Case 289 was operated upon twenty-four hours after having received a shell-wound which broke the patella into fragments and displaced the condyles of the femur in an anterior direction without their fracture. The contused soft parts were carefully cleansed and all the fragments of the patella removed; the character of the fragments suggested those of an explosion. A compress was placed in front of the inter-articular line, and two instillation tubes were placed in the cul-de-sac of the quadriceps and in the patellar fossa. The temperature, which was 39.9° C. (102.2° Fahr.) on the day of arrival, fell by the fourth day to 37.5° C. (99° Fahr.). Similarly, the bacilli and cocci which were numerous in the smears were reduced by the seventh day to one per five or six fields of the microscope. The wound was then closed by elastic traction. Cicatrisation was complete by the fifteenth day, and passive movements of the joint commenced.

Case 594 had a shell-wound of the knee with partial fracture of the external condyle of the femur. The wound, which was still infected the sixth day (Fig. 101), became sterile the fourteenth day, and was sutured the twentieth (Fig. 102).

In the following case, despite the very extensive lesions, we were able to save the lower extremity of the femur.

Case 106, aged 22 years, had had a smashing-up of the lower epiphysis of the right femur, fracture of the left patella, and a large wound of the hand. He reached hospital in a grave condition of shock some ten hours after the infliction of the injury. Immediate transfusion was resorted to, and interference limited to placing instillation tubes in the crevices between the bony fragments which represented the smashed femoral condyles. Into the seat of fracture was instilled para-toluene sulphochloramine, 3 per cent. His temperature never rose above 390 C. (1020 Fahr.), and became practically normal at the end of a month. His general condition remained good, and his hospital stay ended by healing with an ankylosed knee (Fig. 112). In this case no surgical interference was practised at the outset because of the extreme gravity of the case. However, in spite of( the extent of the anatomical lesions of the knee, recovery took place without the patient's condition causing a moment's anxiety.

3rd. Suppurating Fractures. - The greater number of compound fractures treated by the usual methods suppurate more or less abundantly. We have examined the effects of chemical sterilisation on a score of fractures which had been previously treated in other hospitals, for periods varying from two to forty-six days. Suppuration generally disappeared in from one to four days after the commencement of treatment. But the bacteriological curves show that, after the disappearance of the pus, wounds evolve in different ways according to the localisation of the infection.

Fig. 112. - Smash of extremity of femur. Case 106.

Fig. 113. - Suppurating fracture of humerus. Case 624.

(a) In the first category of cases, the number of microbes rapidly lessens after the establishment of instillation, and in a few days reaches one per five or six fields. When the curve presents this aspect, there are in the depths of the wound neither infected fragments nor a focus of osteo-myelitis, and in spite of the suppuration, the seat of fracture becomes sterile as though a newly inflicted fracture were being dealt with. We have observed this result in several fractures of the humerus, radius, ulna, and some of the smaller bones. Here are two examples of this development.

Case 624, aged 34 years, entered hospital twelve days after a fracture of humerus from shell-wound (Fig. 113). He had been operated on a few hours after the injury. The left arm had two wounds, one internal, the other external. A big drainage tube traversed the seat of fracture. The limb was surrounded by a dressing stained with blue pus. The wounds were plugged with iodoform gauze, behind which was found a large quantity of pus. The drainage tube was removed, and instillation tubes inserted into both wounds as far as the seat of fracture. The next day the blue pus had, clinically speaking, disappeared. The following day the wounds had taken on the usual red appearance. The microbes, which were innumerable the first day, had completely disappeared ten days later. The two wounds were sutured twelve days after the entry of the patient into hospital. They united by first intention. Two other cases with similar lesions, at the same period, were sutured with like results.

Case 626 presented a semi-section of the upper portion of the forearm, with smashing-up of the two bones. He had undergone operation in a first-line ambulance, and arrived in hospital nine days later. The wounds were suppurating abundantly, the forearm was a little swollen and very painful. The dressings were soaked in a large quantity of blue pus. On the surface of the wound remained fragments of gangrenous tissue. The wound was dressed with a paste containing 1.5 per cent. of chloramine. Two days later the blue pus had disappeared. After three days the swelling of the forearm was gone and the wound was commencing to "clean up." But the microbes were still innumerable. The wound only became surgically aseptic after the lapse of a fortnight. It was sutured the twentieth day, and healed by first intention.

Case 618, aged 31 years, had a splintered fracture of the femur through the trochanters, due to a projectile which had penetrated the antero-external aspect of the thigh. He was operated on in a first-line ambulance eight hours afterwards. He arrived at hospital twelve days later. The limb was put up in plaster with a "window." A large rubber drainage tube which was found in the wound was removed, and replaced by three perforated instillation tubes. The patient's condition was good. But the region of the hip was painful and a little swollen. The wound presented scanty secretion which did not yield more than ten to twenty microbes per microscope field. Seven days after the arrival of the case at the hospital the wounds were almost aseptic. Then the two instillation tubes were removed and the wound filled up to the level of the seat of fracture with chloramine paste. The wound became aseptic. We waited until the twentieth day before closing it. Union took place by first intention (Fig. 114).