considerable, but a fair result was as a rule
obtained.

Suppuration and osteo-myelitis were the dangerous features when they
occurred; still, even in the presence of these, I never saw a fatal
result in an upper extremity fracture, although in the lower extremity
a considerable mortality followed fractures both of the leg and thigh,
the deaths being most commonly from septicaemia, or from a combination of
this with secondary haemorrhage.

_Treatment._--The general treatment was of a simple character. The
perforations may be at once dismissed, since nothing more was needed
than what has been already described under the heading of wounds of the
soft parts. Again, with regard to the co-existence of vascular injury,
or injury to the soft parts generally, the ordinary rules guiding us in
civil practice were followed.

The first point of importance, and needing consideration in the
treatment of severely comminuted fractures, was as to whether in these
it was better simply to try to obtain union of the wound with as little
disturbance as possible, or to anaesthetise the patient and explore the
wound, removing such fragments as were free or widely displaced. I think
the answer to this question depends entirely on the nature of the
external wounds. If these be of the small type forms, or if the exit
aperture is, at any rate, of only moderate size, a strictly conservative
attitude is the better when the risk of making an exploration under the
circumstances is borne in mind, the more so as an exploration, to be
safe and useful, ought to be done at once. If the exit wound is of the
large or explosive type, on the other hand, there is no doubt that the
best results are to be obtained by early exploration and the removal of
all loose fragments. I saw several excellent results obtained in this
way, even when the patients had to undergo the risk of transport
shortly, in some cases the very next day, after the operation. The loose
fragments are an immediate source of danger, and later may interfere
with the healing of the fracture, even if suppuration does not occur. In
all the cases that I saw the exit wound was dressed, but left freely
open, and I do not think any attempt to close it should ever be made.

The question of operative fixation rarely needs consideration; it
occasionally happens, however, that oblique fractures, such as one
mentioned on p. 166, are met with, in which screwing or wiring of the
bone ends is advisable.