics. anti-septics. In case the surgeon does not employ continuous con-tinuous irrigation, the application of the liquid is made by means of a syringe or by the use of a vessel hung on a hook and joined to the apparatus by a rubber tube furnished with a stop-cock which will interrupt inter-rupt the flow. If he employs continuous irrigation, he uses a regulator inserted in the apparatus which allows five to twenty drops a minute to flow into the wound. The wound is irrigated with care, the dressing is changed and examined at least once daily if not oftener. To avoid the discomforts dis-comforts which might result from the prolonged pro-longed contact of the liquid with neighboring neighbor-ing tissues, these ma3' be covered with some fatty substance, or better, with compresses soaked with physiologic serum (solution of sodium chloride), which will also help the treatment of the wound. The surgeon must then observe the evolution evolu-tion cf the wound. He will not see any pus appear, or, if it existed before the Carrel g-tit, 1917- tv tie fjiar Company. Great R-fln Bights fi Remarkable Process Wliicfi Sterilizes and f N reserves the Tissues id Has Practically tf h UbolisLed tKe Vast lA " Slumber of Gruel I ,f imputations Formerly CJ I I Necessitated by ,1 nfected Wounds f 1 J treatment was wmMI & 1 begun, he will ' If A 1 CV see it disappear, ' fJf replaced by a fiXSkmMSi.M clear - running if'SftWIslft V fluid. The wound A c has no odor, no gray matter, no 4p:l I hardening of the '4mmm 1 treatment was begun, he will see it disappear, replaced by a clear - running fluid. The wound has no odor, no gray matter, no hardening of the adjoining t i s -sues, but, on the contrary, a wholesome and healthily colored look. The development should be watched, microscope mi-croscope in hand. Daily the surgeon gathers up the liquid from the wound and examines it microscopically. He will see the various species of microbes diminishing rapidly and then disappearing altogether. If the wound has been treated early it will become free from microbes about the fifth day. The surgeon sur-geon then brings the edges together with sutures or with adhesive bands. An ingenious innovation at this stage is the proceeding known as "corseting." Two bands of adhesive plaster furnished with hooks are attached to the edges of the wound, which can then be laced up like a shoe with the aid of a rubber lace. Whatever What-ever method of closing the wound be employed, em-ployed, the tissues join up like a surgical wound made under perfect aseptic conditions condi-tions and very differently from an old-timo war wound. Our official war records show the remarkable remark-able results achieved by the Carrel method. Out of eighteen wounds, of which twelve were caused by grenades or shell, and six by bullets, healing was complete between the twentieth and forty-eighth forty-eighth days. These cases occurred under the care of Doctor Uffoltz. Dr. Perret reported a series of 111 serious wounds which were healed without one death or amputation. Dr. De-helly De-helly reported to the Academy of Medicine the perfect healing of 155 wounds. Similar results are published Section of m Deeply Recessed Wound of the Leg With the S Carrel Tubes in Position Surrounded by Packing. W h B E g t B VtZ'V:r'ifj(V'K7S7:v-rAvssrTKis.- srsw : ' '' tT". .. : The "Corscting"or Last Staeeof the Healing of the Wound in the Carrel Treatment. by many French army surgeons, justifying the statement that loss of limbs through wound infection is now a rare occurence. occur-ence. In many cases wounds which were already gangrenous have been treated and cured by the Carrel method. Not only does it save life and avoid 1hc loss of limbs, but it leaves a soft healthy scar which does .eserved. Explanation of the Parts of the Carrel Apparatus: A. Reservoir Res-ervoir Containing the Dakin Antiseptic Antisep-tic Liquid. B. Rubber Rub-ber Tube. C. Release Re-lease Clip to Open or Close Tube. D. Glass Tube Containing Con-taining Measured Quantity of Antiseptic. Anti-septic. E, E, E, E. Tiny Rubber Tubes to Be Inserted in All Corners of the Wound. not produce the crippling effects whicK so often followed on tho cicatrization of wounds. The tremendous shortening of the period of treatment means a great lessening of the patient's suffering, while the healthy efficient effi-cient condition of the cured limb will save an immense amount of productive labor to the community. |