4. Cleansing of Compound Fractures or Wounds of Joints. - (a) Cleaning-tip a Compound Fracture. - The incisions for exploration and cleaning-up of compound fractures should always be very free. A long incision is no drawback, because it can be sutured two or three weeks later. Whenever possible these incisions are made on the anterior aspect of the limb in such a way that the liquid may remain in contact with the bony fragments. Counter-openings at the dependent points are not made. Soft parts are laid open in such a manner that all parts of the seat of fracture may be explored. In fractures of the femur, it is peculiarly important to make an incision so long that the masses of muscle can be retracted sufficiently to lay bare the fissures in the bone, however long they may be. These long incisions should be kept open. Muscular masses have a marked tendency to reunite in such a way that the seat of fracture becomes shut off. The opening can be kept gaping by means of short pieces of rubber tubing, three centimetres in diameter, which are kept separate from each other by a second set of tubes at right angles. Those haematomata which form along the sciatic nerve and in the sheath of the femoral vessels, about the popliteal space and along the posterior tibial vessels, must be reckoned with. Whenever found in this condition, these sheaths must be opened, because they are protected from the antiseptic liquid and become starting-points of infection. Exploration of the soft parts sometimes brings to light tiny splinters which have perforated the muscles. These are removed at the same time as the lacerated portions of muscular tissue.

Splinters are often found lying free between the fractured extremities and in the medullary canal. These splinters are removed. The medullary canal is explored, and in the case of longitudinal fractures, the marrow is removed. All splinters adherent to the periosteum are preserved. Experience has shown, in fact, that fractures so treated become sterile, heal without sinuses, and rapidly consolidate. And, on the contrary, the extensive removals of splinters which too often have been practised in the "ambulances" at the front, have yielded deplorable functional results. Even very serious injuries of the bones should not be followed by immediate amputation, except in the cases of extensive smashing-up of the skeleton, or of destruction of vasculo-nervous bundles. Careful cleansing, as conservative as possible, should be made of the multiple seats of fracture, with the object of placing the conducting tubes in contact with bony surfaces. Thus it becomes possible to save many limbs which otherwise would be condemned to amputation.

Most careful haemostasis is practised. But avoid leaving compresses in the deeper parts of the wound, or only leave them there for a few hours.

{b) Cleansing of Joint-injuries. - Wounds of joints are treated in different ways, according as the synovial membranes are alone concerned, or the bony extremities in addition.

When synovial cavities are alone concerned, the projectile is extracted, and the joint emptied of the blood it contains. The contaminated region is isolated from the rest of the joint cavity by compress or suture, and the instillation tube is placed in the situation previously occupied by the foreign body.

If the bony lesions consist simply of a chafing of the surface, or perforation of one of the extremities by a projectile, or an unimportant fracture of an epiphysis, the course to take is almost identical with that we have just described. The only addition is to scrape the bony surface which has come into contact with the projectile or with shreds of clothing. This region is cut off as completely as possible from the rest of the articular cavity, and submitted to instillation of the antiseptic liquid.

Should the bony lesions be very extensive, it becomes necessary to perform a resection. But primary joint resections are to be made with circumspection. Because, chemiotherapy often allows repair of extensive lesions of articulations, which, under any other treatment, would have had to undergo resection of the osseous extremities.

B. Inflammatory Period

This stage may begin about six or eight hours after the incidence of the wound. But usually it starts towards the twenty-fourth or thirty-sixth hour, sometimes not until after the lapse of several days.

Two quite different classes of phenomena are observed: gangrenous infections and phlegmonous infections. The first are of early onset and rapid progress. The second are slower to appear, more tardy in evolution. Both types of infectious manifestation may coexist in the same wound. Their symptoms have been described by the classic authors. But their pathological physiology is little known. Only it is recognised that the general reaction following surgical traumatism is much more violent during the inflammatory period than during the pre-inflammatory stage. Manipulation and laceration of tissues may set up grave complications when microbes already swarm in the walls of the wound. We have seen cases operated on at the expiration of several days for a localised infection, present signs of septicaemia and die after this interference with the focus of infection. At the beginning of the campaign, tetanus at times occurred a few hours after such operations. And when the nature of the infection was less alarming, still the general condition of the patient remained worse than before, and his temperature chart showed great fluctuations for several days afterwards. Hence, whilst the toilet of a war-wound should be carried out in minute detail before the advent of inflammatory phenomena, it is prudent to confine oneself to what is strictly necessary, during the stage of confirmed infection.

The course to adopt varies according as the infection is of the gangrenous or the phlegmonous type.