The method should only be credited with the results obtained by application in its entirety. If the details of the technique or the composition of the antiseptic be modified at hazard, sterilisation of wounds becomes impossible. The observations made by surgeons who have used Dakin's solution without a precise technique should therefore be looked upon as valueless.

I. Results Of The Sterilisation Of Wounds

Sterilisation of a wound comes to pass in a different manner according as it is recent or old-standing and is associated or not with fracture.

A. Wounds Of The Soft Parts

From the month of December, 1915, the date when the technique was first employed under its actual form as at present, all wounds of the soft parts have attained surgical asepsis. They were subjected to secondary suture, with the exception of those which were very small and healed spontaneously, and those which were accompanied by so great a loss of substance that they could not be closed. Wounds, fresh, phlegmonous, gangrenous, suppurating, all were equally capable of disinfection, but the rapidity of the sterilisation depended in a certain measure on the state of the infection.

PLATE III.

Fig. 91.   Case 465. Section of quadriceps, 3rd day.

Fig. 91. - Case 465. Section of quadriceps, 3rd day.

Fig. 93.   Case 606. Large wound of forearm.

Fig. 93. - Case 606. Large wound of forearm.

FIG. 95.   Case 577. Wound of knee, 5th day.

FIG. 95. - Case 577. Wound of knee, 5th day.

[To face page 217.

PLATE IV.

Fig. 92.   Case 465. Suture, 7th day.

Fig. 92. - Case 465. Suture, 7th day.

Fig. 94.   Case 606. Wound closed, 6th day.

Fig. 94. - Case 606. Wound closed, 6th day.

Fig. 96.  Case 577. Suture, 14th day.

Fig. 96. -Case 577. Suture, 14th day.

[To face Plate III.

1st. Fresh Wounds. - When the treatment of wounds was commenced from five to twenty-four hours after the injury, sterilisation was rapidly produced. Generally microbes disappeared from the fifth to the twelfth day if the wounds contained no gangrenous tissue. The following, which have been chosen from amongst many similar reports, show with what rapidity a large wound can be disinfected and sutured.

Case 465 suffered from a large shell-wound traversing the anterior aspect of the thigh and almost completely dividing the quadriceps femoris. Three and a half hours after the receipt of the injury, the wound was laid open and foreign bodies and torn muscular tissue removed. An extensive wound resulted, more than 10 centimetres long and extending from one side of the thigh to the other (Figs. 91 and 92). At the end of seven days, the wound was surgically sterile, Then careful suture by catgut of the quadriceps was carried out and the skin closed (Fig. 92). It healed by first intention, and shortly afterwards the patient walked normally.

Case 315 was operated upon twenty-three hours after having received multiple shell-wounds, of which two were deep in the buttock. The most extensive of the wounds measured after cleaning-up 18 centimetres long, 9 centimetres wide, and 8 centimetres deep. Sterilisation of this wound was slightly retarded by the presence of gangrenous tissue, which was found near the cutaneous margin of the wound. However, after five days, the wound became surgically sterile, and was closed with adhesive plaster. Nine days later, the strapping was removed and the wound found to be healed.

Case 606: a shell-wound penetrated the forearm, went through the epitrochlear muscles and divided the radial (Fig. 93). The wound was closed the sixth day (Fig- 94).

In wounds of the soft parts, sterilisation is almost always rapidly achieved. Out of 136 wounds closed during the period-December, 1915, and the commencement of January, 1916-121 were closed before the twelfth day. When the cases were operated upon during the first six or twelve hours, closure was practised still earlier. If the tissues have been severely torn by the projectile, and have become gangrenous over a large area, sterilisation is attained more slowly. In case 577 two shell-wounds had lacerated and detached all the tissues of the front of the knee, without fracture of the patella (Fig. 95). The projectiles having been removed from the articulation, the wound could be closed the fourteenth day (Fig. 96). In wounds sterile over almost the whole extent of their surface, microbes often persist near the aponeuroses and necrosed tendons, and prevent closure being carried out. This slow elimination of shreds of necrosed tissue was the commonest cause of delay in sterilisation of wounds of the soft parts. That is the reason why thorough surgical cleansing of the wound is so important. In cases where necrosed tissue had remained for a long period on the surface of the wound, suture was practised, as a rule, from the fifteenth to the twentieth day.

2nd. Phlegmonous and Gangrenous Wounds. - Cases arriving later at the hospital, with wounds already bearing evidence of phlegmon or gangrene, were treated in a similar manner. After the disappearance of serious infection, many injuries could be sutured.

Case 340, with multiple shell-wounds, was operated upon after nineteen hours. Wounds of the thighs and legs were freely laid open, shell-fragments removed and instillation tubes placed in the tracks. Three of the wounds developed along normal lines and were closed on the ninth day. The fourth, situate at the inferior extremity of the right thigh, suffered a grave complication. The projectile had opened a vein in the popliteal space, and caused a haemorrhagic infiltration of the whole of the cellular tissue of the calf. This haematoma had remained undetected at the time of operation. But, after twenty-four hours, the temperature reached 400 C. (103.5° Fahr.). The calf and the popliteal space were purple, and very painful. The inflamed region was then incised from the popliteal space to the lower third of the leg (Fig. 97). At the end of eleven days, the great wound had become sterile, and the temperature came down from 40° to 37° C. (103.5° to 98.5° Fahr.). Next, along the margins of the wound elastic traction was applied, for the tissues were too far retracted to allow of immediate union. Under the influence of elastic traction, the margins of the wound steadily approached each other, and united three days later, that is to say, twenty-one days after the infliction of the injury (Fig. 98). Sterilisation came about more slowly than in an ordinary wound. However, it should be looked upon as rapid, taking into consideration the gravity and extent of the infection.