When there is a compound fracture of the os fe moris, and if the bone protrudes such a length that it cannot be with facility reduced within the skin and muscles, it should be sawn off, for it would pro duce too much injury of the soft parts, to make an incision calculated to replace the protruded por tion ; but in the tibia, and other thinly covered hones, the integuments may be incised to permit the bone to be replaced. After the os femoris has been replaced, the wound, if simple, ought to be approximated with adhesive plaster, but if contuse, leeches and poultices, or fomentations are requi site. No callus is secreted during suppuration ; and as this wound will suppurate, the limb should be placed in an easy attitude on M'Intyre's frac ture-splint, an eighteen-tailed bandage applied to prevent the pus burrowing, and to keep on the dressings, which should be simple; and as suppura tion ceases callus is secreted, and then the attitude of the limb must be attended to. When suppura tion is established, the diet should be nutritious. If the fracture be comminuted, we extract the loose fragments of bone, and treat it afterwards in the same way as has been described; hut from the depth of muscular substance, which prevents extraction of these fragments, and the escape of pus when formed, amputation often becomes a mat ter of consideration for the surgeon; or if in this fracture the femoral artery is wounded, or the knee joint involved, amputation should be performed. This mode of treating compound and comminuted fractures of the os femoris is also applicable to those of the tibia, fibula, os brachii, ulna and radius.
In fractures of the bones of the upper extremity, we have to consider that the arm has no weight to support, is nearer the source of the circulation, and its arteries inosculate more freely with each other, and its returning or venous circulation is more easily performed, consequently in compound fractures, an attempt to preserve the limb may be made with more propriety.
The os brachii when fractured is probably more disposed to form a false joint than any other bone, although in several cases the thigh bone has been affected with this disposition. In this process each Fractured extremity secretes callus, which becomes cartilaginous, but never ossifies; and around these ends a synovial pouch is formed by the cellular or muscular tissue, which secretes synovia, and thus forms a rude joint, but so move able as to render the arm useless. This flexible condition is to be treated with a simple apparatus of leather and iron, to prevent this false joint from moving; and if this fails, the ends of the hone may be rubbed on each other with the view of inflaming and exciting them to more action, the limb after wards being firmly bound up for a time, or an incision may be made down to the disunited ends of the bone, and rasped or sawn off, and then the bleeding ends put in apposition, and treated as if recently fractured. A third method is the em
ployment of a seton, all of which have occasionally succeeded, and as often failed.
The ribs are generally fractured near their centres, and commonly more than one at a time, and the middle ones more frequently than the extremes; from the lungs being close to them, and their fracture oblique and splintery, such accidents are extremely dangerous. When a simple fracture occurs, it is treated as directed in luxation of their sternal ends, together with local and general blood letting. If the pleura costalis be injured in this ac cident, inflammation and suppuration of this mem brane may follow, and lay the foundation for empyema (from within, and pus), or a collection of matter in the pleuritic bag; but em pyema may be produced by various other causes besides a Fractured rib. The greatest difficulty in this, and in all diseases, is a correct diagnosis, which if clear in this case, the matter must be evacuated by an operation termed paracentesis thoracis (from RildpdX•VTIG0 to perforate), which consists in holding up the integuments over the sixth and seventh ribs in their centres, in order that they may act afterwards as a valve, and making an incision through them to the extent of two or three inches, parallel and close to the upper edge of the seventh rib, then dividing to a more limited extent the serratus magnus and in tercostal muscles carefully until the pleura costalis appears, which should be punctured with a lancet, and a canula afterwards inserted to remove the matter. When all the fluid has been removed, the wound should be closed and treated on the princi ple of chronic abscess, which it more frequently resembles, than the acute. This operation is also performed for collections of serum or water, for cxtravasated blood, and for diffusion of air in the pleuritic bag. A fractured rib occasionally wounds one of the intercostal arteries, which pours out its blood into the pleuritic bag, oppresses the lungs, and afterwards produces empyema; and various instruments have been contrived to suppress this hemorrhage, but the finger of an assistant is un doubtedly to be preferred, and if there was only one rib injured and hemorrhage continuing, the sur geon would be justified in making an incision and thus compressing the artery, or first dividing it so as to allow its ends to retract, and then applying compression; on the contrary, however, in conse quence of there being more than one rib fractured, he is only authorized in using the lancet freely and administering digitalis and hyosciamus. One of these arteries may be wounded by a small sword or bayonet, in which case the above treatment by compression is to be adopted. The lungs them selves are sometimes wounded by a fractured rib, producing either hemorrhage or emphysema (from ouoraw to inflate.) When hemorrhage is the result, it is commonly alarming and requires active an tiphlogistic treatment.