[Treatment of Burns and Prevention of Wound Infections]
[From the U.S. Government Publishing Office, www.gpo.gov]

TREATMENT OF BURNS AND PREVENTION OF WOUND INFECTIONS
MEDICAL DIVISION
U. S. OFFICE OF CIVILIAN DEFENSE
Washington, D. C.
FOREWORD
These recommendations on the care of burns and the prevention of surgical infections were prepared jointly by the Committee on Chemotherapeutic and Other Agents and the Committee on Surgery of the Division of Medical Sciences of the National Research Council. They are issued by the Medical Division of the Office of Civilian Defense for distribution to members of the Emergency Medical Service and to civilian hospitals as a"guide to the care of civilian casualties.
CONTENTS
Page
Part I. Prevention of Infection
in Wounds and Burns -	4
I.	Preoperative Use of Crystalline Sulfanilamide in Wounds- ________	4
II.	General Principles Governing the Prevention of Infection _________	4
III.	Technique of Wound Dressings __________	5
IV.	Surgical Care of Wounds _ _	5
V.	Intra-abdominal Wounds Leading to Perforation of Hollow Viscera _____	5
VI.	Postoperative Chemotherapy of Wounds:
A.	Oral Therapy- _ _ _ _	6
B.	Local Use ______	6
1.	Open Wounds _ _	6
2.	Penetrating or Through-and-Through
Wounds _ _ _ _	6
3.	Compound Fractures Treated by the Orr-Trueta Method _ _ _ _	7
4.	Infected Wounds _	7
Page
VII.	Biological Factors Which Influence Wound Healing _ _	7
Part II. Treatment of Burns - -	8
I.	Emergency Care	8
II.	Definitive Treatment _ _	_	_	9
A.	Treatment of Shock	_	_	9
1.	Morphine _ _ _ _	9
2.	Plasma _____	9
3.	Other fluids _	_	_	9
4.	Blood Transfusions _____	9
B.	Care of the Burned Area _____	9
1.	Bums Other than Those of the Hands, Face, and Genitalia _	9
(a)	Tanning _ _ _	10
(b)	Infection Beneath Tan-n e d S u r -faces _ _ _	10
2.	Hands, Face, and Genitalia _ _ _ _	10
III.	Oral Chemotherapy of
Burns-	_________	10
Appendix	11
Recommendations of the Committee on Surgery and the Committee on Chemotherapeutic and Other Agents^ Division of Medical Sciences of the National Research Council
3
Part I. THE PREVENTION OF INFECTION IN WOUNDS AND BURNS
I.	Preoperative Use of Crystalline Sulfanilamide in Wounds.
Recent experiences have demonstrated the value of the application of crystalline sulfanilamide to wounds which are awaiting debridement. There is no indication that such a practice adversely affects later surgical treatment, and there is every indication that it prevents the development of infection in contaminated wounds. Sulfanilamide is preferable for local use to sulfadiazine, which is alkaline, or sulfathiazole, which tends to cake.
Hence it is recommended that crystalline sulfanilamide be applied liberally to all wounds as soon as practicable after they have been incurred. It is desirable that all crystalline sulfanilamide for local application be sterilized by exposure to dry heat for 2 hours at a temperature of 150° C.
At present, sulfadiazine is the drug of choice for oral therapy, with sulfanilamide the second choice, and sulfathiazole the third. Sulfonamide therapy, 6.0 grams orally, should be given or taken at once following wounding, and 1.0 gram should be administered every 4 hours thereafter. It is recommended that every wounded man be given 1.0 gram of a sulfonamide by mouth at 4 a. m., 8 a. m., 12 noon, 4 p. m., 8 p. m., and 12 midnight until definitive surgical treatment has been accomplished. Sulfonamide therapy should then be carried out as directed under the section entitled, “Postoperative Chemotherapy of Wounds.”
Nothing in this manual shall be construed as an excuse for not debridin^ wounds as promptly and as widely as time and circum-stances permit.
II.	General Principles Governing the Prevention of Infection.
All too frequently, the ordinary practices which prevail in wards containing surgical patients are forgotten or neglected under the stress of emergency conditions. The following suggestions for the prevention of infection in wounds and burns are based upon practical experience and scientific
information. They may be considered Utopian, but they represent a goal, the achievement of which should be attempted if the best results are to be obtained.
A.	All burned patients should be segregated.
B.	In wards containing burned patients, no dressings should be done until 1 hour after the bed linens have been changed and the floor swept. In wards containing wounded patients, a like period of time should be allowed to elapse before wounds are dressed.
C.	All soiled bed linen should be placed in a bag as it is removed from the bed. Under no circumstances should bed linen be thrown upon the floor.
D.	During the dressing period, traffic in the ward should be reduced to a minimum. All patients should remain in bed and the ward doors and windows kept closed.
E.	All dressers and assistants must be adequately masked and gowned. Dressers should scrub their hands for 10 minutes before beginning the day’s dressings. In every ward containing casualties regular dressing schedules should be made out and posted for each day of the week.
F.	Dressers or their assistants who are suffering from upper respiratory tract infections such as common colds, grippe, sore throats, or from any infection of the hands or fingers should be relieved of their duties as dressers until they have recovered.
G.	Patients should be masked during the dressing period.
H.	Soiled dressings should be placed in a covered container immediately after removal.
I.	Containers, arm baths, urinals, bed pans, apparatus, blankets, linen, etc., should be sterilized immediately after they have been in contact with an infected patient.
J.	If a plaster cast becomes contaminated with infectious material, it should be changed unless there is a serious surgical contraindication. The surface of a cast cannot be sterilized by antiseptic washes. Casts should be moistened along the line of division with a solution of vinegar at the time they are cut to keep down dust and prevent the spread of infection.
4
K.	If a bandage must be removed in the X-ray or physical therapy departments, this procedure should be done by a surgical dresser. It is better to prepare the patient in the ward so that his dressing need not be removed in the X-ray or physical therapy department.
L.	Crusts, pus, pieces of tan, extruded foreign bodies, bits of tissue or any other infected material should be placed immediately in a suitable covered container for disposition.
III.	Technique of Wound Dressings.
In dressing wounds, it is not necessary that the hands be encased in sterilized rubber gloves. The following method is adequate if carried out carefully:
A.	Before beginning the day’s dressings in a ward, scrub the hands for 10 minutes as you would prior to an operation.
B.	Dresser and assistants should be masked.
C.	Have a properly equipped dressing cart and competent assistants at hand before beginning work. (See Appendix for equipment of dressing cart.)
D.	Do the clean dressings first and the most severely infected ones last.
E.	Be sure you do not further contaminate wounds.
F.	Bandage scissors are usually contaminated. Do not use them except for the removal of bandages.
G.	Use forceps to remove and apply gauze dressings. Never use fingers in a wound. If forceps, hemostats, and scissors are used (the so-called “knife and fork” technique), the dressings can be done satisfactorily without gloves.
H.	Place soiled and contaminated dressings in a receptacle as soon as they are removed.
I.	Irrigate suppurative wounds thoroughly with physiological saline solution. Then use crystalline sulfanilamide as discussed in the section on “Chemotherapy of Wounds.”
J.	Remember that a wound need not be dressed merely because the dressings become moist from serum. Repeated opening of dressings creates opportunities for contamination. Whenever a wound is dressed, finish the wound toilet by sprinkling crystalline sulfanilamide on the wound surfaces.
IV.	Surgical Care of Wounds.
A.	A wound should be debrided as soon as possible after injury. Major blood vessels and nerves should not be sacrificed. All necrotic skin, fascia and muscle must be excised. The wound should then be thoroughly irrigated with sterile physiological saline solution.
B.	Following this, crystalline sulfanilamide should be placed in the wound. Not more than 10 grams in one wound nor more than 20 grams per patient shall be used.
C.	Wounds should not be closed except for superficial flesh wounds; these, when debrided and sprinkled with sulfanilamide, may be closed at the discretion of the operator if the casualty is seen and operated on within 6 hours after injury.
D.	If the wound has been treated with crystalline sulfanilamide, debridement should be carried out regardless of the number of hours elapsed following the injury.
E.	Following debridement, irrigation, and local application of sulfanilamide, the area should be covered with vaseline gauze and carefully dressed.
F.	All wounded persons who have been immunized with tetanus toxoid should receive a “booster” dose of tetanus toxoid. Nonimmunized persons should receive 1,500 units of tetanus antitoxin.
V.	Intra - abdominal Wounds Leading to Perforation of Hollow Viscera.
A.	Institute shock therapy: (1) Give morphine; (2) keep patient warm; (3) give plasma.
B.	If an expert anesthetist is not available, use only open-drop ether anesthesia. Spinal and intravenous anesthesia are borne badly by these patients.
C.	Scrub the abdominal wall with soap and water, protecting the wound of entrance with moist sterile gauze soaked in crystalline sulfanilamide solution (0.2 percent in 0.9 percent saline).
D.	Excise wound of entrance and pack wound with crystalline sulfanilamide. Enter the abdomen through a separate incision.
E.	Gross fluid soiling the peritoneum should be removed by suction.
F.	Suture perforations of the bowel, avoiding resection unless absolutely necessary. Close in-
5
testînal wounds transversely so as not to narrow the intestinal lumen.
G.	Inspect the entire bowel for additional perforations.
H.	Control all bleeding points in the’mesentery.
I.	Introduce from 6 to 8 grams of crystalline sulfanilamide in the peritoneum before closing it.
J.	Drainage must be left to the judgment of the individual surgeon, but remember:
1.	You cannot drain the entire peritoneal cavity.
2.	Drainage interferes with the healing of intestinal suture lines. Avoid it unless absolutely necessary.
3.	If soiling of the abdominal wound has occurred during operation, drain the wound. Place sulfanilamide crystals in the abdominal wound as it is closed.
K. Continue sulfanilamide therapy (1.0% solution in physiological sodium chloride) by a parenteral route, 150 cc. every 6 hours for from 4 to 7 days after operation, depending on the condition of the patient. For parenteral administration, sulfanilamide is the drug of choice. To prepare sulfanilamide for parenteral use, add 1.0 grams of crystalline sulfanilamide to 100 cc. of very hot physiological saline solution, boil for 5 minutes to sterilize, cool to 37° C. and administer by the subcutaneous route under the fascia of the lateral side of the thigh. Make up such solutions freshly each day.
Dosage: 150 cc. of 1 percent sulfanilamide solution (1.5 grams) subcutaneously every 6 hours for 4 to 7 days following operation. If the patient’s condition warrants, the dose and time of administration may be reduced.
Sodium sulfadiazine intravenously may also be used. Never give solutions of sodium sulfadiazine by the subcutaneous or intramuscular routes; they are highly alkaline and may cause sloughing of the tissues. To prepare, add 5 grams of sodium sulfadiazine to 100 cc. of sterile distilled water. (Do not attempt to sterilize.)
The initial dosage should be calculated on the basis of 0.1 gram per kilo of body weight. Subsequent dosage should be 0.03 gram per kilo of body weight, given as a 5 percent solution in distilled water at 12-hour intervals for 4 days.
VI. Postoperative Chemotherapy of Wounds»
A.	Oral Therapy
On the morning after the wound has received definitive surgical treatment, oral sulfonamide therapy should be resumed.
Dosage of sulfadiazine, sulfanilamide, or sulfathiazole:
1	.0 gram every 4 hours, day and night for 7 days. If the wound is then clean and there is no fever attributable to infection, oral therapy should be discontinued. If the wound is infected, however, therapy should be continued as indicated.
If the patient is not voiding normally (1,000 cc. per day), the blood concentration of the drug should be determined daily and the dose adjusted downward if necessary. If complete urinary suppression or oliguria occurs, omit the drug and force fluids orally if possible and intravenously (glucose and water) if necessary.
B.	Local Use
Crystalline sulfanilamide appears to be the most satisfactory sulfonamide compound for local use. Sulfathiazole powder when applied to wounds tends to cake and may at times act as a foreign body. It is, therefore, not recommended.
1.	Open Wounds.
Every time the dressing is changed, the wound area should be sprinkled with enough crystalline sulfanilamide to “frost” it. Local applications of sulfanilamide should be continued until the wound is healed or is secondarily sutured. It is essential in the preparation of wounds in which skin is to be grafted.
2.	Penetrating or Through-and-Through Wounds.
Sulfanilamide may be introduced into deep wounds as a suspension of sulfanilamide crystals in sterile physiological saline solution. The suspension should be made up just at the time of use, and the syringe containing it should be rotated during injection in order to maintain the suspension.
Where gauze drains or wicks are being used, they should be moistened in sterile saline solution and then dipped in crystalline sulfanilamide before being introduced into the wound. The wound should be “frosted” with crystalline sulfanilamide before the dressing is applied. Local therapy with crystalline sulfanilamide should be continued at each dressing until the wound is healed.
6
3.	Compound Fractures Treated by the Orr-Trueta Method.
Every time the cast is removed, the wound area should be “frosted” with crystalline sulfanilamide after the wound toilet has been made. When the cast is finally removed, the wound area should be “frosted” with crystalline sulfanilamide at each dressing until healing takes place.
4.	Infected Wounds.
In wounds already infected or in which infection arises, the purulent or necrotic material should always be removed prior to “frosting” the wound with crystalline sulfanilamide. Pus should be removed by gentle irrigation with warm physiological saline solution, or, if a necrotic crust is present, by irrigation with azochloramide or some comparable solution every 6 hours until the necrotic material is removed.
The full value of local sulfanilamide therapy is not obtained if crystalline sulfanilamide is dusted upon pus or necrotic material in the wound.
When the wound has been cleaned, it should be “frosted” with crystalline sulfanilamide at each dressing until it has healed.
If after a thorough trial crystalline sulfanilamide appears to be ineffective and signs of infection persist, cultures should be made to determine whether an anaerobic streptococcal infection is present. If so, the wound should be treated with “Zinc Peroxide Medicinal,” according to the technique of Meleney.*
* Meleney, F. L.: U. S. Naval M. Bull., 40:53 (Jan.) 1942: Ann. Surg., 101:97 (April) 1935.
VII.	Biological Factors Which Influence Wound Heal^ ing.
Two biological factors play an important part in the healing of all types of wounds.
A deficiency in plasma protein (hypoproteinemia) is usually a manifestation of deficiency in the large storehouses of protein in the body. Tissues cannot regenerate maximally unless protein is available for cellular proliferation. Transfusions of plasma will soon build up the stores of protein in a patient with hypoproteinemia. Be sure that patients with healing wounds receive sufficient protein by mouth or intravenously (plasma) or both. Cellular repair requires protein.
It has been definitely shown that a reduction of vitamin stores in the body (especially vitamin C) will interfere with normal wound healing by interfering with the laying down of collagen. It is recommended that all wounded or burned patients receive the following amounts of vitamins daily until recovery is complete:
Vitamin A	5000	Interna-
tional Units
Thiamin	2 mg.
Ascorbic Acid	75 mg.
Riboflavin	3 mg.
Nicotinic Acid (Niacin) Amide	20 mg.
Vitamin D	400	Interna-
tional Units
If large amounts of glucose are being administered by the intravenous route, from 10 to 20 milligrams of thiamin chloride and 100 milligrams of ascorbic acid should be added daily to the fluids.
7
Part II. THE TREATMENT OF BURNS
The extent of a burn should be recorded on the earliest permanent record of the patient, and the method of Berkow* should be adopted for this purpose.
I.	Emergency Care,
In those instances in which definitive treatment cannot assuredly be carried out within 2 hours,
The therapy of a burn should be directed toward prevention of its two complications, shock and infection. Often the ideal must give way to the practical, but it is easier to prevent these complications or to treat them in the early stages than it is to relieve them in the late stages.
Whenever persons with extensive burns can be admitted to hospitals without delay, and definitive treatment can be instituted promptly, morphine sulphate, grain one-half, should be administered at the First Aid Post or at the site of the incident and no local therapy applied except sterile gauze to exposed surfaces to prevent infection. These casualties should be transported to hospitals as soon as possible.
* Berkow, S. G., Am. J. Surg., 11, 315 (Feb.) 1931.
the following therapy is advised for all surfaces except the face, hands, and genitalia:
The patient is to receive an amount of morphine adequate to relieve pain, not less than one-half grain. The burned surfaces are to be covered liberally with a water-soluble jelly containing 10 percent of tannic acid and 5 percent of sulfadiazine. This is to be covered with sterile gauze. No effort is to be made to remove any more clothing than is necessary to expose the burned surfaces. The patient is to be wrapped in a blanket before evacuation, but the blanket should not come in contact with the burned area.
The hands, face, and genitalia are to be covered with an aqueous emulsion containing 5 percent of sulfadiazine, or, if this is not available, boric acid
8
ointment. These surfaces (face, hands, and genitalia) are to be covered if possible with a fine (44) mesh gauze. A firm pressure bandage using cotton waste should be applied to the hands. In most instances, no bandages should be applied to the face or genitalia. If the eyes need treatment, they should have a single instillation of a 2 percent butyn ophthalmic ointment. The patient must be warned not to rub the eyes once this anesthetic agent has been applied; rubbing may severely injure the cornea.
A large proportion of burns are sterile or nearly sterile at the moment they occur. Every effort should be made to maintain the asepsis. If time does not permit application of a first aid dressing, and a casualty is sent from a First Aid Post to a ward for definitive treatment, he and those caring for him should be warned not to touch or otherwise contaminate the burned areas.
The initial injection of undiluted plasma (250 to 500 cc.) should be administered as soon as possible. If diluted plasma is used, a proportionally greater amount must be given.
II.	Definitive Treatment.
This should be carried out at the first place where the patient remains sufficiently long, and the facilities are available. If the patient cannot be transported to the hospital within two hours, it may be necessary to administer plasma at the First Aid Post or Casualty Station.
A.	The First Consideration Is the Treatment of Shock.
1.	Additional morphine should be given if needed. These patients require large doses of morphine. Following the initial dose of one-half grain, an additional one-fourth grain may be required as often as every 3 hours.
2.	Plasma Transfusion.—To replace the volume of serum lost from the burned area and into damaged tissue it is necessary that the patient receive additional plasma. Since every severely burned patient will require plasma, it can be administered intravenously before any laboratory work is done. If the burn involves 10 percent of the body surface the casualty should receive 1000 cc. of undiluted plasma by the end of the first 24 hours and twice this amount (2000 cc.) if the bum involves 20 percent of the body surface. The plasma should be given in
divided doses of 250 cc. It must never be administered by any other than the intravenous route. If facilities for hematocrit determinations are available, the following rule can be used for guidance regarding the amount of plasma required: For each point that the hematocrit is above 50 percent cells, 100 cc. of plasma should be injected slowly.
3.	Other Fluids.—Normal saline and glucose solutions injected should not exceed the volume of plasma injected in any one 24-hour period. The only exception to this is under the condition of severe hemoconcentration (hematocrit above 70 percent cells), when larger amounts may be injected slowly. The administration of large amounts of neutral sodium salts, such as sodium chloride, will intensify the tendency to edema. Casualties may be permitted to drink moderate amounts of water. No food should be offered to the patient until the stomach is retentive and the phase of shock has passed. Fluids may then be given orally as freely as desired.
When the patient is in a state of shock, the extremities cold, the pulse weak and thready, caution must be exercised against warming the patient too rapidly by externally applied heat. Sudden warming in the presence of an inadequate blood volume may precipitate complete circulatory collapse by opening widely the peripheral vessels.
4.	Whole Blood Transfusions.—Blood should be given in the early treatment of a burned casualty when actual hemorrhage has occurred from other injury and then only when the state of shock has been fairly well overcome. In the subsequent course, anemia frequently develops. In this case, 500 cc. of blood should be administered daily until the anemia is overcome.
B.	Care of the Burned Area.
Remove dressing carefully and inspect. Remove clothing carefully, cutting where necessary.
1.	Burns Other Than Those of the Hands, Face, and Genitalia.—If the surface is covered with oil, cleanse with detergent. Open blisters and excise all necrotic epidermis under aseptic precautions and with minimal trauma.
Cleanse first the surface of the burn and then the surrounding skin with plain soap and water, using pledgees of cotton and nothing else. Do not scrub the burned surfaces. After this cleansing, rinse the surface freely with physiological
9
saline solution. The surface is then ready to be tanned.
(a)	Tanning.—Two solutions are to be employed:
(1)	A freshly prepared 10 percent solution of tannic acid.
(2)	10 percent solution of silver nitrate.
Two spray guns are to be available. One is to contain only the tannic acid, and the second, equal parts of tannic acid and silver nitrate solutions. Less pain is caused if the tannic acid alone is applied first, to be followed immediately by the tannic acid-silver nitrate spray. One half hour later and every half hour for four applications, spray with tannic acid-silver nitrate mixture. If the tan is not then adequate, continue spraying the surfaces every hour until the objective is achieved.
Once the tan has developed, it should not be removed. If infection beneath it is suspected, treat as described in section (b). If the burn is of the second degree, skin will regenerate beneath the tan, and the latter will separate spontaneously. If the burn proves to be of the third degree, skin grafting will be necessary, but the tan should not be removed, if it remains intact, until six weeks have passed. It should then be cut away, and the surface prepared for grafting.
A burn more than 24 hours old should not be tanned, but should be treated as an infected burn. Any burn grossly contaminated, even if less than 24 hours old, should be similarly treated.
(b)	Infection Beneath Tanned Surfaces.
If the patient shows systemic or local signs of sepsis, the tan should be carefully inspected for the presence of infection beneath it. If any area looks suspicious, a hole should be made through the tan, and if pus is encountered, the entire area of suppuration should be unroofed by means of sterile sharp instruments. This should be done with as little trauma as possible, preferably without general anesthesia.
The suppurating surfaces must be cleansed with warm saline irrigation or a solution gently applied with cotton pledgets. After thorough cleansing, crystalline sulfanilamide is to be dusted lightly over the surface. If the area of infection is large, excessive absorption of the sulfanilamide may occur. Therefore, not more than 15 grams of sulfanilamide should be used in any one 24-hour
period. The area is to be covered with saline packs moistened either by the use of Dakin’s tubes or by pouring the saline over the dressings every 3 or 4 hours. Whenever the dressings are changed, a light “frosting” of crystalline sulfanilamide should be applied.
For infected burns of an extremity an alternative treatment is the use of waterproof irrigation bags. The solution to be used in these is physiological saline, containing not more than 0.2 percent sulfanilamide. Care should be exercised that the constricting mouth of these bags is not so tight as to interfere with the circulation to the part.
Cultures should be obtained from granulating surfaces before skin grafting is attempted. If hemolytic streptococci are present, continue local application of crystalline sulfanilamide until the cultures are negative. As soon as the surface is ready, skin grafts should be applied.
2.	Hands, Face, and Genitalia.
Dressings are to be removed, and the surfaces cleansed as previously described. The surfaces are to be debrided. An aqueous emulsion containing 5 percent of sulfadiazine or boric acid ointment is to be generously applied to the burned area and covered with a fine mesh (44) gauze. The pressure dressing on the hands should then be reapplied. Open surgical drainage is to be maintained and the dressing changed only when necessary.
Ill, Oral Chemotherapy of Burns,
Sulfadiazine is the drug of choice. The dosage is 1.0 gram every 6 hours day and night for 10 days.
If the patient is not voiding normally (1,000 cc. per day), the blood concentration of sulfadiazine should be determined daily and the dose should be adjusted downward until a concentration of 10 mg. percent is reached. If complete suppression of urine occurs, omit the drug and force fluids, orally if possible, and glucose and water intravenously if necessary.
Sulfanilamide or sulfathiazole may be used in the same dosage if sulfadiazine is not available. Sulfathiazole is the least desirable of the three drugs for the oral treatment of burns.
10
11
APPENDIX
List of supplies to be included on a typical dressing cart
Instruments:
Scissors __________ 18
Tissue forceps ________ 18
Hemostats _________ 25
Grooved directors _______	6	In	separate	trays	covered with sterile towels.
Handling (instrument) forceps _ _ _	2
Scalpels __________	6
Pus basins _________	6.
Drugs:
Saline solution ______________ 0.85 percent.
Azochloramide solution _ _ __________ 1:3300, aqueous with Turgitol.
Hydrogen peroxide _____________ 3 percent.
Sulfanilamide crystals (crystal size 60 mesh).
Sulfanilamide solution 1 percent in physiological saline solution.
Lysol.
Gentian Violet.
Gentian Violet 1 percent—silver nitrate (5 percent) solution.
Benzine or carbon tetrachloride.
Ether.
Tincture of iodine _____________ 3 percent.
Silver nitrate sticks.
Cod liver oil ointment.
Petrolatum jelly.
Boric acid ointment.
Zinc oxide ointment.
Green soap.
Acetic acid—alcohol ___ __________ 10 percent.
Potassium permanganate crystals.
Alcohol ________________ 95 percent.
Dressings, etc.:
Large gauze dressings.
Small gauze dressings.
Bandage (assorted sizes).
Adhesive (assorted sizes).
Wound covers.
Packing (a) vaseline gauze, (b) plain gauze ______ Large and small sizes of each.
Gloves ________________6 pairs.
Alcohol sponges.
Rubber tubing (assorted sizes).
Alcohol lamp.
Rubber dam.
Culture tubes and swabs.
Safety pins.
Large abdominal pads.
Needles and syringes (assorted sizes).
Lubricant jelly.
Irrigating sets, Asepto and Triumph syringes or equivalent.
Solutions for Intravenous Therapy:
5 percent glucose in distilled water.
5 percent glucose in physiological saline solution.
Physiological saline solution.	16—28055-1 u. s. government printing office