The antiseptic solution, only sterilising what it touches, must enter into intimate contact with the microbes infecting the wound. This contact has been considered impossible by the majority of modern surgeons. Sir Almroth Wright considers that, in the wounds inflicted in war, microbes are found so deeply buried in the irregularities of the wounds, in the middle of necrosed muscles and blood-clots, that it is hopeless to try to reach them by means of an antiseptic. It is also supposed that, in suppurating wounds, microorganisms inhabit the depths of granulation tissue, muscular interstices, and lymphatics, and that, in consequence, they are beyond the reach of substances poured over the surfaces of the wound. It is certain that if the topography of infection is such that the microbes cannot be brought into actual contact with the antiseptic, chemiotherapy of wounds ought to be abandoned.

But the opinion expressed by Sir Almroth Wright was based upon hypotheses and arguments, and not upon exact observation of what takes place in war-wounds. In order to find out if antiseptic treatment ought or ought not to be applied to infected wounds, it is necessary to study the topography of infection in both fresh wounds and suppurating wounds, and to inquire if it be possible to bring the antiseptic into contact with the microbes.

A. Topography Of Infection

1. Fresh Wounds. - The topography of infection was studied at first in freshly inflicted wounds, superficial and deep, with fracture and without. Specimens of the secretions were taken from various regions of the wound, from around projectiles, shreds of clothing, splinters, and from the surface then examined by means of smears (p. 182) and cultures.

During the first few hours following the infliction of the wound, the smears in general showed no microbes, whilst cultures were positive. The apparent asepsis of the smears was due to two causes, the dilution by blood of the microbes infecting the wound, and their relatively small number at this early period of the infection. In fact, to show themselves in the secretions, the organisms need to have had the time to multiply and spread themselves from the foreign bodies on to the surfaces of the wound.

At the end of five or six hours, in wounds which are not bleeding, rods and cocci are sometimes found. These were localised in the regions close to the foreign bodies. Frequently also, no microbe was visible, though bouillon in which shreds of tissue taken from the immediate neighbourhood of the foreign bodies had been placed yielded abundant cultures, aerobic and anaerobic. The direct examination of foreign bodies, shell splinters, or particles of cloth, gave varying results. In general, no microbes were found on the surface of projectiles, although in more than half of the cases they gave positive cultures. Shreds of clothing, on the contrary, always yielded an abundant microbial flora. Often scrapings of fragments of great-coat, five or six hours after the infliction of the wound, showed some rod-like bodies; and nearly always anaerobic cultures made from these debris gave off gas abundantly.

At the end of about twelve hours, bacteriological examination practised under the same conditions, showed microbes more constantly and in greater abundance.1

1 See also Policard et Phelip, C. R. de l'Acadimie des Sciences July 5,1915. Fiessinger, La pratique dela chirurgie de guerre 1916. Fiessinger et Montaz, C. R. Sociite de Biologie, June 9, 1916.

Wounds commenced to react, and polynuclear cells appeared in numbers more or less great.

After twenty-four hours the topography of infection of the wound had greatly changed, for the bacterial harvest was no longer localised on the surface, or around foreign bodies. The examination of smears revealed the presence of microbes over almost the whole extent of the wound. At the same time a greatly increased number of polynuclear cells was to be seen. In short, during the first twenty-four hours there may be witnessed, first, the multiplication of microbes on the surface and in the neighbourhood of foreign bodies, especially of fragments of clothing, and later their diffusion over the superficies of the wound.

The modifications of the bacteriological aspect of a wound from the fifth or sixth hour to the twenty-fourth hour were due to the rapid division of micro-organisms. If it be supposed that each microbe divides every half-hour, it will give birth in twelve hours to more than fifteen million other microbes. This extreme rapidity of multiplication explains why wounds twenty-four hours old are already invaded by myriads of micro-organisms.

Close examination of a great number of wounds has shown that these micro-organisms remain, as a rule, on the surface of wounds, and do not penetrate deeply into muscular interstices nor into lymphatics. They invade blood-clots and tissues without circulation. They follow the blood poured out along vascular sheaths, and they may also bury themselves in fractured bones. But usually during the early hours, and even the first few days following the infection of the wound, they live on the surface of the tissues; that is to say, within reach of a liquid, if this liquid be applied under suitable conditions.

The existence of this fact has been made plain in the course of experiments made upon the wounds themselves. When the antiseptic liquid was brought into contact with the infected surface, the number of microbes rapidly diminished, and at the end of a short time the wound became completely aseptic. Wounds of the surface could be sterilised thus in twenty-four hours; irregular wounds, even when accompanied by fracture, became sterile in five or six days. The tissues were surgically sterile in their substance as well as on the surface. In fact, when the treatment had been applied from the beginning, it was possible to close up the wound by deep interstitial sutures, without this being followed by rise of temperature. Secondary operations practised in cases where wounds had been closed after sterilisation, did not determine the appearance of febrile phenomena. When comparing such results as these with what is observed always in the case of non-sterilised wounds, it is fair to conclude, with every semblance of probability, that the microbes have been destroyed in all parts of the wound.