Mr. Syme, for instance, says, in his clinical remarks:- "I was able to say, that in the course of twenty-five year's practice, I had always succeeded in restoring firmness by attention to the insurance of stability in the position of the limb; and I expressed a strong impression, almost amounting to conviction, that various means of remedy, such as setons, subcutaneous division, ivory pegs, &c., owed any share of the credit which they had acquired to the care conjoined with their employment to keep the bones quiet."

We may here mention a case of ununited fracture of the tibia, which was some time ago under the care of Mr. Dixon, at St. Thomas's Hospital. The fracture had remained ununited for a whole twelvemonth, when Mr. Dixon made powerful extension of the limb, upon which something was heard to crack. The leg was cased in gutta percha, and union eventually took place. Now it was suggested that if ivory pegs had here been used, they might perhaps have obtained more credit than they really were entitled to. In fact, a change of action, by whatever means, may sometimes produce union.

Mr. Poland had at Guy's Hospital a young woman, about twenty-four years old, under his care, with ununited fracture of the femur. He gave her good food and plenty of vegetables, made her walk about, cased the limb in a starch bandage, and at last obtained union.

It is extremely probable that one of the most frequent causes of nonunion in fracture is an imperfect apposition of the ends of the fragments, or an interposition of muscular tissue. Incomplete adaptation has to all appearance a great share in results of this kind, and this circumstance should stimulate surgeons to pay especial attention to the setting of fractures, and to satisfy themselves, by an almost daily inspection, that the parts are actually and truly remaining in the position first obtained.

When it is considered that the usual evacuations necessitate an unavoidable amount of disturbance of the whole frame, and that these are very frequently repeated, it is surprising, as far as the femur and the bones of the leg are concerned, that ununited fractures are not more frequently met with. All patients with fractured femur should be placed on those beds which allow of all the functions being performed without the slightest shifting. It has also being suggested that a latent syphilitic taint is perhaps more frequently connected with the occurrence of non-union than is generally supposed.

We shall not omit to quote the excellent results which Dr. Valentine Mott, of New York, obtained by means of the seton. ("Transactions of the New York Academy of Medicine,' analysed in 'British and Foreign Medico-Chirurgical Review, July, 1852.') Dr. Mott gives nine cases of success by using the seton in cases of ununited fracture. He also relates the case of a boy, twelve years of age, with whom the seton failed in an ununited fracture of the humerus, (1826). "The ends of the fragments were then sawn off, and a silver wire pased through each, twisted, and brought out externally through a canula. The wire cut out from one of the bones in a few days, and the other was soon after removed. No great inflammation followed, and in a few weeks consolidation was complete. Dr. Mott calls these "wire sutures," and the

writer in the 'British and Foreign Medico-Chirurgical Review' remarks, "The wire suture' was thus employed several years prior to its adoption by Flaubert, of Rouen, to whom Malgaigne attributes its origin.” Ununited fracture, and the use of the pegs, are subjects of so much importance, that we have not hesitated to group together the preceding cases, under the impression that the collection of these nosocomial facts may prove of practical utility.-Lancet, Aug. 14, 1852, p. 152.

67.-ON COMPOUND FRACTURES.

By G. J. GUTHRIE, Esq.

SA fracture of a bone, however simple it may be in its nature, is said to be compound when accompanied by an external opening in, or a wound of, the soft parts, communicating with the broken bone-a complication which usually gives rise to ulcerative inflammation and suppuration throughout the whole extent of the injury, preventing thereby those milder processes being effected which, under the more favourable circumstance of the skin being unbroken, lead to a speedy union of the broken parts; whence the desire manifested by the surgeon, in ordinary cases of compound fracture, to close the external wound, if possible, but which, from the nature of a gun-shot wound, it is useless to attempt. A fracture is said to be comminuted when the bone is crushed, as by a heavy wheel passing over it. It may still, however, be a simple fracture, or without an external wound; and is, in that state, much less dangerous than a similar injury accompanied by an external opening, however small, the edges of which cannot be immediately and permanently reunited.

§ An arm or a leg, as a general rule, is not to be amputated in the first instance, for a compound or gun-shot fracture. An effort should always be made to save it; and, under reasonable circumstances with regard to the extent of injury, the comfort, climate, and ordinary good health of the sufferer, the object will usually be obtained, under good surgical treatment.

§ It is not so with the thigh. After the battle of Toulouse, forty-three of the best of the fractures of the thigh were attempted to be saved under my direction, and even selection. Of this number, thirteen died; twelve were amputated at the secondary period, of whom seven died; and eighteen retained their limbs. Of these eighteen, the state three months after the battle was: five only can be considered well, or as using their limbs; two more think their limbs more valuable, although not very serviceable, than a wooden leg; and the remaining eleven wish they had suffered amputation at first. Of the officers with fracture of the femur, one, having been taken prisoner during the action, died under the care of the French surgeons, by whom he was skilfully treated; the other has preserved a limb, which he rather wishes had been exchanged for a wooden leg.

In the five successful cases, the injury was in all at or below the middle of the thigh. In the thirteen others who retained their limbs, the injury was not above the middle third; and of those who died unampu

tated, several were near or in the upper third, and either died before the proper period for secondary amputation, or were not ultimately in a state to undergo that operation. Of the seven amputations which died, two were at the little trochanter, by the flap operation; and the others were for the most part unfavourable cases. In one case only was the head or neck of the bone fractured. This man lived for two months, and, from the dreadful sufferings he endured, it was much regretted that he had not lost his limb at the hip-joint at first. The operation ought, however, to have been the removal of the head and neck of the bone; but he was not seen in time by those who could or would have done this operation, which was then, however, only contemplated for the first time.

Nearly all the wounded, after this battle, had every possible assistance and comfort, from the second day after the action. The hospitals were well supplied with bedsteads-no inconsiderable point in the treatment of fractures, and several of the surgeons had been in almost every battle from the commencement of the war. The medicines and materials for their treatment were in profusion. The sick and wounded (1359 in number, including 117 officers) were in charge of two deputy inspectorsgeneral, ten staff-surgeons, six apothecaries, and fifty-one assistant surgeons; and the whole worked from morning until evening with the greatest assiduity. The surgery of the British army was at the highest point of perfection it attained during the war; and this enumeration is given to show the number of medical men required under the most favourable circumstances for 1500 wounded men, if they are to have all the aid surgery can give them. Doctors are not the most ornamental part of an army, but there are days in a campaign when many poor fellows find them the most useful.

Every broken thigh or leg was in the straight position, and the success was greater than on any previous occasion. Nevertheless, with all these advantages, there can be little doubt that if amputation had been performed, in the first instance, on the thirty-six out of the forty-three who died or only partially recovered, some twenty would have survived, able, for the most part, to support themselves with a moderate pension, instead of there being perhaps five, or at most ten, nearly unable to do anything for themselves. The Baron Larrey, with the elite of the military surgeons of France, as well as those of Germany, have maintained this opinion; and in the present state of our knowledge, it is perhaps the safest practice, particularly under doubtful circumstances, in which it cannot be ascertained whether rest, the best surgical care, and comfort may not be wanting, without all which a favourable result cannot be expected.

§ The peculiar difficulty in treating a gun-shot fracture takes place when the bone is splintered for some distance, as well as broken. In these cases, inflammation occurs internally in the membranous covering of the cancellated structure of the bone, which ends in the death of the parts affected; whilst the periosteum takes on that peculiar action externally, which ends in the deposition of ossific matter around the splinters which have lost their life, and are enveloped by it. The bony matter at first small in quantity, is gradually augmented, and deposited for some distance in the surrounding parts, so that it has been known to include the

the neighbouring vessels and nerves in less than twenty days; and at the end of a few weeks the quantity of ossific deposit is often very remarkable. Each splinter of bone becomes the sequestrum of a necrosis, in a similar manner as it is known to occur in the bones of young persons spontaneously affected by this disease, with this essential difference, that in the idiopathic disease there is only one, as if worm-eaten, sequestrum, perhaps the length of the shaft of the bone, and easily removable by one operation, whilst there may be in the traumatic disease several dead centres of dead deposit, each of which requires to be removed by an operation to effect a cure. This new bony deposit will often be half an inch and more in thickness, and at a late period is as hard as the old bone. The repetition of operations required in such cases is very distressing, particularly in the thigh, in which the disease often continues for months, and even years.

§ A musket-ball will often lodge in the less dense parts of bones, such as the great trochanter and condyles of the femur, without fracturing the bone; it will sometimes even pass through the femur above and between the condyles, merely splitting, but without separating the bone in parts or pieces. Balls sometimes lodge in the shaft of the femur, without breaking it, and frequently do so in the tibia, the humerus, the bones of the cranium, and even in others of less size. Balls thus lodged will sometimes remain for years-nay, during a long life, without causing much inconvenience. It is, however, generally the reverse, and they are often the cause of so much irritation and distress, that the sufferers are willing to have them, and even their limbs, removed at last, at any risk.

Whenever, then, a ball can be felt sticking in a bone, although it cannot be brought into sight, it should, if possible, be dislodged and removed, by the trephine, by small chisels, by small strong-pointed curved elevators, or by any of the screws invented for the purpose, which have sometimes been found efficient. An apparently useful instrument of this kind is attached to the forceps for extracting balls, more used in France than in England. When the ball can be seen as well as felt, the surgeon must be guided by his own experience and judgment with respect to the most fitting instruments. It is to be removed, if possible, whatever may be the means used for its abduction, after the wound has been properly enlarged for the purpose.

§ When a ball merely grazes a bone without breaking it, and passes through the limb, and no splinters can be felt by the finger, dilatation is unnecessary in the first instance; although some small splinters may be cast off subsequently, or a layer of bone may exfoliate, requiring assistance for their removal.

The bone may be fractured in a case of this kind transversely, and will require only the simplest treatment in an almost similar

manner.

§ If the ball should enter and be flattened against the bone without breaking it, and lodge against it or in the soft parts, it should be sought for and removed. When the ball is flattened and the bone broken, it may lie between the broken extremities, and even lodge in one of them,

rendering the case more complicated, and the necessity for close investigation more urgent.

§ When a ball strikes the shaft of a bone, such as the femur, directly and with force, it shatters it often in large, long, and pointed pieces, retaining their attachment to the muscles inserted into them. A fracture of this nature in the middle of the thigh will often extend downwards into the condyles, and as high as, although rarely into the trochanters. These are cases for immediate amputation.

§ Gun-shot fractures of the head and neck of the femur have been hitherto fatal injuries, unless the whole extremity has been removed. It is hoped death may be prevented without this most formidable operation, by the removal of the head and neck of the bone. If the upper third of the femur, below the trochanter, is badly fractured, and an attempt is made to save the limb, death generally occurs after several weeks of intense suffering. Few escape with a useful limb, which had been badly fractured in the middle part, their strength and health being destroyed by the pain, suppuration, and constitutional irritation which ensue.

The least dangerous and the most likely to be saved, are fractures of the lower third, or at most the lower half of the thigh, and when they do not communicate with the knee-joint an attempt ought always to be made to save them.

§ The preservation of a fractured femur from a musket-ball, when splintered to any extent, ought only to be attempted if the principal splinters can be removed. When the splinters of the femur are long and large, it has been supposed that if they retain their attachments to the soft parts, they may be placed in apposition and preserved. It ought, however, only to be attempted under the most favourable circumstances, and will not often even then succeed. In the humerus it is different. An examination by the finger, in the first instance, is necessary to ascertain the extent of the injury to the bone, and to enable the surgeon to remove the broken portions, as well as the ball or any extraneous substances which may be in the wound. The incisions necessarily required for this purpose in the thigh are sometimes neglected, or the surgeon refrains from making them from the great thickness of the muscular parts, and from the wound having taken place on the inside, near the great vessels, so as to render incisions of sufficient size or extent in some degree dangerous. The thickness of the muscular parts is not a sufficient reason for avoiding an incision, neither is the vicinity of the great vessels and nerves, although they may not be divided; and if the situation of the bone on the outside of the thigh be attended to, the broken portions may sometimes be got at, at that part, if not on the inside. If this cannot be done, amputation had better be had recourse

to.

The object of the examination of such a wound being to ascertain the state of the fracture and to remove the splinters and any extraneous substances, the extent and number of the incisions must depend on them; the true principle of what has been called dilatation in wounds. If the ball should have merely struck and grazed the bone, and passed out, causing a transvere fracture only, there is no necessity for making incisions at the moment, although one or more may be subsequently