y amputation is necessary the
observations as to the transport of fractured thighs are equally
applicable. I never saw a primary amputation do well that was moved
during the first week; sloughing of flaps or haemorrhage followed as a
rule, and often death.

Intermediate amputations were indicated in cases of septic infection and
those of haemorrhage; they seldom did well, and should be avoided if
possible. Secondary amputations for sepsis or haemorrhage were attended
by fair results, but I can give no statistics. Unless extensive
osteo-myelitis is evident, or very widespread cellulitis of the limb
exists, I am strongly of opinion that the amputations when the fractures
are above the middle of the thigh should be through the fracture, and
not at the hip-joint, even if a subsequent secondary operation is
risked.

[Illustration: PLATE XXI.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson, Ltd.

(39) PERFORATION OF THE SHAFT OF THE TIBIA, AND INCOMPLETE OBLIQUE
FISSURE EXTENDING FROM THE LOWER PART OF THE OPENING TO THE CREST OF THE
BONE.

Range medium. Entry and exit wounds at same level.

The patient was standing when struck, and fell backwards, his rifle
falling at the same time and striking the shin. The fibula is intact.

The perforation indicated by the well-marked translucent spot is small.

The forking of the lower extremity of the cleft suggests the starting of
the fissure from above. The fissure comes to the surface at the seat of
election, but its position may possibly have been determined by the blow
from the falling rifle.

The backward fall of the patient clearly explains the mechanism of
production of the fissure, and throws light on the production of an
oblique fracture such as shown in plate XVI.]

_Fractures of the patella._--Punctured fractures of the patella were
common with direct impact of the bullet; these were often difficult to
palpate, and were only to be certainly diagnosed by attention to the
direction of the track, and the development of haemarthrosis. I saw at
least three or four in which the bullet, in addition to traversing the
knee-joint, injured the popliteal vessels. I have notes of one case in
which a bullet traversed the soft parts from above downwards and scored
a vertical groove on the surface of the patella; this was readily
palpable, but produced no solution of continuity. In several cases the
margin of the patella was notched by a passing bullet.