Mr. Joseph G. Butler, Jr., Youngstown, O.

My dear Mr. Butler:--

In compliance with my request, Dr. Joseph Lawrence, of the American Ambulance, has kindly prepared a short note on the Carrel treatment of wounds, and this I am now enclosing. I trust that you will find it sufficiently explicit for your purposes, and that it will be of use and interest to you.

Now that you are again home I hope that your wonderful trip in France will be less than a mere memory and that the labors of the Industrial Commission will prove, as they should, most valuable to the manufacturers and exporters of the United States. Believe me that it was to me a great privilege as well as a great pleasure to have met you and your distinguished colleagues, and that my only regret is that I was unable to be of greater use to the Commission.

I am, with very kind regards,

Sincerely yours, LAURENCE V. BENET 1 encl.

The Carrel Treatment of Wounds.

The Carrel treatment consists in thorough irrigation guided by the bacteriological observation of the wound.

For the irrigation of the wound, Carrel has chosen a certain size of rubber tube about 4 mm. in diameter into which he punches small holes at intervals. The one end of this tube is shut, the other end is allowed to protrude from the dressing.

On the surface wound, the tube is laid over the wound in the direction of the greatest diameter of the wound with the open end towards the most elevated part.

In perforating wounds, the tube or several tubes, when the wound is large, are pa.s.sed through from both sides, or pushed into cavities or pockets that may exist.

If the wound is not a perforating wound, but a deep wound, the tubes are planted deep into the cavity that may be formed. These tubes are always of sufficient number to thoroughly irrigate the broken surface.

Over the uninjured skin, about the wound, is placed thin strips of gauze which have been steeped in vaseline, the skin having been thoroughly washed before with soap and water.

To keep these tubes in place, a bandage wet with Dakin"s solution is placed over them. The wound is flushed every two hours with Dakin"s solution. The amount of solution used per wound, varies in proportion to the size of the wound from 500 c.c. per day up.

Wounds are dressed daily.

The bacteriological observation is made by taking a smear from the most vicious part of the wound at intervals of two or three days.

The number of bacteria on these smears is noted and counted per oil immersion field. A count of more than 75 bacteria per field is considered infinity. When there are less than 10 bacilli to the field, and not less than 5 to the field, three fields are counted.

When less than 5, and not less than 7, five fields are counted.

When less than one, from five to twenty fields will be counted.

A wound that retains a count of one bacillus to two fields or less for three observations, is considered bacteriologically clean, and suitable for operation. If the wound is a compound fracture, it is advisable to close the wound, converting it into a simple fracture.

If this can be done without exerting too great tension on the sutures.

If the wound is a flesh wound, and can be drawn together without too great tension, its closure is indicated.

[Ill.u.s.tration]

The important parts of the treatment consist in thorough irrigation, and careful bacteriological observation. The bacteriological observations are charted on charts similar to temperature charts.

Dakin"s Solution.

(Sodium Hypochlorite at 0.50%)

1--To prepare 10 litres of solution, weight exactly: Chloride of Lime (Bleaching Powder) 200 grms.

Carbonate of Soda (dried) 100 grms. or if used in crystals 200 grms.

Bi-carbonate of Soda 200 grms.

2--Put the Chloride of Lime into a large mouthed bottle of about 12 litres capacity. Add 5 litres of water (half the quant.i.ty) and shake well two or three times. Let this stand all night.

3--Dissolve in another 5 litres of water of two Soda salts

4--Pour this latter solution directly into the bottle containing the maceration of lime. Stir well and let the solution stand in order to allow the precipitate of Carbonate of Lime to settle.

5--At the end of half an hour, siphon the clear liquid and filter by means of a paper, in order to have a perfectly clear solution.

This should be kept away from the light.

6--No heat should be employed in the manufacture of Dakin"s and ordinary Tapwater should be used.

Preparation of Dakin Solution.

Technique of Dr. Daufresne.

The solution of sodium hypochlorite for surgical use must be free of caustic alkali; it must only contain 0.45% to 0.50 of hypochlorite. Under 0.45% it is not active enough and above 0.50 it is irritant. With chloride of lime (bleaching powder) having 25% of active chlorine, the quant.i.ties of necessary substances to prepare ten litres of solution are the following:--

Chloride of Lime (bleaching powder) 25% CI act....200 gr.

Sodium Carbonate, dry (Soda of Solway) 100 gr.

Sodium Bi-carbonate....80 gr.

Pour into 12 litre flask the two hundred grammes of chloride of lime and five litres of ordinary water, shake vigorously for a few minutes and leave in contact for six to twelve hours, one night for example. (Shake until dissolved) at least the big pieces are dissolved, large pieces float--notice only floating pieces. At the same time, dissolve in five litres of cold ordinary water the carbonate and bi-carbonate of soda.

After leaving from six to twelve hours, pour the salt solution in the flask containing the macerated chloride of lime, shake vigorously for a few minutes and leave to allow the calcium carbonate to be precipitated. In about half an hour, siphon the liquid and filter with a double paper to obtain a good, clear liquid, which should always be kept in a dark place.

Tritration of Chloride of Lime (Bleaching Powder).

Because of the variation of the products now obtained in the market, it is necessary to determine the quant.i.ty of active chlorine contained in the chloride of lime which is to be used.

This, in order to employ an exact calculated quant.i.ty according to its concentration. The test is made in the following manner:--

Take from different parts of the bar a small quant.i.ty of beaching powder to have a medium sample, weigh 20 grammes of it, mix as well as possible in a litre of tap water and leave in contact for a few hours. Measure 10 c.c. of the clear liquid and add 20 c.c. of a 10% solution of pota.s.sium iodide, 2 c.c. of acetic acid or hydrochloric acid, then put drop by drop into the mixture a decinormal solution of sodium hyposulfite (2.48%) until decoloration. The number "N"

of cubic centimeters of hyposulfite employed multiplied by 1,775 will give the weight "N" of active chloride contained in 100 grammes of chloride of lime.

The test must be made every time a new product is received. When the result obtained will differ more or less than 25%, it will be necessary to reduce or enlarge the proportion of the three products contained in the preparation. This can be easily obtained by multiplying each of the three numbers--200, 100, 60 by the factor N/25 in which N represents the weight of the active chlorine per cent of chloride of lime.

Measure 10 c.c. of the solution, add 20 c.c. of pota.s.sium iodide 1/10, 2 c.c. of acetic acid and drop by drop a decinormal solution of sodium hyposulfite until decoloration. The number of cubic centimeters used multiplied by 0.03725 will give the weight of the hypochlorite of soda contained in 100 c.c. of the solution.

Never heat the solution and if in case of urgency one is obliged to resort to trituration of chloride of lime in a mortar, only employ water, never salt solution.

Test of Thetalkalinity of Dakin Solution:--