Some modifications have to be made in this technique, due to the nature of the injury.

(a) Infected Fractures. - The course to pursue in compound fractures, the seat of acute diffuse inflammation, is similar to that we have just laid down for wounds of the soft parts. Only what is strictly necessary is done in the first place; that is to say, simple laying open of a seat of fracture without minute cleansing, and the placing of several instillation tubes in the diverticula of the wound. After a few days the general condition improves. Swelling, redness, pain, diminish. Then, when the dangerous stage of infection is passed and the number of microbes per field of the microscope remains considerable, the toilet of the seat of fracture is made. This new interference is as complete as possible. Foreign bodies, carefully registered by suitable apparatus, are removed at the same time as the splinters, but the periosteum of the splinters is preserved with care. The operation ends by arranging in the seat of fracture multiple tubes destined for supply of the antiseptic solution.

{b) Suppurating Joint-injuries. - In arthritis without bony lesions, arthrotomy more or less free, followed by the extirpation of foreign bodies and cleansing of the articulation, suffices generally to ward off evil results, if the antiseptic treatment be carefully employed and the joint immobilised absolutely.

In joint-injuries with bone lesions intervention is limited to the measures which, aided by chemical sterilisation, check the spread of infection. The general condition of the patient, the nature and the virulence of the infection, play an important part. Streptococcal infections are the most grave, and call for more extensive interference than the other infections. In these cases, sometimes, the prospect of amputation must be faced.

(c) Secondary Haemorrhage. - Haemorrhages are often due to the detachment of a scar produced by contusion of the wall of a large arterial trunk. But they arise also from the breaking down of clot, which had previously brought about spontaneous haemostasis of a wound of an artery or vein. The clot disappears under the influence of infection, and the artery finds itself more or less widely open. In this manner a primary haemorrhage is produced, perhaps only slight, but which is followed some days later by a loss of blood much greater, often mortal. Haemorrhage may also follow the loosening of a ligature, silk being readily dissolved by hypochlorite, as Fiessinger has shown. That is why we ligature vessels with catgut or chromic catgut. When these precautions are taken, haemorrhages are never observed.

The preventive treatment of haemorrhage consists in careful examination of the vessels at the time of surgical interference, and in bringing about definite haemostasis if a vessel be wounded.

When a case presents a primary haemorrhage, most frequently a tampon will stop the bleeding. But several days later a new haemorrhage will not fail to appear, and the patient may succumb. It will not do to be content with a tampon; ligatures must be used above and below the injury, and as near as possible to the seat of ulceration.

Haemorrhages have occurred in certain hospitals after using badly prepared Dakin's solution. The solution then contains free alkali, which is just as capable of producing vascular ulceration as eau de Javel or Labar-raque's liquor.

In wounds chemically sterilised the classic secondary haemorrhages due to suppuration are never seen.

(d) Wounds of the Brain. - For wounds of the brain the projectile should be removed, whenever possible, through its orifice of penetration. It is important to avoid causing traumatisms of the cerebral substance by rough manipulations or by washing out the wound by means of a liquid under pressure. The walls of the wound are freed as thoroughly as possible from all foreign bodies which may be found in them. As it is of the highest importance to the future of the patient that the wound should be absolutely sterilised, all its parts should be brought carefully into contact with the antiseptic. It is therefore essential immediately after operation, to introduce a special appliance which will permit of its sterilisation, and as far as possible this appliance must not be removed until the bacteria have completely disappeared.

C. Suppuration Stage

The manipulation of wounds which have arrived at the stage of suppuration is effected with all the more precaution because still nearer the inflammatory stage. Two extreme types of suppurating wounds may be present. The first type is the wound covered with pus more or less blood-stained, accompanied by lymphangitis, swelling and pain. It is the transition period between the inflammatory stage and the period of true suppuration. Unless there are urgent indications to the contrary, these suppurating wounds must be treated with as much respect as wounds in the inflammatory period. The other type is represented by wounds of longer standing. From the orifice, already covered by granulations, thick "laudable" pus escapes. The tissues are no longer oedematous. The temperature is only slightly raised, or presents great variations. At this stage it is possible to interfere surgically with less danger than in wounds of the first type. Between these two extreme types a number of intermediate conditions are found. Surgical interference becomes less and less dangerous as the wounds are removed further and further from the first type. In a general way the cleansing of the wound follows the same rules in all cases; the more inflamed the wound the more sparing should be surgical interference.

1st. Chemical Cleansing. - In the great majority of cases the wounded who arrive at the hospital at the end of two, ten, or fifteen days have already been operated upon. On the surface of the limb, therefore, openings are found leading down to the solutions of continuity in soft parts, to opened joints, to seats of fracture. These openings are often too small, and inadequate to drain the pus-laden burrows. Nevertheless, it is better not to interfere at the outset. Even at this stage it is hardly wise to open up an abscess. It is enough to remove the drainage tubes which generally have been placed in the wound, and replace them by the small instillation tubes which are gently coaxed into the orifices already in existence, down to all the diverticula of the soft parts and to the seats of fracture. This is done without anaesthesia and without distressing the patient. Then Dakin's solution is instilled, according to the method which will be described later, until suppuration ceases, temperature drops, and the general condition improves. From the clinical point of view, suppuration disappears after the lapse of a space of time varying from twenty-four hours to about four days.