osed
tissue for many weeks.

[Illustration: PLATE XV.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson, Ltd.

(33) COMMINUTED FRACTURE OF THE FEMUR

Range 'short.'

Normal entry wound of slightly oval form.

Oblique lateral impact on the part of the bullet, the mantle of which
burst into numerous fragments. The bullet is seen to the inner side of
the shaft, almost devoid of its mantle, and little deformed at the tip.
The comminution of the upper portion of the fracture is very fine; the
bullet has merely cut its way down the lower portion, and one or two
long fragments are separated. The skiagram shows well the result of
lateral impact by the side of the bullet.

Compare this plate with No. VI. as illustrating lesser resistance, and
No. VIII. as illustrating the effect of lower velocity.]

In a large proportion of the cases which were transported for any
distance suppuration occurred; this must have been the case in at least
60 per cent. of the fractures. Suppuration was of the character already
described in the general section, affecting particularly the bone
itself, and accompanied by very marked signs of general infection.

_Prognosis in fractures of the femur._--As regards mortality fractures
in the upper third of the bone proved one of the most formidable
injuries which came under treatment. Suppuration was common, at least 60
per cent. of the wounds becoming infected. This depended on several
reasons, often inseparable from the injuries, or from their treatment in
Field hospitals: such as (1) the exit wound being situated in the
dangerous region of the thigh; (2) ineffective dressing and fixation;
(3) the impossibility of ensuring primary cleansing and removal of
detached fragments of bone; (4) the necessity of the early transport of
patients to the Stationary or Base hospitals, often for great distances;
(5) the comparatively long period that often had to elapse before the
opportunity of doing the first efficient dressing arrived.

Fractures in the middle and lower thirds of the bone were more easy to
treat successfully, but these also added to the list both of amputations
and fatalities.

Punctured fractures of the lower articular extremity were usually of
little importance, as they progressed without exception, as far as my
experience went, favourably.

I can give no idea of the general results obtained during the whole
campaign, but I am able to state the results of the fr