reely incised by Mr. Alexander. It
was then found that the bullet in its passage had just touched
the posterior aspect of the tibia and wounded the ankle-joint.
A localised collection of pus which had formed in the deep part
of the wound had been diffused into the joint by the movements
made when the splint was removed, in a similar manner to that
described in the last case. This joint also did badly, and an
amputation of the leg had to be performed by Mr. Alexander to
save the man's life.

These two cases are particularly instructive as showing, first, how
quietly a small amount of deep suppuration may sometimes take place;
and, secondly, the importance of keeping the joints quiet on a splint
when there is any reason to suspect their implication by wounds of this
character.

_The general treatment_ of the wounded joints was simple. The old
difficulties of deciding on partial as against full excision, or
amputation, were never met with by us. We had merely to do our first
dressings with care, fix the joint for a short period, and be careful to
commence passive movement as soon as the wounds were properly healed, to
obtain in the great majority of cases perfect results. Careful light
massage, if available, was used to promote absorption of blood.

If suppuration occurred, the choice between incision and amputation had
to be considered. In the early stages this choice depended entirely on
the nature of the injury to the bones. If this were slight, incision was
the best plan to adopt. I saw several cases so treated which did well,
although convalescence was often prolonged, and only a small amount of
movement was regained. Amputation was sometimes indicated in cases of
severe bone-splintering, when the shafts were implicated, but was as a
rule only performed after an ineffectual trial to cut short general
infection of the septicaemic type by incision.

I have dwelt at such length on the subject of suppuration on account of
its importance, but I should add that, on the whole, suppuration of the
joints was uncommon, except in the case of injuries far exceeding the
average in primary severity.

_Special joints._--Such deviations from the general type of injury as
above described depended entirely on peculiarities of anatomical
arrangement, and peculiarities in the situation of the joint clefts in
the different parts of the body. A few words as to these are perhaps
necessary.

_S