THE ANAEROBIC BACILLI 767 



Debridement should be carried out as soon as possible after 

 infliction of the wound. Primary suture may be employed only 

 during quiet periods in case of war, and in hospitals where the 

 patient may be retained for careful observation. Otherwise suture 

 of the wound may lead to enclosure, within an imperfectly debrided 

 wound, of various microorganisms, including those which produce 

 gas gangrene. In regard to delayed primary and secondary suture, 

 the following observations of Dr. E. H. Pool are not without interest. 



"The determination as to when a wound may be sutured depends on bac- 

 teriologic findings and clinical observation. It must be emphasized that the 

 co-operation of a bacteriologist is indispensable in making a decision aS to the 

 indications for delayed primary and secondary sutures. The practical func- 

 tion and indisputable importance of the bacteriologist in war surgery lies in 

 this. In the consideration as to whether a wound is suturable or not, reliance 

 must be placed chiefly on cultures, the important feature being the determina- 

 tion of the presence or absence of hemolytic cocci. For this, a routine blood- 

 agar examination is essential. 



Bacterial counts are far from exact, yet they give an in.dication as to the 

 degree of bacterial contamination of a wound, especially the progress from 

 day to day, and are of value especially for one untrained in estimating 

 clinically the indications and contraindications for suture. 



From eighteen to forty-eight hours after the original operation of de- 

 bridement or excision of tissues, the wound is dressed and a culture and a 

 smear are made. A report is returned as soon as possible. This contains the 

 approximate number of organisms per field and the varieties of organisms. 

 If no organisms are found, suture is indicated. If hemolytic cocci are present, 

 suture is not considered. In the absence of hemolytic cocci, if the wound is 

 clinically suturable, the presence of a few anaerobes or other organisms 

 (approximately one in two fields) does not contraindicate suture. A con- 

 siderable number of organisms of any kind indicates delay of suture, until 

 the bacterial growth declines. A culture and a smear should be repeated at 

 the following dressing ; the results of this examination will determine suturing 

 or further delay. If the wound is left open for a considerable period, e.g., 

 over a week, or is definitely infected, a smear is made every two days. It is 

 also advisable to make a culture occasionally. Care must be taken not to 

 touch the skin surface in making the smear, since skin contamination vitiates 

 the value of the report. From the smear a bacterial curve is plotted accord- 

 ing to Carrel's plan. When the organisms in two successive counts are few, 

 that is, approximately one per two fields, and a culture shows an absence of 

 hemolytic cocci, the wound is considered susceptible of secondary suture 

 except when the wound has contained hemolytic cocci at any time. In that 

 case careful cultures are made from granulation tissue and from the discharge 



