145. The peculiar difficulty in treating a gunshot fracture takes place when the bone is splintered for some distance, as well as broken. In these cases, inflammation occurs internally in the membranous covering of the cancellated structure of the bone, ending in the death of the parts affected; while the periosteum takes on that peculiar action externally which ends in the deposition of ossific matter around the splinters which have lost their life, and are enveloped by it. The bony matter, at first small in quantity, is gradually augmented, and deposited for some distance in the surrounding parts, so that it has been known to include the neighboring vessels and nerves in less than twenty days; at the end of a few weeks the quantity of ossific deposit is often very remarkable. Each splinter of bone becomes the sequestrum of a necrosis, in a similar manner as it is known to occur in the bones of young persons spontaneously affected by that disease, with this essential difference, that in the idiopathic disease there is only one, as if worm eaten, sequestrum, perhaps the length of the shaft of the bone, easily removable by one operation, while there may be in the traumatic disease several dead centers of ossific deposit, each of which requires to be removed by an operation to effect a cure. This new bony deposit will often be half an inch and more in thickness, and at a late period is as hard as the old bone. The repetition of operations required in such cases is very distressing, particularly in the thigh, in which the disease often continues for months, and even for years.
The following case, related by Colonel Wilton, is instructive: “Lieutenant Timbrell, late of my old regiment, the 31st, had both his thighs broken at the battle of Sobraon; he would not allow amputation, so the doctor put him in a boarded ‘dooley,’ and his legs in a kind of trough. As I was also wounded, I used to see him almost daily, and I never heard him complain except the days when the doctor tried to extend his legs. Some time after our return to England (perhaps seven or eight months) I went to visit him, and found him quite recovered, and able to enjoy a day’s shooting as well as most people. He showed me many pieces of bone which had come away from his wounds, and appeared to have lost about three inches of his height; his limbs were rather bowed. He is now paymaster of the 6th Foot; and when I saw him, a few days before he embarked for the Cape, he was as active as ever, although I do not think he could either run or jump.”
146. A musket-ball will often lodge in the less dense parts of bones, such as the great trochanter or the condyles of the femur, without fracturing the bone; it will sometimes even pass through the femur above and between the condyles, merely splitting, but without separating the bone in parts or pieces. Balls sometimes lodge in the shaft of the femur without breaking it, and frequently do so in the tibia, the humerus, the bones of the cranium, and even in others of less size. Balls thus lodged will sometimes remain for years—nay, during a long life—without causing much inconvenience. It is, however, generally the reverse, and they are often the cause of so much irritation and distress that the sufferers are willing to have them, and even their limbs, removed at last at any risk. Whenever, then, a ball can be felt sticking in a bone, although it cannot be brought into view, it should, if possible, be dislodged and removed by the trephine, by small chisels, by small, strong-pointed curved elevators, or by any of the screws invented for the purpose, which have sometimes been found efficient. An apparently useful instrument of this kind is attached to the forceps for extracting balls; it is more frequently used in France than in England. When the ball can be seen as well as felt, the surgeon must be guided by his own experience and judgment with respect to the most fitting instruments. It is to be removed if possible, whatever may be the means used for its abduction, after the wound has been properly enlarged for the purpose.
147. When a ball merely grazes a bone without breaking it, and passes through the limb, and no splinters can be felt by the finger, dilatation is unnecessary in the first instance; although some small splinters may be cast off subsequently, or a layer of bone may exfoliate, requiring assistance for their removal.
The bone may be fractured in a case of this kind transversely, and will require only the simplest treatment in an almost similar manner.
148. If the ball should enter and be flattened against the bone without breaking it, and lodge against it or in the soft parts, it should be sought for and removed. When the ball is flattened and the bone broken, it may lie between the broken extremities, and even lodge in one of them, rendering the case more complicated, and the necessity for close investigation more urgent. A leaden ball when striking on the sharp edge of a long bone, such as the spine of the tibia, has been known to be divided on it, without the bone being broken. This has happened in the arm.
149. When a ball strikes the shaft of a bone, such as the femur, directly and with force, it shatters it often in large, long, and pointed pieces, retaining their attachment to the muscles inserted into them. A fracture of this nature in the middle of the thigh will often extend downward into the condyles, and as high as, although rarely into, the trochanters. These are cases for immediate amputation.
150. Gunshot fractures of the head and neck of the femur have hitherto been fatal injuries, unless the whole extremity has been removed. It is hoped death may be prevented without this most formidable operation, by the removal of the head and neck of the bone, according to aphorism 85. If the upper third of the femur below the trochanter be badly fractured, and an attempt be made to save the limb, death generally occurs after several weeks of intense suffering, more particularly when the bone is broken by the large two-ounce balls now used by the Russians in the Crimea.
The least dangerous and the most likely to be saved are fractures of the lower third, or at most of the lower half, of the thigh-bone. When they do not communicate with the knee-joint, an attempt ought always to be made to save the limb.
151. The preservation of a femur fractured by a musket-ball, when splintered to any extent, ought only to be attempted if the principal splinters can be removed. When the splinters of the femur are long and large, it has been supposed that if they retain their attachment to the soft parts, they may be placed in apposition and preserved. This may be doubted. It ought, however, only to be attempted under the most favorable circumstances, and will not often succeed even then. In the humerus it is different. An examination by the finger in the first instance is necessary to ascertain the extent of the injury to the bone, and to enable the surgeon to remove the broken portions, as well as the ball or any extraneous substances which may be in the wound. The incisions necessarily required for this purpose in the thigh are sometimes neglected, or the surgeon refrains from making them from the great thickness of the muscular parts, and from the wound having taken place on the inside, near the great vessels, so as to render incisions of sufficient size or extent in some degree dangerous. The thickness of the muscular parts is not a sufficient reason for avoiding an incision, neither is the vicinity of the great vessels and nerves, although they may not be divided; if the situation of the bone on the outside of the thigh be attended to, the broken portions may sometimes be got at at that part, if not on the inside. If this cannot be done, amputation had better be had recourse to. The object of the examination of such a wound being to ascertain the state of the fracture, and to remove the splinters and any extraneous substances, the extent and number of the incisions must depend on them; the true principle of what has been called dilatation of wounds. If the ball should have merely struck and grazed the bone, and passed out, causing a transverse fracture only, there is no necessity for making incisions at the moment, although one or more may be subsequently required to aid in the discharge of an exfoliated piece of bone, or of a splinter which may have been overlooked. If the ball lodge deeply in the soft parts, after breaking the bone, it should be removed, if practicable, by a second or counter-opening, and a free vent should always be made for the discharge. It may, however, be laid down as a general rule, that whatever is likely to be required during the first few days had better be done on the first than on the second or third; for after inflammation has commenced, any handling or examination of the limb, however gently made, gives great pain.