he use of an anaesthetic
without causing undue suffering to the patient, it allows of ready
change of the dressing, it is comfortable and permits considerable range
of movement on the part of the patient, it is as efficient with patients
lying on the ground as in a bed, it keeps the limb in good position and
allows of constant inspection on this point, and it is the only method
which provides satisfactory extension without constant readjustment.

[Illustration: PLATE XX.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson Ltd.

(38) TRANSVERSE FRACTURE OF THE TIBIA, COMMINUTED FRACTURE OF THE FIBULA

Range '300 yards.'

Wound of soft parts nearly transverse, entry on tibial aspect. The
bullet crossed and grooved the posterior aspect of the tibia, but struck
the fibula full. This is the only instance of a transverse cleft which
came under my notice.

The wound suppurated, and a number of fragments of the fibula needed
removal; hence the amount of callus present.]

Cases in which operative fixation is indicated are rare, but a few
oblique fractures may be treated with advantage in this manner if the
conditions surrounding the patient admit of it. Screwing is generally
preferable to wiring.

Lastly, we come to the cases in which primary amputation is necessary. I
may say at once that I saw no case of wound from a bullet of small
calibre in which this was indicated, and only one shell injury in which
it was performed. I believe with small bullets that injury to the main
blood-vessels is almost the only indication which is likely to be met
with, and this by no means always indicates an amputation. First of all
the question arises as to whether the wound in the vessel is caused by a
bone fragment or by the bullet itself; reference to the chapter on
blood-vessels would seem to prove that a bullet wound is by no means a
necessary indication for amputation. Given favourable conditions, it
might be treated locally by ligature at the time, while if haemorrhage is
not proceeding, developments should be awaited before proceeding to
amputation. In the case of bone fragment punctures, secondary haemorrhage
is a more likely indication for amputation than primary.

Broadly, it may be laid down that very extensive injury to the soft
parts is the only indication for primary amputation beyond primary
haemorrhage, and it may be added that the condition is rare with wounds
from small-calibre bullets. If a primar