1 Burghard, Leishman, Moynihan and Wright, Office international d'hygiene publique, 1915, vol. vii. p. 946.

Although Sir Almroth Wright's doctrine was founded, not on observations and experiments made upon wounds under actual war conditions, but upon ingenious theories and experiments in vitro, it was accepted by the majority of surgeons. One of them even affirms that asepsis ought to take the place of antisepsis, and that antiseptics not only fail to sterilise wounds, but that they actually favour the development of microbes!2 Therefore wounds came to be treated with saline solutions, or the hypertonic solutions of Wright. The fundamental observations of Lister were forgotten completely. Nevertheless, theories remained impotent and infection flourished.

II. However, setting aside theory and confining oneself closely to fact, the problem of wound sterilisation seems very simple. It is to be remembered that the surgical infection, at the outset, is always local. In war-wounds, it is carried by projectiles, and especially by fragments of clothing, impregnated with micro-organisms. Before crossing the boundaries of the wound, these flourish on the surface of the tissues. Therefore, during a period more or less long, the infection is under control, since the microbes are, so to speak, within reach of the hand. The question then is simply, how to destroy them without harming the tissues?

1 Sir A. Wright. An Address on Wound Infections. British Medical Journal, April 24, 1915, p. 721.

2 Pierre Delbet, Bulletin et Memoires de la Societe de Chirurgie, Janvier, 1916.

As a difference of resistance exists between, on the one hand, the tissues provided with a circulation, and, on the other hand, microbes, isolated anatomical elements and necrosed tissues, it was useless to seek a substance which would exercise an elective action on microorganisms. Better seek to discover, for a given antiseptic, that degree of concentration of the solution, and that length of time during which it must be applied, which, fatal to microbes, will not produce obvious damage to the tissues.

When, at the end of December, 1914, Henry D. Dakin and one of the authors of this book sought to discover the best means of treating wound-infections, they adopted, for the reasons just stated, the method of chemio-therapy. Besides, it seemed probable that the infection of war-inflicted wounds would be unsuitable for treatment by vaccines or serums. As the inoculation of the tissues by projectiles or fragments of clothing is massive, and as the germs protected by necrosed tissues or blood-clots multiply beyond the reach of lymph-flow, it is extremely unlikely that such thera-peusis could be effective. Besides, the bacterial flora of war-wounds is extremely varied. As the large numbers of wounded and the conditions of the dressing-stations render impossible identification of the microbes which infect the wounds, it would be necessary to use vaccines or serums against dozens of types of germs, aerobic and anaerobic. Failure of such an attempt is foredoomed.

On the other hand, the problem would appear to be readily solved by using a substance unirritating to the tissues, and of a sufficient bactericidal power to kill all the microbes present in a wound, be their nature what it may.

It was in this direction that the researches tended. Dakin studied the action on tissues and micro-organisms of a considerable number of antiseptics, old and new. More than two hundred substances were examined in this manner by him, and he was led, for various reasons, to make chloramines,1 and, by a special process, hypochlorite of soda.2 Thanks to his excellent researches, we quickly had placed at our disposal substances endowed with feeble irritating qualities, with a toxicity for the organism almost nil, but of considerable bactericidal power. We then studied under what conditions these substances could sterilise a wound. These researches demonstrated that the microbes disappeared, if the antiseptic remained in contact with the surface of the wound at a certain degree of concentration during a prolonged period. Bacteriological examination showed that infected wounds, treated according to these principles, became sterile. Thus, quite simply, was realised what Sir Almroth Wright and modern surgeons consider to be impossible.

III. The method was applied in the first place to old wounds, afterwards to recent ones. Sterilisation was attained in both cases, but the earlier treatment gave the more rapid results. It has long been admitted that preventive treatment of a malady costs less in money and toil than curative treatment However, infection can be checked even after suppuration has become established. In a word, all infected wounds were brought more or less under control by chemiotherapy.

1 Dakin, Cohen, Daufresne and Kenyon, Proceedings of the Royal Society, 1916, vol. 89, p. 232.

2 Dakin, Presse Me'dica/e, Sept. 30, 1915.

From May, 1915, it became evident that wounds treated after a certain method by the aid of hypochlorite or the chloramines of Dakin were sterilised, without any harm resulting to the tissues or the patient. From that date, it has been possible to prevent, in the greater number of cases, infection of wounds, and to abolish, almost entirely, suppuration in hospitals. At this time the method was practised in some hospitals of the first line by le medecin principal Uffoltz, Directeur du Service de sante d'un corps d'armee. To him and to his colleagues is due the merit of demonstrating that infection of wounds treated under the ordinary conditions of a field hospital can be almost entirely done away with.

During the months of July and September, 1915, Dakin1 published an account of the substances which gave these results, and the mode of preparation. In October of the same year, M. Pozzi demonstrated in our name at the Academie de Medecine the principles which are fundamental to the chemiotherapy of wounds.2 These principles were later set forth in a more complete manner in 1916, in the Archives de Medecine et de Pharmacie Militaires.3 On several occasions at the Academie de Medecine, and at the Societe de Chirurgie, M. Pozzi,4 spoke at length upon the technique and upon the results of the method, which, from this time forth, enabled us to sterilise infected wounds, whether newly inflicted, or of long standing. In communications made to the Societe de Chirurgie, M. Tuffier1 pointed out the results which it was possible to obtain by the same technique. Le medecin principal Uffoltz published in 1916 (January) an important article,2 upon results obtained in hospitals under his control, by MM. Perret, Dupuy, Lemaire, Hornus, Perrin, Vigne, Moyroud, etc. About the same date, M. Pozzi communicated in our name to the Academie de Medecine observations demonstrating that sterilisation allowed wounds to be closed, in many cases, after a period varying from four to ten days. On March 28th, M. Pozzi read a paper on a report by M. Uffoltz concerning the secondary union of wounds. On April 11th, M. Perret read before the Academie de Medecine a paper in which he announced the results obtained by the sterilisation of wounds in wards under his care. Not one of 111 cases had suppurated. On May 2nd, one of us read a paper at the Academie de Medecine on the subject of 153 wounds treated in the hospital at Compiegne during the month of December, 1915. Of these 155 wounds, 135 were closed. Of the 135 successes, 121 were united before the 12th day.