Case 321 came to hospital four hours after having received a shell-wound in the right arm. He presented an extremely comminuted fracture of the superior extremity of the humerus directly below the head. The superior orifice was laid open freely and cleansed carefully. A counter-opening on the anterior surface of the arm was made, to remove the projectile, and to take away a large number of small fragments of bone which were lying free. The medullary canal had to be curetted because several splinters had been projected therein. There resulted an extensive loss of substance; three instillation tubes were introduced. After twelve days the patient's temperature was normal, and the surface of the wound no longer yielded microbes to the test. On the fifteenth day the loss of bony substance was made good by Beck's paste, and the wound was closed by a series of intermuscular sutures, and a line of cutaneous stitches (Fig. 103). The twenty-first day stitches were removed. Union was perfect. The man recovered all the movements of the limb.

In non-comminuted fractures of the humerus, suturing was generally done from the tenth to the fifteenth day, and consolidation was brought about as rapidly as in a simple fracture.

(b) In fractures of the tibia, surgical asepsis was attained in a more leisurely fashion. Besides, the loss of integumental substance was often too great to allow of the margins of the wound being brought together. Then we had to be content with sterilising the seat of fracture and awaiting closure by granulation.

In this manner consolidation without a sinus of highly comminuted fractures may be obtained. Case 494 was injured in the middle third of the leg by a shell which fractured the tibia. In the course of the first surgical interference by MM. Hornus and Perrin, only the smallest of the free bony splinters were removed, the larger fragments being left lying between the osseous extremities. For nine days, Dakin's solution was instilled every two hours. When the case was brought to the hospital, ten days after receipt of the injury, there were still ten microbes per microscope-field, but the wound bore an excellent appearance, and the tissues presented neither redness nor swelling. The only operative interference was to blunt the point of a splinter which projected into the wound. A month after the injury, all the bony fragments had been covered by granulations, and the instillation tubes were discontinued. By reason of the extensive loss of skin substance cicatrisation came about slowly, but two months after the injury, healing was complete without a sinus (Fig. 105).

Fig. 103.   Fracture of humerus, fill ing in with Beck's paste. Case 321.

Fig. 103. - Fracture of humerus, fill-ing-in with Beck's paste. Case 321.

Fig. 104.   Fracture of tibia. Case 494.

Fig. 104. - Fracture of tibia. Case 494.

The conservation of fragments of bone is of great importance from the point of view of ulterior function of the limb. In sterilising splinters more or less denuded, we succeeded in making use of them, and in obtaining consolidation of the bone. In case 516, a shell had caused a serious fracture of the tibia, at the level of the junction of epiphysis and diaphysis. The internal two-thirds of the bone had been destroyed, while the external portion presented two long splinters almost completely denuded of periosteum. They were kept, nevertheless, because their ablation would have shortened the bone by seven or eight centimetres (Fig. 106): the anterior tibial nerve and vessels had been severed. The wound rapidly sterilised, but by reason of loss of substance it was impossible to close it. Seventeen days after the injury, there was to be seen at the upper part of the tibia a large wound, at the bottom of which was a bony cavity the size of a small egg. This wound no longer contained microbes. It was then filled with a paste containing chloramine, under which asepsis was maintained. Immediately it was filled up by granulations, whose surface became covered with epidermis. Cicatrisation was complete three months after the infliction of the injury. The fracture was almost completely consolidated, without either reinfection or elimination of sequestra being produced.

FlG. 105.   Same fracture , healed. Case 494.

FlG. 105. - Same fracture , healed. Case 494.

Fig. 106.   Suppurating fracture of the upper part of the tibia. Case 516.

Fig. 106. - Suppurating fracture of the upper part of the tibia. Case 516.

In some cases it is possible to close fractures of the leg. In case 627 the fracture of the tibia above the malleoli was found to be sterile ten days after the infliction of the injury (Fig. 107). The eleventh day it was completely closed, and on the sixteenth day the wound had healed by first intention.

(c) Even highly comminuted fractures of the thigh are sterilised in such a manner that in about half the cases suture can be practised. The degree of asepsis obtained in the non-sutured cases was sufficient to allow the seat of fracture to be isolated from the external wounds. Consolidation was produced almost as if a simple fracture had been in question. In none of the cases which reached us during the first twenty-four hours did a sinus persist. Infected fractures of the femur could be closed the 15th, 23rd, and the 25th day.

Case 560, aged 42 years, arrived at the hospital seven hours after having been struck by a shot which produced an extremely comminuted fracture of the left thigh. The diaphysis of the femur had been broken at the level of its middle third into multiple fragments (Fig. 108). The orifice of entry of the missile, which was internal, was very freely laid open, the contused muscular tissue was excised, and only two small splinters, which happened to be completely free, were removed. Four instillation tubes were placed in the seat of fracture. The temperature never rose above 380 C. (100° Fahr.) during the first four days, then steadily dropped and became normal. The number of microbes, which the second day was 30 per microscope field, diminished to one the 13th day. The 15th day the wound was hermetically sealed by silkworm gut (crins de Florence, Fr.). Union took place by first intention. The fracture was firm on the 47th day.