counter, her forehead reddened with shame, her hands twisted together in self-loathing.

"Get me some hot tea, my dear," gasped Miss Frenzy. She still shook and her voice was as the voice of a dying person. The fine raiment of courtesy and punctilious speech that she had all her life worn had been torn from her by her own fierce old hands; in her own gentle eyes she was hopelessly degraded. Yet she smiled triumphantly at the anxious young face of the girl as she proffered the steaming tea. "Young," muttered Miss Frenzy, her eyes following the movements of the other. "Young.'

At last she roused herself and went slowly toward the door of the little private room, the girl hurrying to assist her. She paused, took the dark young head between her wrinkled hands and kissed it. "I called her a 'worm,' my dear," said Miss Frenzy. "It was a

NY one whose wound suppurates has the right to demand of his surgeon the reason why." Such is the text upon placards posted conspicuously in every ward of the Hospital of the Maison Blanche, over which Doctor Tuffier presides in Paris.

To the uninformed, this message may not seem impressive, but to the medical profession that pronouncement is of the utmost import. In so many words, it means that infected wounds should no longer dismay the physician or entail continued and needless suffering upon the patient. Not only that, but this victory over disease, won in the first place within the sound of hostile cannon, is bound to prove a lasting boon to suffering humanity at large.

This achievement is primarily the consequence of the brilliant work of Dr. Alexis Carrel, who, in the face of professional antagonism of a marked character, had the courage to attack what the great majority of his confrères declared a lost battle; and, by persistence, was able to prove that a septic wound can be sterilized by antiseptic treatment if proper care and skill be exercised. As one of England's foremost military surgeons, Sir Anthony A. Bowlby, has said, "The lesson he has taught was very necessary."

Infected wounds are an old story, and, as well-nigh every one now knows, are the consequence of microbial activities. Man has waged many struggles with germs of one kind or another, and the tactics employed have varied from time to time. The strategists of the medical profession have by no means been in agreement always as to the best plan of campaign; but after some decades of professional wrangling they had commonly arrived at an understanding which made it possible, less than three

years ago, for the leaders of their general staff, so to speak, to make this positive pronouncement: "The treatment of suppurating wounds by means of antiseptics is illusory, and belief in its efficacy is founded upon false reasoning.

Half a century ago Joseph Jackson Lister, later Lord Lister, began the preaching of the doctrine of antisepsis. At that time conditions in the average civil hospital were little short of awful. Because of ignorance of the genesis of infection, lockjaw, blood poisoning, erysipelas, and gangrene flourished in the path of the surgeon's benign efforts. Compound fractures then, if they did not entail death, nearly always necessitated the amputation of the affected limb, owing mainly to the complication of septic developments.

But Pasteur, in his laboratory, discovered the manner in which microorganisms were carried broadcast upon particles of dust floating in the atmosphere; and he proved that these germs were responsible for the decomposition of vital tissues exposed to them. Pasteur's experiments appeared to Lister in the light of a veritable revelation. His logical mind questioned, Why, since the cause of decomposition is now known, should we not be able to prevent the suppuration of wounds and banish, at the same time, those hospital diseases that are due to microbes transported by the air?

Judged by past conditions, Lister achieved wonders in his day; with a paste of lime saturated with carbolic acid he both sterilized wounds and effectually kept out baneful microbes. True, his protective agents cauterized the injury and actually destroyed sound tissues; but the hurt closed in time without infection, and the pain and resultant scar were deemed by him trifling compared with the greater sacrifices which might otherwise have been exacted. Lister was able to banish suppuration

and to effect cures in cases of compound fracture. Gauged by modern standards, that great surgeon worked somewhat crudely, but he nevertheless fashioned a foundation stone for the upbuilding of modern surgical practice.

With a growing understanding of the true functions of disinfectants, sterilizing mediums, and germicides generally, the practice of antisepsis in or at the wound was largely supplanted by what came to be known as aseptic treatment, or asepsis. This, in so many words, is a preventive measure, and amounts to nothing more than holding the potential causes of infection farther away from the hurt, thus leaving the curative work of nature to proceed more advantageously. Plainly, aseptic treatment is logically a direct evolution of Lister's antiseptic method; but it is not what he urged as a remedy for conditions as they then existed in so many of the hospitals of his time. That is to say, with a betterment in the sanitation and the administration of surgical wards, asepsis has sufficed when everything was subject to precautionary control. These distinctions should be held in mind in order to appreciate what Doctor Carrel has done and has made possible.

As a patriotic Frenchman, he hastened abroad soon after the beginning of hostilities. Shortly after arriving in France Doctor Carrel was busily engaged in ambulance service just back of the western battle-line. The thing that impressed him most was the rarity of the uninfected wound. The germ-laden soil of the fields and trenches and the bacteria wafted by the dust of the highways were fundamentally responsible. These lurking microbes were borne into the bodies of the soldiers on bits of clothing and fragments of missiles, and, according to the violence of the impact and the nature of the injuring agent, the germs were buried more or less deeply in the torn tissues. In this fashion a bacterial colony was established. Once so implanted, the micro-organisms soon started to multiply by a process of selfdivisioning at maturity. In the course of only half a day, starting with a single microbe, the splitting-up action led in the end to a septic array of more than fifteen million bacilli!

His problem, as Doctor Carrel saw it. was very much akin to that which had confronted Lister half a hundred years before. It was not a case of preventing infection by aseptic precautions, but of eradicating virulent micro-organisms already lodged in the torn and exposed body substance. His task was twofold: first, to discover a germicidal liquid of sufficient potency and yet non-toxic and so mild that it would not irritate the healthy parts of the raw surfaces; and, second, to apply the antiseptic in a way that would make sure of its reaching every section of the infected area. The battling soldiers on the firing-lines were using ancient weapons brought up to date, and Doctor Carrel, in his openmindedness and desire to achieve beneficent results, saw no reason why he should not borrow freely from Lister's teachings and modernize his method so that it would meet in every respect present requirements. This was a stroke of genius.

Working with him abroad were Dr. H. D. Dakin, of New York city, and Dr. Maurice Daufresne, of Paris; and after trying out more than two hundred antiseptics-trying them out under conditions that left no room for doubt-it was determined that hypochlorite of soda was the sterilizing liquid that would best fulfil the exacting requirements. which Doctor Carrel imposed. Strange as it may seem, the antiseptic is fundamentally nothing other than the common chloride of lime known to most of us as a household disinfectant of long standing; but before the solution was acknowledged fit for the service expected of it, Doctor Dakin had to free it of a certain irritating alkali and to devise, with the aid of Doctor Daufresne, a technique for its preparation that would insure purity and an extremely nice degree of strength in application.

A peculiarly valuable characteristic of the hypochlorite solution, apart from its marked antiseptic powers when much diluted, is its remarkable property of quickly separating and dissolving dead tissues present in an injury, and facilitating their removal by drainage without harming, even after continuous application covering many days, perhaps, the tender living body substance exposed to

it. There is something well-nigh magical in the way Dakin's solution does its discriminatory work. This has been strikingly emphasized in certain experiments made upon the extremely delicate abdominal wall of the tadpole. If the creature were alive and the normal circulation active, the hypochlorite would not erode the tissues, and latent vitality, lasting for some time after the death of the tadpole, also sufficed to check the solvent action of the antiseptic. It was only after the organism had surrendered its residual bond with life that the solution was able to dissolve the abdominal substance.

One of the things most feared in suppurating wounds is erosion that may lead to secondary hemorrhage. This is a peril that is present in the case of any seriously infected injury, whatever be the cause. An impressive example of how the Carrel-Dakin treatment has lessened this hazard was reported recently by a British surgeon. In one of his cases he had occasion to ligature a large blood-vessel in an open wound. The free end of the artery, from which the circulation was cut off by the ligature, began to show signs of disappearing under the action of the hypochlorite solution, and secondary hemorrhage was apprehended. However, nothing of the sort happened; just before the point of ligature was reached, and the zone where circulation was maintained was neared, the erosion stopped!

Hypochlorite of soda has, in itself, no curative properties, but by killing the bacilli present in a hurt it leaves Nature to carry on her work of repair untrammeled. When a wound is satisfactorily sterilized, then, from the surgical viewpoint, the worst is over. The raw surfaces, with their ruddy, healthy granulations, can be brought together in a variety of ways and closure of the injury effected. Doctor Carrel has demonstrated that the freest use of the scalpel in opening up a wound is desirable, for in this way every foreign body, so often the focus of infection, can be removed and all parts and byways of the injury can be made accessible to the sterilizing fluid. Hurts so treated heal without complications, or, as they say in medical parlance, by first intention.

The climax of the labors abroad of Doctor Carrel and his able co-workers, Drs. G. Dehelly, M. Guillot, and H. Woimant, is typified in the present procedure followed at the War Demonstration Hospital, established by the Rockefeller Institute for Medical Research, in New York city. This hospital was made ready for service early last fall, and was intended primarily to teach our own military surgeons how to give our fighting men the benefit of a revolutionary advance in the treatment of battle wounds. As it happened, the executive staff found it necessary to draw upon various domestic sources for patients, and without exception these were chosen because of the obstinate character of their afflictions and the failure of other accepted surgical practices to effect cures. Indeed, the fact that warwounded were not available and that civil sufferers, instead, were used for the purpose of demonstration, has brought to light the amazing potentialities of the Carrel - Dakin treatment in every - day life.

The hospital is modeled along the most approved lines for military service, and represents a unit type of structure susceptible of ready expansion agreeably to the growing demands of the base. The patients there, as a rule, see the paths to complete recovery opening before them, grave though their cases may have been considered previously; and week by week members of their colony leave restored and sound who a short time before faced the prospect of continual pain and crippled limbs. Cruel burns that would not yield to ordinary treatment, raw wounds upon which new cuticle would not form, gangrenous sores that threatened the loss of an arm or a leg, and deep-seated and persistent inflammation of bones, have all surrendered to surgical cunning aided by the hypochlorite solution. The germicidal liquid has achieved what possibly the knife could not have done as thoroughly and well; it has battled with insidious microbes and won, and the cleansed body-substance has reacted and lent itself vigorously to the work of repair.

Hung above each cot is a glass reservoir containing hypochlorite of soda, and the antiseptic liquid is led to the

wound or wounds by rubber tubing. At predetermined intervals, ranging from an hour to two hours, according to the nature and extent of infection, the antiseptic liquid flushes afresh the cavity of the injury. The tubing at its lower end is provided with perforated branches, if the hurt have many recesses, and in this way the germicide reaches and spreads over all of the exposed surfaces. The periodic renewal of the antiseptic is effected by releasing a compressor on the supply-tube, and it is practicable for a single attendant to take care of a large number of patients.

Because of the variableness of the chlorine content of the raw materials of commerce used by Dakin and Daufresne in France, and other objectionable characteristics, the preparation of the hypochlorite solution took much time. Today the antiseptic is far easier to make here because of native technical facilities. Liquid chlorine is passed into a solution of carbonate of soda, and laboratory apparatus make it possible to control to an exact degree the proportion of this ingredient.

While Dakin's solution, so-called, does not irritate the raw surfaces, which it sterilizes, still it affects the sound cuticle surrounding a wound, and the skin must, therefore, be protected. Vaseline answers admirably for this purpose and is extensively employed, but a paste made of thiosulphate of soda has also given very satisfactory results. Thiosulphate of soda is commonly used as a "fixative" in photography, and has the power to neutralize the irritant action of the antiseptic's chlorine content. It is this chemical, so helpful in the treatment of infected wounds, that likewise plays an important part in the finished gas-mask. The respirator is saturated with this stuff, and this suffices to rob the enemy's asphyxiating attack of its baneful potency.

The mere clinical appearance of a wound is, unfortunately, a very uncertain index of its readiness for closure. The eye of the surgeon alone will not suffice to detect lurking microbial flora. Doctor Carrel has shown that only by means of the microscope and bacterial smears," made from specimens taken from numerous parts of the open injury,

VOL. CXXXVI.-No. 816.-109

can it be definitely determined when it is safe to halt the sterilizing process and to suture or otherwise close a wound without fear of reinfection. By this typically modern method it is possible to avoid distressing, if not fatal, mistakes. This is an innovation which is bound to benefit any one upon whom a surgical operation has been performed and who may have become unsuspectedly the victim of incipient infection.

The average layman does not know that in cases of suppurating wounds, no matter what their original cause, microorganisms may be imprisoned within the scar-tissues and be held there without indicating their presence by septic activity. However, in suturing a wound of this sort, the closing stitches may be the means of freeing the microbes and thus bringing about reinfection. On the other hand, the germs may be encapsuled in the scar-tissues and kept impotent for years. Even so, they constitute a potential peril, for they may be liberated by a subsequent injury at that point or by the promotion of a physical condition favoring their multiplication. It is to prevent this dreaded secondary infection that Doctor Carrel insists upon the thorough excision and surgical cleanliness of septic wounds.

At the foot of the cot of each patient at the War Demonstration Hospital

This

there are two charts. One is the record of the number of microbes found in the wound from day to day by the microscope; the other is a comparative graph which indicates by two curves whether or not the healing process is favorable. The standard or control curve, based fundamentally upon discoveries made by Doctor Carrel about ten years ago, is the result of an algebraic formula developed by Captain de Noüy, a young French physicist, at Compiègne. curve shows how any uninfected wound, of ascertained measurement, would heal from day to day. If the periodic measurement of the injury betrays a conspicuous lag in the rate of repair, then the attending physician knows that there is something wrong, and it is incumbent upon him to discover the cause. This may be due to a tiny bit of infected bone, hidden deep in the hurt; it may be the result of microbes multiplying in recesses