Alexis Thomson

“ A charge of small shot is much more destructive to blood vessels, tendons, and ligaments than a single bullet, which in many cases pushes such structures aside without dividing them. In the abdomen and chest, also, the damage done by a full charge of shot is much more extensive than that inflicted by a single bullet, the deflection of the pellets leading to a greater number of perforations of the intestine and more widespread laceration of solid viscera. ”

“ Wounds inflicted by shell fragments and shrapnel bullets tend to be extensive in area, and show great contusion, laceration, and destruction of the tissues. The missiles frequently lodge and carry portions of the clothing and, it may be, articles from the man's pocket, with them. Shell wounds are attended with a considerable degree of shock. On account of the wide area of contusion which surrounds the actual wound produced by shell fragments, amputation, when called for, should be performed some distance above the torn tissues, as there is considerable risk of sloughing of the flaps. ”

“ If the wound is aseptic, the fate of the foreign body varies with its character. A substance that is absorbable, such as catgut or fine silk, is surrounded and permeated by the phagocytes, which soften and disintegrate it, the debris being gradually absorbed in much the same manner as a fibrinous exudate. ”

“ The situation of the burn is important. Burns over the serous cavities--abdomen, thorax, or skull--are, other things being equal, much more dangerous than burns of the limbs. The risk of oedema of the glottis in burns about the neck and mouth has already been referred to. (3) Children are more liable to succumb to shock during the early period, but withstand prolonged suppuration better than adults. (4) When the patient survives the shock, the presence or absence of infection is the all-important factor in prognosis. ”

“ Death of skin is more liable to occur in bleeders, and when the slough separates the blood-clot is exposed and the reparative changes go on extremely slowly. _Suppuration_ may occur and lead to the formation of an abscess as a result of direct infection from the skin or through the circulation. ”

“ It must be observed, however, that burns met with at the bedside always illustrate more than one of these degrees, the deeper forms always being associated with those less deep, and the clinical picture is made up of the combined characters of all. A burn is classified in terms of its most severe portion. It is also to be remarked that the extent and severity of a burn usually prove to be greater than at first sight appears. ”

“ When, however, the deeper parts of an extensive wound cannot be brought into accurate apposition, and especially when there is any prospect of oozing of blood or serum--as in amputation stumps or after excision of the breast--drainage is indicated. It is a wise precaution also to insert drainage tubes into wounds in fat patients when there is the slightest reason to suspect the presence of infection. ”

“ It is usually necessary to enlarge the wound, freely dividing injured fasciae, paring away bruised tissues, and purifying the whole wound-surface. Any blood vessel that is punctured should be cut across and tied; and divided muscles, tendons, or nerves must be sutured. After haemorrhage has been arrested, iodoform and bismuth paste is rubbed into the raw surface, and the wound closed. If there is any reason to doubt the asepticity of the wound, it is better treated by the open method, and a Bier's bandage should be applied. ”

“ In the course of many operations foreign substances are introduced into the tissues and intentionally left there, for example, suture and ligature materials, steel or aluminium plates, silver wire or ivory pegs used to secure the fixation of bones, or solid paraffin employed to correct deformities. Other substances, such as gauze, drainage tubes, or metal instruments, may be unintentionally left in a wound. ”

“ Substances like paraffin, strands of silk used to bridge a gap in a tendon, or portions of calcined bone, instead of being encapsulated, are gradually permeated and eventually replaced by new connective tissue.
Embedded bodies may remain in the tissues for an indefinite period without giving rise to inconvenience. At any time, however, they may cause trouble, either as a result of infective complications, or by inducing the formation of a mass of inflammatory tissue around them, which may simulate a gumma, a tuberculous focus, or a sarcoma. ”

“ The hard covering is employed to enable the bullet to take the grooves in the rifle, and to prevent it stripping as it passes through the barrel. It also increases the penetrating power of the missile, but diminishes its "stopping" power, unless a vital part or a long bone is struck. By removing the covering from the point of the bullet, as is done in the Dum-Dum bullet, or by splitting the end, the bullet is made to expand or "mushroom" when it strikes the body, and its stopping power is thereby greatly increased, the resulting wound being much more severe. ”

“ Sometimes large patches of skin are scorched or stained, the discoloured area showing an arborescent appearance. In other cases the injured skin becomes dry and glazed, resembling parchment. Appearances are occasionally met with corresponding to those of a superficial burn produced by heat. The chief difference from ordinary burns is the extreme slowness with which healing takes place. Localised paralysis of groups of muscles, or even of a whole limb, may follow any degree of lightning-stroke. ”

“ The embedded foreign body at first acts as an irritant, and induces a reaction in the tissues in which it lodges, in the form of hyperaemia, local leucocytosis, proliferation of fibroblasts, and the formation of granulation tissue. The subsequent changes depend upon whether or not the wound is infected with pyogenic bacteria. If it is so infected, suppuration ensues, a sinus forms, and persists until the foreign body is either cast out or removed. ”

“ The wad of the cartridge behaves erratically: so long as it remains flat it goes off with the rest of the charge, and is often buried in the wound; but if it curls up or turns on its side, it is usually deflected and flies clear of the shot. It may make a separate wound.
Wounds from sporting guns are to be _treated_ on the usual lines, the early efforts being directed to the alleviation of shock and the prevention of septic infection. There is rarely any urgency in the removal of pellets from the tissues. ”

“ Amputation is usually called for if there is complete absence of pulsation in the distal arteries and if the part beyond is cold. If at the same time important nerve-trunks are lacerated, so that the function of the limb would be seriously impaired, it is not worth running the risk of attempting to save it. If, in addition, there is extensive destruction of large muscular masses or of important tendons, or comminution of the bones, amputation is usually imperative. ”

“ Large, black, dry eschars are formed, surrounded by a zone of intense congestion. Pain is less severe, and is referred to the parts that have been burned to a less degree. Infection is liable to occur and to lead to wide destruction of the surrounding skin. The amount of granulation tissue necessary to fill the gap is therefore great ”

“ At ranges varying from six inches to thirty feet, grains of powder may be found embedded in the skin or lying loose on the surface, the greater the range the wider being the area of spread. When black powder is used, the embedded grains usually leave a permanent bluish-black tattooing of the skin. When the weapon is placed in contact with the skin, the subcutaneous tissues are lacerated over an area of two or three inches around the opening made by the bullet and smoke and powder-staining and scorching are more marked than at longer ranges. ”

“ On covered parts the clothing, by deflecting the shot, influences the size and shape of the wound; the entrance wound is increased in size and more ragged, and portions of the clothes may be driven into the tissues. ”

“ A blue or bluish-black discoloration occurs in patches, varying in size and depth with the degree of force which produced the injury, and in shape with the instrument employed. It is most intense in regions where the skin is naturally thin and pigmented. ”

“ When shock is absent or little marked, however, the amount of suffering may be great. When the injury proves fatal during this period, death is due to shock, probably aggravated by the absorption of poisonous substances produced in the burned tissues. In fatal cases there is often evidence of cerebral congestion and oedema.
The _second period_ begins when the shock passes off, and lasts till the sloughs separate. ”

“ Wounds by Sporting Guns.#--In the common sporting or scatter gun, with which accidents so commonly occur during the shooting season, the charge of small shot or pellets leave the muzzle of the gun as a solid mass which makes a single ragged wound having much the appearance of that caused by a single bullet. ”

“ For the approximation of the skin edges, stitches of horse-hair, fishing-gut, or fine silk are the most appropriate. These _stitches of coaptation_ may be interrupted or continuous. In small superficial wounds on exposed parts, stitch marks may be avoided by approximating the edges with strips of gauze fixed in position by collodion, or by subcutaneous sutures of fine catgut. ”

“ In doubtful cases the possibility of rendering the parts aseptic will often decide the question for or against amputation. If thorough purification is accomplished, the success which attends conservative measures is often remarkable. It is permissible to run an amount of risk to save an upper extremity which would be unjustifiable in the case of a lower limb. ”

“ Many other factors, such as the physical and mental condition of the men, the facilities for affording first aid, and the transport arrangements, also play a part in determining the nature and condition of the wounds that have to be dealt with by military surgeons. ”

“ The ignorance of patients regarding the possible lodgment in the tissues of a foreign body--even of considerable size--is remarkable. In such cases the X-rays will reveal the presence of the foreign body if it is sufficiently opaque to cast a shadow. The heavy, lead-containing varieties of glass throw very definite shadows little inferior in sharpness and definition to those of metal ”

“ The lesions of individual tissues--bones, nerves, blood vessels--are considered with these.
Treatment of Gunshot Wounds under War Conditions.#--It is only necessary to indicate briefly the method of dealing with gunshot wounds in warfare as practised in the European War.
1. _On the Field._--Haemorrhage is arrested in the limbs by an improvised tourniquet; in the head by a pad and bandage; in the thorax or abdomen by packing if necessary, but this should be avoided if possible, as it favours septic infection. If a limb is all but detached it should be completely severed. ”

“ Lightning-stroke.#--In a large proportion of cases lightning-stroke proves instantly fatal. In non-fatal cases the patient suffers from a profound degree of shock, and there may or may not be any external evidence of injury. ”

“ These phenomena are much more prominent when bacterial infection has taken place, and it seems probable that they are to be attributed chiefly to the infection, as they have become less frequent and less severe since burns have been treated like other breaches of the surface. Albuminuria is a fairly constant symptom in severe burns, and is associated with congestion of the kidneys. ”

“ In old people with enfeebled circulation mere exposure to a strong fire may cause severe degrees of burning, the clothes covering the part being uninjured. This may also occur about the feet, legs, or knees of persons while intoxicated who have fallen asleep before the fire.
The damage done to the tissues by strong caustics, such as fuming nitric acid, sulphuric acid, caustic potash, nitrate of silver, or arsenical paste, presents pathological and clinical features almost identical with those resulting from heat. Electricity and the Rontgen rays also produce lesions of the nature of burns. ”