Every infected wound should respond to chemiotherapy, when this is applied in correct manner. It is necessary, therefore, that the progress of treatment should be controlled each day by examination of the wound, and that the technique should be modified according to the results of this examination. Clinical and bacteriological study of the wounded patient, and of the wound, is the indispensable guide in therapeusis.

I. Clinical Examination

The aspect presented by wounds is modified under the influence of treatment in a manner more or less rapid according to the nature and age of the lesion. This evolution varies according to the period of infection during which sterilisation was commenced.

A. Modifications Of The Local Conditions, 1st. Fresh Wounds

Immediately after the infliction of the injury, blood pours out between the edges of the wound and forms a clot. Up to the sixth or twelfth hour, there is not, as a general rule, either swelling of the tissues or secretion on the surface. At the same time, we have sometimes met with wounds only six hours old containing gas and giving off a putrefactive odour. Towards the twenty-fourth hour wounds secrete slightly. When instillation is begun between the sixth and the twelfth hour, the tissues retain their normal appearance. Muscles remain red and cellular tissue is not changed. If the tissues have been severely bruised they necrose, but neither redness nor swelling is seen at the margin of the wound. At the end of three or four days the necrosed tissue becomes of whitish colour and soft consistence. It begins to become detached in fragments from the deep parts. Red portions begin to show themselves. Towards the eighth day following the injury, the wound is usually clean. The surface is of a bright red. Secretions are almost nil. The margins of the wound are not swollen and present no evidence of lymphangitis. Should signs of inflammation appear, it is certain that a fault in technique has been committed, either in the manufacture of the liquid, or the disposition of the instillation tubes. Towards the tenth day, the entire surface of the wound is even and red. In the most irregular portions, and by the lymphatics of vasculo-nervous bundles, sometimes a few drops of pus may be seen. The limb has regained its normal size. The integuments about the wound are supple and not tender on pressure. The skin is not yet adherent to the deep parts. That is the reason why, wherever possible, wounds should be closed before the twelfth day.

The integuments are sometimes modified, after the lapse of a few days, by the application of Dakin's solution. They become red and painful. This complication may be due to one of several causes. The tincture of iodine which has already irritated the skin is generally the cause. But the Dakin's solution may have been badly made. If Dakin's solution contains too much alkali, it becomes as dangerous as eau de Javel or Labarraque's liquor. The moment irritation of the skin occurs, the solution should be examined to see if it fulfils the conditions laid down by Dakin. It sometimes happens that a solution perfectly prepared may cause redness in subjects who have an exceptionally delicate skin, or when the wound occupies the posterior aspect of the trunk, the pelvis, or the limbs; or when the dressings are too tightly applied, or changed too infrequently. The best way to avoid irritation of the integuments about a wound is to cover the skin with squares of gauze sterilised in yellow vaselin. If the wound is on a limb, it is useful to employ American suspension apparatus. If the trunk or pelvis be affected, the patient should be placed bodily upon a Bradford's frame. Irritation of the skin due to Dakin's solution is very rare, and is easily distinguished from the lymphangitis so frequent in wounds treated aseptically.

Towards the twelfth day, granulations begin to cover the wound at the same time as the epithelial margin develops. The skin becomes adherent to the subjacent parts. The whole surface of the wound is composed of rose-tinted granulations. Cicatrisation comes about in a regular manner, without any interval of retrogression, such as one is accustomed to in wounds treated by the aseptic method. The cicatrisation curve develops symmetrically, following the algebraic formula of Lecomte du Nouy.

The secretions of wounds thus treated are not very abundant, especially when pains have been taken carefully to resect contused tissues. At the beginning, the compresses are covered with a thick greyish secretion, resulting from the combination of pus and hypochlorite. Then, little by little, the secretion becomes more sticky, clearer, and at last, colourless. At this stage, it is probable that sterilisation has been attained.

2nd. Gangrenous and Phlegmonous Wounds. - When wounds have reached the stage of inflammation by the time the treatment is commenced, the clinical modifications which they undergo under the influence of sterilisation are less rapid. If the liquid can reach all the infected regions, redness, swelling, and pain diminish at the end of one or two days. But if the lesions cannot be reached, even at the price of free incisions, results of treatment are negative. In a general way, when tubes have been placed in all the infected regions, the wound takes on the appearance previously described at the end of a few days. When the tubes have not been able to reach all the infected regions, but when a great portion of the wound has become sterile under the influence of the treatment, the septic regions situate beyond the reach of the liquid accelerate their spontaneous disinfection. It would appear that, the volume of infection being lessened, the organism defends itself more readily.

In all the cases where incisions facilitate the penetration of the antiseptic into gangrenous foci, gas and odour are the first to disappear, then the necrosed tissues dissolve. They are eliminated after the lapse of a few days, without the margins of the wound presenting any inflammatory reaction.