Fig.107.   Fracture of the tibia. Case 627.

Fig.107. - Fracture of the tibia. Case 627.

Fig. 108.   Fracture of the femur. Case 560.

Fig. 108. - Fracture of the femur. Case 560.

Another case, No. 495, aged 29 years, had received a wound from the explosion of a mine which fractured the right femur at the junction of the lower with the middle third. Some hours afterwards at the V- field-hospital, MM. Hornus and Perrin removed some fragments and the foreign body, cleaned up the contused muscles, and placed conducting tubes for antiseptic liquid in the seat of fracture. The 23 rd day, microbes having disappeared from the secretions, the wound was closed with silkworm gut. At this date the case was brought to us (Fig. 109). Union of the edges of the wound took place by first intention. Consolidation was attained, and the patient walked on the 43rd day. There was three centimetres of shortening, and the knee possessed its normal mobility.

Case 493, aged 38 years, had a fracture of the right femur caused by shrapnel (Fig. no). He was first treated at the V- field-hospital, where MM.

Hornus and Perrin removed the projectile and some small splinters. Like the preceding, the wound was irrigated by means of Dakin's solution. After seven days he was sent to Compiegne. The temperature was 370 C. (98.5° Fahr.), the wound was a healthy red and presented no sign of suppuration, the surrounding integuments were supple and free from tenderness. At this stage, the number of microbes was about twenty per microscope field. On the 23rd day it had dropped to one per three fields. The wound was closed the 25 th day by silkworm gut, and healed by first intention. Consolidation was complete 44 days after the infliction of the injury.

The number of fractures of the thigh treated by us was very limited. But there is no doubt that similar results can be obtained when fresh compound fractures are treated by methods similar to ours. Recently M. Hornus treated, in one of the hospitals at the front, thirteen cases of compound fracture of thigh. After four or five days the cases had a normal temperature and no suppuration. In eleven cases, secondary suture was practised. We have seen also, with M. Depage at the hospital of La Panne, fractures of the thigh which had attained surgical asepsis and been closed.

Fig. 109.   Comminuted fracture of femur. Case 495.

Fig. 109. - Comminuted fracture of femur. Case 495.

Fig. 110.   Fracture of femur. Case 493.

Fig. 110. - Fracture of femur. Case 493.

It appears, therefore, quite evident, that in fractures of the thigh, and with still more reason in fractures of the tibia and humerus, it is quite possible to avoid suppuration while making very limited resections (esquillec-tomies, Fr.). Consolidation comes about rapidly, and cases are protected at the same time against pseudar-throsis and the interminable suppuration which so often follow compound fractures treated by the ordinary methods.

2nd. Fractures accompanied by Wounds of Joints. - When a wound was associated with the opening of an articulation, results differing according to the region were observed. When the lesion was limited to synovial membranes or to the edges of the articular condyles, arthrotomy followed by disinfection of the seat of fracture permitted the osseous extremities to be retained. Often functional integrity remained complete. The scope of simple arthrotomy could be enlarged, and the number of resections diminished.

In the cases of deeper osseous lesions and more extensive fracture of the articular condyles, we have also been able to avoid resection, and to preserve all the movements of the articulation. Here are two examples of compound fractures of the inferior extremity of the humerus completely restored by sterilisation of the wound.

Case 433, aged 25 years, had a fracture of the neck of the humerus, due to a fragment of shell which remained in the joint. Four hours after the infliction of the injury, the orifice was laid open freely, the walls of the track cleaned, and a resection performed, limited to the detached fragments of bone. After the missile was removed, tubes were placed in the seat of fracture. After fifteen days (Fig. 99) sterilisation was attained, and two days later the joint was closed with silkworm gut (Fig. 100). Union took place by first intention. The twenty-fifth day movements of the joint were begun. The functions of the articulation were reestablished completely.

Case 497 had a shell-wound of the right elbow which fractured the humerus, separating the epicondyle and part of the condyle of the humerus.

This case was treated at the Vfield-hospital by MM. Hornus and Perrin, who were content with sterilising the large wound by means of tubes going down to the seat of fracture. In fifteen days the wound was sterile. It was sutured the sixteenth day with silkworm gut, and united by first intention (Fig. 111). The movements of the elbow were re-established almost completely. There remained only a slight limitation of extension.

In wounds of the knee-joint results were observed comparable to a certain extent with those obtained in lesions of the elbow. In those cases where the anatomical conditions permitted, we have endeavoured to sterilise the articulation in such a way as to retain the normal movements.

Fig. 111.   Fracture of condyle of humerus. Case 497.

Fig. 111. - Fracture of condyle of humerus. Case 497.

Case 472 had multiple wounds of the soft parts, which were cleaned and disinfected, and a wound of the right knee with injury to the external condyle. A piece of a grenade had penetrated the external surface of the knee, traversed the synovial membranes, and lodged in the thickness of the condyle. The aperture of entrance was freely laid open, the walls of the track' resected, the projectile extracted, and the tunnel in the bone carefully curetted. The articular cavity was then dried and shut off by a compress placed beneath and within the damaged condyle, and an instillation tube introduced to the bottom of the bony track. The wound rapidly cicatrised. The eighth day the compress used for "shutting off" was removed, and on the twelfth day the articulation was closed. Union by first intention followed, and passive movements were commenced on the thirteenth day. The movements of the joint were so perfectly restored that the patient walked in a normal manner when he went out of the hospital.