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.  A full dose of morphin is given hypodermically.  The ampoule of iodine carried by the wounded man is broken, and its contents are poured over and around the wound, after which the field dressing is applied.  In extensive wounds, the “shell-dressing” carried by the stretcher bearers is preferred.  All bandages are applied loosely to allow for subsequent swelling.  The fragments of fractured bones are immobilised by some form of emergency splint.

2. At the Advanced Dressing Station, after the patient has had a liberal allowance of warm fluid nourishment, such as soup or tea, a full dose of anti-tetanic serum is injected.  The tourniquet is removed and the wound inspected.  Urgent amputations are performed.  Moribund patients are detained lest they die en route.

3. In the Field Ambulance or Casualty Clearing Station further measures are employed for the relief of shock, and urgent operations are performed, such as amputation for gangrene, tracheotomy for dyspnoea, or laparotomy for perforated or lacerated intestine.  In the majority of cases the main object is to guard against infection; the skin is disinfected over a wide area and surrounded with towels; damaged tissue, especially muscle, is removed with the knife or scissors, and foreign bodies are extracted.  Torn blood vessels, and, if possible, nerves and tendons are repaired.  The wound is then partly closed, provision being made for free drainage, or some special method of irrigation, such as that of Carrel, is adopted.  Sometimes the wound is treated with bismuth, iodoform, and paraffin paste (B.I.P.P.) and sutured.

4. In the Base Hospital or Hospital Ship various measures may be called for according to the progress of the wound and the condition of the patient.

#Shell Wounds and Wounds produced by Explosions.#—­It is convenient to consider together the effects of the bursting of shells fired from heavy ordnance and those resulting in the course of blasting operations from the discharge of dynamite or other explosives, or from the bursting of steam boilers or pipes, the breaking of machinery, and similar accidents met with in civil practice.

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.