COMPOUND OR COMPLICATED ILLUSTRATING THE VALUE OF OPERA TIVE INTERFERENCE IN THE TREATMENT OF THESE INJURIES.
the kindness of Colonel Girard, Chief Surgeon at the United States General Hospital at San Francisco, he had been able to inspect a large number of gunshot fractures, and had been deeply im pressed by this consideration,—that a very considerable amount of loss of tissue may be sustained without succeeding material de formity after repair has taken place, or, in other words, a large amount of interspace may be expected to be filled in efficiently during the process of repair. He recalled one case in which a Mauser bullet carried away nearly one-half of the femur for a distance of two and one-half inches, fracturing the bone com pletely. The remaining portion of the bone was comminuted, so it was doubtful if there were more than two-fifths of the circum ference of the femur which were brought into apposition with its opposing fragment. In that case the result, after some four months, was almost perfect.
DR. JAMES E. MOORE, of Minneapolis, said that plaster of Paris was in great favor with the Western surgeons as a fixation agent. Where the patient is under the immediate control of the surgeon the plaster of Paris is not infrequently applied at once. Where he is not under immediate control, or where he is not seen immediately after the accident and until after swelling has taken place, he is cared for very much as he had seen them cared for in the hospitals in Philadelphia, until the swelling has gone down, then the plaster-of-Paris dressing is applied. There is no question but that the operative treatment in many cases of fracture is the only proper treatment. One of his colleagues at the present time was making a series of experiments bearing upon the possibility of injury to the nerve supply of some of the long bones as a causative factor in non-union or delayed union. His experiments, however, are not yet complete, although he has given verbally some very strong evidence pointing towards that as a cause for non-union.
DR. WHARTON remarked, with reference to the case of com minuted fracture in which a large fragment had been retained, that in many cases of comminuted fragments he would have re moved them all and have gotten marked shortening, but here, where he had one large fragment, he thought he could reduce the shortening by wiring, and he felt justified in making the attempt. He thought that in this case he would eventually get a useful limb by having a plaster-of-Paris bandage put on, and allowing him to go around as they do in the ambulant treatment; that is, by walking in the plaster bandage, or by having the brace adapted so that a certain amount of weight can be brought to bear on the limb and a certain amount taken off the limb at the seat of fracture by means of the brace.
With regard to the method of fixation in compound fractures, he was not at all wedded to the silver plate. In the larger number of compound fractures in which he secured fixation by suture, it was by means of heavy silver wire. By applying more than one heavy silver-wire suture one can get as good fixation as by the silver plate. In using the plate, the screws, unless very carefully made, are apt to have the heads turn off or split. A mistake in using the silver wire is in not using it heavy enough in order to stand a certain amount of strain.
With regard to the question of compound fractures involving the joints, he agreed with Dr. Allis that in a majority of cases the functional result would be better if operative methods were adopted. He was not able to agree with him as to the advisability of operating in patients suffering from intracapsular fractures of the femur, for such operations would be followed by a very heavy mortality ; but in younger patients, and in some other joints, operation would be followed by much better results as regards the function of the limb.