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Un dee symbolaa suivants apparaftra sur la derniire image de cheque microfiche, selon le caa: le symbols -^ signifle "A SUIVRE". le symbols y signifle "FIN". Maps, plates, charts, etc.. may be filmed at different reduction ratioa. Thoaa too large to be entirely included in one expoaura are filmed beginning in the upper left hand corner, left to right and top to bottom, aa many framea aa required. The following diagrama llluatrata the method: Lee cartaa. planchee, tableaux, etc.. peuvent Atre fiimie i dee taux da rMuction diffArants. Lorsque le document est trop grond pour Atre reproduit en un seul cllch4, 11 est filmA i partir da Tangle supArieur gauche, de gauche i droite, et de haut 9n baa, en prenant la nombra d'Images nAceesaire. Las diagrammes suivants illuatrant la mithoda. 1 2 3 1 2 3 4 5 6 (L\ SVNeV>\\e<"<^ , "VvavNCA'b RE-PB JITED FROM THE "CANADA MEDICAL & STTROICAL JOUBNAL." JULY. 1886. CLINICAL REMARKS ON THE TREATMENT OF COMPOUND FRACTURES. PBLIVBHtm) AT THB MONTRBAL GbNERAL HOSPITAL, 12t« MaY, 1886. Bt FRANCIS J. SHEPHERjg^M.D., Sargwn to the Hotpital. Gentlemen : — The treatment of compouud fractures was, up to the period of the introduction of antiseptics, in a very unsatis- factory state. The surgeon always dreaded the occurrence of such fractures in his practice, knowing how uncertain the results of treatment were, and liow often these cases died of blood-poiton- ing. If the external wound was small, good results frequently resulted by immediately scaling the wound with its own blood, collodion, or the compound tincture of benzoin, but not unfre- quently the wound failed to close and suppuration ensued, often necessitating an amputrtion, which frequently ended in death. Occasionally there was not time for amputation, the patient dying rapidly of pyaemia. If such results not infrequently followed fractures acoom- panied by slight wounds, in larger wounds, with much laceration of tissues, the leg was rarely saved, and if not amputated imma" diately, fatal pyaemia generally followed. The idiosyncrasy of the patient and not the surgeon and his methods had to bear the blame of the fatal issue. It was only with the knowledge of the principles of antiseptics and their influence in wound treat- ment that the cause of failure of success in the treatment of wounds was understood ; then it was found that it was from external and not internal sources that danger was to be feared. Lister was the first to insist on the necessity of absolute cleanli- ness, not only of the wound, but of the surgeon himself and the instruments employed by him. He introduced the method of treating compound fraoturM by carbolio «Qi4. It wm fini am- r^ ployed in the form of a paste made with whitening and linseed oil, and gave very fair results, remarkably lessening suppuration. Later, the gauze, spray and Mcintosh were employed, and wounds connected with fractures were treated like wounds in other parts with the best results, but with an infinite amount of trouble. Still later, iodoform and bichloride of mercury came into vogue, and dry and infrequent dressing of the wound with some anti- septic absorbent material, such as cotton-wool, jute, peat, wood- wool, etc., surpassed any method that had previously been em* ployed. This method of treatment I shall shortly describe, the results have been most excellent, and, armed with a know- ledge of modern antiseptic surgery, no surgeon need now dread treating a compound fracture of the leg, even if the bones be comminuted and the wound large. Compound fractures being most common in the leg, I shall describe the treatment adapted to such a case. The method is a6 follows* ; — When called to treat a compound fracture of the leg, if there is severe hemorrhage and the wound is small, it would be better to enlarge it and search for the bleeding point. Having arrested all hemorrhage and placed the fragments in proper position, the wound should be thoroughly irrigated with a solution of 1-1500 of mercuric bichloride and then dusted freely with iodoform ; over this, some washed gauze wrung out of bichloride solution is placed over the wound, and over this a pad of finely- carded sublimate jute, covered with bichloride gauze, and dusted with iodoform. This pad is kept in place by an antiseptic gauze bandage, and the leg placed in a Mclntyre or other sphnt. The pad, if there be much oozing, should be removed next day and a new one applied, but the gauze over the wound bad better not be disturbed. After this the dressings should not be changed unless the temperature and general condition of patient indicate that something has gone wrong in the wound. In my cases, as a rule, the second dressing has been left on a month, with result of finding, on its removal, the wound perfectly healed. If the * In dMoribing this method, it is, of onurve, understood that before trefttiog the wound the surgeon's hands and instruments should be rendered aseptic by the luual means, a deeonption of which is unnecessary here. wound ig not of very large size, I have been in the habit of im- mediately putting up the leg in plaster-of-paris bandages, leaving a window opposite the wound, protecting it with an antiseptic towel whilst the plaster is being applied. The edges of the window I stuff with antiseptic jute to prevent the blood and serum getting under the plaster. After the plaster has been applied, the wound is dressed in the way I have described above. It is a very rare occurrence that the dressing has to be removed after the second day, when oozing generally ceases. In one case treated in ward 23 last summer, where there was a com- pound fracture of the ankle joint, with rupture of the posterior tibial artery, the wound was enlarged, the artery tied, and the parts dressed with iodoform and a large jute pad, and left un- disturbed for a month, with the result of finding, at the end of that time, the wound completely healed. The temperature never rose above 99^F. In another case of compound fracture of the thigh, the same result followed the same course of treatment ; and many fractures of the leg have healed in this way without the slightest febrile reaction. When thd wound is large, sutures of catgut are used ; but when not very large, no sutures at all are employed, the wound apparently, with the aid of iodoform, which forms a crust over it, healing as under a scab. I take this opportunity of presenting to your notice the patient, Ed. N., aged 33, sailor, now before you, who has occupied abed in ward No. 23 for the last nine months. His history is shortly as follows : On the 11th of August, 1885, he was brought to the hospital with severe compound fracture of both legs, consequent on falling some twenty feet into the hold of a ship. He had lost a considerable amount of blood, and there was a good deal of oozing when he was admitted. My house surgeon. Dr. Eberts, as it was near the visiting hour, merely put on an antiseptic towel and bandage. On my arrival, I found that patient had sustained a compound comminuted fracture of left leg, the wound in soft parts being some two inches long, and a compound fracture of right leg, with considerable riding of bones and a large amount of laceration of soft tissues. Both legs were much swollen. After cleansing the wounds in both legs thoroughly, the left was put 9^" "^ up in plaster'of-paris bandages, a window being arranged for opposite the wound. The right leg was so severelj lacerated that it was not thought wise to put it up in plaster, so a Mclntjre splint was employed. The wounds were dressed in the manner I have already described. The same night, owing to the pro- fuse oozing of blood, the dressings had to be changed. From that time till the 9th of September (nearly a month) the dress- ings were not removed, and then the wounds were found com- pletely healed, or, rather, scabbed over. After the third day, the temperature, which, on the second day, rose to 100*^, was perfectly normal. The fracture of left leg, on removal of dress- ings, was found to be firmly united, but there was no union in the right, in which, as I said before, there was considerable riding of fragments, the bone being broken about the junction of lower with middle third. The bones were rubbed together and put up in plaster-of-paris. From time to time this was renewed, the man being allowed to go about early in November, and at present you see he has fair union in right leg. but some shortening. He leaves hospital during the present week to return to his occupa- tion. I have advised him to wear for a time the plaster splint on his right leg. This case is a very good example of the happy results of this method of treating compound fractures when the wound is very extensive. Before the introduction of antiseptics the man would probably have had one leg amputated, and might possibly have lost his life by some form of blood-poisoning h the effort to save the other. As it is, the man is in a fit conciit'ini ■to resume his ordinary vtork, and the accident will not in the slightest degree interfere with his future prospects.