[11] Dupuytren made a division of the splinters of bone broken by gunshot into three classes, viz.: primary sequestra, those directly and completely separated by the force of the projectile; secondary sequestra, those retaining partial connections by periosteal, muscular, or other attachments, but afterward thrown off during the suppurative process; and tertiary sequestra, or necrosed portions, produced by the effects of the contusion and prolonged inflammatory action in parts adjoining the seat of fracture. In accordance with this arrangement, the removal by the surgeon of the primary and secondary splinters has been regarded as simply anticipating nature in her work; but Dr. Esmarch states, as one result of the experience of the surgeons of the Sleswick-Holstein army, that, in the majority of comminuted fractures, the removal of splinters retaining any connection with periosteum is unnecessary and often injurious, as is also the practice of sawing off the broken ends of the bone projecting from the comminuted part. By proper treatment and under favorable circumstances, he asserts, such splinters become impacted in callus, and in time unite with the other fragments of the bone, and in this manner a cure is completed without operative interference. It is a matter, however, of frequent observation that splinters which have thus become impacted in callus lead to mischief in various ways, or are subsequently discharged as if they were so many foreign bodies, while the removal of the jagged ends of the broken bone seems to be a valuable means of preventing irritation, and thus of favoring union between them; and English surgeons, therefore, generally pursue the practice above recommended.
[12] The officer referred to must have greatly improved in condition since Dr. Macleod wrote, as he has been of late on active service in India.
[13] Notes on the Surgery of the Crimean War, p. 264.
[14] In the surgical history of this war, this statement, which was quoted by the late Mr. Guthrie, in the Addenda to his Commentaries, is said to be a mistake, on account of the absence (not to be wondered at, amid the confusion of that period) of official records on the subject. Special reports on these cases were obtained at the time from Scutari, and were shown to the writer by the late Director-General shortly before his decease.
[15] A committee was appointed by the Surgical Society of Paris to examine and report upon this essay of Dr. Legouest on Coxo-femoral Disarticulation for Gunshot Wounds. Baron Larrey drew up the report, which will be found in the 5th vol. of the Mémoires de la Société de Chirurgie, 1860. It confirms the principle laid down by Dr. Legouest, excepting only those cases of fracture where the mutilation of the limb from a heavy projectile has been so great as to partly separate it from the pelvis, and those in which there has been simultaneous lesion of the crural vessels and femur near the pelvis, with extensive laceration of the surrounding tissues.