COMPOUND FRACTURES.-If the wound leading to the fracture is small, clean, and not contused, as is usually the case, in compound fracture by indirect vio lence, the wound and any projecting ends of bone should be thoroughly cleansed, the fracture reduced with as little enlargement of the external wound as possible, the wound loosely sutured, and primary union expected. In case the wound heals aseptically the course is that of a simple fracture, but, if suppuration sets in, the wound must be promptly opened up, thorough drainage provided for at dependent points, and irrigation instituted either continuously or, at least, often enough to keep it mechan ically clean until healthy granulations occur, after which the healing is con cluded under local treatment appropri ate to granulating wounds.
If, on the other hand, suppuration has already set in or seems inevitable from the contusion or the dirty condition of the tissues, provision must be made at once for thorough drainage, and the preliminary irrigation must be copious, better results being obtained from irri gation with large quantities of a weak solution than with smaller quantities of a stronger one, whose irritating proper ties kill the tissues as well as the bac teria. Yet even the most desperate cases may do well if after this extensive cleansing they are left alone for five or six days in the hope that during that time partial healing may at least di minish the size of the abscess-cavity and perhaps shut off the bone from it en tirely. Of course, in the presence of evi dences of existing suppuration, the sur geon may not hesitate to institute the most vigorous antiseptic treatment, but in doubtful cases the disturbance inci dent to frequent changes of dressing will certainly result in suppuration, while the expectant treatment may have a happier issue.
The necessity of removing detached fragments of bone depends almost en tirely upon the prospect of suppuration. In a clean wound fragments that are entirely detached may lie, while in the presence of pus even the ends of large fragments will be cast off.
To estimate the amount of sloughing that will occur Esmarch's artificial is chmmia is a safe guide, those parts being doomed to which the blood does not flow on the removal of the bandage. But it is inadvisable to attempt any exten sive clearing away of dead tissue until the bone has begun to granulate and the line of demarkation has formed.
The suture of periosteum, fasciae, mus and tendons and the ligation of bleeding vessels merit no especial no tice here.
As to the indications for resection or amputation, no definite rules can be laid down. In cases of doubt, however, it is always safe to delay amputation until it is clearly impossible to save the limb. Thus the patient is given every chance and the surgeon may avoid being sued for malpractice.
As to suppurating compound fract ures of the larger bones they need al most never be despaired of, from twelve to eighteen months being none too long for their ultimate and satisfactory re covery.