IF small shell fragments produce lesions more or less analogous to those of bullets, it is not at all the same thing with large fragments nor exceptionally with the entire projectile. In the soft parts these wounds show extensive and deep contusions, crushing, contused lesions, tearing away of tissues.

The contusions are of all degrees. In their highest degree of severity they are marked by extensive effusion of blood or of serum. When they take effect on the splanchnic organs, which themselves, however, have apparently not been touched by the projectile, we see deep and extensive attritions which formerly were attributed to the wind of the projectile.

The contused wounds are vast erosions, big furrows, large lesions forming a cul-de-sac, wounds with large pieces of tissue hanging from them, fimbriated, ecchymotic contused in their depths; they are abrasions with torn surfaces and quivering and herniated muscles. Very frequently the wounds in their deep parts are complicated by metallic foreign bodies, by earth, by fragments of clothing. We have good reason to be surprised at the enormous size of some of the foreign bodies that are extracted. Otis speaks of a 12-pound shell lodged in the gluteal region; Constan of a shell fragment weighing 850 grammes lodged in the thigh, into which it had penetrated through an opening only 4 centimetres in length.

Occasionally we observe widely gaping setons.

Large and average sized fragments of armour-piercing shells give rise to large slits, partial or total abrasions of the limbs; very different to the tearing away and crushing contusions brought about by large fragments of other shells. The cul-de-sac wounds of these armour-piercing shells are rarely deep; they are often complicated by pieces of clothing Generally the orifice is clean. We still see total perforations with an irregular, big aperture of exit whose lips are everted.

By the side of these excessive disturbances let us remember, as a sort of antithesis, the ingraining of the integument, the small wounds, often very numerous, produced by the metallic dust of melinite shell, the cul-de-sac wounds with a very small orifice that harbour small shell fragments at a depth varying from a few to 15 centimetres.

To return to the large fragments. Their contused wounds, often complicated by local numbness, foreign bodies, both metallic and derived from the clothing, bleed very slightly, but are doomed to suppuration and threatened by grave complications (gangrene, tetanus).

Treatment. Large traumatisms occurring in labouring men enable us in everyday practice to foresee the extreme limit to which we can push conservatism in the cases of soldiers wounded by big shell fragments.

In their treatment it has been proposed to utilize the method called "Reclus's packing." The following is the way in which it is applied:

The patient's state of prostration having been relieved by injections of normal saline, of caffeine, of ether, the wound itself and its diverticula are disinfected by a current of water at 60 C., which is at the same time antiseptic and haemostatic. Clots of blood, free splinters,

and all tissue that has lost its vitality, are removed; the wound surface is wiped with a pad, which is soaked in a solution of permanganate of potassium; then we apply an ointment containing corrosive sublimate, salol, antipyrine, carbolic acid, iodoform, with Vaseline for excipient.

The ointment should be covered with a thick layer of hydrophile cotton-wool arid a. muslin bandage.

To this local treatment Reclus added injections of normal saline with a dessertspoonful of brandy, injections of caffeine, etc.; a long interval should elapse before a change of dressing; it is removed in about the third week.

Irrigation with hot water has been retained, but the antiseptic packing has been replaced, after antiseptic washing with hydrogen peroxide, by a dressing, only changed at long intervals.

We do not think that this dressing with long intervals, after one or two cleansings with antiseptics, is preferable to the use of topics with a more persistent action.

If Reclus's dressing is considered complicated, we need only simplify it, but its general idea -

(1) dressing rarely changed,

(2) use of topical remedies with a persistent action

- should be maintained. The treatment is not new; it forms part of our old and good traditions.

In 1870-71 we saw used for wounds rarely changed dressings of powdered charcoal, mixed with powder of cinchona and of camphor; later still, Lucas-Championniere advised in these cases the employment of antiseptic powders with a lasting action.

All these are treatments to be recommended.

Chapter 10: Notes on Amputation