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Show macrmzrs BY GUN-SHOT. 269 ration, that it is of the utmost consequence to watch and to " APPENDIX, keep the patient low. II. There is a considerable difference of character between the gun-shot fracture of the cranium and the fracture from a bludgeon, or from the head striking the ground; the fissures do not run so extensively from the shattered cen. tre; the injury is more local ; the fractured pieces are smaller, and more numerous; often comminated. IN the chapter of fractured bones I have omitted to give the varieties of fracture by gun-shot. As it is a subject neglected also by other authors, I take this opportunity, (though somewhat irregularly,) of remedying the omission. r.~'~"'\:" "UJ'A‘O-WVNAH wv ‘w‘ m .5.T.._ . .-n-v- m»,- OF THE VARIETY IN THE FRACTURE OF BONES BY GUN-SHOT. I. THE surface of a bone may be struck by a ball so that the ball is flattened on it, and yet no exfoliation of the bone takes place. I cut out a ball from the arm seven months after it had struck the humerus, and although it was flattened on the bone, the bone was not injured. I have seen the head of the humerus struck by a ball, which ball I found in the muscles of the back, as if divided, and yet no exfoliation took place. When the surface of a skull is hit by a ball, there is undoubtedly great danger, but still nothing is to be done in the way of operation; the skull will often escape unhurt, having suffered neither contusion, nor such injury of its surface as to make it exfoliate. My pu~ pils have related many cases to me where they have seen the skull struck by balls without a bad symptom; but lately, I have myself seen three cases of this kind, in one of which the ball was flattened, and passed two inches under the scalp, and yet there was no injury to the skull. How- In taking away these pieces the trephine will seldom be necessary ; yet let me here once more guard my reader against forcibly pulling away the pieces of the broken skull, for if he tear the (lura mater, a new and more dangerous case is established. III. When a ball strikes the cylindrical and middle part of a bone, it will break it into many pieces; but if it strikes the head of a bone, it will enter into it. If, in putting the finger into the shot-hole, where the ball has struck the centre of the bone, many bruised pieces are found,-if the ball has not merely hit the bone and struck off splinters, but has passed through its substance, then, I believe, the limb must be con- demned, for no good comes of the attempt to preserve it. The suppuration not only takes place amongst the soft parts, but in the centre and medulla of the bone; a bad discharge comes from within the bone ; the shaft of the bone dies, and a kind of imperfect and irregular necrosis is formed. The old bone does not unite; new bone is formed round both pieces; the sequestra remain loose, and yet so wedged, that it cannot be taken out, and it is therefore a tedious source of irritation, and after months of sulfering, amputation must be had recourse to. IV. There is a marked distinction, however, betwixt such a case and that where the ball does not perforate the bone with unsubdued violence, but merely breaks the bone; and there is of course a great ditference betwixt the ball perforating the ever, where the danger is so imminent, and where if symp- arm bone, the thigh bone, or tibia, and when the bones of the fore arm, or the fibula, are broken. I have seen the arm am- toms of an affection of the brain be allowed to commence, it is so seldom in our power to stop the progress of suppu- putated for the shattered state of the ulna ; but I believe this was wrong; for before and since I have seen worse cases do 1,7,; .,.":...,. u ‘ _y_mm More |
