THE first stage of treatment consists in preparing for the penetration of the liquid by surgical interference and by mechanical cleaning of the wound. This intervention is indispensable, in order that intimate contact between antiseptic and microbe may be established. It differs only by some details from the methods in general use to-day.

I. The Time For Mechanical Cleansing

Surgical interference and mechanical cleaning-up of a wound are practised as soon as possible after the infliction of the injury. The time for interference is of the greatest moment, for the surgical proceeding has a gravity varying according to the stage of infection in which it takes place.

I. Every infected wound at first goes through a stage which might be termed pre-inflammatory, during which the various local symptoms are very slight or nonexistent. Muscles and cellular tissue preserve their normal appearance. So far there is neither swelling of the tissues nor the reddened tracks of lymphangitis.

The temperature is normal or rises slowly. This stage usually lasts from twelve to twenty-four hours, and is sometimes prolonged to forty-eight hours. During this pre-inflammatory period free incisions and search for foreign bodies or projectiles present no danger. This is the period of the infection, during which all surgical interference should be carried out as far as possible. It is with wound-infection as with appendicitis. Interference during the first twenty-four hours carries with it little danger, and nearly always yields excellent results.

2. At the end of a period varying from twelve to forty-eight hours, and occasionally longer, the inflammatory stage begins. The temperature goes up, and marked symptoms of infection appear on the surface of the wound. These infectious complications present themselves under two aspects, gangrenous or phlegmonous. In the gas form of infection multiple incisions with thorough opening-up do not aggravate the patient's condition, and as a rule allow the progress of infection to be checked. It is not the same with infections of the phlegmonous type, which are due often to the presence of streptococci.

Every one knows the appearance of the phlegmonous wounds. Neither gangrene nor gas is present, but the tissues are infiltrated and painful. Serum pours from the wound. Sometimes there is lymphangitis, and the glands of a limb near the trunk are swollen and tender on pressure. This stage may last several days, and sometimes several weeks. When the patient is in this condition, the surgical measures which might have been practised had the operation taken place during the first twenty-four hours are no longer indicated. Free incisions and prolonged search for foreign bodies or splinters might set up septicaemia, or at least aggravate phenomena both local and general. During this anxious period one has to be contented with no more than is absolutely necessary. To operate at this moment is to make the patient run the same risks as a case of acute appendicitis which is operated on after three or four days.

3. When the stage of acute infection is past, and suppuration has commenced, the search for projectiles, shreds of clothing, splinters may be undertaken with far less danger. But osteo-myelitis in some cases has made its appearance, and wound-cleansing cannot be as efficacious as at the outset.

Upon the whole, the most favourable time for any operation called for by reason of anatomical lesions is the pre-inflammatory stage. If the general condition permit, now is the time to carry out without danger any necessary surgical interference. It is the reason why the wounded man should be got as quickly as possible to the hospital, where complete surgical treatment can be carried out.