It is important to notice the rapid disappearance of pain in these cases of infected wounds. As soon as Dakin's solution has got rid of the infiltration of the tissues, the dressings cease to be painful. Wounded men whose wounds are sterile do not suffer.
3rd. Suppurating Wounds. - In wounds of long standing, which are already freely suppurating when the antiseptic treatment is begun, the earliest sign of the action of the antiseptic is a characteristic change in the pus. This takes on a viscous consistency, while its colour becomes yellowish, transparent. In a few days it lessens in quantity, then disappears. Granulations change their aspect and become red and even. If, the technique being correct, these modifications do not present themselves, it is certain that in the depths of the wound there exists a foreign body.
In wounds of the soft parts, suppuration disappears completely at the end of two or three days. A little thick transparent liquid still remains on the surface of the wound after it has become surgically sterile. In compound fractures, suppuration continues so long as the liquid is not introduced into all the cavities where microbes are found. If suppuration remains stationary, it is certain that there is a sequestrum, or an infundi-bulum where the liquid is not penetrating. Without further delay, the necrosed splinters should be removed, and the wounds placed under conditions which will allow the liquid to penetrate everywhere.
At the outset of the evolution of fresh shell and bomb wounds, fever persists for several days. Frequently, beginning at the third or fourth day, the temperature drops, little by little; sometimes, in deep irregular wounds, it may keep up longer. When the tubes are well placed and the instillation of the antiseptic is adequate over the whole surface of the wound, a dissociation or want of relation between the temperature and the other signs of infection is produced. Often cases are seen with an elevated temperature, but without the general signs of intoxication. They eat and sleep in almost normal fashion. The tongue is pink and moist. They are calm, complain of no pain, and do not look like sick men. This condition may be attributed to the destruction by the hypochlorite of the substances which produce the general symptoms of infection, or to a considerable diminution in the volume of infection. In these cases the infection manifests itself only in the high temperature.
The persistence of pyrexia amongst cases whose wounds are in a fair way of sterilisation is due, generally, to the presence of a small diverticulum where the liquid is not penetrating. In fresh compound fractures the wound surface may be protected against the antiseptic by necrosed tissue, by a compress, or by a blood-clot. As a consequence, infection develops and persists in the region which is in this manner withdrawn from the action of the antiseptic. It may happen also that the tubes are not placed deep enough, or that the liquid is not distributed over the whole surface of the wound. Almost the whole of the wound is sterilised, but at the point not irrigated infection continues. But, usually, this infection is too slight to give the patient the appearance of a sick man. There is a profound difference between the facial appearance of a patient whose wounds are in a fair way for sterilisation, even if he still has some fever, and the "look" of a man whose wounds, treated aseptically, are still suppurating. In suppurating cases, even when the wounds are well drained and the temperature but slightly raised, frequently the general signs of septic intoxication are found. These men do not sleep. Appetite is gone and the tongue is dirty. They are at the same time agitated and depressed, and they are in pain. The complexion is leaden. In a word, they are sick men. Immediately these cases are treated by the antiseptic method and suppuration begins to lessen, the general condition changes. After a short time they take on the appearance of cases whose wounds are sterile.
Very rarely, there are cases in which septicaemia develops at the same time as the wound is becoming sterile. We have seen a case die of staphylococcal septicaemia, while the fractured thigh from which he suffered was in excellent condition. Staphylococci had invaded the circulation before sterilisation had had time to become effectual. But, happily, experience has shown that septicaemia is exceptional when the cases are suitably treated.
Clinical observation allows one to presume what may be the state of the wound, but it yields no certainty. In fact, wounds whose margins present neither oedema nor redness, whose surface is covered with even granulations and whose secretion is of the slightest, may still be strongly infected. The following case is an example of this. After section of the deep femoral by a shell-wound, a free incision had exposed the sheath of the sciatic nerve, which was filled with blood. After a few days this extensive wound had an excellent appearance. The man was in no pain, and had no pyrexia. A little lemon-coloured serum flowed from the wound. It was collected in a pipette. But the general appearance of the wound was so favourable that it was closed with strapping, without waiting for the results of the bacteriological examination. That evening the case had a temperature of 400 C. (nearly 1040 Fahr.), and the wound had to be taken down. The surgeon then asked for the bacteriological report, and learned that the transparent liquid contained chains of streptococci. Hence in certain cases clinical observation is absolutely impotent to instruct us as to the real condition of a wound.
Wounds also are met with, covered with greyish granulations and with a puriform liquid, which are aseptic, and which may be sutured with success.
Clinical observation should be looked upon as an adjunct to the bacteriological examination. Wounds identical in appearance, from the clinical point of view, may be in very different microbial conditions. Between a wound which yields five or six microbes per field of the microscope, and a wound which contains none, usually there is no appreciable clinical difference. All the same, the few microbes which remain on the surface of the first wound can retard by one-half the rapidity of its cicatrisation. The presence of these microbes is important, for it prevents our suturing. Hence the aid of the laboratory is needed constantly to ascertain the progress of sterilisation.