However, to my mind the question assumes a totally different light when viewed by the pathological results we had occasion to witness. It may be remarked, before proceeding further, that it is impossible not to recognize the practical nature of the division of the sequestra made by Dupuytren into primary, secondary, and tertiary, according to their degree of connection with the parts, and this, notwithstanding Esmarch's assertions to the contrary; nor can I see that the distinction of them, proposed by the latter, into "fracture-splinter," and " necrosed-splinter," makes the thing a whit clearer, or the division a bit more useful; so that in the following remarks I will adopt the old division. The longitudinal sections into which the bone is split are mostly capable of consolidation, except at points where their connection, or the contusion they have undergone - of them in tin' M undetermined ' Tin-not of course
or those loosely connected haniri! r ly an edge, to the periare commonly Very juid li- ly i',-hcd parts in all directions to the primary. 'hose wholly! from their connection l>y the accident, are, in ures from the conical lall, peculiarly iiiiincroiis and ueiive in tin ir action. In some cases which I have had an ojijmrtunity of examining, the>c found, not only at the served in where partial olidation had taken place, the dead seijiiestra had n involved in the new bo&e,:nnl we, ta t look like the porcupine.
Whni to these ct.nsiderations liance of dtli.. pieces of acr cloth, r liftween Suggested l.y wor further reasons will be seen for tinwhich, 1 Ufollowed the ially it' it le t!i 'lent,: it he;i ( 11 which has occasioned it T. OF THE CRIMEAN WAR. ing all loose and slightly-attached fragments, and keeping t lu 4 aperture open, so as to allow of the free flow of the pus. We have seen that the severe commotion at the seat of fracture occasions the formation of that large " foyer" which is found full of detached and dead sequestra, disorganized tissue, and acrid pus, and which, unless it be got rid of, continues to bathe the ends of the shaft, gives rise to inflammation in the medullary membrane, supplies a depdt of absorption for the uncollapsing veins of the bone, and finally causes constitutional poisoning.
Now, as a ball traversing a limb carries the fragments it detaches towards its place of escape, it is evident that they will be the more easily got hold of and removed on that side of the limb. These are the grounds on which the practice, advocated above, is founded. Unless such a step as is indicated be had recourse to, I cannot see how it is possible, except in very rare and exceptional cases, to hope for the cure in the field of a compound fracture of a large bone by a conical ball. Dupuytren, recognizing the necessity of getting quit of these fragments, recommends the enlargement of both orifices to an extent so great as " that the fingers, introduced by either opening, should pass freely and meet without impediment."* This., he thought, however, should be avoided, if the part was very thick and muscular.
The proceeding sketched above, is in no way so severe as this, and would be probably as efficient in fulfilling the end in view. All surgeons who have had much to do with gun-shot wounds, are agreed as to the propriety of removing those fragments which are wholly detached; but some oppose This is a mere repetition of the opinion of Percy, p. 188 of his " Manual.' 01 THE r.x OU L the removal of any which retain the least attachment. 'I'll.' objections which have been advanced against the extraction of these, are.chieily, that they assist in tin of the breach, by throwing out bone, and that if i le, thev will be extruded by the suppurative process.
To this it is replied that, it' these fragments are at all extensively attached, their removal is never contemplated, but that if they are connected only by a border, or an end. to tinshaft or the periosteum, they can contribute but very slightly to form callus, and will almost in every ne small part that is covered by periosteum may L renerate callus, but the.rest of their bulk will surely perish, and give rise to abscesses and fistulous.ings; and the amount of irritation, constitutional rbanee. and wasting suppuration which they will cause, before they are thrown out by the elimi native force of nature, are such as to make it impossible for any but those whose constitutions are the strongest and i nous to withstand it.