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UNITED STATES NAVAL |
MEDICAL BULLETIN |

» PU BLISHED FOR THE-

- INFORMATION. OF THE MEDICAL
DEPARTMENT OF THE SERVICE.

 

ISSUED BY
THE: ‘BUREAU OF MEDICINE AND SURGERY:
“NAVY DEPARTMENT |
~' DIVISION OF PUBLICATIONS

 

REPORT.

MEDICAL AND SURGICAL
DEVELOPMENTS « oF THE WAR

WILLIAM SEAMAN BAINBRIDGE

/ LIEUTENANT COMMANDER, MEDICAL CORPS
UNITED STATES NAVAL RESERVE FORCE ;

 

WASHINGTON
GOVERNMENT PRINTING OFFICE "
, JANUARY, 1919

 

 

 

 

 
 

 

 

SPECIAL NUMBER

UNITED STATES NAVAL

MEDICAL BULLETIN

PUBLISHED FOR THE

INFORMATION OF THE: MEDICAL
‘DEPARTMENT OF THE SERVICE

 

ISSUED BY

THE BUREAU OF MEDICINE AND SURGERY
NAVY DEPARTMENT
DIVISION OF PUBLICATIONS

 

REPORT

MEDICAL AND SURGICAL
DEVELOPMENTS oF THE WAR

BY
WILLIAM SEAMAN BAINBRIDGE

LIEUTENANT COMMANDER, MEDICAL CORPS
UNITED STATES NAVAL RESERVE FORCE

 

WASHINGTON
GOVERNMENT PRINTING OFFICE
JANUARY, 1919

 

 

 

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‘Navy DeparrMENT,
Washington, March 20, 1907.
This Unrrep Srares Navan Mepican Burierrn is published -
direction of the department for the timely information of the Medi-
cal and Hospital Corps of the Navy.
Truman H. Newserry,
Acting Secretary.

 

NOTE.

Owing to the exhaustion of certain numbers of the ButLerin and the frequent
demands from libraries, etc., for copies to complete their files, the return of any
of the following issues will be greatly appreciated :

Volume X, No. 1, January, 1916.
Volume XI, No. 1, January, 1917.
Volume XI, No. 3, July, 1917.
Volume XI, No. 4, October, 1917.
Volume VII, No. 2, April, 1913.

SUBSCRIPTION PRICE OF THE BULLETIN.

Subscriptions should be sent to Superintendent of Documents, Government
Printing Office, Washington, D. C.
Yearly subscription, ‘peginning January 1, $1; for foreign subscription add
25 cents for postage. ‘ : §
Single numbers, domestic 25 cents; foreign, 31 cents, which includes for-
eign postage. , : :

Exchange of publications will be extended to medical and scientific organiza-
tions, societies, laboratories, and journals. Communications on this subject
should be addressed to the Surgeon General, United States Navy. Washing-
ton, D. C.

i
CONTENTS.

REPORT:
TREATMENT OF WAR WOUNDS BY THE ALILIES............¢...02.-02--.-
Wound suture; primary, delayed primary, secondary.................
Carrel-Dakin treatment.............0.0 0000000 ce cece cece eee ceeneeee

Trephined cases........... joisid ee ald one lercia tag aclordenery amt e elwale
ATH PU tations acto. cs tt ee cciehne $a y Secede cane eh is poe a cauis o cc
Plastic and oval surgery......-...-.-02. 2-2. s eee cece eee ee eee eee eens
Trenco Frver......-. #g)e eqaalesandass so 6 as eeatemeeeew e ¥ Fee saGGe dee s ook
Care OF WOUNDED FROM Firine LINE To CONVALESCENT OAMP.......
Surgery of the forward area, and transportation of the wounded.......
Special notes on some of the hospitals visited........................
Military orthopedic hospitals...........2..2..2-.2..02 0020 e cece eee
Convalescent camps...|..-..-- 2022-2 2--e eee eee eee eee nee eeees
REEDUCATION FOR THE DISABLED..........--..2-0--2-20--2-0eec ec eeeee
Functional ses scsxsseenag sss va teetwaness + 642 sejtaccudyheoss scared
Vocationshees: <2 xsicsscsieu ed Sakiiganivs oy bb ae egaene odo vane

Inter-allied conferences of surgeons..................--020.--es eee ee
AUXITIARY NORGHS asc sccomesccceeun es aueaiaeiieds sch oiseegne eS ees SS
MIGCELUANEOUS wos songs sore giun c's 64.9 Hee sOeNes pe oes ae eee Yew ees se

Provisional legs sess vec asroeewaw «'s 2 x's) etwas «on 5 cleinbreseiiaueeale se

Plan for surgical evacuation hospital formation.............-....-...-
Proposed organization of educational service in war surgery...........
Special points with regard to disposal of U.S. A. casualties. .........

Plan for surgical sanitary formations.............-.-.-------2-+--++--

" RECOMMENDATIONS..........000000ec cece cece eee eee eee eee e ee eeeeee
TecuNnicaL Instructions ror IMPENDING MILITARY ACTIVITIES.......-
Rerort oF TECHNICAL ADVISORY COUNCIL...........02-.-000e eee eee eeee
Base HospitalizaATION AND Sure@icaAL MEASURES FOR AN ATTACKING
PREFACE.

4

The"publication and issue of a quarterly bulletin by the Bureau of
Medicine and Surgery contemplates the timely distribution of such
information as is deemed of value to the personnel of the Medical
Department of the Navy in the performance of their duties, with the
ultimate object that they may continue to advance in proficiency in
respect to all of their responsibilities,

It is proposed that the Navan Mepican Buurerin shall embody
matters relating to hygiene, tropical and preventive medicine, pa-
thology, laboratory suggestions, chemistry and pharmacy, advanced
therapeutics, surgery, dentistry, medical department organization for
battle, and all other matters of more or less professional interest and
importance under the conditions peculiar to the service and pertain-
ing to the physical welfare of the naval personnel.

It is believed that the corps as a whole should profit, to the good of
the service, out of the experience and observations of the individual.
There are many excellent special reports and notes beyond the scope
of my annual report being sent in from stations and ships, and by
communicating the information they contain (either in their entirety
or in part as extracts) throughout the service, not only will they be
employed to some purpose as merited, but all medical officers will
thus be brought into closer professional intercourse and be offered a
means to keep abreast of the times.

Reviews of advances in medical. sciences of special professional
interest to the service, as published in foreign and home journals, will
be given particular attention. While certain medical officers will
regularly contribute to this work, it is urged that all others cooperate
by submitting such abstracts from the literature as they may at any
time deem appropriate. ,

Information received from all sources will be used, and the bureau
extends an invitation to all officers to prepare and forward, with a ~
view to publication, contributions on subjects relating to the pro-
fession in any of its allied branches. But it is to be understood that
the bureau does not necessarily undertake to indorse all views and
opinions expressed in these pages.

W. C. Braistep,
Surgeon General United States Navy.
v
FOREWORD.

This report comprises observations on the western front and in
England during December, 1917, and the first six months of 1918,
miade pursuant to the instructions of the Surgeon General, United
States Navy. For purposes of comparison, there have been added
certain data obtained while in Germany during the autumn of 1915.

In making the survey, the following objects were kept constantly
in mind:

1. To record the surgical lessons of the present war based on the
experience of our allies.

2. To secure anything likely to be of value to the United States
Naval Medical School, Washington, D. C., or helpful in the prepara-
tion of medical men and hospital corpsmen for active service.

The United States Navy is justly proud of its efficiency and fore-
sighted policy of preparedness. Accordingly, it desires to have its
medical corps fully abreast of the Army in learning the lessons being
taught by this world war. The medical service of the Navy has not
only the usual duty of caring for the incidental casualties in the Navy
and of being constantly ready for sea warfare on a large scale, but
is responsible for the marines fighting on land, maintains its own
base hospitals abroad, some of which at times are ‘used exclusively for
the Army wounded, sends forward operating teams to aid in times
of crisis, and is entrusted with the care of the sick and wounded
from all branches of the Army as well as of the Navy, on their way
home. Our troop transports going over are ambulance transports
on the return trip.

“As ‘the men return to this side, the great questions of aftercare,
restoration of function, plastic surgery, reeducation, and the like
become matters of great importance. While the Army with its
enormous numbers is most deeply concerned, it is just as vital from
the standpoint of the needs of the bndlistduall that the naval per-
sonnel should be thoroughly equipped to deal with the same problems,
although they may be called upon to care for fewer cases.

In harmony with the policy of making ready, and in order to
supplement the individual reports which from time to time have
come from various sources to the Bureau of Medicine and Surgery,
Surgeon A. M. Fauntleroy, United States Navy, was sent abroad in

VII
VIIT rGREWORD.

1915 and upon his return made a report on the medico-military
aspects of the European war. His observations have proved of
much value and have helped to a larger knowledge of many matters
connected with the war on the part of the medical officers of the
Navy, as well as of surgeons in civil life. As indicated above, a
somewhat different field is covered in the present survey.

In writing a report of this kind, where the material gathered is
so exhaustive and illuminating, there is a strong temptation to go
‘into detail. An effort has been made to combat this temptation and
to cover only such points as seem to have a practical bearing on the
objects for which the survey was made.

Every source of information which could be reached in the time
at my disposal has been utilized. The experiences of the British, the
French, the Belgians, and of those American surgeons who were in
active war service with our allies before we entered the conflict, were
unreservedly placed at my disposal. To all who so materially as-
sisted me I am most grateful.

In both of my preliminary reports (April 27, 1918, and July ‘10,
1918) to the Bureau of Medicine and Surgery I mentioned some of
those who aided me with advice and with information. Here and
there in the text which follows will be found the names of some who
furnished special data or contributed material for exhibits to accom-
pany this report. If space permitted there are others to whom a
special word of thanks should be given for their cordial cooporation
and assistance. Particularly am I indebted to the American Red
Cross, through Major J. H. Perkins, Major Alexander Lambert, Mr.
Homer Folks, and their staffs; to the British. Red Cross, through
Colonel Sir Arthur Lawley, Q. C. S. I.; to the French authorities,
through M. Jean de Piessac, Prof. Theodore Tuffier, General Gou-
rard, and Major Alexis Carrel; to the British Army, through Lieu-
tenant General Sir Beauvon de Lisle and many others, for the many
opportunities and hospitalities extended to me at the request of
Director General Thomas H. Goodwin; to the Colony of Strangers,
through M. Lawrence V. Binnet and Dr. Ernest H. Lines. Without
their aid, and that of Commander W. R. Sayles, United States Navy,
late naval attaché at Paris; Dr. Herbert Adams Gibbons, of the
American Committee on Public Information, and General A. E.
Bradley, until recently chief of the Medical Corps, American Expe-
ditionary Force, this survey could not have been made. . |

- W. S. B.
New York, September 14, 1918.
REPORT ON MEDICAL AND SURGICAL DEVELOPMENTS OF
THE WAR.

TREATMENT OF WAR WOUNDS BY THE ALLIES.

In the many hospitals and casualty clearing stations visited, the
method of treating war wounds varied greatly. There were those
who believed in the use of the strongest antiseptics, as at the Grand
Palais, where phenolization was employed, while others favored in-
cising freely with drainage and practically no antiseptics. More and
more, the two extremes are being emphasized; on the one hand, the
Carrel treatment with its scientific laboratory control and systematic
use of strong antiseptic solutions, and on the other, débridement and
immediate closure. . :

Late in September, 1915, after having spent considerable time in
the hospitals of both the German and French armies, Prof. Kocher,
of Berne, said to me: “The great lesson of the war so far is, back
to antiseptic surgery. Asepsis is not enough.”

Tm contrast with this, three years later (in June, 1918) Major A.
L. Lockwood, D. S. O., who has had one of the largest experiences
im acute war surgery in the present conflict, said when I was at
casualty clearing station No. 36, behind the British front: “One of
the greatest lessons of this war is that aseptic surgery and not anti-
septic surgery should be practiced, the former in all cases, the latter
associated with it in selected cases.”

Between the two extremes of the Carrel-Dakin treatment and
primary suture, both of which are described in detail hereinafter.
there are many other methods and agents employed with more or less
satisfactory results. These are also taken up somewhat briefly.
Their classification is arbitrary for there is overlapping all along the
line.

. After going from hospital to hospital and station to station and
hearing éach of these many methods acclaimed or criticized, it be-
comes convincingly apparent that the obtaining of satisfactory re-
sults depends far more upon the surgeon himself than upon the agent
which he employs. The lesson to be learned from all this diversity of
opinion is that those who are to be given charge of this surgical work
should have first, a thorough knowledge of surgery, second, sufficient
1
2 I. WOUND SUTURE.

experience to give them an adequate technique, and third, the neces-
sary judgment to select and employ such of these methods or agents
as seem best for the particular case at the given time.

From the purely therapeutic viewpoint, the surgery of wounds in
the present war may be grouped under fairly approximate chrono-
logical headings, as follows: ;

1. The period of ordinary antiseptic agents; second half of 1914
and first half of 1915. ;

2. The period of wound drainage combined with antiseptics, 1915.

3. Introduction of hypochlorites; later in 1915.

4, Evolution of the Carrel’ technique of intermittent wound in-
stillation; early in 1916. ;

5. Ascendency of Bipp method; 1916.

6. Period of approximately equal use of the Morison and Carrel
methods; 1916-17.

7. Prominence of flavine and colored wound pastes, such as bril-
lant green; 1917.

8. Progressive general adoption of wound-excision method (which
had its beginnings early in 1916) ; late in 1917.

9. Period of primary wound suture, immediate or delayed;

- 1917-18. .

10. Period of attempted selection, adaptation and standardization;
late 1918.
I, WOUND SUTURE.

In the recent remarkable advance of the science and art of surgery,
with its exacting demands upon the time and energy of modern
operators, its modest beginnings are sometimes overlooked, but a rich
vintage is in store for the investigator of medical records of the past.

After visits to the front and observing much of primary and
delayed suture, I determined to secure the memoirs of Paré and the
life of Larrey, with a view to learning if any of the modern war
wound treatments was foreshadowed by those two great surgeons
who lived so much in advance of their times, and who, many years
ago, fought over northern France and southern Flanders much as
we are now doing. Neither in Paris nor London was I successful.
Finally, by advertising, both volumes were obtained from the North
of England.

There, in the last of the sixteenth century was described immediate
closure; and in the days of Napoleon, molded splints and early
primary amputation, much as we know them to-day, except for the
phraseology of the time.

The pioneer in the proper treatment of gunshot wounds, and per-
haps the forerunner of ultramodern methods of treating fractures
and other war wounds, was Ambroise Paré, the father of French
I. WOUND SUTURE. 3

surgery, who was enabled to add the surgical observations of many
years of. warfare to his early experience as an army surgeon in the
Piedmont campaign.. Later on he became the premier chirurgien
of the French kings, Charles IX and Henry III. The first English
translation of his works appeared in London in 1578. In Book IX
of his “ Chirurgery ” he devoted to wound suture a chapter enriched
by illustrations showing “ The figures of pipes with fenestels in them,
and needles fit for sutures,” and introduces his subject as follows:

When wounds are made alongst the thighs, legs, and arms, they may easily
want sutures, because the solution of continuity is easily restored by ligatures,
but when they are made overthwart, they require a suture, because the flesh
and all such like parts being cut are drawn towards the sound parts; whereby
it comes to pass that they part the further each from other: wherefore that they
may be jointed and so kept, they must be sewed, and if the wound be deep you
oust take up much flesh with your needle; for if you only take hold of the upper
part, the wound is only superficially healed; but the matter shut up, and
gathered together in the bottom of the wound, will cause abscesses and hollow
ulcers; wherefore now we must treat of making sutures.

As to the first dressings to be used in “ wounds made by gunshot,
other fiery engines, and all sorts of weapons, after the strange bodies
are plucked or drawn out of the wound,” Paré laid stress on the im-
portance of tight binding up and rolling the part; “for it doth not
a little conduce to the cure to bind it so fitly up as it may be without
pain.” The presence of Paré in Metz during the attack of Charles V,
was regarded as a providential dispensation, for the garrisons saw,
to their dismay, that death followed on practically all wounds.

Modern methods of war-wound treatment are distinctly fore-
shadowed in the writing of some of Paré’s pupils, for example in the
little known, but most interesting Sclopotarie of Josephus Querce-
tanus, Phisition, or his booke containing the cure of wounds received
by shot of gunne or such like engines of warre (published in English
in London in 1590). In the third chapter, speaking of wounds in
which the benes of the arms and legs are broken, he differs from
some of his contemporaries who favor open-wound treatment, in that,
in his judgment, he thinks it best “that the bones by and by before
inflammation be engendered be brought in their seat and natural
form, with as little pain as may be to the patient, and then to use
such medicines as are profitable to both intentions—that is, for the
wound and fracture. Moreover, you must see that the wounded part
be rightly placed, and if need be, rolled in a plate of lead, bowed to
the fashion of a leg or an arm, or else with sodden leather fastened
together with buckles, whereby the bones which were broken, may the
surer be holden together, which ought not (as little as may be) be
shaken and moved, until he is cured, and the bands loosed * * *
by which only I have seen fractures cured, the bones being rightly
placed,” ete. ,
4 I, WOUND SUTURE.

The originator of much modern military surgery was Baron Lar-
rey, surgeon in chief of the first Napoleon’s Grande Armée, who has
been called the father of military surgery. It is interesting to note
that he was nominated surgeon of the Royal Navy in 1787, and took
part in a cruising expedition in North American waters. Although
no mention of immediate closure of war wounds occurs in his writ-
ings, a surgical memoir read by him at the Royal Academy of Medi-
cine in Paris on February 19, 1819, describes at length an extensive
operation for the removal of a large glandular mass from the neck
of a man 40 years of age, the edges of whose wound were at once
drawn together and united by a series of sutures. All the stitches
held well, and the large wound healed promptly, the patient being
cured on ‘the thirty-first day after the operation and leaving for his
home in excellent condition on the forty-first day.

Practically the identical words which, in the present war have been
pronounced in connection with the progressive danger of infection
of all war wounds, were spoken a century ago by Larrey, in comment-
ing upon the utility of immediate amputations: An hour’s delay is
often responsible for the death of the patient. This is doubly inter-
esting and remarkable in view of the fact that a large part of Lar-
_ rey’s work was done on Flemish soil, made familiar to us by .the
events of the world war; for we read of his being sent to Louvain
and Brussels, or of his visiting the military hospitals of Great
Britain, like contemporaneous army surgeons. The brilliant career
of Baron Larrey brings us close to the present day, when war sur-
gery has perhaps reached its zenith, the operator standing at the head
of the medical profession just as the man in uniform represents the
dominating factor in both the Eastern and the Western Hemispheres.

IMMEDIATE, DELAYED, AND SECONDARY SUTURE.

Under favorable conditions, primary union by immediate or de-
layed suture of war wounds which have been operated upon and
properly purified, is now the last word in this branch of surgery.
Experience in the world war has taught entirely new lessons to the
surgeons who found themselves confronted with unprecedented con-
ditions both in regard to the masses and classes of war wounds they
were expected to handle. Perhaps the most important lesson of all,
with the closest bearing on wound treatment in general, consists in
the recognition of the fact that antiseptics are inefficient without the
most careful and thorough mechanical purification of the wound, in-
cluding the complete removal of all dead or nonviable tissue. Cer-
tain phases of antiseptic wound treatment are passed in review in
“An Address on Primary Suture of Wounds at the Front in
France,” by Surgeon General Sir Anthony Bowlby, delivered at a
meeting of the Royal Society of Medicine on February 13, 1918, and
I. WOUND SUTURE. 5

published in the British Medical Journal, Volume I, March 28, 1918.
page 333.

Strong antiseptics, such as were used early in the war, in the ex-
pectation of arresting sepsis, were foredoomed to failure, as a re-
sult of the unprecedented bacterial contamination of war wounds
sustained in the germ-laden battle fields of Flanders. The prompt
discarding of these antiseptics involved the abandonment of primary
union by suture of war wounds, followed as it was at first by dis-
couraging results. On the other hand, the opposite method of leay-
ing the wounds wide open and maintaining a free discharge of the
wound secretions, in its turn proved disappointing. A successful
outcome was found to depend upon the performance of excision be-

fore the infectious bacteria have had time to penetrate far into the
depth or surroundings of the wound. The period which has elapsed
since the infliction of the wound thus becomes a factor of great prog-
nostic importance. In a general way, and with certain reservations,
“delay means danger” (Bowlby). According to the report of Duval,
at the allied surgical conference in November, 1917, 80 per cent oe
the lightly woinded cases, without fracture, were successfully su-
tured within 8 to 12 hours after the injury.

By “delayed primary suture” is meant.a wound suture which is
applied at the end of a day or two after the infliction of the wound.
Even after three or four days’ delay, the wound may be sutured with
the same favorable results as obtained by immediate suture. The
experience of French operators, who are the pioneers in this field,
shows that such delay, of 48 or more hours, is advantageous rather
than otherwise in a large number of cases. The observations at the
front on the part.of Sir Anthony Bowlby are in conformity with
this experience. According to him, “no definite rule can be laid
down as to the lapse of time after which suture should not be done,
‘but the sooner the wound can be operated upon, the greater is the
probability of success. It can be sutured later.” Asa matter of fact,
it is not advisable to close at once war wounds involving extensive.
lacerations, or:complicated fracture cases, for all oozing from the
wound must have ceased before a successful suture can be applied.
Circumstances alter cases, and the best treatment for a given wound
rests with the surgeon in charge. Doubtful wounds are preferably
left open, after excision of all dead or dying tissue, until conditions
permit of a decision. It goes without saying that the ever present
contingencies of infection and suppuration are materially lessened by
the early performance of complete wound closure.

Scrupulous asepsis is the imperative condition of primary wound
suture, immediate or delayed. While thorough in the removal of all
hopelessly damaged tissue, the excision should: be as conservative
and restricted as possible. No part of the wounded region must be
6 I. WOUND SUTURE.

neglected or slighted, the greatest care being especially required in
all deep wounds and in open or compound fractures. The perform-
ance of primary suture transforms the latter into simple or closed
fractures, and thereby greatly lessens not only the danger of sepsis
but also the soldiers’ enforced rest in bed or in hospital.

Certain limitations of primary suture of war wounds, emphasized

by Doval, are that the procedure can not be used in emergencies, and

also that its performance is not advisable unless the patient can be
kept in the hospital for at least a fortnight, under the care of the

same surgeon.
-There are certain cases of relatively old wounds, not yet operated

upon and clinically noninfected, or very mildly infected, capable of

being closed by suture, which under these conditions must be de-

scribed as delayed primary suture, for the reason that the operation
is performed after the first 12 hours, namely, after the usual stage
of bacteriological latency of war wounds. Such sutures differ: es-

sentially from the purposely delayed sutures in cases where the:

cleansed and surgically sterilized wound is left open and covered .

with aseptic dressings in the first aid stations, being united by
sutures later on at a greater distance from the front. According to

Chalier (Le Progrés Médical, No. 27, 1918), this delay can often be °

advantageously utilized, for instance, for the radiological localiza-
tion of a projectile, the removal of which is essential to the success
of a complete operation terminated by wound suture.

The desirability of extending the benefit of primary suture to all
wounded soldiers, in time of attack, provided that operative: and
hospital facilities permit, is emphasized by recent French writers
(such as Marquis, Descazals, Luquet, and Morlot; Bull. et Mém. d. 1.
Soc. de Chir. de Paris, 43, 2, 1917, p. 2281). In their experience,
primary suture proved apparently most advantageous in wounds of
the joints, where very accurate union was obtained; the method at

the. time of the report had been utilized in nearly 450 cases, including |
wounds of the bones, joints, and soft parts. Wounds of the skull,

the thorax, and the abdomen were likewise sutured with favorable
results. The mortality for all suture cases amounted to 21 deaths
or 4.7 per cent.

That primary suture is at present the rational and as it were the
obligatory treatment for war wounds is the declaration of Gross
Tissier, Houdard, Di Chiara, and Grimault (ibid.). From being
exceptional, primary wound suture has become a common procedure
largely through the work of Tissier, who first showed that all war

wounds which are not infected by the streptococcus will heal after -

suitable surgical treatment followed by the performance of primary
suture.
I. WOUND SUTURE. fe

In the surgical automobile ambulance No. 12, which takes charge
of the gravest injuries, such as extensive destruction of soft parts,
long seton’ wounds, shattering and crushing of entire limbs, etc., 430
of 549 wounded men were sutured (78.8 per cent). Altogether, 759
sutures were applied in these 430 cases, and in 675 instances led to
healing by first intention, which is equivalent to a successful out-
come in 88.8 per cent of the cases. There were 209 fracture cases
with a favorable result. .It is noteworthy that even conditions of
such gravity as amputation of shattered extremities (22 cases), frac-
tures of the vertebra, lesions of large blood vessels, deeply embedded
projectiles in the cervical region, and other severe injuries of war are
amenable to primary suture.

The routine application of primary sutures is advocated by Gross
and Tissier whenever the removal of the projectile and the excision
of the necrotic tissue is practicable. Unless streptococci be detected
in the early wound discharge, the sutures should not be disturbed.
but the appearance of the streptococcus is.an indication for removal
of the sutures and the performance of radical excision, in order to.
check the putrefactive process. Secondary wound suture is recom-
mended at the earliest possible date, where primary suture could not
be applied. Only those war wounds are now left open in which there
is-an association of anaerobic and streptococcic infection. The vast
field of opportunity for the application of wound suture is illustrated |
by figures such as the 880 cases of Potherat, in Delbet’s service, with
291 primary sutures, 209 of which proved successful, and 459 sec-
ondary sutures. Perfect union after primary suture is reported by
Picot in 25 of 30 cases of complicated diaphyseal fractures. —

Barnsby (Revue Internationale de Médecine et de Chirurgie, No. 2.
1917, p. 26), in a series of primary sutures of soft-part wounds, ob-
served healing by first intention in 160 of 172 cases. In the remain-.
ing 12 cases, the stitches had to be removed, the wounds healing by
second intention, without harm to the patient. The application of
primary suture of war wounds is advocated by him in the 10 hours
following the traumatism, in injuries of the following description:
Simple articular wounds, or lesions of joints combined with slight
bony lesions; wounds of soft parts (supra-aponeurotic) ; superficial
glancing subaponeurotic wounds, the floor of which can be plainly
seen after incising. All such wounds should be sutured, provided a
reliable: asepsis and sufficient surgical cleansing can be secured.
When the asepsis is uncertain, however, or when the wound is of.
more than 20 hours” standing, especially when it is obviously in--
fected, or in serious injuries such as deep subaponeurotic wounds.
large muscular seton wounds, extensive bone shattering (diaphysi<
or epiphysis) and, finally, when there is any doubt, even in appa-
8 I. WOUND SUTURE.

rently simple wounds, primary suture should be omitted, and the
wound be treated according to Carrel’s method of intermittent instil-:
lation, the proper time for the performance of delayed suture being
determined by the daily bacteriological control of the wound.

In justice to the method of primary suture, it should not be at-
tempted in very large wounds with irregular tracks, where there is.
extensive shattering of bone, or in injuries dating back more than |
half a day or so (12 to 18-hours at most). In fracture cases, the im-
portance of complete fixation and immobilization from the earliest
possible moment can not be overestimated.

The advent of primary wound suture, representing as it does a
wonderful economy in time, money, and material, has brought about.
a striking change in war surgery. Formerly, even after the deplor-
able stage of overwhelming septic wound contamination was past, a
long time was required for the repair and cicatrization of wounds
which healed but slowly under laborious aseptic dressings. Before
the application of at least secondary wound suture had become a
reality, large numbers of wounded soldiers had to be evacuated before:
their wounds were properly closed. The introduction of primary
suture has greatly simplified modern wound treatment, which now
consists essentially in passive supervision of the repair process, with-
out dressings. The suture threads are removed on the tenth to
fifteenth day. At the end of three weeks, the patient is evacuated to:
the base hospital, or discharged on leave, according to the gravity
of the condition.

Credit must be given, especially in these days of precarious inter-
allied communication, to War Medicine, published by the American
Red Cross Society in France, for giving in the English language a re-
view of the notable reports on primary wound suture published in
the Bulletins et Mémoires de la Société de Chirurgie de Paris. The
March number (1918) of this Red Cross bulletin also brings in full
several papers on. this subject, by Engligh surgeons and bacteriolo-
gists, indorsing the treatment of war wounds by primary and. es-
pecially by delayed primary suture (the secondary suture of French
writers). Colonel Gask emphasizes the nonoccurrence of deaths in a
series so treated, though many of the cases were severe; no bad re-:
sults were attributable to the early suture; the comfort and well-be-
ing of the patients were noteworthy.

In conclusion, it may be said that this procedure has come to stay,
and that with the reservation of its three requirements—namely, an
experienced operator, a convenient locality, and sufficient time—the
adoption of primary wound suture will steadily extend. It is im-
perative that the operator be one who knows how much tissue to re-
move. If too little be removed death may result ;,if too much, a
mutilation which is sometimes worse than death.
9

Aside from the benefit accruing to the severely wounded, primary
wound suture involves the enormous advantage of restoring to ac-
tivity, at the earliest possible moment, the hosts of men with minor
wounds which, without this new technique, necessarily constituted a
serious handicap for the armies in the past. In striking contrast
with this prolonged disablement, Pierre Duval reports, after primary
suture of flesh wounds, seven days’ leave and return to service in more
than half the cases; and after delayed: primary suture, seven days’
leave and return to the regiment in 32 per cent of the cases; one
month’s convalescence in 30 per cent of the cases,

The overabundant clinica] material is being constantly replenished
by the casualties of the war, as illustrated for example by the report
of Lemaitre, in whose experience since July, 1915, when the use of
antiseptics was definitely abandoned in favor of operative surgery,
2,664 (of 4,072) wounds were united by primary suture, 231 by de-
layed primary suture, and 324 by secondary suture, for the most part
between the seventh and fifteenth day after the infliction of. the in-
jury, with a very small number of Poniuiness Med. Bull. (Red Cross),
March Supplement, 1918.

Although prior to the European war the closure of contaminated
wounds by suture would have been regarded as foredoomed to fail-
ure, and no such procedure at first entered the. minds of Army sur-
geons, this method of wound treatment is not strictly speaking novel.
nor is it incident to the current war. Far from being new, the com-
bined surgical acts which culminate in primary wound suture. have
been.in use for many years, and as stated before, the closure of gaping
war wounds by sutures: with specially devised needles is described
at length in the Chirurgery of Ambroise\Paré. Observation and.ex-
perience have matured and improved the technique of the procedure,
which at the present writing seems to have reached a stationary
degree of perfection.

~The most extensive available statistics of primary suture of war
words (2,587 cases) were, published in this year by Lemaitre of
the V Army (Lyon Chirygical, Tome XV, 1918, p. 65) and show
that 79 per cent of injuries can be treated successfully by primary
closure, immediate or delayed, without excision of scar tissue. The
statitstics comprise:

Two thousand and thirty wounds of the soft parts; (1,060 very seri-
ous, and 250 associated with bony, vascular, or nervous injuries) ; 87
injuries of large joints; 263 wounds with diaphyseal fractures; 110
wounds of hand and foot, with injured tendons, bones or joints; 40
injuries of the skull and brain; 7 injuries of the thorax.

The method proved unsuccessful in only 0.84 per cent of cases.
There were only four subsequent deaths, including three brain
injuries and one penetrating wound of the thorax. Contraindications

         
10 II. CARREL METIIOD.

are: Spreading infection, gas gangrene, a bad general condition,
shock, shattered limbs necessitating amputation, association with
vascular lesions of large blood-vessels.

The suture method was gradually reached by Lemaitre in July,
1915, after successive phases of nonintervention, free exposure and
surpical purification, complete excision of the entire wound track,
fixation of microbes by means of iodine, and Carrel’s method of
multiple instillation. The original technique of wound suture has
been considerably improved in the last three years. Filiform drainage
by means of silkworm gut, removed in three or four days, is recom.
mended on the basis of favorable experience. Minute asepsis, and
scrupulous hemostasis are indispensable, and radioscopy or operating
on the radioscopic table, are helpful adjuncts) When performed by
experienced surgeons, primary closure by suture constitutes the ideal
modern treatment of war wounds. The method needs no defense, for
it is its own best vindication. Lemaitre aptly calls it a worthy
daughter of French surgery, destined to live and prosper.

II. CARREL METHOD.

CARREL-DAKIN TREATMENT.

None of the procedures devised to meet the exigencies of the world
war has aroused so great an amount of controversy in surgical circles
as the Carrel-Dakin method of treating infected war wounds. Even
among those who have used it there are bitter critics as well as earnest
advocates. The result. is that a decision for or against its employment
can hardly be arrived at by the surgeon without personal experience
and observation of its results.’

After visiting scores of military hospitals abroad, and obtaining
at first hand the views of the acknowledged leaders in war surgery,
I have attempted to describe impartially the method and its appli-
cation: It was first put to the test in the Compiégne Hospital, early
in 1915, where the surgeons associated with Major Carrel became its
ardent supporters. Although professional opinion is still divided
regarding the value of wound treatment by continuous instillation
of a special antiseptic fluid, the method has undoubtedly attained
popular fame and favor. It has been accepted by the United States
Government for its military medical services; and even behind the
enemy’s lines there is a tendency to regard sodtigm hypochlorite as
the turning point in the treatment of infected: war wounds and the
answer to the puzzle of chemical wound disinfection. I have been
so fortunate as to witness much of its development, having seen it
employed in Compiégne i in the fall of 1915; at the War Demonstra-
tion Hospital, New York, in the summer and fall of 1917; again in
Compiégne late in 1917; and forward of Soissons, in the ‘galvnced
U. S. S. GEORGE WASHINGTON

 

BACTERIOLOGICAL CHART

see Ward: surg.

Nature of the wound. Infected Brush Buins, Left Leg.

anterior
‘iddle

5D

ESeyr Fret

25GE
=

Lo Manvanenx, imp.

10-1
 

 

F.—.C. Picture taken December 5, 1917.

 

F.—.C. Picture taken December 20, 1917.

10-2
Il. CARREL METHOD. 17

Carrel Hospital, in December, 1917. In November, 1917, on my
recommendation, this method of treatment was put into operation
on the U. S. S. George Washington, including the Carrel-Dakin
treatment proper and various modifications of it. Major Carrel and
others of the staff of the Rockefeller War Demonstration Hospital
and Rockefeller Institute personally aided in the establishment of
this floating war demonstration hospital, fully equipped with ade-
quate laboratory facilities, special splints, X-ray apparatus, and
photographic plant. Preparation was made for the treatment of
200 cases by the Carrel-Dakin method for one month without the
necessity of renewing supplies. We have had most gratifying re-
sults where it has been employed. Charts, etc., of two tpyical cases
are included herein.

U.S. 8. George Washington.

Carrel case No. 1 —-Sarpeon, Bainbridge, Wm. S.; date, December 6, 1917; name
C., F. E.; rate, Sea., 2c.; age, 26.

Date and. nature of wound: November 15, 1917. Loop of rope caught left leg and
cut into flesh. It was dressed with a saturated sol. mag. sulph. Worked but became
worse. Seemingly well for three days; became worse, glands in groin became swollen
and painful, back to sick bay. | , /

Date and nature of operation: December 3, 1917. Picture ofleg taken. Condition,
cellulitis of leg. Wounds discharging pus, leg swollen. Wet dressing of mag. sulph.

 

 

December 5, 1917, incision of leg over shin. — e
Treatment.
Date. Condition of wound. Temp. B. count.
1917
Dec. 6 | Three wounds; 2 burns, 1 incision as | Normal....| Inf. all types.

above; 1 tube: No. 3 covered;
‘Dakin’s sol. 30 c. c. q2h. :
7 | Patient states that he has no more |..... do....| Middle 26, anterior 22.
pain or throbbing; leg less swollen, :
almost no discharge; 3 tubes ap-
plied; Dakin’s sol. 30c: c. q2h.

8 | Looking better, less pus; 3 tubes; |.....do.... Middle 9; anterior dry,
Dakin’s sol. 30 c. ¢. q2h. - no smear.

9 | Anterior wound cde: middle look- |...-. do....| Middle 6.
ing better; 1 tube; Dakin’ s sol. 30 |
c. ¢. q2h.

10 | Looking better, no pus; 1, tube; |.....do....| Middle 4.
Dakin’s sol. 30 c. c. q2h. : 7

11 | Condition about the same; 1 tube; |..... do....| Middle.5.
Dakin’s sol. 30 c. c. q2h. be ae

12 | Wound looking better; a clean bright |...:.do....| Middle 1-5.
red color; no pus; it tube; Dakin’s :
sol, 30 c. c. q2h.

13 | Condition of wound much better; |..... do.... do.

Dakin’s sol. discontinued: chlora-
zene cream applied.

14 anch pe chlorazene cream ap- |....-. do.... do.
plied. :
15 | Condition of wound much better; |..... do....

chlorazene cream discontinued;
‘thymol iodid applied.

 

 

 
12 II, CARREL METHOD.

Treatment—Continued.

 

 

Date Condition of wound. _ Temp. B. count.
1917
Dec. 16 | Wound much better; thymol iodid | Normal ..
applied. ; .
17 | Wound sterile and healing rapidly; |.-.-. do....
dusted with thymol iodid: _ :
18 | Looking well; thymol iodid applied...|..... do....
19 | Wound practically healed: dusted |..... do....
with thyme iodid; discharged to
duty. ¢ silts
20 | Picture taken....:.4.-.-.---- dpaceiceid ah Efe Sects

 

 

Carrel case No. 10.—Surgeon, Bainbridge, Wm. S.; date, January 5, 1918;
name, M., P. F.; rate, SF-2; age, 25. ;

Date and nature of wound: November 15, 1917, while standing watch in a
lookout aboard the U. 8S. 8..De. Kalb, he got a sudden, pain in his right side
so bad that he had to be relieved from duty. Next morning he was admitted
to the sick bay. 5

Date and nature of operation: November 17, 1917. An aspirating set was
used to draw oft about a liter of milky pus; this relieved the pain for a time.
November 18, 1918, transferred to base hospital No. 5 at Brest. December 1,
1917, a second puncture was made, this time drawing off about the same amount
of milky pus. Two weeks later an incision was made postero-laterally in the
region of the seventh rib of the right side. About three-fourths of an inch of
the seventh rib was extracted. Two liters of a milky pus evacuated at this time.

Treatment: Dichloramine-I. Slight improvement. Patient had practically
no temperature at any time. Patient had been up and about for two weeks
prior to his transfer to the U. S. S. George Washington on January. 5, 1918.
Treatment changed to the Carrel-Dakin sol. every two hours. Patient improv- .
ing rapidly under new treatment. i

Treatment.

Date. Condition of wound. Temp. B, Count.

 

1918
Jan. 5 A. M. Dressed at Brest, where D. T.

5 | Great loss of flesh; right chest con- ; Normal... Cavity, pus, granula-
tracted; right lung collapsed; regu- tion, inf. all types:
lar diet; a tube 8 inches long and
14 cm. in diameter was removed
from cavity, followed by about 250
ec. c. of a dark, slimy pus; irrigated
with Dakin’s sol. 6; No. 1 tubes in-
serted; Dakin’s sol. 120 c. c. q2h.
6 |. Condition a little better, 1 pint of pus |...do...... Cavity 40, pus 16,
evacuated; irrigated well with gran. 18.

Dakin’s sol.; return well bleached. ;
#16 sees Paki sol. 120 c. c. q2h.
ondition much better, irrigated out |...do...... Cavity 6, pus 10, gran
with Dakin’s sol.; tine normal 9. one ae
ea 5 tubes; Dakin’s sol. 120 c. c.

q2h. .

8 | Looking much better, much less pus, |...do......| Cavity 4, pus 5, gran.

much less contraction of the chest; 6.

irrigated with Dakin’s sol.; 6 tubes;

aly Deere Bal 120 c. c. q2h.

ooking much better, practically no |...do.....- | Cavity 2 3 ;

pa 4 tubes; Dakin’s sol. 90 4 c. ths Le a
q2h.

 

 

 
 

U.S. S. GEORGE

 
  
       

BACTERIOLOGICAL CHART
Name: She chest telon Ward: , No. 1-«

Nature of the wound...

 

 

 

 

 

U.S. S. Gecrge Washington,
12-1 1
 

 

Preparing to give Carrel-Dakin treatment on U.S. S. George Washington,

 

 

 

Sick bay on U.S, S. George Washington

12-2
Date.

II. CARREL METHOD.

13

' 4!" Preatment—Continued.

Condition of wound.

Temp. B. count.

 

1918

Jan.

10

il
12

13°

14

15

16

17

 

Looking much better, less pus, prac-
tically no pain; 3 tubes; Dakin’s
sol. 90 c. c. q2h.

Much better, no pain, no pus; 2 |...

tubes; Dakin’s sol. 50 c. c. q2h.

Looking much better, small amount
of pus, less contraction; patient up
and about; great change in
strength; putting on weight; blow
bottle b. i. d.

Looking much better, less pus; blow |...

bottle b. i. d.; 2 tubes; Dakin’s sol.
50 c. c. q2h.

Patient feeling much better, less |. .

pus, no pain; blow bottle bid; 2
tubes; Dakin’s sol. 50 c. c. q2h.
Een. aes "
weight rapidly, practically no pus;

plow bottle b. i. a 2 tubes; Dakin’s

sol. 50 c. c. q2h.

Continued gain both general and |...

local. About ready to permit of
closure. ~

Arrived at Norfolk, Va., to be trans-

ferred to hospital for treatment... .|:

well, is putting on |...

Normal. ..| Cavity 1, pus 2, gran.
2.

Pay 1-5, pus 0, gran.
Cavity 1, pus 1-5, gran.

Cavity 1-5, pus 1-2,
gran. 1-2.

-d0.....4 Cavity 1-5, pus 1, gran:

.| Cavity 1-5, pus 1, gran.
1.
Cavity, pus, granula-
tion. '

 

 

 

Carrel-Dakin titrations during voyage from December 4, 1 917, to December 21, 1917

Stock solution showing effects of time.

 

 

 

Dee. 4, WOU ccs cue Se ve bs eeeee sda eeeeenee 3h ease aseeny sys ci aseecalses 12.1
Dees 6; WOM ccc 33 Fee Seetae Sowa eeeee 5 Boa eee eee 6 cceiladwanie ds 11. 9
Decu8, WM sss acacenidie sak sees Rete ied: saa aenae ae nae parbictaie oacevaceee iL.3
Dee: 10;1 917.5. ses oie crac ween saitonesec cn emeuaaueeeeen oe 11.0
Decil2 A Fe cecsece suse paiccecutah oneteaaet ceases eeceeets 10.7
DCC! AD, AOL Fecsescrsce spajssere aie via atone es ees Raided a hiyeic ow Seipeins SeARa LAS cana eils 10.1
Dees lS: LOU Gen ae iste eataasaianis sisiayekGuit: exis POugneeUais: eoss asta 9.2
Dee. 20, VW Fessccsostes sss emcees s oases cbse ss ceteseeees tee st esaeeeacee 8.6
Solution used. Solution used.
Dec. 4, 1917......--..--- 12.1 0.45 | Dec. 18, 1917...- 12.1 0. 45
Dec..5, 1917.....-------- 1211] .45 | Dec. 14, 1917....02h..... 121] .45
Dec. 6, 1917.......-.-..- 12.1] .45 | Dec. 15, 1917..........-. 12.1 . 45
Dec, 7, 1917...... Pe ceess 19.1 | AB | 86.16, 1917 ccnaenn cece 121} .45
Dec. 8, 1917 -.-....---.-- 12.1 .45 | Dec. 17, 1917... - 12.1. . 46
Dees 9; 1917 30.2 se sseucws 12.1 .45 | Dee. 18, 1917... 12.1 - 45,
Dec. 10, 1917......-.---- 12,1 .45 | Dec..19, 1917......--.--- 12.1 . 45
Dees 11, WOU oc02s2 seins 12.1 .45 | Dec. 20, 1917.....-.-..-- 12.1 ~45-
Dec. 12, 1917...--..----- 12.1]. .45 | Dec. 21,1917.......-..-. 12.1 . 45

 

 

  

 

 

Lai ae oa

The novelty of this method of wound treatment consists in its
providing a close and protracted contact between the solution used
and the infected wound surface. In order to maintain an unchanged
concentration of the antiseptic, a special technique is required for
14 Il CARREL METHOD.

the constant renewal of Dakin’s fluid, which is very unstable and
easily decomposed. The treatment requires as a preliminary the
earliest possible thorough cleansing of the infected wound, within
the first six hours, with free incisions, removal of foreign bodies,
and excision of all dead or dying tissue. This surgical purification
is then supplemented by the Carrel instillation method of wound
sterilization by chemical means, more particularly in the form of
Dakin’s fluid, which is claimed to be approximately isotonic with
blood serum.

The point emphasized by Carrel in his treatment is.the principle
of its application; which is a direct reversal of the accepted princi-
ple of gravity drainage and a revival of the doctrine of antisepsis,
not as opposed but as subservient to asepsis. The old Listerian
teaching has thus been vindicated, and antisepsis has been developed
into a practicable therapeutic procedure. In view of the fact that
sepsis is responsible for the loss of countless lives and limbs after
recovery from the immediate effects of the traumatism, efficient anti-
sepsis seems to offer a more hopeful outlook for the wounded, A
most important feature of this treatment is that it permits of early
closure of the disinfected wounds by suture, thereby preventing
tedious convalescence, threatened septicemia, and more or less loss
of function.

Under this method, all war wounds are treated as suspects, which
means that under no circumstances may such a wound be closed
without sterilization under bacteriological control. Clinical appear-
ances, no matter how favorable, must be corroborated by micro-
scopical examination. On coming under treatment within 24 hours
after the infliction of the wound, the patient is placed on the operat:
ing table and the affected region is freely exposed by incisions, bring:
ing all wound corners and recesses into view. In conformity with
modern conservative principles, all vascular, nervous, or tendinous
structures are respected as far as practicable. At the same time, an
effort is made to convert an irregular angular wound into one large
open chamber or cavity. Aside from the radical removal of all
foreign bodies and other contaminations, the fleshy tracts of pro-
jectiles and the like must be excised as completely as possible, this
being the only way to accomplish absolute wound purification. Sac-
rifice of muscular tissue under such circumstances is more apparent
than real, as extensive sloughing of the walls of seton wounds is sure
to-occur. Hemorrhage is to be controlled by means of plain catgut
or linen ligatures, which alone are capable of resisting the action of
the antiseptic fluid. It is essential.that all oozing be checked with
hot saline solution, for the presence of blood not only interferes
with proper sterilization, but prevents the taking of satisfactory
smears for determining the microbic content. Hidden foreign bodies
Il. CARREL METHOD. 15

in the depth of the wound are best located by the X-rays, which ave
also useful for ascertaining the presence or absence of bone fractures.
Neutral oleate of soda is employed for the preliminary cleansing
and again for washing the skin around the sterilized wound, to pre-
vent reinfection.

The next stage of the treatment consists in the introduction of
hypochlorite solution into the prepared wound by means of one or
several red rubber instillation tubes, with a lumen of 4 mm.; thickness
of wall, 1 mm. When destined to flush a single large cavity, the
tubes are open at both ends, whereas tubes’ which supply several
smaller cavities are closed at one end and perforated at the. sides.
Not the tubes, but the solution must be renewed every two hours, be-
cause by that time its efficiency has been greatly lessened by the loss
of concentration due to the union of the chlorine with the protein
elements of the bacteria and tissues. The renewal of solution is ef-
fected without removing the dressings, by the simple expedient of
allowing more of the fluid to flow in through the instillatien tubes.

The dressing is carried out as follows: Compresses soaked in
Dakin’s solution are applied to the wound in such manner as to hold
the tubes in position and prevent kinking or other obstruction to the
flow. Small squares of gauze, smiearéd with sterilized vaseline, are
placed over the skin around the wound to prevent cutaneous irrita-
tion which otherwise might follow on prolonged exposure of the
skin to the solution. In addition the dressing comprises another
layer of gauze, a sheet of absorbent cotton wool, a second sheet of
nonabsorbent cotton wool, and. still another layer of gauze. These
four layers come ready made in pads, so that they can be quickly
applied and easily retained with saféty pins or wooden clothespins.
The dressing is applied with the absorbent cotton wool nearest the
wound in order to absorb secretions, while the nonabsorbent layer
prevents these from escaping and soaking the bed. .The perforate«l
portion of the tubes is all beneath the dressing; either upon the
wound, if superficial, or inside of its cavity. '-'The nonperforated
part is connected with the distributing tubes, which are divided so
as to provide as many outlets as may be needed. These distributing
tubes are of glass and come either in the form of a Y or a three to
four-toothed comb; their lumen is about 7 mm. ‘They are connected
with the instillation tube (same lumen) from the reservoir, which is
a flask holding 1 liter, with a diameter of 7 mm. at the outlet. This
instillation tube is fitted with a pinch cock to control the flow when
intermittent instillation is used, and with a drop counter and screw
pinch cock to serve in continuous instillation. The latter method is
employed only in cases where one tube open at the end is placed in

or on a wound.
16 Il. CARREL METHOD.

Where two or more tubes with lateral perforations are used, the
' intermittent method alone is practicable. Every two hours the nurse
presses on the pinch cock for a few seconds and permits the inflow of
enough fluid approximately to fill the cavity. The overflow is caught
by the absorbent gauze of the dressing and when properly managed
will not wet the patient. Protective pads may be placed underneath,
but waterproof wound dressings are prohibited. Chutro uses a shal-
low metal pan under the dressing with a tube connecting it with a
receptable beneath the bed for possible overflow.

The hypochlorite solution in the reservoir is colored pink with
potassium permanganate in order to distinguish it from other irri-
gating fluids and also to shelter it from the decomposing effects of
light. It is a rather unstable solution. ,

The aim and object of the Carrel method of wound treatment is
the continuous contact of injured parts with an efficient nonirritating
antiseptic, which is; moreover, a solvent of necrotic tissue. “Other-
wise, this dead or dying tissue would maintain infection in spite of
the bactericidal power of the instillation. A further most essential
feature of the method is the scientific control by way of bacteriologi-
cal examination, usually on alternate days, of smears from various
parts of the wound to determine its progress toward asepsis. The
time for closure of the wound by suture is governed by the labora-
tory reports, and has not arrived until: the proportion of bacteria
under the microscope is as low as one to five or six fields. 'The smears
are taken by the surgeon himself after the instillation has been dis-
continued for two hours. When closure under these conditions is
followed by a rise of temperature and evidences of local disturbance.
the wound must be reopened without delay and search made for an
undetected foreign body. If such be discovered and successfully
removed, the wound may be closed again after a second period of
observation. Sometimes in long-standing cases bacteria are im-
prisoned in cicatrices and set free when an attempt is made to close
the parts. More or less incomplete sterilization is indicated by pain
and rise of temperature and calls for an immediate repetition of the
course of instillation.

Regarding the composition of the antiseptic agent used in this
method, the neutral hypochlorite of soda was selected by Dakin,
after considerable experimentation, as the most advantageous and
nonirritant to the interior of the wound, although slightly attack-
ing the skin. The latter can be simply and effectively protected by
means of vaseline. Soda hypochlorite in a concentration between.
0.45 and 0.5 per cent destroys all bacteria without distinction. Be-
low 0.45 it loses its bactericidal powers; while above 0.5 the tissues
will not tolerate it. Between these two extremes it will disintegrate
pus-cells and dissolve necrotic tissue, being superior in this respect
Il. -CARREL METHOD. 17

to chloramine, a better antiseptic, but without the power of dissolv-
ing necrotic tissue. Moreover, chloramine decomposes more rapidly
on contact with the tissues and must therefore be used in larger
amounts than soda hypochlorite, which after exhaustive experimen-
tation under identical conditions is advocated by Carrel as the best
available. It is cheap and readily made up, provided care be taken
to secure the correct ingredients and to make the proper combina-
tions.

Dakin’s fluid is prepared according to two fowraulad. one with and
the other without the addition of boric acid, the latter having proven
most acceptable in practical experience. ‘The process of making the
solution is described as follows:

Neutral hypochlorite prepared without boric acid is best made according ta
the formula given by Daufresne, and at the present time is perhaps more
generally used than any of the other modifications. Two hundred grams of
good bleaching powder are put in a 12-liter bottle with 5 liters of tap water.
The solution is shaken vigorously and allowed to stand for at least six hours.
unless a mechanical shaker is used, when half an hour’s shaking will be found
sufficient. In-another vessel, 100 grams of dry sodium carbonate and 80 grams
of sodium bicarbonate are dissolved in 5 liters of cold water and then added to
the bleaching powder mixture. The whole is shaken vigorously for a few
minutes, and the precipitate allowed to settle. At the end of half an hour the
clear solution is siphoned out and then filtered through paper. The proportions
given above for the carbonate and bicarbonate of soda are those given by
Daufresne. It is our experience, however, that with most brands of American
bleaching powder it is better to use 90 grams of each salt. This solution must
invariably be tested for neutrality by adding a pinch of solid phenolphthalein
to a little of the solution. If, the solution should give an alkaline reaction, one
of three methods must be employed to correct it, otherwise skin irritation will '
surely result.

(a) Pass carbon dioxide gas into the solution until a sample shows no
alkalinity when tested as described. This is perhaps the best method.

(0) A neutral hypochlorite may be secured by reducing the proportion of
carbonate of soda and increasing the bicarbonate.

(c) Boric acid may be added until neutrality is secured. An advantage ‘of
the carbonate preparation is that it possesses greater stability and can be
kept for several weeks without much deterioration. On the other hand, with
varying qualities of bleaching powder, containing different amounts of free
lime, it is more difficult to adjust the proportion so as to obtain a neutral solu-
tion directly. Probably those having adequate laboratory facilities will prefer
the carbonate-bicarbonate solution, while the mixture containing boric acid is
readily made under less favorable circumstances.

Titration of the solution.—Measure 10 c. c. of the solution, add 20 ¢. ¢. of 1:10
iodin solution and 20:c. c. of acetic acid. Pour into this mixture a decinormal
solution (2.48 per cent) of sodium thiosulphate (hyposulphite) until decolora-,
tion. Let N equal the number of cubic centimeters of thiosulphate employed.
Then the quantity of sodium hypochlorite for 100 c. c of the solution would be”
giyen by the equation: T=NX0.08725.

Precautions.—Never heat the solution. If, in case of ah emergency, it is
necessary to titrate the chlorinated ims; use only water, never with the solu-
tion of soda salts.
2

18 ll. CARREL METHOD.

Other means of preparing the hypochlorite solution. by passing
chlorine gas into soda solutions are coming into favor, because of the
readiness of obtaining ‘an exact chlorine concentration without the
trouble and delay of titrating the lime. Transportation of the
chlorine tanks is as easy as that of the lime outfit. We have found
the chlorine gas method very satisfactory on one of our largest trans-
ports. Thousands of these gas tanks have been ordered for the United
States Army. ,

The apparatus for making Dakin’s solution directly from liquid
chlorine (designed and manufactured by Wallace & Tiernan Co., New
York, tested and indorsed by the Rockefeller Institute, and shown in
the illustration) consists of a seamless steel cylinder of chlorine with
a special regulating valve, connections from the cylinder to a meter,
connections from the meter to a diffusor stem and diffusor for dis-
tributing chlorine in the sodium carbonate solution.

Pure anhydrous chlorine can be obtained in compressed cylinders
of various sizes. The second illustration shows the arrangement
suggested for connecting the apparatus to a large cylinder. The
valve in the head of the large cylinder is not sufficiently sensitive to
control the minute quantities of chlorine passing through the Dakin’s
solution apparatus. It is therefore necessary to attach to the main
tank valve as shown, an auxiliary tank valve capable of fine adjust-
ment as indicated in the cut. The connection from the auxiliary
tank valve to the meter block is made as shown.

The progressive sterilization of infected war wounds is ascertained
through the bacteriological control of the wound, an essential feature
of the Carrel treatment. Smear specimens are prepared from time
to time, according to the judgment of the surgeon in charge, and
the number of germs in several microscopic fields is estimated, espe-
cially toward the end of the treatment, when the question of closure
by sutures enters into consideration. Practically complete absence
of germs is noted in the average case at the end of from 4 or 5 to
12 days’ treatment of soft-part wounds free from gangrenous tissue,
or from 13 to 25 days in extensive wounds complicated by fractures,
When treatment can be begun within 24 hours after the infliction |
of the wound, sterilization is as a rule rapidly accomplished. Two
weeks or more may be required to sterilize a compound fracture,
uncomplicated by gangrene, when the instillation is begun within 24
hours. In such cases, after the sterilization has been effected, large
bone splinters may be fixed in position with Beck’s paste, or large
gaps bridged with adipose grafts, after which the wound may be
closed and managed as a simple fracture.

Neglected or improperly treated inflamed wounds of more than
24 hours standing may be bathed with the Dakin solution, and fomen-
tations of hot water and alcoho! applied, but local interference is
‘dapul[AD aulsojyd adie] UyIM Snyesedde uoljynjos s,uly4eq
3

 

“snyeiedde uoljnjos s,ulyeg

 

 

 

 

 

vounos \\
ORV? WADE

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ANA on, INNO LP

18-1
 

 

 

War Demonstration Hospital, New York,

 

 

 

The War Demonstration Hospital. Carrel-Dakin method
of treatment being demonstrated at a special course given
for Army and Navy surgeons by Dr. Carrel. Prof.W.W.
Keen speaking to class, contrasting treatment of wounds
in the Civil War and the present war.

18-z
Il, CARREL METHOD.

contraindicated during the inflammatory period, which lasts several
days or even weeks. Suppuration once established, existing abscesses
may be evacuated and instillation tubes introduced, postponing the
search for foreign bodies or the exposure of sinuous tracks until
more favorable conditions have been provided by the antiseptic solu-
tion. The Italian proverb, “Chi va piano va sano,” is a good one
to follow in these cases.

Should convalescence be unduly protracted, with persistence of
microbes notwithstanding careful observance of all rules of treat-
ment, the wound must be explored in order to discover the cause of
the trouble; which may be in the form of ‘minute foreign bodies,
particles of necrotic bone or infected marrow, fistulous tracts, or
the like. Neglected wound recesses, not reached by any tube, are
frequently responsible for delayed healing. One of the conducting
tubes may slip or drop; or one or more tubes may become bent or
kinked. Again, the instillation apparatus may have been incorrectly
installed, or the relative calibers of the several tubes may not cor-
respond to the rules for the treatment.

_At the War Demonstration Hospital of the Rockefeller Institute
in New York, where everything needed for the complete exposition of
the subject lies been provided, large numbers. of surgeons have been
enabled to: study this valuable method of wound sterilization prac-
tically as well as in the war hospitals abroad. A hospital with 100
beds, with a first-class equipment for this particular purpose, has
been erected, and! nothing is. omitted in the demonstration of every
feature of ‘he treatment and in the exhibition of the theory and prac-
tice of this novel adaptation of Lister’s teachings to, the wounds of
modern warfare. The teaching includes the preparation of the solu-
tion and of the patient; the adjustment and operation of the instil-
lating apparatus; the application of the dressings; the taking and
testing of smears; briefly, the entire. technique of the method. The
clinics of Major Carrel and lectures of Dr. Loewy have contributed
largely to the popularizing of the system among the students, who
thus have become acquainted with it theoretically at the fountain-
head of information, and practically through some of the trained
members of Carrel’s Compiégne staff.

The regular course given by Major Carrel, with Dr. Dehelly and
Dr. Loewy, has attracted, many United States Army medical officers
and.a few Navy men. Dozens of hospital corpsmen have been
enabled to take interim courses in the hospital between trips. Small
groups are instructed at a time for a period of 10 days to two weeks.
This hospital'thus provides an excellent and accurate demonstration
of the treatment as it should be carried out according to the ideas
of its originator. However, one can not here form an accurate esti-
mate of the results in the treatment of war wounds, for the horrors
20 Il. CARREL METHOD.

of infected wounds at home are as nothing compared with those
abroad.

The underlying principles of wound sterilization are applied uni-
formly in recent as well as in long standing wounds, the technique
varying only according to the mechanical difficulties attributable to
the location of the injury. The solution must be kept in contact with
all parts of the damaged area, and this is difficult to accomplish in
wounds so situated as to be quickly drained. In such cases the effects
of gravity must be counteracted by plugging the dependent aper-
ture with gauze, so as to make a basin of the cavity. Under no
circumstances must gauze be allowed to come between the tube and
the discharges, as this would prevent the penetration of the steriliz-
ing fluid. .

Wounds of the brain require thorough sterilization after the care-
ful removal of the projectile or any other foreign bodies that may
be present. It is essential that the solution be brought into contact
with all parts, but extreme caution is needed to guard against dam-
age being done to the delicate cerebral tissue. A special apparatus
has been constructed for the purpose, which to quote Carrel, consists
of “an external tube permeable to liquids, and an internal tube of
small caliber by which the antiseptic substance is injected. The
external tube consists of a very light framework, on which is stretched
a thin fabric which has been rendered hydrophilous. This frame-
work Du Nouy constructs of bamboo hollowed and perforated by a
thermo-cautery, while Daufresne makes it of thin wire. The diameter
of these tubes varies from 1 to 1} centimeters, and the length from
4 to 6. In the interior of the tube is fixed a small rubber tube about
2 millimeters in diameter, which is attached to the framework. « This
little appliance is fixed in the cerebral wound so that the movements
of the head can not displace it. The meninges are protected by a.
piece of gauze impregnated with vaseline. The appliance is con-
nected with a special apparatus which instills we liquid drop by
drop.”

Many claim that Dakin solution is too irritating for brain cases;
others employ it and agree with the staff at Compiégne that it can
be used advantageously in cerebral surgery.

Secondary hemorrhage, which is occasionally encountered, may be
due to the destruction of the silk or chromic catgut ligatures by the
hypochlorite solution. Plain catgut or linen is safer. It may some-
times be attributable to a faulty Dakin solution, which with free
alkali will be capable of ulcerating blood vessels as quickly as Labar-
raque’s solution. Again, it may result from the breaking down of a
hemostatic clot under the influence of infection. It can be prevented
by care in the initial control of hemorrhage. Its occurrence must
be met by prompt ligation above and below the danger point.
Il. CARREL. METHOD. 21

Several methods of closure are available when the microscope de-
cides that the proper time has arrived. Strapping with adhesive
plaster across-the wound is perfectly satisfactory when the skin is
movable and cicatrization has not begun. There is no pain and no
need for anesthesia. A strip of sterilized paper or celluloid should
be laid along the wound to prevent reinfection by the plaster, which is
not sterile. When the wound is gaping and can not be closed com-
pletely, elastic tension may be applied to it and gradual coaptation
of the edges be brought about. Strips of plaster three inches wide
and long enough to extend 2 inches beyond the wound at both ex-
tremities are laid parallel with it and are fitted with shoe-lace hooks
which are connected across the wound by means of elastic lacing.
The traction exerted by the elastic laces gradually draws the edges
near together, and even if complete closure can not be effected: be-
cause of the loss of tissue there is a great reduction in the interspace
left: to cicatrize. :

If suture should be selected as the means of closure, general anes-
thesia may best be employed. The skin should be released from the
deeper parts if adherent, and its edges freshened by being cut away
for the width of about 2 millimeters. Deep suturing may be needed
for divided aponeuroses, for example. The bacteriological examina-
tion having shown the requisite freedom from bacteria there is no
need of drainage. As soon as the wound is in this condition, divided
muscles, tendons and nerves should be brought together.

Wounds associated with fracture may be closed, as a rule, the same
as wounds of the soft parts. Even in badly crushed limbs, if asepsis
can be secured in a few days closure may be effected without any
anxiety regarding the bony element of the problem. It will take care
of itself. In certain old fractures it-may be necessary to fill an osse-
ous ‘gap with Beck’s paste or an adipose graft.

Amputation is nearly always the consequence of infection. An
infected wound can not be closed primarily, and hence there is a
marked tendency of the soft parts to contract. This may be over-
come in great measure through traction, by means of adhesive plaster
and a weight. The necessary apparatus does not interfere in the
sterilization of the wound. On amputation stumps, a loop of tub-
ing perforated in its middle portion and connected with a Y dis-
tributor may be laid next the tissues, and the fluid carried all over:
the area at the stated intervals. After a few days, according to the
bacteriological improvement, the stump may be sutured and treated
like any other fresh aseptic operative field.

Joint injuries are treated on the same principle. Simple. lacera-
tien of synovial membranes quickly resolves under the instillation
methed. Even where bone injury has occurred, better results and
fewer resections follow the gradual sterilization. ‘In‘streptococcic in-
22 I. CARREL METHOD.

fection of the joints, amputation has to be gravely considered. If
the surface of the bone should have been abraded by the missile ‘it
must be scraped to get rid of any infectious material.

The results claimed by Carrel for this departure in the manage-
ment of war wounds are in broad general terms the salvation of
life and limb under circumstances heretofore considered prohibitive.
Specifically he cites the “diminution in the frequency and intensity
of general complications; diminution in the number of amputations;
diminution in the length and cost of treatment.” Under the first
heading is cited the fact that of 303 cases received from advanced
dressing posts in the hospital at Compiégne from December, 1915, to
October, 1916, 13 died “after a stay in the hospital of more than 24
hours.” Of these, eight had extensive visceral damage, and three had
“multiple wounds of thorax, lower and upper limbs.” Two cases
only died of septicemia. One was due to gas gangrene, the other to
staphylococcus infection following extensive damage to the femur.
Under the second head, the suppression of infection prevented the
complication of lymphangitis, abscess and purulent tracts, thus dimin-
ishing the number of amputations. In one year, only three abscesses
were observed. Where the extent and character of the lesions did
not allow of speedy sterilization they did allow of a great deal of
local improvement. This favored the conservative management of
many wounds ordinarily calling for amputation. From December,
1915, to October, 1916, only 23 amputations were performed, and
where resection of joints was the usual course, the simpler expedient
of arthrotomy and sterilization sufficed to save the limb. The am-
putations were due mostly to such extensive destruction of tissue
that nothing else was possible. In only three cases was the cause
sepsis. Two have been referred to. The third was a “fracture of
the upper part of the forearm with extensive vascular destruction
and considerable diminution of the circulation of the limb.” This
patient recovered. At the hospital at Villars, M. Perret amputated
only once in 100 cases. In another series of 100 infected cases MM.
Guillot and Woimant did not amputate at all.

Under the third heading “diminution in the length and cost of
treatment,” Carrel claims that wounds of the soft parts, no matter
at which stage treatment is begun, are closed in 90 per cent of the
cases between the 5th and 20th day. The other 10 per cent heal more
slowly but much faster than under other forms of treatment. Six
months would otherwise be needed to close many of these which are
closed in less than one month. The duration of wound treatment is
reduced two-thirds. In compound fractures “of short bones, flat
bones, and such long bones as the fibula, radius, and ulna, the same
progress was made as with wounds of the soft parts.” Under “ ordi-
nary methods such fractures sometimes suppurate for months.” With
 

 

Case No, 1.—Wound closed,

22-1
 

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22-2

Case No. 2.—One of Dr. Carrel's cases. Large shell wound trav-
ersing the anterior aspect of the thigh and almost completely divid-
ing the quadriceps femoris. Three anda half hours after the re-
ceipt of the injury the wound was laid open and foreign bodies
and torn muscular tissue removed. An extensive wound resulted
more than 10 centimeters long and extending from one side of
the thigh to the other.

 

 

 

Case No, 2.—At end of seven days the patient walked normally.
Tl. CARREL METHOD. 23

regard to compound fractures of the “tibia, humerus, and femur.
considerable diminution in the duration of treatment is also pro-
duced.”

The cost of treatment is lessened by the shorter period of care.
The materials used are cheap. The net cost of a quart of Dakin’s
solution is less than 1 cent. Dressings are but slightly soiled and
may be resterilized for further use.

The method favors the speedy suturing of nerves and tendons
which in a condition of prolonged suppuration would be impossible.
Hence the saving of function is very great.

On an average, 97 per cent of old bone sinuses coming to him for
treatment are now closed by Chutro, who has used the Carrel-Dakin
treatment in all infected cases since 1916 with excellent results. The
time required before closure usually amounts to 30 or 40 days.

Pozzi, surgeon in the Hépital Militaire du Pantheon, was an early
advocate strongly in favor of this mode of treatment.

Edred M. Corner, M. C., F. R. C. 8., chief surgeon in the Fifth
London General Hospital. St. Thomas's Hospital and the King’s
Hospital, writing in the Clinical Journal of London, April, 1918.
advocates this method and quotes Sir George Makins’s paper in the
British Journal of June 16, 1917, to the effect that “ At the present
time the most successful eesti which are being attained in all forms
of wound treatment are undoubtedly those in which the Carrel-
Dakin: method i ‘is employed. ue

In the British Medical Journal of June 2, 1917, Sir Anthony
Bowlby and Mr. Cuthbert Wallace say that “the method of Dr.
Carrel has been increasingly used and wounds treated in this way
have done exceptionally well.”

Sir Almroth Wright, who objects to Dakin’s fluid on several
grounds, considers the Carrel method as the most, important contri-
bution made to surgical antiseptic technique since the beginning of
ithe war, which moreover provides a new and improved technique
for physielogical treatment of infected wounds (Lancet, June 23,
1917).

Sir Thomas Crisp English, on his return from Salonica and Italy,
in an interview with me in London and in a subsequent written com-
munication, summed up his experience as follows: “I feel that the
Carrel-Dakin treatment is great. I used it extensively in Salonica
with excellent results. All of these things call for an open mind
and no dogmatic utterance.”

In their notes on recent surgery in Salonica (Brit. Med. Jour..
March 16, 1918), Colonels English and Kelly, on the basis of their ex-
perience as consulting surgeons of the British Salonica force, state
that the general treatment of wounds has followed the same evolu-
tion as in other theaters of war. At first the ordinary eusol dressing
24 Il. CARREL METHOD.

was most in use. A reaction in favor of the hypertonic saline solu-
tion and salt packs then set in. Finally, Carrel’s method of treat-
ment has become the one preferred. They emphasize the advantages
of continuous wound treatment by one method, and the desirability 4
of adopting a standard plan of treatment, provided an ideal method |
can be found. “Carrel’s method of treatment; ” they go on to. say,

“appeared to us to approach most closely to the ideal, and during
the past eight months it has been used as’ the standard method. in
many of the hospitals. Other forms of wound treatment have been
in use, but we have not yet seen with them the same consistency of
results, the quick sterilization of the wound and its secondary suture,
which certainly occurs with Carrel’s method.”

The rapid and radical removal of all necrotic tissue is now gener-
ally conceded to be imperative in checking infection. In the appli-

cation of the Carrel-Dakin treatment the proper preparation of the

wound in this particular is assisted and supplemented by the. con-
stant contact of the damaged tissues with a neutral hyperchlorite
solution having a powerful proteolytic action. While further, re-
search must show the exact nature of the resulting chemical changes;
the activation of proteolytic processes may even now be considered
the best-fitting key to the success achieved by the Carrel-Dakin
method of treating infected war wounds.

Regarding the mode of employment of hypochlorite solutions, sev-
eral types of simplified instillation apparatus have been devised which
obviate the necessity for a trained hospital staff, carrying into. the
wound at stated intervals an amount of antiseptic fluid which. can
be arbitrarily regulated.

The use of soda hypochlorite solutions has been objected to on the
following grounds: (a) their irritating effect upon the skin;.
(0) their brief efficiency; (c) the necessity for uninterrupted contact
of the antiseptic fluid with all wound recesses. The dichloramin-T
in oil method, described. later herein, was devised by Dakin for the
removal of ‘these and other minor objections. The double chloramin .
used is known commercially as chlorazene; it is dissolved in chlorin-
ated: eucalyptol, or chlorinated liquid paraffin may be added. The
oils are chlorinated to limit their decomposing action on the di-.
chloramin-T. The bactericidal action persists longer than the -ac-
tivity of hypochlorite solutions. The dressing is simplified by. the
elmination of the Carrel tube, the dichloramin-T being sprayed over
superficial wounds or poured into deep wounds as into a cup. How-
ever, the oily fluid does not seem to reach the deep corners of war
wounds as the watery solutions do. Besides, necrotic tissue is not
dissolved by dichloramin-T, which is all-important in many cases.
The consensus of opinion is tending strongly toward the retention
of the hypochlorite in the Carrel-Dakin treatment and the employing
 

 

 

French.surgeon giving a practical illustration of the Carrel-Dakin treatment.

 

Hospital corpsman learning to adjust splints at the War Demonstration Hospital, New York,

24-1
 

 

 

War Demonstration Hospital, New York. Hospital corpsmen learning the Carrel-Dakin
treatment.

24-2
Il, CARREL METHOD. 25

of dichloramin-T as a spray in certain infections of the throat, and,
if used at all in wounds, only in those which are superficial.
Chloramin paste contains 8 per cent of sodium stearate and 4 to 15
parts per 1,000 of chloramin-T. “It is designed to maintain in an
aseptic condition wounds which have already been disinfected, or to
sterilize slightly infected wounds. It should only be applied to
wounds which yield small quantities of secretion, have little or no
necrotic tissue, and little or no infection. Neutral sodium oleate is
poured into the wound and the surrounding skin from a flask with
asmall opening. The granulations, the epithelial edges, and the skin
are gently swabbed with a piece of absorbent cotton attached to a
forceps. (Great gentleness is required so that there will be no
bleeding from the surface-——W. S. B.) By this means an excellent
cleansing process is effected. The patient should feel no pain; any
suffering indicates either that the sodium oleate is incorrectly pre-
pared or that the cleansing is imperfectly carried out. The sodium
oleate is removed with a plug of cotton soaked in water, and the sur-
face of the skin is dried by carefully applying a compress of absorb-
ent gauze. A sufficient quantity of chloramin paste is withdrawn
from the receptacle by means of a sterilized wooden spatule and
applied to the surface of the wound to the thickness of at least 1
centimeter. It should cover not only the granulations, but also
the epithelial edges and part of the surrounding skin. If the wound
should be deep and anfractuous, the tube containing the chloramin
paste is introduced into the opening, and sufficient chloramin paste is
expressed to fill the cavity. But no pressure should be applied during
the process. A compress of dry gauze, much larger than the wound
itself, is next placed over the chloramin paste. The compress is
applied to the surface of the skin and attached to it by means of two
or three strips of adhesive plaster. It is important that the gauze
should be placed exactly over the wound, for if the bandage is shifted
the gauze will introduce bacteria from the surrounding skin on the
surface of the granulations and reinfection will ensue. Above the
gauze is placed a piece of absorbent cotton enveloped in gauze. The
dressing must not be compressed by bandages and should be renewed
every 24 hours. The wound is washed out with sodium oleate every
‘day or two, depending on the condition of the skin. The application
of chloramin should be painless; any sensation of pain signifies tech-
nical error on the part of the surgeon. The bacteriological condition
of the wound is examined every day in film preparations of secretions
taken from various parts of the wound.” (Carrel and Hartmann,
Jour. Exper. Med., July 1, 1918, p. 95.)
While claiming brilliant results and supported by eminent sur-
geons, the Carrel-Dakin treatment is opposed by surgeons. just as
eminent. Thorough wound cleansing, with immediate suture is held

93696—19-——3
26 It. OTHER METHODS.

in high esteem and is undoubtedly the ideal method. for treating
many cases received at a very early stage. The use of other anti-
septices besides the hypochlorites and the chloramines, either in con-
junction with the Carrel method of instillation or without it, is also
credited with most successful results. Certain excellent authorities
with large experience condemn the use of all antiseptics on the
ground that they damage still further the injured tissues and eon-
tribute nothing to the healing process or the prevention of infection,

The failure of so many able and honest men to agree upon a
uniform method of treatment suggests the suspicion that each has
hold of a thread of the truth but does not perceive the whole, which
is that while much depends upon the sort of wound and the period
when it comes under treatment, more depends upon the judgment and
skill of the surgeon in first selecting the proper method for each
particular case and then applying it. a:

Personal observation in the war zone of the various modern
methods of treatment, and the excellent results accomplished by
many of them, leads me to accept the judgment of a growing number
of surgeons that while most of these methods have definite fields
of usefulness, none of them is a panacea. The revival of the sixteenth
century practice of immediate wound closure, with thorough dé-
bridement, is of undoubted value, and there is reason to hope that it
will not again be relegated to the limbo of forgotten things, re-
quiring rediscovery in wars to come. Meanwhile, the Carrel
technique has come to stay, as through its employment certain great
truths have been revealed. Asepsis, whenever possible, reinforced
by antisepsis as required, is the keynote of success. ‘The type of
antiseptic and the extent of its employment, may be definitely de-
termined by the future, but at present they are largely matters of
individual opinion and preference.

III. OTHER METHODS.

At the many centers visited, numerous antiseptic agents were be-
ing employed and varying opinions were held as to the value of such
agents. I have attempted to set forth the more important of these
and the claims made for them by their originators or those using
them, as follows: a

HYPOCHLOROUS ACID PREPARATIONS—EUSOL AND EUPAD.

The antiseptic action of hypochlorous acid, and its application to
wound treatment, was pointed out in 1915 by Lorrain Smith, Drem-
man, Rettie, and Campbell, of the department of pathology in the
University of Edinburgh. The hypochlorous solution is known as
eusol, which is standardized at 0.5 per cent of hypochlorous acid,
 

 

St. Bartholomew's clinic. Hospital corpsmen making Dakin's solution,

 

 

 

St. Bartholomew's clinic. Hospital corpsmen strapping a sprained ankle and preparing Dakin’s
solution,

26
Il, OTHER METHODS. 04

and was originally prepared on a large scale from dry bleaching
powder and boric acid. In smaller quantities, eusol is advanta-
geously prepared, at a moment’s notice, by diluting and mixing two
stable stock solutions, as follows:

Preparation of eusol—Take 185 c. c. of liquor calcis chlorinatae
(a 10 per cent solution of bleaching powder in water) ; dilute with
water to 1 liter; add 10 grams of boric acid, and shake until dis-
solved. The solution remains clear, and without further treatment
is ready for use. If preferred, a saturated solution of boric acid may
be stocked at room temperature; this contains 4 per cent boric acid,
therefore 250 c. c. give the amount required for 1 liter of eusol. In
making eusol in this way, the 185 c. c. of liquor calcis chlorinatae
should be diluted to 750 c. c. and the 250 c. c. of boric acid solution
added. This prevents the formation of the precipitate which occurs
if boric acid be added to undiluted liquor calcis chlorinatae.

Preparation of eusol for intravenous injection in septicemia.—F or
this purpose, it is necessary to add sodium chloride in the proportion
of 8.5 grams to the liter. In this case, therefore, the 135 c. c. of
liquor calcis chlorinatae would be diluted to 500 c. c. with distilled
water, the 250 c. c. boric acid solution added, and also a solution
containing 8.5 grams of sodium chloride dissolved in 250 c¢. c. of
distilled water.

These methods of preparing eusol were published in the British
Medical Journal, September 22, 1917, by J. Lorrain Smith, Tirchie,
and Rettie, who say that since liquor calcis chlorinatae keeps well, the
method described above has suggested itself as a simple and con-
venient way of preparing eusol in any quantity desired. Each liter
of the liquor yields at least 7 liters of eusol.

(The quantities given in the prescription are calculated on a
chloride of lime assaying 25 per cent available chlorine, which is the
average obtained from'commercial samples at the present time.)

Eusol may also be prepared as follows: To 1 liter of water add
12.5 grams of bleaching powder, shake vigorously, then add 12.5
grams boric acid powder and shake again, allow to stand for some
hours, preferably overnight, then filter off, and the clear solution is
ready for use.

The solution contains:

 

 

 

Per cent.

Hypochlorous acid 0. 54
Calcium chlorate 1. 28
Calcium chloride _-_------~---------- 4 .17
Total / 1.99

 

Another method of preparing eusol.—Shake up 25 grams of eupad
(equal parts of commercia. bleaching powder and boric acid, inti-
mately mixed and ground in a mortar) with 1 liter of water. Let
28 Ill, OTHER METHODS.

stand for a few hours, then filter through cloth or filter paper. Keep
the mixture in a closely stoppered bottle, and do not expose to light.

Eupad is the name given to hypochlorous acid in powder form,
and consists of equal weights of finely ground bleaching powder
(chloride of lime) and of boric acid.

Hypochlorous solution, electrically produced from hypertonic
saline, was recommended as a strongly bactericidal disinfectant for
septie wounds, by Beattie, Lewin, and Gee (Brit. Med. Jour., I,
1917, p. 256). Their apparatus can be installed in any hospital or
institution, and a supply of the solution produced at a very small
cost. The lymph flow in the wound is encouraged by the hypertonic
solution which is used for the production of the hypochlorite. Sur-
face bacteria on septic foci seem to be destroyed almost immediately,
and the stimulating action on the lymph. fiow tends to wash to the
surface the more deeply situated organisms.

It is claimed that this lymph increase is very evident in the wounds
treated with this solution.

Mode of preparation of eusol, according to Fraser and Bates (Jour.
Roy. Army Med. Corps, London, Vol. X XVII, 1916, p. 791): “In
a Winchester quart bottle 27 grams of dry bleaching powder were
placed, and to this 1 liter of water was added; the mixture was
shaken, and 27 grams of boric acid were added; the bottle was now
filled with water, the solution was thoroughly shaken, allowed to
stand for a few hours, and then filtered through cotton wool. The
‘clear solution is eusol; it is slightly alkaline to litmus and it contains
approximately 0.5 per cent hypochlorous acid. The solution was
stocked in air-tight stone jars.”

The same writers report most gratifying results from intravenous
injections of eusol, varying in amounts from 40 cubic centimeters
to 70 cubic centimeters in cases of autotoxemia subsequent to infec-
tion of a wound with gas-producing organisms.

Packing with salt sacks (Gray’s method), to which eupad powder
has been added, is advocated in the treatment of septic gunshot
wounds on the basis of good results in a large series of cases by
Major Hull, of the Royal Army Medical Corps. A convenient method
of combining the eupad with salt is to pack the wound with ordinary
salt sacks sterilized in the autoclave and introduce into the middle’
of the sacks without touching the wound an unsterilized sack filled
with eupad. (Sacks filled with eupad and salt in the proportion
of one to three are destroyed in the autoclave owing to the corrosive
action of the hypochlorous acid upon the fabric.) The solid salt
sack consists of a two-walled sack of suitable size, made of bandage,
between the layers of which four layers of gauze are placed. The
interior of the sack is filled with salt and the tail of the bandage
forms a drain. The sacks are made in different sizes, sterilized in
Il.. OTHER METHODS. 29

_an autoclave and stored ready for use. One or more of these sacks
is used to pack wounds, the spaces between the sacks being filled with
gauze. A tube of perforated zinc or rubber may be passed into the
depth of the wound in case of large septic wounds. Six days may
be said to be an average time for the sacks to remain in the wound.

The successful results of this treatment largely depend, as all
treatment of septic wounds must, upon an early attack on the sepsis
and upon the thoroughness with which it is possible to remove septic
and necrosed tissue. :

SALT PACK METHOD OF WOUND TREATMENT.

The salt pack treatment of wounds was introduced by Colonel H. M.
W. Gray (Brit. Med. Jour., I, 1916, p. 1), for the purpose of pro-
moting a lymphagogue action and obviating the need for elaborate
drainage or continuous irrigation. As to results of the treatment
with salt pack, Donaldson and Joyce write in The Lancet of Septem-
ber 22, 1917: “The adoption of this method has considerably cur-
tailed the patient’s period of convalescence, and has, moreover, suc-
ceeded where other methods have failed, including the much-advo-
cated Carrel-Dakin procedure.”

The method is distinguished by its simplicity, the avoidancé of
daily dressing of the wound, the prompt development of healthy sur-
face granulations, and rapid improvement of the general condition.

Application of tablet and gauze packs.—After the wound has been cleaned
by operation, all the recesses of the wound (these recesses should be sought
out by the finger) are filled, fairly firmly, with gauze wrung out of 5 to 10
per cent salt solution, in the folds of which are placed numerous tablets of salt.
Blood clots which may form during the packing should be wiped away. The
gauze should be packed concertina-wise, a tablet being placed between every
third or fourth fold. A fairly large, fenestrated rubber tube is placed so as
to reach to the deepest part of the main cavity, which is then filled with gauze
and tablets. The dressing is made flush with the skin and the tube projects
slightly from its midst. The surrounding skin is painted with solution of
iodine or other antiseptic application. Two or three layers of gauze are then
used to cover the wound and surrounding skin. A suitable amount of absorbent
cotton wool is applied and a bandage wound on smoothly and firmly. Should
pus collect in any isolated part of the wound, it is not necessary always to
remove the whole of the pack, and thus to cause the patient unnecessary pain,
and to jeopardize the healing of the rest of the wound. Irrigation and drain-
age of the affected part may be instituted. The rest of the “ pack” will prob-
ably become loose in a few days. If it is suspected that any part of the wound
will give trouble in this way, a drain down to that part should always be
inserted.

In the answers to questions regarding saline treatment sent to 22
hospitals in July, 1915, tablet and gauze packs were judged to be
best for deep and fairly recent wounds.
30 Ill, OTHER METHODS.
DICHLORAMIN-T.

This chlorine compound was introduced by Dakin, and on account
of its greater chlorine content is claimed to exert a much stronger
germicidal action than the sodium hypochlorite solution used as
Dakin’s fluid in the Carrel method of wound treatment. Its basis
is a by-product in the manufacture of saccharine, and it is known
commercially as chlorazene.

The conclusions arrived at’ by Professor Sweet, working with the _
United States Army Base Hospital No. 10, in France, show that
Dakin’s dichloramin-T, in solution in eucalytol and paraffin oil, is
of great advantage in wound treatment, because—

(1) It saves the pain of wound dressing.

(2) It effects an appreciable saving of dressing material.

(3) The amount of solution needed is small in bulk.

(4) The number of wounds which a surgeon can dress in a given
time is far greater than by any other method.

(5) The elimination of the Carrel tube simplifies the dressing and
the problem of transportation of the wounded.

(6) The elimination of the Carrel tube saves the time taken by
the nurse for the periodic flushing.

Lieutenant Commander R. G. Le Conte, Med. Corps, U.S. N.R.F.,,
of Navy Base Hospital No. 5, is a strong advocate of this agent
in war wound treatment. Some, however, have found its usefulness
confined to superficial wounds. Others who were at first enthusiastic
have now discarded its use.

Some very favorable reports have recently been made on the value-
. of dichloramin-T solution, 1 or 2 per cent in chlorocosane, as a spray
in infections of the upper air passages.

“ Chlorocosane” is an oil obtained by the chlorination of paraffin
wax, and has been found by Dr. Dakin and Dr. Edward K. Dunham,
of New York, to be the most satisfactory solvent. They describe
as follows the way in which the antiseptic action of dichloramin-T
is exerted:

It is well recognized that antiseptics incorporated with or dissolved in oily
substances usually possess little, if any, antiseptic activity, because intimate
contact with the infected matter is hindered by the oil. When, however, such
oil solutions of dichloramin-T as will be described are brought in contact with
aqueous media, the partition coefficient between the oil and the water is such
that a certain amount of the dichloramin-T passes into the water and there
exerts its germicidal action. The amount of dichloramin-T thus passing from
the oil is enhanced by the presence in the aqueous medium of substances
capable of taking up chlorine, so that the oil solution serves as a store for the
antiseptics, which is drawn upon to maintain the germicidal activity of the
aqueous. medium with which it is in contact. Thus the amount of antiseptic
leaving the oil solution is, to a certain extent, dependent upon the rate at which
it is used up in the aqueous médium.
Ill, OTHER METHODS. $1

MAGNESIUM SULPHATE.

The practice of Morison and Tulloch (Jour. Roy. Army Med.
Corps, London, Vol. X XVII, 1916, p. 375) in treating recent wounds,
both of bone and soft parts, has been to swab the wound freely with
pure carbolic acid, packing it afterwards for 24 hours with gauze
steeped in carkclic lotion (1 in 20). This, together with free and de-
pendent drainage, has been frequently successful in obviating or
minimizing sepsis.

This is followed at the end of 24 hours by the application of the
magnesium sulphate dressing, which is painless and easily carried
out. Even in the most septic cases the dressings need be changed only
twice a day.

The effect on the wound is very striking. In two or three days pus
has almost disappeared, sloughs begin to separate, and the whole sur-
face presents a bright color. The granulations never become flabby
or edematous, but instead a firm vascular healing wound is seen.
Scratching the surface of the wound with a probe hardly disturbs
the vascular granulations. The growth of epithelium from the edges
. of the wound proceeds vigorously, and the treatment may be con-
tinued with advantage until the entire wound is healed. The result-
ing scar is firm and elastic and seldom tends to contract or become
painful.

Magnesium sulphate solutions are not recommended as a first dress-
ing for fresh wounds, but as a curative dressing in the succeeding
phase of wound repair.

BIPP (RUTHERFORD MORISON’S METHOD).

The name was chosen by Rutherford Morison for the sake of brev-
ity and because it indicates the constituents of the bismuth-iodoform-
paraffin paste. Bipp is bismuth subnitrate or carbonate 1 part,
iodoform 2 parts, paraffin in quantity sufficient to make a soft paste.
_ The Morison treatment, in conformity with the most advanced
surgical views, consists primarily in the mechanical removal of all
necrotic material and tissue detritus from the surface and interior of
the wound. Blood clots, wound secretion, bacterial and other con-
taminations are removed through energetic friction of all wound
recesses, and after the wound has been dried with alcohol, the anti-
septic paste known as bipp is spread over the wound surface. and
rubbed in. The wound is then sutured, closed, dressed, and left to
‘itself for about twelve days, after which time it is expected to have
healed or nearly so.

Sir Berkeley Moynihan, in a recent paper on'surgical experiences
in the present war, says that Rutherford Morison’s method is widely
practiced in the base hospitals in England, and by many surgeons
32 {. OTHER METHODS.

considered the most satisfactory of all. . This method of wound treat-
ment in the opinion of Sir Alfred Pearce Gould (Brit. Med. Jour.,
II, 1917, p. 677) constitutes the highest attainment yet achieved.

The following results have been obtained by means of this up-to-
date method of wound treatment:

(1) Healing of large infected wounds, without special drainage,
and without change of dressings up to a period of six weeks.

(2) Safe closing of such wounds by sutures, at any stage of their
repair.

In the opinion of Colonel H. A. Ballance, Medical Bulletin (Red
Cross), March, 1918, there is as yet no reliable scientific evidence to
show that “this much recommended bipp” enables a surgeon to sew
up a wound successfully which without it he would have been unable
to close.

Bipp first came into prominence early in 1916, and in the winter
of 1916-17 was a close competitor of the Carrel method in the Brit-
ish army. Morison’s recent book urges most convincingly the merits
of his method.

FLAVINE.

Flavine is a chlorine compound, with strong bactericidal proper-

ties, and was originally known as trypaflavine, on account of its
therapeutic effect on trypanosome infections. On its first introduc-
tion into the treatment of war wounds, it was enthusiastically re-
ceived, and at first highly commended, more particularly by Brown-
ing and his coworkers in the Bland- Sutton Institute of Pathology |
of the Middlesex Hospital, London (Brit. Med. Jour., I, 1917, p. 78).

Later experiments, by Hewlett (Lancet, London, I, 1917, p. 493)
showed the germicidal value of flavine to be much lower than was
originally claimed for it. Moreover, this antiseptic was found by
Fleming, in the research laboratory of a base hospital in France, to:
have a very destructive effect on leucocytes, this effect during 24
hours being greatly in excess of its bactericidal action.

Major W. Pearson, surgical specialist, in comparing the relative
value of flavine with other substances used under similar conditions
(using no hypochlorites or other agents for which special merit has
been claimed) noted no substantial differences between flavine and
the other substances, such as normal saline, boric lotion, weak
biniodide solution, and cyanide gauze, in regard to the control of
sepsis and constitutional signs of toxemia, but in regard to the
procerses of repair, flavine proved definitely inferior to the others.

“ That is to say that I found flavine not only not an excellent wound
dressing but relatively a bad one,” he writes in a letter to the editor
(Brit. Med. Jour., I, 1918, p. 271). On the other hand, Colonel E. M.
Pilcher and Lieutenant Colonel A. J. Hull (Brit. Med. Jour., I, 1918,
Ill. OTHER METHODS. 33

p. 172) point out that in the many hundreds of cases (rather more
than, 5,000 at present) treated with flavine in the hospitals under the
conmmand of one of them, they have found that for ease of prepara-
tion and application, rapidity when dealing with large numbers of
cases, early cleaning of the wounds, and abatement of constitutional
reaction to absorption, flavine (and also its congener brilliant green)
is an admirable application under all circumstances, but especially
where surgeons are few, time is short, and wounds are many. No:
skin irritation was noted in the 5,000 or more wounds under their
- observation.

Both acriflavine and proflavine were found by Major Robert B.
Carslaw and Lieutenant W. Templeton (Lancet, London, I, 1918,
p- 634) to be of undoubted value in controlling and preventing the
spread of sepsis, as shown by the rapid improvement in local and
general conditions. “This object having been gained, there is no
advantage in continuing their use, as a condition is reached in which
the reparative changes are slow, although not by any means absent.
Following on the substitution, after a few days, of a. more stimu-
lating antiseptic, e. g., eusol, a clean wound is obtained sooner than
by any other form of treatment known to us.”

‘Comparison of action of acrifiavine and proflavine—Although the
action of these two salts is very similar, there can be no doubt that
proflavine is slower. The improvement in the general condition of
patients is not so rapid. The formation of the fibrin membrane is
not usually complete until the fifth, sixth, or seventh day in con-
trast with its presence on the third, fourth, or fifth day when acri-
flavine is used. Further, separation of membrane and attainment
of a clean wound are also slightly delayed.

The conclusions of Captain W. Parry Morgan, on the action of
acriflavine and proflavine (Lancet, London, I, 1918, p. 256), are as
follows:

1. Acriflavine is, as regards both its antiseptic and toxic properties,
more potent than proflavine.

2. Acriflavine has a very marked bactericidal inhibiting action on
streptococci and a less marked one on staphylococci, but on some
other organisms its effect is practically insignificant.

3. Its action is therefore strikingly selective.

4, It has a marked but slow toxic action on the tissue.

5. This toxic action of acriflavine is not so great that when used in
dilute solution (say 1:4,000) it should not make an effective appli-

-cation in a dressing for a wound infected with streptococcus or
staphylococcus.

6. It should be applied after the wound has been thoroughly
cleansed by washing, first with a rapidly acting antiseptic lotion,
such as Dakin’s soultion, and then by a normal saline.
34 I, OTHER MUTHODS.

In a paper (which is the substance of an official report in Oct.,
1917) published in The Lancet, I, 1918, page 370, Major W. Pearson
reports unfavorable clinical observations on the effects of flavine in
wound treatment, and states that since completing his observations
he has entirely abandoned the use of flavine in his work. “In cases
where infection and sepsis are active and uncontrolled, the use of
flavine following suitable operative measures has no beneficial effect

on the, subsequent progress of the case in so far as the control of sepsis
is concerned. Any slight differences observed were unfavorable. In
cases where sepsis has already been controlled and repair has begun
flavine acts injuriously, chiefly by producing an unhealthy granulat-
ing surface.” While these conclusions do not prove that flavine may
not possess powerful germicidal properties in certain experimental
conditions, he believes they show that its clinical use is not attended
with good result.

Flavine is preferred by Sir Anthony Bowlby, as a dressing with
sterilized gauze, after excision has been done, before the performance
of suture for the reason that it has no toxic or irritating qualities
and the gauze soaked in it (and kept moist by jaconet and non-
absorbent wool) does not stick to the tissues, and leaves a good
surface for suture (Brit. Med. Jour., I, 1918, p. 335).

Flavine, brilliant green, malachite green, and other colored pastes
consisting of a greasy base and an aniline dye, enjoyed their greatest
vogue for war-wound treatment during the year 1917.

‘Brilliant green, or ethyl green, is homologous with malachite
green, which is benzaldehyde green and makes a bluish-green solution,
more intense. than brilliant green solutions, decolorized by hypo-
chlorites.

Proflavine is a preliminary product in the manufacture of acriflav-
ine (diamino-methyl acridinium chloride) and its preparation is
therefore more simple and less expensive. The employment of flav-
ine antiseptics as well as all others must be preceded by the excision
of all hopelessly damaged tissue, combined with careful mechanical
purification of the wound.

Composition of brilliant green paste——This paste, which was in-
troduced by Captain Wilson Hey in the treatment of infected war
wounds, is composed of boric acid, paraffin, chalk, and brilliant
green.

The application of this paste is reserved for those war wounds
which can be freely opened and excised, with removal of all necrotic
matter and foreign bodies. Small, completely excised wounds could
be primarily sutured after the application of brilliant green, in the
experience of Captains Rendle Short, Arkle, and King. In war
burns, under the care of Major Hull, irrigations with brilliant green
lotion, followed by paraffin paste, yielded better results than any
other treatment.
Il, OTHER METHODS, 85
CRYSTAL VIOLET AND BRILLIANT GREEN.

The use of a mixture of crystal violet and brilliant green in
strong solution, for the sterilization of the skin and other surfaces,
was recently suggested by Dr. C. H. Browning, director of the
Bland-Sutton Institute of Pathology, Middlesex Hospital, where the
method has been a part of the routine for the last two and a half
years. The method rests on the theoretical consideration that these
substances are both extremely potent antiseptics, and at the same
time devoid of irritating effect on the skin when applied in high con-
centrations. The solution in use contains 1 per cent of a mixture
of equal parts of crystal violet (the substance employed should be
hexa- or penta-methyl violet or a mixture of these) and brilliant green
(specified as brilliant green sulphate, zinc free) dissolved in equal
parts of rectified spirit and water.

This violet-green mixture was found to be highly efficient, and
strikingly superior to iodine, as a means of effecting both thorough
and rapid sterilization of the skin. Streptococci and staphylococci
are among the organisms most susceptible to these dyes. (Brit. Med.
Jour. I, 1918, p. 562.)

In the experience of Captain R. Massie, covering 46 cases of severe
gunshot wounds in which the soldiers’ subsequent progress after
wound treatment with brilliant green could be ascertained, brilliant
green proved a useful antiseptic, especially in a solution of 1:500 in
0.5 per cent chloretone. It produces exuberant, but very vascular,
bright red granulations. Noticeable features in cases treated with it.
are the absence of edema and inflammation around the wound and
the rapidity with which sloughs and sequestra separate. It is pain-
less in application, and does not appear to interfere with the growth
of epithelium. Although it can by no means atone for a complete or
faulty primary excision it may. be used with advantage where
anatomical conditions render complete primary excision impossible.
(Lancet, London, I, 1918, p. 635.)

HYPERTONIC SOLUTIONS (LYMPHAGOGIC AGENTS).

Substances which produce a free flow of lymph from the tissues
with which they come in contact, thereby indirectly flushing the wound
and diluting the toxins, have been recommended in the treatment of
infected war wounds by Sir Almroth Wright and his followers. A1-
though the lymphagogic effect increases in proportion to the strength
of the salt solution, it is not desirable, on account of the resulting
pain and irritation, to go beyond 10 per cent of salt, even in the
case of sloughing wounds. In order to prevent the lymph coagulat-
ing on the siphon bandages, and on the walls of the wound itself,
citrate of soda is employed in combination with hypertonic salt
36 Ill, OTHER METHODS.

solutions. Blood mixed with pus is prevented from clotting by 5
per cent of salt mixed with 0.5 per cent of citrate of soda. For the
sole purpose of irrigation and removal of pus, the citrate is unneces-
sary.

In order to encourage a free outpouring of lymph from the whole
internal and external surface of the wound, Sir Almroth Wright pro-
poses an arrangement of bandages by means of which the irrigating
fluid can be led into the wound where it is required, be distributed
so as to wash down all walls, and then be carried away without any
leakage into the bed. Loops of sterile bandages, previously soaked
in a solution of 5 per cent sodium chloride and 0.5 per cent sodium
citrate are introduced into the wound, after this has first been
syringed out with the solution. The free ends of the bandage are
carried out from the wound, to be inserted between piles of lint well
soaked in the solution and folded over so as to form a thick pad.
Finally, one or two tabloids of salt should be placed in between the
back layers of the pad, and over the top of all a layer of impervious
protective tissue.

Formula of Wright’s solution.

 

 

 

Sodium citrate ___-centigrams__ 0. 50
Sodium chloride 2S do_.-. .380
Distilled water. grams. 100

The employment of this “antiseptic anodyne” yielded excellent
results in the experience of Dickinson, who has used it for two years
in all sorts of cases, the wounds remaining clean and healing more
rapidly than under the use of any other liquid.

Sir.Almroth Wright says with regard to this lymphagogic solu-
tion, or rather with regard to a simple 5 per cent salt solution, which
he finds works in most cases equally well, that it has in this war
proved itself permanently useful. When brought into action upon
a dry and infiltrated wound, or a wound that is foul and covered with
slough, it resolves the induration, brings back moisture to the sur-
faces, and cleans up the wound in a way that no other agent does.
Applied in gaseous gangrene in the form of a wet dressing to in-
cisions which have been carried down into infected tissues, it causes
lymph to pour out of the wound, and arrests the spread of the infec-
tion. And, again, applied in gaseous gangrene to an amputated
stump in cases where it has been necessary to leave infected tissues
behind, it reverses the lymph stream and draws out the infected
lymph, saving life in almost desperate conditions.

The activity of salt solutions depends on this “phylacagogic”
character, meaning their capacity for bringing the protective ele-
ments of the body, blood fluid and leukocytes, into activity in the
wound.
Ill OTHER METHODS. 387
SUNLIGHT TREATMENT OF INFECTED WOUNDS.

Heliotherapy, or sunlight treatment of war wounds, deserves to
be more extensively employed as a physiological curative method,
the routine adoption of which is urged by Dr. M. Cazin (Monograph,
Paris, 1917) as a measure capable in many cases of greatly abridging
the duration of the treatment of war wounds and essentially reducing
the number of war invalids. Sunlight treatment, first recommended
by Rollier in tuberculosis and traumatism, is most successful when the
patients are exposed nude for many hours to the rays of the sun.
Although total insolation is always to be preferred, local insolation
with a graded action of the sun on the course of the wounds materi-
ally assist the processes of repair. The exposure to the sun must be
direct, and in the open air, in order to improve nutrition and promote
oxidation, and total, including the entire body, the resistance in-
creasing in proportion to the extent of the insolated surface. In-
solation of the clothed body is cautioned against as liable to induce
visceral congestion.

The insolation method should be carried out progressively, always
beginning with the less: sensitive lower extremities, even when the
wound concerns the thorax or an upper limb.

Aside from the analgesic action of the sun bath, its local effect
promptly induces a change in the condition of the wound. In the
second stage of the treatment, about the eighth to tenth day, the sup-
puration diminishes, after having notably increased following the
first sessions, and healthy granulation tissue develops; the wound
becomes dry and clean, its borders retract, and a zone of epidermi-
zation makes its appearance. Constant phenomena in the sunlight
treatment of wounds are regional pigmentation, a change in the
character of the pus, and an abundant serous exude over the entire
surface of the wound, which soon dries up more or less completely.

In the experience of Cazin, atonic and indolent wounds, on ex-
posure to the sun, became regularly covered with a layer of healthy
granulations, and in other wounds without an apparent tendency
towards epidermization, an epidermal margin promptly appeared at
the borders and advanced without arrest toward the center of the
wound.

Sunlight treatment was found to hasten recovery, not only in
wounds of the extremities, but also in wounds of the thorax and ab-
domen. Excellent results were obtained in infected fractures, and in
several cases where the bony lesions were such as to endanger the pres-
ervation of the limb, heliotherapy led to complete consolidation and
perfect recovery. Some cases of infected fracture of both leg bones
healed in a few weeks under sunlight treatment, after the condition
had remained stationary for months, in spite of repeated interven-
38 Id. OTHER METHODS.

tions and all other treatments. The results of heliotherapy were
equally favorable in joint infections, and in the cicatrization of am-
putation stumps with bony fistulas.

In Delbet’s service, all wounds are exposed daily for as long as
possible to air and light, covered only with a fourfold layer of gauze
without cotton or bandage. Very remarkable results were obtained
with this simple treatment. Gravely infected wounds which yielded
a highly positive pyoculture became transformed, so that in two
days the pyoculture became entirely negative. In one instance, the
wound secretions became in 48 hours not only bactericidal but bac-
teriolytic for the vibrio. This simple plan of wound treatment is
warmly recommended by Delbet (Presse médicale, XXIII, 1915,
p. 237).

Artificial light, in the form of electric lamps, is always available,
and in the experience of Chaput (Presse méd. XXII, 1914, p. 606)

was found to be as valuable as the sun bath for local use in burns. .

and ulcerations. An ordinary electric lighting outfit provides a
simple, cheap, practical and highly efficient method of treating in-
fected or gangrenous wounds, and it is suggested that this mode of
treatment may find its uses in certain complications of war wounds.

PHENOLISATION AND EMBALMMENT OF SEPTIC WAR WOUNDS.
(Menciére’s method.)

The modern spirit of conservative surgery is embodied in the
embalming method proposed by Dr. L. Menciére, the Médecin-Chef
of the Hépital de la Compassion in Rheims, in 1916. A part of the
Grand Palais is used as a hospital, and here I found this method of
septic wound treatment extensively employed, although in no other

place that I visited did I find it used. Dr. Menciére has published

a book, which is most interesting, with pictures and statistics of
cases. I append hereto pictures of two of his cases.
By phenolisation is meant the subjection of infected war wounds

to the energetic action of strong carbolic acid (90 per cent) fol-'

lowed by washing out with alcohol. Reinfection of the cavity is
most reliably: prevented by the so-called embalmment of the wound,
which consists in permanent dressing with gauze wicks soaked in
the following powerful antiseptic solutions:

 

 

 

 

Solution A.
Grammes.
Iodoform 10
Guaiacol oe S Sie Seca s eRe eee 10 ¢
Hucalyptol 10
Balsam of Peru 30
Ether. : ‘100

 

A weaker solution, B, consists of ether, 1 liter; iodoform, guaiacol,
eucalyptol, of each 10 grams, balsam of Peru, 30 grams; and alcohol
 

 

 

 

 

* (a) (b)

April 29, 1916, shell splinter wound, left foot: (a) May 20, 1916, photograph of left foot; (b) June
22, 1916, photograph of left foot. July 25, 1916, walked normally, without a cane; had all
movements of hip, knee, and foot.

 

 

 

 

qi) (2) (3)

Wounded March 2, 1916. Admitted March 5, 1916. Muscles torn otf by explosion of '' Minen-
werfer.”’ (1) Photograph taken March 10, 1916; (2) photograph taken March 19, 1916; (3)
photograph taken April 2, 1916.

38
Ill. OTHER METHODS. 389

(90 per cent) 100 c.c. The results obtained with these antiseptic
solutions were superior in Menciére’s experience to practically every-
thing else.

Phenolisation and embalming of war wounds is advocated by the
originator of the method on the basis of favorable experience in
wound treatment including the gravest articular traumatisms, and .
especially in the treatment of gas gangrene. The performance of
primary suture, immediate or delayed, is often made possible by the
employment of this procedure. About 24 primary sutures of bone
and joint wounds, with a successful outcome, after systematic ex-
temporaneous wound embalming, were reported by Gaudier at a
meeting of the surgeons attached to the Sixth French Army (Soc.
de Chir., February 1916). Preservation of badly wounded extremi-
ties, and application of delayed sutures, were made possible in a
relatively large number of soldiers apparently doomed to amputa-
tion. - 7*

ELECTRICITY.

Galvanic, faradic, and static currents are used extensively in the
treatment of scars and devitalized tissue resulting from wounds and
other war injuries. Lately, the high frequency current and ultra
violet ray have been recommended by Riviére of Paris and a number
of others. Dr. Riviére showed me some of his work, and urges as
follows:

Judicious employment of the high frequency current, also known
as Darsonvalization, is a valuable adjunct in war surgery, constitut-
ing a potent physiotherapeutic measure for the regeneration of
tissues, nerves, and blood vessels. Due to its practically pure content
of violet rays, without admixture of heat radiations, this high-
frequency treatment exerts a most favorable effect upon cicatrization,
besides producing a deep local anesthesia. To this is added the oxi-
dizing and antimicrobic action of the generated ozone, through which
the wounds become enabled to resist bacterial invaders. At the same
time the ozone, by stimulating the capillary circulation, ensures a
beneficent absorption of tried and tested remedies, such as various
mineral oils and balsams, iodides, salicylates, etc. The condensed
and electrified oxygen stimulates phagocytosis, furthers the forma-
tion of red blood corpuscles, and improves the nutritional condition —
in the surroundings of the lesion.

For the treatment of certain very slowly healing infected war
wounds, Riviére, on the basis of favorable experience with a number
of cases, suggests the combination of the high-tension current with
the most reliable antiseptic balsams; these are atomized by the high-
frequency current and superoxygenated through the condensation of

‘the ozone and the static breeze.
40 Ul. OTHER METHODS.

OXYGEN AND OZONE IN WAR WOUNDS.

Wound infections and gas gangrene have, in certain cases, been
markedly benefited by oxygen-therapy, and aside from older reports,
the experience of the present war, although not unanimous, points”
in the same direction. In the hands of Vennin, Girode, and Haller
(Phipps, Thése de Paris, 1916) oxygen, in the form of injections
into the healthy parts, prevented the onset of gas gangrene in badly
infected wounds caused by explosive projectiles. In other cases of
manifest gas gangrene, but in which the infection was restricted to
the wound and its immediate surroundings, its spread was effectively
aborted, and when swelling and bronzed discoloration had already
invaded the limb, the process was successfully arrested provided no
gangrenous patches had developed. Finally, even when the limb was
invaded by the putrefactive process, the destruction was successfully
limited in certain cases, and in this way a number of lives were saved.
Fourteen cases are reported in support of this line of argumentation,
and one of these is quoted as especially illustrative of the severity of
the infection and the excellent results.

Soldier, shot at short range; comminuted fracture of the humerus,
at the level of the upper third, with explosive lesions. The limb
promptly became infected, and the gas infiltration soon reached the
shoulder, with invasion of the deltoid, pectoral, and part of the
supraclavicular regions. Oxygen injections were applied at the root
of the limb, the adjacent portion of the thorax and the correspond-
ing side of the neck. Difficulties were encountered in the form of
respiratory disturbance due to the tissue-inflation, and the patient’s
condition appeared desperate. The oxygen injection was repeated
the next day, the condition remaining stationary. At the end of
another day there was decided improvement, the extension of the
gangrene at the root of the limb was definitely checked and a line
of demarcation appeared at the level of the fracture in the deltoid
region, in the gangrenous area. Improvement continued during the
next days, the cleansed wound assumed a good appearance and
healthy granulations developed. The patient was evacuated as a
convalescent.

It is not claimed that the oxygen method should be employed in
war wounds without the assistance of free incisions, or amputation
if unavoidable. In Belgium, oxygen has been used to inflate the
tissues above and below the wound area to limit infection. It has
been extensively employed in gas gangrene by Depage (Bull. et mém.
Soc. de chir. de Paris, March 23, 1915, p. 697), who found these in-
jections highly serviceable in the presence of septicemia with sub-
cutaneous gas infiltration. The oxygen spreads under pressure in
the entire subcutaneous cellular tissue and checks microbic growth
wherever it penetrates. Remarkable changes follow its employment
Ill. OTHER METHODS. ‘41

in the more superficial cases, but when the infection is deep and has
invaded the deep cellular tissue of the thigh, buttock, back, or
shoulder, the action of the oxygen is-necessarily reduced, and the
result of its application rendered more doubtful.

. Hydrogen peroxide is hard to get but is much favored and con-
sidered valuable in sloughing septic wounds.

Ozone treatment of war wounds is a very recent innovation, recom-
mended on the basis of the satisfactory results obtained by Major
George Stoker, of the Royal Army Medical Corps (1917). The
necessary portable apparatus for generating ozone employed by him
is known as the Andriolis ozonizer, which is called into operation by
a four-volt battery animating a quarter-inch sparking Ruhmkorff
coil. The oxygen passes from a cylinder through the ozonizer, and.in
doing so comes in contact with a metal armature, the effect of this
being to transform the oxygen into ozone.

The treatment consists in the application of ozone to-the affected
parts. At first ozone causes an increase in the discharge of pus;
later on the pus is replaced by clear serum, which at.a still later
stage becomes reddish or pinkish. Ozone has the peculiar power of
disclosing dead bone, foreign bodies, septic deposits and so forth.

Mode of application—The ozone is applied on the wound surface
or to the cavities and sinuses for a maximum period of 15 minutes, or
until, the surface becomes glazed. It is a strong stimulant, and
causes an increased flow of blood to the affected part. It is claimed
to be so strongly germicidal that all hostile microorganic growths
are destroyed.

_Acetozone, or benzoyl-acetyl-peroxide, is a powerful disinfectant
of the same group having a remarkably pleasant pungent. odor of
ozone. It-can be applied to deep: wounds by Carrel tubes or used
cold as a bath containing 5 grains to the pint; in a waterproof bag;
or by, wet: dressings of 10 grain strength solution, renewed two or
three times daily. The solution. must be made by adding 5 to 7
grains to 1 pint of sterile water at 112. F., left to, stand for two
hours, and should not be filtered... Ora 10-grain to 1-pint solution
can be used with dressings or Carrel-Dakin tubes, etc.. In very septic
cases swarming with anerobes, etc., a 20-grain to 60-grain solution
may be used. It. should be made fresh every seven days, and the
bottle shaken before using. In the experience of Gore Gillon and
others, numerous septic wounds healed in three weeks. under this
treatment, after having resisted. other measures for four or five
months., The action of this germicide is very rapid, and it is claimed
that. unhealed amputation stumps will heal quickly if placed for
30 minutes daily i in a bath of a: 7-grain | solution. with one-third hot
water added, the bath to. be followed by dressings of sterile gauze
soaked in.a 10- -grain solution. (Brit. Med. Jour., II, 1917, p. 209.) .

93696—19—4
42 Ill. OTHER METHODS.

From the historical viewpoint, it is.interesting to note that over
50 years ago, ozonoscopes were installed at Metz, Versailles, and
Paris, for the purpose of determining the chief peculiarities of air
in inhabited places, and the very suggestive findings are reported in
an essay by Gaillard, which was awarded the Fiske Fund premium
of the Rhode Island Medical Society, in June, 1861. “ The’ instru-
ments, placed in the halls or wards of hospitals give no trace of
ozone, whilst placed on the exterior of the buildings they manifested
hues corresponding to degrees 7,:8, and even 10 of the ozonometric
scale. These hospitals were in the most cleanly and perfect condition,
well-ventilated, and manifested no perceptible odor on entering them.
Ozonoscopes were placed in the halls for the wounded on the ground
floor and in rooms where the windows were opened twice a day, and
in which were placed not more than 18 or 20 patients. In the wards
for the venereal and fever patients, where the same influences ‘existed,
ozonoscopes were placed also, the hygienic relations being equally
good, and the thermometer’ in all instances not exceeding 60 F,
Rooms were also selected for these experiments, where the windows
were kept always open (by day). The ozonoscope, judiciously’ ar-
ranged in all of these places; remained in situ for 15 days, and ex-
hibited no change Sa there being not-even a trace of ozone
present.”

The part reserved fon ‘oxygen and its congeners in the fight against
infection was foreshadowed prior to the war, and 10 years ago, my
own investigations dealing with'the use of oxygen by infusion into
the peritoneal cavity proved So encouraging as to cause me to con-
tribute an article on its use in medicine and surgery to an American
periodical, and this has been quoted as one of the sources of informa-
tion of a very recent French thesis on the subject (Phipps, De
Vemploi en therapeutique chirurgicale de oxygéne 4 Vétat gazeux,
1916). My own experience at the time led me to anticipate the
results which the experience of to-day seems to establish. The de-
fensive forces of the organism beiig peculiarly weakened for a va-
riety of reasons against the infections of war wounds, it seems espe-
cially desirable to secure a therapeutic agent which will not exert
an injurious action upon the tissue cells. Oxygen, as a matter of
fact: far from damaging the cells, has been shown to stimulate cel-
lular activity, to activate phagocytosis, and to favor all defensive
reactions, such as diapedesis and secretions. Aside from its effect
on anaerobes, it has no direct destructive action upon microorganisms,
but by stimulating the activity of the natural defensive forces, it
furthers the power of resistance and in this way becomes a valuable
physiological assistant in the fight against infection, upon the win-
ning of which depends the success of surgery in general, and of
war surgery in.particular.
TREATMENT OF WAR WOUNDS BY THE GERMANS.

The lessons of war can not be adequately determined until long
after the conflict ends. This is due largely to two factors which are,
first, the heat of passion which must have time to cool sufficiently to
permit the forming of correct judgments, and, second, the lack, of
_ authentic data from both sides. In our search for those, lessons
which may aid us along medical and surgical lines, the first of these
factors may be eliminated, but the second remains, largely as an
intentional barrier set up by the enemy.

Germany is making and has made a systematic effort to prevent

the leakage of dependable information relating to military medi-
cine and surgery. During a half century of preparation for war
the Germans had perfected an organization of ambulance and. hos-
pital service, nicely coordinated with the military branch and equal
to it in efficiency. They apparently believe that this organization
is superior to that of the enemy, and that an interchange of exper-
iences which might.tend to prevent suffering and to save life and. limb
would not be to their particular advantage. This is consistent with
their philosophy but devoid of the first elements of humanity.
‘ The severance. of postal communication with Germany ‘since
our entry into the war, her systematic attempt to prevent trust-
worthy information from reaching us, and her dissemination of
misleading statements prevent us from ‘obtaining full knowledge
concerning her progress. in military medicine and surgery, but in
spite of these barriers there are a few facts relating to her methods
and results which we have established from our present. sources of
information. These are perhaps more valuable by way of compar-
ison than as affording any actual addition to our knowledge. .

During the summer and fall of 1915, I was privileged’ under ex-
ceptional auspices to make a hospital, Red Cross, and sanitary sur-
vey through Holland, Germany, Switzerland, and back to the United
States by way of France and England:

In Germany we were to all appearances received cordially and
shown what we desired to see, but it was soon evident that we were
even then looked upon in many quarters as future enemies. We were
shown what they wished us to see and told only what they were
willing we should know. All that we learned could, I felt, be no
real basis for generalization, but there must be continnation and
very careful weighing of the whole before any deductions could be

drawn.
: 43
44 CONDITIONS IN GERMANY LATE IN 1915.

The sources from which the following was obtained were:

1. Personal observation during the trip.

9. Discussions with those who had been at work in Germany since
the beginning of the war, including representatives of the American
Red Cross, Y. M. C. A., sanitary agencies, etc.

3. Contact with neutrals or Germans in Holland and Switzerland,

4, Examination of German prisoners in allied camps.

5. Articles in neutral scientific papers.

6. Such books or articles as have been allowed to get through from
Germany.

7. Statements by workers in advanced areas at the allied front
where the swaying backward and forward of the line often reveals
the medical and surgical secrets of one side to the other.

CONDITIONS IN GERMANY LATE IW 1915.

The ambulance and hospital organization at that time was ex-
tremely efficient. All had been made ready, and there was indubit-
able evidence that for years they had clearly foreseen and provided
for what was coming. A good example of this forethought was a
' pavilion hospital at Buch, on the direct line from Berlin to the
eastern front. This hospital of 6,000 beds was beautifully situated
in the country 40 minutes by express from Berlin. It was already
fully equipped for 3,000 patients a few weeks before war was de-
clared and it contained 4,000 patients at the time of my visit. A
small railway system connecting the main line with each set of wards
made it possible for the wounded entrained at Warsaw to remain
undisturbed until their arrival at the entrance of the particular ward
to which they were assigned. The most modern methods were em-
ployed here, and there was even a special department for gassed cases.
This is particularly interesting when the dates are noted, as showing
that they were prepared in advance to treat this class ae cases,

The equipment throughout was superb and included electrical and
mechano-therapy departments, baths of all kinds, a gymnasium with
special apparatus for the mutilated, a recreation park, and. a theater,
seating 600, for plays and moving pictures. Here they showed scenes
of peace and pictures of other lands, including, for example, the
Yosemite Valley and Niagara Falls; and here also the latest news,
always encouraging and patriotic, was flashed upon the screen.

‘A special feature was the continuous bath ward. Here they treated
those patients, who, on account of wounds of the back or, in cases
of paralysis, for fear of bedsores, could not remain even on the
water bed. Some of the patients had been in the bath for months.
This method was also being tried out in cases of septic wounds.
 

 

 

 

Hospital in Buch.

 

 

 

Kriegs Lazarett, Buch,

 

 

Kriegs-Lazarett der Stadt Berlin in Buch,
 

44—2

 

 

Patient in continuous bath doing industrial work.
CONDITIONS IN GERMANY LATE IN 1915. 45

Aside from the strictly medical care of the patients, their mental
state was carefully considered, on the principle that “the more hope
and courage, the better the healing and the shorter the convalescence.”
At the earliest date possible patients were urged to do something to
occupy their minds and if possible to learn at the same time a trade.
The patient shown in the accompanying illustration was suffering
from paralysis below the waist and had been six months in the bath,
but was learning to do some work with his hands.

We were shown large amounts of food supplies being accumulated,
including great quantities of American canned and dried foodstuffs.
Evidently the blockade was not very effective up to that time.

In Berlin we saw the central sanitary laboratory, a very large and
splendidly equipped building where the various vaccines for the
army: were prepared. A professor of the university was in charge,
and the following statements which he made to us may be of interest
in this connection:

We give as a routine three vaccinations, practically all at the same time—
for smallpox, for cholera, and for enteric fever. Each man throughout the
entire German army now has these three. .The cholera vaccination is the
most effective. We have had no cholera. The smallpox vaccination comes next
and is highly protective. The typhoid vaccination has been wonderfully suc-
cessful in preventing this disease, but there have been a few cases. The
tetanus vaccine is protective in a considerable measure when used in wounded
cases, but after the onset of the disease it is of very little, if any, value. In
these cases I use magnesium sulphate intraspinally. This is coming into gen-
eral use and is often proving successful in the active stage. Other vaccines
than the four alluded to are not of any real value. .

At Cologne there i is a military hospital of 2 ,000 beds, an enlarge-
ment. of a smaller hospital connected with the university, where, at
the time of my visit, there remained only one student. They have
here a large physicotherapeutic, department with. all, kinds of elec-
trical apparatus, X-ray equipment, Finsen light, and i many mechani-
cal devices for special exercises.

Before the war Germany. had adopted, a policy of far-reaching et-
fect. The establishment of a gymnasium with baths and a physi¢o-
therapeutic institute in connection with a certain large hospital had
proved of great benefit to the patients; in fact, considered as an eco-
nomic measure alone, it had been found worth while. So for years
such departments have been established in connection with many
of the hospitals throughout Germany, as well as in various hospitals
founded by Germans in other countries. ‘When war ‘started these be-
came of double value, inasmuch as they, were ready to give special
treatment of all kinds to the war wounded.

We have had to introduce these very things, after much delay, and
are only now really making a good beginning. In July, - 1917, when
the plans for enlarging the Brooklyn Naval Hospital were bene dis-
46 CONDITIONS IN GERMANY LATE IN 1915.

cussed, at the request of Captain G. A. Lung, Medical Corps, United
States Navy, commanding officer, I drew up and submitted a paper
entitled “Some Medico-Military Suggestions,” embodying much data
on this subject, based upon my observations in Germany.

We found many of the private hospitals had been taken over and
were being operated as military hospitals for officers. The only hos-
pitals: we saw which we could really criticize were those. in Paee
camps, as at Darmstadt.

- The wound treatment then in use consisted in early long i esata
free drainage, and strong antiseptics, with invariable early splinting
of fractures and immobilization of wounded parts. Their expert
surgeons were stationed well'up in the forward areas, so that they
could decide what was to be done in each:case. This method gave ex-
cellent results, since it enabled the wounded men to have the best ad-
vice at the time when it was most needed. Severe abdominal wounds
and head injuries were rarely moved back and early treatment was
instituted at the front in all cases in which it was thought advisable.
« Since 1915 it has become increasingly difficult, for the reasons al-
ready noted, to secure any reliable information relating to military
medicine and surgery in Germany. It has been possible, however,
to. verify certain facts bearing on this subject, which are herewith
presented. ,

In Germany, no one method of controlling wound infection seems
to have been adopted to the exclusion of competitive procedures, as
on the side of the allies, where the Carrel-Dakin method of wound
treatment has been so largely adopted. Although irrigation with
dilute antiseptic solutions is employed by German surgeons, opin-
ions vary widely as to the value of antiseptic agents. Irrigation with
hydrogen peroxide has been extensively used in their military hos-
pitals and is claimed to be especially efficacious in the treatment of
infected fractures.

Brun, writing in one of the leading German periodicals (Deutsch.
Zischr. f. Chir., vol. 183, 1915) advocated the use of the following so-
_ Intion, with shiek he claimed to secure very satisfactory results:

 

Oleum(Olivar,. ste@vilo 2.2520 cen 2 nee ee eee Be ee ore bees 100
ENGR ke eet ee ln Spe oe Sette 100
Tlodoform.......-.----------+--.--- ee 4
sae a wii aoe aes See SaaS 10

 

'Todine 2 may be substituted for iodoform if desired. In using this
solution the surrounding skin should be painted with iodine, the
wound cavity drawn well apart with hooks, and the solution then
poured in so as to penetrate all the recesses. The wound is then
loosely covered with gauze, which is fixed in place by means of mastic,
and the limb i is immobilized.
CONDITIONS IN GERMANY LATE IN 1915, AT

Vernisanum purum, a combination of iodine, phenol, and camphor,
has also been recommended as an especially valuable antiseptic in
war surgery.

In 1916 a hemostatic antiseptic consisting of a solution of iodo-
form in acetone, was introduced into Germany. This is applied to
the wound by means of gauze strips dipped in the mixture, and the
burning sensation which follows its use in wounds of the skin and
soft parts is controlled by the applications of compresses dipped in
1 per cent acetone-soda solution. The iodoform-acetone solution di-
minishes the wound secretions and stimulates the formation of
healthy granulations, but its most valuable property consists in its
prompt action as a hemostyptic in parenchymatous hemorrhages,
especially from’ porous bones.” (Miinchen med. Wschnschr. Feld-
aerztl. Beilage, No. 48, 1916.)

Various chlorin-containing substances have been in use since early
in'the war, calcium hyperchloricun: having been perhaps the most
extensively employed.. This has been used in a 1 or 2 per cent
solution for bathing and irrigating wounds or, in combination with
animal charcoal, magnesium sulphate, and bolus alba, as a dusting
powder. In January, 1917, the Correspondenz-Blatt fiir Schweizer
Aerzte, a Swiss periodical published in the German language, in an
abstract from French original sources, brought the Carrel method of
ireating infecting war wounds to the favorable attention of its
readers. '

Other antiseptics.advocated by German surgeons include Karlsbad
salt; leukozon, a mixture of equal parts calcium perborate and talc;
pellidol, a substitute for scarlet-red; liquid tar, etc.

In opposition to the antiseptic method of wound treatment, and in
analogy with the physiological lymphagogic method indorsed by Sir
Almroth Wright, some German writers on early wound treatment
at the front have proposed the use of nitric salts, which on coming
into contact with organic substances are at once reduced to nitrous
salts. The object aimed at is to increase the hyperemia in these in-
variably infected war wounds, and to produce a free flow of lymph.
Muller, writing in the Mtinch. med. Wschnschr. Feldaerztl. Beilage.
No. 27, 1916, expresses himself as well pleased with the results of this
“ abortive” treatment of gunshot wounds, although it necessitates a
frequent change of dressings. After the wounds have been incised
and foreign bodies removed, he introduces into the wound cavity
cotton wool soaked in silver nitrate solution (1:2 000) and wrapped
in gauze. The permanent irritation thus induced in the wounds
leads to the rapid detachment of nonviable tissues, usually with a
rise of temperature due to absorption of toxins.

For fixation of the extremities in fracture cases, German surgeons
make extensive use of Cramer’s wire splint and Volkmann’s T-splint,
48. CONDITIONS IN GERMANY LATE IN 1915.

femoral fractures being usually treated with extension apparatus.
Plaster bandages are considered as unsuitable where a frequent
change of dressings is required.

Repeated plastic operations on the mouth and nose are recom-
mended in the treatment of glancing gunshot injuries to the facial
region. Soldiers with injuries of the jaw are transferred as soon as
possible to the dentist for orthodontic treatment.

_ Germany has given considerable attention to the after care of the
wounded soldier, with a view to returning him to the ranks if possible,
or, if he must be sent back to civil life, making him self supporting
and not a burden to the community. In an article published in 1916
(Med. Klin., April 16, 1916, No. 16) Prof. H. Spitzy describes some of
the work being done at the Orthopedic Hospital in Vienna. Here
between three and four thousand wounded are under treatment at
one time. Mechano-therapy; hot air, steam, electricity, massage, etc.,
are used whenever indicated, and when a joint is certain to stiffen
great care is exercised to obtain fixation in such position that it will
be of the most use to the patient in the future. Occupation therapy
is used to its fullest extent, 30 different occupations being taught.
In order to restore the disabled men’s working capacity to the utmost,
soldiers who have lost an upper extremity are usually equipped not
only with an arm prosthesis, but also with a set of different attach-
ments, up to 20 or more, according to the requirements of the various
occupations.

__An interesting fact, possibly bearing on economic.as well as surgi-
cal conditions, is that in 1915 and 1916 sawdust was being used as a
dressing for many wounds, instead of cotton. This was called
“scobitost.”  .

-Dr. H. M. Richter, of Chicago, who was for six months in 1916 in
charge of a German base hospital has published. an article, covering
his work at that base, which he summarizes as follows:

Recent injuries are best treated by wide excision of the wound, including all
contused, and soiled tissues, and immediate closure. This applies with greatest
force to the larger joints quite as well as to the wounds of soft tissues. Im-
mediate antiseptic treatment of wounds, with free drainage by means of tubes
or gauze pack, ‘{nvariably results in infection though the infection. remains
localized in proportion to the adequacy of the drainage.

Carrel’s treatment has been successful in relatively few hands; The numer-
ous details to be observed in the preparation of the solution and its ee
probably offer an insuperable obstacle to its general use.

The open, treatment of infected wounds forms the simplest ana “most con-
venient method of handling patients in large numbers.

The routine tubbing of patients with infected wounds, irrespective of the
parts involved, gives remarkable and instantaneous comfort to the patient, and
controls suppuration more rapidly than any one method at our disposal, its

field of usefulness being limited only by lack of facilities, under ordinary mili-
tary conditions.
CONDITIONS IN GERMANY LATE IN 1915. 49

Nonunion in fractures, simple and compound, clean or infected, rarely oc-
curs where the interposition of tissues is prevented and no foreign bodies are
left in the wound.

Compound fractures into the larger joints, present a high rate of mortality,
only partly controlled by wide open drainage and resection.

All larger shell fragments must be removed. Stereoscopic roentgenography,
aided by the proper placing of markers and the insertion of probes along the
track of the missile, forms the best means of locating foreign bodies.

In closing this section it may be of interest to point out two con-
trasts which must strike forcibly any one who is conversant with
the facts The one contrast lies between the marvelous efficiency of
Germany at the outbreak of the war and the conditions, best de-
scribed as chaotic, which existed at that time among the allies. The
other contrast, more gratifying to us, is shown when we compare
those same conditions with the truly. wonderful improvement to be
found today on the side of the allies.
. DEVELOPMENTS IN WAR SURGERY.

ANESTHESIA.

War surgery is demonstrating more clearly than has ever been
appreciated in the past, the close relationship between anesthesia
and the extent of mortality and morbidity. Major Marshall, who has
been for over three years in a casualty clearing station in an active
part of the forward area, summed up for me his experience by say-
ing that the bulk of preventable deaths ata casualty clearing station
was due to improper anesthesia, “giving the wrong anesthetic, or
giving the right anesthetic wrongly.”

As a result. of this realization, new methods are-being devised
and old methods improved upon by those actively engaged in war
surgery. Chloroform has been rather generally discarded, although
many surgeons still employ it and feel safe in its use. As a pre-
liminary to the general anesthetic, morphin and atropin or omnopon,
with or without scopolamine, are often used. Ethyl-chlorid as a pre-
liminary or for short cases has some advocates.

The various types of anesthesia that have increased in favor and
the newer methods that are receiving consideration are:

1. Local and regional anesthesia.

2. Gas and oxygen (with or without ether).

3. Oral anesthesia.

4. Spinal anesthesia.

5. Rectal anesthesia.

Local and regional anesthesia—This method is being extensively
used in many centers, either alone or combined with light general
anesthesia. At various hospitals, I saw it successfully employed in
cases involving major operations, such as laryngectomy, trephining,
amputations of the thigh and leg, and transplanting of bone and
cartilage successfully. It is obviously valuable in many kinds of
war surgery.

Gas and owygen.—The sequence of gas and oxygen, alone or com-
bined with ether, has steadily gained in favor and bids fair to be the
method preferred where local anesthesia is not applicable. The
work of Crile, Gwathmey, Marshall, and others who have had a large
experience with desperately wounded cases seems to establish this
method as lessening mortality and reducing morbidity. Without
ether, it is especially valuable for abdomen, chest, and abdomen with.
chest cases. Open ether is dangerous in chest cases, and local anes-

' 51
52 ANESTHESIA.

"i +
thesia or gas and- oxygen without ether are favored. No gassed
(inhalation) case should have either chloroform or ether. Moynihan
and some others believe that for full relaxation, especially in cases
of laparotomy, a preliminary hypodermic is necessary and the addi-
tion of ether.

Until recently, the various types of apparatus for the use of gas,
oxygen, and ether, especially those which warmed the vapor, were
most complicated and expensive. In spite of these drawbacks, in-
creased numbers were being put into use in the hospitals of the
allies. Fortunately, the American Red Cross in France, through the
work of the staff of its chief surgeon, has recently devised a simpler
and far less expensive apparatus, which seems destined to have a -
large field of usefulness. Already considerable numbers have been
ordered for the American expeditionary force. In the selection of
a standard apparatus for the United States Army and Navy, the
following requirements must be borne in mind. It should be:

1. Simple; no complicated parts to get out of order.

2. Efficient; in supplying continuous flow of gases at uniform
pressure.

3. Inexpensive; in order to permit of the gases being administered
to every case requiring them.

An English Hewitt apparatus, or some modification, falls short
of meeting the requirements in that it depends upon rubber bags for
the reduction of pressure, and is therefore inaccurate in this respect.

The many types of American apparatus depend usually upon re-
-ducing valves weighing from 5 to 15 pounds. Some ‘have as many
as four reducing valves to each apparatus, while most of them have
a separate bag for the nitrous oxide and the oxygen, respectively.
Furthermore, they are all provided with a clock dial or indicator
to show the rate of consumption per hour of the respective gases.
They all fall short of the first and third requirements.

The American Red Cross apparatus—The use of needle valves
reduces the gases as effectively as the usual large reducing valves,
the weight, size, and cost being at the same time decreased to one-
fourth that of any other suitable and efficient apparatus. The weight
is estimated to be about 8 pounds and the cost about 125 francs.

The sight feed (i e., two tubes immersed in water contained in 2°
‘glass bottle for the nitrous oxide and the oxygen, respectively, the
bubbles made by the gases escaping from the holes in these’ tubes in-
dicating the approximate percentage) replaces the clock dials and
indicators. The first hole in the oxygen tube is approximately 5 per
cent by volume of the four holes in the nitrous oxide tube, which is
the usual proportion with only slight variations for individual
patients.
 

 

 

 

 

 

 

 

 

 

Apparatus for anesthesia,

52
ANESTHESIA. 58

Furthermore, only one rubber bag is required, the space in the
glass bottle above the water being utilized as a mixing chamber for
the gases. There is an ether chamber attached to the sight-feed appa-
ratus which permits of the giving of varying percentages of ether
according to the relaxation desired.

The patient is the final index irrespective of apparatus (if
eyanosed, more oxygen is needed, if too lightly under, nitrous oxide
is indicated) ; therefore an even flow of gases with an approximate
and dependable percentage is all that is necessary in an apparatus.
The possibility of breakage is greatly reduced by the fact that the
needle valves and sight feed are placed immediately upon the tanks.
The gases are conducted from the sight feed by two to three feet of
rubber tubing to a rubber bag, which is placed near the patient’s
face in order to reduce the respiratory effort to a minimum. All
authorities are agreed that an unnecessary burden would be placed
upon some patients if rebreathing were entirely eliminated.

Tanks of nitrous oxide and oxygen adopted by the American Red
Cross contain 3,840 kilos each, one nitrous oxygen tank being suf-
ficient to anesthetize 100 patients, and one oxygen tank sufficient for
200 patients. Thirty-two kilos of nitrous oxide and 10 kilos of
oxygen are sufficient for one patient in military surgery. The height
of the tanks is 56% inches; circumference 294 inches. Weight of the
nitrous oxide tank (gross), 186 pounds; weight of the oxygen tank

(gross), 143 pounds.

Captain Gwathmey, Medical’ Corps, United States Army, suggests
that if a large tank is impractical for use in the Navy, a 2,000-gallon
tank, 36 inches high, be used, instead of the 4,000-gallon tank, 60 to
70 inches high. The smaller sized tank will be sufficient for 50
patients.

Oral anesthesia, or general anesthesia by oral administration.—
This is among the newer methods employed in hospitals and casualty
clearing stations. It was introduced by Captain James T. Gwathmey,
Medical Corps, United States Army, in conjunction with Captain
Howard T. Karsner, Medical Corps, United States Army. From
the favorable results recorded by them and reported to me by others
who are employing it on the British front, the future use of this
method in surgery seems assured. While in France I discussed the
subject at length with Captain Gwathmey and saw some of his work.
For the sake of brevity, however, the following is taken from his
report on the subject, printed in the British Medical Journal of
March 2, 1918, and in the Journal of the American Medical Associa-
tion of April 6, 1918.

Captain Gwathmey calls attention to.the fact that many war wounds
are accompanied by fractures of bones, and the importance of keep-
ing the patient quiet during the dressing of wounds is obvious. He
54 ANESTHESIA.

finds that a preparation containing 50 per cent ether in liquid petro-
latum or other bland oil, administered by mouth, is a safe general
analgesic, has apparentiy no deleterious effects on the stomach and
is not followed by the nausea and vomiting that frequently accom-
pany inhalation anesthesia. It may be given without unpleasant
taste when “sandwiched” between mouthfuls of port wine., The
patient does not need to be taken from his bed, thus reducing the
pain and the danger of displacing bone fragments before and after
dressings, and saving the time of surgeons, nurses, and orderlies.
Supplemented by local or light inhalation anesthesia, or a hypo-
dermic of morphine; when necessary, the method is being developed
to embrace short. surgical operations. While it is well not to give
the analgesic immediately after a meal, no especial preparation of
the stomach is necessary, and the patient is able to take food and
water shortly afterward. Captain Gwathmey and three messmen
tried the oral analgesic successfully. He now uses the following
formula:

 

Peppermint Walls cone nae ean te ee ese eee dees 5 minims.
Ether. . oo, . oeoes 4 fluid drachms.
Tid. paraffins 22sec Se es eee 4 fluid drachms.

The report describes a number of cases which were dressed in No.
9 (Lakeside U. S. Army) General Hospital, among them the fol-
lowing:

Case 1: A soldier, aged 36, who had received a gunshot wound of
the right thigh, and had an infected, compound, comminuted_ frac-
ture of the femur, had found previous dressings very painful, and
the splint could not be changed without general inhalation anesthesia.
He was given paraldehyd, 1 fluid drachm; ether, 3 fluid drachms, and
liquid petrolatum, 4 fluid drachms. ‘In 15 minutes he fell into a light
sleep. The wound was dressed, the splint removed, the through-and-
through wound irrigated with ether, a gauze drain inserted down to
the femur and a Thomas splint applied with extension. The patient
talked during the dressing, felt practically no pain, and suffered no
nausea or other unpleasant after effects. The dressing was repeated
in a similar manner every other day for four dressings, and in none
of them was there pain or any alternation of pulse or respiration.

Case 2: A soldier, aged 28, who had a gunshot wound of the left
thigh, with a compound comminuted fracture of the femur, was
given the same mixture as in case 1. He feel asleep after 12 minutes,
The Thomas splint was removed and replaced, the gauze packing re-
moved, the wound irrigated with ether, and another gauze packing
reinserted. The patient groaned when the pack was reinserted, but
after regaining complete consciousness he said that he had felt no
ANESTHESIA. 55

pain during the dressing. Three subsequent: dressings were done on
alternate days with no nausea or other after effects nor alteration of
pulse or respiration. The patient complained of the taste of the
mixture, but said it was far to be preferred to the extreme pain of
the dressings.

_ Case 8: A soldier, aged 23, with gunshot wound of the left leg, a
compound comminuted frackite of the tibia and fibula, a through-
and-through infected wound, was given the same mixture. He fell
asleep after 15 minutes and slept for 30 minutes during which the
dressings were done. The Thomas splint was repadded, the packing
was removed and reinserted, ‘and ether’ irrigation was done. Two
dressings were done without bad after effects.

I found that Major Marshall, anesthetist at Guy’s Hospital, who
for three years has been at No. 17 C. C. S., has somewhat modified the
Gwathmey method and is most enthusiastie over the results obtained.
The formula used by him is:

Ether fis z i woe __.-ounces-_ 14

 

 

Chloroform____- Se aa _..-minims.._ xx
Liq. paraffin, q. s. adi. cali, alae __-__-_ounces__ 4

 

This is administered 20 minutes before the operation and the
patient is not allowed to smell the mixture, in order to avoid nausea.
He lies back with a towel over his face, to induce a sort of rebreath-
ing. The analgesic is effective for 40 to 50 minutes. It may be rein-
forced by light inhalation.

Major Marshall has used this method in more than 50 cases with
excellent results and points out its usefulness in mild cases in saving
the time of an anesthetist. He used no hypodermic with this method.
He declares it to be the only type of anesthesia that may safely be
used after a meal, and that the patient may eat as soon as he recovers
consciousness.

I found this oral anesthesia being used in a number of centers
which I visited, such as the Duchess of Sutherland Hospital, near St.
Omer. Chapple, Schlesinger, and Morgan have used it with success.
In fact, wherever ’ found it had been employed they spoke favorably
of its use.

Spinal anesthesia.—For operations on the lower extremities, spinal
anesthesia with a 4 per cent novocain solution is favored by a num-
ber of surgeons. Chutro, E. V. Morrow, and others with wide expe-
rience advocate this method for painful dressings and wound closures
below the waistline. At Buffon Hospital, I saw aie employ it
with excellent results in a number of cases. .

Marshall has pointed out that in spinal anesthesia ne is a dis-
tinct fall in blood pressure. Crile has confirmed this after experi-
56 JOINT LESIONS.

ments on animals in his laboratory. He sums up the situation as
follows:

Spinal anesthesia is, therefore, of value in all rush ald provided that
the consequent great fall in blood pressure may be prevented and the psychic
factor may be eliminated.

He adds that the psychic factor (i. e., the effect upon the patient of
knowing what is taking place) may be largely overcome by a pre-
liminary dose of morphia or by. nitrous oxide analgesia or a light
ether anesthesia.

Personal observation in over a thousand cases of spinal analgesia
leads me to confirm the fall in blood pressure. So far as the psychic
factor is concerned frequently no preliminary hypodermic is needed
for there is often a sufficient dulling of me: -mental perceptions to
largely eliminate this factor.

Rectal anesthesia.—In certain base ‘oan where it is possible
to prepare the patient properly beforehand, rectal anesthesia is
being employed. It should not be used where there is respiratory
difficulty, but where there are to be long operations with plastic work
on the head or face it is giving satisfaction. At Sidcup, England, it
has been successfully used in over 300 cases.

JOINT LESIONS.

C. Willems, in charge of the Belgian Military Hospital at Hoog-
stade and part of the Military Hospital at Bourbourg, has done some
remarkable work in the treatment of joint lesions, and the subject
seems to be of ‘sufficient importance to warrant reporting his tech-
nique in full. His book is to be brought out at the end of the war,
but in view of the frequency of such lesions in war surgery, and of
the marked improvement in clinical results frequently following
treatment by his method, it seems desirable that this knowledge
should be within the reach of.all before that time.

His claims were so extraordinary as to arouse a natural skepticism,
but after a number of his truly remarkable cases were shown at a
surgical meeting in Paris, I felt that a closer study of his methods
would be well worth while. Accordingly, I visited the hospitals at
Hoogstade and Bourbourg and found that, far from overstating the
facts, he would have been warranted in making. even greater claims.

The following gives in some detail the treatment of joint lesions
by Dr. Willems in his hospitals at Bourbourg and at Hoogstade.

In dealing with joint lesions of all kinds, immobilization has been
the method of treatment invariably followed.’ It has, however, given
such poor functional results that, even before the war began, tenta-
tive efforts were made to devise some treatment which would be more
successful in preserving the function of the joint. Willems was one
 

 

 

 

 

 

 

 

A. DeG. Fracture with loss of substance of the external condyle of the femur.
Radiographs on entrance.

 

 

 

A. De G. Fracture of thigh. Active movements on fifth day.
56-1 . ,
 

 

 

 

 

 

(a) (b)

A. De G. Condition three months after the injury: (a) Arthrotomized knee sup-
porting the weight of the body; (b) flexion of the arthrotomized knee.

 

 

 

 

 

 

A. De G. Radiograph after cure.

56-2

 

 
JOINT LESIONS. 57.

of the first to abandon this principle of immobilization, and his work
bids fair to revolutionize all of the old ideas on the subject. Since
the war began he has had the opportunity of studying a large num-
ber of cases and perfecting his method of treatment, which is based
on the principle of immediate active mobilization of the joint. He
points out that in order to obtain the best results certain general rules
must be observed.

The motions must be carried out by the patient himself; they must
involve those muscles ordinarily used in moving the joint; they must
be begun the moment that the patient comes out of the anesthetic;
they must be carried out to the point of their maximum ee
and they must be as nearly as possible continuous. They should not
be supplanted by or combined with passive motion.

These movements cause practically no pain unless they produce
displacement of a large fragment of bone, in which case such move-
ments are contraindicated.

This method calls for the constant supervision of a trained at-
tendant, and its success depends to a large extent on the courage and
good will of the-patient, as well as on his power of coordination.

The details of the treatment vary considerably according to the
nature, extent, and location of the injury.

Joint lesions without injury to the bone.—A simple traumatic
hemarthrosis or hydrarthrosis is treated by aspiration and immediate
active motion, the patient being instructed to walk if the knee is
involved or to flex and extend the forearm if the elbow is involved.

Wounds by projectiles call for a resection of the edges of the
wound, a uni- or bilateral arthrotomy (always using a vertical in-
cision), removal of the projectile and any other foreign bodies,
cleansing of the wound with ether, closure without drainage, and in--
stitution of active motion as above described.

Joint wounds with injury to the bone—The treatment in these
cases varies according to the importance of the fracture and the
degree of displacement.

When the larger part of the articular surface is intact, and when
there is no detached or easily detachable fragment of bone. the treat-
ment is exactly as in the preceding cases, plus the removal of any
splinters of bone. The cases in this class which give the poorest
results are those in which there is more or less extensive injury to the
articular cartilages.

Another class of cases includes those in which an important frag-
ment of bone is detached or easily detachable, thus changing the
articular surface and affecting the statics of the ‘oint. If the wound
is in one of the arm joints, especially the elbow, the case can be
treated as if no fracture existed. The constant motion’ of the joint

93696—19—5
58 JOINT LESIONS.

prevents the formation of any intraarticular exostosis and the
functional result is good. If the wound is in the knee, certain pre-
cautions must be taken. Active flexion and extension must be begun
immediately, but the patient can not begin to walk until the bones
have knit sufficiently so that there can be no danger of displacement.
This requires about three weeks, after which the treatment is as usual.

A third class of joint wounds includes those with considerable
injury to the bony tissue. This may be subdivided into the follow-
ing groups of cases: Those involving an extensive loss of substance
of one of both epiphyses; those involving the fragmentation of one
or of both epiphyses.

In the first group, part of one side of the epiphysis has been
destroyed, the corresponding part of the other epiphysis has lost its
point of contact and the statics of the joint have been disorganized.
In the elbow this is not of much importance since this joint does:
not have to support much pressure. The patient will make active
flexion and extension as quickly, completely, and easily as with a
lesser injury. There will be some lateral deformity and at most some
lateral mobility which tends to improve or disappear, but the func-
tional result is good.

When the knee is affected, the usual treatment should be followed
while the patient is in bed. When he starts to walk he is at first
unable to bear his weight on the affected knee and should be given a
jointed Thomas splint. After several days of walking with this
apparatus the patient will be able to walk, using only a cane for.
support. A certain lateral mobility will persist, tending sometimes
to improve or disappear, though in certain cases the patient will
have to wear a jointed leather support for the knee before he can
walk without a cane. The improvement or disappearance of the
lateral mobility is brought about partly by a contraction of the ~
muscles on the opposite side to the lesion and probably partly also:
by the contraction of the ligamentous capsule on the healthy side.

If the destruction of tissue has been too great, resection will have
to be done, but Willems states that if not more than one whole con-
dyle or half of the articular surface of the tibia have disappeared
conservative treatment should still be tried, resecting the joint later;
if the result is not satisfactory.

When there is extensive loss of substance of both epiphyses, con-
servative treatment should be tried if, in the knee, the crucial liga-
ments are still intact and if more than half of the articular surface
is preserved. Resection can be resorted to later if necessary. Pa-
tients with wounds of this sort can begin to walk as soon as the
wound is cicatrized or well granulated, using at first the apparatus as
above described.
 

 

 

SER

 

 

 

 

 

 

 

J. M. Open fracture of the fibula with infection; purulent arthritis of the tibio-tarsal joint:
Arthrotomy.
58-1
E8-2

 

 

 

 

 

.M,

 

After two months,

 

 
JOINT LESIONS. 59

When there is extensive fragmentation of one or more epiphyses,
the treatment must be somewhat modified, inasmuch as the fracture
is accompanied by marked displacement.

In this class of cases, it is convenient to consider separately injury
to the knee and to the elbow, and injuries involving one and both
of the epiphyses. Wounds of the knee joint involving only one
epiphysis call for a careful removal of all fragments which mani-
festly can not be saved, and the application of an extension apparatus
fastened by screws above the malleoli. This apparatus, with screws,
chains, and foot tractor, is made by Collins in Paris. Active flexion
and extension should be begun immediately. This is at first difficult
and limited in its action, but may be facilitated by 1 momentary re-
laxation of the extension. The length of treatment necessary and the
functional result will depend upon the possible infection of the
wound and upon the extent of the injury. If one epiphysis is en-
tirely gone, there will of course be shortening and almost complete
loss of function. If, however, the larger part of the articular surface
on one side is intact, the extension will bring the fragments into
place and keep them there and the functional result will usually be
good. Wounds involving the tibia are much more apt to become
infected than those involving the femur.

When both epiphyses’ have been shattered into numerous frag-
ments, conservation can still be tried if a sufficient number of them
remain adherent and, fall into position, after the extension apparatus
has been applied. If the treatment succeeds, the joint will be anky-
losed, but not shortened. If callus does not form properly, or if it
is manifest in the first place that conservative treatment will not
succeed, resection or, if necessary, amputation may be performed.
If, on the other hand, the damage is less extensive and if after exten-
sion part of the articular surfaces of the two epiphyses on one side
can be preserved, the fracture may consolidate, and there may even be
some mobility of the joint. Of course if the popliteal vessels are
injured, amputation will have to be resorted to immediately.

When the elbow is involved, conservative treatment should be tried
so long as any part of the articular surface of the two epiphyses or
even of one epiphysis alone can be preserved. After cleansing the
wound in the usual manner, the splinters of bone should be removed,
the wound closed if possible and active flexion and extension imme-
diately begun. Remarkable results can often be obtained with a
minimum amount of articular surface.

It is, however, in the treatment of purulent arthritis that the most
surprising results can be obtained by immediate active mobilization.

It is exceedingly difficult to secure the proper drainage in these
cases by arthrotomy, and resection has been, ordinarily, the opera-
tion of choice. Willems’ method has the immense advantage of pre-
60 JOINT LESIONS.

serving in almost all cases the function of the joint, as well as of
simplifying the treatment. He advises a uni- or bilateral arthrotomy
followed by immediate active motion of the joint, even instructing the
patient to walk after the temperature has fallen below 100 F. and
while the joint still has a large opening. So far from being painful,
the motions relieve the pain by emptying out the secretions and re-
lieving the distention of the joint. Pus is expelled with each con-
traction of the muscles, and if the movements are repeated often
enough and vigorously enough, the secretions are disposed of as
rapidly as they are formed and complete drainage is assured. This
treatment should not be supplemented by irrigation, which is, to say
the least, useless.

As soon as the treatment is begun, the general condition of the
patient improves very rapidly, and the temperature loses its septic,
character, falling to at least 100 F., although it may not reach normal
for some weeks.

‘Locally the suppuration follows the course of an ordinary abscess,
though somewhat prolonged. The swelling around the joint di-
minishes, but does not quite disappear until the wound has healed.
Periarticular abscesses are practically unknown. The secretion is
abundant at first, but gradually decreases and finally disappears
completely.

The motions of flexion and extension are easily made at first, but
as the secretion begins to dry up there is a slight tendency to stiffen-
ing of the joint. To avoid this danger it is wise to close the arthrot-
omy wounds partially, as soon as the secretion has become consid-
erably less. It will usually be found that the wound has become
canalized along a certain path where the pus is discharged, and this
is the only sinus which it is necessary to keep open.

Other things being equal, the drainage will be better in those
joints in which the movements are more extensive. Thus the elbow
and the knee respond best to this treatment, whereas the wrist and the
ankle, in which the movements are more limited and the secretion
consequently less easily expelled, will respond less quickly.

_ The function of the joint will almost invariably be preserved to a

large extent, if not completely, and it is not unusual to see a perfect
result, especially in the elbow. There is, moreover, practically no
atrophy of the muscles.

The success of the method seems ‘to be due to the complete drain-
age which limits the infection to the synovial membrane and pre-
vents it from spreading to the cartilage or bone.

At the hospitals at Bourbourg and at Hoogstade I saw many
elbow, ankle, and knee cases, fresh and old. Dr. Willems explained
his work, which began long before the war, when he felt that sur-
geons were doing wrong in not moving joints early enough. This
 

 

A. Van H.

Arthrotomy for projectile in the right knee: (a) Active
movements on the fourth day: (b) active movements on the
eighth day.

 

‘| s : SM)

 

 

  

(a) (b)

. Van H. (a) Arthrotomized knee supporting the weight of the
e body; (b) fexion of the arthrotomized knee three weeks after
the injury.
60
 

J. Van H. Extension and flexion 14 days after the
wound, in spite of gas gangrene,

 

 

J. Van H, Extension 18 days after the wound,

60-1
 

 

J. Van H. Active movements two months after the wound
before skin grafting.

60-2
 

 

 

(a)

 

 

 

(b)

J. Van H. (a)7After skin grafting; (b) extension and flexion
five months after the wound,

60-3
 

 

 

 

 

 

 

 

 

 

 

 

(c)

(a) J. Van H. Splintered fracture of the external condyle of the femur in the right knee. Radio-
graph after cure. (b) V.R. Wound of the right elbow; fragmentation of the olecranon process

and splintered fracture of the ulnar epiphysis. Radiograph on entrance. (c) V. R. Radio-
graph after removal of splinters.

60-4

 

 
 

 

 

 

 

V.R. Radiograph after removal of splinters.
60-5
  

V.R. After three days,

  

V.R, After seven days.

 

V.R. After ten days.

  

V.R. After four months.

60-6
 

 

 

 

 

 

J. M. Two splinters of shell in the right knee.

 

 

J. M. Active flexion and extension on the eighth day.

60-7
 

 

 

 

 

 

 

 

(a) (b)

J. M. Condition three months after the injury: (a) Arthrotomized knee supporting
the weight of the body; (b) flexion of the arthrotomized knee.

60-8

 
JOINT LESIONS. 61

was in nonseptic cases. Since the war he has enlarged the scope of
his work. He willingly answered all questions and furnished me
with pictures of some of the cases I saw. These are annexed
hereto.

One case which I saw was a purulent synovitis of the knee, strepto-
coccus in type, which had been’ under treatment for three months.
Pus squeezed out from the joint as the leg was fully flexed and ex-
tended, but the joint surfaces were of a clean red color, and there was
no pain on motion, or when the patella was grasped and pushed or
pulled from side to side.

Another streptococcus knee case, seen on the fourth day, was able
to flex and extend his knee with a fair amount of freedom.

A compound fracture of the ankle, operated on the previous day,
had been opened, cleansed, and sutured up tight, and the patient was
already beginning to move it without pain.

A fractured patella had been sutured with silk-worm gut, which
was left in, and the patient, six days later, was walking easily.

Another patient had had a compound fracture of the elbow, in-
volving the external condyle and epicondyle. The bone had been re-
moved, the edges of the wound cut away, the wound cleansed with
ether and sutured up without drainage. Seven months later there
was perfect union with no loss of function. .

Willems gives the following statistics with regard to 100 consecu-
tive knee cases. Eighteen of these were accompanied by.a purulent
synovitis of a virulent type, chiefly streptococcus, but in the 100
cases there were no deaths and no amputations. There was one re-
section in a case in which the crucial ligaments were gone and the
popliteal artery was thrombosed, and there were two stiff joints, one
of which it was hardly fair to count, since the patient had. failed to
follow directions.

Dr. Willems was thoroughly imbued with the belief that many
would be saved joint and limb by the treatment which he recom-
mended, and his great desire was to save the soldiers and not to
prove his theory to be correct.

Both Major Lockwood, D. S. O., B. E. F., chief surgeon C. C. S.
No. 36, who accompanied me, and I had been skeptical when we went
to see the cases, but came away greatly impressed by what we had
seen. The results certainly were wonderful and bore out Dr. Wil-
lems’s claims. :

There is unquestionably much to be learned from this man. The
treatment of joint cases by his method without doubt gives better
functional results and a larger percentage of cures, and it seems
evident that when this method. becomes more generally known it will
modify, to some extent at least, if it does not supplant, the practice
of most surgeons to-day.
62 FRACTUBES.

FRACTURES.

In 1911 the International Congress of Surgeons selected the sub-
ject of simple fractures as the main topic for discussion’ at the session
held in Brussels. Leaders from all over the world gathered for a
three days’ conference and freely exchanged their views in an at-
tempt to-arrive at a conclusion as to the best treatment for this class
of injuries. In a large hall near by were exhibits, such as charts,
pictures, drawings, slides, apparatus, models and graphic statistical
records of fracture cases.

To those of us who were onlookers, it was obvious that there were
three groups with conflicting opinions. There were those who em-
phasized the value of open operative treatment and reinforced their
arguments by showing the poor results obtained from the employ-
ment of other methods. Again, there were the earnest advocates
of the practically exclusive use of apparatus, who sought to demon-
strate that operative results did not compare favorably with those
obtained when the essentials of mechanical treatment were observed.
Then there was the third group which pointed out the unfortunate
consequences likely to follow if either of the first two methods were
adopted. They maintained that in a large number of cases the best
results could be obtained by insuring immobility and correct align-
ment through the use of sand bags or the like, while at the same time
minimizing circulatery interference by reason of pressure. They
used massage at once and passive motion early. In all three, the
adoveates admitted that there were exceptions but maintained that
the rule was as they severally claimed.

Here were the wisest honestly differing. Apparently at the close
of the conference there were still the three opinions, although each
group had learned much of the viewpoint of the others.

Since 1911, there has been a gradual coming closer together, but
at the beginning of the war there was still a wide divergence of
opinion as to the best treatment of many fractures, simple as well
as compound. After four years of war experience, while there are
radically differing methods in vogue, there are nevertheless, certain
essentials as to which there is close agreement.

Early in 1915 the death rate in some classes of compound fractures
was appalling, but owing to improved methods this has been greatly
reduced and a contrast between the mortality and morbidity then
and now is most gratifying.

Immediate immobilization, the use of a Thomas splint or some
modification of it, careful splinting so as to allow of no grating
of bone ends, the removal of foreign bodies introduced with the
projectile, the types of cases which may be safely evacuated and
those which should be left behind and the importance of not: dis-
 

KETTLE OR IRON PLATE. RECHAUFFMENT.
~-at

    
 

 

FIG ut. We eee
BLANKETS & STRETCHER FIG \

PATIENT HEATING UP Wh Bey
HEATED READY FOR PATIENT PATIENT READY FOR TRANSPORT

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Wate: proof Sheet

 

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FIG |!

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Jit. Cleve pitch over Buot

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Ficatie

 

FRONT LINE APPLICATION OF THOMAS SPLINT ‘
FIRST ARMY (R.A.M C) SCHOOL OF INSTRUCTION 1917,

 

 

e

Front line application of Thomas splint. First Army (R. A. M. C.) School of Instruction.
62

 
FRACTURES. 63

turbing the injured parts any more than is imperative are all sub-
jects upon which there is substantial agreement. Other questions,
such as the extent and character of operative interference, whether
antiseptics should be used at all, and if employed, which one is best,
and the kind of splint which should be used after the case leaves the
casualty clearing station are as yet matters of varying opinions.

The field of special hospitals is developing rapidly. The French
have established certain hospitals for the ‘care of fractures, each
with a specially trained staff in charge. Other institutions have set
apart entire wards for this work, resulting in uniformity of treat-
ment and increased efficiency. The British in their orthopedic cen-
ters have gone a step farther and are sending to the Eighth General
Hospital at Wimereux, and the Red Cross Hospital at Netley, as
many as possible of their thigh fractures. Thus there is being
created a specialty within an already specialized field.

Colonel J..A. Blake has been particularly interested in the treat-
ment of fractures and formerly at the American ambulance, Neuilly,
and now at the American Red Cross Hospital No. 2, is devoting him-
self largely to their care. Recently a start was made on a hospital to
be used exclusively for fractures near Chalons-sur-Marne, but the
German drive interfered with Colonel Blake’s plans. Doubtless this
. unit, with those of Colonel Goldthwaite and Major:John B. Walker,
all of the Medical Corps, United States Army, and others, will do for
us what Jones, Sinclair, Souttar, Thevenot, Patel, Leriche, Gosset,
Depage, Willems and their confréres have done and are doing for
our allies.

Colonel Sir Robert Jones, C. B., director of the orthopedic centers
of Great Britain, will shortly jase a volume on his experiences in
dealing with this line of cases. Colonel Blake has in press a book on
fractures. Prof. R. Leriche of Lyons, lately at Bouleuse in charge of
fracture cases, has already brought out this year the second volume
of his work on this subject. Prof. Willems and Major Sinclair state
that they will not have their books ready until after the war.

All these authorities differ materially in theory and practice, but
all are doing excellent work and obtaining good results.

I refer only thus briefly to those whose books are bringing within
our reach at the present time their views and opinions. The work of
Sinclair and Willems, however, is extremely important, and as now,
when we most need to know what they are doing, it can only be
learned through a personal ‘visit or through some one who has had an
opportunity to see it at first hand, I have attempted to describe some
of the outstanding features.

Essentials of Sinclait’s method—I visited the Eighth General
Hospital a number of times and went through the fracture wards
with Major Sinclair and saw many wonderful results of his treat-
64 FRACTURES.

ment, especially in cases of compound fracture of the femur, in which
he is particularly interested. He said:

Immobilization and drainage are the main elements of success in the treat-
ment of compound fractures. My method is—Thomas splint, sterile dressings,
free drainage. Immobilize as early as possible. I would do this at the ad-
vanced dressing stations, putting on a Thomas splint at once. Treat the wound
after immobilization. Thus the ends of bone are kept from doing harm and
opening up new avenues of infection. Wait and see if there is trouble before
overdoing the surgery. Never mind the fragments of shells or bullets unless
they do harm. It is the infection that injures—the organisms. I often leave
in bullets that are doing no harm—leave them unless they require removal.

Preserve pieces of bone that are in any way attached. In the beginning of
the war we removed all the pieces and some do this still. Don’t do it. What
is the use of taking away a natural graft and months later transplanting
bone frofn the tibia? We never see shortening unless part of the femur has
been removed, in fact, the patients go out with the leg a little longer than
normal, Splint early and do not disturb any more than necessary. I even do
‘small operations in the ward, such as inserting calipers or traction screws, in
order not to move the patient about. Drain with rubber tubes, putting as
little fluid as possible into the wound, if any is used at all. I employ a little
peroxide full strength to clean the wound. We do not use Carrel-Dakin. .The
antiseptic is injurious to the tissues and washes away the blood serum con-
taining the antibodies with which nature fights off disease. I use alcohol and
then 3 per cent picric acid upon the skin before incising. In compound frac-
tures of the femur incise at least 4 inches in length where there is good de-
pendent drainage, fhen use dry dressing. Introducing the finger into the wound
and feeling about, tearing the tissue or curreting is bad. Drainage by repeated
clean cuts is the best.

Any plaster which contains rubber is ‘Likely to irritate and blister the skin.
I have prepared a glue which acts well and holds for some weeks without
difficulty (see formula).

Unless drainage is necessary most of the cases of fracture of the thigh do not
require any anesthetic for reduction, but proper traction for 24 to 48 hours
accomplishes it. Sixty per cent will be held down by the use of glue; 40 per
cent need other holding points. In order of preference, the points of direct
bone traction are: /

1. Three fingers below the tubercle on either side of the tibia; two screws
should be inserted part way through the bone but be sure they do not go all
the way through. Then tape is fastened on metal loop.

2. Calipers to malleoli, so fixed as not to go more than one-quarter inch into
the bone on either side of foot.

8. Condyles of the femur, with large calipers.

4. Calipers to os calcis.

There will be no pain or discomfort of any moment, and none at all after 24
to 48 hours.

Do not move the patient from where he is, and if properly treated he will be
able to walk in three or four months. For fractures of the upper third of the
thigh, while in a position of marked abduction, the patient is supported in a
swing bed on a sheet made of a network.of strings. In all other cases, and for
the upper extremity, I use a Thomas splint as slightly modified by me. Observe
temperature and pulse and examine local condition with X-rays. It takes the
greatest care of details to succeed with this work, but if the method is followed
strictly one does not see those terrible sinuses persisting and having to be re-
FRACTURES. 65

peatedly curetted for dead bone. For anesthetic I use chloroform 1 part, ether
2 parts.

There should be special hospitals for the care of fractures, and the surgeon
who applies the permanent dressing should see it through to cure. There is not
the- interest or uniformity of treatment if the case changes hands. America
had better leave her thigh fractures over here until they can walk.

For the purpose of collecting any discharge from a dependent
wound, a small sterilized pus basin is placed under the outlet of
the tube which is inserted for drainage. Major Sinclair emphasizes
the importance of noting the character of the discharge, as it affords
clinical data of value. The tube itself has perforations within the
wound, but is not spirally cut and has nothing over the outlet. He
considers this importaht, as there is no danger of damming the drain-
age. (This is a practical point and should be considered in other
conditions requiring drainage.)

He says: “ Bone is formed from bone, not from periosteum alone.”
In this he differs from Chutro and agrees with Sir William Macewen
of Glasgow. The latter has grown an entire shaft of a humerus by
chipping off pieces of solid bone (in operating for bowlegs and
knock-knees) and placing them between the two ends of the humerus,
the whole shaft growing solid from these pieces. This took a number
of years.

SINCLAIR’S FORMULA FOR ADHESIVE GLUE.
TEST FOR GLUE.

Place 4 ounces of glue in 4 pounds of cold water and leave in a cool place
fer 12 hours.

If dissolved, it is bad.

If coherent and gelatinous, weighing 8 ounces, it is good.

If coherent and gelatinous, weighing 16 ounces, it is very good.

If coherent and gelatinous, weighing 20 ounces, it is excellent.

The following is the formula:

Very good glue. oi 220-2 eee we esses seeeseceeeseseeses 50 parts
WateReoce scene sot een leek ss soso e ee eh ee ea 50 parts
Gly C6LING@L. asso ose Sssee een aceetaesepee eee esiesel Sosa cess snd 4 or 6 parts
Menthol 23 ane eh ee ee Se eo Se ee eso 1 part

Soak for 12 hours and then melt on.a water bath.

Neutralize to litmus with sodium hydrate, as commercial glue at times
contains free hydrochloric acid.

Add 4 parts in summer and 5 parts in winter of glycerine and 1 part of

menthol.
Frequent heating evaporates the water, which should be added from time to

time. When reheated many times, adhesive power is lost.
Technique:
1. The skin is not shaved.
2. Wash the skin with soap and hot water, which contains about 4 drams

of washing soda to the pint, to convert the oil of the skin into soap, as glue
will not adhere to a greasy surface.
66 FRACTURES.

3. Dry the skin.
4. Apply the warm glue evenly, brushing all the hairs of the limb in an

upward direction.

5. Keep a tension on the gauze all the time, bring it quickly but carefully
into contact with the limb (inner and outer surface), and apply neatly a loose-
woven bandage, starting a hand’s breadth above the malleoli up to the knee
joint.

6. When dry apply traction.

(The adhesive can be made waterproof with a 2 per cent solution of potassium
bichromate applied in the dark and then ‘exposed to the light, or by means of
formalin.)

_ %. The extension must always be very carefully applied, whether with Maw’s
elastic cotton net or with gauze.

8. The extension must be changed at once if the patient complains of a tick-
ling or burning sensation under it, but it generally requires changing about the
tenth, twentieth, and fortieth days.

WILLEMS’ SCREW EXTENSION APPARATUS.

This apparatus for continuous extension of fractures of the femur
and leg bones consists essentially of 2 screws,‘a bolt with 2 short at-
tached chains, and a stirrup at the 2 ends of which the chains are
fastened. For femoral fractures, the screws are introduced into the
uppermost portion of the condyles close to the diaphysis, and are
inserted to a depth of 2 to 8 centimeters. For fractures of the leg
bones, the screws are placed above the malleoli, at a depth of about
2 centimeters. The bolt is approached close to the skin so as to
render the traction juxta-cutaneous. Counter-extension is made by
suitable adjustment of the bed. ei

The principal advantages of this apparatus are that: 1. Traction
is exerted directly on the lower fragment, a condition not met by any
other method of continuous extension. The result is great accuracy
and efficiency of the traction. No part of the force being lost, the
object is accomplished by a relatively weak traction. 2. The disad-
vantages. of indirect traction through one or more articulations are
obviated by this method exclusively. 3. The apparatus leaves free
the entire surface of the limb, thereby facilitating the care of the
wound. 4. Mobilization of all joints is possible during the entire
treatment. 5. The apparatus not only prevents overriding of the
fragments, but permits the correction of angular deviations by chang-
ing the axial into lateral traction.

The screws are very readily tolerated provided they are firmly
fixed in the bone, above the epiphyses, where they remain indefinitely
in place, causing no tenderness. The insertion of the screws never
breaks the bone, and radiography has never revealed the smallest
fissure, even in the case of the fibula.

Screw extension is easily combined with suspension by means of
the Thomas splint. For the evacuation of the wounded, to which
 

Fig. 1.—Extension apparatus; two screws with two
short chains terminating in a stirrup which bears a
hook for the traction cord.

 

Fig. 3.—Apparatus in place for fracture of the thigh,
combined with suspension.

 

Fig. 4.—Apparatus in place for femoral fracture. © Spring
; extension for evacuation.
 

 

 

 

 

 

 

 

 

 

 

 

 

Many hospitals are doing excellent work in caring for fracture cases, and the accompanying
pictures show a fracture ward at the Val-de-Grace Hospital, with its many varieties of appa-
ratus needed, and also a fracture splint in position as used at that institution,

 

66--2
FRACTURES. 67

the apparatus is very well adapted, it suffices to substitute for the ex-
tension with weights an extension on a spring interpolated between
the stirrup of the Willems apparatus and the extremity of the
Thomas splint. (Presse méd. No. 69, 1917.)

A splint which is receiving much favorable attention and being
widely used is one devised by Leclercq and Varigard, and about to

be described.
APPARATUS OF LECLERCQ AND VARIGARD.
4

(For reduction and maintenance of fractures of the humerus.) _
|

This continuous extension apparatus has been adopted by the
sanitary service of the French Army, and is in use in the English
Army. It is intended to reduce and retain complicated fractures
of the arm (humerus), while permitting the application of dressings
and other interventions necessary for the healing of the fracture.
Made entirely of metal, nickel-plated copper, in order to avoid oxi-
dation, this apparatus has been devised and manufactured in con-
formity with modern methods. It serves for the right as well as the
left arm (symmetrical and interchangeable axillary splint) and is
easily and quickly applied (in about 10 minutes) with only two flan-
nel bandages. With the apparatus once adjusted the patient has no
further pain or inconvenience; he is not kept immovable in bed, but
may go and come, or be evacuated in the sitting position. Suppura-
tion is reduced to a minimum, and reduction is as complete as pos-
sible. Dressings are easily applied without displacing the appa-
ratus. Bony consolidation takes place rapidly. In grave cases, am-
putation may thus be avoided. The apparatus saves time, suffering,
limbs, attendance, and money.

The adjustment of the apparatus, which serves for either arm,
is best understood by a study of the explantory illustrations. Some
preliminary precautions should be observed. The hooks for fastening
the arch must be on the side of the thorax; when they are on the arm
side the position is incorrect. Open the screw, turn back arch A,
replace the screw after having pressed the bolt into the hole of
arch P, as shown in the illustration.

Before applying the apparatus the wound must be dressed (not
too thickly). Lightly stuff the axillary arch with cotton wadding,
held in place by a strip of gauze or oiled silk. Pad the forearm with
a good thickness of cotton wadding held in place by a strip of gauze.
Make three small cushions, to be placed between the extremities of
the arch and the shoulder, as well as over the shoulder itself. These
cushions are best made with cotton held in a napkin or a piece of cot-
ton wadding may be wrapped in a strip of gauze closed at the end
with a few stitches. Place the apparatus on the healthy side to

oY
68 FRACTURES.

ascertain the proper length. Lengthen or shorten, by opening the
screw and changing the hold. There are four such holes on the
splint, No. 2 from below fitting a medium-sized arm. The apparatus
is now applied by slipping the arch under the screw and then ad-
justing the forearm plate, the patient being instructed to hold his
elbow with the healthy hand. Note that the attachment of the ap-
paratus is thoraco-suprascapular. The arm should be placed
slightly backward, so that the thoracic hooks are very straight.
Hold in place with very long (6 meters) flannel or cotton bandages
about 10 centimeters in width.

The fore-arm plate must not lie too tightly in the bend of the el-
bow. In order to change the dressings, the fore-arm plate can be
loosened, slipped forward, and then replaced. The shoulder can be
mobilized after having opened the screw, then proceeding to abduc-
tion or to adduction. In forcibly holding the lower portion of the
humerus so as to immobilize it, the elbow joint may be made to work,
by means of a special contrivance. This should be done every day
when the wound begins to improve.

The apparatus having been adjusted, the tension of the spring is
regulated by turning the tension buttons near the fore-arm plate.
The spring gives 2 kilos of extension when its length taken vertically
is 4 centimeters. This is the most that should be used. The rule is
to tighten the spring gradually and to verify the proper position of
the bone fragments by radiography. There is always a tendency to
overtighten the spring; great care must be exercised, for the frag-
ments would separate and consolidation would not be obtained. Keep
in mind that the extension is continuous. Some edema of the elbow
in the first days is not serious, and simply requires lessening the
extension.

Other splints of various types are being used, such as the Paterson
splint for fractures of the humerus, and the American Red Cross
splint, which are illustrated here.

The French Army has developed an admirable system for the care
of fractures and joint injuries which insures the patient remaining
under the control of the same staff of surgeons from the time he is
injured until he is discharged from further treatment. This results
in uniformity of treatment, a definite feeling of responsibility on the
part of the staff, and a higher measure of success because of these two
factors.

This system, as it is now in operation behind four of the French
armies in the field, is arranged as follows:

The patients are received in hospital No. 1 from Chee to six hours
after injury. They are X-rayed and operated upon and the proper
splint is applied. If possible they are not moved until the union of
broken bones has been established. There’ is some criticism of this
 

 

FIG. 1 VUR DE WAPPARELL

A are axillure

 

riculanan
d/assemblage articulee
3 arrima ¢ C

     
  

 

 

 

 

 

 

 

    

FIG. 2

 

 

68-1

 
sin position. Front view,

 
 

 

 

 

 

 

 

 

 

Device for immobilization of fracture of arm applied.

 
 

 

 

 

Paterson splint.

68-4
 

 

 

 

Paterson splint.

68-5
68-6

 

 

 

 

 

 

 

Adjustable abduction arm splint made in the American Red Cross
splint shop.

 
68—7

 

 

 

New adjustable abduction splint perfected for the U. S. Army
by the American Red Cross splint shop.
 

 

|

 

 

 

 

2—Arm extension splint in place.
68-8
 

 

 

 

 

Photograph made from pencil sketch by Maj. H.S, Souttar. (See special section, British
Red Cross Hospital, Netley.)

68-9

 
TREPHINED CASES. 69

arrangement on the score that it is harmful for a patient to be re-
tained for a long period within the battle area with its noise of con-
flict and constant danger of the necessity for a rapid evacuation. It
may be that in the new French Army plan this will be changed and
such hospitals placed much farther to the rear. After leaving hos-
pital No. 1, the patients are transferred to hospital No. 2 from 30 to
50 kilometers to the rear. Here any necessary repair work is done,
bone infections are treated, and the cases remain until convalescent,
when they are sent to hospital No. 3. This class of hospitals is lo-
cated well to the rear and in such centers of physiotherapy as have
been established; where there is provision: for. massage, mechano-
therapy, fitting of artificial limbs and the like.

A board composed of Colonel William L. Keller, Medical Corps,
Colonel Joseph A. Blake, Medical Corps, and Captain Nathaniel
Allison, Medical Corps, visited four French Army areas where this
system was in vogue and made the following report to the chief
surgeon of the American Expeditionary Force as to their conclu-
sions:

1. The board has carefully observed the character and efficiency of the
splints and appliances used at these various centers for the treatment otf
fractures and as a result is gratified to state that in its opinion the appliances
in splints recommended for use in the American Army under your direc-
tion are sufficient and practical to meet all the conditions even better than those
in use by the French Army.

2. The board feels that an improvement can be made in this system by
having the simple splints which supply the principle of traction applied when
the man receives his first surgical dressing.

3. Infection is to be avoided if possible. To this end the French system ‘1s
admirable. The board feels that fractures and wounds of the soft parts and
injuries to joints can he primarily closed in a large percentage of cases if they
reach an operating hospital in the first few hours after receiving their wounds.

4, Hospitals for the treatment of fractures and injuries to joints should be
special services and should be equipped for X-ray work and operation and for
after care. The most capable surgeons should direct the work at these stations.

5. The board feels that so far as is possible the above outlined system should
be followed in the American service. It has taken the French three years to
evolve this system. It is still not in use by the British. We feel strongly
that our own results will be greatly improved by following the principles of

this system.

6. The staff arrangement for fracture services should be as follows: The
chief surgeon of the group should direct the entire service from hospital No. 1,
that is the hospital near the front. The surgeons at Nos. 2 and 3 hospitals
should work in complete cooperation with him.

TREPHINED CASES.

A very difficult class of patients to deal with is composed of those
who have been trephined. At the schools for reeducation, the farms
for the mutilated, and the clearing depots, such as at 28 Quai Debilly,
Paris, the frank statement is made that these men are usually mis-
70 TREPHINED CASES,

fits. They do not get along well with other patients, and while they
often look entirely well they never seem to feel right. They are
obsessed with the idea that something is going to press on their
“soft spot,” and their actions are frequently peculiar. Headaches
and a long train of nervous symptoms are complained of. —

Dr. Lines, at the clearing house of the Colonie des Etrangers, in
speaking of two such cases who had been returned from other insti-
tutions to Paris, “because they could not get along with the others,”
said:

No reeducation, even on a farm, could do much for trephined cases. It is
almost useless to try to help these men. . :

The same opinion was expressed elsewhere, and I early realized
that here was one of the great problems of the war wounded. Medi-
cal treatment gave very indifferent results. I was therefore anxious
to learn whether anything of real value had been developed in sur-
gery for the relief of these unfortunates. I found that Morestin,
Gosset, Chutro, and a few other surgeons had done considerable work
along the line of filling up the gaps left in the skull by introducing
between the skin and the dura a plate of some kind. By this means
protection is secured from pressure and relief from direct adhesion
between the dura and the subcutaneous tissue—often the scar.

Upon learning that many of these operations had been performed
at the Buffon Hospital, and that Prof. Babinski, not only the lead-
ing neurologist in France, but one of the greatest in the world, had
followed the results, ,I went to him for his views. He very courte-
ously and freely discussed the treatment of this class of cases, show-
ing histories and patients. He said:

Trephined cases usually are a most unfortunate lot. I have nothing special
to offer them in the line of treatment. I either wait to see how time will affect
them or have an operation, Some get a little better after awhile if left alone,
Gosset’s and Chutro’s results are excellent from the surgical standpoint. The
cranioplastie operation should be tried, but I am not willing to give a final ver-
dict from the neurological point of view. Years must pass before that can be
given. I would advise operation in all cases where the symptoms are persistent
and marked, and the scalp is adherent to the deeper structures. Whether

cartilage or bone should be used is a matter for the surgeons to decide. Some
say that bone is absorbed and others that cartilage is absorbed.

,

To sum up, the opinion of this great authority is, in trephined
cases with persistent symptoms; do a cranioplastic operation, but
do not. promise too much.

The employment of perforated silver plate coverings for cranial
gaps has been found serviceable in the experience of Mitchell (Brit.
Jour. Surg., July, 1917). The thin plate (not so thick as an ordinary
visiting card) is punched with holes one-eighth of an inch in diam-
eter as close together as possible. The orifices, aside from helping
TREPHINED CASES. 71

to fix the plate, permit the escape of blood or other fluids thereby
guarding against pressure.,on the brain through accumulation be-
tween the plate and the dura. The fitted plate is held in position
by a series of catgut sutures passing through the periosteum and out
through the most convenient perforations. The scalp flap is sutured
over it, and a drainage tube inserted at the most dependent angle
for 24 hours, so as to avoid the formation of a hematoma. In the
experience of ‘the originator of the method, primary union was ob-
tained in all of his six cases and the operation was followed by
marked relief of symptoms.

Cranioplastics by means of osteocutaneous or osteoperiosteal flaps
proved highly satisfactory in the experience of Cazin, and Mayet
recommends the repair of a loss of cranial substance by turning
down an osteoperiosteal flap cut from. the external table of a con-
tiguous region of the skull. ;

After the performance of a trephining operation, the gap in the
skull is probably most advantageously closed by means of cartilage
which combines a certain yielding property with sufficient solidity
to provide the necessary protection. The relief obtained in cases
of painful cicatrices is most gratifying. The cartilage may be ap-
plied in a series of autoplastic or homoplastic layers, according to
Morestin’s method, or in the form of a sometimes voluminous single
‘segment of cartilage, with its perichondrium, in order to prevent
the ultimate formation of adhesions with the brain. The last named
plan is followed by Gosset, who reports 15 successful cranioplastic
operations with excellent results (Bull. et mém. Soc. de Chir., de
Paris, vol. 42, 1916).

The repair of the gap left in the skull after trephining, by means
of cartilaginous grafts, has the advantage of providing a perma-
nent and physiological protective covering of the head. These grafts
are accorded preference by Warren Woodroffe, surgeon to the Ulster
Volunteer Hospital, because they are safe, simple, autoplastic and
autogenous. Cartilage moreover is highly resistant against infec-
tion, making this tissue a practically ideal material for reconstructive
surgery. The grafts are shaved from the sixth, seventh, or eighth
costal cartilage, and may be held in place by a network of catgut
attached to the margin of the pericranium, the hole in the skull being
filled by an adjustment of overlapping grafts beneath this catgut
trellis. Although no bony change follows, the cartilaginous plate
affords a satisfactory and reliable closure of the gap in the bony skull.
It must be mentioned, however, that phenomena of cerebral com-
pression have been reported, following the closure of a cranial gap
by a large piece of cartilage (Bull. et mém. Soc. de Chir., de Paris,

12 Dec., 1917).
72 AMPUTATIONS.

To return to the Buffon Hospital. At Chutro’s clinic I saw a
number of these cranioplastic operations and some post operative
results. The patients I examined certainly were in excellent condi-
tion and the records were most satisfactory. Chutro’s operation is
a modification of Gosset’s, with the use of rib cartilage, and done.
under local anesthesia. He has had 62 cases with uniform success
and I was most favorably impressed with the method of operating,
the technique of the surgeon, and the results in those patients ob-
served.

Although the details of this work have not been published by Dr.
Chutro,; in response to my request he allowed me to send an artist to
his clinic and he himself wrote out, in Spanish, a description which
is to be made a part of this report. <A translation of the paper and
the original pictures I am advised are on the way from Paris and
will be submitted as soon as they arrive. (See page 237.)

AMPUTATIONS.

There is practically unanimous agreement that in the early days
of the war there was much unnecessary amputation. The develop-
ment of better methods of treatment and facilities for the care of
the wounded have resulted since then in a great saving of limbs.

In those cases where amputations are still found necessary a most |
important consideration is the point of amputation. While the sav-
ing of bone and tissue and the early healing of the wound are of
great moment, the opinion of those who have had the greatest ex-
perience in this line of work is that the main object to be borne in
mind is the obtaining of such a stump as will develop the greatest

_ functional activity in connection with the use of an ‘artificial limb. ,

Captain P. D. Wilson, Medical Corps, United States Army, at the
American Red Cross orthopedic department showed me cases at his
clinic which clearly demonstrated the truth of his statement that—

Often good prosthetic stumps are, according to old ideas, bad surgical re-
sults—skin adherent to bone end, etc. Nevertheless they are very much better
from the standpoint of function, and for the artificial-limb maker, than if even
a few centimeters were removed in order to give what were surgically con-
sidered, up to the time of the war, satisfactory stumps. Let more bone be

removed if necessary; even a centimeter may count greatly against function
for prosthesis.

The following views of Dr. Stassen, at the head of the great
Belgian hospital at Port Villez, are concurred in by many of the lead-
ing surgeons abroad. These were furnished to me eae Dr. Stassen
in a personal communication after my visit:

The idea of a “preferred spot” for amputation has taken root -in France

since the day of Ambroise Paré, and the experience of the war tells in its
favor.
AMPUTATIONS. 73

The cooperation which exists between the front and rear hospitals has re-
sulted in a renovation and an improvement in the technique of amputations.
The progress made in prosthetic art and the study of scientific methods apper-
taining thereto will soon lead surgeons to invoke the collaboration of the gym-
nasium and prosthetic doctors with regard to the aftertreatment of the patient,
and the subsequent obtaining of maximum good results. This is already being
done, and the revision of amputation technique is the result. The following
principles ought henceforth to serve as a guide to the surgeon:

1. In the amputation of a member, it is necessary to preserve the maximum
of stump to be used as a lever, even to the extent of placing the wound of the
operation in a position classically known as bad. A long, conical stump even
with a wound clinging to the bone is better than a stump too short, but well
padded.

2. The amputé must begin to actively mobilize the different segments of his
stump in the early hours which follow amputation. The logical and necessary
complement of this method is a speedy functional utilization of the stump, and
to this end, the patients must in the early days, even before cicatrization is
complete, be provided with provisional apparatus.

These latter should be light and simple, easy to manufacture and replace and
would consist of (@) an encasement exactly modeled to fit the stump. Plaster
is the best material for this purpose; (b) simple attachments made with a
view to :

1. Maintaining the normal orientation of the longituainal and articular axes
of the member.

2. Maintaining the normal integrity of articular movement and the function
of the muscular groups.

(c) A terminating apparatus (a shank in the case of lower member ampu-
tations; terminal instruments and implements for use in relation to therapeutic
work in the case of those of the upper member).

The three items on the therapeutic program are:

1. Immediate active mobilization.

2. Speedy functional utilization.

3. Functional reeducation through walking or working with prosthetic
apparatus.

If carried out the result will be a mutilé more able to fake his place as an
active member of the economic life of the nation.

Upper member—-Hand: Preserve as much as possible, even rudiments of
the fingers, metacarpals, all of which are of use.

Wrist: Disarticulation of the wrist with resection of the styloid apophysis
of the radius is preferable to amputation of the two bones of the forearm
above the articular interline. The position of the wound should be on the
back plane; the point is, the preservation in the stump of the forearm of the
normal pronation and supination movements in the lower radio-ulnar articu-
lation.

Forearm : Preserve the maximum amount of bony leverage, even to the detri-
ment of the situation of the wound.

Arm: Apply the above principle in all its force. In high amputations, pre-
serve as much of the humerus as possible, even the rudiments of the humeral
head and have recourse to disarticulation of the shoulder only if and when the
worst comes to the worst.

Exception—Elbow region: Where this is unavoidable, it is as well to reject
any high amputation of the forearm, because the result will merely be an inert
stump devoid of all utility. Disarticulation of the elbow or better still, ampu-

93696—19-——6
*

74 AMPUTATIONS,

tation above the condyles of the humerus is to be preferred. Which of these
two alternatives is the better, is still a matter of controversy. For the utiliza-
tion of automatic arms it may be an advantage to preserve the condyles of the
humerus, i. e., disarticulate the elbow. The condyles of the humerus may even
serve as a stop for the armpiece of the automatic apparatus. When, however,
a working arm is required, amputation above the condyles of the humerus is
preferable, because it does not cause dissonance between the real and artificial
elbows. Whatever be the case, however, the question merits still further study.
At present, one can not establish a general rule and state that amputation above
the condyles is to be preferred to disarticulation of the elbow or vice versa.

Lower member.—Foot: Amputation of all the toes with preservation of the
heads of the first and second metatarsals is a good amputation. The preserva-
tion of a portion of the big toe and its metatarsus, with amputation of all the
others, is preferable to Lisfranc’s amputation. The question is still under dis-
cussion as to which of those two amputations is better, viz (@) amputation
of the first four metatarsal bones. with preservation of a part of the fifth toe
and its metatarsus, or (b) the amputation of Lisfranc (tarso-metatarsal). We
have not had occasion to see cases where the second or third or fourth metatar-
gals ought to have been amputated, and we can not therefore give a formal
opinion as to this operation. Classically speaking, this kind of operation is
more prejudicial to the patient than a veritable Lisfranc’s operation.

As an amputation of the forefoot, Lisfranc’s operation is excellent.

Chopart’s amputation (medio-tarsal disarticulation) is a rather bad one.
There nearly always ensues a certain degree of equinus, and a dislocation of
the instep. Moreover, the foot acquires a vicious attitude and the patient sutf-
fers largely from his mutilation.

Pirogoff’s operation is to be recommended as it enables patients to walk very
satisfactorily. It is to be preferred to tibio-astragalar amputation with resec-
tion of the malleolus.

The instep: When Pirogoff’s amputation can not be performed, it is pre-
ferable to have recourse to amputation above the malleolus.

The leg: Between the line passing above the malleolus and below the line
passing by the insertion of the patte-d’oie, and the insertion of the quadriceps
muscle in the tuberosity of the tibia, the principle must be the preservation
of the maximum of bony leverage, and that to the detriment of the position
of the operating wound, and the padding of the stump.

Thigh: Above the femoral condyles apply the same principles. In high am-
putations of the thigh, preserve as far as possible the length of the femur, and
consider coxo-femoral disarticulation only as a final resource.

Haception.—Knee region: High amputations in the leg, in the region of the
knee, ought to be rejected. The same refers to disarticulation of the knee.
The result of each of these interventions is a stump as difficult to apparatus
as an iron bell-tongue. Amputation on the thigh above the condyles is pre-
ferable.

When possible this latter amputation should be replaced by amputation after
the method of Sabanejeff, and especially by Gritti’s operation which give ex-
cellent stumps.

Prof. Tuffier, of Beaujon Hospital, said:

Reamputations were frequent at the beginning of the war; they are less
so now. This is due to the traction exercised upon the skin and flaps during
the whole period of cicatrization.

‘Out of 1,731 amputés at the Maison Blanche on the 1st of December, 1915,
who were examined by me, 1,474 were fit to be apparatused straight away, but
257 had to undergo a complementary operation in my service, say 17.4 per cent.
AMPUTATIONS. 15

Furthermore, questions elicited the fact that 279 of these 1,731 wounded had
had to undergo previously two to four successive amputations, say 16.1 per
cent. That makes a total of 536 amputés whose first operation was inade-
quate, say 30.9 per cent. The majority of the amputations, according to
the Maison Blanche statistics, give results which, if not perfect, suffice for
prosthetic purposes, in only 69.1 per cent of the cases, and consequently after:
one amputation, the chances of a fresh operation are thirty to a hundred.

Statistics from the the sixteenth region show for the upper member, 90.5 per
cent of good stumps, and 9.5 per cent of bad ones; for the lower member, 68
per cent good for the thigh and 32 per cent bad; and for the leg, 53 per cent
good and 47 per cent bad.

Out of 279 amputés who have been retouched in some way, regulation or re-
operated upon, practically all were cases of the lower members; 252 lower
members, say 90.8 per cent (111 thighs, 141 legs), 27 upper members, say, 9.7
per cent.

(Copy. )
(Translation. ]
Paris, May 25, 1918.
DrEAR Dr. BAINBRIDGE: I have received your letter of May 22.

(1) The number of amputations is due in part to the severity of the trau-
matism and in part to the infection.

The infection was responsible for one-half of the amputations. This figure is
very low at the present writing, but I find it impossible to fix a percentage.

(2) The promised drawings to show the conditions which can lessen the num-
ber of reamputations appear in the contribution which I have caused to be for-
warded to you at the Hotel Crillon.

(3) I have also answered this question, and have sent you detailed statements
concerning an army in the period of an offensive.

(4) The results of each offensive are not published.

(5) A reply has ‘also been given on this matter, indicating which wounded
should be returned to America. I have likewise indicated to you what classes
of wounded are better sent to America than kept in France.

With kindest regards, etc.,
SUFFIER.

The following résumé of the lessons of the war with regard to am-
putation was given to me by Captain H. W. Miller, of the American
Red Cross bureau for the manufacture of artificial limbs, and by
Captain P. D. Wilson, detailed from the United States Army to the
orthopedic department of the American Red Cross, in Paris, and is
said to represent the consensus of opinion to-day among those best
qualified to judge:

‘1. No amputation should be sutured primarily. When a man is seen with
a good stump and there has been a primary suture there has no doubt been
needless removal of part of the limb. Always conserve length BE the lever.
Primary suture does not do this,

2. Early secondary suture, after smears show less than one per field of
bacteria, then suture. Never suture, however, when there are streptococci, no
matter how few.

8. Never do a Chopart’s amputation. You can never get a good apparatus
to fit it. There is always shortening of the tendo Achillis. If the tendo Achillis
be cut the part is much weakened so never employ this amputation.

4. A Pirogoff amputation is not good. Syme’s is best.
76 > AMPUTATIONS.

FOR THE LEG.

5. If one can not do a Syme’s, do an amputation at the junction of the lower
with the middle two-thirds. This is an exception to No. 1, which says: ‘“ Con-
serve the length of the lever.” Don’t operate in the lower third of the leg if
you can help it. The objections to the lower third are as follows:

(a) The stump is always cold because of poor circulation.

(b) It is always sensitive,

6. The minimum length of the lever in ordinary cases which is utilizable is
2 inches below the knee.

7. Never take out the head of the fibula because you sacrifice the attachment
of important flexible muscles.

_ 8. The preferred length of the lever of the leg is 4 inches below the knee.
With 4 or 5 inches one can secure practically 100 per cent efficiency with an
artificial member ; 75 per cent efficiency with 2 to 3 inches.

The steel and leather orthopedic leg with laced corset about the stump has
been given up practically by the French. They have adopted the American
leg and principle. This was done about June, 1917. At the present time they
are using approximately 15 per cent of American legs. We know this because
they are being manufactured to that extent for them. The French have not yet
gotten around to doing it successfully. The steel and leather leg is gone for
good. '

The improved American leg is the one gotten up by Hendricks and Martin,
of Belgium. They differ somewhat in theory but very little in practice. One
can read their articles, which deal more with theoretical than practical
differences.

Prothesis has been extended since the war far beyond the field of dentistry
where it originally started. We may define prothesis as a system of restoring
an amputé to his maximum efficiency.

FOR THE THIGH.

(a) Operation.

(0) Treatment.

Cushions are bad. Put.the thigh out straight, not flexed. Extension after
amputation helps save from contraction, deformity, and ankylosis. Tends te
prevent adhesion of the scar to the bone. .

(c) Always turn a patient on his face and extend the thigh for a few minutes
each day. One such movement daily will do an immense amount of good and
saves contraction. s

(d) Disarticulation of the knee or other joints, except the shoulder or hip,
is bad.

(e) In thigh amputations get the maximum length.

(f) Disarticulation of the hip ought to be done in two stages, as it means
much less mortality. Amputate the thigh and later disarticulate the bone by
lateral vertical incision.

FOR THE LOWER LEG.

(g) Crutches are very bad. They change the statics of the body. Bad
habits are formed. They can walk early with provisional apparatus. End
bearing pressure does not exist. Bad-looking stumps often are most useful.
This doing away with crutches is best, yet we have many crutches. The Gov-
ernment has not yet taken hold practically of the provisional apparatus. The
crutches are easy to get and supply and it looks well to get the patients up
quickly.
AMPUTATIONS, 77

WHY DO AWAY WITH CRUTCHES?

1, Deformities are produced by crutches in the way the man carries himself.

2. There is always pressure atrophy when apparatus is used. There is atrophy
of disuse which is prevented when we employ provisional apparatus. Thus
by the early use of provisional apparatus we save one kind of atrophy, which
can be prevented, and we have early the atrophy from the pressure of the ap-
paratus and can more quickly adjust the permanent apparatus. Then a stump
has, as a rule, an extra accumulation of fat if it hangs, so by early use
of apparatus we save this extra increase of fat on the stump, which must later
disappear. This takes time.

3. Loss of time. The form of the stump does not take its final shape as
quickly if crutches are employed, as when provisional apparatus is used.

4. Bad statics. The statics of an individual are transformed. He gets a
new habit of walking which has to be overcome. Provisional apparatus can
be used in about 14 days for amputations below the knee and three weeks for
the thigh. Don’t use crutches. Instead use provisional apparatus, The
patients get out very nearly as quickly.

PROVISIONAL APPARATUS,

The best is plaster of Paris molded with steel rods at the sides, a bolt in
the center for the knee, so as to allow all flexion, and suspenders over the shoul-
ders holding up the apparatus which is molded to the extremity. A leather
corset is used above on the thigh. Use the end bearing when it exists, but it
is not usually necessary. When both legs are off use provisional peg legs but
no crutches. Give them a stick to walk with.

our
VALUE OF PROVISIONAL APPARATUS.

1. Correct statics.

2. Active agent physicotherapy.

8. Hastens atrophy of stump; lessens time of evolution of stump one-half.

4, Saves cost. Provisional apparatus can be had for $7 or $8, whereas if no
provisional apparatus is made there will be an additional fitting adjustment to
the permanent apparatus costing $20 to $40. The extra period of fitting is most
trying on the patient.

5. Finally, there is the mental side of it all. When the member is removed
profound depression comes on. The patient sinks down to the level of a
professional cripple. He feels himself a human derelict. Provisional apparatus
lessens this greatly and combats this tendency as early as possible. At Rouen
they get the patients to hop before they have provisional apparatus, so as to
encourage them. Begin as early as possible to let them see they are going to
do something and be something in the future.

6. Saves by early use much stiffness and maybe ankylosis of near-by joint.
Prevent the crutch habit. A Danish surgeon, Dr. Svindt, developed one of the
best provisional apparatus, a cardboard peg leg for provisional use with a
starched bandage. The funnel end is open.

POINTS OF SUPPORT.

1. Bony prominences the points for support in all apparatus.
2. The soft parts of the stump.
8. The end of the stump when utilizable.
18 AMPUTATIONS.

Legs and thigh are so far all that we have studied.

Musculo-spiral paralysis or crutch paralysis—So many of these cases of
crutch paralysis have been seen in France that there has been demanded and
produced an ultra-brachial crutch. Still it is bad. Get the amputated leg
case up early, but don’t use the crutch.

FINAL APPARATUS.

This depends largely on what the patient is to do hereafter.

1. The peg leg.—It is simple, any one can use it and it is not expensive.
When going to do hard work it is the best. It gives the maximum strength
with the smallest cost for repairs. It is well constructed, and the French have

, developed it exceedingly well. With a decent socket and a joint-lock at the
knee the man really sits in it with comfort.

2. The articulated leg—It looks much better. The splint manufacturers are
entirely against the peg leg.

An artificial member is to serve always either of two purposes: One is fune-
tion and the other appearance. One must weigh up the two. A peg leg may
mean added advantage in some cases; in fact, with a peg leg a man may even
capitalize his injury. This is a dangerous philosophy, but it is actually a fact,

WHAT CAN A MAN DO WITHOUT A LEG?

1. After an amputation below the knee, as indicated above, he can do any-
thing as he did it before. There is no problem of reeducation here at all.

2. Above the knee there is need of reeducation. The man may become a shoe-
maker, a basket maker, a shopkeeper, or he should certainly be taught a trade
which would allow him to sit a good part of the day, fruit culture, etc. There
are many outlets for him. The French have turned most of them into shoe-
makers and basket makers. Of course, these cases of mutilés of the lower
extremities are usually young men and they can easily learn. Most manufac-
turers will tell us that they can take a man from any place in which he is
working and make him do more work and better work than the trade he has
himself selected. A time may come when efficiency engineers will put the
man in his most useful place.

Captain Miller states that in making legs they have developed a real
business which is growing every day. The Red Cross stands ready
to furnish limbs or give any aid along the lines indicated herein. It
will put its resources at the disposal of both Americans and French.
to be of assistance from the time the patient leaves the operating
table until his return to his maximum efficiency.

He also states that up to date in the war there have been 60 per
cent reamputations, necessitating greater loss of limb, which is a dis-
tinct economic waste.

From the standpoint of fitting splints, the flaps in amputation are
bad. The site of the scar is negligible—absolutely of no importance.
Flap amputations being bad, circular amputations are first choice.
AMPUTATIONS. 79

Statistics of amputation from August 4. 1914, to March 1, 1917.

 

 

 

 

FRANCE,
Upper limbs : ‘ 25 per cent.
Lower limbs. 75 per cent.
: 64 per cent thigh.
Of the lower limbs. : =e 34 per cent leg.
Disarticulation of hip 4 1 per cent minus.
Syme’s and Pirogoff amputations epi ieeeerte pe es, 1 per cent plus.

Of considerable interest is the questionnaire sent out to the Eng-
lish and Belgian centers of prothesis and to 12 cities in France, in-
cluding not only the ones in charge of these centers but also the chief
surgeons. The answers represent a large majority of those who
replied. ‘

In order that this bureau may render an intelligent report to the United
States Army as to the best methods of amputation of the lower limb, will

you have the kindness to answer the following questions and return to me in an
inclosed envelope.

All of these. questions are in regard to amputating stumps of the
thigh or leg and do not include disarticulation of the knee or hip or
amputations of the ankle such as the Symes or Pirogoff.

1. Do you consider the ability of a stump to bear weight on its end as of any
importance?

No.

2. When a stump is able to bear weight on its end, do you utilize this ability
when fitting an artificial limb? If so, how?

No. :

8. With an artificial limb fitted so that the end of the stump bears much of
the weight, have you ever remarked improvement in the epishy of the mutilé to
walk or work?

No. Because they have had no experience with it.

4. Given that end bearing is usually secured in the types of stumps, above
described at the expense of length, do you think the surgeon shoud be advised
to strive for end bearing when making an amputation?

Secure maximum length of lever.

Major Edred Corner, of the Fifth London General Hospital, gave
me a synopsis of his experience as to amputations, which will be
found under the description-of the work at that hospital. (See Fifth
London General Hospital.)

From the experience of all of these authorities, the following
generalizations may be made:

1. Every surgeon who amputates should know the best place for
amputation consistent with the obtaining of the best functional re-

sults for the use of apparatus.

2. The horror of amputation should be mitigated in thie minds of
those injured and they should be shown that often those who retain
a deformed limb have much less function than those with artificial

extremities.
80 AMPUTATIONS.

3. After the patient has an artificial limb and begins to learn a

trade, his work should be such as to fit him to do that which is of
most benefit: in the community where he expects to live. For ex-
ample: If a mutilé has his limb, and when able to return to work
is taken to his home, say in Montana, there to live and be reeducated,
he should be encouraged to do mining or farming. If on-the other
hand he comes from Massachusetts, he should be taught jewelry work
or shoemaking or the like. In other words fit him for the trade
where there is the greatest demand. We in America should have such
centers of reeducation thoroughly adapted to teach in accordance
with the needs: of the community or section. Of course, we must al-
‘ways consider what the mutilé can do and whenever possible he
should return to the trade or occupation in which he was most pro-
ficient before his disablement.
. At the Roehampton Hospital, 5 miles from Charing Cross, Lon-
don, there are 900 beds for convalescent amputated cases, and there
are always hundreds awaiting admission. This is only one of a num-
ber of similar hospitals, and 14,000 cases have been fitted with arti-
ficial limbs here and sent out. The manufacturers of the instru-
ments work on the premises, and while waiting for the apparatus
or learning its use, the men may take up new trades. Sailors come
here as well as soldiers and we saw one of the British Navy ‘sur-
geons fitting splints.

It would seem to be an excellent idea for the Navy to be thoroughly
in touch with this work. With our marines in the thick of the fight-
ing, we should be prepared to let them profit by all that experience
has taught our allies.

At Roehampton( an old sailor, J. M. Andrews, who is also a skilled
mechanic, is of the greatest aid in advising the men as to their future.
He is full of cheer as well as most practical, and goes about and talks
with each man and discusses his future occupation and how he can
best be fitted for it.

Lieutenant Colonel MacLeod, who is in charge, said:

Most of the cases should have provisional apparatus before they come here.
Up to the present time they have had none, but I believe it will come soon.

He said that there had lately been an increase in the number of
double amputations—61 such cases in the preceding month. The
average stay in the hospital is thirty days for a leg, but less for an
arm. Double amputation or joint amputation means, of course, a
much longer stay. High amputation of the thigh with only 3 inches
of bone left was of no value asa rule. Such a case is treated. as if it
were a hip joint amputation.

He considers the hip joint amputation apparatus one of the really
great things of the war. The patient “sits” in the apparatus quite
comfortably and can walk for miles with ease.
AMPUTATIONS. ': 81

He says: “Ninety per cent of the amputated cases should before
long be self-supporting.”

In the matter of provision by the Navy for artificial limbs, the
following letter from Captain Miller should be given careful consid-
eration:

AMERICAN RED Cross,
DEPARTMENT MILITARY AFFAIRS,
ARTIFICIAL Limge SERVICE,
Paris, June 27, 1918.
From: Capt. H. W. Miller, 12 Rue Boissy d’Anglas, Paris,
To: Surg. William S. Bainbridge, U. S. N., R. F., Hotel Crillon.
Subject: Mutilés.

1. The bureau of manufacture of artificial limbs of the American Red Cross
has been in operation for over a year. It has made what we hope has been a
careful survey of the manufacture of artificial limbs in France, Belgium, Italy,
and Great Britain. At the same time we have conducted a workshop, where
the past nine months we have been actually manufacturing artificial limbs. As
the result we have adopted a type of leg which, although far from ideal, is
nevertheless, in our opinion, the best that can be made to-day.

2. The greater part of it can be manufactured’ in quantity. It is of the
wooden American type, following on the whole the principles of Dr. Martin,
of the Belgian Army, as to statics. It has been adopted by the surgeon
general’s office of the French Army and is being supplied to the orthopedic
division, A. E. F. Following design of Capt. P. D. Wilson, M. R. C., we are
manufacturing for the A. E. F. a type of provisional apparatus which we have
found satisfactory. '

3. The organization and equipment of our workshop has taken considerable
time and has been attended with a good deal of difficulty. We beg, therefore,
to call this to the attention of the Navy Denekneny: and to make the following
suggestions :

(a) That this bureau shotlld be prepared to haaihastans samples of any
prothetic apparatus which the department desired to have manufactured.

(b) On application from the Navy Department to the American Red Cross
(to Maj. J. H. Perkins, commissioner for Europe, 4 Place de la Concorde,
Paris) arrangements could be made to manufacture such aepeRins in
quantity.

4. The Navy Department could send'a personnel to this bureau to be in-
structed in the production of prothetic apparatus, such personnel to consist
of a foreman (not necessarily a man with previous experience in the artificial-
limb business) and an orthopedic surgeon. These men could enter our shop
and work there as long as desired. It would give us pleasure at the same
time to put them in touch with the various French centers. In our opinion it
is essential that the manufacture of artificial limbs be studied in Europe, it
being impossible to obtain a correct knowledge of the problem through the
American manufacturers, plus a study of the French and English literature
on the subject. Much of the latter, although interesting, is extremely mislead-
ing and must be checked up with the actual results being obtained here.

(Signed ) H. W. MILter.
Capt. H. W. Mirier, Chief.
82 . PLASTIC SURGERY.

PLASTIC SURGERY.

In our enthusiasm over the results being obtained in plastic surgery
during the present war, we are apt to regard the work as a recent
development and to overlook the fact that there is no other branch
of surgery in which such advance has been made during the 25 years
preceding the war. Indeed, while antisepsis and asepsis have done
much toward making possible the successful treatment of cases re-
quiring bone and tissue transplanting, plastic surgery is by no means
a discovery of our own day. The ancient Hindus, to whom so many
wonderful achievements are popularly attributed, are credited with
having performed plastic operations 2,000 years ago. Doubtless this
was brought about by reason of the fact that quite a popular form of
punishment was the cutting off of the nose. Strange as it may seem,
the tile makers, who are reputed to have been a more or less despised
class, delegated to themselves the task of nose mending. Presumably.
the thought came to these particular artisans as a result of their
familiarity with cements and repairs calling for the adhesion of one
substance to another.

In more modern times, the ingenuity of the most skillful surgeons
has been taxed to enable them to remedy congenital defects, such
as cleft palate and harelip, or the results of accidents, such as ex-
tensive burns, and also deformities from lupus or malignant disease.
Pieces taken from the ribs and from other parts of the framework
of the body have been successfully utilized. Lane, Brophy, and a
host of others were doing wonderful work along these lines before
the horrors of war multiplied many times the number of patients
requiring such treatment.

Restorative surgery, in the broad sense of the term, includes plastic
work in many lines, such as bone grafting, the restoring of nerve
continuity, tendon transplanting, and the implanting of adipose tis-
sue to fill bone or lung cavities; but perhaps the most gratifying
results have been obtained in case involving the restoring of the
jaw and the remedying of gross defects of face and mouth.

‘Modern warfare has resulted in much deformity, especially hor-
rible when the head and face are involved, and it is to plastic surgery
that all are hopefully looking for relief for those who have suffered
such injury. The injury may be slight and only of cosmetic interest,
or so great as to endanger life. Between these extremes there is a
multitude of unfortunates who must have repair work performed in
order that they may be made more presentable before they can go
back either to the fighting force or to civil life and be economically
self-sustaining. ;

It is evident that one of the great responsibilities with which we
shall be faced at the end of the war will be the aftercare which must
 

 

 

 

 

 

 

 

 

 

82-1
 

 

 

At Queen's Hospital, Sidcup, by Maj. H. D. Gillies: 1, On arrival; 2, wnen healed:
3, after first operation; 4, first stage of second operation; 5, side view of same;
6, second stage of second operation; pedicles returned to scalp,

82-2
‘PLASTIC SURGERY. 83

be given to those whose injuries require plastic work. While the pre-
liminary care of such cases should be started immediately in order
to avoid contracture of muscles, stiff joints, and atrophy of tissues,
the plastic surgery needed will, in many cases, extend over a period
of years. Just as we must make plans now for the postwar care to
be given those who have suffered amputation, we must also make
ready by plastic surgery to assist those unfortunates who otherwise
would be more or less shut off from society. :

With this object in view we should establish special departments in
certain hospitals or, if the number of cases requires, a special hos-
pital where the best dental and mechanical work will be joined with
the most advanced plastic and oral surgery. (It would be well if
this center could be so located that those taking such courses as are
given by the United States Naval Medical School could have the
benefit of the clinical teaching.)

This assumes that the patients are to be brought back to the United
States promptly, but, as stated before, in every case there should be
some temporary splint work done immediately and before the men are
sent across the ocean.

One of the distinct advances growing out of the present war has
been the recognition of the need for cooperative work in this field
between the general surgeon and the dental surgeon. In the organi-
zation of military hospitals the dentist is established as indispensable,
and the value of his work along the line of dental repair can not be
overestimated. -But the field of the dental surgeon is being greatly
enlarged by reason of the vast number of jaw-and face wounds re-
sulting from present-day warfare, involving loss of bone, teeth, and
soft parts, and cooperation between the general surgeon ‘and the
dental surgeon is bringing about such satisfactory results that every
means must be taken to encourage and extend this teamwork.

The need for such cooperation was pointed out by Surgeon A. M.
Fauntleroy, United States Navy, in his report on the medico-military
aspects of the European war (1915), and has steadily grown more
apparent, until it is now regarded as an essential feature in plastic
surgery of the mouth and face. A number of surgeons are de-
voting their attention to work in this line and achieving noteworthy
results. .

The American Ambulance at Neuilly, now Red Cross Hospital
No. 1, was one of the pioneers in establishing an enlarged dental
department and advocating a close relationship between the dental
and the general surgeon. Some of the striking results that have
been obtained there have been published, the report of Dr. Faunt-
leroy, above referred to, containing at page 100 et seq. an excellent
description of the general technique and methods employed. Major
Du Buchet, Major Powers, of late, and especially Dr. Hayes and
84 PLASTIC SURGERY.

Dr. Davenport, working with Colonel Blake and others, have made
distinct advance in this line. In 1915 and again in 1918 I was
enabled to see the work at this institution, and while progress is
being made in other branches, such as Colonel Hutchinson’s nerve
grafting, in no line are more gratifying results being obtained than
in this field of plastic oral surgery batted on jointly by the gen-
eral and dental surgeons.

So valuable has been the work at this center that.a report on it is
being prepared, accompanied by an exhibit showing in detail the
apparatus used and pictures of the results. This is to be filed as a
permanent record with the Army Medical School at Washington,
and at my urgent request a duplicate has been promised for the
Naval Medical School at Washington.

While many other centers are doing excellent work in this field,
the ones selected for me to visit as being the ones from which we
could learn most were the hospitals at Sidcup, England; Le Mans,
France; the Val-de-Grace Hospital at Paris, and General Hospital
No. 83 at Boulogne, as well as the hospital at Neuilly.

(1) Queens Hospital at Sidcup, Kent, is devoted exclusively to
plastic and oral surgery and has accommodations for 500 patients.
It is located in one of the most beautiful spots in England, but a
short distance from London. Sir W. Arbuthnot Lane, Bart., is
deeply interested in the work of this hospital, and recently at the
meeting of the American Medical Association at Chicago he spoke
of it-as the center of plastic surgery in Great Britain. Major H. D.
Gillies, R. A. M. C., the chief surgeon, is a recognized authority on
plastic surgery, and most of the jaw cases in the British Army are
sent here or to King George’s Hospital, London. (See accompany-
ing pictures.) This hospital is divided into five units, as follows:

Two units British.
One unit Canadian.
One unit. Australian.
One unit New Zealand.

I am told they will be very glad to add an American unit if
requested.

Casts are taken and the mechanical side is well studied. At pres-
ent there are three teams from the United States Army here observ-
ing and assisting, each team consisting of one dentist and one
surgeon.

This institution has an excellent dental department, and there is a
great wealth of material for study. The Navy could well take ad-
vantage of the opportunity offered and send some of its dentists and
surgeons here and to other centers specializing in this work, in order
that the marines and sailors requiring such treatment may have the
 

 

 

 

 

(1 and 2), Condition on admission; (3) adjustable intranasal support carried from a metal
cap splint cemented to the upper teeth; iv improvement obtained by operation and

insertion of nasal splint; (5 and 6) result of insertion of cartilage graft from rib. Taken
three months after operation. (At Queen's Hospital, Sidcup, by Maj. H. D. Gillies.)

84-1 :
 

 

 

 

 

 

 

 

Private J. P. Horizontal right portion of mandible missing from third molar to canine. Cartilage
of larynx exposed. Tracheotomy tube inserted from the side at the casualty clearing station.
Shows large flap taken from chest, leaving buccal fistula, which was finally closed. Prosthetic
ae was made for the pseud-arthrosis, (At Eighty-third British General Hospital, by Maj.
Valadier,

84—z
PLASTIC SURGERY. : 85

benefit of the experience acquired by our allies in four years of active
war work.

(2) At Le Mans, France, Delagéniére is doing excellent recon-
structive work for the French wounded, and I was fortunate enough
obtain the following description of his methods, which I quote in

ull:

THE RECONSTRUCTION WORK OF DELAGENIERE.

As an offset to the appalling mutilations wrought by the destruc-
tive implements of modern warfare, the new and vast experience in
surgery has brought forth some wonderful achievements in the re-
pair of such injuries. The remarkable reconstructive work of Dela-
géniére on bones and joints ranks among the foremost of these con-
temporary contributions to surgical resourcefulness in apparently
hopeless or insuperable tasks. Credit for the conception of this
method of bone repair belongs to Ollier, but for the elaboration of
the surgical technique, the formulation of the operative indications,
and its introduction as a practical procedure, we are indebted to Dela-
géniére. In view of the fact that this important work is hardly
Imown as-yet on this side of the Atlantic, it appears desirable to
present a brief review of the procedure and its results.

Delagéniére’s first report, covering 41 personal observations, pub-
lished in the Bulletins et Mémoires de la Société de Chirurgie de
Paris, Tome 42, I, 1916, page 1048, dealt with the utilization of osteo-
periostéal grafts from the tibia for the reconstruction of bones or the
repair of lost bone substance, more particularly for the repair of
bony defects of the skull after trephining, as well as in the treat-

ment of pseudarthroses of the shaft bones. The fresh osteoperiosteal

grafts from the tibia are immediately transferred to the operation
wound, without intermediaries of any kind, taking care to handle
them only with sterile compresses or instruments. The tibia is
treated simply by rapid skin suture over the denuded bone surface
from which the periosteum has been stripped, and a small drain is.
left under the skin for 48 hours in order to guard against the forma-
tion of a hematoma; the wound heals in 8 to 10 days, without com-
plications. The graft must be transferred without delay to its new
position in the interest of perfect asepsis. The employment of anti-
septic agents is contraindicated as interfering with the vitality of
the graft. As far as possible, the two surfaces of the graft must
be in contact with living tissues. While this condition is easily met
with in the closing of bony defects of the skull, more serious diffi-
culties are encountered in the case of the extremities. The entire
graft must be well covered with skin in order to guard against
necrosis and sequestration of the uncovered bony portions of the
grafts.
86 PLASTIC SURGERY.

About a year later Delagéniére discussed the repair of bony. de-
fects and the reconstruction of bones by means of osteoperiosteal
grafts from the tibia on the basis of 118 personal observations.
(Bull. méd. chirurg. du Mans et de l’ouest, Tome I, No. 6, 1917.)
The results in the series of 118 cases were as follows: Fifty-four
cranioplastics, with a very favorable outcome in 44 cases; 7 good
results and 1 failure through elimination of the graft; a second
operation proved highly successful. Of 27 grafts for pseudarthrosis
of the inferior maxilla, with loss of bone substance, 10 had an excel-
lent permanent result; in 7 cases, not completely healed at the time
ef the report, the outlook is favorable; satisfactory results in 2
cases, partial results in 3, and no success in 5 cases. Delagéniére’s
21 grafts for pseudarthrosis with loss of bone substance in the shaft
bones yielded 15 good results, 3 partial results, and 1 recurrent
pseudarthrosis, requiring a second operation; 1 result was zero, due -
to complete elimination of the graft. Finally one patient, a chronic
inebriate, died of chronic septicemia three months after the opera-
tion. Three bone cavities were closed by means of grafts, with a
favorable outcome.

Sixteen grafts for reconstruction of the bony framework of the
face were entirely successful in 14 instances and partially successful
in the remaining two cases. Conditions in the facial region are espe-
cially favorable for the healing of the grafts, which can be placed
in living tissues where it is easy to avoid dead spaces and to secure
good hemostasis. Failure is accordingly rare, and almost invariably
due to the opening of a natural cavity of the face. The bony frame-
work of the nose can be entirely repaired by means of these osteo-
periosteal grafts.

It is emphasized by the pioneer worker in this promising field
that the indications for the applications of osteoperiosteal grafts are
extremely numerous and varied, and will constantly increase when
once the procedure is adopted as a routine method. In his last report,
published in the Journal de Médecine, volume 89, 1918, page 81,
at which time Delagéniére was enabled to base his conclusions on
altogether 159 observations, he points out that any missing portion
of the bony framework of the body cah be repaired and recon-
strusted by means of osteoperiosteal grafts. It is perhaps superfluous
to comment upon the marvelous vista opened up in the formerly
so discouraging treatment of maimed and mutilated warriors. The
results obtained through this procedure are lasting, so that. the
function of any bone can be restored with the assistance of these
grafts.

Summarizing, it may be stated that the results of plastic work on
the skull are excellent and always obtainable, provided the correct
 

 

 

 

 

Private P, Fracture of inferior maxilla. One inch of left ramus pulverized; imme-
diate suturing and insertion of flange splint to hold jawin position. Bone reformed
completely, notwithstanding that root of molar tooth was subsequently discovered
oe final X-ray was taken. (At Eighty-third British General Hospital, by Maj.

aladier.) :

86-1
 

 

 

Private J. P. Fracture of superior and inferior maxilla; extensive loss of tissue;
immediate suturing. Removal of scar tissue and formation of angle. Teeth in-
serted. (At Eighty-third British General Hospital, by Maj. Valadier.)

86-2

 
 

 

 

 

 
 

 

 

 

J

 

Private W. S. Premaxillary bone missing, both antra foul, shattered and septic Fracture
of left ramus. (At Eighty-third British General Hospital, by Maj. Valadier.)

 

 

 

 

 

Private J.S. Fracture of inferior maxilla; symphysis missing; two molars and bicuspid standing.
Angle band and bar inserted to retain arch as far as possible; flap from neck taken to fill gap
and artificial hare lip made. Hare lip operated and teeth inserted. (At Eighty-third British
General Hospital, by Maj. Valadier.)

86-3
 

 

 

 

 

 

 

Private W. Fracture of inferior maxilla; nose shot away. Ninth and tenth cartilaginous por-
tion of rib inserted in forehead in 9 weeks; flap, all of cheeks, turned down; in 9 days pedicle
severed and skin graft over space where flap was lowered. Prosthetic appliance made to
help shaping of nose. (Final result of this case has never been published.) (At Eignty-
third British General Hospital, by Maj. Valadier.)

86-4
PLASTIC SURGERY. 87

technique is adopted and properly carried out. A favorable outcome
may be anticipated in. practically all cases.

In pseudarthrosis of the lower jaw, where the grafting method has
been definitely introduced and established, the causes of failure are
more numerous on account of the site of the graft, which is more
accessible to infection. However, the actual results already equal 72
per cent of complete success, and this percentage will steadily grow.
In bony defects of the limbs conditions are similar to those obtaining
in the case of the maxille, and the results are analogous, but even
better, with 85 per cent of successful cases.

Practically constant results, equaling a percentage of 100, are ac-
complished by osteoperiosteal grafting in the repair of bony cavities
and in the reconstruction of the face. With special reference to the
latter, the transformation by the operator’s skill of those unfortu-
nates whose countenance has lost all semblance to humanity through
’ the frightful ravages of bomb and shell is little short of miraculous,
and for a variety of considerations, ethical as well as medical, must
be regarded as one of the greatest triumphs achieved by the beneficent
art of surgery.

(3) The Val-de-Grace Hospital, at Paris, is one of the largest in
France. Here and at the Hopital St. Louis Dr. Hippolyte Mores-
tin is accomplishing excellent plastic surgical results. He has at the
Val-de-Grace a museum containing a most interesting and instruc-
tive collection of wax casts and slides showing not only the work in
the present war but what was done during the war of 1870 and 1871.
The contrast between what was then the high-water mark of achieve-
ment and what is now being accomplished is encouraging in the
highest degree.

(At the University of Lyons also a large number of casts and pic-
tures are on exhibition and show the remarkable results obtained by
the French surgeons at this center. The collections of casts, pic-
tures, and drawings at these centers of plastic work are well worth
study by those about to take up this line of surgery. They will be
invaluable records for the future.)

(4) At No. 83 British General Hospital, Boulogne, I met Major
A. Charles Valadier, R. A. M. C., who is in charge of the oral sur-
gery. He is an American graduate physician, and before the war
was a practicing dentist in Paris. He is now an officer in the Brit-
ish Army and has 50 beds in the hospital where he does special jaw
work, some of which I witnessed. The accompanying illustrations
show the results of his skill. He attributes part of his success to
the fact that he at once puts in an apparatus for the jaws so that
the parts will not contract badly. He said: “Save all the bone
possible. Whenever any piece is attached at all, save it. I would
rather chance its sloughing out than remove it. Early in the war
88 PLASTIC SURGERY.

I needlessly sacrificed bone, but do better now.” He uses only sterile
water for dressings and mouth washes, irrigating every hour under
hand-pump pressure. His collection of wax models, pictures, and
stereoscopic photographs in color is really remarkable. -

In certain cases of injury to the face and jaw, it may be found
that the defects are too great for immediate repair or that the con-
dition of the patient precludes operative treatment. Sometimes it
takes months or years to do the necessary work ‘because it must be
done in stages. For this class of cases, other means of relief must
be found, and this need is being met by mechanical substitutes for
portions of the face.

« The American Red Cross in Hagics is doing excellent work in
this line (see accompanying pictures) ; also the Third London Gen-
eral Hospital.

Striking are the accompanying examples of plates made for mask-
ing facial defects at the Third London General Hospital by Captain
Derwent Wood, R. A. M. C., the well-known sculptor.

Case I: Driver F. Skull wound April 25, 1915. Admitted May 28, 1915.. No
operative treatment.

Picture 1. Deformity after shealing.

Picture 2. With plate in position.

Case II: Trooper E. Gunshot wounds face and arm, May 13, 1915. Admitted
September 2, 1915. Plastic operations by Capt. Richard Cruise, R. A. M. C.,,
September 29, 1915; again October 8, 1915, and finally October, 27, 1915. Con-
dition of patient greatly improved by these extensive repair operations. Mouth
closed off from nares, antrum sinus closed, and large opening into left nasal
cavity repaired.

Pictures 3 and 4 show unsightly deformity even after excellent surgical
restoration.

Pictures 5 and 6 show facial mask which enabled patient to return to his
former occupation as a taxicab driver.

. Captain Wood described his methods and showed me many casts
and masks. The work is of great value and I therefore give largely
in his own words a description of the process.

PROCESS.

(1) Casting patient's face.—It is essential that a good fit on the edges of the
plate should be secured ; to this end a plaster mold of the face is obtained.

In the case of*driver F., and in consideration of the nature of his wound, I
filled the cavity with his usual dressing, cotton-wool, covering this and his left
eye and eyebrow with goldbeater’s skin, bandaging all portions of his head
that were not wanted in the mold; his nostrils were blocked with cotton-wool,
the patient during the casting breathing through his mouth and being seated
with head thrown back and pillowed on a box. After the exposed portion of
face has been oiled, the plaster is mixed with tepid water and applied. In five
minutes the mold is removed, bandages stripped, and the patient cleaned up.

(2) Modeling.—The mold having been obtained, it is dried, French chalked.
and a clay or plasticine squeeze is obtained from the mold, giving a positive
 

Views of masks made by Mrs. Ladd, of the American Red Cross, Paris. The
masks at the top are taken direct from nature; the lower ones are the remodeled
faces.

88-1
‘S]d¥q ‘SSO1D pay UBJJaWY 84} JO ‘PpeT ‘sAW Aq ope eovs OU} JO Sal}WIOJep Jol SySBI

 

88-2
 

Masks made by Mrs Ladd, of the American Red Cross, Paris.

 

Driver F.

88-3
 

eTrooper E.

88—4
 

 

Showing the use of masks to conceal disfigurement.

88-5
 

 

 

Disfigurement from wounds concealed by face masks,

38-6
TRENCH FEVER. 89

model of the patient’s dressed wound and the surrounding healthy tissues, This
is fixed to a board on a modeling stand, and a sitting from the patient with
undressed wound is obtained. Modeling now commences, and such art as the
sculptor may possess is brought to the test. A reconstruction of the wound
in every detail is established, taking care that the depths and widths of the
wound are accurately measured and modeled. The sculptor having completed
his model, he proceeds to cast it and procures the plaster positive of the wound
and its surrounding structures. Another sitting is obtained, and the portions
which are to be hidden eventually by the metal plate are modeled in clay or
wax, the edges being blended to the uninjured portions of the face, thus effec-
tively masking any trace of wounds. This is once more molded in plaster, and
the,edge of proposed plate being marked on the negative, a cast is obtained,
edges are trimmed to marking, and the model is ready to have the artificial
eye fitted to the lids; this is done from the back of the model. The plaster
eyeball is dug out, the requisite thickness of lids carefully worked down, the
glass eye placed in position, and the edges of the lids made good with thin
plaster.

(3) The plate——The model is now taken to the electrotyper, where an exact
reproduction by galvanoplastic deposit is made in virgin copper # inch in
thickness. This is finally well coated with silver. Thin bands are soldered
in on the back to clamp the eye in place. The plate is again fitted to the
patient, strong spectacles are adjusted at the requisite angle to give a well-
distributed pull on the plate. In the case of a large plate being used, an elastic
band around the back of the head is necessary. :

The final sittings are devoted to the pigmentation of the plate. I have found
a thin coating of cream-colored bath enamel a good preparation for flesh color
matching, as it leaves the oil-color mat when dry, which is essential to the
illusion of a good blending of plate with face; should the patient have shiny
skin, this is easily obtained by varnish rubbed down to match the skin.

I have tried false hair on eyelids and eyebrows, but they will not stand
the weather, and have adopted tinfoil split with scissors and soldered into
lids for the eye, and for the eyebrows pigment applied to the modeled forms.

TRENCH FEVER.

A vital medical problem for a4 long time confronting those respon-
sible for the health of the armies abroad has been what the British
have termed “P. U. O.” (pyrexia of unknown origin). Compara-
tively recently the louse has been definitely incriminated as the
carrier of the disease, and through this discovery a long step forward
has been taken toward the elimination of much serious illness and
disability resulting from this cause.

In June, 1918, I was present at the conference on this subject,
held at the headquarters of Major General Guise Moores, D. G. M. S.,
and was privileged to hear the discussion between Lieutenant General
Burtchaell, C. B., chief of the medical service of the British forces
in France, and Colonel G. A. Moore, C. M. G., D. S. O., D. D. M. S.,
who had been given this important problem to study practically in
the field and make a report. In describing his work he spoke first

93696—19——7 ,
90 TRENCH FEVER.

of the cases of trench feet which developed early in the war and
which called for vigorous measures:

First we learned what caused the trouble and then took steps to check it,
and now we prevent it altogether. An official order prescribes definite detailed
care of the feet, such as clean, dry socks and rubbing the feet thoroughly with
oil at stated periods. This treatment has put an end to trench feet.

We can now stop trench fever by keeping the skin clean and disinfecting the
clothing properly with the Foder-Thresh machine, By doing this once every
12 to 15 days the lice can be killed off. Nits are more difficult to kill. They
come on the hair in the pubic and axillary regions, about half to a quarter of
an inch from the skin. The question of louse extermination is the main one
to-day, medically considered, in relation to the trenches. Frequent bathing ‘and
the rubbing of a small amount of blue ointment into the hairy regions of the
body, together with clean clothes, will eliminate the scourge. To-make such
sanitary conditions possible for 4,000,000 of men is a stupendous problem.

Now that the importance of the louse as a factor in the transmis-
sion of disease is being recognized, it becomes evident that the eradi-
cation of these vermin is one of the most urgent problems to-day of
the medical officers in the Army and Navy.

At the beginning of the war many cases of disease not conforming
to any known type were classified under the heading of “ P. U. 0.”
Further. experience showed that three-fourths of these cases gave a
fairly definite symptom complex and could be safely included under
the term “trench fever.” There are two types of this disease; one,
the “short” type, lasting from 5 to 10 days, with a slight remission;
the other, the “long” type, sometimes lasting several months, being
recurrent in character. This disease is an important source of dis-
ability, as it is responsible for a large percentage of hospital admis-
sions in all the armies. Major Swift, for example, states that 20 per
cent of the admissions to his hospital are definite cases of trench
fever, and in some of the armies of northern France the percentage
has risen as high as 333 per cent. While the ultimate prognosis of
the disease is good, it is very likely to be followed by general debility
and disordered action of the heart (D. A. H.), thus incapacitating a
large number of men for active service. It will readily be seen, there-
fore, that the prevention of this disease is a matter of the first impor-
tance. Thetrench-fever investigation committee, of which Major Gen-
eral Sir David Bruce, K.C. B., M.D., F.R. S., A. M. S., is chairman, has
definitely established the fact that this disease is louse borne. When
the louse feeds upon a patient with trench fever its intestinal canal
becomes infected, and if then the excreta are deposited upon the
skin of a new victim the organism gains access to the blood of the
patient through scratching, and the disease is transmitted in this
way. The problem of eradicating trench fever, as well as typhus and
relapsing fever, thus becomes very largely the problem of eradicating
the louse.
TRENCH FEVER. 91

That the task is not an easy one will be realized from the fact that
the trenches on all the fronts are louse ridden from one end to the
other. The transport service has to face the same problem, inas-
much as at present on some transports the percentage of lice is
high on disembarkation of our troops in France. Colonel Seiler and
Lieutenant Colonel Strong, of the Central Research Laboratory at
Dijon, are working on this problem.and have collected considerable
data. Lieutenant Colonel Darrach, United States Army, with whom
I talked at Etretat, was much impressed with the importance of the
subject and felt very strongly that as in one instance 90 per cent of the
men on a certain transport were found to be infested with lice, the
Navy as well as the Army should take up the matter. He said that a
number of men in his unit had become infected with trench fever
after handling the clothes of the patients, but that since that time
they have been more careful about protecting these men.

When the problem of louse eradication is considered, it is to be
remembered that the soldier himself is the chief source of infesta-
tion. As Dr. Peacock says, the louse “is a parasite which is de-
pendent utterly upon man’s blood for sustenance and man’s body
and clothing tor prolonged, prosperous longevity and reproduction.”
They are spread chiefly by contact, crawling from soldier to soldier,
and leave the human body only when the surroundings are warm
aud moist, as in bed. The louse can live 10 days at longest when
unfed, and according to Warburton the nits can remain dormant
when away from the body for not more than 40 days. The nits may
survive freezing, but when they are kept dry and away from the
body they usually begin to shrivel up in a few days. The eggs are
laid chiefly in the seams of the clothing, being found in greatest
numbers in the underclothing and in the fork of the trousers. They
are laid also on the body ‘hairs, and the infested parts, or even the
whole body, may have to be shaved in order to prevent a rapid
reinfestation.

Frequent bathing and at least a weekly change of underclothing are
usually sufficient to prevent infection, when there is no overcrowding.
Under such adverse conditions as exist in time of war among men in
active service, the problem becomes a very difficult one.

When circumstances are such that the men can not be provided
with adequate bathing and laundry facilities and disinfectors are
few in number or altogether lacking, palliative measures must be re-
sorted to. Many of the lice and nits can be killed and removed by the
men themselves, especially in warm weather, when the clothes can be
taken off, hand-picked and thoroughly brushed or beaten. Under-
clothes can be immersed in boiling water and the outer garments can
be baked in the sun or in an improvised oven, or the seams can be
ironed or passed along a jet of steam from a kettle of boiling water.
92 \ , TRENCH FEVER.

Insecticides are useful in killing the lice themselves, but usually do
not affect the nits.

The multitude of remedies suggested for this purpose proves that
the ideal insecticide has not yet been wound. Creolin,1 percent solu-
tion for steeping or spraying clothes or from 8 to 10 per cent solution
vaporized, is apparently the most satisfactory preparation, as it is
noninflammable, nontoxic, cheap, and not injurious to fabrics.
Cresol-soap solution is also very useful and may be used for bathing,
as well as for soaking clothes, including boots and leather articles.
Naphthaline 96 parts, creosote 2 parts, and iodoform 2 parts, known
as N. C. I. powder, has been extensively used in the British Army for
dusting on the clothes and body, and was recommended by Peacock
as the most satisfactory insecticide which he had tested.

The measures above described will do much to mitigate the evil.
and when thoroughly carried out, being controlled by frequent in-
spection of the men, will give excellent results.

When a unit comes out of the trenches, the process of freeing the
men from vermin can be carried out more thoroughly and on a larger
scale. Hot dry air or steam, applied by various methods, has proved
most efficacious in accomplishing this purpose.

G. H. F. Nuttall, M. D., Ph. D., Sc. D., F.R.S., has done consider-
able research work on.the viability of lice and nits under varying
conditions of temperature, moisture, etc. His experiments prove that
both lice and nits are killed by a moderate degree of dry heat, by
55 C. in five minutes, or by 65° to 75° in one minute. He advises
that in practice the infested clothing should be exposed to a tempera-
ture of 60° to 65° for 15 minutes, in order that every part of the
garments may be penetrated by the hot air. Both lice and nits are
killed in five seconds when immersed in water at 70 C., but in practice
the infested clothes should be left in the water for one or two minutes
at this temperature, or for 10 minutes at 55 C. They are killed in-
stantly by moist heat at 80 C., and the period of exposure in a steam
disinfestor, when the clothes are not too tightly packed, should be
about 15 minutes.

When it is impossible to obtain apparatus especially designed for
the purpose of disinfestation, it is almost always possible to improvise
more or less simple apparatus which is fairly efficient. An ordinary
baking oven or a brick superstructure, placed over a kitchen range,
will furnish dry hot air of the desired temperature, or a packing case
or barrel resting on a sheet-iron plate with a thin layer of earth may
be used over an out-of-doors fire. A very simple and efficient hot-air
hut has been devised by Captain Harold Orr, C. A. M. C., and modified
by Grant and Peacock. Plans for the various models of this hut may
be found in Nuttall’s excellent pamphlet on Combating Lousiness
among Soldiers and Civilians.
TRENCH. FEVER. 93

In disinfesting barracks, railway carriages, etc., steam is the most
efficient means that can be used. Clothing, blankets, and other equip-
ment, if hung or packed very loosely, can be sterilized at the same
time. Steam disinfection huts or disinfecting vans or trains, the
latter having the advantage of mobility, are extremely useful in dis-
infesting outer garments and blankets.

Whenever possible, it is, of course, more satisfactory to use the
more elaborate apparatus especially designed for the purpose of
disinfestation. Numerous types of hot-air and steam disinfestors
have been devised and of these perhaps the most extensively employed
have been those made by the Thresh Disinfector Co., 4 Central Build-
ings, Westminster, London, 8. W. They manufacture a fixed type,
to be used in hospitals and disinfesting stations, a horse-drawn type,
and one mounted on a Foder steam lorry, commonly known as the
Foder-Thresh machine.

It is highly important in the use of any disinfector, from the sim-
plest to the most elaborate, that it should be properly managed, as
carelessness in any one detail may render the whole procedure value-
less. If the clothes are too tightly packed, or if the temperature
does not reach the necessary height, some nits or lice will survive
and the garments will be quickly reinfested. If the clean garments
are not kept strictly separated from the verminous, or if the per-
sonnel attending to the disinfection are themselves infested, the
same result will follow. Thoroughness and attention to detail are
absolutely essential. Experience with each particular disinfector
will enable the operator to standardize the load which it can treat
at one time. The problem of ascertaining the temperature in a dis-
infector has proved to be a rather difficult one. Nuttal considers the
method of Captain C. G. L. Wolf, R.A.M.C., to be the most practical
when it is desired to record different temperatures. In this method
advantage is taken of the fact that various substances have different
melting points. Any colorless substance having a melting point of
the desired temperature is mixed with a minute quantity of any
aniline dye and placed in a small glass tube sealed at both ends. If
the dye is finely divided, the mixture will be practically colorless, but
when the substance melts it will instantly take on the color of the
dye.

Where a complete disinfestation plant can be established, with
baths and laundry facilities, freeing the men from vermin is com-
paratively simple. The men are usually treated in groups of 20 to
100. The station is divided into two sides, clean and unclean, these
two sides being separated on the outside also by a high wall. The
men strip when they come in and hand all of their belongings to an
attendant, to be taken to the disinfestor. The men then bathe, are
shaved or receive a hair cut when necessary, and after due precau-
94 TRENCH FEVER.

tions are transferred to the clean side where they receive their disin-
fested garments. As far as possible, care should be taken to keep
the clean men from mixing with the unclean, and’ new men coming
into a unit should be inspected before being allowed to come into
contact with the other men.

It seems to me that the importance of this question can hardly be
overestimated, and that the proper working out of the problem will
result in an incalculable i increase in efficiency in both the Army and
Navy.

The following statistics, furnished to me by General Moores, show
the need for vigorous measures to prevent the spread of this disease
among the fighting forces. They are the figures relating to sick
admissions in casualty-clearing stations for the second British Army
in France for the period of 12 months ending April 6, 1918, and
show over 25,000 cases of illness traceable to this source.

 

 

 

 

P; U. O., (mostly trench fever) ___ ~ 15, 392
Trench fever ____ u 5, 244
Myalgia (mostly trench fever) 4, 755.
Rheumatism (mostly trench fever) a om 633
Debility (mostly result of trench fever, late) --------------.-----____ 2, 535
Cardiac (mostly result of trench fever, late) -----------_------------- 2, 587

KEY TO DIAGRAM SHOWING THE PROCESS OF EVACUATION OF CASUALTIES AND THE
DIFFERENT COMMANDS OPERATIVE IN EACH SECTION.
I. Collecting:
1. Trenches.
(a) Firing line.
(bv) Support line.
» Casualty.
Regt. S. B.’s dugout.
Regt. Med. orderly’s dugout.
. Communication trench.
Trench stretchers used.
Light cases walk.
6. Regt. aid post .(M.. O.).
First aid and hot drinks.
7. Field ambulance.
(a) Advanced dressing station, bearer subdivision.
(bo) H. Q. and tent subdivision.
(c) Collecting station for light walking cases.
8. Surgical team, for immediate operation.
9. Divisional rest station.
10. Casualty clearing station.
It. Evacuating:
11. Railroad.
12. Canal (12A barges).
138. Railroad.
14. Base and port.
15. Stationary hospital.
16. General hospital.
17. Convalescent camp.
18. Hospital ship.

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DIAGRAM SHOWING THE PROCESS OF EVACIATION UF CASUALTIES, 4,
AND THE DIFFERENT COMMAKDS OPERATIVE IN EACH SECTION), J G
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TRENOH FEVER. 95

III. Distributing:
19. Home port.
20. Hospital for cases unable to travel.
21. ©. C. S. for light walking cases.
22. Central hospital, near patient’s home.
23. Hospital for special cases.
24, Auxiliary hospital, draining central hospital.
25. Convalescent depot.
26. Patient’s home (sick leave).

KEY TO ABBREVIATIONS.

. M. S.—Director general medical services.
. S.—Director medical services.
. M. S.—Assistant director medical services.
. M. S.—Deputy director medical services,
. 8S. (L. of C.)—Director medical services, line of communication.
. D. M. S.—Deputy assistant director of medical services.
. C.—Inspector general communications.

AOOoPoUD
A Laas
CARE OF THE WOUNDED FROM FIRING LINE TO
CONVALESCENT CAMP.

SURGERY OF THE FORWARD AREA AND TRANSPORTATION OF THE
WOUNDED..

A complete description of a trip which, through the courtesy of
Director General Goodwin and his aides, I was enabled to take in
order to observe every step in the history of the wounded man from
the moment of receiving first aid until he was either restored to
military duty or discharged as unfit for further service, would be full
of human interest, but would serve no useful purpose in this report.
However, some observations made at certain points in that trip may
be found to be of practical value, and these are recorded as briefly
as possible. The trip itself began at the trenches in the British zone
and progressed, step by step, from the stretcher on which the wounded
man was borne from the battle field, through regimental aid post,
advanced dressing station, field ambulance,. walking wounded post,
main dressing station, casualty clearing station, ambulance train,
stationary hospital, ambulance transport to England, ambulance
train to the base or special hospitals, and finally to the convalescent
camps. <A graphic chart of the present plan of the British military
medical service for handling casualties was especially made for me
and a small photographic copy is included in this report for con-
venience, and a close study of it will show how systematically the plan
has been worked out.

The wounded are collected at certain points or aid posts, where
there are medical orderlies. They are then carried’ by stretcher
bearers or, if able, are allowed to walk back to the advanced dressing: -
station (A. D. S.). On the way the regimental aid post is passed,
where a medical officer with R. A. M. C. men is ready to give first
aid. Part way back, for the walking wounded, there is'a camou-
flaged station by the road where they may rest under shelter and
receive food and have their wounds dressed, if needed.

The advanced dressing station is usually found in some.old church,
house, outbuilding, or improvised hut, and there the first: field dress-
ing is applied. At times of extreme urgency a major operation may
be done to save life, but the rule is to evacuate as rapidly as possible
to the casualty clearing station (C. C. S.), 6 to 10 miles from the
front. The A. D. 8. is usually about midway between the advanced

a | OF
98 SURGERY OF THE FORWARD AREA.

trenches and the C. C. S. The field ambulance includes both the ad-
vanced and the main dressing station, the latter being between the
A. D. S. and the C. C. S. Here light cases and walking wounded
are cared for and often directly evacuated by the Army Service
Corps to the base hospital.

The C. C. S is the hospital nearest the front in the given sector
and the real center of surgical activity. Each British army has
about 15 ©. C..S.’s. Experience has taught that they should be
located near the railway by means of which they usually evacuate
to the base, but not too near for fear of bombing. — ,

While I was privileged to see the work of many C. C. S.’s, No. 36,
at Watten, which is considered one of the best and has had a wast
experience, was particularly selected for me to study most closely.
Lieutenant Colonel J. S. Hardey, C. M. G., A. D. M. S., was in com-
mand, and Major A. L. Lockwood, D. S. O., R. A. M. C., was the
surgical specialist. The entire staff made me most thoroughly wel--
come and did everything possible to contribute to the success of my
visit. Major Lockwood accompanied me to the Belgian and northern
French fronts and to many centers in the British advanced area. He
is regarded as an authority on the surgery of the forward area and
has been requested to write up this subject, and his book, it aeroped
will appear next year.

A description of this station and a summary of the results. of the
experience of Colonel Hardey and Major Lockwood as given by them
to me may be found of value.

C. C. 5S. No. 36: This is a mobile unit of 800 beds, with apacily
for large crisis expansion, well equipped, and having an excellent
X-ray outfit. The staff consists of 7 medical officers, 9 nursing
sisters, 180 orderlies, and 3 chaplains. During the “Kimmel push”
5,000 cases were received in five days. When a drive jis on surgical
teams are drafted from quiet sectors and sent from the ‘base to help.
A team usually consists of one surgeon, one trained orderly (who
acts as assistant), one sister, and one anesthetist. These teams work
in day and night shifts. In September, 1916, 17,000 stretcher cases
passed through this C. C. S. and there were over 700 deaths. Often
75 die within 24 hours. ‘“ We need all three chaplains when busy.”

Three per cent of the walking wounded are usually bad cases who
have missed the stretchers. A medical officer should see all cases on
arrival, whether walking or carried, and cut down the dressing to
determine the disposition of the cases and whether there should be
(1) immediate operation; (2) delayed’ operation; (3) no operation .
required.

Major Lockwood said:

The C. C. S. should operate as a rule upon everything which will require

any surgery for six weeks or two months. No case should be moved until it
can be done without harm. .
: e
 

 

 

 

First aid to the wounded, French Army.

 

Slightly wounded French soldiers.
 

 

 

 

Arrival of a wounded soldier at an aid post.

 

  

: wttniallasonesi * &

 

General view of an evacuation hospital.
98-2
SURGERY OF THE FORWARD AREA. 99

Place cotton in the ears of the men upon arrival. This saves anxiety. Keep
the ears dulled for some days. Whenever there is a raid or bombing, if cotton
has been removed, replace it at once.

(I was reminded of this practice later when visiting Queen Alex-
andra’s Hospital for officers. The chief surgeon there said: “ These
wounded ollthers who can stand shelling in the trenches and never
fear going ‘over the top’ get panicky at once in these night raids.
The poor chaps in bed with fracture apparatus holding them there
suffer mentally as never before.”)

Shock is a complex problem and one that is still shrouded in un-
certainty. Major Lockwood’s-advice is:

Control hemorrhage and do necessary splinting early. Never use stimu-
lants. Quiet and external heat are the best restoratives. At times saline
under the skin may be useful but this must be given carefully. There have
been cases of which I know where there has been sloughing of the breasts due
to -hypodermoclysis into the breast and needles have been broken off and left.
Bicarbonate of soda solution with glucose by rectum is excellent. to support the
patient’s vitality.

Wounds, he suggests, should be treated as follows:

1. Primary suture wherever possible. Use picric acid, 3 per cent, in pure
methyl alcohol for the skin instead of iodine. Excise some skin’ around the
wound. Remove-all injured tissue. Follow this by ether’ or Dakin i
then suture with deep, interrupted silkworm gut.

2. Where the wound can not be closed after the débridement, pack loosely
with gauze in glycerine, with 5 per cent sodium chloride and one-half sodium
citrate. This may be left in situ from four to seven days. There will bea
large amount of flow produced, but when the gauze is removed healthy tissue
remains.

8. When it is impossible to get rid of the tissues injured, or for some other
reason it is not advisable to treat as above, use Carrel-Dakin from four to six
days and then close by delayed primary suture, provided bacterial tests allow.

I tried bipp on 60 cases, but the results were so discouraging that I discon-
tinued its use altogether. Flavine also has not proved satisfactory.

Filling up the wound with salt tabloids and leaving on the dressing from a
week to ten days is an excellent method. Nature irrigates through the great
amount of serum produced, and when the gauze is taken off there is a healthy
surface: . But there is great danger of death of tissue from too much pressure,
and this method needs so much care and experience that I have given it up.

In head cases, operate as early as possible, preferably in a forward unit.
Entire head should be shaved, careful neurological examination made, and
stereoscopic plates. Use local anesthesia, novocaine one-half per cent. Never
use general anesthesia. Make a small perforation one-fourth inch back from
fractured area and nibble out:a button of bone with the jagged fractured sur-°
faces in center. Remove sufficient bone to expose one-fourth inch of healthy
dura. Excise jagged edges of dura. Use a catheter to locate missile and
‘magnet for extracting same. Sometimes, with the head lowered so as to make
the track dependent, an undistorted bullet may be ‘driven back through its own
course by several forcible blows on the opposite side of the head. In 96 per
cent of cases it is possible to completely close the skin. Never leave a solid
drain in the brain. Wounds of the sinuses may be closed with the very thin-
nest (postage stamp) of peri-cranfal tissue. Never attempt suture. Plugging
100 SURGERY OF THE FORWARD AREA.

of the sinuses with gauze or muscle is absolutely wrong. Patient should not
be moved for at least 14 days.

‘Bone or cartilage transplantation to close aperture in skull should not be
attempted earlier than three to six months after incision has entirely healed.
Repeated lumbar punctures will: relieve headache and prevent tendency to
hernia cerebri.

Chest cases are as urgent as abdominal cases and should be evacuated direct
to the casualty clearing station as soon as they can stand the journey.

The better the evacuation from the battle field and from the advanced medical
units the severer is the type of case that reaches the casualty clearing station.
Thus deaths occur in the casualty clearing station which would otherwise take
place farther forward.

The percentage of severe chest wounds reaching the casualty clearing station
is very much greater when the casualties are principally due to shelling and
bombing, especially of the back areas, when the casualty clearing stations are
the nearest medical units.

Cases of traumatopnea should be closed (preferably by suture) at the ad-
vanced dressing station or even, if possible, at the regimental aid post.

All chest cases should be given morphine early.

Active resuscitation must be carried out at the casualty clearing station im-
mediately upon admission. The majority of severe chest wounds require blood
transfusion.

The value of X-ray examination in chest surgery can not be overestimated.

The complete intrathoracic operation is a serious one and should not be
lightly undertaken.

Local anesthesia, combined with gas and oxygen (if meeet: should be em-
ployed in chest surgery.

Speed and absolute asepsis are essential to success.

The operation must begin with excisio in toto of the wound and end with
hermetical sealing of the thorax.

No fluid must be allowed to collect in the pleural cavity after operation.

Resection and drainage should be a late resort and are rarely necessary,
never unless severe constitutional symptoms of infection are present.

Nonoperated cases should be treated precisely as post-operative cases.

Men who have been exposed to asphyxiating gases bear chest wounds badly.

At certain seasons broncho-pneumonia is a complication greatly to be feared.
(Vide autopsy report.)

In March, 1917, Major Lockwood, with several of his confréres,
published the reports of their observations on the treatment of gun-
shot wounds of the abdomen in 500 cases. In June, 1918, after hav-
ing had under observation about 1,000 cases, he indorsed “tha conclu-
sions then reached, and said:

. Wounds of the large vessels to the liver, kidney, and spleen are fatal before
they can come to operation. Wounds involving the pancreas are seldom seen
on the operating table, by reason, perhaps, of the contiguity of the organ to
large vessels. Only one case was seen here. In that a foreign body was lodged
in the tail of the pancreas.

Antero-posterior wounds, especially in the epigastrium, are least dangerous,
and wounds from side to side, especially low down, are dangerous.

Wounds of solid viscera are not as dangerous as those of hollow viscera.
 

 

 

A church transformed into a hospital. France.

 

 

 

 

 

An advanced underground dressing station. Sorting the wounded.
100-1
 

Pavilion Henry. A hospital improvised from a private home in France,

san

 

 

 

Railroad terminus of La Chapelle. The sanitary train presented by the United States to the
French Government.

100-2
SURGERY OF THE FORWARD AREA. 101

Cases that come to operation with a herniated loop of bowel exposed do badly,
especially if much bowel is lying exposed; the same is true when the stomach
is partially herniated.

Wounds of the stomach, colon, and especially the small intestine, require
exploration, but in posterior wounds involving the colon the greatest care
should be taken not to convert a retroperitoneal condition into an intraperi-
toneal one.

Wounds of the liver and kidney should be carefully determined as such only,
and then treated expectantly, doing no more than exploring and cleaning up
the track, and not that if probably a through and through wound produced by
an undistorted rifle bullet or shrapnel ball.

Avoid resection.

Iind-to-end anastomosis is preferable to lateral when resection is essential.

Wonnuds of the diaphragm are not necessarily fatal, nor even to be greatly
feared. Careful repair gives excellent results.

Multiple drainage tubes are rarely necessary, and always to be avoided if
possible. ,

Abdominal lavage is a dangerous practice.

Never leave free, unprotected gauze in the abdomen.

Paul’s tube should be relegated to the museum, except in very rare cases.

Speed in operating is essential, not only for the benefit of the patient, but
because of the demands of scores of less, vitally wounded men requiring atten-
tion during an active offensive.

Resection for fecal fistula is better done late, when the patient is in England.

During a heavy rush of work the question inevitably arises, “Is it possible
to give every case of penetrating wound of the abdomen the chance of operative
interference without prejudicing the chances of others who are wounded less
vitally?” The answer is obvious that, granted an adequate and sufficient per-
sonnel—surgeons, nursing sisters, trained orderlies, etc.—it should be feasible
to deal with every case as its urgency demands, and that no class of case should
be relegated to expectant treatment when surgical interference is indicated and
capable of giving a wounded man even a remote chance of life.

The following instructions issued in March, 1918, at C. C. S. No.
36 are of considerable interest and show the diligence with which the
care and comfort of the patients are looked after:

Efficient work during a heavy rush, when personal supervision of every case
is impossible, will be much facilitated if the sister will impress on orderlies
the vital importance of a definite routine in dealing with surgical cases.

On “taking-in” days:

“1. In the preoperation ward.

The lamps attached to the blanket warmer and bed heater will be lit and then
turned off or on as required by the number of cases and pressure of work; in’
any case they must always be kept ready for immediate use. Beds will be kept
equipped with fracture boards.

2. In the postoperative wards.

Spare beds will be kept equipped with fracture boards and 4 to 6 beds
always kept warmed.

Preparation of patient for operation: If feasible, castor oil, 1 ounce, will
be given the night previous; an enema before going to the theater and the
bladder ‘emptied. Omnopon and. scopolamine, 1 ampoule (unless counter-
ordered) one hour before operation. Parts adjacent to the wounds must be
102 SURGERY OF THE FORWARD AREA.

shaved. Patients will invariably be sent to the theater dressed in clean bed-
clothing, and during cold weather every patient must’ have a pneumonia
jacket with him. All cases on admission to the preoperation ward will have
@ small pellet ef wool inserted into each ear, which will be left until the
patient is quite convalescent. During any heavy shelling of the neighbor-
hood all surgical cases in bed will have cotton-wool plugs placed in their ears.

Postoperative treatment: Orderlies must not allow undue exposure of pa-
tients recovering from anesthesia. Fatal postoperative broncho-pneumonia
may result from such exposure. In case of collapse the foot of the bed
should be raised, except in abdominal cases, and saline, 8 ounces, administered
‘per rectum, to be repeated every three hours if necessary. Subcutaneous saline
will be given only when wounds are in the vicinity of the rectum or when
rectal injection is difficult. All abdominal and serious chest cases will receive
saline, 8 ounces, per rectum—three hourly—for two injections, then continuous
sodii bicarb. and glucose aa, 5 per cent for 48 hours. All cases fo receive 10
or 20 grains (depending on the severity of the case) of soda bicarb. by the
mouth four hourly, and, except abdominal cases, to receive 8 ounces of 2 per
cent glucose by the mouth every two hours until the patient is convalescent.

No stimulants of the camphor in oil, coffee, and brandy type, etc., will be
given.

Except in abdominal cases, sips of brandy and champagne may be given to
more or less convalescent patients or to allay vomiting. Morphia and pituitrin
are never to be given unless by orders of an-officer, and pituitrin, when given,
will be administered intramuscularly. :

‘A cylinder of oxygen, with fittings, will be kept in each ward. Two tour-
aiquets will haug in a prominent place in the postoperative wards. Urotropine,
20 grains, and pot. brom., 15 grains, will be given 4 hourly to all head cases,

Dressings.

Sterilized towels, gauze, wool, and dressings must always be used and
sterilized gloves must be worn.

-Dakin’s solution or saline, ‘according to the case, will be used to clean up
skin and wounds unless otherwise ordered.

Picric acid, 3 per cent, to be always available.

Carrel’s tubes to be syringed two to three hourly as directed by the surgeon
{n charge of the case. The end of the tube protruding through the bandages
must always be covered with sterile gauze. Tubes should be taken out, thor-
oughly cleaned and boiled, every 48 hours.

Glycerine and saline flavine or bip dressings should not have the last piece
of gauze adjacent to the tissues removed earlier than-four days after opera-
tion unless specially ordered. Tach ward should have at least one complete
intravenous set sterilized and ready for immediate use. Soda bicarb. and
saline for intravenous use will always be obtainable from the theater.

‘ Attention is particularly drawn to the great value of “forced” and fre
quent feedings of all foods, especially gelatine, ete., in all cases which are
seriously ill with grave septic infections, ;

Divisional rest camp, located near C. C. S., and relieving the strain
upon it. This is an important institution. Many men while not
injured or really ill, yet are nervously worn out and unfit for active
service. Such cases are sent to one of these camps. for rest and
change. All lice are removed and they spend 10 days in sleeping,
frequent bathing, eating good food,’ and amid surroundings which
 

 

 

The hospital ship ‘‘ La France " arriving from Saloniki.

 

 

 

Stretchers suspended in car of a sanitary train in France.

102-1
 

 

 

France.

Operating room, sanitary train.

 

 

 

Somme.

Embarkation of wounded,

102-2
SURGERY OF THE FORWARD AREA. 103

direct their thoughts to other things and help them to forget the tense
strain of the battle. The plan is worked out at the rest camp near
C. C. S. No. 86 very successfully. It is situated in a beautiful part
of the country and all signs of the horrors of war as far as possible
are eliminated. There are no wounded and no mutilated here. Any
who do not get back their nerve in 10 days are sent overseas to
England. There were 500 in the camp the day of my visit and the
general impression created was of men enjoying a vacation.

British ambulance trains—For some days I was a guest of Colonel
G. A. Moore, C. M. G., D. S. O., D. D. M. S., at Ebblinghem, behind
the British lines. Colonel Moore organized the ambulance train serv-
ice for the British early in the war, and there are now 42 splendidly
equipped trains in use, and our own Government has ordered a large
number of the same model with only slight modifications. His
official report, “ The Story of the British Ambulance Train Service
in France from August, 1914, to April, 1915,” giving the details of
the carrying, in that period, of 67,000 of Britain’s best from the
battle line to the sea, with equipment improvised as the exigencies
of the occasion permitted, isa story of -a magnificent SuENEBle against
almost overwhelming _ odds.

Each ambulance train now consists of 16 cars, 10 of which’ are
ward coaches while the others are for stores, kitchens and dining
room, staff, personnel, officers, etc. The normal load of patients in
such a train is 118 lying and 462 sitting cases. In a crisis, the load
is 118 lying and 690 sitting. Usually a captain or a major is in com-
mand, with a lieutenant as an assistant. There are two medical
officers, one sister in charge, two trained nursing sisters, four order-
lies, one quartermaster sergeant, two sergeants, and three corporals.
Tt has been found that operating rooms are not needed on these
trains. This demonstrates how carefully the patients are selected
and cared for before entraining.

In addition to inspecting a number of the British ambulance trains,
I went over the American ambulance train No. 66. It is practically
the counterpart of the British train and at that time had made five
trips with British wounded aboard. It was admirable in every way.

Ambulance transports—At Boulogne I went aboard the Jan Brey-
del and St. Denis, which, with two other ships, convey the British
wounded from Boulogne to Dover. Both were well equipped and
they had provision for 686, and 751, respectively. As the passage
takes only two hours, there is practically no need for an operating
room. Over each cot there are suspended rings so that the patients
may raise themselves. In fine weather many stretchers, with patients
on them, are left on deck. All have life belts on and each one is as-
signed to a place on raft or life boat. It is a pathetic sight. Inas-
104 SURGERY OF THE FORWARD AREA.

much as the Germans have avowed that they will not respect the Red
Cross in these waters, none is displayed, and the ships are used as
transports one way and hospital ships the other way. They are con-
voyed by destroyers. On the Atlantic and the North Sea also the
Red Cross is not a protection.

The transfer of the patients to the boat and later from boat to
train at Dover, was accomplished with system and dispatch under
intelligent oversight. All. knew what to do and the men were care-
fully moved and kindly treated. Every effort was made to keep.
up their spirits.. On the boat there was a victrola playing; some had
games, each had three cigarettes to smoke upon arrival at Dover,
but not on the trip, for the life belts are inflammable. All were seen
by the doctors to make sure they were comfortable. A small
stretcher cart is used which not only adds to the comfort of the
patient but saves the stretcher bearers materially. We should have
these for our wounded (see illustration). One suggestion to the
bearers might be valuable—that they should not keep step as it
swings the patient too much.

A British ambulance transport, which I saw, had successfully used
electrolysis for three years for purifying the water.

At Dover there are 20 trains, 7 for sitting cases and 18 train
ambulances. At the station there is an excellent system, exact tele-
phone communication and wire confirmation as to the kind and
number of cases arriving. The men are quickly and carefully sorted
and an effort is made to sertd them to hospitals near their homes.
Cases requiring specialized treatment are sent to the centers equipped
to give such care. Tuberculous, infectious, and mental cases are
sent to hospitals with special facilities, but if there is a choice, the
wishes of the patient are consulted. There are certain restrictions
for colonial and overseas troops as their Governments prefer to
have them in particular localities so that they may keep track of
them.

The atmosphere was most human and kindly. Patients were gently
handled and no orders were seemingly given. Women of refine-
ment, volunteer workers, were at hand with a dainty tray for each,
with coffee, chocolate, sandwiches, sometimes a few strawberries, a bit
of sugar, a cigarette, a tiny bouquet of flowers, and a small white or
khaki handkerchief. The latter all enjoy, the first often for many
a long day. To every one—the men on stretchers, walking, in
motors—there is a cheerful word of welcome.

The following résumé of the organization and work of the ambu-
lance column, London district, under the British Red Cross Society,
gives an idea of the magnitude of the undertaking and the value
to the Government of this work in the hands of volunteer aids:
 

 

 

 

 

 

The Leslie-Wolstenholme stretcher trolley. As used by H. M. Govern-

104-1

ment and the British Red Cross Society in France. The use of these
trolleys greatly relieves the suffering of the wounded when they have to
be removed. Extremely strongly built of 14 by 4 steel, with steel angle
frame, mounted on 12-inch by 43-inch cushion tired, automatic wheels.
These are fitted to the framework on resilient, highly tempered spiral
springs. The whole highly enameled. ‘it will take a stretcher 23 inches
wide. Inside distance between uprights, 4 feet. Distance from ground
to stretcher, 2 feet 5 inches. Over all measurements, width 2 feet 3
inches, length 4 feet 11 inches, height 2 feet 7 inches. Alleged advan-
tages: Fewer men and less work required; vibration practically elimi-
nated; stretcher always on a level; can be wheeled in any direction with
the greatest ease. Of convenient height (about that of a bed) and of
width only a few inches greater than that of a stretcher.
 

 

 

A canal boatin France. Room fitted up for the sick.

 

 

 

Wounded being put aboard a sanitary train in France.

104-2
SURGERY OF THE FORWARD AREA, 105

BritisH Rep Cross Sociery, Crry or Lonpon Brancu, AMBULANCE COLUMN,
Lonpon District, 9 Gower StrEet, W. C. 1.

Lieut. Gen. Sir Francis Lloyd, K. C..B., ete, G. O. C. London district.

Director.—Maj Gen. S MacDonald, C. M. G., D. D. M.S.

Deputy Directors.—Commandant W. F. Symons, bearers; Commandant R.
B. W. Crothers, vehicular.

Commandants.—Miss M. Byron, womens’ detachment and headquarters staff ;
A. D. Hastie, honorary treasurer and headquarters: staff; Philip Runciman,
garages, etc., and Baltic ambulances; Sir. Wm. Savory, Bart., honorary sec-
retary; F. V. Simmonds, F, H. Tallack, S. J. Toms, bearers.

The first train was met on August 30, 1914.

The total wounded (all ranks) carried is 596,038.

The total volunteer workers on the column is 600.

 

The value of the vehicles lent or given is estimated at-_______-.____ £135, 000

The estimated saving for vehicle maintenance and services May
31, 1918, at £1, 210, 000
£1, 345, 000

The ambulance column, London district, works as a self-contained unit of the
City of London Branch of the British Red Cross Society.

_ ADMINISTRATIVE HEADQUARTERS, 9 GOWER STREET.

Commandant.—Miss M. Byron (day).

Commandant.—A. D. Hastie (night), in charge of the headquarters staff
and responsible for organization and. administration.

Petrol room.—Quartermaster Straker, in. charge, owner and driver of the
first ambulance on the column.

A complete record of every vehicle on the column is kept in this room.

Every gallon of petrol used is accounted for by the drivers on journey cards,
which are returned to this room. These are checked and compiled here from
records kept, and are sent once a month, to the Army service and transport,
where they.are again examined.

Records room.—Quartermaster, Mrs. Glover (day); assistant quartermaster,
Miss Hulse (night), in charge.

Every telephone message, telegram, or letter received in connection with the
transfer of the wounded, exchange prisoners, air raids, etc., is recorded in this
room at any time of the day or night.

Orders are received on a direct line from the D. D. M. S. office, or by the
D. D. M. S. instructions from hospitals, railway stations, and the ports of
embarkation; also air-raid warnings and action,

Orders are then transmitted from records to the bearers and to those offi-
cers responsible and in charge of each branch of the work.

Details of the distibution of the wounded to various hospitals are received
from the D. D. M. 8. before the arrival of each train and instructions issued.

Cards are filled in for every hospital on receipt of the distribution and at
the station these cards are handed to the sister in charge of each ambulance,
or to the drivers of the cars.

The names of the wounded carried are entered on these cards, and they are
signed at the hospital by the M. O. and returned to headquarters as a receipt
and a means of checking the safe arrival of the wounded and their kits at the
right hospital.

93696—19—_8

¢
106 SURGERY OF THE FORWARD AREA.

Records are kept of every case handled since the column was inaugurated
in August, 1914.

Books are kept showing every journey done by each individual driver or
sister on the column, as well as the time of day or night they finish. This iy
done to enable headquarters to prevent, as far as they possibly can, drivers
md sisters being out all night every consecutive night. As 90 per cent of the
workers on the column are either rejected grade 3 men or over the military
age before the recent act, this point in connection with their work gives rise
for anxiety, especially with volunteer workers, and “ go-to-bed” orders have to
be issued frequently for the sake of efficiency and safety.

Telephone room.—The switchboard: has a private line to the D. D. M. S. office,
6 main lines, and 18 extension lines,

The switchboard is in charge of trained telephone operators. Three of these
operators are telephone girls who, after being remunerated for a week or two,
found that workers were volunteers and at once refused to accept remunera-
tion. They give their services after business hours, working alternately, and
one as a relief.

No messages are taken at this board, and about 1,000 calls are frequently
registered in a day. :

The headquarters staff, including the telephone operators, remain at their
posts voluntarily throughout air raids. It may be mentioned that in addition
to the military transport, the column has given its services for air raids since
the first Zeppelin raid on London through the L. C. C. Ambulance Corps and the
police,

Eight ambulance stations in London are supplied with ambulances, and the
column has moved the major portion of the casualties as the result of bombs,

During air raids the column keeps in touch with the L. C. C. and supplies
additional ambulances as requested by telephone.

Whenever any serious damage is reported, a responsible officer goes at once
from headquarters to the scene.

Extension 1 Ambulances: Whoever is on duty at this extension, immeiiately
the time of the arrival of the train, and arrival station is chalked up, proceeds
to call the required number of ambulances for a given time, half an hour
before the arrival of the train. When the distribution is received he calls
any more necessary. This is to allow the bearers time at the station to
remove the stretchers, with the used blankets and pillows from the last train.
These stretchers have to be redressed with clean blankets and pillows at the
station before the train arrives.

Drivers must go when called, at any time of the day or night. The move-
ments of every driver between trains are recorded on the ambulance board.
He must be in such touch with the column that he can be found at any moment.

The ambulance board is so kept from hour to hour that any officer can take
it over at any moment and carry it on without fear of mistake.

Extension 2.—Sisters: At this extension the comfort of the wounded is ar-
ranged for. '

The blanket and pillow department is kept fully advised of every order about
trains. :

The free buffets at the stations are advised of the numbers arriving by
each train.

Sisters and orderlies to accompany the wounded in each ambulance are called.

Hetension 3.—Cars: The same remarks apply as those against extension 2
except that the car drivers are called to be at the station 15 minutes before the
train is due. The transfer work done by the cars from hospitals to trains or
other hospitals makes this extension very busy and responsible.
SURGERY OF THE FORWARD AREA. 107

Extension 4.—This extension is used when under pressure (with trains clash-
ing) to receive incoming calls from drivers and sisters reporting from hospitals.

Every driver ‘and sister must, under standing orders, report immediately
they have arrived and safely delivered the wounded at a hospital.

Bedrooms.—Three bedrooms on the top floor are provided. One of these is
always occupied by one of the vehicular commandants and another by a quar-
termaster of the vehicular detachments.

GOWER MEWS.
Commandant, P. Runciman, In Charge.

Machine shop.—The vehicles on the column include a large number of Rolls-
Royce ambulances, and it can be safely said it is the finest fleet of ambulances
in the world.

The Baltic Exchange, Coal Exchange, Lloyds, Tea Trade, Rubber Exchange,
Master Lightermen, Silver Thimble, and many individuals have subscribed
large sums of' money for ambulances. These ambulances are unique in con-
struction and are designed on the experience of the drivers. Water bed, arm or
leg extension cases of any kind can at once be put into any ambulance without
a moment's delay. : :

Appliances and tools to repair every kind of breakdown are provided and
the usual men’s timesheets are kept.

The column keeps all its vehicles under repair either at the expense of the
driver or if the vehicles are given to the column at the column’s expense.

An expert engineer is in charge of the mechanics.

Stores house.—As a register is kept of every vehicle, spare parts, tires, oils,
etc., to meet the requirements of these vehicles aré always in stock.

It is also so arranged that the stores can be mobilized for emergencies.

Complete books are kept, so that accounts for repairs, stores, etc., can be
rendered monthly to the many drivers who maintain their vehicles.

Garages and flats—Garages for blanket buses, stand-by ambulances, cars,
and sleeping accommodation for stand-by mechanics £0r breakdowns and
blanket bus drivers are provided.

Blanket room.—Section Leader Peall in charge. Full detail of every train
is received from extension 2 and recorded on the blackboard.

The blanket bus is then packed with clean pillows and blankets, equipment
for special cases, hot-water bottles, surgical emergency outfit, gifts for the
wounded, including handkerchiefs, cigarettes, etc. ;

Pillow slips are changed after every train, and blankets are sent away for
disinfection, ete.

Ladies give their services daily, sewing, folding, etc., and generally taking
every precaution that can be taken to insure cleanliness.

The blanket busses return from the trains with soiled blankets and pillows
which have to be unloaded and sorted.

Officers’ and sisters’ kit—vVehicles and drivers are provided by the ambulance
column for the carriage and distribution of kit to the various hospitals. The
sorting when necessary is done through a central depot rented by the column.

BEARERS’ HEADQUARTERS, ‘7 GOWER STREET.

- Commandants.—F. V. Simmons, T. H. Tallack, and 8. J. Toms in charge.
Telephone extension.—All calls are received from records by the section leader
in charge and transmitted by him to the various squads.
108 SURGERY OF THE FORWARD AREA.

On receipt of the distribution of a train from records, the due complement
of bearers is dispatched to the station and arrangements are made for squads
to proceed to the various hospitals to receive the patients as they arrive from
the station. Calls are received from records throughout the day for squads re-
quired at ‘hospitals for transfer work.

Work.—The work of the bearers entails not only long hours on duty but
great physical strain. They are voluntary workers mainly recruited from
sedentary occupations in the city. All are either over age, rejected, or of low
military category.

At the stations stretchers are unloaded from the ambulances, blankets and
pillows removed, and the stretchers are redressed with clean blankets and pil-
lows, and carried down to the platform. The patients are transferred by the
bearers from their beds in the train to the stretchers with the utmost care and
are then carriéd down the platform and loaded into the waiting ambulances.
Many of the station platforms are several hundred yards in length.

Club.—No. 7 is also used as a club waiting house, and ‘the sitting rooms have
accommodation for 180 men.

5 GOWER STREET.

Sleeping quarters.—-No. 5 is furnished solely as sleeping quarters for the
bearers. Special sanitary arrangements, : ‘including shower baths, etc., have
‘been provided. Bearers are thus available night and day for any. emergency
such as air raids, etc.

Training.—Each recruit before acceptance on the column undergoes a course
of several weeks’ training, and is then required to pass an examination.

Lectures.—Lectures are given by the City of Lordon British Red Cross doc-
tors with the object of keeping the men up to date.

 

I visited the Southwark Military Hospital in company with Mrs.
Katharine Glover, quartermaster of the ambulance column. She or
her assistants meet all trains, and with Mr. Robert Crothers, deputy
director, are in charge of the work at the stations. All ambulances
were either gifts to the unit or loaned and are often maintained by
the givers.

The following copy of arrangements for receiving convoys at that
hospital is an excellent model which any institution might well copy.

ARRANGEMENTS FOR RECEIVING CONVOYS.

The following procedure will be adopted as a means of showing the number
and disposition of the vacant beds in the hospital:

A card will be provided for each bed, to be known as the ward-index cardi
On this will appear the description of the block and the number of the ward.

The ward sister will see that these ward-index cards are kept with the papers
during the period for which the bed is occupied, and upon the discharge of the
patient will be responsible for sending the card to the sergeant major, who will
file it in the case provided in the general office.

Thus there will always be an index card for each occupied bed in the ward
and an index card for each unoccupied bed in the general office. |
SURGERY OF THE FORWARD AREA. - 109

Surgical and medical wards will each have their distinctive colors, and the floors
to which the ward-index cards relate will be further distinguished by snipping,
i.e, the ground floors will have a complete 24 by 4% card; the first floors will
have the right-hand upper corner of the card removed diagonally; the second
floor will have both upper corners of the card removed diagonally.

In filing in the office the index cards relating to each floor in each block will
be filed together.

Upon the arrival of a convoy, as the cases are admitted to the hospital, the
orderly medical officer will ascertain which are medical and which surgical
cases. :

The medical cases will be directed to the left-hand side of the entrance cor-
ridor; the surgical cases to the right-hand side.

The orderly medical officer will then as rapidly as audible inspect each case,
recording the name of the patient and the ward to which he is allotted on the
slip, at the same time’handing to the orderly who receives the patient the index
card of the vacant bed to which he allots the patient.

The patient will then be removed as promptly as possible, the orderly handing
to the ward sister the ward index card, and the sister will then allot a bed
and file the card in accordance with the above instructions.

Immediately after the convoy has been admitted the orderly will return to
the ward and fill in the details relating to the case on the slip provided, and
will then hand the slip to the sister who will fill in the particulars required
to be entered by her.

This slip will be completed by the orderly medical officer on his visit to the
ward immediately upon the completion of the admission of the convoy.

All necessary entries on the slip having been completed, the ward sister
will then return it to the general office.

The absence of a suitable admission room makes it extremely important
that the admission of patients should be conducted with the greatest possible
expedition.

Every patient should be seen by the orderly medical officer as soon as pos-
sible after the patient has been admitted to the ward.

Any necessary dressings or surgical or medical attendance is to be given at
this visit, and the necessary record made on the slip.

J. W. Crane, Major, R. A. M. C. I.,
‘ Registrar for O. C.

SouTHWARK Mixirary HOospirat. ,

On arrival at the hospital to which he has been assigned, the
patient is given a postal card to be sent to his next of kin announcing
the fact that he is there and giving information as to how a relative
may obtain either a free or half-rate railroad ticket to the nearest
station if unable to pay the full fare. Vouchers for such tickets are
issued by the medical officer in charge of the hospital upon applica-
tion, except that in case a soldier is in a grave condition, the authori-
ties telegraph the next of kin to come without delay, and upon pro-
duction of this telegram at the nearest police station a free return
pass is issued immediately by the police. This system has been
found to work exceedingly well. 3

I have gone into considerable detail in describing the British
system of caring for and transporting the wounded because they have
110 SPECIAL NOTES.

so satisfactorily solved some of the problems with which we are now
struggling.

The French have recently modified their sanitary organization for
the care of the sick and wounded and will shortly adopt a new plan.
A copy of this, with pictures, is promised for the Bureau of Medi-
cine and Surgery when it is in operation. Elsewhere I have re-
ferred to the system now in vogue, and have spoken particularly of
the special-fracture hospitals which are being established. A’ copy
of the sanitary plan of the Fourth French Army, furnished me by
Colonel Gosset, and a sketch of a proposed new evacuation hospital
are contained in this, report and present some interesting features,
(See illustrations, pp. 211-216.) -

In so far as'the Belgian organization is concerned, their problems
are to a certain extent simplified by the fact that the battle line is so
close to many of their base hospitals that they serve also in the
capacity of advanced dressing stations and casualty clearing sta-
tions. While this has certain advantages in that patients need not
be carried long distances, on the other hand the proximity to the
sight and sound of conflict and the danger from bombing render
such location most undesirable.

The American authorities have made an excellent start in organiz-
ing the service of supplies, under whose supervision these problems
are being worked out for our Army, and, with the lessons before
them learned during the past four years by our allies, should reach °
a high standard of efficiency in caring for and transporting the
sick and wounded.

SPECIAL NOTES ON SOME OF THE HOSPITALS VISITED.

After careful consideration by those most thoroughly acquainted
with the details of the work being carried on in the various hospitals
in Britain, France, and Belgium a number were selected as being
the ones which it would be most advantageous for me to see in the
time at my disposal. It would take volumes to do justice to the
work being done at the various centers visited and to chronicle all
the points of interest, and therefore I have chosen for special men-
tion only a few where there is either some particular type of work
or special feature which seems to me to have a direct lesson for us.

LIST OF HOSPITALS VISITED.

A. E. F. Base Hospital No, 4, loaned to the British as B. E. F. Hospital
No. 9, Rouen (ordinarily called the Lakeside unit).

Chalons-sur-Marne Hospital, the Barracks.

H, 0. BE. De La Veuve.

Carrel Hospital No. 21, Compiagne.
SPECIAL NOTES. 111

Advanced Carrel Hospital.

Beaujon Hospital, Paris.

Buffon Hospital, Paris.

H6pital Broca, Paris.

La Panne Hospital (Ambulance de 1’Océan).

Zuydcoote, Belgium.

No. 8 Stationary Hospital, Wimereux, B. E. F.

H6pital De La Marine, Brest.

American Red Cross Hospital No. 1.

American Red Cross Hospital No. 2, Paris.

American Red Cross Hospital No. 3, Paris. :

Thirteenth General Hospital (B. E. F.), Boulogne.

Fifty-third General Hospital, B. EB. F.

Highteenth General Hospital and Twenty-second General Hospital, Dannes
Camiers.

British Red Cross Hospital, Netley, England.

Second Northern General Hospital, Beckett Park division.

Alder-Hey Military Orthopedic Hospital, Liverpool.

Military Orthopedic Hospital, Shepherd’s Bush.

Royal Victoria Hospital, near Southampton.

Queen Alexandra’s Hospital for Officers.

Fifth. London General Hospital (formerly St. Thomas Hospital).

Hyde Terrace Hospital, Leeds.

Third London General Hospital.

A. E. F. BASE HOSPITAL NO. 4 LOANED TO THE BRITISH AS B. E. F.
“HOSPITAL NO. 9 AT ROUEN, ORDINARILY CALLED THE Le ekee
UNIT.

Lieutenant Colonel G. W. Crile, of Cleveland, senior consultant ‘in
surgical research, A. KE. F.,is clinical director. The hospital is located
4 miles southeast of Rouen, where Napoleon had his training camp
when he was preparing for an invasion of Britain. It is in the midst
of fighting units, gas schools, artillery parks, replacement and train-
ing camps. There is provision for 1,600 beds, two-thirds located in
huts, one-third (for crisis expansion) in tents. Here the insignia of
the Red Cross is not employed at all for protection. Sandbags and
trenches are about the tents and hut wards for defense.

Colonel Crile formed the Lakeside unit and went over to cooperate
with the British about a year before we entered the war. He has
spent much of his time in keeping in close touch with the work in
the field of the British and French. During my visit he summed
up for me the present status of advanced surgical opinion upon a
number of important subjects. He went over the field carefully, and
I am deeply indebted to him for the following, which I reproduce
from my notes of our conversation:

Lessons learned from the world war to date——The best economy fn war

hospitals is to have large units from 1,000 to 3,000 beds. Have considerable
movable canvas always ready for crisis expansion. Any building used through
112 SPECIAL NOTES.

one battle must be counted as having me for itself; still it is well to have
something you can salvage.

It is always essential for efficiency to — the professional end and the ad-
ministrative absolutely distinct but cooperating. No clinical authority to the
one and no administrative authority to the other.

In periods of battle, as a general rule, the chief of the surgical staff should
perform no operations with his own hands. He should make decisions and
direct. He thus operates with many hands, and many hands have the advantage
of his expert and mature judgment.

In every rush time Colonel Crile sees each case and dictates to a
stenographer notes concerning the care of each patient.

After seeing every case I spend in the operating room as much time as I
have left. I decide not only what is to be done, but who is to do the operation.
I know my men and select the best man for the special work. Some do certain
work better than other work.

Wounds should be carefully read. We try to treat each phase of a wound.
Treat the wound and treat the man, but follow no dogma.

Since the drive of March 21, 1918, the character of war wounds has somewhat
changed and there is less primary suture being done.

WOUND PHASES.

L Period of contamination.—1. Forward area in the casualty clearing station
(contamination period about 10 hours). Revise the wound and close if you
can keep the man at least for one week under your own observation.

2. Revise and pass the man on for a delayed closure at the base. It really
does not matter much which of many things is used on the wound—flavia, bipp,
Carrel-Dakin, ete.—no decision as to which is best. Wright’s hypertonic salt
solution is useful. Bipp should not be employed in excess, for the filled-up
wounds may cause poisoning. There should always be physiological rest,
whether there be any fracture or not. Early and proper splinting is essential.

8. If in a crisis and it is impossible to carefully revise, incise freely, and
pack with some antiseptic of your choice, not “plug shutting,” but allowing
free drainage. Many cases have previously suffered from having wounds
plugged tight.

II. Period of infection—1. Acute phase: Physiological rest essential. Hot
pack with alcohol is excellent, but there are many other things from which
to choose. Impossible to say which is best.

2. When infection passes into the neighboring parts, and whether there be
tension or not, incise early. Often we have waited too long. After the incision,
hot packs,

3. After acute stage, if superficial wound, use alcohol or electric lights, or
make delayed closure.

4, In all inaccessible deep wounds and all compound fractures use Carrel-
Dakin ; this can not well be used for traveling cases.

On ambulance trains and ambulance transports going to England,
I saw the Carrel-Dakin treatment being employed. On a card fas-
tened to the man iand on a .case- report list “Carrel” is marked.

Injected by nurse every few hours. It is more trouble but is carried
out very well.
SPECIAL NOTES. 113

Effects of infection are:
I. Abscesses.

II. Septicemia.

III. Secondary hemorrhage.

1. Abscesses: Often a hidden abscess causes chronic sepsis. _

2. Septicemia: This is largely preventable. Roughly dressed compound frac-
tures are likely to result in septicemia. Avoid all grating ends of bones.

Improper anesthesia means the anesthetizing of a man’s phagocytes, thereby
weakening his resistance to disease. I always use gas and oxygen for dressing
painful wounds.

In prolonged infection with anemia and emaciation, use whole blood trans-
fusion. Paraffin tube method is the one we have been employing.

‘3. Secondary hemorrhage: In this war there has been a great amount of
secondary hemorrhage, due, we believe, to infection within the wall of the
artery itself. This is an entirely new theory. The trouble, then, is higher up.
Follow up the artery to a sound place by feeling the wall. As to secondary
hemorrhage from veins, we think it possible that here we have an infection
within the lumen of the vein, like an endocarditis. This subject is being care-
fully studied.

SHOCK.

This we believe is due to effects upon the central nervous system. There is
no specific treatment. We use:

1. Transfusion of blood.

2, Morphine in repeated doses, always given with saline hypodermocylsis.

When there is cyanosis in shock, morphine should never be used.

In closing Colonel Crile said:

Every man should be working on a problem as well as doing his daily work,
if for no other reason, for the effect upon his own mind, to keep it fresh and
virile. His routine work is bettered.

It was most interesting and inspiring to see how this is developed.
Colonel Crile goes over the work with the men and often gives them
the problem. A research laboratory, fully equipped, is at hand, and
several specially trained workers are there to lend aid.

In company with Colonel Crile I visited members of the staff in
their wards and found them enthusiastic. Many of them gave me
detailed accounts of their special work. I mention two, the results
of whose work seem most striking:

I. Captain Barney, Medical Corps, United States Army.

II. Captain Shawan, Medical Corps, United States Army.

1. Captain Barney. Blood transfusion for chronic sepsis. Pro-
cedure:

Blood count taken and blood cultures made. Customary means of
combating infection used. In a few days or a week another count
and another culture. If no gain and no organisms in the blood, then
transfuse from matched donor. Kempton-Brown tube, ,700 cc.

Marked improvement in practically every case. After the infusion
the temperature goes down gradually and there is a gain in weight,
with improvement in the blood. This is an added means of combat-
114 SPECIAL NOTES.

ing the diseased state. Of course the local surgical condition is
treated carefully. .s

There have been 12 cases treated in this way and all have recovered
sufficiently to go back to England, and, so far as known, are well.

2. Captain Shawan. Careful study of skin grafting.

Skin grafting seems to take along blood law lines. Four groups:
One will take all. Four will give all. Two will take 2 and 4. Three
will take 3 and 4.

He has made a large number of experiments involving pieces of
skin from many on different parts of the same raw surface.

This is a very important find, and our work here establishes the fact abso-
lutely.— Crile. '

If the donor law is to apply to the transplanting of skin, then
when transplanting any tissue we should conform to the same law.
It may be that this will make possible the successful transplanting
of glands, like the ovary and thyroid.

 

CHALONS-SUR-MARNE HOSPITAL, THE BARRACKS.
(Colonel Gosset, Chief Surgeon.)

This is a large military hospital on the outskirts of the city, and
at the time of my visits about 18 kilometers behind the front. Pa-
tients are frequently received within three to five hours after being
wounded. The main buildings are of stone, and many hut wards
have been added.

Dr. Gosset in peace times is a professor of surgery in Paris. He
is now senior consultant to the Fourth French Army, and one of the
foremost leaders in war surgery. He showed me the sanitary for-
mation of the fourth army and a number of hospitals, including this
one where he has been actively at work since early in the war.

He was interested in the objects of my survey, and most courteously
gave me the following synopsis of the lessons which he and his staff
had learned:

War surgery may be said to be divided into two periods, before Carrel and
after Carrel. At first there was great opposition to this method, but it is dif-
ferent uow. Since Carrel has pointed the way we can not properly treat war
wounds without a laboratory at hand. Before that there was much uncer-
tainty aad many antiseptics. Each surgeon had a different one. Now there is
practical agreement that the best results are obtained by first using soap and
‘water, with shaving, alcohol, and ether to the skin, and iodine as well; then
excising all traumatized tissue (cutting as for a cancer) and applying an ab-
sorbent sterile dressing. Control any hemorrhage by catgut ligatures. After
the end of the third day, before granulation has started, close with silk and
maybe a few strands of silkworm gut. This latter is excellent. Much care
must be taken in all of this work, and plenty of instruments and gloves pro-
vided so that nothing will be used a second time without resterilization.

If there is bone fracture, bad infection older than 20 hours since injury,
bone exposed, large vessels and nerves exposed and therefore impossible to cut
SPECIAL NOTES. 115

out fully, use Carrel-Dakin regularly every two hours until the bacterial count
is well down. If there is to be success with Carrel-Dakin, solution must be
made fresh daily and used regularly and careful laboratory control employed.
Use sterile vaseline on skin about wound.

Often streptococci come from the skin and you can see them spread from the
edges to the surface of the wound. Dichloramin-T will kill organisms on the
surface, but is not good deep in the wound.

Sterile dressing with no packing, or Dakin and ether, alcohol, and iodine for
the skin; that sums up the situation to-day.

In war surgery, never use chloroform. Ether or gas and ether are best.
Never drain anywhere unless absolutely necessary. Drainage is Taaly plug-
ging the wound.

For the brain, I use normal or isotonic salt solution freely. Dakin here is
too irritating. Do not open the dura if possible. When open, ask patient to
cough, and all the portion which should be remoyed will protrude. For ex-
tracting pieces of metal, use instrument with powerful magnet. Close dura
without drainage.

Never use general anesthesia in brain cases; use local—novocain.

‘In the abdomen, when a bullet penetrates and perforates, clean up by wiping
peritoneum with pure ether on gauze.

Treat compound fractures with Carrel-Dakin if necessary. After a time, use
traction by American apparatus first to last, or aeons with Depage addi-
tion.

In joint injuries, such as knee, disse at once—no other treatment—and
begin moving joint the first day. This will give perfect success in 8 out of
10 cases. If the other two are not successful or are infected, open and drain
through and through with Carrel-Dakin, taking out tubes every day and having
patient move joint himself. ‘Begin this within the first day or two and keep
it up. There will be no especial pain and excellent results will follow. If one
waits four or five days before beginning active movement, there is great pain.

Colonel Gosset has had over 150 knee-joint cases. He showed me a
series where foreign bodies had been removed and the joint closed
primarily with perfect healing and function, and others where, due
to injury to the joint cartilage, there had been a primary resection
with good results, good intention, and no infection.

As showing the great amount of work to be done, he said:

A team of experts, one surgeon and two assistants, can give the necessary
treatment to over 50 severely wounded cases in 24 hours. That means working
from 16 to 18 hours. I have done this for some days nmiyself with my two
able assistants.

He sounded a note of warning to surgeons, pointing out that war
surgery of the ordinary type tends to injure the technique and spoil
the touch resulting in loss of ability to do fine work.

H. O. E. DE LA VEUVE.

(Dr. Legrand, Chief Surgeon.)
This is a large evacuation hospital of 3,000 beds for the Fourth

French Army situated back of the Champagne front north of Cha-
lons-sur-Marne.
116 SPECIAL NOTES.

Along this particular front there are many cases suffering from ter-
rible burns due to mustard gas, and at this hospital special large tents
and alkaline bath facilities are provided for their care. The cases
must have these baths as early as possible.

No attempt has been made in this report to go into the subject of
the treatment of those suffering from gas inhalation or gas burns, as
it is understood that a special report on this is to be made by another
observer.

The nearness of this unit to the front makes primary suture feasible
in many cases.

Dr. Legrand, who is also chief surgeon of autochir No. 9, advocates
the use of formol and methylene blue in fresh wounds and excising of
the colored tissue. This is followed immediately by suture. He
kindly described the method in detail:

Solution of methylene blue in formol possesses the property of coloring the
contused tissues to various depths, and it also permeates all the diverticuli of
the wound. It serves, therefore, as a guide to the complete excisions neces-
sary for successful primary sutures.

Applied to healthy tissue on an excised surface, the color merely penetrates
superficially. ‘Nevertheless, it must be applied cautiously. Solution:

 

Formol, pure solution, 40 per cont hag 50 aa eu,
Water
Methylene blue 5 grams.

 

This can be preserved indefinitely in corked flasks.

TECHNIQUE. :

I. Large surface wounds.—Inundate the wound, especially the edges, which
often present subcutaneous detachments, then wash with a neutral liquid after
Several seconds (boiled water or Dakin’s solution) in order to remove super-
fluous fixture. Then excise the colored part with bistoury or scissors. Suture.

Il. In-cul-de-sac wounds containing foreign bodies.—Gently catheterize the
tract with a rather rigid rubber catheter, avoiding any error in direction. The
situation of any foreign body can be revealed by radiograph.

With a 10 centimeter 3 syringe, gently inject the mixture. After the blue
inject. a little boiled water or Dakin’s solution in the same manner. Then
largely excise the colored parts.

Ill. Fractures.—After ablation of the contused tissue and loose splinters do
not be afraid to leave the splinters adherent to the periosteum or the bony
extremities tinged by the mixture. Formol is distinctly osteogenetic in action.

When in contact with a healthy vessel for a sufficiently long time formol
may have a hardening effect, but a very thin layer of tissue serves as a pro-
tection to the vessel.

In itself, a vessel isolated in a wound is dangerous, and its coloration, conse-
quently, is of no importance since it must always be examined and tied. _

Nerves prove resistant to impregnation and are not affected by the action of
the solution. The operator must wear rubber gloves.

In cases not suitable for suture, the Carrel-Dakin treatment is
employed.
 

Outside of the Carrel Hospital,
Hospital, Compiégne. Porch
Carrel Hospital, Compiégne.

and grounds, Compiégne.

 

Carrel -

patients. Making rounds at the
SPECIAL NOTES. 117

This hospital is well planned, admirably equipped, and has a large,
up-to-date laboratory. Close by is an animal house well filled for
clinical and experimental purposes. Although not many miles from
the front some research work is being done here.

 

CARREL HOSPITAL NO, 21 AT COMPIRGNE.

Beautifully located in a converted hotel on the northeastern edge
of the city this was a general surgical hospital and had a fully
equipped laboratory with a number of special workers. Swiss
trained nurses were employed, being the best obtainable.

Here Carrel perfected his technique, Dakin worked out his solu-
tion, and du Nouy developed his curve of wound cicatrization and
established his law of healing. The typical Carrel treatment was
here seen at its best, and the results were most gratifying. With this
method a new era in septic war-wound treatment has dawned. I was
fortunate enough to see the actual development of this work, visiting
the hospital on several occasions, the first time in the fall of 1915,
and the last time December, 1917. I saw many interesting cases of
the employment of this method; also cases involving the filling up
of bone cavities either by flaps “oF flesh slid over or grafts of fat
transplanted. Many pictures in color of actual cases treated were
most convincing as to the great value of this method.

_On March 28, 1918, the Hun deliberately bombed and destroyed
the hospital. It: was a bright night and the Gotha flew very low,
seeming to carefully plant the bombs and aerial torpedoes—five in
all—about the main building. From the time of the alarm until all
was over about six minutes elapsed. In that time all of the patients
were taken to the cellar except a double compound fracture of the
thigh. He was covered with mattresses and his nurse stood against
the wall at his bedside quietly on duty while the front and side walls
of the building were blown in. Two doctors were slightly injured,
but no one else.

I go into the details because they furnish a wonderful example of
the efficiency of the staff, especially as many of the patients had only
a few days before been evacuated from the advanced Carrel ed
about 4 miles beyond Soissons.

Dr. Carrel says Dr. Depage has made a special study of the money
loss - ‘resulting from improper treatment of compound fractures of
the femur in the-present war, and places it at over 300,000,000 francs.
At present there are also under treatment in France over 70, 000 with
bone sinuses. With proper treatment, most of these cases could have
been prevented.

(See description of Carrel frentinian ‘under separate heading.)
118 SPECIAL. NOTES.

ADVANCED CARREL HOSPITAL,

This is a 100-bed tent hospital, located, at the time of my visit,
between Soissons and the German lines. It was later forced to with-
draw, owing to the German drive. It had a complete equipment—
electric lights, laboratory, operating, and X-ray rooms, all capable
of being quickly packed up and removed in camions. In front of
our tent was a large red cross, clearly indicating the character of the
unit. We were near enough to the battle lines for the noise of guns
to be heard clearly every few minutes, and occasionally the hospital
had been bombed.

During my visit Prof. Tuffier came from Paris in his motor
car and took us to see the sanitary formation of the French Sixth
Army, including the underground hospital. This was very close to
the front lines and used for shell shock and other cases which could
not safely be taken back. It was 30 feet below the level of the
ground, through solid rock, and the entrance was elaborately camou-
flaged. Several dozen patients could be accommodated, and there
was the necessary equipment for ordinary emergency surgery.

The location of a hospital close to the front, where serious cases
can be given care without being moved a great distance, is considered
by the French of great importance. This underground type is par-
ticularly valued, since it is safe from bombardment and yet near at
hand.

BEAUJON HOSPITAL, PARIS.
(Prof. Theodore Tuffier, Surgeon.)

Repeated visits to this hospital were found to be most profitable.
Dr. Tuffier is the chief consulting surgeon of the Sixth French Army
and mainly responsible for its excellent sanitary formation, which is
now being adopted in great measure throughout the French Army.
Both at this hospital and at other hospitals with which he is con-
nected his services in the field of war surgery have been of the
greatest value.

An interesting fact is that Dr. Tuffier, without uniform or military
rank, goes about freely as a civilian, but with all the power of and
receiving the deference due an officer of high rank. The only other
instance that I saw of this was Dr. Chutro, with his important work
at the Hopital Militaire, Buffon. He also i is in mufti and has no
rank, yet he is chief surgeon to one of the important military hos-
pitals of Paris. Both of these men are recognized leaders. in war
surgery. Dr. Tuffier said frankly : “I can do better work; I am freer
without a uniform and can more safely give advice and tell what I
SPECIAL NOTES. 119

see than I could with a uniform.” My own conviction was that no’
military title could add to the greatness of Prof. Tuffier. He is fre-
quently sent on important sanitary missions for the Ministry of War.

Dr. Tuffier emphasizes the following points:

1. Primary or delayed primary wound suture should be employed
in suitable cases received early enough.

2. Carrel-Dakin treatment of empyema is excellent. He has made
a special retractor to separate the ribs so as to get at the entire ab-
scess cavity in all its ramifications. X-rays are used to determine
the extent of the cavity and also to ascertain that the Carrel tubes
have reached every part. I saw a number of these cases at two of
Dr. Tuffier’s hospitals. The results were very satisfactory. The
method employed is as follows, dressings being made each day: A
smear from the inside of the pleural cavity is taken to be examined
by microscope. The cavity is flushed out with Dakin solutien, indi-
vidual tubes are tested, and fresh tubes are inserted when necessary.
Often four Carrel tubes, stiffened with fine silver wire, are inserted,
endeavoring to reach all parts of the cavity. Then compresses wet
with Dakin solution are placed in the external wound to prevent a
too rapid interchange of air. The skin is protected with vaseline
compresses or zinc oxide ointment and a cotton pad and chest binder
are applied. The external dressings are changed by the nurse when-
ever necessary. After the tubes and compresses are in place an X-
ray examination is made to determine whether the tubes reach all
parts of the cavity. When the cavity is surgically clean the wound
is closed. By this method convalescence is materially shortened.

3. For general septic wound treatment employ the Carrel-Dakin
method.

4, Adipose grafts may be used satisfactorily to fill up lung and
bone cavities.

5. In the case of a knee joint where there is need of ankylosis, as
in a beginning tuberculosis, small strips of bone from the patient’s
tibia have been used, pegged through the femur above and into the
tibia below, coming through the joint like an X.

Prof. Tuffier showed many pictures and slides of amputation
stumps in the present war. He has often had to reamputate in cases
where other surgeons have done the first work, because pieces of bone
were left behind or the bone was too long or there were overhanging
bits of periosteum where new bone formation existed. He has had
over 350 such cases, most of which were preventable. He says:

Do not leave the periosteum too long; cut it off even with the bone.

With improved methods of treatment of wounds, larger experience, and better

judgment, the number of amputations has greatly decreased since the earlier
days of the war, when there was much needless sacrificing of limbs.
120 SPECIAL NOTES.

It was rather interesting to note in Dr. Tuffier’s hospital the fol-
lowing sign in the wards: “ Tout blessé qui suppure a le droit d’en
demander la raison & son chirurgien.”* On inquiry it was stated
that the signs had been placed there some months before by direction
of the chief surgeon.

BUFFON HOSPITAL, PARIS...
(Dr. Pedro Chutro, Surgeon.)

At this hospital there are 350 surgical cases under the care of Dr.
Chutro, who was professor of surgery at Buenos Aires, Argentina,
and who came to Paris early in the war as an assistant to Dr. Gosset,
For over two years he has had full charge of this clinic, doing
remarkable work, and his name is now included in the first half
dozen surgical leaders in Paris. He is a firm believer in the Carrel-
Dakin method and treats all cases, when he does not get them early
enough for primary suture, by this plan. However, he does not use
the bacterial examination control except when about ready to close
the wound. All dressings are done by the surgeon, and, with a per-
fected system, he goes rapidly from bed to bed, covering the work in
scores of cases in a remarkably short space of time.

The technique of operating is excellent. No one except the op-
erator is allowed to touch the instruments, dressings, or even the
towels about the operative field.

Because of his success, Chutro has had sent to him many cases of
old bone sinuses, some of which have had from one to twenty previous
operations. He says: “There are in France at present over 75,000
unhealed bone sinus cases under treatment. Many have had repeated
operations and years of suffering. This is one of the tragedies of
the war! Most of these could have been prevented:”

He added: “ The secret in handling old bone-sinus cases is to get
rid of the cavity. Chisel away the bone until either periosteum,
fascia, or other soft parts come in contact fully with raw bone sur-
face. Often by incising the periosteum laterally in the long axis of
the bone it can be drawn over to cover. Bone is replaced from peri-
osteum, not from the cancellous or other part. Usually the Carrel-
Dakin treatment in 14 days will render the wound sterile, but the
treatment must be continued until the bone surface is covered with
healthy granulations before. suturing. In the femur this is usually
about six weeks, in the tibia and humerus 30 to 35 days. I can get
97 per cent permanent closures.”

A free incision method is employed. All the diseased tissue is
thoroughly removed, and all overhanging osseous structure, retaining

 

1 Every wounded man who has suppuration is entitled to ask his surgeon to explain it.
SPECIAL NOTES. 121

that part of the bone which seems the strongest; for the tibia it is fhe
antero-external; for the femur the posterior; for the humerus there
is no choice.

The incision should always be curved, as one is able later to better
fashion flaps. “Never. leave a cavity; cut away ‘the edges, then fill
up the cavity by a flap of muscle or other soft tissue.”

' (See special section on trephining.)

 

HOPITAL BROCA, PARIS.
(Prof. Pozzi, Chief Surgeon.)

In this institution particular emphasis is laid upon the therapeutic
value of a bright atmosphere and pleasant surroundings. For years
Dr. Pozzi has had upon the walls of the wards paintings full of hope
and cheer, real works of art. The wards themselves are light and
airy. When I was with him a short time ago, only a few weeks before
his assassination, he said:

These wards with the beautiful pictures have done a great deal of good in
peace times, but now they are of double value for the poor mutilated and
wounded soldiers. I am glad we had: them ready.

Dr. Pozzi was one of the first and most enthusiastic advocates
among the medical profession in France of the Carrel-Dakin method.
He said:

The advantages of this method are that it shortens the time of treatment,
diminishes very materially the number and the seriousness of complications,
and insures a minimum amount of scar tissue, decreasing thereby the possible
stiffness, deformity, or loss of function.

 

LA PANNE HOPITAL (AMBULANCE DE LOCEAN).
(Dr. A. Depage, Belgian Army, Chief Surgeon.)

Ever ‘since the war began this institution has been a prominent
and active center. It is so situated on the Belgian coast, close to
the border of France and not far distant from the line of battle in
Flanders, that it acts in a triple capacity as field ambulance, clearing
station, and base hospital. The splendid surgical work of Dr. De-
page and his staff is everywhere recognized, and anything originat-
ing with them is deserving of careful consideration and study. In
fact, in Prof. Depage and Prof. Tuffier we have two surgeons whose
experience and ability have been among the most potent factors in
shaping and developing modern war surgery.

In June, 1918, when I was at this hospital, it had been largely
evacuated owing to bombing and fear of another drive. Only 250

93696—19——9
122 SPECIAL NOTES.

beds were left, the remaining patients having been sent to a center
in Brittany and to another near Calais. American aid, in money
and in personnel, have been: gratefully received and have helped to
make possible the good results which have been obtained.

In septic cases the Carrel-Dakin treatment is employed.

Dr. F. Martin is doing excellent splint work here. His “La
Prothése du Membre Inférieur,” published this year, sets forth
clearly the methods of aiding by apparatus those who have suffered
amputation of the lower extremities. The importance of provisional
apparatus, the mechanics of artificial leg making, and the results

* of their work are given in a most interesting way. Lieutenant Com-
mander R. G. Le Conte, Med. Corps, U. S. N. R. F., has recently
translated this brochure and forwarded a synopsis of the work to
the Bureau of Medicine and Surgery, and I will therefore not dis-
cuss the subject in detail. The main points have been carefully
studied and made use of in large measure in the construction of the
new American Red Cross artificial leg, which is receiving so much
commendation and being ordered in large numbers for the French
and American Armies.

 

ZUYDCOOTE, BELGIUM.

(Major Pierre Duval, Chief Surgeon; Consulting Surgeon of the Seventh French
Army.)

This unit is an automobile ambulance called Autochir No. 21, at
the time of my visit working with the French Army of the nari
There are 24 such in the French Army. It operates very close to the
front and goes with the soldiers into the field, utilizing wherever pos-
sible buildings which it may for the time have at its disposal, such
as the former tuberculosis sanitorium at Zuydcoote-by-the-Sea, where
it is now located. The hospital has 500 beds, with a possible crisis
expansion to 2,000.

Points suipliacized by Dr. Duval:

1, Primary closure with silkworm gut, using ether after débridement.

2. Use of Carrel technique in some cases but substituting ether instead of
Dakin,

8. Fracture treatment of Sinclair. He adds a special feature, pulling the
patient up into a flying position when dressing the back. (See illustration.) »

4. In very septic cases, open freely and use sunlight. Cover the wound with
tin netting so that no flies can get at the surface. He begins with one-half
hour exposure, then 1 hour, 14 hours, and on the fourth day 2 hours. After
that the part should be sterile, he claims, and showed me a series. Uses
sterile gauze between light exposures.

5. Takes X-rays on celluphone. This largely avoids carting bulky glass and
does away with much breakage, Dr. Béclére, radiographer of the unit, intro-
duced this method, which is described as follows:
 

 

Fracture treatment of Sinclair. (Feature added by Duval. Patient in flying position when
the back is to be dressed.)

122-1
 

Fracture treatment of Sinclair.

122-2
SPECIAL NOTES. 123

Pellicles prepared according to the Caillods method, can be mounted between
two sheets of transparent celluphone paper, so as to keep the specimens on file.
The celluphone permits the taking of positives, as well as all markings or
inscriptions with a dermographic pencil.

Caillods technique:

1. Submerge the dry cliché (plate) in the following solution during a quarter
of an hour:

 

 

 

Grams.
Water cris 1, 000
Formol at 40 per cent 160
Potassium carbonate 50
Glycerine - 10

 

2. Remove the plate and gently wipe it with a pledget of cotton soaked in
the same solution.

3. Let it dry, without washing, ‘at a practically even and cool temperature
(10° to 20 C.).

4, After thorough drying, clip off the gelatine at 1 to 2 millimeters from the
border of the plate, using a ruler and a good penknife, cutting close to the glass,

5. Cautionsly lift a corner, and the pellicle will come off spontaneously or
after gentle traction.

A great amount of thoracic surgery is done here—pieces of shell
removed from the lungs by Dr. Duval. He showed me a number of
X-ray pictures taken before and after operation.

NO. 8 STATIONARY HOSPITAL AT WIMEREUX, B. E. F.
(Major Maurice Sinclair, C. M. G., R. A. M. C., Chief Surgeon.)

The capacity here is 1,240 beds, one-half medical and one-half surgi-
cal; but often there are more surgical than medical cases. Special
emphasis is laid on the treatment of fractures, mostly of the femur;
10 per cent of those treated being simple, 90 per cent compound. All
such cases from the entire district are sent to this hospital to be under
Major Sinclair’s care. In 1915 I saw him in Boulogne in the same line
of work, and upon my recent visits to Wimereux was much impressed
by the great advances he has made. The method which he has devel-
oped is being adopted in many centers as the best. Certainly, as one
goes about the wards the results seen are most convincing. Nowhere
that I have been is his work excelled, and it is not often equaled.

Repeated requests have been made for a book from Major Sinelair
on fractures of the femur, but he replies that he will have no time
for this until the war is over. The importance of the subject is such,
however, that I have felt it wise to give considerable space to his

views. (See “ Fractures.”)
124 SPECIAL NOTES.

HOPITAL DE LA MARINE, BREST.
(E. Damany, Médecin Chef.)

Here I found the following features emphasized :

X-rays are absolutely essential to good war surgery. In every well-
equipped hospital, even in advanced ambulance units, X-rays must be
available. It will be found advantageous to have the X-ray room
adjoining the operating room; so that the patient may be easily taken
from one to the other.

In this and a number of similar hospitals, a dark room is fitted up
for an operating room, so that the removal of the bullet or piece of
shell may be accomplished under the fluoroscope, the surgeon first
locating the foreign body and then, through a small incision, direct-
ing his instrument down to it.

If the bullet or shell fragment is in the lung, the ribs are parted
and the forceps are pushed through the lung, the foreign body is
extracted, and the wound closed.

I saw excellent work being done here in this line.

 

AMERICAN RED CROSS HOSPITAL NO. 1.

CLighienank Colonel J. P. Hutchinson, Medical Corps, U. 8S. Army, Commanding
Officer.)

This was formerly known as the American Ambulance, Neuilly.
The word ambulance has several meanings in France. A convey-
ance for the sick, a mobile hospital unit, and an improvised building
used as a hospital, may all be so designated. The latter class is the
one within which this institution falls, for it is located in a large
school building on the outskirts of Paris converted temporarily into
a hospital and to be later returned to the authorities fit for its
original work.

Early in the war a committee of Americans organized the Amer-
ican Ambulance at Neuilly, and for years before the United States
became involved it had been at work. The splendid cooperation of
that committee and the unselfish devotion of its staff of volunteer
workers will always be held in grateful remembrance by the French.

There have been many changes in the personnel of the hospital
staff, but at the time of my visit Lieutenant Colonel Hutchinson was
in command, assisted by Major Charles Powers and Captain S. F,
Jones. In the dental department, which is so widely known and
commended, Dr. Hayes is in charge, assisted lately by Dr. Dunning.
It is being ‘further enlarged and the teaching facilities augmented.
Under “ Plastic Surgery” I have more particularly described work
done here.
SPECIAL NOTES. 125

Both French and American wounded are cared for, and special
emphasis is placed upon nerve suture as well as plastic surgery.

At first the experience here with Carrel-Dakin treatment was dis-
appointing, but, like.many others, they found later that to obtain
satisfactory results full attention to every detail was necessary.
Colonel Hutchinson said:

We believe fully in the Carrel-Dakin treatment. Dichloramine-T spray may
be of use in superficial soft parts, but for deep wounds I prefer Carrel-Dakin.
Carrel will go down in history for two lessons relating to war wounds: 1. They
can be made sterile. 2. They can and should be closed when sterile. Another
solution may supplant Dakin, but the Carrel technique is a great step in
advance.

The work which has been done at this hospital entitles it to rank
among the best in France.

 

AMERICAN RED CROSS HOSPITAL NO, 2, PARIS,

(Lieutenant Colonel J. A.-Blake, Medical Corps, U. S. Army, Commanding
Officer.)

This was formerly the large private hospital of the late Dr. Doyen,
splendidly equipped and well manned, where in peace times many
Americans have been treated. The patients now are both French and
Americans, but mainly the latter, both officers and enlisted men.

Dr. Blake’s work at Neuilly with plastic and oral surgery is men-
tioned more in detail elsewhere. At this hospital he has emphasized ”
the treatment of fractures and is soon to publish a book on the sub-
ject, giving the results of his experience during the past four years.
In April he expected to establish a special fracture hospital near
Chalons-sur-Marne, but the night bombing delayed the project and
the recent offensive has further postponed it. The need for hospitals
near the front, where severe compound fractures, chest injuries,
abdominal wounds, and cases of marked shock can be treated without
being transported a long distance, is urged as certain to result in a
great saving of life.

In gas gangrene, so much better denominated by Surgeon Fauntle-
roy, United States Navy, “progressive emphysematous necrosis,”
Colonel Blake has been using, with excellent results, the following
acidulated solution:

Quinine hydrochloride, 0.1 per cent in distilled water, physiological salt
solution, or simple boiled water.

Acidulate with 1 ¢c. c. hydrochloric acid (strength 50 per cent).

The efficiency of the above solution is increased by acidulating with hydro-
chlorie acid.

For moist dressings 1 per cent quinine hydrochloride solution in distilled
water, with addition of 1 per cent alcohol, to prevent formation of precipitate
on contact of alkaline solution with gangrenous wounds.

+
126 SPECIAL NOTES.

For continuous irrigation, 1 per cent quinine hydrochloride solution in
physiological salt solution. In freely suppurating wounds, the same quinine
hydrochloride solution is used in simple boiled water.

Quinine hydrochloride solution, 1 per cent in physiological salt solution, has
been used for hypodermic injection into infected tissues around wounds with
definitely established gas-gangrene infection.

Results in the Neuilly hospital are so good that a weaker concentration
(half the above strength) may prove equally efficient against the microbe of
gas gangrene. :

This solution is used every two hours with the Carrel tube and
technique and is almost specific in Colonel Blake’s judgment.

He believes that the Carrel-Dakin treatment of wounds is no
better than dichloramin-T, and says that the best treatment is the
excision of bruised tissue, control of hemorrhage, and immediate
closure of the wound, with perhaps a little iodine applied. Or, if
one gets rid of the bruised tissue and sterile gauze is placed on the
wound for three days and then closed, excellent results are, as a rule,
secured. In recent wounds in soft parts one can get 90 to 95 per
cent closures. In compound fractures there is not so good a per-
centage.

We have learned that the joints which were supposed to be extremely sus-
ceptible to infection are not easily infected. When infected, if one simply opens
them, washes them out, and then'drains to the joint, but not into the joint, the

patient may get up and walk around while there is still pus coming from his
knee, for example, with no harm but with good results.

 

AMERICAN RED CROSS HOSPITAL NO. 3, PARIS.
(Lieutenant Colonel Samuel Lloyd, Medical Corps, U. 8. Army, In Command.)

This hospital is so beautifully arranged and equipped that it is a
model of comfort and convenience. Mrs. Whitelaw Reid has taken
one of the art students’ centers near the edge of the Latin Quarter
and fitted it up as a hospital for American officers. There are already
75 beds, and plans have been made to enlarge the capacity. Nothing
reasonable is lacking that money can buy which would add to the
comfort or aid in convalescence. The open court with its trees and
flowers, and the location on a quiet side street off the boulevard
afford surroundings that are most attractive and restful.

 

THIRTEENTH GENERAL HOSPITAL (B. E. F.), BOULOGNE.

(Lieutenant Colonel Harvey Cushing, Medical Corps, U. S. Army, Chief
Surgeon.)

This, as well as Lieutenant Colonel Hugh Cabot’s unit, are popu-
larly known in America as the Harvard Units. While the hospital is
SPECIAL NOTES. 127

British, the staff is composed cf Americans (80 nurses, 24 medical
staff, 190 enlisted men), and they have been engaged in this work
since before our entry into the war. The old casino at Boulogne,
beautifully located on the water front, was made over for hospital
use; and a number of hut wards have been constructed in the garden,
making provision for 650 beds. Colonel Cushing said: “I would
rather have some of these up-to-date hut hospitals for my work than
the best hospitals at home.” Since the early days of the war Sir
Almroth Wright has been here engaged in laboratory research work.

While there are all kinds of cases cared for, special emphasis is
placed on head surgery. Colonel Cushing is strongly of the opinion
that there should be a mobile unit for head and neurological cases,
and there is considerable talk at the present time of forming one.
He also urges the importance of special hospitals for a number of
departments of war surgery with experts in charge. _

The joint work here is having excellent results. No irrigation is
allowed.

Dichloramin-T has proved only evanescent and not as good as Carrel-Dakin.
The early advocates were too enthusiastic—Cushing.

One of the chiefs of the surgical staff said:

One disadvantage in our work is that we can not follow our cases. The
patients get a certain improvement and then are evacuated to England. We
have return postals, but a word after two months is not enough. There would
be better results if the same treatment could be continued. Many an amputa-
tion would be unnecessary, we believe. We have had bad cases astonish us
by improving and, while still serious, seem on the high road to recovery. Then
they have been transferred and the next surgeon, not knowing about the gain,
takes off the leg, and a limb is unnecessarily lost. :

Colonel Cushing confirmed this view, saying:

“There should be not circumferential areas under consultants, but
lines from front to back,” that is, all the way from the battle front
to the base hospital the patient should be under the control of the
same directing head.

Recently this plan has been tried in one of the French Armies and
has worked exceedingly well.

 

FIFTY-THIRD GENERAL HOSPITAL, B. HE. F.

This is the usual 1,040-bed unit, some huts and many tents, and
is beautifully situated on a hill west of Pernes. In the absence of
the commanding officer, the registrar, Major A. Elliott, showed me
the institution. It is an excellent one in every detail, and is un-
usually well arranged and equipped from a sanitary standpoint.

Here a number of German prisoners are detailed for work. They
come down in squads from the prison camp about a mile away.
>

128 SPECIAL NOTES.

One is deeply impressed at this camp as everywhere else, with the
excellent care that Britain gives to her prisoners. Every essential
comfort is provided. For example a complete corrugated iron shed
is furnished in a suitable place where the prisoners may eat their
meals without discomfort from sun or rain.

One of the best equipped hospitals in Britain, located on a beau-
tiful site, at Belmont, Sutton, Surrey, is used for German prisoners.

The contrast between the care given to wounded or unwounded
prisoners by the British and French and that which I saw given
to prisoners by the Germans late in 1915 is a striking example of
the difference between the standards of humanity held by the allies
and by the central powers.

 

BIGHTEENTH GENERAL HOSPITAL, DANNES CAMIERS.
(Lieutenant Colonel Beasley, Medical Corps, U. 8. Army, Chief Surgeon.)
This is largely a “hut” hospital with about 2,000 beds, located 18

miles from Boulogne. At the time of my visit the unit had been in
France just one year, and in that time 40,000 cases had been treated.

 

TWENTY-SECOND GENERAL HOSPITAL, DANNES CAMIERS.
(Lieutenant Colonel Hugh Cabot, B. E. F., Commanding Officer.)

A hospital of about the same type and size as the 18th general,
which it adjoins. (In almost all cases “ hut” hospitals contain 1,040
beds and have tents for crisis expansion.)

Because of bombing at Etaples, some days before, both of these
hospitals were practically evacuated at the time of my visit. The
same was true of Etaples, which presented a marked contrast with its
aspect of great activity upon my former visit, when it was full to
overflowing. The destruction of hospitals and town buildings was
very evident.

So far as view and sanitation are concerned Etaples hospitals are
well located, but from a military standpoint they are most unfor-
tunately situated. Surrounded by replacement camps accommodat-
ing two score thousand troops, a drill ground, machine-gun depot, and
antigas school, the wonder is that bombing did not occur earlier and
more often.

In this connection a word in general as to the location of war hos-
pitals may not be out of place. In selecting sites for such hospitals
as must be located fairly close to the area of military activity, more
stress should be placed upon the desirability of separating them as
far as possible from centers which are legitimate targets for the
enemy. There has been a great stir because of the bombing of the
SPECIAL NOTES. 129

hospital at Etaples, but to those who know the environment at that
center no surprise was caused. In such places the Red Cross can not °
be and is not relied upon very greatly for protection, because where
a hospital is located in the center of a military area one can not
expect safety. In addition to this most important consideration of
safety is the fact that from a medical standpoint such surroundings
are bad, inasmuch as the dust and noise attendant upon the move-
ments of troops, and the general military atmosphere, are injurious
to the patients. By circumstances, frequently unavoidable, very
many of the hospitals on the western front are subject to criticism
for being thus located.

On the other hand, where hospitals are far removed from the for-
ward area, perhaps in another country altogether, while the selection
of the general locality must be governed by several considerations
such as climate, accessibility, etc., the particular site of each such
hospital should be not only one where the sanitary conditions are
favorable, but, equally important, where beautiful view and sur-
roundings will have a chance to lend their undoubted therapeutic aid
to the recovery of health.

Among the hospitals visited many were thus beautifully located.
In particular the surroundings of the British general hospital No.
1 (in charge of the Presbyterian Hospital unit), at Etretat, seemed
almost ideal, Here the casino and some private houses along the sea
front have been converted for hospital purposes, and it is an ex-
cellent example of good judgment in selecting a site.

Another delightfully located hospital is the one now approaching
completion at Sarisbury Court, near Southampton. Here upon one
of the most beautiful sites in England, the American Red Cross is
building nearly 10 acres of “huts” for the wounded American sol-
diers. It overlooks the bay, and is surrounded by acres of woodland
and is far enough from the main roads to be free from. noise and
dirt.

A word of commendation should be said for the good work done
by both our Army and Navy medical forces when they have found
it necessary to take over and adapt various antiquated buildings,
such as convents, monasteries, schools, barracks, etc. These buildings
were often utterly unfit for hospital use, lacking all sanitary facili-
ties and the like, but, in spite of serious obstacles in the way of ob-
taining necessary supplies and labor our men have made the best of
the very difficult situation, and have converted the buildings into
more or less satisfactory bases. A number of examples could be
cited, such as the work of the Red Cross at Beauvais and Orleans, the
Army at Pontanezen Barracks, and the Navy at Brest. All are en-
titled to great credit for the satisfactory results thus far obtained.
130 SPECIAL NOTES.

BRITISH RED CROSS HOSPITAL AT NETLEY, ENGLAND.

Major H. S. Souttar, R. A. M. C., Chief Surgeon; Assisting Consulting Surgeon
for the British southern command.)

Major Souttar has been actively engaged in war surgery since Sep-
tember, 1914. During his nearly two years on the Continent in the
thick of the work as surgeon in chief, Belgian field hospital, and in
the past two years at Netley, he has learned at first hand the lessons
of the war. His book, “A Surgeon in Belgium,” dealing with ex-
periences in the early days of the war, has been widely read and is
considered one of the most impressive books that the war has pro-
duced. A man of wonderful optimism, his personality permeates the
hospital at Netley, which I visited in his company. At my request
Major Souttar has briefly summarized as follows, some of the surgical
treatments particularly emphasized at Netley and some of his ex-
periences:

In a military hospital the conditions of work, the nature of the cases, and
the results aimed at, all present differences from those of a civil hospital. I
propose to sketch in the briefest possible manner those features of the work
which have seemed in my personal experience to merit special attention, and
to mention the conclusions to which that experience has led me. Though I
am solely responsible for the views I express, I may say that they are in close
agreement with those of my colleagues.

1. Wounds.—These, as they reach us, either are sutured or are large granu-
lating areas. The deep puncture of earlier days does not now pass the 6.6. 8.
Our treatment of wounds therefore resolves itself into that of large granulating
areas, more or less clean. At this late stage we have not found Carrel’s treat-
ment nearly so satisfactory as it has proved in early wounds. We have found
great difficulty in obtaining sterility, and it appears to have been followed by a
deep and permanent fibrosis. Where the wound can be sutured it is our practice
to smear the surface with a very thin coating of bipp (equal parts of bismuth
subearbonate, iodoform, and liquid paraffin, by weight), after swabbing with
spirit. The bipp appears to abolish the febrile reaction which occurs in general
after any interference with a septic wound, and we have obtained primary union

‘in a large number of cases. We use the same method in performing reamputa-
tions.

Where suture is impossible we cover the surface with Thiersch grafts, holding
these in place with a very fine metal gauze (known as “ tinsel dress trimming”).
By deep retaining stitches this can be held down firmly over any irregular area.
It absolutely prevents displacement of the grafts, which may be dressed with
saline daily. The large areas we have covered, and the uniform success of our
grafts has been striking.

Only in rare cases have we employed flaps, and then not often with success.
Flaps would appear to be quite unsuitable for open wounds and should be
reserved for plastic operation's after healing.

For the cleansing of large wounds of the buttocks and genitals, such as are
frequent in gas burns, we have recently employed continuous baths. Our in-
stallation consists of 10 baths, through which there is a constant flow of water
at the rate of 50 gallons per hour in each bath. They are kept by this flow at @
temperature of 98° to 100 F. Our 10 baths, with the hut and water heating and
 

 

Netley.

General view.

 

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Nadia) THS

130-1

Netley.

 

Whirlpool baths
 

 

 

 

 

130—2
SPECIAL NOTES. 131

utomatic controls, cost about £1,500, and are expensive to run. The ‘results
tained are, however, extremely good, very dirty burns and wounds cleaning up
upidly, while the degree of comfort to the patient is very remarkable. I con-
der that the method is a very great asset to a hospital receiving patients
‘ithin a few days of injury.
2. Fractures.—Fractures of the humerus as received by us are usually put
p in a Thomas splint, with the elbow fully extended, and with some extension
pplied. This is a good and comfortable position for transport, but if main-
lined for more than 10 days a stiffness of the elbow will result which is very
ifficult to free. At the end of that time we therefore bend the elbow to a right
agle, under gas if necessary, and place the limb on a bracket splint with the
rm well abducted and pointing forward. The splint we use is made of thin
uleanized fiber; it. is very light, and it provides a flat surface on which the
mb rests and on which it can be moved about for the purpose of massage or
ressing. This flat surface is supported by a body piece which comes well down
slow the iliac crest and is attached to the chest by straps. Two wooden struts
aintain it at any inclination desired. In some cases, or when some degree of
1ion has been obtained, a wedge-shaped piece attached to the chest by straps
ill be found more satisfactory. In all injuries near the shoulder the full
»duction given by the bracket is of great advantage.
Fractures of the femur and of the tibia, we treat on a Thomas or a Wallace-
aybury splint. The latter possesses the advantages that the degree of ex-
msicn can be readily adjusted and that the greater width of the frame
icilitztes dressing. We have used a glued-on extension entirely and we have
und it satisfactory.
3. Nerve injuries —From the number of these cases and their gravity, they
rm one of the real problems of war surgery. As a special center for their
eatment we have had exceptional opportunities of seeing the difficulties and
meeting them. We are preparing for publication a report on our work. In
ir report we draw the following conclusions.
Nerve injuries should only be treated in special centers, and by surgeons
ecially trained for this work. Without such special training we consider
at no surgeon, however skilled in other fields, has any right to undertake
rve suture. The problems both of diagnosis and of operation are too intricate,
id the results of any error in technique are of too serious consequence to the
tient. On the other hand the after treatment of these cases is very pro-
nged and involves the use of expensive and complicated apparatus which can
ily be economically used on a large scale.
In most of these cases there is a long period before suture can be performed,
id after operation there is always a long period, varying between 6 months and
years, during both of which skilled physico-therapeutical treatment is essential
r recovery. During all this time it is important that occupation, mental and
ysical, should be provided for the man who, apart from his particular injury,
probably in full health. Workshops of all kinds should be provided for the
2chanics, and farms and gardens for the open-air workers. With proper
ganization these should be self-supporting and they should provide training
well as occupation for the men, many of whom have never learnt any trade.
4. Physico-therapeutical department.—As soon as his wounds are healed every
in passes into this department, where he is under the charge of a medical
icer specially skilled in this branch. It includes electrical, massage, mechani-
l, and whirlpool bath sections. In general, each man passes every day
rough a'section, thus obtaining a maximum of treatment with a minimum of
lium. The baths soften the limbs and prepare them for the massage and
‘ctrical treatment which follow. The mechanical section aims especially at
182 SPECIAL NOTES.

developing volitional power and movement. Each department can deal with
16 to 20 men at one time, and in each the treatment occupies either 10 or 29
minutes.

In the electrical section we have 8 sets for faradic and galvanic current, 2
multostats, 1 Wilson modulator, 2 diathermy sets, and a large static machine,
This appears to be sufficient for a hospital of 1,000 beds. The faradic-galvanic
sets and the modulator are indispensable for the treatment of nerve injuries;
the multostats may also be used for sinusoidal work, as in the treatment of
trench feet, and the diathermy sets are of great use in relieving chronic pain in,
the limbs.

The mechanical section has a full set of Zander machines, of the French type,
two rowing machines, mariner’s wheel, etc. These are of use in developing the
mobility and power of limbs in which the voluntary action of the muscles is
already present. /

The whirlpool bath is an extension of the eau courant, which has been used
with such success in France. We regard its use as of the highest value, and
as our system is somewhat different from those in use elsewhere, I shall de
scribe it at length. Our baths have now been at work for 18 months, and we
can therefore speak of them with some confidence.

They are so arranged that heated water from a tank is driven by a cen-
trifugal pump through the baths, and returns to the tank by gravity. The
temperature of the water is maintained by a small gas heater through a
separate circulation. This system is extremely economical, both in construc-
tion and in use, for only about 300 gallons of water are required to operate 11
baths, and the loss of heat is so small that only a by-pass is used for the gas
after the water has once been heated. As 4,000 gallons of water per hour are
driven through the baths, the economy of water and of heat will be obvious,
The water is cliunged once a day and this appears to be quite sufficient. No
inconvenience has arisen from the repeated use of the same water. One great
advantage of the system is that it is self contained, requiring only a small
water supply, a small source of heat, and a small source of energy. It can ‘bem
controlled by an orderly of average intelligence and it is almost impossible to
put it out of order. It is well suited to the requirements of a hutted hospital.
The cost of our original installation of 11 baths was £200, and the cost of
running it about 5 shillings a day. We are enlarging our installation and we
shall shortly be running 20 baths at the same cost.

In these baths we have treated during the last six months a number of
patients per day, varying between 100 and 150, the number of treatments per
week varying between 500 and 730. It is our routine practice to give 20 min-
utes in a bath, followed immediately by 10 minutes’ massage. The chief effects
of the bath are a great increase in vascularity and a remarkble softening
of the tissues, with the result that massage is greatly facilitated and much
time and labor are saved, The freedom of movement of joints and muscles
which follows immersion in a bath is very striking. In a few days the skin,
from being glazed and atrophic, becomes soft and thick, the muscles become
supple and elastic, and the mobility of the joints is increased. Even in the
case of extensive nerve lesions the appearance of the limb becomes almost
normal and the familiar trophic changes are almost entirely absent.

We regard the whirlpool bath as the most powerful curative physical method
at present at our disposal. It facilitates other methods, softening the limb
for massage, increasing its conductivity for electricity; it reduces pain and it
produces in the patient a feeling of well-being in the limb, which stimulates
him to those voluntary exercises without which no complete recovery cal
be obtained.
 

 

 

Ward. Netley

 

 

 

Red Cross Hut, Netley.

 

 

Netley.

132-1
pee

GNSTALLATION OF WHIRLPOOL BATHS
— BRITISH RED CROSS. NETLEY ——

 

 

 

 

 

—— Seace mmm

— FUSEELL & inLeeR
— beenncer —

SS THAveR Srecer LoMpON Ww.

— HS. sourral
—Merier

 
  

 

 

 

 

ea

 

 

Netley.

 

 

 

 

Officers’ quarters, Netley.
132-2
SPECIAL NOTES, 133

SECOND NORTHERN GENERAL HOSPITAL, BECKETT PARK DIVISION.
(Lieutenant Colonel Harry Littlewood, In Command.)

A large hospital, within 3 miles of Leeds, caring for 2,500 cases,
1,700 of which are orthopedic.

A special feature here is the sanitary school for doctors, where
a course covering five to six weeks is given. There is a small build-
ing housing an exhibit, consisting of pictures, charts, specimens,
models, ete., graphically showing how disease originates and spreads.
In a nearby lot are all the necessary sanitary arrangements for an
army—trench latrines, closets, disposal furnaces, sleeping and cook-
ing quarters, water carts, etc., etc. Actual trenches are made, defec-
tive as well as correct, with reasons clearly indicated. It is a very
practical course. Thirty to fifty United States Army men may take
this course at one time. When not engaged in the school the men
spend their extra time in the wards watching the orthopedic work.

More American doctors could advantageously be sent here. I was
told: “ We could use twice as many; we are short of doctors. They
could remain from 5 to 10 months and get real experience, at the
same time helping man the British hospitals, with their lessening
ranks of medical men.

Another feature of this center is the use of the paraffin bath.
Colonel Littlewood said: “ Paraffin is put in the large tub and by elec-
tricity kept hot as required. The injured part is put into the paraffin,
when it is 180 F. or a little less, and kept there 15 to 20 minutes. This
is a preliminary to massage, and patients are greatly relieved. It is
better than electrotherapy in bad contractions and painful scars.
The soft parts are made very pliable. We consider it much better
than the whirlpool baths.” (I put my hand into the bath and it
became very supple.)

Other hospitals are adopting this treatment. Sir Robert Jones is
introducing it in a number of orthopedic centers.

Sinclair’s method of splint work is followed here. He came in
person to demonstrate the use of the splints and explain the points
of his splendid method.

In the large department for the treatment of jaw cases the secret
of the successful results being obtained lies in the close cooperation
between the surgeon and the dentist.

Dr. William Cuthbert Morton, a civil medical practitioner, one
of the staff, is doing remarkable work in functional reeducation.
The British Medical Journal for April, 1918, contains an article by
him describing his work, and Colonel Littlewood said: “ His results
at this hospital bear out his statements.”

Dr. Morton says that there are two types of so-called malingerers:
true, pseudo. In the second class are those whose muscles and cen-
134 SPECIAL NOTES.

tral nervous system are incoordinated through no fault of the indi-
vidual. The muscles have forgotten how to act and react. Educa-
tional training sets this right. The muscles must again interpret
aright the brain cells’ activity and their message. The patient is
first assured that while his disability is real there is no reason why
it should not yield to treatment. If any part of the disability.is due
to actual and permanent damage to the tissues he is warned not to
look for any improvement in this direction. If an organic lesion is
causing no trouble except through suggestion he is assured that this
is not disabling him. Where there is no organic lesion, or one which
causes no trouble whatever, he is told that through shock or other.
wise he has lost control of his muscles, which require to be disci-
plined if he is to regain control. As far as possible he is trained to
observe what muscles are at fault and wherein the fault lies, so that
when the treatment is being carried out he may realize what he is to
try to do, and above all when he has succeeded in doing it. Elec-
tricity, massage, gymnastic exercises, and drill all have their place in
the treatment, the electricity being employed in the form of the
faradic current with two terminals, or in a bath.

This is a most important field of work and should be carefully
studied and developed.

 

ALDER-HEY MILITARY ORTHOPEDIC HOSPITAL, LIVERPODE.

This is one of the two representative military orthopedic -centers
which I was especially advised to visit, the other being the mili-
tary orthopedic hospital at Shepherd’s Bush, London. Both of these
institutions are under the direction of Colonel Sir Robert Jones, C. B.

For a general discussion of the subject of military orthopedics,
see special section.

The Alder-Hey Hospital is beautifully located on the outskirts
of Liverpool, on high ground. It is well equipped as a general hos-
pital, with added massage, gymnastic, hydrotherapeutic, and electric
departments; also curative workshops, as they are denominated,
where I found dozens of men learning trades and at the same time
doing something which would hasten the restoration of function.

Captain W. H. Broad, R. A. M. C., in charge of the massage and
gymnastic departments, with the approval of Colonel Sir Robert.
Jones, C. B., has lately drawn up rules for massage. These have
proved so useful and admirably explicit for those who are beginning
the work, as well as those somewhat familiar with the procedure,
that it would seem that a copy of them, put into the hands of all of
our nurses and aids rendering similar service in our Army and Navy,
would be of distinct advantage.
 

 

Second Northern General Hospital. Beckett Park, Leeds,

 

 

 

 

Quean Alexandra's Hospital for Officers. The old house and north corridor.

134
SPECIAL NOTES. 135

The directions as given and practiced at Alder-Hey are appended
in full:
RULES FOR MASSAGE.

Preliminary.—It is essential in every case for which massage is ordered
that the masseur or masseuse, to whom the work is intrusted, should have a
clear knowledge of the nature and extent of the injury, and also of the meth-
ods by which recovery is to be obtained. This is especially necessary in ortho-
pedic cases. Consequently, an examination of the patient is made by the officer
in charge of the massage department in the presence of the mmasseur or mas-
seuse who is to undertake the case. <A history of the case is taken on this occa-
sion, with a detailed description cf the present condition, movements, electrical}
reactions, and angles of affected joints. The X-ray photographs should also be
examined when they are available, and the nature and object of any operation
that may have been performed should be understood.

The officer in charge then suggests the particular massage movements suit-
able for the case, and where joints are involved, the extent and degree of
manipulation advisable. Any abnormal condition of a patient occurring during
treatment should be reported immediately to the officer in charge.

After the orthopedic surgeon has effected structural repairs or alterations, it
is massage which can assist in restoring function as far as restoration is
possible.

It is a privilege to have the opportunity of assisting in this restoration to
health, activity, and usefulness of our wounded soldiers. The massage depart-
ment of a military orthopedic hospital presents this opportunity as, perhaps,
no other does; therefore, let the treatment and progress oe each case be negmnded
with the keenest personal interest.

Lubricants.—Hffective massage is impossible in the majority of cases without
, the use of a lubricant. The object of a lubricant is to make manipulation easy,
to prevent chafing of the skin or dragging of hairs. What lubricant is used
is immaterial as long as this object is attained. The slightest chafing or bruis-
ing of the patient’s skin during treatment is inexcusable and is evidence of
faulty technique. Ordinarily, French chalk or one of the talcum preparations is
used, but where there is a considerable growth of hair, trophic changes, or an
unusually dry skin, an oily: material such as olive oil or white vaseline is indi-
cated. The virtue of massage lies not in the lubricant but in the manual dex-
terity employed.

Muscle cases.—It is essential that a paralyzed limb should not be allowed to
lie in a position in which the affected muscles are stretched, allowing the undis-
puted antagonism and possible contraction of the opposing healthy muscles. A
normal, healthy muscle, even when at rest, is in a condition of slight contrac-
tion in order to respond instantly to an impulse. This condition of “tone” is
absent in a paralyzed muscle. Paralyzed and weak muscles are kept from
being stretched and elongated by a support applied to the affected limb. For
example, a hyperextension wrist splint is worn in a case of musculo-spiral
paralysis, a rectangular foot splint where the flexors of the ankle are weak,
an abduction shoulder splint for a paralyzed deltoid muscle. The necessary
massage can often be done in these cases without removing the supporting
splint, but when its removal is essential the limb must instantly be passively
supported by a pillow or sandbag as the splint is withdrawn to prevent any
stretching of the affected muscles.

Heavy tapdtement, or percussion, movements should never be performed upon
paralyzed or wasted muscles, as the attenuated muscles and weak nerves are
136 SPECIAL NOTES.

easily injured. The gentlest pétrissage, or muscle kneading, shouid be used,
increasing in vigor as recovery proceeds. ,

Pétrissage is best performed with the muscles or group of muscles ‘in a
relaxed and supported position. To illustrate this, when working upon the
extensors of the forearm, the patient’s wrist should be “ dorsi-flexed,” with
hand and fingers supported on a sandbag to secure relaxation of the muscles,
In the case of the flexors of the forearm, the hand must be “ palmar-flexed ” to
secure similar relaxation. Relaxation of the quadriceps may be procured by
placing a large pillow or sandbag behind the knee. A similar pillow will also
be found useful to secure semiabduction or semiadduction of the various joints
where muscular relaxation is required.

Joint cases.—All passive movements should be performed by firmly grasping
the limb just above and just below the joint. The necessary movements are
made slowly, gradually, once only, and up to a point just short of giving pain.

Body weight will assist to immobilize the pelvis while the hip joint is moved.

Force is sometimes required to obtain additional movement of a joint, but
should only be used when especially ordered by the officer in charge.

Pain, heat, swelling.—Any abnormal condition cecurring in a joint such as
pain, heat, or swelling should be immediately reported.

Bandages or splints which have been removed during massage should be
carefully replaced in the same manner and position as worn before.

Bone cases.—When massaging cases of fracture, bone grafting, cr other condi-
tions producing callus, depletion movements should be employed to empty the
main veins and lymphatic vessels, especially in that portion of the limb which
is distal to the graft or fracture. Increased vascularization and consequently
improved nutrition, essential to repair, will thus be promoted.

Tendon transplantation cases—Encourage active rather than perform passive
movements of the particular muscles upon which operations have been per-
formed. Apply careful pétrissage to the transplanted muscle, and_ friction
massage along the new course of the tendons, to prevent adhesions. It is essen-
tial that these newly transplanted muscles and tendons should not be stretched ©
until they are able to perform their new functions. Similar precautions must
be taken in the handling of these cases as with paralyzed or weakened muscles
(see muscle cases).

Functional cases.—Massage of these cases should be accompanied by moral
and mental suasion. The patient should be encouraged to think hopefully of
his recovery, and be interested in his future possibilities. Try to convince him
of the importance of making a real effort to use the functionally weak muscles,
and the serious results if he neglects to use them.

Massage before operation—Diagnostic massage—A course of massage is
frequently ordered for cases before operation for bone grafting, tendon trans-
plantations, or nerve suture in which there is old scar tissue near the site of
operation. Moderately vigorous kneading should be applied to any fibrous
thickening or scar tissue to liberate any latent infection which may possibly
be lurking in it, which, if undiscovered before operation, would retard or pre-
vent its success.

Note making.—When making the weekly or fortnightly notes on the clinical
progress of a case, vague generalities should be avoided, such as “ Patient seems
better,” or “Arm improved,” and the like. Incorporate in a sentence or two 2
tangible, clear, and concise statement bearing on the progress of the case in the
direction of the main object of treatment.
SPECIAL NOTES. 137

Heamples.

The girth of the thigh muscles has increased 1 inch.

The left quadriceps reacts well, with the exception of the vastus internus, which is
jacking in tone and substance, as compared with the right.

The extensors of the toes show faint voluntary contraction this day, June 1, 1917.

Cutaneous sensibility noted over whole dorsum of hand. /
Fingers of the right hand are now of the same color and temperature as those of the

left hand.
Active flexion at the elbow is obtained to an angle of 90°, passive flexion to 100°, etc.

Nerve cases.—The lesion may be partial or complete.

A. Muscles: Note the complete (paralysis), or partial (paresis) absence of
muscular activity, stating the particular muscle or groups of muscles affected.

B. Skin. 1. Cutaneous sensibility—Note the areas of the loss of cutaneous
sensibility. This is done with a camel-hair brush or with cotton-wool. The
patient’s eyes should be closed or bandaged while the tests are made.

2. Trophic conditions.—Note the condition of the skin, and state any trophic.
conditions, whether dull, shiny, or scaly, the presence of any trophic ulcers,
ete.

8. Color and temperature.—Describe the color and temperature as compared
with the corresponding sound limb, and state whether ischemia or cyanosis is
present,

4. Return of power and sensibility—After all nerve operations note the
date of return of sensation to a previously insensitive portion of the skin, or
return of voluntary power in a paralyzed muscle.

5. Electrical reactions.—The electrical reactions in nerve cases are periodi-
cally examined. Inquire of the officer in charge the results of these examina-
tions.

MUSCLE CASES.

1. Measurements.—Frequently take the measurement of the circumference
of limbs under: :

Thigh: Seven inches above the upper border of patella.

Calf: Six inches below the upper border of patella.

Upper arm: Six inches above the tip of olecranon process.

Forearm: Four inches below the tip of olecranon process.

2. Muscular tone.—Describe the condition of the muscles with regard to
the degree of resilience, firmness, and tone, i. e., their prompt response to a
voluntary stimulus, and compare the amount of contraction with the corre-
sponding sound muscle or group of muscles.

Note the absence or presence of spasm or tremor.

To test the power of grip use the dynamometer frequently and record the
readings.

JOINT CASES,

1. Freedom of movement.—State whether the movements are free, and if
not, whether accompanied by creaking, grating, or clicking. Also, note if the
joint is swollen or not. In the event of a click being detected, state at which
particular position of the joint it occurs.

2. Range of movement.—Measure the range of movement in the joint which
is under treatment at intervals of a fortnight. The anglemeter is used for
“testing the degree of movement in the shoulder, elbow, wrist, knee, and ankle.
State whether the degree of movement obtained is active or passive.

In the case of fingers or toes, state whether one-fourth, one-half, three-fourths,
or full normal flexion or extension is obtained.

93696—19——_10
138 SPECIAL NOTES.

Ischenvic hands and feet and trench feeét—Describe the color, temperature,
amount of movement, and degree of pain compared with the corresponding
hand or foot.

Any sign of retrogression should be noted at once. : -

Exercises —When massaging a limb it is essential to perform full move-
-ments at the several joints. :

In proportion to the amount of movement at the joints and the muscular
condition of the limb, the exercise should, in the early stages, be passive in
character ; as improvement advances active movements should be practiced and
later movements with resistance.

In this way a gradual sequence of passive, active, and resisted movements
of the joints accompanies the increased range of movement and improved mus-
cular power.

‘

MILITARY ORTHOPEDIC HOSPITAL, SHEPHERD’S BUSH.

A large hospital, situated in'a suburb of London, devoted to the
same class of work as the Alder-Hey. The consultants come from
the Middlesex and University College hospitals. Each ward has
surgeon, physician, and resident. They have additional consultants
in eye, nose, nerves, etc., all specialists in their respective fields, who
come from London. It is somewhat larger in all departments than
the Alder-Hey and is making a special feature of its workshops and
splint manufacture. A great amount of apparatus is made here
and much repair work is done. “ We try to put the men back in their
trade if they have any.”

Both Sir Robert Jones, C. B., and Major Elmslie, R. A. M. C., who
have direct charge, gave me every opportunity to see and to learn.

Major Elmslie said: “ We do not use much Carrel-Dakin; we often’
use hypochlorite solution, twice daily in compound fractures, without
typical Carrel. Bipp, flavin, and lately malachite green are em-
ployed. We found that scarlet red was too stimulating.”

He classifies wounds sutured as:

1. Primary suture.

2. Delayed primary; excise and pack, then suture before granula-
tion starts.

3. Secondary suture; after granulation has taken place.

Method of suture:

(1) Undercut and under-running suture.

(2) Cut out scar and suture. A disadvantage here is that this
means added loss of tissue.

On secondary stumps Major Elmslie advises the cutting away of
dead tissue and the rubbing in of bipp.

He added: “ We use the following method for closing bone sinuses:

“1. Bevel the edges.

“2, Remove all sequestra and granulation tissue.
 

Queen Alexandra’s Hospital for Officers. Patients on the veranda.

 

 

 

Queen Alexandra's Hospital for Officers. Operating room.

138-1
 

 

CSN

4 es

 

 

The south veranda.

s Hospital for Officers.

Queen Alexandra

 

RAR TOT

 

 

Matron in one of the rooms of Queen Alexandra's Hospital for Officers.

138-2
SPECIAL NOTES. 189

“3. Place soft tissue, usually muscle, in cavity to fill up defect..

“Gas and oxygen is too expensive for general use. We usually
use chloroform, followed by open ether. Gas and oxygen with ether
increases the cost over ordinary ether £1 per case. Chloroform is
cheapest.”

In this hospital they consider Sinclair’s fracture work excellent.
However, they do ‘not often employ the direct bone traction.

They are looking forward to more work after the war than they
ure doing even now. For long years to come the crippled and in-
jured must have treatment and many must be supplied with appa-
ratus. There will need to be permanent centers for this work.
Years of treatment will bring results which hardly seem possible

to-day.
ROYAL VICTORIA HOSPITAL, NEAR SOUTHAMPTON.
(Captain Crowell, R. A. M. C., In Charge of the Surgical Neurology.)

This hospital is beautifully situated on the bay and has accommo-
dations for 1,700 patients. Here and at the British Red Cross hos-
pital at Netley there is much excellent work being done in nerve
suture. Captain Crowell has had a wide experience in this field and
showed mea number of interesting cases. Where as much as 5 inches
of the sciatic nerve has been destroyed, excellent results have been
obtained by bending the leg for some days after suture, then grad-
ually extending. In the arm, where there has been a loss of some
inches of an important nerve, a section may be cut from the humerus
and the severed nerye ends brought together without weakening the
extremity.

I saw some cases in which this procedure had been followed and
found that the muscles and tendons had contracted and there were
excellent, functional results.

The long time required for convalescence was emphasized, and
the wisdom of making this clear to the patients in the beginning in
order to save disappointment later was urged.

 

QUEEN ALEXANDRA’S HOSPITAL FOR OFFICERS.
(An-example of improvised hospitals in private homes and estates.)

In Great Britain many wealthy people have shown their patriotic
zeal by offering and wherever possible equipping their homes and
-estates in the country for hospital purposes. In consequence numer-
ous small private hospitals have been established amid the most
beautiful and healthful surroundings. A similar condition is likely
to develop in the United States, as on every side there are those whc
' 140 SPECIAL NOTES.

are ready to offer their homes for the use of convalescent soldiers
and sailors. According to reports, we are soon to have scores of
such places in various parts of the country, but the desirability of
this is a mooted question.

In England there are strong advocates of this system—those who
maintain that the small hospital, beautifully located, with every-
thing to take the minds of the patients from their injuries and the
terrors of war, tends to shorten the period of convalescence, and that
the results altogether are better than those obtained in large institu-
tions, especially those in metropolitan districts.

A very successful hospital of this type, which has reoaived much
flattermg comment and attention, is Queen Alexandria’s hospital for
officers, at Highgate. It is surrounded by some 8 acres of private
grounds, is 300 feet above sea level, and adjoins Parliament Hill
Fields and Hampstead Heath, which, with their 400 acres of open
country, supply the patients with an abundance of fresh air. The
old house on the grounds has been remodeled. The one-time draw-
ing room is used as a ward; the adjoining winter garden as a smok-
ing and sitting room. The hospital proper, a new wooden building,
is connected with the old house, and contains the wards, operating
theater, sterilization room, ward kitchen, X-ray room, sanitary
annex, kitchens, and scullery. As this building is considered tem-
porary and for use only during the war, it has been constructed as
economically as possible, with due regard to efficiency. It is built
on a foundation of wooden piles and in shape is like a modified Y,
this form being adopted so that each ward would obtain the maxi-
mum amount of sunshine; in a day of 10 hours’ sunshine, each ward
obtains about 8 hours of it. Although everything has been kept
plain and simple, the equipment is very complete. There is an ade-
quate X-ray installation and an operating theater. The wards
open on a broad verandah and the French windows are wide enough
to allow the beds to be wheeled outside; .even the worst fracture
cases can be moved into the open air, and many patients sleep out
of doors when the weather is suitable. The administration offices
are located in the original house, as well as the matron’s sitting room
and bedroom, a sitting room for the nurses, the nurses’ bedrooms
(each nurse having a room to herself), and the maids’ dormitories.
There is a tennis court on the grounds for the use of the staff. The
hospital has.a total of 55 beds available for patients.

The honorary surgeon in charge, Mr. Herbert J. Paterson, M. C.,
M. B., F. R. C. S., frankly admits that he has here made use of many
points which he gathered on his visits to the United States. He
states very positively that he has come to the conclusion that “treat-
ment in pure fresh air, amid quiet surroundings, means a lessening
of the stay in hospital by at least 30 per cent. In other words, if in
 

 

 

meena Ss at

Queen Alexandra's” Hospital. Officers"on the south veranda.

 

AIOON: VIEW
rm THE: 4% OMDOM
GENERAL HOSPITALS
WANDSWORTH: 5W |
I GL HE BRE fORTER
Than

 

General Hospital, Wandsworth.
140

 
SPECIAL NOTES. 141

the case of a patient in a London hospital 100 days’ stay would be
necessary, about 70 days only would be necessary in a similar case
under treatment amid country surroundings.”

On the other hand, there are those who are very strongly opposed
to the small hospital plan. They consider it poor economy, unneces-
sarily expensive, and that it tends to prolong convalescence, and
favors “ indolence in the lap of luxury.” In fact, one of the leading
members of the British war medical council said to me recently:
“Tt is a great mistake to have these small hospitals; they de-
militarize, they are a waste of money, and they de not allow of uni-
formity of treatment and efficient supervision.” There are others,
however, who believe that, with proper supervision, these objections
can be eliminated and the benefits secured.

 

FIFTH LONDON GENERAL HOSPITAL,

(Formerly St. Thomas Hospital.)

Major Edred M. Corner, R. A. M. C., who is connected not only
with this institution, but also with King ‘George’ s Hospital, has been
in active service for nenely four years. I requested him to epitomize
the experience of himself and his assistants In war surgery, and he
has done so as follows:

In many ways the war has changed the practice cf surgery. For simplicity’s
sake the question should be divided for the consiccration of those abroad and
of those at home. Some surgeons have been sent abroad and some kept at
home to treat such cases as are returned. In times of stress patients can not
be kept in hospitals abroad but have to be sent home quickly. In consequence,
far the greater part of surgery is done at home. All preparations must be
made for that.

The war practice of sUreety should be divided up into immediate and remote
surgery.

Immediate surgery is practiced near the front. Its first and foremost con-
sideration is infection. Many methods have been elaborated for combatting
infection. All do well in the hands of their promoters and of enthusiasts, but
none do well when carried out perfunctorily. Thus many antiseptics have
gone or are going to the land of the forgotten—flavine, proflavine, hypochlorite,
peroxide, ete., have had their day. All are successful if used well. It is not
the drug but the dresser who does the good. Carrel taught us a great technique
for cleansing the inside of the wound. It will ever remain with us. It will do
well so long as the dressings are not left to the nurse in charge.

Antiseptics used at first help the patient at the beginning of his illness
when he most wants help. Hypertonic saline can be used later when the
patient is fit enough to be stimulated to help himself. Antiseptics may thus
be abolished, but they will always help at the commencement.

Excision of the wound is excellent when the wound and the infection can be
excised. It is of limited application and if used on a grand scale may inflict
as much or more injury than the wound, ~
142 SPECIAL NOTES.

The great keynote for the immediate treatment of a wound is, firstly, use
antiseptics, remove all foreign bodies and damaged tissues from the wound;
later use hypertonic saline.

Immediate surgery has improved in many technical directions. Abdominal
injuries are operated on as soon as possible. So are joint injuries and
thoracic injuries. The same principles are employed and the wounds cleaned
and closed. Enormous improvements have resulted.

Remote surgery means the surgery after the wound has healed. It consists
of the excision of joints, amputation surgery, nerve suture, face surgery, jaw
surgery, and so on. Its practice is colored, as is immediate surgery, with the
possibility of infection. Even when a wound is healed, infection may lurk
within its depths and may convert surgical success into failure and disaster
to the patient. Therefore one never hurries before starting constructive
surgery. A course of treatment with heat and mechano-therapy is an excel-
lent thing before attempting constructive surgery. Just as the results of
infection color the whole of immediate surgery, so the results of infection
affect remote surgery. Let me quote only one case in which I grew micro-
organisms from the nerve endings over three years after an amputation wound
had healed and remained healed. To make the difficulties in the way of
satisfactory remote surgery greater, I have a specimen of a nerve regenerating
and neuratizing an infected coagulum. This is sufficient to say that the
great surgery in the remote period is limited. The infection may get less and
weaker as years go by, the body chemicals slowly winning. Hence, more and
more can be done in the way of constructive surgery as time goes by. Thus
we find in remote surgery the springing up of special technicalities, surgery
of the face, the surgery of bones, amputations, and so on. It is part and parcel
of what I have termed remote surgery to prepare a man to return to civil
life and work. Orthopedic centers throughout the kingdom have sprung up
and are doing great work. In fact, there is perhaps no department of remote
surgery which has made greater advances and which has greater work.

Personally I have more conversance with amputation stumps and their
troubles. These are quite typical of war scars elsewhere. The improvement
in artificial limbs is often so great that it-reintroduces the question of not
deferring an amputation under certain circumstances. Certain operations have
been condemned. The Chopart amputation should never be done, similarly the
Pirogoff. Both have given way to a Syme’s amputation. But the present
artificial foot, which is fitted on to a Syme stump, causes more expense (socks,
trouser, etc.) than does the amputation through the leg. Hence, we are
likely to see more and more amputations just below the seat of election. These
men walk practically as well as ever, provided the details and technique of
the amputation are carefully performed. All through-knee amputations are
gone, and an amputation through the lower third of the femur holds sway.
Amputations about the region of the femoral trochanters are gone, because
such men walk badly and less far than after an amputation through the hip
joint. The artificial limb for an amputation of hip is a sound, practical appa-
ratus. An amputation of the shoulder joint is popular on similar grounds.
Amputations leaving behind the tuberosities are unpopular with instrument
makers. In these cases the surgeon is merely the fashioner of the stump which
is to be made useful by the instrument maker. The amputating surgeon is
indirectly only a means to the end. The instrument maker is the direct means
to the end. :

Behind all, and’ clouding all results ‘of remote surgery, is neurasthenia.
This war has shown neurasthenia as it was never seen before. All our present
patients have undergone many emotions, heard many hospital tales, seen men
SPECIAL NOTES. 143

die, have laid out wounded and been carried in, and so on ad infinitum. All
are neurasthenic in degree, and, as time goes on, this will be found an increas-
ing obstacle in returning men to civil life. It has always to be calculated on.

To recapitulate: The outstanding features are:

Of immediate surgery: Infection; technical advances in abdominal and joint
wounds.

Of remote surgery: Orthopedic surgery ; technical advances such as in facial,
joint, amputation surgery, nerve surgery, etc.

Neurasthenia is the ill which pervades the results of all injuries.

Major Corner added:

The recommendations that I would make to those surgeons doing the amputa-
tions are: 7

1. Let technique be as surgically clean as possible. Much harm results from
“lighting a fire” in a wound.

2. Use only absorbable sutures.

8. Cut all nerves as short as possible, using the ‘‘swing-door method” to
close their mouths.

4, Cut all vessels short, as by them is the greatest channel for the spread of
infection. By cutting them short “the door is closed.”

5. Drain temporarily all amputation wounds, using a large tube and at least

» one.

6. Start the Carrel-Dakin treatment at the time of operation in dirty cases.
7. In clean cases close the deep wound with a few catgut stitches.

 

HYDE TERRACE. HOSPITAL AT LEEDS.
(General Sir Berkeley Moynihan, K. C. M. G., C. B., Chief Surgeon.)

While an active member of the British Medical Advisory Board,
Sir Berkeley Moynihan is also chief surgeon at the Royal Infirmary
at Leeds (a large hospital given over in part to the care of the war
wounded) ; and, in addition, finds the time to do a certain amount
of private work in his own hospital at 9 Hyde'Terrace, which I
visited in his company.

In the treatment of war wounds, he advocates:

1. In cases received within 8 or 10 hours after.injury (which is the
period of contamination rather than of spreading of infection)
thorough mechanical cleansing and excision followed by primary
closure.

2. In infected early cases, mechanical exposure and cleansing fol-
lowed by either physiological or antiseptic treatment directed to the
removal of the remaining infection, and aimed to permit of the
earliest prudent secondary closure of the wound.

3. In infected late cases, thorough mechanical exposure and cleans-
ing, followed by immediate secondary closure if certain antiseptic
pastes are used.

In certain cases of infection, while admitting the favorable results
frequently following the use of antiseptics, he is strongly of the
144 SPECIAL NOTES.

opinion that “the natural defenses of the tissues already awakened
are ample to deal with the infections then remaining.” :

As to the Carrel-Dakin treatment the conclusion which he appar-
ently has reached is that the excellent results obtained are in large
measure due not so much to the antiseptic value of the Dakin fluid
as to the general care of the wound involved in the application of the
Carrel technique.

It ig the natural defensive powers of the body fluids and tissues, of serum,
and leukocytes that are the chief agents in finally subduing the bacterial infec-
tion in a wound. * * * Full emphasis must always be laid on the para-
mount necessity for the complete immobility of wounded parts at all times and
on all occasions.

He points out that early in the war in treating joint wounds drain-
age tubes were almost universally employed, but that “there can be
no longer any doubt that any form of tube introduced into the joint
cavity in the early cases is productive of nothing but evil.”

He said: “ You in America will want to get your convalescent
cases home. It is better to have them among their own people, bet-
ter for the men, and good for the community to care for them and
see the actual evidence of the war. It brings home to the people
the facts. It is bad to have small, individual places care for the men
who are to be returned to service, as it demilitarizes them and dis-
turbs treatment. Of course, the question of feeding these patients
over here is a serious one, and with the empty ships returning to
America doubtless many of the convalescent will be sent home early.”

An interesting matter of routine at Hyde Terrace, to save the eye
strain of the operating force, is the employment of black sheets over
the patients and dark-colored pads and red towels for the soiled
instruments,

 

THIRD LONDON GENERAL HOSPITAL.
{Lieutenant Colonel H. E. Bruce-Porter, R. A. M. C. T., Commanding Officer.),

Located 5 miles from Charing Cross Station, at the time of my
visit, this hospital was caring for 1,440 officers and 500 more patients.
There are 80 acres of ground, with flowers and trees, and the location
is excellent. In fact, this institution seems as nearly ideal as possi-
ble; no noise, no confusion, no odors. Stress is laid on the importance
of harmony throughout all departments.

The whole atmosphere is that the patient comes first. AII the pa-
tients are known and addressed by name. Colonel Bruce-Porter said:
“An institution is a failure if the human side is left out. The official
side alone squeezes out the human and the result is failure.” The
bath house is always open so that a bath may be had at any time,
 

Third London General Hospital, Wandsworth, Massage and electricity.

 

 

 

 

 

Ah

Iu
re

a

Tan
ne

 

‘ Welcome Hut, Blackpool.
144-1
 

a ae Gare, BLackPoo. INTERIOR OF or

 

 

Interior of a hut, Blackpool.

 

 

 

 

 

Hydrotherapeutic: Whirlpool bath. Blackpool,

144-2
SPECIAL NOTES. 145

Every effort is made to eliminate the military aspect, and a feeling of
fraternity and good will prevails. I heard a totally blind cavalry
officer cheering up some others, saying: “ We are not so badly off as
those who have always been blind, for we know what things look
like.” Notices are not given in the form of orders but appeal to the
reason. “These men are from the battlefield. Don’t say ‘must!’
Don’t drive! ”

There are several types of ward huts here. In each an essential
is that there be plenty of light and air, and there should always be
a ward room or two for very bad cases. No patient should die in a
ward. (This is a matter which is often neglected in.the construction
of civil as well as of military hospitals. Of course, under conditions
at the front, it is frequently impossible to have such provision, but
in a base hospital wherever possible it should be arranged for.)

All this has a far-reaching practical value and should be regarded‘
not as sentimentality but rather as psychotherapy.

Sun and air are considered very important in bad septic cases.
Through the generosity of his friends, Colonel Bruce-Porter has had
erected a number of open-air shelters, each a unit for one patient and

nurse, revolving to the sun. Those in use are giving such satisfaction
that more will be added. They are cheap and made of ‘wood.

He said: “In an institution like this there should always be a
special fund at the disposal of the commanding officer. There are
a thousand and one little things needed, and one should not be com-
pelled to wait for official machinery. With a fund things go along
well. I am always begging for my boys.”

He also added, “ My advice is to mix the men in the hospital. Put.
the Americans in with our men and those from all parts of the
empire. This will result in better understanding all through. In
the field this is not so easy, of course, for the men are brigaded
together. By mixing in the hospitals they make friends, upset old
antagonisms, and thus stimulate immigration and future trade.”

There is a most remarkable system of conservation in effect here.
“Nothing is wasted. AII bones are used for soup. Even the small
pieces of bread left on the plate and the grease on the platter are
‘wed. By giving small portions little is left. The patients under-
stand that they may have more and as much as they want. I exam-
ined the swill for 24 hours from 2,400 people—all in one small cart
drawn by one horse—practically nothing that was usable.

Sir Alfred Pearce Gould is the senior surgeon. Every case requir-
ing amputation is seen by him and he makes the decision; his is the
responsibility. He decides and directs. Any serious medical case
must likewise see the chief medical consultant.

Under the excellent system now in operation the British Army and
Navy hospitals in and near London are enabled to have the benefit of
146 SPECIAL NOTES.

the services of such leading specialists as Sir Alfred Pearce Gould,
Sir Watson Cheyne, Bart., Sir Arbuthnot Lane, Bart., Sir John
Bland Sutton, and many others, while the general public is not
entirely deprived of their expert knowledge. These men are commis-
sioned and on active duty in the mornings at the several hospitals
to which they are assigned, directing, operating, and advising. Each
is placed in charge of that branch of work in which he is a master.
In addition, a number of prominent specialists are devoting half of
their time to inspecting the professional work in the hospitals, going
from one institution to another as consultants, with sufficient Army or
Navy rank to insure that their suggestions carry weight. Thus many
of London’s leaders in surgery and medicine in the various branches
who are not at the front are‘doing a great work for the Army and
Navy, while at the same time those at home are not deprived of
expert advice and help in time of need.

This plan has proved-most satisfactory and has resulted in uni-
formity of methods and a higher standard of efficiency, and a num-
ber of other centers have adopted the same plan.

It must not be thought, however, that this system was evolved
without lessons having been learned from hard experience. Early
in the war the British were confronted with such chaotic conditions
in the assignment of physicians and surgeons that one would find,
for example, a laparotomy being done by a general practitioner, as-
sisted by an eye, ear, and throat specialist, while the anesthetic was
given by a recognized leader in the field of abdominal surgery. Ex-
cellent orthopedic surgeons were given clerical work and an abdomi-
nal surgeon of international reputation was assigned to purely med-
ical work. These and scores of similar instances were cited to me
by those who were acquainted with the conditions prevailing. The
situation finally became so serious that chiefly through the initiative
of Sir Almroth Wright, the matter was taken up and the existing
evils largely corrected.

May it not be that we stand in considerable danger of repeating the
unfortunate experiences along this line of the British? Unfortu-
nately, the bestowing of high rank frequently takes a surgeon out of
active work in his own line and places him in a purely administrative
position where his particular ability and skill are more. or less
wasted.

Of course, in the rapid expansion of our military forces, there is
bound to be a certain amount of maladjustment, and instances of it
in both our Army and Navy could be cited. Nevertheless, before
there is an unnecessarily great wastage of talent and ability, might
it not be well for us to take a leaf from the book of experience of
our allies and make sure that there is a proper relation, at home as
well as abroad, between the surgeon in the hospital and his task? It
MILITARY. ORTHOPEDIC HOSPITALS. 147

would also seem to be the counsel of wisdom, in view of the heavy
drafts being made upon the medical fraternity, that we take imme-
diate steps to procure for the war hospitals here the benefit of the
services and advice of such specialists as are available for part-time
duty, without depriving the general public of their assistance in time
of need.

MILITARY ORTHOPEDIC HOSPITALS.

It is to the conservative trend of modern surgery, more perhaps
than to any other factor, that the development and extension of the
field of orthopedics at this period of medical history is to be attrib-
uted. Made familiar by experience with the protracted suppurations
of tuberculosis and osteomyelitis, and having learned the lesson that
patience and perseverance often win the day in the face of appar-
ently insurmountable obstacles, the orthopedic surgeon is as it were
predestined to make the best of well-nigh hopeless conditions result-
ing from the traumatisms of “ civilized” warfare. Amputations and
mutilations of many kinds are often avoided through a timely re-
course to orthopedic methods of treatment, which at the same time
help to prevent or minimize the bodily deformities and functional
disablement of the wounded. The wide scope of military orthopedic
hospitals is suggested by Calot’s statement (Orthopédie de Guerre,
Paris, 1916) that two-thirds of the wounded brought to the first-aid
stations fall within the domain of war orthopedics, including those
who have suffered wounds of the bones, joints, muscles, tendons,
nerves, or vertebre; for injuries to all portions of the locomotor
apparatus properly belong to the orthopedic surgeon. Military
orthopedic hospitals are charged, furthermore, with the care of nine-
tenths of the cases of war invalidism or infirmity, in the form of
deviations, shortening, stiffness, ankylosis, paralysis, or loss of power,
all of which conditions are subject to improvement through the
therapeutic measures employed in these hospitals, such as’ massage,
electrotherapeutics,. mobilization, reeducation, and equipment with
suitable prosthetic apparatus. It is generally conceded that the
selection of the permanent prosthesis is perhaps best carried out
in the orthopedic hospital, whereas the fitting of the immediate pros-
thesis should be left in many cases to the operating surgeon.

Military orthopedic cases are held by the British Army council to
include the following:

(a) Derangements and disabilities of joints, simple and grave, including
ankylosis.

(6) Deformities and disabilities of feet, such as hallux rigidus, hallux valgus,
hammer toes, metatarsalgia, painful heels, flat and claw feet.

(c) Malunited and ununited fractures.
(d) Injuries to ligaments, muscles, and tendons.
148 MILITARY ORTHOPEDIC HOSPITALS.

(e) Cases requiring tendon transplantation or other treatment for irreparable
destructiton of nerves.

(f) Nerve injuries complicated by fractures or stiffness of joint.

(g) Certain complicated gunshot injuries to joints.

(h) Cases requiring surgical appliances.’

These cases naturally fall into two groups—those whose disable-
ment is only temporary and who after treatment will be fit for mili-
tary service again, and those who are so disabled that they must
inevitably be discharged from the Army or Navy.

The wounded soldier receives immediate treatment in a general
military hospital. If his case should come in the category of ortho-
pedics, as defined above, he is then transferred to one of the orthro-
pedic centers for special treatment.

If his disablement has been only temporary, he may be sent for
aftertreatment to a command depot until ultimate recovery and
return to military duty.

Colonel Sir Robert Jones, in an address delivered before the
Hunterian Society on January 2, 1918 (reprinted in the Brit. Med.
Jour., Jan. 12, 1918), classes the conditions which, taken together,
create an orthopedic case under the following heads:

1. The mechanical injury to bone, joint, muscle, or nerve.

2. The atrophy and disease of these structures primarily due to the injury.

3. Incoordination of movement due to disease of the brain, a result of atrophy
and disease of peripheral structures. : :

4. Psychological conditions which can be overcome by reeducational processes.

Mechanical-therapeutic aftercare of soldiers whose wounds have
healed and whose condition has become stationary falls within the
domain of the modern military orthopedic hospital. Another impor-
tant sphere of usefulness lies in the relief and prevention of certain
conditions which impair the fitness for service of unwounded sol-
diers; for example, flat feet and painful heels.

The most gratifying results have been obtained by the special
methods of orthopedic surgery in a remarkably large number of
war casualties, sometimes estimated at more than half of all wounds.
In recognition of this fact, England has been particularly active in
establishing and constantly adding orthopedic centers with an ex-
perienced operating staff and up-to-date surgical appliances of all
kinds. On January 1, 1918, there were 16 orthopedic centers in
Great Britain and Ireland, containing close upon 15,000 wounded;
and of the men treated in these centers 75 per cent are eventually
returned to the army. As types of the best of these institutions,
which are distributed over various parts of the country, the assistant
inspector general selected the military orthopedic hospitals at Shep-
herd’s Bush, London W., and Alder Hey, Liverpool, the latter being
the first orthopedic center established, having been started by Colonel
MILITARY ORTHOPEDIC HOSPITALS. 149

Sir Robert Jones with 250 beds. I visited these two, as well as
others, some of which are especially mentioned.

The Shepherd’s Bush Hospital is considered the headquarters of
military orthopedics in the British Isles. The total accommodation
for patients at present is 1,200 beds. Four auxiliary houses near by,
run on the barracks system, receive convalescent patients. The officer
in charge is Major Walter Hill, and the registrar is Captain Picton
Phillips. The surgical staff of the hospital is large, and has recently
been increased by the appointment of several American orthopedic

_ surgeons.

The treatment employed is of a widely diversified character, and
the different forms are applied separately or in combination, accord-
ing to the requirements of a given case. In the introduction to a
pamphlet entitled “ Organization and Methods of the Military Ortho-
pedic Hospital, Shepherd’s Bush” (London, 1917), the various forms
of treatment are grouped as follows: (a) Operation; (0) electro-
therapy; (c) massage; (d@) hydro-therapy; (¢) fixation methods; —
(f) exercise; (g) manipulation; (%) curative manual treatment in
workshops, etc.

The Shepherd’s Bush Hospital offers a three months’ course of
instruction in military orthopedics. A program of demonstrations
and lectures has been arranged to cover the whole work of the
hospital, so that any one able to attend the whole course will see all
the methods in use; but each individual lecture or demonstration is
complete in itself fiir the benefit of those Who are able to attend
only at particular times. The departments covered include gym-
nasium and workshops, hydrotherapy, plaster demonstration, mas-
sage, and electrical divisions. The time-table shows a carefully ar-
ranged sequence of ward classes, operations, demonstrations, and
lectures on topics of surgical and orthopedic interest.

The total number of patients discharged from the hospital since it
opened in March, 1916, until September, 1917, is 1,787, and of these_
only 890 were discharged as permanently unfit, 325 were returned to
duty, 507 were sent to command depots for further treatment, and
515 to light military employments. The new electrotherapeutic de-
partment of this hospital, under Captain W. R. Bristow, gave over
1,600 treatments during three months, and as many cases were treated
in the massage department. In the hydrotherapeutic department,
opened on July 24, 1916, an average of 79 patients are receiving treat-
ment. At present 120 men are employed in the curative workshops
and about 500 in the hospital generally. The new workshops which
are being completed will provide places for 100 more men. The
courses include engineering, electrical work, metal grinding and
polishing, felting, tailoring, fancy leather work, carpentering, pho-
tography, art iron work, oxy-acetylene welding, French polishing,
150 MILITARY ORTHOPEDIC HOSPITALS.

painting and sign writing, metal engraving, coopering, motor-car
overhauling, surgical bootmaking and repairing, and splint making.
In the last named over 2,500 stock splints were made, and 889 special
splints, and in addition, numerous repairs and alterations were car-
ried out. Of 74 men who had passed through the workshops and been
discharged from hospital to August 4, 1917, 10 had returned to duty,
35 to a command depot, and 20 to employments, making a total of 65
returned to the Army, leaving only 9 as permanently unfit. This
hospital still needs a new operating theater, but when this has been
built it will be complete. .

The military orthopedic hospital at Alder Hey, near Liverpool,
now has 800 beds. An excellent course in military orthopedics is
given and a number of American surgeons are receiving instruction
while acting as internes, and caring for the patients under the super- -
vision of the British staff. There is also a considerable amount of
plastic surgery, especially nerve suture, being done here. It has ap
annex in the Pilkington Special Hospital for disabled soldiers and
sailors at St. Helens, well equipped and under the medical charge of
Dr. J. R. Kerr. A hospital at Calgarth, beautifully situated on
Windermere Lake, is approaching completion, and will be provided
with electrotherapeutic, hydrotherapeutic, and massage departments,
also curative workshops. It is planned to operate this us an addi-
tional annex to the hospital at Alder Hey.

The Second Northern General Hospital at Becketts Park, Leeds,
provides accommodation for 800 orthopedic’ patients, a number
which will shortly be raised to 1,000. It is composed in part of huts,
and has two operating theaters devoted to orthopedic work, the one
for aseptic operations, the other for surgical manipulations and the
application of plaster splints. The curative workshops are nearly
completed. New massage, electrotherapeutic and hydrotherapeutic
departments and a gymnasium are required. The work at this hos-
pital has been described more in detail elsewhere in this report.

At Oxford satisfactory progress is being made toward the estab-
lishment of an orthopedic center in connection with the third South-
ern General Hospital. Captain Girdlestone is the head of this center,
which will provide 250 beds in the base hospital, the Wingfield Hos-
pital, the Radcliffe Infirmary Hut, and a hut hospital about to be
built.

It has been decided also to arrange for an orthopedic center at
Newcastle-on-Tyne in connection with the first Northern General
Hospital in the Royal Victoria Infirmary; the infirmary hopes to be
able to use a large area of the town moor (Castle Leases) for the
erection of an orthopedic department. In Newcastle also is the Cowen
Home for the training of disabled men.
MILITARY ORTHOPEDIC HOSPITALS. 151

In Scotland there are three orthopedic centers; one at Bella-
houston, Glasgow, with 500 beds, under Major Parry; in its curative
workshops more than 100 men are engaged in learning various trades.
The hospital possesses a fine hydrotherapeutic department and good
massage and electrical departments.

The Bangour War Hospital, Edinburgh, provides 500 beds for
orthopedic cases; the surgical work is conducted under the direc-
tion of Colonel H. J. Stiles, deputy inspector of military orthopedics
in Scotland. At this hospital a large permanent hydrotherapeutic
department is being erected, but it still requires new workshops.

At Oldmill Hospital, Bherdeen, there are 500 orthopedic beds,
under the supervision of Prof. Marnoch. It has three large huts for’
use as curative workshops, and extensions are contemplated to pro-
vide more workshops, a gymnasium, and a hydrotherapeutic depart-
ment.

At the Military Orthopedic Hospital, Blackrock, Dublin, there are
300 beds, with massage and electrotherapeutic departments and work-
shops for carpenters, smiths, tailors, and shoemakers, and a lathe
house; in addition there are 6 acres of land on which patients are
regularly instructed in the principles and practice of horticulture.
This hospital, which is under the charge of Major Potter, was opened
on May 19, 1917; it needs additional workshops. .

The Ulster Volunteer Force Hospital, Belfast, was opened on
March 1, 1917, in an entirely new building situated in the grounds
of the Queen’s University. It provides 194 beds for orthopedic and |
limbless patients, but the accommodation has proved inadequate. It
also stands in need of electrical, massage, and hydrotherapeutic de-
partments.

In this review, which has been adapted from the British Medical
Journal, Volume II, September, 1917, page 469, the double func-
tion of curative wonkshone 4 is more than once insisted upon; they are
useful not only for the exercising of the injured limb and the train-
ing of the men to useful work, but also as a mental stimulus, helping
the men to a more active life, both mental and physical.

The Hépital de ’Océan, in La Panne, Belgium, has been called
a wonderful medicosurgical laboratory, where everybody can learn
something, and the attention of orthopedists is invited to this ad-
mirable educational center, under the direction of Depage. The work
_ comprises orthopedic surgery, post-operative treatment, and the ap-
plication of prostheses, provisional and permanent (Lamy, Paris
médical, VII, 1917, page 505). Aside from the Belgian orthopedic
surgical department of La Panne, regional centers were officially
created in France by the French War Ministry, on June 2, 1916,
for the equipment of mutilated allied soldiers with so-called military
prostheses, as well as for reeducational training.
152 MILITARY ORTHOPEDIC HOSPITALS.

Italian orthopedic surgeons are entitled to credit for the perform-
ance of amputations, on a large scale, in such a conservative manner
as to take advantage of the intrinsic powers of the formerly useless
stump. According to recent statements (Popular Mechanics Maga-
zine, September, 1918), this means that a man who has lost a hand,
for example, can open and close the fingers of the artificial hand by
means of tendons and muscles instead of cords and levers; or, with
an artificial arm applied to a stump only 18 inches in length, the man
is able to flex the forearm and extend the fingers; voluntary exten-
sion of the knee is also possible, etc. The tendon being best adapted
for the transmission of muscular contraction, it is employed where

-possible. When it is missing, muscles must be utilized. The opera-
tion can be performed on healed stumps. “The work is known as
kineplastics. Briefly, it consists of forming at the end of a stump
what is known as a motor flap. This is covered with perfect well-
nourished skin of normal sensibility. It is built of such muscular
masses, tendons, and tissues as are available, and is of such shape
and dimensions as to be suitable as a point of attachment for the
hooks, wings, rods, or thongs to be used in transmitting movements
of the muscles remaining in the stump to artificial limbs. The motor
may be single, double, or multiple, and on this, of course, depends
its degree of usefulness.”

A single type of motor flap is being extensively utilized in Ger-
many in imitation of the more advanced cooperative work of Italian
surgeons and mechanics. The proverbial preparedness of the foe
for the world war finds a further illustration in the summoning of
German orthopedic surgeons, within the first weeks of the war, to
the first-aid dressing stations for the most proficient treatment of
gunshot fractures. A large orthopedic institute, known as Reserve
Hospital XI, and comprising an orthopedic hospital as well as re-
educational schools for invalided soldiers, has been established in
Vienna by the military authorities and is under the administration of
the Austrian Government. Another large orthopedic hospital is
located in Nuremberg, southern Germany, and to this there are
attached a number of workshops for reeducational training. Me-
chanical treatment is employed with appropriate temporary supports
for cases of paralysis. German writers emphasize the favorable
curative conditions of their hospitals, as illustrated not only by the
high percentage of wounded soldiers who can be returned to the
front but also by the extraordinary number of gravely wounded men
who can be restored functionally to such an extent as to remain self-
supporting through appropriate aftertreatment in orthopedic hos-
pitals.

In the United States the organization of a national orthopedic
reserve is now being worked out by the orthopedic surgeons of our
country, together with detailed plans for an orthopedic base hospital.
CONVALESCENT CAMPS. 153

As pointed out by Colonel Sir Robert Jones (loc. cit.), “The fact
that about 50 per cent of the wounded of this war have received
injuries resulting in impairment of locomotor function and useful-
ness of limbs has brought the importance of orthopedic principles
and methods of treatment into a prominence which no one had
foreseen.”

Our fedenenas to the work of Buzaglo at the end of the eight-
eenth century for some of the methods reintroduced by Owen Thomas
and Robert Jones is commented upon in the writings of McCrae
Aitken on Orthopedic Methods in Military Surgery (Lancet, Lon-
don, Vol. I, 1917, p. 10). An old engraving, dated 1783, shows the
‘abducted position for the treatment of the shoulder and hip, the
right-angled shoe, and a splint which is the forerunner of the Thomas
knee splint, introduced at the end of the nineteenth century. This is
naturally of interest in view of the tracing of immediate wound
closure by sutures to the days of our forefathers, as mentioned i in aD-
other section of this report.

CONVALESCENT CAMPS. .

No survey of the care of the sick and wounded soldiers by our
allies would be complete without including some description of the
work of the two great British convalescent camps—the King’s Lan-
cashire Military Convalescent Hospital near Blackpool, and the
Summerdown Military Convalescent Hospital at Eastbourne.

After a man has received at a general or special hospital the neces-
sary medical and surgical care, there is frequently a long period
during which he is unfit for active service and requires a certain
amount of care, and the convalescent camp has been called into exist-
ence to meet this need.

The objects of such camps are well expressed by Lieutenant Colonel
J.S. Bostock, in charge of the Eastbourne camp:

From the military point of view.—The main object is to obtain a quick return
of fit men to the front. The patient is enabled to complete his treatment under
inedicai supervision, and at the same time, to commence his hardening course
of physical training, thus materially shortening his period of noneffectiveness.

From the medical point of view.—These hospitals relieve the pressure upon
the more expensive beds in ordinary hospitals, as facilities exist for providing
minor medical and surgical treatment. Further, in the Massage Institute,
cases requiring more or less prolonged periods of massage and electrotherapy
can be dealt with. Under these circumstances, from 3,000 to 5,000 cases can,

be cared for in each hospital.
The essential factor in all cases for transfer te a convalescent hospital is

that, at the time of transfer, they shall be “fit to be up and about,” able to
eat ordinary barrack rations, and to fend for themselves.

98696—19——11
154 CONVALESCENT CAMPS.

It is a link between the general hospital and the military depot.
The length of stay varies from two weeks to a year, or even more in
special cases, the average stay being eight weeks.

We are finding it necessary to establish convalescent camps for our
men, and we should therefore take advantage of the lessons learned
by those who have developed this type of institution from its in-
ception to its present high plane of efficiency.

General Thomas H. Goodwin, Director General of the British Army
Medical Service, recommended that I visit the two hospitals above re-
ferred to, inasmuch as under the leadership of Colonel Netterville
Barron at Blackpool, and of Lieutenant Colonel Bostock at East-
bourne, they have reached a standard of excellence which may wel]
serve as a model. Word was sent ahead of my intended visit, and
upon my arrival I was made cordially welcome at each place, and
every facility was given me to inspect and observe in detail. I came
away filled with admiration for what is being accomplished in
restoring to physical and mental health those who are sick and
wounded, and deéply impressed with the spirit of those in charge,
which alone has made such success possible. ; ,

The problems confronting those who undertake this work were
described by Colonel Bostock as follows:

While a man is in hospital proper, in “ blighty,” with nurses and comfort-
able surroundings, all seems well; but on arrival at a convalescent hospital he
recognizes the penultimate phase, and from that moment, with a vista of
trenches before him, his outlook on life is a darkened one. And then his rhev-
matism (it may be) gets a little worse, and the wound, although healed and
which had ceased to worry him hitherto, “‘ aches, doctor.” and who shall say
otherwise.

It is this mental disorder which it must be the care of those concerned to
cure. It is one big psychological study, never to be lost sight of or to be
unprovided for during the patient’s progress in the hospital. It should be the
aim so to restore his mentality that he may eventually again attain the high
level of the normal-minded Britisher, where he recognizes his duty to the state
and accepts the inevitable with good grace.

For this purpose it is essential that a healthy atmosphere and tone should be
infused, and it is contended that this can only be done by the persevering and
unremitting attention of the commanding officer and his staff. It should be an
accepted but untalked of fact that all will after a happy convalescence find
their way back to the front.

It is suggested that in some similar institutions concerned in dealing with
temporary noneffectives this psychological study is lost sight of. The men, on
entering, are confronted with a distant vision:of a Hun with bayonet and rifle,
and during each successive phase this picture looms larger and larger. Thus,
it would appear that the patient’s return to the condition of the healthy-minded
Britisher is retarded. During convalescence the Hun with the fixed bayonet
should be camouflaged and should not be allowed to obtrude; there is time
enough for that when the patients return to their reserve units.

An essential part of the convalescent treatment is that the men should be
allowed as much freedom as is consistent with their treatment or duties.
CONVALESCENT CAMPS. 155

Every encouragement should be given to games, recreations, and other pleasur-
able occupations, and these should be free, or as nearly free as possible. The-
atricals, concert parties, etc., should be encouraged, and a wealth of talent
may be found among the patients. A band is a sine qua non.

The patient, once convalescent, feels that he has a right to be amongst his
relatives, and as this can not be permitted the next best thing is to provide
facilities for these relatives to visit him. This can be effected by the provision
of a hostel in the neighboring town, where relatives can obtain accommodations
at a very low charge.

Colonel Barron’s views agree with Colonel Bostock’s, and he adds:

Make your camp as beautiful as possible. It is wiser to spend inoney freely
on green banks and flowers than on works by standard authors.

Give free access to amusements outside the camp and encourage decent female
society both inside and outside. The more women, the less venereal disease.
The craving for feminine society is as natural in a soldier as it is in a civilian.
Natural young women, with healthy bodies and healthy minds, are what is
wanted.

Convalescents require better officers and noncommissioned officers to handle
them than do soldiers in a training camp or depot. The officers need know less
drill, but should know more of humanity. A convalescent ‘should be under
discipline, but should, as far as may be, be taken away from war and affairs
military.

‘Colonel Barron’s attitude toward the subject of venereal disease
has created a great deal of discussion. As carried out at the Black-
pool camp it is almost unique. The results, however, have been most
remarkably gratifying and are certainly worthy of thoughtful con-
sideration.

THE KING’S LANCASHIRE MILITARY CONVALESCENT HOSPITAL,
: BLACKPOOL.

This was primarily established by private enterprise and later
enlarged and taken over by the War Office.

Colonel Netterville Barron, C. O., the presiding genius of the place,
was a London physician with a large practice and conducting an
electrotherapeutic establishment when he was selected by the War
Office to make the experiment of building up this hospital. Success
has crowned his efforts, and a model camp has resulted. ‘There is
provision for 4,600 beds; 3,100 for noncommissioned officers and pri-
vates,-1,500 for officers.

While the hospital is under military discipline, every effort is made
to efface, so far as possible, that aspect. Newcomers are met by a
sergeant, who greets them informally and conducts them to the
“Welcome Hut.” Here they are given tea, coffee, or cocoa and other
refreshments by the staff of women volunteers from the locality, and
then are assigned to their quarters. The barrack-like appearance
of the camp is relieved by beautiful lawns, flower gardens, good roads,
and gréen sward of the bowling grounds and cricket field. A 30-
156 CONVALESCENT CAMPS.

acre farm under ¢ultivation on the outskirts of the hospital gives
the men exercise, and is a financial success as well. There is a well-
equipped writing room, with free stationery, recreation and billiard
rooms, and a large gymnasium with a stage for use in theatrical per-
formances. A small hospital is provided for the care of the sick,
but all surgical cases are at present transferred. It is expected soon
to have a small surgical adjunct, so that in the occasional cases which
require operation the men need not be removed from the camp. No
cases of total incapacity are sent here, but only such as are expected
to be made fit to return to military duty or to civil life.

The men are classified according to their physical condition, and
the section in which they belong is indicated by a colored arm band.
“Bands about the arm tell which section they are in and therefore
we know how much they can do and what they should be at.”—
Barron.

In addition to general medical care and surgical dressings, the °
treatments include remedial exercises, electrical massage, apparatus
work, psychic analysis, etc. Whirlpool baths are used and are com-
mended where nerve endings are involved in a scar and as prepara-
tion for massage, but Colonel Barron thinks if this bath is to be used
at all, there must be a cooling-off room to avoid taking cold.

An original and highly successful type of apparatus in use here is
the special flat-foot ladder designed by Colonel Barron. Pictures of
this ladder and of a few examples of the results obtained have been
furnished by him and are reproduced in this report. His records
show that, after 20 to 30 minutes’ exercise each day for three
weeks, practically every case of flat-foot has been cured. Wherever
men are taken from sedentary occupations and given training which ~
requires that they be on their feet for hours at a time and doing
heavy work, tired arches and flat-foot are common developments.
Therefore, every Army and Navy training camp could well be
equipped with this device. Moreover, its use may well be extended
so that hereafter it will be found in every gymnasium in civil as well
as in military centers.

There is a wonderfully well arranged chart record room where
the daily doings of the hospital are analyzed and charted and sta-
tistics compiled, and here also free railroad tickets are issued for
relatives to come and visit the boys, or half-fare vouchers for those
in better circumstances.

For a few months Colonel Barron kept a so-called blacklist, upon
which were charted such diseases as are established to be preventable
by cave and the number of cases of each counted against each bat-
talion in the British Army in France. The labor involved in com-
piling it, however, grew to such proportions, and the private funds
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CONVALESCENT CAMPS. 157

abandoned, but not before it had created a great stir and pointed
many a serious lesson.
The diseases so charged as being due to exposure and dirt were:
1. Trench feet.
2. Infection of cutaneous tissue.

A large number of cases under these two
heads are undoubtedly due to trench fever,
which is P. U. O., or pyrexia of unknown
origin but now thought to be carried by the
‘| louse.
5. Skin disease due to irritation.
6. Dental caries.

Of the 9,503 men who passed Gee this camp in 1917, 42.4 per
cent were returned to full military duty; 19.4 per cent to the com-
mand depot for further hardening (almost all of these later go over-
seas for full military duty) ; 28 per cent to employment (not over-
seas); 6.3 per cent to other hospitals for treatment; 2.62 per cent
invalided out of the service; 0.03 per cent (8 men) died.

A recent development here, and one which is a step in the right
direction, is the “Khaki College,” established in February, 1918.
A near-by technical school, St. Anne’s, has arranged a number of
courses, each extending over two months, covering the fields of com-
mercial training, languages, mathematics, arts and sciences, any two
of which a man may undertake. There are also evening classes in
commercial branches and music at the camp itself. This is a very
valuable addition to the hospital and one which is receiving enthusi-
astic support from the patients themselves.

Colonel Barron said: “ We have found the Khaki College started
here is popular because a man can learn Greek, or how to draw carica-
tures, or wood carving, and not be bothered by well-meaning visitors
inquiring whether he is learning a new trade for after the war.
Our professors are all drawn from the staff or patients. Any subject
under heaven is taught excepting military subjects.”

3. Myalgia.
4. Rheumatism.

 

y

SUMMERDOWN MILITARY CONVALESCENT CAMP AT EASTBOURNE.

(Lieutenant Colonel J. S. Bostock, R. A. M. C., ©. 0.)

General Goodwin said: “A trip to Eastbourne Camp is most
interesting and instructive; a meeting with Colonel Bostock is an
inspiration. He is an institution in himself.” And after my visit
to Eastbourne I agreed with him.

The camp is delightfully situated on the downs near the sea, and
everything possible i is done to make the men forget the battle line and
take a normal view of life once more. After noonday there are no
158 CONVALESCENT CAMPS.

guards about. Equipment is furnished for every sort of game—base
ball, bowling, fishing, golf, tennis, boating, billiards, marbles, cricket,
etc. There are handball courts and squash courts and every ‘kind of
healthful sport is encouraged. Near by there are some links where
the men can caddy if they desire. This gives them some pin money,
as well as out-of-door life and exercise.

The whole atmosphere of the place is that of a club or fraternity.
Here, as at Blackpool, there is a “ Welcome Hut” at the entrance,
where, on arrival, men are given a good meal. There are flowers all
about and an atmosphere of cheer. Notices are posted on the walls of
good times coming. The camp has well-equipped writing and recre-
ation rooms, also a theater.

The treatment consists of:

1. Reeducation and massage.

2. Remedial exercises under medical officer in gymnasium.

3. Physical therapy, proper; army gymnastics.

Three thousand six hundred men were at this camp at the time of
my visit. They wear a regulation convalescents’ uniform of dark
blue with red tie. There is a blacksmith shop, where, with volun-
teer labor, considerable money is saved. On the farm, all the plow-
ing is done by hand by the men for the sake of the exercise. This
year they are getting all of the vegetables for four months, for the
entire place. There is a great variety of small flower beds which
are voluntarily kept by the men, and there is much competition
among them, each group striving to make its hut entrance the most
attractive.

The basket making and other industrial work is in charge of Miss
Samuel. She and the men divide the returns. Out of her half,
she keeps up the work in manual arts, the art shop, and book bindery.
A fortnightly magazine is published by the men, giving all the camp
news.

Economy is impressed upon the men by example. Nothing useful
is wasted. The grease from plates is collected and used for making
soap and- glycerine. They have saved 50 tons of pure fat in two
years. Even the leaves from the tea are saved (a by no means in-
considerable item in a British establishment) and mixed with coal
dust and used in the fire.

Colonel Bostock says: “ We need 3,600 calories daily for each man.
They must have plenty of proteid to refit them for fighting.”

He thinks there should be two types of convalescent hospitals;
one for men who can probably be sent back for military duty in two
months, the other for those who require longer and more technical
treatment. This latter type would be more of an auxiliary hospital.

The ordinary convalescent remains here from 27 to 30 days, while
severe cases remain occasionally for a year. :
EASTBOURNE.

 

 

 

 

 

 

 

 

Mess Hall.

158-1
 

 

   

Eastbourne, The band, i Bs

 

 

Eastbourne. Patients from convalescent camp at work.

1658—z
 
 

cn
vl

i é =

Wa)

 

Eastbourne,

159
CONVALESCENT CAMPS. 159

“We do not use the Red Cross sign; we found it of no value as a
protection. The Red Cross brassards were used in the field ambu-
lance for the first three days of the war, then done away with and
never since used by us. The Germans use them always.”

All through this institution there is apparent a carefully studied
effort to make the men feel at home, cheerful and happy and proud
of their camp.. Many of them wear away rings bearing the name or
picture of the place, and there is a bond of interest and fellowship,
even in the trenches, among those who have been here.
 

 

a
oO

Physical training of mutil

 

Hospital’ Bon Secours, Rouen.

 

161

 

 

 

 
REEDUCATION FOR THE DISABLED.

John Galsworthy says in his foreword to the report of the second
meeting of the Inter-Allied Conference on the aftercare of disabled
men, held in London in May, 1918: “In every township and -vil-
lage of our countries, stricken heroes of the war will dwell for the
next half century. The figure of youth must go one-footed, one-
armed, blind of an eye, lesioned and stunned, in the home where it
once danced. The half of a generation can never again step into the
sunlight of full health and the. priceless freedom of unharmed
limbs.” ’

Before so tragic a picture of the ruin wrought by war, the heart
at first utterly fails. But youth still has some gifts and many powers,
the more to be cherished because of what is gone. Science, educa-
tion, charity in the Bible sense, gratitude for heroic sacrifice must
rise up together to work for the stricken ones who return to our
shores. Ours is the task of teaching them to look not at what is lost
but at what remains and of helping them so to use the unharmed
faculties and muscles that they shall become not mere onlookers but
active participants in the great battle of life. There will be those
disabled through amputation, through loss of sight or hearing,
through facial wounds and through neuro-organic or neuro-psychic
wounds, and many others who must have special care and training.

France and Britain recognized their. responsibility in this field
early in the war and we, the newcomers, may well learn from them
and Belgium the lessons that four years of experience have taught
with the idea of ascertaining what is the utmost we can do toward
the physical and economic rehabilitation of those who return to us
cripped and maimed.

Terribly significant is the fact that no country now at war per-
mits the publication of official statistics as to the number of amputa-
tions performed, but in every center where the wounded are treated
one hears the same story. Early in the war there was much sacrific-
ing of limbs which more recent developments indicate could have
been avoided. Even with the improved methods now in vogue there
is necessarily a large amount of amputation, and public sentiment
is being aroused to solve the problem of how to give to those who
have suffered loss of limb such aid—surgical, mechanical, and educa-
tional—that they may be returned to the ranks of the self-support-
ing. To this end, there must be the closest cooperation between the

161
162 REEDUCATION FOR THE DISABLED.

surgeon, the artificial limb maker, and those who shall be entrusted
with the economic reeducation of men who are unable to resume
their prewar occupations. In deciding the point at which a limb
should be severed, the good surgeon will bear in mind not only the
question of the speedy healing of the wound, but the type of arti-
ficial limb best adapted to the needs of the patient in his future oc-
cupation and the kind of stump which is necessary for the fullest
use of such apparatus. Comparatively few of our surgeons now car-
ing for the wounded are fully informed as to the work in reeduca-
tion already being done in France and Great Britain, and the first
step which should be taken by those in authority should be the im-
mediate disseminating of this information among our Army and
Navy surgeons and hospital corpsmen. The inspiration which will
come to them through a full realization of the possibilities in the
future for the disabled men will enable them to encourage and cheer
the patients and bring an atmosphere of hope to replace the dark-
ness of despair which comes when a man looks forward to a future
of enforced idleness and dependence. The psychological effect can
hardly be overestimated and the earlier in his convalescence that a
patient is furnished with provisional apparatus, taught to use it and
his unharmed muscles to the fullest extent, and aided and encour-

aged in selecting a new trade or profession in case he is unable to

take up his prewar occupation, the more quickly will he recover

physical and mental health,

As stated in another part of this report, fis subject of the con-
struction of artificial limbs has been given much consideration and
study by all of the warring nations, and each has produced apparatus
more or less satisfactory. The American Red Cross has perfected a
leg with a centrally controlled knee, which is generally considered
the best so far evolved. It is lighter than the others, and has better
action at the knee and ankle, and some motion at the junction of the
toes and tarsal bones. The English arm is considered best for the
workingman as it is stronger and lighter, while for clerks the more
complicated French arm is better adapted.

For years there will be much work in this field, as we must
furnish not only the best possible provisional and permanent appa-
ratus, but also keep these artificial limbs in repair. There is some
question as to whether this should be done for the Government by
private enterpise, or whether the Government should establish cen-
ters under its own control. Whichever course is pursued, it is im-
perative that the limbs be made and fitted by skilled workmen at
the center where the patient is, in order that there may be close
cooperation, as said before, between the surgeon and the artisan.

In former days men, who had lost limbs in the service of their
country, were given such surgical treatment and meager equipment
 

 

Hospital Bon Secours, Rouen. Physical training of mutilés.

 

 

 

 

 

Lord Mayor of London and group of delegates at the Interallied Conference, London, May, 1918,

162-1 .
 

 

L. C. Cook, aged 29, wounded at Verdun, Both forearms amputated.

 

 

 

 

 

L. C. Writes legibly by means of. wooden hand and jointed thumb
after a three months’ course of reeducation.
162-2
I. FUNCTIONAL REEDUCATION. 163

in the way of artificial limbs as the times afforded, and then turned
back upon'the community with a pension or placed in a soldiers’ or
sailors’ home.

In our day no enlightened nation would be satisfied with so limited
a course. Economically, the waste of man power would be unthink-
able; ethically, the failure to recognize a wider responsibility
would be inexcusable. The heart of the world, stirred by the
tremendous ‘sacrifice that youth is making, demands that such poor
reparation as is possible be made. In addition to surgical care and
artificial limbs, the disabled man must be given, first, functional re-
education, in order that he may make the best. possible use of the
unharmed muscles and of the new prosthetic apparatus; and, second.
vocational reeducation in order that he may become economically in-
dependent in case he is not able to return to his former occupation.

I. FUNCTIONAL REEDUCATION.

Experience in England and elsewhere has already shown that it
is unwise to leave this reeducation to the time after the wounds have
entirely. healed and the patient is ready to leave the hospital.
Habits conducive to permanent helplessness and reliance on others,
difficult of eradication, have then been formed, and the self-
assertion and energy of a man who has once resigned himself in
despair to what he deems his lot as a war cripple, are not: easily
aroused for the overcoming of his infirmities. It is important to
prevent this more or less subconscious psychic adjustment to the
supposedly inevitable, and thereby to keep the man’s will power at
a high standard. There is not much more to be done with a broken
spirit than with a broken back. We must remember that it is a
human trait, fostered by generations who have extended pity to the
maimed and crippled, to exaggerate rather than to make light of a
loss of bodily health and strength.

This attitude of weak sentimentality toward invalids of all kinds
requires changing, in their own best interest. While it is never a
disgrace to be sick or disabled, it is one to remain unnecessarily a
burden to the community. In our enlightened days, much can be
and is being done to save our gallant soldiers from the gloomy fate
of crippled war veterans. ,

Excellent suggestions along this line have recently been offered
by Dr. M. Stassen, in charge of the work of reeducating the Belgian
mutilés at Port Villez, in France, who emphasizes and in a personal
letter repeats that this assistance ought to begin in the hospitals at
the front immediately after the infliction of the wound or the per-
formance of an operation, without waiting for anatomical repair
and consolidation of broken bones. It is during this period of en-
164 I, FUNCTIONAL REEDUCATION.

forced inactivity thut the prospects of a final cure, with functional
efficiency, are often seriously damaged or even entirely lost by the
patient’s acceptance of what he deems a hopeless struggle against
overwhelming odds. ° Of special bearing on the ultimate outcome is
the loss of muscular tonus in the fleshy. coverings of the affected
limb, in consequence of its functional disuse. The only remedy
against this insidious deterioration, and incidentally a permanent
loss in working capacity, is functional reeducation through the me-
dium of work. ;

.For the welfare of the disabled soldiers, this functional reeduca-
tion must not be postponed until anatomical consolidation has actu-
ally occurred. The educational treatment should begin directly
after the traumatism or the curative intervention. Early mobiliza-
tion is often of well-nigh the same importance in the treatment of
war wounds as is wound sterilization. We improve the nutrition of
the damaged limb by determining a healthy flow of blood to the
part, and thereby activate the process of. repair.

The correct application of work as a therapeutic measure for dis-
abled groups of muscles naturally presupposes familiarity on the part
of the physician in charge with the corresponding laboratory methods
and mechanical manoeuvers.

The method of immediate active mobilization finds a promising
field in a great variety of cases, such as amputations, fractures, in-
juries of joints or soft parts, etc., briefly, in the majority of all the
ordinary wounds of war. Soldiers with injuries of the nerves or
blood vessels, of the spinal cord and cranium, no matter how seriously
disabled, will, with few exceptions, be likewise benefited by prompt
functional utilization of all those muscular groups which have
escaped destruction.

Postoperative treatment should be carried out under the collabora-
tion of the operating surgeon, the bactericlogist, the mechano-thera-
peutist, and the specialist in prosthetic appliances. A very responsi-
ble part of the treatment devolves upon the physician charged with
persuading the patient that his injured limb can and should be used
from the first hours following the traumatism or operation. The
patient must be taught the performance of the active movements
needed to maintain the teamwork of the muscles and tendons as well
as to preserve the suppleness of the articulations. Willing and in-
telligent compliance with these instructions is equivalent to the best
possible functional utilization and reeducation of the limb. Simple
and easily renewable prostheses should be provided and fitted within
the first few days, thereby facilitating the functional activity to the
highest possible degree.

Exercise rooms and laboratories of this type should be under the
direction of experienced physicians capable of prescribing the work-
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164-1
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164—2
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164-4
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164-5
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164-7
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164-8
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164-9
 

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164-10
 

Belgian reeducational school for war cripples, Port Villez.
Linotyping.

164-11
 

 

 

Agricultural school, Juvisy.

 

 

Agricultural school, Juvisy. Group of men who were farmers before the war. They “are

unfit for farm labor because of paralysis of the hand.

164-12

Reeducation for light work.

 
I. FUNCTIONAL REEDUCATION. 165

jing movements adapted to the different groups of disabled soldiers.
For example, there exists: a special series of selected and graded
working exercises for those who have lost an upper extremity; an-
other series is destined for resections of the elbow or shoulder, etc.
Special walking and marching exercises, on peg legs, have been
«devised for cases of amputation of the lower extremity.

This physio-therapeutic method of treatment is distinct from the
workshops which have been established for the vocational reeducation
* of the wounded, either to refit them for their occupation before the
war, or to train them for other work, according to their personal in-
clinations or the exigencies of their physical condition. The mechani-
cal movements under present consideration have no vocational but
simply a therapeutic bearing. The selection of the curative exercises .
is governed exclusively by the lesion itself and aims at insuring the
best possible working capacity of the man on his return to civil life.

The beneficial influence exerted by immediate active mobilization
and functional utilization on the course of the injuries themselves is
such as to reduce to mere accessories the ordinary mechano, electro,
or hydro therapeutic methods of treatment.

Functional reeducation by work hastens consolidation in severe
fractures, and the shattered limb accordingly reaches its permanent
condition earlier than otherwise, with the result that the patients can
be equipped proportionately sooner with their definite prosthetic ap-
paratus, and can then be evacuated from the hospital to the institu-
tions for vocational reeducation. Here it will prove advantageous
and even indispensable, at least for certain groups of cases, to con-
tinue the functional reeducation started in the hospital.

In the Port Villez Military Institute, under the direction of Dr.
Stassen, courses of general gymnastic exercises and reeducation in
walking have been established for trephined patients with hemi-
plegia or paraplegia, as well as for cases of spinal cord lesion, etc.
Patients with sutured nerves, which heal very slowly, are also given
the benefit of routine reeducation exercises under medical supervision.

For the maintenance of the results achieved by functional reeduca-
tion Dr. Stassen has arranged a course in general gymnastics for men
whose lower extremities have been amputated. Under the direction
of an Army officer rapid marches are frequently made with the arti-
ficial limbs. Men whose upper extremities are paralyzed or have
been amputated likewise take a course in general gymnastics. An-
other course, for the utilization of artificial so-called “automatic
arms,” under the direction of amputated men who are experts in the
use of their prosthesis, is now under contemplation. For hygienic
reasons, courses in physical reeducation are soon to be extended to
mutilated men following sedentary occupations, such as shoe and

harness makers.
166 Il. VOCATIONAL REEDUCATION.

An attractive adjunct to this system of physical reeducation con-
sists in a large hall and open grounds for the enjoyment of games,
outdoor sports, and similar healthful activities.

II. VOCATIONAL REEDUCATION.

In repairing the ravages of the war probably no measure will
make a stronger appeal to the sympathies of the American people
than this one of vocational reeducation. If by reason of injuries
received in the service of his country a man is debarred from return-
ing to his former occupation, he must be given every opportunity
to learn some other trade or profession which will enable him to
become at least self-supporting.. The welfare of the Nation no less
than the welfare of the individual demands it.

While the general public in this country is not yet fully awake
to the need of taking energetic steps to prepare to meet the require-
ments in this field, small beginnings are being made in various
centers, and the periodicals of the country are giving considerable
space to the question of what must be done. The old feeling that
these unfortunates should be hidden away in obscure corners has
given place to the belief that by facing the question squarely and
inviting public discussion and cooperation much can be done toward
bettering their condition and returning them to useful occupations.
Much propaganda work is needed to enlighten those at home as
well as those in the field as to what has been accomplished by the
other warring nations, and by means of moving pictures and other
publicity agents the interest of the people should be stimulated, in
order to eradicate the present tendency to regard thos. suffering
from loss of limb as permanently out of the ranks of labor. To
this end the Red Cross has epitomized for us in four cinema reels
the work that is being done in restoring to economic independence
the disabled, and these reels are herewith presented to the Navy
Medical Sichoot.

The French Government has found it advisable to institute a simi-
lar campaign of education in order that not only the general public
but the mutilés themselves may learn of the work that, i is being Hone
in this field. At the cinema a few pictures are “sandwiched in,”
and the official army photographers have prepared many photographs
of mutilés actually at work.

In Europe almost from the beginning of the war the importance’
of reeducation has been recognized. Two interallied conferences
have been held to consider the “Aftercare of disabled men,” the last
of which I was privileged to attend, in May, 1918, when delegates
from Belgium, France, Great Britain, Italy, Portugal, Serbia, Siam,
 

 

 

 

Grand Palais, Paris.

 

 

Tinsmith workshop at the Grand Palais.

166-1
 

 

Shoemakers’ workshop at the Grand Palais.

 

 

 

Carpenters’ workshop at the Grand Palais.

166—2
 

 

“The Boarding School,’’ 28 Quai Debilly, Paris.

 

 

 

 

Front of institute on Quai Debilly, Paris,
166--3
 

 

 

 

 

Bookbinders' shop, Quai Debilly.

 

 

 

French course, Quai Debilly.

166-4
 

 

 

 

 

Crippled Serbians preparing vegetable garden.

 

Ecole Professionnelle des Mutilés, Tourvielle, Lyon. Fur industry workshop. This is an
unique industry as applied to retraining of war cripples.

166-5
 

 

 

Ecole Professionnelle des Mutilés, Tourvielle, Lyon. Mutilé wearing mechanical-arm
apparatus and carving wooden shoes.
166-6, -
re II. VOCATIONAL REEDUCATION. 167

United States, and the British overseas dormminions met and discussed
the work being done in their several countries.

A monthly ‘magazine, the Revue Interalliée, is being published,
devoted to the study of questions relating to war cripples, and the
American Red Cross, always alert to encourage and carry on any
enterprise which will be of benefit. to mankind, has organized in
France a bureau for reeducation of mutilés, under the charge of Miss
Grace Harper, ‘and is aiding and supplementing the work of the
French. The Union des Colonies Etrangéres, largely composed of
Americans, has also taken an active part in the development of these
measures, and hundreds of centers have been established where
reeducation is being carried on.

Through the foresight and vision of M. Edouard Herriot, mayor
of Lyons, France, was the first country to recognize ‘officially the
wisdom and necessity of training its mutilés to become self-support-
ing. <A little over three months after war was declared, M. Herriot
proposed to the city council that it should. organize a school where
men incapable of resuming their prewar occupations should be
taught new trades.’ On December 16, 1914, the school, called the
Ecole Joffre, was opened with three mutilés as pupils. By May,
1915, it was full to overflowing, and an annex was opened at Tour-
vielle, just outside the city. The work at these centers is descrjbed
more in detail later herein. Well may the city of Lyons be proud
of the initiative and progressive spirit. which have made it the leader
in this and other fields of war usefulness!

Shortly after the organization of the Ecole Joffre, the French
National Government took over the National Home for Convales-
cents and Industrial Cripples at St. Maurice, on the outskirts of
Paris and converted it into the National Professional Institute for
War Cripples. It has been made a model school, capable of training
300 men, under the direction of Dr. Maurice Bourrillon, one of the
foremost experts in this field of education.

Over 100 other centers have been established in France, some
through private initiative and others through the use of civil schools

_adapted for professional reeducation. They are scattered through-
out France and vary greatly in the. number of pupils accommodated
and the training given. This has resulted in a lack of uniformity
in methods and standards, and in establishing our own centers we.
should profit by the lesson and see that under Government adminis-
tration they all have the same high standard.

Some indication of the number of disabled who require such train-
ing may be gained from the fact that between June 30, 1916, and
July 1, 1917, over 17,000 French mutilés completed courses in these
schools. This does not include British, Belgian, or Italian soldiers.
168 Il VOCATIONAL REEDUCATION.

In Great Britain also this work had its inception through philan-
thropic enterprise, the Soldiers’ and Sailors’ Help Society opening
workshops in London, and later throughout the country, for the
employment of disabled men. They were called “ Lord Roberts
Memorial Workshops.” Later the Government took up the question
of systematic reeducation, and the royal warrant of 1917 provided
in detail for pensions and occupational training. The numerous
trade and technical schools throughout Great Britain are being
utilized in this work, the cost of tuition being defrayed by the
Government, and the disabled soldier or sailor is now cared for from
the time he is wounded until he is again, if possible, established in
civil life as a trained worker.

Belgium, Italy, and the British colonies are likewise engaged in
solving the same problem, while Germany, with its preparedness,
had the matter excellently in hand long before any other country.

In order to learn at first hand what was being done in France,
where this work has reached its greatest, development, I visited a
number of the leading centers, and, through the courtesy of the
American Red Cross in Paris, made a trip of inspection in company
with Miss Grace Harper, chief of its bureau for reeducation of
mutilés, to certain institutions which she chose as those from which
I could learn the most in the short time at my disposal. They were:

Institut National Professionnel des Invalides de la guerre at St. Maurice,
near. Paris.

Maison Blanche, at Neuilly-sur-Marne.

Ecole Nationale Belge des mutilés de la guerre, at Port Villez.

FKeole Joffre and Tourvielle, at Lyons.

Hospital No. 40, French Army, at Lyons.

Ecole de l’Union des Colonies Ktrangéres, Grand Palais, Paris; Quai Debilly,
Paris; Hétel des Invalides, Paris; Juvisy Farm. , ‘

A special car was placed at my disposal and all arrangements were
made in advance for our trip. Everywhere we were received with the
greatest courtesy and attention and had the work of the various insti-
tutions explained in detail. Miss Harper has been in charge of the
American Red Cross bureau for the reeducation of mutilés for over
a year, and her thorough acquaintance with the work made it possible
for me to see much in a short space of time.

ST. MAURICE.

We left the hotel in Paris early in the morning of March 18 and
motored to St. Maurice, 30 kilometers away, where we were received
by Dr. Maurice Bourrillon, the director of the institution. Before
the war this was the national home for convalescents and the national
asylum for industrial cripples. It was therefore peculiarly well
adapted for its present use, and Dr. Bourrillon, for many years in
 

 

No. 1.—National Institute for War Cripples, St. Maurice, Paris. Machine shop.

 

 

 

 

 

No. 2.—National Institute for War Cripples, St. Maurice, Paris. Tailoring shop.

168-1
 

 

 

 

 

 

No. 3.—Machine shop at National_Institute for War Cripples, St. Maurice, Paris.

 

 

 

 

 

 

 

 

No. 4.—Mutilés receiving instruction in stenography and typewriting, National Institute for
; War Cripples, St. Maurice, Paris.

168-2
Il. VOCATIONAL REEDUCATION. 169

charge of the training of the disabled industrial workers, is one of
the foremost authorities on the subject. Through private beneficence
the institute was enlarged after the war began, and now it has 750
patients under treatment for deformities of all kinds and provi-
sion for the vocational training of 300, many of the latter still under-
going treatment while learning trades, The hospital section is thor-
oughly equipped for restorative work, having departments for hydro-
therapy, mechanotherapy, and uleetrothemipy, etc. The patients who
are having industrial training spend an hour or two a day in receiv-
ing necessary treatments tending to increase functional activity and
devote the balance of the day to the vocational training. Dr. Bour-
rillon advises and guides the men in selecting the line of work for
which they are best qualified. Shoemaking, tailoring, leather work,
harness making and repairing, machine work, bookkeeping, mechani-
eal drawing, industrial design, farming, and many other branches
are taught. Instruction is being given in the repair of farm and
automobile machinery. This course in farm mechanics takes from
five to six months and gives the pupils a thorough understanding of
gasoline and electric motors for farm use and their repair. ‘The
American Red Cross has recently donated a tractor for training
purposes, and at the time of our visit was erecting two buildings, one
for instruction in wireless telegraphy, the other for all kinds of elec-
trical work. Before the war the Germans had a practical monopoly
of such work in France, and therefore an excellent field is now
opened up for the men who are being instructed in this branch.

We saw the men busily engaged in these various industries, and
found them cheerful and apparently interested. We were told that
ihe average length of time required for each of the various industries
is as follows: Bookkeeping, 4 months; tinsmithing, 6 months; shoe-
making and agricultural mechanics, 8 months; harness making, 10
months; and a year for primary instruction for the illiterate, as well
as industrial design. The men are paid a franc a day while learning,
and; if they have saved their wages, are given a small bonus when
they leave. They are also provided with a full set of tools, sometimes
costing as much as 500 francs, and thus equipped are ready to start life
again. «

The school gives diplomas when courses are completed and places
the men in positions. With labor at a premium, this is at present an
easy matter.

Miss Harper has recently published a “Report on Professional
Reeducation for War Cripples in France,” which gives many details
relating to this institution, particularly as to administration, etc.,
which are most instructive and valuable.

93696—19——_12
170 II. VOCATIONAL REEDUCATION.
MAISON BLANCHE.

From St. Maurice we motored to Neuilly-sur-Marne, where the
Maison Blanche is located. This is one of four centers for reeducation
organized by the Union des Colonies Etrangéres,.a group of foreign
residents in France, including members from all of the allied and
neutral nations who have raised large sums for the establishment
of schools for French soldiers. The others are at the Grand Palais,
in Paris, where many of the patients are injured and deformed; No,
28 Quai Debilly, Paris; and Juvisy Farm, about 10 miles south of the
French capital. At Maison Blanche most of the pupils come from the
adjoining convalescent depot for amputation cases.

Before the war the buildings were used for an asylum, but through
the beneficence of an American 700,000 francs were procured for the
enlargement of the plant. While there is provision for 350 pupils,
there are many vacancies. This is true in practically every center of
reeducation, and the main reasons are said to be:

(1) The natural desire to return home at the earliest possible
moment.

(2) The ease of obtaining employment in war industries and the
like, owing to present lack of labor.

(8) Hope of obtaining a Government position (preference being
given to wounded soldiers in many lines).

(4) Fear of a decrease in pension owing to increase in earning
capacity. (This is unfounded, but belief in it is widespread among
the French soldiers.)

The mutilés come here not for treatment (except in so far as any |
manual training will improve the physical condition) but for voca-
tional training. Dr. Hubert Kresser is the director and in charge
of the work. There are 50 acres of land under cultivation by the
mutilés, whom we saw at work, some with artificial arms and many
also with artificial legs. Scores of these men are working in the
grounds and even operating machinery. Gardening, basketry, draw-
ing, bookkeeping, stenography, and typewriting are taught, as well
as many other branches.

 

PORT VILLHZ.

On the following day, after a delightful motor trip along the
Seine, we reached Port Villez, near Vernon.

This institution is for the reedueation of the Belgian mutilés, and
is under the supervision of the Belgian military authorities. It was
erected on land presented to the Government by a Belgian gentle-
man and is beautifully located. The buildings are wooden “ huts”
with double walls and cement foundations. There is a steam saw-
 

 

 

 

Maison Blanche, Farmer, age 23 years, wounded at Verdun. Both
thighs amputated very high. After six months’ reeducation is able
to support himself as a basket maker.

 

 

 

 

Maison Blanche, agricultural division. Haymaking time.
170-1
 

 

Maison Blanche. Mechanic, age 25 years. Wounded at Rheims: left forearm amputated.
After one month's reeducation begins work at the vise.

170-2
II. VOCATIONAL REEDUCATION. 171

mill, carpenter shop, garage and repair shops, poultry yard, stables,
and a large garden. Dr. M. Stassen, formerly practicing in Liége
and in charge of the surgical work in connection with a large in-
dustrial center there, is medical director of this institution. He re-
ceived us most cordially and took pains to show us the work in
detail. This is a splendid plant and is doing great work. Within a
year after its completion, 1,200 men were being trained here.

In the medical departments functional reeducation is carried on
systematically. I have already referred to Dr. Stassen’s excellent
work along that line. While this functional reeducation i is proceed-
ing, a man begins a course of general schooling, being classified ac-
cording to his preliminary education, and also takes up such branch
of technical training as he may select. The workshops fill orders
for the Belgian Government and the men are paid half a franc or a
franc per day while learning. There are courses in toy making,
wood carving, leather work, mechanics, plumbing, electrical work,
wireless telegraphy, shoemaking, tailoring, saddlery, typesetting, en-
graving, dairying, truck gardening, and in all the commercial lines.
The accompanying pictures give a far better idea of the scope of the
work than can mere words.

Considerable success has been attained in teaching massage to the
blind. They learn the positions of the muscles by means of wax
casts with the muscles elevated. This has been found to be a par-
ticularly satisfactory field of work.

 

i
GRAND PALAIS, PARIS.

!

This great art center, occupying a full square on the Champs
Elysées, has been taken over by the French Government and has
been made the model center of physiotherapy in France. In connec-
tion with this hospital, the Union des Colonies Etrangéres has or-
ganized a school for the industrial reeducation of the disabled.

Nowhere is the work of coordinating. functional and vocational in-
struction more successfully carried out. It is an inspiring example
of French activity assisted largely by American money. The hospital
is excellently equipped, having departments for hydrotherapy, me-
chanotherapy and electrotherapy, everything which modern science
can suggest for making over the damaged body. The guiding prin-
ciple is to use the muscles and nerves to the fullest extent, increasing
‘the work as the strength returns, and inspire the patients to ever
greater effort. And while ‘this physical develpoment is going on,
many patients are learning trades and professions, and the mind, as
well as the body, is being encouraged to work.
172 IJ. VOCATIONAL REEDUCATION.

In a great central court the general and special exercises are carried
on. There is every variety of apparatus, in the use of which the men
are instructed, and equipment for games and sports. Mechano-
therapy alone, however, is not sufficient and must be supplemented
by hot air, steam, electricity, massage, etc., which have been highly
specialized by the French. Blind soldiers who have been trained
through the use of plaster casts work in the massage department
under supervision. Whirlpool baths are used extensively and highly
valued, and electrical treatments, including high frequency, galvanic
and faradic currents and violet rays are given by special nurses under
medical direction. Radium is used quite extensively and the X-ray
is indispensable. The walls of the great halls in which these special
treatments are given are hung on one side with patriotic paintings,
full of inspiration, and appeal to the imagination. On the other
side are anatomical charts and drawings showing the gradual steps
by which the body is restored and developed from its first state of
injury until the patient is able to return either to civil or military
life. Hope, encouragement, and patriotism are infused and the
effect upon the men is stimulating.

The first treatments given are remedial, followed as soon as the
condition permits by remedial and mechanical work with special
apparatus, and later supplemented by vocational training. , The
place is a veritable beehive of activity, the men devoting two or three
hours daily to the necessary physical development and the balance
in learning trades or professions. There is provision for vocational
training for 400 patients at one time, and a wide variety of subjects
are taught, such as soap making, glass blowing, shoemaking, tin-
smithing, hair dressing, cabinet making, baskelny making and re-
pairing of artificial lin:bs, commercial branches, such as bockkeeping,
stenography, and typewriting, and some of the fine arts, portrait
painting, and sculpture, for those who display talent.

The Union des Colonies Etrangéres has also established a school
for mutilés ‘at 28 Quai Debilly, Paris, one at the Hétel des Invalides,
Paris, and a farm at Juvisy, 10 miles southeast of Paris.

At the Quai Debilly. Dr. Lines, an American, is devoting much of
his time to this work, together with M. Binnet. Weekly conferences
are held here to determine what the newcomers shall be taught, and
where they should be sent for the best training. This is a valuable
feature. About 100 pupils are provided for and many branches are
taught, but the place is largely used as a sort of clearing, house from
which the men are sent to other centers for training.

One of the problems confronting those who are engaged in this
work is what can best be done for the trephined cases. Dr. Lines
says that they are most unsatisfactory as they seem unable to be
helped much. They do not seem to fit in anywhere.
 

 

Centre d’Appareillage et de Rééducation ‘de Lyon, Hépital No. 40. Crippled Serbian,
left arm amputated, wearing special arm apparatus.
172-1
 

Centre d’Appareillage et de Rééducation de Lyon, Hépital No. 40. French mutilé who has
lost part of each arm. Pen secured by elastic band.

 

French mutilé writing by means of special apparatus which holds his pen,

172-2
II, VOCATIONAL REEDUCATION, 173

My observations led me to believe that.an attempt should be made
to repair the defect in the skull in a larger number of. these cases,
especially where the skin is adherent to the scar of the dura. (See
section on trephining.) In going through the various centers it was
also apparent that much more could and should be done to increase
the efficiency of certain of the mutilés by further plastic surgical
work. With the press of other war work, doubtless these must wait
for operative treatment until later.

At the school established in the old Hétel des Invalides, the dis-
abled are being taught drawing, painting, sign making, typewriting,
and other branches not involving much. physical effort. Many of the
patients are chronic cases and too ill to do very much.

The farm at’ Juvisy, near Paris, provides scientific training in
agriculture, stock raising, and machine work. It is an excellent
.and well-conducted center and one which is doing most valuable
work, for after the war France will need trained agriculturists more
than almost any other class of labor.

These are but a few of the centers:in France where educational
work is being carried on and prosecuted vigorously even in the midst
of the conflict.

In Great Britain, as said before, the training is being largely
undertaken in connection with the trade and technical schools, but
this is possible only because of the vast number of such schools
scattered throughout the country. Special centers for teaching the
blind, such as St. Dunstan’s Hostel and its annexes, are achieving
great success. In addition to being taught to read Braille, the men
learn many special occupations, such as telephone operating, type-
writing, massage, basketry, mat making, and poultry farming.

In our own country, using the Grand Palais as a model, such
centers should be established as will combine the most advanced
metheds of functional and vocational reeducation. The value of
beginning the latter while the patient is being taught the former is
summed up by the experience of France and Great Britain as
follows:

(1) Manual work of some kind is chief among the therapeutic
agents in restoring functional activity and preparing the stump to
use fully the artificial limb.

(2) An interesting occupation tends to restore a normal frame of
mind and eliminate moroseness and brooding. ,

(3) In the selection and fitting of an artificial limb, the surgeon
and instrument maker will be greatly aided by Imowledge of the
special line of work which the patient intends to take up.

(4) After a man is discharged from a hospital and returns home,
it is difficult to get him to return to a school for vocational training.
The tendency is for him to become demoralized through the pity
‘

174 II. VOCATIONAL REEDUCATION.

and adulation of his family and friends and to take the attitude
that nothing more should be expected from a man who has sacrificed
so much for his country. The insurance to be paid by the Govern-
ment will seem to many of these sufficient for their maintenance
without further effort.

(5) Time is saved and the disabled man becomes a pees
factor at an earlier date.

The advice or suggestions of those who are leading in this work
would be that while such schools must probably be under military
discipline, this should be camouflaged as completely as possible.
It should be borne in mind that these men are broken in body beyond
complete repair and their future looks most gloomy and dark. They
are sick of military routine and resent control. Everything possible
should be done to cultivate an atmosphere of cheer and hope. The
schools should be near enough to a town or city for entertainment
and as much liberty granted as is possible. In selecting the sites it
is wise to have not only good sanitary surroundings but, as far as
possible, beauty of outlook. The centers themselves, in addition to
thorough equipment in every department, should be made homelike
and attractive, with amusements and games of many kinds provided.
Only thus can the greatest amount of physical and mental health be
restored to war cripples.

Miss Harper’s report on professional reeducation, above men-
tioned, contains many suggestions which will be found valuable to
those who are considering the system of control and the plan and
scope of this work.

ECOLES JOFFRE AND TOURVIELLE, LYONS.

As noted before, the Ecole Joffre was the pioneer in this field in
France, having been opened with three pupils in December,
1914, through the efforts of M. Herriot. So rapidly did it grow
that in 1915 an annex was opened, the Ecole Tourvielle, in
the suburbs, and the two schools. now accommodate 365 men.
Ecole Joffre, in the city, now specializes in commercial training,
bookbinding’ and in the manufacture of toys, while the Ecole
Tourvielle, with its charming country. surroundings, teaches horti-
culture and many industrial pursuits. M. Gustave Hirschfeld is the
director of the Tourvielle school, and is an authority on the subject
of reeducation. The pupils are not undergoing any surgical treat-
ment, but devote their entire time to vocational training. There is
no military discipline, and the men appear happy and busy. Ifa
man’s conduct is not satisfactory he is dismissed from the school.
At Tourvielle tailoring, fur-making, shoemaking, cabinet work, wire-
 

 

Centre d’Appareillage et de Rééducation de Lyon, Hépital No. 40. Mutilé cutting grain,

 

 

 

 

Centre d’Appareillage et de Rééducation de Lyon, Hépital No. 40.
Arm amputated above the elbow. Mechanical apparatus adjusted
to a scvthe.
 

 

 

 

Centre d’Appareillage et de Rééducation de Lyon,
Hépital No. 40. Mutilé using a scythe by means
of a mechanical-arm apparatus.

174—2
II, VOCATIONAL REEDUCATION. 175

less telegraphy, etc., are taught. The men are paid 1 franc a day
while learning, and the profits from the sale of the products of each
shop are divided among the workers.

 

HOSPITAL NO. 40, FRENCH ARMY, CENTRE D’APPAREILLAGE ET DE
REEDUCATION, AT LYONS.

After leaving the Ecole Joffre, we visited hospital No. 40, under
the Service de Santé of the French Army. This is a large center,
and we were accompanied on our inspection by the chief surgeon, Dr.
Chatin. Here Serbians, as well as French, are being reeducated.
We also visited one of their large farms, just outside of the city.
The men are instructed in farm and garden work and many inter-
esting examples were seen of special apparatus adapted to the partic-
ular needs. Cabinet work is taught and the blind learn massage.

We saw an Algerian, blind and having lost both arms. When the
American money, came that was to double the pension of the blind,
he requested that it be allotted to his aged mother in Algeria.

Another man, with his right arm shot away above the middle, is
being given special aid by the Red Cross in drawing, as he shows
talent. This policy of helping in selected cases has been adopted
by the American Red Cross, and is warmly appreciated by the
French.

Later we visited the University of Lyons, where there is an exhi-
bition of war surgery, showing wonderful examples of plastic work
and special apparatus invented by Julien and Lumiere, the latter of.
whom invented colored photography. Lyons is justly proud of these
men and of its pioneer work in the field of reeducation.

At the Neurological Institute, which we also visited, they are treat
ing cases of shell shock and nerve disorders. Toy making is taught
in order to give light and interesting occupation and to divert the
minds of the men.
 

 

 

Centre d’Appareillage et de Rééducation de Lyon, Hépital No. 40. Crippled Serbian, right
arm amputated, operating a plow.

 

 

This machine has a seat especially adapted to the driver, who has: had one leg amputated.

176-1
 

 

 

Mutilé driving a plow by means of a mechanical arm replacing amputated limb.

 

 

Manipulation of muscles and joints by blind war cripples. Functional reeducation at Centre
d'Appareillage et de Rééducation de Lyon, Hépital No. 40.

176-2

 
CONFERENCES OF SURGEONS.

The undoubted value in peace times of meetings and conferences
of physicians and surgeons for the purpose of comparing methods
and results is greatly increased to-day by reason of the war. Surgery
and medicine are learning many valuable lessons and the fighting
forces should have the immediate benefit thereof.

To this end the American Red Cross, through Major Alexander
Lambert, chief surgeon, has organized a research society, open to all
physicians and surgeons of the allied nations, which meets monthly
in Paris, and through papers, discussions, and demonstrations seeks
to keep its members closely informed. A journal is published
monthly giving the substance of the matters discussed, and a medical
library has been established at 12 Place Vendome, Paris, where many
of the latest medical books and papers are to be found. Upon request,
these are loaned to the various base hospitals.

With the same object in view—that is, the discussion and dissemi-
nation of all new ideas in the fields of war medicine and surgery—
the inter-allied conferences of surgeons were inaugurated. Delegates
from all of the allied countries meet and exchange views and publish
their conclusions. There have been four such meetings, and the
conclusions of the first and second conferences are annexed hereto;
also preliminary outlines of the conclusions of the third and fourth
conferences. The full reports of these two have been promised, and
when received will be forwarded to the Bureau of Medicine and
Surgery.

These conferences have been very valuable and helpful. However,
as the speed. of a convoy is that of the slowest vessel, so the formal
conclusions of a conference are limited to those facts which have been
established to the satisfaction of the most conservative member. In
general it is well that, this should be so, but in this time of great need,
when we are reaching forward eagerly toward anything which prom-
ises to be of assistance, it seems advisable also to keep in touch with
the newer developments and not wait to try them until their value
has been proven through long use. For this reason many of the ideas
which are still in the experimental stage have been described in this
report although not as yet indorsed by the inter-allied conference.

117
178 TREATMENT OF WOUNDS OF WAR.

GENERAL PRINCIPLES GUIDING THE TREATMENT OF WOUNDS OF WAR,’

I. THE GENERAL PRINCIPLES WHICH SHOULD GUIDE THE TREAT.
MENT OF THE WOUNDS OF WAR, ESPECIALLY WITH REGARD TO
THE PREVENTION OF INFECTION AND THE DISINFECTION OF THE
WOUND.

1. The medical service should be organized in such a manner as to
-provide for continuity in the treatment of the patients.

2, At the first-aid posts and to a still greater degree in the trenches,
surgical intervention should be reduced to a minimum. . It should
be restricted to dealing solely with complications likely to prove
promptly mortal, and to protecting the wounds from contamination.
Wounds at this stage should never be explored or washed, but simply

covered with a dry aseptic or antiseptic dressing.

3. It is essential that the patients be transferred as quickly as
possible to a field ambulance or casualty clearing station 10 to 20
kilometers from the front.

4. It is of great advantage to establish in connection with the
casualty clearing stations one or more special hospitals nearer the
front, for the reception of the most serious cases (those of severe
shock, grave hemorrhage, and wounds of the thorax and abdomen)
at the earliest possible moment. .

5. Speaking generally, every wound of war should be regarded &
either contaminated or already infected.

6. The aims of treatment should be:

(a) To prevent the development of infection if the wound is
merely soiled, or to sterilize it if infection has already developed.

(6) To close the wound secondarily by suture when “clinical”
sterilization has been obtained.

7. The general rule governing the treatment should be free open-
ing up of the cavity combined with resection of all contused and con-
taminated tissues, and removal of all fragments of clothing or other
foreign bodies. No deviation from this rule is justifiable except in
certain instances of apparently clean wounds, and then the closest
after attention is essential.

8. The procedure above outlined (7) may be followed in some
instances by primary closure of the wound, notably in the case of
wounded joints. Primary suture is only justifiable when the wound
is of some hours’ standing only (at the most eight hours), and under
circumstances which allow the patient to remain under the observa-
tion of the same surgeon for 15 days.

9. If primary closure be not attempted, secondary suture should be
performed, when the “clinical” sterility of the wound appears to
warrant it.

oe

 

1 Conclusions adopted by the Inter-Allied Surgical Conferences held in Paris, March
and May, 1917, delegates from Great Britain, Belgium, France, Italy, Japan, Portugal,
and Serbia being present. Published by His Majesty’s Stationery Office, London, 1917.
 

 

Centre d’Appareillage et de Rééducation de Lyon, Hépital No. 40. Shoemakers’ shop.

178
TREATMENT OF WOUNDS OF WAR. 179

10. The progress of the wound should be systematically controlled
by a series of bacteriological examinations; thus, a bacterial chart
may be usefully constructed and the degree of sterility determined.

11. When circumstances demand the prompt evacuation of patients
after the primary cleansing operation, a form of dressing capable
of providing a continuous antiseptic action during the period of
transport is desirable.

Further researches in the direction of the most suitable form of
dressing are highly desirable.

12. Several methods of progressive sterilization of the wound are
available, which permit of habitual resort to the method of secondary
suture.

II. THE PLACE OF LABORATORY METHODS AS AIDS TO THE SURGEON
IN DETERMINING THE ADVISABILITY OF ACTIVE INTERVENTION.

1, An experienced bacteriologist should be attached to every surgi-
cal unit of importance, together with capable assistants and a prop-
erly equipped laboratory.

2. In the treatment of wounds of war intimate collaboration is
necessary between the surgeon and the bacteriologist. The latter
should observe the patient’s wounds himself, and discuss with the
surgeon the researches to be made and the course that should be
taken. .

3. The researches likely to prove most generally useful are bac-
teriological, cytological, and humoral.

4, The researches should not be restricted to a narrow scope, but,
as a general rule, the following directions are suggested as likely
to prove fruitful:

(@) The bacteriological condition of wounds immediately after their inflic-
tion.

(bo) The bacteriological condition of wounds before and after surgical inter-
vention, also before and after a prolonged period of transport of the patient.

(ec) The bacteriological condition of wounds which continue to suppurate, or
of those in which complications occur during the course of healing.

(d) Bacteriological control of the progress of sterilization of wounds with a
view to determining their fitness for closure.

(e) Bacteriological and biological control observations of the course of heal-
ing of wounds, made with a view to determination of the most efficacious
methods of treatment.

(f) Examinations of the blood; cultures, counts, tests of coagulability, inves-
tigation of defensive properties; the indications for transfusion of plood.

(g) Special infections of certain anatomical regions; joints, serous mem-
brane, connective tissue, muscle, brain, cerebro-spinal fluid; bacteriological
‘cytological, and humoral examinations.

(h) The general indications for, and application of, vaccine therapy.

5. In addition to these laboratories attached to surgical units to
aid in the ordinary practical treatment, laboratories for scientific
180 TREATMENT OF WOUNDS OF WAR.

research and the study of general questions of military surgery need
to be created, or where already existing to be more highly developed.

Ill. THE COMPARATIVE VALUE OF DIFFERENT METHODS OF LOCALI-
ZATION AS FACILITATING THE EXTRACTION OF PROJECTILES.

1. A complete radiological examination should be made of every
wounded man as soon as his general condition warrants it.

2. The extraction of projectiles should not be attempted in the
absence of localization by. radiology or other means.

3. In hospitals in the front lines, and especially under the press of
heavy work, radioscopic methods are the most valuable.

4, It is indispensable that the surgeon should have at hand during
an operation some one of the means of localization and control—ra-
diography, stereoscopy, electrovibrator, compass, telephone probe, ete.

5. Radiographic methods are the most useful in permanent hos-
pitals and in times of moderate work.

6. The conference draws attention to the stringent necessity of
providing every radiological installation with all the means indis-
pensable for the protection of the radiologist and surgeon from the
action of the X-rays.

IV. PATHOGENESIS AND BACTERIOLOGY OF GAS GANGRENE.

(A) Pathogenesis—Under this heading the predisposing: causes
are considered.

For the moment and from a surgical point of view the most im-
portant rdle must be assigned to predisposing causes, because cer-
tain of these are more or less amenable to therapeutic measures.
They may be divided into two classes: (a) General; (6) special.

(a) General causes.—1. Geographical distribution. The frequency
of the clinical entity known as gas gangrene is to a considerable ex-
tent dependent on the locality in which patients may be wounded. |

2. Wounds inflicted by fragments of shells and bombs are the
most dangerous variety.

(6) Special causes—1. Localization of the injury in the fleshy
parts of the limbs, especially in the lower extremity.

2. The special characteristics of the wounds, such as narrow orifices
associated with serious deep lesions.

3. The impaction of foreign bodies, especially débris of clothing,
which may carry soil with all its contaminations or fecal material
with them.

4. Extensive contusion of the tissues leading to mortification.

Other predisposing causes, although of inconstant occurrence, are
none the less frequent.

5, Severe comminution of bones, or of fractures implicating joints.
TREATMENT OF WOUNDS OF WAR. 181
\

6. The ischemia dependent on injury to large vessels, obliteration
of large vessels by ligature, or the prolonged application of the
tourniquet.

7. Multiplicity of wounds.

8. The presence of a hematoma.

9. Traumatic shock. ;

10. The risks of gas gangrene diminish in direct proportion to the
efficiency with which surgical measures are carried out, and the
promptitude with which the measures are undertaken.

11. Even when surgical intervention has been both prompt and
efficient, the occurrence of gas gangrene may be favored by too early
evacuation and transport’ of the patient; or, by the employment of
unsuitable methods of treatment, especially dressings which allow
the wound to rapidly become dry.

12. Attention should be directed to the investigation of certain
factors in the toxemia accompanying gas gangrene, especially acid-
osis, local or general. Researches in this direction may result in
the establishment of indications for treatment.’

(B) Bacteriology.—l. Researches carried out since the commence-
ment of the war have confirmed the infectious origin of the process,
and the anaerobic nature of the organisms that give rise to it.

2. Among the organisms met with, special importance should be
attributed to the vibrion septique, B. bellonensis (the exact relations
existing between B. bellonensis and B. wdematiens are not yet de-
termined) and B. perfringens.

3. The anaerobic infection is often aggravated in its effects by the
association of other microorganisms, especially the streptococcus.

4, In consonance with the general principles of bacteriology, at-
tempts should be made to cbtain sera active against the organisms
enumerated above, with a view to serum-therapy. Such sera have
been prepared, and their activity in the case of animals has been
demonstrated.

V. TREATMENT OF GAS GANGRENE.

1. Gas gangrene is most often the consequence of delayed ov in-
sufficient primary surgical intervention.

2. Prophylactic treatment is of the first importance; it includes
rapid evacuation to a surgical unit in order that proper measures
may be promptly undertaken, free exposure of the wound cavity in
its whole extent, excision of contused or sloughing tissue, removal
of all foreign bodies, and careful hemostasis.

3. When the process is localized, whether the tissues are already
infiltrated or not, the curative dreatiicne consists in—

(@) Complete exposure to the air of all deep recesses of the wound.

(0) Excision of all tissue already gangrenous or even open to suspicion.
(c) Free incisions in the zone of infiltration, and at the limit of that zone.
‘182 TREATMENT OF WOUNDS OF WAR.

4. Amputation is imperative; in the presence of acute massive
gangrene, especially when complicated by lesions of the bones, or
serious injury to the vessels; also in instances of very rapid exten-
sion with threatening general symptoms (rapid fall in tension of
the pulse, is a valuable symptom in this respect). The method of
choice is the “ flush” amputation.

When the amputation can be carried through healthy tissue, Eng-
lish surgeons prefer to fashion short flaps fixed by suture in a posi-
tion of complete eversion.

When the amputation is carried through infiltrated tissues, addi-
tional incisions should be made in the infiltrated zone, extending
upward to the limits of the limb or even on to the trunk.

5. Anesthesia procured by a mixture of nitrous oxide and oxygen
is the method of choice; failing this, ether should be preferred.

6. When secondary operations or the late removal of foreign
bodies are undertaken, the danger of reawakening a laten anaerobic
infection must be borne in mind.

To these conclusions M. M. Depage and Derache wish to add that
interstitial injections of oxygen, both superficial and deep, above
and below the wound, and sufficiently abundant to distend the in-
tegument form a useful addition to operative intervention.

VI. TRAUMATIC SHOCK.

Traumatic shock is a disturbance in functional equilibrium, char-
acterized by reactions of the depressing class, which may even extend
to death. A fall in the body temperature and in the arterial blood
pressure constitute its essential elements...

It is often associated with profuse hemorrhage, or with very acute
toxemia, which make it difficult to recognize the part which the
shock itself has contributed to the patients’ condition.

It may be caused or aggravated by pain, by exposure to cold, or
by exhaustion.

If the diastolic blood pressure remains below 60 millimeters of
mercury, independently of hemorrhage or toxemia, the patient is in
a state of severe shock, and treatment is imperatively indicated; the
sphygmo-manometer will afford useful guidance in carrying it out,
and the treatment may be summed up in the following propositions:

(a) In regimental aid posts, and in advanced dressing stations:

1. Stimulant injections, especially of camphorated oil, in doses of 10 cubic
centimeters, repeated every two hours, are often the only resources available
for the surgeon.

2. The wounded should be evacuated as far as possible in warmed carriages.

(b) In main dressing stations or clearing stations.

The position in which the patient is placed, aids to the recovery of his

natural heat, and the reestablishment of his blood pressure are the three
essential points of treatment.
TREATMENT OF WOUNDS OF WAR. 183

(1) The patient must be laid horizontal, or with the head slightly down-
ward; this position will, of course, be avoided in wounds of the chest or
brain. Compression may be applied to the limbs by a roller bandage.

(2) It is most important to get the patient warm. Care must be taken that
the surface of the body be kept in an atmosphere of about 40 C. (104 F.).

(3) The patient must be kept absolutely at rest. Every useless movement
and every source of pain and irritation must be avoided.

(4) Intestinal irrigation drop by drop of isotonic solution with the addition
of 10 per cent alcohol is to be recommended.

(5) Attempts should be made to reestablish the arterial pressure by intraven-
ous injections of saline solution either in one massive or in repeated smaller
doses. Small doses (250 cubic centimeters at the most) are more useful in true
shock without notable loss of blood. The action on the arterial pressure is more
lasting when the injection is made at the end of an operation. The later injec-
tions will be indicated by the curve of blood pressure, which should be taken
every half hour. A fresh injection should be made each time that the blood
pressure falls.

As an isotonic solution for injection, the best to use is Locke’s liquid:

 

 

 

 

 

Grams.
Sodium chloride 8.0
Potassium chloride mus a2
Sodium bicarbonate 2
Calcium chloride 1
Glucose 1.0
Water. 1, 000

 

The injection is carried out slowly, taking about 10 minutes. In cases where
a second injection becomes necessary, a solution containing a higher proportion
of calcium chloride than Locke’s liquid (hypertonic solution) may be employed.
If the pressure falls markedly, the third injection should contain some adrenalin.
At the moment of injection mix 0.5 ccm. of a 1-per-1,000 solution of adrenalin
with 50 ccm. of the isotonic fluid. The injection is made slowly, never in less
than 10 minutes. Every solution of adrenalin must be rejected which is not
perfectly colorless. The action of adrenalin or pituitrin is transient. Trans-
fusion of blood seems also to be without effect save in cases of hemorrhage.

IS SHOCK:AN INDICATION FOR OPERATION OR A CONTRAINDICATION ?

In answering this question, both the gravity of the shock and the
nature of the operation must be taken into account.

In a severe case of true shock, without hemorrhage, when the
patient is cold and pulseless, the shock must first be treated. The
same is true if the operation that is to be practiced is long or com-
plicated, as is the case in abdominal operations. Extensive destruc-
tion of limbs necessitating amputation is, on the contrary, an indi-
cation for operation...

Local anesthesia, or general anesthesia with nitrous oxide and
oxygen gas are the methods of choice. Intraspinal injections have
given results varying with different surgeons, especially for amputa-
tion of the lower limb. The use of chloroform is dangerous.

The state of shock demands a rapid and simple operative pro-
cedure. Care should be taken that before operation, all hemorrhage
be stopped, at any rate, for the time.
184 TREATMENT OF WOUNDS OF WAR.
VIL AMPUTATIONS.

1. Amputation is only indicated when conservation of. the limb
would lead to the death of the patient, or if eventual loss of the
limb is inevitable. |

2. The two chief indications of amputation, are: (a) Extent of
the injury, (4) infection.

3. Amputations for infection are always the more dangerous.
French statistics of 29,1839 amputations, show that the general mor-
tality of 6 per cent is elevated to 28 per cent in case of infection.
Again, a review of 3,633 disarticulations furnishes the same result.

4, Amputations of the upper extremity are less frequently indi-
cated than those of the lower. This depends upon the facts that in
the upper extremity serious infections are less frequent, resections
are followed by more favorable results, and the prospects offered
by prosthesis are unsatisfactory to both surgeon and patient.

5. The indications for primary amputation are found in the na-
ture and extent of the injury; pulverization, crushing, partial avul-
sion of the limb, and especially rupture of the main blood vessels.

6. The indications for secondary amputation are found in massive
gangrene either ischemic or infective. Other extending infections
(superficial gangrene) may be treated by conservative measures.

7. Late amputations are most often indicated in cases of chronic
infection with cachexia, which do not respond to any form of treat-
‘nent. Primary amputations or those delayed for 24 or 48 hours,
should (having due regard to the gravity of the lesions) as far as
possible be made to correspond with the site of the fracture, the soft
parts being simply divided and the bene trimmed or rounded off,
if necessary. In less serious injuries, the site of the amputation
should be as near the seat of fracture as possible. Amputations
called for by infection should be performed by the “ flush method,”
or with short everted flaps fixed by suture to the skin of the limb
above. When the wound has become sterile and the soft parts have
been drawn down as far as possible by extension methods the ampu-
tation flaps may be refashioned if it be required.

The technique of late amputations should be guided by the
method most likely to adapt itself to prosthetic necessities.

When long fissures run upward from a fracture, the amputation
may still be carried through the point of complete solution of con-
tinuity, and the fissured portion of the bone retained,. due care being
exercised in the disinfection of the wound.

1. When shock is severe, nitrous oxide combined with oxygen is
the anesthetic of choice; if this can not be obtained, ether should be
substituted.
TREATMENT OF WOUNDS OF WAR. 185

2. Asa general rule, shock is not to be regarded as a contraindica-
tion to amputation.

3. Provisional hemostasis (by a tourniquet or by preliminary liga-
iure of the main vessel) is necessary and should be complete.

4. The periosteum should be divided at the exact seat of section
of the bone, and periosteal flaps should not be raised..

5. In primary amputations, especially those indicated by infection,
the wound should be left widely open. Care should be taken not to
open up the intermuscular planes. With this object the vessels and
nerves should not be followed into the intermuscular clefts but should
be cut long.

6. Post-operative measures are mainly directed (1) to disinfection
of the field of operation, which should obviate the occurrence of
osteomyelitis; and (2) to controlling cicatricial contraction of the
flaps.

7. The length of the resulting stump is of more importance than
perfeetion of its coverings.

AMPUTATIONS OF THE LOWER EXTREMITY.

Disarticulation of the hip joint is a more serious operation than
amputation through the neck of the femur, even when performed by
a racquet incision and with preliminary ligature of the vessels.

For satisfactory fitting of an artificial limb an amputation through
the thigh should leave a stump extending 12 to 14 centimeters below
the trochanter.

Amputations through the upper fourth of the thigh are difficult
to accommodate with an apparatus, in consequence of the abduction
of the femur which takes place.

Amputations through the middle and lower thirds of the thigh
give good results. The great sciatic nerve should be divided above
the level of the flaps.

Gritti’s method is only suitable to late amputations.

Disarticulation of the knee joint is a useful provisional procedure.

_Amputation through the tuberosities of the tibia gives a good
result, as the patient can wear an apparatus fitted to the flexed knee.

Amputations of the leg should be performed at the lowest practi-
cable level. A posterior flap appears to be preferable.

The fibula should be cut an inch shorter than the tibia.

Tibio-tarsal disarticulation with removal of the malleoli, sub-
astragaloid amputation, Lisfranc, Syme, and Pirogoff, all give excel-
lent results. .

Chopart’s method is only suitable for secondary or late amputa-
tions.

93696—19-_18
186 TREATMENT OF WOUNDS OF WAR.

Any resection of the bones of the foot which insures a perfect sole
and preserves the normal axis of the leg should be preferred to any
amputation.

AMPUTATIONS OF THE UPPER EXTREMITY.

In amputations of the shoulder the head of the humerus should be
preserved, if possible.

Amputation of the arm should be performed at as low a level as is
practicable. Either the circular or the flap method may be employed.
Ten centimeters of the humerus are necessary for a useful stump.

In the forearm every effort should be made to preserve a lever at
least 10 centimeters in length below the elbow joint and to maintain
the movements of pronation and supination.

In the hand, whenever possible, trimming operations should be
adopted, since every renee which can be preserved may prove of
great service.

Movements of the jain above an Aeon and attention to the
nutrition and mobility of the muscles should be maintained during
the whole course of cicatrization.

The application of artificial limbs should be prompt and a provi-
sional apparatus should always be insisted upon, especially in the
case of the lower limb.

The “cinematic method”? may sometimes be indicated in amputa-
tions of the arm and forearm.

VIII. PROSTHESIS.

1. The aim of prosthesis (of mutilated men) should be both func-
tional and esthetic, that is to say, function should be reestablished
and, if possible, the form of the missing member also. The mutilated
man needs to be reeducated both functionally and professionally.

2. Prosthesis should be prompt. For the lower extremity measures
should be commenced as soon as the state of the amputation wound
permits. The use of crutches should be restricted as far as possible.
To allow the patient to walk before cicatrization of the stump is com-
pleted provisional apparatus should be worn in place of crutches.
The best of such apparatus are those devised by the surgeon himself.

3. For the upper extremity the apparatus should be made of
leather strengthened with metallic bands.

They are of the following varieties:

(a) Provisional (bras de secours). A working apparatus, simple, light, and
cheap, which may be worn by a craftsman until his amputation stump is per-
fect.

(b) A permanent apparatus (bras de travail-parade), more esthetic and more
complicated than (a), but at the same time stronger and more useful.
 

 

 

 

 

Preparation of temporary artificial limbs.

186-1
 

 

eg YUE

 

 

Preparation of temporary artificial limbs.
186-2
TREATMENT OF WOUNDS OF WAR. 187

These include: (1) Means of attachment to the shoulder and thorax (leather
shields, corsets, waistcoats, furnished with straps and buckles), to which an
armlet of leather is added for amputation stumps of the forearm; (2) a bucket
which ensheathes the stump, to which tools can be attached and onto which
an artificial hand with a mobile thumb (automotor) can be fixed.

4. For the lower extremity the form of apparatus differs as to
whether the stump has not already assumed its permanent shape.
and proportions (a period of 12 months may be required for this
change), or whether this stage of development has been reached.

(a) Kor stumps during the period of evolution the apparatus should be. of
leather strengthened by metal bands, which have the advantage of being able
to be adapted to changes of shape as they develop. These include: (1) Means
of suspension and fixation (pelvic band, braces for thigh amputations, thigh
bracelets for amputations of the leg). (2) A bucket which ensheathes the
stump and by which the weight of the body is received and borne during walk-
ing; the upper margin of the bucket must be padded and exactly fitted to the
points of support; to the bucket either a pin leg or an artificial limb is attached,
provided with a foot and articulated at the knee, movements of the joint being
‘either free or controlled by a bolt.

In the Belgian Army no intermediate apparatus is provided, the
provisional apparatus being retained until the stump is fit for a per-
manent artificial limb.

(b) For fully developed stumps the bucket of leather, strengthened with
metal, is replaced by one of more rigid material (wood in American apparatus;
wood shavings built up with a special cement in Belgian apparatus; poroplastic,
sheet iron, etc). These buckets are much lighter, simpler, and more durable
than those of leather reinforced by metal bands. The interior of the bucket
must be exactly modeled to fit the surface of the stump and the prominences
which serve as points of support for the limb when the apparatus is worn.
The artificial limb should reproduce accurately the form of that removed, and
thus serve to preserve the normal balance and attitude of the body. It should
also be provided with joints permitting movements approaching those normally
possible. ;

IX. FRACTURES.

(A) CHOICE OF SPLINTS.

1. In the treatment of fractures of the shafts of the bones fixation

takes priority over reduction.

2. The mode of immobilization to be chosen is of three varieties,
thus:

(@) Provisional immobilization at first-aid post.

(b) Definite immobilization at the casualty clearing station.

(ce) Immobilization for purposes of evacuation and transport.

The provisional method should as far as possible coincide with
that to be definitely adopted, and the latter should be such as to

allow of safe transport of the patient.

!
188 TREATMENT OF WOUNDS OF WAR.

3. Fixation apparatus should be of such nature as to permit the
employment of mechanical extension of the limb, free access to the
wound, if present, and safe evacuation of the patient.

Fractures of the arms.—(a) Provisional immobilization of the first-aid post.
Splints of the Thomas type, or crutch splints (bequillons), afford excellent
results. Their general employment throughout the armies is much to be
desired.

(0) Definite immobilization. The provisional splint may be retained, or
splints permitting abduction of the limb and capable of adjustment (Jes bequil-
lons extensibles) are useful for the definite immobilization.

Fractures of the fore arm—(a) Provisional immobilization at the first-aid
post. A metallic gutter splint flexed at a right angle at the elbow, or a simple
wooden splint suffice.

(0) Definite immobilization. The fore arm should be fixed in a pusition of
supination, the apparatus should allow of the application of extension, and
yariation in the degree of flexion of the elbow.

These indications are fulfilled by splints of the types of Thomas,
Sinclair, or Hey Groves, interrupted plaster of Paris with metal
bands, or Vamelvede’s splint.

Fractures of the thigh.—(a) Provisional immobilization at the first-aid post.
‘The best splint is the Thomas. An arched support should be attached to the
foot of the stretcher and the limb slung in order to avoid the heel resting on
the stretcher and being pushed forward. :

(0) Definite immobilization. The apparatus chosen should allow extension,
abduction, and flexion of the limb (splints of the Thomas type, suspension .appa-
ratus such as Sinclair’s or the Anglo-American. The apparatus of Delbet or
Alquier). Delbet’s apparatus allows the patient to walk at a very early date.
The presence of multiple wounds, an inconvenient seat of fracture, extent of the
lesion, or intolerance of any of the ordinary splints, justify the employment of
Finochietto’s stirrup. When combined with a Thomas splint, this stirrup per-
mits transport of the patient with a properly extended limb.

Fractures of the leg—(a) Provisional immobilization at the first-aid post.
Thomas splints, metallic gutter splints, or wooden splints are suitable.

(b) Definite immobilization. The apparatus chosen should permit the appli-
cation of mechanical extension. Interrupted plaster splints with lateral metal-
lic-screw extension supports and a movable posterior metallic band; all the sus-
pension methods in which mechanical extension can be maintained; and
Thomas splint are suitable.

It is of advantage to allow the patient to commence to walk at the
earliest possible date. The apparatus which most surely attains this
object is that of Delbet, in which, if necessary, one of the lateral!
plaster bands can be replaced by an arched metal support to allow
of proper access to a wound. Finochietto’s stirrup alone or in com-
bination with a Thomas splint is indicated for employment in frac-
tures of the leg under the same conditions as those above enumerated
for fractures of the thigh.

Fractures of the wrist—(a) Provisional immobilization at the first-aid post.

A grooved metallic splint, or one of wood, serve to secure the necessary
immobility.
 

 

 

 

Preparation of temporary artificial limbs.

188-1
 

 

 

 

 

Preparation of temporary artificial limbs

188—2
TREATMENT OF WOUNDS OF WAR. 189

(6) Definite immobilization. Robert Jones’s splint is excellent.

Fractures of the ankle.—(a@) Provisional immobilization at the first-aid post.
A metallic gutter splint is the best.

(6) Definite immobilization. An interrupted plaster splint with loops across
the gap obtains perfect immobility, and the same Splint allows the patient to
walk.

Robert Jones’s metallic splint serves the same purpose. If the definite appa-
ratus requires to be removed for purposes of transport, it should be replaced by
a plaster-of-Paris splint. :

(B) SURGICAL TREATMENT OF FRACTURES.

1, At the first-aid post the treatment comprises:

(a) Dressing the wound.

(6) Immobilization.

(c) Immediate treatment of such complications as shock and hem-
orrhage. ~ :

Immobilization of the limb is attained by provisional means (see
“Choice of Splints”)—blind laths, wooden splints, metallic splints.

2, At the casualty clearing stations every fracture should be exam-
ined radiologically or otherwise, and the wounds cleansed by opera-
tion if necessary. ;

(i) Limbs hopelessly damaged and gangrenous parts should be
amputated ; when practicable, through the seat of the fracture.

(ii) In traversing bullet wounds with small openings of entry and
exit, without intervening swelling or lesions of the large blood ves-
sels, the fracture should be immobilized by the application of a
Thomas splint, a metal gutter splint, or plaster of Paris. The wound
should be treated aseptically. The patient should be kept under ob-
servation for seven days, and if signs of either local or general infec-
tion appear the fracture should be exposed.

(iii) Every other form of fracture should be submitted to primary
‘operation.

(@) Treatment of the wound: The soft parts should be sufficiently opened
up to thoroughly expose every extension of the wound, and contused and con-
taminated tissue and all foreign bodies must be removed (see “Section on
Wound Treatment in General’).

(b) Treatment of the bones at the seat of fracture: Treatment of the com-
minution is the main task; splinters absolutely free or those lightly attached
and driven into surrounding muscle should be cautiously removed. In every
case the periosteum should be respected and preserved. Irregular bone ends
which may endanger neighboring vessels should be rounded off with cutting
forceps. The choice of the solutions employed for washing the wound is left
‘to the surgeon concerned, but Dakin’s fluid or ether are the two most generally
relied upon. .

The wound may be closed primarily or secondarily by suture.

In point of fact, primary suture is rarely resorted to, and only under the
following conditions: A really experienced surgeon, proper equipment, a period
of military calm, a wound of not more than eight hours’ -duration, slight
190 TREATMENT OF WOUNDS OF WAR.

damage to the bones and soft parts, even if excision of all the contused tissues
has been carried out, ready approximation of the wound surfaces without ten-
sion, and conditions which allow the same surgeon to take charge of the patient

until the wound is firmly united.
The most favorable regions for primary closure are the face, the scalp, the

ilat bones, the patella, the hand, and the foot.
On the first sign of any: trouble the wound must be opened up and disin-

fected.
Secondary suture should follow a progressive sterilization of the wound.
The Carrel-Dakin method, and also that of Rutherford Morison have been

successfully employed with this object.

3. Fractures should not be evacuated during the period of acute
infection. a

4. Reduction of the fragments into good position is effected either
by operation, position of the limb, or extension, and the result should
be controlled by X-ray examination.

5. Fractures which it proves impossible to maintain in good posi-
tion may be treated by direct mechanical fixation. These operations
should not, as a rule, be undertaken until the seat of fracture is free
from infection.

6. Uniformity in the methods of treating fractures in the hospitals
at the front and on the lines of communication is essential, if the best
results are to be obtained.

7. Mobility of the joints, muscles, and tendons of limbs which are
the seat of fractures, should be striven for during the whole dura-
tion of the treatment, and efforts to maintain these conditions should
be commenced at as early a period as possible.

X. WOUNDS OF JOINTS.

1. At the dressing station wounds. of the joints should be immobi-
lized with great care, in an appropriate apparatus.

2. At the clearing station all injured joints in which the wound is
extensive, the joint tissues are lacerated, or the missile is retained, and
especially when a fracture is present, should be operated upon, if
possible, in the first six or eight hours. The French surgeons extend
this rule to all cases, except certain bullet wounds with a punctiform
orifice and without fracture.

3. Radioscopy is indispensable in every case.

4. The operation should include a wide aseptic arthrotomy, with
excision of the track, complete exploration of the joint, systematic
removal of foreign bodies and splinters, and cleaning and curetting
of the lesion in the bone. This should be followed either by comi-
plete closure or by closure of the capsule with superficial drainage.
A compressing dressing should be applied. .

5. Resection, typical or atypical, should only be practiced when
there is considerable damage to the bone. In the knee the operation
 

 

 

 

Temporary artificial limb.

190
 
TREATMENT OF WOUNDS OF WAR. 191

, should be primary, whereas in the elbow and shoulder secondary
operation is preferable.
6. In severe suppurative arthritis the first measure should be a
wide arthrotomy with complete immobilization and progressive dis-
infection of the wound. If this treatment fails, then resection should
be practiced, with at first, separation of the articular surfaces by
extension. In very grave cases immediate resection is required.
M. Gosset recommends a simple operation, with a compressing dress-
ing by cotton-wool pad, without immobilization. MM. Depage and
.Tuffier recommend rigorous immobilization for 8 or 10 days, after
which mobilization should be begun. MM. Willems and Derache
consider that mobilization should be begun much sooner.

XI. WOUNDS OF THE BLOOD VESSELS.

The projectiles of war may give rise to (a) contusions; (6) wounds
of the blood vessels. The wounds may consist in complete sever-
ance, lateral wounds, or pure perforations. Contusions may be.
followed by thrombosis, which accident often remains undiscovered
until it is manifested by the occurrence of an embolism or a secondary
hemorrhage. Wounds of the vessels are usually indicated by severe
external hemorrhage if the wound of the soft parts is open and ex-
tensive. When the wound is situated in the course of a narrow
track a diffuse hematoma commonly results. At a later date, when
the patients arrive in the hospitals on the lines of communication or
at the base, traumatic arterial and arterio-venous aneurysms may
develop as a consequence of vascular lesions which have been pre-
viously overlooked or have escaped treatment. ,

Treatment.—1. Arterial thrombosis should be treated by ligatures
placed upon the vessel above and below the limits of the clot. Arteri-
otomy and-evacuation of the clot should not be performed.

2. Wounds of the vessels accompanied by external hemorrhage de-
mand treatment which commences at the first-aid post and is com-
pleted at the field ambulance or casualty clearing station.

At the first-aid post the procedure is governed by the severity of the bleeding.

If the amount of blood escaping be small, compression may be made above
or over the wound itself. If the hemorrhage is severe a tourniquet may be
applied.

Every patient on whom a tourniquet has been placed must be
marked with a distinctive label and evacuated promptly to either the
field ambulance or casualty clearing station for immediate operation.
When conditions render the period likely to be occupied by trans-
port uncertain, or the journey is long, the bleeding vessel should be
controlled at once either by ligature or forci-pressure.

At the field ambulance or casualty clearing station, as a genera
rule, the bleeding point should be exposed and a ligature placed
192 TREATMENT OF WOUNDS OF WAR.

above and below the wound of the vessel on undamaged tissue. The
ideal procedure is to restore the integrity of the vessel by suture,
either lateral or circular as the conditons may demand. The circum-
stances favorable to the method of suture are, a limited and easily
accessible lesion, and an aseptic wound suitable for immediate and
complete closure.

8. Secondary arterial hemorrhage should be treated by ligature
of both ends of the injured vessel. If this be impossible, forci-pres-
sure may be resorted to, or proximal ligature of the main artery.
If all these methods fail, amputation is the ultimate resource.

4. In cases of diffuse arterial hematoma, provisional hemostasis
should first be effected by a rubber tourniquet, or by exposure and
_ temporary occlusion of the main vessel above the arterial lesion; the
hematoma is then opened freely and the wound in the vessel sought
for. Ligatures are applied immediately above and below the
wounded point, or, when possible, the arterial wound should be
.closed by suture. Conditions favorable to the latter proceduré are
rare.

When the lesion is seated on an artery the occlusion of which may
be followed by insufficient establishment of the distal circulation

(axillary, common carotid, common femoral, popliteal), the two ends
of the wounded vessel may be connected by a silver tube coated with
paraffin. The tube is tied in position and removed at the end of
four or five days, after ligature of the artery above and below. This
procedure gives time for a progressive enlargement of the col-
lateral circulation, and thus diminishes the risk of gangrene.

Diffuse hematomata are not rarely complicated by gangrene. Con-.
trary to what has until now been believed, simultaneous ligature of
both artery and vein when both vessels have been wounded, does not
give rise to increased risks of gangrene, in fact, it diminishes them.
Facts tend to prove even when the wound is limited to the artery,
that simultaneous occlusion of the unwounded vein is to be recom-
mended.

5. For traumatic aneurysms, after effecting provisional hemos-
tasis, the sac should be laid open. This procedure gives direct. ac-
cess to the primitive lesion and allows the vessel to be ligatured
immediately above, and below it, thus insuring the safety and non-
exclusion of collateral branches which may arise in close proximity
to the injured point.

(a) For arterial aneurysms; ligature above and below the point of com-
munication with the vessel should be followed by complete, or when not practica-
ble, partial removal of the sac. Here, again, suture of the opening in the
arterial wall is the ideal procedure if it be realizable.

(b) For arterio-venous aneurysms; a more frequent and less dangerous form

than the arterial, and less frequently complicated by gangrene, the ideal opera-
tion consists in extirpation of the sac, and reestablishment of both the arterial
TREATMENT OF WOUNDS OF WAR. | 1938

and venous channels by suture. In practice, complete or partial extirpation of
the sac followed by ligature of the four ends of the implicated vessels, is more
commonly resorted to. G

XII. INJURIES TO THE NERVES.

1. It is indispensable that all lesions of the peripheral nerves
should be investigated with the greatest care in the hospital at the
front when the wound is subjected to primary treatment; both with
regard to the clinical signs present, and direct examination of the
nerve trunk itself.

2. Whenever a divided nerve trunk is discovered, it should be
united by primary suture, if the condition of the wound permits. A
special note describing the operation performed should accompany
any patient so treated when he is evacuated.

3. If primary suture is impracticable, or if the lesion has been
overlooked, the nerve should be united at the same time that sec-
ondary suture of the main wound is undertaken.

4, Either the primary or secondary operation may suffice to obtain
restoration of function; but should they fail, the operation has, at
least, insured that the trunk is placed under the best conditions for
later intervention.

5. At a still later date, any functional deficiency due to a nerve
lesion may be a proper subject for operation by the surgeon after
consultation with a neurologist.

6. During the wliole course of treatment, care must be exercised
that the limb is kept in good position, and that the mobility of the
joints and the nutrition of the muscles is maintained.

7. Operations on the nerve trunks of whatever character (freeing
from adhesions, neurolysis, suture, etc.), demand the maintenance
of perfect asepsis, and punctilious care and delicacy in the manipu-
lation of the nerve itself.

8. For purposes of suture the nerve ends require to be refreshed or
resected until healthy tissue is exposed; the peripheral end should
appear normal and free of all fibrous tissue which would be an
obstacle to regeneration.

9. Direct contact of the refreshed nerve ends appears necessary for
regeneration ; but in the present state of knowledge, suture of approx-
imated ends or union obtained by splitting off a part of the peripheral
end is still worthy of trial.

10. Nerve grafting has not up to the present time afforded any
striking results.

11. Under certain circumstances nerve suture may be replaced by
tendon transplantation: (1) When nerve suture is impossible; (2)
when the functional result attained by nerve suture is unsatisfactory.
194 TREATMENT OF WOUNDS OF WAR.
XIII. WOUNDS OF THE SPINAL CORD.

1, At the dressing station apply the usual dressing and combat the
shock phenomena which cord injuries frequently present.

2. At the clearing station:

(a) If there is a bullet wound with punctiform orifice, the wound should be
dressed and an expectant line of treatment adopted.

(bd) If there is a shell wound with a large wound of entry, it is best to treat
the wound in the usual manner, but not to interfere with the spinal lesion.

Evacuate the patient as soon as possible. French surgeons recommend a
‘ponnet-gutter splint.”

8. At the base: From the therapeutic point of view, here are two
quite distinct categories of cord injuries:

(a) Those with complete section of the cord for which surgery is of
no avail,

(6) Those with compression of the cord by the projectile, by splint-
ers, by dislocation, or by meningeal hemorrhage. These form the
only class in which operation can be of assistance.

From the point of view of prognosis, a complete distinction should
be made between lesions situated at the level of the cord itself, or
those at the level of the cauda equina.

Intolerable pain is a factor to be taken into account when consider-
ing the question of operation.

4. When to operate:

(a) In the majority of cases primary intervention should be re-
jected. In the Italian ‘Army they have adopted, in cases of bony
compression or of retention of the projectile in the spinal cavity, the
principle of intervention at the earliest moment possible for removal
of projectiles, pieces of clothing, clots, and splinters in order to free
the cord and the spinal veins. The mortality of these primary opera-
tions is very high. To diminish the severity of the operation and to
preserve the stability of the spinal column, surgeons in the Italian
Army prefer to practice unilateral laminectomy.

(6) Secondary operation should be performed after healing of
the wound.

XIV. WOUNDS OF THE BRAIN.

1. At the dressing station wounds of the brain should be covered
with a simple aseptic dressing.

2. Men wounded in the cranium and brain should be evacuated
according to the apparent gravity of their lesions:

(a) Where there is large loss of substance with severe general symptoms, to
the nearest possible hospital.

(6) If the lesion appears. less severe and the general symptoms are not threat-
ening, the patient should be evacuated to an operating center provided with a
surgeon and a neurologist, where he can be retained for a considerable time.

(c) The operation should be undertaken early.
TREATMENT OF WOUNDS OF WAR. 195

3. A brain case should not be evacuated under three weeks after
being trephined for cranio-cerebral injury.

_4. The skull must be submitted to radiological examination and
the projectile and fragments of bone carefully located.

5. When fracture is not manifest and there is no cerebral symp-
tom, the indications for operation are still disputed.

6. Local anesthesia for the operation is the method of choice. The
sitting position has the advantage of diminishing hemorrhage; it
is specially suitable for secondary and late operations.

7. The wound is freed by resection of its edges. It is enlarged ac-
cording to the seat, the direction, and the form of the bony lesions.

8. The breach in the bony substance must be enlarged beyond the
limits of cerebral contusion with a gouge forceps, or exceptionally
with a trephine, never with a mallet and chisel.

9. If the dura mater is intact it should be left alone, and, in
favorable cases, the wound may be united by first intention. If the
dura is torn, its edges must be trimmed and the opening enlarged
to the limit of the focus of cerebral lesion.

10. Clots, diffluent cerebral matter, and superficial foreign bodies
must be removed under a current of warm saline solution. Deep
splinters and projectiles easily accessible must be removed with the
greatest possible precaution.

11. Very small projectiles deeply situated and difficult of access,
projectiles of larger volume lying on the base of the skull or in the
ventricles, and those which lie in the hemisphere of the opposite side
to the lesion should in primary operations be left alone.

12. In through and through wounds, each orifice should be suit-
ably treated and the deep portion of the track left alone.

13. It.is best not to put any tube or gauze plug in the cerebral
substance. A cranio-cerebral wound can be treated by primary
suture or by secondary suture after sterilization. Further research
is needed to show which of these two methods best protects against
immediate, secondary, and late septic accidents.

14. When the patient recovers from the shock of the operation he
should be placed in a half sitting position.

15. Early cerebral hernias without deep infection should be treated
by enlargement of the breach in the bone.

16. Thin scars with large losses of bony substance, and those
which give rise to cerebral troubles, should be treated by plastic
operation.

17. Secondary accidents should be treated according to their origin
(cerebral abscess, foreign bodies, adherent cicatrix) by operation
appropriate to each of these conditions, and after consultation be-
tween a neurologist and a surgeon.
196 , TREATMENT OF WOUNDS OF WAR.
XV. PENETRATING WOUNDS OF THE CHEST.

1. The mortality attendant on penetrating wounds of the chest in
military hospitals may be estimated as 20 per cent.

2. The immediate mortality in the front lines is greater in conse-
quence of deaths from hemorrhage and asphyxia.

3. The later mortality is usually a result of infection and consecu-
tive pleuropneumonia. | -

4, The: anatomical lesions of the lungs resemble those met with
elsewhere as a consequence of gunshot wounds. The mechanical
damage is the same; the infections are the same, except for the fact
that the pulmonary tissue is more resistant than any other; but the
gravity of the pulmonary lesion is greatly aggravated by coexisting
infection of the pleura, whether extending from the external wound
or the lung. .

5. The treatment is dominated by two factors, (1) early interven-
tion and (2) absolute rest for the patient.

While the primary condition of shock persists, the general treat-
ment of shock should be adopted.

A large number of patients suffering with these wounds recover
as the result of medical treatment alone, and no complications,
either early or delayed, develop.

Surgical treatment should be directed to care of the wound in the
thoracic parietes and to dealing with early or late complications.

In every instance thorough treatment of the injury to the thoracic
parietes (wound of the soft parts, fractured ribs, etc.) is, as in the
case of all other gunshot wounds, absolutely necessary.

(1) Early complications—(a) Open thorax: Prompt closure of
the aperture in the parietes either by plugging or direct suture is
essential. .

(0) Hemorrhage: When the chest is open, bleeding must be ar-
rested either by plugging or direct suture of the lung.

When no patent opening exists, if the arterial tension falls pro-
gressively, and it is proved that the fall does not depend upon shock
but must be attributed solely to internal hemorrhage, the ideal pro-
cedure consists in thoracotomy and direct hemostasis of the bleeding
lung. The necessity for intervention of this character is extremely
rare, and such operations must not be undertaken except by a highly
skilled surgeon with access to every operative convenience.

(c) Hemothorax: Puncture or aspiration of a recent hemothorax
is indicated only when it is necessary to relieve obvious signs of me-
chanical compression. It is advantageous to replace the evacuated
blood, either during or after aspiration, by air or by oxygen intro-
duced with the view of maintaining the collapse of the lung, with
consequent decrease of the risk of recurrent hemorrhage.
TREATMENT OF WOUNDS OF WAR. 197

When a hemothorax is accompanied by fever, it is justifiable to
make repeated exploratory punctures for the purpose of bacterio-
logical examination of the fluid.

(2) Late complications —(a) Persisting aseptic hemothorax : This
form of hemothorax should be treated by repeated aspiration with a
view to facilitating expansion of the lung. Replacement of a certain
proportion of the evacuated fluid by oxygen is a very useful measure.

(6) Infected hemothorax: When bacteriological examination
proves infection to have taken place, a thoracotomy is indicated.

(c) Empyema: A purulent pleurisy is to be treated on the same
lines as an infected hemothorax. When drainage of the pleural
cavity is necessary, the opening should be located at a dependent
point of the posterior part of the base of the thorax.

6. Treatment of purulent pleurisy by progressive sterilization of
the pleural cavity.

Either recent or chronic empyemata may be treated by progressive
sterilization of the pleural cavity and secondary suture of the drain-
age aperture. There is no reason to fear the result of closing the
opening in the thoracic wall before the-lung is expanded and the
cavity filled up, for this procedure is the. most successful method of
inducing rapid expansion of the lung and obliteration of the pleural
cavity (Depage).

7. In cases of urgency demanding operative intervention, retained
projectiles should be removed when they can be readily found.

8. The prophylactic treatment of pleuropulmonary infections by
direct surgical treatment of the wounded lung (extraction of for-
eign bodies and suture of the pulmonary wound, with or without
excision of the bounding tissue), seems a logical procediiee in any
circumstances. The question merits attention and should be care-
fully studied.

9. Hemopericardium: Effusions of blood into the pericardial cav-
ity are susceptible of treatment on the same lines as have been laid
down for those into the pleural space.

XVI. ABDOMINAL WOUNDS.

1. As a general rule all recent wounds of the abdomen should be
operated upon systematically except when it is certain that the in-
jury is limited to the liver or kidney and there are no pele of
severe hemorrhage.

2. The operation should be performed as early as possible, atisih
in patients in a state of shock. When there is a doubt between shock
and hemorrhage it is better to operate than to refrain. Laparotomy
should not be practised systematically later than 36 hours after the |
time the patient has been wounded.
198 TREATMENT OF WOUNDS OF WAR.

3. Centers provided with full necessary surgical equipment, to
which abdominal wounds can be quickly brought for operation by
competent surgeons should be formed as near as possible to the line.

 

THIRD INTERALLIED SURGICAL CONFERENCE.
(November, 1917.)

At the Third Interallied Surgical Congress, which sat from Novem-
ber 8 to 8 at the military section of the Val-de-Grace, under the -
presidency of M. Justin Godart, undersecretary of state for the
Service de Santé, six questions were raised on which numerous con-
clusions were based, some of them of great importance.

With regard to the first, secondary, and delayed complications
of wounds of the brain, surgeons agreed that delayed infection of
such wounds is much rarer than was commonly supposed; that
organic disturbances following wounds of the brain, e. g., hemiplegia,
monoplegia, aphasia, visual disturbances, frequently have a tendency
to spontaneous improvement; and that epilepsy, if amenable to sur-
gical intervention when a foreign body or splinters of bone are pres-
ent, is not so in other cases. In cases of cerebral hernia lumbar punc-
ture should be avoided during the acute febrile phase in order to
avoid the possible dissemination of a local infection. Foreign bodies
tolerated by the brain may be left. Cranioplasty is only indicated in
cases where the extension of the cicatrix is the sole cause for the
symptoms observed, except in the frontal region for esthetic
purposes.

The second question dealt with the later results of treatment in
the case of fracture of the shaft of the femur. A primary steriliza-
tion of the wound is the chief factor to realize. Stiffness of the
joints of the knee, hip, and foot can be avoided by early movement.
Adherence of muscles to callus is the origin of many disturbances of
function necessitating freeing by surgical methods. Strongly marked
deviation is amenable to osteotomy, with resection of the callus if
‘there is osteomyelitis.

The third question referred to operation for injuries to nerves.
The congress admitted that the ultimate results are not generally
satisfactory, especially in the case of total lesions, and when the
operation takes place among suppurating tissues. Primary suture
of a nerve in a milieu rendered aseptic by modern methods has
given better results. Functional recuperation is slow, occupying
months or even years, a fact which must be taken into consideration
in working out compensation.

The treatment of fracture of the joints (fourth question) has made
great progress since primary sterilization has been the object aimed
at and operative measures initiated within 10 to 12 hours. Com-
TREATMENT OF WOUNDS OF WAR. 199

minution of the epiphysis is to be treated by gouging out and cleans-

ing followed by immediate suture of the joint. Early resection is
only indicated in exceptional cases where severe comminution is
present. Primary amputation is limited to cases of extreme contu-
sion with destruction of the principal artery. Immediate active,
movement gives better results than immobilization.

The fifth question deals with the treatment of chronic osteomyelitis,
which should be mainly preventive and completed either by im-
mediate closure of the wound after removal of all sequestra or by
chemical sterilization with secondary autoplasty.

With regard to thoraco-abdominal wounds (sixth question), the
congress gave special attention to wounds of the diaphragm. Radio-
scopic examination is necessary to recognize hernia of the abdominal
organs and determine the displacement of the heart. Operation is
nearly always indicated, and a transpleural route by way of the
thorax is,generally to be siretexred associated with laparotomy when
desirable. (Lancet, London, Dec. 15, 1917, p. 908.)

TREATMENT OF WOUNDS IN WAR.!
I. TRANSFUSION OF BLOOD.

The results obtained by the transfusion of blood justify its being
looked upon as the method of choice in the treatment of serious
hemorrhages,

(a) FHarly—tThe clinical condition of the wounded man affords
the main indications for transfusion, and in the advanced posts must
alone be depended upon, but additional information may be obtained
from repeated observation of the blood pressure, and by red blood
cell counts which are of value in wounds of the limbs. In circulatory
collapse, due to a very acute infection (gas gangrene) no favorable
result has been observed after transfusion. The indications for
transfusion in the treatment of shock have not yet been sufficiently

defined.

(6) Later—Corpuscular anemia after hemorrhage is generally
well borne, and does not justify transfusion if the general condition
of the wounded man is satisfactory. On the other hand, secondary.
hemorrhage, diminution in the coagulability of the blood, failure
of regeneration of the corpuscles, and chronic infections causing
anemia, may afford indications for transfusion.

PRELIMINARY PRECAUTIONS.

(a) Risk of transmission of diseases —Donors should be examined
and classified in order to avoid transmission of diseases such as

syphilis or malaria.

1¥Fourth Inter-Allied Surgical Conference held at the Val-de-Grace, March 11-16,
1918. From Brit. Med. Jour., April-May, 1918.
200 TREATMENT OF WOUNDS OF WAR.

(0) Incompatibility of corpuscles ——Fatal results have been ob-
served in cases in which the corpuscles of the donor were aggluti-
nated by the plasma of the recipient. Such results are rare, and can
be completely avoided by agglutination tests which can easily be ex-
temporized. This being so, it is indispensable to examine the aggluti-
nation in all cases in which the circumstances render it possible or to
have the donors classified beforehand. At advanced posts it is justi-
fiable to resort to transfusion, even if it be impossible to test the
agglutination, as the risk of serious results is relatively small; but it
should be tested in all other units.

(c) Asepsis—Transfusion should never be undertaken unless an
appliance in perfect condition is available and unless strict asepsis is
possible.

METHOD.

The method of transfusion employed should make it possible to
measure the quantity of blood transfused. The use of blood which
has been preserved for several days has given satisfactory results,
and has proved specially valuable in advanced posts during intense
military activity. Indirect methods for the transfusion of fresh
blood are more easy to employ than vascular anastomosis. The three
indirect methods have all given good results, namely, the use of
citrated blood, the aspiration of pure blood into an ampoule treated
with paraffin, and its aspiration in a syringe. The general principle
should be to practice transfusion as early as possible after the
receipt of the wound, but it must not be employed until hemorrhage
has stopped. In hemorrhage from thoracic or abdominal wounds or
wounds of the limbs, transfusion should be’practiced either before or
during the operation, the time of transfusion depending on the condi-
tion of the wounded man.

II. TRENCH FOOT.

1. Trench foot is a pathological condition provoked by moist cold
and complicated as a rule by secondary infection.

2. The disorder presents four stages, as follows: (1) Painful anes-
thesia; (2) edema; (3) phlyctenules; (4) sloughing. Three clinicat
forms may be described: (a) Slight (85 to 90 per cent of the cases),
characterized by painful anesthesia, cedema,.and redness; (b) mod-
erate (13 to 14 per cent), characterized by phlyctenules and limited
sloughs; (c) severe (1 per cent on an average) characterized by ex-
tension of sloughing and the appearance of septicemic complication.
This form may produce serious mutilation or death.

3. Trench foot, especially the more serious forms, is not infre-
quently complicated by tetanus or gas gangrene, and relapses and re-
eurrences may take place. Trench foot occurs almost exclusively i in
_TREATMENT OF WOUNDS OF WAR. * 201

soldiers who live in the trenches, more particularly in certain
trenches. Soldiers coming from hot countries, dark-skinned races
particularly, are more frequently attacked than Europeans. (In
Italy soldiers from the south-have suffered more often than soldiers
from the north.) Youth, hyperidrosis, and a previous attack are
predisposing causes.

4. Blood stasis due to prolonged standing, to long iiamobility:
and to a bad attitude (stooping), compression of the leg and inter-
ference with the venous circulation, particularly by puttees, and more
especially remaining long in cold and damp (muddy and flooded
ditches and shell holes), are the principal causes of trench foot.

5. Trench foot may be confused with true frostbite and with chil-
blains. True frostbite is characterized by sudden massive mortifica-
tion of a part of a limb (the front of the foot, the whole foot, etc) ;
trench foot, on the contrary, is characterized by limited destruction
(gangrenous patches on the dorsum of the foot, the sole, or the toes)
and by progressive invasion of the tissues of the foot. Frostbite is
met with in severe dry cold, especially in mountainous regions.
Trench foot occurs only in damp weather and at low altitudes (val-
leys, plains) ; it disappears in frost. Chilblains are characterized,
at any rate in their early stages, by very severe itching, whereas
those forms of trench foot—that is to say, the slight forms—which
are liable to be confused with chilblains produce painful anesthesia
without any itching. It has to be admitted, however, that sometimes
the diagnosis between ulcerated chilblains and the ulcerated phlycten-
ules of trench foot may be doubtful.

6. The treatment of trench foot is preventive and curative. Pre-
ventive treatment energetically applied and supervised may be fol-
lowed by the disappearance of cases of trench foot, or may at least
render them very rare. The treatment includes (a) collective meas-
ures, hygiene, and draining of the trenches, gratings, trench boots,
dry warmed shelters, with, if necessary, frequent reliefs; and (0)
individual preventive precautions taken daily (drying, cleansing,
and massage of the feet, change of socks in the shelters, super-
vision of puttees, and of everything which can cause compression
of the lower limbs). Belgian medical officers attribute the extreme
rarity of cases of trench foot in their army to the disuse of puttees.
The curative treatment of trench foot includes the following meas-
ures: (a) Slight cases; a warm foot bath should be taken every
two or three days and the feet washed with boric camphor soap. A
large moist boric camphor dressing should be applied to the foot
every day. (6) Severe cases; when phlyctenules only are present
they should be opened and touched with camphorated ether, and a
moist boric camphor dressing applied. If there are sloughs the
same treatment should be persistently applied. Sloughs should not

93696—19———14_—
902 , TREATMENT OF WOUNDS IN WAR.

be removed with the knife; they should only be scarified, without
causing bleeding, so that the drugs used may act on the subtnoent
tissues. Spontaneous separation must be awaited, and complica-
tions carefully watched and thoroughly treated surgically and fully
at their onset. The principle by which operation ought to be guided
is that it should be late and confined to the rectification. of stumps
which are défective from a functional point of view. Amputation
should be performed only in cases in which the surgeon’s hand is
forced by serious general complications. In every case preventive
antitetanic treatment should be used (injection of antitetanic serum
repeated every week until the wound is cicatrized).

Ill. THE TREATMENT OF WOUNDS OF THE PELVIS, AND OF THE
BLADDER AND RECTUM IN PARTICULAR.

Of the pelvis alone.—The general principles are the same as for
war wounds of soft and bony parts. Comminuted fractures of the
ilium call in particular for large trephining. The removal of pro-
jectiles or bony fragments which are often driven into the psoas
and iliacus muscles is particularly difficult, and must be carried out
systematically.

Of the bladder—(a) Intraperitoneal wounds are amenable to
laparotomy and suture; (0) extraperitoneal wounds, if suprapubic,
should be treated by primary suture of the bladder. Wounds of the
walls or base of the bladder inaccessible to operation do not entail
immediate cystotomy as a matter of routine. Surgical treatment of
the wound of entry and of its track will assure sufficient drainage.
Later on tying in of a sound will favor the closing of the urinary
fistula. Primary cystotomy should be reserved for wounds of the
bladder with retention or progressive perivesical infiltration. Seri-
ous hematuria or the presence of a foreign body in the bladder justify
early cystotomy. Secondary infection of the bladder calls for cys-
totomy with drainage.

Of the rectum.—(a) Intraperitoneal wounds, like all other wounds
of the intestines, are amenable to laparotomy with suture; (b) the
majority of cases of extraperitoneal wounds should be treated by the
laying open of the traumatic center, followed by plugging of the
rectal wound. An indispensable adjuvant to this treatment is to
keep the bowels constipated. In rupture with extensive detachment
the method of choice is free opening up, with, if necessary, posterior
rectotomy. Primary colostomy is only exceptionally required.

Combined wounds of bladder and rectum.—The greater number of
cases will recover under surgical treatment of the extravesical tract
of the projectile. Colostomy should be reserved for cases in which
the communications between the bladder and rectum are very exten-
TREATMENT OF WOUNDS IN WAR. 203

sive. Primary cystotomy is often useless; the tying in of a sound,
ventral decubitus, and micturition in the genu-pectoral position favor
spontaneous closure of the vesico-rectal fistula.

IV. TREATMENT OF PSEUDARTHROSIS,

1. The unavoidable cause of false joints in war fractures is the
primary destruction of a part of the diaphysis. The other causes
which actually have to be taken into account are infection, excessive
removal of splinters of bone, and bad reduction, and these ought to
disappear. A certain number of false joints can be avoided by
sterilization of the seat of fracture, prudent removal of fragments
of bone, good reduction carefully supervised, and in certain well-
defined cases by immediate or early fixation of the bones.

2. Save in exceptional cases, false joints should only be operated
upon after a considerable interval, when the skin wound is com-
pletely cicatrized, and when clinically the existence of buried or-
ganisms should be investigated by all means at our disposal, such
as forcible active and passive movements, elastic bands, vigorous
massage, etc.

The following note is added at the request of Sir Arbuthnot Lane:

(a) In cases in which the lower end of the femur, or the upper end
of the tibia, or both, are removed, the treatment may differ accord-
ing to the occupation of the wounded man. In workmen an atiempt
should be made to obtain ankylosis between the femur and tibia
either directly or by means of a graft; in men following sedentary
occupations a false joint fixed by an apparatus which permits. of
flexion may be more advantageous. Either of these two conditions
is preferable to amputation of the thigh and an artificial limb.

(6) In a case in which there has been extensive loss of substance
‘of the lower end of the humerus, the elbow being intact, it is often
desirable to obtain a false joint permitting flexion between the hu-
merus and its shattered lower end, leaving rotation to be produced
at the radio-humeral articulation. This condition is more useful
and permanent than that given by resection of the elbow.

3. From the point of view of treatment two conditions are to be
distinguished: (a) In simple false joints and in certain examples of
false joint with a loss of substance in the part of a limb containing
only a single bone, it is possible, after freshening the bone in the
manner that pathological anatomy suggests, to unite the bones by a
metal plate. The best method appears to be fixation with a metal
plate, using screws, the screws being placed as far as possible from
the false joint. The combination of the use of the metal plate and of
an osteo-periosteal graft has given very good results. (6) A false
joint with loss of bony substance usually requires a bony or osteo-
periosteal graft.
204 TREATMENT OF WOUNDS IN WAR.

4. Perfect asepsis. Complete excision of the fibrous tissue which
surrounds the fragments and of any diseased portions of the bones
are conditions indispensable to success.

The following note is added at the request of Sir Arbuthnot Lane:
An additional means of detecting and eliminating the persistence
of infection is the use of autogenous or stock vaccine.

V. CONSERVATIVE OPERATIONS ON THE FOOT.

As it is very desirable to maintain the integrity of the sole, in-
cisions or resections through it should only be performed when abso-
lutely necessary. Every endeavor should be made to obtain primary
union in every case. The same considerations apply to the dorsal
surface of the foot when cicatricial contraction might interfere with
the functions of the sole of the foot. It is even justifiable to resect
certain bones in order to permit primary or secondary union and
the maintenance of the skin of the sole in its normal condition. Am-
putation of one or several toes causes little inconvenience. The
preservation of one toe, especially the first or the fifth, is often em-
barrassing. Disarticulation of the metatarsal bones, with preserva-
tion of the corresponding toes, generally gives bad results. Resec-
tion of the first and fifth toes, with their metatarsal bones, generally
gives a satisfactory result. The result of preservation of the great
toe alone, with its metatarsal bone, is not generally good. Excision
of the second, third, and fourth metatarsals produces a narrow foot,
and walking and standing are seriously impeded. As a general rule
the loss of three metatarsal bones seriously upsets the mechanism of
the foot. The results of amputation through the metatarsus with a
good plantar flap, whether performed through the anterior or poste-
rior part of the metatarsus, are very favorable. After Lisfranc’s dis-
articulation walking may be easy and even elastic if the remainder’
of the foot is in good condition. As it is a difficult operation, it may
be simplified by leaving the bases of the metatarsal bones. Prescaph-
oido-cuboid amputation gives good functional results. In short.
all the operations through the front of the tarsus give good results
if there be no complication due to the cicatrix or the conditions of
the articulations. Chopart’s amputation when done under good con-
ditions and carefully watched may give a good result, but the equin-
ism and the displacement of the stump often cause functional
troubles which render it inferior to the amputations of Lisfranc and
Syme. Partial resections of the astragalus and calcaneum, or hori-
zontal resection of the calcaneum, check the tendency to equinism.
Amputation below the astragalus (Pirogoff’s amputation and more
especially Syme’s) leaves the patient able to walk easily and quickly.
On the other hand, operations on the posterior tarsus are very often
TREATMENT OF WOUNDS IN WAR. 205

followed by functional difficulties. Total or subtotal excision of the
astragalus gives good results, but they, are not so’ good as those
obtained in peace; the causes of failure are infection of neighboring
tissues, stiffness of joints and tendons, and insufficient supervision
of the attitude of the foot after operation. Excision of the whole or
greater part of the calcaneum, if bony regeneration does not take
place, leaves a bad condition, very frequently attended by tibio-
tarsal or mediotarsal ankylosis. Partial resections, whether posterior
or inferior, give less unfavorable results if the foot is well main-
tained at a right angle during the whole course of treatment. Com-
bined resection of the calcaneum and the astragalus gives usually
a bad result.

Atypical operations —Resections of the anterior part of the tarsus
involving the scaphoid and cuboid are often followed by equinism,
with valgus or varus, or falling in the arch of the foot. The func-
tional condition can be greatly improved by an orthopedic boot. The
seriousness of the consequences of excision of either of these bones
seems to be about equally great: The results of atypical operations
on several bones of the anterior part of the tarsus are determined
much more by the degree of preservation of the arch of the foot,
the strength of the points of contact of the sole with the ground, and
the preservation of the action of joints and tendons than on the site
of the operation itself. Vicious positions of the foot, if the joints
be freely movable, can be cured or improved by the division or trans-
plantation of tendons. Transplantations are particularly useful
when certain tendons have been destroyed. Some vicious positions
with ankylosis call for secondary operations on the bones (resection
of the cuneiform or astragalus). In short, conservative operations on
the metatarsus are good, but in the posterior tarsus excision of the
calcaneum or resection of several bones often cause functional dis-
turbances which are graver than those following disarticulation or a
Syme’s amputation.

(Prof. Depage points out that in suppuration of the joints of the
tarsus persisting in spite of excision of the astragalus, an operation
turning the foot forward and inward by extensive section of tendons
and ligaments, and the maintenance of the position by means of a
bandage, favors disinfection of the suppurating focus. The foot can
be replaced in the normal position after a week or a fortnight.)

VI. FIXATION OF COMPOUND FRACTURES.

A distinction must be drawn between a primary operation for
fixation of a compound fracture and an operation performed during
the period of infection.

Primary fication —The possibility of applying primary suture or
delayed primary suture to a great number of wounds complicated by
206 TREATMENT OF WOUNDS IN WAR.

fracture justifies in principle the immediate fixation of compound
fractures, but the indications for the operation are uncommon. They
are:

1. In certain fractures of jointssin which the operation appears to
be a method of choice to obtain anatomical and functional restoration.

2. In fractures of shafts which are irreducible or can not be main-
tained in correct reduction (especially subcondylar fractures of the
femur, fractures of the arm, etc.) and when large displaced frag-
ments of bone are present.

Modern improvements in splints, however, render it possible in the
majority of cases to obtain satisfactory adjustment without a fixation
operation. Primary fixation is a difficult operation which exposes
the patient to grave complications; it should be performed only by
surgeons who have specialized, and at the present time the indications
for it are uncommon. In the British Army it is not the custom to
have recourse to a primary fixation operation, for two reasons: (1)
The good results now obtained with splints; (2) the bad results which
fixation operations have often given in the past.

Fixation during infection—Operation for fixation during infec-
tion is accepted by some, but expressly rejected by others; those who
accept it hold that it lessens the infection at the seat of fracture, is
not accompanied by prolonged osteomyelitis, and is rarely attended
by secondary sequestra. The results obtained, as a whole, are favor-
able. The indications for the operation would be the impossibility of
reducing certain fractures of shafts or of maintaining them in cor-
rect reduction. Nevertheless, modern improvements in splints render
possible such satisfactory reduction that fixation by operation is
rarely indicated. Temporary fixation by means of plates and screws
commands a majority of suffrages.

VII, ANALYSIS OF THE METHODS OF WOUND STERILIZATION.

These contributions, according to a note in La Presse Médicale, No.
91, 1918, page 194, are to be published only in extenso.
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- ROCKEFELLER FOUNDATION.

. AMERICAN LIBRARY ASSOCIATION.

“9, SERVICE UNITS IN FRANCE, BELGIUM, AND ELSEWHERE.

10. UNIVERSITY UNIONS.

11, AMERICAN COLLEGE WOMEN’S UNITS.

12. OTHER ORGANIZATIONS, USUALLY FOR CONSERVATION OF EF-

FORT AND EFFICIENCY, COORDINATED WITH THE ABOVE.

The Honorable Secretary of the Navy, Josephus Daniels, a short '

time ago, spoke of the Young Men’s Christian Association, the Red
Cross, and similar organizations as “part of the militant forces of
the country second only to the men who meet the deadly fire of the
enemy.”
.. Through the broadening of our horizon, modern warfare has come
to be recognized as a conflict between whole nations, every individual
being intimately concerned in the struggle and its outcome. Any-
thing which seriously affects the civil population is reflected directly
in the morale of the fighting forces, and any potent factor. which
helps the allied peoples in the great struggle is an auxiliary force,
whether preventing disease in the trenches, nursing the wounded,
fighting tuberculosis in the crowded cities of France, or caring for
the starving children of Belgium.

Inasmuch as it was my privilege to see the splendid work of
many of these agencies, this report would be incomplete without
some mention of them. If it were possible within the limitations
of time and space, it would be a pleasure to endeavor to present by
photograph and word picture an epitome of their work. But noth-
ing short of a very considerable volume would be at all adequate
for such an attempt. Everywhere the unselfish and humanitarian
service of America through the Red Cross, the Y. M. C. A., and
the many other agencies at work is recognized as a great source of

WO OADAR WHE -

-help to our own fighting men as well as to our allies.

Working in the devastated districts, helping the homeless to
reconstruct their habitations, caring for the destitute refugees, aid-
ing the poor repatriated, conserving the health of the civil popula-

207
208 AUXILIARY FORCES.

tion, carrying on an educational campaign of how to prevent tuber-
culosis and at the same time furnishing ways and means for the
relief of those who have already contracted the disease, lending
material assistance to local charities, acting as an emergency depot
for Army and Navy, nursing the sick and caring for the wounded,
affording healthful recreation and amusements, helping to keep the
men fit for fighting, aiding those at home who are in need and thus
relieving the soldier or sailor of worry, furnishing comradeship,
giving useful information, opening opportunities for the study of
what will"be of value now and later, becoming the banker and the
means of sending home money, furnishing food and hot drinks when
needed, housing the men, saving the babies by proper care and
adequate food, teaching the mothers how to do the best for their
infants, even showing the children how to play and grow strong in
war time, writing the last letters home, and often marking the grave
or photographing the spot and sending the picture home to the
family—all these and many other details of the vast work of these
. forces I met in my survey. On the ships, in the camps, along the
railways, at the depots, all the way to the front, even up where real
danger lurks were these same forces rendering services of which
we may justly be proud and for which multitudes are devoutly
thankful.
- It would seem that nothing has been left undone, no stone left
unturned. to aid the men in the service and the great cause of
humanity. It is an earnest, understanding, tireless civilian army
that stands behind the men at the front; the hearts, brains, and
hands of our whole country are seeking to serve in new and moré
helpful ways and to furnish everything that will make for efficiency.
comfort, and mental and physical happiness. There is nothing
spasmodic or uncertain about the movement. It is a concerted effort
inspired by a pure love of service and with one great objective—
to win the war and establish a permanent peace.
MISCELLANEOUS.
AMBRINE.

MODERN TREATMENT OF BURNS.

The modern treatment of burns is essentially a paraffintherapy and
was introduced by Dr. Barthe de Sandfort. His “secret” consists
of paraffin with an addition of succinite (oleum succini) or oil of
amber, and belongs to the Ambrine Co., in Paris, France. Equiva-
Seb preparations lave since been offered, notably Hull’s “ Paraffin

even.” ,

Application of ambrine——Wash the burns with sterile water, and
after drying cover or spray the surface with a layer of ambrine;
place a thin layer of cotton wool over the parts. and then apply a
second coat of ambrine. Applied to the skin, the preparation im-
mediately solidifies into a tough tissue-paper like film.

In the application of ambrine with a spray, as preferred by the
originator of the method, the paraffin must be at a temperature of
about. 50 C. (122 F.). A metal spray producer is in use in the
British Navy Medical Service (Brit. Med. Jour. I, 1917, p. 549). A
small slat of the ambrine is put into the apparatus and heated, either
over a spirit lamp or in a water bath, up to the temperture at which
the ambrine melts. The bellows of the spray producer is then
adjusted, and the liquid wax is pumped as a very fine spray onto the
burnt surface, which has been previously dried thoroughly. A cake
of wax forms over the surface, and is both air-tight, and from the
heat at which it is applied, aseptic. A thin layer of cotton wool is
then laid on this wax and the whole is again covered with the liquid
wax by a brush.

The directions for the use of ambrine as they come with the
original package are as follows:

- ‘According: to the extent of the burn or wound, melt in the water
bath 10 to 100 grams of ambrine in a small receptacle. Heat about
10 minutes in the water bath, then take out the receptacle with the
liquified ambrine. After it has slightly cooled spread the ambrine
_ over the lesion with a small soft brush, with a spraying not a sweep-
ing motion. The ambrine should be used as warm as the patient
will tolerate it. When applied it at once solidifies and will form an
adherent layer. The brush dipped in ambrine should be passed

several times over the same spot so as to produce a sort of varnish
209
210 AMBRINE,

of several superimposed layers. Cover this varnish with a layer
of absorbent cotton, as thin as possible, moistening it likewise with
ambrine, and again passing the brush over the cotton layer so as to
drench it thoroughly with the ambrine. In case of large wounds, small
surfaces should be treated in this manner and joined together. The
crust formed by the ambrine and the thin layer of cotton promptly
becomes solid and impermeable and is then covered like all dressings
with a layer of cotton held in place by a bandage.

The remnant of ambrine in the receptacle will serve for the next
dressing, as ambrine may be liquified several times. in succession
without losing any of its properties.

Certain precautions are to be observed, as follows: Guard against
even a drop of water from the water bath penetrating into the
ambrine. Do not place the layer of absorbent cotton directly on the
wound, but first place several layers of ambrine on the wound. Dur-
‘ing the first days, in extensive burns, renew the dressing every 24
hours; later on, when the exudation diminishes, one dressing in 48
hours will suffice. To remove the dressing, cut with scissors the
ambrine cast and the thin layer of cotton. Wash the wound with
ordinary boiled water, using no antiseptics, or only in very weak
solutions. Do not pack the wound with pledgets of absorbent cotton,
but gently touch the surface with a cotton wipe so as to guard against
bleeding from the granulations. Dry the wound if possible with a
current of hot air or with absorbent cotton without rubbing, before
beginning the next dressing. Do not mind a grayish appearance or
unpleasant odor of the wounds; under the serous exudate, new skin
is often seen to appear.

The employment of ambrine represents an important advance in
the treatment of burns. While the preparation is not an antiseptic,
and has no therapeutic effect upon the tissues, it at once relieves the
severe pain and forms a film-like covering over the burned surface,
replacing the epidermis and acting as both a protecting and purify-
ing factor, for it tends to collect in its substance any foreign con-
_ taminating material to which such wounds may be exposed.

Plastic procedures in modern surgery are accomplishing most re-
markable results in the serious deformities following the scars of
burns, not only in the lessening of disfigurement, but also in the
ultimate restoration of functional efficiency.

PROVISIONAL LEGS.

The great importance of early temporary apparatus for the ampu-
tated leg cases has been repeatedly emphasized. :

The following pictures taken at the H6pital Bon Secours, Rouen,
show a simple and excellent method of making a proper provisional
leg while the patient is still in the hospital under treatment.
 

 

Sketch of canvas cot.

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210-2
PLAN FOR SURGICAL EVACUATION HOSPITAL. 211

PLAN FOR SURGICAL EVACUATION HOSPITAL FORMATION.

The attached illustration of a plan for an evacuation hospital to
meet the exigencies of the present war has been worked out by me from
a sketch and data furnished by Lieutenant Albert E. Le Play, of the
French Army, developed by him from his experience of over three
years at the front in France, Roumania, and Belgium. By many
the plan is considered to be the best'so far evolved, and it has been
recommended for adoption to the Bureau de Santé. It embodies the
best features of the evacuation hospitals now in use in France, with
some additional points of value. A study of the sketch will give a
clear idea of the more important conditions and problems to be
faced. in a center of this kind.

It has seemed wise to include this plan in the report because of its
value in affording a graphic illustration of some phases of hospital
work in the war.

Dr. Le Play is now attached to the French-American Mission as
liaison officer for sanitary service with the Fourth French Army at
Chalons-sur-Marne.

The following are his views:

1. Such an evacuation hospital should be situated—

A. Twenty to 25 kilometers from the front line.
B. Not in a town, but only a short distance away from one.
C. Away from any railway.

2. Four red crosses, adequately large, should be placed at the four
extremities of the hospital site.

3. It is best to have the section for the severely wounded on the
unit plan so that the same staff of nurses and surgeon with assistants
can take care of the cases and at all times know where they are with-
out confusion and loss of time.

Colonel Gosset agrees with all of this scheme with the exception of
the unit plan for the severe cases and of the situation of such a
hospital, which he thinks should have its base 30 to 40 kilometers
from the front, instead of 20 kilometers.

KEY TO SKETCH OF LE PLAY’S SURGICAL EVACUATION HOSPITAL
PLAN.

1. Two or three doctors examining soldiers.
2. The bar, serving hot drinks.
8. Table, with doctors giving antitetanus; nurses, etc.
4, Walking patients.
5. Lines of tables, with clerks taking the names and data for the record and
home.
6. Railways for stretcher cases.
6a. Severely wounded cases, which must remain in the hospital—thigh,
brain, abdomen, and lung cases.
6b. Cases which may be evacuated.
(11)

, ete.
(12) | Depot for arms, etc
212 EDUCATIONAL SERVICE IN WAR SURGERY.

J. CENTRAL FOR ALL SEVERE CASES.

7. X-ray room.
8. Warm ward for shock.
9. Laboratory.
10. Sterilization room.
One surgical unit:
(aa) Two wards—50 beds.
(bb) Two dressing rooms.
(c) One operating room with 2 tables.
(dd) Two small rooms for nurses.
(e) One small room—dressings and supplies for operations, etc., with
‘a window as a door.

II. Cases WHIcH CaN BE EvacuaTED IN A Few Days.

1. Long table in a large room, with places for stretchers and chairs ; this room
is essentially for the soldiers to take off their clothes.

2. Depositories for soiled clothes.

8. X-ray room.

4. Washing and cleaning room.

5. For soiled underclothes.

6. Operating rooms—5 units (can have 6 or 7 if needed).

(A unit consists of 2 tables; 1 operator; 2 assistants. Three units can be
used for operations and 2 for dressings.)

7. Central sterilization room for all operating rooms.

8. Supply rooms.

9. Plaster splints for fractures, etc.

10. Dining room for the surgeons. (They work often 8 to 10 hours at a
stretch, and must have this room near at hand.)

III,

Large wards: One-half for beds; one-half for a sitting room; tables. Clean
clothing is given here.
I, II, III, etc.: Wards, as many as desired; 24 with 50 beds each.

In an average rush time, about 5 to 10 per cent go to I; about 30 per cent
go to II; and about 60 to 70 per cent go to III.

PROPOSED ORGANIZATION OF EDUCATIONAL SERVICE IN WAR SURGERY.

A personal communication from Prof. Tuffier, whose name is too
well known to require, introductory comment, contains a number of
such valuable suggestions for the organization of war-surgery serv-
ices that, although intended primarily to meet conditions as they exist
in France, a brief summary of his plan can not fail to prove helpful
on this side of the Atlantic, where the erection of sanitary institutes
and reconstruction hospitals for our returning soldiers is already
under way. The teaching possibilities of war hospitals are prac-
tically unlimited, and it is not only desirable but imperative that
such facilities, be utilized to the fullest possible extent; aside from
other considerations, for the reason that the exodus in search of
EDUCATIONAL SERVICE IN WAR SURGERY. 213

higher professional education on the part of medical students and
post-graduates to European universities is probably largely a thing
of the past. “The old order changeth” making place for the new.

Briefly commenting on the administration of the post-bellum
establishment, as planned by Tuffier, it may be stated that at its head
would be placed a director, with full administrative power, having
under him two groups of assistants (two executive officers and two
secretaries), and two operating surgeons, to be appointed by the
director, with two surgical teams, in charge of the two surgical
services. Provision could be made for as many demonstrators as
might appear desirable. Consulting specialists would be called upon
as required by the operating surgeon.

With special reference to the opportunities for instruction in medi-
cine and surgery afforded by an institute of this kind, a feature of
the highest importance would be the establishment of courses in op-
erative technique and other branches. The work would include at-
tendance at clinics and practical experience with methods of wound
dressing, demonstration, and application of apparatus, with some
special daily feature of surgical interest, for example, transfusion
of blood and comparison of the different methods in use. Ample
provision should be made for practical work along the line of bac-
. teriological examination of wounds. Theoretical and practical in-

struction in the selection and preparation of material for dressings
used in war surgery would be included in the course.

At the present writing, the teaching in Paris proposes to comprise
also the treatment of wounds of the soft parts, fractures, and hemor-
rhages at the dressing stations and first-line ambulances.

In a general way, Tuffier’s program is planned to cover the repair
of the-entire human body, including cranial, cervical, thoracic, and
abdominal wounds, as well as peripheral injuries and wounds of the
extremities.

The scope of operations performed in a war hospital of this char-
acter will naturally be almost unlimited. Familiarity, and the skill
which comes with experience, will thus be secured by the attendants
in procedures such as transfusion of blood; adequate incisions for
free exposure of wounds; excision and removal of devitalized tissue ;
suturing of wounds; trephining of the skull; the modern treatment
of penetrating wounds of the chest, and of abdominal wounds; the

‘management of maxillary fractures; the methods suggested and
adopted for the closure of vascular wounds, suture, and grafting
nerves; resection of bones and joints; operations upon the upper and
lower extremities. The immensity of the clinical material will insure
abundant opportunities for the performance of both typical and
atypical operations. In the course of a few months a young surgeon
working in an institution of this kind will see and handle a number
214 DISPOSAL OF U. S. A. CASUALTIES.

of conditions of unprecedented variety, such as perhaps have never
before been crowded into the span of the surgical experience of a
single lifetime.

SPECIAL POINTS WITH REGARD TO DISPOSAL OF UNITED STATES ARMY
CASUALTIES,

Major R. W. D. Leslie, R. A. M. C., D. A. D. M. S., embarkation,
has for almost four years been in charge of the medical service of the
war office in London which disposes of the incoming sick and wounded
at Southampton, Plymouth, Avonmouth, etc. In July, 1918, he was
transferred to France for the purpose of straightening out certain
difficulties which had arisen there.

Major Leslie gave me some suggestions, based on his experience, for
the disposal of our casualties, and these are quoted in full, together
with a sketch of the naval cot referred to.

(1) Retention in France.

(2) Retention in United Kingdom.

(3) Return to United States of America.

The first two points do not require much consideration, as arrange-
ments in connection with them have been or are in course of being
made.

The third point is of great importance, and there are many diffi-
culties to be overcome in connection therewith.

It is understood that a large proportion of foodstuffs for the
Allies is brought from America, and, as economy in tonnage becomes
more and more necessary, the feeding of noneffectives in this coun-
try or France, is not desirable. With the large United States armies
which have already arrived and are expected to arrive, one can antici-
pate a large proportion of casualties from wounds and sickness,
many of whom will be incapacitated for fairly long periods and some
permanently. The retention of these cases in France or in England
means an increased demand for food, which is-not only more difficult
to supply, but also in this case, wasted as far as fighting power is
concerned. Transports bringing Americans to England return prac-
tically empty, and it would, therefore, appear feasible to send back
in these ships as many as possible of these noneffective United States
Army troops who are likely to be incapacitated permanently or for
some time, say, two months or even less. At first sight this may ap- "
pear comparatively simple, but there are several difficulties, of which
the chief are:

(1) Selection of suitable cases.

(2) Fitting out of transports.

(3) Medical staff. _
DISPOSAL OF U. 8, A. CASUALTIES. 215

(4) Disembarkation and embarkation, including arrangements in —
connection with trains, etc.

(1) Selection of suitable cases——Here we are confronted with one
of the chief obstacles. To be of any value the selection must be done
rapidly, and at the same time no cases returned who are likely to
recover easily. Efficient medical boards would be required for this
purpose, which would work in conjunction-with each American
hospital in England. These boards would see every case on arrival
from France and decide whether they would be retained or returned
by the first available ship. Nominal rolls of suitable cases with their
disabilities would be returned daily to the medical embarkation
staff (see 3), who, working in conjunction with the Quartermaster
General’s Department, would allocate the cases according to the ac-
commodation in the ships and arrange for their collection and em-
barkation.

(2) Fitting out of transports.—Any elaborate or permanent struc-
tural hospital arrangements would interfere with the value of trans-
ports as ordinary troopships, which should be avoided. Therefore,
some suitable method of rapid conversion from transport to hospital
carrier must be devised.

I am of the opinion that this could most suitably be met by adopt-
ing the British naval cot. The fixtures for slinging these cots ‘are
simple, and when not required the cots can easily be stowed away.
Each ship should be inspected by a competent officer with experience
in this class of work, who would estimate the carrying capacity as re-
gards invalids and arrange with the naval authorities for the fitting
up of the cots and also make arrangements for the provision of a
‘dispensary, emergency theater, etc. The ordinary sleeping bunks in
the transport could be utilized for lying cases, the special cots being
kept for more serious cases.

A sketch of the naval cot is attached.

(8) Medical staff—A medical staff consisting of surgeons, nurses,
and orderlies would be required for each ship returning with in-
valids to America. For this purpose, a transport medical service
could be established. A suitable staff would be allocated to each ship
-at the port of embarkation in England, by the embarkation medical
staff (see 4). The staff would return to England from America, at
the first available opportunity, and report to the embarkation medical
staff, for duty on another voyage. Use could also be made of medical
officers, temporarily unfit for service in the ficlds to do duty on these
ships.

(4) Medical embarkation staff—This staff would be responsible
for all medical arrangements in connection with the care of sick and
wounded in returning American transports. They would receive
216 DISPOSAL OF U. S. A. CASUALTIES.

‘ from the medical boards lists of patients as stated in (1). They
would keep a list of sailings of ships with dates and carrying capacity
of each. They would arrange in conjunction with the D. M. S.. em-
barkation, U. K., for the entraining and transport by ambulance or
ordinary train of all invalids selected to the port of embarkation. ’
They would notify the port of disembarkation in the United States
cf the approximate date of arrival of invalids in America, giving
numbers of lying down and walking cases, or any other special in-
formation required.. They would. arrange for the suitable staffing
with surgeons, etc., of each ship, according to the number carried.

The above is only a very broad outline of a suggested scheme, but
the details could be elaborated quite easily.

SURGICAL SANITARY FORMATION.
KEY TO SKETCH.

. Regimental aid post.

. Station for loading of automobiles.

. Selecting station,

. Nontransportable wounded.

. Advanced dressing station (60 beds).

. Transportable wounded.

. Severely wounded.

Twenty kilometers distance from the front.
. Wounded who will rapidly recover.

. Disabled and sick.

11. Surgical base hospital (3,000 to 5,000 beds).
12. Contagious.

18. Surgical formation of stations, affiliated with base hospit::!.
D. Division.

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216

 
RECOMMENDATIONS.

Throughout this report there will be found many suggestions from
the experiences of our allies which might well form the basis for a
long list of recommendations. For example, the adoption of certain
methods of treatment, the testing of others, and the many questions
relating to the establishment of special hospitals, convalescent camps,
and centers for reeducation. It is not the purpose, however, at this
time to go into such detail, but the following suggestions seem to re-
quire early consideration:

1. More system is urgently needed in. the sending home of the. sick and
wounded. Each transport should take only such numbers of surgical, insane,
tuberculous, and other cases as it is equipped to handle. Before embarkation,
the patients should be sorted by a medical officer having full knowledge of their
condition and requirements and of the accommodations on the various trans-
ports.
> Transports carrying serious surgical cases should have proper operating
room facilities, X-ray apparatus, assorted sizes of Thomas splints, and Carrel-
Dakin equipment, as well as hospital corpsmen with special training. The sur-
geons in charge should be thoroughly familiar with the various’ methods of
treatment now in vogue in order that they may intelligently continue such
treatment as the case has been receiving, or, if occasion requires, change it to
the advantage of the patient.

3. As gas and oxygen, with or without ether, is becoming largely the anes-
thetic preferred in war surgery, our base hospitals and ships caring for many
surgical cases should be equipped for its use. The apparatus recently devised
by the American Red Cross is simple and cheap and has been ordered in large
quantities for the Army, and,as pointed out by Gwathmey, is easily adaptable
for ships.

4, On all large transports and at the Navy base hospitals there should be
provided for the surgical personnel the following books:

(a) Military Medical Manuals (21 vols.); Sir Alfred Keogh, G. C. B.,
L. L. D., F. R. C. S., editor.

(bd) Report on the Medico-Military Aspects of the European War, by Surgeon
A. M. Fauntleroy, United States Navy.

(c) Manual of Military Urology, published for the American Expeditionary

Forces by the American Red Cross.
(d) The Medical Bulletin, published monthly by the American Red Cross

Society in France. .

(e) Certain new books, published or to be published by leading surgeons en-
gaged in war surgery, such as Blake’s book on Fractures, Willems on Septic
Joints, Souttar on Nerve Suture, Robert Jones on Orthopedic Surgery, Lock-
wood on Surgery of the Forward Area, Sinclair on Fractures, and Williams on

War Neurology, etc.

93696—19—15 217
218 RECOMMENDATIONS.

5. On such transports there should also be provided for reference use by our
hospital corpsmen certain of the books now used for instruction in the best
training schools for nurses.

6. Provision should be made at the ports of embarkation for the thorough
elimination of lice from the persons and clothing of troops before they are
taken on board.

7. At all naval training stations and base hospitals there should be installed
the Barron ladder, or such modification of it as seems advisable, for the pre-
vention and cure of flat foot.

8 The beneficial effect of the early use of provisional apparatus in ampu-
tated cases should be recognized and adequately provided for in all Navy base
hospitals where such cases are under care.

9. More Navy surgeons and dentists might well be sent abroad to the special
hospitals and centers where opportunity is offered for practical experience in
the most recent developments in military orthopedics, plastic and oral surgery,
nerve suture, the making and fitting of prosthetic apparatus, ete.

10. The value of blood transfusion in chronic sepsis, and the donor law in
relation to skin grafting and transplanting of other tissues should be deter-
mined as promptly as possible,

11. Rules for massage, such as those in use at the Alder-Hey Military Ortho-
pedic Hospital, should be printed and distributed among those responsible for
the giving of such treatment.

12. By way of neutralizing the insidious effects of enemy propaganda, there
might well be inaugurated for the Navy personnel a series of entertainments
in the form of moving pictures, short talks, etc., with a view to familiarizing
the men with the objects of the war and what is being done at home and
abroad, and especially acquainting them with what is being done toward the
physical reconstruction and vocational. reeducation of those badly injured.
The spread of such information will be beneficial not only to the enlisted
men but to all with whom they come in contact.
TECHNICAL INSTRUCTIONS IN VIEW OF THE IMPENDING
MILITARY ACTIVITIES.

This instruction comprises the conclusions expressed by the differ-
ent chiefs of the technical service of the Sixth Army.

Early surgical attention is the most powerful means to guard the
wounded against all infectious complications. Uniformity and con-
tinuity of treatment are the important factors of success. They are
secured through the technical connection between the surgeons of the
different stages of the sanitary formations. The surgical service of
the Sixth Army has endeavored to put these requirements into prac-
tice, as shown in the following:

ROLE OF EACH SANITARY FORMATION.

1. REGIMENTAL AID POSTS.

The application of simple dressings, immobilization of fractures,
control of hemorrhages, and as rapid evacuation as possible constitute
their principal activity. Wounds are to be dressed by means of ordi-
nary gauze, the surface application of Vincent’s powder serving espe-
cially in those cases whose evacuation is delayed.

Hemorrhage is treated by simple packing of the wound, without
constriction of the limb. The tourniquet is to be reserved for excep-
tional cases, and a special label must indicate its presence, the neces-
sity of immediate evacuation, and a priority examination on arrival
at the grouped ambulances.

Fractures are carefully immobilized by means of one of the appa-
ratuses in the use of which each regimental surgeon has been in-
structed. (On the arrival of the wounded in an ulterior formation,
the apparatus will be exchanged, one apparatus for another.)

For fractures of the thigh, it must be kept in mind that in order
to be efficacious, every apparatus must reach from the axillary re-
gion as far as the malleoli.

Antitetanic injections should be administered as far as practicable.

Symptoms of shock are treated with tonic hot beverages, warming
of the entire body, and injections of camphorated oil repeated every
three hours.

Soldiers who have been “ gassed ” should be undressed, washed, and
provided with a change of clothing.

. 219
220 TECHNICAL INSTRUCTION ON EVE OF OFFENSIVE.

Evacuation—The very severely wounded, when the diagnosis is
positive and the general condition sufficient to tolerate transportation,
whose treatment is extremely urgent, must be at once forwarded, di-
rectly and without any further sorting, to the following formations:

Fourteenth Corps, Hépital de Soissons.

Twenty-first Corps, H. O. E. de Vasseny.

Eleventh Corps, H. O. E. de Vasseny.

Thirty-ninth Corps, H. O. E. de Mont-Notre-Dame.

Severe fractures of the diaphyses are to be directly forwarded,
with the following attached label:

For the Fourteenth Corps, to the fracture center of Vierzy.

For the Twenty-first, Eleventh, and Thirty-ninth Corps, to the
fracture centers of Mont-Notre-Dame or to the center of Chateau-
Thierry.

All other cases of wounds or intoxications are to be directed to the
sorting posts constituted by the grouped ambulances:

For the Fourteenth Corps,

For the Twenty-first Corps, Sermoise,

For the Eleventh Corps, Courcelles,

For the Thirty-ninth Corps, Cerseuil,

 

 

 

 

GROUPED AMBULANCES, SORTING POSTS.

The part played by these is of the utmost importance. Antitetanic
injections are here administered when these have been omitted at
the aid posts.

1. Sorting —This must be left in charge of experienced surgeons.

All dressings are to be removed.. The diagnosis will be based upon
direct examination of the lesion. After readjustment of dressings
and apparatus, the wounded will be directed to a new previously
designated sanitary formation.

All tourniquets should be removed when the origin of the hemor-
rhage can easily be seen. Hemostatic forceps are applied and left in
place. When the hemorrhage is deep, the tourniquet is retightened
and the patient is detained in the hospitalization of the same grouped
ambulances, with a special recommendation to the surgeon in
charge.

All nontransportable cases are detained in the hospitalization.

All gassed soldiers are likewise to be detained and treated, if not
already treated in the aid post at the front.

These nontransportable wounded are, for the most part, cases of
severe shock, with or without hemorrhage; wounds of the skull and
brain, with escape of cerebral substance, and a bad general condi-
tion; extensive shattering of limbs requiring immediate amputa-
tion; penetrating wounds of the abdomen, wounds of the thorax with
persistent hemorrhage or threatened asphyxia.
TECHNICAL INSTRUCTION ON EVE OF OFFENSIVE. 221

Cases of very minor injuries, and the slightly wounded, are like-
wise to be detained when they can not be accommodated in the evacu-
ation hospitals.

2. To be evacuated—l. The disabled, for the Fourteenth and
Twenty-first Corps, to La Ferte Milon.

2. Urinary cases, to the center of Busancy.

3. Fractures, for the Fourteenth Corps, to the hospital of Vierzy;
for the Twenty-first, Eleventh, and Thirty-ninth Corps, to the Frac-
ture center of Mont-Notre-Dame or that of Chateau-Thierry.

4, Lesions of the face, jaws, and orbit, to the H. O. E. of Vasseny.

All other wounded are to be directed to the following centers:

Fourteenth Corps, H. O. E. of Soissons, with overflow to Busaney
and Vierzy.

Twenty-first Corps, H. O: E. of Vasseny.

Eleventh and Thirty-ninth Corps, H. O. E. of Mont-Notre- Dame
or of Saint-Gilles.

All apparatus removed in the grouped ambulances is to be returned
to the corresponding aid post.

ROLE OF HOSPITALIZATION OF THE GROUPED AMBULANCES.

1. Service of nontransportable cases.—It consists in the exclusive
reception of nontransportable wounded, and of soldiers with very
trifling injuries, only in case of overburdening of the evacuation
hospitals.

These wounded are to remain in these formations no longer than
the strictly necessary time to ascertain the harmlessness of their
transportation before or after operation. Any delay in their evacua-
tion is most prejudicial for these wounded. An appeal is made to the

‘ conscience of the surgeons in charge, who may always follow the re-
sults of their treatment in the sanitary formation to which they have
evacuated their patients after operation: To detain a wounded sol-
dier outside of these special conditions is to expose him to compli-
cations.

These wounded, having become transportable, will be evacuated
to—

Fourteenth Corps,-H. O. E. of Soissons.

Twenty-first Corps, H. O. E. of Vasseny.

Eleventh and Thirty-ninth Corps, H. O. E. of Mont-Notre-Dame,
and, if necessary, H. O. E. of Saint-Gilles.

2. Slightly wounded.—Foreign bodies which can easily be ex-
tracted without great tissue destruction are to be removed. Wounds
are to be freely opened, excised, dressed, and bandaged, directing the
patients for suture to the surgical centers.
222 TECHNICAL INSTRUCTION ON EVE OF OFFENSIVE.

ROLE OF THE H. 0. E. OF SOISSONS, THE BUSANCY GROUP, AND THE
H. O. E. OF VASSENY, MONT-NOTRE-DAME, SAINT-GILLES, AND
VIERZY.

The selection and destination of the hospital to be allotted to the
wounded in these centers will be determined and specified by the
chief physician of each of these hospitals.

‘The management of the wounded will be prescribed by each of the
surgeons at the head of the service.

Technical questions will be indicated, when necessary, by the heads
of service in the centers, in accordance with the operating surgeons.

The evacuation of the wounded from these surgical cénters, in
order to establish a connection with the formations at the rear, will
be carried out in the following directions:

The fractures of the Vierzy center and those of the H. O. E of
Soissons are to be directed as soon as their condition permits, namely,
when the cicatrization of the wound allows it, to the fracture center
of Compiégne, by boat or rail.

Those of the H. O. E. of Vasseny and of Mont-Notre-Dame, to
the fracture centers of Chateau-Thierry, and, when this does not suf-
fice, to Paris.

Soldiers with wounds of the face, jaws, orbit, and eyes will be
-directed to the center of Paris as soon as their transportation involves
no danger.

Wounds of the soft parts, after incision and exposure, for suturing,
or immediately after their cicatrization, will be directed to

In case of overcrowding of the wounded, evacuations of all kinds
will be carried out by special trains to Paris.

 
REPORT OF THE SURGICAL TECHNICAL ADVISORY
é COUNCIL.

Composed of Medical Inspector General Frevrire, Profs. HARTMANN and DELBET.

The surgical technical advisory council was consulted as to the best
place for the evacuation hospitals. The absence of its president hav-
ing caused a certain delay in the meeting of the technical advisory
council, before the question could be taken up, a note was submitted
entitled “ General Indications to Serve for the Organization of the
Sanitary Service According to the Regulations.”

As the place of the evacuation hospitals is closely related to the
general organization of the sanitary service, it appeared advisable
to study this note asa whole. The evacuation hospitals, as originally
planned, were based on the imaginary inviolability of the front.
This place has been fixed at a distance of 18 to 20 kilometers from the
fighting lines. This suffices to show that they are impracticable, as
the front may actually vary for a more considerable distance in 24
hours. We have unfortunately learned the cost of fixedness of the
evacuation hospitals located in this zone.

The altered character of the war demands a change in the organiza-
tion of the sanitary service in the zone of the armies. The note sub-
mitted to us by the surgical technical advisory council aims at the
establishment of a new régime and seems to be well conceived in its
general outlines. The points which it seems to us might be modified
are indicated in the following: ,

1. Aid posts.—This question is not considered in the note. We wish
to suggest in this tonnection an organization already proposed by us,
adopted in certain armies, and worthy of general introduction. For
certain wounded, the diagnosis is so obvious as to render undesirable
their passage through the sorting station, this passage being incon-
venient for the patient, whose treatment is thus retarded, and incon-
venient for the center, which is always overworked during a period of
offensive. These wounded should be provided with special labels
insuring their direct transportation, without interruption, to the place
where they are efficiently taken care of. They belong in three groups,
each of which should bear a special label, easily recognizable by its
shape or color.

(a) One group comprises wounds of the abdomen, open thorax
(perforating wounds of the chest), vascular wounds treated with a
tourniquet. Soldiers with such lesions must be sent directly from the
aid post to the advanced dressing station.

‘ 223
224 REPORT OF TECHNICAL ADVISORY COUNCIL.

(b) A second group comprises gross fractures and also gross con-
tusions of the soft parts (calf, thigh, buttock, axilla, shoulder), which
expose particularly to gas gangrene. The wounded of this group must
be taken directly to the primary evacuation hospitals.

‘(c) The third group comprises the fractures of the skull. Ex-
perience having shown that it is better to transport these patients be-
fore than after the operation, we hold that they should be taken
directly to the secondary evacuation hospitals.

2. Army formations —(a) These formations should be very mov-
able. It seems, therefore, necessary to specify those which should be
installed under tents.

(b) We hold that these formations should be divided into two sec-
tions: One sorting section and one surgical section, properly speak-
ing. These two sections must be adjacent but independent.

The note under consideration indicates that these formations are to
treat on the spot the grave nontransportable cases and those which
are in need of emergency measures. There is nothing to add about
the nontransportable cases, but “those in need of emergency meas-
ures” leaves too much room for different interpretations. A few
explanatory words should be added without definite restrictions.
It should be specified that abdominal wounds, perforating wounds of
the thorax, vascular wounds associated with hemorrhage arrested by
a tourniquet, are to be cared for in these formations. In the organi-
zation as proposed by us those wounded would be directly taken
there.

(The submitted note anticipated for these formations an operating
staff able to perform this major surgery.)

3. Primary evacuation hospitals.—We believe that these hospitals
which are to be placed at the rail heads should likewise be installed
under tents, as already requested by the technical advisory council
ina preceding report (by Hartmann).

In our opinion these hospitals should take care of the gross frac-
tures and gross contusions of soft parts, which will be sent to them
directly from the aid post.

The note anticipates these evacuation hospitals to be equipped
with a service capable of adjusting provisional maxillary-facial
prostheses, an ophthalmological service, etc. Such equipments ap-
pear to us out of place in these hospitals. Patients with wounds of
the face are among the most easily transported. A delay of a few
hours is of no importance for them. They should be treated in the
secondary evacuation hospitals.

One of the duties assigned by the note to the secondary evacuation
hospitals is that of directing the lightly wounded, the sick who will
promptly recover, and the disabled to special dean iy destinations.
Leaving aside the sick and disabled—emphasizing, however, that
REPORT OF TECHNICAL ADVISORY COUNCIL. 225

the disabled must not be confused with the slightly wounded—we
wish to call special attention to the latter.

The gravely wounded, whose lives are directly threatened, hold
a predominant place in our preparations. They make a more pro-
found appeal to our sympathy and they gratify our surgical pride.
From the military viewpoint, however, it is evident that the slightly
and moderately wounded are entitled to the same care and must be
handled by skilled surgeons in well-organized formations. The
serious question of man power is far more concerned with the
slightly wounded than with the seriously wounded.

In 1915 we adopted Hartmann’s formula that there are no slightly
wounded; meaning that at the time of distant evacuations many
slightly wounded died of gas gangrene or acute septicemia. The
formula is now resumed in a modified sense. We mean to say that
wounded soldiers with not intrinsically very severe lesions enjoy at
least as much as others the great surgical progress achieved in the
course of this war in the form of resection followed by suture.

Under insufficient care these wounded who represent the great’
majority of war casualties require weeks and often months to get
well; they leave the hospital on convalescent leave; they regain their
fitness very slowly. Some, entirely too many, retain fistulas, intra-
muscular fibrous nodules, adherent cicatrices, which induce func-
tional disturbances, and they never again become: fighters. Prop-
erly managed, with trimming of the wound and primary suture, they
leave the hospital at the end of a dozen days with a leave (per-
mission) of 10 days. In three weeks they are well.

All those who have visited a large number of sanitary formations
know that the slightly wounded, when insufficiently treated at first,
often require more time to recover than moderately or even certain
severely wounded who are well taken care of.

Undoubtedly, at times of great inflow of wounded, surgeons are
obliged to devote their efforts first to those whose lives depend upon
their interventions. But it can not be overemphasized to the sani-
tary service that the slightly and moderately wounded be cared for
in good installations and by competent surgeons.

There is neither necessity of nor advantage in having them treated
in formations near the primary evacuation hospitals; no necessity
because they can tolerate a slightly longer journey, and no advantage
because one can extend to any hospital the right to discharge the
patient on a 10 days’ leave. —

4, Secondary evacuation hospitals—In these formations the ma-
jority of wounded will be operated upon, and it is on this subject that
we have been specially consulted.

As to the importance attached to them we entirely agree with the
note. It properly emphasizes the disadvantages of scattering the
226 REPORT OF TECHNICAL ADVISORY COUNCIL.

wounded and cleverly expresses the situation of surgical staffs in
small formations, where they are alternately overworked and in a
state of inactivity. Strong organizations with a large material are
accordingly needed.

They should be supplied by a special railway with branches per-
mitting the yarding of several trains, and platforms facilitating the
unloading of the wounded. As to the distance at which they should
be placed, this question, specially addressed to us, still presupposes
a certain stabilization of the front. This point does not fall within
our domain. Moreover, as the wounded may be very numerous, as
the neighboring regions have no organization permitting them to be
properly cared for, it is imperative to create large surgical forma-
tions, and the position of these must necessarily be governed by the
‘point where the wounds are inflicted, namely, starting at the front.

The note counts by kilometers (50 to 200). Time is not directly
related to distance, for many other factors intervene. Not the kilo-
meters, but the hours are of importance, meaning the duration of
the transportation. It therefore seems preferable to count by hours.

Two necessities arise, which are to a certain degree contradictory—
that of protecting these large formations against the ordinary fluctu-
ations of active warfare, and that of managing the wounded as soon
as possible. One demands removal, and the other approximation, of
the surgical centers.

Our personal experiences in the course of the last offensives permit
to conciliate proper care of the wounded with the safety of the sec-
ondary evacuation hospitals.

The period during which a medium-sized wound remains capable
of being sutured is more extensive than was assumed to be the case.
While suture was considered very risky after the eighth or tenth
hour, practically all the wounded were systematically sutured who
arrived unoperated in our Paris services. These wounds dated back
24, 86, 48 hours. Such remarks can at present be passed only with
extreme caution. It always remains desirable for the wounded to
be operated upon as promptly as possible, but it is certain that a
competent surgeon should not omit suture for the sole reason that the
wound dates back 24 to 36 hours.

Thus there actually exists a margin which permits placing the
great surgical stations in an at least relative zone of security, for
assuredly no organization can be established which is equally satis-
factory at a time of great disaster or great victory.

Except the wounded of various groups, which have already been
specified, as to be operated upon in the army formations (advanced
dressing stations) or in the primary evacuation hospitals, we believe
that nonoperated patients can tolerate a railroad transportation last-
REPORT OF TECHNICAL ADVISORY COUNCIL. 227

ing at most 10 hours from the point of entraining. Counting that
this point will be reached in an average time of six to eight hours,
they will be operated upon within 24 hours, namely, during the
period in which suture is possible in properly managed cases.

The first thing to be done in order to decide the location of the
secondary evacuation hospitals is to ask the G. Q. G. to indicate
the limits of the zone whose security is believed to be sufficient.
The second point is to request the IV Bureau to specify the points
of this zone where the, roads can be made to converge, so that the
trains coming from the most advanced stations can arrive here in less
than 10 hours.
FIXATION OF THE BASE OF HOSPITALIZATION AND
THE SURGICAL MEASURES NEEDED FOR AN AT-
TACKING ARMY CORPS IN AN OFFENSIVE.

The experience of the different offensives has shown the neces-
sity for organizing a solid base of hospitalization well in advance for
each of the working C. A., to receive the wounded, and a sufficiently
complete surgical service to operate upon them with an average
delay of 24 (exceptionally 48) hours.

The teachings of the present war permit to fix approximately the
conditions which this base must meet for a C. A. of attack like the
first C. A. C.

The essential points to determine are as follows: The number of
beds and the surgical means.

These points rest on three essential factors:

1. The production or incidence of the wounded.

2. Their debit and their hospitalization.

3. Their surgical liquidation.

1. PRODUCTION OF THH WOUNDED.

Calculations concerning the production of the wounded are based
on the losses sustained by the first C. A. C. in the course of the three
great offensives in which it participated:

Battle of Champagne, September—October, 1915.

Battle of the Somme, July-August, 1916.

Battle of Soissonnais, April-May, 1917.

GHRONOLOGIOAL DAILY AVERAGE OF WOUNDED PER DIVISION IN
AN ATTACKING ARMY CORPS.

The average number of wounded must be established in chrono-
logical order for the total of the divisions of the army corps (aligned
or in reserve) during the entire duration of the procedures. This is
indispensable in order to arrive at an average calculation, for in
offensive procedures, the divisions are almost invariably grouped in
army corps and liable to enter in line at a given moment.

A calculation based solely on the divisions having sustained the
greatest losses would no longer correspond to the medium figure of
the chronological series, since all the divisions are never simultane-
ously engaged, and on the other hand the maximal losses are essen-

229
230 BASE HOSPITALIZATION AND SURGICAL MEASURES,

tially variable according to the difficulties of the terrain and the
particular fluctuations of the fight.

The maximal losses in wounded of the divisions of the first C. A. C.
correspond to the figures given below:

Champagne (September, 1915) :

September 25 (3 divisions). 309 1,200 0 tones 1,434 478
September 26 (3 divisions). 543 891 6500 JDivisions 1,509 503
Somme (July, 1916) :

July 1 (4 divisions) ___-__----- 589 789 220 0 1,598 899

July 10 (4 divisions) __-_------ 589 504 951 293 1,748 487
Soissonnais (April-May, 1917) :

April 16 (3 divisions) _-_-------__ 546 386 220 387 976 811

May 5 (3 divisions) _--_-__------__ 546 589 951 387 976 325

Once only, on September 25, 1915, the average surpassed 500 (508) ;
next day it was almost the same (478). The other averages are
around 400.

Table A gives the detailed calculation in the divisions, and’ the
graphic Al permits following the oscillations of the daily average
of wounded in the divisions as a whole, the average man power per
division being 12,000 soldiers.

The curves AQ and A10 show the detailed variations for each
division.

The study of these Bgures and graphics leads to the following con-
clusions: .

1. The maximal losses always occurred on the days “J” and
“ J-1,” then a diminution takes place with some sudden elevations
due to counterattacks, and finally, on a variable day (“J-5” to
“ J-20”), there appears another ascent, often as important as the
maximum at the beginning, and followed by the lowering which
terminates in stabilization.

 

 

“J,” general average of losses per division 884
“ J-1,” general average of losses per division 302
(Following days, fall with oscillations.)

Day “ J-x,” second ascent. 403

 

(Following days, fall with oscillations.)

2. The maximal losses always taking place at “J” and “J-,” these
days must serve as the basis for determining the liquidation:

 

 

 

Offensive of Champagne ; 503 478 981
Offensive of the Somme. 399 338 737
Offensive of Soissonnais, first attack_-------------___-____ 310 170 480
Offensive of Soissonnais, second attack.__.__________________ 325 222 547

Average 2, 745 685

AVERAGE OF WOUNDED ON pays “J” anp “g—1 IN ARMY CORPS AS A
WHOLE.

In an army corps the divisions furnish the majority of the losses,
but it is also imperative to consider the E. N. E., whose importance
BASE ‘HOSPITALIZATION AND SURGICAL MEASURES. 231

_steadily increases with the development of heavy artillery and with
the necessity. of renewing up to the first line the actively engaged
troops (territorial elements). .

These losses. are especially marked in offensives followed by oc-
cupation of new nonorganized positions, as occurred on the Somme
in July-August, 1916. The graphic B gives the figures, which can be
estimated at an average of 30 per day.

In an Army corps of 4 divisions the number of wounded for the
days “J” and “J-1” must accordingly be estimated as:

(6854) +60=2,800.
MAXIMUM OF ATTACKING DIVISIONS ON DAY “3,”

Besides the averages of wounded established in chronological order
on the total of the divisions of an army corps (divisions in line and,
in reserve) it is of great interest to learn the maximum of wounded
calculated exclusively for the attacking divisions.

These maxima (Table C) are significant only on the days “J”
and “ J-1,” for the day of ascent “ J-X” is too variable for the av-
erage, dating from “ J~X,” to possess value as regards the estimation
of the yield in wounded.

The maxima of the days “ J” and “ J-1” have been as follows: :

Battle of Champagne:

 

 

 

 

 

 

 

 

 

 

 

 

Second D. I. C 809 543
Third D, T. C 1, 200 891
Thirty-second D. I 500 543
Battle of the Somme:
Second D. I. C._-- 589 471
Third D. I. C 789 626
Sixteenth D. D. I. C 220 = «249
D. M 215 446
Seventy-second D. I - 208 298
Battle of Soissonnais:
Second D. I. C 546 351
Third D. I. C 386 159
Third D. I. C : 589 —- 806
D. P. : 387 359

The general average of the attacking divisions is thus seen to be
561 on day “J” and 506 on day “ J-1,” making 1,067 wounded for
the two days “J” and “ J-1.”

‘This information is important for the provisions to be made when
in the course of the procedures, a fresh division enters in line and
prepares to attack. From this basis should be planned the required
hospital accommodation and surgical facilities.
232 BASE HOSPITALIZATION AND SURGICAL MEASURES.
II, SUPPLY OF WOUNDED.

For the time being, the wounded are delivered in three stops:

1. Divisional aid posts (ambulance division).

2. Central sorting station of the army corps (gathering of am-
bulances).

3. H. O. E. (evacuation hospitals).

DIVISIONAL AID POSTS.

The divisional aid posts, provided they are sufficiently spacious
and their service is strictly regulated, have an extremely important
réle in the first sorting of the cases.

1. Removal of disabled (lame) by T. M. for transportation to the
depots.

Removal of slightly wounded by T. M. for transportation to the
ambulance for recuperable cases.

2. Immobilization on the spot for absolutely untransportable cases.

3. Evacuation of the other wounded in the order of severity toward
the sorting center of the army corps (gathering of ambulances).

Not mentioning the disabled, whose number is very variable, ac-
cording to the conditions of flood nourishment, and weather (in-
fluence of rain and cold), the divisional aid posts may be estimated to
liquidate as follows:

Twenty-three per cent of recuperable slightly Saude. 1.21 per
cent of very seriously and absolutely nontransportable ‘wounded,
equaling about one-fourth of the total of the wounded, so that the
average of the two first days (J and J—1) drops from. 685 to 518.

SORTING CENTER OF ARMY CORPS.

The sorting center retains the nontransportable wounded, directs
to the service for recuperables the slightly wounded who may have
escaped the first-line divisional ambulances, and evacuates all the
remainder to the H. O. E.

Too much must not be expected from its quantitative yield, on ac-
count of the group of patients which it retains and also because its
surgical facilities will always be limited.

_ Consequently, do not calculate from the number of beds but from
the probabilities of operative material in the 24 hours.

Under these conditions it must not be relied on to retain more than
120 wounded. All the remainder will go to the “H. O. E.,” making
for the days “J” and “J—1,” 518, 120, and 393.

Base of hospitalization—Summarizing, the hospitalization base of
the army corps consists of the following: The beds of the sorting
center ; the beds of the H. O. E, proportioned to the surgical resources.
BA“E HOSPITALIZATION AND SURGICAL MEASURES. 233

As the outflow of wounded does not begin until day “J-2,” this
base must correspond to the number of wounded in these two days,
deducting the slightly wounded recuperable (23 per cent) and the
absolutely nontransportable (1.21 per cent), averaging 513,

But it is absolutely necessary to take into account the conditions
of the debit and number of untransportable cases. .

The debit, insignificant on day J-1, may be estimated:

' At 10 per cent on day J-2; at 20 and 30 per cent on the following
ays.

With special reference to the nontransportable, whose proportion
increases every day, and may reach one-fourth of the beds on days
J to J-4, and even one-third of the beds on days J-6 to J-9; a place
for them is practically guaranteed by raising to 800 per division the
required total of 518 places.

Provisions for new attacks—In.case of an attack in the course of
the procedures by a fresh division, it is advisable to refer to the
figures of maximal losses sustained by a division which enters in
line.

These losses may amount to 561, 506, 1,067 for days J and J-1.
Hence, evacuate so as to have the necessary room and collect the
surgical means which are indispensable.

SUMMARY.

1. A division yielding 685 wounded on days J and J-1: 25 per
cent are removed by the first-line divisional ambulances; 513 are
received in the sorting centers of the army corps and of the
“H. O. E.” (beds and surgical facilities to be provided).

2. In consideration of the duration of the back flow of wounded
(10 to 80 per cent daily) and the number of nontransportable cases
(one-fourth to one-third from days J to J-9) the total number of
beds must be raised from 518 to 800.

8. These calculations are made for one division, on the total of
the divisions of an attacking army corps, including the divisions
held in reserve. ‘

In case of the entrance in line of a new division it is necessary to
tabulate above the maximum figure of losses of the divisions whick
have actually attacked, the days J and J-1, namely, 561, 506, 1,067.

Beds, surgical facilities, and debit must be accordingly pro-
vided for.

SURGICAL LIQUIDATION.

The divisional aid posts liquidate: 23 per cent of recuperable
slightly wounded, who are directed to a special formation (ambu-
lance or H. O. E.); 1.21 per cent of absolutely untransportable

93696—19——_16
234 BASE HOSPITALIZATION AND SURGICAL MEASURES.

cases, kept where they are, so that the total of days J and J-1,
which amounts to 685 wounded per division, drops to 518, shared
between the group of ambulances and the H. O. E.

Of this number, the average of inevacuable cases which must. be
kept: “hospitalized” is 25 per cent; the others can be evacuated
after operation and rest, making—

Inevacuable hospitalized ---- 128
Evacuable transients 385

 

 

LIQUIDATION OF INEVACUABLES.

Of the 128 hospitalized cases, one-tenth are not operable; the
others, amounting to 115, must be operated upon within 24 hours.

The average yield of a very efficient surgical service A rarely
exceeds one wounded per hour. As the activity must be continuous
for several days, it is not possible to count more than 12 working
hours per service, making 12 wounded daily; the 115 grave cases of
days J and J-1 (two days) accordingly require, per division:

115
~g :12=5 surgical services A.

LIQUIDATION. OF EVACUABLES.

The evacuable cases are partly recumbent and partly seated. The
average duration of the operative interference is a little shorter in the
recumbent than in the hospitalized, and the yield may be estimated as
15 instead of 12 per service.

For the seated evacuables the yield is much more considerable and
often exceeds 50; by reducing it to the figure 45, one obtains for the
two groups of evacuables a daily average of:

15-+-45 ‘
=30 operated per service A or B.

 

The 385 evacuables of days J and J-1 (two days) therefore will
require, per division:

885
—:30=7 services A or B.
2

TOTAL LIQUIDATION, ’

For the 513 wounded, to be liquidated by one division, will be
‘required :
5 services A, for the inevacuables.
7 services A or B, for the evacuables.

Total 12 services, of which at least 5 must be of the first class
(service A).
BASE HOSPITALIZATION AND SURGICAL MEASURES. 235

For an army corps of 4 divisions: 12x4=48 Sac with 20 serv-
ices A.

For an army operating with 5 army corps of 4 divisions each (20
divisions), the liquidation of all the wounded of days J and J-1, in
the 24 hours following their arrival, will therefore require:
12X20=240, 100 of which to be A.

For the total, each army corps will provide one service per divi-
sion and one for E. N. E., making for an army corps of 4 divisions
5:services, and for an army with 5 army corps 25 services. Of the
necessary 240 services, 215 would still remain to be furnished.

In order to guard against disappointment, it is advisable to re-
member and ponder on these figures. With the progressive spread
of the offensives, these needs can only increase, and the surgical serv-
ices at the disposal of the armies will be more and more swamped.

It must be positively established that the H. O. E. will hospitalize
only in the measure of its surgical facilities, and that its surgical
output will be unable to meet the requirements of the inevacuable
wounded. It is, therefore, useless to develop it disproportionately. .

But on the contrary, it appears imperative to put it beforehand
in close connection with a specially and very firmly organized sur-
gical center, at no great distance, to which it will pass with the
greatest system and with all desirable rapidity, the total of wounded
which it can not handle surgically, meaning nearly all evacuable
cases.

This arrangement must be provided for beforehand:

In the H. O. E.: Strengthening of the sorting and evacuating
services.

In the transportation service: Collection of necessary trains (for
seated and recumbent) since day “J.”

In the receiving service: Detraining of the wounded, hospitaliza-
tion, mobilization of surgical facilities (ready to functionate on
day “y ee

In this manner it will be possible for all the wounded to be oper-
ated upon at a delay never exceeding 48 hours since their departure
from the aid post.

It does not seem possible, at the present stage of the war, to devise
another solution.

(Signed) Lasnet,
Medical Inspector and Army Physician.
Jury 12, 1917.
 

 

Fig. it,

236--1

 
  

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Infiltration with cocaine; 2, Crucial cicatrix; 3, incision for removal of
most adherent purtion_of cicatrix.

 
 

 

  

  
     
 

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Fig. 2.—1, Incision of pericranium; 2, method of detaching the dura mater,

236-2
CARTILAGINOUS CRANIOPLASTIES.

In the course of a discussion on'trephining (see p. 72 of this re-
port), reference has been made to Dr. Chutro’s promised account of
his cartilaginous cranioplasties. This communication has just come:
into my possession and in view of the interest and far- reaching i im-.
portance of this procedure in war surgery, a full version in English
is presented in the following text:

CARTILAGINOUS CRANIOPLASTIES.

Indications and Technic by Dr. P. CuurRo, Adjunct Professor of the Faculty
of Buenos Aires, Chief Surgeon of the Military Hospital Buffon, Paris. °

A loss of substance of the cranial bones as such produces a series
of subjective and objective phenomena known under the designation
or trephinesyndrome. ” This syndrome is encountered pure and
separately in cases of lesion of the bone, the dura mater and the
superficial layers of the brain which have no differentiated function
of any kind. It becomes superadded on the other hand to the clini-
cal signs of the corresponding organic lesion, in the presence of de-
struction of the cerebral substance of the motor or other zones which
are the centers of various functions such as speech, vision, etc.

The trephine-syndrome disappears almost entirely after a properly
performed plastic operation on the skull, but the concomitant or-
ganic lesions which may be present are in no way directly benefited
by the operation. A case of hemiplegia will take its usual course,
the patient obtaining merely the suppression of the irritable cortical
phenomena through the cranioplastic operation.

A patient with a lesion of the occipital lobe will invariably retain
his ocular lesions.

Cases of Jacksonian epilepsy sometimes improve after cranioplas-
ties, or at least, the attacks will diminish in severity,. duration, and
frequency, although total disappearance is uncommon.

One of our patierts who suffered from monthly seizures, had his
first post-operative attack 14 months after cranioplasty, and at-
tributes it to brain fag caused by overwork as a bookkeeper in a bank.

An officer whose attacks occurred several times daily found them
becoming separated by progressively Iengthening intervals until they

disappeared entirely. He had suffered, moreover, from monoplegia
237
238 CARTILAGINOUS CRANIOPLASTIES.

of the left arm, which almost entirely subsided, leaving only a con-
traction of the muscles of the fist. This officer was enabled to re-
sume his position as an infantry instructor.

In contradistinction from the above case, another officer with a
frontal lesion, who suffered from severe and ‘frequent attacks of gen-
eral epilepsy, was in no way benefited by the operation.

As regards epileptic attacks, it must be stated that the numerous
cases which have come under observation due to the war, have per-
mitted neither the establishment of their etiology nor their patho-
genesis. Some epileptic patients presented at the time of operation
no compression or adhesion of the meninges; on the other hand,
numerous patients with compression and extensive meningeal ad-
hesions never presented the least sign of an epileptiform attack.
Hence, a possible improvement, but no more can be promised to
epileptics.

Cranioplasty must accordingly aim at two ends: (1) Suppression
of the faulty (but cosmetic) cicatrix; (2) suppression of the trephine-
syndrome.

After long experience with war surgery, we have reached the con-
clusion that all faulty cicatrices of the body should be extirpated
because they impede function, create abnormal adhesions, restrict the
action of the muscles and joints, and constitute a permanent risk by
their marked tendency to ulcerate and maintain foci of suppuration.
The extirpation of cicatrices must be obligatory in the skull. In
case of a simple lesion of the scalp which has undergone suppuration,
the cicatrix is very likely to have become keloid and painful. When
trephining has been done, the cicatrix is always adherent to the
meninges and even to the brain. These adhesions cause constant
traction and thereby continuous irritation of the meninges. On the
other hand, superficial cicatrices are lined with a sometimes greatly
thickened or actually keloid, sclerotic layer which when it comes in
contact with the brain, instead of becoming outlined has a tendency
to spread in the cerebral substance, thereby giving rise to a series of
invariably grave secondary phenomena. Briefly, it is desirable to
remove this keloid from the brain in order to put this organ at rest
so that it may heal and limit its lesion.

These irritable phenomena are part of the trephine-syndrome. The
other signs which are frequently observed are as follows:

(1) A sensation of emptiness in the trephined’ side.

(2) A very unpleasant sensation sui-generis, felt by these patients
when they are obliged to stoop or lower the head, manifesting itself
in form of vertigoes and nauseas. The same phenomenon supervenes
when they make some effort or on coughing.

With the patient in a sitting position, a depression is seen at the
site of lost substance; when he bends over, a hernia is seen to appear
 

 

        
   
   

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Robot cde ta porke cle Substance.
a Soler cur yo tenepotace Qa hurd - nicre

 

 

Fig. 3—1, Border of loss of substance; 2, sclerotic tissue which replaces the dura
mater; 3, method of dissecting out adherent cicatrix.

238-1
 

 

 

238-2
CARTILAGINOUS CRANIOPLASTIES. 239

in the same place. These continuous movements of the brain dis-
turb the patient and when the loss of substance is considerable he is
very apt to avoid all changes of position so-as not to experience this
highly distressing sensation.

(3) These patients can not tolerate external vibrations such as the
rolling of a train, the shaking of an automobile, street cars, etc.

A patient in our service refused to submit to operation, but was
so seriously inconvenienced by the vibrations of the car which
brought the meals that he finally begged for an operation. As a
matter of fact, the first thing noticed by him after the cranioplasty
was the disappearance of the trouble caused by the same wagon.

A Chasseurs officer who resumed his service eight months after
the operation, and who had previously been unable to ride in an auto-
mobile, stated that the bursting of the shells now produced no cere-
bral perturbation.

There are in addition a series of small variable signs, according
to different individuals, largely referable to disturbances resulting
from loss of equilibrium in the pressure of the intracranial fluid,
caused by the solution in continuity of the skull cap; these signs sub-
side with the performance of cranioplasty.

The advantage of restoring its uniformity of internal pressure to
the brain, except in cases of over-pressure, is universally conceded.

Our own experience leads us to the conclusion that cranioplasty
causes the disappearance of all the principal signs of the trephine
syndrome: the last to disappear is the vertigo. The headaches and
muscular weakness observed in all patients with cranial lesions sub-
side rapidly.

The following detail illustrates the beneficial effects of cranio-
plasty: Trephined patients are, as.a rule, unable to tolerate the
“movies;” after cranioplasty they can follow the pictures on the
film. The experience of two years does not yet permit the drawing
of conclusions; these cases must be observed for a very long time;
but rneanwhile. it may already be stated that a considerable number
of patients are evidently benefited by the intervention. Before oper-

ating upon them the cases must be carefully studied, refraining from
interference when a contraindication exists.

“All losses of substance, both small and large, must be closed by a
graft.

The contraindications are as follows:

(1) Infection; (2) the presence of intracerebral foreign bodies;
(3) hyper-pressure, even slight, with edema of the papilla; (4) irre-
ducible cerebral hernia; (5) cases of lesion of the occipital region
with visual disturbances: (6) cases of recurrent epilepsy which do
not improve on prolonged rest in bed. Beside these cases there will
240 CARTILAGINOUS CRANIOPLASTIES.

always be special cases in which physician and surgeon will agree as
to the nonadvisability of intervention. .

Concerning the best procedure for grafting, this may be ives
at some time to come on the basis of several hundreds of cases.
Personally and until the contrary has been established, we accord
the preference to cartilage grafts. The employment of metal, ivory,
dead bone, or celluloid plates can not be generalized. Except in a
few fortunate cases, these plates are cast out at the end of a certain
time, or they play the part of foreign bodies.

There is no longer any doubt between dead and living grafts, the
latter being preferable. It remains to determine if bone or rather
cartilage should be grafted.

Bone grafts involve several disadvantages:

(1) Necessity of general anesthesia.

(2) When the pediculated flap is taken from the neighboring bone, it must
be cut with the chisel and mallet, which should be avoided in cranial surgery.

(3) When the graft is taken from the tibia and the loss of cranial sub-
stance is considerable, a single graft does not suffice.

(4) Difficulty of shaping the grafts so as to follow the configuration of the
skull.

(5) Sometimes the bony graft does not fuse with the margin of the loss of
substance and the result is the establishment of a pseudoarthrosis, moving like
the keys of a piano.

(6) After the graft has healed in, one can never tell when the growth will
stop, and real proliferations may result, causing cerebral compression.

(7) The raw surface of the grafted bone remains irregular, which is dis-
advantageous, whether it be in contact with the dura mater or with the scalp.

In a general way bony grafts may be applied in certain small
losses of substance of the frontoparieta] region, when the dura mater
is intact, the graft then playing the part of a lid or a cover.

Cartilaginous grafts possess all the advantages of a living graft;
they heal in with remarkable facility. At the end of a certain time
they acquire the consistency of bone, although without becoming
ossified. The graft may be cut as thin as necessary and it is pos-
sible to shape it perfectly convex as adapted to the skull cap.

There are two methods of grafting the cartilage: Morestin’s
method, with a number of chips, and Gosset’s procedure, with a single
plate. We have nothing to say on the value of Morestin’s method,
as we have never used it, having utilized in all our cases the sa
plate, according to Gosset.

In a few instances we have found it necessary to fit two plates, on
account of the great extent of the loss of substance; in other cases
we have intentionally broken the plate, preserving the perichondrium
intact, so as to make it less rigid.

We have performed by this method 54 cases of simple cranioplasty
and 3 cases of double cranioplasty, meaning that at the same session
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CARTILAGINOUS CRANIOPLASTIES. 241

two cranial orifices were closed in the same patient. None of these
cases were followed by disturbances referable to the intervention.
All wounds healed by first intention, and there was no instance of
elimination of the graft.

The results obtained in the last 50 patients are superior to the
first, on account of the improved technic of the operation. We were
present at the first interventions of Prof. Gosset and obtained from
him the general rules governing the operation. These rules especially
have contributed to the improved results:

(1) The local anesthesia; (2) the extreme thinness of the grafted
plate; (8) the drainage during 48 hours, which guards against hem-
atoma.

As to the proper time for operating upon these patients, some sur-
geons have tried to apply the graft immediately after trephining and
extraction of foreign bodies; followed by complete closure of the
wound. There is not yet a sufficient number of such cases to permit
an estimate of this method. °

Personally we wait for the healing of the wound and the subsi-
dence of the tissue obstruction to apply the graft; which means that
the operation is performed as soon as the condition of the tissues
permits. This serves to prevent the onset of some subjective symp-
toms.

OPERATION.

Anesthésia—Barring a few rare exceptions, the operation is per-
formed under local anesthesia. A morphine injection is given one
hour before the operation; in case of very excitable patients or those
subject to epileptic attacks, it is advisable to give the night before
and a few hours preceding the operation an enema containing 1 gram
of chloral and 1 gram of bromide. oo

Novocain at 1 per cent with adrenalin is used. The scalp is in-
filtrated over a large surface, but at some distance from the region
to be operated on. In case of the temporal region, superficial and
deep injections are made, so as to reach all the nerves.

Anesthesia of the costal margin follows next. A long needle in-
serted near the cartilage of the ninth rib and pushed in horizontally
between the muscles and the cartilages following the direction of the
costal margin as far as the level of the fifth or sixth cartilage, and a
large amount is injected in order to insure a good deep anesthesia.
Without completely withdrawing the needle, it is carried across the
subcutaneous tissues which are abundantly infiltrated in the cus-
tomary manner.

The infiltrated costal margin forms a real “ ridge,” which promptly
subsides because the large amount of regional connective tissue per-
mits the absorption of the fluid.
242 CARTILAGINOUS CRANIOPLASTIES.

Before beginning the operation, it is advisable to have an assistant
hold the patient’s head, not only.to immobilize it, but especially to
lend the patient a moral support and show him that he is not alone.
This is a small practical detail which should not be overlooked.

Intervention —The operation comprises two chief steps: (1) The
preparation of the cranial gap; (2) the removal of the cartilaginous
gratt. os

Extirpation of the cicatriv on the scalp—The most common type
is the crucial cicatrix; next, large irregular cicatrices are found; a
horseshoe cicatrix is rare.

The rule is to make no incision which would add a new cicatrix to
those already present. In the cases of horseshoe cicatrix, one cuts
through the old cicatrix and mobilizes the cutaneous flap as for tre-
phining. When the cicatrix is very irregular, it is entirely extirpated,
followed by the mobilization of one or several scalp flaps, as required
for the plastic work. In cases of crucial cicatrix, the operator limits
himself to extirpating the larger and more adherent branch, which
is cut around by an ovaloid incision.

Figure 1.—In all cases the extirpation of the cicatrix must be very
cautiously done, because it is always necessary to leave a portion of
the fibrous tissue which is to play the part of dura mater, and as
there is no plane of cleavage, the deep aspect of the cicatrix must be
carved with the bistoury. But one should not exaggerate and leave
too much scar tissue. A few perforations of the dura mater or of
the membrane which has replaced it permit the escape of some drops
of cerebro-spinal fluid, but this has no untoward results.

Figure 2—The cicatrix having been extirpated the lips of the
wound are mobilized by some snips with the bistoury, cutting through
the connective tissue which separates the scalp from the pericranium.
The loss of substance appears in the wound. Detachment of the dura
mater. Under the guidance of the finger an incision is applied in
the pericranium at a distance of 1 or 2 millimeters from the border
of the loss of bony substance. Utilizing the curved rugine of Fara-
beuf as a scraper the circumscribed portion of the pericranium is de-
tached and the bone exposed.

Figure 3—With the same rugine, which is insinuated with one of
its angles between the bone and the dura mater, the detachment of
the dura mater is carried out on the entire circumference (Gosset).
From this time on the cerebral pulsations become stronger. By means
of a piece of cloth a pattern is made of the loss of substance to serve
for the removal of the graft from the costal cartilages. (Usually

‘this pattern is cut out the evening before the operation by applying .
the piece of cloth or paper directly over the loss of cranial substance,
the finger serving as guide and radiography as control.) Temporary
 

 

Gig. af bans

 

 

 

Fig. 7.—The graft installed,
242-1
 

 

    

  
  
      

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242-2

Fig, 8.—1, Suture of the hairy scalp; 2, drain left in for 48 hours

  

 
CARTILAGINOUS CRANIOPLASTIES. 243

tamponing of the skull wound with compresses soaked in physio-
logical salt solution. Next the costal margin is approached.

Removal of the cartilaginous graft—For each of the cases we have
‘operated upon the left costal margin has been utilized.

Incision of 8 to 12 centimeters on the anterior surface of the costal
margin: Transverse division of the fibers of the anterior rectus and
major oblique muscles.

Figure 4.—Two strong separators permit the exposure of the costal
cartilages. Next the model of the loss of substance is applied on the
cartilages ; the size of the graft is outlined with the bistoury by an
incision which follows the border of the pattern and takes in only
the perichondrium (Gosset).

Figure 5—The thickness of the graft must not exceed 2 milli-
meters. To begin with, the bistoury is placed almost flatwise grazing
the ribs; the cartilage is then freely incised, cutting with to-and-fro
picpemiente

As soon as possible the border of the graft is picked up with for-
ceps and the incision is continued with the point of the bistoury,
watching the cut surface so as to make the graft neither too thick nor
too thin.

Figure 6—The continuity of the costal margin is preserved and
the loss of substance so trifling as compared to the thickness of the
cartilage that two or even three layers can be removed without pro-
ducing a solution of continuity of the cartilage.

Temporary tamponing of the costal wound. The graft is carried
to the skull. The perichondrium must be placed in contact with the
dura mater. Before putting the graft in its place it is necessary to
mold it by digital pressure so as to give it the shape of a watch glass.
The border of the graft is slipped between dura mater and the
skull. From this instant it ceases to move (Gosset).

Figure 7—This method of fixing the graft has been criticized and
regarded as capable of producing disturbances due to compression.
Untoward results were never observed in our experience. The only
objection against it is that it is not cosmetic in the sense that the graft
lies deeper than the bones of the skull and that consequently after
healing a depression is left at the site of the operation. We employ
Gosset’s method only for losses of substance in the temporal bone;
as the other bones are very thick, the graft is simply placed on the’
dura mater in contact with the bony border (diple). Above the
graft a simple suture of the scalp is performed, leaving a small drain
for 48 hours.

This drainage is indispensable.—Perfect hemostasis of the oper-
ative region is almost impossible and in the absence of drainage
hematomas are observed between the scalp and the graft which some-
944 CARTILAGINOUS CRANIOPLASTIES.

- times cause the elimination of the graft. In an autopsy case we were
enabled to observe a hematoma which had detached the dura mater as
far as the occipital foramen.

Headaches, aphasia, a retarded pulse, somnolence, and nausea,
which some operators have noted after grafting, are very often ref-
erable to compression caused by the hematoma. None of these dis-
turbances were observed in our patients.

The repair of the costal gap is made in three layers—muscles, apo-
neurosis, and skin.

The sequelae are extremely simple. For a day or two the patient
complains of pain at the level of the costal margin, never in the re-
gion of the head. The drain is removed at the end of 48 hours and
the threads at the end of 10 days.

In very rare cases the cicatrix was of such dimensions that
the entire surface of the cartilaginous graft could not be covered
with scalp tissue; the portion of graft thus left bare continued to
live, was not cast off, and became covered by proliferations until
healing was complete.

The patient gets up between the second and third week. The
graft at this time gives the impression of being equally resistant as
the skull, but repeated pressure during the examinations should be °
avoided. We were enabled to observe a patient 15 days after the
operation, on whom a surgeon made a digital compression in order
to ascertain if the graft was movable; this patient had so far had
no Jacksonian attacks but had his. first after this examination and
several others afterwards.

As to the fate of the graft, we look back over an experience of
slightly over two years. In none of these cases has it become
absorbed; on the contrary, it hardens, thickens, and actually blends
with the bones of the skull, but it remains transparent to.the X-rays.
.

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244

Fle. 9.
TOPICAL INDEX.

 

Page.

Treatment of war wounds by the allies................0 ccc ce ceeeccecececeee ; 1
Wot aU bare: 3. ceeds oo rontccieties Hapalateewe's s Vee eeeevs peameucwwaie < 2
Ambrotse-Pares j.'s s'cinjeced 4 vs ebseseae oo ceidadsclacend onaaaeenades 2
Baron: Larrey.s sce 2 vassesewssececiatogac nc cacwbancdosies oluigenaaeck’s 2
Immediate, delayed, ‘and BOCONA ANY 522. eieisicieidceiediaicies'e's cadiastiow 4
Surg. Gen. Sir Anthony Bowlby...............0..02.ee cee ceeeeeeeee 4,5
Limitation of primary suture.................2.002006 Sonisbeamaaeislers 6
Statistics of surgical Automobile Ambulance No. 12.............- ere 7
Bar DY (8s /auieed's's 2 eds Sais Seas Muka ales aban ameeveew Si deseu ee 7
American Red Cross report.........-...-.02- saigistsGein o's Seseiceneey 8
Report: of Lemaitre acccecuyive . ousecenes = fi doeer wena bs dasameges eis 9
Carrel method: oJ 4021s sldadeede Cosaucews bsmese teenie ssadeeasaseen 10
Carrel-Dakin treatment... .... weet tenet cree ene rerreeeeeeee ~ 10
At Complegnes si eicicici sais os caaseawien aes Rat eaelennd ic dcuauedeeaee 10
At War Demonstration Hospital, New York..............2-2--ee0e0- 10,19
SAT SOISBODE caso ost pnaawiMee cistnoowiemioe sv Sepa Medd 2's tated 10
On U.S. 8. George Washington .........0.0 20 eee e cece eee e cence eeees ll
Principle of application.................0.0.ce cece e cece eee eeecences 13
POCRNI QUO: ecieand & ca ualieeys wet hertel Gustave ain hyaua tale ina cual teataselsi ae 14
Preparation of Dakin solution............0.20-2e-ceeeeeeeceeneceees 17
Special apparatus for wounds of brain.............--+20+-seseeeee eee 18
ChUtrO nes joiceds sets syseatene Se on eee evs sue ee ted ys os eeeeeeeee 23
POZE eens sie linkin se evseeie caine oe eee aw e's SeE SEE SEES ee aeeneeaee 23
Corner...... wdsceeies o/s Geil dig Sizer efele aus Sieg walslove-eieloajzisiesecminig’e wie siemeciers aes 23
Bowlby and Wallace........... 22.2 --0- eee e cece cence eee e ee Bs ssc idiaiaedis 23
SipAlmroth Writht::.u.jcdcaqteedosecencet eats eckwcue sag beets zie 23
Sir Thomas Crisp: Mnglish «oo. 2... s:eisusie gis x vs slaisistei esgic ov eie'eisteeree oe 23
English and Kelly is... se0secesde iss anosedesestscwevexs eels seerasee 23
Dichloramine «5-22 eccsieie se bee esd shan Coes een eeeemm ses spas 24
OHIGTAMIN Paste saoseasceotiauccc nantes cue Saeiemiee Sines oe series 25
i Other methods. .....-2...-22--0022 eee eee pied Hoeeniatineses Vag uitins 26
Hypochlorous acid preparations, eusol and eupad...-.-.-..------- -- 26
Salt! packs oo 2c tcus sseedeee sas caine sade sey antewertlne + ciecipeees 29
Dichlotamiin il ooo. oc access teceisce eee se ohana essen wales ease sees eens 30
Magnesium sulphate. .......------- +222 e cece ee eee eee eee e ee eeee 31
Bipp..-..-- 2-22 e ee eee eee cee eee eee tence ence neneee » 31
Flavine x. i. sagen en eee was cee edie e o's iceecnkee ead poneine 32
Crystal violet and brilliant green.....-..-..-----+-+--+eeeee eee tees 35
Hypertonic solution.......---.----- +2122 cece scene cee eee ee ee ce eee te 35
Wright’s formula........-.----- 2202 cece ee cee ence eee eee e eer ce ne eee 36
Sunlight treatment... ....----.-------2-eeeee eee reeee ee tea eee ee ee 37
Artificial light........--.--.-- ete e nee een neers en enaeeenerennccrees 38
Phenolization and embalmment.........-.--------+-e-eee seer renee 38
Blectricity .-..-..--..--00- eee eec eee cee nec eee cece enon eceneeregecese 39
Oxygen and ozone. ..----- +--+ 222 eee e eet e reece eee e reese tteeces 40
246 TOPICAL INDEX.

 

Page.

Treatment of war wounds by the Germans...... Stara aats BP css anette hays yee i 43
Conditions in Germany late in 1915. ...-..2...- 2.0202 e eee eee eee eee 44
Hospitalat: Buel... 2%..002 223 samppedeee eda cnemeted oes Ps cen ened ean 44
Continuous baths..........---.-2--1 202-222 eee eee eee eee eee eee eee ees 44
VaCCiNGS 2.2 Si dsweyccancsietk tons aise 1a eeiabinie Reed obasaseecdeceices 45
« Physico-therapeuties ..c.0:. s.. dcseese es see ieee cee eee aiid wie eel oes 45
Wound treatments seca :osg eciusicetue ss poe scien oe eg ndeeeeearsese ess 46
Antiseptic solutions....0...+ 52 s2ex0esade soa deed cae ee es veeedeweeee ss s3 47
INTL ORC RIO-asaas aceepeSiasks: fe OSes ep SS SE WSS SES 2 EISEN ERO EE 48
MSCODILOSE a4: i anoeaeads te ai omieuiia ence joes Ls ohio cae 48
Work at a German base hospital in 1916............-.-----++---.----++- 48
Developments in war surgery........--.--- 2-22-2222 22 eee eee eee eee 51
; Anesthesia ascgca.cen S20 cee eee ahaw od se cutee es a aie eee 51
Vocal nce caeeies Seley’ isla endless ee wl oa nuelsoles sea eggaier s < aton 51

Gas and Ox ygetl..2 jesq esses seeeseced sev ecumeeeiak ses ecasmeeeeeess + 51
American Red Cross apparatus........--.----. 2-20-22 e ee eee eee ee eee 52
Ona cag crane Sah Neptsrs 22 Shiga Sot iel tah eS eae a Ne ahaa Seas ane 53
GWathMeyo.c.i.¢.ccceusind satwonminetet ed cremeceuntod cates nee eans 54
Marshals avin cen toseeeahnasige hic vets see dewacwk eke esioesn eee ees 55
Spinal goo <ciscgna tiers ates ea vials dice cisieie le Css dcnewale's a gliadin tiers o's 3's 55
Rectal. scceuusassecds sv iss eeedneseeek ties eeeeedees ee aeeewedy “-. 66
Jointilesionss's.cqucetecees soc eehedie ieee sic wemkdadees j psaeekobe xcs 56
Willems: 2ep ieee ce ees ose eatncaues sn 6 Sep chine bee Gn aes 56
Hospitals at Bourbourg and Hoogstaede............-----2-2-20e eens 56
Pra Grease gs cot yaecutwar dud dh iistenae can eae aaeieraee as tet ates nee 62
BIG) Sei, aire cclaes oars Sienna ter omine aie sal i aneeteras Sactdacetenmae 63

Sir Robert: Jon eS :c.50.06 5's vss 2s aonteblees 23 edeweeeee bay aenecee se da 4 63
Sinclair’s method of treating...........-.--2-. 202-222 e eee eee eee ee 63
Sinclair’s formula for adhesive glue.......-....----.--+----2-++-00+- 65
Willems’ screw extension apparatus. .....-..:.2.--2-2--220-eeee eee 66
Apparatus of Leclercq and Varigard.............--.---.---220-20005 67
PatersonSplint. oseiccecetad hacneeecena ds cecutaencass scdeeniiek ees 68
American Red Cross splint.............---.--.2-22-22-e eee eee eee: 68
System in French armies..........-....---.-.--- sehkeeee x oewe ee 69
Trephined cases. ...... ited ae ee raha Sit ahha las eal a ple Aisha Mestalla ae 70
Babineki's) viewsesscis.2 4's vagneteee sts Hsaideesiieses ane Petar 70
Churtro’s-worl’s es. disse ecsemmiuesio ced BS asou ecss ciwanciee ze... 70,72
Amputation s:.'3:cGeisasisyecse te oneahtbves ah omeatacnelns Maaackaek ined 72
WilS0Iis<): sesnnaunene wn wate td cpeeneeedi oe vcthake cate vet arimablece Oae 72
Stassen....-:.-....-.- Goin rari ctcee Sep ate Seta teas clan aint pet tans 72
Upper extremity si sca sess stent anaes ove aoa ee Phe ke ue oe eels 73
Lower extremity....- 2-2... 20222. - cece eee ence cca e ee neeece 74
Tuffier on reamputations.....-... 22.22.2002 0c cece eee eee eee eee eee 74, 75
MU Grits os deaeccienacteneleg oamncneueneds toeubna nen Seicarcaaneaarsaeles 75
Methods and kinds of. ....-.... 2.0.2.2... lec cece cece eee cece eee vi)
APN CIAL NGS sauiee sarah. dercivatioeich le waded a's don peewee ves S28 76
Provisional apparatus................0020020 cesses eeee Maas eae 77
Statistics Of. o.. aias se ssuy sa cacee awk sey eweeeaies ¢ acd Battles Sent 79
Work at 5th London General Hospital.................000000eeee eens 79

American Red Cross, artificial limh service.............-0-...-02005 81
TOPICAL INDEX.

Developments in war surgery—Continued.

Plastic surgery ois. caw dec ese sede lave cou aahealelandd doi, ncushuee wer ceeds
Work at Red Cross Hospital No.1............. (ena antauaeaenne 83
Fauntleroy’s report, 1915.............. dasedmby sss Guides der eccas aa 83
Work at Sid@up sa. 2.2. d eases ss Hearie cess aoateadaned as late 84
Reconstruction work, Delagéniene,, skeucweie igen ke aaieae ane ep ae etas 85
Work at Val-de-Grace..........0..000 000 e eed b cece cece cece cee seeeee 87
Work at Hépital St. Louig.........22.......0.0000 cece eee gavvawace 87
Work at University of Lyons......,..-22..c0000.000cecenceeeeccaceees 87
No, 83 British General Hospital... tuadraiturasa tla co one a saan ooe dre was 87
Third London General Hospital. .............. ths ausscedrandctepae eile 88
Baeia Masks’, ican ayia Pha sane encaoe so wunaseeks ra cataaeeets eke seeds 88
Trench :feveriso . 2 Sisonien sil aod eee ne ede eee er es eas casca tens 89
APPS iss OS oor aes Denese ect behdan ok hh alah gem tue eh Ao CE Ey never bia td 89
OBITICL 5 ately ie is lar tt Atos nla ota ch dik Hevileoal eel a dein 90
Preventive methods... ........... 0.0 ccc cece cece eee ee eee ence eee eeeden 91
Eradication of vermin... ........2.20.020000 cece eceecceceeccecseeeeees 91
Foder-Thresh machine.............0.00- 002 eee ee cece ecececcceceeeceeees 93
GALS tI CH: istry ethic. Lecpautalcqeh to gcizremiscskcers esac aiativs watea eats 94
Care of wounded from firing line to convalescent camp..........-- ramus aieiess bes 97
Surgery of the forward area, and transportation of the onto poitatattcae 97
Process of evacuation of causalties of British medical service.......... 97
OG Si NOs BB i.e weceey Sr cic iceene's He aay alc eeals watt cuplee enero 98
Dock wood §)20533:<.sedese ccs 5 cade aindes Ja odetiaed S225 a rdaeanlan ees 98
BAGCKca candied cn anoenecs ahanaea cues nak Binrauekepata Seren coment 99
Divisional rest camp. .......--. 22-0220 eee c eee eee cece eee el eeeeee 102
British ambulance trains.........-.-.-.-2.2-220-0e ee eee eee eee eeees 103
Ambulance transports............0.0. 002 e eee e eee eee eee eens 103
British Red Cross ambulance column ..............-.2-2---02e+e00+ 105
Receiving convoys—Southwark Military Hospital.........-.......-- 108, 109
French sanitary organization... ........022.00000ecceee ence ee eeeees 110
Belgian organizationwisiess + smheeexGe sss ueeeksake sxe a eeeetessonse 110
American service of supplies..............-.-202022 eee eee cece eee ee 110
Special Notes on some of the hospitals visited: ............-.----------- 110

A. E. F. No. 4, loaned to British as B. E. F. No. 9, ordinarily called
Jaikeside Unit, Crile: csise's os cece vv ce deatetoawe ss ooeeesaaee:« lil
Crisiss@xPanslons ys: cekienee ye sesecaues de sdueeterd eeeed eeeteeee es 112
Wound phaaesi. cos cs cicaiciia te eines eos) daadesdauet ee ssesmeeees 112
BOCK. sc-tcgeaciniicns a xomtiaeceatiroaninad oaacsn ables aileune eotecaed ain 113
Blood tratistusion.: .-c.ca. grains faotaceie eee eecisnssmecaes anus se 113
Skin: praftin gs: octa'ss cetowagind aya wontctieis evs weslactelsiaietele g's <stdherceteiars 114
Chalons-sur-Marne, Gosset......-.-------2e-ee cece eee e erences ite dees 114
H. O, E. de la Veuve, Legrand........-.--2.--+0eeeee eee eee ee cece ees 115
Gassed: Cas6S 2 ..scscne swt aneasiees bc chustewen.saanveneaales ceoeraanet * 116
Use of formol and methylene blue solution. .........--.-..------:-- 116
Carrel Hospital No. 21 at Compiégne ......-..-2.-. 2-2-2 e eee eee eee ee 117
Advanced Carrel Hospital. .......-...-.--5 2-2-2 c eee cece eee eee ences 118
Equipment, ....... 222... -ceceee cece cece cece renee ene c ence erences nee eeee 118
Tuffier—underground hospital Lie sad Shueecurenes anew peeeatink ss ee vate 118
Beaujon Hospital, Tuffier.............- 2.2222 eee eee eee eee e eee ener ee 118
Tuffier’s views......--.. Salut Hakhi yatta gee Sareea Pena acim aeig Stes 119
Buffon Hospital, Chutro......-......2.-.----- 20222 cece eee eee eres “120
Bone sinuses........-- 20-222 e eee ee eee eee n eee eee poe bisneiiaee2 Sas 120
121

Hopital Broca, Pozzi..........+-.-2-2- 22s e eee ere eee eet eee e eee
248 TOPICAL INDEX.

Care of wounded from firing line to convalescent camp—Continued. Pege.
La Panne Hospital (Ambulance de a ea hidciaisioipw'ecausrastatoraeareias 121
Martin, Splint) work: s22.cc¢ e600. 25. shasieddocep a anouweaneesasoscad 122

Le Conte’ 6 translation Sous sca es Sadsve sewed as cdeerouek es gien 122
Zuydcoote, Belgium, Duval.............2.- 0. cece eee cece cence eee eens 122
Methods of treatment at..... 2.2.2.0. 2c eee eee ence cece nee e cece eees 122
Béclére, X-rays on celluphone..........2.02-sescee cece reece eee eeee 122

No. 8 Stationary Hospital, Sinclair..........0-2.2 222.0 eee cece eee e eee ee 123
Fracture treatment...........0- 20-2 cece cece e cece eet e ene eeeeces ‘oer, 128
Ho6pital de la Marine, Damany...........-. 0.0202 eee cece ence ee eeen ences 124
X-ray in thoracic surgery.........2.--.22cccceeesccscececnceeceececs 124
American Red Cross Hospital No. 1, Hutchinson...........-. Setar Saiciey 124
PLASTIC SUPLOLY Soc wise s dienieneied wyiniereie's Buide d ee. gmdlendacien S19 6 Sajayerace 125
American Red Cross Hospital No. 2, Blake .............22..2-20--e000ee- 125
Gas GANGTENe. .... cee ccce nee nec cc cece ene e neces escesn eee sesneees 125
Joint infection. <.ssiiwsssececees <2 gaceses whens s oa nase emer + Heise 126
American Red Cross Hospital No. 3, Lloyd. .......-.--02--eeececeeeeeee 126
Thirteenth General Hospital (B. E. F.), Cushing.......-..........-..--- 126
Views on following up cases........-2..-ecee cee cence eee e eee ecenceee 127
Fifty-third General Hospital..............2....004: sate eee adeisrndeeiioe 127
‘German prisoners at........ 2220 e eee eee ee cee eee ene n en eeneees 128
Eighteenth General Hospital, Beasley............-..2002 eee ece eee ee eee 128
Twenty-second General Hospital, Cabot. ......-.-.-.-.----0----00- weveee 128
British Red Cross Hospital, N etley, Souttar. .... paniantasesiaeie oearenmanice ‘.. 180
Treatment of wounds. ......2..20- 2 eee eee nee eee eee eect ee eneeee 130
Skin pratting.<c.ccscaued ss cenurovelesen's es setivecauiess i sai gpuiav ois tele etek 130
Continuous bathsiccx <iccoeceesceces Seeiesasceess cncdsveressssiages 130
Treatment of fractures... 2.1.2.2 22222 cece eee nee cence nee 131
Treatment of nerve injuries..........------ 22.0 e eee eee eee ee eee eee 131
Physico-therapeutics.............-0- 0. e eee e eee eee eee cece tence 181
Whirlpool baths............--2-2--+----6- Tisanecekeoouseensee ets 132
Second Northern General Hospital, Littlewood ..................2.--- .. «©1383
Sanitary school for doctors. S ecmeeeeimce bse au emem se atelae Seeeaes 133
Paraffin baths) ...<.4.02c5 es dsaetecee ss sccm eces ee reeeeaeieks seas 133
Functional reeducation, Mortons os stele oc saci s sakise cs dnaieeuies oan 133
Alder-Hey Military Orthopedic Hospital, Col. Sir Robert Jones, C. B...... 184
Rial esifOr Massa re iaiat oie s seielae ies ence tee wciectda eaten eee el eels 135
Military Orthopedic Hospital, Shepherds Bush, Col. Sir Robert Jones,C.B. 138
- Workshops and splint manufactures. ..........2-------e ee eee eee ee ee 138
Royal Victoria Hospital, Crowell..........--2-...2.2----- 222s eee eee ee eee 139
Surgical neurology........-...-. 2... eee eee eee eee Bimninescen ace 139
Queen Alexandra’s Hospital for Officers .............0-....20eeeeeeee .-- 139
Advantages and disadvantages of small hospital.............2.--...-- 140
Fifth London General Hospital. . 2.2... 0.20. cece ee ence cece cece eens 141
Immediate and remote surgery... 2.2.20... 2 ec eee ee eee cece eee ceee 142
Corner’s views on amputations.........:..... atienia an vee Shewninie ee 143
Hyde Terrace Hospital, Moynihan..........-..2.--..0ce-eeeee cece cece 143
Method of saving eye strain..... 22.20.00. cece eee eee eee eeeeee 144
Third London General Hospital, Bruce-Porter............... pol aeyeetg nad eea tte 144
Revolving open-air shelters....... 00... .0. 20.0 cece eee cece eee eeeeeees 145

Specialists, utilization of ............. 2.22222. eee eee eee eee ences 146
TOPICAL INDEX,

Care or wounded from firing line to convalescent camp—Continued. Page.
Military orthopedic hospitals------.....0...00 00... ccc eeeeecceee eee. «147
Orthopedic cases, classification by British Army Council........... 147
Col. Sir Robert Jones............ 000.0000 e cece eee ce cece cece cece 148
Mechanical therapeutic after care............2..-0000c cece ce cece ee 148
Shepard’s Bush Hospital............02.2..0000ccececeeeeeeeceeeeee 149
Military Hospital at Alder-Hey...........00. 002. ce cee c cece cece eee 150
2nd Northern General Hospital............ eis Dia wry SRNR eee 150
‘ Orthopedic hospitals in Scotland and Ireland..............2.....2. 151
La Panne Hospital..... 2.2.2... 0 2 cece cece eee cece ee eee eee eeees 151
Italian methods. ........... 2.0.0.0. e cee cece cece et dee eee ceeceeees 152
Orthopedic centers in Germany and Austria.................22---4- 152
Proposed organization of centers in the United States................ 152
Convalescent camps.....- 2... 0..0. cece cece cece cee cee cee eccceeceegecees 153
Objects Of ies cca cose Aten cat ae ene axa otek log: Glos dette tee 153
Bostock!s\ Views sasscisildde ceddaobsiee sd msinngeedlessedanacotes 153
Military and medical points of view..........2...02-ceeceeeeeceeees 153
BaQron’s VAG WSe xe sein ce a:in s dacdiere ¥:< wizisssl dod dicicie «6/3. iS pvelb dieeve nw so scavaus 155, 156
Social problema eiccc cncicsusacces aweswiwan veeeaewstaewa seo cedcaueas 155
King’s Lancashire Military Hospital, Blackpool.................--- 155
‘Whitl pool baths a's: 526 cede he Siva eee oad seen eevee eevee 156
Barron’s flat foot ladder. ........2...0.00ceeceeecceeceeeceeeeeeeeee 156
Barron’s statistics sels c.cccies od cecnoued ated as ascctan wanes manaue 157
“Khaki: College?) aido5 2 usaGe Seca cae aeanseGsau siaaawatexeaaoees 157
Summerdown Military Convalescent Camp, Eastbourne............. 157
BOstOCI son vis's stltewtae ils x aerau take vale Buea ese eee et did peo 158
Treatments. << ees eeesscte 2 csis oda. os Seles Soe ass eee harent sees 158
Industrial work: <2. J0cec 24 ace caccies 04 ae sebwaee oo leeagedenee esd 4s 158
Reeducation for the disabled. ...........02.2- 2-220 ccecee cece eee eee eee 161
Artificial legs, American Red Cross .............. 2022 2ec cece eee e cece eee 162
Artificial arms? oie aceete wee statdecrner stds stash 'ss enadeaiee ies ues 2 te 162
Functional reeducation.........-.-2-- 00 esee ee eee eee e eee e cece ee eceees 163
Stassen’s work at Port Villez.........2..---2.. 22-020 - eee eee eee eee eee 163, 171
Vocational reeducation..........-. Bias it eo gered RTS AD mene apc ie hia ae 166
Inter-Allied Conference, London........------.---0-- eee eee e cere eee 166
American Red Cross, Bureau for reeducation of mutilés .............-.. 167
Miss Grace Harper............0.0. 0202 e eee cece eee eee eee ee eeee . 167,169,174
Union des Colonies Etrangéres...... ise + sabes eee {728s xeepubeeeue ye 167
Work in Great Brita... oc52s ssine deena cian te Sai te eee 2 asd eee eae 168
Ste Mautice. c.cedsteetiedin a Goad bo ahwes nemdemhae de ciaeieecedseescaanatied 168
Maison Blanche. ss ssccseey siroecuce sc ceeccaeet dee nneeise weeded tins 170
Port: Vill@gecew vss peace vis slegecnee 24 ae et eans Ss ee dee eet eee steed 170
Gand Palais) sco: cciis Ss sete vec aneee eedae eae bu ele sis reserictes os ee sists 171.
Qa. Debilly 222.2 aussie: atceoteees sek see deta eee sees wee ee 172
Hétel des Invalides s n.c0snce ss sac cenens ess ecetdene yee seauee tee ey ees 173:
Javisy mie ety bal eee eden ts Dele Smear ia es dentld Soa 173:
Fcoles Joffre and Tourvielle.............22---002 eee cece eee cece ee eeee 174.
Hospital No. 40, French Army.....---------------+-02eeeeeee teeter eee 175.
University of Lyons.......-.-- 2-2-2202 cece eee eee ce cee eee eect eee eee 175.
Conferences of SUrgeONS.....---.- +22 eee eee eee eee ee eee eee rete tere tere es 177
Ttor-Allied Comferencas. 2+ jps-axee cr dnanns ca excczncsendeewee ves nae 177, 198
Research Society, American Red Cross......-.--.+--+-2+2--eeeeeeeeeee l7v

93696—19—_17
250 TOPICAL INDEX.

Page.”
Auxiliary forces acum vs os aanedinees se peamesenees oe eee eed oes ate 207 |
American Red Cross...........-------++-e-ee+++2- varatss ele sua Sais Vangie emaicha 207%
Knights of Columbus... ... . . ....ccec060oe20e eb eee Swed be seed eee ee es ex 207
NOMIORAS si coas bi sonmsasutehes sare VAG dMoniteg «2 uasmes cues CAME RG EE Ses 207
RYO Ws OigAt: to ance cnet Seouanaenes See Sai mace eeeeein lets 207
Salvation Army s: scscisee ee o's ss stones ewig: os cise em andes weed a@med a nies 207 —
Jewish Welfare Board .oes2s.2. ss vectecstes sss cena see ee cetacean ees 207
Rockefeller Foundation...............-------- 2-22 eee eee erect eee 207
American Library Association.............-2-----.00- 2-2-2222 eee eee eee 207
Service units in France, Belgium, and elsewhere...........-..--.------ 207
University unions.......-..-.-- Sauasseueciescemmeae Aras @apeamaan hanna 207
American College Women’s Units............-------0-------- 020s ee eee 207
Other organizations <cccces se se esearvineee ts oveineetees oes s veegeeweee ss 207:
Miscellaneous...........------.-----+-+- oes duniseeeme ses RoRSeddece ess KES 209
ATMbTING. 2 oceseco2 sacaesceicn es -ea8 A ah GG biog Meainnetande oes ete aecemmiss 209
Provisional legs........---.2-2222--2222ee eee eee laid Ae eaee po nebenleams 210
Evacuation Hospital Plan, Le Play.......-.----..------- eee cence cece 211°
Proposed organization of educational service in war surgery....-.....-. 212
Disposal of U. 8. A. casualties...0....-..-2-. 202.020 eee eee eee _ 214
Surgical sanitary formations...........-.----2--2---- 2 eee eee eee eee eee ee 216
Recommend ations.s.,..5:cesecxe sv ss cwersedew es «cg eamlocie.s evs omens Weis Aicpeces’ 217
Technical instructions on the eve of military activities..........-......... 219
Report of Surgical Technical Advisory Council.............--.---.---.-22. 223
Base of hospitalization and surgical measures for army corps in offensive...... 229
‘Chutro—Cartilaginous Cranioplasties............-.---2-----ee eee eee eee cess 237
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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