The corollary to the sterilisation of a wound is its closure. But a wound should never be closed without knowing what it contains. Suture of a wound enclosing microbes may be followed by downright disaster. It is therefore only after having carefully looked into the bacteriological condition of a wound that one may bring its edges together by strapping or suture.
Closure of a wound is practised as soon as we know that it no longer contains microbes. Therefore primary closure should be rejected. Even after precise mechanical cleaning of the wound, and resection of every portion which has been affected by the projectile, still it is impossible to make sure that microbes have not been left on the surface of the tissues. So far as that goes, the negative aspect of smears made with the liquids or tissue taken from a fresh wound has no value whatever. A highly infected wound, at this stage, may not show a bacterium upon the slide. Only cultures made by means of tissues carefully collected from numerous points in the wound can give an idea of its bacteriological condition. But to have the report of cultures it is necessary to wait twenty-four or forty-eight hours. Consequently it becomes impossible to practise primary union of a wound if we insist first upon knowing its bacteriological condition.
At the beginning of the war primary union was employed, and given up because of the disasters it provoked. Nearly all the cases of septicaemia we have seen were due to immediate suturing performed in clearing-stations or hospitals where its danger was not yet realised. We know that for some months primary suture has again become the fashion in the French Army, and that it has been applied in a great number of cases. It is the fact that the surgeon is often favoured by chance, and that he closes wounds which are only slightly infected, and unite by first intention. But this is not always the case. M. Tuffier reported to the Societe de Chirurgie certain series of cases which revealed 33 per cent. of failures. Over and over again has gaseous septicaemia or streptococcic septicaemia resulted in the death of the patient who has undergone primary suture. The complete statistics have not been published, and only favourable series of cases have been made the subject of communications to the Societe de Chirurgie. A batch of cases is regarded as favourable if only 1 or 2 per cent. of the wounded die, and only one or two amputations are performed. But if we consider that sutures are employed in the case of wounds of the soft parts where the extensive opening and the chemical sterilisation are a sure safeguard against death or amputation, it must be admitted that these results are not satisfactory. As a matter of fact, one has no right to make a single patient run an unnecessary risk. And this risk is real, for out of a hundred wounded men subjected to primary suture, one or two men have often been killed who would not have died if their wounds had been left open. Only when an experienced surgeon can watch over his patients incessantly, and when there is no danger that the latter may be hastily evacuated, is it permissible to practise the primary suture of the soft parts. This is an exceptional procedure, to be reserved for certain surgical specialists under certain conditions. One of these conditions is a small number of wounded men in the sector in which the surgeon operates. In periods of activity and rapid evacuation this procedure must be completely abandoned. Generally speaking, the primary closing of wounds must be rejected so long as we have no method which will enable us to ascertain whether they are or are not sterile.
Secondary closure, on the contrary, can be effected under such conditions that it presents no danger. The examination of smears of the secretions of a wound aged twenty-four hours or more enables the volume of infection to be estimated. When the number of microbes has diminished progressively, when it has become zero, and this condition is maintained for two or three days, then we may be sure that an adequate degree of asepsis has been reached, and that the wound may be sutured. At the same time, we must not lose sight of other clinical signs, especially the patient's temperature and the condition of the limb. When the indications furnished by both clinical aspect and smears coincide, then one may suture the wound with a feeling of entire security.
1. A wound of the soft parts whose sterilisation has been initiated a few hours after infliction, and which has never suppurated, may be closed as soon as two consecutive examinations, made after an interval of one or two days, have shown that the smears do not contain more than one microbe to four or five microscope fields. If the wound be deep, and especially if it be associated with fracture, above all, a compound fracture of the thigh, it is preferable to repeat the examinations and to wait, before closing the wound, until it has been surgically sterile for four or five days.
2. The time for the closure of wounds, the sterilisation of which has been commenced after a more or less protracted period of suppuration, must be more carefully determined. And so far as that goes, experience has taught us that the secretions of a suppurating wound, above all when it is deep and accompanied by fracture, may become for a little while sterile, although the wound is not actually sterile. One day the pus is to all appearances aseptic, and the next day are found indubitable heaps of microbes accumulated on certain points of the smear. In these wounds, which have suppurated for a long time before the commencement of the antiseptic treatment, one should find the secretions sterile for a week at least before deciding to suture.
Generally speaking, the average moment for wound closure occurs between the eighth and the twelfth day. Some wounds may be united towards the fifth or sixth day, others after the twelfth. Certain compound fractures should not be closed before the twentieth or thirtieth day of treatment. It is well to practise the closing of wounds at as early a period as possible. As a matter of fact, wounds closed before the eighth day contain no cicatricial tissue, and healing is effected without a legacy of functional troubles. The closure of wounds at an early period also results in considerable saving, both in the cost of treatment and in the work of the staff of the hospital. In a word, as soon as a wound becomes sterile, it should be closed.