A Lecture ON WOUND INFECTIONS AND THEIR TREATMENT: Delivered (with Demonstrations) at the Opening of an Exhibition of Surgical Appliances for the Treatment of the Wounded held at the Royal Society of Medicine from October 8th to 14th

A. E. Wright
1915 BMJ (Clinical Research Edition)  
A CONSULTANT PHYSICIAN TO THE LEXPEDITIONARY FORCE IN. FrRANCE. (From th-e Research Laboratory attached to N'o. 13 Genleral Hospital, Bonlogne-sur-Mer.) (Colntti ute(d from 1). 6i6.) PART Ill. rPhysioloyical Action of Stronlg Saclt Soluttionls. IN connexion witlh the physiological action of strong salt solutions-and whlen speaking of stroncg salt solutions I lhave ill view those conitainingir about 5 per cent. of saltwe have to conisider primiiarily the effect produced upon loucocytes. And we
more » ... oucocytes. And we lhave to distinguish betveeln tlle case where tlhc stLrong salt colues inito direct applicationa, and the case wliere it comues into operation from a distance. In the form-er case-both in pius and blood-tlhe Ieucocytes are broken dowvn; and, in pus, evidence is obtained of a setting free of trypsin. In otlher words, strong salt solutions acting oni a miedium containing leucocytes will promote auto-digestion, and provide a nutrient substratumn wvlichl will, as soon as the excess of salt is remnoved, favour tile grovtll of m-icrobes. To study tlhe effect of strolg salt solutions actinig from a distance we centrifuae blood in an cuigration tube or cell:; let it clot; superpose our 5 per cent. salt solution; allow timne for the salt to diffuse; and then incubate at 37°C. .A B Fig.,12.-We have represented in A and B tle lower portion of tle white and the upper portion of the red clot obtained by centrifuging blood in one of Emery's cells. The white 'corpuscles onily ame shown in the figure. In A strong solution has been imposed upon the free surface of the wBhite clot. In B physiological salt solution has been imposed. Thc appearances are described in the text. Fig. 12 , A, shOWS thIc picture that we tllen get; and I add for comparison Fig. 12 , B, shQwing the picture obtained when we imnpose upon the blood, instead of 5 per cent., 0.85 per cent. salt solution. In eaclh case we lhave: below, the red corpuscles; and above. tlhese, the layer of leucocytes; and above thlese again, the white clot. In A, where the 5 per cent. salt solution lhas been imposed, we have practically no wandering out of the leucocytes into tlhe wlhite clot. We lhave instead a tiglhtly packed and slharply miiargined band of leucocytes interveninc betweeni thle red and whlite clots. Below this we see a good miiany leucocytes wlhiclh have, as it seems, travelled back from the leucocytic layer inito the recl clot. In otlher words, 'we hlave lhere, instead of positive clhemniotaxis as ill B, paralysis, ancd pressumably also negative clhemiotaxis. Thecre would seem to be little dotubt about tlhe neaative chemiotaxis; for in companioni tubes or cells, treated in every otlher respect than the salt soltutionl as exactly alike, the wliite corpuseles have all been by the centrifugalization separated out froim tlhe red. It will be appreciated in conniexion wvith Fig. 12 , A, tllat the elements of the blood The cell referred to is a special formii of cell devised by my fellowworker, Captain dEste-Emnery. and-made -by lutiug together two nieces of glass ,slide nith paraffin -wax. have, first by tlle mecllanical force of the centrifuge, and secondly by thje cheniical stilmulus-of. the istrong salt solution, been disposed in whlat I hlave called the " kakc. tropic " arrangement-tllat is, the blood fluids are in front, and the leucocytes behind. The import of this in connexion witlh the conduct of the wound will presently appear. For the miioment let us mnerely put it down upon our tablets that it would seem to follow from wlhat we see in Fig. 12 , A, that We h'ave in stronlg salt soluitionl.an agent which would be capable of arresting all suppurative processes. Effect of Strong Salt Solution On the Cossdition of t7e WVou,nd anlld-the ilierobic Infection. 'Tlhe effect of strong salt solution oin the wouind will; of course, be the restlitant of its physical. and plhysiological effects; and there will be in addition an effect exertedi directly upon tthe microbes. This last iuay very quicklly be dealt with and disposedl of. Percentages of 2 per cent. will begin to inllibit, and 5 pr cent. solutions wvill comple-tely arrest, the gyrowtlh of pyogenic microbes. In' other Nvoi-ds, undilutted 5 per cent. salt solution will by itself-anid this is to be borne in mind in connexioni. with proposals to colmibine this wvith carbolic acid-prevenit anly growth of miicrobes in the wound. Let us, however, turni-for this is of more momlentto the effect exerted by the lhypertonic salt soltution on the condition of the woundds. MAlid we miay take the case of hiypertonic solution applied to a sloulghling or indurated wound. Now coming, as it will lhere, into direct application upon leucocytes, thle strong salt solution will break these ip, and set free trypsin and favour auto-digestion; and, coming into operation at the samue timiie on the walls, it will promote an outflow of fluid. The effect of this will be to loosen and separate the slouglhs, to disperse the induration, and fitially to give us-always provided tlhat the concentration of the salt is maintained-a wound in whiclh muscles and connective tissue lie before us as bare and clean, and as free from-: ptus, as miieat exposed on a slab at the btutcliers'. Moreover, impression preparations will slhow tllat tlhe surface lymph is practically free fromi leucocytes, and that the sero-saprophytic microbes have disappeared, leaving behiind only a few staplhylococci or streptococci. This complete result is, as a matter of fact, only rarely seenfor applied in the ordinary way on a pad of lint or gauze, the hypertonic solution is by tlle outflow of lymplh very rapidly diluted. But whether we lhave before us thle complete, or only the incomplete, result, we h1ave a w-onderful improvement upon the state of the wound before treatmnent. None tlho le,s, the prospect for the future is not quite reassuring. In point of fact, we lave lhere lying open and naked before us all the lymplh spaces; and, mlloreover, the elements of the lymplh are disposed in tlle ';kakotropic arrangemnent " -the fluid elements which furnislh a favourable culture mediumu in front, and the leucocytes whiclh would be capable of combating tlle streptococci beliind; and at any rate, so far as the superficial lymplh spaces are concerned, thlere would now seemn to be nothing to prevent microbial invasion save only that wYe lhave here an outtlowiug cturrent. But if the salt wlhiclh has becn absorbed into the tissues were iio loniger carried away, or if the saiine solutioni outside were now to be diluted, the tide mighlt easily turn and flow inlward. In slhort, we see that -we lhave made a successful advance, but that we miust, before we can congratulate ourselves, advance a great deal, mnore. Our experimelnts in connexion witlh the bactericidal power of the whlole blood tell us wlhat our next step mutst be. If we wanit to keep the streptococci at bay, anddestroy thenm, we inLust get the elemenits of our lymplh into the agathotropic order; in other words, we must nowv bring forwar(d ouir leucocytes. Our studies on emigration tell us how this is to be. done. We shall have to substitute for our 5 per cest.-0.85 per cent. saline solution. Erect of -Physiolyb-tal Salt Solution?. It will in connexion with plhysiological salt solutionl be uninecessary to go mliucl initto detail with respect to its physical and phlysiological action. All that roquires to be emplasized is thlat 0.85 per cent. salt solution, wlhiic w_ e call normal or pl)ysiological, is normal and plhysiological
doi:10.1136/bmj.2.2863.717 fatcat:zlx2uszy7jhrbo5exaonytv474