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 primary 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.]