COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64058824 1D151 Un3 AbstracteoLwarsuL RECAP fill I ft u* 3 Columbia College of ^Ijpssictang ano gmrgeons JLibxavv Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/abstractsofwarsuOOunit ABSTRACTS OF WAR SURGERY ABSTRACTS OF WAR SURGERY AN ABSTRACT OF THE WAR LITERATURE OF GENERAL SURGERY THAT HAS BEEN PUBLISHED SINCE THE DECLARATION OF WAR IN 11)14 PEEPAEED BY THE DIVISION OF SURGERY. SURGEON- GENERAL'S OFFICE ST. LOUIS C. V. MOSBY COMPANY 1918 Copyright, 1918, By C. V. Mosby Company Press of C. V. Mosby Company St. Louis PREFACE The preparation of these abstracts, in common with many of the other early war activities, was an emergency war measure. Much of the excellent surgical work which had developed as a result of French, English and Italian effort had to be appropri- ated by our medical personnel at a time least favorable for quiet mental effort. To meet the needs of the situation, the Division of General Surgery of the Surgeon General's Office prepared, collected and arranged abstracts of the important general surgical papers bear- ing on war surgery; and, after having them mimeographed, dis- tributed one hundred of them to various surgical instructors in the Army Surgical Schools, and to the surgical chiefs of the war hospitals. This limited issue of one hundred so far failed to meet the demand that we have acceded to the request for a wider distribution in printed form. The volume must of necessity be regarded merely as a con- densed text for ready reference. Most of the abstracts have been used through the courtesy of Surgery, Gynecology and Ob- stetrics, the Journal of the American Medical Association, the Medical Record, the Military Surgeon, and the New York Medical Journal. Some articles in the British Medical Journal and in Surgery, Gynecology and Obstetrics were so fundamental that they were abstracted with a minimal amount of paraphrase. To all these journals and to any others that through inadvertence may not have been mentioned, we express the sincere thanks of the Surgeon General. Washington, D. C. May 29, 1918. CONTENTS GENERAL TOPICS PAGE The Development of British Surgery at the Front. Surgeon-General Sir Anthony Bowlby and Colonel Cuthbert Wallace 17 Development of British Surgery in the Hospitals on the Lines of Com- munication in France. Surgeon-General Sir George H. Malcins . . 47 WOUND INFECTION AND TREATMENT Gunshot Wounds and Their Treatment. Sir Berkeley Moynihan ... 83 Wound Excision 97 Wound Infections: Some New Methods for the Study of the Various Factors Which Come Into Consideration in Their Treatment. A. E. Wright 103 Treatment of Infected Suppurating War Wounds. Butherford Morison 106 Treatment of Infected Wounds by Physiological Methods. A. E. Wright 107 Experiences of a Consulting Surgeon. Enderlen 109 The Advanced Surgical Post. J. and P. Fielle 110 The Working of a Clearing Ambulance. A. Latarjet Ill Interallied Surgical Commission on Treatment of Wounds 112 The Bacteriology of Septic Wounds. A. Fleming 113 Cicatrization of Wounds; The Use of Chloramine-T Paste for the Sterilization of Wounds. M. Daufresne 116 Cicatrization of Wounds; Sterilization of Wounds With Chloramine — T. A. Carrel and A. Hartmann 117 Sterilization of War Wounds. Dehelly and Dumas 120 Considerations on Some War Injuries After Eighteen Months of Cam- paign. B. Proust 120 TETANUS Antitoxin Content of the Serum of Tetanus Patients. H. Wints . . 122 Treatment of Tetanus. T. Kocher .' 122 Intraspinal Administration of Antitoxin in Tetanus. M. Nicoll, Jr. . . 123 Treatment of Tetanus by Endoneural Injection of Antitetanus Serum and Drainage of the Nerve. F. Kempf 124 Late Tetanus. L. Berard 125 Clinical and Therapeutical Experience With Tetanus. B. O. Pribram . 125 Intraneural Injection of Tetanus Antitoxin in Local Tetanus. A. Meyer 127 Statistics of Cases of Tetanus Observed in the War Zone from Novem- ber 1, 1915, to February 1, 1917. P. Chavasse 127 Local Tetanus. F. Brunsel 128 11 12 CONTENTS PAGE A Eeport on Twenty-five Cases of Tetanus. II. E. Dean 129 The Intrathecal Route for the Administration of Tetanus Antitoxin F. W. Andrews 131 A Comparison of Subcutaneous with Intravenous Administration of Tetanus Antitoxin in Experimental Tetanus. F. Golla 131 Tetanus in War 132 GAS GANGRENE Gas Gangrene. (Anaerobic, Acute Bacillary, or War Gangrene) . . . 138 Gas Phlegmons on the Field. G. Seefisch 163 Treatment of Gas Phlegmon in the Field. W. Becker 163 ABDOMEN A Series of 500 Cases of Emergency Operations for Abdominal Wounds. C. F. Walters, H. D. Eollinson, A. E. Jordan, and A.. G. Banks . . 165 Stab and Gunshot Injuries of the Abdomen. S. Basdekis 177 Treatment of Abdominal Injuries at the Front. Schwartz. Thirty- three Laparotomies in Cases of Abdominal Injury. Bouvier and Caudrelier 179 Suture of the Diaphragm for Gunshot Wound with Hernia of Omentum and Transverse Colon. 0. Ortali 181 New Series of Abdominal Wounds Treated in Automobile Surgical Am- bulance No. 2. H. Eouvillois, Gmllaume-Loms, and Basset . . 182 War Wounds of the Spleen. Fiolle 182 Prognosis and Treatment of Abdominal War Injuries. Most .... 183 Gunshot Wounds of the Abdomen. Kort and Schmieden 185 Necessity for Systematic Operation in Abdominal Wounds. E. Leriche . 186 Operative Treatment of Gunshot Injuries of the Intestine. Enderlen and Sauerbruch 187 The Surgical Ambulance and Abdominal Wounds. U. Calabrose and B. Eossi 188 Abdominal Injuries in a Casualty Clearing Station. A. Don 188 Intraperitoneal Rupture of the Bladder. F. Eost 189 Early Treatment of Gunshot Wounds of the Alimentary Canal. C. Wallace 190 Foreign Bodies in the Bladder Resulting from Gunshot Wounds. G. G. Turner 195 Treatment of Gunshot Wounds of the Bladder. V. Saviozsi .... 196 Intraperitoneal Bladder Wounds. E. Brin 197 The Treatment of Simultaneous Lesions of the Rectum and Bladder. F. Crosti 198 Surgical Treatment of War Wounds of the Abdomen 199 CHEST Gunshot Wounds of Lungs and Pleura. Sir Berkeley Moynihan . . . 207 Treatment of Penetrating Gunshot Wounds of the Chest. X. Delore, and L. Armand 216 CONTENTS 13 PAGE. Is Thoracotomy Indicated in the Treatment of Wounds of the Chest to Arrest Hemorrhage? Hartmann 217 Infection of Hemothorax by Anaerobic Gas-producing Bacilli. T. B. Elliott 218 Projectiles in the Pleural Cavity; Different Behavior of the Pleura Ac- cording to the Form of the Projectile. G. Crcsole 220 Extraction of Intrapulmonary Projectiles Under the Screen. E. Petit de la Villeon 220 Technie of the Extraction of Foreign Bodies in the Mediastinum, by the Transpleural Route with an Anterior Costal Opening and Other Meth- ods; Operative Results. B. Le Fort 221 Extraction of Intrathoracic Projectiles. Binet and Masmenteil . . . 223 War Wounds of the Larynx and Trachea. E. J. Moure 223 Penetrating Wounds of the Thorax. E. Bemond and B. Glenard . . 225 Gunshot Wounds of the Larynx and Trachea. K. Kofler, and V. Fruehwald 226 War Wounds of the Lung 227 Gunshot Wounds of the Lungs, and Tuberculosis. H. Bieder .... 244 CARDIOVASCULAR SURGERY Injury of the Heart by the Bursting of a Grenade; Extraction of Pro- jectile from the Right Ventricle; Recovery. Beaussanat .... 245 Conservative or Operative Treatment of Heart Wounds. A. S chafer . . 245 Vascular Injuries in War 246 Further Experience with Aneurisms in War, with Special Reference to Suturing the Vessels. H. von Haberer 273 Experience with Vascular Injuries 274 JOINTS Practical Points on the Use of Immobilization in War Surgery . . . 276 Wounds of Joints 285 Articular Gunshot Wounds. Hatter 295 Resection of the Knee to Avoid Amputation of the Thigh in Fractures of the Knee. Tuffier 296 Treatment of Gunshot Wounds of the Knee-Joint. H. M. TV. Gray . . 297 Resection of the Shoulder in War Surgery. Fourmestrcuux 298 Primary Resection in the Treatment of Articular Gunshot Wounds with Fractures. G. Cotte 299 Treatment of Traumatic Arthritis of the Knee. Marchah and Dupont . 301 Communication from U. S. Army Base Hospital No. 5. B. B. Osgood . 303 The Immediate Results of Surgical Intervention in 111 Cases of Purulent Arthritis of the Large Articulations. Auvray 304 14 CONTENTS PAGE Arthrotomy Followed by Immediate Closure of the Articulation in the Treatment of Certain Wounds of the Knee. M. Gaudier and E. Montaz 305 Treatment of Gunshot Wounds of Knee-Joint. H. M. W. Gray ... 306 Treatment of Wounded Knee-Joint. H. G. Barlmg 309 FRACTURES The Treatment of Gunshot Fractures. E. W. PL. Groves and T. H. Brown 311 Treatment of Shell Fractures of the Femur. E. SuchaneTc 311 Reduction of the Number of Amputations at the Front. E. Marquis . . 312 Primary Transformation of Open Gunshot Thigh Fractures Into Closed Fractures. Lagoutte 313 Infected Gunshot Injuries of Bones and Joints. W. Derik 314 An Important Point in the Treatment of Gunshot Fractures. G. Perthes 315 The Plating of Gunshot Fractures. N. C. Lake 315 Thigh Amputations in War Surgery: 46 Cases. A. Chalier 315 Primary Resection in Articular Wounds of the Knee. PL. P. Bouvillois, L. Guillaume and Basset 319 Functional Value of the Stump after Amputation. Tuffier 319 Treatment of Complicated Gunshot Fractures of the Humeral Diaphysis. H. Alamartine 320 Early Treatment of Compound Fracture of the Long Bones of the Ex- tremities. B. Hughes 321 Secondary Suture of the Wound in Cases of Open Fracture. Depage and Vandervelde 323 Diagnosis of Suppurative Arthritis Following Gunshot Fractures. M. Chaput 324 Treatment of Gunshot Injuries of the Extremities. Axhausen .... 325 Treatment of Gunshot Fractures of the Extremities in War. G. von Soar 326 Ten Rules for Amputations of the Lower Limbs. B. Bitschl 327 BURNS Paraffin Treatment of Burns. Maj. Geo. de TarnowsJcy 328 Paraffin in the Treatment of Wounds and Burns. Observations on Various Preparations. J. B. Beiter 331 ANESTHESIA IN WARFARE Anesthesia in Warfare. Paluel J. Flagg 335 Anesthetics at a Casualty Clearing Station. G. Marshall 346 TRENCH-FOOT Trench-Foot. E. M. Frost 349 Trench-Foot 350 Shock as Seen at the Front. E. Archibald and J. W. Maclean . . . 352 Surgical Shock 353 Fluid Substitutes for Transfusion in Shock and Hemorrhage .... 363 CONTENTS 15 FOREIGN BODIES PAGE Simple Method of Localization of Foreign Bodies. ./. S. Young . . . 368 The Localization of Foreign Bodies. TV. A. Wilkins 368 The Sutton Method of Foreign Body Localization. E. H. Skinner . . 369 Operative Removal of Bullets and Fragments of Grenades, With Special Reference to the Use of the Electromagnet. Von Hofmeister . . . 370 PERIPHERAL NERVE INJURIES Injury to Peripheral Nerves. Sir Berkeley Moynihan 372 The Treatment of Peripheral Nerve Injuries 381 The After-Care of Nerve Injuries 391 JAWS AND FACE Early Care of Gunshot Wounds of the Jaws and Surrounding Soft Parts 398 Surgical and Prosthetic Treatment of Fractures of the Jaws by War Projectiles, in an Evacuation Center. Frison, Dufourmentel, Bonnet- Boy and Brunet 411 War Injuries of the Jaw. N. G. Bennett 413 Suggestions Toward a Systematic Operative Treatment of Gunshot Wounds of the Mandible. TV. Trotter 415 Reconstruction of the Jaws After War Wounds. E. Matti 418 Cases of Gunshot Injury of the Face and Jaw, With Special Reference to Treatment. F. N. Doubleday 419 Vincent's Disease of the Mouth and Pharynx. TV. H. McKinistry . . 419 Treatment of Facial Paralysis Due to Gunshot Injury by Muscular Anas- tomosis. H. Horestin 420 Salivary Fistula? 421 ABSTRACTS OF WAR SURGERY GENERAL TOPICS THE DEVELOPMENT OF BRITISH SURGERY AT THE FRONT. — Surgeon-General Sir Anthony Bowlby and Colonel Cuthbert Wallace. Brit. Med. Jour., June 2, 1917. The Regimental Medical Officer. — The duties of the regimental medical officer in this war are much the same as they have ever been. He shares the dangers common to the combatant, officers and men, and stays with his battalion or brigade, as the case may be. His treatment can only be that of first aid, but he and his orderlies have saved innumerable lives, both by the rescue of wounded comrades from dangerous situations and by careful and rapid transport to the field ambulance sections in the sup- port line. The Field Ambulance. — At the "advanced dressing station," there is a personnel of two or three medical officers, noncommis- sioned officers, and orderlies, and it is here that the first-aid dressings can be supplemented by additional dressings and by suitable splints, so as to ensure a more easy transit to the "tent section" of the field ambulance, a mile or two farther back. The following instructions, which are amongst those issued in all the "armies" at the front, will best indicate the limitations of their work: " (1) Only operations of emergency should be performed in field ambulances, but the following exceptions must be noted : "(a) Completely smashed limbs should be removed, and the patients retained for at least a day before being sent to a casualty clearing station. 17 18 ABSTRACTS OF WAR SURGERY " (b) Hemorrhage should be arrested by ligature of bleed- ing points whenever possible. If this is not possible, then plugging or direct pressure on the wound itself should be resorted to. Patients should never be sent down with tourni- quets on their limbs. "(2) Abdominal wounds and all severe cases requiring early treatment at a casualty clearing station should be sent there by a special motor ambulance direct from the advanced dressing station. They should not be kept waiting for the regular convoys." A further development of the tent section resulted from the conditions at the battle of the Somme, where, on account of the small area and the few good roads, "corps dressing stations' were created by joining up some members of the staffs of various field ambulances, so as to supply tent accommodation for a thou- sand or more wounded, with a staff of about thirty medical offi- cers. A unit such as this performed the duties ordinarily per- formed by several separate field ambulances. Motor Ambulances. — It is the supply of motor ambulances alone that has made it possible to deal adequately with the sur- gery at the front. One aspect of this subject, however, is very commonly overlooked, namely, the use of motor transport in saving the wounded from capture, for there can be no doubt that, had motor ambulances been supplied in large numbers, the tale of British prisoners after Mons and Le Cateau would have been very small. The first complete convoy came to the front in the middle of October, and at the first battle of Ypres was of the utmost possible value, both in getting patients quickly to the casualty clearing stations and also in saving wounded from fall- ing into the hands of the enemy during the retirement to the ground subsequently held. The motor ambulance, indeed, is the very foundation on which all surgery at the front is based. Without it the whole system would break down, for no horsed vehicles could possibly deal with the numbers of a heavy fight unless they were so numerous that they would practically block the roads for all other trans- port, and even then their slowness would result in such delays in delivery that surgery would be of little use. In addition, the well hung and well driven motor causes the patient infinitely less distress than the old ambulance wagon, and so delivers him in a much better condition for recovery. The Question of Time. — This is a matter of so much importance ABSTRACTS OF WAR SURGERY 10 to surgery that it is well to explain the time that is required to take a patient from the front trenches to the casualty clearing station. It is, in the first place, not sufficiently realized that the chief cause of delay, if it occurs, is "the enemy," for there have often been, and there still are, localities from which the wounded can be moved only under cover of darkness, so that a man may have to be kept in a dug-out the whole of a long summer's day before he can be carried to the rear. Again, in the desert of mud behind the firing line on the Somme, stretcher-bearers sometimes took hours to carry a wounded man at night for several miles to the nearest point to which, in the absence of all roads, an ambulance wagon could approach. In yet other cases men lie out in the open ground on the so-called -'No Man's Land" for many hours, or even for several days, before they are rescued. But supposing that none of these difficulties exist, the time occu- pied is very short, for, if communication trenches are good, and if a man is able to walk, he will often get to the advanced sec- tions of the nearest field ambulance within an hour. If the com- munication trench is long and muddy, it may take twice that time. If he has to be carried it may take another half-hour or more, but as soon as he has got to a good road another hour will see him safely delivered to the place where his injuries can be thoroughly treated and where he can be well nursed under ex- cellent conditions. All this is comparatively simple if no great battle is in progress ; and as great battles occur at infrequent intervals, it is evident that in most parts of the line of trenches evacuation is easy and rapid except for unusual local conditions. But in very heavy fighting, and especially when troops are advancing, it is often impossible to find sufficient stretcher-bearers in proportion to the great numbers of wounded, for only a limited number are at- tached to each regiment, and it is therefore necessarily true that the greater the number of the wounded who have to be car- ried, the longer must it be before the last of them can be brought in. No work is heavier than stretcher carrying for long distances and on difficult ground. But even when all difficulties have been surmounted and the patients have arrived at the tent sections of a field ambulance, there are many who are too much exhausted for further immediate moving; and while the staff may have their hands full with dressing the wounded, they have also to care for the needs of the many men who need to be rested, fed, and warmed. While they are thus engaged on these patients, all those who require urgent treatment by operation have been taken 20 ABSTRACTS OF WAR SURGERY direct to the casualty clearing stations, and thus have avoided delay. The Casualty Clearing 1 Stations. — Before the war the "C. C. S.'s," as they may be named for brevity, appeared only on paper and as untried units, for they did not exist at the time of the South African "War. They were originally called "clearing hos- pitals, ' ' and their proposed function was merely to clear the field ambulances and pass the patients on to the base hospitals. Their equipment, therefore, was only very slight, and their staff of eight officers, including the commanding officer and the quarter- master, was less than the staff of a field ambulance. They car- ried 200 stretchers, and were supposed to be able to deal with the same number of patients. These hospitals are situated behind the line of trenches along the entire front, and certain local conditions are essential for the success of their work. First, they must be at or near to rail- way sidings, so that evacuation by train is easy. Secondly, they must be where good roads can connect them with the front. Thirdly, they must have a good water supply. They are arranged in practically two series: (1) Those nearest the front are at a distance of from six to nine miles from the front trenches; (2) those of the second line are from three to six miles further back, and act as a reserve during active opera- tions, or as units for special cases during quieter times. The casualty clearing stations vary greatly in their accommo- dation, according to the size of the buildings they may occupy, or to the amount of ground available for huts or tents when they are encamped- The smallest accommodate 400 to 500, and the largest from 800 to 1,200. Their staff is reinforced, as may be required, from other casualty clearing stations less actively em- ployed, and from the staffs of the field ambulances. Whenever possible the casualty clearing stations at the front are linked in pairs, and take in the wounded alternately. In this way it can be arranged that, after admitting as many as can be adequately treated, the wounded are diverted to the other casualty clearing station, and the staff is left free to treat those they have admitted, without being disturbed by fresh arrivals. Operating" Theaters. — When a casualty clearing station is housed in buildings these theaters must, of course, vary in size with the accommodation afforded. In the hutted or tented hos- pitals, however, which are the most numerous, the operating the- ater is a hut about 60 by 20 feet, giving space for four tables, ABSTRACTS OF WAR SURGERY 21 and for sterilizing and store rooms. Large theaters are essential in dealing with large numbers. The Treatment of Wounds in the Casualty Clearing Stations. — It is the object of every casualty clearing station to treat and retain all patients until they can be safely sent down by ambu- lance train. In times of comparative quiet there is no difficulty in attaining this ideal, and consequently, any standard of treat- ment required from the surgical standpoint can ordinarily be at- tained. In times of heavy fighting, and especially when there is the certainty that many more wounded will arrive during periods extending over days or weeks, it is evident that the pro- vision of empty beds necessitates sending patients away who might, with advantage, be retained a little longer. This pressure, however, does not prevent the performance of all necessary operations, and those are now always performed. If the re- quirements of our army did not place a limit on the number of surgeons, nurses, orderlies and patients who can be retained in close proximity to the fighting line, there would be no reason why all patients should not be kept near the front. It must be re- membered that if many hundreds of patients were kept in every casualty clearing station the staff of nurses and orderlies would be so much occupied in dressing and caring for them that they would not be free to attend to the wants of the recently wounded men coming in convoys from the field ambulances. For more than two years it has been the deliberate policy of the British Army Medical Service to make the casualty clearing station, rather than the field ambulances, the chief place for the treatment by operation of the dangerously wounded man who re- quires prompt treatment. Dressing and Distribution of the Wounded at a Casualty Clear- ing Station. — It is now the custom of all casualty clearing sta- tions to dress their patients in large reception huts or tents as soon as they arrive, and to distribute them from this place in three classes: (1) For immediate evacuation; (2) for retention; (3) for operation. In the first class are included chiefly the slightly wounded. In the second class are patients suffering from shock, from the effects of bleeding, from wounds of the lung, from ex- posure to cold, etc. In the third class are all serious wounds of the soft tissues which require thorough dressing, and especially lacerated wounds due to shells and bombs; most fractures; many injuries of vessels ; all perforating abdominal wounds, etc. The proportion of cases requiring operations to the whole num- ber of wounded will depend on many conditions — for example, 22 ABSTRACTS OF WAR SURGERY the larger the proportion of shell wounds to bullet wounds the larger is the number requiring operation, and if a train is wait- ing to go to the base, men may be sent by it who would require operation if they had to be kept for thirty-six hours. But it may be stated in general terms that the proportion of patients treated under anesthetics may be as high as one in four, but it is more often about one in six. The following table, compiled by Captain Hey, who is the Surgical Specialist at one of the forward casualty clearing sta- tions, will give a very good idea of the operative work of a par- ticular unit, and it includes a period of heavy fighting during a recent battle. Table of Operations Performed at a Casualty Clearing Station. A. B. Ligature of arteries: Carotid 5 Vertebral 2 Subclavian 2 15 39 Radial 18 Ulnar 8 Ext. iliac 2 51 31 16 58 Various 30 277 For treatment of fractures: Skull 189 18 298 133 299 Leg 309 38 119 1,403 For treatment of joints: Knee 183 Other joints 64 247 ABSTRACTS OF WAR SURGERY 23 Amputations: Shoulder joint Upper arm . . . Forearm Thigh Knee , Leg Ankle Various 14 77 31 186 10 76 6 31 431 E. For drainage of pleura 49 F. For wounds of the abdomen 106 G. Removal of testis 33 H. For ruptured urethra 9 J. Enucleation of eye 43 K. Plastic operations 33 T, Tracheotomy 17 280 M. Excision and cleansing of wounds: Head and neck 95 Trunk 309 Upper Limb 249 765 Multiple 398 1,816 N. For conditions not due to gunshot wounds. Appendicitis Strangulated hernia Cellulitis Various 34 1 53 13 It will be seen that the total number of operations performed for gunshot wounds amounts to 4,554, and the total number of wounded admitted during the period in question was 20,589 in this particular unit. It will be noticed that a very large majority of the operations were for fractures of the limbs and wounds of the soft tissues which required complete surgical clearing. The proportion of abdominal operations would have been higher but for the fact that an "advanced operating center" was near at hand, and took charge of many cases of this class. During heavy fighting, operative work such as the above goes on continuously day and night, and consequently necessitates 24 ABSTRACTS OF WAR SURGERY relays of surgeons, nurses, and orderlies. The work is exceed- ingly trying, and it must be reckoned on that not a few of the staff will be more or less knocked up after three or four weeks of it. But it is also quite certain that the early and thorough treatment of a very large proportion of all wounds has done more than anything else to save much suffering and many lives. Advanced Operating Centers. — It has sometimes been found that difficulties of locality have prevented the placing of so large a unit as a casualty clearing station exactly where its position should have been when heavy fighting has been expected, and in such cases a smaller unit has been placed so as to deal with the most urgent cases, and especially with those which required prompt operation. These special hospitals of fifty to sixty beds have done excellent work, and a very large proportion of their cases have been abdominal wounds. The large number of the casualty clearing stations has prevented any necessity for cre- ating many such units. Special Hospitals. — Special hospitals have been established for the care of head cases, shell shock, and diseases of the skin, in addition to a few sanitary hospitals at the front. X-Rays. — At the beginning of the war x-rays were not sup- plied at the front, but, coincidentally with the development of operating work in the casualty clearing stations, the need of these became apparent. At first mobile x-rays vans were sup- plied, but, as demands for these increased, it became necessary to supply stationary plants as well, more especially to those casualty clearing stations to whose share it fell to do most of the operations; and, not only have x-rays been of great service in guiding the operator, but in many of the abdominal wounds where the missile has been retained they have been of the great- est service to the surgeon in deciding whether operation should be done at all. The x-ray plant has become an essential for the work of the casualty clearing stations. Anesthetics. — At the beginning of the war chloroform was in general use, but it was evident that there were many objections to its universal application, and other agents were soon employed as well. Ether has been largely used, and was formerly administered by the open method, but experience has shown that it is often inadvisable to use it thus because of its tendency to irritate the air passages. For at least six months of the year the men who are exposed to the wet and cold in the trench area are suffering in very large numbers from catarrhs of varying degrees of se- ABSTRACTS OP WAR SURGERY 25 verity, and in many of them these are accentuated by the fur- ther exposure which follows, especially when a man falls or lies in mud or water. The result is that the administration of any anesthetic commonly sets up so much bronchial irritation that the patient's life is endangered by an attack of bronchitis or bronchopneumonia. These complications are specially danger- ous in cases of abdominal wounds where abdominal respiration is difficult and where coughing up of mucus is often impossible because of pain or intestinal distention. It is indeed a fact that a very large proportion of all the deaths following abdominal wounds and operations are due to lung complications, and these injuries are at least twice as fatal in the winter as in the summer. Dr. Shipway's apparatus for the administration of warm ether vapor has been of the greatest value under those circumstances, and it is in common use in all the clearing stations. Use of Antiseptics. — It may be stated in general terms that it is the custom at the front to use antiseptics in the treatment of wounds, both at the field ambulances and the casualty clear- ing stations. No attempt is made to use antiseptic agents to disinfect the wounds on the field at the time of injury, for all who know the character of the wounds and the conditions of the wounded men, are agreed as to the complete futility of all such efforts, even if this had not been completely demonstrated during this war. But experience has also shown that in France and Belgium the wounds are so heavily infected from the soil that it is most necessary in all but the smallest wounds to excise very freely all the exposed and torn tissues which have been killed or else partially devitalized by the injury, and which are ingrained with dirt or portions of clothing. If this treatment is not carried out very thoroughly and carefully, and if free drainage is not secured, the gravest forms of sepsis may commence in serious wounds in a very few hours. It is common experience that if a badly wounded man can not be rescued and brought into the field ambulance until after the lapse of twenty-four or thirty-six hours, the wound is often already so badly infected and the patient himself is in so toxic a state that surgical treatment has but little chance. It may be said truly that the most important alteration in treatment since the early days of the war is that excision of damaged tissue has become the routine method and that the earlier it is carried out the more likely it is to be successful. "EusoV and "Dakin's Fluid." — Very many antiseptic agents have been employed, and there is naturally some diversity of opinion as to which is the best. There is no doubt, however, 26 ABSTRACTS OF WAR SURGERY that at the present time hypochlorous acid in the form known as "eusol," or the hypochlorite of soda in the solution known as "Dakin's fluid," are more extensively used than any others. The method of Dr. Carrel has been increasingly employed for the past year, and wounds treated in this way have done exception- ally well, although it is not always possible to employ the method universally at a time when the wounded are in very great num- bers. At other times there is no difficulty, and in order to estab- lish continuity of treatment Dr. Carrel's method is freely em- ployed on every ambulance train taking wounded to the base hospitals. Hydrogen Peroxide. — This is not highly esteemed as a potent antiseptic, but it is of great service in loosening adherent dress- ings. Carbolic Acid. — At an early stage of the war, and in consequence of representations made by surgeons in England, attempts were made to sterilize recent wounds by pure carbolic acid. They entirely failed to achieve this object, but solutions of a strength of 1 in 20 or 1 in 40 are in common use, and many surgeons have had a very favorable experience in using equal parts of solutions of carbolic acid and hydrogen peroxide. Sodium Chloride. — The hypertonic salt solution has not proved successful at the front, and at the present time is hardly used at all. The wounds treated by it were usually very slow in healing, and the granulations were generally pale, flabby, and much overgrown. There has also been a good deal of evidence to show that secondary hemorrhage is not nearly so frequent an occurrence since hypertonic saline has been displaced by other antiseptics. This is not at all surprising when it is considered that rapid cicatrization is the best safeguard against this com- plication. The salt pack largely used at Rouen is also to a great extent supplanted by the employment of "eusol" and "Dakin's fluid." It is, however, at the front a useful method of treatment of large open wounds in patients who are in transit by train. It does not need to be disturbed for several days, and when there are large numbers of wounded to dress this is a very great advantage. "B.I. P." — The mixture of bismuth subnitrate, iodoform, and paraffin, recommended by Professor Rutherford Morison for sup- purating wounds ("B. I. P."), has also been used for the past few months on recent wounds of the soft tissues, and also in cases of frac- ture. The results have been good, and encourage the further use of this remedy at the front. The fact that the wounds do not need ABSTRACTS OF WAR SURGERY 27 dressing for several days gives it the same advantage as the salt pack, while its use permits of an early closure of the wound, which is an additional advantage. Shock, and the Condition of Wounded Men. — The condition of wounded men necessarily differs as wounds are more or less se- vere, but in even slightly wounded men there may have been much bleeding, exposure to cold, want of sleep, or want of food. If to these are added severe pain and the exhaustion due to a hazardous journey over broken roads, it is easy to appreciate that very many patients arrive in a state bordering on collapse. Experience has shown, as a result of knowledge of these condi- tions, that it is not possible to estimate accurately the real con- dition of the patient until he has been rested and warmed, and has taken food ; and especially in winter time the most important of these remedial measures is undoubtedly warmth. This may be applied by warm blankets after the removal of wet clothes, or by hot bottles. But in more severe cases we employ a " light bath" of electric lamps beneath a cradle, or else a "hot-air bath" extemporized by leading under the bed clothes a pipe connected with a Primus stove. Hot liquid food is good if the patient can take it, but he is often nauseated or actually sick in the worst cases of shock, and then small enemata with brandy are very useful. "Warmth and rest are, however, of more importance than nourishment, and if the patient goes to sleep, as he very often does, it is best to leave him undisturbed for some time. Primary Amputations. — Unless a man is bleeding it is usual to treat him, as has just been described, before any operation is performed, but it is often necessary to postpone amputation for as long as a day, or even two days, if the removal of the limb is to be done at the thigh. Many men will survive if they are allowed sufficient time to get completely over the shock of the injury, who would certainly die if subjected to immediate opera- tion. It is, of course, evident that delay in removing a badly smashed limb may result in dangerous sepsis, and there is no doubt that the threat of gas gangrene may necessitate operation earlier than might be wished. Much must therefore of necessity be left to the discretion of the surgeon in each case. When the condition of the limb and of the patient permit, a primary amputation should be performed by one of the recog- nized methods practised in the usual circumstances of civilian surgery, suitable flaps being provided. It is, however, never right to neglect drainage of the stump, and this should always 28 ABSTRACTS OF WAR SURGERY be secured by the use of a large drainage tube, at any rate for a period sufficient to ensure that no serious sepsis exists. The seat of amputation has been much discussed, but in our experience the best general rule is that as much of the limb as possible should be saved, quite regardless of the typical "seat of election" as prescribed in former years; primary amputations through joints are, however, as a rule to be avoided. Not more than ten minutes need be spent on certain grave emergency amputations and, if conducted under the influence of gas and oxygen anesthesia, many apparently hopeless cases can be saved, for there is very much less shock than would be en- tailed by either a longer operation or by cutting through healthy and sensitive skin and muscle higher up the limb. In such a case the making of a suitable stump must be left to a future time. In another class of cases the leg or the forearm may be smashed beyond recovery, while the thigh or the upper arm is the seat of other severe wounds complicated by the presence of mud, of portions of shell, or of clothing. It is quite unwise in such a case to amputate high up the limb, and it is best to perform a "flush amputation" close above the fracture, and again leave to the future the formation of a useful stump at a time when the damaged tissues have recovered. If this is not done, not only is the patient exposed to more severe shock by a high amputation, but his stump may slough and a yet higher up removal may be necessary if he ultimately does survive. Wound Infections. — It is well known that in France wounds are liable to be very heavily infected by numerous pathogenic organisms, and inquiry from surgeons who have had experience in other theaters of warfare enables us to say that, especially in Egypt and in the Dardanelles, gas gangrene and tetanus infections were notably much less common than they are in France. While no time of year or condition of weather brings immunity, it is very evident that wet weather and mud are far more dan- gerous than summer weather and dust ; and this danger is much increased when patients are wounded in very cold weather and are thoroughly chilled before they can be brought in. Most surgeons are also agreed that the coldness and lowering of vi- tality caused by severe hemorrhage have a similar predisposing effect on microbic infection, and it will be found that wounded men are attacked by tetanus and gas gangrene in proportion as the various conditions exist which are inimical to the human organism. It has also been noted that gas gangrene has often ABSTRACTS OF WAR SURGERY 29 affected wounds in patients who have subsequently developed tetanus also. Gas Gangrene. — This disease appeared very early in the war and was a very unpleasant surprise to the surgeons. It had not been described as a usual complication of gunshot wounds, and though seen occasionally in civil life, so that its etiology was known to a certain extent, it was sufficiently unfamiliar to render an accumulation of experience necessary for its proper treatment. Two clinical types of the disease were recognized early and were named "gaseous cellulitis" and "massive gas gangrene." The former term was applied to the milder cases in which the cellular tissue round the wound was considered to be the primary seat of the disease; the latter term to those cases in which the whole limb was rapidly affected and died. The milder type of the disease was treated by incisions and drainage, the severer type by amputation. From a clinical point of view it was found that the conditions that favored the onset of the disease were : (a) The retention of extravasated blood and wound secretions, (b) interference with the circulation, (c) the presence of large masses of partially devitalized or dead tissues, (d) extensive comminution of long bones, (e) the presence of particles of clothing in the depth of the wound. (a) The avoidance of the retention of blood and secretions necessitated the employment of some sort of dressing that would not dry and cake during the transit of the patient to the casualty clearing station and from there to the base. It did not seem to matter what chemical was used so long as the dressing remained moist. (b) Interference with the circulation was brought about in several ways. First there was the tourniquet. Every effort was made to dispense with this instrument, and where this was not possible the patient was taken with all celerity to the nearest place where the hemorrhage could be stopped. Circular band- ages were found also to be a source of trouble. In simple flesh wounds it was easy to arrange that the band- ages and dressings should be loosely applied, but in the case of fractured lower limbs it was necessary to obtain some fixation of the limb, for the movement of the bones was not only painful to the patient, but calculated to produce further damage to the soft parts. The adoption of the Thomas splint largely solved this part of the problem, but there were and still are difficulties in the way of its adoption as far forward as is desired. Some 30 ABSTRACTS OF WAR SURGERY fractured lower limbs are still sent to the casualty stations with the old Liston splint; the rapid evacuation of all wounded that now pertains has, however, lessened considerably the disadvan- tages of this splint. The arrest of the blood supply to a segment of a limb by the rupture or thrombosis of an artery has so far baffled the surgeon. Attempts were made by suture and the employment of Tuffier's tube to restore the circulation ; but, so far, have not met with the success that was hoped. All that can be done is to favor the collateral circulation in every way. (c) The devitalized tissue that formed a nidus for the devel- opment of the gas-producing organism was got rid of by excision through the opened wound, and as the attention paid to this mechanical cleaning of the wound became greater so did the results improve. While surgeons were working out the best methods of treat- ment the bacteriologists were studying organisms found in the wounds. Many bacteria were found, but the blame could not be definitely fixed on any one organism, and in many cases there was a mixed infection. The Bacillus aerogenes capsulatus of Welch was found present in the greater number of cases. The interesting and important observation was, however, made that the numbers of gas-producing organisms steadily decreased with the lapse of time, whilst the pus-producing organisms increased. This bacteriological fact corresponded with the clinical observa- tion that the likelihood of gangrene occurring became steadily less as the wound became older and suppuration more obvious. A later abstract gives a full account of gas gangrene and will supplement the remarks made by Bowlby and Wallace in their paper (see p. 138 et sequi). Abdominal Wounds. — Surgical Opinion when the War Started. — For many years it has been held that the operative treatment of abdominal wounds was not to be advised under war conditions. This was partly due to want of success, as in the Spanish- Ameri- can War, and partly to the fact that many military surgeons were opposed to extensive operating anywhere near the firing line. Although the expectant treatment was the orthodox one when the South African War broke out, many surgeons at that time hoped to prove that it was wrong. Surgeon-General W. F. Ste- venson even issued an appeal for the trial of operation. The result was, however, only to confirm former opinion, though this opinion was now held on two somewhat different grounds. One school held that the expectant treatment was in itself the right ABSTRACTS OF WAR SURGERY 31 procedure, the other that it was the best that could be done in war. Some believed that wounded intestine healed sufficiently often to warrant abstention, others believed that small gut lesions were practically always fatal, and that the success obtained by the "wait and see" policy was due to the escape of the bowel from injury, although the belly had been penetrated. A study of the literature of the South African War, both private and official, makes the real reason for want of success in operating at once obvious — the cases arrived too late. It was not so much a question of the expectant treatment as failure of the operation. The reason for the late operation was the nature of fighting in an unsettled country of great distances. The wounded could not be quickly brought to a hospital with the necessary appliances. To operate in the field with what appliances were at hand was too disheartening. It was impossible to get even moderately good conditions. There was little or no water, and what there was was often too filthy for words — the water of dams. In addition, there was the plague of flies that settled on everything. The conditions were utterly different from those that pertain at the present time. This is the first time since the rise of ab- dominal surgery that a great campaign has been fought in a settled country, and, what is more important still, with a fixed fighting line. In this present war one of the difficulties of establishing the operative treatment was the run of bad luck which any operator might have to face. Even now, with conditions as nearly ideal as possible, a series of nine consecutive fatal cases may be met with. This must have a very depressing effect on any surgeon, especially on one who is not yet convinced that the operative treatment is in the main the best of all. Now nine abdominal cases means roughly about 600 wounded men, taking a moderate estimate of the proportion of abdominal wounds to total wounds. As a matter of fact, in the South African campaign a casualty list of 600 wounded was considered a large one, and if an operator happened to encounter such a series of fatalities, it is not a mat- ter of surprise that he should have had doubts as to the correct- ness of his procedure. Statistics in the present campaign show that an operative mor- tality of 50 per cent is a good result, but such a mortality in civil practice would be considered an awful death-rate to face. And yet it means, looking on the bright side, many lives saved. The South African campaign may, then, be said to have left surgical opinion opposed to operation, but it must always be 32 ABSTRACTS OF WAR SURGERY remembered that not only were there practically no shell wounds in that campaign, but also that the ogival bullet was a much less harmful missile than the sharp-pointed bullets of the present war. Method of Treatment in the Earlier Period of the War. — In the retreat from Mons and on the Aisne adequate provisions for the performance of abdominal operations near the front was well- nigh an impossibility, and all that could be done was to send, the wounded to the base with the least possible discomfort to them. When, in the ensuing winter, the line became fixed the circumstances were very different, and there soon developed a possibility of operating under good conditions. It was no longer a question of whether a man could be operated upon, but whether he should be operated upon. Still, however, a good deal of the old belief in the efficacy of the expectant treatment obtained for some time longer. A man wounded in the abdomen was sometimes kept in a dug-out in the trench system; often he was kept at a field ambulance, usually he was transferred to the casualty clearing station and there treated. The customary mode of procedure was to put the man in the Fowler position, to improve the general condition by rest and warmth, to withhold food and water for three days and to ad- minister morphine. The thirst, which was a distressing symptom of this treatment, was combated to a certain degree by rectal salines and mouth washes. A tribute must here be paid to the great care and attention which the medical officers lavished on the patients. If anything could have got these men well the attention that they received would have done so, and it must be remembered that the medical officers who conducted the treatment were convinced of its ef- ficacy. This belief was strengthened by the behavior of many of the patients, for some who were at first gravely ill, went through a period of improvement which often was very striking. There is no doubt that improvement did take place, and so well were many of them that after several days they were evacuated to the base and arrived there sometimes in fair condition, although more often gravely ill. But the surgeons who had seen the cases leave the casualty clearing stations apparently on the way to re- covery could not at first bring themselves to believe that they did badly at the base, and if evacuation had not been necessary and it had been possible to keep patients at the casualty clearing stations the expectant treatment would not have survived as long as it did, for medical officers would have seen many such cases become worse and worse, and in the end — die. ABSTRACTS OF WAR SURGERY 33 Commencement of the Operative Treatment. — Sumo attempts a1 operation had been made as early as November, 1914. During the winter of 1914-15 operations were done by several medical officers. But the early results wore undeniably bad — so bad that most people abandoned the attempt, and the reasons for failure were no doubt both the late arrival of the patients at a place where an operation could be performed and the want of knowl- edge which later on was acquired by experience alone, for there was no literature which dealt with such injuries as the surgeons were now called on to treat, and each man had to learn the best methods for himself. Owen Richards was the first to publish results of operative treatment in the British Army. His first operation was per- formed on January 28, 1915, and the first successful operation, that of a resection of two and one-half feet of the small intestines, was performed on March 18, 1915, thirty-six hours after the injury was received. In May, 1915, an inquiry into the causes of death after ab- dominal wounds established the following facts : 1. That the injuries were as a rule of such a nature that re- covery must be a very rare event. 2. That hemorrhage was a chief cause of early death. 3. That bullets produced very extensive injuries. The discovery that bullets produced extensive gut injuries was also of great importance, as much stress has been laid on the smallness of the lesions produced by the modern small-bore bullet, and the expectation of spontaneous recovery of gut lesions had been based on the quite erroneous assumption that such projec- tiles were comparatively innocuous. The reestablishment of the fact that hemorrhage was the chief cause of early death was of great importance, as it showed that only rapid evacuation afforded any hope of combating such a condition. Arrangements were accordingly made to insure that all patients suffering from abdominal wounds, and who were not too ill for transport, should be sent by special motor ambulances to the clearing station and not retained in the field ambulance. The result of this diffusion of more accurate knowledge was soon seen in the much earlier arrival of patients. The consequences of these improvements soon became apparent in the saving of many lives, and the operative treatment, now that it was placed under favorable conditions, very soon won for itself the confidence of the medical service, and quickly became universally adopted. Where to Operate. — The British practice has been to operate &4 ABSTRACTS OF WAR SURGERV a short distance behind the line, and the wisdom of this has been demonstrated. Here it is possible to operate under good condi- tions and to nurse the patient among cheerful surroundings for a week or more subsequently. The casualty clearing stations have, as a rule, been used for this purpose. If for some local reason it has not been possible to put one sufficiently far forward at any one part of the line, a small operating center has been opened for the reception of ab- dominal and other urgent cases. Possibility of Escape of Hollow Organs After Penetration of the Abdomen.— A certain number of cases of rupture of a hollow viscus without abdominal penetration have occurred, and have made it advisable to explore the intestine in some instances even when the whole thickness of the abdominal wall was not pene- trated by the missile, but where the symptoms have pointed to the probability of a lesion of one of the hollow viscera. General Line of Treatment.— The practice is now to operate on all cases unless there is some reason to the contrary, and to operate on principle rather than on the indications by symptoms. The cases on which operation has been found, as a general rule, to be inadvisable may be divided into two classes — (1) those in which solid organs alone are wounded and in which there are no signs of continuing hemorrhage, and (2) cases arriving after thirty-six hours. The liver furnishes by far the greater number of cases in class (1). This organ is the only solid organ in which it is possible to say from inspection that no other organ is wounded. In the other solid organs, such as the kidney and spleen, the likelihood of hollow visceral injury nearly always compels exploration. Were it not for this contingency, the solid organs would require little operative attention. In class (2) the time for successful interference in the case of hollow viscera has as a rule gone by, and the bleeding, from whatever source it came, has ceased spontaneously. Before operation a period of rest has found favor with most people. This period is used to combat shock, for which purpose heat in various forms has proved by far the most efficient means. When the missile is retained the position of the projectile should be ascertained by an x-ray picture, as its localization will influence the site of the exploratory incision. The incision should as a rule be placed by the side of the mid-line and should be of ample length. A transverse incision is much favored by some for exploring wounds which traverse one side only of the body. ABSTRACTS OF WAR SURGERY 35 The question of the administration of saline is important. The subcutaneous injection of saline has found favor in the past, hut it is coming to be recognized that very little is absorbed in a shocked man, and that this method presents no advantages over its administration by the natural orifices. If these are not avail- able the intravenous method should be used. Axioms of Operative Procedure. — Celerity is of great im- portance. The body heat must be preserved in every way. There should be the least possible exposure of the viscera, and the in- testines should be kept inside the abdomen as much as is com- patible with the necessary manipulation. The least possible should be done. All the intestine should be examined. Suture of the intestine should always be preferred to resection unless the latter is inevitable, or saves time, and experience has shown that a single continuous suture, applied so as to invert the peri- toneum, is quite sufficient and perfectly secure. Linen thread or thin silk are both preferable to catgut, and care is required not to draw the stitches too tight. If resection is unavoidable, end- to-end anastomosis is preferable to lateral apposition as a rule. Solid organs should be disturbed as little as possible, unless ves- sels have been opened. Excision of spleen and kidney should be practised with great reserve. Through-and-through wounds of the liver are best left alone, but if the x-rays show a large piece of shell or bomb in an accessible position it should be removed, for if left it generally causes dangerous sepsis in the organ. Ab- dominal drainage is most probably of little use except in local lesions. Artificial ani in the colon are to be avoided if possible. Wounds of Special Organs. — Stomach. — Wounds of the stomach, though less severe than those of the small and large intestine, have proved decidedly more dangerous than was supposed. The fatal result has largely been caused by hemorrhage and shock and by complication with other visceral injury. Small Intestine. — In the small intestine the multiplicity of the lesions and hemorrhage from the mesentery have been the chief causes of failure. As many as twenty lesions have been met with. In one case a successful result followed a resection of six feet for twenty perforations. In another case fourteen lesions were sutured and followed by recovery. Large Intestine. — The large intestine wounds have been mostly fatal from sepsis of the retroperitoneal tissue in the case of ascend- ing and descending colons and from complicated injuries in the case of the transverse colon. 36 ABSTRACTS OP WAR SURGERY Rectum. — The rectum proper has not been wounded so often as would be expected, but has a high mortality. Liver. — The liver shows a large proportion of recovery after operation, but many patients would have got well without opera- tion. Spleen. — The spleen injuries have not been very dangerous except where the lesions have necessitated excision, and the same may be said of the kidney. Bladder. — Intraperitoneal wounds of the bladder show a mor- tality of 56 per cent, where uncomplicated, but those associated with small gut injury have proved exceedingly dangerous. Causes of Failure. — Hemorrhage, sepsis, and shock have been the chief causes of death. Sepsis. — Under this head are included peritonitis, retroperi- toneal sepsis, and wound infection. It is unnecessary to say much about peritonitis. It causes death in the same way as seen in civil practice. Many attempts have been made to combat the so-called obstructive symptoms by enterostomies and short circuits, but with little if any success. Retroperitoneal sepsis, accompanied or not by gas formation, has proved a great source of mortality. This has been obvious in the case of the colon injuries. Shock. — It is very difficult to trace any definite relation between the amount of injury and the amount of shock. It can only be said that multiple injuries produce, as a rule, much shock. A severe intestinal lesion will not in all cases prevent a man from complet- ing the task on which he was engaged or even from walking one or two miles, and many who subsequently die arrive at the hospitals in good condition. The pulse rate table gives some indication of the patient's condition. Prolapse of the small gut seems to cause less disturbance than that of the stomach and colon. Hemorrhage is by far the most frequent cause of death, and as it is nearly always present, it is difficult to determine how much shock is due to this cause and how much to the accompanying injury. There is a cer- tain amount of evidence to show that comparatively slight injuries of both kidneys and liver will cause intense collapse, but such cases are not common. Sepsis of the retroperitoneal tissue without severe injury does cause the most intense shock. It is very difficult to compare the present mortality with that of the preoperative period. The whole method of evacuation has completely changed. The operative treatment has attracted to the casualty clearing stations all men wounded in the abdomen, so that those who would have died in dug-outs, at the advanced dressing ABSTRACTS OF WAR SURGERY 37 stations, and at the field ambulances, now reach an operative center. Neglecting the more forward positions, a calculation made in the preoperative days showed that the mortality at field ambulances and clearing stations was 70 per cent. In addition there were the deaths at the base, which raised the mortality 80 per cent. There would therefore seem to have been an improvement from 15 to 20 per cent. Wounds of the Heart. — There has been one successful suture of a heart wound. It was performed by Captain John Fraser. The patient nine months later reported his health as excellent. Wounds of Blood Vessels. — It may in the first place be noted that the conception of many surgeons of the size of the lumen and of the thickness of the wall of arteries in general has under- gone a change in this war, and it has often been remarked by med- ical officers that the arteries are smaller and have slighter walls than was expected. No doubt the class of subjects from which one gained an idea of the size of the normal blood vessels is so different from the class met with in war surgery that there was an exag- gerated idea both of the size of the artery and of the thickness of its walls in healthy young adults. Surgeons, knowing that they would have to deal with healthy arteries, hoped that many opportunities would present themselves from arterial suture, but unfortunately the opportunities have been few, and the injuries have rarely been of such a nature as to offer any prospect of success or even of trial of such treatment. Lateral suture both of veins and arteries has been done in a fair number of cases, and in two instances a lateral rent in the vena cava itself has been closed, although the only successful case was one in which the sides were brought together by artery forceps and not by suture. The opportunity of end-to-end suture of arteries has rarely offered itself at the front, and as far as the writers know has only been even temporarily successful in one case, that of a bullet wound of the brachial artery; and this vessel gave way and formed an aneurysm some three weeks later. In a few cases the femoral artery has been sutured, but in no case has the operation saved both the limb and the patient. Although so far the results have been disappointing, this is not a matter for surprise if the condition of the wounded vessels is examined. The class of case in which it was hoped to try this method at the front was that of open wounds such as are gen- erally caused by- shell ; but unfortunately the wounds of the ar- tery are commonly so far apart that it is found that they can not 38 ABSTRACTS OF WAR SURGERY be brought into apposition after the necessary dissection of the vessel has been done. Even in the popliteal space, where some approximation of the arterial ends can be obtained by flexion of the knee, no case has yet occurred in which arterior- rhaphy has seemed feasible, while small wounds of the limbs or neck with an arterial hematoma seem hardly suitable for this method of treatment. It was under these circumstances that "Turner's tubes" offered some hope of saving limbs from gangrene when arterial suture was out of the question. They have been employed at the front on many occasions, and are, it is believed, well worth trying, as, although they become blocked within about twenty-four hours, they have appeared to tide a limb over this, the most critical period before the establishment of the collateral circulation. It must be remembered that in actual practice the limb below the lesion has been deprived of blood for some time before the op- portunity occurs of inserting a tube and reestablishing the cir- culation, and it may be that this period of starvation produces changes in the vessel walls that favor clotting. There is another observation which may have a bearing on this subject. In civil practice, after the interruption of the main blood supply of a limb and the consequent occurrence of gangrene in its lower part, one looks for and sees the formation of a definite line of demarcation. But in the present campaign it has been found that after the destruction and ligation of an artery this line of demarcation fails to appear in the majority of cases, and the seat of the amputation has to be chosen by noting the place where the limb becomes cold and discolored, on the one hand, and, on the other, where the capillary circulation is still active, as shown by the return of the skin blush after pressure. No doubt the primary loss of blood has something to do with the frequency of gangrene in the first place, and in the second it would appear that the nature of the injury so upsets the blood supply of the limb that the collateral circulation is slow in being reestablished, and that sufficient blood does not reach the part to bring about the rapid and healthy reaction that is necessary for the formation of a distinct line of demar- cation. It is a fact at once curious and important that the arrest of the blood current at a point that is considered a favorable one for the application of a ligature in civil practice is often followed by gangrene when that arrest is caused by a gunshot wound. It may be that the laceration of muscle that so often accompanies ABSTRACTS OF WAR SURGERY 39 such injury is the cause to a certain extent, but there must be other factors at work, as gangrene may follow even a small per- forating wound. Wounds of certain arteries stand out as especially dangerous to the vitality of the limb, notably those of the popliteal and the anterior and posterior tibials. Injuries of Joints. — A great change for the better has taken place in the results obtained in the treatment of wounded joints. Experience was chiefly gained on the knee-joint, for it is the joint most frequently hit, most easy of inspection, and its infec- tion is followed by disastrous consequences more often than in the case of other articulations. In the early days two lines of treatment were followed. The small perforating wounds were let alone and allowed to heal, the progress of the joint being tested by aspirations if neces- sary. The larger wounds with escape of synovia or actual laying open of the synovial sac were drained, and at first the drains were often introduced into the joint cavity. The results of this treatment were undeniably bad, and all sorts of heroic measures were adopted for the arrest of the septic processes which en- sued. But continuous irrigation or an acute flexion of a widely opened articulation gave equally poor results, and the patient was lucky if he escaped with a stiff leg. The first improvement was the abandonment of the intra- articular drains. The next was the excision of the wound, the removal of any foreign body, the flushing of the joint, and in some cases the closure of the capsule and the insertion of a super- ficial drain. The next step was perhaps a bold one. As soon as possible after the receipt of the injury — that is, in the casualty clearing station — the wound was excised, the joint opened, cleaned, and irrigated, and then the whole wound in the synovial sac and the superficial tissues was tightly closed. It was certainly aston- ishing how seldom infection followed such treatment, even when fragments of shell or pieces of clothing had been removed from the joint ; but for its success it is essential that the incisions around the wound edges should be carried quite clear of all infected tissue, and that the strictest asepsis is assured. Now, every knee-joint with such a wound is given the chance of healing by first intention, although the closure of the joint defect may entail the performance of a plastic operation to provide an adequate cover with a flap of synovial membrane or skin. Even if some infection does follow the closure of the 40 ABSTRACTS OF WAR SURGERY joint, it is well not to be in too great hurry to lay the articula- tion open, for a certain number of such joints do settle down and provide a better limb than if submitted to more active treat- ment. When the joint wound is complicated with fracture of bone it may still be possible in some cases to close it with success. In cases of compound fracture of the patella with loss of sub- stance, partial or complete removal of the fragments, and the provision of a skin flap, will often be followed by primary healing. When the tibia or femur are involved the case becomes more serious. Of the two fractures that of the tibia is the most to be feared. In cases of only partial loss of the ' articular surface of either the tibia or femur, and also in linear oblique fractures of both bones running up into the joint, it is often worth while to try to close the joint and to obtain primary union. Where there is much comminution of bone, however, and a dirty wound it is better to abandon all hope of saving the joint and perform a limited primary excision. After such an opera- tion the joint surfaces are usually kept apart by extension on a suitable splint, and Carrel 's treatment adopted until the wound cleans, when the bone surfaces may be allowed to come into contact. The knee is the only joint in the body in which penetration of the synovial sac is at all commonly seen without damage to the bony constituents of the articulation. It is therefore not common to have the opportunity of closing other joints, but the opportunity should be taken when it is offered. More often the surgeon has to treat a greatly disorganized articulation, and in such cases a primary excision is most prob- ably the best course, especially in the case of the shoulder and the elbow. The primary treatment of wounded joints may be summarized as follows : 1. Fixation on a suitable splint. In the case of the knee this splint should be one of the varieties of the "Thomas" as used for fractured thigh. 2. Beyond this treatment nothing more is required in simple perforating wounds. 3. The taking of any x-ray picture in cases where there is a possibility of the retention of a missile or of fracture of the bones. ABSTRACTS OF WAR SURGERY 41 4. The excision and cleansing of the damaged tissues and the exploration and lavage of the joint. 5. The closure, if possible, of the joint cavity. Head Injuries. — At the beginning of the war surgeons called upon to treat head injuries applied the ordinary rules of civil practice and operated on them at once. They were confirmed in their opinion that operation was right, since, apart from the mere physical defects, many patients seemed to be suffering from compression. These operations were done both at casualty clearing stations and field ambulances, but the best method of operative treatment was as yet undeveloped. Next, it was noticed at the base that cases which, from force of circumstances, arrived there un- operated upon, did better than those operated on at the front. This was attributed at first to faulty technic, and within limits this criticism was just, as the right operation was as yet unde- veloped, both at the base and the front. The observation was next made that if patients were kept quiet at the place where they were operated upon they did well, while cases operated on and apparently doing well were reported to have arrived in bad condition at the base when evacuated early. It thus became obvious that there were two reasons for head cases doing badly: (1) The want of a good operation, (2) early evacuation of cases well operated on. There were then two alternatives : The cases must be either operated on at the front and kept, or else evacuated as soon as possible to the base before operation; a patient must not be operated upon and evacuated forthwith. Two procedures were therefore adopted. In times of pressure head cases were cleaned up and sent to the base at once, provided they were fit to travel, and in quiet times they were operated on and kept at rest at a casualty clearing station for a week or ten days. Even this period of rest after operation proved too short, though the results were better than in earlier evacuation. The next step was the establishment of special hospitals for head cases at the front. Advantage was taken of the fact that a head case before operation travelled well, and the special hos- pitals were placed in the back part of an army area. These hos- pitals were never subjected to the sudden pressure that may fall on an advanced casualty station, and consequently the cases could remain there for a long time. By this means patients experi- enced the advantages both of early operation and prolonged rest. 42 ABSTRACTS OF WAR SURGERY If the pulse is slow they are sent on to the special hospital. If the pulse is rapid they are put to bed and evacuated later, should they improve. No special attention is paid to the type of wound — reliance is placed on the slow pulse as a sign that the patient will bear the journey. The type of operation that has eventually been found most beneficial has been arrived at after many changes. Workers, comparatively far apart and not in direct communication, have evolved very much the same operation. At the front a small conservative operation was formerly practised which experience has shown to have been a little too limited in scope. At the base there were two schools — one favored an extensive removal of bone and a scalp flap, the other an enlargement of the scalp wound and a limited removal of bone. Gradually the types of operations have approximated. It has been found that the removal of bone sufficient to expose half an inch square (1.27 cm.) of uninjured dura is best suited to most cases. Opinions still differ, perhaps, as to the comparative merits of making a flap or enlarging the scalp wound. On the whole, the flap is the best as a routine, unless the wound, as in the case of a horizontal one, is so situated as to compel the use of a very large one. The recognition of the fact that a slow pulse is not necessarily a symptom of compression (for it may occur with a wide exposure of the brain), and that the symptoms, paralytic and otherwise, are not due to depression of fragments but to a destruction or commotion of the brain matter which is not remediable by opera- tion, has also had an effect upon procedure. In the first place, a slow pulse is welcomed as a sign that recovery may follow, and it is not taken as a sign that operation is urgently needed, but rather that it is worth doing. The recognition that depression of fragments is not the usual cause of the symptoms has also done away with the notion that their removal must be imme- diately undertaken. It is true, that the sooner a dirty wound is cleaned up the bet- ter, but immediate operation is in many head cases followed by a great drop in blood pressure, so that some delay may be actually beneficial on this account, and Colonel Sargent has pointed out that for at least twenty-four hours after injury the brain is liable to be edematous, and to extrude unduly if operated on while in this condition. A moderate delay has also been said to do good in that it allows adhesions to form between the dura and the pia mater, thus lessening the chance of a spread of in- fection over the brain surface. ABSTRACTS OF WAR SURGERY 43 At the same time that the best type of operation as regards the scalp and bony defect was being evolved many other points were in the process of settlement : 1. Excision of the wound was soon decided on. 2. There was at first considerable discussion as to how far the brain should be explored for bone fragments on the one hand and the projectile on the other. Every one was agreed that an x-ray picture had become a necessity, and the opinion was grad- ually formed that a limited and intelligent search for bony fragments and other foreign bodies was beneficial, but that attempts to reach a missile which was deeply embedded in the brain was not justifiable. Results seem to have proved the cor- rectness of this line of treatment, for fragments of shell are reported to have caused little trouble provided their weight was not enough to cause pressure on the surrounding brain during movements of the patient. 3. The fact that many patients with head wounds suffered from septic complications, and the general demand for the drain- age of all wounds, led at first to the employment of drainage in most cases of cranial surgery, not only of the scalp but of the brain also. The results of drainage of the brain were not satis- factory, and gradually it was abandoned, at any rate as a primary measure. The introduction of tubes was first omitted, and subsequently, systematic attempts were made to cover in the exposed brain, the scalp being brought together over the defect in the bone and dura, either by simple suture, pericranial flaps, or relieving incisions formed by undercutting the scalp. A drain introduced under the scalp is still generally employed. This covering up of the brain seems to have been a decided suc- cess, and, although septic complications are still too often met with, they are less frequent than in former times. There has consequently been a great decrease in the number of cases of hernia cerebri. 4. There is still some difference of opinion as to whether small cranial depressions and linear fractures with slight in- equality of surface, uncomplicated by symptoms, should be operated on in the first instance. 5. Most surgeons have accepted the recommendation of Sar- gent and Gordon Holmes that depressed fractures over the longi- tudinal sinuses should be left alone in the first instance. 6. Most operators are of the opinion that the dura mater should not be opened if found intact. The recognition that true 44 ABSTRACTS OF WAR SURGERY compression of the brain is seldom seen has helped the forma- tion of this opinion. 7. A general anesthetic may with advantage be replaced by the local use of novocaine and adrenalin. If this method is adopted the patient is given either hyoscine and morphine or omnopon and scopolamine an hour before the operation. Fractures. — The tendency throughout the war has been to abandon all constricting splints and to trust to extension for fixation of fragments. In the first place, a bandage round a limb, which might from swelling or movement cause constric- tion, was found to favor the onset of gas gangrene, and in the second, the various forms of Thomas's splint, in which the limb lies on a cradle, gained more and more reputation as a means of efficient splintage. Few other splints are now used on the lower extremity. It is curious that while plaster splints, both as emergency contrivances and as a means of permanent fixation, have steadily increased in use in the French army, in our own they have as steadily fallen into disuse. The treatment of a compound fracture must be divided into two parts: (a) The cleansing of the wound; (b) the setting or reduction of the fracture, followed by its maintenance in good position. In the early stages the first is by far the most important, and on its attainment depends, within limits, the success of the second. Total immediate reduction is good and to be aimed at, pro- vided it can be carried out without prejudice to the cleansing of the wound, but an incomplete reduction, or even no reduction at all, may be advantageous by aiding the disinfection of the wound. Surgeons working at the front are therefore mainly concerned with the primary cleaning of the wound and with the means to transport a patient to the base with comfort and without detriment to the wounded limb. The organisms that infect a compound fracture may be roughly divided into two classes : (a) Anaerobic or gas gangrene pro- ducing infection; (b) infection due to pus-producing organisms. Anaerobic or gas gangrene producing infections affect chiefly the muscles, is sudden in onset and development, but tends to die out if not fatal in the early stages. Infection by pus-producing organisms affects all the structures of a limb, is generally of slower development, and fatal at a considerably later period. The first (a) is the chief cause of death at the front, the second (b) of death at the base. From the fact that it affects muscles, the first is more amenable ABSTRACTS OF WAR SURGERT 45 to treatment by mechanical means — the excision of the affected part or part likely to be infected; but the second giving little indication of its presence, can not be so easily removed by such means. At the beginning of the war fractures were treated very much as they were in South Africa. It is true that fragments of pro- jectiles and clothing were removed, but more attention was paid to the solution of continuity of the bones than to the cleansing of the wound. The occurrence of gas gangrene quickly called for a remedy, which was found in amputation or incisions into the limb. Then came the demand from the base for free drainage. At first small tubes were used; as these proved inefficacious, large tubes were substituted. At the same time came a more systematic search for foreign bodies. This produced an improvement, and it was reported that the cases that came down with adequate drainage, especially those with dependent drainage, stood a far better chance than those in whom such measures were not taken. About this time, attention was drawn to the fact that many flesh wounds, if freely excised, could be sutured with success. The application of this principle, though it could not be applied in toto to fractures, led to more extensive opening up and to better mechanical cleaning by the excision of all dead tissue and the more efficient removal of foreign bodies. These measures greatly reduced the occurrence of gas gangrene and produced an improvement in the suppurative infections. At the same time as these improvements were taking place in operative technic the adoption of the Thomas splint for the lower extremity in one of its many forms was steadily working its own good. The stretcher in the ambulance car and the cot in the train presented a difficulty — there was nothing on which to rest the splint. This difficulty was overcome by two methods: (1) A form of the Thomas splint provided with an attached foot-piece or prop was used so that the splint was raised off the stretcher and the limb lay slung, as it should be in the splint. (2) Two forms of iron bracket, attached to the foot of the stretcher, allowed the Thomas splint to be suspended above the canvas of the stretcher. Patients thus travelled easily in the motor ambulances, and the difficulty of the cot in the train was easily surmounted by sending the patient down on the stretcher. This latter expedient has been of great benefit to the wounded, as once placed on his stretcher at the casualty clearing station he can remain undis- turbed until he reaches his bed at the base. 46 ABSTRACTS OF WAR SURGERY The fixation in a Thomas splint depends upon the extension. An efficient extension is therefore of prime importance. Sinclair's glue has provided the means. It is easily and quickly applied, and has the additional advantage that it produces no constric- tion of the limb. It has another advantage, it can be used when only a short portion of the leg is available, a very great gain when dealing with limbs covered with multiple wounds. There are, of course, a few fractures of the femur that can not be treated with Thomas 's splint — namely, those in which a wound has been received on the part covered by the ring. For these the old Liston splint is used, or in some cases the abduction frame of Jones, though the bulk of the latter makes it unsuitable for work at the front. Below the knee the Thomas splint can nearly always be used, except in those cases in which the fracture is near the ankle. Even here it is often possible to use it by the aid of the sole extension as devised by Sinclair. In the case of fractures of the upper extremity the Thomas splint has not proved so satisfactory, but only for the reason that the straight posture of the arm is unsuited to transport except under special circumstances, as in transit by barge. The form of Thomas splint for the bent arm has not proved a suc- cess. For transport the form of internal angular splint, with a hinged back piece for the upper arm as devised by Captain Colin Clarke, is probably the best. The development of the operative side of the casualty clearing station and the provision of x-rays has been of inestimable benefit to the patient. There can be no doubt that the chance of the patient recovering with a good limb and of escaping a long period of suppuration depends on the attention that can be paid to his wound in the first instance. No amount of after-care can ever make up for the want of it at the first moment. A thorough and deliberate operation is all-important. There must be a free opening; the cavity must be explored by the eye, and not only by the finger, otherwise dead tissue and possibly foreign bodies will be passed over. When first received the wound is dirty, but the number of pus-producing bacteria is comparatively few. In a few days it is probable, no matter what treatment is advised, that they will have greatly increased in number. If the first operation has been incomplete, a second may be necessary at the very time that the wound is in the worst possible state, and the procedure necessary to supplement the primary operation may be disas- ABSTRACTS OF WAR SURGERY 47 trous in exposing fascial planes to infection from a wound teem- ing with bacteria. The early, deliberate and efficient cleansing of the wound i.« the basis of success, no matter what chemicals are used after it is completed. DEVELOPMENT OF BRITISH SURGERY IN THE HOSPI- TALS ON THE LINES OF COMMUNICATION IN FRANCE. — Surgeon-General Sir George H. Makins. Brit. Med. Jour., June 16, 1917. The general hospitals on the lines of communication in France have undergone a steady process of extension in accommodation and development since August, 1914. They have been housed very variously — some in the original tent units, some in huts, and some in large buildings adapted to their present purpose. Tented units under the climatic conditions of France have proved to possess but one virtue, that of mobility, and in all the tented hospitals still remaining a certain proportion of huts for serious cases, operating theaters, mess accommodation, stores and offices, have been added. The most satisfactory units are hutted throughout, and these leave little to be desired either for comfort or for satisfactory work. Most of the buildings now in use are either of the nature of public buildings or of large hotels. Each possesses some special advantages. The large rooms of casinos, etc., form excellent wards, easily overlooked and economical to work, but such buildings need usually considerable reinforcement with regard to sanitary accommodation. The hotels are more convenient for officers as providing a large number of smaller rooms, but this necessitates a somewhat larger nursing staff, and renders attention to individual patients a more troublesome task. Special hospitals are set apart for the treatment of infectious cases, for skin diseases, and for venereal cases. Each unit is complete in itself, possessing operating theaters, clinical laboratory, and its own disinfecting apparatus. The only department that is commonly massed when a number of units are collected in the same area is the mortuary and accommodation for postmortem examinations. The majority of the units — the normal capacity of which is 520 beds — have been extended by the provision of additional ward accommodation to receive 1,040 patients, while in times of stress a further extension of 2,000 is 48 ABSTRACTS OF WAR SURGERY possible by the addition of tents. The number of patients that may need to be dealt with during active fighting may be very large; thus during the first three months of the action on the Somme as many as 8,500 wounded men have been passed through a single unit. This necessitates ample operating theater accom- modation, and in all either a large theater is provided, or in one type of unit two, so that at least four operating tables can be kept at work contemporaneously. In spite of these provisions, at busy times the surgeons may be engaged continuously in shifts for two or three days and nights without cessation. Within certain limits, arrangements exist for the aggregation of special classes of injury, such as fractures of the bones of the limbs, injuries to the face and jaws, compound and complicated fractures of the skull and vertebral column, and wounds of the chest. Hospital Trains and Motor Ambulances. — The vast majority of the patients admitted to the general hospitals are brought down by the hospital trains. The development of the hospital train in France was a matter of extreme urgency and great diffi- culty in the initial stages of this campaign. It seems as if both France and Germany had relied for the railway transport of the wounded on the same means which served the purpose in the war of 1870-71. To add to the miseries of the journeys made in these trains, they were long, sometimes extending over two or three days before the west coast was reached. Odd carriages of every build and description were obtained whenever opportunity offered, and within a few weeks, with alterations hastily but effectively carried out, a number of efficient if not luxuriously appointed hospital trains were forthcoming. One word should be added regarding the fleet of improvised barges which run on the canals between the front and two of the general hospital areas. There is no doubt that the smooth passage of these boats provides the acme of comfort for patients to whom the unavoidable shaking of a railway journey entails both pain and harm. It is unfortunate that the general utility of the barges is limited to the few districts in which canals are to be found. The splendid motor ambulance convoys attached to each dis- trict, and for most of which the army is indebted to the Red Cross Societies of the United Kingdom and the Colonies, have been already referred to as to their work at the front, and no further mention of their devoted work is necessary at this place. As to the last link between the general hospitals on the lines ABSTRACTS OF WAR SURGERY 49 of communication and the base in England, the hospital ships, it suffices to say that they leave nothing to be desired. Wound Treatment. — This question has abated no jot of its capacity for arousing controversy and avoiding a solution which can satisfy all. Experience has in no way controverted that gained in civil practice in the use of aseptic methods, but has, on the other hand, proved conclusively that advance in the treatment of septic wounds in this campaign has had to start from an unfamiliar standpoint, and has progressed but slowly. Practical application has demonstrated the superiority of the Listerian principle and method, but the multiplicity of the chemical media employed affords evidence enough of the difficulty met with in establishing any one means as that suitable for every class of case. On two points alone can no difference of opinion exist: (1) The urgency of an efficient primary mechanical cleansing and exposure of the wound cavity, and (2) the importance of maintaining the wounded part at rest. The latter point raises the first great difficulty which has to be met by the military surgeon, the absolute neces- sity of early transport of the wounded man; and lends directly to a second, the amount of interference advisable in wounds which have reached the "intermediate stage," that is, the period of established infection during its first phase, the condition, in fact, in which a large proportion of all gunshot wounds reach the general hospitals on the lines of communication. Speaking generally, it has been shown that if the primary mechanical cleansing of the wound has been thoroughly carried out, no further gross intervention should be necessary; further, that if want of time and medical officers has not allowed of this procedure being fully carried out, yet if the wound has been sufficiently opened up and primary drainage ensured, the subsequent treatment is comparatively simple. From the point of view of the surgeon on the lines of communication, free in- cisions are never objectionable, provided they be made in such directions as not to render the subsequent secondary closure of the wound impracticable, — the one structure for which he pleads is the integument. The primary cleansing, given satis- factory surroundings, can not have been undertaken too early, as every hour of delay adds to the subsequent task of dealing with the infection. In this relation the immediate removal of shell fragments and clothing is of the first importance, because if allowed to remain, the deferred operation, even in minor wounds, may prove a procedure of great danger when the patient 50 ABSTRACTS OF WAR SURGERY has arrived at the general hospital on the lines of communica- tion. Such an apparently trivial operation may be followed at this stage by an acute extension of anaerobic infection involving the whole segment of a limb, the entire member, or, indeed, may be sufficiently extensive to lead to the loss of the limb, or even the patient's life. The conditions of war, however, not infrequently prevent an ideal early treatment of the wounds. It may be impossible to remove patients from "No Man's Land," or even from the trenches, for many hours or even days after reception of the wound. On the occasion of serious fighting the number of the wounded may make it impossible for the requisite amount of time to be spent on individuals, especially those less seriously injured. Lastly, unavoidable delay in transport may result in extension of infection and conversion of a promising case as it left the casualty clearing station into one arriving at the general hospital in a highly unsatisfactory condition. Happily, whatever the initial procedure and application may have been, in many cases the young and healthy patients arrive in good general condition, the local wound progressing satis- factorily, in some instances devoid of any serious infection. In a considerable proportion, however, men are admitted suffering, both generally and locally, with every grade of infection from the slight to the most severe. The former class present little difficulty, the wounds heal readily under any form of simple appli- cation, or, as a time-saving and precautionary measure, the smaller wounds may be completely excised and the gap sutured. Wound excision, of wounds in general, became a fixed principle later, and is now most enthusiastically advocated by the English surgeons as a rule. A vastly more difficult problem is presented by patients arriv- ing in the stage of acute development of infections. The wound has already been primarily opened up and cleansed, and the question arises whether further surgical interference will effect improvement or lead to increased extension of the infective process. On the one hand, it is evident that the patient is suf- fering from an exacerbation directly due to the disturbance involved by transport; on the other, the possibility is always present that delay, even of a few hours, may allow such progress as to render any further intervention useless. A rough-and- ready distinction between cases in which clinical evidence sug- gests anaerobic or aerobic infection, respectively, to predominate forms the most useful guide. In the former case delay may be ABSTRACTS OF WAR SURGERY 51 fatal to life and limb, in the latter an interval of rest often results in a rapid subsidence both of local signs and general symptoms, and no further incision may be required. Patients arriving at the general hospitals may have been sub- jected to several varieties of primary wound treatment. Speak- ing generally, the principles adopted have consisted in the main- tenance of rest, moisture, and an antiseptic application. In the earlier stages of the campaign numerous antiseptic solutions were employed, also the hypertonic saline solution, but of late, in the great majority of cases, solutions of which the active constituent is chlorine have found most favor and have proved the most satisfactory in practice. Eusol, and with gradually increasing frequency the Dakin-Daufresne solution of hypo- chlorite of sodium, are those now most commonly resorted to. In the case of the former, moist gauze dressings, in combination with ordinary rubber drainage tubes, have been generally em- ployed; for the latter the technic of Carrel is used. A smaller number of cases have been treated by other methods, such as primary suture, the salt pack, closure after the introduc- tion of a mixture of iodoform, bismuth subnitrate and paraffin (Rutherford Morison's method), a solution of brilliant green, etc. A word may be added regarding the salt pack method advocated by Colonel H. M. W. Gray. This method, consisting in a thorough packing of every crevice of the wound with gauze, between the layers of which tablets of sodium chloride are en- closed, is suitable for wounds of the large funnel type or of a superficial nature. It is not safe for tunnel wounds, wounds implicating the large vessels, or highly comminuted fractures. The early action of the sodium chloride is inhibitory, and gives no aid to the healing process; indeed, the tablets, even when enveloped in gauze, cause local necrosis of the tissues opposite to them. On the other hand, wounds dressed in this manner may be left untouched in many cases for a week or ten days, during which period the patient's general condition remains excellent. The pack, acting as a foreign body, excites a local reaction around the wound, with a consequent narrow wall of inflamma- tory infiltration which protects the general system from the absorption of toxic products from the wound. Suitable cases dressed in this manner arrive in a surprisingly good condition at the general hospitals, and the wounds do well with subse- quent cleanly antiseptic treatment. Subsequent introductions of the pack are conducive neither to rapid closure of the wound, to cleanliness, nor to the amenities of the ward, and are undesirable. 52 ABSTRACTS OP WAR SURGERY It may be well here to mention the experience which has been gained as to three points in the technic of the treatment of septic wounds — drainage, irrigation, and baths. Drainage. — The methods of maintaining the free escape of septic discharges from the wound have undergone considerable modification, although no doubt has arisen as to the cardinal im- portance of the principle to be carried out. In the earlier stages of the war it was effected mainly by the introduction of rubber tubes of large caliber and other devices and these were retained for prolonged periods at the general hospitals. The objections to this method — the tendency of the tube to form for itself a local- ized channel useless for general escape of fluid, the presence of a foreign body in the wound capable of exercising injurious local pressure, the establishment of a track by which infection could be freely conveyed from the surface to the depths of the wound cavity, and lastly, the difficulty of determining the moment at which the tube might be safely removed after its prolonged stay — were obvious, but they were faced for a time in view of the very serious infections that had to be dealt with. A revulsion, however, soon followed, in consequence of the unsatisfactory results attained, and the tube is now retained as a provisional measure, and in many cases not employed at all. The main ele- ment in the decreased use of the cylindrical tube has been the introduction of what may be called the "curtain" method. This is well illustrated in two forms by Carrel's and Rutherford Mori- son's systems respectively. In Carrel's, the wound surfaces are kept apart not by the small tubes employed for the purpose of instillation, but by the layer of fluid constantly renewed between them and the light gauze packing introduced to retain it. In Rutherford Morison's, a thin layer of an antiseptic medium cov- ers every part of the surface of the exposed tissues, and forms a curtain or cleft which allows for the escape of such fluids as may collect within the wound. The drainage effected by the salt pack is of a similar character, supplemented by the absorp- tive power of the pack itself before it becomes thoroughly impregnated with the discharges. Irrigation. — Continuous irrigation has greatly lost in favor; it has the primary objection of inconvenience to the patient, while experience has demonstrated the difficulty of preventing the fluid from forming definite runlets, and consequently of ensur- ing the flow of the fluid employed over the whole surface of the wound. Its use has consequently been more and more restricted ; ABSTRACTS OF WAR SURGERY 53 and, except in the form of a periodical flush, irrigation is little employed. Baths. — Antiseptic baths have also lost in favor with the development of more effective antiseptic methods. Beyond the obvious difficulties, the bath entails the serious disadvantage, in dealing with a septic limb, of the impracticability of preventing hurtful movements of the part. At the present time the most successful results that are being attained in all forms of wound are undoubtedly those in which the Carrel-Dakin method is employed. This method has not only shown itself successful in the early treatment, but also in the later treatment of septic wounds, even in the stage of chronic established suppuration. It has been definitely proved that simple flesh wounds dealt with during the first twelve hours after infliction can be rendered practically sterile in an average of six days, those dealt with later in an average of twelve days, that compound fractures may be sterilized within three weeks, and that all three classes of cases may be secondarily sutured and closed at these dates. Economy in time, diminution in the risks of secondary complications, increase in the comfort and well- being of the patient during treatment, are all insured by the method. It also insures what has become the supreme object in dealing with septic wounds, the possibility of early secondary suture. The importance of using a bacteriological test to determine the date of closure of the wound can not be too strongly impressed if anything like habitual success is to be attained. Opportunity has not yet been afforded for the trial of the method during a great rush of wounded men, but arrangements have been made to carry it out if possible. Even should this prove impracticable, the system can readily be carried out in quieter times for a very large number of patients. It has one obvious advantage over any other method of treating septic wounds, the production of a thin supple scar, not likely to interfere with the mobility of the parts, or to cause trouble by subsequent contraction. The alternative method of secondary closure, that of Ruther- ford Morison, avoids the tedious process and careful manipula- tion essential to the success of Carrel's method, saves much time on the part of both surgeons and nurses, and the patient has not to undergo the discomfort of repeated dressings. Little experience has yet been gained of its suitability as a primary procedure, but in infected suppurating wounds it has attained great success. It must, however, be allowed that the cicatrix 54 ABSTRACTS OF WAR SURGERY obtained is very inferior to that which follows the use of Carrel's system, "from the initial period onward, and the inclusion of par- ticles of bismuth and iodoform has some disadvantages, both immediate and remote. One great advantage of Rutherford Morison's method is also lost in the cases treated by it in a field ambulance or casualty clearing station and the patients must undergo transport with its consequent shaking and disturbance of the wound; hence, patients with the slighter injuries, whose wounds have been closed by this method, often arrive with the composition escaping from a wound in which little or no union has taken place, and no appreciable benefit has been conferred. While it may be said fairly that the Listerian principle has been more nearly attained by the method of Carrel than by any other in use, and that the results are of a very satisfactory nature, yet it must still be allowed that an ideal antiseptic medium remains to be found, especially in respect of consistency of strength and persistence in action. In both respects the bis- muth iodoform methods offer some advantages to make up for the cruder character of the cosmetic results obtained. Secondary Hemorrhage. — As a manifestation of septic infec- tion, it is obvious that improved methods of wound treatment offer the best chance of reducing the frequency of secondary hemorrhage, and it may be confidently stated that with the devel- opment of more satisfactory methods the accident has become less common. Still it must be recognized that in dealing with gunshot wounds we are likely to be of necessity limited to the process of secondary sterilization of an infected wound ; further, that we stand in the face of a variety of wounds in which incom- plete primary lesions of the blood vessels are more common than in any other. The eventual perforation of the vessel wall, there- fore, is up to a certain date more commonly the result of the separation of a slough of primarily devitalized tissue than due to the extension of a process of ulceration from without. Secondary hemorrhage may occur from any large vessel, or in old toxemic or septicemic subjects it may be of the parenchyma- tous variety. Given this generalization, however, we find that certain vessels are much more commonly the source of bleeding than others. The localization is determined by the degree of fixation of the vessel and the firmness of the bed upon which it lies. Thus the circumflex branches of the axillary artery, the subscapular or posterior scapular vessels in proximity to the scapular, the gluteal artery, the articular branches of the popliteal artery, the circumflex branches of the profunda femoris, ABSTRACTS OP WAR SURGERY 55 the femoral artery in the lower part of Hunter's canal, and the anterior tibial artery as it lies on the interosseous membrane, are all common sites, and, it may be also remarked, troublesome ones in which to deal comfortably with the injured vessel. Another peculiarity is the comparative frequency with which large trunks in mobile positions, such as Scarpa's triangle, may escape damage by displacement and lie exposed on the surface of a large open wound. Such vessels may not infrequently have suffered con- tusion with consequent thrombosis. As to the general treatment of these injured vessels, little new has been evolved; direct local ligature, prolonged forcipressure, or at the last extremity local plugging, are still the means on which the surgeon must depend. On rare occasions, as an emergency measure, a proximal ligature may be applied, but this is rarely successful and often harmful. A single exception to this rule must be allowed in case of uncontrollable hemorrhage from wounds of the gluteal region; here in several instances ligature of either the internal iliac artery or its posterior trunk has proved a successful measure. The proper method of treatment of an exposed arterial trunk, whether thrombosed or not, has opened up a question upon which the civil surgeon rarely has to form a decision. It may be broadly stated that the line of treatment depends mainly upon the degree of septicity of the wound of the surrounding soft parts. If the arterial coats are not seriously damaged and the wound be in a condition likely to respond to antiseptic treat- ment, an expectant attitude should be assumed if the vessel be pervious. If, on the other hand, the artery is thrombosed, the right course is to place ligatures both above and below the oblit- erated portion of the vessel, because such arterial thrombi in any case result in permanent occlusion, while in many instances the vessel may give way at the limits of the clot, a solid cylinder, like a pencil, coming away with great risk of hemorrhage ; beyond this the clot provides a possible source of a peripheral embolus. As to the general treatment of patients in whom a secondary hemorrhage has occurred, internal styptics such as calcium lactate have proved useless. This is easily intelligible in the case of the larger vessels, for in such a more or less rounded opening is usually present, the occlusion of which by a mural clot is of no more than very temporary use, while a local thrombus ob- structing the whole lumen is unlikely to form. Even in cases of the parenchymatous variety internal remedies have proved useless. 56 ABSTRACTS OF WAR SURGERY The main advance in treatment has consisted in a return to the practice of transfusion of "whole blood" which has in great measure displaced the unsatisfactory saline infusion. For the popularization of this method we are mainly indebted to our Canadian colleagues in France. Several methods have been employed — the Kimpton tube, the Unger two-way stopcock, direct connection of the radial artery of the donor with the vein of the recipient by a paraffin-coated rubber tube provided with silver cannulas at either end, the employment of a series of Record syringes, or the citrated method. Generally speaking, the good results have been obtained in cases of pure anemia ; when the anemia has depended in part on hemorrhage, in part on septic infection, the procedure has not been satisfactory. Again, it has been more frequently successful as a measure in primary than in secondary hemorrhages. Military conditions have allowed small opportunity for pre- liminary hemolytic tests applied to either donor or recipient, but, when practicable, a small preliminary transfusion of 10 c.c. of the donor's blood has been made the day previous to the main procedure; accidents due to hemolytic reaction have not, how- ever been common. In a few cases alarming symptoms have passed off with no further result when the transfusion was dis- continued, and two patients have probably died as a direct result of the treatment. Ill effects have not been sufficiently numerous, however, to raise the question of justifiability in the desperate cases for which the procedure is undertaken. Tetanus. — Tetanus, the terrible scourge which gave rise to so great anxiety in the autumn and early winter of 1914, has become a comparatively infrequent wound complication since the adop- tion of prophylactic injections of antitoxin in all cases of wounds and in cases of "trench foot" accompanied by vesication. Never- theless cases still occur, in some instances because the primary injection has been given late as a result of the patients' not being able to be "collected" from the zone of fire, a few men escape treatment as a consequence of the number of wounded needing to be dealt with after a serious engagement, and special idiosyn- crasy may account for others. At an early date it was also recog- nized that the protective influence of the antitoxin is often exhausted at the end of eight or ten days ; hence a general order was given to the effect that the injections should be repeated at intervals of seven days in all cases of serious wound and to patients whose wounds were not progressing well. The cases met with include every degree and variety of the ABSTRACTS OF WAR SURGERY 57 disease. Thus, very acute cases with general spasms, slight cases in which trismus is the main feature, cases of "head tetanus" either of the paralytic class or with clonic spasms of the muscles of mastication, splanchnic tetanus, local tetanus of the limbs, sometimes remaining confined to the wounded member, in others becoming general, and cases of the so-called delayed class. In one remarkable instance of the last variety the patient, who had been sent to England in August with a small wound of the but- tock, at the bottom of which was a small retained foreign body, returned to duty two months later. When on duty in the trenches stiffness of the corresponding limb, at first ascribed to sciatica, developed, and later general tetanic symptoms. Active treatment with antitoxin was followed by an uninterrupted recovery. Accumulated experience has negatived the utility of treatment with carbolic acid or magnesium sulphate, both of which remedies were vaunted in the early stages of the campaign. Curative treatment by antitoxin is still upon its trial, and considerable difference of opinion exists both as to its utility and as to which route should be chosen for its exhibition. The subcutaneous route is generally considered unsatisfactory on account of the delay in conveyance of the antitoxin to the required area ; hence, although generally chosen for prophylactic purposes, its use as a method of curative treatment is restricted to an auxiliary role. The intramuscular route has found more favor, although its efficacy is doubted by many. The intravenous route has not been shown to be specially efficacious, and as accidents of an anaphy- lactic character have followed its use it has been practically abandoned. The general applicability of the intrathecal route is still under discussion; the chief objection to its use lies in the large quantity of serum which requires to be introduced and the comparatively serious nature of the procedure itself if repeated injections are made. In some cases a definite disturbance of the intracranial pressure appears to result, and in some local inflam- matory changes in the spinal theca have occurred. In spite of these objections the intrathecal method has been very largely employed, and a trial is now being made of a highly concentrated antitoxin. The prognosis has depended in individual cases on the length of the incubation period, and, in spite of treatment, the mortality has remained above 70 per cent of all cases treated. Symptomatic treatment by chloral and morphine, particularly the former, has retained its character both in the relief of suffering and as cura- 58 ABSTRACTS OF WAR SURGERY tive, in so far as it tends to delay exhaustion dependent on the spasms. Other Wound Infections. — Little new can be said regarding the remaining forms of wound infection, but it may be generally stated that the antiseptic solutions depending upon chlorine for their active element have proved the most successful application. One form of streptococcus infection deserves special mention as possibly corresponding to the variety of "classical hospital gan- grene" described as the membranous. Cases of this nature have not been common, although sufficiently so to have become familiar. A wound which has previously been apparently pro- gressing favorably becomes covered with a dense grey tough membrane, firmly adherent to the subjacent granulations. In the earliest stage this membrane does not materially differ from the thin layer of coagulated fibrin and included leucocytes which not uncommonly forms in cases of streptococcic infection which after a time fail to respond to treatment. The same cessation of free discharge from the wound surface is observed, a condi- tion well described by Colonel Almroth Wright, as ''lymph bound." The membrane then thickens so as to resemble one of the diphtheritic class; in fact strong suspicion was aroused in the earlier stages of the war that the change was due to a diphtheritic infection. Bacteriological examination has, how- ever, in all cases resulted in the discovery of streptococci alone. With the development of the membrane a continuously increas- ing hard white edema spreads up the limb or on to the trunk, the patient meanwhile suffering with pronounced signs of toxemia. Incisions into the edematous area give rise only to the escape of a small amount of serous discharge, and the tension wounds tend to dry up with little change. Amputation is usually followed by a recurrence of the same type of wound surface, and the patient dies in from four days to a week's time after the commence- ment of the process. No successful method of dealing with this special form of wound infection has been devised. Septicemia. — The most common form has been in connection with streptococcal infections. It can not be said that any ad- vance has been made in the treatment of this condition. A more or less extended trial has been made of intravenous injections of hypochlorous acid in the form of eusol, but no satisfactory results have been obtained. The same remark obtains to a more limited trial with colloid chloride of gold. The work of Dakin has shown that the antiseptic power of injections of eusol must be small in consequence of the minute amount of the antiseptic ABSTRACTS OF WAR SURGERY 59 in proportion to the volume of the patient's blood. If either this solution or that of chloride of gold can effect any useful purpose, it is probably only by exciting as irritants a certain degree of activity in the endothelial lining of the blood vessels, and in neither case has this proved sufficient to serve the pur- pose aimed at of sterilizing the blood. Injuries to the Great Vessels. — The dangerous nature of in- juries to the great vascular trunks has been amply demonstrated by the fact that, except one or two injuries to the innominate vessels, the subclavian artery in the thoracic part of its course, and possibly a few to the iliac, injuries to the vessels of the trunk have been conspicuous by their absence on the lines of com- munication. A considerable experience has been gained regarding the ef- fects of contusion of the vessels, which has in the main sub- stantiated the French pre-war experimental observations. At the same time, the occurrence of single simple linear fissures of the intima has been a more common form of lesion than one would have been led to expect. The chief importance of these lesions has been in connection with secondary hemorrhage, and in the frequency with which the injury is followed by throm- bosis. Several instances of subsequent embolism has been ob- served, this particularly in the case of the cervical vessels, where cerebral embolisms are readily detected as a consequence of the obvious signs with which blockage of the cerebral vessels is attended. This experience, combined with that of similar acci- dents occurring in connection with actual wounds of the vessels, raises the question of how great a proportion of the instances of gangrene of the extremities following injuries to the vessels of the limbs, either spontaneous or following ligature, is due solely to the local occlusion of the main vessels. It seems likely, if all these cases could be thoroughly investigated, that em- bolism in the distal circulation plays a more important part than has hitherto been accorded to it. The frequency with which various forms of missile have been employed has been followed by considerable change in the na- ture of the lesions, the highly contused lateral wound of the artery, and the clean perforation made by the modern bullet, have of late been less in evidence than extensive lateral lacera- tions and more or less limited lateral perforations caused by fragments of shells or minute fragments derived from bombs. Occlusion of wounds of the vessels by retained shell fragments, the removal of which has been followed by free hemorrhage, 60 ABSTRACTS OF WAR SURGERY has not been rare. On the other hand, instances of missiles en- tering and traveling along the blood vessels have rarely been observed. The most striking instances have been those in which shrapnel balls have obtained entrance to the heart or large veins of the trunk and travelled downwards by gravitation. The most interesting feature of these cases, observed also in some wounds of the inferior vena cava, is the moderate degree of primary hemorrhage which had taken place. Wounds of the great vessels arrive in the hospitals on the lines of communication usually some days after their infliction, but a considerable proportion may arrive at an earlier date in consequence of the absence of primary hemorrhage, or the co- existence of some more serious or more easily recognized injury having allowed them to be overlooked. This is especially the case in multiple bomb or shell injuries, where one out of twenty small wounds produced by as many fragments widely distributed over the whole body may have implicated an artery; or in the case of severe fractures of the long bones, accompanied by great swelling of the soft parts. The result of this experience has been greatly to widen the scope of the stethoscope in the diagnosis of arterial injuries, since auscultation will often reveal the presence of the pathognomonic systolic bruit, when the absence of local pulsation in the swollen area and the presence of pulsation in the distal arterial circula- tion may, if depended upon alone, lead to a serious error in diagnosis. Further, it has been observed that the local vascular bruits may, in some third of the whole number of injuries to ar- teries of the lower extremity, and less frequently in other ves- sels, be conveyed to the cardiac area, and distant vascular lesions have in some cases been detected by the presence of the appar- ently cardiac murmur. This phenomenon is observed both in pure arterial and arteriovenous injuries. It has also been ob- served that the distal blood pressure of the limb is materially lowered in the presence of a lateral arterial lesion — in fact, prac- tically to the same degree as if the main vessel has been occluded. As a consequence of the period at which arterial injuries reach the hospitals on the lines of communication the treatment has been for the most part expectant, the large majority of the pa- tients being evacuated to the base in England. The importance of rest in allowing subsidence of the general circulatory excite- ment, and the consolidation of the aneurysmal tumor, has been obvious. It is also held that during this period, the enlargement of the collateral circulation makes some progress. Some evidence ABSTRACTS OF WAR SURGERY 61 in favor of this view is offered by the fact that the nutrition of the limb is not observed to suffer during this period, while wast- ing, sometimes of a rapid character, often follows the perform- ance of necessary ligation. Accidents during this probationary period have not been com- mon ; gangrene has been rare ; secondary hemorrhage uncommon, unless the wounds were large and badly infected ; and suppura- tion of the aneurysm has been an accident of extreme infrequency. Active treatment has consisted, in the main, of ligature of the vessels. This has been indicated by extension of the blood effusion in the limb, secondary hemorrhage, signs of pressure on the trunk by increasing size and firmness of the false aneurysmal sac, or signs of inflammation. When the hospital accommodation has allowed a sufficiently long stay a certain number of cases have been operated upon in the absence of any untoward symptoms. For purely arterial injuries, ligature of the vessel above and below the wounded spot has been the most common operation. In a number of these cases the main vein has been found to be thrombosed, but this accident has not had any adverse influence on the result. The same statement may be made as to the results observed when coexisting wound of the vein has made it obliga- tory to tie both vein and artery, or in the cases where the main vein had already suffered complete division and occlusion. The same experience has followed ligature of both artery and vein above and below the communicating channel in arteriovenous aneurysms or aneurysmal varices. Hence it has been claimed that simultaneous occlusion of both artery and vein is a neg- ligible occurrence with regard to any increase of risk to the vitality of the limb. Further, that insomuch as a better balance is maintained between the arterial and venous elements of the collateral circulation, and the blood pressure within the limb increased, the operation is preferable to that confined to the wounded artery alone. In certain vessels — for example, common carotid, common femoral, popliteal — after ligature of which acute local anemia and gangrene is specially liable to follow, a limited trial has been made of Tufner's tubes to maintain temporarily the main cur- rent pending the increase of the collateral circulation. In a small series of eight cases (common carotid 1, axillary 1, femoral 2, popliteal 4) in which this method was used, in no instance did gangrene take place. In one femoral case, in which the tibial pulses were absent at the time of operation, feeble pulsation re- turned and persisted for a few hours, and in the second the foot, 62 ABSTRACTS OF WAR SURGERY which had been cold, at once became warmer and remained so. Such evidence as has been obtained, however, does not suggest that the maintenance of the main current persisted more than a few hours, and the clots expressed from the tubes when removed on the fourth day, although firm in comparison with the terminal projecting into the proximal end of the vessel, did not suggest a very gradual formation. Moreover, in one of the popliteal cases, in which it would have been difficult to place a ligature on the lower end of the artery, it was not found necessary to do so, as the vessel was closed by a firm thrombus. Such experience as has been gained is, however, definitely in favor of a more ex- tended trial of this method. Suture of the vessels, either end-to-end or lateral, has been employed only in few cases. At the period during which the patients are still in the hospitals on the lines of communication the vessels are still comparatively fixed and difficult to free with- out damage to the coats, as well as rigid in themselves; hence, if sutures are introduced, the tension upon them is far greater than is the case with normal arteries. Again, a large proportion of the wounds are too extensive for anything but an end-to-end union after removal of the damaged extremities of the vessel, and here again both local tension and an undesirable temporary flexion of the limb to reduce it are opposed to successful suture. Cases, however, do occur in which either form of operation can be carried out. In a small series of six operations the following immediate results were obtained: Brachial 3: (a) Lateral suture, lumen of vessel reduced more than one-third; no radial pulse before operation, but it returned four days after, (b) Refresh- ment of ends and end-to-end suture. Radial pulse palpable after operation and persisted. At the end of the third week the distal blood pressure in the limb had risen by 22 mm. of mercury, (c) Excision and end-to-end suture. Radial pulse absent during first two days after operation, then returned. Five days after the operation the distal blood pressure was 30 mm. of mercury greater than before. Popliteal 1: Lateral suture. A good anterior tibial pulse was present the day after operation, but the posterior tibial was absent. Femoral 2: (a) Lateral suture of an arteriovenous communication of six months ' standing. Distal tibial pulses pres- ent at the end of the operation and persisted, (b) Lateral suture in Hunter's canal. Tibial pulses absent before operation, but were just palpable four days later. Distal blood pressure still 50 mm. of mercury lower than in other limb. Time and a considerably more extended observation is needed Abstracts of war surgery 63 to determine whether the operation of suture does attain very much better results than simple ligature. The above results, in- cluding no sort of accident, seem to do little more than prove that the operation is practicable and not dangerous in selected cases. That a patent lumen is preserved in the vessels in the majority of cases is, however, not yet proved. Fractures. — At an early stage in the campaign, when wounded men were streaming in large numbers into the improvised hos- pitals in Boulogne, it became evident that neither the regulation outfit of splints nor the supply of emergency splints manufac- tured by the mechanics attached to each hospital unit sufficed to cope with the large number of fractures admitted. An oppor- tune paper by Lieutenant-Colonel Robert Jones which appeared about this moment moreover impressed all those concerned in the treatment of these injuries with the enormous advantages offered by splints of the H. 0. Thomas class for military use, both in facilitating the early and safe transport of patients, and in allowing efficient extension of the limbs to be continuously maintained. Further a number of modifications of the type of splints which have subsequently proved of much value were quickly in demand. In order to meet the requirements thus sud- denly arising, application was made to the Medical Director- General at the War Office for the supply of a skilled surgical mechanician to undertake the control of a central splint manufac- tory at Boulogne. Mr. Salmon was sent out, and since that time an enormous number of splints have been manufactured locally and supplied not only to the general hospitals on the lines of communication, but also to advanced units throughout the army. It would be difficult to overestimate the practical value of this establishment. The first question which has arisen in connection with these injuries is the relative importance of the primary treatment of the wound of the soft parts, or the adjustment of the bony frag- ments themselves. Cases may occur in which either assumes the first place — thus the limb may be threatened by anaerobic infection ; reduction of the displacement and maintenance of the bone in position may prove a matter of extreme difficulty as a result of the position and direction of the fracture; or the pres- ence of multiple wounds in inconvenient positions may render it impossible to apply such apparatus as will maintain sufficient extension. Under any of these circumstances treatment of the wounded soft parts may claim priority, but as a general rule the principle of prompt reduction of the displacement and main- 64 ABSTRACTS OF WAR SURGERY tenance of extension has been adhered to. It has been recognized that secondary efforts at reduction when a septic wound has cleaned and settled down is a serious operation involving risks of lighting up again a condition which has been with difficulty overcome. The next question which arises is whether rigid extension in the direct long axis of the limb is to be maintained or the joints placed in the flexed position. For patients treated in France the former method has been the more widely adopted, in order to utilize the facilities in transport which the Thomas splints un- doubtedly offer. As an invariable custom, however, this practice has not been able to be followed, as many surgeons have not been able to obtain good position of the fragments in such posi- tions as the upper and lower thirds of the femur. To meet this difficulty the Thomas splints have been bent or other methods employed. For instance, Hodgen's splint for the upper third of the thigh bone, or a swinging frame of the same dimensions of the bed, the feet being fixed by plaster extension strips to the angles of the lower end, and the head and body lowered. For the lower third the wire double-inclined plane of Hey Groves has occasionally been employed. All these methods, however, require additional attention and longer stay in France, hence they have not been widely resorted to. The method of maintaining extension has also been a ques- tion much discussed, and fixed extension by a stirrup attached to the end of the Thomas splints has been commonly adopted. Yet in a large number of cases weight and pulley extension has been preferred and is sometimes necessary. The question, in fact, has not been settled in favor of either of v the opposing parties. A third method, that of a continuous screw, has also been considerably employed, both in conjunction with the type of Thomas splint with a spat attachment, in the Wallace-Maybury modification of the Thomas, and also in the bent Thomas splints and their modifications for treating fractures of the humerus with the elbow flexed. The use of the pin transfixing either the lower end of the femur, or the upper extremity of the tibia, for the attachment of extension apparatus in cases of fracture of the femur, has found little favor in France. This has perhaps mainly depended ' on unwillingness to make a fresh wound in a limb already the seat of a septic wound ; but beyond this, the fact that practically all patients need to be transported at an earlier date than would ABSTRACTS OP WAR SURGERY B5 be convenient for removal of the pin renders the method unde- sirable. One great feature in the wards, and an incalculable blessing to the patients and attendants, has been the wide adoption of the overhead rail for the suspension of limbs, and to take the place also of the pulley arranged over the head of the patient's bed in most hospitals to allow him to lift himself by his arms. This was devised at an early date in Boulogne as a result of seeing patients with fractured thigh put up by the so-called Balkan method by Lieutenant-Colonel Miles. It has consequently acquired the name of the Balkan support. Two of them, one placed on either side of the bed, may also be employed for the support of an entire hammock bed. For fixation of the thigh in the abducted position, the abduc- tion frame of Kobert Jones was ready to hand, but in the case of the upper extremity much difficulty was experienced in the earlier part of the campaign until the capability of a short Thomas knee splint for this purpose was fully appreciated. A great amount of ingenuity has been expended on splints devised to facilitate transport or to meet special emergencies, also on various adjuncts to the splints themselves. Thus many varieties of rubber, metal, or flannel slings to support tne limbs in wire splints, extension attachments, forms of glue for fixing extension strips to the limbs, and lastly, the highly efficient coun- terpoise suspension apparatuses of Major Sinclair. Plaster of Paris has on the whole been but little used, and mostly for the purposes of transport. The difficulty of keeping plaster splints clean has mainly militated against them. Lastly, as to the treatment of the wounds. In this place it is assumed that proper cleansing, drainage, and removal of loose fragment and foreign bodies has been carried out at the casualty clearing stations. Under these circumstances no further imme- diate procedures are needed on the lines of communication. Even in the case of inefficient drainage or extending infection great judgment must be exercised in interference on the first arrival of the patient. The object to be aimed at is the secondary closure of the wound at the earliest date practicable, and with this object a continuous antiseptic method should be carried on. Up to the present time the most conspicuous success in this direction has been attained with the Carrel-Dakin method, and if treatment has been com- menced at the casualty clearing station, the wound may in a 66 ABSTRACTS OF WAR SURGERY considerable proportion of all cases be closed within a period of three weeks. The date at which sequestra should be removed to allow a com- plete surgical sterilization of the wound has raised some discus- sion. When the fracture has not been accompanied by sufficient loss of bone for risk of nonunion to occur, there can be no doubt that the earliest possible date is desirable. If, on the other hand, little but the periosteum and a few fragments remain, the prob- ability of securing a sufficiently active osteogenesis to effect union is no doubt increased by leaving apparently dead fragments of bone in connection with the periosteum for some time, because a few bone cells may have escaped to help in repair which will probably perish if exposed in a suppurating wound. In suppurating fractures of some standing Rutherford Mori- son's method of secondary closure after introduction of the iodoform, bismuth, and paraffin compound has been imported from England, and is giving good results. Radical treatment for the condition of chronic osteomyelitis has not often been undertaken, unless the cases are of such a character as to be subjected to amputation; the majority are transferred to England, where prolonged stay in hospital is more readily assured. Lastly, methods of mechanical fixation by plates and screws or by wiring have been very little resorted to as primary meas- ures. A very large proportion of the cases so treated failed from the septic character of the wound, but in the face of the results more recently obtained by secondary sterilization and closure of the wound it is probable that these methods may be revived in cases of difficulty of maintaining the fragments in position, or at any rate resorted to at a much earlier date under more favorable conditions. Both in Boulogne and elsewhere special departments have been established for the treatment of fractures alone, and in the hos- pitals generally an attempt has been made to collect the patients with fractures under the charge of one medical officer. This plan has obvious advantages in ensuring special aptitude on the part of the surgeons concerned and the possibility of attain- ing general results approaching the ideal. At the same time, its general adoption is impracticable; the cases are of a nature to necessitate a long stay in hospital, their collection in one ward imposes a very heavy task on the nursing staff, which needs to be largely increased, and, finally it not only removes a source of great interest from the general surgeon, but it also renders ABSTRACTS OF WAR SURGERY 67 him less fit to treat such cases when heavy fighting produces them in such great numbers as to render segregation impossible. Wounds of the Joints. — The experience gained in recent previ- ous wars regarding the treatment of wounds of the joints has proved of small avail in the present campaign, because it was obtained almost entirely from observation of the lesions pro- duced by rifle bullets, which had proved themselves of minor gravity and capable of healing spontaneously with good results when subjected to simple treatment founded on the sovereign principle of rest. The problem of dealing with grossly infected joints, often enclosing a septic irregular fragment of shell and dirty clothing, perhaps further complicated by extensive fractures of the can- cellous articular extremities of the bones, was therefore prac- tically a new one to the surgeons engaged. Some definite facts have emerged from the first flood of difficulties encountered, and these may be shortly summarized as follows : 1. The wound of the soft parts clothing the joints is vastly more difficult to deal with than the articular cavity itself, and demands the most scrupulous care on the part of the surgeon. 2. The synovial capsule itself is capable of dealing unaided with an infection often of a really serious grade. 3. A strong tendency exists for an infection to localize itself, and the remaining portion of the capsule may remain free. 4. Drainage in the sense of the insertion of large tubes left in position for days or more is not only useless but also harmful. 5. That a gunshot wound of a joint can not be dealt with too early, and with proper treatment forms one of the best subject wounds for primary suture. 6. That following the primary surgical intervention the main principle to be observed is that of complete rest gained by im- mobilization and extension. General appreciation of these facts has resulted in the con- clusion that a large majority of the joint injuries should be subjected to their chief active surgical procedure in the hospitals of the advanced lines, and hence the general hospitals at the present time receive only cases well upon the road to recovery, or such as present the more difficult problem of dealing with estab- lished infection and suppuration. The line of treatment which has been adopted in the former class of case has been already laid down elsewhere (June 2nd, p. 718) ; it only remains to add that even cases which eventually do excellently often arrive on the lines of communication with 68 ABSTRACTS OF WAR SURGERY synovial effusion and local redness over the joint and in the neighborhood of the closed wound, signs due entirely to an ex- acerbation consequent on the disturbance inseparable from trans- port down the lines. Such cases usually settle down rapidly if only strict care be taken to maintain complete immobilization, while any premature intervention may be the direct cause of disaster. The class of case may be first dealt with in which a patient arrives with a foreign body still occupying the joint cavity. This may be the result of the impracticability of early x-ray examina- tion, the nature of or the small size of the foreign body, or of a large number of patients having to be rapidly dealt with. If the foreign body be a rifle bullet, and the condition of the external wound satisfactory, no immediate action beyond fixation of the joint is advisable at this period. It is far safer to leave the bullet in situ until all chances of awakening or spreading an infection have passed by. The same attitude of masterly inactivity is to be recommended in instances in which the included foreign body consists of very small fragments of shells or bombs, especially if the bodies lie without the actual confines of the articulating surfaces. Such foreign bodies may never need re- moval. Thirdly, when fragments of shell are of larger size and need removal they may be found to have rebounded from the surface of the bone and actually lie without the confines of the joint cavity, although the capsule has been wounded. Special care needs to be exercised in dealing with these cases, since por- tions of clothing carried before them by the shell fragments may still occupy the joint cavity. Lastly the foreign body may be impacted more or less deeply in the articular end of the bone, and if a shell fragment, it should be removed, although in a pa- tient who has recently undergone transport undue haste in the procedure is not advisable. Wounded joints which arrive with obvious local and general inflammatory signs need to be treated with great judgment. The condition may have been aggravated by transport and may rapidly improve when complete rest is assured. Again, the seri- ous infection may be situated in the periarticular structures rather than in the joint itself. Precipitate action under these circum- stances is to be deprecated. The safer plan is to place the limb at rest for twenty-four hours or longer, and observe the result, meanwhile making a puncture and withdrawing fluid, if present, for bacteriological examination. If want of improvement or the result of the bacteriological examination indicate the advisability ABSTRACTS OF WAK SURGERY 69 of intervention, the type of operation should be of the nature advocated by Colonel Gray — excision of the wound or wounds in the joint coverings, flushing of the synovial cavity after evac- uation of its contents, and suture of the synovial membrane. The treatment of the external wound differs according to its size and condition. In some instances it may be closed completely, in others a drainage tube may be inserted down to the sutured cap- sule, or, where the wound is extensive or obviously not free from infection, it is better to leave it freely open and treat it by anti- septic measures until surgically sterile and suitable for secondary suture. Naturally some of the more extensive wounds must be left to heal by granulation. The treatment of a freely suppurating joint requires to be of a different character; here the joint cavity must be maintained open and sterilization effected by an antiseptic method, of which Carrel's has undoubtedly given the best results. When, for instance, the cavity of the knee-joint in general needs to be drained, the method carried out by Captain Campbell and ad- vocated by Captain Gill is worthy of special mention. It is generally agreed by all observers that when suppuration ex- tends backwards from the knee the line of progress is not from the pouches lying on either side of the crucial ligaments but around the lateral aspects of the condyles — in point of fact, by the popliteus, extension of the capsule on the outer side and the semimembranosus extension on the inner. Hence posterior drain- age from the center of the joint is not only inconvenient to arrange but also inadequate to meet the requirements. Posterolateral incisions have therefore been devised, but Campbell and Gill have regularized a method which simplifies greatly the accurate and adequate drainage of these regions. Lateral incisions having been made corresponding in position with the reflection of the synovial membrane from the femur, a pair of artery forceps is pushed down on the outer and inner aspects of the lower end of the femur respectively until the points of the forceps can be palpated in the popliteal space. An incision is then made down on the guide thus furnished, and a direct route is established to the bursal extensions from the posterior aspect of the joint, and by this Carrel's tubes are conducted for the requisite depth. Should still freer drainage be required, the incision is enlarged, the respective heads of the gastrocnemius exposed, and a por- tion of the origins of the muscle excised, so that a free opening is insured. Further mention of the treatment of the extensions by the subcrural pouch, the internal intermuscular septum, be- 70 ABSTRACTS OF WAR SURGERY neath the popliteus or along the semimembranosus tendon is un- necessary. The upper pouch of the joint may need several in- stillation tubes, which are gradually decreased in number and totally removed at as early a date as possible. For suppurating joints of some standing Rutherford Morison's method has been adopted with success. The influence of a coexisting fracture on the prognosis in a joint injury is a matter of great moment in any class of case, but the frequency with which this condition is met with in gunshot wounds invests it with a very special degree of importance. There is little doubt that the actual risks to the safety of the limb attached to this complication were somewhat overestimated at the commencement of the war, and that today, in the presence of a more satisfactory and rational treatment of the wound, and also the knowledge acquired as to the possibility of saving the joint entire, or subjecting it to either primary, intermediate, or secondary excision, the prospects of avoiding amputation are much improved. It may be laid down generally that tunnels, cavities contain- ing missiles, fissures, and even T-fractures, do not of necessity entail a very serious prognostic gravity provided the wound in the soft parts can be and is satisfactorily dealt with, and the fragment of shell removed. In a large proportion of such injuries a more or less movable joint can be attained, and in many a perfect result. Still, in no form of injury does this more depend upon the continuous attention of the surgeon, care in the initial treatment of the joint, and subsequent daily precaution. Injuries affecting both bony elements are more serious, but may be treated by excision. Severely comminuted articular ends commonly need amputation, except where the single articular end can be removed, as in the case of the upper ends of the humerus and femur, or where bones, such as the carpal and tarsal, can be completely removed. The position today may be fairly summed up by the remark that, putting on one side articular injuries in which the bony de- struction is irreparable, the fate of the case depends upon the success with which the wound of the soft parts surrounding the articulation is treated, the actual joint lesion taking a place of secondary importance. Excision of Joints for Gunshot Injury. — The operation of ex- cision is certainly struggling for a return to its former position as a procedure in military surgery. The operations were no doubt in older wars often performed for what would now be ABSTRACTS OF WAR SURGERY 71 considered injuries not sufficiently extensive to demand so radical a procedure ; further wound treatment was often defective. Yet excision occupied a prominent place until, with the introduction of the bullet of small caliber and oval or dome-shaped tip, in- juries of the joints began to be regarded as of minor importance. Early Excision. — By this is meant immediate operation at the casualty clearing station. It is obvious that a certain number of joints may be excised as an alternative to amputation. Thus a severe localized comminution of the lower end of the femur or the upper end of the tibia may render any chance of recovery with a useful limb improbable, while the uninjured shaft may still be of sufficient length to allow of ultimate union. The same remark may apply when both articular surfaces have been de- stroyed by a traversing missile. In the case of the upper end of the humerus, and also of the femur, comminuted fractures with destruction of the articular surface also form good subjects for the operation. In the case of the elbow a partial excision may often be done. The possibility of these procedures is limited, however, by the definite condition that circumstances will allow the patient to remain a sufficiently long time to be able to bear safely the risk of transport down the lines of communication to the general hospital. Intermediate Excision. — Concerning this operation the gravest doubts were felt in the earlier stages of the war, and even now it can be undertaken only with the definite intention of following it at once by an amputation if the procedure is followed by local extension of infection and signs of systemic absorption. It has, however, proved that excision may be a successful alterna- tive when the severity of the general and local signs seems to indicate amputation as the only resource. The explanation of this experience can be found solely in the facts that better drain- age can be insured when the articular ends of the bones have been removed, and the wound can be treated more effectively. It is a striking fact that progressive osteomyelitis from the sawn ends of the bone has not developed, especially when the fre- quency of this complication in ill-drained comminuted fractures is remembered. Two special details need mention: (1) Should the synovial membrane be removed? As a general rule this ques- tion is to be answered in the negative. The synovial surface in itself is better capable of dealing with an infection than a freshly cut layer of subsynovial areolar tissue; further, when no ex- tensions of suppuration have taken place, it forms an effective barrier against such extensions when proper drainage is pro- 72 ABSTRACTS OF WAR SURGERY vided. (2) Should the refreshed ends of the bones be placed in apposition, or be temporarily kept widely separated by exten- sion? The latter plan has been most generally adopted. The excision of bone should be of the most limited extent in the case of the knee. Lastly, in this joint as in all others, excision is not to be regarded as a proper alternative where efficient drainage can be expected to insure the end desired. Late Excision. — The principles guiding the performance of ex- cision at a later date do not materially differ from those laid down above; moreover, as far as the hospitals on the lines of communication are concerned, the distinction is rather one of date than of actual pathological conditions to be dealt with. The Results Obtained in Wounds of the Knee-Joint. — In HO consecutive cases of knee-joint injury coming from the fighting on the Somme, 14 were classified as very severe, 17 as severe, 13 as slight, and 16 as having retained foreign bodies. Three died and one required amputation. The three deaths were due in two cases to secondary hemorrhage and in one to septicemia. The other 56 cases were transferred to England in good condition, the great majority with every prospect of good movable joints. In a second series of 69 cases, in 31 the injury was inflicted by a bullet, and in all an uninterrupted recovery was obtained by rest alone. Amongst the remaining 38 cases one died as a result of menin- gitis following a fracture of the skull, and in four cases, one of which developed delayed tetanus and recovered, amputation was required. Thus in 129 cases amputation was required in 3.87 per cent, and death occurred in 3.1 per cent. Injuries to the Head. — A great change has taken place since the commencement of the war both in the nature of the cases and in their actual number. This change depends on the one hand on the fact that a larger number of these injuries are re- tained and operated upon at the front lines, and on the other on the protection afforded to the head by the helmet. The early treatment of these injuries has already been dealt with ; it suffices here to say that the patients who now arrive have either already been operated upon and are in good condition, or they come down already suffering from septic complications. The general lines governing the treatment of the latter class of case have been admirably laid down in a paper by Sargent and Holmes in the British Journal of Surgery, and certain points in the technic of the operative procedure elaborated. These authors have also dealt ABSTRACTS OF WAR SURGERY 13 with the anatomical and histological changes associated with trau- matic injuries and infected wounds of the brain and their bearing on the surgical treatment of these conditions. Further, exam- ination of a considerable number of patients some months after their return to England proved much more satisfactory than had been generally expected. It was found that the proportion of patients who die after transference to England is small; later complications, such as cerebral abscess, are comparatively rare, and serious sequelae, such as insanity and epilepsy, are much less common than had been foretold. In only 15 per cent of the patients examined, however, had more than one year elapsed from the date of the injury. It also appeared that many patients with foreign bodies deeply lodged in the brain recover, and are scarcely more liable to serious complications than men in whom the brain has been merely exposed and lacerated. These conclusions are obviously only tentative, but as far as they go, appear to be hopeful. Holmes and Sargent have also described a condition hitherto rarely seen, and established a definite symptom-syndrome for its recognition. It is characterized by an immediate spastic paralysis of the legs and frequently associated with static paresis of the proximal segments of the upper limbs ; they have shown it to be due to occlusion of the superior longitudinal sinus of the veins that enter it, by a depressed fracture of the vertex of the skull. Experience showed the results of surgical interference with cases of this class to have been extremely unsatisfactory. Thus, among 39 cases observed which were operated upon either by the authors or others, 15 deaths occurred, while among 37 cases, in which no operation was undertaken only one died before transference to England. While it is allowed that these figures have no absolute value, as naturally only the most serious cases were selected for operation, and in seven of the fatal cases direct injury to the brain was present in addition, yet the results empha- sized the danger of operation. Moreover, the uncomplicated cases showed a remarkable tendency to improve, probably owing to the free venous anastomosis permitting a reestablishment of the cir- culation. An important contribution to the localization of function in the brain has been published by Lister and Holmes, who from a study of a large number of cases with injury in the occipital region were able to determine the relative positions in the cor- tical visual areas of the foci that subserve vision of separate portions of the visual fields. They bring forward strong evidence 74 ABSTRACTS OF WAR SURGERY with regard to the site for the center for macular or direct central vision of which very little had been previously known. The following conclusions are come to : 1. The upper half of each retina is represented in the dorsal, and the lower in the ventral, part of each visual area. 2. The center for macular or central vision lies in the posterior extremities of the visual areas, probably on the margins and the lateral surfaces of the occipital poles. 3. That portion of each upper quadrant of the retina in the immediate neighborhood of, and including the adjacent part of, the fovea centralis is represented in the upper and posterior part of the visual area in the hemisphere of the same side, and vice versa. 4. The center for vision subserved by the periphery of the retinae is probably situated in the anterior end of the visual area, and the serial concentric zones of the retina from the macula to the periphery are probably represented in this order from behind forwards in the visual area. Holmes and Smith have recorded observations on the nature and localization of motor apraxia, or the inability to perform purposeful actions despite the preservation of movement and power, and in disturbance of the faculty of localizing objects in the external world by vision. Probably in no other branch of medicine have so many and such difficult problems arisen as in the treatment of wounds and diseases of the nervous system. Further, in this field an extraor- dinary opportunity has occurred to observe, analyze, and record the effects of local lesions, many of which are rarely, if ever, seen in civil life. When the results of this work are eventually corre- lated, they must throw much light on the physiology and the symptoms of disturbance of different parts of the brain, spinal cord, and peripheral nerves, and thus increase our knowledge of the diagnosis and treatment of nervous diseases. Special arrange- ments have been made in order that cases under early observation in France should be sent to special hospitals in England, so that continuous records will be maintained of a very large number of patients. Colonel Percy Sargent adds a note to the effect that the very large experience gained of gunshot wounds of the head has led to a considerable degree of modification in their treatment. Im- mediate routine operation, often incomplete and, in the absence of full neurological information and x-ray examination, sometimes ABSTRACTS OF WAR SURGERY 75 unnecessary and even misdirected, is no longer widely practiced. It has long since been made abundantly clear that early evacuation of operated cases is often followed by disaster. As it is impossible to operate upon these cases and to retain them at the clearing •stations for a period which renders transportation safe, more especially during times of great military activity. The practice now generally adopted is to transfer them without operation as soon as possible to hospitals further down the line. It has been made quite clear that surgical intervention is rarely required for relief of cerebral symptoms, whether general or local. Its chief aim is the prevention of intradural infection. On this conception all cases of gunshot wounds of the head fall into one or two categories, according to whether the dura mater has or has not been penetrated. Nonpenetrating wounds have a low rate of mor- tality, whether operated upon or not, provided that the surgeon respects the integrity of the dura mater. It is customary, therefore, to do in these cases only as much as may seem advisable to ensure speedy healing, such as excision of the edges of the wound, removal where necessary of bony frag- ments, and partial or complete closure of the gap in the scalp either by suture or by some form of plastic operation. Penetrating wounds, on the other hand, afford more room for difference of opinion regarding their treatment. Individual cases continue to present difficulties even to those who have seen large numbers, but, broadly speaking, there is a consensus of opinion in favor of the following line of treatment : The wounds having been cleansed and dressed, the patient is transferred as soon as possible to a hospital where he can be retained for at least a fort- night after the operation. A complete neurological and radio- graphic examination is made and the operative treatment then directed according to the diagnosis thus arrived at. In some cases of penetrating wounds no operation is indicated, such as those in which a bullet has passed completely through the head ; or those in which a bullet or a metallic fragment is embedded in the brain at a distance from a small clean entrance wound, and is giving rise to no symptoms. Another class of case for which operative interference is usually contraindicated is that in which the longi- tudinal sinus has been injured. Cases where a track from the scalp wound leads down to indriven bony fragments, or to an easily accessible missile, are operated upon, briefly, as follows: A moderately large flap is turned down after resection of all damaged tissue round the scalp wound; the bony opening is enlarged sufficiently to expose thoroughly the opening in the dura 76 ABSTRACTS OF WAR SURGERY mater ; the indriven fragments of bone and metal are removed under a constant stream of hot physiological saline solution ; and the track is drained by a celluloid, metal, or rubber tube brought out through the original wound. In cases of more superficial cerebral laceration, where track drainage is unneces- sary, the principle is employed of covering the denuded brain by some plastic operation on the scalp ; in these circumstances drain- age tubes emerging from the angles of the scalp flap are usually employed for a few days. Retained Missiles. — Opinions still vary regarding the advisa- bility of operating for the removal of bullets or shell fragments. There is much evidence to show that these foreign bodies are well retained, and, apart from the uncommon accident of late sup- puration, cause no symptoms. Removal of bullets, even when the wounds have healed and the risk of septic infection thereby is largely minimized, must be, even in skilled hands, attended by an amount of damage which in most cases would have more serious neurological consequences than could the presence of an aseptic bullet. Primary removal of a deeply-seated missile car- ries with it the additional risk of septic infection. The treatment of indriven fragments of bone is more debatable. When driven into the brain by a missile which is itself retained, the bony fragments are rarely, if ever, more deeply placed than the projectile. When driven in by the impact of a missile which does not itself enter the cranial cavity, the bony fragments are rarely found so deeply situated but that they can be removed along the tract with little, if any, additional damage being done. With regard to the septicity of these indriven metallic and bony fragments, it has been found that a large proportion, when dropped into the culture media immediately upon removal, fail to provoke any bacterial growth, either aerobically or anaerobically. The question of the intracranial pressure has been the subject of repeated observation. Among the conclusions of practical im- portance which have been arrived at are the following : 1. Apart from the rare instances of extensive intracranial hemorrhage, traumatic edema, whilst playing an important part in symptomatology, does not reach a sufficient degree of intensity to endanger life. 2. The instances of severe intracranial hemorrhage not rap- idly fatal are very few ; and even amongst these there is a certain number which surgical intervention is not likely to save. Experi- ence has shown that an intracranial hemorrhage which is suffi- ciently severe to demand operative relief, and which can be ABSTRACTS OF WAR SURGERY 77 recovered from, gives unmistakable signs of its progress. The operation can be deliberately planned and carried out with the definite object in view. Exploratory operations on the chance of discovering a hemorrhage are rarely if ever called for. 3. In case of intracranial pressure from secondary edema which is causing severe headache and herniation of brain, this can almost always be controlled by lumbar puncture. Occasionally contralateral decompression has been done for these eases and has afforded good results. Such evidence as is at present available from the later results (six months to two years) is all in support of the general policy of treatment outlined above. The steel helmets have played an important part. The study of cranial wounds before and after their general adoption brings to light many interesting points. The outstanding feature, how- ever, is that which concerns the penetration of the dura mater. The proportion of penetrating wounds has very largely dimin- ished, as also has the mortality, another amongst many indica- tions that the surgeon can not attach too much importance to the integrity of this membrane, or treat it with too much respect. Injuries to the Spinal Cord. — Wounds and injuries of the spinal cord, when amenable to treatment, demand early surgical inter- vention. At the commencement of the war but little was known regarding the actual structural changes attendant on gunshot injuries, and what was known was concerned mainly with the changes which were found in spinal cords examined at a compara- tively late date. The position of the surgeon was rendered yet the more difficult, in that past clinical experience had shown the extreme difficulty which exists in forming a correct prognosis, particularly in view of the remarkable ultimate recoveries ob- served in patients whose primary symptoms had not been able to be distinguished from those observed as attending total destruc- tive lesions. In order, therefore, to recognize when surgical intervention can be undertaken with a reasonable prospect of success, it was necessary to obtain an accurate idea of the nature of the patho- logical changes produced in the cord by modern projectiles. An investigation on this subject was undertaken by Gordon Holmes. He found that even slight local injuries are very frequently asso- ciated with extensive edema, hemorrhages, softenings, and often with ascending cavity formation, which may extend a consider- able distance both above and below the level of the original injury Or wound. These changes he refers to the concussion 78 ABSTRACTS OF WAR SURGERY effect produced by the missile through, the walls of the spinal canal; they may exist even without the presence of a fracture of the vertebrae. Such changes can obviously not be relieved by any reasonable operation, and the fact that, apart from the sec- ondary cavities that develop later, they occur immediately or within a very short time of the infliction of the injury, diminishes the favorable prospect of any surgical intervention. In some cases undoubtedly the symptoms are largely or in part due to compression of the spinal cord by either the missile or a fragment of depressed bone, but numerous examinations have proved that even in these the same intraspinal lesions exist. Even relatively slight injuries often produce for the first few days, the period when operation offers the best chance of success, symptoms that may be confused with those of total and irreparable damage to the cord, and some clinical indications of the severity of the spinal injury is consequently necessary before an operation can be reasonably undertaken. This question was investigated in a large number of cases and the conclusions were published in the same lectures. These are to the effect that the safest guide to the severity of the injury is afforded by the form and character of the sensory disturbances, and especially by the changes and modifications in the reflexes of the affected limbs. In most cases the site of the wound or radiographic examina- tion permits an accurate diagnosis of the medullary lesion, but not infrequently this can be determined only by a study of the symptoms produced by it. The method by which an accurate local diagnosis can be made is also dealt with in these lectures. Here, too, many important and interesting symptoms which result from injuries to different portions of the spinal cord are described. It was found, for example, that when its lower cervical and the upper thoracic segments were severely affected, the patients often presented a serious symptom-syndrome characterized by hypo- thermia, bradycardia, low blood pressure, reduced secretion of urine, and mental hebetude. The body temperature may fall as low as 80° F. (27° C), the pulse-rate to 35 or 40 per minute, the blood pressure to 60 mm. of mercury, and only 4 to 8 oz. of urine may be secreted in the twenty-four hours. Injuries to the region from which the vasomotor fibers to the kidneys pass off may, on the other hand, produce an extraordinary polyuria, and lesions in the higher cervical segments were shown to be often associated with hyperpyrexia. The acquisition of wider knowledge has not, however, greatly widened the scope of operative intervention. Operations are still ABSTRACTS OF WAR SURGERY 79 for the most part confined (1) to cases in which a radiographic or direct examination reveals the presence of displaced and de- pressed fragments of bone or the lodgement of foreign bodies either within the canal or buried in the cord (it may be mentioned that several cases have been observed where retained bullets have travelled long distances within the spinal canal, particularly in its lower part) ; (2) to cases in which the patients suffer severe and unbearable pain; (3) to cases in which pressure from hemor- rhage around the cord is suspected, such cases being very rare. An additional class may be added in which a late operation is performed on the chance of some improvement being gained, mainly as a question of expediency. Patients with injuries to the nerves of the cauda equina have as a rule been evacuated to England. No striking change in operative technic has been developed, beyond the general tendency to partial rather than classical laminectomies, and perhaps the development of an increased con- fidence in the utility of placing a muscle graft over the opening in the spinal membranes when leakage of cerebrospinal fluid has been associated with the performance of the operation. An intact dura has throughout been an important immediate prognostic element, as in the case of injuries to the head. Early drainage of the bladder by a suprapubic tube has been advocated by Percy Sargent since the commencement of the cam- paign, but the difficulties in the transport of patients thus oper- ated upon, and the increased responsibility devolving on the nurse in keeping the back in good condition, have militated against an extensive adoption of this measure. Injuries to the peripheral nerves have been extremely common ; it has indeed been estimated that in 18 to 20 per cent of all limb wounds slight or more serious lesions of the large nerve trunks coexists. But owing to the facts that when, as is usually the case, extensive septic wounds are present, the early surgical treatment of nerve injuries is impracticable, and that the patients with small and clean wounds can be safely transferred to England, neither the treatment nor the study of these injuries has been an urgent question in the general hospitals on the lines of commun- ication in France. Abdominal Injuries. — The chief interest in injuries to the abdomen has rightly been transferred from the general hospitals to special hospitals at an advanced line or to the highly developed casualty clearing stations. Prior to the summer of 1915, however, the great majority of injuries to the abdominal viscera were 80 ABSTRACTS OP WAR SURGERY dealt with on the expectant system, and such of the patients as survived arrived in the general hospitals. The experience gained from the observation of these afforded some information regard- ing the prognosis of wounds of both hollow and solid viscera, which may in the future not be so readily obtained. The enormous mortality attending injuries to the small intes- tine was clearly demonstrated, both by the comparatively small number of patients arriving, and by the simple nature of the injuries found at postmortem examination compared with the extensive and multiple character of the lesions which have been almost uniformly discovered by early operations. This experi- ence exerted a healthy influence in supporting the advisability of early operation. The lesser fatality attending wounds of the colon, excluding the transverse colon and the sigmoid flexure, was also clearly brought out, since a larger porportion of wounds of the large gut arrived at the general hospitals, and of these more than 50 per cent recovered sufficiently to be transferred to England in good condition. This number obviously has no bearing on the actual mortality of wounds of the colon, but com- pared with a percentage recovery of less than 16 per cent in a small series of minor injuries to the small intestine, it is suffi- ciently striking. A few points of some interest also emerged from the series of postmortem examinations made on patients who had survived several days, thus the general character of the peritonitis in cases of wounds of the small intestine, and the localized nature of that developing in consequence of wounds of the large intestine; the observation that when the wound tract traversed the psoas muscle and its sheath, extravasation of fecal contents extended to the thigh, and indeed, might travel the whole length of the lower limb ; that, while patients dying from the effects of wounds of the small intestine uniformly succumbed to peritoneal infection, deaths following wounds of the colon were, in 40 per cent of all the cases, the result of a general infection from the septic wound of the soft parts of the trunk, and not from the peritoneum itself, the main feature of the general infection being a purulent bron- chitis; lastly, in a series of postmortem examinations made by Captain Henry, in every case a general postmortem invasion of the blood stream by anaerobic organism was discovered. Experience again proved the practical futility of performing operations for the closure of intestinal wounds after thirty-six hours has elapsed from the time of injury, and it is probable that any successes obtained in this field can be counted upon the ABSTRACTS OF WAB SURGERY - I fingers. On the other hand, the good results often obtained by performing a proximal colostomy in large wounds involving the colon, and thus preventing the occurrence of the late systemic infection referred to above, have been amply proved. The few- cases in which an attempt has been made to obtain the same result by making an intestinal short circuit by anastomosis have not been encouraging, and it is obvious that this class of case is not a favorable one for such procedure, both by reason of the general condition of the patient and the difficulty in performing a clean operation. No novel features have been disclosed by observation of the numerous instances of wounds to the solid abdominal viscera, except that perhaps more attention has been given to interference with their secretory activity, and that the favorable course commonly following these injuries in the absence of serious septic complications has tended to confirm the propriety of maintaining an expectant attitude in the question of surgical intervention. Speaking generally, it may be said that the formation of an abscess or the occurrence of secondary hemorrhage are the only indications for interference at the period at -which the patients reach the general hospitals. Septic infection has been the common cause of death in all cases of fatal injury to the solid viscera, and in 40 per cent of deaths from wounds of the liver second- ary hemorrhage has accounted for the fatal issue. Intraperitoneal injuries to the urinary bladder, even discovered during operation, have been rare throughout the campaign, and for some reason probably connected with the conditions of trench warfare extraperitoneal wounds have been far less often seen than in the earlier stages of the war. These latter cases were the source of much interest because they were sometimes difficult to diagnose from injury to the small intestine in the early stage, and also because treatment by simple suprapubic cystostomy was found so successful. Of thirty such consecutive operations only two proved unsuccessful, and in each of these comminuted fractures of the pelvis were coexistent. If treated expectantly, in many instances the urine escaped freely from apertures in the abdominal wall, the buttock, or the thigh for a week or ten days, and the patients appeared to be doing well, when infection of the urine took place, extended to the bladder, and toxemia fol- lowed. Even in the latter class of case, however, a late operation may save the patient. The condition of cases arriving at the general hospitals sub- 82 ABSTRACTS OF WAR SURGERY sequently to the primary operations at the advanced lines deserves a word of mention, although the patients are for the most part birds of passage. The general results have been remarkably good, the most com- mon defect, now not so common as in the earlier stages of the adoption of early operation, has been incomplete union of the wound in the abdominal wall. In some cases this has been accounted for by a primary use of the initial entry or exit aper- ture for the site of exploratory incision, in others from the per- sistency of a gap left for a drainage tube; but beyond these complicating factors, an obvious difficulty has been experienced in obtaining firm primary union. In some cases this may have depended on an actual deficiency in vitality of the patient, but in the majority it has undoubtedly been due to infection, and when it is borne in mind that these operations are performed on the subjects of intestinal perforations in whom infected blood is present and has to be evacuated from the abdominal cavity, it is not to be wondered at. Such wounds have usually healed readily by granulation. The next occasional trouble has been the secondary formation of abscesses or fistulse. These have not been common, the abscesses usually following colic wounds and the fistulae wounds of the small intestine. It is noteworthy that fistulas have formed secondarily in several cases in which the primary exploration has been negative — a fact bearing on the common occurrence of severe contusion of the wall of the intestine unaccompanied by perforation. As a rule, the bowels have acted regularly and well; in some instances diarrhea has been troublesome, and the writer has only seen one patient in whom secondary obstruction was caused by adhesions. On the whole, the evidence seems against troublesome peritoneal adhe- sions developing with any degree of frequency. In one post- mortem examination made upon a patient who died from pneumonia the abdominal cavity was absolutely free from adhe- sions, and an end-to-end anastomosis was so perfect as to be with difficulty discovered. As is usually the case, however, the bowel on the proximal side of the line of union was already somewhat dilated. WOUND INFECTION AND TREATMENT. GUNSHOT WOUNDS AND THEIR TREATMENT.— Sir Berke- ley Moynihan. Surg., Gyn. and Obstet., December, 1917. Surgeons who were responsible in the early weeks of the present war for the treatment of the wounded soldiers com- ing home from France are never likely to forget their experience. There were wounds of many dimensions and of every tissue, all characterized by the most profuse and offensive suppuration. A challenge was, so to say, thrown to the profession, which we may now with due modesty claim has been splendidly and trium- phantly met. Rebukes and taunts at our incompetence were not seldom heard in those far off days. We are asked if Lister had worked in vain; we were told we had failed to learn the lesson he had spent his life in teaching. It is interesting to read again the works of Lister, and to see how helpless he felt himself in dealing with putrefactive pro- cesses once firmly established in a wound. Lister everywhere distinguishes between the "prophylactic" and the "therapeutic" uses of antiseptics. All the marvelous achievements of modern surgery are due to the adoption by surgeons the whole world over, of the principle of the prevention of infection in wounds about to be made as distinguished from that of the subduing of an infection already rampant. Lister writes : ' ' The original idea of the antiseptic system was the exclusion of all microbes from wounds." Again, "During the operation, to avoid the introduction into the wound of mate- rial capable of inducing septic changes in it, and secondly to dress the wound in such manner as to prevent the subsequent entrance of septic mischief." Again, "In wounds already septic attempts are made with more or less success to restore the aseptic state." Again, "In speaking of the antiseptic system of treatment, I refer to the systematic employment of some antiseptic substance so as entirely to prevent the occurrence of putrefaction in the part concerned, as distinguished from the mere use of such an agent as a dressing." The distinction between the preventive and the curative use of antiseptics is in many respects that existing on the one hand between the power of a germicide as determined by experiments 83 84 ABSTRACTS OF WAR SURGERY in vitro, and on the other hand, its capacity to destroy organisms when it is introduced among the living and the dead tissues of a wound. In the former there is a direct conflict, a clean fight, between the microbe and the chemical agent. Few or none of the many intervening conditions are present which have to be considered when a bactericide is introduced into a wound cavity wherein there are a multitude of actions and reactions which even now seem very obscure and are so often conflicting. When after the lapse of many weeks from the outbreak of war, there came a full appreciation of the several circumstances which had to be reckoned with when a soldier was wounded, it was recognized on all hands that a new and grave problem had arisen which cried urgently for solution. What then were the several new factors that had to be considered? In the early days a very large number of the wounds were inflicted by rifle fire. The German bullet has a muzzle velocity of approximately 1000 yards per second. In the first 800 yards or thereabouts, the flight of the bullet is not steady but "wob- bling. ' ' There are three movements : a movement forward along the line of flight ; a rotary movement, in which the bullet spins round on its longitudinal axis as a result of the "rifling" of the barrel; and a third movement, a mouvement de bascule of such a character that while the point of the bullet keeps steady the base of the bullet is moving round a circle, or an ellipse, of a gradually diminishing size. The result of the last form of motion is this, that when the bullet impinges upon any substance, even the soft clothing or the flesh, the infinitely brief arrest of the point which strikes first, allows the base, which is of course much heavier, to overtake the apex, and the bullet then lies sidewise or begins to turn over and over as it ploughs its way through the soft parts. In this early part of the trajectory the missile has, of course, a great momentum ; it is a heavy bullet travelling with great velocity. The consequence is that the damage inflicted is not confined to the track it rudely makes through the limb : the parts around the track are damaged also, often to a great extent, and microbes are driven deeply into all adjacent tissues. Every wound, therefore, caused by a bullet at short range, consists not only in a visible tearing and destruction along the path the bullet has followed, but in a dead zone everywhere surrounding that track. And even that is not all. The momentum of the bullet is such that to everything it encounters it imparts some of its own velocity. As we all know, shreds of the clothing or belt, ABSTRACTS OF WAR SURGERY 85 or the contents of the pocket, may be carried deeply into a wound. So also are pieces of skin or muscle. And if the bullet should chance to strike a bone, the bone is not only broken into many fragments, the "splinter" fracture, but to all fragments there is conveyed enough of the momentum of the bullet to convert them into projectiles also, capable of tearing a way into the softer tissues. Many of the wounds, therefore, were deep, irregular in shape, with large or small cavities. Into these recesses blood escapes, and owing to the tearing and unequal retraction of cut muscles, pools of fluid may be shut off from the main track of the wound, and form an ideal breeding ground for all microorganisms, especially those which are anaerobic. If a rifle bullet is not checked in the first 600 yards of its flight, it begins to steady down, and probably when it has travelled 1,000 yards it is moving evenly. An injury inflicted then is of a quite different character. The bullet cleaves its way through the soft parts, bores a neat hole through a bone, and little des- truction is done. We see many cases where the chest or abdomen are traversed from side to side, or where the neck has been pierced, and miraculously, no real damage has been done. Examples of this form of injury were, of course, common enough in the South African War. They have been less frequent in this war because the range has often been shorter, and the bullet in respect to velocity and weight is different. During the last two years a very large proportion of these wounds have been inflicted by shrapnel bullets, hand grenades, or shell casing. The immense velocity of the projectiles, espe- cially when a high explosive shell bursts, their irregular shape, their pitted surface and sharp edges, all combine to cause w r ounds of very diverse forms. The track is a distorted one, the parts around it are bruised and battered or dead, and the infection carried into the wound by a piece of metal or cloth has unre- stricted opportunities of spreading rapidly. In many cases large areas of the limbs or trunk are blown away. The wound remaining shows a shattered and irregular surface ; the muscles are torn and crushed, or "pulped" and lose their structure. They dry rapidly on exposure and therefore fall easy victims to a bacterial attack often of great ferocity. The condition of the battlefields of Flanders and of France accounts for the quality of the infective agents. Many parts of the lands over which the fighting has taken place, both before and since trench warfare set in, were cultivated assiduously by 86 ABSTRACTS OF WAR SURGERY the rural inhabitants before the war. Probably no soil in Europe has been more liberally manured in efforts at intensive cultiva- tion. Certainly no contact between the soldier and the soil has ever been more intimate or more protracted. Every projectile passing through the garments to the body will certainly be cov- ered with the mud or dust in the clothes, and with the many organisms that a respite from ablutions has allowed to penetrate the skin. All bacteriologists and surgeons are now agreed that no influence perpetuating infection in a wound is so malign as that which is harbored in the torn fragments of clothing. The physical condition of the soldier himself, when he is wounded, no doubt plays an important part in exalting the virulence of any infection which may settle upon him. Though in the best of health and physical condition at the moment of attack he may, by the time he is wounded, have suffered great fatigue, and bleak exposure, for hours, or even days, before succor comes to him. The organization for the collection and dispatch to the field am- bulances and casualty clearing stations, of wounded men is prob- ably as perfect as any endeavor can make it. But there are times, especially in a "push" when a man may lie out undis- covered for long periods. Not infrequently by reason of such causes, and on account of pain and hunger and loss of blood he may be reduced to a state in which his power of resistance to a bacterial attack is greatly impoverished. Bacteriology. — The bacteria infesting the wounds in France have been studied by Wright, Fleming, and others. The general conclusion drawn from their work is that the microorganisms, as might be expected, are those found in highly manured soil; they are, that is to say, of fecal origin. Wright suggests the new names ' ' serophytes ' ' for those organisms which will grow in normal serum, streptococci, and staphylococci; and " serosaprophytes " for those which can only grow in digested albumens. The native albumens of human serum are "protected" from bacterial development at their expense, and Wright points out that, if this were not so, human life would have been impossible. Among the serosapro- phytes are the larger number of the organisms found in wounds, in- cluding all the anaerobes; the bacillus of Welch, the bacillus of tetanus, the enterococcus, a streptococcus of intestinal origin de- scribed by the French, the bacillus coli, and putrefactive bacilli X and Y, which are the cause of the foul odor often met with in wounds. There is often a "wisp" bacillus, and a diphtheroid bacillus appears in later stages of the infection. All these microorganisms find a most fertile medium for their ABSTRACTS OF WAR SURGERY 87 growth in wounds of the character described. In every wound, where the recesses are many and intricate, blood or serum may be poured out; tryptic digestion begins as a consequence of the destruction of the leucocytes, peptones are formed and bacteria, finding everything to their liking, grow apace. From many of the wound surfaces the circulation has been cut off by the powerful stunning effect of the blow given by the projectile, and gangrene and sloughing make haste to develop. During the first four to six, or in some cases even eight hours, few organisms, or none, can be recovered from the wounds, either by smear methods or by cultural methods. The organisms are there nevertheless, and given the prodigal fertility of the soil in which they are sown, will quickly show the evidence of their growth. In this brief early period the wound is said to be "contaminated," in all later periods "in- fected." The chief defense is in the blood serum and in the leucocytes (phagocytes). The capacity of these two, if only they have an adequate chance, may be said to be almost illimitable against all organisms but the streptococcus. The serum possesses strong bac- tericidal powers of its own; the phagocytes can devour bacteria greedily. But in exerting their powers, both serum and white cells are apt to undergo degradation. The leucocyte breaks down and its power of tryptic digestion is then exerted upon the fluids around it, and peptones are produced in quantities which make easy the growth in them of all forms of bacteria. Moreover, the surface of the wound soon becomes "lymph-bound." A mesh of fibrin entangles the blood-cells, and a sort of matting of coagulated lymph spreads over all the surface. No fresh serum can then reach the wound, nor are fresh leucocytes available for the attack. The infective process can then proceed apace, unhindered by those powerful natural defenses which for the moment have quite broken down. The Principles and Methods of Treatment of Gunshot Wounds. — (a) Primary Closure. — Everyone to whose lot it has fallen to undertake the surgical treatment of wounds in this war will agree that the most urgent need is to secure their complete closure at the earliest possible moment. In the early hours, dur- ing the period of "contamination," it is now the common prac- tice to excise freely all damaged and dead tissue if possible in one piece. This requires some skill and no little practice to do excellently. The most careful preparation of the skin and the parts around the wound is a necessary antecedent to any operative measures. The wound, of whatever type, is excised together with OO ABSTRACTS OF WAR SURGERY a wall not less than one-third inch around it. In order to make certain that all the walls of the original wound are excised, Wilson Hey has suggested, and has long employed, a method of staining with brilliant green, which is injected into all parts of the wound and allowed to remain not less than two minutes. The staining of a wound not only makes a more thorough removal possible, but it also indicates those parts which can not, or may not, be removed, to which therefore a simple mechanical cleansing must be more particularly directed. The walls of the cavity remaining after excision should bleed everywhere ; perfect hem- ostasis is then secured. Every soiled instrument or glove is at once discarded. The wound may then be stitched up completely with- out drainage, and with much confidence may be expected to heal well. The cases coming to the base hospitals in England show that in a great variety of injuries this method of the primary closure of wounds is meeting with a very remarkable success. If the operation is carried out with scrupulous exactitude and with something near to technical perfection in cases of "con- taminated" wounds, probably not less than 90 per cent will heal by first intention. The failure occurs in those cases where a piecemeal removal of the infected wall has been carried out, where, that is to say, there has been frequent reinfection of the newly made raw surfaces. There has been in all armies a certain timidity, very natural, and perhaps from many points of view very desirable, in carry- ing out the method of primary closure. No one who has worked even for a brief period in the armies in France can have failed to realize the desperately serious results which come from the injudicious closure of septic wounds. Gas gangrene, for example, may develop in an amputated stump, if even one stitch is put in to approximate the flaps. And there has consequently sprung up on all sides a fear of the premature closure of wounds. But recent experience would seem to show that at least in the early cases, in cases reaching a well-equipped surgical unit, say within 8 or 10 hours, in the period of contamination rather than a spread- ing infection, a mechanical cleansing of the most thoroughgoing kind, carried out ruthlessly and rapidly, will allow the great majority of the cases to be closed with an excellent chance of primary union. There can no longer be any doubt that many of the cases which have proved so successful under the Carrel- Dakin method, applied during the first 6 to 8 hours, would have ABSTRACTS OF WAR SURGERY 89 closed equally safely, and far more rapidly, under the method of immediate suture ; and that consequently a certain degree of suffering and much expenditure of time and no little expense would have been saved. To put this statement in what may seem an extreme fashion, it may be said that the Carrel-Dakin method has achieved its greatest triumphs in cases where it need not in fact have been applied. But if this opinion is true it must at once be admitted that one of the chief experiences which have led to its realization is the practice of this method, with great success during many months. More than ever are we now con- firmed in our strong opinion that it is the primary mechanical cleansing, after thorough exposure, and with every precaution and care, that is the supreme necessity in all cases ; and that this alone, if complete, will allow the natural defenses of the body to secure the blameless healing of the wound. In doubtful cases, indeed in any case, a small drain of a few strands of silkworm-gut may be left in the corner of a wound closed by primary suture. All cases are watched carefully for a few days. If the tempera- ture remains high, or if the wound on being uncovered looks angry, inflamed, and especially if a streptococcus infection is found, the wound must be opened up completely and treated by one of the methods to be presently described. (b) Secondary Closure. — If, however, owing to one or more among a great diversity of circumstances, the patient arrives at a base hospital with a freely suppurating wound, the problem is quite different. The chance of primary closure has passed away perhaps long ago ; the wound now may be covered, sparsely or thickly, with sloughs of varying size, and in various stages of detachment. Layers of lymph adhere at one point, or at many, to the wound surface, and the discharges are thick, purulent, and offensive. The problem here is first to secure a healthy and rela- tively uninfected surface, and secondly to close the wound by suture on the earliest prudent occasion. What are the principles which we must now put into practice? For purposes of tabula- tion and description, they may be spoken of as ''physiological" and "antiseptic," though the difference between the two may not be so sharp as such a precise and limited statement might appear to indicate. Physiological Methods. — These owe their origin to Sir Almroth Wright. The problem Wright set himself to solve, in the case of the septic "lymph bound" wound, was that of rendering 90 ABSTRACTS OF WAR SURGERY available, once more, all the natural defensive mechanisms pos- sessed by the body fluids and tissues, and of exalting their power by bringing them into play in far larger quantities than are usually at our command and in a condition which, as a result of vaccine injections, or because of the increased antitryptic power of the blood serum of a wounded man, finds them greatly augmented. "We have, he says, to promote the destruction of the microbes which have been carried into the deeper tissues; we have to resolve the infiltration in the walls of the wound, and to get rid of infected sloughs ; we have to prevent the ' ' corruption of the discharges, ' ' and to inhibit microbic growth in the wound ; we have to be constantly on our guard in order to prevent these active and passive movements which propel bacteria along the lymphatics, and which carry poisonous bacterial products into the blood ; and finally, all this being done, we have to get rid of the surface infection, promote the processes of repair in the wound, and bring together the wound surfaces so that they may heal. How are these various tasks successfully accomplished? The blood serum, as Wright has shown, possesses certain remarkable properties. Mechanically it is the agent by which phagocytes are washed on a rising tide into the wound, and chemically it has a powerful bactericidal efficiency against all microorganisms, but the "serophytes," streptococci, and staphylococci (the anaerobic organisms that is to say) are destroyed by it. The phagocytes, as Metchnikoff long ago showed us, can devour and digest microorganisms of all kinds, but, tried beyond a certain point, they perish in the fight, and liberate at their death a ferment, trypsin, which digests the native albumens in the serum, converts them into peptone, and therefore adds enormously to the cultural value of the wound discharges. The blood, how- ever, is normally antitryptic, and this quality appears in cases of infection to be increased — there is an antidote, that is to say, to the local defect of the phagocytes and the consequence at- taching thereto. The coagulability of the serum is also increased with the result that a "rolling" of fibrin forms on the walls of the wounds, and prevents the access to the wound of reinforce- ment of serum and of cells. Wright's method consists in the application of a "hypertonic" solution of salt, 5 per cent or anything over that, together with one-half per cent citrate of soda (this is not necessary). The principle of the hypertonic method is to make use of the bactericidal power of fresh serum ABSTRACTS OF WAR SURGERY 91 which is encouraged to flow from the wound surfaces by the application to them of a more concentrated saline solution than blood serum. A process of osmosis is at work. The action of hypertonic saline solutions is complex, and its virtues conflicting. It attracts water from the blood together with all the protein substances contained therein; it inhibits leucocytic migration, prevents phagocytosis, disintegrates those leucocytes with which it is brought into direct contact and thus sets free a tryptic ferment which digests the albumens of the blood serum. It delays or prevents the action of this very fer- ment which it has caused to be liberated. It inhibits coagulation and so prevents the sealing up of the channels through which lymph pours into the wound. It appears definitely to inhibit bacterial activity and propagation. Antiseptic Methods. — Among these, pride of place will cheerfully and gratefully be conceded to the Carrel-Dakin procedure. It consists of a free mechanical exposure and cleansing of the whole wound. This is so easy to say, and alas, so difficult in all cases to carry out adequately. The wound so made is then lightly packed with gauze into which a number of Carrel's tubes are laid; through these tubes at intervals of about two hours Dakin's fluid is instilled. Probably full realization of the need for careful preparation and testing of Dakin's fluid is not universal; nor of the rapid deterioration in its potency if it is allowed to be heated, or exposed to the air, or stored in transparent glass bot- tles in warm places. The method allows of the early secondary closure of wounds, at an average period of 8 to 12 days; and coming when it did, before the end of the first year of the war, it is no exaggeration to describe its effects upon the treatment of wounds as revolutionary. In what way does the Carrel-Dakin method act? Are its ef- fects produced by reason of the strongly antiseptic properties of Dakin's fluid, or because of other properties not directly con- cerned with the killing of microorganisms? Or is the most excellent technic for which we can not be too grateful to Carrel chiefly responsible in that it necessitates a greater general care of the wound, a free opening of all recesses, and that constant supervision which detects at the earliest moment any harmful development on the granulating surface? If strict dependence is placed upon the microbial curve, it would appear that the author of the method believes that progressive sterilization of 92 ABSTRACTS OF WAR SURGERY the wound is produced by the chemical action of Dakin's fluid upon the bacterial flora. The reduction in the number of organ- isms even irrespective of their nature, is held to be the index of the germicidal effect of the fluid applied. Even when compara- tively small quantities of a potent bactericidal fluid, like that discovered by Dakin, are instilled frequently into wound cavities covered by sloughs or granulations, the killing of microbes can hardly be a serious consequence. For these organisms can prop- agate themselves at a rate with which the most powerful germi- cide could hardly "catch up," however frequently or adequately supplied. I can easily conceive of an "antiseptic," using the word in its clinical sense, which is not in the smallest degree "germicidal." I can understand, that is to say, that a wound, however gravely infected, may by the application of some chem- ical substance be deprived of its bacterial flora, in very great measure, or even completely, though no single microorganism is killed by this substance. An "antiseptic," if not germicidal (that is, not acting chemically upon the substance of which bacteria are composed), might yet render the wound sterile either by destroying the pabulum of the bacteria, so that they are unable to flourish and to propagate, or by exalting those normal powers of resistance possessed by body tissues apd fluids, or by holding up the bacteria until those powers, without increase, are capable of destroying or dispelling the infective agents. Or does the action of chemical agents on the leucocytes so alter their metabolism as to produce substances which cause degenerative processes in the bacteria? That is, are involution forms of bac- teria developed by the relationship of these agents to them? The most striking effect visible to the eye in a wound treated by the Carrel-Dakin method is that the surfaces are cleaned very rapidly. Dead tissue, even large sloughs, are quickly di- gested away, and the surface becomes smooth, clean and bright red in color. In a wound not yet clean in all its parts a very different microbial curve can be drawn if smears are taken from the smooth red portion of the surface and from the edge of a slough. It is the dead tissue in the wound that keeps the septic processes going. If this is destroyed, bacterial profusion and virulence both rapidly diminish until the wound is ' ' clinically sterile." If, therefore, a substance could be found which, without having a directly noxious effect upon bacteria, could rid the wound of all dead tissue and allow the natural defensive mech- ABSTRACTS OF WAR SURGERY 93 anism to have a free chance, it is probable that the wounds would heal as kindly as they do under the Carrel-Dakin system. What appears to be a fulfilment of this supposition has been published since the above paragraph was written. Donaldson and Joyce {Lancet, London, 1917, ii, 445) describe a nonpathogenic sporebearing anaerobe, which acts apparently in virtue of its proteolytic powers only on devitalized tissues, and possibly on tox-albumens, and appears to possess no power of attacking healthy tissues. The powers of this organism are directed toward the removal not only of the grossly damaged tissues, but it suc- ceeds also in attacking the microscopically damaged structures. As a result, the body forces are freed from the constant menace of septic poisoning and are thus allowed to commence the work of repair. It is, therefore, an arguable proposition that Dakin's fluid as applied by the Carrel technic does not act as a germicide but rather as a proteolytic agent, as an agent destroying those parts of the wound on which alone, or chiefly, organisms can find a place to propagate. It is, after all, therefore the mechanical cleaning of the wound which is of the greatest importance, and the action of Dakin's fluid is perhaps very much the same as that of the surgeon's knife in those cases where the wound is excised. The Carrel-Dakin method always stops short of perfection in asepsis. The wound in my experience is never rendered "sterile" by this method. Organisms can be found in smears and developed in culture, however long the treatment is continued in a large wound, a fact which seems to me of great significance in relation to the question of the bactericidal value of Dakin's fluid. For when fluid in the same quantity as ever is applied, and but few microorganisms remain, their ultimate annihilation appears to be impossible. Perfect sterility, however, we have long known is not necessary for a healing by first intention, though the quality of that healing varies decidedly according to the relative infectivity of the wound. The fewer and less harmful the organ- isms the more blameless is the healing. Surgeons who have worked, as surgeons should work, with a bacteriologist at their elbows, will admit they have frequently closed wounds which were proved to contain microorganisms, and yet have obtained a union of the wound that was good. Until I adopted my present technic, this was a frequent experience; but many years ago I began (I was, I believe, the first to begin) the covering of the 94 ABSTRACTS OF WAR SURGERY skin by tetra cloths which, overlapped the skin edges, and since then I can be certain that in all clean cases the wound remains sterile to the end of the operation and a flawless healing can be confidently expected. Carrel has coined the phrase "clinical sterilization" to indicate that condition in which organisms are •so few that the wound can safely be closed and good healing obtained. Regard should, however, be paid not only to the num- ber of the microbes but to their nature. I do not like to find a streptococcus present when the day approaches for the second- ary suture of a wound. Carrel's method must rely at the last upon the living properties of the tissues to destroy or render innocuous the organisms still remaining in the wound when it is closed. It is true that they are few; but they are there never- theless, and must be overcome if the wound is to heal, and to remain healed. What most surgeons have learned since the introduction of this technic is that which those surgeons who worked with a bacteriologist by their side have long known; namely, that infected wounds (wounds "clinically sterile") may heal in a manner to which the term "first intention" may without injustice be applied. What are the disadvantages of the Carrel-Dakin method? I often hear it said that it is a difficult method, requiring a special training of the surgeon, that it requires a large amount of glass and rubber tubing, bottles, etc. ; that it is costly in dressings, and that it calls for constant supervision or direction by the surgeon. There is truthfully no great validity in these objections. A spe- cial instruction of the surgeon is certainly necessary if he is to observe the ritual carefully, and to understand what it means ; but so it may be said is a special training necessary for the surgeon when any new technical procedure is introduced. The apparatus is cheap, and is easily obtained and lasts, with care for months. If nurses are carefully trained to do the dressings with punctilious care, only that supervision is needed from the surgeon which he should give to every case. From a military point of view, however, it is a difficult method of practice, for in our army we are compelled to evacuate a large proportion of cases to England, retaining only those for whom movement has proved disastrous. The circumstances under which Carrel worked and under which he produced his splendid results could not con- ceivably be made applicable to a whole army. Some part of ABSTRACTS OF WAR SURGERY 95 his success must truthfully be given to his opportunities both for receiving the cases early and retaining them for long periods. The chief disadvantage of the method is that if it is interrupted it fails lamentably. When cases have to be transferred from France to England, it may for certain reasons be impossible to survey all the cases on board ship or on the train; and infection then spreads and a rancid and rampant suppuration is present when the patient arrives at a base hospital in England. This is, it is true, an objection to a particular application of the method, rather than to the method itself. But it is the reason, I think, that the procedure has never found a wide or general acceptance in the British Army, though it has many warm advocates, and many who practice it with a success equal even to that of Carrel or of Chutro. The chief successes obtained by this method are in the early cases, in those in which treatment can begin at intervals of not more than six or seven hours after the wound is made. But we are by degrees becoming less timorous in our efforts at primary closure in precisely this group, and our results justify a wider acceptance and a more general adoption of this practice. In later cases the Carrel method is beyond question a therapeutic procedure of the first magnitude, but it then requires, unwearying care and inexhaustible patience if the best results are obtained. Rutherford Morison's Method. — This method is widely practiced in the base hospitals in England, and by many surgeons is con- sidered the most satisfactory of all. The technic is as follows : A wound, say of the arm, leading down to a compound com- minuted fracture of the humerus is freely opened up, after such preparation of the arm and of the surrounding parts as is made in all cases about to undergo operation. The wound may be en- larged in any direction in order to make sure that no recesses in it remain undiscovered. All granulation tissue is vigorously scraped away from the wound surfaces ; bleeding points are secured; obviously dead and loose portions of bone, or pieces of cloth, or projectiles are removed. The wound is packed with dry gauze for a minute or two, while towels about the wound are changed if necessary, and while the surgeon replaces all instruments, gloves, etc., with those freshly sterilized. The dry gauze is removed, the wound sponged everywhere with gauze moistened with methylated spirit. On to the raw wound surface a thin layer of a preparation known as "Bipp" (bismuth subni- trate or carbonate, one part; iodoform, two parts; paraffin in 96 ABSTRACTS OF WAR SURGERY quantity sufficient to make a soft paste) is applied. With a gauze swab this paste is rubbed well into the wound, which is then sutured from end to end without drainage. The arm is fixed on a splint, and the wound left untouched for 10 days. At the end of this period it is usually found healed or nearly so ; another dressing is applied, and allowed to remain 10 days. No further dressing is needed. The absence of frequent dressings is an im- mense advantage and a comfort beyond words to an anxious, overwrought patient. Why does Morison's method prove so successful? Is it the free mechanical cleansing of the wound that is of chief import- ance, or is there some antiseptic or physiological virtue in the "Bipp" as a whole, or in any of its constituent parts? It is almost certain that in the perfect mechanical cleansing of the wound lies the secret of the method. For I have treated wounds in exactly Morison's method and have omitted the paste, and have seen the wounds heal as kindly as when it was used. If there is a virtue in the paste, in which of the ingredients does it lie? Probably in the paraffin which produces that anaerobic state in which healing can most rapidly take place. Morison, at my sug- gestion, tried his methods in two cases, omitting the ''Bipp," and he allows me to say that they healed as well as the others treated with the paste. Such is a brief statement of the present position with regard to the treatment of war wounds. It must never be forgotten that the time element is always an important factor and that the problem of dealing with an early contaminated wound is not identical with, indeed may be marvelously different from that concerned with a late infected wound. The conditions in the early hours, when the patients are at the casualty clearing sta- tions in France, are very different from those to be combated when the patient reaches a base hospital in England, after the lapse of many days or many weeks. Finally, in the English Army, with the Channel and the long train journey interposed between the hospitals in France and those at home, a new and very difficult set of circumstances must be taken into account. But, wherever and whenever the patient is seen, the most urgent desire and the paramount concern of the surgeon is to adopted, whatever procedure, whether of physiological or of antiseptic principle, is trusted, it is the suture of the wound at secure closure of the wound. Whatever mode of dressing is ABSTRACTS OF WAR SURGERY 97 the earliest opportune moment that must be the goal of every effort. So far as our present knowledge will allow us to formu- late conclusions, the following deductions may usefully be drawn : Conclusions. — Perfect mechanical cleansing — that is, the exci- sion of all contaminated, infected, or dead parts — the removal of all fragments of clothing (by far the most important of all causes of continuing infection in a wound) and of all projectiles, is the supreme necessity in all cases. In early cases this may allow of immediate closure of the wound, which will be followed by healing in the great majority of cases, say in 80 per cent or perhaps even 90 per cent of those in which there is no loss of tissue. In infected early cases the mechanical exposure and cleansing may be followed by a treatment directed to the removal of the remaining infection. Physiological and antiseptic methods have each their advocates. The aim of both is to permit of the earliest prudent secondary closure of the wound. In infected late cases, a thorough mechanical exposure and cleansing of the wound and the parts around will allow of secondary closure forthwith if certain antiseptic pastes are used. Experience shows that sim- ilar results have followed upon this mechanical treatment of the wound without the introduction of antiseptics. A further trial in this class of cases may show that the natural defenses of the tissues are ample to deal with the infections then remaining. It is the natural defensive powers of the body fluids and tissues, of serum and leucocytes, that are the chief agents in finally subduing the bacterial infection in a wound. Sufficient reliance does not appear to be placed upon the stupendous power the body tissues possess for controlling infection. Finally full emphasis must be laid on the paramount necessity for the complete immobility of wounded parts at all times and on all occasions. So will one of the most powerful agencies making for reinfection and autoinoculation be kept in check. WOUND EXCISION.— Rev. of War Surg, and Med., May, 1918, i, No. 3, p. 21. At the February meeting of the Association of Military Surgeons of the United States Army in France, Prof. A. Depage furnished an account of the principles underlying wound excision in such clear and orderly fashion that we reprint it, with only insignificant deletions, from the Journal of the American Medical Association, March 23, 1918, page 880 : 98 ABSTRACTS OF WAR SURGERY When we find ourselves in the presence of a flesh wound from a bullet, with punctiform orifice, we consider it useless in most cases to incise, the opening healing as a rule spontaneously with- out showing any complications. We have, however, found ex- ceptions in wounds from a gun fired point-blank or at a short distance, such wound being sometimes in pressing need of inci- sions. In fact, in these cases the projectile almost always causes a tearing of tissues, a veritable laceration, with an area of attri- tion more or less deep, in danger of mortification; it would be imprudent not to take measures of relief. We relieve by in- cisions also when the bullet has severed an important artery and when an aneurysmal hematoma has manifested itself. Here, however, the greatest precautions and the avoidance of any care- lessness are necessary. Cases of this kind are among the most serious and should be undertaken only by an expert surgeon, very sure of himself. When a large artery is cut and the nutrition of the member is in danger he can with great advantage use Tuffier's paraffined tube. Large severed nerves form another class of wounds in which we incise immediately. We can not insist too much on the examination of the motor and sensory functions in the region of the nerve supposed to be injured. The course to follow is summed up by the laying bare of the nerve, the suturing of the two ends, and the placing of the sutured nerve in the neighbor- ing muscular tissue. Fractures caused by bullets require in general an incision. The operation necessary depends more on the complications just cited than on the fracture itself. In wounds from artillery projectiles the conditions are not the same; wounds from bursting shells or bombs are much more serious and are practically always infected, and for this reason require more treatment. Only the small splinters the size of a grain of wheat are left in the flesh, especially if there are a great many of them. All the projectiles of more important dimensions are extracted, and the wound is treated according to the superficiality or depth of the lesion. Subcutaneous through-and-through wounds, suppurating com- paratively little, do not imperatively require incision. However, it is better to have recourse to it, because of the frequent pres- ence of shreds of clothing in the wound. If circumstances per- mit, we extract the foreign matter en masse through the healthy tissue, and we make the suture at once. ABSTRACTS OF \\ \i; SURGER7 '■'> If the wound is slight with subcutaneous course, the extrac- tion of the projectile is in order. However, if the course is no more than 2 or 3 cm., we do not incise. We extract the foreign body with the shreds of clothing by means of a simple curette. If the course is longer, we treat it as a through-and-through wound. In deep through-and-through penetrating wounds with the pro- jectile included, the question is no longer debatable ; incision is necessary in every case. Object of Treatment. — An incision, by opening wide the injured area, relieves the compression of the tissues, constricted by the aponeurotic coverings, and helps the secretions. There must be eliminated from the wound not only the infected foreign bodies (splinters, shreds of clothing, etc.), but also the contaminated tissues, such as injured or mortified flesh, favoring the spread of germs. Let us notice in this respect that the area of attrition, of cellular compromise, is not limited to the tissues that have been directly in contact with the projectile, but extends to a depth of 0.5 to 1 cm., sometimes even to 2 cm. The vitality of these tissues is affected, and there is a great advantage in not allowing them to remain for any length of time with elements less af- fected or completely unaffected. Subsequent progress of the wound in its rapid cure depend on the promptness of the first treatment and the care in its administration. Technic of Excision of Dead Tissue. — Certain surgeons have recommended the removal of the traumatic matter en masse as one would take out a tumor. The length, depth, and direction of the wound being exactly ascertained at need by the introduc- tion of a metal conductor, and the wound being completely isolated from the field of operation, they circumscribe the open- ing with an oval incision, of which the large axis corresponds to the direction of the wound. They cut successively the skin, cel- lular tissues, the aponeurosis, and the muscles, constantly keep- ing in healthy tissue, in such a way as to limit the area that sur- rounds the entire wound. Then they remove en masse the in- jured tissue, being careful to keep the healthy from the con- taminated. The suture may follow immediately. Such a complete operation would constitute without doubt an ideal method of treatment, if the traumatic sources were definitely limited and if we could cut into the flesh without considering the organs it surrounds. But it is needless to say that these con- ditions do not exist when it is a question of deep and extended lesions. It is better then to reserve this process solely for super- 100 ABSTRACTS OF WAR SURGERY ficial and short wounds of which it was a question before. The only incision truly rational consists in a wide opening of the seat of the wound, such as is practiced by the great majority of surgeons. Two things are necessary, the incision and the ex- cision of tissues. Before proceeding to the excision of dead tissue, the surgeon must find out, as accurately as possible, the shape of the wound by different anatomic methods. They are indicated in the follow- ing manner: (1) For through-and- through wounds, orifices of entrance and exit. (2) For the lesser wounds, the orifice of en- trance, on the one hand, and the situation of the projectile as determined by the roentgen ray, the fluoroscope, or the electric vibrator, on the other. The form of the channel being determined, the incision must be made so as to permit a perfect access to the wound without any further damage anatomically. According to our experience, the direction of the incisions must vary according to the part wounded and the nature of the wound: (a) In wounds of the arm, forearm, and lower third of the leg, transverse incisions are inadmissible because of the danger of cut- ting important organs, longitudinal incisions alone are allowed. Whether it is a question of the lesion of a single aspect, or whether both the anterior and posterior aspects have been simultaneously affected, these incisions will always be sufficient to permit of complete excision of dead tissue. The anterior aspect of the leg requires likewise a longitudinal incision, with this restriction, however, that in its upper third a wound of the anterior tibial artery may demand a transverse cutting of the muscle. (&) Wounds of the thigh (anterior and posterior surface), the popliteal space and the calf, through-and-through wounds, and simple penetrating wounds, involving both aspects, must, in gen- eral, be treated by incisions parallel to the axis of the member. A transverse incision would not in this case offer any advantage, and would be of such a nature as to occasion very serious dam- age. Two longitudinal incisions, one in the anterior and the other in the posterior surface, will always permit of a wide approach to the seat of the wound. In the case of a seton or deep penetrating wound, taking in only one aspect, longitudinal incisions would no longer suffice. The muscular masses are too thick to give access to the deep parts of the wound. It is important, however, that the latter should be deeply incised in order to avoid accidents of gas infection, especially to be feared in great muscular masses. Under these ABSTRACTS OF WAR SURGERY 101 conditions one will often be led to make a tranverse incision, cut- ting all the organs or a part of the organs interposed between the cutaneous surface and the deep wound ; on the anterior surface of the thigh the anterior muscle is incised, also the vastus ex- ternus, and perhaps the tendons of the fascia lata ; on the pos- terior face, the biceps and the semimembranosus on the thick of the calf, the twin muscles; and on the posterior surface of the arm the triceps. It goes without saying that the transverse in- cisions must concern only the muscles and the aponeurosis, and respect the nerves and the vessels. After the excision of dead tissue it is well when possible to reestablish the continuity of the severed muscles, with catgut stitches in U form, with the object of reuniting the two ends, suturing at least partially the aponeurosis and the skin. The transverse incision thus made leaves no functional trace, on con- dition, of course, that the suture holds. If there is any doubt on the subject of the cleanliness of the deep wound, the suturing of severed muscles may be postponed two or three days. By this time the surgeon will be sure of the nature and degree of the possible infection. Under certain circumstances, when the excision is done late, and there is already a deep infection, immediate suture of the muscular ends must be given up. If it is a question of superficial through-and-through wound, the free edges of the two orifices are resected and then united by cutting the intervening bridge of tissues, so as to transform the course of the wound into a groove. Then, with a pair of heavy scissors, the injured tissues are completely removed from the sur- face of the groove. To follow then the course of the wound in its depth, precau- tions must be taken against introducing a conductor, such as a grooved probe, which might easily be lost in the muscular tissues. The best way to reach the depth of the wound is to lift the edges of the muscles with two forceps, following the direction of the wound, and to resect the injured parts. If at any time one loses the direction, which happens often in the deeper parts of the wound, a gloved finger introduced into the opening will find it again without difficulty. It is important to notice that the cut muscles contract, and in the course of the work of cleaning the ends must be looked for in order to excise the injured parts. The injured muscles must be resected on all the surface of the wound up to the healthy tissue. This is recognized by its con- 102 ABSTRACTS OF WAR SURGERY tractibility and by its redness, which contrasts with the dull color of the bruised flesh. The incision in the course of its progress leads to the foreign body, which is extracted with the shreds of clothing. When the surface is largely exposed it is well to irrigate the wound with neutral solution of chlorinated soda or with warm physiologic sodium chlorid solution, which shows up the bruised and wounded parts. Regarding the proper disposition of bone fragments, some find it better to remove all splinters by the subperiosteal method; others cling to the idea that only those splinters that are free should be removed, but my idea in this respect is that if the wound is such that immediate suture may be attempted I take out the fragments. If, on the contrary, it is evident that the suture can not be made, by reason of the extent of damage, I do not remove any splinters in the course of the operation, considering it prefer- able to let those splinters affected by necrosis eliminate them- selves spontaneously as fast as the growth progresses. This process has the great advantage of not being followed by a psen- darthrosis and of shortening noticeably the first operation, a thing to be taken into account when it is a question of a serious fracture, and the patient is in a state of shock. Suture of Wounds. — When we incise a wound to prevent in- fection we must at the same time try to put it in a state most favorable to a suture. This may be done immediately after the excision of dead tissue (immediate suture), or within the first five or six days (delayed primary suture), in which case it is executed, as in the immediate suture, by the simple approximation of the edges, or finally, the suture may be made after sterilizing the wound with neutral solution of chlorinated soda (secondary suture). The latter is done the eighth day, after the wound is covered with granula- tions. This necessitates always the freshening of the edges, and it is that which distinguishes it from the preceding sutures. In immediate suture, the treatment varies according to the seat of the lesion: (a) For articular wounds, immediate suture is in order, unless the bony lesions are too extensive. (6) For wounds on the head, face, feet, or hands the richness of venous blood and lymphatic fluid allows the surgeon to make the immediate suture in perfectly systematic fashion, (c) For flesh wounds and frac- tures, indications for the immediate suture are very relative, but surgeons are inclined more and more to generalize them. The suture must be made within 12 hours after the wound has been ABSTRACTS OF WAR SURGERY L03 inflicted and only when the surgeon can watch it during at least 15 days. It offers, as special advantage, automatic reparation of the torn tissues, but the infections that it occasions are always rapid and serious diffuse phlegmonous infections or gas gangrene. Delayed primary suture is especially adapted to flesh wounds and open fractures. It is done after bacteriologic tests, made in the following way: (a) At the first dressing (from 12 to 24 hours after excision of dead tissue) we make a culture test by direct examination. •(&) At the second dressing (from 36 to 48 hours after excision of dead tissue) we take a new culture. If the first, culture does not show the presence of streptococci, and if the microbic enumeration does not go beyond one microbe to two fields, we make a suture. We never suture if the enumeration at the second dressing shows a rising in the microbic curve, even if the microbes are not streptococcic. The delayed primary suture rarely results in failure, involving serious accidents. It offers the inconvenience of requiring two operations ; but the second is of minor importance. Secondary suture is reserved for wounds nonsuturable during the first days because of too much torn tissue or some threatened infection. It offers the great advantage of giving perfect security, but it retards the cure and never gives so complete an anatomic restitution as the preceding sutures. We use it regularly when the microbic curve keeps below one microbe to four fields in two successive examinations, and the culture discloses no streptococci. The deplorable results obtained in those cases have allowed us to establish fairly exact rules on the treatment of wounds, for and against, by suturing. WOUND INFECTIONS: SOME NEW METHODS FOR THE STUDY OF THE VARIOUS FACTORS WHICH COME INTO CONSIDERATION IN THEIR TREATMENT.— A. E. Wright, Proc. Roy. Med. and Chir. Soc, London, 1915, viii, p. 41. In the present war the fact which is of astonishing importance is that always every wound is infected, some of them very badly so. The clothing and skin of the soldiers are usually in a filthy condition. The projectile passing through this zone of filth neces- sarily carries infection along its path, many times very deep and beyond the reach of antiseptics. This results in a primary in- fection of streptococcus with organisms from the feces, especially the gas bacillus and tetanus bacillus. Death may result from 104 ABSTRACTS OF WAR SURGERY erysipelas, cellulitis, tetanus, or gas gangrene. If the wound becomes open, and aerobic conditions prevail, a secondary in- fection with other pus organisms — especially bacillus proteus — may result. The author has undertaken a series of experiments in connec- tion with wound infections. The first problem attacked was: Can the microbes which are found in wound infections live and multiply in the unaltered blood fluids? By means of capillary pipettes successive dilutions of pus were made, 1 to 10, 1 to 100 to 1 to 100,000. These were then separately mixed with an equal quantity of normal serum. After incubation it was found that : (1) higher dilutions of pus gave only streptococcus; (2) lower dilutions gave streptococcus, staphylococcus, and an anaerobic bacillus; (3) all other organisms were inhibited or appeared only after fairly heavy sowing with pus and comparatively late. Pyogenic organisms are therefore classified into (1) serophytes — those finding foodstuffs ready made in blood fluids and can, in the absence of phagocytes, grow without restraint; and (2) sero- saprophytes — those which can not grow and multiply in the blood fluids until a change, probably a degenerative change, has passed over those fluids. The next problem was to determine whether the lymph in a wound acted similarly to the normal blood serum. By means of a special glass leech it was possible to collect the lymph from the wall of a wound and obtain it practically free from phagocytes. It was found that, whereas the wound itself was teeming with many varieties of pus organisms, both serophytes and serosapro- phytes, the lymph within the leech showed a pure culture of streptococcus. The problem next arose as to what was the cause of this "cor- ruption of the lymph" in the wound which allowed all forms of organisms to grow. It has been shown that serosaprophytes re- quire a change in serum before it can be utilized by them as food. This change is opposed to the antitryptic property of the serum. It is only when this antitryptic property has been over- whelmed by an excess of trypsin that the proper preparation of the serum for the serosaprophytes can result. In a wound the antitryptic power of the serum may be overwhelmed by the trypsin obtained either from an especially large number of bac- teria or by the trypsin liberated from broken down phagocytes. This "passive defense" of the blood afforded by its antitryptic power prevents microbes from converting to their uses the nutri- ent substances of the blood fluids and must greatly assist the ABSTRACTS OF WAR SURGERY 105 "active defense" afforded by the phagocytes and the bacterio- tropic substances in the blood. The next problem attacked was : What are the factors which influence the emigration of white blood corpuscles into the wound. The method used was as follows : Capillary tubes were filled with blood and the chemotactic substance under question and immedi- ately centrifuged. On clotting the cellular elements were at the bottom of the tube and, after incubation, it was possible to determine how far the phagocytes had emigrated into the clear clot above. By this method, the following data were determined: (1) Leucocytes will move in any direction toward a chemotactic sub- stance. (2) Anaerobic conditions are more favorable for emigra- tion than aerobic. (3) Emigration occurs more freely at 40° than at 37° ; does not occur at 15° ; when exposed to a temperature of 0° for one hour and when the temperature is raised emigration takes place as before. (4) Vapor of ether does not affect emigra- tion. Vapor of chloroform abolishes it. (5) Physiological salt solution causes vigorous emigration of white cells. Strong salt, e. g., 5 per cent solution — suppresses emigration. (6) Bacterial suspensions when concentrated suppress emigration ; weaker dilu- tions cause vigorous emigration; very weak dilutions act only as diluent acts. The end-result in these tubes with blood and bacteria may be : (1) either destruction of the bacteria or (2) an overrunning by the bacteria with the breaking up of the clot due to the liberation of trypsin from broken down phagocytes. In the treatment of wound infections the first method which suggests itself is the antiseptic method. Antiseptics are of great use as a preliminary application before operation and in recent superficially infected wounds, e. g., a compound fracture. In wounds in war, however, the conditions are different. When the wound reaches the surgeon it is already infected deeply beyond the reach of antiseptics. The track of the projectile is blocked by blood-clot and hernia of muscle. The best that could be ob- tained in these infections would be only a partial sterilization and the infection would in a few days be as bad as before. Concen- trations of the antiseptic which would be effective on the skin would be ineffective in a wound, because its action would be neutralized by the body fluids and pus. Is there any reasonable prospect of sterilizing the wound by the application of antiseptics? It is possible to sterilize the pus in the cavity of the wound. There are, however, recesses which 106 ABSTRACTS OP WAR SURGERY can not be reached and the granulation tissue in the walls of the wound hold microbes which it would be impossible to sterilize. Since it is impossible to sterilize a wound what is the advantage to the patient of having the number of microbes reduced ? "Wright does not believe there is any advantage since the reduction is merely temporary. The soil may be even made more favorable for the microbes by the use of antiseptics. Apparently the only use of antiseptics in the treatment of wounds is as a prophylactic of the graver infections which were present before Lister's time. As treatment the method is not effective. The next method discussed is called the physiological method. This method is the basis of the surgical methods usually advo- cated : namely, the opening and draining of abscesses ; free in- cisions into infiltrated tissues ; hot fomentations ; leaving opera- tion wounds unsutured ; and dispensing with flaps. These meth- ods cause an outflow of pus with the influx of fresh lymph and phagocytes. It is of advantage in most wounds to have a marked outgoing current of lymph with sufficient phagocytes with it to antagonize microbes present but not to destroy the antitryptic power of the serum. In wounds where the infection is in dry and infiltrated tissues with a small amount of serum exuding, it may seem undesirable to have emigration of many phagocytes, also their destruction in the absence of fresh lymph may result in the overpowering of the antitryptic substance in the serum. This would result in a favorable medium for serosaprophytes. The lymphagogue which the author has used successfully for many years consists of a solution of sodium chloride 5 per cent, sodium citrate 0.5 per cent. The third method of treatment is vaccine therapy. In civil life vaccines have proved eminently successful in prophylaxis of certain diseases and in the treatment of certain local infections. In war, experiments have not been carried out to an extent to warrant conclusions. In cases of erysipelas and cellulitis the results are often brilliant. In well-drained wounds vaccines seem to favor phagocytosis and increase the outpouring of lymph. In closed wounds and in septicemia, vaccines do not appear to give good results. TREATMENT OF INFECTED SUPPURATING WAR WOUNDS. — Rutherford Morison. Lancet, London, 1916, cxci, p. 268. The method advocated by the author is as follows: The operative field and wound are first carefully cleansed with 1 :20 ABSTRACTS OF WAR SURGERY 107 carbolic lotion. The wound is then filled with a paste made as follows : bismuth subnitrate 1 ounce ; iodoform 2 ounces ; sufficient paraffin liquid to make a thick paste. The wound is then covered with sterile gauze and the superficial dressing only is changed as often as necessary according to the amount of the discharge. The results have been uniformly satisfactory. TREATMENT OF INFECTED WOUNDS BY PHYSIOLOGICAL METHODS.— A. E. Wright, Brit. Med. Jour., 1916, i, p. 793. The treatment of septic war wounds divides itself naturally into three therapeutic procedures: (1) The aim is to promote the destruction of the microbes deep in the tissues, reestablish normal conditions in the tissues and prevent spreading of the infection. (2) When the deep infection has been exterminated the surface infection must be dealt with. (3) The processes of repair are promoted, tissues brought together, and the denuded surfaces covered. The ordinary antiseptic combines with every kind of albumen, thereby losing its bactericidal and penetrating power. In the customary treatment of wounds, drainage is entirely inadequate. In tissues of normal density nothing like adequate effusion may be obtained, the lymph flow being here rapidly arrested by clot- ting and desiccation. No steps are taken to disperse infiltration or accelerate the separation of the sloughs or bring antibacterial lymphs or phagocytes to the seat of infection. Lastly, in the ordinary treatment of septic wounds not nearly enough care is taken to prevent those active and passive movements which lead to the mechanical impulsion of microbes along the lymphatics and to autoinoculations. Saline dressings supply a means for evoking, in the infected wound, certain requisite physiological reactions. By their aid we can, while inhibiting bacterial growth, drain the tissues, re- solve infiltration, and promote the separation of the sloughs, besides giving other assistance. As to the physical and physiological action of concentrated salt solutions the following facts are noted: (1) A concentrated salt solution will attract water which will carry out with it the whole of the protein substance which it holds in solution. This means that a hypertonic salt solution applied to tissues lying bare in the wound, will operate as a lymphagogue, drawing out from the infected tissues lymph which has spent all its antibac- terial energy and drawing into the tissues from the blood stream 108 ABSTRACTS OF WAR SURGERY lymph, inimical to microbic growth. (2) Brought into direct application upon leucocytes a hypertonic solution will disintegrate them, setting free trypsin. (3) It will inhibit the action of the tryptic ferment. (4) It will inhibit coagulation. (5) It will inhibit leucocytic emigration. (6) It will inhibit microbic growth. Physiological sodium chloride exerts a positive chemiotactic effect on white blood corpuscles. In moderately dilute solution salt does not interfere with the activity of trypsin, nor does it inhibit blood or lymph coagulation, phagocytosis or microbic growth. By the time the patient reaches the clearing station his wound will generally have assumed the character of a lymph-bound, infiltrated, and sloughing wound. By free incision and the ap- plication of hypertonic saline solution a fresh supply of lymph will be drawn into the wound and conditions established in the depth of the wound favorable to the extermination of the mi- crobic infection and in the cavity of the wound conditions which will restore microbic growth. As the salt solution becomes more dilute the tryptic ferment comes into action and goes about its work of cleaning digestion. At the same time leucocytes emigrate into the wound and the discharge begins to assume a purulent character. In cases of gas gangrene, streptococcic cellulitis, infection of joints, continuous lymph-lavage is acquired and necessitates the continuous use of hypertonic salt solution. So also in cases which are threatened with secondary hemorrhage and it is very important to prevent any tryptic action. The author goes into detail as to the method of making proper solutions, and the method of applying hypertonic salt solution so that it may produce an adequate lymphagogic action, and afterwards provide opportunity for digestive cleansing of the wound. Several methods of supplying hypertonic salt solution are described. The author does not favor the use of small sacs containing sodium chloride. As regards the external covering to go over the wet salt dress- ings, the author favors the use of an impervious covering to pre- vent the drying up of the dressing and the subsequent deposi- tion of sodium chloride in the dressings. A septic wound requires to be dressed under two quite different conditions : (1) it requires redressing as soon as tryptic ferment is set free in the cavity of the wound; (2) again, every septic wound should be redressed as soon as it is lymph-bound. The usual method of showing preference in the dressing of ABSTRACTS OP WAR SURGERY 109 wounds where the dressings have become saturated with dis- charges, the author believes, is wrong. A gravely wounded man may have unsoiled dressings. It should be definitely determined that the wound is not lymph-bound and the poisons being ab- sorbed into the system. In order to prevent autoinoculations and a dispersal of septic infection along the lymphatic channels great care should be taken in the handling of infected extremities and in the moving of pa- tients so as to prevent dissemination of infected material. Espe- cially is this true in cases of compound fractures when too often the assistant is allowed to use the lower part of the extremity as a lever to support the limb. A moist dressing with an impervious covering is usually the best method for caring for wounds in preparation for long jour- neys during which they can not be kept under close observation. The method of correcting certain undesirable after-effects which may supervene upon the ill-considered or too long con- tinued use of hypertonic salt solutions; and indications as to when the hypertonic salt solution ought to be discarded in favor of a weaker solution is discussed and several conditions are de- scribed in great detail which may arise following too prolonged use of hypertonic sodium chloride. Physiological salt solution is used in the destruction of the surface infection. As to the final stages in the treatment of the wound, secondary suture is always to be desired if the wound can be made suffi- ciently clean. Careful observation is necessary for at least a week afterward. EXPERIENCES OF A CONSULTING SURGEON. — Enderlen Beitr. z. klin. Chir., 1916, xcviii, p. 419. Enderlen gives his experiences of German war surgery from his diary notes. In the early part of the war, the conservative treatment of wounds was found to be unsuccessful and after October, 1914, active treatment was instituted in lieu of it. Gas phlegmons, or gas burns as they are called by Fraenkel, were seen not only in the superficial but in the deeper tissues, and seemed to result from all kinds of wounds. In the lighter epi- fascial phlegmons incisions and bandages soaked with hydrogen peroxide or acetic acid, and oxygen insufflation generally suf- ficed ; but in the more serious cases and deep involvement ampu- tation of limbs was necessary. 110 ABSTRACTS OF WAR SURGERY During 1914, Enderlen lost 27 out of 34 cases of tetanus, al- though all the usual means were used. The scarcity of tetanus at the present time is due to prophylactic injection. Cranial wounds since October, 1914, have been reexamined, and active measures instituted. Drainage and suturing have given good results. In the case of chest wounds the thorax was closed when possible. In larger defects of the chest wall the lungs were sutured in to prevent mediastinum depression. Autopsy in two cases showed completely collapsed lungs and empyema. Hence, it is best before closing the chest cavity to inflate the lung by simple pressure. Enderlen operated from the beginning in intestinal gunshot wounds and had 67 successful cases out of 154. After ten hours, if not operated, the chances of success are slight. Liver and kidney injuries are better adapted for conservative treatment. Intraperitoneal bladder injuries are mostly fatal. Extraperi- toneal bladder injuries can usually be managed with continuous catheterization. Urethrotomy is generally called for in uretheral injuries. In spinal region injuries the outlook is not entirely hopeless. Treatment should be instituted even though the prognosis is gloomy. In the lumbar spine the results give even better promise. Enderlen mentions a few cases of sectioned nerves which were sutured with good anatomic result. For vascular injuries Enderlen has used ligatures, suturing, and transplantation. The ligature is generally confined to the smaller vessels, but suture will be used in the femoral, popliteal, carotid, and other large vessels as in these cases the ligature of the vessel is liable to cause gangrene in the limb. In the brachial and femoralis Enderlen both sutured and transplanted with good results. THE ADVANCED SURGICAL POST.— J. and P. Fielle, Rev. de chir., 1916, xxxv, p. 302. The authors believe the establishment of advanced surgical posts in the battle line is necessary. In such a post properly constructed and protected the surgeon can operate safely and calmly. Such operations are not only acceptable, but are de- manded by the wounded. The utility of such posts as regards hemorrhagic injuries is unquestionable. In other conditions, such as abdominal wounds, early interven- tion is the essential condition for success. For such the advanced ABSTK \<"I'S OF \V \i! SURGERY 1 1 I post is necessary. Amputations must yield to early resections. Infection is, next to hemorrhage, the cause of numerous amputa- tions which can be avoided by care and attention in the advanced post. Where the wounded can not be despatched every day to clearing hospitals, the advanced surgical post is indispensable. Details are given of 84 operations carried out in such a post, also of the necessary accommodations, construction, and equip- ment. THE WORKING OF A CLEARING AMBULANCE.— A. Latarjet. Lyon chir., 1916, xiii, p. 166. The author gives very interesting particulars of the surgical work done in a field ambulance during a period of offensive. To this ambulance service was assigned the work of receiving all the wounded from an army corps. During the 5 days of at- tack, 9,328 wounded were disposed of. Of these, 5,011 were slightly wounded, and 4,317 had more or less grave wounds. Of the 5,011 slightly wounded, 656 were immediately dispatched to the clearing hospital. The remaining 4,355 were examined and had their wounds dressed. These wounds comprised : Head and neck 732 Thorax 354 Abdomen 102 Upper limbs 1600 Lower limbs 1330 Multiple wounds 46 Shock 191 After the wounds were dressed these men were sent on to the clearing hospitals at the base. The 4,317 injuries of the seriously wounded were as follows : Head 516 Neck 96 Thorax 531 Abdomen 267 Upper limb 816 Lower limb 1443 Spine 18 Genital organs 24 Multiple wounds 565 Gas intoxication, etc 41 Of these 4,317, 108 died during the period within five days, 112 ABSTRACTS OF WAR SURGERY mostly a few hours after arrival and without intervention. Sixty- three died while being conveyed from the field to the ambulance. The total immediate mortality was 254. Of the 531 thoracic wounds, 176 were shell wounds, 132 bullet, and 20 bomb wounds. Twenty-three died between the first and third day from hemorrhage or shock ; 16 died from the fourth to twelfth day. Of the 267 abdominal wounds, 124 were pene- trating. Two hundred and fifty-four of the wounded, intrans- portable and inoperable, were hospitalized on the spot. The others were dispatched to the clearing base hospitals, either by auto or train. Hospitalization within a few hours of injury, immediate large evacuation of wounds, and evacuation only toward the interior when the patients are in a fair way to recover are the ends to be sought if lamentable consequences are to be avoided. INTERALLIED SURGICAL COMMISSION ON TREATMENT OF WOUNDS.— Bull, med., Paris, 1917, p. 125. The Surgical Commission appointed by the allied nations to discuss the treatment of wounds, of which Professor Turner was appointed president, arrived at the following conclusions at its first meeting March 15, 1917 : 1. It is desirable that the organization of service be so ar- ranged as to permit a continuity of surgical direction in the treatment of the wounded. 2. In the fighting posts and especially in the trenches, surgery should be reduced to the minimum. It must be limited to dealing with complications which may be immediately mortal and to the cleansing of wounds. The wound should neither be explored nor irrigated. It should simply be protected by a dry aseptic or antiseptic dressing. 3. It is essential to transport the wounded as quickly as pos- sible to one of the large hospitals at the front which are situated at from 10 to 20 kilometers from the firing lines. 4. It is advantageous that each of these hospitals should have one or several attached advanced annexes, nearer to the firing line, so as to quickly receive certain classes of severely wounded, those in shock or attacked by severe hemorrhage, thoracic, or abdominal injury, etc. 5. Generally speaking war wounds should be considered as contaminated or infected. 6. The object of treatment should be: (1) to prevent infec- ABSTRACTS OF WAR SURGERY 113 tion of the wound if only contaminated, or to obtain steriliza- tion if infection is evident; (2) to permit suturing when clinical sterilization has been obtained. 7. Wide opening up of the wound with resection of contused tissue, removal of debris of clothing, etc., should be considered a matter of course, with exceptions only in certain cases which can be rigidly supervised. 8. After such intervention immediate suture is capable of giving favorable .results, especially in articular wounds. It should be executed only in cases in which the wound is but of a few hours' duration, maximum 8 hours, and when the surgeon can continue supervision of the patient for fifteen days. 9. If immediate suture is not done, secondary suture must be resorted to when sterilization of the wound is sufficiently evident clinically. 10. Evolution of the wound should be systematically con- trolled by periodical bacteriological examinations which will al- low the construction of a microbian curve and determine the degree of sterilization. 11. When there is necessity of evacuating patients whose wounds have been opened up and excised a dressing should be ap- plied, the action of which would continue during all the time of transport. There is need of research in this respect. 12. Several methods of progressive sterilization of wounds exist, which permit secondary suture regularly. THE BACTERIOLOGY OF SEPTIC WOUNDS.— A. Fleming. Lancet, London, 1915, clxxxix, p. 638. The flora of infected war wounds as determined in this war, differs from that of infected wounds in civil practice. The wounds examined — mostly bullet and shell wounds — were all in- fected by the projectiles first passing through dirty clothing covered with mud. Shreds of clothing were commonly found in the wounds, and pieces of clothing of considerable size were found in the larger wounds. The presence of blood and con- tusion in the wound area augmented the tendency to the de- velopment of infection. The organisms found in wounds are divided in three groups : (1) spore-bearing microbes of fecal origin; (2) nonspore-bearing microbes also of fecal origin; and (3) pyogenic cocci. The first group includes bacillus tetani, bacillus aero genes cap- sulatus of Welch and certain putrefactive organisms referred to U4 ABSTRACTS OF WAR SURGERY as bacilli X and G. The habitat of this group is fecal soil, or fecal accumulations from animal and human excreta. The non- spore-bearing organisms of fecal origin are the streptococcus, bacillus proteus, and bacillus coli group, the streptococcus being the most important. It is found in nearly all wounds at a late stage. The third group comprises the streptococcus and staphy- lococcus. The latter is not commonly found in animal feces; it occurs in the later stages of a wound, and it probably invades it from the surrounding skin in which it is normally found. The odor of the cultures of bacilli X and G is very putrid; they are gas producing; they are not pathogenic for guinea pigs. To determine the relationship between the infections in wounds and the bacteria on the clothing, 12 samples of the latter were taken from the wounded on arrival at the base. Pieces an inch square were cut away from the location of the wounds and were planted into broth tubes and cultivated aerobically and anaerobically. Bacillus aerogences capsulatus was found in 10 of the speci- mens ; bacillus tetani in 4 ; streptococcus in 5 ; and staphylococcus in 4. From a study of the bacterial flora of the wounds one recog- nizes three phases. If we take a compound fracture of the femur during the first week, the discharge is a dark reddish-brown fluid, foul-smelling, consisting of blood more or less altered by the growth of fecal organisms which constitute the primary infec- tion. In this stage, the spore-bearing anaerobes and streptococci are mostly present. The second phase represents a transition between the primary anaerobic infection and the infection with pyogenic cocci when the discharge becomes purulent, next less marked, and finally disappearing altogether. This stage lasts from two to three weeks. The third phase is at the end of the third week during which the fecal elements of infection disap- pear and we have a simple infection of pyogenic cocci, staphylo- cocci, and streptococci. A bacteriological study of a number of severe wounds shows that the bacillus aerogenes capsulatus, associated with the strep- tococcus and a few staphylococcus albus, produced gas gangrene on about the third day. The bacillus of Welch is the most prom- inent organism in the pus until the eighth day when coliform bacilli, like proteus and pyocyaneous appear in the wound. A few Welch bacilli may persist in the wound until the thirty- second day. ABSTRACTS OF WAR SURGERY 115 The author finds that there is no difference noticeable in the flora of wounds with gas gangrene and those in which there is no clinical manifestation of this infection. The onset of the in- fection by the Welch bacillus is not so much due to the nature of the infection as it is to the mechanical condition of the wound, such as the presence or absence of free drainage. The tetanus bacillus was found in the clothing of the wounded soldiers and in a large number of the discharges from the wounds. In most of these cases the wounds were serious, with heavy in- fection from other organisms. It was found in company with the Welch bacillus in wounds showing infection from the latter, and a few of such cases actually developed into tetanus. Blood cultures from a number of compound fractures with per- sistent high fever were made, and in 25 per cent of such cases a streptococcus was isolated. Streptococci, as already deter- mined in civil practice, are responsible for septicemic conditions. In one case a pure culture of bacillus coli was isolated. The streptococci recovered from the blood were all of the "strep- tococcus longus" type. One striking feature of the discharges from the wounds was the extraordinary amount of phagocytosis. It was uncommon to see pus in which large numbers of the organisms had not been appropriated by the leucocytes. Cultures from this pus were found quite sterile, showing that the leucocytes had not only in- gested the cocci, but had apparently killed them. This phagocy- tosis leads one to believe that the resistance to infection in war wounds is very great, as compared to the resistance found in in- fection in civil practice, where infection occurs more or less spontaneously in individuals possessed with lower resistance. In civil practice it should be remembered that the infecting agent has often acquired increased virulency in passing from one in- dividual to another ; whereas, the virulency of the agents infect- ing war wounds has been more than likely attenuated by the unfavorable surroundings under which they were existing, the severity of the wound infections being merely the result of the destruction of tissues marked by the presence of laceration, con- tusion, etc., which furnish an admirable culture medium for the bacteria out of reach of the natural protective forces of the body. It is suggested by the author that if all devitalized tissue could be completely removed infections would sink into insignificance. Since this can not be done it is incumbent to practice efficient drainage, remove blood-clot, and do all that is possible to di- minish the amount of culture medium upon which the bacteria 116 ABSTRACTS OF WAR SURGERY are developing. Along with this wound treatment the patient's resistance should be maintained at a high level by the administra- tion of an appropriate vaccine. In this connection Fleming thinks that it is of advantage to administer in every case of infection streptococcus vaccine in small doses of about 1 to 5 millions every five or six days. CICATRIZATION OF WOUNDS; THE USE OF CHLORAMINE- T PASTE FOR THE STERILIZATION OF WOUNDS.— M. Daufresne. Jour. Exper. Med., 1917, xxvi, p. 91. The author draws attention to the fact, as shown in a previous communication, that a wound cicatrizes rapidly if the surface is sterile, and if it is more or less infected, the rate of cicatriza- tion is slow or the wound enlarges. In order to obtain a con- venient method for the sterilization of wounds, Daufresne has endeavored to prepare an antiseptic paste which will retain its aseptic properties. It has been found that ointments and other fatty substances are inefficient when applied to wounds, because the bacteria and antiseptic are covered with fatty material which isolates them from each other and permits the bacteria to multiply freely. Hence the antiseptic paste must be soluble, and the bactericidal agent must be embodied in a substrate suitably chosen so that the whole constitutes a system physically homogeneous. On the other hand, the author states, to enable the antiseptic to act con- tinuously the base should be absorbed slowly by the tissues in order to renew the surface of contact constantly. Neutral sodium stearate was used for this purpose because of the facility with which it is made antiseptic and also because it is not injurious to the tissues. As he states, it is well known that the slightly soluble sodium soaps, far from being irritating agents, are, on the contrary, soothing. Moreover, they give pastes sufficiently plastic for the dressing of wounds. One of Dakin's chloramines was selected as the bactericidal agent, and after many trials the following formula was used by Daufresne. Neutral sodium stearate 86 gm. Chloramine-T 4-10 gm. Distilled water 1000 ccm. Of the less soluble sodium soaps he considers it essential to choose those derived from saturated fatty acids and not having double ethylene linkages. The presence of such groups which ABSTRACTS OF WAR SURGERY 117 readily take up the elements of hypochlorous acid (HCIO) he believes, causes a rapid disappearance of chloramine. On the other hand, stearic acid is a product of sufficient purity and is easily procured ; its sodium salt obtained by boiling the calculated amount diluted with caustic soda is aseptic. Daufresne chose as an antiseptic to combine with the sodium stearate one of the substances studied by Dakin, known as chloram- ine-T, which is the sodium salt of toluene sodium p-sulfochloram- ide. His reasons for choosing this substance were its high bactericidal power, the absence of caustic action on the skin, the possibility of an exact estimation of its strength, and its stability at a high temperature, which allows the substances to dissolve in a boiling solution of stearate. The question of using sodium hypochlorite was not considered because this product changes rapidly under the influence of heat, and especially be- cause of the sensitiveness of soap solutions to the action of electrolytes. The principal disadvantage of this paste is its poor power of preservation ; numerous trials showed that 10 per cent of chlora- mine-T disappeared per month, the author states. Substances which might have rendered the paste more stable were either in- efficient or lessened its keeping properties. The stability of the paste is limited by the stability of the solution of chloramine-T because the antiseptic is in solution in the paste. Daufresne concludes that Dakin 's toluene sodium p-sulfochlora- mide, mixed with sodium stearate, forms a paste sufficiently active and stable to be used in the treatment of wounds. CICATRIZATION OF WOUNDS; STERILIZATION OF WOUNDS WITH CHLORAMINE-T.— A. Carrel, and A. Hartmann, Jour. Exper. Med., 1917, xxvi, p. 95. The authors draw attention to a previous article in which it was shown that the presence of bacteria at the surface of a wound retards the normal process of cicatrization, and accord- ing to the nature and size of the infection, the curve represent- ing cicatrization deviated from the calculated curve. In order to investigate the substances which are capable of influencing tissue repair, they state, it is, therefore, imperative that the wound should be kept in an aseptic condition, as no specific influence on the progress of healing could be attributed to the substance experimented with unless the possible action of in- fection was entirely eliminated. 118 ABSTRACTS OF WAR SURGERY Sterilization of a wound has been found to be easily effected by the application of Dakin's hypochlorite solution at the sur- face of the tissues under appropriate conditions of concentra- tion and duration. In the experiments described in this article, the authors attempted to simplify the method by substituting for the instillations of Dakin's hypochlorite solution a paste designed gradually to yield up to the tissues one of Dakin's chloramines contained therein, and investigations were under- taken to ascertain whether this paste would be able to keep a sterile wound in an aseptic condition, as well as to sterilize an infected wound, and whether it would retard tissue repair. The influence of sodium stearate containing 4 parts per 1,000 of chloramine-T was first tested on surface wounds which had been rendered almost aseptic by instillations of Dakin's hypo- chlorite solution, and in the first experiment a comparison was made of the effect on the bacteriological condition of a slightly infected wound of sodium stearate alone, and of sodium stearate containing 4 parts per 1,000 of chloramine-T. The authors' observation showed, on the one hand, that sodium stearate had no effect on a slightly infected wound, and, on the other hand, that sodium stearate containing 4 parts per 1,000 of chloramine- T, produced surgical asepsis. The bacteria disappeared com- pletely from the films taken from the portions of the wound treated with chloramine-T; whereas they were present in all the films from the part not so treated. Experiments were then undertaken to attempt to maintain in an aseptic condi- tion wounds which had been rendered surgically sterile at the beginning of treatment. Sodium stearate, the authors found, had no effect upon the bacteriological condition of a wound, but the addition of 4 parts per 1,000 of chloramine-T rendered it antiseptic. Their first experiment enabled them to compare the action of sodium stearate alone with that of sodium stearate containing 4 parts per 1,000 of chloramine-T. Wounds which had been previously sterilized could be maintained in an aseptic condition by 4 parts per 1,000 of chloramine-T, although in some cases reinfection occurred. For this reason the concentration of chloramine-T was increased. Surface wounds, deep-seated wounds, and osseous cavities, which had previously been either completely or almost com- pletely sterilized, were maintained for days and even weeks in a condition of surgical asepsis by the use of a paste contain- ABSTRACTS OF WAR SURGERY 119 ing 7 and 10 parts per 1,000 of chloramine-T. Slightly in- fected wounds were sterilized in the same manner. Next, the authors attempted to sterilize wounds which were suppurating and more or less infected, and in some cases ac- companied by fracture. This attempt was probably successful because the wounds used for the experiments showed but slight quantities of secretions and only a shallow layer of necrotic tissue. It was useless to attempt to sterilize severely infected wounds with a paste, for the volume of chloramine-T that could be applied was too limited. A large volume of an active substance was required to sterilize a wound which secreted great quantities of pus, for owing, on the one hand, to the dilution of this substance with the secretions, and, on the other, to its combination with the other proteins contained in the pus, the concentration of the antiseptic was rapidly dimin- ished. For those reasons the authors considered it essential that the antiseptic solution should be constantly renewed, so that the concentration would be sufficiently strong to effect the destruction of the bacteria. Therefore, the chloramine-T they found, could not sterilize a severely infected wound. The concentration of the active substance contained in a paste, they state, must at the same time be sufficiently weak to be innocuous to the tissues, and should not exceed 15 parts per 1,000. Thus, it was evident that if the secretions from the wounds were abundant, the substance could exert its ac- tion upon the microorganisms for the space of only a few hours. For this reason the chloramine paste, they believe, should be applied only under the conditions specified in their experiments, that is, in connection with moderately infected wounds which have been carefully washed with sodium oleate, and possess but slight quantities of secretion. Under these con- ditions the chloramine paste affected the complete disappear- ance of the bacteria and maintained the sterility thus secured for as long a time as wished. If the technic followed in the dress- ing was not exactly as described by the authors, reinfection oc- curred. If applied in this manner the chloramine paste was not injurious to the tissues, for the cicatrization curves of the wounds thus treated showed but slight modifications from the calculated curves. Chloramine paste makes it possible, therefore, the authors conclude, to keep wounds sufficiently free from microorganisms so that the effect of substances which are believed to influence cicatrization can be studied. Under the conditions of their ex- 120 ABSTRACTS OF WAR SURGERY perhnents the paste maintained the asepsis of a wound already sterile and sterilized an infected wound, and under the same conditions it caused no apparent modification of the cicatriza- tion curve of an aseptic wound. STERILIZATION OF WAR WOUNDS.— Dehelly and Dumas. Presse med., 1916, p. 203. The authors give the technic of their treatment for the rapid disinfection of war wounds. They use a solution of 1 :200 of hypochlorite of sodium prepared according to Dakin's method. The special technic for obtaining access to the deeper parts of wounds is described. The treatment comprises surgical inter- vention, continuous instillation, and careful after-treatment. Intervention is done aseptically as under operative conditions, and following this it is necessary that all parts of the wound be kept in permanent contact with the antiseptic solution. For closure of the wound the authors prefer adhesive strips to su- tures. Of 155 cases of extensive wounds due to shells, bombs, and mines which have been treated by this method, 135, or 87.4 per cent, have closed. Of these, 119 were cicatrized in less than 30 days. Twenty-five of the 155 cases were complicated with frac- tures and of these 18 were cicatrized in less than 30 days. CONSIDERATIONS ON SOME WAR INJURIES AFTER EIGHTEEN MONTHS OF CAMPAIGN.— R Proust. Bull, et mem. Soc. de chir. de Paris, 1916, xlii, p. 1270. Proust submits some general ideas gained from eighteen months' experience in field ambulances. From May, 1915, to February, 1916, while in charge of Surgical Automobile Am- bulance No. 1, he cared for 1,800 wounded, most of which had severe infected wounds. The mortality was 23 per cent. In injuries to veins or arteries the author ligates the vessel some distance above and below the injury and resects the in- jured part. In bone lesions, free splinters of bone should be removed, but care must be used as regards other lesions. For articular wounds, Proust believes that when any articu- lation is traversed by a projectile other than a bullet the open- ing must be largely widened so as to ensure drainage ; and cer- tain resections such as of the patella and astragalus may have ABSTRACTS OF WAR SURGERY 121 to be resorted to. Patellectomy has given 15 recoveries in 19 grave wounds of the knee ; 16 shoulder-resections gave 14 recov- eries. Operative indications are exceptional for nerve-resections. In the case of wounds which are difficult of disinfection even after free opening up, Carrel's method, i.e., intermittent instil- lation of freshly prepared Dakin's solution, has given the best results. When amputations are necessary Proust always resorts to plane section. In the 1,800 wounded treated there were 152 amputations with a total mortality of 15 per cent, distributed as follows : 52 thigh amputations 47 per cent mortality. 31 leg amputations 16 per cent mortality. 9 foot amputations 18 per cent mortality. 29 arm amputations 27 per cent mortality. 18 forearm amputations 5.5 per cent mortality. The mortality, however, has decreased under better conditions. Thus from June to July the mortality was 72 per cent, from September to November, 32 per cent, from December to January, 20 per cent. TETANUS ANTITOXIN CONTENT OF THE SERUM OF TETANUS PATIENTS.— H. Wintz, Mimchen. med. Wchnschr., 1915, lxii., p. 1564. Wintz describes his experiments on mice, in which he injected tetanus toxin and the serum of tetanus patients to see if the latter had any antitoxic effect. He found that the serum of tetanus patients contained antitoxin that was capable of neutral- izing tetanus toxin in vitro. The amount of antitoxin varied with the stage of the disease, seeming to be greatest in the be- ginning of convalescence. An amount was found that was pro- tective but not curative for mice. Practically, however, the amounts are so small that they give no hope of being effective in treatment. TREATMENT OF TETANUS.— T. Kocher. Correspondenzbl. f. schweiz. Aerzte, 1915, xlv, p. 1249. Kocher says there are three things to be considered in the treatment of tetanus ; the care and disinfection of the wound as a prophylactic measure, the prophylatic injection of anti- toxin, and the use of magnesium sulphate after the disease has developed. He describes three cases of his own. One of the patients, an adult, died of pneumonia after the tetanus was controlled, while the other two, both children, recovered. One extremely severe case in a boy of 10 had had an incubation of six days and no prophylactic injection of endotoxin had been given. In order to control the convulsions four injections of the magnesium sulphate had to be given the first day, three a day from the second to the tenth day, and one a day from then on till the eighteenth day, the total amount given in the eighteen days being 315 gm. The chief object of the magnesium sulphate treatment is to gain time until the body can form antibodies to overcome the tetanus toxin. Meltzer and Auer found that the maximum dose was 1.5 gm. to 1 kg. of body weight, but Kocher finds that by giving it in fractional doses throughout the twenty-four hours this amount can be given on from six to eighteen successive days 122 ABSTRACTS OF WAR SURGERY 123 without doing any harm. The severer the case the larger initial dose is given, and it may be well to give it intravenously for quicker action. From his experience Kocher has come to the conclusion that it is not necessary to give the full dose recommended by Meltzer and Auer for producing complete relaxation of the muscles ; it is sufficient to reduce the excitability of the centers to such an extent that the convulsions stop, even though some stiffness persists. In giving a dose large enough for this purpose there is practically no danger of producing paralysis of respiration. This is explained by the fact that the hyperexcitability of the nerve-centers that produce convulsions is overcome sooner than their capacity for reaction to physiological stimuli. Large amounts of sulphate can be given because it is excreted very rapidly. INTRASPINAL ADMINISTRATION OF ANTITOXIN IN TETANUS.— M. Nicoll, Jr. Jour. Am. Med. Assn., 1915, lxiv, p. 1982. The results obtained in this series of cases, taken indiscrimi- nately and regardless of clinical conditions, with the low death- rate of 20 per cent, Nicoll claims is due largely to the intraspinal dosage. He recommends the following method of administra- tion: 1. Using 3,000 to 5,000 units an injection is made into the lumbar region of the spinal canal, preferably under an anes- thetic, the volume of the fluid being brought up to 10 to 15 c.c. by the addition of sterile normal saline, the exact amount being regulated according to the age of the patient and the amount of spinal fluid withdrawn. 2. Ten thousand units are used intravenously at the same time. 3. The intraspinal dose is repeated in twenty-four hours. 4. A subcutaneous dose of 10,000 units is given three or four days later. Nicoll strongly urges the adoption of the well recognized ad- juvants to specific treatment, as quiet, subdued light, sedatives, etc. The histories of the 20 cases treated by this method show that the period of incubation ranged from 7 to 11 days; in 4 of the cases this period was undeterminable. In each case the serum was given intraspinally, and, when the symptoms indi- cated, was repeated in 24 hours. It is interesting to note that 124 ABSTRACTS OF WAR SURGERY in one case, a male, the period of incubation 14 days, after 5,000 units had been given intraspinally and 10,000 units in- travenously, there developed marked anaphylaxis, with general urticaria and edema of the glottis and lungs. This, however, passed away after the administration of epinephrin. Forty- eight hours afterward the intraspinal dose was repeated with less reaction. This patient is among the cured. The four fatal cases died suddenly, probably due to a short incubation and the long delay in beginning the treatment. One developed tetanus after a herniotomy, and though he was able to take fluids by mouth, and the convulsions had ceased, he died from pulmonary edema. Nicoll believes that a few of these cases would undoubtedly have recovered if the intraspinal injection had not been given, but the re- sults obtained are so much more favorable than when large doses are used by the intravenous and intramuscular meth- ods that he can not help but claim better results from this method. TREATMENT OF TETANUS BY ENDONEURAL INJECTION OF ANTITETANUS SERUM AND DRAINAGE OF THE NERVE.— F. Kempf. Arch. f. klin. Chir., 1915, cvi, p. 769. Kempf thinks tetanus can be treated much more effectively than it is at present by injecting the antitoxin directly into the nerve-trunks. He describes two cases in which he has used this method. They were quite severe cases with pronounced trismus, difficulty in swallowing, stiffening of the muscles, and attacks of dyspnea. The incubation period was 18 to 20 days, but he is not convinced that the prognosis is dependent on the length of the incubation period. The injections should be made into the nerve-trunks of the motor nerve of the limb affected, in his case the nerves of the axilla. In wounds of the head the trifacial and facial should be injected, and in wounds of the trunk any anatomical atlas will show what nerves supply the region. The endoneural injection blocks the nerve for any toxin that may be produced later and also sends antitoxin to the motor centers in the medulla to overcome the toxin that is already anchored there. Endoneural injection, he thinks is both less dangerous and more effective than subdural injection. The injection needle is pushed into the nerve-trunk toward the center and the fluid emptied by slight pressure. The nerve ABSTRACTS OF WAR SURGERY 125 distends and the distention subsides as the serum is taken up by the nerve, leaving very little at the site of injection. The eye can follow the progress of the antitoxin upward in the nerve. In Kempf's second case, in order to strengthen the effect of the injection, he drained the nerve, the object being to drain the toxin from the body. He used metal tubes fastened with catgut into a longitudinal slit in the nerve. It would be better to use tubes bent at right angles, one arm being inserted into the nerve, the other projecting out of the wound. The tubes should be of soft metal so they can be bent at any desired point and they should be almost as large in diameter as the nerve, so there will be no danger of being occluded. LATE TETANUS.— L. Berard. Bull, de VAcad. de med., Paris, 1915, lxxiv, p. 234. Berard describes a series of cases of tetanus coming on late after the original infection. They begin gradually ; at first there are only slight contractures, which are gradually progressive. All the classical symptoms of tetanus are present, but in mild degree only. One sign which is almost constant is permanent and progessive contracture of the abdominal muscles. It is gen- erally taught that cases which develop late end in recovery, and the ones that have a sudden and stormy onset are fatal. But these cases of which Berard speaks generally result in death from paralysis of the respiratory muscles and asphyxia. He believes they are in general due to reinfection caused by the awakening of latent spore forms of tetanus through secondary surgical operations. In order to prevent reinfection a third dose of antitoxin should be given, in addition to the two regular ones, before any sur- gical intervention is contemplated. The objection might be made that there was danger of anaphylaxis from giving a third dose of the antitoxin, and though this objection would appear to be justified on theoretical grounds Berard has never known it to occur in practice, and since pursuing this course he has had no further difficulty with these cases. CLINICAL AND THERAPEUTICAL EXPERIENCE WITH TETANUS.— B. 0. Pribram. Berl. klin. Wchnschr., 1915, lii, p. 916. Pribram gives the case histories of a series of over 40 cases and comes to the following conclusions : 126 ABSTRACTS OF WAR SURGERY The localization of the spasms is of great importance in prognosis. In cases of lockjaw, opisthotonos, and spasms of peripheral muscle groups the prognosis is relatively good, while in spasm of the glottis and diaphragm it is practically hopeless, even if no other muscles are involved. An early symptom that is a certain precursor of spasm of the diaphragm is epigastric pain. The old rule that the severity of the infection is propor- tional to the shortness of the incubation period does not always hold good. The true incubation is to be reckoned from the time of the production of toxins by the invading bacteria, and this does not always coincide with the moment of infection. The localization of the spasms is independent of the point of injury and also of the intensity of the infection. The most frequent complication of tetanus is confluent lobular pneumonia ; barring suffocation from spasm of the glottis and diaphragm, it causes the most deaths. In many tetanus patients and in almost all who die of tetanus there are marked signs of status lymphaticus, which indicates that predisposition plays an important part in the infection. The best treatment of the wound is the radical removal of all necrotic tissue until fresh bleeding tissue is reached; escharotic antiseptics and the cautery do not appear to be particularly effective. The question of amputation should be decided on the usual surgical principles. The severity of the infection is not at "all parallel to the severity of the wound. It is not logical to give prophylactic treatment except in cases of severe in- jury. Because of the danger of pneumonia ether should never be used. Antitoxin should be given in large doses ; daily injections of 200 to 300 units and in addition, on the first day an intradural injection of 400 to 500 units, with the head lowered. The spasms can be controlled by chloral hydrate, as much as 10 gms. daily, and the subcutaneous injection of magnesium sulphate, 20 c.c. of a 25 per cent solution 5 to 6 times daily. In spasms of the glottis, efforts should be directed toward limiting normal re- spiratory movements and inducing artificial respiration. The former can be accomplished by bilateral phrenicotomy combined with tracheotomy, intradural injection of magnesium sulphate, and the administration of large doses of morphine. If one is prepared to give artificial respiration there is no danger in large doses of morphine. Artificial respiration of oxygen is of great value. \BSTRACTS OF WAR SURGERY 127 INTRANEURAL INJECTION OF TETANUS ANTITOXIN IN LOCAL TETANUS.— A. Meyer. Berl. klin. Wchnschr., 1915, lii, p. 975. It has previously been demonstrated experimentally that the injection of antitoxin into the nerve-trunk of the affected limb saves animals that have been infected with tetanus. Meyer thinks, however, that this method of treatment has not been applied clinically as much as it should be, and describes cases in which he feels confident that such intraneural injections have saved the lives of patients. Many surgeons believe that the prognosis in local tetanus is good even without treatment, but he finds that local tetanus is often only a precursor of gen- eral tetanus, which may be warded off by intraneural injection before the distribution of the toxin becomes general. STATISTICS OF CASES OF TETANUS OBSERVED IN THE WAR ZONE FROM NOVEMBER 1, 1915, TO FEBRUARY 1, 1917. — P. Chavasse. Bull, et mem. Soc. de chir. de Paris, 1917, xliii, p. 1249. The statistics of Chavasse are collected from the reports of the chief of the medical staff of the French field armies and comprise nearly all cases of tetanus occurring at the front be- tween Nov. 1, 1915, and February 1, 1917. The statistics do not indicate cases occurring in the interior hospitals, etc. The eases are included in three categories: (1) Tetanus oc- curring following accidental lesions or after current surgical operation; (2) tetanus occurring as a result of frozen feet (trench-foot) ; (3) tetanus due to gunshot wounds. During the period under consideration 213 cases were re- ported by the armies at the front, 29 being of the first variety, 38 of the second, and 146 of the third. Of the 29 cases of tetanus, accidental and otherwise, 4 had received a prophylactic injection — 2 died and 2 recovered. Of 25 cases which had re- ceived no preventive injection, 16 died. Of the 38 cases of frozen foot tetanus there had been no preventive injection in 36 cases. All died. Thirty-two cases had received from 1 to 3 injections. These cases gave 29 deaths and 3 recoveries. Of the 146 gunshot tetanus cases 9 had received no injec- tions. These gave 6 deaths and 3 recoveries. There were 137 postserum cases with 107 deaths, 5 of which might be imputed to other causes. 128 ABSTRACTS OF WAR SURGERY The general conclusions drawn by Chavasse from his detailed study are : 1. If preventive injections of antitetanic serum, employed in gunshot wounds do not always prevent the development of tetanus, they have incontestably demonstrated their efficacy in bringing about a very notable diminution in this formidable complication. But it can not be held as an unfailing prophylactic. 2. The gravity of tetanus has been shown to be in accord with the gravity of the local lesions. It has been especially prevalent with cases of frozen feet. The gravity at least in war injuries appears to diminish according to the number of preventive injections even though the wounds are very exten- sive. 3. The prophylactic dosage has not always been proportioned to the gravity of the wounds. The usual dose of 10 c.c. ought to be doubled or even trebled at least for the first injection in the case of very extensive wounds or dirty wounds, especially when foreign bodies are present. In wounds of medium grav- ity, if the first dose has been one of 30 c.c, the repeated doses should be from 10 to 15 c.c, but if the first dose has been only 10 c.c. then successive doses should be stronger, say from 20 to 30 c.c at seven to eight-day intervals. This will avoid anaphylaxis. 4. In frozen foot with phlyctenular ulceration or sphacela, the first dose should be 20 to 30 c.c, renewing with from 10 to 15 c.c. or even 20 c.c. in severe cases every eight days till recovery. 5. In order to fortify against late postoperative tetanus it is necessary, according to Berard and Lumiere, to make a pre- ventive injection before any surgical operation whatever. The dose should be 1.0 to 20 c.c. according to the importance of the operation. LOCAL TETANUS.— F. Brunzel. Berl. klin. Wchnschr., 1916, liii, No. 40. Brunzel reports the case of a soldier who after being wounded displayed symptoms of tetanus which was evidently local, there being none or only very slight general manifestations. After treatment by serum the man appeared to be out of all danger when suddenly the temperature rose and within a couple of days he died in delirium cordis, fifteen days after the last serum injection. ABSTRACTS OF WAR SURGERY 12ft Autopsy showed the heart, brain, lungs, etc., quite normal and the cause of death was not determined. It must be ad- mitted as very probable that the death of the patient was due to the tetanus poison, notwithstanding the large dosage of anti- toxin administered. The author thinks the case of interest not merely because it is one in which the tetanic symptoms were purely local, but more so on account of the delayed death which occurred notwithstanding the fact that the local tetanic symp- toms had disappeared for twelve days and that there were no general symptoms clinically recognizable. It is possible that in this case there may have been a ques- tion of a particular variant of the tetanus bacillus, the toxin produced having a predilection for the nerve-centers of the heart since the death was a sudden cardiac death. The case is of particular interest to surgeons because the prognosis of a purely localized tetanus can not a priori be said to be favorable. The local form is only a special form of the general type which is always local at first. The evolution of any particular case can not be foretold so that it is best to treat all cases alike energetically. A REPORT ON TWENTY-FIVE CASES OF TETANUS.— H. R. Dean, Lancet, London, 1917, cxcii, p. 673. Dean reports a series of twenty-five cases of tetanus treated during an interval of four months at the Second Western Gen- eral Hospital. The majority of the men had been wounded in the battle of the Somme. Most, if not all, had probably received prophylactic injections of antitoxin in France. All had sup- purating wounds but, in the majority of cases, they were like the average case sent to a hospital in England. It is significant, however, that a compound fracture was present in 11 ; in 2 a leg had been amputated; and in 7 there was a history of foreign body in the wound. In these cases there was probably dead tissue present providing a suitable medium for the growth of the saprophytic tetanus bacillus. Presence of fracture or foreign body therefore constitutes a strong indication for pro- phylactic antitoxin injection. The length of time elapsing be- tween injury and dressing does not seem to be a factor in the incidence of infection. The incubation period in many of these cases was enormously increased. In 10 cases it was over fifty days. In 5 cases it was about three months. In 9 the wounds at the time of on- 130 ABSTRACTS OF WAR SURGERY set of symptoms were completely or almost completely healed. In at least 5 cases the wounds were such that probably no one would have selected the cases for prophylactic treatment. This latency of infection is due to the prophylactic infection. Un- less this fact is recognized incipient cases will be overlooked and valuable time lost in instituting treatment. The earliest signs may be rheumatic pain and stiffness. Of the 25 cases, 6 received aspirin at the onset. Or the first symptom may be tonic or clonic spasm of muscles in the im- mediate neighborhood of the wound, usually in the nearest flexor group. In 4 of these cases it remained so localized, in 10 others it finally became generalized, and in 11 there was sudden involvement, first of muscles of the jaws and neck. Some of these had received prophylactic injection. Of 5 mild cases treated by intramuscular injection, all re- covered. Of 14 serious generalized cases treated by intraven- ous injection, 13 recovered. Of 5 treated by intrathecal injection with or without other injection, 3 recovered. The choice of method of injection should be governed by the essential principle of treatment, which is to neutralize the toxin at the earliest possible moment. This object can be most eas- ily attained by the intravenous route. The subcutaneous and intramuscular injections are absorbed but slowly and valuable time is lost. As regards the regulation of the size of dose the intrathecal method is the least advantageous. In 5 of the cases injected intravenously cerebrospinal fluid was obtained by lum- bar puncture and antitoxin demonstrated by injection into animals. It is obviously desirable to distribute antitoxin to every part of the central nervous system. The arteries and capillaries afford ideal channels for such distribution. It is difficult to believe that serum injected into the lumbar theca reaches the cells in the medulla more quickly than serum which is injected into a vein. From experimental study of the blood serum of 7 of the patients it was determined that from twenty to thirty-nine days after injection of 30,000 units the blood of the patient may contain appreciable quantities of antitoxin. This, together with clinical evidence in 6 of the patients who received only one injection and who promptly recovered, would seem to indicate that there is no advantage in frequent injections of serum. ABSTRACTS OP WAR SURG) i; , 131 THE INTRATHECAL ROUTE FOR THE ADMINISTRATION OF TETANUS ANTITOXIN.— F. W. Andrews. Lancet, London, 1917, cxcii, p. 682. The relative merits of the subcutaneous, intramuscular, in- travenous, and intrathecal methods of administering tetanus antitoxin practically can not be determined by the statistical method. The primary object always being to cure the patient, more than one route is employed, and wide variation occurs in the dosage. The cases differ widely in the severity of infec- tion and in accidental complications and the more heroic method of injection is apt to be chosen in the most desperate cases. Reliable data is, however, available from animal experimen- tation. Permin of Denmark, showed that antitoxin intrathecally prevented tetanus when intravenous injection did not. Park and Nicoll injected two minimal lethal doses of toxin into guinea pigs, waited until spasm of the legs commenced, and then tried antitoxin by various routes. In experiments on 18 guinea pigs, 2 controls and 6 treated by the intracardiac and 4 by the intraneural routes, all died, while of 6 receiving much smaller intrathecal doses 5 recovered. Sherrington, working with monkeys, found that 10 control monkeys and those treated subcutaneously all died. Of 12 treated intramuscularly all died. Of 16 treated by intravenous injection 10 died, 62.6 per cent. Of 18 treated by the intrathecal route 5 died, 27.7 per cent. The author reports 20 cases, 16 of which were treated in- trathecally with 2 deaths. He believes there is less danger of anaphylactic reaction by intrathecal than by intravenous injec- tion and that the danger of meningeal infection with ordinary care should be negligible. An insufficiently treated case of local tetanus tends to become general. The intrathecal rather than the subcutaneous route should therefore be chosen in all incipient cases. Except in established cases the intrathecal method seems safer in local tetanus also because of the tendency to become general. A COMPARISON OF SUBCUTANEOUS WITH INTRAVEN- OUS ADMINISTRATION OF TETANUS ANTITOXIN IN EXPERIMENTAL TETANUS.— F. Golla. Lancet, London, 1917, cxcii, p. 686. Tests on rabbits and cats show an indubitable superiority of the intravenous and intrathecal route over the subcutaneous, 132 ABSTRACTS OP WAR SURGERY possibly due to the slower absorption by the latter route. The whole problem of serum therapy seems to be to cut off a fresh supply of toxin by bringing antitoxin into relation with the focus of infection. The toxin apparently can not be neutralized after it has entered the central nervous system. The prophylactic administration of serum has converted man from a susceptible to a resistant organism, as evidenced by the occurrence in the majority of cases of local spasm of muscles supplied by the spinal segment directly in nervous continuity with the wound — a clinical picture previously very rare in man but common in highly resistant animals. The toxin may remain localized or may invade the whole nervous system. It is therefore of greater importance to use the more rapid intravenous or intrathecal methods in those not having received prophylactic treatment, but the more rapid method is also the safer in either group. TETANUS IN WAR.— Rev. of War Surg, and Med., July, 1918. A survey of the literature of Tetanus accumulated during the present war, impresses one with the truth of Major Eobertson's (U. S. R.) statement that there is hardly any other disease or any other bacillus about which so much is known, yet about which, beyond the limits of that knowledge, so many questions could be raised. Many of the doubts and uncertainties were in a measure clarified at the meeting of the Research Society of the American Red Cross in France on January 14 and 15, 1918, reported in the Red Cross Medical Bulletin, No. 4. At this meeting Colonel Sir William Leishman, R.A.M.C, stated that experience had taught that the prophylactic dose of 500 units which we in America were accustomed to administer, was a quite sufficient dose for the majority of war wounds, but in instances of severe injury, where the wounds are large, deep and heavily contaminated, and especially when fracture constitutes a wound complication, a prophylactic dose of 1,000 to 1,500 units is necessary. All medi- cal officers are now under direction to administer this larger dose in instances of severe wounds, and also in those instances where the wounded man has lain out in "No Man's Land" for two or three days. Leishman also called attention to the necessity of administering tetanus antitoxin prophylactically in all cases of trench foot. Early in the war, this was done only in those cases of trench foot where there was obvious blistering of the skin. Tetanus, how- ever, continued to be such a constant complication of trench foot, ABSTRACTS OF WAR SURGERY 133 that this order was changed and a prophylactic injection was given even where there was no obvious skin lesion. Since this last order has gone into effect, tetanus has been practically stamped out as a complication of trench foot. The question of repeating prophylactic doses has been actively discussed for two or three years. Sir David Bruce, of the English Tetanus Committee, has recommended that four prophylactic doses should be given at intervals of from seven to eight days. In France this recommendation has been adopted, with the reserva- tion, however, that it need not apply to those soldiers with only slight wounds. This reservation was made in order to avoid hold- ing men unnecessarily long in hospitals. In the lesser injuries, only two doses are given, but the graver cases receive four pro- phylactic injections. Sometimes the third and fourth doses are administered after a soldier has been transported back to Eng- land. Statistical proof is lacking regarding the increased amount of protection given by multiple doses, and on this ground the Tetanus Committee considered it to be an obviously sound policy to maintain the antitoxin concentration in the blood over the period during which danger might be anticipated. From this point of view of prophylaxis, it is important to re- member that tetanus spores may lie dormant quite a while, only to be stirred into activity at the time of the necessary second operation. The practical significance of this fact is that second operations should always be preceded by prophylactic injections. "Wounds involving injured bone or those complicated by retained foreign bodies, are with particular frequency associated with the late development of tetanus following secondary operation. The question which more than any other is shrouded in doubt and uncertainty is the common one regarding the method of administration of antitoxin. It may be administered intraven- ously, intrathecally, intramuscularly, intraneurally, and subcuta- neously. Leishman stated as his belief that we were neither in a position to favor definitely any one of these methods, nor to say which was unqualifiedly the best system of dosage. From innu- merable laboratory experiments a great deal is known of the effects of antitoxin on infected animals, and the rate of absorption, but we can not determine in the case of the wounded soldier to what degree either the tetanus toxin has penetrated or to what extent the outpouring of fresh tetanus toxin is still going on. The dose of the remedy is known, but not the dose of the poison against which it is administered. 134 ABSTRACTS OF WAR SURGERY The impressions gained in France have led many observers to attach more value to the intramuscular and subcutaneous chan- nels than to the other three methods. The English Tetanus Com- mission, however, were not in accord with this, but held rather that repeated intrathecal injections should hold the first place. No one seems to attach much importance to the intraneural route. Figures and analyses appear to indicate that the channels by which the antitoxin was more slowly absorbed (intramuscular, subcutaneous) had given better results on the whole than those by which the antitoxin was more rapidly absorbed (intravenous and intrathecal). On the other hand, there is a large amount of experimental data which would appear to emphasize the value of the intrathecal method, especially if employed early. The intravenous method seems not to be in very common use, a fact which Leishman considers unfortunate, for the reason that it is obviously the most rapid and thorough way by which to saturate the blood and tissues with antitoxin. No case in France treated only by this method has recovered. Robertson stated that experiments upon laboratory animals had shown that each successive inoculation lessened the period of immunity. After the first prophylactic injection, the immunity period lasted approximately twenty-one days. The second injec- tion, however, was as quickly eliminated by the body as any other foreign substance, requiring only seven to eight days as a max- imum. The third dose was effective for even a shorter period. Theoretically, then, by repeating the doses, we reduce the patient's ability to hold the antitoxin in the blood. This fact is important in pointing out the lesson that a prophylactic dose administered before a second operation may not afford protection over a very long time. On the question of doses in the treatment of the disease, there seems to be a general agreement only on a few points, namely — the necessity of high dosage ; the early administration of treat- ment and the persistence in administration well along into con- valescence. It must be stated, however, that huge doses have failed to save a patient, whereas in other instances, what appeared to be totally inadequate doses were accompanied by recovery. Robertson reported that a careful examination of the soil from all parts of the Western front showed that wherever it had been cultivated it had been infected to such an extent that the inocula- tion in a laboratory animal of only one grain invariably produces tetanus. One must, of course, always bear in mind that the body ABSTRACTS OF WAR SURGERY 135 as well as the clothing of every soldier is saturated with infected soil. The general tendency of the members of the Research Society, as mirrored in remarks by both Major Blake and Colonel Sir William Leishman, was very distinctly against the use of mag- nesium sulphate. That this drug undoubtedly controlled convul- sions was not disputed, but it was very far from certain that it did not unfavorably influence the course of the disease. One of the most significant points brought out in the discussion was that we should always bear in mind that the tetanus bacillus itself was not the only factor in the development of symptoms. We must reckon in the first place with the resistance of the wounded individual, and an even more important consideration is the nature and condition of the wound. Clean incised wounds are followed by tetanus as a complication with markedly less frequency than are badly contused lacerated wounds. Although The Medical Bulletin report contains no specific state- ment regarding wound excision, one is thoroughly warranted in assuming that careful wound excision is in itself a powerful factor in combating tetanus. The discussion seemed to confirm the old-fashioned fact that the severity of the clinical symptoms are in inverse proportion to the length of incubation period of the disease. The shorter the incubation period, the more severe the attack. As to methods of treatment other than the specific use of anti- toxin, Leishman stated that the two methods chiefly tried in the earlier period of the war were magnesium sulphate and carbolic acid, both of which have gradually fallen into disuse. Both have been disappointing. The use of carbolic acid seems to have been completely abandoned. Chloral, morphine, and bromides were relied upon and were found to be generally useful, provided they were not administered in poisonous doses. In the Lancet for December 22, 1917, Sir David Bruce furnishes an extensive analysis of all the tetanus cases treated in the home military hospital. This analysis, abstracted in the Medical Record, January 26, 1918, shows a decided decrease in the mor- tality rate (19 per cent) over that of the first analysis, which gave a mortality of 57.7 per cent. He considers that whatever the cause — the prophylactic dose of serum, better surgical treat- ment, quicker diagnosis, more thorough therapeutic treatment, etc. — the result is gratifying. In regard to the proportion of wounded men who contract tetanus in home hospitals, the number may be roughly put down at 1 per 1,000, but since the number of 136 ABSTRACTS OF WAR SURGERY wounded in England has not been published, it is impossible to tell this with exactness. This last analysis deals with 100 cases and shows that if the symptoms of tetanus appeared within ten days of receiving the wound the mortality was 40 per cent; if from the eleventh to the twenty-fourth day, 25 per cent. The remaining 66 cases, with an incubation period of from 25 to 786 days, averaged a mortality of 13.66 per cent. This last incuba- tion period of 786 days is a doubtful case, according to Bruce. The man was reported to have three attacks of tetanus. The last attack, with such a lengthy incubation period, was probably due to a nervous, hysterical condition which was mistaken for tetanus. It has been demonstrated, however, that the tetanus bacilli may remain quiescent for long periods at the site of old wounds, so that 786 days would not seem to be an impossible incubation period. The shortest period of incubation was 3 days, the longest 239. There were only 10 cases with a short incubation period, and 69 cases with an incubation period of more than 22 days. Statistics are showing that the average incubation period has been steadily lengthening since the beginning of the war. Bruce attributes this change principally to the prophylactic injection of antitoxin. In the first year of the war there were 47 per cent of cases with a short incubation, while the last analysis showed a reduction to 10 per cent. In 1914-15 there were only 6.4 per cent of cases with a long incubation period; this has risen to 69 per cent. During the first year of the war many of the wounded did not receive the prophylactic dose of antitoxin, hence the num- ber of acute cases with a short incubation period. Of the 100 cases under consideration in this last analysis, 81 were classed as cases of general tetanus and 19 as cases of local type. In the 81 cases of generalized tetanus there were 58 recoveries and 25 deaths, a mortality of 28.3 per cent. All the cases of localized tetanus recovered. There were 6 cases in which tetanus followed on an operation with one death. In none of these cases was a prophy- lactic inoculation of antitetanic serum given before the operation. As a result the Tetanus Committee advises that when operations are performed at the site of wounds, even if they are healed, the prophylactic injection of serum should invariably be given. Among the 100 cases, 73 received a prophylactic injection of serum in France. Twenty-one cases received secondary prophylactic injection; 8 received three injections, 4 received four injections, and 1 received five injections. Of the 73, 60 recovered and 13 died, a mortality of 17.7 per cent. Of the remaining 27 cases, ABSTRACTS OP WAR SURGERY 137 13 gave no history of prophylactic treatment, 11 of which recov- ered and 2 died. The remaining 14 cases gave no history of prophylactic injection of any kind; of these 10 recovered and 4 died. In the 100 cases reviewed the mortality was 19 per cent. While but 78 of these cases were reported as having received a prophylactic injection in France, the whole of them were treated with antitetanic serum. Eighty-one recovered, 19 died, giving a mortality of 19 per cent. The various routes of injection of the antitetanic serum were employed with no definite results as to the advantage of any special route, nor was the influence of the amount of dosage brought to any definite conclusion. Bruce sums up the results of his fifth analysis as follows : ( 1 ) In the 100 cases of tetanus under review the mortality was only 19 per cent. (2) The incubation period tends to become longer, due to the prophylactic injection. Hence there are only 10 cases reported with an incubation of 10 days or under. (3) Only 14 cases are reported to have received secondary prophylactic injections of antitetanic serum in home hospitals. (4) In regard to the thera- peutic effect of antitoxic serum, the evidence is still inconclusive. GAS GANGRENE GAS GANGRENE.— (ANAEROBIC, ACUTE BACILLARY, OR WAR GANGRENE.— Rev. of War Surg, and Med., March, 1918, i, No. 1. In facing the problem of gas gangrene, three fundamentally significant considerations must be borne in mind if one hopes to gain an orderly conception of this vitally important subject of war surgery : 1. Bacteriologically there is some doubt as to whether we have to deal always with the same strain of gas-producing bac- teria. This point has an important bearing on the problem of developing a specific antiserum. Of even more significance than this is the fact that gas-producing organisms almost al- ways occur in common with other bacteria (symbiosis). 2. Clinically the cases vary along general lines, depending upon the predominance of symptoms referable to the presence of gas, the development of edema, and the tendency to gan- grene. 3. Anatomically variations occur, depending upon whether the process is superficial (subcutaneous) or deep (intramuscu- lar). (Taylor contends that subcutaneous gas is always es- caped intramuscular gas). One of the most important contributions to the bacteriology of gas gangrene was made by Bull and Pritchett of the Rocke- feller Institute, who experimented with five strains of Bacillus welchii, four from infected wounds in the western theater of war, and one obtained from a personal article of clothing. Tests for motility, spore formation, quantitative acid and gas pro- duction, liquefying action on gelatin at 22 and 37 C, patho- genicity for guinea pigs, rabbits, and pigeons, and for still other properties, place all five cultures among the group of B. welchii; so far as they relate to specific properties, e. g., spe- cific and cross agglutination, they indicate certain differences among them such as have been commonly observed among mem- bers of the group. Considering the cause of death in B. welchii infection, Bull and Pritchett state that in man infection with this organism tends to be a local process, even when severe, and invasion of 138 . ABSTRACTS OF WAR SURGERY 139 the general blood occurs, if at all, only during the death agony or postmortem. In a small number of cases in man general infection seems to have played an important part in causing or hastening death. But as these cases are the exception, even when death occurs, in man as well as in the pigeon, rabbit, and guinea pig, it may be assumed that soluble chemical substances entering the circulation from the local lesion bring about the severe symptoms and the fatal termination. From further experiments upon rabbits, the purpose of which was to discover, if possible, soluble toxic substances in the fluid cultures, it was found that an acutely fatal effect can be pro- duced from large quantities of a broth culture injected in- travenously. From the experiments thus far, it would appear that the acutely fatal effects of massive doses of the broth cul- tures as such or when separated in large part from the bacilli themselves are due to some body causing rapid and extensive blood destruction. Acidity was ruled out, by further experi- ments, as the main factor in causing either blood destruction or the fatal effects. It was also found that, in the test tube at least, the B. welchii produces an active hemolysis. Experiments, several times repeated and always consistent, showed that intravenous injections of broth cultures are at- tended by extensive blood destruction and death ; intramuscu- lar injections of like doses cause death with equal certainty and rapidity, but no blood destruction. The essential toxic agent, then, appears to be not an acid and not an hemolysin. Experiments with the toxic filtrate show that B. welchii, when the conditions of growth are suitable, yields toxic prod- ucts of high potency. These products produce two sets of ef- fects, according to the manner of their injection into animals : (a) Hemolysis, in which they resemble the effects arising from ordinary glucose broth cultures; (b) inflammation and necrosis of subcutaneous tissue and muscles, in which they resemble the effects produced by the bacilli themselves. Even moderate quantities of the toxic filtrate locally injected may also bring about rapid death of pigeons. The cause of death, then, in B. welchii infection is not a blood invasion of the microorganisms and not acid intoxication, but an intoxication with definite and very potent poisons pro- duced in the growth of the bacilli in the tissues of the body. The authors call attention to the fact that this conception of the manner of pathogenic action of the Welch bacilli is totally different from any view previously held. 140 ABSTRACTS OF WAR SURGERY Kenneth Taylor, the pathologist of the American Ambulance in Neuilly, considers as possible factors responsible for the gan- grene: (1) The endotoxin contained in the bacillus; (2) the exotoxin elaborated by the bacillus; (3) the toxin elaborated from the tissue undergoing, or which has undergone, degenera- tive changes due to the action of the bacillus (this agent the author terms "tissue toxin") ; and (4) the gas produced by the bacillus. No endotoxin of appreciable activity is present in B. aerogenes capsulatus, the exotoxin is an important part of the infection, the tissue toxin is perhaps a more active fac- tor in the intoxication than is the toxin formed by the bacilli, and the presence of gas is important from (1) its toxicity, and (2) its mechanical action. Taylor experimented extensively in his study of the role played by gas and determined that the actively growing bacilli are capable of producing a pressure which must be extremely destructive to living tissue, and, further, that this pressure must be generated within a very short period of time if the process is, as frequently occurs, restrained by a firm muscle sheath. This pressure must, of course, produce a complete anemia of the muscle within which the pressure is generated and maintain this anemia until the rupture of the muscle sheath occurs. The author concludes further that the subcutaneous crepita- tion, which is so often a symptom, is probably produced by gas which has forced itself through the muscle sheaths, and not by gas produced by the bacillus in this tissue, where, indeed, it is rarely to be found. He believes that when such passage is occluded, the explosive type of the infection may be the re- sult. He thinks it also probable that the bacteria are scattered by the gas pressure, especially when it causes the rupture of restraining tissues. Taylor calls attention to the new surgical problem involved in the effective drainage of the gas instead of a purulent ma- terial. The bulging of the muscle often closes the surgical in- cisions. Incisions parallel to the muscles are inadequate. Transverse section is impracticable. The author believes that the success of many amputations in serious cases is in part due to the opportunity for effective drainage made possible by the transverse section. The author further concludes : 1. The gas produced by the B. aerogenes capsulatus is of little or no importance as a toxic factor. ABSTRACTS OP WAR SURGERY 141 2. The mechanical action of the pressure produced is usually, if not always, the most important part of the infection. To it may be charged the development of highly pathogenic pos- sibilities in a usually rather innocent infection. It brings about (a) the death of the tissues from the resulting anemia pro- duced by a pressure much higher than that of the circulating blood; (b) the actual mechanical fragmentation of the tissues, especially muscle; and (c) the mechanical scattering of the in- fection. 3. One of the chief problems in the treatment of the infec- tion is that of establishing drainage for the escape of the gas before the pressure has resulted in the death of the tissue. Taylor's emphasis of the importance of the mechanical fac- tor is supported by Heitz-Boyer, who, in a paper on "Hema- toma and Gaseous Gangrene," calls attention to the relationship that may exist between a localized hematoma and gaseous gan- grene in the region just below it. Some such hematomas caused by lesions of the large blood vessels serve to check a serious hemorrhage, but in so doing they may lead to gaseous gangrene. Thus a kind of secondary gaseous gangrene is almost inevitable in the case of soldiers whose clothing and skin present a rich and varied bacterial flora. After referring to Sacquepee's bacteriological study of such phenomena, Heitz-Boyer concludes that only amputation can save a case in which this form of gaseous gangrene has set in; but he insists that by proper preventive treatment it may be avoided. In every wound involving lesions of the great blood vessels, he would have the surgeon hunt out carefully all hema- tomas, open them, and ligature the bleeding vessel. The mixed bacterial flora usually associated with gas gangrene were studied by Ivens, who found, in 107 cases studied, that there was usually a mixed bacterial flora: B. perfringens (aero- genes capsulatus) was present in nearly every case, B. sporogenes in 41 cases, Vibron septique in 6 cases (several fatal), B. histolyticus, B. Hibler IX, and B. edematiens were all reported, but less frequently. Streptococci of a virulent type were present in 59 cases, and added to the gravity of the infection. Tetanus occurred in 15 cases and was demonstrated bacteriologically in 7. Eecent studies by Dalyell attach much significance to the B. edematiens as a factor in gas gangrene. The method of cul- tivating this organism is described by him as follows : The test tube containing fluid medium is inoculated and is 142 ABSTRACTS OF WAR SURGERY then heated above the level of the fluid and drawn out into a thin neck. The mouth of the tube is unaltered, and the cot- ton-wool plug is pushed down toward the constriction and the tube attached to a pump and exhausted. During the process of exhaustion gentle heating of the fluid drives out all air dis- solved in the liquid, and the tube is then sealed by Bunsen flame at the constricted neck and is ready for incubation. The author adds that B. dematiens is associated with a pecu- liarly severe form of gas gangrene, characterized by an acute general intoxication and extensive spreading solid edema, with little gas formation other than that due to associated organ- isms in the neighborhood of the wound. He believes that a more careful search under anaerobic conditions would reveal its presence in many cases of gas gangrene. Two important papers by Douglas, Fleming, and Colebrook and Weinberg and Seguin deal with the important aspect of symbiosis. Douglas, Fleming and Colebrook recall the im- portance of bacterial symbiosis which has for many years been well established, especially in the association of anaerobes and aerobes, and of B. influenza with staphylococcus or A. xerosis. In the wounds of the present war, bacterial flora is varied. The primary infection is usually fecal. In the early stages of a wound the anaerobic organisms, B. perfringens, (aerogenes capsulatus) and organisms of putrefaction, flourish together with streptococci, B. proteus, and diphtheroids. The anaerobes gradually disappear, and finally only streptococci, staphylococci, diphtheroids, and, occasionally, B. proteus remain. Besides the B. tetanus, the organisms causing the worst in- fections in the early stages of a wound are B. perfringens, pos- sibly B. edematis maligni and streptococci, while in the later stages streptococci are responsible for almost all the serious complications. Although the others do not produce such com- plications, their presence in the wound may be of very great importance if it can be shown that they in any way stimulate the action of the more dangerous varieties. The experiments are reported in the paper to show that this is probably the case. In milk it was found that the broth culture of B. perfringens would grow only when transferred in the dilutions of 1:10 or 1 :100. When, however, it was combined with staphylococcus and streptococcus it flourished in sowings up to 1 :1,000,000. When thus combined B. perfringens (aerogenes capsulatus) de- veloped gas much more rapidly than under any other conditions ; ABSTRACTS OF WAR SURG] R i 1 t3 it showed first in two and one-half hours, and within lour hours the gas equaled the bulk of the culture fluid. Further experiments with varying technic showed an im- mensely increased activity of B. perfringens when grown in symbiosis with staphylococci or streptococci, and that this in- crease of activity remained the same when the serum media were neutralized either with respect to their alkalinity or to their antitryptic power. It was ascertained also that streptococci and staphylococci are greatly stimulated in growth by the presence of B. per- fringens, and that streptococci are stimulated by the presence of diphtheroids, although diphtheroids appear themselves to be retarded in growth by the presence of the streptococci. The authors believe that symbiosis may be responsible for some of the phenomena of gas gangrene generally considered baffling, such as terrible infections from only a few bacilli, the onset of gas gangrene after careful surgical cleansing and the "explosive" character of gas production within a few hours. Weinberg and Seguin give a summary of the results thus far obtained from their study of gaseous gangrene since 1914. The Bacterial Flora of Gaseous Gangrene. — The authors have studied 91 cases ; all but 2 were military. They were from all parts of the front. No cases were caused by aerobes alone. In 24 cases the anaerobes were unaccompanied by aerobes; in 67 they were found in sym- biosis with one or more aerobe. In 37 cases there was but a single anaerobe; in 54 there were more than 1. According to their frequency, the anaerobes take precedence as follows: B. perfringens (aerogenes capsulatus) in 70 cases (77 per cent), B. edematiens in 31 cases (34 per cent), B. sporogenes in 25 cases (27 per cent), B. fallax in 15 cases (16.5 per cent), Vibrion septique in 12 cases (13 per cent), B. tetani in 9 cases (10 per cent), B. histolyticus in 8 cases (9 per cent), B. aerofsetidus in 5 cases (5.5 per cent), B. putrificus in 2 cases (2 per cent), B. bifermentans in 2 cases (2 per cent), B. Ghon-Sachs II in 1 case (1 per cent), and B. tertius in 1 case (1 per cent). The authors call attention especially to the frequency of four organisms, two of which, B. perfringens and B. sporogenes, were already known at the beginning of the war, and the other two of which, B. edematiens and B. fallax, have been discovered by the authors during the study here outlined. All writers now agree that B. perfringens is the organism most 144 ABSTRACTS OF WAR SURGERY commonly associated with the infection. The importance of B. edematiens (found in a little more than one-third of the cases) lies rather in the fact of the seriousness of most of the cases in which it is concerned. Of the aerobes present, streptococci appeared in about 40 per cent of the cases; it seriously affected the prognosis. Diploccocci (enterococci) appeared in 33 per cent of the cases. Staphylococci were somewhat less frequent. Emery believes that B. aerogenes capsulatus is the sole organ- ism responsible for gas gangrene, and explains the excessive viru- lence of this ordinarily less virulent organism on the ground that, for some reason, the characteristic power of the leucocytes has been lessened. Taylor, in an article in which he traces the effect of the B. aerogenes from its earliest entry into the body, agrees with Emery as regards the sole agency of capsulatus aerogenes, but disagrees with him in that he thinks the mechanical presence of the gas is the main agent in producing gangrene. The first stage of gas in- fection Taylor describes as "dormant." This condition is present in the majority of wounds. The organism has been found present in 70 per cent of all wounds examined bacteriologically at a general military hospital. The bacteria are to be found in the dead mus- cle and gas is sometimes evident in the depths of the wound. The second stage, that of "gaseous distension," is marked by a gaseous infiltration of healthy tissue. Retention of the gas causes sustained pressure. The rapid increase of this intramuscular pres- sure may quickly deprive the tissues of blood until they appear to be wrung dry of fluids. At this point the condition of gangrene supervenes. The "explosive stage" may then follow, in which there is rapid progress of the infection due to the invasion of the gangrenous muscle by the bacilli. The "stage of systemic toxemia" may accompany or follow rap- idly upon the preceding one. Collapse and death usually result. Occasionally a stage of terminal bacteriemia is reached. Evidently the conditions which determine the extension of the process from stage 1 to stage 2 are the most important from a therapeutic point of view. After gaseous distension has developed the problem becomes much more complicated. The author reviews the various explanations of this change: 1. It is contended that several different organisms may pro- duce the disease. Taylor believes, on the other hand, that there is but one distinct species — B. aerogenes capsulatus — responsible for ABSTRACTS OF WAR SURGERY 145 nearly all cases of gas gangrene. B. edematis maligni is the only- other gas-producing organism that may cause extensive lesions in the muscles, but this bacillus rarely, if ever, gives rise to extensive gaseous phlegmons. It is, however, frequently found in the wound itself. The frequent occurrence of subcutaneous edema, the author believes, is due to the obstruction of the deep lymphatics and veins by intramuscular pressure and not to this organism. 2. Taylor does not believe that the different forms of the disease are due to variations in the virulence of the organism, because the various strains of B. aerogenes capsulatus appear almost equally virulent for animals, even when taken from human cases of varying severity. 3. Taylor does not believe that the invasion of the blood by the organism can be responsible for the malignant type of the disease, because the bacillus is rarely to be found in the blood before death. 4. As to the theory that the absorption of soluble toxic products of the bacteria breaks down the natural immunity of the patient, Taylor contends that the exotoxin from the organism is of only small toxicity. Symptoms of toxicity from a local limited focus are slight. 5. Against the theory that the progress of the disease is due to the failure of active immunity, Taylor contends that the spread of the infection is too rapid to allow time for the production of antibodies. 6. The spread of the infection is frequently charged to injury and thrombosis of important blood vessels. Taylor has found thrombosis in autopsy in only a few cases (3 out of 19), and be- lieves it to have been the result rather than the cause of gaseous distention. Ligature of the main artery to a limb, however, may produce the death of tissues in much the same way as gaseous distention. 7. Taylor has shown that the gas itself is not toxic. 8. To the contention that symbiosis of the gas bacillus with other organisms is responsible for a malignant infection, Taylor replies that there is no constant similarity between the flora of the various cases of gas gangrene. Mullaly and McNee and Hartley furnish rather striking clinical evidence to prove that in gas gangrene we are dealing not only with a toxemia but also with an actual bacteremia. Laying aside for a moment the purely bacteriological aspect of the problem and considering only the pathological phenomena of the spread of the gangrene, we learn from McNee and Dunn that 146 ABSTRACTS OF WAR SURGERY they have never seen gas gangrene commence where injury to mus- cle could be excluded. Even in cases of metastatic gas gangrene, local muscular damage seems to be the causing agent. No case of gas gangrene beginning in, and remaining localized to, sub- cutaneous tissue has been noted. The rapidity of the spread of gas gangrene appears to be its most astonishing characteristic. They have found the condition established within 3y 2 hours after a wound, and they have known of a fatal issue within 12 hours after a thigh wound. They note especially that rapid fatality often results from small wounds with a comparatively small gangrenous bulk of muscle, and they conclude that "the material elaborated by the bacilli, whether it be a true toxin or not, is at any rate a powerful systemic poison." The authors summarize the outstanding facts derived from their own observations and those of others, noting that gas gangrene tends to spread longitudinally from end to end of a single muscle while neighboring muscles remain intact, also that the anaerobic organisms are often to be found in perfectly healthy tissues at a considerable distance from the seat of infection, and when so sit- uated they appear to produce no serious results. Although many organisms are frequently to be found in the flora of gas gangrene, B. aerogenes capsulatus appears to the authors to be the commonest. The authors conclude that the rapid spread of gas gangrene is due to the peculiarities of muscle structure, the sheaths of muscle "being so easily detachable as to form potential spaces into which toxic material can readily pass, causing necrosis of the fibers." Bashford summarizes his studies of the pathology of gas gangrene as follows : "The combinations in which 'anaerobic' bacilli occur in gunshot injuries are exceedingly virulent. While the bacilli themselves multiply mainly in the areolar tissue of the endomysium, their products actively destroy the endothelium of vessels, muscle fibers, and blood. Destruction of capillaries, veins, and lymphatics is the outstanding feature of the rapid spread of the infection, which is also accompanied by swelling and degeneration of muscle fibers, and later by the formation of gas. Constitutional symptoms aris- ing from interference with the cardiovascular and heat-regulating mechanism ultimately supervene and usher in the end." He believes that this theory helps to reconcile the contradic- tions noted by Wallace between the D'Este Emery and Taylor theories, while it agrees with Wallace 's clinical account. The author however, adds : ABSTRACTS OP WAR SURGERY 147 "The production of gas is a late and really a subsidiary phe- nomenon, which attracts attention from its mere peculiarity. I have not found it plays any part in the advance of the infection, although it contributes to the later swollen condition. It arises in tissues long dead; for this reason the term 'gas gangrene' is un- fortunate, owing to its implying the necessity of awaiting the de- tection of gas before making a diagnosis." Clinical Considerations. — Clinically gas gangrene presents itself as a fairly definite entity, and yet, as the work of Sacquepee 14 reported by Quenu, shows there are some moot points also in this chapter. Sacquepee encountered what he considered to be a special type of gangrene. The form of gaseous gangrene described in this article is what Saquepee terms "malignant gaseous edema." The clinical char- acteristics are : A considerable edema of the limb, generally more marked at the extremity than near the body ; a bronze discoloration at one point but paleness elsewhere ; an abrupt demarcation of the swelling as in erysipelas. The neighboring muscles as well as the subcutaneous tissues are infiltrated. The discharge from an incis- ion in the skin near the wound appears brown, but slightly yellowish or colorless from an incision at a little distance. An emphysema of a much less extent appears at the same time, and is sometimes im- perceptible clinically, affecting only those tissues in the vicinity of the wound. Incisions show no gas to be present in the region of the edema. For this reason Sacquepee considers the edema the prin- cipal symptom, and the emphysema of secondary importance. He notes the peculiar odor of purification that escapes from the lesions and the infrequent appearance of blebs on the skin. The general condition is characterized by dyspnea without any considerable pulmonary lesions, cooling of the body, weak, high pulse, and a pale, thin, yellowish complexion. The mind remains clear. In a few hours the gaseous edema develops, and when left to it- self, invariably proves fatal. It may continue for 12 hours or up to 4 days. The general and local phenomena do not correspond necessarily in their development, for, although the general phenom- ena appear together with local ones, they may become acute, even resulting in death, while the local phenomena remain limited, rarely involving the whole of a single member. From a careful anatomical study Sacquepee concludes that at the start the lesion is entirely muscular. There is usually found at a definite point in the muscular mass near the wound, although not necessarily contiguous, a gangrenous center, sometimes the size of a 148 ABSTRACTS OF WAR SURGERY fist, appearing as a homogeneous necrosed mass easily crushed ; at a less advanced stage, this center may be no larger than a thumb, and may be hidden away in the muscles so as to escape detection. Gases escape from this mass, but often remain for a considerable time in the muscle before reaching the subcutaneous tissue. Weinberg and Seguin 7 classify the clinical types of gaseous gan- grene as (1) classic, (2) toxic, and (3) mixed. Classic Gaseous Gangrene. — This is characterized as having the following symptoms: " Abundant gas production, considerable gaseous crepitation, often superficial, bronze tint on the skin, blebs, and in fatal cases septicemia often setting in a few hours before death." Of this type of gaseous gangrene the authors believe B. perfringens and V. septique, either singly or in symbiosis, to be the causative agents. Sometimes an extremely toxic organism like the B. edematiens may be associated with the other agents in this type of the disease. Toxic Gaseous Gangrene. — This type differs from the classic in that progressive, spreading edema masks the infiltration of the tis- sues with gas, and together with general symptoms of intoxication, constitutes the most apparent outward sign of the infection. There is rarely septicemia, even in fatal cases. So different is this type from the classic, that surgeons tend to associate it rather with strep- tococcic infections (white erysipelas) than with genuine gaseous infections. The authors consider the B. edematiens the causative agent of this form of the disease, although they state that B. per- fringens sometimes produces similar results. They give in detail a case in which the B. edematiens was responsible, and which was cured after it had reached an alarming stage by the use of antiede- matiens serum. They note, however, that the two organisms are often associated, and that the action of one may disguise the pres- ence and activity of the other. Mixed Gaseous Gangrene. — This form includes cases which pre- sent not only the complex flora (B. edematiens and B. perfringens) but also the leading symptoms of the two preceding varieties (clas- sic and toxic). These symptoms are usually edema and gaseous crepitation. Passing to a consideration of the manner of the infection, the authors discuss: (1) mechanical factors; (2) bacteriological fac- tors. Mechanical Factors. — These include traumatism and bony or vascular lesions. They agree that all injured muscle should be ex- cised as early as possible, and they call attention to the great ABSTRACTS OF WAR SURGERY 149 danger attending cases complicated by bone fracture. About three- fourths of all fatal cases have been complicated by fracture. They note also the gravity of any interruption of circulation, whether due to the nature of the injury, or to artificial causes. They agree with K. Taylor that gas pressure is an important agent in interrupt- ing the circulation and in producing local asphyxiation. Especially serious is any injury to the great vessels which supply the region of the wound. Even after a considerable lapse of time (often weeks or months) gaseous gangrene has broken out as a result of hindrances to the circulation. Bacteriological Factors. — As to the influence of aerobic organ- isms upon the anaerobic bacilli of gaseous gangrene, the authors are not prepared to accept the conclusions of H. Tissier, who contends that B. perfringens and the anaerobic organisms of gaseous gan- grene in general are innocuous except when assisted in their devel- opment by aerobes. Like Taylor and others they have obtained no significant results in laboratory experiments with combinations of aerobes and anaerobes. As to the influence of anaerobic organisms, however, they are better prepared to draw conclusions. They give briefly the results of various experiments with the guinea pig in which the B. hystoli- cus, associated with either B. perfringens or B. edematiens, appears to favor in the most marked manner, the development of the infec- tion. This action the authors explain by the characteristic effect of the B. hystolicus upon the tissues which it invades. They state that it transforms vascular connective tissues into softened hemor- rhagic masses which favor the growth of the other organisms in the same manner as the tissues devitalized by projectiles or other agents. The B. sporogenes also appears to favor the growth of B. per- fringens, but does so by a putrid and gaseous destruction of the tissues. Similarly V. septique and B. perfringens stimulate each other. The authors insist especially upon the fatal nature of the inter- action of B. edematiens with B. perfringens, for the latter is not only stimulated itself by symbiosis, but causes the B. edematiens to flourish to such an extent that this organism gains the upper hand, and, by means of its superior toxicity, is often responsible for death. Inoculation of the guinea pig with any of these mixed cultures produces the same results as are observed clinically. In conclusion they mention the sera which they have prepared against the three most virulent organisms (B. perfringens, V. sep- 150 ABSTRACTS OF WAR SURGERY tique, and B. edematiens), and they state that the injection of these separately or mixed has often given encouraging results as a supplement to surgical treatment. They believe also that this mixed serum will prove more valuable by way of prevention. They hope that it may come to be used as a matter of routine like the antitetanus serum. Wallace 15 studied the subject clinically at a casualty clearing station, and came to the following conclusions : 1. It is rare to meet gas gangrene without a muscle injury. 2. It is chiefly a disease of the muscles and is rarely dangerous unless muscle is involved. 3. The lesion, in its early stages, may be described as a longi- tudinal one, running up and down the wounded muscles from the seat of the lession * * * Muscles and groups of muscles are in- volved while others escape. 4. It is rare to find all the muscles of a segment of a limb in- volved, save in a segment distal to one in which the main blood supply has been cut off. Thus the whole leg dies and becomes gaseous when the femoral artery has been blocked in the thigh. 5. The muscles affected are, in the first instance, the wounded ones. If the pressure caused by the disease is relieved, the gangrene will most probably be confined to these muscles, but if the pressure is not relieved the other muscles may so have their blood supply checked as to fall victim to the infection. 6. Muscles contained in rigid compartments, such as the ante- rior tibial group, are especially prone to die if wounded. 7. There is but little tendency for the infection to pass from one muscle to another. This is well shown in amputation stumps, where one muscle dies and becomes gaseous, while the rest of the cut muscles remain healthy. 8. The infection is farther advanced in the muscles than in the intermuscular areolar planes. 9. The muscles become resonant from the pressure of gas long before they become crepitant to the finger, though this phenomenon may be perceptible at an early date by means of the stethoscope. # # # 10. The presence of gaseous crepitation does not necessarily mean microbic infection. * * * 11. Crepitation is usually a comparatively late phenomenon and is due to the escape of gas into the areolar and subcutaneous tissue. 12. In an infected limb, a vascular lesion will be followed by ABSTRACTS OF WAR SURGERY J 5 1 the death of the muscle or the muscle group, which death would not have followed in an uninfected limb. It is believed that the pres- sure produced by the gas so raises the tension in the limb as finally to arrest the circulation. 13. In an infected limb there are several conditions of the muscles: (a) Normal purple red contractile muscle which may or may not be infected as judged by cultural experiments, (b) Dead, noncontractile, noncrepitant muscle which has a peculiar red color and is less translucent than normal muscle, (c) Dead, noncon- tractile, crepitant muscle which has the same appearance as the last, (d) Brown, black, or diffluent muscle. [Muscle dead from the cutting of the blood supply is a purplish brown and its naked-eye appearance quite different from (b) and («)]■ 14. The microscopic appearance of muscle dead from cutting off its blood supply are different from those of a muscle dead from infection. The striation is present in the former and absent in the latter. 15. The bacteria are between the muscle fibers and not in them. 16. Microscopical examinations suggest that the gas may find its way between the muscle fibers in front of the bacterial in- vasion. 17. In dead infected muscles the fibers are separated from one another. This separation is more marked in muscles that are crepi- tant than in those that have not yet reached that stage. Wallace further calls attention to the fact that muscles with an intact blood supply are also liable to be killed, although the method of their death is not clear. The way in which the infection spreads also is not known. The author believes that pressure is a great factor, but he is uncertain as to whether it acts wholly by cutting off the main blood supply or by allowing the gas to penetrate the muscles and produce an anemia of the individual fibers, or by favor- ing the penetration of the still living muscle by toxins derived di- rectly or indirectly from the bacilli. The extension of the infection Wallace believes may be brought about in two ways : 1. The Toxins Provided By the Bacteria. — Most strik- ing in microscopic section of the muscles dead of gas infection is the loss of striation and the breaking up of the muscle fiber substance. These appearances are quite different from those seen in uninfected dead muscles. Wallace believes there must be some 152 ABSTEACTS OF WAR SURGERY reason for this difference other than the action of gas or the pres- sure of the bacillus, because it appears often to the same extent in microscopic sections in which few or many bacilli are present, and in which there is much or little distension due to the action of gas. He adds : ' ' The change in the muscle fibre may, therefore, be due either to some toxin produced directly or indirectly by the bacteria." Wallace is inclined to agree with Taylor's theory that toxins produced by disintegration of the muscle substance by bac- terial action may supplement the action of the exotoxins of the organism, and Wallace adds that the toxic muscle substance pro- duced in the traumatized portion of the muscle may be carried into the more distal parts of the muscle and cause its death. 2. The Part Played By the Gas. — Regarding the part played in the limb, Wallace believes that nothing but the rapid evolution of gas could possibly account for the tense and tympanic state of the limb, and the rapidity with which this condition is reached. In another communication Wallace 16 discusses the color changes seen in skin and muscle in gas gangrene, declaring himself con- firmed in his support of Taylor's contention (q. v.) that gas gan- grene is primarily and mainly a disease of muscle. The color changes in muscle have a distinct clinical importance, especially from a surgical point of view, as is recognized by Frankau, Drum- mond and Nelligan, Kellogg Speed, and others who have discussed the surgical management of gas infection. Wallace adds to his previous observations a description of the naked-eye alterations in the appearance of the skin and muscle in the sequence in which they occur, with illustrative colored drawings. The x-ray may be used to advantage as an aid in the diagnosis of gas gangrene. Lardennois and Pect 17 have written an instructive article on this topic, in which they show that by following the ex- ample of the Americans and of Ledoux-Lebard in France, they ap- plied this method to the study of gangrenous infections of war wounds. A plate taken of a sound limb shows a gray image of fleshy masses, almost homogeneous. A plate taken of a swollen limb infected by the usual pyogenic organisms gives an aspect only slightly different. The image shows a limb which is increased in volume, the shade is still homogeneous but a little uncertain, light lines mark the muscu- lar interstices. The radiographic aspect of a gangrenous limb is very different. At the beginning during the stage of malign and muscular tume- faction it is easy to follow the progress of destruction of the mus- ABSTRACTS OF WAR SURGERY 153 cles around the infected track, where a light zone with irregular outline becomes visible. At the second stage the destruction has progressed and the gan- grene becomes diffuse. One can then see on the plate spots and strire delineating the muscular bundles in course of digestion. At a later stage the clear spaces are enlarged. The muscular com- partments appear occupied by bubbles of irregular outline and pre- sent a characteristic cloudy aspect. The radiographic aspect of putrified ischemic gangrene without gas is very different. "Wide light spaces separate the muscles but the latter give a normal shadow. In the form of pure malignant edema, the image does not present any of the characteristic aspects that we have just described. To a competent radiographer the nuoroscope gives the same findings. The information furnished by a radiographic examination of gas gangrene is not merely of interest for the study of the method of destruction by the anaerobes and the localization of the process in the muscles. It can also be very useful for the diagnosis of a point of gangrene and even more for the evaluation of its extent. In cer- tain cases this information has rendered valuable service and has permitted us to institute a rational treatment. Treatment. — Under the head of treatment there is, fortunately, a rather striking tendency toward unanimity of opinion. Leriche 18 undertakes to establish : 1. That immediate mechanical cleansing of war wounds suf- fices, without the use of antiseptics, to insure the arrest of serious infections, and normal evolution toward healing; this is accom- plished without any suppuration if the operation is very early, and with only slight suppuration if the operation is performed reasonably soon. 2. That the opening of infected wounds by means of large exci- sions, and with immediate removal of all foreign bodies remaining in place, and of organic gangrenous matter, is sufficient, without antiseptics to arrest the* infectious processes, and permits of healing as early as is usual in civil cases. 3. That disinfection and the repair and healing of infected wounds are accelerated by the early and methodical use of the physical agents of sun, hot air, etc., without any recourse to chem- ical preparations. 4. That in chronic infections of long standing, such as fistulae or other results of infection, and in delayed healing of the soft 154 ABSTRACTS OF WAR SURGERY parts against which antiseptics are of no avail, active surgical treatment permits of rapid healing by reason of the removal of for- eign bodies, of sequestra, and of bony cavities, as well as by skin grafts and the use of large autoplastic subcutaneous detachments. In short, the author declares : "Opening to the air in the fashion of Poncet, by means of a generous and purely aseptic operation, aided from the start by physical agents, is the best manner of treatment for war wounds in all stages of their development ; these wounds are not, at any time amenable to chemicotherapy ; they arise in mechanical disturbances and their treatment should be physiotherapy." At the start the operator should regard every wound as suspi- cious, if not actually infected, and in every case should enlarge it, cleanse it mechanically, and expose it to the open air, according to former theories of primary cleansing, such as would control treat- ment in civil cases. In civil practice all the surgical principles nec- essary in the treatment of war wounds have long since been known and put into practice. Leriche believes that if war surgeons, like civil surgeons, will open deep infected pockets, remove all centers of infection, and provide for adequate drainage there will be no larger proportions of deaths from infections in war than in times of peace. Such treatment, the author believes, is especially effective in deal- ing with gaseous gangrene. The three wound conditions most to be feared in this type of infection are destruction of muscle, the pres- ence of foreign bodies, and hidden pockets. Since gas gangrene is exclusively a muscle infection, and since it arises not from the mere presence of the organism, but from certain conditions in the wound, especially necrosis, which favor the fatal activity of the bacteria, the only sure way of dealing with this infection is com- plete excision of the affected muscle. It suffices, however, to remove only the toxic and gangrenous tissue with the whole zone of the infection. Generally the infectious process is confined to a single muscle, although the gas may have extended far beyond. In case of injury to the blood vessels, Leriche urges removal of all hematoma, and the application of ligatures to the vessels so as to leave no media for infection in the wound. With regard to the bones, Leriche insists upon the removal "not only of free bone fragments in the wound, and of bone splinters on which bits of garments are sometimes found, but also of adherent splinters with a vital periosteum, the health of which might be en- ABSTRACTS OF WAR SURGERY L55 dangered by infection, and which might hinder the ventilation of the fracture." The author reviews, with considerable detail, his own extended experience in dealing with war wounds. Out of about 2,000 limb wounds treated according to these principles practically no cases of serious infection occurred, except when the operation was incom- plete, or certain fragments of foreign matter were overlooked. He believes that the surgeon ' ' ought not to proceed according to imme- diate clinical indications of infection, but with a view to the possi- bilities of its development." By way of postoperative treatment he urges recourse first of all to heliotherapy, and testifies to the remarkable and immediate results of this method of dealing with infected surfaces which are properly exposed. If sun treatment is impossible, hot air and artificial-light methods, although not so effective, are sure to give good results. Frankau, Drummond, and Nelligan 19 recommend early resec- tion of the infected muscles as a conservative measure. The authors have based their work upon the observations made by Wallace, especially to the effect that gas gangrene is chiefly a disease of the muscles ; that it rarely invades all the muscles of a limb, except in a segment completely cut off from blood supply ; that it progresses longitudinally ; that there is little tendency for the infection to pass from one muscle to another. The authors believe that these points can not be controverted. They have made it a point first to explore the primary focus so as to arrest infection by a resection of the infected areas. Such resection may involve a part or the whole of single muscles or groups of muscles. Eesection should be limited, however, to limbs in which the main blood vessel is intact, and which would be worth more than an artificial limb when saved; otherwise amputation should be preferred. Resection of large groups of muscle is to be chosen, nevertheless, if amputation involves too great a risk of life. The resection should extend until muscle is reached with normal color, normal contractibility, and a good blood supply. Even if there is still infection in such muscles, the opening of the wound and free drainage arrests further development. After resection, the following treatment is applied: (1) The dressings are reduced to the minimum ; that is, one or two layers of gauze are placed over the wound so as to allow free access of air, and, if possible, sunshine to the wound region; (2) constant 156 ABSTRACTS OF WAR SURGERY or intermittent irrigation of the wound by some modification of the Carrel method — eusol, saline, or hydrogen peroxide being used as the irrigating fluid. The authors detail 14 cases in which such treatment has given excellent results. They call attention especially to one case in which the removal of only half of a muscle was necessary, because the infection showed no disposition to progress trans- versely. They also cite several cases in which generous resection took the place of amputations that would surely have proved fatal. Basing his views upon bacteriologic and histologic findings, Kellogg Speed, 20 Major, M. R. C, United States Army, France, recommends early and radical operation. When the discharge from a gunshot wound stimulates gas infection, when pain and swelling are out of proportion to the size of the wound tract, gas bubbles can be expressed by slight pressure, and the toxic condition is supervening, one should at least explore thoroughly the suspected gaseous area. Excision of the tousled tissue of the wound of entrance one-half inch from the margin is first per- formed. Constrictors should never be applied, because even a temporary arrest of the circulation may lead to a rapid spread of the infection. If wounds of exit and entrance are both pres- ent, they are treated alike regardless of location or extent. The affected tissue should then be laid open by a bold incision con- necting the two wounds if present, or in the long axis of an ex- tremity, if an entrance penetration wound alone exists. Dam- aged infected muscle is then removed either by sharp or finger dissection, through normal planes of cleavage as much as can possibly be done without the opening of uninvolved muscles of fascial areas. It is unusual to find all the muscles of a limb involved unless the main blood supply has been cut off. Nor does infection tend to travel into neighboring muscles, unless they have been damaged by the missile. Very extensive dissections which disregard the future function of a limb are indicated, according to Speed, when the patient's condition or other factors will not warrant amputa- tion. In the presence of gunshot fractures, these excisions, fol- lowed by suitable splinting and extensions, lead to favorable results. If the mutilation is such as to render the limb func- tionally useless, amputation is best, provided the patient's con- dition permits. The use of spinal anesthesia (stovain) in lower extremity surgery should not be overlooked when amputation shock is to be avoided. ABSTRACTS OF WAR SURGERY 157 The muscle excision should be carried to the point at which the fibers remain uncolored by the advancing infection — until the muscle belly jerks under the cutting knife, or until normal contractility is found, and until bloody oozing from the cut muscle bundles indicates a healthful blood supply. These operative steps, which are limb and life saving devices, must be thoroughly, rapidly, and anatomically performed. A small amount of tissue hemorrhage is not disturbed by the operator; large bleeding points must be ligated, but the amount of circu- lation present should be left undisturbed as much as possible by operative manipulation. These wounds should be left wide open without suture, and for the most part should be treated by the Carrel-Dakin method until danger of extension is past, or by warm baths selected by the surgeon. The leucocyte infiltration and outpour of pus mean an end to the gas infection. Taylor 9 outlines the treatment of gas gangrene as follows: 1. Prophylactic treatment during the dormant stage. 2. Treatment during the stage of gaseous distention. 3. Treatment of accomplished gangrene. Prophylactic Treatment During- the Dormant Stage. — This includes: First, an attempt toward the removal or destruction of the bacteria present in the wound and toward depriving them of their necessary soil, the dead muscle; second, the institution of precautionary measures against the occurrence of gaseous distention. Time is an important factor. The shorter the inter- val between injury and treatment the more certain is a success- ful result. Thorough cleansing of the fresh wound is necessary, including the removal of all foreign bodies possible. (Under "foreign bodies" we include dirt, fragments of cloth, fragments of bone, and also any portions of muscle showing signs of necro- sis.) Following the cleansing of the wound, the use of an anti- septic active against the gas bacillus is clearly indicated. For this purpose Taylor recommends a one-tenth per cent solution of quinine hydrochloride in physiological saline as effective clinically. * Oxygen, injected subcutaneously, can not reach the seat of the infection in the muscle, and it probably only increases the difficulties of circulation and tends to give a wrong idea of the extent of the gas formed by the bacilli. The use of antisera and vaccines is of doubtful value, if we consider the organism as a saprophyte, which has not invaded 158 ABSTRACTS OF WAR SURGERY living tissue, and the damage done to the tissues as of a mechan- ical nature. It is also very uncertain that the muscle — toxic, hemolytic principle formed by the bacteria is a true soluble exo- toxin for which an antitoxic serum can be produced. Treatment During the Stage of Gaseous Distension. — This stage is marked by increasing intramuscular pressure, which may result in the speedy death of the muscle. The pressure should therefore be relieved at the earliest possible moment. It is neces- sary to practice more incisions for the release of gaseous pressure than are needed for the draining of exudates. It is highly im- portant, if possible, to find the focus of necrotic tissue where the gas is being formed and to remove all necrotic portions. Post- operative treatment should be similar to that mentioned above. Treatment of Gangrene. — If incisions into the muscle show a pale, dry, dull pink surface, and a consistency as if wrung dry of blood and lymph, the condition of gangrene is probably accomplished. The dead muscle is then a great menace to the patient, first, because it will speedily become an active source of gas production by the rapid invasion of the bacilli, and secondly, because the products of autolysis of a large mass of tissue may of themselves produce a profound toxemia. Muscle in this con- dition will never regain its vitality. If the patient lives, it will be found to slough out in large fragments, sometimes as an entire muscle. Hence the treatment indicated is to remove the gan- grenous tissue as quickly and as thoroughly as possible. This can usually be done only by amputation, if the process is in an extremity. No attempt should be made to cover the stump with skin flaps. The transverse section of the muscle fibers allows of free drainage of gas, and, unless extensive necrosis has occurred in the muscle tissues remaining, the process is fre- quently checked. The presence of subcutaneous crepitus above the possible limit of amputation, or even the presence of muscle involvement above that line, does not mean that the process will continue after the operation. Wallace 15 bases on his clinical experience the following four conclusions regarding treatment : (a) The avoidance of all pressure or other hindrance to cir- culation, and recommends especially that all hemorrhages and hematomata be hunted out and corrected. In cases involving the injury or thrombosis of great vessels he urges that an attempt be made to suture rather than resort to ligature. Tuffier's tube may be serviceable. ABSTRACTS OF WAR SURGERY 159 (b) In considering amputation it is well to remember that only the wounded muscle is likely to be infected with gaseous gangrene, and that excision or the ablation of this muscle usually suffices to arrest infection. This is not so easily accomplished, however, in the thigh as in the leg, in which case it is fairly easy to save the limb by the ablation of the anterior tibial group. The same holds true for the muscles of the forearm. The brick red color and the noncontractibility will show at once which muscles are past saving. (c) "When gas gangrene occurs in a segment of a limb distal to the segment wounded it nearly always means that the main artery is blocked and amputation of the gangrenous segment is the only course. (d) "Wallace warns against taking the extent of crepitation of the skin as an indication for amputation, for it may not neces- sarily indicate a state of infection requiring such drastic treat- ment. The surgeon before deciding should determine accurately the exact condition of the muscles and the number involved. Otherwise many limbs may be sacrificed when the removal of only a single muscle might serve to check the infection. One of the newer phases of the treatment of gas gangrene is the use of serum. In 1916 Weinberg 21 published a paper on this subject, stating that at the beginning of the war he and his associates prepared an anti B. perfringens (aerogenes capsula- tus) vaccine which seemed to yield good results in cases of sub- acute gas gangrene in which the B. perfringens was the most pathogenic organism. The author believes, however, that the best vaccine would be one prepared with all the organisms, both aerobes and anaerobes, to be found in the wounds. Such vaccine could not be prepared by the classic method, because the spores resist the temperature, but it has been produced by treating the mixture of organisms with iodine. Since the vaccine should be used at the earliest possible moment, the author prepares the omnivalent iodized autovaccine from the wound discharge with a delay of not more than two hours. Several injections are made daily or every two days. Later, if thought best, an autovaccine may be prepared with cultures of the isolated organisms. Weinberg believes that this treatment should be employed as a supplement to the large excision and antiseptic methods, but he believes that it has yielded good results. Weinberg tells of a serum obtained from horses after B. perfringens had been injected for a year. Although the activity of this serum is comparatively small, it has given excellent 160 ABSTRACTS OF WAR SURGERY results in a number of eases, although, it appears powerless against septicemia. Similarly antitoxic sera of the Vibrion septique and B. ede- matiens have been prepared. On the whole the results of such experiments .have been disappointing, and the sera difficult to obtain. The Use of the Serum of Leclainche and Vallee. — Weinberg speaks favorably also of the use of Leclainche 's and Vallee 's polyvalent serum, especially in wounds infected with strepto- cocci. The use of this serum for gas gangrene is mentioned favor- ably by M. Quenu, M. L. Bazy, and M. Eoutier in a discussion of a paper on the "Reappearance of gaseous gangrene in second- ary amputations" (Archives de Medecine et de Pharmacie Mili- taires, March, 1917, p. 402). Bull and Pritchett, 1 having demonstrated that the toxic products of the growth of B. welchii exhibit antigenic activities and readily give rise to the formation of active antitoxic sub- stances, next investigated the question of whether the immune serum developed possessed protective and curative properties. Their investigations in this direction indicate that in B. welchii infection in nature, the development of the spores into vegative bacilli may be prevented by protective inoculation of an anti- toxic serum, and also that the vegetative bacilli may be deprived of their toxic products, which appear to be their real offensive instrument. Thus, not only is there developed a new point of view regard- ing the manner of the pathogenic action of the Welch group of bacilli, but there is provided a new means of combating their pathogenic effects. Following this new therapeutic suggestion, Bull 22 conducted a more extensive and systematic series of experiments with ref- erence to the preventive and curative powers of the antitoxin. The highly suggestive experimental results thus obtained derive their significance from the fact that B. welchii infections in guinea pigs and other susceptible animals are comparable with infections with this organism in man. The experimental infec- tions in the guinea pig differ, however, from the natural infection in man. The possibilities of this passive serum protection has natural limits of time, depending upon the rapidity of elimination of the foreign serum. The experimental data presented, which agree with the experience with antidiphtheritic and antitetanic anti- ABSTRACTS OF WAR SURGERY 101 toxins, indicate that, in all probability, a passive immunity to B. welchii infection of at least two weeks' duration can be conferred upon a man by a single injection of the antitoxin. This immunity will be sufficient in the majority of instances, since only sporadic cases of B. welchii infection arise later than the tenth day after injury, and the greater number occur within 48 hours of that time. In the light of the results obtained in treating the infection in guinea pigs, it is reasonable to hope that the antitoxin will be of value also as a therapeutic agent. The indications are that early infectious cases can be readily arrested and the more advanced and severe ones ameliorated, if not wholly checked, so that surgical interference may be resorted to with greater prob- ability of effectiveness. The antitoxin in man should be administered intravenously and probably locally, about the wound, as well. In a later communication Bull and Pritchett 23 detail at length a series of experiments with 22 additional strains of B. welchii, collected from widely different sources, and tested with regard to toxin production. It was found that each strain pro- duces a toxin which, on animal inoculation, gives rise to lesions comparable in every respect to those produced by the toxins pre- viously reported on, and each toxin was neutralized by an im- mune (antitoxic) serum produced with one of the former toxins. The toxins obtained from the several individual strains varied in potency, the lethal dose ranging from 0.3 to 3 c.c. The antitoxin for B. welchii toxin can apparently be pre- pared from a single strain of the organism which yields under the conditions described a high titer of toxin, and this antitoxin can be employed to combat infection with or prevent infection by any strain whatever of the bacillus. The report of the Third Interallied Surgical Conference, held in November, 1917, did not furnish a very enthusiastic outlook for the serum treatment of gas gangrene. This conference reported as follows: Because of accidents, in some cases of gas gangrene, an alkaline treatment* has been instituted. This may be for the purpose of rendering a later operation possible in the case of patients whose condition does not permit of a primary operation ; or it may be employed for disintoxication. Encouraging results * Intravenous injection of 500 grams of the following solution, sterilized in the autoclave: Bicarbonate of soda, 50 grams; distilled water, to 1,000. 162 ABSTRACTS OF WAR SURGERY have been obtained by this treatment. Further attempts should be made in this direction. Some cases have been treated by various specific sera: anti- Perfringens, anti-Vibrion septique, anti-Bellonensis. These three sera have produced no unfavorable results. The anti-Perfringens serum, which has been used prevent- ively in several cases, seems to have given encouraging results. As a cure it has been sufficiently successful to warrant further attempts. The use of anti-Vibrion septique and anti-Bellonensis has given very marked results, by way of cure as well as of preven- tion, even when administered in very advanced stages of toxic forms of the disease. These results make further tests desirable. Bibliography. lBull, Carroll G., and Pritchett, Ida W. : Toxin and Antitoxin of and Pro- tective Inoculation Against Bacillus welchii, Jour. Exper. Med., July, 1917, xxvi, No. 1, p. 119. 2Taylor, Kenneth: Factors Responsible for Gaseous Gangrene, Lancet, London, January 15, 1916, (Abs. from Med. Bull.*). 3Heitz-Boyer: Hematoma and Gaseous Gangrene, Arch. d. M6d., et d. Pharmacie Militaires, November, 1916, (Abs. from Med. Bull.). 4Ivens, H. F.: A Clinical Study of Anaerobic Wound Infection, Lancet, London, December 23, 1916, p. 1058, (Abs. from Med. Bull.). 5Dalvell, E. J.: A Case of Gas Gangrene Associated with B. edematiens, Brit. Med. Jour., March 17, 1917, (Abs. from Med. Bull.). ^Douglas, S. R., Fleming, A., and Colebrook, L.: Studies in Wound Infec- tions: On the Question of Bacterial Symbiosis in Wound Infections, Lancet, London, April 21, 1917, (Abs. from Med Bull.). ^Weinberg, M. and Seguin, P.: Studies Concerning Gaseous Gangrene, Ann. d. l'lnst. Pasteur, September, 1917, xxxi, 442, (Abs. from Med. Bull.). 8Emery, W. d'Este: Some Factors in the Pathology of Gas Gangrene, Lancet, London, May 6, 1916, (Abs. from Med. Bull.). 9Taylor, Kenneth: Gas Gangrene: Its Course and Treatment, Bull. Johns Hopkins Hosp., October, 1916, xxvii, No. 308, (Abs. from Med. Bull.). lOMullally, G. T., and McNee, J. W.: A Case of Gas Gangrene Exhibit- ing Unusual Proofs of a Blood Infection, Brit. Med. Jour., April 1, 1916, (Abs. from Med. Bull.). HHartley, J. N. J.: Metastatic Gas Gangrene, Brit. Med. Jour., April 14, 1917, (Abs. from Med Bull.). i2McNee, J. W., and Dunn, J. Shaw: The Method of Spread of Gas Gan- grene into Living Muscle, Brit. Med. Jour., June 2, 1917, (Abs. from Med. Bull.). i3Bashford, E. F.: General Pathology of Acute Bacillary Gangrene Arising in Gunshot Injuries of Muscle, Brit. Jour. Surg., April, 1917, (Abs. from Med. Bull.). i^Sacquepee, M. (Reported by E. Quenu) : A Form of Gaseous Gangrene, with Special Reference to Malignant Gaseous Edema, Bull, et Mem. Soc. de Chir. de Paris, June 1, 1915, (Abs. from Med. Bull.). loWallace, Cuthbert S.: Gas Gangrene as Seen at the Casualty Stations, Jour. Roy. Army Med. Corps, May, 1917, (Abs. from Med. Bull.). *The Medical Bulletin. A Review of War Medicine, Surgery, and Hygiene. December, 1917. Vol. 1, No. 2. Published by the American Red Cross Society in France. ABSTRACTS OF WAR SURGERY 163 iGWallace, Cuthbert: The Color Changes Seen in the Skin and Muscle in Gas Gangrene, Brit. Med. Jour., June 2, 1917, (Abs. from Med. Bull.). iTLardonnois, G., and Pech.: Radiographic Aspects of Gangrenous Infec- tions of War Wounds and of Gas Gangrene in Particular, Jour, de Radiologic et d'Electrologie, May-June, 1917, (Abs. from Med. Bull.). i8Leriche, R.: Aseptic and Physical Means of Treatment for War Wounds in Various Stages, Lyon Chirurgical, January-February, 1916, (Abs. from Med. Bull.). i9Frankau, C. H. S., Drummond, Hamilton, and Nelligan, G. E.: The Suc- cessful Conservative Treatment of Early Gas Gangrene in Limbs by the Resection of Infected Muscles, Brit. Med. Jour., June 2, 1917, (Abs. from Med. Bull.). 20Speed, Kellogg: Localized Gas Infections in War Wounds Treated by Muscle Group Excision, Jour. Am. Med. Assn., January 26, 1918, p. 225. 2iWeinberg, M.: Treatment of Gaseous Gangrene by the Use of Serum, Proc. Roy. Soc. Med., 1916, ix, p. 119, (Abs. from Med. Bull.). 22Bull, Carroll G.: The Prophylactic and Therapeutic Properties of the Antitoxin for Bacillus welchii, Jour. Exper. Med., October, 1917, xxvi, No. 4, p. 603. 23Bull, Carroll G., and Pritchett, Ida W.: Identity of the Toxins of Differ- ent Strains of Bacillus welchii and Factors Influencing their Produc- tion in Vitro, Jour. Exper. Med., December, 1917, xxvi, No. 6, p. 867. GAS PHLEGMONS ON THE FIELD.— G. Seefisch. Deutsch. med. Wchnschr., 1915, xli, p. 256. Gas phlegmons, which are frequently observed after injuries from artillery fire, very frequently lead to gangrene, but the prognosis, even when there is very great development of gas is not bad if extensive incisions are promptly made into healthy tissue. Amputation must be performed near the boundary of the gangrene, and care must be taken to make a useful stump; secondary suture should be performed as soon as possible — within the first week. If a gas phlegmon is recognized early and free incisions made, gangrene can be prevented. Seefisch has treated 12 severe cases of gangrene on these principles without losing one, and most of them could be discharged within a few weeks with a good stump almost completely healed. Of course most of the cases of gas phlegmon, and the severest ones, are seen in the field hos- pitals, where it is difficult to give oxygen treatment, because the physicians are so overwhelmed with the numbers of wounded brought in during the day that there is no time for it. The cases may be irrigated, however, with hydrogen peroxide. TREATMENT OF GAS PHLEGMON IN THE FIELD.— W. Becker. Med. Klin., 1915, xi, p. 329. The author treats superficial wounds by painting the sur- rounding skin with tincture of iodine and irrigating the wounds with three per cent hydrogen peroxide. Dry dressings should 164 ABSTRACTS OF WAR SURGERY always be used, as moist dressings favor the development of bac- teria. Pockets and cavities should be kept open. Unnecessary dressings and too early transportation should be avoided, for rest and fixation are the best treatment. During the dry weather of the first few months of the war there was little severe infec- tion, but after the rains set in and the wounds were soiled with mud from the trenches conditions were much worse. The per- centage of tetanus infections was very high, and in spite of the administration of tetanus antitoxin, the majority of the patients died. Gas phlegmon is more unusual. It is distinguished by a cop- per color of the skin, rapidly increasing edema, and in the worst cases, gangrene. The danger lies in the rapidity of its develop- ment. The mortality is at least four-fifths of the total number of cases. Three cases are described illustrating the rapidity of development of gangrene. After gangrene has developed ampu- tation is the only treatment ; if the cases are seen early and treat- ment given at once, insufflation of oxygen is effective. It is difficult to keep a supply of oxygen at the front, but the author suggests that an abundant supply of oxygen tanks be kept at a field hospital as near as possible to the lines and the wounded rushed to it as quickly as possible by automobile. ABDOMEN A SERIES OF 500 CASES OF EMERGENCY OPERATIONS FOR ABDOMINAL WOUNDS.— C. F. Walters, H. D. Rol- linson, A. R. Jordan, and A. G. Banks. Lancet, London, 1917, cxcii, p. 207. The 500 cases were operated upon at a clearing station near the fighting line in a house with steam heat, which already had one operating room to which another was quickly added. The report is more of an attempt to summarize results of experi- ence in diagnosis and treatment than to attempt an elaborate description of them. The patients were received as early as three hours after being shot, but some were received after the lapse of a greater length of time. Time Element in Prognosis and Treatment. — The authors state that an abdominal patient's chances diminish with every hour of delay. The vast majority received hospital care in 8 to 10 hours, and a large percentage in half that time. Some arrived three to four days after they were shot. These late cases are usually inoperable, the visceral injury is not severe and nature has made an effort to deal with the condition. In cases wounded four or five days, with general peritonitis, the practice was to drain the pouch of Douglas through a small incision. In cases where intestinal wounds had healed recovery followed. The authors recognized that in this war, as in other recent wars since the adoption of the armored rifle bullets, not all cases of perforating wounds of the abdomen are fatal and "that severe visceral injuries can be and are cured by natural means." Still, operation is believed to enormously increase the patient's chances of recovery. The mortality of a large number of cases operated upon is fixed at about 50 per cent and although there is no data in this war on which to base the mortality of unoperated cases, the authors have reason to believe that it would be somewhere in the region of 90 per cent. In the diagnosis and prognosis of patients on admission, two questions arise: (1) Is the patient able to stand operation? (2) Is he suffering from a true penetrating abdominal wound with injury to hollow viscus? 165 166 ABSTRACTS OF WAR SURGERY In answering the first question, the patients exhibiting the two extremes are soon passed upon: (1) The obviously mori- bund man — cold, pulseless, and dying— offers no difficulty in com- ing to a decision. Operation on a patient in this condition can not be considered. (2) On the other hand there is no doubt of the patient's ability to stand operation, if his condition is good, and he has been shot only four or five hours before examination. Whether the case is doubtful as to the actual presence of a per- forating wound, it is always one for exploratory operation at least, because the shock of laparotomy is not considered harmful in such cases. The chief difficulty in deciding whether the patient is able to stand operation is found in patients who occupy the middle ground between those discussed — those whose condition is poor, who have received their wounds hours before. If serious visceral injury is certain, as in the case of protruding intestines, operation is in order unless the patient has reached the moribund stage. Such a patient may improve if kept in a ward, warm and at rest, for one or two hours. His condition is then more favorable for operation. If he fails to rally in that time — in two hours — he seldom recovers sufficiently to be operable in less than thirty or forty hours. In regard to the second question — "Is he suffering from a true penetrating abdominal wound with injury to hollow vis- cus?" There are cases of severe injury to a hollow viscus with- out penetration of the peritoneum — in cases for instance in which the abdominal wall has been bared by a passing shot. Again, in such cases the crushing force exerted outside has been known to tear subjacent loops of intestine in two. Another preliminary point to consider is that of injury to solid viscera. If it can be determined that only a solid organ has been injured, is operation indicated? The authors answer the question in the negative except in kidney wounds. Wounds of the liver are seldom if ever benefited by operation. When severe they are fatal ; when not severe the hemorrhage has usually ceased at operation. The same rule applies to wounds of the spleen, except in those cases in which the spleen wound is caus- ing shock and then operation is undertaken with a view to splenectomy. In the diagnosis of penetrating abdominal wounds, speaking generally, the main point is injury to hollow viscera. The principal points of value in diagnosis are: protrusion ABSTRACTS OP WAR SURGERY 167 of intestine or escape of intestinal contents, fluid or gas through the wound, or when an injury to a viscus can be seen or felt through the wound. It should be remembered that surgical emphysema due to escape of intestinal gas subcutaneously, occurs in a small percentage of cases. If the intestine protrudes in the wound, it is necessary to determine whether it is strangulated or what its condition may be. If in fair condition and not strangulated the prognosis is more favorable. The authors mention a case in which all of the small intes- tine, the transverse colon, and the great omentum were prolapsed through the wound; the parts were wrapped in a khaki shirt in which they laid for eight hours. On examination the intestines were found to be covered with mud. After a cleansing process under anesthesia the protrusions were returned to the abdom- inal cavity and the patient subsequently made a good recovery. When resection becomes necessary in such cases the result is nearly always fatal. Protruding omentum is not a dangerous condition, but it is an invariable guide for operation as it denotes visceral injury. Through-and-through shots are at times misleading. A shot entering the flank and escaping at the umbilicus may traverse muscle alone. It is well to be guided by the anatomy of the parts lying between the wounds of entrance and exit. The degree of dilatation of the stomach and urinary blad- der, and the position of the diaphragm at the time of the injury are factors impossible to determine. The authors call attention to a valuable sign, namely, that wounds of the chest alone may give all the signs of an abdominal injury, and also, wounds of the back and buttocks which give rise to retroperitoneal hematomata may set up marked abdominal rigidity and tenderness. The latter of these wounds had been mentioned by nearly all observers of experience in abdominal wounds. Pain does not rank high as a symptom since most of the. patients have been dosed with morphia en route to the hospital. Severe pain immediately after injury lasting a few minutes is often noted in visceral injury. Vomiting occurs in the majority of visceral wounds. It is common in stomach wounds. There may be a wound of the stomach without hematemesis. Passage of flatus following recep- tion of the wound, negatives injury to the large gut, especially the descending colon. 168 ABSTRACTS OF WAR SURGERY An appearance of extreme shock betokens grave injury, and it is a better guide than the condition of the pulse. A normal facial expression favors the existence of a small amount of injury. Abdominal Signs. — 1. Rigidity and absence of free move- ment is of much importance from a negative point of view. Its absence precludes visceral injury. Its presence, however, may be due to other causes: chest wounds, retroperitoneal hematoma, or injury to the abdominal wall alone. 2. Tenderness is of far more importance. Its presence at some distance from the wound, especially on the opposite side from the wound, is almost diagnostic of visceral injury. It should be remembered that tenderness may also be due to hem- orrhage in the peritoneum, or in the tissues of the anterior wall. The latter will at times cause extreme tenderness. 3. Percussion signs are fallacious, and little importance is attached to them. 4. Rectal examination is seldom of value. 5. The passage of a catheter may afford valuable evidence in cases of injury to the bladder and urinary passages. In deciding whether to explore or wait in a case which presents doubt as to the presence of perforation, the deciding factor is the patient's condition. When good, so that operation presents little risk and the wound is so recent that possibly serious vis- ceral injury is present, it is far better to explore. A small incision may be made in the middle line and a swab inserted in the pouch of Douglas, to determine the presence or absence of blood. Cases in which there is little doubt of the existence of visceral perforation should nevertheless be watched most carefully. Without visceral lesion they tend to improve at once. Such causes may remain quiescent for a long period and then take a sudden turn for the worse. A rising pulse-rate, in the absence of elevation of temperature is a pretty sure indication for operation. Contraindications to Operation are as follows : 1. Apart from the hopeless condition of the patient which presents itself in a certain percentage of cases, the only other condition hopeless to operate is a complete spinal lesion with paralysis. In addition to this serious condition, these cases are difficult to fathom as to diagnosis since the spinal lesion will give all of the abdominal signs without perforation existing. Lest spinal lesions be overlooked, every patient should be asked to move his legs. ABSTRACTS OF WAR SURGERY 169 2. An abdominal wound complicated by a chest wound with hemoptysis or surgical empyema. The mortality in these cases is enormous and they are better left alone. 3. Any other serious wound forms an important complica- tion. In a limb demanding amputation, the best chance lies in doing the abdominal operation first, leaving the amputation to be done later. If both operations are to be done at the same time, one surgeon should be detailed to each operation. Operative Measures. — Anesthesia. — Open ether by experienced anesthetists, with or without chloroform is used preceded by atropine. Warm ether apparatus has recently been used with satisfaction. The use of saline, before, during, and after operation: Pri- marily it may be said that saline has been of no value in shock, and of the utmost value in hemorrhage. The most effective way to administer it is intravenously. Rectal administration is of lit- tle value as the solution is not readily absorbed in severe cases, and the danger of mechanically harming the abdomen should always be borne in mind. In good and fair condition of the patient subcutaneous saline with Lane's bag has been used during operation; 1 or 2 quarts with 1 c.c. of pituitrin and occasionally one dram of adrenalin being infused during operation. Two cases were followed by cellulitis and both were fatal from gas gangrene in the original wound and in one the patient was infected at the point of inocu- lation with the Bacillus aerogenes capsulatus. In severe cases with hemorrhage it is always preferable to use the saline intravenously, 2 quarts or more to be administered with 2 drams of brandy, 2 drams of adrenalin solution, and 1 c.c. of pituitrin. The practice is to give it slowly during the course of the operation in one pint portion at once and the remainder later. Eectal saline in after-treatment by intermittent small enemata, 5 to 10 drams (with brandy 2 drams to 1 quart to promote ab- sorption) is given as a routine measure for some days. Intra- venous saline in collapse, when collapse comes after operation, is useless unless the collapse is due to secondary hemorrhage — a condition seldom seen in abdominal cases. Incisions. — 1. If the location of the injury is uncertain and the small intestine is almost certainly injured, a long (6-inch) middle-line incision, extending above and below the umbilicus, is recommended. It should be made to one side of the linea alba. 170 ABSTRACTS OF WAR SURGERY 2. When the injury is to one side of the abdomen, with a pos- sible colon wound, a vertical incision through the rectus has been most generally employed, but a transverse incision through the oblique muscles, extending into the rectus sheath (that muscle being pulled inward) may be employed. 3. Where injury to the flexure of the colon or the spleen is suspected, a paracostal incision through the muscles, and when necessary extended in the same way into the rectus sheath, has been frequently employed. Such an incision gives good exposure and heals well. 4. Sometimes where a primary lumbar incision has been made in the case of a wounded kidney and the missile has not been located, if injury to the peritoneum is suspected, it should be remembered that the peritoneum may be opened and explored, at least suf- ficiently to establish the fact of presence or absence of injury through the lumbar region. Except in cases of large wounds, the incision should be made •separate from the original wound. It should be closed com- pletely to obtain first intention healing — drainage tubes are put in place through separate buttonhole incisions, unless the original wound can be utilized for a drainage tube. Excision of the skin about the original wound is recommended, likewise cleaning and draining with care all large ramifying wounds in the abdominal wall proper. Gas gangrene has been noted in such cases and it is very fatal. Great emphasis is placed on the value of utmost care in closing the wound because of a relatively large number of wounds which have been known to give way as long as a fortnight after opera- tion. The wound should be closed in layers. The use of a single row of deep sutures has been abandoned except in most desperate cases. The sewing in layers is done with chromic catgut, and the retention sutures of strong silkworm-gut, set well back, are removed on about the twelfth day. The tendency of sutures to give way in war wounds of the abdomen and operative wounds in this region is due to the fact that the incisions are usually longer, and owing to frequent bronchitis and paralytic distention the sutures are subject to a greater strain than in civilian abdominal surgery. In cases in which the damaged area can not be identified, a complete examination of abdominal contents is in order, and to save time and lessen shock it should be done in an orderly careful manner. ABSTRACTS OF WAR SURGERY 171 It is preferable to examine the injured area first for the reason that in a desperate case it may be found that, for example, suture of the stomach, colostomy, and a double resection of the small intestine would be necessary, procedures that require more time than the patient's condition could warrant since the patient would certainly die on the table if any of the operations sug- gested were attempted. In such cases the abdominal wound is closed, the patient is returned to the ward as inoperable, and morphia is administered until death occurs. After the damaged area has been successfully cared for a rou- tine examination should next be undertaken. Then the middle- line incision is used, the surgeon beginning his examination at the ileocecal valve or junction, since wounds are most frequently found in this region. The ileum is rapidly brought out in short lengths of one foot and examined, the uninjured gut being at once returned by the assistant. When a rent is discovered the injured portion is retained outside, the position of the first rent or hole being marked by a light clamp or otherwise. The por- tions retained outside are kept warm and moist by a hot towel, wet in saline, being placed over them. Having thus examined the ileum and jejunum, the transverse colon and sigmoid are in- spected in situ, while the flexures, rectum, and bladder, which are not readily visible, should be inspected by touch. In some cases the missile will be found in Douglas' cul-de-sac, and this should be invariably examined. Wounds of the Upper Viscera. — In considering the wounds of these organs it is well to remember that the stomach may be distended in the presence of a considerable hole or tear through its wall. Having found one orifice, a second should be looked for unless the missile has been located in the stomach. Liver Wounds. — Uncomplicated liver wounds do not require operation. If the wound is small without hemorrhage it is let alone. If large and bleeding, it should be packed. Suture is seldom possible, owing to the friable nature of liver tissue. Spleen Wounds. — Small spleen wounds which are not bleeding may be let alone. Usually hemorrhage is taking place, or it is easily excited by manipulation. Suture is easier than in liver tissue and moderate-sized tears are sutured or packed. Splen- ectomy is resorted to in serious cases in which hemorrhage can not be controlled. Kidney Wounds. — The authors prefer to deal with all kidney wounds through a lumbar incision since it is not always possible 172 ABSTRACTS OF WAR SURGERY to diagnose the extent of injury otherwise. Other complicating visceral lesions are treated through an abdominal incision in the usual way. As to whether to suture, pack, or remove the kidney, the latter has been resorted to only when extensive damage has been found, such as a tear across the hilum with persistent hemorrhage. In cases of injury where isolated portions of the cortex had been removed the large gap was successfully sutured. Wounds of the Intestines. — Small Intestines.— Where the holes are small, a purse-string or single row of Lembert sutures will suffice. Double sutures are indicated only in large wounds prone to hemorrhage. Resections give twice the mortality found in sutured cases. If a resection is contemplated merely to save time, it is safer to employ sutures. Large resections recover as often as smaller ones. End-to-end anastomosis has been done in preference to the lateral union. The latter takes a quarter of an hour longer and it does not give freedom from paralytic distention as claimed by some operators. Time should not be wasted in "over-elabor- ate stitching in anastomoses." The "leak" at the mesenteric attachment is classed by the authors as a surgical "bogey." Short-circuiting of the injured and repaired gut to avoid paralysis is not recommended because postmortem evidence has shown that paralysis is general as a result of peritonitis and not confined to the injured area. Large Intestine Wounds. — The authors report that these wounds are twice as fatal as small gut wounds. Fecal fistulse are common. Suturing is much more difficult than in the small intestine, making it necessary to invariably employ a double row. The use of antiseptic fluid is recommended after the first row has been put in place. A piece of omentum may be stitched over the repair. When necessary a separate "gridiron" in- cision in the flank may be made to deal satisfactorily with as- cending and descending colon wounds. When possible suture is always preferable to colostomy. The statement that large intestine wounds are nearly twice as fatal as those of the small gut does not accord with the ex- perience in previous wars, notably, that of the British surgeons in the Anglo-Boer War. The experience in the Civil War also left a like impression. Otis records 59 cases of spontaneous recovery from gunshot of the cecum and ascending colon, the descending colon, and sigmoid flexure and a few instances of ABSTRACTS OF WAR SURGERY 173 the transverse colon. Nearly all the cases were complicated by fecal fistula which closed spontaneously in the large majority of cases. In forty cases in the Anglo-Boer War, Stevenson fixes the mortality at 32.5 per cent, notwithstanding the fact that some of them had sustained injury to the liver, bladder, and kidney. The same author fixes the gravity of gunshot wounds of the in- testinal tract, irrespective of the stomach, probably in this order : small intestine, transverse colon, ascending colon and descending colon, sigmoid flexure and rectum. The more hopeful outcome of injury to this part of the in- testine has been ascribed to the fact that the walls of the gut are thicker than those of the small intestine, and the aperture in them is partially closed by the greater amount of tissue in- volved in the perforation. In addition the fact that the gut is fixed to the wall of the abdomen by the overlying peritoneum, it is more or less immobile, extravasation is not so likely to occur, and lastly the contents of the large gut being more solid, extrav- asation was less likely. The difference in the prognosis of small intestine and large intestine wounds by the different authors mentioned may only be ascribed to the fact that the operators in the 500 cases under discussion were dealing with absolute facts as to location of lesions, whereas, the authors who have collected data in pre- vious wars have largely estimated the lesions by guesswork — without opening the abdomen, by estimated perforation of cer- tain organs in accordance with the location of the wound of en- trance and the straight line between them. Compared to direct evidence as obtained after doing an abdominal section, the older method is fallacious and the authors are to be congratulated in having definitely settled an important point. (Reviewer.) Wounds of the Bladder. — Intraperitoneal wounds of the blad- der only may be sutured with safety without draining supra- pubically. A catheter is tied in place, and the pouch of Douglas is invariably drained. Extraperitoneal bladder wounds through the buttock which can not be sutured should be drained thor- oughly through the original wound down to and around the bladder wound by inserting a tube outside the peritoneum. Most buttock wounds involving the bladder are serious unless proper drainage can be accomplished. Hexamethylenamine should be given in all wounds of the urinary tract from the start until all danger of sepsis has passed. 174 ABSTRACTS OP WAR SURGERY Drainage of the Abdomen After Operation. — Escape of visceral contents in every instance calls for drainage via Douglas' pouch. A drainage tube in contact with a suture in a large gut is apt to result in fecal fistula unless it is promptly removed about the second day. Any drainage tube has served its purpose of forming a chan- nel in a very short time. Its presence therefore should not be unnecessarily prolonged. After-treatment. — The use of salines in after-treatment has been referred to. Fowler's position is the rule. Rapid collapse, secondary shock, in twelve to twenty-four hours when a patient has apparently rallied from primary shock is one of the disap- pointing phenomena noted by the authors. In these cases in- travenous saline is uesless. Strychnia and brandy have ac- counted for a second rally at times. Laparotomy in war is followed more often by vomiting than in civilian acute abdominal cases. If acute distention of the stomach is present, a stomach tube may cure the vomiting, but it should not be used in a condition of collapse. The chief danger to a man shot in the abdomen is not general peritonitis, but shock and hemorrhage. It is estimated that if these elements of danger could be eliminated the mortality in gunshot wounds of the abdomen could be reduced by 30 to 40 per cent. The chief symptoms from peritonitis are paralytic distention, vomiting, and constipation. As a phophylactic, a hypodermic of pituitrin followed in a half -hour by an enema on the day after operation is recommended by one of the operators. When ob- structive symptoms with paralytic distention threaten a valu- able drug is hypodermic eserine, 1-1000 gr., every two hours. Small doses of calomel, hypodermic pituitrin, and turpentine enemata are also recommended. When these measures fail general peritonitis is usually pres- ent, and the case is well nigh hopeless. The incision can be opened up, and a collection of pus sought by separating adhe- sions near by. In such cases this plan has saved some lives, not many. Drainage tubes are removed early. Gauze packing — in liver and spleen wounds— is removed about the fourth day, under anesthesia or in stages. Operated cases are often disturbed by transport, which should be delayed as much as possible — never earlier than the end of ABSTRACTS OF WAR SURGERY 175 one week, however well the patient may be. Most of the cases are transported to the base between the tenth day and a fort- night. This valuable report is accompanied by a table which is full of interest. It should be noted that among the 500 emergency operations there were 57 laparotomies in which no injury to viscera were found, with the high recovery rate of 92.9 per cent. Classed as a report on gunshot wounds of the abdomen, with the results as far as laparotomy is concerned, these should properly be excluded from the table results. The chances are that the cases would have recovered without operation. Without wish- ing to criticise the judgment of the operators in opening the abdomen for these injuries, it is fair to state that more of the cases would have recovered without operation. If these cases are put out of the reckoning, the recovery rate in military hospitals is very good, in keeping with the recovery rate in civil hospitals for laparotomy after gunshot wounds by pistols and revolvers. In Table I the mortality for colostomy is very high. So is it for retroperitoneal hematoma, gas gangrene of the abdominal wall, and wounds of the lung and abdomen. In the latter re- coveries are confined to solid viscera. Table II brings out the high mortality of abdominal wounds complicated by buttock wounds. Deaths here are caused by hemorrhages, sepsis, and pelvic cellulitis. Wounds of the loin and flank, and chest suffered solid viscera involvement, and among them also are included the majority of the 27 cases in which no injury was found on operation, hence the low mor- tality. The pulse chart shows that when the pulse is below 85 on ad- mission the prognosis is very good, and when it registers above 110 it is very bad. It is noticeable that most fatal cases with low pulse-rate are buttock cases. Conclusions. — War wounds of the abdomen compared with those in civil practice show many radical differences as to (1) gravity, (2) complications, and differences in (3) characteristic features, (4) environment. 1. War wounds are more apt to be grave than those in civil practice. This is especially true of wounds by shell fragments, shrapnel balls, and rifle bullets, including, of course, those from machine-guns when shots are inflicted at close range. In civil practice, the shots are nearly always received when the ad- 176 ABSTRACTS OF WAR SURGERY versaries are facing each other, the direction of the bullet tract is usually anteroposterior. The anteroposterior shots are at- tended with a greater percentage of recovery than the oblique, transverse, and vertical wounds in war. 2. There are a number of complications that are especially prone to appear in war wounds as compared to wounds in civil hospitals. (a) The high power military rifle, which has a maximum penetration of 28.5 inches in green oak across the grain at 50 feet, is capable of enfilading the body from the head to the buttock, a degree of penetration not possessed by pistols or re- volvers, the weapons which usually inflict wounds in civil com- munities. As a consequence soldiers often show wounds through the chest and abdomen, or vice versa, and these shots are not- ably attended with high mortality. . (b) Infection by fecal microbes, in the present world war at least, is a very fatal complication — only one case recovered out of eleven noted in this report. (c) Mental shock, exhaustion, and fear are no doubt more frequent complications of war wounds than in those occurring in civil practice. (d) Poison by gas shells, not known in civil practice, comes in this present war to add to the gravity and complication in abdominal war wounds. (e) As to the difference in characteristic features of civil practice and war wounds of the abdomen, in civil practice the shots are delivered by weapons of much lower velocity. The pro- jectiles are mostly from regulation pistols and revolvers of medium caliber, 32, 38 and less often 45 caliber. The amount of laceration and devitalized tissue is less than that of the mili- tary rifle bullet at close range, the shrapnel ball, or shell frag- ments. (f) Environment plays a great part in peace and war. In war the surgeon is at the mercy of the conditions about him. For many reasons it may be hours and days before a patient can be transported to the hospital for treatment. Adverse con- ditions of the kind mentioned are seldom noted in civil practice. The surgeon dominates the surroundings and it is seldom more than one hour before operative interference can be undertaken should it be deemed necessary. ABSTRACTS OP WAR SURGERY 177 STAB AND GUNSHOT INJURIES OF THE ABDOMEN.— S. Basdekis, Beitr. v. klin. Chir., 1915, xcvi, p. 223. Basdekis reports 63 cases of abdominal injury treated at the Freiburg Clinic, some of them injuries in civil life, others from the Balkan War; they include stab and gunshot wounds, penetrating and nonpenetrating, and with and without perfora- tion of the intestines and other abdominal viscera. Typical cases in the different groups are described in detail. The possibility of spontaneous recovery, the difficulty of oper- ation under the proper conditions in war, and the severity of the operation itself have caused many authors to treat abdominal wounds expectantly, even in civil life. Among the most ardent advocates of this treatment are Reclus, Berger, and Stimson. There are others who advocate operation in all cases. The statistics brought forth by different authorities vary greatly. Reclus had only 18 per cent mortality in 114 revolver injuries treated expectantly, while others with the same treat- ment have a mortality of 70 per cent or more. Siegel collected several series of statistics and found that the mortality with operative and expectant treatment was about the same — 55 and 51 per cent. But on working out the mortality of 376 operative cases he found that the mortality of the cases operated upon during the first four hours was 15.2 per cent, after five to eight hours 44.4 per cent, and after nine to twelve hours 63.6 per cent, and for all later laparotomies 70 per cent. Therefore the con- census of opinion in Germany today is that the earlier operation is performed the better the prognosis. But the prognosis in the individual case is and always will be doubtful. Most surgeons agree with Madelung that the danger in pene- trating injuries of the abdomen is over twenty-four hours after the injury. Kuttner and others hold that all patients with abdominal in- juries operated upon* on the field die, while Filert, Perthes, and others demand operation within twelve hours. Von Oettingen advises that the following classes of cases be operated upon on the field: (1) extensive injuries of the abdominal wall, where it is probable that the intestines also are injured; (2) large open- ings of the abdominal wall with unincarcerated prolapse, or small openings with incarcerated prolapse; (3) small gunshot wounds where there is no doubt that there is intestinal injury; (4) cases of continuous hemorrhage into the abdominal cavity; 178 ABSTRACTS OF WAR SURGERY and (5) when the picture of acute peritonitis or sepsis has de- veloped. In these cases transportation must be avoided both be- fore and after operation. Other cases must not be touched on the field. Irrigation and sounding must be avoided. In the Bul- garian War the Greeks only painted the wound with iodine and applied dry aseptic dressings. Then the patients were trans- ported as quickly as possible to a hospital where they could be operated upon under proper conditions. The tincture of iodine gave excellent results. The wounds treated with it looked clean and showed more active granulation than those not painted with it. Bornhaupt reports from the Russo-Japanese War that of 13 patients operated upon on the battlefield 2 died, that is 15.4 per cent, while of 28 operated upon after six to ten days thir- teen died, or 46.4 per cent. In peace the theory is that . abdominal wounds should always be operated upon, but on account of the uncertainty of diagnosis and the difficulty and danger of the operation itself this does not always hold good. Operation should be performed if there is internal hemorrhage, as all cases die if not operated upon. But in simple penetrating wounds, without signs of peritonitis, with good general condition and good pulse, expectant treatment is best. In collapse or shock operation is indicated; both col- lapse and shock often change for the better under anesthesia. The mortality of the penetrating abdominal wounds described was 25 to 28 per cent in cases operated upon within twelve hours ; 50 per cent on those operated upon later. Their method of operation was as follows : Mixed or chloro- form anesthesia was given. In stab wounds the cut was merely extended; in gunshot wounds an incision was made near the en- trance wound and a second perpendicular to it if necessary. If the omentum was prolapsed it was replaced or ligated with cat- gut and removed and the stump buried in case it was soiled or inflamed, as it often was. If the intestine was prolapsed it was carefully cleansed and then replaced. If the prolapsed intestine was injured the wound was first sutured and then the intestine buried. Resection was not necessary in any case. If the intestine is so severely injured by torsion or incarcera- tion in the abdominal wound that there is doubt of its recovery, two procedures may be followed: either an artificial anus is formed or the intestine is protected with iodoform gauze or damp sterile gauze and left outside the wound until its condition im- proves enough so that it can be replaced, or if gangrene develops it is resected, the ends sutured circularly, and it is replaced. ABSTRACTS OF WAR SURGERY 179 For the toilet of the abdominal cavity either lukewarm sterile water was used or sterile salt solution. But if even the slightest amount of intestinal contents has escaped into the abdominal cavity it must not be irrigated, but only sponged for fear of scattering infective material. Many authors hold that even ef- fusions of blood into the peritoneal cavity must not be sponged up. Blood, as well as intestinal contents must be thoroughly re- moved, for it has been observed that the peritoneum becomes inflamed much more easily if there is blood in the abdominal cavity. To find injuries of the intestine or mesenteric vessels the in- testine must be examined methodically; that is, drawn out bit by bit and examined throughout its length and then replaced. If there is profuse hemorrhage or much intestinal contents in the peritoneal cavity, eventration may be necessary. The intestines in such cases must be kept damp and not allowed to lie too long on the epidermis, which has been painted with iodine. Com- presses moist with physiological salt solution should be laid over and under them. If a mesenteric vessel is injured it is ligated at once with catgut. Sometimes, however, it may necessitate re- section of the intestine if the injured vessel lies near the intes- tine and gangrene of the intestine is to be feared. If the field of operation is infected a strip of gauze, or better, a Mikulicz tampon, should be introduced. The abdominal wound must not be entirely closed if there is the slightest suspicion of infection. This delays healing somewhat, but decreases the dan- ger of infection. For suturing the abdominal wall aluminum- bronze wire is used. All the layers of the abdominal wall except the skin are included and then the skin sutured with silk. Some- times only two or three wire sutures are used and between them catgut sutures, which also include everything but the skin, which is sutured with silk. TREATMENT OF ABDOMINAL INJURIES AT THE FRONT. —Schwartz ; THIRTY-THREE LAPAROTOMIES IN CASES OF ABDOMINAL INJURY.— Bouvier and Caudrelier. Bull, et mem. Soc. de chir. de Paris, 1915, xli, p. 1257. Reports by Schwartz and Bouvier and Caudrelier are reviewed and discussed by Quenu, who deduces from them an argument in favor of operative treatment of abdominal injuries in war. Schwartz operated upon nine cases, eight of them with perfor- 180 ABSTRACTS OF WAR SURGERY ation of the small intestine and one without any intestinal lesion, but with injuries of the spleen, mesocolon, and great omentum. There were two complete recoveries, two operative recoveries and five deaths, but one of these deaths was due to the careless- ness of the patient, not to the operation. He was getting along splendidly on the sixth day, but that night got up to go to the window to look at a fire and the next day developed peritonitis. Bouvier and Caudrelier report 33 cases of laparotomy for ab- dominal injuries. In all there were 18 deaths and 15 recoveries, or a total mortality of 54.5 per cent. The mortality was 66 per cent in injuries of the small intestine, 40 per cent in injuries of the large intestine, 60 per cent of only perforating injuries of the large and small intestine are counted. They were favored by the fact that they were very near the front and their patients had to be carried only a few meters; but their mortality is in- creased by the fact that they operated on all cases as they came, no matter how severe the injury or in what condition of shock the patient was at the time. They generally operated through a median incision; sometimes they merely enlarged the existing wound. When there was an evisceration of the intestine they sutured or resected it outside before opening up the abdomen. Perforations of the intestine were treated by suture; if there were multiple perforations in a short segment the intestine was resected. They used only end-to-end suture. In almost all cases the peritoneum was irrigated with ether after the operation; it was not always drained. Every effort was made to make the operation as short as possible. These results are decidedly in favor of operative treatment. The opinion of surgeons is very much divided still as to the question of operative or conservative treatment in abdominal injuries. Quenu quotes a report of Sencert, who prefers expectant treat- ment. Sencert had 58 cases, with only 13 recoveries, a mortality of 77.5 per cent, while Bouvier and Caudrelier had only 54.5 per cent mortality from operative treatment. Moreover Quenu con- cludes from a study of Sencert 's cases that not all of them were perforations of the intestine, so that, in addition to having a higher mortality, he had less serious cases. The published cases of various other authors are reported. Summing up all the oper- ative cases, the average mortality is 62 per cent; while the aver- ABSTRACTS OF WAR SURGERY 181 age mortality of the conservative cases is 78 per cent. Quenu concludes that operation is indicated except in some cases of tan- gential shot with both orifices posterior, indicating that the in- testine has not been perforated. It is the perforation of the in- testine, not of the peritoneum, that is most significant. The indications for operation depend less on the site of the wound than on the time when the surgeon gets hold of the pa- tient and the facilities at his command for operation. Patients with abdominal injuries should be operated upon as near to the trenches as possible, to avoid jarring. They should never be car- ried more than 15 to 20 kilometers. One of Sencert's arguments for conservative treatment is that the patients are in too bad condition to be able to stand the shock of operation, but Quenu reviews the causes of death in Bouvier and Caudrelier's cases and shows that none of them died of shock. One of the questions now to be solved in these cases is the proper time for evacuation of the patients. So far they seem to have been evacuated too soon, for quite a number of cases are reported of patients who recovered from the operation but died as a result of the journey home. Quenu thinks they should make the journey by stages, traveling only a few hours at a time, preferably by automobile, and resting a number of days between the stages. SUTURE OF THE DIAPHRAGM FOR GUNSHOT WOUND WITH HERNIA OF OMENTUM AND TRANSVERSE COLON. — 0. Ortali. Gazz. d. osp. e. d. din., Milan, 1917, xxxviii, p. 369. "Wounds of the diaphragm observed in peace times are usually on the left side as they are produced by cutting or pointed weap- ons in the right hand of the striker. But war gunshot dia- phragmatic injuries occur on both sides. One of the gravest complications of such wounds is the hernia of abdominal viscera. The author reports such a case in which omentum and transverse colon had herniated. The former was resected after a breach was made by resecting a rib and the intestine reduced to its place. The ruptured diaphragm was sutured with silk. In this case the diagnosis of diaphragmatic rupture was made easy by the fact that a piece of omentum projected through the external wound. 182 ABSTRACTS OF WAR SURGERY NEW SERIES OF ABDOMINAL WOUNDS TREATED IN AUTOMOBILE SURGICAL AMBULANCE No. 2.— H. Rou- villois, Guillaume-Louis, and Basset. Bull, et mem. Soc. de chir. de Paris, 1917, xliii, p. 705. The authors' ambulance was stationed about 15 kilometers from the first line of trenches and since their previous report, March, 1916, they have observed 503 abdominal wounds. These are divided into: (1) extraperitoneal wounds — parietal, visceral; (2) peritoneal wounds — simple, visceral; (a) univisceral, (b) multivisceral. 1. There were 150 extraperitoneal wounds, 126 being parietal and 24 visceral. The 24 visceral wounds included 14 kidney les- ions (13 recoveries and one death) and 10 wounds of the bladder, rectum, and colon, with five deaths. 2. Of 12 simple peritoneal wounds without visceral lesion, three recovered and nine died. Of the visceral peritoneal wounds 120 gave indications for laparotomy. The authors find that wounds of the lateral abdominal regions (hypochondrial and iliac fossa) are much less grave than those traversing the median line and the neighborhood of the um- bilicus. Multiplicity of perforations is a lesser factor of gravity than duration of the wounds. Some of the cases in which there were from six to ten perforations recovered owing to very early in- tervention. The first series of cases reported by the authors (March, 1916) showed a mortality of 75 per cent for univisceral and 90.5 per cent for multivisceral wounds. In this second series the corre- sponding figures were 63.9 per cent and 66.6 per cent. The authors' experience has led them to abridge the period of drain- age in cases that are operated upon early, but in late oper- ated cases it must be prolonged and associated with rec- ognized methods of dealing with peritonitis (Murphy irrigation, Fowler position). The authors report 72 thoracicoabdominal wounds in a separate category. WAR WOUNDS OF THE SPLEEN.— Fiolle. Bull, et mem. Soc. de chir. de Paris, 1917, xliii. Fiolle reports on 9 splenic wounds observed in his ambulance since 1916. Of the nine cases, two were abdominal wounds and ABSTRACTS OF WAR SURGERY 183 seven were abdomino-thoracic wounds; six recovered and three died. According to Fiolle spleen injuries are not so serious in war as has been represented. Of 33 cases which have been reported to the Society of Surgery of Paris, since the beginning of the war the mortality is 60.6 per cent. The mortality in isolated splenic wounds, six deaths in 9 cases, is the same as in spleen wounds asso- ciated with other injuries, 12 deaths in 18 cases; but in Fiolle 's per- sonal statistics the associated wound cases show five recoveries in eight cases. Fiolle is a partisan of splenectomy in the treatment of such wounds, especially when there is rupture or extensive laceration. Technically, suture is possible for partial tears or seton wounds; but splenectomy is preferable on account of the tendency to sec- ondary hemorrhage. Tamponade is applicable only to wounds which are slight as regard surface, extent, and depth. Generally speaking, therefore, splenectomy is the operation of choice in war injuries of the spleen. Regarding the route of approach, in the case of purely abdominal splenic injuries Fiolle prefers to extend the classical anterior in- cision in the lumbar region. Most splenic wounds are, however, abdomino-thoracic and the entry wound is situated low. Duval, who submitted Fiolle 's report, recommends an incision starting from the orifice wound and descending vertically or obliquely so as to cut the costal circle perpendicularly and thus become a left lapa- rotomy directed toward the anterosuperior iliac spine. A couple of ribs are sectioned and removed and the thorax opened. Then the diaphragm is sectioned from its costal attachments to the required depth and the parietal peritoneum opened as much as is necessary. This procedure gives large access to the thorax and abdomen and allows the treatment of pleural or pulmonary lesions, if there are such, as well as abdominal lesions. The diaphragm is afterwards sutured and the abdomen and thorax closed. PROGNOSIS AND TREATMENT OF ABDOMINAL WAR IN- JURIES.— Most. Beitr. z. klin. Ckir., c, 1916 ; Kriegschir., H. 16, p. 184. Most gives a report of 71 abdominal wounds observed at the front. Of 26 rifle bullet wounds 12 did not involve the intestines. In two the bladder was injured, in two the liver, and in three the pleura and diaphragm. There were two deaths. 184 ABSTRACTS OF WAR SURGERY Five of the wounded had slight intestinal injuries. Of these patients, four died. Of six cases of severe gastrointestinal injuries all died. Altogether about 44 per cent of rifle bullet abdominal in- juries recovered. Of three abdominal injuries due to shrapnel bullets two recov- ered. In five cases of nonpenetrative grenade abdominal injuries only one recovered. Of four penetrating grenade wounds of the abdomen two died. There were 20 injuries of the abdomen by grenade with accom- panying intestinal perforations; six of the small intestine, nine of the large intestine, one of the small and large intestine, one with intestinal prolapse, and three with pleural and diaphragm injuries. Seven cases were operated upon and died. The nonoperated cases all died. Of seven grenade injuries involving the chest and ab- dominal wall without intestinal injury only two recovered. Both were treated conservatively. As regards the prognosis of abdominal injuries the author con- cludes from his observations that as a rule rifle gunshot wounds, as well as shrapnel injuries, have a less serious prognosis than gren- ade and mine abdominal wounds, the prognosis of which is ex- tremely serious, and to a great extent hopeless. There are several matters which specially influence the prognosis, comprising : 1. Concomitant gastrointestinal canal injury. In exceptional cases small perforations may heal spontaneously, but more fre- quently such wounds progress to a fatal perforation peritonitis. 2. Hemorrhages, which as a rule are so profuse as to cause death. 3. Concomitant injuries of parenchymatous organs, liver, spleen, kidney. Small, smooth, through shots may heal. Large lacerations have a bad prognosis. 4. Infection, which is especially likely to occur in grenade and mine injuries. 5. Shock. 6. The manner and time of transportation of the wounded. In the diagnosis of concomitant gastrointestinal and organic in- juries none of the known symptoms (facies abdominalis, faint pulse, abdominal tension, local tenderness, etc.) are distinctly spe- cific. They can be considered of diagnostic value only. For in- volvement of the viscera the trajectory of the shot must be con- sidered. In infantry gunshot abdominal injuries, manifest symptoms of intestinal involvement is an indication for immediate surgical in- ABSTRACTS OF WAR SURGERY 185 tervention. In doubtful cases it is advisable to wait for a few hours and examine the patient repeatedly. The time limit is from ten to twelve hours after injury by rifle shots. If the condition of the patient is then promising one can wait longer. In grenade injuries or when there is persistent hemorrhage, Most advises operation if there is any hope of success. In operative procedure the presumption is that laparotomy can be carried out in an efficient manner; intestinal resection should be restricted as much as possible, all dirt and blood removed, with Mikulicz tamponade and abdominal closure in layers. The after- treatment of such injuries requires very special care and observa- tion and therefore hospitals for such cases should not be too near the front where the nursing and other conditions can never be such as is demanded for these cases. GUNSHOT WOUNDS OF THE ABDOMEN.— Korte and Schmie- den. Beitr. z. klin. Chir., 1916, xcvi, p. 509. Korte and Schmieden reported on abdominal wounds at the meeting of military surgeons at Brussels this spring. Korte presented statistics of 312 cases and from his experience is an advocate of conservative treatment. He says it has not been demonstrated that more lives are saved by operation than by ex- pectant treatment. It is not always possible to make an early diagnosis as to whether there is perforation of the intestine or not. If operation is to be performed it must be within the first twelve hours, the patient should not have been carried far, his general condition must be reasonably good, and the surgeon must be skilled and observe strict asepsis. Schmieden advocates operative treatment. He says that spon- taneous recovery in abdominal wounds is extremely rare, and even of those who apparently recover many die later of chronic periton- itis. He agrees that operation should be done within the first twelve hours, and thinks that arrangements should be made to get hold of as many cases as possible within that time and treat them operatively. War statistics, he says, are not particularly reliable, but he presents a series of statistics in which the per- centage of recoveries was considerably higher after operation than after expectant treatment. "With armies on the march, of course, it is difficult to bring about the necessary conditions for operation, but with the armies in the trenches it should be the treatment of choice. 186 ABSTRACTS OF WAR SURGERY In the discussion, Friedrich said that with the conditions that prevail at the eastern battle fields it is almost impossible to operate with any chance of success. Kraske stated his belief that cases with and without intestinal injuries should be considered separately. Practically all cases with intestinal injury die if not treated. He has operated upon 14 cases recently with six recoveries. Sauerbruch advocated early operation. He has operated upon 54 cases with 23 recoveries. Rehn advocated operation with the armies in the trenches, but not with armies on the march. Hanken advocated operation on all cases that come into the surgeon's hands within twelve hours. NECESSITY FOR SYSTEMATIC OPERATION IN ABDOM- INAL WOUNDS. — R. Leriche. Presse med., 1915, xxiii, p. 221. Contrary to most writers on the subject Leriche is an earnest advocate of operation in abdominal wounds. He says that the chief objection urged against it is that it is impracticable on ac- count of the large number of wounded to be taken care of. He sug- gests the establishment of a stationary ambulance near the field, to be used as an operating room for abdominal cases. Another objection is the high mortality; but there is of necessity a high mortality in abdominal wounds, whether the treatment is surgical or expectant. He has seen 117 cases treated expectantly with a mortality of 85 per cent, and other surgeons give mortality sta- tistics of 70 per cent and up. Leriche thinks this mortality could be materially reduced by operation. He has operated upon only two cases himself, with recovery in both. Many patients with abdominal wounds die from hemorrhage from the mesenteric vessels, when no other organs are injured. These cases could certainly be saved by suturing the vessels. Many wounds of the intestine and stomach could be sutured and the pa- tient saved if they could be operated upon early. Patients with wounds of the liver and spleen certainly stand a much better chance with operation than without. He urges that a systematic attempt at operative treatment be made to see whether the high mortality can not be reduced in this way. ABSTRACTS OF WAR SURGERY 187 OPERATIVE TREATMENT OF GUNSHOT INJURIES OF THE INTESTINE.— Enderlen and Sauerbruch. Med. Klin., 1915, xi, p. 823. Enderlen and Sauerbruch report on 227 cases of operation for abdominal injuries, in 211 of which the intestine was injured. They are ardent advocates of operative treatment in such in- juries. The favorable results that some surgeons have reported from conservative treatment are due to the fact that they included all cases of abdominal injury, a large percentage of them being extraperitoneal. The authors had 53 cases of intestinal wounds that were treated conservatively; 46 of them died in the field hospital and three of them died later; only four were discharged and sent home appar- ently well ; even if they all lived the mortality would be 94 per cent. On the other hand among the 211 operated cases the mor- tality was 44.4 per cent. It is of course sometimes difficult to make a diagnosis as to whether the intestine is injured or not, but if the abdomen is tense and painful, the pulse small and frequent; if there is nausea and vomiting, and particularly if there is costal breathing, there is probably intraperitoneal injury, and if so operation is indicated whether the intestine is injured or not. Even those who oppose operation for intestinal wounds admit the necessity for it in intra- abdominal hemorrhage. Among the author's more than 200 cases a mistaken diagnosis of intestinal injury was made only eight times, and none of those patients were injured by the operation. The operation is per- formed in the same way as in civil practice, and careful after- treatment is necessary. Salt solution is given by the drop method. Hot packs and hot-air treatment are beneficial when possible to use ; they stimulate peristalsis and are pleasant to the patient. The patients are given fluid the first day; if the intestinal suture is firm it will hold anyway and if it is not abstinence does no good. The patient should not be transported for four weeks, but if it becomes necessary to move them the operated patients are in better condition to stand it than those without operation. The patients should be operated on if possible within twelve hours of the injury. The results have been better the past few months than in the early months of the war. The authors feel that operation for intestinal injuries may come to be one of the most hopeful fields of military 188 ABSTRACTS OF WAR SURGERY surgery, as those patients are not left helpless and crippled after- wards as are the amputation cases. THE SURGICAL AMBULANCE AND ABDOMINAL WOUNDS. — U. Calabrose and B. Eossi. Policlinico, Rome, 1917, xxiv, sez. Prat., p. 890. In Calabrose 's ambulance service 264 abdominal wounds were treated. There was a total percentage of recovery of 47 per cent; true operated and recovered abdominal wounds showed 36 per cent. Eossi treated 315 cases and also had a total recovery of about 47 per cent. The extraperitoneal wounds showed 82.65 per cent re- coveries. Of the 139 penetrating abdominal wounds which were operated upon 26 involved the parenchymatous organs only and give 61.53 per cent recoveries. There were 110 gastrointestinal lesions with 31 per cent recoveries. The author thinks that only four or five of the 110 could have been expected to recover spon- taneously. Eeferring to the high figures of recovery claimed by abstentionists he thinks that many of the cases in which a diag- nosis of abdominal penetrating wound is made are really only su- perficial wounds of the walls or of the neighboring parts. Eossi thinks that the conduct to be observed is immediate inter- vention in penetrating wounds in which there is certainty or a well-founded suspicion of endoperitoneal lesion of a hollow vis- cera where there is hemorrhage, flow of urine, or flow of bile, since there is still a chance of saving such patients. Expectant and med- ical treatment should be used in other cases. ABDOMINAL INJURIES IN A CASUALTY CLEARING STA- TION.— A. Don. Brit. Med. Jour., 1917, i, p. 330. In discussing the general principles of treatment of war wounds as compared with those in civil life, the author states that he can see no reason for departing from the pre-war attitude of explora- tory laparotomy in all cases of acute abdomen. Even if a patient be in extremis there is a better chance by operation. There is often none after waiting. The chief danger in the first twenty-four hours is hemorrhage. The bowel seems completely paralyzed at first by the blow of the missile, so that no movement takes place for at least twenty-four hours, the injured bowel lying directly beneath the wound of entry. The indications for operation are pain and rigidity of recti, ABSTRACTS OF WAR SURGERY 189 marked shock, or signs of hemorrhage. Hemorrhage seems to cause more pain and rigidity than any other condition. The reason for this is not clear. Incision is made with the bullet wound at its center. The injured portion of the bowel is sutured or excised. The peritoneal cavity is then washed out with hot normal saline solution. Saline is given intravenously before, during and after operation. The greater portion of the cases are treated in the horizontal position. There is usually little to guide one as to diagnosis of the organ involved, but during the first six to twelve hours hemorrhage is nearly always distinguished from simple perforation because of the greater severity of symptoms. Hemorrhage is the chief danger in wounds of the liver. Concussion may destroy half the liver, even when the bullet has not hit the organ. The stomach and small intestines were the organs most frequently wounded in the author's experience. Wounds of the stomach were sutured in all cases. Those of the intestines were repaired by circular anasto- mosis with very low operative mortality. A detailed report of twelve typical cases is given. INTRAPERITONEAL RUPTURE OF THE BLADDER.— F. Host. Milnchen. med. Wchnschr., 1917, lxiv, No. 1. The author says that according to Zuckerkandl, Rovsing, and others a rapid peritonitis is the cause of death in the case of in- traperitoneal bladder rupture. Bartels, who on investigation found that the mortality in the first three days after the acci- dent was 50 per cent, found also that in many of the autopsies there were no signs of grave peritonitis, or even no peritonitis recorded. This he has doubted, believing that peritonitis must have been present. Where the peritonitis is not apparently suf- ficient to have caused death, Bartels thinks that this is due to shock. A study of the literature shows that in untreated bladder ruptures spontaneous recovery occurs, but very rarely. The ma- jority of patients die without marked peritonitis within three days, from a cause unknown. Some die later part from peri- tonitis and part from some undefined cause with slight peri- tonitis. Rost reports two cases of this last kind. The first was a man of 42 years. After a severe fall no urine could be expelled. The urine and blood were withdrawn by catheter but at low pressure. The patient died after four days. The vesical lesion was considered a laceration of the mucosa, but 190 ABSTRACTS OF WAR SURGERY a possible laceration of the ureters could not be excluded. Autopsy showed a transverse tear in the bladder posterior wall near the neck about 5 cm. long. The catheter had passed through this into the abdominal cavity in which there was a large quantity of urinous fluid. No inflammatory alterations of the peritoneum could be found. The second case of rupture was also found at autopsy and was not suspected and there was an irregular intraperitoneal tear of about 1.5 cm. There was a slight degree of peritonitis. EARLY TREATMENT OF GUNSHOT WOUNDS OF THE ALIMENTARY CANAL.— C. "Wallace. Lancet, London, 1915, clxxxix, p. 1336. In trying to arrive at the relative frequency of abdominal wounds the following data were obtained in a certain number of casualty clearing stations : 1. 1.88 per cent of all wounds, 2. 1.5 per cent of all wounds, 3. 0.75 per cent of all wounds, 4. 0.62 per cent of all wounds. The statistics from 9 field ambulances and 7 casualty clear- ing stations for a period of six months showed the following results: Percentage of abdominal wounds to total wounds, field ambulances, 1.92 per cent, casualty clearing stations, 0.72 per cent. The difference is attributed to the greater mortality in field ambulances. In 1,098 abdominal wounds in 9 field ambulances during a period of six months the mortality was 30.33 per cent. In 131 cases of perforating abdominal wounds in the same period from 6 casualty clearing stations the mortality was 58.49 per cent. As to the influence of position of the wound and direction of the missile on the probable nature of the injury, it is noted that in the region above the pyloric plane are found the least serious among abdominal wounds. Side-to-side wounds, especially if they are located far back, are very serious. Vertical wounds, from above downward, are also serious. Midline anteroposterior wounds are seldom seen, due to the vena cava and aorta occupying this line, wounding of which causes immediate death. The liver is most apt to be hit on the right side of this line, and the stomach occupies the space ABSTRACTS OP WAR SURGERY 191 on the left side. Stomach wounds usually occupy both sur- faces of the organ. On the right side the liver will be hit; the cardia and greater curvature of the stomach will be perforated on the left side. The kidneys will be perforated by shots traversing the lateral lines of the body including the spleen and splenic flexure on the left side. Uncomplicated liver and stomach wounds are as favorable as similar wounds in the epigastric region. Oblique epigastric and hypochondriac wounds are necessar- ily more serious and they become more so as they become more oblique. The character of the liver wounds in these shots is marked by greater laceration and greater tendency to hemor- rhage, and the stomach wounds are marked by a long slit or double opening when the axis of the flight of the bullet be- comes parallel to the anterior wall, in which case extravasation is prone to occur. The liver and stomach wounds are apt to be complicated by spleen, kidney, and splenic flexure involve- ment. Vertical epigastric or hypochondriac wounds are nearly all inclined downward, though they may be almost vertical, the entrance and exit wounds being located on the front of the body. In such cases the wounds of the liver and stomach are complicated by involvement of the colon or small intestine. Vertical wounds on the lateral surface appear as thoracic wounds when they show no exit wounds. Those on the right side are not so dangerous since they traverse only liver sub- stance ; those on the left are more dangerous as they are apt to implicate the spleen, stomach, or colon. These at first point entirely to thoracic injury. Posterior and lateral wounds of the hypochondriac region are apt to be single entry wounds. Those from side to side are seldom seen, owing to their great fatality. They involve the liver, spleen, stomach, pancreas, and even the great ves- sels. Wounds between the axillary lines often exhibit omentum protruded through the ribs. They are more serious on the left side from the spleen, kidney, and splenic flexure involve- ments. These wounds are often caused by shrapnel or shell fragments. Access to this region is not easy; the wounds are therefore difficult and unsatisfactory to treat. "Wounds between the transpyloric and intertubercular planes are very serious. Above the umbilicus they are like those above 192 ABSTRACTS OF WAR SURGERY the transpyloric plane, and below the umbilicus the small in testine is involved. Anteroposterior shots in the midline are seldom met with. On either side, in the upper part of this region the colon is in- volved and injuries to it are easily dealt with. Lower down, near the midline, the wounds are grave as they involve the small intestine. Toward the sides in the lumbar regions, we find wounds of the ascending or descending colon. If the peritoneal surface alone is involved the danger is not so great unless the wound in the wall is large. Wounds in the left lumbar region are very much more dangerous as the coils of jejunum overlie the great bowel. In flank wounds the colon and peritoneum may both escape owing to the thickness of the abdominal wall. Wounds entering the back in this region are apt to plow up the retroperitoneal tissue by mechanical violence or by sub- sequent hematoma, and they are consequently more fatal than anteroposterior wounds. Single entry wounds of the loin often injure the retroperitoneal tissue and pass into the colon tissue. Shell fragments and wounds in this location are grave ; they cause a large opening with escape of feces but free drainage and the fact that the traumatism is in plain view assists in the steps to be taken. This is seldom the case in wounds caused by smaller projectiles where leaks in the retroperitoneal tissue may occur which may cause death before sufficient drainage is provided. Side-to-side wounds are very apt to be fatal. If the small and large intestines are both involved, the spine or great vessels are injured since the vertical colons are set well back. For this reason side-to-side wounds which involve the small intestine alone seldom include the colon. The amount of damage done varies. In some cases the gut is lacerated and cut across, the transverse colon and central portion of the stomach may be all but completely cut by one bullet. There may be only clean cut perforations or the peritoneum only may be penetrated. All wounds below the intertubercular plane are very serious. They include shots through the hips, thighs, and buttocks. Anteroposterior wounds in the hypogastric region are very serious, especially when compared to anteroposterior shots in the epigastric region. Midline wounds are fairly frequent; the bladder is not often implicated unless it is full at the time of injury; the pelvic colon and rectum may be involved. ABSTRACTS OF WAR SURGERY 193 In the iliac regions the iliac colon and cecum may be impli- cated. Small intestinal wounds are nearly always multiple, the bladder and rectum wounds may be intra- and extraperitoneal. In vertical wounds the wound of entry is often through the buttock, perineum, or thigh, and the iliac vessels may be in- volved. The perineal wounds are often overlooked, but pain in the abdomen is often present and should lead to suspicion of internal injury. The fatality in these cases is due mostly to hemorrhage from the iliac vessels and the fact that perineal wounds are often overlooked. Wounds of the rectum are quickly fatal from peritonitis. The possibility of a bullet traversing the peritoneal cavity without injury to the viscera is discussed in an interesting way. The author gives a chart which shows a number of cases in which the abdomen was opened for exploratory laparotomy and in which no hollow viscera were opened although the en- trance and exit wounds clearly pointed to such an injury. In these operations tears of the peritoneal coats of the hollow viscera, stomach, or intestine, were not infrequently seen, a fact which would indicate that even a modern bullet can push aside the visceral wall without perforating it. Such cases are believed to account in a certain proportion of cases for com- plications like fecal fistula and intraperitoneal abscess. Determination of peritoneal involvement to make sure that the wound is penetrating is frequently difficult. This is es- pecially true when there is no wound of exit. Symptoms of shock, hemorrhage, rigidity, peritonitis, and rapid pulse point to penetration, but these are not always present. Below the transpyloric plane an entrance wound on the right of the midline and the exit wound anterior to the right lateral line of the body is apt to be nonpenetrating. On the other hand above the transpyloric line such a wound is almost sure to be penetrating. In the longitudinal direction an entrance wound near the costal margin with an exit wound above the groin points to penetration. In the case of single entry wounds the symptoms alone indi- cate penetration or nonexistance of peritoneal involvement. A vertical wound entering from the thorax may give no sign for some time. A vertical wound entering from the buttock is apt to be attended with pain at the time of injury. Absence of liver dullness is no criterion of visceral penetra- tion. Abdominal injury from a bomb explosion which exhibits 194 ABSTRACTS OF WAR SURGERY multiple small wounds may be attended with doubt as to the existence of penetration. Rather than explore one or two of these wounds for the purpose of diagnosis it is best to make an abdominal incision, and to be guided in accordance with the findings. The author has found as many as 14 perforations in the small gut from small fragments issuing from one bomb. Symptoms of peritoneal involvement are generally: (1) rigid- ity of the belly wall; (2) rapid pulse; (3) indications of hemorrhage; and (4) absence of liver dullness. Eigidity is seldom absent after 4 to 5 hours; the same is true of the pulse-rate. Local trauma without penetration may show rigidity but the pulse-rate may not rise. Symptoms of hemorrhage are hard to distinguish from shock. There is blanching and rapid pulse in both. In the case of hemorrhage restlessness is seldom seen. The same is true of air hunger and failure of sight. The amount of hemorrhage is generally very great before dullness can be of significance as a symptom. Retroperitoneal hemorrhage causes decided abdominal rigid- ity and well marked shock. The effect that shock, hemorrhage, peritonitis, and septic in- fection of the retroperitoneal tissue have in causing death is shown as follows : 1. The amount of shock is usually severe and it may be absent or nearly so for a number of hours. What actually causes shock is undecided. Usually it is proportional to the extent of the injury; but profound shock may be present with a limited lesion or may be clearly absent in an extensive one. 2. Hemorrhage is probably the most frequent cause of death. Its source is from (1) great vessels, (2) the mesentery, (3) the omentum, (4) the abdominal wall and retroperitoneal tis- sue, and (5) the solid viscera. Of these, the mesenteric are the vessels most frequently found bleeding when the abdomen is opened. 3. Peritonitis is the common cause of death, sometime after injury. It may be fatal within twenty-four hours if the infec- tion comes from a wound of the rectum. 4. Infection of the retroperitoneal tissue may come from the bowel or the aerogenes capsulatus. In the case of the former the infection usually comes from wounds of the colon. Trench fighting has permitted the establishment of well-ap- pointed operating centers close to the fighting line, so that cases of abdominal wounds can be collected rapidly into an operat- ABSTRACTS OF WAR SURGERY 195 ing room under the management of expert abdominal surgeons. This fact has materially changed the management of abdominal wounds in military surgery. The conditions on the western front so far as this class of wounds is concerned approximate those in civil practice in well-appointed hospitals in which the surgeons control all the environments. The rule of operating early has become the vogue at the casualty stations on the western front. The rest-treatment supplemented by morphia, which obtained in the Spanish-American, Anglo-Boer, Russo- Japanese, and other recent wars in which the mobile armies were fighting in the open, is no longer favored. In caring for patients before operation morphine is at once employed for the relief of pain and to allay anxiety during transport to the casualty station. Fluids should be adminis- tered in very moderate quantities. On reaching the operating hospital the patient is put to bed, and is given subcutaneous saline for the treatment of shock. If no improvement takes place hemorrhage is probably present and operation should be undertaken. If hemorrhage is found the chances of saving the patient's life are good. At operation a paramedian incision is employed and it should be used in all cases unless it is contraindicated. A long incision saves time and shock. The first indication is to arrest hemor- rhage and the second to systematically examine for wounds of the hollow viscera. In resection circular enterorrhaphy is better than lateral anasto- mosis. Lesions of the small bowel must be dealt with first and the colon next. The author gives no figures on the results of the cases oper- ated upon but he promises to do so when a series of cases has been collected for six months. He states that the results se- cured so far indicate positively that the mortality at the cas- ualty clearing stations has been very much reduced by early operative interference. FOREIGN BODIES IN THE BLADDER RESULTING FROM GUNSHOT WOUNDS.— G. G. Turner. Lancet, London, 1916, cxc, p. 958. The author cites three cases of wounded soldiers in the pres- ent European War, in which the foreign body had presumably lodged in the bladder at the time of the casualty, for in each instance there was some urinary trouble from the outset. The 196 ABSTRACTS OF WAR SURGERY lodgment of a missile in the bladder is an event well recog- nized in all campaigns. In most museums there are specimens of calculi in which the nucleus is formed by some type of bul- let. In the x-ray investigation of such cases plates should be made with the patient in various positions and with the blad- der empty and distended. Marked alteration in the position of the shadow will then be a guide as to the freedom of the foreign body in the viscus. A routine cystoscopic examination ought also to be carried out, for there may be some nonmetallic foreign body in addition to that shown by the x-rays, or the foreign body may be entirely nonmetallic, and a negative x-ray examination is therefore not enough to establish the diagnosis. It is interesting to observe how the wound in the bladder spontaneously closes. Small foreign bodies always tend to es- cape with the urine, but those that can not negotiate the urethra may sometimes be safely removed in the eye of an evacuating catheter. Legueu, using a specially modified lithotrite, has re- moved rifle and machine-gun bullets per urethram rapidly and without general anesthesia. For shrapnel bullets, large or ragged fragments of shell, or incrusted foreign bodies, the author considers the suprapubic route the method of choice, and he believes it will certainly be the safest in the hands of those without special training. TREATMENT OF GUNSHOT WOUNDS OF THE BLADDER. — V. Saviozzi. Clin, chir., 1916, xxvi, p. 324. Saviozzi reports two cases of gunshot injuries of the bladder treated by suprapubic cystotomy and tamponing the bladder opening with favorable result. In one of the cases there was found located in the bladder a bullet as well as some spicules from the fractured innominate bone. Gunshot wounds of the bladder are more frequent than any other kind of bladder wounds. Bartels collected 285 such cases, but it is only very rarely that, as in one of these cases, a bony fragment is carried into the bladder by the projectile. Bladder injuries of this kind are classed either as intra- or extraperitoneal. In the intraperitoneal variety the prognosis according to most writers is absolutely fatal. Although this prognostic conception seems rather exaggerated to the author, yet in the statistics of 152 intraperitoneal cases, collected by Rivington, there was no recovery, nor was there a recovery in any of the cases reported by Bartels. ABSTRACTS OF WAR SURGERY 197 Extraperitoneal injuries have, however, a more favorable prognosis, but it is difficult to determine whether the injury is intra- or extraperitoneal as the early symptoms in both are identical. Regarding treatment, the prime necessity is to arrest hemor- rhage and assure the flow of urine. Some recommend the sonde a demeure in extraperitoneal injuries, others recommended suture of the bladder and a laparotomy in either variety of injury. As to the treatment adopted by the author, i. e., cystotomy with tamponade of the bladder (with laparotomy also in the first case), he thinks that the brilliant results obtained author- ize him to strongly recommend this procedure because it is rapid, safe, and in serious cases can even be carried out under local anesthesia. In these cases suture of the bladder was technically impossible and in gunshot wounds accompanied by a perivesicular hemorrhage the difficulties of suturing are such as to favor the simpler and equally safe method adopted by him. INTRAPERITONEAL BLADDER WOUNDS.— H. Brin. Bull. et mem. Soc. de chir. de Paris, 1917, xliii, p. 1086. Brin does not think that intraperitoneal lesions of the blad- der are very grave; generally it is easier to treat them than the generality of visceral lesions. In the scale of gravity they may be classed: (1) The least grave are evidently those which attack the anterior surface under the peritoneal cul-de-sac. (2) Then come intraperitoneal lesions. (3) The most serious are those involving the fundus of the bladder or the lower part of the lateral surfaces, because direct treatment is more deli- cate and especially because they are often associated with rec- tal or osseous lesions which lead to general infection. Although there are some spontaneous recoveries the treat- ment of bladder injuries is entirely surgical. The technic varies according to the nature of the injury. 1. For extraperitoneal injuries of the anterior surface, if high and if after regularization they can be correctly sutured, the practice should be suture with a sonde a demeure. If the lesion is in the vicinity of the neck, suture should not be tried. The practice should be cystostomy as high as possible and a sound placed after an interval. 2. For intraperitoneal injuries if in the apex or in the posterior face region, intervention should be by resection of the edges, 198 ABSTRACTS OF WAR SURGERY suturing in two places with fine catgut, and placing a sonde a demeure. The Douglas sac should be closed by a row of sutures, thus carefully isolating the wound from the rest of the abdominal cavity, followed by cystostomy. As wounds of the fundus are usually produced by perineal projectiles, they necessitate a lateral perineotomy or even transverse as wide as possible so that a loose tamponade in contact with the bladder wall may be made. THE TREATMENT OF SIMULTANEOUS LESIONS OF THE RECTUM AND BLADDER.— F. Crosti. Biforma med., 1917, xxxiii, p. 604. The author has collected 45 cases of rectal lesions treated at the war hospitals. Among these 14 showed a concomitant lesion of the bladder, 2 of the posterior urethra. One of the latter showed a perforation of the left prostatic lobe. In 9 cases there was urinary infiltration; in 3 a diffuse phlegmon of the pelvirectal space. In the cases with urethral lesions there was ischuria; in the other cases there was more or less abundant flow of urine mixed with particles of feces, although the orifice of issue was situated high in several of the cases. In the 14 bladder cases there were five deaths. With regard to the treatment of these cases the usual prac- tice is to prevent infiltration and stagnation of urine in the tissues with consequent infection through the rectal opening. Although in some cases recovery may be obtained by simple ap- plications of a sonde a demeure and without treatment of the rec- tal lesions, in others an intervention must be made with cystoto- my and colotomy to draw off the feces. The first indication is to widely open up all along the tract of the projectile. If there is a bony barrier opposed to reaching to the urofecal collec- tion it will be necessary to use a transversal perineotomy with the Albarran or Jung incision. In order to avoid the constant danger of infection, the formation of a permanent anus contra natura for the complete deviation of the feces is recommended. In the majority of cases after the perineotomy a simple sonde a demeure will suffice to cure the bladder lesions and recourse to cystotomy will be rare. Deviation by colostomy was executed by the author 6 times with only 1 death. ABSTRACTS OF WAR SURGERY 199 SURGICAL TREATMENT OF WAR WOUNDS OF THE ABDOMEN.— Rev. of War Surg, and Med., April, 1918, i, No. 2. As the war has progressed, the only evolution that has taken place in ideas regarding abdominal wounds has been in the direction of improving facilities for the early operative care of this type of injury. It has always been difficult for the civil surgeon to grasp the dictum that penetrating war wounds of the abdomen were to be treated expectantly. Col. Cuthbert Wallace, in three Lettsomian lectures on the subject of war surgery of the abdomen (Lancet, 1917, i, pp. 561, 597, 637), traces the explosion of this fallacy, and then furnishes the most il- luminating exposition of war wounds of the abdomen that has yet appeared. The opinion that the operative treatment of abdominal wounds was not to be undertaken under war conditions was partly due, according to Wallace, to want of success, as in the Spanish- American War, and partly to the fact that many military sur- geons were opposed to extensive operating anywhere near the firing line. As abdominal surgery, to be successful, must be done at once, it is obvious, he says, that it could not be under- taken with success where all operations had to be postponed to a late period. When the South African War broke out the expectant treatment was the orthodox one. Many civil sur- geons hoped to prove it wrong, and an appeal was issued by the Surgeon-General recommending the early operative treat- ment of abdominal penetrating wounds. Opposing opinion, however, was brought to bear, on the basis that expectant treat- ment was in itself the right procedure, and that it was the best that could be done in war. The South African campaign ended with surgical opinion opposed to early operation for penetrating abdominal wounds. This opinion seems to have been strengthened by succeeding wars — the French War in Morocco, the Balkan War, and the Russo-Japanese War. Shortly after the beginning of the present war, according to Wallace, Souttar commenced early operation in the Belgian Army. Owen Richards was the first to publish results of opera- tive treatment in the British Army (Brit. Med. Jour., Aug. 7, 1915). The first case of operation was performed on January 28, 1915, and the first successful case, that of a resection of 2y 2 feet of the small intestine, was performed on March 18, 1915, 36 hours after receipt of the injury. Holding the opinion that early operation was indicated, Wal- 200 ABSTRACTS OF WAR SURGERY lace commenced operating and making postmortem examina- tions, and soon convinced himself that abdominal injuries were, as a rule, of such a nature that recovery without operation must be a very rare event. It was also found that hemorrhage was a chief cause of early death, and that bullets produced very extensive injuries — two very important points. The re- establishment that hemorrhage was the chief cause of early death was of great importance, as it showed that only by rapid evacuation could one hope to combat such a condition. Wallace bases his communication on all abdominal wounds, which reached an operating hospital from a certain sector of the line over a period of 18 months. In arriving at a conclu- sion of the mortality of abdominal wounds and what can be done for them by operative treatment it is necessary, accord- ing to Wallace, to take a sector of the line and to include all the cases, no matter at what hospital they are treated. Re- sults differ in different hospitals, more or less depending upon their distance from the firing line ; they will also differ accord- ing to the nature of the fighting. It is necessary not only to reckon the operative mortality but to bring into account all cases which arrive too bad for operation. This has been done in the present series. The statistics were collected from the records of all the hospitals called upon to treat abdominal cases, each institution having been provided with a book in which certain headings were written down and filled in by the medical officers at the time of operation. The following figures show the differences in results which may be obtained in different hospitals under different condi- tions, and the necessity of including them all in statistics if accurate results are to be obtained. The total mortality at four different hospitals during the same battle was : Per cent (4) A casualty clearing station 54.00 (2) An advanced operating hospital 36.36 (3) An advanced operating hospital 82.64 (4) A casualty clearing station 72.73 The time which has elapsed between the receipt of the in- jury and the performance of the operation influences the mor- tality. Most cases arrive some time between 6 and 10 hours after receipt of the injury. If over 12 hours, the mortality ABSTRACTS OF WAR SURGERY 201 mounts; above 24 hours there is little hope of getting a good result. From the operative point of view, the sooner the patient is operated upon the better. From a postoperative point of view it is desirable to do the operation in some place where the patient can be kept quiet and properly nursed. For obvious reasons it is not possible to satisfy both conditions. Taking it all in all, the best place for abdominal surgery is a casualty clearing station, preferably selected some 10,000 yards behind the line on a railway or canal with good roads leading to it. If a patient arrives at a casualty clearing sta- tion 10 hours after the receipt of a wound it will most prob- ably be found that only 60 minutes have been spent in travers- ing the distance from the trench system to the casualty clear- ing station. Discussing the mechanism of wound production after pene- tration, Wallace expresses the view that the different types of wound are caused by the varying state of distension of the small gut. As is well known, one meets with lengths of the small intestine alternately distended with aid and collapsed. If the bullet strikes a distended portion, it will perforate it or cut a hole in it. If it strikes a portion which is collapsed, the intestine is so small that the diameter of the bullet is such that it could divide both coats. Wallace directs particular attention to the difficulties en- countered in making a diagnosis of intraperitoneal damage. Even with all possible care and an extensive experience and a full appreciation of the numerous fallacies, it is frequently difficult to make sure that a wound is penetrating. If it is difficult when there is an entrance and exit wound, it is still more so when there is only one wound. Shock, hemorrhage, rigidity, a rapid pulse may be present, but in some cases which are received early there will be no such guides. The wound of a hollow viscus may in itself have no symptoms if it is not extensive enough to produce shock; it is usually hemorrhage or peritonitis which gives the danger signal. As there is a dis- tinct relation between the interval since the receipt of the wound and the operation, it is important to be able to deter- mine the probability of penetration. Wallace warns against making a negative diagnosis without great care. Experience has shown the wisdom of operating in doubtful cases. This is particularly true of bomb wounds, which often are so small and insignificant that, as he says, it 202 ABSTRACTS OF WAR SURGERY sometimes takes some strength of mind to explore the abdomen, although the symptoms point to the possibility of visceral in- volvement. "While, as a rule, a man who has been hit in the abdomen, looks ill, this may not be the case. Before rapid evacuation was the rule, Wallace was struck by the fallaciously good facial expression of some of these cases, when the hands were cold and clammy and the pulse running or even not palpable. Such cases, he says, invariably die, and operation only hastens their end. A rapid pulse, a pulse that does not fall, or a rising pulse is an indication for operation. A slow pulse is not necessarily a contraindication unless the wound is in a nondangerous area such as the liver. A rapid pulse, which is caused by loss of blood, and later on by peritonitis and sepsis, does not seem to have any very definite connection with the number of lesions of the intestine. The pulse often falls with rest and infusion, and it often happens that a falling pulse is more an indication of the possibility of operation than a contraindication to opera- tive measures. A rising pulse is an indication for operation. Vomiting, in these cases, has no special significance beyond the fact that its absence shows that the stomach is most prob- ably not involved. With the exception of blanching and rapid pulse, both of which may be produced by other causes, the classical signs of hemorrhage are usually absent. Rigidity is a constant but varying symptom when the cases arrive. It is seen in low thoracic injuries, wounds of the ab- dominal wall, and in contusions of the abdomen and with true visceral injuries. Shock is considered under two heads: (1) Subjective sensa- tions, (2) shock proper. The subjective sensations of a man shot in the abdomen vary in a remarkable degree, being influenced by the size of the projectile. As regards the abdomen, a state of clinical shock is produced in various ways — by a violent blow; by multiple intraperitoneal abdominal injuries; by hemorrhage, by sepsis, which seems to be of the nature of poison shock, and by pain. Apart from certain generalizations, it is difficult to make any definite statement as to the relation between the amount of shock present on the one hand and the organs injured and the amount of individual damage on the other. There is con- ABSTRACTS OF WAR SURGERY 203 siderable difficulty in ascertaining the connection between the actual damage done and the amount of shock. Regimental medical officers who see cases early can form no idea, apart from the loss of abdominal wall or protrusion of viscera, what the extent of the abdominal injury is, and by the time the cases come to operation there are the added factors of loss of blood and sepsis. The amount of shock seems to be largely due to the loss of blood. If an easy method of supplying this fluid could be found, results might be greatly improved. The transfusion of blood can be employed only when conditions are quiet and when a donor is available. The care of the patient before operation is important. Dur- ing transit to the hospital the man wounded in the abdomen is more comfortable if he is placed in such a position that his abdominal muscles are relaxed. "Warmth and morphia are im- portant. Water, in reasonable amounts, may be given. Having reached the hospital, the question of immediate opera- tion arises. On the whole, Wallace believes, it is better to put the man to bed and watch his condition for a while than im- mediately to subject him to operation. The actual moment of performing the operation must be left to the judgment of the operator. Cumulative experience shows the wisdom of operation in most cases, and it is now mostly a question of excluding cases on which it is best to operate. On the whole, it may be said that a policy of "look and see" is better than one of "wait and see." Cases which are best left alone are: (1) Cases in very bad condition; (2) cases shot high up in the abdomen and in the liver area, in the absence of symptoms of hemorrhage; (3) high abdomino-thoracic wounds on the left side; (4) cases arriving late (24 hours is given as the usual limit within which a pri- mary operation is likely to be successful). The operating table, in the Trendelenburg position, should be ready for use. Most important is the provision of some heating arrangement on which the patient can lie. The incision is planned rather with a view of dealing with the probable nature of the injury than with any reference to the wounds. With an in-and-out wound the course of the pro- jectile is known and a fair estimate can be performed of the organs likely to be involved. With a single wound this is practically impossible, and here an x-ray examination will en- 204 ABSTRACTS OF WAR SURGERY able the operator to make the incision in the best possible place. A paramedian incision is the standard method of opening the abdomen, and should be used in all cases unless there is some distinct indication to the contrary. It is always better to prolong the incision than to make lateral right-angle exten- sions. The length should be 6 to 8 inches, probably the longer the better, as free access means a very great increase in celer- ity. In some anteroposterior wounds toward the lateral line of the body a rectus sheath incision may be employed. Such an incision permits easier access to the colon, and the limiting of the field of operation. The disadvantages are that it is not a good in- cision to close, and it divides many nerves. Where the missile has perforated through the body from near the mid-line to the loin, whether this direction is shown by an entrance or an exit wound, or by the aid of a skiagram, the transverse incision, either horizontal or parallel to the upper or lower abdominal limits, has much to recommend it. If more room is required it can be obtained by cutting the anterior rectus sheath, but leaving the rectus muscle intact. Such an incision allows free access to the hepatic and splenic flexures, to the vertical colons, to both kidneys, and to the spleen. It is the only incision that allows the ascending and descending colons to be easily and properly repaired. Its posterior ex- tremity is a convenient situation for an artificial anus at the site of the colon wound. It is not a convenient incision for the stomach, except for that portion situated near the spleen. A similar incision starting behind and prolonged forward, if necessary, can be used with advantage in exploring lateral wounds of the body in the neighborhood of the cecum and sigmoid. A subcostal incision is also good in certain liver wounds. In some cases of wounds in the back of the loin it is better to open the abdomen in the mid-line and make sure that the peritoneum has not been involved. If this is so, the wound is closed and the loin opened up and the necessary steps taken to deal with the condition found. Such horizontal wounds suture easily and heal kindly. The method of closure of the wound must depend on the con- dition of the patient. If the condition is critical it must be closed by through-and-through sutures. If the condition of the patient allows it the wound can be closed in layers, but in ABSTRACTS OF WAR SURGERY 205 every case there should be at least three through-and-through supporting stitches. Opinions differ concerning abdominal drainage. Wallace never uses it, nor does he believe that it has any points to rec- ommend it. By abdominal drainage is meant the ordinary drain to the pelvis or loins. It is quite another thing, he says, to tie a small drain to a suture line which mistrusts, the idea of which is to form a local track in the case of a leak. Flushing the abdomen is favored by some, especially when the abdomen is full of septic blood. It is difficult, however, to flush efficiently without much exposure of the intestines. Both saline and eusol have been used. When eusol is heated to the requisite temperature its efficiency is destroyed. The cold pro- duced by ether is sufficient to damn it, in Wallace's opinion, even if its use could cleanse the abdomen. A small amount used to produce leucocytosis finds favor with some. The technic and details of treatment, of course, vary with the organs or parts involved. The postoperative treatment differs in no essential detail from that employed in ordinary surgical practice after any severe operation. As to the choice of anesthetic in. cases of abdominal injury, Wallace states that men who have been wounded less than 40 hours previously are not good subjects for spinal anesthesia. Intrathecal injection of stovaine is followed by a great fall of blood pressure, which may be fatal. Chloroform is an unsuit- able anesthetic. The blood pressure falls steadily during the course of the administration. In prolonged operations death may occur before the abdomen is closed, or during the next few hours. Ether is the drug most generally used. Its chief dis- advantages are loss of body heat caused by the prolonged in- halation of cold vapor, and irritation of the respiratory tract. Ether should not be given by the intravenous method to men suffering from shock. Wallace has found the most satisfac- tory way of administering ether or chloroform is by the method which permits the inhalation of a warmed mixture of air and anesthetic vapor. When the projectile has entered the chest wall as well as the abdomen, Wallace advocates a preliminary injection of hyoscine one one-hundreth grain, morphia one- sixth grain, and atropine one one-hundreth grain, followed by a minimal amount of warm chloroform vapor and oxygen. The results obtained by operative treatment are given in the appended table. The mortality has been reduced at the front by some 10 per cent, and fewer cases now die at the base. The 206 ABSTRACTS OF WAR SURGERY 18 months covered by Wallace's observations were what, as he says, is euphemistically called a quiet time, but included one period of strenuous fighting: Total number of cases 1,288 Arrived moribund 250 Total mortality (excluding moribund) . .per cent. . 50.06 " (including moribund) do.... 60.2 Considered with view to operation 1,038 No operation considered advisable 73 Total operations 965 Total operative mortality per cent. . 53.9 Total hollow viscera mortality do. . . . 64.7 Stomach mortality 1 do ... . 52.7 Small gut mortality 1 do ... . 65.9 Colon mortality 1 do ... . 58.7 By way of emphasizing the fallacy underlying the doctrine of conservation adopted by surgeons in the Boer War, Armstrong (Lancet, 1917, i, p. 82; abstracted by Surg., Gyn., and Obst.) sub- mits a report from Lady Paget 's Hospital in Serbia. In Serbia, we are told, conditions are similar to those in South Africa, and yet a far better outlook for patients with penetrating abdominal wounds was furnished by operative intervention than by con- servative treatment. He pleads for operation in all cases of per- forated intestine due to bullet wounds. Twenty-four cases are reported by Armstrong. Ten consecutive cases of over 30 hours' duration were explored and perforations sutured with three re- coveries. It is noteworthy that none of these cases were drained. Seven consecutive cases of the same duration were treated by saline, Fowler's position, opiates, stimulations, etc.; all died. Autopsy proved that two which were moribund at admission died of hemorrhage from large vessels (gastroepiploic and hemor- rhoidal veins) 30 hours after injury. Three cases of probable injury to the diaphragm showed an intermittent rigidity of the recti muscles lasting for several minutes with intervals of flaccid- ity lasting about an hour. The sign ceased after 36 hours. The author contends that many cases of "cures" accredited to the medical treatment have in reality probably been only wounds of the abdominal wall, because it has been repeatedly demonstrated that a bullet can cross the abdomen without causing material damage to the viscera. iUncomplicated by other intestinal lesion. CHEST GUNSHOT WOUNDS OF LUNGS AND PLEURA.— Sir Berke- ley Moynihan. Surg., Gynec. and Obst., December, 1917. The mortality of chest wounds in all zones of the army is extremely difficult to ascertain with anything approaching ac- curacy. Pierre Duval, whose work in the surgery of the lungs during this war has been characterized by originality, insight, prudent courage, and great technical success, has gathered to- gether the records from many parts of the French Army. Of a total of 3,455 cases there were 688 deaths, roughly a mortal- ity of 30 per cent. But the mortality differs, as may well be imagined, at various parts of the line of communications. At the aid posts it is terrible, not less it is asserted than 25 to 30 per cent. At the ambulance chirurgical automobile, or cas- ualty clearing station, the mortality is about 18 to 20 per cent. In the base hospitals the death rate is about 10 per cent. There is, it will be seen, a progressive diminution in mortality from the front to the base. Pierre Duval scrutinized these figures in the following remarkable way: At the aid posts, where the mortality is 25 per cent, there will remain alive of 100 patients, 75. At the ambulance, of these 75, 20 per cent will die and there will remain 60 patients. At the base, of these 60, 10 per cent will die, so that finally 54 cases will survive. Two series of cases falling under individual observation may be quoted. Gregorie records a total of 404 cases of chest wounds, pure and simple, i.e., without other injury, with 47 deaths, a death rate of 11.7 per cent. Of these 75 patients were operated upon for empyema, with resection of the rib and drainage ; 26 died, a mortality of 45 per cent. All observers are agreed that there is a difference in the mor- tality according to the projectile inflicting the injury. If a rifle bullet causes the wound, the condition resulting is either very serious, if a large vessel is struck, or very benign if the lung tissue is traversed without serious vascular injury. Wounds with high explosive shell, the fragment causing the wound being irregular and jagged, when pieces of clothing or 207 208 ABSTRACTS OF WAR SURGERY of skin are driven deeply in, are always serious by reason of the infection that is so prone to follow. Death occurs chiefly from two causes: from hemorrhage or from sepsis. Hemorrhage is fatal early, generally within the first 24 or 48 hours. Sepsis proves fatal at a later stage, gen- erally from the seventh day onward. The most fatal cases are those where there is a gaping wound of the chest so that the lung is freely exposed. The mortality in cases where the chest wall is closed behind the projectile is rather less than one-half of that which results when there is an open wound. The injuries inflicted by a projectile entering the chest may be considered in their effects upon (a) the chest wall, (b) the injured lung, (c) the opposite lung. The Chest Wall. — The damage done to the chest wall may be of the most diverse forms. There may be a clean penetra- tion of the thorax from front to back by the projectile. In many of these cases, however, and in a still larger number when there is a shell-wound, there is a fracture of one or more of the ribs or of the scapula. Fragments of bone, tiny spicules or larger pieces, are carried into the chest. In severer cases a part of the chest wall may be destroyed, being driven inward by a massive piece of shell casing, or being swept away by a glancing blow. Few cases reach a base hospital in France, and still fewer, of course, in England, where any large portion of the parietes is lost. The Injured Lung. — The effects produced in the lung are strictly comparable to those produced in other parts of the body by the various forms of projectile. The points of en- trance and of exit in the case of perforating wounds bear all the appearances of those seen in the soft tissues of the thigh. The entrance wound is small, even punctate; the orifice of exit is larger, more irregular, and bears signs of greater injury, and of a tendency to protrusion of wounded parts. Along the track of the missile there are the same evidences of diffused injury. The parts around are bruised and lacerated, there is a hemor- rhagic pulmonary infiltration of varying, but often wide, ex- tent. The injury to the damaged lung is not, however, confined to the path of the bullet, and the parts immediately adjacent. The distant portions of the lung or the pleura bear traces of lesions due to the force with which the parts are struck. There may be hemorrhages by contrecoup, in the upper lobe if the lower is wounded or in the lower if the upper is injured, or in both ABSTRACTS OF WAR SURGERY 209 if the projectile has passed near the base of the lung. These, as Duval has shown, may be recognized at once by the opacity seen on the radiograph. Such meager postmortem experience as exists confirms the impression that is derived from the clinical examination of operated cases: that wounds of the lung heal rapidly and kindly. The Opposite Lung. — It is a new experience, gained during this war that the opposite lung suffers damage also. Such lesions are frequent; in the severer cases probably constant. They consist in small or large hemorrhages, beneath the pleura or in the substance of the lung. In a late stage the lung may present all the evidences of a bronchopneumonia, at one point, or in many. The increased activity imposed upon the lung by the restricted function of that which has been wounded, no doubt renders it an easy prey to any malady. Hemorrhage. — When a missile enters or traverses the chest any of the vessels contained therein may be lacerated. If the larger vessels in the mediastinal cavities or in the root of the lung are divided, the loss of blood is so copious and rapid that death results at once and the patient does not reach even an advanced aid post. In the cases not immediately fatal, the blood comes, in the very great majority of cases, from the lung tissue. Apart from the cases dying instantly from Hemorrhage, the deaths in the first 48 hours are all due to loss of blood from lung tissue. Both in the French and the English armies, pre- cocious operative measures are being adopted in such cases with a degree of success that encourages a wide adoption of this practice. If death does not occur speedily from hemor- rhage, a recurrence of bleeding is not often seen. Patients rarely die from hemoptysis, and secondary hemoptysis is ex- tremely infrequent. The occurrence of hemorrhage through the wounds of entry or of exit is probably responsible for the erroneous belief that it is from the chest wall, from the inter- costal vessels, that the blood is lost. Hemothorax. — The amount of blood extravasated into the pleural cavity varies very much, from a few ounces up to 4 or even 5 pints. The escape of blood is hindered and at last arrested by collapse of the lung, and by the pressure exerted by the blood which has already flowed into the pleural cavity. The response of the pleura to the contact of blood is expressed in an inflammatory reaction which also helps in some degree 210 ABSTRACTS OF WAR SURGERY to seal the leaking orifice though it also increases the mass of fluid lying in the chest. The admixture of fluid effused from the pleura accounts for the fact that in many cases the condi- tion of the combined fluids does not conform with that seen when only blood is extravasated. Hemothorax in itself, though disabling enough and productive of such general effects as the loss of a large quantity of blood necessarily entails, is not dangerous to life apart from infection. The most common as- sociation is of the bacillus coli with the gas gangrene bacillus. The frequency of infection may be gauged from the figures given by Captain Henry. Out of 500 specimens of fluid ob- tained by tapping, in the ordinary routine of work, 195 were found to be infected, and of these 87 were infected by anaerobic organisms. The aspirating syringe introduced into the upper fluid part of the hemothorax may discover no organisms, whereas one made lower down into the more solid fibrinous clot may give positive results. The infection may be derived from the projectile or clothing carried into the wound at the moment of the infliction, or may be derived at a later stage from the focus in the lung, or from the suppurating external wound. Treatment. — Upon one point all those who have been respon- sible for the treatment of a patient with a chest wound are in com- plete and confident agreement. The earliest and the most perfect immobilization is necessary. Movements of all kinds are to be avoided, and therefore retention of the wounded man at the cas- ualty clearing station for many days is a paramount necessity. The fact that in the first two days the deaths are due chiefly to hemorrhage and in later stages to sepsis must direct the timely and appropriate treatment. Early operations for the purpose of ar- resting hemorrhage from the lung tissue have been tried only in certain hospitals in either the French or the British zones; but so far as the results of the work have gone, they appear to justify a continuance, and indeed a general adoption, of the principle of early direct treatment of the wound. It is, I think, largely owing to the advocacy and to the successful practice of Pierre Duval that an earlier surgical attack is now considered necessary upon the graver kind of lung case. Immediate intervention, according to Duval should comprise: (1) Closure of the chest wall in cases of "open thorax." (2) Thoracotomy with suture or plugging of the lung in case of grave hemorrhage or of threatening asphyxia. (3) Treatment of pro- gressive surgical emphysema. ABSTRACTS OF WAR SURGERY 211 1. Closure of the chest wall, an operation practiced by Larrey in the Napoleonic wars, has as its aim the suture of the muscles and skin in order to avoid traumatopnea, pneumothorax and a continuing infection of the pleura from the suppurating external wound. The results in the saving of life and suffering are incal- culable. The gravity of the cases of "open thorax" can hardly be exaggerated. When a part of the chest wall has been torn away, the lung often bruised or lacerated, is exposed. It retracts toward the hilum and leaves gaping and bare, a huge cavity wherein putrefaction may occur, and a large surface from which absorp- tion can take place. 2. Thoracotomy is formally indicated in all cases of wound of the lung causing hemorrhage. Suture of the lung tissue affords perfect hemostasis. When any foreign body, projectile or se- questrum, is felt, the lung is incised over it if necessary, and after extraction of the foreign body, the wound is stitched up accu- rately. Any blood lying in the pleura is carefully evacuated, per- fect cleansing of the cavity is insured, and the wound is closed, it may be after a gentle wiping of the parts with ether. There is no need for drainage. 3. In the treatment of progressive emphysema, closure of the wound in the lung will shut off the channel through which the air escapes into the tissues. Multiple skin incisions will relieve the tissues already distended and crepitant. In cases of simple pene- trating wounds, a cleansing and excision of the wounds followed by a complete approximation of the edges is all that is necessary. In many cases, even excision is not required; the points of en- trance and of exit may be cleansed and covered with a sterile dressing. When a hemothorax is present, no interference as a rule is needed for some days. There may be exceptions to this rule when the rapid or the large accumulation of fluid is causing urgent dyspnea which threatens the life of the patient. The dangers of early aspiration of the fluid are, of course, related to the reopening of the pulmonary wound, which, lightly sealed, may bleed afresh, as the lung expands. At the end of a week or thereabouts, aspira- tion of the blood has probably a most beneficial effect upon the lung, allowing it to expand much more rapidly than would other- wise be possible and preventing the formation of those dense crip- pling adhesions which may embarrass the free action of the lung for a long time to come, or even permanently. Operation on cases in England, in which the blood has been left in the pleural cavity, 212 ABSTRACTS OF WAR SURGERY reveal an extreme density and a wide extent of adhesions. X-ray examination also demonstrates the firm union that is formed be- tween the two layers of the pleura. Withdrawal of the fluid is therefore most desirable; its replacement during aspiration by oxygen allows more fluid to be taken, and causes the minimum of distress to the patient. In cases of large hemothorax which presumably have remained sterile and in which no active treatment has been adopted, there is a protracted period of incapacity of the lung. "When a hemothorax has become infected, then thoracotomy is necessary. In the early period of the war the operation was prac- ticed on the lines of the civil operation for empyema. A short piece of rib was excised, the putrid and most offensive fluid evac- uated, and a large drainage tube introduced. Such cases remain sometimes for weeks, even for months, with open wounds. Tuffier has modified, profoundly for the better, the treatment of these tedi- ous and most trying cases by adapting to their needs the Carrel- Dakin technic. The operation, in so far as resection of the rib and evacuation of the fluid are concerned, is precisely similar to the procedure in cases of empyema. But instead of one large tube, several small tubes threaded with wire are placed over the cavity at well judged intervals. Their position and proper distribution may be confirmed if roentgenogram is taken. A little loose gauze is packed into the wound and a safety tube, for drainage of excess fluid, lies in one angle of the incision. Dakin's fluid is instilled in the usual manner. At the end of ten days all discharge (there is rarely more than an extremely small quantity after the first two days) has ceased, and the tubes are therefore removed and the wound closed. There is no doubt that many cases of suppurating hemothorax would do better if operated upon quite early, by a wide opening of the chest, and a complete clearing away of all masses of clot and pleural lymph often so tenaciously adherent, and by removal of any projectiles. Patients not operated upon or operated upon by the older methods linger on in unsatisfactory condition for such long periods at home, that every fair opportunity that offers for curtailing the tedious and not wholly safe period of their con- valescence must be embraced. The Carrel-Dakin technic will here find one of its most valuable indications. This is only to bring the treatment of wounds of the lung into line with that practiced elsewhere. "What is the history of patients in whose lungs projectiles are ABSTRACTS OF WAR SURGERY 213 retained? Our knowledge does not allow us as yet to answer this question fully. But a certain experience is not likely to be changed by a larger survey of cases. We may say with confidence that a rifle bullet, or a small piece of shell casing, may be retained for months or years without causing distress and without affecting appreciably the normal functions of the lung in which it lies bur- ied. But with large or irregular pieces of shell the case is differ- ent. For these reasons I have recently given special attention to these patients and have submitted a number of them to operation. The results so far entitle me to say that it is probably a safer, as it is certainly a speedier, procedure to submit all patients, in whose lungs a large projectile is retained, to operation rather than to leave them untreated. In almost every case operated upon the pro- jectile has been dropped at once into a culture medium ; with one exception all missiles were infected ; the organisms most commonly found were staphylococci. The following are the details of the procedure adopted for the extraction of bullets from the lung. The new features in the method are chiefly due to the initiative and the superb technical skill of Pierre Duval : The patient lies flat on his back, with the arms to the side, under the oxygen anesthesia. A curved incision about five or six inches in length is made exactly along the line of the fourth rib. The fibers of the pectoralis major are split, and the pectoralis minor separated from the rib. There are many points of hemorrhage requiring a clip or a ligature. All must be carefully secured so that there is a perfectly dry field. The rib and the costal cartilage are exposed for a distance of not less than five inches. An incision is made through the periosteum midway between the upper and lower borders of this membrane is stripped from rib on both sur- faces. A Doyen's curved raspatory is very useful for the purpose. Care is taken in excising the rib and in lifting it away not to wound the pleura, which must be separated widely from the ribs above and below, to the inner and the outer side of the wound. Unless this is done, accurate closure of the pleura later on, always diffi- cult, will be impossible. A retractor is now placed in the wound to widen the interval between the ribs above and below. Any ab- dominal retractor will do ; but the best instrument is that invented for this special purpose by Tuffier. As wide a gap as possible is made, so that the whole hand can be easily passed into the chest. The pleura is now incised along the line of the rib and air enters 214 ABSTRACTS OF WAR SURGERY freely and at once into the pleural cavity. As a rule this causes no disturbance and does not alter the rate of the respirations or the pulse. The hand is now passed into the chest cavity. Adhesions of the lung to the parietal pleura may be encountered. These are some- times very slender and easily broken through. At times they are tough and strong and are with great difficulty severed. If they are numerous or thick and tough, bleeding may occur quite freely for a minute or two. With gentle pressure from a hot moist swab, the oozing is soon checked. Thoracic adhesions bleed, I think, far more freely than those encountered in the abdomen. When all are loosened, the collapsed lung lies free within the pleural cavity. It may now be seized with the fingers or with a special light form of clip and drawn up to the anterior wound, and, little by little, be coaxed out of the wound. It is surrounded as it appears by warm cloths soaked in normal saline solution. When a lobe of the lung is freely delivered it is palpated from top to bottom. Any projec- tile embedded in it is felt as a rule at once. Even little sequestra blown in from a rib may be recognized without any difficulty. These foreign bodies are as easily recognized as the particles of gritty sand in a new sponge. When the projectile is felt, the part of the lung containing it is made prominent, the lung tissue lying over it is incised, the metal removed, and the wound sutured. Deep stitches of catgut are passed through the lung substance, and with gentle tension act as a hemostatic. If necessary very fine catgut sutures may be used to secure the accurate apposition of the pleural edges. If there is any bleeding from the collapsed lung, it is slight and easily controlled, but pre- cision in suture is most desirable, for expansion of the lung will rapidly be secured when the operation is completed. When the sutures are completed the lung is replaced, the cavity of the pleura most carefully dried, and emptied and a gauze swab wet with ether wiped over the visceral pleura, and over any adhesions which may have been separated. The retractor is removed and the parietal pleura now stitched up. This is quite the most difficult part of the operation, indeed I have not been able to close the pleura accur- ately unless this membrane has been stripped up freely from the chest wall before being incised. The rib, if it has been turned back, is replaced, and fixed in position by a suture through the cos- tal cartilage. The muscles are carefully sutured and the wound edges accurately approximated without drainage. The closure of the wound should be so carefully done as to seal the chest hermet- ABSTRACTS OF WAR SURGERY 215 ically. When the dressing is applied, a two-way needle may be plunged into the chest, and the ether and air extracted therefrom. The lung then rapidly expands and faint breath sounds are heard at once. No shock follows this operation. Conclusions. — The following general conclusions may be stated: 1. The approximate mortality from gunshot wounds of the chest at all parts of the line of communication is 20 per cent. 2. The causes of death are hemorrhage as a rule within 28 hours; and sepsis after the third or fourth day. 3. The local conditions in wounds of the chest wall and lung are in all respects similar to those met with in wounds elsewhere. The missiles are the same, their destructive effects upon the tissues are the same, and the infecting organisms are the same. 4. The lung tissue is more resistant to attack than many other tissues. The opening of the pleural cavity and the resulting ex- posure of a large serous sac to infection and all its consequences add, however, a danger of the most threatening character. 5. The chief essential in the treatment of all cases of penetrating wounds of the chest is rest. 6. In clean perforating wounds of the chest rest, together with the cleansing and dressing of the wound of entrance or exit, will lead to the recovery of the great majority of cases. 7. In cases of "open thorax," the earliest and most complete effort possible must be made to secure closure of the wound after an appropriate toilet. 8. In these rare cases of grave hemorrhage, when hemoptysis is present or when the blood escapes by the wound, a direct access to the source of the bleeding must be obtained, when all contingent circumstances permit, and the wound in the lung must be treated by suture, preferably ; or by plugging of the cavity from which the blood escapes. 9. In cases of hemothorax when the blood effused is small in quantity and remains sterile, no active measures are necessary, unless absorption is long delayed. Aspiration, repeated if neces- sary, may then be performed. 10. In cases of hemothorax, when the blood effused is large in amount and remains sterile, aspiration after the seventh or eighth day, or earlier in cases of urgent dyspnea, certainly hastens convalescence, permits a more rapid expansion of the lung, and prevents the formation of firm adhesions which may perma- nently cripple the free movement of the lung. 11. In cases of hemothorax, whether the amount of blood is 216 ABSTRACTS OF WAR SURGERY small or large, when infection takes place, open operation is neces- sary. Early operation both when the Carrel-Dakin technic or Morison method are adopted saves many weeks of convalescence and permits of a more perfect functional recovery. 12. Small foreign bodies, or rifle bullets, imbedded in the lung, often cause no symptoms ; they become encapsulated and may safely be left. 13. Larger foreign bodies retained in the lung may cause dis- tressing or disabling symptoms for long periods. In such cases removal after resection or elevation of the fourth rib through an anterior incision will allow of the safe removal of the projectile from any part of the lung. Pieces of metal so removed are al- most always infected. TREATMENT OF PENETRATING GUNSHOT WOUNDS OF THE CHEST.— X. Delore, and L. Armand. Lyon chir., 1917, xiv, p. 280. The authors treated and followed 71 penetrating chest wounds with 46 recoveries and 25 deaths. Of the 71 injuries 18 were due to rifle bullets, five to shrapnel balls, and 48 were shell wounds, 15 of the deaths being due to the last. Regarding the treatment of such wounds the authors recommend the following: 1. For punctiform wounds, medical treatment only: complete immobilization of the chest, large doses of morphine — 3 to 4 cen- tigrams daily. These wounds due to rifle bullets are not usually infected and are rarely associated with severe vascular lesions. But if the bullet wound shows any symptoms of abdominal pene- tration then immediate operation is necessary and the authors pre- fer an abdominal operation. Contraction of the abdominal wall as a single symptom does not authorize a laparotomy as it often exists when the wound is confined to the chest alone. 2. For large wounds the authors advise operation as early as possible even if the man is severely shocked. The procedure after x-ray examination is: (a) A parietal wound is widely opened up and thoroughly cleansed, all foreign bodies, pieces of ribs and manubrium removed and the remaining bone surfaces smoothed; the injured soft parts are cut away. After careful hemostasis if the projectile has not ABSTRACTS OF WAR SURGERY 217 penetrated the lung the pleura is cleansed, sutured if lacerated, and wound dressed. (b) If the projectile has penetrated the lung, the gap is enlarged, any blood found in the pleural cavity is removed, and the pleural sinuses, lung, and diaphragm thoroughly examined. It is useful to operate under the radioscopic screen. The lung may be drawn out of the wound if the projectile is situated deeply ; and if not clin- ically infected nor too much lacerated it may be sutured as well as the pleura. If not, the edges of the lung wound must be fixed to the wound of the skin by some catgut stitches to avoid a later retrac- tion. (c) If there is a wound of the diaphragm it is enlarged suffi- ciently to explore the liver or spleen. If the latter is injured, its removal through the gap is easy. A wound of the upper surface of the liver may be plugged with a gauze tampon. (d) If other abdominal organs appear to be injured, a com- plementary laparotomy will be necessary after closure of the dia- phragm wound. Even in those cases where abdominal symptoms predominate the authors begin the operation by the treatment of the chest wound which often avoids a laparotomy and at all events prevents all secondary complications from the pleura or the lung. IS THORACOTOMY INDICATED IN THE TREATMENT OF WOUNDS OF THE CHEST TO ARREST HEMORRHAGE? — Hartmann. Bull, et mem. Soc. de chir. de Paris, 1917, xliii, p. 404. Hartmann takes exception to a recent recommendation of Duval favoring early thoracotomy in the case of chest wounds with ex- tensive hemorrhage. From inquiries made of several of the automo- bile surgical ambulance services, Hartmann finds that in cases where thoracotomy is not done the mortality varies from 12.7 to 18 per cent, which is the same percentage reported by Duval with thoracotomy. Moreover, no report is given of any patient dying from hemorrhage in the statistics gathered by Hartmann. He is therefore of the opinion that thoracotomy, as a preliminary to hemostasis of the lung, although theoretically rational, is not in- dicated. Duval, in the discussion, brought forward some additional cases to those included in his first report making the mortality of all his cases 32.1 and the recoveries 67.9 per cent. He reiterated that 218 ABSTRACTS OF WAR SURGERY in severe hemorrhages thoracotomy with suture of the lungs saves two-thirds of the patients. INFECTION OF HEMOTHORAX BY ANAEROBIC GAS-PRO- DUCING BACILLI.— T. R. Elliott. Brit. Med. Jour., 1917, i, pp. 413, 448. One-fourth of all cases of hemothorax from gunshot wounds of the chest are infected, and because of this frequency early explora- tion for bacteriological infection is adopted in all military hos- pitals. This paper deals with the growth in a hemothorax of certain an- aerobic bacilli producing gas. In a series of 195 cases of septic hemothorax, 87 or 44.6 per cent were infected with such bacilli. After a latent period of varying duration, the gas and poisons produced by the bacilli may develop, in many instances with fulminating rapidity, amid the hemothorax, so that a case which on the second or third day following the wound was regarded only with suspicion of sepsis has often been seen to pass in the next forty-eight hours into a state of the gravest danger. How- ever, under the present methods of early diagnosis and proper treatment, the mortality has been reduced to 10 or 15 per cent. There is a greater liability for anaerobic bacilli to be carried in by shell fragments than by rifle bullets. The infection may be a generalized form being disseminated throughout the fluid hemothorax, or it may be localized in a mass of blood-clot lying at the bottom of the pleural cavity to begin with and later disseminated by the organisms escaping through the blood-clot to the entire fluid hemothorax. The exploring needle is the most valuable means of arriving at an early accurate diagnosis and should be used daily whenever doubt arises. An offensive odor of the sample withdrawn justi- fies surgical treatment at once. Several varieties of fluid may be obtained : (a) Blood with an offensive odor, purple color which is darker and more transparent than venous blood. The purple color is characteristic of an infection by anaerobic bacilli, but the foul smell is the chief criterion. (b) A fluid loaded with pus, reddish-pink or deep buff in color, slightly or not at all offensive. ABSTRACTS OF WAR SURGERY 219 (c) A red fluid like ordinary sterile hemothorax fluid, but containing bacilli, on culture. (d) A yellow serous fluid containing bacilli on culture. The offensive odor is the only criterion which can be accepted without further study. The examination of hemothorax fluids consists of the immediate microscopic examination of the fluid or the centrifuged product, and the preparation from it of both aerobic and anaerobic cul- tures. Methylene blue and gram stains are made. Many organ- isms may be found in the examination of these hemothorax fluids; however, the strong gram positive bacilli are the gas-producing organisms. The examination of morphological features in a film is never sufficient for their identification but must be supple- mented by cultural test. Both aerobic and anaerobic cultures are made. The gas-producing organisms of most importance are the bacil- lus perfringens and bacillus sporogenes. The clinical features of these septic hemothorax cases may be classified under three heads : ( 1 ) those indicating a general toxic action on the patient of the septic substances produced; (2) those caused by inflammation of the pleural cavity; (3) the spe- cial physical signs within the chest. Jaundice, especially if associated with epistaxis, is an index of very severe type of infection by anaerobes. The forms of infection of a hemothorax by the anaerobic gas bacilli fall clinically into five groups which are differentiated by the predominance of toxic symptoms of the features of gas for- mation respectively. These may be fatal in two or three days. The conclusions are: 1. Infection by anaerobic bacilli occurs in about 10 per cent of all cases of hemothorax from gunshot wounds of the chest. 2. The infection leads to the development of malodorous gas. 3. In the majority of cases the septic features are much more prominent than gas formation. 4. Diagnosis depends upon exploratory puncture. 5. Life can be saved in at least 80 per cent of the cases if the infected blood is drained away. 220 ABSTRACTS OF WAR SURGERY PROJECTILES IN THE PLEURAL CAVITY; DIFFERENT BEHAVIOR OF THE PLEURA ACCORDING TO THE FORM OF THE PROJECTILE.— G. Cresole. Gazz. d. osp. e. d. din., Milan, 1917, xxxviii, p. 51. From the clinical and radioscopic examination of three cases the author states that, quite independently of any pleural in- flammatory process, the pleura, in the presence of a foreign body with a rough, uneven surface, may originate an aseptic reaction capable of organized products which will encapsulate the foreign body ; but that when such foreign body has a smooth and aseptic surface such reaction on the part of the pleura is lacking, and the body remains free in the pleural cavity. EXTRACTION OF INTRAPULMONARY PROJECTILES UN- DER THE SCREEN.— E. Petit de la Villeon. Presse mid., 1917, p. 301. Petit de la Villeon 's experiences are based on 200 operations for the extraction of 230 intrapulmonary projectiles. All recov- ered except one, and in most cases the recovery was rapid after extraction. The forceps extraction under screen control is the adaptation of general radio-operative methods to pulmonary surgery. The entrance of the x-ray not only into diagnosis but also into opera- tive procedures has given surgery a new turn. Instead of the older methods of large open dissections there is now what may be termed the economic radio-operative method, economical be- cause it avoids unnecessary opening up and unnecessary surgical procedures. To the objection that the method is blind and nonanatomical it may be replied that the contrary is the fact. A thorough prac- tical knowledge of regional anatomy as well as the acquired abil- ity to "see" under the screen is necessary. This is essential to pick out the organs involved as well as the best and safest route of approach to the projectile by a simple and economic opera- tion. The author gives the technic and indications for the removal of intrapulmonary projectiles. The contraindications to the radio- operative method are : (1) projectiles situated in the hilum region of the lung; (2) very voluminous projectiles or fragments; (3) when there is an abscess around the projectile. ABSTRACTS OF WAR SURGERY 221 In the case of projectiles in the hilum region the author prac- tices inter-omo-vertebral thoracopneumotomy in three stages, which he describes in detail. TECHNIC OF THE EXTRACTION OF FOREIGN BODIES IN THE MEDIASTINUM, BY THE TRANSPLEURAL ROUTE WITH AN ANTERIOR COSTAL OPENING AND OTHER METHODS; OPERATIVE RESULTS.— R. Le Fort. Bull. et mem. Soc. de chir. de Paris, 1917, xliii, p. 26. The surgical rule of the present day is to extract projectiles from the lung, and allow those of the mediastinum to remain. But projectiles of the lung which become encysted are often well tol- erated and are infinitely less dangerous than those of the medias- tinum situated near the heart and large vessels and which are al- ways moving in the midst of delicate organs. For many reasons surgery of the mediastinum is not well es- tablished. The occasions for practice are rare ; published obser- vations and cadaver experiments do not give much help ; the routes of approach are difficult and interventions are reputed to be very dangerous. Le Fort's object in making this report is to give a precise tech- nic supported by integral statistics which demonstrate that a well- conducted operation is not very serious. It is indispensable that such surgery should be undertaken only by experienced operators. Le Fort's experience is based on 30 operations in the three fol- lowing groups: 1. Operations on the mediastinum for abscess, thymic tumors, stab wounds, etc. 2. Operations undertaken for the extraction of foreign bodies, but which proved to be situated outside the mediastinal pleura. 3. Operation for extraction of foreign bodies which were sit- uated between the right mediastinal pleura and left mediastinal wound or intramediastinally. The best method of approach in the majority of cases is the anterior transpleural route through the costal opening. The route remains good in case of a projectile deemed to be medias- tinal but which in reality is situated in the pleural cavity or in the pulmonary parenchyma. Before intervention, except for urgency, cicatrization of anter- ior thoracic wounds must be awaited. Le Fort gives the full de- 222 ABSTRACTS OF WAR SURGERY tails of his method of extraction of foreign bodies by this route removing a costal flap. This includes the selection of the side of the thorax, the ribs included in the flap, the cutting of the flap ; mediastinal liberations ; search for the foreign body ; and extrac- tion with closure of the wound. Pneumothorax is remarkably well supported and there does not appear to be much more inconvenience in a large opening of the pleura than of the peritoneum. Flattening of the lung against the vertebral column in pleural incisions is only a fable ; it occurs only in the cadaver. It is not necessary to puncture in order to extract air remaining in the wound after operation. Le Fort has not done it in any of his cases. The efforts of the patient will drive out in part any air remaining in the cellular tissues. But this method of operation by anterior costal flap is not the only one to be recommended; there are other methods for which there may be formal indications, viz. : 1. Simple intercostal incisions with or without a limited resec- tion of one rib (for foreign bodies easily reached). 2. Anterolateral transpleural route with large resection of the sixth rib. This provides ample opening of the inferior medias- tinal zone and of the diaphragm. 3. Posterior transpleural route, which gives access, limited to the aorta, brachiocephalic trunk, etc. 4. Extrapleural route. By this route access can be obtained to foreign bodies situated in front of the two first dorsal verta- brse. The approach varies for the anterior and posterior medias- tinum. Le Fort calls attention to the absolute necessity of a complete radiologic study before any intervention. This will give the geometric localization of the foreign body ; the anatomic localiza- tion and the relations to the surrounding organs; the physiolog- ical localization movements communicated from the heart, dia- phragm, and vessels. La Fort expects soon to publish all the details of his interven- tions of the various kinds enumerated. He gives a short account of 15 operations for extraction of intermediastinal projectiles, with only one death. In 14 of these cases the foreign body was extracted. The postoperative course was as a rule simple. In the discussion following the paper opinions were divided. ABSTRACTS OF WAR SURGERY 223 Those who criticised Le Fort's procedure expressed the opinion that the costal resection should be limited to a single rib. EXTRACTION OF INTRATHORACIC PROJECTILES.— Binet and Masmenteil. Bull, et mem. Soc. de chir. de Paris, 1917, xliii, p. 78. The difficulties met with in the extraction of mediastinal pro- jectiles have been exposed in a recent report by Le Fort. The authors in 107 cases found 15 intrathoracic projectiles — exclud- ing intrapleural, intrapulmonary, and intracardiac. Of these, 7 were mediastinal, 5 being anterior and 2 posterior mediastinal pro- jectiles; 3 were juxtacardiac in contact with the pericardium. The majority were small pieces of shell. The authors studied in detail the route of approach on the mediastinum. When the projectile is seen radioscopically above the third rib, in front and above the fifth spinous process behind, they approach it by the anterior route. Below this zone which cor- responds to the pulmonary hilum they prefer a lateroposterior incision. Foreign bodies included in the diaphragm can be reached by a thoracico-abdominal incision. The superficial or deep position of the projectile rather than other circumstances determines the method of excision. The authors reserve the thoracic flap for cases where the foreign body is in a dangerous zone in the vicinity of large vessels, in which case it is necessary to have a full and clear field of obser- vation so that grave accidents may be avoided. They agree with Le Fort that for the upper mediastinum large rib resections com- prising the second, third, and fourth ribs, and for the lower mediastinum, the third, fourth, and fifth ribs, are desirable. The pleura should not be exposed unless necessary, but if neces- sary it should be fully opened up without fear of any result- ing pneumothorax, the dangers of which have been greatly ex- aggerated. All cases operated upon by the authors have recovered and primary union has been obtained in all cases except one. WAR WOUNDS OF THE LARYNX AND TRACHEA.— E. J. Moure. Rev. de chir., 1916, xxxv, II sem., 1. Military statistics show that laryngotracheal injuries are not frequent. In the present war only an approximate percentage 224 ABSTRACTS OF WAR SURGERY has been established. Wounds of the neck may be taken as about 3 per cent of the total wounds. In an experience with several thousand wounded the author has found only about 30 wounds of the larynx and trachea. They class laryngotracheal injuries as (1) neuropathic dis- turbances, (2) extrinsic or extralaryngeal lesions, and (3) lesions of the laryngotracheal region. In the second category the author gives some clinical examples of nerve and muscle lesions and lesions involving the esophagus. In the third category are lesions of the laryngeal region (cartilage, muscles, articulations, and ligaments), of the cricoid, epiglottis, and trachea. The immediate results of laryngotracheal injuries are hemor- rhage, emphysema, asphyxia, and sudden death. In the great majority of cases of penetrating wounds of the laryngotracheal tract, the respiration was compromised to such an extent that tracheotomy was necessary to save the life of the patient. Be- sides this preliminary preventive tracheotomy the wound, as is the common practice in all war injuries, must be opened up and cleaned and foreign bodies, etc., removed. These procedures of tracheotomy and cleansing constitute the immediate treatment of such injuries. The results consecutive to laryngotracheal injuries are classed by the author as (1) edema of the laryngeal mucosa; (2) sup- purations; (3) inflammatory stenoses; (4) paralyses. Such re- sults may necessitate a second tracheotomy. This should be systematically performed. Intercricothyroidean laryngotomy ought never be done, according to the opinion of the authors. A large portion of the author's extensive article is devoted to a detailed study of laryngotracheal cicatricial stenoses, including (1) circular or membranous stenoses; (2) tubular stenoses; (3) complications ; perichondritis, . etc. ; and the treatment by tracheolaryngostomy, including their special technic. Only when the surgeon is quite assured that cicatricial retrac- tion has terminated and that laryngotracheal permeability is perfect should any plastic procedures be attempted. The author describes the detailed technic of Moroi's special laryngotracheal autoplasty. This consists in making two cutane- ous flaps around the laryngotracheal opening which superimpose on each other so as to form a double layer over the opening. In concluding the author states that the cicatricial laryngeal ABSTRACTS OF WAR SURGERY 225 stenoses of war are quite different from those observed in peace and the prognosis is much more serious. The article appears to be well worth careful study by laryngologists. PENETRATING WOUNDS OF THE THORAX.— E. Remond and R. Glenard. Paris med., 1915, v, p. 450. The authors are stationed in a hospital about 30 kilometers from the firing line. In the five months they have been there they have treated 1,830 wounded men, 150 of them being wounds of the thorax, in 110 of which the projectiles penetrated the thoracic wall. About three-fourths of these patients had hemoptysis, a much higher percentage than is given by most authors; but absence of hemoptysis does not necessarily mean that the lung is uninjured. Twelve of their patients died, but in 6 of them there were severe complications, leaving only 6 fatalities from the pulmonary wound alone. As they were in danger of having to move their quarters at any time they could not establish an x-ray room, but there was an x-ray carriage that could be summoned and reach them with- in twenty-four hours, so that they were able to locate the pro- jectiles in a number of cases, and extract them if superficial. The lung complications that they encountered were prolonged hemoptysis, hemopneumothorax, purulent pleurisy, pulmonary congestion, bronchopneumonia, simple bronchitis, and abscess of the lung. Aside from the lung complications there were 6 cases of subcutaneous emphysema, 3 cases of paralysis of the arm from injury of the brachial plexus, and a number of cases of abdominal injury and fractures of various bones. The first essential in treatment is to place the patient at rest as quickly as possible. The author's patients were placed in large, well-aired rooms, not more than two in a room, and they were cared for in their beds to avoid moving them to the cen- tral dressing room that was used for other kinds of wounds. No probing should be done for deep-seated projectiles, as the lung tolerates their presence very well, and there is danger of both infection and hemorrhage from probing. The general treatment for hemothorax is expectant; puncture should be done only when the volume of the effusion threatens serious complications or when it shows signs of becoming puru- lent. Such operations as ligation of intrathoracic vessels, suture of the lung, and extraction of deep projectiles are too serious to 226 ABSTRACTS OF WAR SURGERY be undertaken at the hospitals at the front. The only opera- tion that has to be performed quite frequently is rib resection for empyema. If a hemothorax is accompanied by persistent fever an exploratory puncture should be made and if pus is found operation should be performed at once. Patients with in- juries of the lung should not be transported for at least eight days, even though they are apparently well. One patient was sent away after five days and he died of secondary hemorrhage when he reached the hospital in the interior. Some of the patients were obliged to stay as long as forty days. GUNSHOT WOUNDS OF THE LARYNX AND TRACHEA.— K. Kofler, and V. Fruehwald. Wein. klin. Wchnschr., 1915, xxviii, p. 1337. The authors give the histories of one case of injury of the trachea and 16 cases of injury of the larynx which they have had occasion to treat in their hospital in the home zone. A table is given showing the treatment and results in each case. The symptoms that immediately follow a wound of the larynx are more or less severe bleeding and the expectoration of blood for several days, and in some cases emphysema of the skin; varying degrees of hoarseness to complete aphonia and in many cases increasing difficulty in breathing. Sometimes there is loss of consciousness and difficulty in swallowing. The only symptom that demands immediate attention in the field is difficulty in breathing, for which the field surgeon often has to do tracheotomy or syndesmotomy. Among the authors' cases each of these operations had been performed twice. The symptoms the patients complained of in the home hospital were perichondritis, smooth or nodular swellings in the larynx, scars and cicatricial adhesions in the form of web- like membranes, in one case a hematoma that recovered spon- taneously and speech difficulties due to nervous or inflammatory changes of the cords. Treatment in most cases was expectant in the hope that the condition would improve with the dis- charge of necrotic bits of cartilage. This often occurs in civil practice. In one case the findings in the larynx and the voice did improve markedly after bits of cartilage were coughed up. The danger that such bits of cartilage may fall into a bronchus or be aspirated is slight. In three cases exuberant granulations were removed with sharp forceps, resulting in improvement in breathing and speech. Three cases were dilated with bougies ABSTRACTS OF WAR SURGERY 227 or dilators, with the result that one could have his tube re- moved and be discharged with normal breathing and speech, while the other two are still under treatment. In one case an adhesion of the subglottic space was removed after which the laryngeal findings became completely normal. Inhalations and electricity were utilized as aids in treatment. Of the 6 patients who had tracheotomy or syndesmotomy performed, only 2 still wear the tubes, while the other 4 have recovered sufficiently to have them removed. The results so far as the voice was concerned were good in 8 cases, though some of these were very severe injuries. In some cases the patients remained aphonic, while in one case the voice became deeper and in one case speech demands considerable effort. WAR WOUNDS OF THE LUNG.— Rev. of War Surg, and Med., June, 1918, i, No. 4. In recent French literature there are two particularly valuable contributions to war injuries of the lung by Pierre Duval (Les Plaies de Guerre du Toumon, Masson et Cie., Paris, 1917) and M. Piery (Le Poumon de Guerre, Rev. Gen. de Path, de Guerre, 1917, no. 5. p. 509). From these two articles mainly the following col- lective abstract has been built up. Other data bearing on lung injuries will be appended in the form of separate abstracts. Clinical Aspects of Lung Wounds. — Piery points out that whereas before the war surgeons approached the lung in a more or less timid fashion, they have become bold and sure as a result of a recent experience gained by them in war sur- gery. Practically all war wounds are caused by projectiles of one sort or another — very few stab wounds are described up to date. These projectile wounds can best be considered under the following five heads: (1) Simple chest wounds with hemo- pleuro-pneumonic symptoms; (2) complicated chest wounds; (3) etiological and pathological factors; (4) symptomatology of chest wounds; (5) treatment of chest wounds. Under the first head of simple chest wounds, Piery says the really striking thing is the fact that simple war wounds are practically always accompanied by a definite symptom com- plex, the only variation being in the intensity and duration of the symptoms. This symptom complex he has called syndrome hemo-pleuro-peumonique, because anatomically it is character- ized by hemothorax with an accompanying pneumonia. 228 ABSTRACTS OF WAR SURGERY There is the first shock immediately followed by dyspnea, both of varying intensity, and followed in turn by more or less inconstant hemoptysis, rarely profuse. The following day there appear physical signs that are quite striking in their constancy. Over the lower third of the lung posteriorly there is flatness, absence of voice sounds, absence of or diminished breath sounds ; from the middle third, dullness, with normal or exaggerated voice and tubular or almost tubular breathing. The radioscopic examination shows a large, dark shadow re- placing the clear lung area ordinarily seen under normal cir- cumstances, which extends over the lower two-thirds of the wounded lung. This shadow fades out gradually, with no tendency to demarcation into two zones. This x-ray examina- tion may also disclose a projectile. Exploratory aspiration (indispensable in these cases) con- firms the diagnosis. A cell count of the aspirated fluid shows: (a) A gradually rising polymorphonuclear leucocytosis — de- fense against infection — during the first five or seven hours, followed by (b) a drop in the number of leucocytes, due to dilution of the blood and lasting 4 to 30 hours, followed by (c) increase in leucocytosis, but chiefly of the eosinophiles and mononuclears. This last phase ushers in the stage of absorp- tion and lasts 8 to 20 hours. Hemoptysis (immediate, delayed, and secondary), cough, and dyspnea require no special description. The elevation of tem- perature which occurs in these cases merits special mention be-, cause it is one of the most characteristic symptoms. It begins within 12 to 24 hours, and then after the third or fifth day maintains a height of from 101.5° F. to 102.5° F. for about 15 days. Defervescence occurs by lysis and is usually completed in about three weeks. These cases may clear up completely, the physical signs or remnants of them existing from three to five weeks, the pa- tient, however, being in good physical condition; or the patient may become seriously ill, with marked elevation of temperature, lasting from four to six weeks and unaccompanied by any confirmatory evidence of empyema or other complications. This fever is due to pneumonia, and it is for this reason that Piery uses the phrase syndrome hemo-pleuro-pneumonique. He also insists that the temperature is due to pneumonia, even though typical symptoms be absent and physical signs not in evidence. Cases of this type will frequently drag along from six to eight weeks. ABSTRACTS OF WAR SURGERY 229 The significant fact is that both the mild and severe cases of simple lung wounds (provided there are no complications) always terminate favorably. Piery treated 25 patients with simple pene- trating wounds, with a 100 per cent recovery. This does not mean that there is complete restitutio ad integrum. About one-third of the patients develop recurrent bronchitis, and many of them have more or less persistent chest pains, dyspnea on effort, dry cough, and general irritability over quite a long period of time. All in all, however, over 50 per cent of the patients lead ac- tive lives and are fit for army duty. Under the head of complications of penetrating wounds of the lung, we have to consider immediate and remote complica- tions. Immediate complications are fairly well understood, having been well described by the medical men at the front. The remote complications, seen mostly by the personnel of the base interior hospitals, have been less accurately described. Of the immediate complications, the three most important are: (1) Pneumothorax, (2) secondarily infected hemothorax, (3) primary pyopneumothorax. Pneumothorax is extremely frequent, occuring in about 47 per cent of the cases seen by Piery. A striking fact is the frequency with which partial pneumothorax occurs without playing any part whatever from the point of view of symp- tomatology. As a rule, pneumothorax is due to the escape of air from the lung parenchyma. Much more serious is the type of pneumothorax due to a gaping wound of the chest wall. This type of pneumothorax is almost always total, and almost always results in infecting the pleural cavity, setting up acute empyema. The secondarily infected hemothorax occurred in about 13 per cent of Piery 's cases, and manifested itself by a recurrence of fever about the third or fourth week. Exploratory aspira- tion serves to differentiate this condition from the fresh pneu- monia. It is unnecessary to add that this condition is much more serious than is pneumothorax. Primary pyopneumothorax may be partial or total. The par- tial ones are very difficult to diagnosticate. X-ray, however, aids a great deal in reaching a conclusion concerning them, and exploratory aspiration is invaluable. Total pyopneumothorax occurs usually with severe infections of the pleura and is always of grave prognostic import. Under the head of remote complications we must group: 230 ABSTRACTS OF WAR SURGERY (1) Late hemoptysis, (2) abscess of the lung, (3) gangrene of the lung, (4) late pneumonia, (5) accidents which are followed by rapid, sudden, unexplained death, possibly related to those cases which, in civil practice, have been grouped under the head of "Accidents due to pleura reflex." Mortality of War Wounds of the Lung 1 . — Duval has collected 3,453 cases of lung wounds reported by 37 different surgeons, showing a mortality of 20 per cent. This mortality varies in the different formations. At the Regimental Aid Station the mortality is very high, 25 to 30 per cent being the figures usually given. During the early days of the war one authority is quoted as having said that at the front all cases of grave in- juries of the lung died. Hemorrhage and asphyxia due to mechanical interference with respiration are the two principal causes of death. In the surgical automobile ambulance sta- tions the mortality has been from 18 to 20 per cent. In the hospitals of the line of communication the mortality falls in a general fashion to about 10 or 12 per cent, thus demonstrat- ing that the mortality of injury to the lungs diminishes pro- portionately with the distance from the front. The rule in the French Army is to consider all chest wounds as not transport- able, and to hold them permanently at the first hospital in the line of formation that is equipped to receive them. For this reason, there arrive at the more distant hospitals only those lung cases which are in very good physical condition. As a general broad figure, one-half of the chest cases die in the first few days after reception of injury. Duval is ex- plicit in his statement that in these deaths he does not include fatalities due to empyema, abscess of the lung or to other late complications, and he is equally emphatic on the stress that he lays on this high mortality rate, which he characterizes as "frightful and stupefying to a degree not even suspected be- fore this war." The fact that in civil life gunshot wounds of the chest were originally looked upon as particularly benign is explained on the basis that these civil wounds are almost always the result of bullets. A large proportion of wounds of war are, on the contrary, due to artillery projectiles. Depage noted a mortality of 17.6 per cent after bullet wound and 26.8 per cent after shell wound. The bullet wounds are either im- mediately fatal as a result of grave vascular injury, or else they are relatively benign. They are attended by very few late complications, and, on the whole, are innocuous. All this is in marked contrast to wounds caused by artillery projectiles. ABSTRACTS OF WAR SURGERY 231 In the case of artillery projectiles, the mortality rate depends in large measure on whether the shell fragment completely traverses the lung or whether it remains imbedded in it, as a foreign body. Duval determined in the first instance a mor- tality of 21 per cent, which in the second instance was raised to 30 per cent. Furthermore, the mortality varies with the length of time elapsing after the injury. About 50 per cent characterizes the mortality of the first day — about 60 per cent of the first two days. Furthermore, we have to consider the wound in the chest wall itself; a so-called open thorax (that is, gaping wound in the chest wall) is attended by almost twice as high a mortality as occurs after the closed wound. On the topic of mortality Piery says that the prognosis of the simple, penetrating wound is very much better, as regards life, than one would be led to imagine. In Piery 's experience, wounds of this type have been attended by far better results than wounds of the femur, and, on the whole, have been aston- ishing in their benignancy. His mortality has been 9.4 per cent, the mortality of Maissonet 20 per cent, and that of Depage and Jannsen 15.3 per cent. Piery emphasizes that in speaking of this low mortality rate he is considering only the simple, pene- trating wounds of the chest and not those serious accidents ac- companied by injury to the heart and large vessels. Another interesting fact is that pneumothorax, not even the total pneumothorax, seems to influence the prognosis unfavorably. Indeed, pneumothorax may be looked upon as a beneficial symp- tom in that it compresses the lung and checks bleeding. The two gravest prognostic elements are the large, open chest wound and generalized infection. It is well to call attention to the significance of the pulse in prognosis. Piery stating that a pulse which alters from about 100 beats to the minute to a rate of 120 to 130 with slight irregularity, is a sign of the gravest possible significance. Mortality of Lung Wounds (Duval) (based on 3,453 Cases). Per cent. Total mortality rate 20 Mortality in the various zones : Regimental aid 25 Ambulance divisions and evacuation hospitals . . 20 Lines of communication hospitals 10 232 ABSTRACTS OF WAR SURGERY Mortality according to nature of projectile : Bullet wounds 5-15 Shells 25 Mortality according to nature of wound : Through-and-through 21 Eetained foreign body 30 Closed thorax 15 Open gaping thorax 27 Mortality according to time interval : Mortality during first 24 hours 32-50 Mortality during first 48 hours 60 Pathological Anatomy of Lung Wounds. — Wounds of the lung present themselves as (a) through-and-through wounds; (b) wounds of the surface; (c) tunnel wounds. Bullet wounds need very little consideration, because they very rarely call for opera- tive interference. The through-and-through wound caused by shell fragment is sometimes clean-cut and regular. If the shell fragment is large, the wound may be very irregular, with numerous branches, the point of exit being larger than the point of en- try. The two serious lesions characterizing this type of in- jury are the destruction of pulmonary tissue and the accom- panying hemorrhagic infiltration in the region about the wound. All lung wounds are made up of cellular necrosis more or less extensively combined with the parenchymatous destruction which is seen in all the wounds of other soft parts. The tis- sue immediately surrounding the wound is dead and cold, with only slight tendency toward crepitation. The vascularity of the lung explains the hemorrhagic infiltration; one wonders why, in such richly vascular tissue, severe hemorrhages are not even more frequent. Wounds of the lung may or may not contain projectiles, and, what is even more important, they may contain other foreign bodies such as pieces of clothing. It is important to bear in mind that these foreign bodies may be retained in the lung, even though the projectile has passed completely through and out. Another type of foreign body of importance is the bone fragment carried in from fractured ribs. These fragments are particularly dangerous, both primarily and as the cause of later complications. These bone fragments almost always cause bone suppuration and a very grave type of pleuropneumonia. The ABSTRACTS OF WAR SURGERY 233 development pathologically of a lung wound is in reality the same as that of all other war wounds. They are from the outset contaminated by the foreign body which created them, and they present a more or less marked degree of necrosis, which serves as a culture medium for the infection, which de- velops within a certain number of hours after the infliction of the injury. Anatomically, lesions are the same, the infected foreign bodies the same, the types of bacteria the same, and the biological development the same. On these important facts, proper treatment of war wounds of the lung rests. An interesting factor in these injuries is the disturbance which occurs at quite some distance from the injured side, sometimes even in the opposite lung. These lesions have some- times been termed "conlre-coup." The opposite King is not infre- quently the seat of marked congestion or purulent pleurisy. Treatment of War Wounds of the Lung. — Treatment is divided under the heads of immediate treatment, consecutive treatment, and treatment for complications. Immediate treatment has to do, in the first place, with assur- ing the wounded man rest during transport, treatment at the regimental aid station and at the evacuation hospital. Trans- port over any appreciable distance is contraindicated. After application of the first-aid dressing, one limits his efforts to combating the tendency to collapse, the dyspnea and pain (morphine). As a matter of fact, the chest should be im- mobilized on the injured side, but Piery says that one should not worry if the immobilization is not very thorough, because there are few bad effects caused by transport over ordinary distance. Copious hemorrhages of a very threatening nature are from the very outset hopeless. This does not mean, however, that nothing should be attempted in the way of hemostasis for im- mediate hemorrhage in lung wounds. Last year the Societe de Chirurgie was divided into two schools, one group of men feeling that nothing could be done in these early, grave in- juries, another group thinking that since they were practically all fatal if untried, some attempt should be made at hemostasis. Duval agrees with those surgeons who believe that in certain cases of single massive pulmonary hemorrhage, operative inter- ference saves the patient, and refusal to operate causes the loss of a patient who might otherwise have been saved. The high mortality of 60 per cent during the first two days after the injury is probably accounted for largely by these massive, 234 ABSTRACTS OF WAR SURGERY acute hemorrhages. Reports by Sencert, Gatallier, Latarget, de Beyre and others, all confirm this fact, and they all in a meas- ure justify an emergency hemostatic operation. These hemorrhages occur in two types: (a) Immediate; (b) late. The immediate type requires no lengthy explanation. It may be external, or purely intrapleural. The intrapleural variety does not cause death as frequently as does the open hemorrhage, because the imprisoned blood causes compression of the injured lung. It must not be forgotten, however, that although compression of the lungs checks hemorrhage, and checks it with a degree of certainty proportional to the degree of compression, yet nevertheless this is not entirely a beneficient factor, for this very pressure may mechanically affect the op- posite lung and the heart, and thus indirectly prove fatal. Certain cases of hemorrhage do not seem to prejudice the patient at first, but later, after transport, the patient collapses and dies, or the same unfortunate result occurs during trans- port. The explanation of this fact is that either a steady, slow hemorrhage exsanguinates the patient, or bleeding which had spontaneously ceased is set up again as a result of the transport. It is for this reason that Depage, Duval, and others recommend the so-called emergency operation for checking hemorrhage even at the front. The practical disadvantage connected with this advice is the difficulty of determining which cases should be operated on. The differential diagnosis between shock and hemorrhage is a very difficult one to establish, and many of the patients with chest injuries are in profound shock. It is true that the early operation for severe hemorrhage rescues the wounded man from death, but, on the other hand, if opera- tive interference be instituted on false grounds, no hemorrhage existing, and if death ensues, it may properly be placed at the door of unnecessary operation. Duval himself characterizes this problem as an agonizing one. Should one rather allow a wounded man to die without furnishing surgical aid, or should one resort to an emergency operation carrying with it the gravest dangers? It is the need of answering this question, again to quote Duval, that weighs most heavily on the con- science of the surgeon working at the front. The problem may in part be solved by dividing the patients into two groups : In the first group belong the wounded who arrive at a field hospital with a grave, initial, or late hemor- rhage. In this type of patient, emergency operation is indicated, "For in some part of the lung there is a blood vessel which ABSTRACTS OF WAR SURGERY 235 must be tied" (Terrier). In the second group, the hemorrhage is partly intrapleural and menaces the life of the patient, not so much as a result of blood loss as by the compression of the heart and lungs. In this group of cases it is essential to ob- serve the patients over a period of time. Frequent examina- tions should be made, always with the caution in mind, how- ever, not to disturb the patient unduly. Radioscopy, it must be borne in mind, is of very little use in these cases, unless the patients are examined in a sitting posture. Aspiration of the chest is a valuable aid. It used to be thought that the coagula- tion of aspirated blood indicated progressive hemorrhage, whereas conversely, failure to coagulate indicated that the hemorrhage had ceased. This, however, is not true. In these doubtful cases, the entire surface of the patient's body should be kept warm, and every half hour the blood pres- sure should be taken. During this period the head of the pa- tient should not be depressed, and he should receive no intraven- ous saline. If the pressure steadily falls, it means that the patient is bleeding, and if one has been able to determine this fact with a fair degree of assurance, he may proceed on the basis that direct hemostasis of the lung wound is a veritable operation of salvation. Duval has done this without an anes- thetic in cases that seemed, in every sense of the word, desper- ate, and he is inclined to draw the conclusion that so long as these cases of hemorrhage are not dead one ought to try to save them by operation. This is particularly true in view of the fact that the operation has no effect in blood pressure and may be performed in the face of a pressure which would ab- solutely contraindicate any type of abdominal operation. In 21 cases of this sort, which were formidably grave, Duval suc- ceeded in attaining a cure in 70.6 per cent. Infection in Wounds of the Lung". — The very nature of lung war wounds caused by artillery is such that they carry the same type of infection that one meets in all other war wounds. Wounds caused by bullets are very frequently sterile, al- though they are not infrequently followed by pulmonary con- gestion, a mild pleuropneumonia, or, rarely, by a more or less severe suppurating hemothorax. Small shell fragment wounds, provided they are not com- plicated by bits of clothing, are also frequently sterile. The pulmonary wound is in this instance rapidly closed by the col- lapse of the lung and by the layer of fibrin which covers the lung, thus protecting the pleural cavity against infection. The 236 ABSTRACTS OF WAR SURGERY pulmonary congestion which usually results is to be construed as a parenchymatous reaction on the part of the lung rather than as a microbie infection. A microscopic examination of the sputum shows the ordinary intrapulmonary bacteria. Wounds caused by larger shell fragments are practically al- ways followed by a grave type of infection due to anaerobes. This is particularly true if a bone splinter has been driven into the lung. The infection may develop in the lung itself, in the hemothorax or in the opposite lung. If the hemothorax is of large volume, the lung, which is totally collapsed, does not readily become infected, the hemothorax itself bearing the brunt of bacterial infection. If, on the other hand, the hemo- thorax is small in quantity and the lung not in total collapse, or if old adhesions prevent collapse of the lung, then we are more apt to have pulmonary infection in the form of broncho- pneumonia, septic pneumonia, abscess of the lung, or gangrene of the lung. Owing to the large amount of oxygen in the lung substance, there is only a slight tendency for the gas bacillus to develop to its usual full extent, and Duval says that in his autopsies he has rarely seen a case of lung gangrene which he could say positively was gas gangrene. The hemothorax itself, ac- cording to Elliot and Henry, who analyzed 500 cases, was in- fected 195 times. In these 195 instances, 87 were traceable to anaerobes. Pneumococci, staphylococci, tetragenus, bacillus of Pleiffer, streptococci, colibacillus, prefringens, and sporogenes were found in the course of routine bacteriological examina- tion. The general statement therefore holds true that the hemothorax is infected by the transport into it of the differ- ent varieties of anaerobes, and aerobes, with the projectile. If the thorax presents a large, gaping wound, then we have in addition the infection that is carried in from the external air. Infection of the hemothorax leads to a hemopyopneumothorax either free or loculated, always grave and often fatal. In ad- dition to this type of infection, we have to bear in mind al- ways the possibility of a generalized systemic infection. Knowing what we do regarding the resistance of the lung against the development of anaerobes (we can not say posi- tively whether this resistance is due to an abundant supply of oxygen, a high degree of vascularization, or to total collapse of the lung), it is not illogical to close a penetrating wound of the lung at both these extremities. In doing this, with fair success, we protect the pleura against infection. ABSTRACTS OF WAR SURGERY 237 Operative Indications. — Duval was among the first to assert that one should treat wounds of the lung from the very outset just as he treats wounds of the soft parts elsewhere. He based this statement on the fact that the mortality from untreated lung wounds was so very high and had so successfully resisted the application of all other than operative treatment. Infec- tion and hemorrhage are the prime factors of danger, and the type of injury differs very little from injuries of the soft parts. In other words, the lesions in the lung and in the soft parts are similar — the bacteriology is identical — the patholog- ical course is identical, the same type of foreign bodies have to be reckoned with, and the consequences are the same. Furthermore, it is well known that although the lung tissue resists infection better than most of the soft tissue, too much reliance should not be put on this, because, although the lung resists fairly well, the pleura has a low grade of resistance. Since it is an accepted principle of war surgery that prohphy- lactic surgical treatment is the best type of treatment, it be- comes necessary to institute surgery in injuries of the lung very early if one hopes to accomplish the necessary prophylactic measures. As a matter of fact, almost up to the present time the lung has been the sole organ which has not been subjected to the ordinary rules of war surgery. Even in the presence of severe hemorrhage which could be checked by ligation, the lung has not been attacked as often as it should be. The seri- ousness of operative interference has been urged as an argu- ment against radical lung surgery, but this argument will not hold, because during this war facts have developed which have occasioned a veritable revolution in this field. Among other things, it has been shown that the fear of pneumothorax dur- ing operation is unfounded, and that without any particular danger, one may perform a large thorocotomy or eventrate the lung, lobe by lobe, just as one does loops of intestines, palpate, incise, resect, and then replace it in the thorax. The lung is not the redoubtable organ that it was before the war. In discussing operative indications, Piery sounds a moderate note of conservation when he points out that he considers it unfortunate that the early optimistic reports regarding the safety of lung surgery must in a measure be modified — in other words, one must bear in mind that surgery of the lung, in spite of the remarkable recent advance, is still surgery of a very grave sort. For this reason, largely, Piery states that we 238 ABSTRACTS OF WAR SURGERY have no right to assume that every foreign body in the lung must of necessity be extracted. We should rather base the need of removal on some complication of menace referable directly to the foreign body. The most urgent indication is hemorrhage. Pulmonary abscess is another indication. Fin- ally, there is to be determined the important fact as to whether pneumonic process is dependent on the foreign body. Duval emphasizes the necessity of determining: (1) How should one extract a projectile from the lung? (2) Is it neces- sary to treat the lung wound itself, and how? (3) What is the best moment to institute operative intervention? It may be considered as definitely certain that the mere re- moval of the retained projectile is in itself insufficient. All other foreign bodies must be removed at the same time. The projectile itself may be removed by forceps, but if it has pene- trated almost completely through the lung, it may be extracted after having made an incision directly over it. As regards treating the wound of the lung, it may be said that the ideal treatment is excision. For various reasons, this can not always be done. When it can not be done, the tract of the wound is cleansed, with a strip of gauze, which in its removal will bring with it fragments of metal and clothing as well as tesselated necrotic lung tissue. After this cleansing, the pleural orifice or orifices (if it is a through-and-through wound) are sutured in order to protect the pleura against infection. Duval says that it is not illogical to close the openings of a lung wound, thus protecting the pleura and allowing the lung itself to combat the infected material which may have been left in the wound after all foreign bodies have been removed. The wound toilet should not, of course, be considered complete without the thorough cleansing with the strip of gauze before closure of the orifice. When the wound is near the surface, excision should be considered as ideal treatment. Kegarding the opportune moment for instituting operative intervention, it is frankly admitted that a conclusion can be reached only after much thought. Immediate intervention is to be recommended above all, but only after due account has been taken of the general condition of the patient. These lung injuries are frequently quite shocking, and it becomes neces- sary to afford the patient more rest and warmth and to com- bat the shock before operating on the lung. It is apparently true that the operative attack on the lung is not accompanied by the depressing factors that attend laparotomy. Just as it ABSTRACTS OP WAR SURGERY 230 would be dangerous, however, to rush in too hurriedly, so, un- fortunately, it would be equally perilous to wait too long. The septic reaction of the lung after injury is notoriously rapid, even more so than that of the pleura. The lung passes through a period of asepsis, just as do the soft parts, the period during which they are contaminated, though not infected. It is dur- ing this period that we may operate with most favorable out- look. In all attempts to reach a conclusion regarding operative interference, one should bear in mind that wounds from bul- lets should be placed in a group by themselves ; because, aside from urgent hemorrhage, they only exceptionally justify opera- tive interference, and their healing is usually without compli- cations. This same statement may hold true for very small shell fragment wounds, but when we come to deal with wounds caused by larger shell fragments, we may say with assurance that the complicating septic pleuropneumonia is the rule. In those wounds occupying a place between the innocent bul- let wounds and the very grave shell wounds, it is almost im- possible to establish definite operative indications broad enough to meet all needs. Even at the risk of adding an element of confusion, it is well to add the counsel of Piery regarding the proper time to in- stitute operative interference for the removal of foreign bodies : "The best time to operate is in the so-called interval after the hemopleuropneumonia has abated. Piery says that the situa- tion is very much the same as the one confronting the surgeon in cases of appendicitis, where it is always desirable to operate in the interval if possible, or where the surgeon should never hesitate to allow his hand to be forced by threatening symp- toms. As a general rule, extraction of foreign bodies should be considered as an operation to be performed in interior hos- pitals rather than in the hospitals at the front." Emergency Operation for Open Thorax. — The term "open thorax" is used to describe those cases in which the offending missile has left a gaping wound in the thoracic wall. This gaping wound must be closed in order to overcome the resultant mechanical embarrassment of respiration and the resultant pleural infection. As a matter of fact, closure is to be con- sidered as an emergency operation. Thevenot has practiced this type of closure 109 times, with a mortality of 24.7 per cent and a subsequent pleural infection of 8 per cent of the cases. The reason for this high mortality rate is that (Theve- 240 ABSTRACTS OF WAR SURGERY not) the closure of the thoracic wound was regarded as the essential thing. The fact should be appreciated that such an operation is in reality an incomplete one. Unless the lung it- self be attacked, hemorrhage checked, foreign bodies removed, and asepsis combated, one can hardly hope for other than a high mortality rate. Operative Technic. — The first point of importance in the operative technic is appreciation of the fact that one should not fear the entrance of air into the pleural cavity and total pulmonary collapse. Methods of combating this may be ra- tional, but they are very inconvenient to perform, and if we practise them we must make up our minds that it will be im- possible to relieve injuries of the lung. It is necessary to handle the lung, to inspect it, to incise it, and to swing it around on its pedicle. In order to do these various things, the lung must be in a state of collapse. All of the maneuvers described above, namely, the seizing of the lungs with forceps, separa- tion of adhesions, traction on the pedicle, if they are made with gentleness, have no influence on the respiration of the heart. The respiration maintains its normal rhythm, frequency, and amplitude. If, on the other hand, we operate under positive or negative pressure, the lung does not collapse, and it can not therefore be handled. The heart is not in the least excited, and Duval has never observed any reflex disturbance of cardiac rhythm. Thoracoto- my, with manipulation of the lung, is not a shocking operation. Indeed, even those cases that come to the field hospital in a state of moderate shock should not be held until the blood pres- sure completely reestablishes itself, but one should rather be inclined to hasten operative intervention in order to complete it before the lung enters the stage of inflammation which it ordinarily does so quickly after injury. The question of anesthesia has not been definitely settled. General anesthesia is, of course, treacherous in these cases, and local anesthesia in a measure inadequate, but when local anesthesia can be used it is the method of choice. The chest may be opened by one of two procedures, either by making a thoracic window or by the extensive resection of one rib. Duval has always contented himself with a simple re- section of 10 cm. of one rib, followed by forcible retraction of the neighboring ribs above and below. In operations per- formed for the late removal of foreign bodies, the chest should be opened at the point nearest to the foreign body, but the ABSTRACTS OF WAR SURGERY 241 early emergency operations call for extensive incision so as to permit a thorough inspection of the entire lung. One should plan this incision rather with this object in view than with any preconceived notion regarding drainage of pleural cavity. It is almost beyond question that the anteroexternal incision running from the axillary to the parasternal line in the neigh- borhood of the fifth rib gives the best exposure of the whole lung. It goes without saying, of course, that special lesions, such as rib fracture, call for special treatment and may even demand a second incision. The French refer to the delivery of the lung as exterioriza- tion. When the rib has been resected, the imprisoned air of the pneumothorax rushes out in gusts. It is well to pay no attention to this and not to attempt to extract all the air, but to proceed at once to treat the lung wound, leaving the re- moval of intrapleural air and blood for a later stage of the operation. The lung is gently seized with light, elastic, non- crushing fenestral forceps and by gently swinging, rotating movements, the lobe is exteriorized. It is received immediately in warm, moist compresses, and is thereupon carefully inspected on all its surfaces. After the lesion is located, the thorax opening is plugged by a thick gauze compress in order to obviate the to-and-fro movements of air during operation. The wound is then dealt with appropriately in accordance with the methods already described, and the other lobes treated in turn, provided they have been injured. It is necessary to operate as gently and quickly as possible and to get the opening in the chest wall closed at. the earliest possible moment. In case there should be any evidence of mechanical interference with breathing, it is advisable rapid- ly to deliver the lung, plugging the chest wall with gauze. This procedure is usually followed by cessation of all respira- tory embarrassment. In case the lung is bound down by adhesions, these are divided gently and bluntly if possible, by sharp division if necessary. In combating hemorrhage, three methods may be used: Tam- ponade, suture, or ligature. Tamponade is not to be advised except in cases where the wound is inaccessible on account of old adhesions or where the wound is large and the infiltrated lung tissue so friable as not to hold suture or ligature. Ligature requires no explanation. It is the ideal method of hemostasis. 242 ABSTRACTS OF WAR SURGERY Suture, however, should be explained, as it is in a large num- ber of cases effectual even when it is used merely to close the opening of a blind wound or openings of a through-and-through wound. According to Duval, this method seems to be illogical, but it has worked excellently in his hands. The presence of foreign bodies in the lung requires special mention. Radioscopic examination furnishes evidence regard- ing the presence of metallic foreign bodies, but unfortunately does not disclose the presence of bits of clothing, or even of fairly good-sized bits of fragmented bone. The infiltrated hemorrhagic lung does not permit one to pal- pate, with any degree of certainty, bits of clothing, moderate- sized bone fragments, and often not even bullets. Metallic foreign bodies may have to be removed under some circumstances with the aid and under the control of the radio- scopic screen. The foreign body is grasped by forceps in- serted in the lung wound or through a deliberately made new incision in the lung substance. The wound should always be gently cleansed with a strip of gauze, in order to remove pos- sible foreign bodies other than those disclosed by x-ray ex- amination, or recovered by the use of forceps. After the foreign bodies have been removed and the necrotic lung tissue cleaned away by the gauze strip, or when possible after a clean incision of the wound has been made, the lung wound is sutured. Care must be taken to include the depths of the wound in the suture, and also accurately to approxi- mate the pleural edges. These sutures should not have too wide a bight, in order to guard against their tearing through lung substance during inspiration, when tension is put on them. After the lung has been carefully attended to, the pleura and pleural cavity demand attention. The lung is replaced in the pleural cavity, and gentle attempts are made with gauze sponges to mop out every vestige of intrapleural blood and blood clot. It is, of course, impossible to remove all the intra- pleural air as long as the chest is open. Since it is desirable, however, for the sake of the patient's comfort to get all this air out, Duval recommends that it be aspirated with a syringe after the chest wound has been completely closed. This clos- ure of the chest wall must be done very carefully in order to avoid the leakage of air; the resected rib ends should be cov- ered with muscle in order to get an air-tight wound. It goes without saying that the wound in the chest wall demands the ABSTRACTS OF WAR SURGERY 243 usual careful operative treatment accorded all other war wounds. As a general proposition, Duval is an unqualified advocate of the practice of wound excision (when practicable) for the lung and always for the chest wall. Piery takes diametrically the opposite stand, however, and says that one should not practice excision of the wound. Gasquet and Le Nouene agree with this advice. Of course, this is contrary to the usual method of handling wounds, but except in very rare cases, such as subcutaneous hematomas, which harbor infection, abscess of the pleura requiring opening, or for late pneumothorax, ex- cision of the wound is dangerous. The opening, caused by a foreign body passing between the ribs, permitting the wound to close itself behind it immediately, if excised, thereby creates a portal of entry for infection of the pleural cavity. (De Martell makes this same statement in re- gard to penetrating wounds of the skull, in which the points of entry and exit are closed.) One must bear in mind that although the operation is de- scribed as sometimes remarkably simple, it is nevertheless ex- ceptional for these patients to run other than a rather stormy postoperative course. Pulmonary congestion is particularly frequent, and if it occurs on the opposite side also, it is almost always fatal. Pain, restlessness, and groaning are practically constant postoperative occurrences. The respirations are rather shallow, the pulse small and rapid, and the expectoration bloody, for the first day. It is necessary that these patients should be kept in a semiupright posture and be judicially mor- phinized. The temperature, which is elevated after operation, usually returns to normal about the fourth or fifth day, and if any air is left in the chest it is usually entirely absorbed at the end of the fifth or sixth day. Sometimes, the pleural reac- tion is manifested by a chill, followed by serofibrinous or hemorrhagic pleurisy, which is spontaneously restored. From all of this it goes without saying that postoperative care constitutes a most important chapter. These patients must be made comfortable, and it is much more difficult to do this in war hospitals than it is in times of peace. They should be placed in a special ward where the temperature is constant and kept constantly above the usual normal level and where there are no currents of air. This ward should be near the operating room or at all events connected with it by an in- closed, warm passageway. These patients should furthermore 244 ABSTRACTS OF WAR SURGERY be kept well protected by warm coverings and should not be permitted to breathe dry, cold air. It is advisable that im- mediately after operation they should be placed in specially warmed beds, GUNSHOT WOUNDS OF THE LUNGS, AND TUBERCULOSIS. — H. Rieder. Miinchen. med. Wchnschr., 1915, lxii, p. 1673. The prognosis of gunshot wounds of the lungs is comparatively good so far as immediate recovery is concerned, but there is no doubt that they leave the lung with a decreased functional capacity that tends to favor the development of tuberculosis later. There is no proof that there is such a thing as true traumatic tuberculosis. But existing cases of tuberculosis grow worse and a latent process, which perhaps the patient never knew of, may be awakened into activity by trauma. Roentgen examination often shows the presence of such an old tuberculosis in cases where it had not been clinically evident. The prognosis in posttraumatic tuberculosis is always grave. In order to prevent it patients after gunshot wounds of the lungs should be given a period of heliotherapy or sanitarium treatment. They should be protected as far as possible from con- tact with infection, should be given respiratory gymnastics for several weeks after the injury, and for several months periodical examinations should be made of the lungs, even when there are no symptoms. CARDIOVASCULAR SURGERY. INJURY OF THE HEART BY THE BURSTING OF A GREN- ADE; EXTRACTION OF PROJECTILE FROM THE RIGHT VENTRICLE; RECOVERY.— Beaussanat. Bull, de I' Acad, de med., Paris, 1915, lxxiii, p. 554. Beaussanat describes a case of operation for injury of the heart which illustrates the remarkable tolerance of this organ. A sergeant was struck by a bursting grenade. A fragment was removed, and he was then discharged, but for four months continued to have difficulty in breathing and precordial distress, worse at night and when lying down. He had to move gently and speak slowly to avoid making his symptoms worse. After roentgen examination a diagnosis was made of a fragment of shell in the pericardium. On incising the pericardium, how- ever, the fragment could not be seen, but it could be felt free in the right ventricle. The heart was brought outside the peri- cardium and held by two silk threads passed through the muscle. The fragment was brought as near to the apex of the ventricle as possible and held by the thumb behind and three fingers in front while an incision was made through which it was extracted. It weighed 1.5 gms. The heart was sutured with silk. For three days the patient had intense dyspnea, the pulse was feeble and irregular and the facies anxious. There were three attacks of cough and blood-stained sputum, evidently from pulmonary em- bolism. But in a month the patient had completely recovered and auscultation showed the heart normal. CONSERVATIVE OR OPERATIVE TREATMENT OF HEART WOUNDS. — A. Schafer. Munchen. med. Wchnschr., 1915, lxii, p. 647. Schafer describes two cases in which he sutured the heart ; one a case of stab wound with suicidal intent, the other an accidental gunshot injury. Both cases recovered. He concludes that opera- tion is not only justified but unconditionally indicated in gunshot injuries of the heart if they can be operated upon within a few hours after the injury with proper aseptic precautions. 245 246 ABSTRACTS OF WAR SURGERY Ether is the best anesthetic ; stimulants are contraindicated be- fore the operation, as they increase the bleeding ; after the opera- tion they are of value combined with the administration of physio- logical salt solution. The intercostal incision is the best. Positive or negative pressure apparatus is not necessary; in most cases pneumothorax has already occurred from the wound and even if produced by the operation it is not of great consequence. The author thinks drainage of the pericardium is dangerous and drainage of the pleura unnecessary. Fixation of the lung to the anterior ribs hastens the reexpansion of the lung. VASCULAR INJURIES IN WAR.— Rev. of War Surg, and Med., September, 1918, i, No. 7. Anatomical Considerations. — Inasmuch as the course of vas- cular lesions is determined by the general characteristics of the wound, which, in turn, depends upon the types of projectiles em- ployed, Sencert (Blessures des Vaisseaux, Masson et Cie, English translation, Appleton & Co.) points out the anatomical possibilities involved. Isolated injury of either artery or vein may occur, but associated wounds of both artery and vein are more frequent. Any of the types of injuries given below may involve vein or artery alone or both simultaneously. Any of these varieties of wounds may be found in combination. It is particularly important to note that not only may the artery and its companion vein be injured, but the Avound may involve also collateral branches arising below the point of injury and situated on a deeper plane or a bifurcating branch behind the chief trunk. This multiplicity of lesions is important from the point of view of treatment, forming one of the chief reasons for the preference given by some surgeons to the method of ligation in the wound itself over that of tying the vessels above the injury. Reference to this point is made under treatment. Types of Vascular Wounds. — The types of wounds of vessels seen in the present war vary with the types of projectiles em- ployed, and as the range of weapons used is greater than in any previous war, so the wounds seen exceed in variety and severity those which have characterized previous warfare. Thus, as Seucert points out, vascular wounds produced by rifle bullets, shrapnel balls, shell fragments, grenades, and aerial torpe- does vary greatly one from another. Wounds caused by rifle bullets ABSTRACTS OP WAR SURGERY 247 may be lateral and partial, complete and circumferential, or per- forating. Grenade fragments may cause actual punctures, more or less extensive lateral tears, amounting sometimes to complete rup- ture, true perforation, which is a rare lesion, and complete division or crushing, as when limbs are torn off or severely crushed by large fragments of shell or by minor projectiles. In cases of the last- mentioned type the artery or vein may be seen gaping, or lacerated and flattened, but not bleeding, on the surface of the stump or at the bottom of the extensive wound. In lateral wounds which are caused by projectiles striking the outer third or fourth of the transverse diameter of the vessel, the adventitia, the middle coat and the internal coat, are lacerated, while radiating rents of the intima, of varying extent, prolong the external lacerations along the interior of the vessel. The wound is enlarged and hemorrhage is favored, in consequence of the retracti- bility of the middle coat, which tends to separate the lips of the wound and to cause a slight change in the axis of the vessel, so that the segments above and below are deflected toward each other. Lateral wounds vary in size from a mere slit to complete division of the vessel. In medium-sized arteries complete division is almost the only kind of wound encountered, and it is more frequent than one would sup- pose even in large vessels. The explanation offered for the frequency of this type of wounds in large arteries is the fact that at short range the explosive effect of the bullet is such that the artery tra- versing its track is extensively torn and broken up, sometimes with great loss of substance. At medium or long range, on the other hand, the bullet is less stable, and consequently is very easily di- verted, so that the arterial wall is hit more or less obliquely by the side instead of the point of the bullet. The vessel is thus torn as by a large projectile. For the reasons just given, few perforations are met with in arteries, and then only in the larger trunks. The perforations are smaller when the velocity of the bullet is low. There may be a perforation of artery and vein, complete division of both vessels, or a lateral wound of each. In bullet wounds, as a rule, if the range is fairly long, the orifices of entrance and of exit are punctiform, and the whole track, subcu- taneous, aponeurotic, and muscular, is barely visible on operation. The tissues, separated for a moment, close up in normal position and resume their normal relationships directly the bullet has passed. No foreign body is left in the track, inasmuch as the bullet pene- 248 ABSTRACTS OF WAR SURGERY trates the clothing by severing the threads, pushing no debris before it. Such wounds, therefore, are not septic. Shell wounds, on the other hand, are broad and narrow, never punctiform. The cutaneous opening is irregular, with contused and lacerated edges exuding a sanguineous fluid. Beneath the skin the cellular tissue is lacerated, the aponeurosis, torn or perforated, covers a deep and tortuous cavity in which the muscle lies contused and crushed. Contusion and sepsis are the leading characteristics of such wounds. The degree of the contusion may be such that actual mortification of the tissue results. The extent of the contusion caused by shell wounds is always greater than the apparent limits of the wound, and includes, to a varying depth, the whole length of the track, whether subcutaneous, muscular, or osseous. Pathological Considerations. — The pathological course, as well as the anatomical characteristics, of bullet wounds differ from that of shell wounds. In vascular bullet wounds three conditions are encountered which are of particular interest in vascular surgery: (1) Spontaneous hemostasis from cicatricial closure, more or less complete; (2) diffuse hematoma; (3) traumatic aneurisms. Spontaneous Hemostasis (so-called Dry Wounds). — An arterial bullet wound is immediately followed by an escape of blood which is effused round the vessel. The perivascular sheath, supported and kept rigid by the neighboring tissues, is not destroyed by the bullet in its passage. A few muscular fibers are separated, but these come together again after the bullet has passed. There is no bullet track, and no wound cavity. The escaping blood, therefore, immediately encounters this perivascular barrier, and is thus prevented from spreading very far. Confined in this manner, the blood coagulates rapidly in the immediate neighborhood of the vessel, forming a clot which closes the arterial wound like a plug or cork. This spon- taneous hemostasis is favored by the anatomical conditions in com- plete division of the artery, the retraction and curling up of the middle and internal coats within the adventitia obliterating the lumen of the artery. In a lateral wound, on the contrary, there is retraction of the internal coat only, which tends to render the wound more gaping. Once this preliminary hemostasis is established, cicatrization of the vascular wound proceeds rapidly, and may involve both ends of the divided vessel. Sencert (Lyon chir., 1917, xiv, 640, abstracted in Surg., Gyn. and Obst., January, 1918), reported 20 cases of injuries to the ABSTRACTS OF WAR SURGERY 249 axillary, femoral, and popliteal vessels, arriving at the ambulance, in which there was already spontaneous hemostasis. Alamartine {Lyon chir., 1917, xiv, 687, abstracted in Surg., Gyn. and Obst., February, 1918), reported 32 cases of so-called dry vas- cular injuries. The clinical types, he holds, are conformable to the anatomic types, and are divisible into three groups: (a) Those showing symptoms or arteriovenous fistulae; (b) arterial wounds or arteriovenous wounds with diffuse hematoma; (c) traumatic aneur- isms. The 32 cases observed included 5 of arteriovenous fistulae ; 21 of arterial or arteriovenous wounds with diffuse hematoma; 6 of traumatic aneurism. Perrenot {Rev. de chir., Par., 1917, liii, 232, abstracted in Surg., Gyn. and Obst., March, 1918) records four cases of so-called "dry" vascular wounds, all found at operation: (1) Wounds of the two humeral veins with contusion of the artery; (2) an arteriovenous fistula of the femoral vessels in Scarpa's triangle; (3) a lateral wound of the humeral artery; (4) complete rupture of the humeral artery. In all these cases hemorrhage from the injured vessels was prevented by clot formation which was sufficiently strong to prevent the flow. In seeking the cause of this phenomenon of "dry" vascular wounds, Perrenot finds that they occur when the agent is a piece of shell and not a bullet. In this, it will be noted, his observation is diametrically opposed to that of Sencert, who points out the reasons bullet wounds may be characterized by spontaneous hemostasis (dry wounds). A bullet, according to Perrenot, makes a clean section in the ves- sel, with considerable hemorrhage and the rapid development of hematoma, whereas shell injuries are contused and lacerated wounds. The projectile is usually found in an "attrition chamber" of lacerated tissue which forms its walls; and when the projectile is large, these walls may be several millimeters thick. An important vessel may become incorporated in such a chamber. Even if com- pletely sectioned, its walls may be pressed against each other by one of the projectile surfaces. The area all around is contused and every condition for the formation of a clot is present. There is another type of spontaneous hemostasis, to be referred to later, in which, although the wound is dry, the spontaneous closure of the vessel is so insecure that dangerous secondary hemor- rhage is of frequent occurrence. Diffuse Hematoma. — Spontaneous hemostasis and cicatricial clos- ing pf the wound resulting in the so-called dry wound, form the ex- 250 ABSTRACTS OF WAR SURGERY ceptional rather than the usual course of an arterial bullet wound, according to Sencert. Under the influence, he says, of the repeated pulsations, the blood extravasated outside the vessel tends gradually to infiltrate beyond the sheath into the intercellular spaces and the interstices of neighboring muscles. Once the cellular tissue has given way, the infiltration continues until the pressure of the ex- travasated fluid equals the arterial tension. Owing to the fact that the wounds in the different tissue layers do not correspond, the blood does not reach the cutaneous wound and can not escape ex- ternally. Thus a diffuse arterial hematoma is formed. The hema-, toma is superficial, forming a tumor visible to the eye, when the vessel is subcutaneous or superficial, as the femoral in Scarpa's tri- angle or the brachial at the bend of the elbow. On the other hand, if the vessel is deep, like the popliteal or the posterior tibial, the hematoma is infiltrated into the interstices of the deep muscles, dis- tending and swelling the limb, but not forming a visible tumor. By following the adventitia of the collateral vessels, it may pass from one muscular layer to another. A diffuse hematoma of the super- ficial femoral, for example, may extend into the region of the ad- ductors, and thence, by following the course of the perforating ar- teries, it may reach the posterior aspect of the thigh. The hema- toma may be multilocular in character, presenting an anterior and a posterior sac separated by a muscular wall. When the deep and superficial femoral are both wounded at the same time, a multi- locular hematoma is apt to form. This periarterial effusion of blood is variously termed diffuse aneurism, false aneurism, diffuse aneurismal hematoma, or pulsating hematoma. Sencert considers these terms are meaningless, and agrees with Monod that arterial hematoma, the name originally ap- plied by Cruveilhier, sufficiently describes the condition. The blood, coming in contact with the limiting tissues, gradually coagulates at the periphery of the effusion. The coagulated blood contracts, the irregular prolongations of the effusion are reduced, and the hematoma, as it becomes established, assumes a certain regularity. There follows infiltration of serum and leucocytes into the neighboring tissues which have been irritated by the clot, and a sort of edematous perihematie mass is formed ; this later becomes a firm lardaceous wall, gradually differentiated, by progressive tis- sue organization, in proportion to the age of the hematoma. Coin- cidentally, the deposition of clots assumes the form of white lamina- tion, which lines the internal surface of the sac, giving it the ap- pearance of a vessel wall. This phenomenon accounts for the fact ABSTRACTS OF WAR SURGERY 251 that a hematoma is sometimes mistaken for a true aneurism. The pseudo-sac of this encysted arterial hematoma may be made to dis- appear, up to at least the fifth week, by pressing out the contained clots. There is, therefore, no true aneurismal wall which may be isolated and removed. The less fortunate course of an encysted arterial hematoma may involve its progressive growth and its infection, to which reference is made under treatment. Its more favorable course involves its metamorphosis into a true arterial aneurism. Aneurism (arterial, arteriovenous, aneurismal varix). — The de- velopment of an arterial hematoma into a true arterial aneurism takes place, according to Sencert, in the following manner: The inflammatory connective tissue wall becomes defined and hardened, and the peripheral layers of the clot become laminated and adherent to it. The center of the hematoma, on the other hand, which is close to the arterial wound, and is continuously under the influence of the systolic pulsations, becomes softened, and is gradually hollowed out into a regularly shaped cavity, into which the bloodstream en- ters with each heartbeat. The pressure of the circulating blood against the wall of this cavity causes it to become thinner, and it is more or less completely lined by an endothelial proliferation from the edges of the arterial opening. A sac with organized walls, lined with endothelium and bounded by a progressively defined connective tissue sac, is thus formed round the vessel. It is in direct communi- cation with the interior of the artery, and pulsates synchronously with it. The types of arteriovenous aneurism are illustrated in Figs. 1 to 5. TYPES OP ARTERIOVENOUS ANEURISM 1. Direct communication between artery and vein. 2. Vein evenly dilated. 3. Venous sac. 4. Connecting fibrous canal. 5. Intermediate sac. When an arterial bullet wound is associated with a wound of the accompanying vein, the following circumstances may ensue: (1) The bullet may pass between the artery and the vein, in- 252 ABSTRACTS OF WAR SURGERY flicting a lateral wound on each. The two orifices may correspond exactly, and, from the beginning, may adhere so accurately and so completely by their margins that there is no appreciable effusion of blood around the vessels. These cases are not frequent. "Where the two openings do not exactly correspond, conditions are favor- able for the formation of an arteriovenous hematoma, but the ex- travasated blood so easily finds the central end of the vein, and is so rapidly taken up by it, that nothing remains but a slight effusion in the perivascular sheath. Cicatrization of the two wounds is accomplished by an endothelial proliferation, which quickly unites the edges of the fistula. Be- tween the two vessels, above and below the opening, the blood takes part in the organization of a fibrous tissue connection between the arterial and venous walls for a distance of an inch or more. This adhesion of the two vessels is of great importance, since it prevents the ligation of the communication and the reconstruction of the two vessels by a double suture. Dilatation of the central and peripheral ends of the vein in the neighborhood of the union is an invariable and immediate conse- quence of arteriovenous communication. The venous tension is enormously increased in consequence of the violent projection of blood toward both ends of the vein, which dilates and thickens, presenting the characteristic features of aneurismal varix. The dilatation may be regular, and spindle-shaped, as in I of diagram. It may become irregular and bulging, forming an arteriovenous aneurism, with the sac entirely venous, as in II of diagram, or the central end of the artery may become thin and atrophied, losing its tension, and becoming dilated, thus forming the simplest type of arteriovenous aneurism. (2) The bullet may cause a double perforation of artery and vein ; it may make a lateral wound in the artery, with complete di- vision of the vein, or vice versa; it may completely divide both artery and vein. Immediately after the passage of the bullet, in every case, there is hemorrhage, arterial and venous, which spreads around the vessels, inside and outside of the adventitia, like a diffuse arterial hematoma. This diffuse hematoma is soon bounded by an inflammatory wall, being thus transformed into an encysted hema- toma, the center of which is a channel of communication between the artery and the vein. This intermediate hematoma may undergo progressive retraction until a small fibrous canal, about half an inch in length, unites the two vessels, as shown in III of the diagram. In other cases the vessels are united by a true sac, as in IV of dia- ABSTRACTS OF WAR SURGERY 253 gram. The communication may take place in the vicinity of a trib- utary vein. The arteriovenous aneurism, in such cases, assumes forms and relationships difficult to anticipate, and it occurs in all possible varieties, from the simplest to the most complex varicose aneurism. Wounds from shell splinters are divided by Sencert into two classes: (1) Those in which the external wound gapes widely; (2) those in which it is partially or completely obliterated. Of the first category are the extensive, widely gaping wounds made by large splinters and the still more widely gaping wounds due to comminuted fractures with much cutaneous and muscular laceration, or to the loss of the whole limb. Hemorrhage, primary, reactionary, or secondary, one or all, are the concomitants of wounds of this character, in which crushing and contusion play an important part. Various factors tend to check the dangerous and often fatal pri- mary hemorrhage. Those of secondary importance are diminution of arterial tension due to acute anemia, retardation of the blood flow, and syncope. Of primary importance is the high degree of contusion of the vessel in the neighborhood of the actual wound. In lesions of this kind, with no sign of hemorrhage, careful ex- amination will reveal that the middle and internal coats of the vessel are mangled and frayed, with hanging shreds which adhere to- gether, favoring the obliteration of the vessel. The protecting clot thus formed often extends an inch above the wound. This spontaneous hemostasis, quite unlike that of the so-called dry wounds already described, is extremely precarious, since the slightest movement, sometimes a mere increase in the blood pressure, may displace the clot, even after hours, and set up a fresh reaction- ary and perhaps fatal hemorrhage. In the majority of cases (9 times out of 10, according to Sencert) the large vessel lying injured at the bottom of this gaping shell wound is discovered and complications averted by suitable treat- ment. Sometimes, however, the case may be regarded as one of simple injury of the soft parts. Such wounds, open, gaping, and exposed to air and light, however contused and septic, will never become the seat of serious and rapid sepsis. It can never, as in the case of the narrow, confined wound, become a closed chamber for the multiplication of germs, and it is exceptional that gangrene and diffuse suppuration are found in it, a simple localized infection dur- ing the progressive elimination of the contused walls of the injured area being the usual course. 254 ABSTRACTS OF WAR SURGERY It is not unusual, however, for the vascular wall, severely bruised for some distance from the wound, to undergo gradual necrosis, in which event the separation of the resulting slough, 8, 10, or 12 days after injury, may open the vessel above the obliterating clot. The inevitable secondary hemorrhage may prove fatal at once, or it may recur until death is the final outcome. This type of wounds without hemorrhage apparently called forth the recent observations of Neuberger (Rev. gen. de clin. de therap., 1917, xxxi, 16, 251), who reports a series of cases seen in a surgical ambulance of which he was director, which were interesting by vir- tue of the fact that the wounds were dry for a period of eight hours after injury, and then the vascular injury became known as the re- sult of severe hemorrhage. The significance of these wounds, Neu- berger warns, is that they indicate the necessity of immediate in- vestigation of all wounds that lead to the suspicion of vascular injury, even though there be no active hemorrhage. Unfortunately, the absence of pulse does not help one in reaching a conclusion re- garding the presence of these dry wounds, because the vessel is not infrequently thrombosed as a result merely of vascular con- tusion. Neuberger quite graphically characterizes these wounds as "mute" wounds, on account of the scarcity of symptoms, and says one's chief reliance in making a diagnosis is the fact that an- atomically the course of the projectile is such that probably a large vessel is injured. The reason for these dry wounds is that the internal tunic curls out in the lumen of the vessel, forming, with the tissue debris and coagulum, a progressively formed closure. In the second class of shell wounds, viz., punctured wounds, or those in which the external wound is partially or completely closed, the conditions are quite different from those enumerated in connec- tion with gaping wounds. There is not the external hemorrhage of external wounds, but instead, a diffuse arterial hematoma, some- times of enormous size, is formed, as with the bullet wounds previ- ously described. The contusion of the vessel and the extensive laceration of the internal coat for some distance from the wound greatly facilitate arterial thrombosis and spontaneous hemostasis. The effusion may be sufficiently extensive to reach collateral branches, obstructing them and thus facilitating the rapid gangrene of the wounded limb. Wounds of this type, moreover, unlike the extensive gaping wounds, are severely septic from the beginning, the infection often being accompanied by the evolution of gas. The increased distension caused by the gas completes the blocking of the collateral vessels, rendering gangrene inevitable. Instead of ABSTRACTS OF WAR SURGERY 255 an anaerobic infection leading to gas gangrene or gaseous cellu- litis, a simple slow phlegmonous inflammation, leading to simple suppuration of the hematoma, may develop. This state of affairs is particularly apt to involve small hematoma. Secondary hemor- rhage is the natural termination. Thus, when shell wounds are narrow and restricted, septic arterial hematoma results. If this is considerable, it leads to septic gangrene ; if small, to local sepsis and secondary hemorrhage. Contusion of vessels. — Contusion, which plays so important a role in the subsequent history of extensive shell wounds involving large blood vessels, may, under certain exceptional circumstances, ac- company bullet wounds, but vascular contusion is more frequently caused by shell, grenade, or torpedo than by bullet. A spent ball, or a ball which has been retarded by passing through a bone, may be arrested in contact with a large vessel, which is struck more or less violently but is not ruptured. Contusion may be caused by the passage of a ball at some distance from the vessel. The mechanism of contusion varies. It may be the outcome of direct shock, as where an artery is struck by a spent ball. Direct shock is more frequent in association with wounds caused by shrap- nel balls than by bullets of small caliber. Contusion may result from hydraulic shock to the vessel, effected at the moment when the ball comes in contact with it or with the tissues in its immediate neighborhood. It is more frequently due, however, to the elongation or stretching of the vessel. In contusion caused by fragments of shell, grenade, or torpedo the mechanism may involve direct shock, indirect shock conveyed from a distance, or the overstretching of the vessel. The degree of contusion varies from immediate and rapid gangrene at the site of injury to slight bruising at a distance. The degree of contusion varies with the volume and velocity of the projectile, on the one hand, and its distance from the direct point of contact, on the other. Experimental observations have led to the differentiation of three degrees of contusion, involving, respectively, the internal coat only, in the first ; both the middle and internal coats, in the second ; and rupture of the intima and media circularly around the entire cir- cumference of the vessel, in the third. These experimental findings have been confirmed by the surgical experience of the war. Contusion of the first or second degree, when it is the sole injury, is too slight a lesion to produce appreciable symptoms. In cases characterized by contusion of the so-called secondary degree, in which thrombosis occurs, secondary symptoms resulting from the 256 ABSTRACTS OF WAR SURGERY migration of clots from the thrombosed portion of the vessel give the only evidence of the contusion. If the embolus is arrested in the cerebral vessels, hemiplegia or monoplegia, transitory or per- sistent, results ; if in the peripheral arterioles of the limbs, cutane- ous sloughs, or even dry gangrene result. Such lesions are signifi- cant in connection with vascular suture, to which reference is made later. Contusion of the third degree sometimes appears as a narrow constriction corresponding to the site of retraction of the torn inner coats. As a rule, however, a fusiform dilatation of the vessel is seen, on exposure, corresponding to the contused portion, the wall of which is formed only by the adventitia. Effect of Contusion on Contents of Vessel. — In contusion of the first degree the characteristic fine striation of the intima does not, as a rule affect the circulation of the blood through the vessel. In contusion of the second degree thrombus formation is a frequent accompaniment, the thrombosis varying from the lateral thrombus very limited in extent, to the thrombus that completely occludes the lumen of the vessel. In contusion of the third degree — subadventitial rupture of the internal coats — thrombosis is the invariable accompaniment. Pri- mary thrombosis, the direct outcome of the laceration of the internal coats, may be complicated by secondary thrombosis due to infection of the wound in the neighborhood of the contused vessel. Involvement of the Periarterial Sympathetic. — Burrows (Brit. Med. Jour., Feb. 16, 1918, 199) calls attention to the fact that in war injuries of main blood vessels, little inquiry has been made into the effects upon structures which lie within the area of dis- tribution. Injury of a main artery—such, for example, as the common femoral, the popliteal, or the brachial — may produce im- mediate and remarkable consequences in the affected limb. Inas- much as the ensuing symptoms are paralytic, they are apt to be regarded either as "functional" or as arising from concomitant nerve lesions. Owing to the close association and common ana- tomical relations between the vessels and the nerves, simultaneous injuries of the structures are indeed of frequent occurrence. Eleven cases are detailed by Burrows to show the extensive paralytic phe- nomena that may follow a vascular lesion independently of any nerves. The main symptoms are: (1) Subjective sensation in the distal part of the affected limb; (2) anesthesia, more or less of the "stocking" or "glove" type, and involving all kinds of sensation, ABSTRACTS OF WAR SURGERY 257 including light touch, pin-pricks, and deep pressure; (3) muscular paralysis; (4) in certain cases hardness and inelasticity of the muscles; (5) edema. It is noted that in all cases in which no arterial pulse could be felt distally to the injury the patients complained of subjective sensations, variously described by them, but referred to by the writer as "pins and needles." On the other hand, in cases in which a distal pulse could be felt there were no "pins and needles." In these cases the area of anesthesia was most extensive, reaching to a level considerably above the wound. Cutaneous sensibility was lost in all cases tested except one. Motor paralysis was present in all. In one case muscular and sensory paralysis rapidly passed away after a wounded popliteal artery had been ligated together with the vein. When the distal pulse was not obliterated, with motor and sensory paralysis, the muscles were flaccid and soft; whereas, in cases of complete arterial lesion, the muscles were hard. No case of paralysis was observed as a sequence of injury to the radial. The pressure of packing may have played a subsidiary part in the causation of symptoms in cases in which the wounds were plugged at the time of admission to the general hospital. The fact that ligature of an artery in one patient may lead to little or no evil consequences, while in another, seemingly as favor- able at the time of operation, grave consequences may follow, is difficult to explain. In one case cited fracture close to above the elbow- joint, ligature of the brachial artery seemed to exercise a favorable influence. Cases of this sort illustrate the fact that what- ever the actual cause of angiotic paralysis may be it is not clearly defined at present. The following theory concerning the pathology of the cases under consideration is given by Burrows : The attractive and simple course of attributing all the nerve phenomena to ischemia — to an insufficient supply of blood to the tissues — at once suggests itself, and, if we follow this course, we may describe the symptoms collectively under the title of ischemic paralysis, and be done with all further speculation. Objections, however, to this title become apparent on close scrutiny. In the first place, it involves the acceptance of a hypothesis of causation which at present is not fully established. The symptoms may be due to the small quantity of blood which is circulating, to injury of the sympathetic nerves in the vessel sheath, to the low pressure of the blood stream below the injured artery, to cold, to some other cause altogether, or to a combination of causes. Moreover, although 258 ABSTRACTS OP WAR SURGERY some of the cases just described show that a paralysis similar to the so-called Volkmann's ischemic paralysis often does follow occlusion of an artery, yet it is clear that this is not the only form of paralysis which may follow a vascular lesion. For these reasons it appears better to adopt a general title which will not implicate us in any hypothesis other than that the symp- toms are consequent upon damage to a blood vessel. Accordingly, the term "angiotic paralysis" may be applied with convenience to the symptoms described in these cases. At the outset we must assume that two factors at least take part in the causation of the symptoms. On the other hand, we may have extensive degeneration of muscle and massive gangrene, without any loss of cutaneous sensibility, except in the area of mortification, while on the other there may be widespread loss of sensation and muscular power without gangrene, without gross myopathic change, and even without obliteration of the distal pulse. From this it is clear that there is no exact correlation between the neuropathic and the myopathic symptoms. Probably ischemia is one of the factors, the one which is asso- ciated especially with Volkmann's myopathy. If, however, we accept ischemia as the cause of this myopathy, there must be at least some other cause for the flaccid paralysis and sensory loss which are to be observed after certain vascular injuries in which the artery is not completely divided or obstructed, and in which the distal pulse can still be felt. The fundamental cause in these cases seems to be the actual damage to the arterial wall or to its sheath, rather than any consequent effect upon the supply of blood to the limb. Further, it appears that an incomplete injury — that is to say, an injury in which the artery is not completely severed — is more likely to be followed by extensive sensory loss and flaccid paralysis than is a complete division or ligation of the artery. There is reason to suppose that these symptoms are reflex in nature. Accepting this to be so, we classify the effects of arterial injuries into ischemic paralysis and reflex paralysis. Let us consider these two factors in detail. A wound in the popliteal region is followed by absence of pulsation in the dorsalis pedis and posterior tibial arteries. The foot becomes cold and white, and remains so for 24 hours, at the end of which time there are signs of returning circulation, except in the toes and a small portion of the foot, which become gangrenous. The whole leg up to the knee is slightly edematous; the muscles are hard and abso- lutely paralyzed. Inspection of the muscles after amputation ABSTRACTS OF WAR SURGERY 259 show them to have undergone a striking change of color— they are no longer red, but quite pale and almost buff-colored. This change affects some of the muscles more than others, and the change is more complete in the distal than in the proximal ends of the muscles. What the actual change and its cause may be we do not know, though the suggestion has been made that it is identical with rigor mortis. Sections of the muscles in this case were made, and the following pathological report rendered: "Portions of the peronei and gastrocnemius muscles were cut; each showed gross pathological changes. No normal muscle fibers were seen. In sections stained by hemalum and eosin the general impression was that given by an anemic infarct. The muscle fibers and the interstitial tissues stained a uniform pink. The fibers showed various stages of degeneration — some had almost normal striation but no nuclei ; others had completely lost their striation, and appeared as granular masses. Fibers showing different degrees of change were often found next to each other. The majority of fibers appeared swollen. Some were broken up into irregular masses; others were split into longitudinal fibrillae and transverse discs. There was no hyaline degeneration, and no gross fatty change was seen. The interstitial tissue appeared edematous, stained a faint pink with Van Gieson, and was almost cell-less. There were few capillaries. Throughout the sections there was but little trace of inflammatory reaction. The large vessels, arteries, and veins contained blood, not clot, and appeared normal. ' ' The characteristics of ischemic cases are summarized as follows : 1. An arterial injury with obliteration of the distal pulse. 2. Subjective sensation of "pins and needles." 3. Muscular paralysis; the muscles being hard and inelastic to the touch. 4. Anesthesia of a "stocking" or "glove" distribution, confined to the portion of limb which is distal to the injury, and involving all forms of sensation. Seven of the writer's cases belonged to the ischemic type of paralysis (Volkmann's ischemic paralysis). The damaged muscles do not recover. Any resumption of function is attributable to the fact that portions of the muscles, especially the proximal portions, usually escape and are capable of limited activity later on. The cases in which the paralysis has seemed to be of a reflex nature have the following characteristics : 260 ABSTRACTS OF WAR SURGERY 1. An arterial injury without complete blockage of the vessel. 2. Absence of "pins and needles" sensation. 3. Flaccid paralysis of the muscles which do not feel hard and inelastic. 4. Widespread loss of cutaneous sensibility, extending in two instances well above the level of the wound. These cases, according to Burrows, give the impression of being less organic than the ischemic ones. The hypothesis that these cases are of a reflex nature has been adopted partly for convenience of argument, but largely because this explanation seems plausible. The suggestion that the anesthesia is of a functional nature was not borne out by several controls — patients with fractures, wounded joints, and other bad wounds of limbs, in whom tests revealed no case of "stocking" anesthesia except in those who had arterial lesions. In his general conclusions the writer sounds a warning note in giving the following advice : "Although the importance of these paralytic effects of arterial injuries can not at present be estimated, yet, until we are better informed as to prognosis, we may well be more reluctant in the future than we have been in the past to tie a main artery for the ar- rest of hemorrhage. ' ' We shall be more particular and persistent in our endeavors to find the exact source of bleeding, in the hope that it may prove to concern a branch only instead of the main trunk. And, in those instances in which the main trunk itself is wounded, we shall be more disposed to cure the leak by suture of the vessel, or failing this, to attempt an escape from the ill consequences of direct liga- ture by the temporary use of the Tuffier tube. Furthermore, when we are compelled by the nature of the case to tie a main artery, we shall take care to tie the main vein also; because, as Sir George Makins has pointed out, the results which follow ligation of both vessels are better than those which ensue upon a blockage of the main artery alone. ' ' Leriche and Heitz {Lyon chir., 1917, xiv, 754, abstracted in Surg., Gyn. and Obstet.) give very complete clinical histories of 18 cases of reflex nerve disturbances consecutive to war wounds which they treated by periarterial sympathectomy. They have attempted to show what may be demanded and expected from sympathectomy in the treatment of contractures and paralysis of the Babinski-Fro- ment type. The operation is performed by a thorough dissection of the ABSTRACTS OF WAR SURGERY 261 cellular arterial sheath carrying the sympathetic vasomotor fibers, or, if the artery is occluded, the whole thrombosed segment is re- sected. The results of the operations carried out demonstrate several facts : 1. The operation is followed, after a short period of arterial con- striction during the manipulations of the vessel, by an elevation of the blood pressure in the operated limb. 2. Operation is always followed, after the period of arterial con- striction, by an intensive vasodilatation, lasting for several weeks and resulting in a considerable elevation of the temperature of the subjacent segment of limb. 3. The resection of an obliterated artery produces the same re- action of vasodilatation, but even more intensive and lasting than sympathectomy by denudation. 4. Both operations have a striking action on the voluntary con- traction of the muscles whose motor power was abolished before. Circulatory disturbances in paralysis and reflex-contractures are constantly accompanied by local vasoconstriction which may tem- porarily disappear by artificial heating. Hence the favorable action of periarterial sympathectomy is satisfactorily explained by the vasodilatation and consecutively increased temperature produced; and concerning muscular contracture, by the intensified blood irri- gation of the muscles which bring more oxygen and stimulate the process of dissimilation. The disappearance of reflex disturbances, contractures, numbness, cyanosis, edema, etc., is not always definite at once, and it may be advisable to aid the effects of vasodilatation obtained by sympa- thectomy by hot baths of paraffin and by suitable exercises. But in any case the resultant improvement, even in the most severe cases, is sufficient to justify the intervention. Although sympathectomy is not proposed for cases in which the vasomotor and thermic disturbances are not pronounced, the inter- vention is inoffensive. In no case where the operation was done was the patient's condition aggravated, and in most cases the authors have observed a period of change which tended toward recovery. Leriche (Bull, et mem. de la Soc. de Chir. de Par., 1917, xliii, No. 5, 310) calls attention to the train of symptoms ordinarily characterized as trophic consequent upon arterial ligature or injury. This syndrome as seen in the upper extremity may be described as presenting the following symptoms : The hand is cold, bluish, the skin glossy, the fingers numb and stiff, the muscles of the forearm 262 ABSTRACTS OF WAR SURGERY hard, rigid, and atrophic. In addition to this there is no pulse and the arterial pressure is either zero or very feeble. This symptom complex is very paradoxical in that it has the appearance of being venous stasis, and yet there is no rational basis for assuming such a stasis to exist. According to Leriche, the explanation lies rather in the fact that the sympathetic nervous mechanism has in some way been injured. Leriche characterizes the lesion as "lesion du sympathique periarterielle," and advises that in all instances of arterial ligature the vascular sheath be divided. In other words, that what he calls a peripheral sympa- thectomy be done. He cites cases to show that this procedure is followed by an immediate disappearance of all trophic symptoms, and although admitting that he can not furnish an absolutely re- liable explanation, he tentatively explains the improvement by the fact that the injury to the vessel has set up some sort of disturbed nervous impulse in the sympathetic leading to vasoconstriction, and that the sympathectomy, causing the immediate vasodilatation, brings with it marked improvement of symptoms. Leriche is frank to say that observations are not yet sufficiently numerous to permit one to say that the relief is permanent. As a matter of fact, one may expect in 10 days or 2 weeks, in a certain percentage of cases, a return of the vasomotor syndrome. Since Leriche published his first results from denudation and excision of the sympathetic periarterial plexus in neuralgia and other trophic disturbances others have tried the operation. He now reports 37 cases upon which he has personally operated. (Presse med., Paris, 1917, p. 513, abstracted in Surg., Gyn. & Obst., March, 1918.) The operation should be more precisely termed a peripheric sym- pathectomy, and, according to the situation, should be designated as axillary, humeral, femoral, etc. When the artery is laid bare the cellular sheath is opened by the bistoury, the artery is isolated for 8 or 10 centimeters, and as far as possible is denuded of all adhering tissues, either with the bistoury or a cannulated sound. By careful manipulation the arterial wall is not menaced while the cellular decortication is being done. The wound is then closed by layers. Arterial sympathectomy is followed by a characteristic physio- logic reaction. From the very first intervention on the sympathetic sheath there is contraction of the artery. The caliber is reduced to one-third or one-fourth the normal size over the whole denuded segment. The segments immediately above and below keep their ABSTRACTS OF WAR SURGERY 263 normal volume. The rapidity with which this occurs varies in different patients, and the contraction is more marked in arteries of medium caliber than in the larger trunk vessels. The secondary signs are a weakening or imperceptibility of the pulse and numbness in the limb, observed in the first hours after operation; but in from 3 to 15 hours the characteristic reaction occurs. It is marked by a local increase in temperature of from 2° to 4° and by elevation of arterial pressure. The reactions are tem- porary and last for about 15 days. A study of the first operative results shows : 1. That voluntary muscular contraction apparently depends on the sympathetic. 2. The method of production of "dry" arterial wounds, which are at least facilitated by the arterial contraction occurring after destruction of the sympathetic, is explainable. 3. The true nature of certain neuralgias, if not of all, as such are cured by excision of the periarterial sympathetic nerves. 4. The sympathetic nerves play an important part in the produc- tion of Babinski-Froment reflexes, and also of the motor paralyses which follow certain arterial lesions. The author has performed sympathectomy in different types of cases — in those in which the chief element was pain, in those with contracture, or with vasomotor or trophic disturbances. In 11 cases the operation was done for pain ; some patients were entirely cured, but it does not give an absolute result, although often favorable. Five cases were operated upon for trophic ulcerations and all were successful. Three cases were for large edemata; one resulted suc- cessfully, one relieved the symptoms, and one gave an incomplete result. In 18 cases operated upon for reflex disturbances there were 3 practically complete recoveries, 10 showing more or less improve- ment, 2 showing improvement followed by recurrence, 1 in which after a check voluntary movements were resumed, and 2 complete failures. In the severe forms of the Babinski-Froment syndrome hot paraf- fin baths, with massage and reeducation, were found necessary to supplement the operation in order to obtain the best results. Therapeutic Considerations. — In extensive wounds, with or without loss of a portion of a limb, profuse external hemorrhage, primary or reactionary, and the resulting acute anemia (shock) are the immediate indications for intervention. Hemorrhage. — In the trenches, according to Sencert, on the field, and even at the aid post temporary arrest of hemorrhage is 264 ABSTRACTS OF WAR SURGERY all that is possible. The best method of accomplishing this is by- compressing the limb above the wound. The elastic bandage found in the stretcher-bearer 's bag, a napkin, a handkerchief, the wounded man 's necktie, or a boot lace are usually employed for this purpose, a piece of wood, a stone, or a lump of turf being slipped between the band and the skin to convert the former into a tourniquet. It is important to bear in mind, however, that a tourniquet should not be applied unless it is fairly certain that a large artery is wounded. Not only orderlies and stretcher-bearers, but medical officers as well, too often apply the tourniquet indiscriminately, thus gravely endangering both life and limb. If the constriction is soon removed, the danger is insignificant, but prolonged con- striction is conducive to gangrene of the portion of the limb thus isolated. The propagation of germs deposited on the surface of the wound is favored by the devitalized and anemic condition of the tissues, and under these circumstances the development of gas gangrene is favored. A special label should be attached when, a tourniquet has been applied, as indication that the case is suitable for evacuation. In wounds so located that a tourniquet can not be employed, as at the root of a limb, in Scarpa's triangle, the axilla or the neck, temporary arrest of hemorrhage under emergency conditions may be effected (1) by direct pressure upon the bleeding point, exerted by means of one or more fingers thrust into the wound or by an extem- porized pressure pad, and (2) by temporary closure of the skin wound, as by means of Kocher's forceps. When hemorrhage has been controlled by such temporary meas- ures as are feasible, the patient is conveyed to a dressing station without loss of time. Here the surgeon endeavors to secure per- manent hemostasis and to overcome the profound anemia. Permanent Hemostasis. — When a main vessel is wounded, per- manent hemostasis may be accomplished in one of three ways (1) by ligature; (2) by prolonged f orcipressure ; (3) by vascular suture. Ligature of both ends of the divided artery (Sencert maintains, contrary to general opinion, that No. 2 catgut is strong enough for the largest artery) brings about permanent hemostasis by the following mechanism : When the ligature is tied tightly the middle and internal coats are ruptured and retract within the adventitia, their extremities coming together in the form of an actual ' ' dome. Union by first intention, or cicatrization with a minimum of throm- bus, takes place, provided two essential conditions are maintained : (1) That the ligature remains aseptic; (2) that it is applied to a ABSTRACTS OF WAR SURGERY 265 healthy portion of the vessel. Union by first intention may be interfered with by sepsis or vascular contusion. However slight the sepsis in the region of the vascular wound, and however inconsider- able the lesion extending up the internal coat, the blood coagulates in the end of the vessel, the clot in the central end projects for a varying distance into the lumen, possibly blocking an important collateral branch. The maintenance of the aseptic condition of the ligature presup- poses its use in a surgically prepared field. It is easy to foresee the difficulties involved in the ligature of an artery at the bottom of a war wound the walls of which have been contused and devitalized from the beginning, on the surface and in the depths of which germs, carried in with the projectile, multiply rapidly. The diffi- culties are further increased when, under the influence of the de- fensive reactions of the 'body, all the dead skin, cellular tissue, muscle and bone forming the walls of the wound become liquefied, detached from the surrounding healthy tissues, and gradually elim- inated. Inflammation, ranging in intensity from a simple and transient serous discharge to a profuse and persistent suppuration, is the natural consequence. Sencert is very emphatic in his belief that the safe method of preventing suppuration in war wounds is by the immediate excision of the contused tissues. The cutaneous edges of the wound, the cellular tissue, the debris of muscle and aponeuroses should all be excised. Free and adherent splinters of bone should be removed, leaving a large, clean wound with fresh bleeding walls, at the bot- tom of which lies the injured artery. The first condition of success- ful arterial ligation is thus assured. The excision of the contused and infected tissues makes possible the fulfilment of the second condition of successful ligature, namely, the application of the ligature to a healthy part of the vessel. An aseptic ligature thus effected will progress under aseptic conditions, and terminate in cicatrization of the artery without thrombosis. Former experience favorable to the permanent control of hemor- rhage by means of ligature has been abundantly confirmed by results obtained in war wounds. The method is not devoid of danger, however, the abrupt sup- pression of the circulation in the area supplied by the vessel tend- ing to result in gangrene of the limb. Statistics published before 1914 show that the average incidence of gangrene was as follows : After ligature of the subclavian, in 5 per cent of cases; after ligature of the axillary, in 15 per cent of cases; after ligature of 266 ABSTRACTS OP WAR SURGERY the brachial, in 5 per cent of cases; after ligature of the common iliac, in 50 per cent of cases ; after ligature of the common femoral, in 25 per cent of cases; and after ligature of the popliteal, in 15 per cent of cases. These figures are not representative of recent vascular wounds, as they include ligature in diffuse arterial hematoma and in aneurism. On the other hand, gunshot wounds are more liable to gangrene than those of any other class, inasmuch as they are invariably con- tused and are associated with extensive laceration and contusion of the neighboring arteries and veins. The ischemia provoked by the application of a tourniquet, the vasomotor disturbances due to irri- tation of the collateral vessels and the contusion of the periarterial sympathetic nerve plexuses are all factors that inevitably predis- pose to ischemic gangrene of the limb. Despite all this, gangrene after ligature of a recently wounded artery is exceptional. The circulation after ligature is rapidly reestablished by way of the collateral vessels, and at the end of three or four days the pulse reappears. In the majority of cases, therefore, simple ligature of a large artery is not in itself sufficient to provoke gangrene. The true causes, then, of gangrene after ligature, are those that impede the establishment of the collateral circulation, such as vas- cular thrombosis, reaching from the ligature to the collaterals above ; and periarterial hematoma, which compresses the collateral above and below the wound. Ligature, then, of a sound portion of an arterial trunk in a large wound which has been surgically prepared is accompanied by only slight risk of ischemic gangrene. Forcipressure, which is a makeshift procedure to be employed only where ligature is impossible, is rarely indicated in recent vas- cular injuries, nor does it altogether apply to old and infected wounds and to secondary hemorrhage. Suture of a vessel is in theory the ideal method for the perma- nent arrest of hemorrhage, since it assures hemostasis, at the same time preserving the lumen of the vessel intact. Its success, how- ever, depends upon the same conditions as apply to ligature, viz., the aseptic course of the suture, and the absence in the neighbor- hood of the suture of lesions likely to provoke thrombosis. Owing to the specific anatomical conditions incidental to war wounds, ar- terial suture is in general a long and complex operation, which is assured of success only when preceded by extensive excision of the wound. As Sencert points out, this explains why the number of arterial sutures done since the beginning of the war is limited. ABSTRACTS OF WAR SURGERY 267 The decision in favor of ligature is natural in view of the simple, easy, and certain method it presents, almost entirely free from danger, contrasted with arterial suture, a long and tedious opera- tion, leading, at great cost, to the same results. In Sencert's opinion, nevertheless, suture should not be excluded. If, when the wound is well opened up, excised and cleansed, hemor- rhage controlled, and the arterial wound examined, extensive lacera- tion is found, or if there is complete rupture, with or without loss of substance, each end of the artery should be ligatured in the wound. Where there is a slight lateral wound the choice lies between section of the vessel with ligature of both ends and lateral suture. In such a case the edges of the wound should be caught with fine forceps and everted, the artery emptied by washing it out with a little saline solution, and the damage then examined at leisure. If the lesions are very limited and there is no laceration of the in- tima, lateral suture may be safely undertaken. When the condi- tions are the reverse of these, the vessel should be divided and each end ligated. Sencert sums up the question of ligature versus suture by the statement that ligature is the method par excellence for the arrest of hemorrhage from recent vascular wounds and that indications for suture are exceptional. Acute anemia, the second indication for immediate intervention in extensive wounds, is overcome by the use, in addition to minor measures (warmth, bandaging the limbs over a wool compress, inclination of the body with the head low, oxygen inhalation, hypo- dermic injections of ether, camphorated oil, or strychnine), of injections of physiological saline solution, direct transfusion of blood by means of Elsberg's cannula, or indirect transfusion by means of tubes sterilized in paraffin (Carrel's method modified by Berard). Sencert voices the opinion of the majority of surgeons when he states that for everyday use the intravenous injection of physio- logical saline solution is the best method because of its simplicity, rapidity, and efficacy. In punctured wounds, including penetrating bullet wounds with punctiform skin wounds, and penetrating or perforating wounds produced either by a shrapnel ball or a fragment of shell, grenade, or torpedo, certain manifestations are to be reckoned with ; namely, (1) internal hemorrhage; (2) hematoma; (3) wounds without hemorrhage. 268 ABSTRACTS OF WAR SURGERY Internal hemorrhage occurs in association with penetrating wounds of the chest and abdomen. Inasmuch as this discussion does not embrace regional vascular surgery, consideration of the subject here may be limited to the following general statements : (1) Intraperitoneal hemorrhage constitutes one of the most im- perative indications for immediate laparotomy. (2) Pleural hemorrhage, on the other hand, seldom calls for exploratory thoracic operation unless the vessel wounded is def- initely determined. When the pleural hemorrhage is of parietal origin it is amen- able to direct surgical hemostasis. When it is derived from the root of the lung it is almost invariably beyond the resources of surgery. Hematoma, the mechanism of production of which is outlined above, calls for therapeutic measures, the aims of which are largely preventive ; and directed against the appearance of gangrene, ische- mic or septic, or both. To prevent ischemic gangrene in the presence of extensive and rapidly forming hematoma it is necessary to evacuate the hema- toma, the centrifugal pressure of which obliterates the collateral circulation, and to guard against its recurrence by permanent hemo- stasis. To prevent a gangrene which is both ischemic and septic, the wound should be freely opened and all its ramifications laid bare. All clots, which are very susceptible to infection, all infective portions of clothing, as well as the missile itself, should be removed. In other words, a blind contused wound should be transformed into an open and clean one. Preventive hemostasis should never be undertaken without first securing as complete a provisional hemostasis as possible. Unless this precaution is taken the hemorrhage may be overwhelming from the very outset. In such case it is impossible to distinguish any- thing, and the sole resource is to apply forceps at random, running the risk of tearing the vessel and increasing the hemorrhage, or seizing an important nerve, with the most serious complications. After preventive hemostasis has been secured, the hematoma is laid open by one free incision and rapidly cleaned of clots. Permanent hemostasis is the next step to be accomplished. Here arises the question of the advisability of ligature. It has been stated already that in extensive wounds ligature of a main artery does not, in itself, endanger the vitality of the limb to a great ex- tent; the same can not be said with reference to ligature in hema- toma. Double ligature, after the evacuation of a large diffuse hema- ABSTRACTS OF WAR SURGERY 269 toma, in the case of certain large arteries, is followed by partial or total necrobiosis in nearly one-third of the cases. Under these circumstances it is important to know beforehand whether the re- establishment of the collateral circulation is probable. If, after having provisionally checked the flow of blood in the artery for a few seconds, no signs of arrested circulation are evident, it may be hoped that the circulation will be reestablished. This may be confirmed by means of a small incision at the extremity of a toe or finger, or even the exposure of a small terminal arteriole, or an artery, such as the dorsalis pedis. If the accompanying vein is compressed and its distal end swells rapidly in spite of the occlusion of both ends of the wounded artery, the conclusion is obvious that the blood continues to flow into the limb and to return by the veins. Lastly, when blood escapes from the distal end of the wounded ves- sel at the moment when the forceps are removed from it, the col- lateral circulation is present and is sufficient. If this triple test is negative, the indications favor arterial suture. Despite the difficulties attendant upon arterial suture and the limited successful resort to the method in war wounds, Sencert believes it should be persisted in. The great success which has followed its use in the treatment of aneurism suggests the possi- bility of like success, though less easily accomplished, in the treat- ment of diffuse hematomata. Tuffier (Bull, et mem. Soc. de Paris, 1917, xliii, No. 25, 1469) recommends the ligation of the accompanying healthy vein when one of the larger arterial trunks has to be ligated. It is a well- demonstrated fact, he says, that simultaneous ligation of vein and artery does not increase the risk of ischemia and gangrene. More- over, English statistics show that ligature of the larger arterial trunks is in a general way followed by gangrene in 40 per cent of cases, and that this percentage drops to 24 per cent in the cases where vein and artery are simultaneously ligated. This percentage difference is particularly marked in the case of the popliteal. Liga- ture of the popliteal alone gave 41.6 per cent gangrene, whereas ligature of artery and vein gave only 21.5 per cent gangrene. The treatment of medium-sized or small hematoma of slow growth, following a shell wound, resolves itself into the management of (1) a hematoma of medium size recently formed and easily diagnosed, (2) a suppurating wound with either diffuse secondary hematoma or secondary hemorrhage. In the first case the measures called for are provisional hemostasis, 270 ABSTRACTS OF WAR SURGERY free exposure and incision of the hematoma, and treatment of the vascular wound as outlined above. In the second case the problem involves the treatment of sec- ondary hemorrhage. The first operative measure is the free ex- posure of the traumatized area; the second, the isolation of the bleeding vessel and its ligature above and below the opening. If, because of the condition of infected traumatized tissues, this is impossible, ligature at a distance may be employed as a last re- source. The treatment of hematoma following a bullet wound is by in- cision of the hematoma and direct hemostasia of the vascular wound. This operation should be performed as soon as the hemostasis is diagnosed, whether at the field ambulance the next day or at the base hospital two, three, four, or five weeks later if it has only then been recognized. Treatment of wounds of arteries without hemorrhage, whether caused by bullet or by minute shell fragments, escape detection, in the vast majority of cases, both at the front-line stations and at base hospitals. It is not until later that certain minor functional troubles, in association with a small aneurism or an aneurismal varix, make their appearance. Perrenot (loc. cit.), discussing the treatment of dry wounds of large vessels, holds that the wound orifice should be ignored and a classic incision made to discover the vessels involved. The incision should be large enough to permit thorough examination. When lesions are found, treatment is the same as in other wounds of the vessels. Ligatures should be used rather than sutures, owing to the contused edges and the necrotic portions of vessels excised. Alamartine (loc cit.) emphasizes the necessity of early opera- tions, which should be performed before the formation of an aneur- ism ; the importance of the minor symptoms which often reveal the existence of a vascular injury ; and the necessity of acting by direct operation at the site of the vascular lesion and not by a distant ligature. Neuberger (loc. cit.) advocates double ligatures placed beyond the obtunding clot in wounds of the ' ' mute ' ' type. Of 80 vascular wounds observed by Gregoire and Mondor (Lyon chir., 1917, xiv, 625, abstracted in Surg., Gyn. and Oost., 1918) 23 were of the "silent" variety. In these, as in all other forms, these surgeons advocate ligature of the vessel or vessels above and below the site of injury. They do not favor ligature at a distance except ABSTRACTS OF WAR SURGERY 271 in eases where the artery is deprived of its sheath for a certain length. Aneurism, the remote consequence of untreated vascular lesion of the dry kind, has received a great deal of attention in the litera- ture of the war, which has witnessed a relatively greater number of traumatic aneurisms than any previous wars, as pointed out by Forgue (Rev. de chir., Par., July-August, 1917). Inasmuch as their treatment under war-time conditions differs in no essential point from that of civil practice, it will not be considered here at length. The excellent work of Forgue on arteriovenous aneurism, however, merits mention. The ideal treatment for arteriovenous aneurism, he says, consists in operating within a few days after the reception of the wound. The technic is then simple: The wound is enlarged or a fresh incision is made, the clots are turned out, the vessels are recognized and isolated, and the wounds in the vessels are treated as lateral rents and sutured. In practice this method of treatment is exceptional of accomplishment. Usually the treatment is deferred until signs of aneurism appear and operation is done to prevent the appearance of the later dis- turbances. An unfavorable time for operating is the second and third week, because at that time the surrounding tissues are infil- trated with inflammatory exudation and the technical steps are difficult. The best time is at the end of the fourth week, at which time the inflammatory reaction has subsided and mostly disappeared and there has been no time for the formation of any hard scar tissue. In addition, the circulation of the limb has, by that time, had time to accustom itself to the new conditions and the danger of resulting gangrene is minimized, if, at operation, it be found neces- sary to tie the vessels completely. The exact level of the intravascular communication is determined in three ways: (1) By determining the exact trajectory of the missile between the points of entrance and emergence of the bullet, or the point of entrance and the position of the projectile, when there is only one wound; (2) the point of maximum projection of the tumor when the latter exists; (3) the level at which the thrill and bruit are loudest. Any method by which it is attempted to cause coagulation of the blood in the aneurism is useless, likewise ligature of the artery above the aneurism. This method has not any effect on an arteriovenous aneurism. In addition there is usually a relative anemia in the part of the limb below the lesion and ligature of the artery above may cause gangrene. In certain cases, as in the carotid and jugular 272 ABSTRACTS OP WAR SURGERY with large tumor formation and with no collaterals, it may be the only method possible. Ligature of the artery above and below the aneurism is con- demned except in segments of the common carotid or external iliac, which have no collateral branches. The methods which can be used to advantage are as follows : 1. The Four-ligature Method. — The artery and vein are ligated above and below the aneurism. The method has yielded a con- siderable number of successes and the condition for its efficacy is the absence of any collateral circulation in the ligated area. The three danger localities for this method are (a) the bifurcation of the common carotid; (o) the point of division of the femoral artery; and (c) the branching of the popliteal into the tibioperoneal and anterior tibial trunks. 2. To guarantee a cure one must extirpate the segments of vein and artery together with the aneurism. In order not to compro- mise the circulation as short a segment as possible should be excised. The method of procedure advised is as follows : An Esmarch is not used because the suppression of the circula- tion in scar tissue makes it difficult to recognize the vessels. A long incision is made — long enough to uncover the entire aneurism. One goes immediately to the proximal side and isolates the artery and vein in healthy tissue and immediately it is surrounded by a provisional ligature which is tied if hemorrhage makes it necessary, or when no method of conservative surgery is shown to be avail- able. From this point methodical dissection is carried on along the vessels which are always found infiltrated with extensive and dense adhesions. When the structures are all isolated, and in certain locations, as at the root of the neck or in the popliteal space, it may be difficult or impossible, account should again be taken of conditions and it may be possible to be conservative and retain one of the vessels. If not, the whole segment is excised. The complications to be feared after this method are : Secondary hemorrhage. The best preventive is a rigid asepsis at the time of operation. Gangrene is always an uncertain factor, and its occurrence is reduced to the minimum in the upper extremities, and in young patients with healthy arteries. Conservative operations are always to be chosen when possible. The ideal method is to isolate the arteriovenous communication, divide it, and treat the two openings which result as two lateral ABSTRACTS OF WAR SURGERY 273 openings which are closed by suture. The same effect is secured by isolating the communication and then obliterating it by ligature or suture. Bickham described the method by which the communica- tion is obliterated by suture from the interior of one of the vessels — a transvascular approach. These methods are most advantageous at the divisions of the carotid, the femoral, and the popliteal vessels. If both artery and vein can not be conserved an attempt should be made to retain the arterv. The vein is doubly ligated above and below and the segment between is isolated down to the arterial communication ; the artery is then compressed above and below by Crile clamps, the venous segment is cut away, and the opening in the artery is closed by a lateral suture. If a lateral suture is im- possible the vessel may be divided and an end-to-end suture made provided the gap is not too large. A large gap can be made good by a transplant taken from the saphenous vein. Extirpation of the pathological structure with arterial and ven- ous segments in the lower limbs has, in a certain number of the successful cases, resulted in edematous conditions which have in- capacitated them for infantry duty. FURTHER EXPERIENCE WITH ANEURISMS IN WAR, WITH SPECIAL REFERENCE TO SUTURING THE VES- SELS. — H. von Haberer. Wien. klin. Wchnschr., 1915, xxviii, pp. 435, 471. Von Haberer reported 13 eases of operation for aneurism in 1914, at which time he thought ligation of the artery with ex- tirpation of the sac was the method of choice, and all of his cases were operated upon in that way. A little later he had occasion to suture the artery in a case of aneurism of the com- mon carotid. Since then he has had 28 additional cases, in 16 of which he did ligation and extirpation and in 12 suture, mak- ing a total of 42 cases, 29 ligations and 13 sutures. He gives the histories of the last of 28 cases, and concludes that suture is the operation of choice in all cases in which it can be performed. In many cases, however, it is impossible to suture, though with added experience he is continually extending the indications. Five of his cases were lateral suture, once on the common car- otid, twice on the subclavian, once on the axillary, and once on the tibialis anticus. The case of aneurism of the common carotid was infected, but in spite of that recovery was uneventful and restoration of circulation perfect. Of the seven cases of circular 274 ABSTRACTS OF WAR SURGERY suture four were of the femoral artery, one the brachial, and two the subclavian. From his total of 42 cases he finds that the results were better with suture than with ligation. Among the 29 cases of ligation, amputation was necessary in two, and one patient died of hemor- rhage from erosion. There was another death, but this patient was in such bad condition that death can not be attributed to the operation. There was not the slightest complication in any of the 13 cases of vessel suture, in spite of the fact that some of them were very difficult cases. In addition to the infected case mentioned above there was one case of aneurism of the femoral complicated by fracture of the femur. The leg was placed in extension immediately after the operation, but the suture held perfectly and there was no interference with circulation in the leg. In one case of aneurism of the subclavian the sac extended far down into the thorax, and it was so difficult to get at that the operation took three hours ; there was, moreover, a defect of 4 cm. in the artery. Considering all these facts the result was surprising. The author has tried transplantation of a piece of vein in only one case, in which it was unsuccessful. EXPERIENCE WITH VASCULAR INJURIES.— P. Graf. Beitr. z. klin. Chir., 1916, xcviii, p. 332. The author gives his experiences derived from 58 vascular wounds observed during the fighting around Warsaw. In these 58 cases, 62 interventions were made ; three times arrest of hemorrhage in dying men ; 43 ligatures ; 5 amputations of limbs ; 8 suturings; 3 tamponings under narcosis. The general mortality was 25 per cent. The carotid externa was ligated six times, the carotid interna once, and the maxillaris externa twice. Tamponade was absolutely necessary in one case. There were 15 ligatures and 3 suturings of the subclavian, brachialis, and cubitalis for arm wounds. In the leg region 30 interventions were made for 29 injuries ; 23 ligatures — 5 amputations for infection; 5 vessel suturings; 2 tam- ponades under narcosis. Of these interventions, 16 were on the femoralis — 11 ligatures, 6 suturings. In 4 out of 5 interventions on the popliteal, infection was already manifest, and in the fifth case the patient died of secondary hemorrhage after a couple of weeks. In the tibialis ligature generally stopped the hemorrhage. ABSTRACTS OF WAR SURGERY 275 In one of these cases amputation was found necessary and the pa- tient died after a few days owing to loss of blood from the stump. Eight arterial suturings were done without any subsequent sec- ondary hemorrhage, infection, or death. The author's experience leads him to think that vascular injuries coming to the field sur- geon are under all circumstances to be considered as life endanger- ing. In only the minority can a smooth, infection-free encapsula- tion of the blood outlet be obtained; and by the development of aneurisms bleeding may continue for weeks. Every secondary hemorrhage, even if slight, makes an opening up of the bullet tract imperative. This should be done even if the bleeding ceases. Later hemorrhages may be expected with certainty. Therefore, it is al- ways best under narcosis to lay bare the larger vessels in suspected, and particularly in infected, cases. For clean wounds suture of the vessels is the best procedure; and even slightly infected cases may be sutured, when the external wound is well trimmed. The vessel must be clearly separated away from the cavity by muscle-suturing. Ligature of the larger vessels must be kept up for two or three weeks, especially when the collateral blood flow can be regulated and checked by a proper disposition of the limb. Hyperemia and the procedure of Moszkowicz are adaptable when there is a question of the development of collateral circulation. JOINTS. PRACTICAL POINTS ON THE USE OF IMMOBILIZATION IN WAR SURGERY.— Rev. of War Surg, and Med., April, 1918, i, No. 2. Since much uncertainty exists in the minds of civil surgeons when first plunged into the whirl of war surgery as to the reason for many of the accepted procedures, the Division of Orthopedic Surgery presents the following discussion of practical points in the technic of immobilization. During his student days one learned that certain diseases require a prescribed course of treat- ment, but too often the general principle underlying the specific case was not recognized. Methods familiar enough in civil life are not available in war, and the man accustomed to follow rou- tine treatment and ungrounded in the fundamental principles upon which that treatment is based finds himself at a great dis- advantage. Many of the everyday methods of war surgery are the result, not of facts learned in the classroom or the civil hospital, but of the necessity of applying well-known principles with the help of limited material. In no branch of work is this better shown than in the methods employed to fix or immobilize wounds for trans- portation or for convalescence in hospital. Realization of the importance of fixation was not appreciated by surgeons during the early days of the war. For example, frac- tured thighs were often moved considerable distances without splints. The result was an extraordinary mortality in these cases, 80 per cent at times. Such alarming statistics called for investi- gation, and thighs were immobilized in the trenches with a re- sulting decrease of 50 per cent in the mortality. Conditions met in war which demand immobilization may be roughly classed as (a) fractures, (b) joint injuries, (c) injury to periarticular tissue, (d) injury to muscle, nerve and other soft tissue. The objects to be achieved are: (1) Rest, one of the most im- portant factors in the cure of injury or disease ; (2) correct posi- tion of wounded parts, to avoid subsequent deformity and main- tain function; (3) comfort of the patient. 276 ABSTRACTS OF WAR SURGERY 277 Immobilization is secured by fixation. Fixation may be denned as the process of securing rest or immobility of an injured or diseased part of the body in any desired position. It is accom- plished by splinting or traction, or by the two combined. There are certain well-known forces to be met in applying fixa- tion to an injured limb : (a) gravity exerts a deforming tendency in a downward direction and requires support from below for its correction; (b) muscular spasm acts constantly to shorten the leg, creating pressure on joint surfaces or overriding of frag- ments; (c) the uneven pull of counterbalancing groups of mus- cles causes angular deformity at the seat of the lesion. While enumeration of these familiar facts seems puerile, it is done for the sake of laying stress on the fact that the basic principles of immobilization demand that all forces be kept con- stantly in mind while applying fixation apparatus. Materials and appliances employed in civil practice are often not available. It is essential at all times to keep the principle in mind and adapt the means at hand to carry out the required principle cor- rectly. Particular stress should be laid on the distinction between the two methods used to overcome these deforming forces and secure fixation. By means of splints physiological rest is secured and position is maintained. But the use of splints alone only partially relieves muscular spasm. This spasm produces constant pressure on diseased joint surfaces or causes overriding in case of frac- ture. Therefore another principle must be applied to overcome this pathological condition— the principle of traction. Splints. — It is evident that the vast variety of splints in use in civil practice is out of the question in war. Moreover, the oppor- tunity to manufacture splints to measure for the individual is impossible. To eliminate wasted effort the value of splints must be carefully tested for : (a) efficiency; (b) simplicity; (c) adap- tability for: (1) easy access to wounds; (2) facility in transporta- tion. The efficient splint must be capable of easy and, above all, speedy application and must give adequate fixation. Time is of the utmost importance in the overwhelmingly heavy work often encountered during severe fighting. Simplicity is essential from the point of view of supply. Splints must be easy to manufacture, economical in the matter of materials used in their construction, and must pack well and 278 ABSTRACTS OF WAR SURGERY bear transportation and rough handling without breakage or injury. There should be no loose keys or wrenches to be lost, no mechanical adjustments or screw threads to get out of order or to become useless from rust. Iron wire splints have been found to fulfil these requirements better than those of any other ma- terial and most of the splints now in use are of this kind. The splint must also be simple in the manner of its application. Fre- quently bearers or comparatively unskilled assistants are called on to apply them and the principles involved in their use should be such as are easily grasped. Adaptability should be considered, at the front, in relation to transport ; at the base, for ease of access to wounds. Wire splints are best adapted for both purposes. Many splints can be used for more than one type of lesion. Other things being equal, the more injuries for which a single splint can be used, the better adapted it is for war work. It is of great importance to reduce the variety of splints used to the lowest efficient minimum. In this connection it is well to point out that conditions often arise which exhaust the local supply of splints. The ingenious medical officer must constantly improvise substitutes from boards, wire, or other materials at hand. Too much emphasis can not be laid, therefore, on the importance of a knowledge of the basic mechanical and surgical principles involved in their construction and use. There is another point, perhaps too often overlooked in dis- cussing splints. In the great majority of cases wounds are mul- tiple, owing to the extensive use of high explosives. Treatment is suggested for single wounds which is frequently impossible to carry out, and here again the surgeon's ingenuity will be taxed to adapt the dressing to the individual emergency. Cases may eome down with a fractured thigh and 20 or 30 flesh wounds sprinkled over the thigh, leg, and foot. The problem of apply- ing adequate traction is a difficult one to meet. In the application of splints for any purpose, but particularly for fractures and joint injuries, gentleness must never be for- gotten. A very real danger to the technic of the war surgeon is that he will become careless in handling wounds and callous to the suffering he may be causing his patient. This danger is increased by the extraordinary endurance and stoicism of the wounded soldier, in very marked contrast to most of the cases met in civil life. ABSTRACTS OF WAR SURGERY 279 The splints in the following list have been tested by long use in advanced line work and have been proved of value. They fulfil the requirements of efficiency, simplicity, and adaptability, and they are all of use in hospital work as well as for cases dur- ing transport, thus obviating a duplication of types for differ- ent zones of activity. The list is inclusive and covers wounds of any part of the body. It is by no means exclusive, however, as there are many good substitutes of proved efficiency. They are classified for convenience according to regions of the body. It is not necessary to describe them, as the full specifi- cations for each splint will be found in the "Manual for Ortho- pedic Surgery" or the "Splint Manual of the U. S. A. Commis- sion Abroad." It is desirable again to stress the point that these splints are not mandatory but are given as examples of appliances that embody correct principles. Splints For Use in the Advance Zone. — Trenches, Regimental Aid Posts, Advanced Dressing Station, Field Hospital. — /. Upper Extremity. — 1. Hand and forearm wounds : Straight or coaptation splints of — (a) Standard sheet iron, 20 gauge, 12, 16, and 20-inch lengths. (b) Splint wood or slats from bully beef boxes. (c) Wire gauze, 6 by 36-inch lengths. 2. Elbow, arm and shoulder wounds: (a) Thomas traction arm splint. (b) Jones humerus traction splint. II. Lower Extremity. — 3. Forefoot wounds. Jones rectangular foot splints. 4. Foot, ankle and lower leg wounds. (a) Jones combined ankle and lower leg splint. (b) Posterior leg splint with straight coaptation splints. (1) Posterior splint of wood. (2) Cabot posterior wire splint. 5. Knee and thigh wounds : (a) Thomas traction leg splint. 6. Hip and pelvis wounds : (a) Long Liston splint. (b) Straight "bed slat" splint. , : , 7. Spinal wounds. 280 ABSTRACTS OF WAR SURGERY Exhaustive comment on the principles embodied in these splints and the method of their application is out of place. One splint, however, the Thomas traction splint, will be considered as illus- trating all the essential principles required. Previous to the war this splint was in common use among orthopedic surgeons for the immobilization of the knee joint, the function for which its orig- inator designed it. At present it is used in the war areas for fractures of all long bones and injuries to the joints of both upper and lower limbs. The splints for leg and arm are the same, except for size and the obliquity of the ring on the leg splint, its position in relation to the long axis of the arm splint being at right angles. These are destined to remain as important resources of the surgeon after the war. They are employed to maintain direction or position of the limb by their splinting function, and fixed distance by their traction principle. Splints of the Hodgen and Blake types are modifications of the Thomas splint. In them position alone is secured; traction de- pends on additional apparatus and has the advantage of supply- ing an actual extension or lengthening force more effective in overcoming the pressure on joint surfaces, or the overriding of fractures, than the fixed distance principle. The Thomas splint may be modified to serve the same purpose. The posterior half of the ring may be cut away with a hack saw, transforming it into the Hodgen type of splint, or extension may be applied to the Thomas splint itself after securing fixed distance by leg traction and counter bearing of the ring on the ischial point of support. The splinting principle is secured by means of slings of non- elastic material hung from the uprights forming a retaining gut- ter in which the limb lies relaxed. Coaptation splints may be added, but a bandage serves the same purpose and makes dress- ings much less disturbing to the wound. These slings are often made of sheets of perforated zinc or of wire gauze. In practical use strips of rubber sheeting three inches wide will be found as effective and more adaptable to the contour of the limb. They are waterproof, easy to keep clean, nonelastic and strong. Whereas the metal is difficult to fit accurately and alter as needed, these strips are easily and rapidly adjusted. They are fastened to the uprights most conveniently by clips of steel (the ordinary paper clip) or by wooden spring clothes-pins, which are always available. Safety pins or lacings may be substituted if necessary or desirable. The narrow strips of sheeting are more useful for severe cases, as they make dressings easy. Unclipping ABSTRACTS OF WAR SURGERY 281 one or more of the strips does not alter the position of the limb and a dressing can be done through the opening thus provided. For Carrel dressings their waterproof qualities are of the great- est value. Before applying the splint it may be bent to conform to the variations in the line of direction of the individual limb, as genu valgus or varus, and about 15° of flexion should be given opposite the knee joint. This flexion can be greatly increased to meet the requirements of a double inclined plane apparatus for low fracture of the femur. The line of extension may be car- ried in any direction desired by flexing or abducting the hip joint. The above suggestions account for correct immobilization by splinting of injuries to the limbs save in two particulars, toe drop and wrist drop. Further apparatus must be supplied for these purposes. A foot wire is made to fit the uprights and extend like an arch several inches above the toes. To the keystone of this arch the foot is suspended and then bandaged to the uprights of the arch, securing fixation in all directions. For the hand, a cock-up splint should be added. Applications of the suspension apparatus to the foot are often secured by carrying the bandage under the heel. This is a method involving some risk. It must be borne in mind that in severe wounds circulation of the limb is often greatly impaired. Pressure sores develop with extraor- dinary readiness. Any method that brings even mild contin- uous pressure on any part of the skin is to be avoided with great care. The most generally useful method of support is by means of a strip of gauze or flannel glued to the sole of the foot and fas- tened to the arch of the foot piece, after which the bandage is applied for lateral fixation. Traction. — Traction serves a double purpose. It aids fixation by maintaining the limb in the straight line of pull and it coun- teracts the attractive pull of muscles due to their normal tone or their spasm from pathological irritation. The second and very important function is called extension of the muscles. It acts immediately to lengthen a limb when first applied and more slowly to overcome shortening by tiring the muscles. From this it is evident that traction by fixed distance as provided in the Thomas splint is less efficient than traction by weight and pulley, which acts over a prolonged period. It is the modified use of the Thomas splint, combining it with the use of traction (Balkan 282 ABSTRACTS OF WAR SURGERY frame), that has made it of such very great value in the treat- ment of war wounds at the base hospitals. The practical application of traction has occupied the thought of military surgeons to a very large extent. As stated above, the skin in severely wounded limbs is very sensitive to pressure. Efficient traction demands strong support for the heavy weights frequently required. Therefore, great care is needed to secure efficiency without damage from skin pressure. Methods may perhaps best be considered under the two heads, temporary traction and permanent traction. Temporary Methods. — These are required in providing for front line and transportation dressings. They are needed for the leg, the arm, and the trunk in spinal injuries. The materials for this form of traction are adhesive plaster, bandages, folded blankets, as pillows for spinal extension, splint supports on stretchers to give proper direction to the traction, etc. Ingenious use for foot traction is made of canvas anklet, nails, screw eyes, and wire tongs. By far the most serviceable and universally obtainable material is gauze or muslin bandage. At the front, both ankle and wrist may be used for the application of temporary traction. The bandage for ankle traction is applied outside the shoe, which protects the skin and the circulation of the foot. It is well to cut the lacing of the boot and apply a smooth pad of sheet wadding or cotton over the instep. The bandage should be a doubled piece of 3 or 4 inch gauze or muslin, 2 yards long. The middle of the bandage is brought around behind the heel just above the counter of the shoe, the two ends are carried forward and then downward under the shank of the shoe, crossing each other over the instep and under the shank. The ends are then brought up along the respective sides of the foot, passed under the first part of the bandage applied just back of the malleoli, and then downward to the cross bar of the splint as two traction bands. The pull should be taken from a point well behind the ankle joint to prevent any tendency to cause plantar flexion of the foot. For temporary wrist traction, the clove hitch is most satisfactory. It is a simple clove hitch made with doubled bandage and takes its grip on the eminences of the hand. Bringing the knot in front tends to extend the hand, and there is no danger of constriction as there^ is in the use of a slipknot. ABSTRACTS OF WAR SURGERY 283 In either case, the ends of the traction bands are brought outside the uprights of the Thomas splint, one above and one beneath, wrapped half round and then carried to the cross piece where they are again half wrapped, the desired traction is applied and the ends tied in a square half bowknot. The uprights act as a spreader and the more familiar type of separate spreader is made unnecessary. This bandage method of applying temporary traction is quite suf- ficient for rapid work. Several substitutes have been suggested by ingenious surgeons but they have the disadvantage of introducing separate small parts which are not always easy to keep on hand. Nails have been driven through the heel of the shoe and traction bands tied to the projecting ends. This is unwise as it involves dis- comfort to the patient from the hammer blows. Sharp skewers may be passed through the vamp of the shoe beneath the patient's foot. This causes no pain but involves a separate piece of apparatus. A pair of tongs has been devised to grip the sole of the shoe, open to the same criticism of adding complication without sufficient benefit. A canvas anklet laced up the front of the foot is good but does not possess material superiority over the bandage. It must be remembered that no temporary method provides grad- uated traction, true extension. The maintenance of fixed distance is the only object attained. To correct this a grave mistake has been made by some surgeons. A piece of rubber tourniquet has been sub- stituted for the traction bands and attached to the crosspiece of the splint. There is no way of gauging the pull in this elastic traction and mishaps have arisen from its use. It should be condemned. In the hospital, elastic traction may sometimes be of service where it can be most carefully watched, but it is always contraindicated for transport purposes. Permanent Traction. — The weight and pulley method has dis- placed the traction methods applicable to the Thomas splint itself (fixed distance and elastic traction) in hospital work. This is merely the familiar Buck's extension principle. Iron weights are rarely available, but a sand bag answers every purpose. Pulleys have to be improvised at times. Methods of attaching the adhesive bands to the skin are the usual Z-0 adhesive plaster and various forms of glue. Moleskin is quite unnecessary. Adhesive plaster is frequently used, but has been superseded in the hands of most base hospital surgeons by glue and bandage methods. There are two types of glue in use. The Heusner and Sinclair glues require heat- ing, the Venice turpentine glue or "Mastisol" is applied cold. The 284 ABSTRACTS OF WAR SURGERY hot glues have deliquescent substances added to take up the per- spiration, and remain firm and flexible over long periods. On the whole, their use is more common than that of Mastisol. The latter has no serious drawbacks and when properly applied has a holding power equal to the others. The writer used Mastisol whenever available. It must be kept tightly corked, is a very sticky, rather thick glue, difficult to remove from hands or gloves and rather harder to apply than the hot glues. But its great advantage lies in the fact that it can be used cold, saving annoying delays, not rarely encountered in the use of the others. There is no danger of burning the patient, a very real advantage as many cases of serious burns have resulted from the careless or too hasty use of the hot glues. Mastisol sets more slowly than the others, 10 min- utes being necessary for firm adhesion. But light traction may be applied as soon as the bands are bandaged on and this may soon be increased. The glue also has the advantage that the part does not have to be shaved as it does if adhesive is used. The applica- tion of the glue with upward strokes of the brush is advised to avoid pull on the hair. Glue adhesion is effective for two to four weeks, sometimes even longer. Skin lesions beneath the traction bands are of rare occur- rence compared with their relative frequency under adhesive plaster. The patients do not complain of discomfort while wearing them. Their removal is very easy. Hot water washes off the heated varieties; turpentine or petrol removes the Mastisol. In the many cases of multiple wounds where the skin of the leg is involved traction bands can not be applied to the leg. In these cases mechanical means must be employed. The most common methods make use of the Steinmann pin under the Tendo Achilles, taking a bearing on the calcis; or tongs in the condyles of the femur. In spite of the fact that all wounds are septic, these ap- pliances have been used very commonly and complications from infections are not at all frequent. The patient is surprisingly com- fortable and fair extension may be secured. Special gentleness is needed in doing dressings and the nurses and orderlies should be cautioned in their care of these cases. Traction methods by means of clamps applied to the bone frag- ments have been tried in cases of fracture, but the danger of sepsis has proved too great to make interference with bone desirable be- yond the point of absolute necessity. ABSTRACTS OF WAR SURGERY 285 WOUNDS OF JOINTS.— Rev. of War Surg, and Med., April, 1918, i, No. 2. One of the almost dramatic surgical surprises of the war has been the demonstration that joint synovia tolerate and even dispose of infection to a degree not hitherto suspected. This fact naturally has an important bearing on establishing principles for treating joint wounds. In general, the treatment of joint wounds is well covered by the conclusions reached at the Interallied Surgical Conference (March and May, 1917), which are as follows: 1. At the dressing station wounds of the joints should be immo- bilized 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 com- 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 opera- tion should be primary, whereas in the elbow and shoulder second- ary 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 sur- faces by extension. In very grave cases immediate resection is required. Recent publications on knee-joint injuries by Kellog Speed, E. Tissington Tatlow, J. R. Judd, R. Mosti, and F. Achille, furnish adequate material from which one may draw rational conclusions regarding the present status of joint surgery. Speed's article was submitted as a report to the Surgeon-General, embodying his ex- 286 ABSTRACTS OF WAR SURGERY periences on the western front. The papers by Mosti and Achille were abstracted from the Italian by Surgery, Gynecology and Ob- stetrics. Speed reports that, in the light of the results of recent experi- ence, the soldier, after a knee-joint injury, should be splinted at the first dressing post and not allowed to walk on the leg. All operations should be done at the casualty clearing stations, within 24 hours after reception of wound, when possible, better within 8 hours. When this arrangement is not possible, as under severe battle circumstances, the following types of knee injury may be evacuated at once : 1. The wound that shows no inflammation, is quiescent, and lacks pain. 2. Small clean wounds of entrance and exit, or entrance alone, probably caused by rifle bullet. 3. "Wounds with no serious bone or blood vessel complication. 4. Foreign body not evident and joint not painfully distended. Wounds of the posterior aspect of the knee are more favorable for transportation — they drain out by gravity. On the anterior aspect they may drain into the knee during the journey. The Thomas splint, with extension and flannel bandages from toe to thigh, should be used. Types of knee injury to be retained at the casualty clearing sta- tion are: (1) Those complicated by serious bone or blood vessel injury; (2) distended, painful joint, or early signs of septic in- flammation; (3) foreign body visible or palpable after it has opened joint; (4) large superficial wound generally caused by shell fire, opening into the joint. Sepsis is certain to spread into the joint and immediate operation is wanted. Early operative treatment is either radical or conservative. Radical. — Amputation is advised if: (1) Severe blood vessel in- jury exists — even a large hematoma, with probable infection in the popliteum; (2) severely comminuted fractures into the joint exist; (3) gas infections of the periarticular tissues are present; (4) sepsis has already set in, and the patient is in poor general condition. Resection is advised if a comminuted fracture leaves little normal joint surface. Most of these result later in amputa- tion — only those resected very early do well. Conservative treatment is reserved for the penetrating and through-and-through wounds, even in the presence of fracture not sufficiently extensive to indicate resection or amputation. If the patella is shattered it is removed, its periosteum is spared, and the synovial membrane is closed if possible. If a foreign body's pres- Abstracts of war surgery 287 ence is even suspected, the patient should not be operated upon until there are skiagrams in both lateral and anteroposterior planes. Every knee-joint gunshot should be operated on if time and cir- cumstances permit. The most innocent appearing may lead to serious trouble. The technic recommended is as follows: 1. Careful skin shaving and disinfection. The leg should be held up off the table by an overhead swing. 2. The track of the missile is completely and slowly excised with a sharp scalpel — no scissors. Sliding of the tissues over each other is avoided and the contused edges are removed in one piece. Suffi- cint skin opening is made to permit access to the foreign body or joint surface. Fresh towels and instruments are then displayed. No fingers or instruments are inserted through the soiled wound into the joint — not only may infection be carried in, but the foreign body may be pushed into an inaccessible area. The foreign bodies and comminuted bone are removed ; the synovial surface should not be sponged, irrigated, or exposed for any greater period of time than necessary. It matters little about the length of the skin in- cision, but the amount of skin removed should be sparing to avoid undue tension in the closure. Skin plastics may be performed. If the foreign body is buried in bone it is removed, taking with it sur- rounding damaged bone. 3. The joint may be irrigated with normal salt solution. Vari- ous operators use ether, flavine, proflavine or eusol. As far as the author can tell, the solution used makes little difference. Mechan- ical cleansing without joint trauma is desired. 4. Closure of the wound in layers. The synovia is closed by stitching to bring smooth surfaces only in contact, and the super- ficial tissues and skin are closed snugly unless there is great edema and contusion. In that case a small drain may be put down to the closed synovial surface, not into the joint. If the synovia can not be closed a gauze pack is placed down to its surface. Injec- tion of formalin, glycerine, ether, or other irritants into the closed joint is of doubtful value. 5. A Buck's extension is attached to a Thomas splint on the leg and flannel bandages cover all. For comfort and steadiness the application of the splint should be exact — it requires skilled attention. Most patients should be retained 24 to 48 hours be- fore transportation. Dressings and splint are not disturbed unless there is pain, fever, or looseness. These operations take from 40 minutes to 2 hours. When aseptic healing is ensuing and the joint is not painful, slight 288 ABSTRACTS OF WAR SURGERY passive motions may be started in the second week. Should the joint become distended, should temperature rise and sepsis seem starting, an aspiration may be performed to decide the character of the intraarticular fluid and to obtain a culture. Staphylococus infection is less feared than streptococcus; it may even subside after aspiration with rest. Objections to aspiration are found in the wounding of the synovial surface and leakage of the in- fected joint contents through the puncture hole into poorly re- sisting periarticular tissues, resulting in rapidly spreading sepsis. The resistance of the joint surface is as great or greater than the periarticular tissues. The reason for excising these wounds, trimming the synovial edge, and irrigating the joint after bone fragments and foreign body are removed, is found in the fact that the synovial surface, if given a chance, is almost as well able to take care of itself as the peritoneum, and the resistance of the joint surface is greater than it was formerly believed to be. After trimming and irri- gating, the joint is closed snugly; its own resistance will often do the rest. A joint not so treated ultimately becomes contami- nated by the extension of the infection when the unexcised tract of a missile which has become septic is opened. It has been proved by many clinical observations that joint infection may come on late, after the wound infection has developed and seeped into the articular surface. This happened, according to Speed, to most of the septic joints in the early part of the war. By closing the joint after wound excision, if infection arises extra- articularly it is recognized and drained, and the joint is saved. This principle is employed constantly in operations on fractures of the patella. Splinting prevents motion, hence favors an early healing of the sutured synovia. It also saves the patient from pain and loss of sleep. When septic joint threatens to follow conservative treatment or no operative treatment at all, Speed coincides with the view that no classical drainage of the knee-joint is satisfactory, and that joint excision after infection is valueless. Early amputation is advised. It gives a lower mortality, and a satisfied living pa- tent. A drained joint may result in a useless leg which is removed within a year. Analysis of the 85 cases in the series reported gives the follow- ing: The synovial lining of the joint was opened by the missile in every instance. The synovial surface alone was involved in ABSTRACTS OF WAR SURGERY 289 42 instances, of which three were amputated (7 per cent). There were bone injuries accompanying 43 knee wounds, of which 6 were amputated (14 per cent). Foreign bodies were present in the joint in 25 case's, in the bone in 18. The amputations numbered 9 (approximately 10 per cent). Six of these had com- plicating bone injury. The foreign body was removed in 7. The wounds of 6 of these 9 patients were excised early at casualty clearing stations or field ambulances ; 1 was excised late at the base; 2 were never operated upon. In addition to these 9 there were three patients who might possibly have gone on to ampu- tation later in England. There is no record of them after leav- ing the base. There were 2 deaths. Both patients suffered bone injuries at the knee. One died from a gas infection of the arm, which was amputated, the knee apparently doing nicely. In real- ity, then, there was but one death caused by the knee injury (gen- eral sepsis, no secondary operation). The general results of the series of 85 were : Excellent in 25 instances, good in 36 instances, fair in 13 instances, loss of limb in 9 instances, death in 2 instances. Technic of Subcrural Pouch Drainage and Inversion Treatment. — In July and August, 1917, Speed began draining these septic knees very early, according to the following technic : Cultural proof of intraarticular infection having been obtained, drainage is instituted at the earliest stage. Under anesthesia an opening one inch long is made in the mid-line of the thigh at the upper margin of the pouch. The quadriceps extensor muscle fibers are separated longitudinally by a pair of Mayo scissors, and the joint and synovial surface carefully opened through its upper re- flection only. The lower synovial wall should not be damaged. A medium-sized rubber tube extending just into the joint is sewn in place. The incision around the tube is left wide open to favor secretion running out and not backing into the thigh tissues. A Thomas splint and extension are applied, the leg being supported by crosspieces of perforated metal both anter- iorly and posteriorly, thoroughly padded and so bandaged that the portion over the wound can be removed for dressing without loosening the splint. The patient is put to bed, a Balkan frame is rigged over him, and for two hours night and morning he is turned over on his face. Later these periods are extended until he can lie thus for hours at a time. If the tube clogs with pus and debris, it can be mechanically 290 ABSTRACTS OF WAR SURGERY washed out with normal salt or eusol until it is freely open. The joint may be thus partly irrigated if desired. "When the discharge becomes serous, pus ceases, and temperature falls, the tube is re- moved and the small wound is allowed to heal, the joint being safe- ly started on its own resistance looking toward recovery. The splint, of course, is retained until the joint is quiet and painless. Six patients have been treated by subcrural pouch drainage and inversion and observed over a long period. In four the results were very good, one recovering from a gas infection of the joint. One had a doubtful outcome and one required amputation. Speed believes that there is a distinct field for this type of treat- ment, which necessitates such a small amount of operation on pa- tients who would otherwise be subjected to extensive drainage, in- cisions, and prolonged suppuration. Patients so treated should be those in the early stage of joint infection, before cartilage erosion has taken place and before the infected contents of the joint have mechanically burst or pathologically necrosed through the synovial surface to set up a suppurative periarthritis. Some of the points made by Speed are in keeping with the prin- ciples guiding the treatment of war wounds of the joints adopted at the Interallied Surgical Conference given above. Speed advises that data covering knee-joint injuries should be collected under the following heads: 1. Type and location of wound related to a transverse line through patella: (a) Was there exit and entrance? (b) Was synovial surface alone involved? (c) Was there fracture accompanying? Which bones? (d) Was foreign body present ? In joint? In bone? (e) Was joint traversed by foreign body? 2. Type of first treatment: (a) Where given: Field ambulance? Casualty clearing station? Base hospital? (b) Was joint opened by missile or by operation? (c) Was joint irrigated? (d) Was joint bipped? (e) Was foreign body removed? Or bone fragment? (f) Was joint closed by sutures? (g) Was joint left open? (h) Was joint drained by foreign material, e. g.. gauze, gut- ta-percha, tube? 3. Were splint and extension used? ABSTRACTS OF WAR SURGERY 291 4. General data: (a) Condition of patient on admission? (b) Joint pain, swelling, redness, discharge (pus or syno- vial fluid) ? (c) Temperature curve? ( d ) Cultures made ? Kesults ? (e) Was joint aspirated? Drained? (f) Other secondary operation? (g) Condition on discharge from hospital? (h) Probable prognosis? Tatlow reported his series of knee-joint wounds in the British Journal of Surgery for January, 1918 (p. 462). The cases included in the series were treated at a base hospital during the year 1917. Of the 100 cases, 2 died, both after amputation; 4 were successfully amputated ; 9 were successfully resected ; and 12 were unoperated. The remaining 73 were evacuated to England, after operation either at the base or at the clearing station, with a normal temperature, and either healed or granulated wounds, or at most a small dis- charging sinus. From his experience with this series of cases Tatlow draws the following conclusions: 1. Early operation, if the procedure be radical and especially if the entire capsule can be sutured, results, in 94 per cent of the cases, in a sterile joint, and therefore in a successful issue. 2. Where a pack or drain is used down to a tear in the capsule or to a cavity in bone, the results can never be depended upon. 3. The removal of missiles from the joint within the first week, even in the presence of sepsis (other than that due to the strepto- coccus), can be followed by immediate suture, B. I. P. P. being used to aid sterilization. 4. The Carrel-Dakin method is most useful for the treatment of bone lesions or septic periarticular conditions. It is almost impos- sible to sterilize a severely infected joint by this method. 5. In the presence of a general infection of the joint by the strep- tococcus, resection gives good results, even when performed in the second or third week. 6. Cases with a severe bone injury should be treated more often than they are by an immediately primary resection of the joint at the clearing station. Judd (Surg. Gyn. and Obstet., 1918, xxvi, No. 2, p. 139), basing his observations on personal experience among French wounded 292 ABSTRACTS OF WAR SURGERY extending over a year, and upon the views and methods practiced by French surgeons, draws the following conclusions: 1. Wounds of the knee-joint in modern warfare maintain the same importance and gravity that have existed since the birth of surgery. 2. The resisting power of the synovia and ankylosing tendencies vary in individuals. 3. In the presence of an infected projectile and infected joint fluid, the synovia may still be uninfected for a certain period. 4. Fissures extending to the articular surface are important and are often unrecognized. 5. Secondary infection of the ankle joint sometimes occurs unex- pectedly and is a grave complication. 6. The earlier methods of noninterference, drainage tubes, and wholesale removal of bone have yielded disastrous results. 7. The mortality has been greatly reduced by improved methods of treatment. 8. Perforating wounds traversing the joint should be treated by puncture, compression, and immobilization. 9. For wounds with foreign bodies included, with or without bony lesions, early intervention is the secret of success. 10. The new era in knee-joint surgery calls for arthrotomy within 48 hours, removal of projectile, foreign bodies and loose fragments, excision of path of projectile, cleansing of joint and suture without drainage. 11. Extensive bony lesions demand primary resection. 12. It is in the decision as to what cases should properly be treated by the new era method and what cases demand resection on account of the extent of bony injury that difference of opinion between individual surgeons is bound to exist. 13. From all points of view vital preservation of the limb and its function and duration of hospital stay, the results of the improved method are vastly superior. Mosti's paper (Policlinico, Rome, 1917, xxiv, p. 458) deals only with the technic of arthrotomy of the knee-joint. He advocates the transpatellar method devised by Bougot and De la Rue as the most rational method of executing arthrotomy of the knee-joint in war surgery. In this procedure the incision is vertical and median on the anterior face of the knee, starting from the lower extremity of the patella across its anterior face and rising above it for about four or five finger-widths to the point where it meets the subquadri- cipital cul-de-sac. But the method is too multilating owing to the fact that the cutaneopatellar strip, left free until complete recov- ABSTRACTS OF WAR SURGERY 293 ery, undergoes a very marked retraction and not only leaves a large deforming scar of the knee but also a very notable functional defect, i. e., the abolition of movements of extension. There is interrupted continuity of the patellar tendon. For the purpose of avoiding these undesirable results Mosti applies a continuous extension to the cutaneopatellar strip, using a simple procedure: On the cutaneous face he fixes two wide strips of adhesive plaster. The two free ends brought together are fastened to an elastic tube. The tube is fixed to the end of a metal- lic stirrup fixed in the part of the immobilizing plaster cast which corresponds to the plantar part of the foot. The tube is kept in slight tension. The cutaneous strip thus acquires a strongly oblique position and the articular cavity is kept gaping so that the Carrel method can be applied. When a relative sterilization of the articu- lar cavity has been reached, the tendon stumps are united with catgut by a tenorrhaphy and the cutaneous margins sutured with- out drainage. This is easily done as the strips have preserved their full length owing to the traction exerted on them. In general the secondary suture can be attempted from the tenth to the fifteenth day. Mosti has adopted this method for some time past in the ma- jority of knee wounds with the best results; he reports some typi- cal cases. He claims that the transpatellar arthrotomy with the modifications made by him is applicable to every type of knee wound, no matter how much time has elapsed since the injury. It also fulfils other conditions which can not be satisfied by other methods. He sums up the advantages as follows: 1. It widely exposes the greater part of the articulation, thus giving means for better drainage. 2. It enables a wide exploration of the articular cavity to be made, and by bringing eventual lesions into full display, facilitates the operative manipulation. 3. Elastic traction applied to the cutaneopatellar strip, while keeping it in a strongly inclined position, hinders its retraction, whatever may be the duration of the treatment. 4. Secondary suture both of the patellar tendon and of the cu- taneous incision, made possible by the prevention of retraction, allows an almost complete restoration or a solid ankylosis in the best position. It obviates the large and deforming scars which gen- erally result from other methods. 5. It is almost always possible in this method to conquer sepsis in the shortest possible time, and secondary resection very rarely becomes necessary, if it is not altogether eliminated. 294 ABSTRACTS OF WAR SURGERY Achille's experience (Gazz, d. osp. e. d. din. 1917, xxxviii, p. 723) in the military hospital of Ravenna, and his study of the results obtained by others as reported during the war, leads him to think: 1. That small transfossal wounds of the knee generally heal with- out intervention. 2. That it is not always advisable to extract small projectiles buried in the articular head without serious bony lesions, as the op- erative act can awaken infective processes of extreme gravity. Careful immobilization and watchfulness ought to be the surgical aim in these cases. 3. In recent lacero-contused articular wounds, early inter- vention, the use of noncaustic fluids and the promotion of pro- teolysis by hypochlorites is the procedure of choice. 4. When an infective process is evident, the existence of a fracture of the articular head will be assured by radiographic examination, as well as the presence of any foreign body. Sim- ple arthrotomy is always insufficient to dominate an infection. In such cases, if the condition of the patient permits, an atypical resection should be attempted, using the low curved Mackenzie in- cision; this should be completed by the excision of all the syno- vial and by removal of the patella. 5. In cases of infective arthritis not complicated by osseous lesions, when a wide aggressive arthrotomy and immobilization do not suffice to arrest the infective process and there is a threat of sepsis, there should be a recurrence to the occlusive plaster apparatus, according to procedure suggested by Ruggi. This is kept in place from 15 to 20 days. In this way a limb otherwise doomed will often be preserved. 6. Amputation of the thigh ought to be reserved for extreme cases or those in which the complication of an ascending infec- tive osteomyelitis renders any attempt at preservation vain. The author's statistics cover 65 cases, 27 of which were strongly infected penetrating wounds, some complicated by fracture and retention of the projectile. "Wide arthrotomy was practiced in all 27 cases, with removal of foreign bodies and arthrectomy or par- tial resection. Of these 27 cases 14 healed without other intervention; one died from sepsis ; 12 had secondary amputation of the thigh with 8 recoveries and 4 deaths. There were 4 cases of pyoarthrosis with existence of fracture ABSTRACTS OF WAR SURGERY 295 and osteitis of the articular head. All were treated by atypical resection, removal of the patella and synovial sac. Three were cured; one had secondary amputation of the thigh. There were 2 cases of comminuted fracture of the articular head with acute sepsis due to grenade injury and in which am- putation was not advisable ; both died. The remainder of the 56 cases recovered. ARTICULAR GUNSHOT WOUNDS.— Haller. Bull, et mem. Soc. de chir. de Paris, 1916, xliii, p. 1404. Haller reports his experience based on 74 cases of articular injuries observed by him in the field ambulance service up to last March. He divides these lesions into four varieties : 1. Articular wounds with injuries of the soft parts only. 2. Articular reactions in diaphyseal or diaphyso-epiphyseal fractures with fissures into the joint. 3. Articular injuries with more or less extensive breakage of the articular surfaces. 4. Large disruptions, destruction of the joint with laceration of the muscles, vessels, and nerves. A different method of treatment has been adopted for each of these varieties. For the first group Haller after disinfecting the orifice uses immobilization and compression. In 5 cases of knee- joint injuries such treatment sufficed. In 2 of these cases the projectile remained embedded, and in 2 other cases subsequent arthrotomy was necessitated owing to infection. In 9 cases of the second variety arthrotomy was done. In all these cases there was a septic reaction. Haller thinks that in certain cases simple arthrotomy does not suffice and that an early partial resection may be necessary ; but this may be avoided by a minute clearance of debris and wide drainage at first. In the third class of lesion Haller counsels economic resection limited to the soft parts and osseous surfaces. He has made 6 such interventions in the shoulder, 11 in the elbow, 4 in the wrist, 1 in the hand, 1 in the hip, 1 in the ankle, 4 in the foot, and 7 in the knee. In 10 cases of the fourth group Haller amputated immediately. The total results in the 74 cases give 15 deaths ; 50 patients, or 80 per cent, left the hospital in good condition. 296 ABSTRACTS OF WAR SURGERY Articular injuries of the knee treated by compression and im- mobilization were cured without complication. In 16 arthroto- mies Haller had only 1 death, a case of suppurative arthritis of the shoulder with fracture of the humerus operated upon the fifth day after injury. In two others an amputation and resec- tion respectively were necessitated subsequently. Of 35 atypical resections, there were 7 deaths and 28 recoveries. The deaths occurred generally in cases that had other complica- tions. The results in these resection cases gave 20 per cent mor- tality, 8.57 per cent of necessary secondary operations (amputa- tions), and 71.43 per cent of recoveries in good condition. Secondary amputation was necessary 6 times in 55 cases of arthrotomy or resection. Of these 6 cases 4 recovered and 2 died. The immediate amputations, of which there were 19, gave 12 recoveries and 7 deaths. RESECTION OF THE KNEE TO AVOID AMPUTATION OF THE THIGH IN FRACTURES OF THE KNEE.— Turner. Presse. med., 1915, xxiii, p. 227. Comminuted fractures of the knee with suppurative arthritis are very severe injuries, but Tuffier thinks amputation of the thigh is practiced much too freely in such cases. Among 200 patients upon whom amputation was performed at Maison Blanche, 30 were for injuries of the knee by rifle bullets, which is the least severe form of injury; those by shells and shrapnel are much worse. Of 74 cases of amputation of the thigh at Saint Maurice 22 were for wounds of the knee. Turner thinks many of these limbs could have been saved by resection at the knee-joint. The con- dition of a patient with an amputation of the thigh is incompar- ably worse than that of one with resection at the knee; moreover, the mortality in amputation at the thigh is very high. Some- times these injuries of the knee recover with ankylosis after long treatment, but in some cases general septicemia develops and amputation becomes necessary. In the great majority of cases resection is sufficient. He cites four cases in his own practice. The case histories are given showing that they were very severe cases. ABSTRACTS OF WAR SURGERY 297 TREATMENT OF GUNSHOT WOUNDS OF THE KNEE- JOINT.— H. M. W. Gray. Brit. Med. Jour., 1915, ii, p. 41. The author reports that in the earlier part of the present war the result of treatment in gunshot wounds of the knee among those who recovered was marked by ankylosis in the majority of cases. The period of convalescence was usually most painful and precarious. These results are attributed to erroneous ideas of treatment which have been abandoned. Among the errors men- tioned are : (1) the belief that suppurative infection of the joint demanded free and prolonged drainage ; (2) the use of drainage tubes, more or less large in size, inserted deeply into the various recesses of the joint; and (3) the use of strong antiseptic treat- ment which was inimical to a restitutio ad integrum, because the deleterious action of the antiseptics destroyed the synovial mem- brane and cartilage, forming a fruitful source of ankylosis. In lieu of the foregoing line of treatment the following factors are now insisted upon: (1) wounds of the joint that are apt to become septic demand mobilization; but few such cases when received from the front are provided with properly applied splints. This important lapse in treatment is apt to favor the entrance of sepsis to a knee previously infected, and again there is danger that it might stimulate a virulent, diffuse inflamma- tion instead of a mild, localized one. It is insisted upon that dur- ing the treatment the splint be retained two or three weeks at least. Later, gentle passive movement is recommended; (2) for- merly, foreign bodies were removed ' ' only if they led to trouble ' ' ; now only those embedded in bone outside the joint are left un- disturbed, all others are removed whether they are the source of immediate trouble or not; (3) excision of the wound in the skin and superficial tissues is now a routine process. The present treatment is summarized as follows: Excise wounds of the skin and superficial soiled or necrotic muscle and fascia. Enlarge the wound freely if necessary. Remove foreign bodies, previously localized by x-rays, after possible enlargement of the synovial membrane. Flush the synovial cavity with 5 per cent saline solution. In very acute cases make fresh in- cisions. Trim the edges of the wound in the synovial membrane ; suture if the sepsis is not acute. Insert drainage tube down to but not through the wound in synovial membrane. Fill the rest of the wound firmly with "tablet and gauze" dressing. Inject formalin, glycerine, or ether, through the fresh puncture. Clean 298 ABSTRACTS OF WAR SURGERY and redisinfect the surrounding skin. Apply superficial dress- ings and light bandage. Immobilize in suitable splint. If this fails free arthrotomy and possibly amputation should be em- ployed. In looking over the 36 cases detailed briefly for the most part, the reviewer finds that 27 were due to shrapnel or shell frag- ment, and 9 resulted from bullets or missiles the nature of which is not specified. To have cured 28 of these with movable joints is an achievement that is heartily commended, considering the nature of the missiles causing the wounds. The author insists on immobilization as a prime factor in all knee-joint wounds. The treatment is not new since it is an es- tablished mode of treatment in surgery as a rule, and military surgery in particular. We have taught the value of immobiliza- tion for years, not only in joint injuries and fractures from gun- shot, but in all gunshot wounds including those of soft parts even where immobilization is impossible. Fixation of wounded parts plays a great role as a prophylactic against the development of in- fection. When enforced transportation is necessary, as often hap- pens in military practice, it adds to the comfort of the patient in keeping down pain, it prevents the recurrence of hemorrhage, and it also favors early healing. The only thing recommended by the author that savors of new treatment is excision of the wound of the skin and super- ficial soiled or necrotic muscle and fascia, and this is only new as it may apply to the channel of a bullet wound and not to shell wounds or gunshot wounds which exhibit the characteristics of explosive effects. Here we have a great deal of devitalized tissue and the rule of treatment is the same as that practiced in all wounds with coagulation necrosis; i. e., the removal of con- tused parts. The rest of the so-called new treatment which refers to free drainage, removal of foreign bodies in the joint after localization by x-rays, flushing the synovial cavity with saline solution, insertion of drainage tubes to and not into the synovial cavity, etc., is sound practice. RESECTION OF THE SHOULDER IN WAR SURGERY.— Fourmestraux. Bull, et mem. Soc. de chir. de Paris, 1916, xlii, p. 1677. Among 1,300 ambulance patients Fourmestraux found 41 shoulder injuries with isolated or simultaneous lesions of the hu- ABSTRACTS OF WAR SURGERY 299 meral head of the scapula and of the clavicle; in 11 of these re- section was necessary. In these 11 cases of resection of the shoulder Fourmestraux made a vertical incision starting from the acromioclavicular articulation. This incision was continued behind and below on the spine of the scapula. The acromioclavicular articulation was bared ; the acromion temporarily detached ; the capsule opened ; the humeral extremity more or less resected, the circumflex nerve having been pulled down out of the way for protection. This incision allows a good exploration of the scapula and the removal of crushed parts of the superoexternal angle, an injury which is often a concomitant. It allows good drainage also. The end-results can not be stated by the author at the present time but he hopes to report later. PRIMARY RESECTION IN THE TREATMENT OF ARTICU- LAR GUNSHOT WOUNDS V/ITH FRACTURE.— G. Cotte. Rev. de chir., 1916, li, p. 383. Cotte shows the results obtained for each joint in the treat- ment of articular injuries with fracture by means of resection. From this study he deduces the conditions in which resection should be employed, in which cases it should be reserved, and at what time it should be practiced. A general study of articular wounds, such as are observed at the front, shows that these are of three types. The first com- prises those which fall into the abstention class. These comprise bullet wounds with punctiform orifices. In these the lesions al- most always heal in an aseptic manner providing no hasty maneu- vers are used. The treatment should be rigorous immobilization of the injured joint in a plaster jacket, and not the least injection should be made into the trajectory under pretext of disinfecting it. Of 78 articular wounds with fractures treated by Cotte, 16 were of this class, and abstention has always given good results. Although the end-results are generally good, yet in certain cases such as those in which a wedging of the articular surface, difficult to reduce, exists, a prudent and experienced surgeon will intervene after some days to effect reduction of the fracture, etc. It suffices to say that the aseptic evolution of the wound is com- patable with all operative measures. The second type comprises those injuries which call for early amputation. Such are ruptured and crushed joints in which the 300 ABSTRACTS OF WAR SURGERY soft parts are so badly damaged that a conservative operation can scarcely be thought of, with vascular concomitant lesions and the consequent expectant development of grave infection. More- over, this class includes those cases in which the patient's gen- eral state is too feeble to permit a much longer conservative intervention. Of the 78 articular wounds treated 14 were of this type. Of these amputations 8 were due to the primary condition. In the other 6 an early and better treatment would have avoided it. Aside from these two types the author is of the opinion that all other articular wounds call for resection. This experience at the front has convinced him that the simpler procedures of widely opening up the wound and clearing it out do not suffice. Resec- tion does all that these operations do and does it better and the end results are much more satisfactory. The clear and regular sur- faces due to resection are better than the irregular surfaces left in a ripping up of the wound. Again the facts justify it. Of the 45 cases treated by resection, only 2 have died. The facts in these 2 cases (alcoholism and embolism) show that a more conservative treatment would not have averted these results. As regards end-results there can be no doubt but that after resection the wounded recover much more simply and rapidly than after clearing operations. Regarding the orthopedic results of re- section the small number of cases operated upon by Cotte is not sufficient to authorize him to affirm the superiority of resection over conservative procedures. While a priori it must be admitted that many resected joints will not recover their mobility, or the limb may recover with imperfect functioning, yet a limb only partly useful is better than no limb, and it can be said that resec- tion will almost certainly obviate infection or check the results of it. Regarding the time of intervention and the method, resection should be as early as possible, as it is impossible to say what will be the evolution of an articular injury after its occurrence. The author has recourse to the subperiosteal method following the general rules of resection laid down by Oilier. The anatomic route is selected which allows the largest exposure of the articulation while avoiding the nerves, muscles and tendons. With these limi- tations, the resection will be as economic as possible. Cotte gives the clinical details of several cases of different artic- ular lesions treated by resections to illustrate his contentions. ABSTRACTS OF WAR SURGERY 301 TREATMENT OF TRAUMATIC ARTHRITIS OF THE KNEE. — Marchak and Dupont. Bull, et mem. Soc. de chir. de Paris, 1916, xlii, p. 1387. The memoirs of these two authors were reported on by Del- bet, who pointed out that they were totally at variance with each other. Marchak sustains four points: (1) the necessity for early arthrotomy; (2) for large arthrotomies to follow Delbet's technic; (3) the utility of extension after arthrotomy; (4) the inconvenience of systematic resections. Dupont abstains from all interventions, immobilizes the limb and packs it in ice. He was led to adopt this technic by the bad results from arthroto- my. Marchak cared for 15 cases of purulent arthritis of the knee. Of these 1 died from tetanus, and 1 from repeated hemorrhages. In 4 cases amputation was necessary. There were 9 recoveries with ankylosis. Besides these 15 cases he had 3 other cases in which early arthrotomy was done at the field hospital. In these 3 cases evolution was simple and they are now without compli- cation. Marchak therefore concludes that the knee must be opened on the least showing of articular reaction. Dupont treated 7 patients with immobilization and ice pack. One died on the fifteenth day from purulent arthritis, arthroto- my followed later by amputation having been tried in vain. The other 6 cases recovered. All these were severe cases and in 5 of them a projectile was lodged in the articular cavity. In 2 cases these were not extracted and in the others the extrac- tion was only made secondarily when the articular reaction had completely disappeared. In discussing these contrary reports Delbet states that the end sought in making a large opening of the knee is not the removal of a foreign body but the avoidance of infection. Infection is not constant, and its frequency can not be stated with precision, but its presence may be detected by making a pyoculture. The result of this will absolutely set at rest all questions as to ab- stention or intervention. This will not take more than three to five minutes. If microbes are found then a simple arthrotomy is made. If not, the limb is immobilized and examination again made the next day. If streptococci are abundant in the pus wide arthrotomy will be done. If there is a foreign body in the articulation it is preferable to remove it at once, but the 302 ABSTRACTS OF WAR SURGERY question of suturing, draining, or leaving the wound open de- pends as before on what is found in the pyoculture. Osseous lesions in themselves do not afford any special indications. In- fection and the patient's resistance must be the guide. Delbet's personal experience in treating knee injuries accord- ing to this procedure is not large. Of 17 cases, 4 were aseptic and cured without arthrotomy. In 3, simple arthrotomy was done, the pyoculture being weakly positive. The 3 recovered but one was ankylosed. In the other 10 cases the pyoculture was strongly positive, and all had osseous lesions. In all these, wide arthrotomies were made with immobilization and exten- sion. In 1 case a resection was done. Five of these patients recovered without ankylosis ; in 4 it was necessary to amputate. In 3 of these amputation cases the course was adopted be- cause while the patient's resistance was declining, the successive pyoculture showed increase in the number of microbes. All the patients recovered. Pyoculture, therefore, while it indicates ab- stention in a certain number of cases, suggests intervention when necessary in infected cases, and limits it to the resistance of the patient with a simple dressing, until further treatment can be given in a general hospital, provided there is no evidence of infection. In comminuted fractures, the authors state with positiveness that however freely the wound is opened up, the bone fragments must be left in situ. There are only two exceptions to this rule of not removing bone fragments: (1) when the articular end of a bone is shattered, all loose bone should be removed from the joint; and (2) if a bit of bone is clearly devoid of all vas- cular connection and lies in a septic wound, it should be taken out. Operative fixation of fragments is not recommended. If much communition is present, plating or wiring is useless and a mechanical impossibility, and when the fracture is not com- minuted, it should be treated by extension. Boring bone for plating invariably leads to necrosis when the wound is already infected. A very good description is given of the latest and best ap- paratus made of wire, which is easily transported in the field, as well as a careful description of the technic in the practice of immobilization. ABSTRACTS OP WAR SURGERY 303 COMMUNICATION FROM U. S. ARMY BASE HOSPITAL NO. 5. — R. B. Osgood. Am. Jour. Orthop. Surg., 1917, xv, p. 668. If a foreign, body has perforated a joint and its tract appears to be reasonably clean, the joint is immobilized and carefully watched even in the presence of increased surface heat and a tight synovitis. At most, an aspiration is done, and the nature of the fluid and its bacteriology determined. Many of these cases quiet down in a surprisingly satisfactory manner. In the case of a penetrating wound with the foreign body still present, actually in the joint or in the tissues involved in its mechanism, action is dictated by several considerations — the size and location of the foreign body, the reaction of the joint, the possibility that a part of the active joint symptoms have been caused by the inevitable trauma of transportation and bj- the temperature and general condition of the individual. In general, it may be said that foreign bodies of any size, within a joint cavity proper or embedded in the articular ends of the bones near the cartilage line, should be removed at some time. It is often wise to allow the first traumatic reaction to subside before opening the joint. Under rest and complete fixa- tion, they frequently quiet down quickly and may then be opened more safely. If operation is undertaken, the external wound is excised, the joint opened, and after the foreign body has been found and removed, the joint is washed out for at least ten minutes with a weak bichloride or sterile normal saline or perhaps even the antiseptic solution devised by Dakin. The form most commonly used is the so-called eusol in strength of 1 :200 or 1 :400. After thorough irrigation by means of a soft catheter tube inserted into the deepest recesses of the joint, the joint cavity is tightly closed with fine chromic catgut, and the external wound only partially sutured, or not at all, de- pending upon the severity of the infection and the tissue drain- age. A small drain of rubber tissue is left in, extending down to but not through the capsule. Many of the surgeons, especially at the casualty clearing station, are using, in addition, a sub- stance known as "bipp" (bismuth-iodoform-paraffine) in thick liquid or soft paste consistencies, leaving a small amount in the joint and wiping it over the external wounds and incised tis- sues. It is the antiseptic treatment returning. An article by Morison gives a full description of the method which its origi- 304 ABSTRACTS OF WAR SURGERY nator considers the best. The author and his colleagues have had certain cases of iodoform and bismuth poisoning follow- ing its use, the former shown by mental disturbances and per- haps vomiting, also later by a dark line at the margin of the gums and sometimes by real stomatitis. There seems to be a marked individual idiosyncrasy and susceptibility, but it is cer- tainly often followed by these effects. The compound fractures complicated as they all are by sepsis, call for the most efficient methods of fixation, which must at the same time provide adequate room for copious dressings and treatment by the Carrel technic. At the primary operation, when adequate drainage is provided and the tissues damaged beyond repair are removed, it has been proved to be an axiom never to remove even seemingly completely separated fragments of bone. The early or even late excisions of joints and the clean removal of bone fragments have not resulted in a quick subsidence of sepsis, nor has joint function or union of bony ends been favored. The results of these procedures are often deplorable. Plaster-of-Paris dressings with wide openings bridged by loops of metal or plaster offer the most perfect fixation and greatest comfort to the patient. These are employed in spe- cially difficult and painful cases. Their disadvantages in an Eng- lish general evacuating hospital, where there are often periods of great rush, are their time-consuming initial application and the practical certainty that they will be removed when they reach the home hospital. Thomas and Jones splints are admir- ably adaptable, easy to make, capable of quick application, can be supplied in large quantities to the front stations, and al- low of comfortable transportation. They leave little to be de- sired. They have adopted combinations of these splints by which arms may be fixed in abduction and the patient made ambulatory. THE IMMEDIATE RESULTS OF SURGICAL INTERVEN- TION IN 111 OASES OF PURULENT ARTHRITIS OF THE LARGE ARTICULATIONS.— Auvray. Bull, et mem. Soc. de chir. de Paris, 1917, xliii, p. 683. All of the 111 cases observed by Auvray were clearly purulent. They occurred in the rear hospitals several days and even weeks after injury, and the arthritis had been overlooked. Only the immediate results of intervention are reported as ABSTRACTS OF WAR SURGERY 305 the majority of the patients could not be followed up. The 111 cases comprised: 34 purulent arthritis of the knee, 32 puru- lent arthritis of the elbow, 20 purulent arthritis of the shoulder, 12 purulent arthritis of the ankle, 7 purulent arthritis of the wrist, 4 purulent arthritis of the hip, 2 purulent arthritis of the sacro-iliac joint. Of the series 8 patients died, total mortality, 7.2 per cent; 12 were amputated, all being of the lower limb. All the shoulder cases have had to be resected. Auvray says that the results show very clearly the great gravity of purulent arthritis of the lower limb, there being 12 amputations and 6 deaths; especially the knee-joint lesion which is incontestably the most severe. Also he points out how powerless an arthrotomy is in stopping the evolution of infected joint complications. After several such drainage operations resection has had to be resorted to, resulting in the cure of the patient. In many of the cases the bad results are due to faulty and insufficient arthrotomy methods and other causes; but Auvray 's experience leads him to think unfavorably of simple drainage operations, as resection in his experience has saved many lives and limb?:. He points out the necessity for early diagnosis and treat- ment at the surgical stations at the front. On the preliminary dressings, especially in the case of purulent arthritis of the knee, often depends the future of the limb, and even the life of the patient. ARTHROTOMY FOLLOWED BY IMMEDIATE CLOSURE OF THE ARTICULATION IN THE TREATMENT OF CER- TAIN WOUNDS OF THE KNEE.-^-H. Gaudier and R. Montaz. Lyon chir., 1917, xiv, p. 77. The immediate suture of the synovial membrane after arthrot- omy in knee-joint wounds requires the following conditions: (1) prompt surgical intervention; (2) complete excision of all injured tissues after extraction of foreign bodies; (3) very careful hemo- stasis ; (4) the possibility of supervision of the patient during the first few days; (5) thorough immobilization. In a series of fifteen cases reported by the author the aver- age time elapsing between injury and operation was from six to ten hours. In some cases it ran from twenty-four to seventy- two hours. Satisfactory results were obtained in all except one case which became transformed into septic arthritis. Such 306 ABSTRACTS OF WAR SURGERY good results are to be explained by the long period that artic- ular fluid may remain sterile in spite of existing infection of the surrounding tissues and the presence of the bacillus per- fringens on the projectiles, which fact is known from the re- searches of Feissinger. The indications after x-ray examinations are : 1. Surgical cleansing of all soft parts; excision of wound edges and injured tissues; thorough hemostasis. 2. Wide parapatellar arthrotomy, saving the quadriceps ten- don if possible. 3. Very careful cleansing of bone injuries; extraction of the projectile by curette if in the bone; scraping the whole frac- ture area and smoothing of bone edges. 4. Lavage of the articular cavity by hexamethylene or ether. 5. Suture of the synovial membrane by isolating, if possible, the bone injury from the main cavity of the joint. A small plug of gauze is left in the bone cavity and removed after twenty-four hours. In suitable cases there should be suture of the soft parts above the closed synovial membrane, followed by immobilization of the limb. The evolution is nearly always simple; but there may be a slight rise of temperature during the first days. After two weeks when all inflammatory reaction has vanished, mobiliza- tion may be begun. Contraindications are : clinical signs of infection ; great de- struction of soft parts rendering suture impossible; serious bone injuries calling for primary resection. In the author's 15 cases, 14 recovered with a movable joint; 1 recovered with ankylosis. TREATMENT OF GUNSHOT WOUNDS OF KNEE-JOINT.— H. M. W. Gray. Jour. Am. Med. Assn., Oct. 6, 1917, p. 1202. In dealing with operative cases Gray believes that if the in- jury has implicated the main vessels so that the foot is already cold and dead, amputation should be done just above the knee if the wound is likely to remain fairly clean, and through the knee if sepsis is present and the condyles are undamaged. In the latter class of cases reamputation is frequently necessary, and when the condyles are left it can be done so as to provide the longest possible thigh stump. If, as sometimes happens, one or other popliteal nerve is shot away so extensively that it ABSTRACTS OF WAR SURGERY 307 can not be sutured later on, and if the bones are much soiled as well as comminuted, the probability is that primary ampu- tation is the best course. If sepsis is well established in pres- ence of much comminution, especially if there be gas gangrene, and the patient in low condition from hemorrhage or toxic ab- sorption, amputation must be done. If, in less severe cases, the opposing ends of the long bones are so comminuted that smooth articular surfaces are not available, it is probably best to do primary resection in the way recommended by Fuller- ton. If large fragments have resulted from the injury, if the patient has been received early and is in good condition, and if one is fairly sure of getting away infective material, the patient should be given a chance. As a general rule, if the patella alone has been shattered, as happens fairly frequently, the fragments should be removed. If possible, the synovial cavity should be closed, except for a small drainage opening, by suturing the lateral edges and aponeuroses, possibly after undercutting the synovial mem- brane on each side, or by loosening the suprapatellar pouch as already described. If this can not be done, a "salt pack" should be used. The same procedure should be carried out if con- comitant injury to other bones is not extensive. In consider- ing the question of amputation, these points are of great im- portance : the possibility of removing or neutralizing infective material successfully, the amount and kind of comminution, the concomitant injury to vessels or nerves, and the condition of the patient. When conservative measures are decided on, the following are the most important operative details: determina- tion of the track which leads to the depth; thorough disinfec- tion of skin and track; careful and complete excision of exter- nal wound and track, including the edges of the wound in the synovial membrane, if possible in one piece. Pockets must not be cut into. The least little bit of infected tissue left behind may prevent success ; provision of ample access to foreign bodies or comminuted surfaces in the joint. Careful removal, under direct vision, whenever feasible, of all foreign material, whether free in the joint or embedded in the articular surfaces. Closure of the wound in layers, using fine catgut for the synovial membrane. Drainage tubing should not project into the joint. If the wound in the synovial mem- brane can not be closed, a small "salt pack," separate from any other which may be required for the rest of the wound, should be inserted firmly "down to but not into" the joint, and 308 ABSTRACTS OP WAR SURGERY should be left until it is absolutely loose. Tendinous or liga- mentous structures exposed during operation should be covered by skin and subcutaneous tissue; otherwise they are very apt to slough, and this postpones closure of the wound, and there- fore prolongs convalescence. If there is much effusion into or from the joint, of whatever nature, or if raw surfaces, whether of bone or soft tissue, are left in the joint, at the end of opera- tion, a tube should always be inserted "down to but not into" the synovial cavity. The injection of ether, formaldehyd solu- tion, glycerin, or hypertonic (5 per cent) saline solution into closed joints, is of doubtful value. They are all irritants. In dealing with wounds of the knee-joint Page urges that the natural defensive powers of the part against infection should be borne in mind. Primary prophylactic (that is, within twenty-four hours of injury) operations should be rad- ical, and secondary operations undertaken on account of pro- gressing infection, should be planned, short of amputation, on conservative lines. The expectant treatment of wounds of the knee-joint is only justifiable in the case of typical perforating injuries due to a rifle bullet. All wounds of the joint caused by shell fragments or distorted bullets should be considered as primarily infected. The primary prophylactic treatment should consist in the removal of any foreign bodies present and in the excision of the whole wound track at the earliest pos- sible time after injury. The results at present are particularly bad in cases in which gross comminution of the diaphyses is present. A primary excision or erasion of the joint (within twenty-four hours) would probably improve the results in such instances by preventing the development of osteomyelitis. Re- peated aspiration of the joint and the intra-articular injection of any of the antiseptics in common use are calculated to prej- udice the natural defense. It is safest to leave for a few days some drainage along the wound track after operation, certainly when bone injury is present. Any infection then left may be- come localized in the same way as occurs in the case of the peritoneum. A gauze wick makes a satisfactory form of drain. Immobilization of the joint during all critical periods is es- sential. An interrupted plaster-of-Paris splint affords the best means of effecting this. When general infection of the joint has taken place treatment by fixation, lateral arthrotomy and immunization gives the best chance of saving the limb. Sec- ABSTRACTS OF WAR SURGERY 309 ondary abscesses are to be expected, and should be evacuated after their complete development. Neither cross-section and flexion of the joint nor secondary excision of the knee are sound procedures. TREATMENT OF WOUNDED KNEE-JOINT.— II. G. Barling. Brit. Med. Jour., Sept. 1, 1917, p. 277. Barling analyzes 845 cases. In a very high proportion of cases excision of the wound, removal of bone when necessary, removal of any retained foreign body, irrigation of the joint and closure by suture has been followed by a perfectly satis- factory healing without further interference. The proportion of these cases requiring further intervention is 25.5 per cent, and Barling believes that free use of the joint is likely to re- sult in a large majority of those in whom, the primary opera- tion was successful. In the group in which complete closure was not possible or was deemed inadvisable, and in which the wound was packed, the results are not so good. This group includes the worst cases of injury to the bones entering the knee-joint. Here the proportion of cases in which further operative interference was required is 38.4 per cent. Very use- ful joint function may result in many cases. Excision of the wound, removal of bone when required, removal of foreign body, suture of the wound, if possible, and packing as an alter- native in selected cases, is the program Barling recommends. In a considerable number of instances materials such as for- maldehyd solution and glycerin or ether have been injected and retained in the joint cavity. A few surgeons pack the 'joint with urea, and favorable results were obtained. One operator makes a separate incision at some distance from the wound of entry, thus securing that at all events he drives noth- ing septic into the joint. Barling questions whether it matters much what fluid is used to wash out the joint, the main advantage is the mechanical cleaning out of septic material, fibrin and blood clot; but this should be done thoroughly through a free opening; the use of cannulas for this purpose is insufficient. Barling deprecates aspiration of the joint and irrigation or injection with an anti- septic fluid, to which he would resort only when the fluid showed a low corpuscular element, a moderate polymorphonuclear count, 310 ABSTRACTS OF WAR SURGERY and a sparsity of infective organisms, — conditions rarely found. Mere aspiration is apt to be followed by a breaking of infection through the capsule of the joint and a spread into the surrounding tissues, a grave addition to the patient's troubles most difficult to overcome. Regarding aspiration as rarely a wise measure, Barling mentions three other courses: (1) free opening up of the joint; (2) excision of the joint; and (3) amputation. FRACTURES THE TREATMENT OF GUNSHOT FRACTURES.— E. W. H. Groves, and T. H. Brown. Lancet, London, 1916, cxc, p. 900. In a typical gunshot fracture the authors call attention to three main characteristics: (1) great comminution with dis- placement; (2) severe sepsis; and (3) pain which becomes in- tolerable with movement. The indications are directed to saving life and limb and to restoring function. To accomplish these results, four things are necessary: (1) immobilization for a long period; (2) free drainage and frequent redressings; (3) extension in a correct line; (4) maintenance of both wound treatment and extension for a period which may be prolonged for several months. In addition the nearby joint should be semiflexed, so that the limb is in physiological rest; and the flexors are relaxed. Mas- sage and movement of the limb from an early period should be practiced. Grossly infected wounds are frequent after fracture by bombs and shell fragments, also by military rifle bullets at proximal ranges. They should be opened up freely at the earliest mo- ment. Treatment should not be delayed for x-ray evidence if it is not at hand. Missiles and particles of clothing as well as all extraneous matter should be removed. Small punctured and penetrating wounds should be left alone. TREATMENT OF SHELL FRACTURES OF THE FEMUR.— E. Suchanek. Wien. klin. Wchnschr., 1915, xxviii, p. 32. At the von Eiselsberg Clinic the treatment of shell fractures of the femur is decidedly conservative. In discussing the con- dition in which the patients reach the clinic the author reviews the different methods employed for immobilization of the limb at the front and the results obtained with the different meth- ods. In subcutaneous fractures and in fractures with only slight flesh wounds a plaster of Paris cast properly applied over two long boards and the limb sufficiently padded serves admir- 311 312 ABSTRACTS OP WAR SURGERY | ably for transportation purposes, although the cast may crum- ble as a result of moisture. He warns against its use, how- ever, in cases with bad wounds or where infection is suspected, as phlegmons repeatedly develop and are overlooked until the cast is removed. The method is rather impracticable at the extreme front, as the necessary boards and other supplies do not reach the front lines in most instances, and the technic of applying the cast is not common to all physicians. The Cramer wire splint and the one modified by von Eiselsberg have also proved very satisfac- tory for the transportation of femur fractures. The treatment after arrival at the permanent hospital con- sists in extension. In cases of longitudinal displacement this treatment is supplemented by the Florschutz method of sus- pension and slight flexion at the knee, allowing access to the injury without moving the limb and without causing any pain. If on account of lateral displacement a reposition of the fragments is not possible by the single traction of this method, the Bardenheuer extension method is employed, eventually supplemented with traction strips according to Euckert, thus exercising traction on the individual fragments. Before ap- plying either method x-ray pictures are taken, and a later pic- ture is taken before a permanent cast is applied. This should not be done too early, as phlegmons may develop beneath the cast without any appreciable temperature elevation and may cause considerable damage before they are noticed. After all flesh wounds are healed, the danger of phlegmon over, and the frag- ments in good apposition, a cast may be applied, usually dur- ing the fourth week of extension. The author warns against the more energetic measures and against redressment in narcosis, as well as against the nail ex- tension method of Codivilla-Steinmann. The danger of spread- ing the infection in a fracture complicated by phlegmon speaks against the former, whereas the danger of infection of the drilled canal speaks against the later. The author is well satis- fied with the results obtained with the conservative method, a good functional result being striven for and usually obtained. REDUCTION OF THE NUMBER OF AMPUTATIONS AT THE FRONT.= — E. Marquis. Bull, et mem. Soc. de chir. de Paris, 1915, xli, p. 502. Marquis pleads for the most conservative treatment possible at the front and the reduction of the number of amputations ABSTRACTS OF WAR SURGERY 313 to a minimum. He describes 36 cases in which he saved limbs where amputation would have been considered necessary by- many surgeons. Amputation was performed only in 16 very severe cases, with 8 recoveries and 8 deaths. Five patients died without having had amputation performed, but two of these died of tetanus and could not have been saved, even by immediate operation ; two were too severely injured to stand amputation, leaving only one case in which the failure to am- putate might have been blamed for the death. This was a patient who was apparently recovering and died suddenly, evi- dently from embolism. The chief danger in conservative treatment is that the best moment for amputation may be passed by in the effort to save the limb. In order to avoid this, the greatest watchfulness is required on the part of the surgeon. It takes the patient longer to recover, too, and he may sometimes blame the sur- geon for minor operations performed to avoid amputation; but the final results more than justify the added trouble. PRIMARY TRANSFORMATION OF OPEN GUNSHOT THIGH FRACTURES INTO CLOSED FRACTURES.— Lagoutte. Bull, et mem. Soc. de chir. de Paris, 1917, xliii, p. 1546. In seven cases Lagoutte attempted immediate primary re- union and transformation into closed fractures of open frac- tures of the thigh. Four of the cases were successful. The wound was cleansed without using an antiseptic. These cases were treated four hours, fourteen hours, seventeen and one- half hours, and forty-nine hours respectively after injury. In the cases which did not give good results, infection had already set in at the time of operation. In the successful cases con- solidation was effected in a period varying from 25 to 42 days. The steps of the technic are radioscopic examination; wide opening up by suitable incisions; extirpation of contused tis- sues ; vigorous cleansing of the bone in the injured area and re- moval of free and devitalized bone chips ; currettage ; removal of clots; and wiping out cavities. After complete surgical cleansing the first principle to observe is not to place any foreign body, drain, mesh, etc., in the fractured area. To en- sure evacuation of any blood, etc., the first sutures need not be hermetic. After forty-eight hours if there is no temperature, nor local reaction, the sutures are drawn tightly, which renders 314 ABSTRACTS OF WAR SURGERY the closure complete. American immobilization apparatus is used. If there should be fistulization a simple secondary inter- vention is called for to remove some badly tolerated bone chip, etc. INFECTED GUNSHOT INJURIES OF BONES AND JOINTS. — W. Denk. Wien. klin. Wchnschr., 1915, xxviii, p. 701. In the treatment of infected injuries of the bones and joints every possible effort should be made to save the limb. In injuries of bones if there is no gas phlegmon or other malignant infection, expectant treatment is indicated at first, careful watch being kept of the patient's general condition. If im- provement does not take place incision with removal of bone fragments or secondary trough-shaped osteotomy is indicated. The indications for incision and removal of bone fragments are : continuous high fever, putrid suppuration, signs of begin- ning sepsis, hemorrhage, and streptococcus infection. After such operations care must be taken to avoid shortening of the extremity, especially the lower. It is well to keep the limb in extension with moderate weights until a callus is formed. In case of fistula or bone abscess sequestrotomy and trough- shaped osteotomy are indicated. The periosteum and soft parts are inverted into the trough and a tampon placed over them to keep them in place; no skin incision is made. The trough fills up with new-formed bone, as is shown by a series of roentgen pictures. To avoid spontaneous fracture, soon after the operation a fixation dressing is applied for five or six weeks. In infected gunshot injuries of joints conservative treatment is indicated. Often even after infection in the joint has become manifest it is sufficient to immobilize the limb absolutely, apply moist dressings, and give large doses of salicylates. If this treat- ment is not effective arthrotomy and drainage, with the opening of any periarticular or burrowing abscesses, are indicated. If this treatment is not successful, resection is justified. This should also be the primary treatment in cases with severe crushing of the ends of the joints and virulent infection or necrosis of frag- ments. If all conservative methods fail or if the patient's life is threatened by a general infection, amputation should not be delayed too long. ABSTRACTS OF WAR SURGERY 315 AN IMPORTANT POINT IN THE TREATMENT OF GUN- SHOT FRACTURES.— G. Perthes. Miinchen. med. Wchnschr.. 1915, lxii, p. 754. Perthes calls attention to the fact that absolute immobilization is of the greatest importance in the treatment of fractures. Many surgeons seem to forget this in dressing and the fracture is moved during the dressing. As a result there is pain, temperature, and increase in wound secretion. This is almost unavoidable if any of the numerous forms of splint are used that have to be removed during the dressing. Fenestrated plaster casts should be used which allow free access to the wound. Illustrations are given of casts which permit this and also protect the edges of the window in the cast against being soiled. When the wound has healed the usual treatment for simple fracture can be applied. THE PLATING OF GUNSHOT FRACTURES.— N. C. Lake. Brit. Med. Jour., 1915, ii, p. 44. The questionable practice of plating in compound comminuted gunshot fractures among wounds is dealt with interestingly by the author in a recital of his nine months' experience at the front in France. He did not see it used in any of the French military hospitals that he visited nor did he hear of its use in many English ones. The importance of obtaining a good anatomical result in the presence of comminuted bone and the difficulties which the latter offers is fully appreciated by the author. The hindrance, from the presence of sepsis which is found in all cases, is also noted. Lake 's wide experience has taught him that fresh infection of soft parts is negligible in view of the already extensive damage, and that fresh infection of the bone does not occur to any extent worthy of consideration. In some of the smaller bones a previ- ously septic wound has been found to heal completely over a plate, a fact which may be attributed to the healthy condition of the tissues prior to the injury. In most cases, however, the plates tend to loosen in the presence of sepsis, but not to the extent he was led to expect, and the loosening does not occur to an extent sufficient to affect the original object of the plates until the fragments have become partly fixed, in, say, two or three weeks. The plates seem to have little effect on the septic process and some of the loose ones become consolidated again. For these 316 ABSTRACTS OP WAR SURGERY reasons the author is of the opinion that objections to the use of internal splints are rather theoretical than otherwise. The ease with which the dressing can be manipulated, and massage and other treatments be applied to neighboring joints and soft tissues, as compared to a limb under treatment by external splints is specially noted. The amount of comminution necessitates the use of longer plates than those in ordinary use. In some shell wounds com- minution is so extensive as to exclude the use of plates, and in these cases a divided plaster having a soft iron connecting piece bent to form a handle to manipulate the limb is found to be of value. The plating operation is not undertaken until acute sepsis has been subdued and radiographs have been taken — about four days after admission. The taking of radiographs in two planes, at right angles, to estimate the amount of destruction and to better reconstruct the damage done, is considered very essential. No routine method is used to combat sepsis, each case being treated according to indications. Ether, a dusting powder com- posed of benzoic acid 25 grams, salol 5 grams, quinine 25 grams, and magnesium carbonate 25 grams, proved of use in very dirty cases after a preliminary cleaning under an anesthetic. To establish the lymph now, as recommended by Sir Almroth Wright, hypertonic saline solutions with and without vaccines are used; but once the sepsis is limited, more reliance is placed on the application of a Bier's bandage or a suction cup when practicable. Sun-baths and injections of colloid gold, so highly recommended by French surgeons, have been used with doubtful results. By the energtic use of the methods mentioned sepsis is con- siderably reduced after a few days, at which time plating can be done. In most of the war wounds an incision is unnecessary or the original wound needs to be only enlarged. The good exposure thus obtained is an advantage in point of drainage. The fragments are carefully replaced except those entirely detached that must obviously die. While this preliminary arrange- ment is being made, surrounding structures are carefully examined for injury. In a search of this kind, in two cases of plating of the humerus, the musculospiral nerve was found in such a position that it would later have been involved in callus. It was promptly freed and buried in muscle to prevent symptoms of pressure later on. Many such cases involving tendons, vessels, and nerves were found and remedied in accordance with the ABSTRACTS OF WAR SURGERY 317 indications offered. After exposing the ends of the main fragments the plates are put in place without disturbing the periosteum unduly. The most useful plate employed was one having two screw holes near together at the end, with one or two intermediate ones. The latter often hold intervening small fragments in good position. It is preferable not to put screws near fractured ends. Holes are carbolized before putting the screws in place. Fresh incisions may be closed, although they may be left open a few days to insure drainage, and closed by suture later. The limb is found quite rigid after plating and the subsequent management is devoted to keeping down sepsis for the next three or four weeks. The author states that the limb may be treated the same as one without fracture, as far as early movements and massage may be indicated. After one month the parts have become solid enough so that any plates that show a tendency to be loose may be removed except where there is a gap, and the plate is then retained as it may assist in preventing shortening. Several weeks later a seques- trum is found embedded in a cavity of bone or fibrous tissue, which should be removed. To close the remaining cavity bismuth paste has given good results. Before this is resorted to, the cavity is swabbed with pure carbolic acid, and iodoform paste is used for a few days. Skin-grafting was often resorted to to assist in rapid closure of wounds. Many cases remained ununited except by deposit of fibrous tissue between the bone-ends. For these bone-grafting is recom- mended later. The concluding paragraph should convince anyone that it will be a long time, if ever, before plating becomes an adopted mode of treatment in gunshot fractures in military surgery. . Even in simple fractures asepsis has always been the sine qua non to intervention. Bone tissue at best offers poor resistance against infection, and for that reason the propriety of plating bone in compound fractures has always been questionable. In gunshot fractures where so much comminution and laceration of tissue exists in the presence of heavy infection, and amid surroundings which often forbid the possibility of carrying out the rules of asepsis completely, as is found in the emergency conditions of field surgery, the practice of plating at best could only be under- taken by experts in selected cases. In military surgery it should also be remembered that the gaps which are apt to occur in the continuity of the long bones from shell fracture and the comminution common to bullets of high 818 ABSTRACTS OF WAR SURGERY velocity, have hitherto been filled in a surprising way by new bone. In the few cases in which Nature fails to provide the bone ; there is an opportunity of replacing the intervening fibrous tissue with bone graft. In pseudoarthrosis with loss of bone substance bone-grafting offers absolutely safe and nearly perfect results. Lambotte states that personally he has never resorted to a muti- lating operation for pseudoarthrosis from loss of bone substance. He strongly advocates strict asepsis in the use of bone-grafting and emphasizes his belief that living bone will graft itself perfectly and continue to live in its natural state, and this is especially true of autoplastic grafts. THIGH AMPUTATIONS IN WAR SURGERY: 46 CASES.— A. Chalier. Lyon chir., 1917, xiv, p. 591. Chalier reports 46 thigh amputations for gunshot wounds, 24 of which were for gaseous gangrene, with 9 deaths; 6 for vas- cular gangrene, with 2 deaths ; 5 of secondary hemorrhage of main vessels, with 2 deaths; and 11 for early or late septicemia, with 2 deaths. As regards technic, Chalier performed 2 flap and 44 napless amputations. Of the latter, 21 were in the classical manner, circular and funnel-shaped, and 23 guillotine amputations. He prefers this last method in emergency cases, such as gaseous gangrene, because it occupies the least amount of time, permits the greatest possible free drainage, and saves length of limb, the skin being divided at the lowest possible point. If better conditions permit, a definite operation can be per- formed immediately, and the author employs the funnel-shaped cir- cular or the flap amputation. In 6 cases he sutured primarily and had 5 successes. The stump is immobilized in a high position and must be care- fully watched during the first days if the operation has been done for gaseous gangrene. As regards complications, the following were observed: reten- tion of pus in some cases of crater-shaped circular amputations ; 2 cases of gaseous gangrene; 2 cases of tetanus (1 fatal) ; 4 cases of phlebitis of stump; and 3 cases of pulmonary embolism, 2 of which died. Five stumps needed a secondary regularization and recovered within ten days by first intention. ABSTRACTS OF WAR SURGERY 31 9 PRIMARY RESECTION IN ARTICULAR WOUNDS OF THE KNEE.— H. P. Rouvillois, L. Guillaume, and Basset. Bull, et mem. Soc. de chir. de Paris, 1917, xliii, p. 1364. In 197 cases of articular wounds of the knee the authors per- formed primary resection 11 times. They think that primary re- section should be reserved for cases of articular shattering. Par- tial resection with the ideal technic of arciform arthrotomy, ap- pears applicable in a wide number of cases. Extended resection will give surprising results in many cases which from bone lesions alone appear condemned to amputation. Every doubtful case should be resected in the absence of important vascular or soft part lesions. In dia-epiphysary breakages resection is the operation called for ; this should be atypical and follow the lesion. The nature of the resection will be especially determined by the length of the at- tacked diaphysis. In uni- and bi-epiphysary fractures the orthopedic value of re- section is incomparable, as it gives a maximum economy of the less attacked or intact epiphysis. Whatever method of resection is adopted, the more rapidly immobilization is resorted to the better will be the results when the surfaces are strictly adapted. FUNCTIONAL VALUE OF THE STUMP AFTER AMPU- TATION.— Tuffier. Acad, de med., Paris, 1915, lxxiv, p. 786. A second operation has to be performed in a great many ampu- tation cases. Ninety per cent of these secondary operations are on the lower limb. The best prophylactic measure is early and thorough disinfection of wounds. Wrong methods of operation and insufficient after-treatment are responsible for a certain num- ber of these secondary operations. In the lower limb the flap method should be used instead of the circular method, for it gives a more supple scar and one which is not located at the end of the stump. Elastic traction on the soft parts after operation will prevent a large percentage of vicious healing; pain due to the inclusion of nerves may be avoided by a little care in cutting the nerves high up. Terminal osteomyelitis, which frequently neces- sitates a second amputation, is due to persistence of the original infection. Disarticulation at the hip-joint gives favorable results for the wearing of an artificial limb. Subtrochanteric amputation in the 320 ABSTRACTS OF WAR SURGERY upper fourth of the femur makes the adaptation of an artificial leg more difficult, but it is a less serious operation than disarticu- lation. A stump less than 10 cm. long is of no use as a lever in walking. A posterior scar is much better than the scar from a circular amputation with reference to fitting the artificial leg, but the flap method necessitates cutting the bone higher up and thus shortening the stump. If the flap method does not change an amputation in the middle third, into one in the upper third, it should be given the preference over the circular method. In- tracondyloid amputations give good results, while disarticulation of the knee does not. Amputations below the knee should be as low down as possible. If it is necessary to amputate in the upper fourth the leg should be removed as near the knee as possible, for the stump is useless and dangerous. The scars of amputa- tions below the knee have given very bad results. The circu- lar method should be entirely abandoned; a posterior flap is the best. Tibiotarsal disarticulation and intramalleolar amputation enable the patient to walk with very little limping. The same is true of Lisfranc's and Syme's amputations; but Chopart's am- putation almost always necessitates secondary operation and should be used only in exceptional cases. Secondary amputations are the exception in the arm, so the aim here is to preserve as much of the limb as possible. Intra- deltoid amputation is much preferable to disarticulation of the shoulder for it makes the application of an artificial arm much easier. The circular method is preferable in the arm, because the terminal scar does not have to bear any weight. In the fore- arm it is especially important to keep as long a stump as pos- sible. A difference of three or four centimeters is of the greatest importance in the function of the forearm. At the wrist a pal- mar flap is preferable to the circular method. In any amputation it is of great importance to preserve the function of the adjacent joint by early mobilization. TREATMENT OF COMPLICATED GUNSHOT FRACTURES OF THE HUMERAL DIAPHYSIS.— H. Alamartine. Lyon Chir., 1916, xiii, p. 877. The treatment of complicated gunshot fractures of the humeral diaphysis differs considerably from that of the same fractures observed in civil practice. In the two cases the lesions are very dissimilar. In war surgery the vulnerable agents are driven by enormous ABSTRACTS OF WAR SURGERY 321 force and produce special destruction. The condition of the wounded and the surgical means at disposal are also very spe- cial. These demand special methods of treatment. The fractures are of different types : 1. Benign type, due to small projectile or projectile of reduced velocity. In this, lesion of the radial nerve is the only usual element of gravity. 2. Grave type : (a) shattering, due to small projectile with con- siderable velocity. The osseous lesion is extended and grave. Many spiculas are in the region; (b) crushing, due to large pro- jectile acting by its mass. Extensive injuries of the soft parts. The spicule are adherent. 3. Very severe type : Destructive crushing of the upper limb, or with complications such as gas gangrene, etc., which ordinar- ily call for amputation. Treatment as far as possible should be conservative. A con- siderable functional restoration is compatible with extensive muti- lation and even with a very defective consolidation. Continuous extension is the best method to obtain reduction, using Delbet's apparatus. Sequestrotomies, followed or not by osteosynthesis, at times may be necessary. Early treatment, either at the first aid or in the surgical ambulance, consists of wide and early surgical disinfection, removal of foreign bodies, etc.; immobilization of the fractured limb (Delorme's thoraeo- brachial splint). Osseous interventions, sequestrotomies, etc., also continuous ex- tension, when required, are carried out in the base hospitals. EARLY TREATMENT OF COMPOUND FRACTURE OF THE LONG BONES OF THE EXTREMITIES.— B. Hughes. Brit. Med. Jour., 1917, i, p. 289. Upon what is done for men suffering from compound fractures of the longer bones of the extremities in the hours immediately following their infliction depends to a great extent their subse- quent utility, and often their life. In the case of a man wounded in action, one must consider: (1) fatigue; (2) shock (especially in fractures involving the femur); (3) local tissue stupor; (4) infection. Local tissue stupor is brought about in the muscles and other soft structures as a result of injury caused by a piece of shell. The naked-eye appearance of such tissue is characteristic. The muscle looks dry and lifeless, it is quite insensitive, does not bleed 322 ABSTRACTS OF WAR SURGERY when cut, and does not contract when stimulated. This tissue, though not dead, is very apt to die, and while in this stunned state is very prone to infection. If a tourniquet be applied to the limb above such tissue, or if antiseptics be used, gangrene is al- most certain to ensue. Under these conditions, if necessary, a limb can be amputated quite painlessly. All shell wounds are bound to become infected, whatever care be taken. The bacteria most to be feared are: (1) bacillus per- fringens, (2) Vincent's bacillus, (3) bacillus tetanus, and (4) streptococcus fecalis. It is therefore important as early as possible to follow out the rules applying to open wounds: (1) prevent further infection; (2) get rid, as far as possible, of infection already carried in; and, in cases of fracture, a third may be added : (3) prevent what infection has already been carried in from becoming further dis- seminated by thoroughly immobilizing the limb. The author states that quite a number of wounds have become fly-blown, and that the presence of maggots in such wounds seems to exert an inhibitory action on the growth of the more virulent bacteria, and so acts beneficially. Maggots thrive only in dead tissue, and seem to hasten its removal. Two of the worst but- tock wounds seen by the author became accidentally fly-blown, and from the time of the appearance of the maggots both cases began to improve. Motor transport from the advanced dressing station to the field ambulance has, as a rule, to be as rapid as possible, owing to enemy shell fire. This necessitates shaking, and brings into prominence other complications; (1) embolism (pulmonary) ; (2) increased shock; (3) increased damage to tissue and so further dissemination of infection; (4) hemorrhage. From the field am- bulance these men proceed by motor to the casualty clearing sta- tion, often a considerable journey. The condition of their wounds on arrival will depend upon the length of time they have been wounded and the manner in which the fracture has been im- mobilized. Perfect immobilization, as early as possible, in the position in which the fractured limb is found, whether in trenches or in the open, is the first essential to success. If a limb is hope- lessly shattered, with vessels and nerves divided, it is wiser to amputate at once at the regimental aid post, and tie the main vessels. Owing to tissue stupor the operation is painless, and the risk of shock and fatal hemorrhage during transport is avoided. Tourniquets for transport should not be used. They ABSTRACTS OF WAR SURGERY 323 tend to slip; they are painful, and increase shock; and they cause irretrievable damage to the tissues they constrict. The author discusses treatment at casualty clearing stations and describes various practical splints. For the femur a rifle padded with sandbags or a great-coat is placed with the butt end in the axilla, Fractures of the humerus can be immobil- ized with rolled sandbags strengthened with entrenching-tool handles. Splints of special designs suitable for treatment at the casualty clearing station, and applicable to the femur, leg, humerus, and forearm, are described and illustrated. As to the dressing, if the wound be extensive, that used for the first few days before sending these cases to the base has either been a salt pack or Carrel's tubes with Dakin's solution. The latter method requires more time, and can only be under- taken when there is not an undue rush of casualties. The salt pack has given good results, and does not require the same amount of attention. The aftertreatment is described in detail. If infection still persists in the wound, and is spreading, though not sufficiently to threaten life, treatment will depend upon the organism pres- ent. If bacillus perfringens and streptococcus fecalis (for these two organisms generally coexist) be the cause, then a barrier of hydrogen peroxide or potassium permanganate (strong solu- tion) injected into sound tissue above and below the infected area, and completely encircling the limb, has done good in some cases and sufficed to arrest further spread. In a few desperate cases the author has tried intravenous injections of eusol, as recommended by Fraser and Bates, but has had no success from its use. SECONDARY SUTURE OF THE WOUND IN CASES OF OPEN FRACTURE.— Depage and Vandervelde. Bull, et mem. Soc. de chir. de Paris, 1917, xliii, p. 477. In treating open fractures in their ambulance service, by rigorously following the Carrel method after preliminary strip- ping and clearance of the wound, the authors have been able to sterilize wounds after a lapse of time varying from fifteen days to a month, and to definitely close them without acci- dent. In effecting the change from an open to a closed frac- ture not only the time of treatment, but also that of recovery of normal function, has been shortened. The method pursued may be summed up as follows : 324 ABSTRACTS OF WAR SURGERY 1. On arrival of the patient (in from two to six hours after being wounded) the fractured area is opened up, cleansed and cleared, leaving only such bone fragments as are clearly vital. Carrel tubes are then placed in position. 2. The wound is irrigated every two hours by Dakin's fluid (Carrel's prescription). 3. The dressings are renewed every day, the wound being cleaned at the same time. 4. Bacteriologic control is noted every two days. When the microbian curve remains at zero after two or three examinations the wound is sutured. 5. Suture is effected after freshening the edges and remov- ing any cicatricial tissue. The authors proceeded cautiously to suture in their cases early; but since November last all fractures which have been stripped and cleared are regularly closed. They have operated upon 75 such cases. The authors' conclusions are that an open fracture can re- cover aseptically. They do not know whether the Carrel method is the only one capable of giving this result, but it is the only one that has given proof of it. DIAGNOSIS OF SUPPURATIVE ARTHRITIS FOLLOWING GUNSHOT FRACTURES.— M. Chaput. Presse med., 1915, xxiii, p. 124. Gunshot fractures are very frequently complicated by sup- purative arthritis and often this complication is not diagnosed. Chaput says that 9 out of 10 fractures of the epiphysis involve the joint. If there is a fistula through which the pus is dis- charged the case may be afebrile but the patient becomes cachectic from gradual absorption of septic material. Some patients die from an acute attack following the closing up of the external opening of the fistula, some become affected with severe erysipelas, and some die of septic embolism. When the fracture is of the diaphysis, diagnosis of a joint complication is more difficult. Sometimes if the fracture is opened up and examined carefully a minute fissure leading to the joint will be discovered. A further test may be made by injecting sterilized methylene blue 1 :1000 into the joint until the synovial membrane is slightly distended; in a few seconds the blue color will appear at the fracture, showing that there is a communication with the joint. After a diagnosis has been ABSTRACTS OP WAR SURGERY 325 made in one of these ways a considerable number of times, it will be found that whenever a juxta-artieular fracture prop- erly drained still causes fever, it is almost always complicated by joint infection. Sometimes even when there is no pus in the joint the bones will be found friable and the cartilages, ligaments, and synovial sac will have a violet color, showing infection. TREATMENT OF GUNSHOT INJURIES OF THE EXTREMI- TIES. — Axhausen. Deutsch. med. Wchnschr., 1915, xli, p. 640. Conservative treatment of injuries of the extremities is rec- ommended in the textbooks on military surgery. Axhausen practiced this during the first few months of the war and was appalled at the number of infections resulting. He thinks this is due to the fact that the wounds in this war are of a differ- ent character from those of previous wars. There is much more crushing and mangling of the tissues, owing to the conditions in the trenches and the high percentage of wounds from artil- lery fire. For the past few months the author has adopted an entirely different treatment. The cases with much destruction of tis- sue are taken in hand at once. The crushed skin and tissues are removed, till there is a clean bleeding surface over the whole wound; all foreign bodies, including fragments of shat- tered bone are removed ; fractured ends of bone are brought to- gether and sutured with silver wire. Muscles and nerves are sutured after proper freshening and the ends of the nerves are embedded in muscle tissue. The wound is tamponed, drainage and counter-drainage established, the skin wound sutured, and the limb immobilized. He believes that it is not necessary to observe the strict asepsis demanded in civil practice. He sterilizes his instruments at the beginning of his day's work and then uses them on dif- ferent cases without further sterilization. He also sterilizes his hands thoroughly once and then washes them only between cases. It is only necessary to help the natural forces of the body by coarse mechanical measures. The time saved by omit- ting the finer details of asepsis enables him to care for many more cases. He has not had a single case of tetanus or gas phlegmon fol- lowing this treatment. In all cases the temperature soon fell 326 ABSTRACTS OF WAR SURGERY and the tampons and drains could be removed on the eighth to the twelfth day. He describes a typical case — that of an officer who had a des- tructive wound of the right elbow, involving the ulnar nerve. He treated it in November and by January the functional use of the nerve was restored without a sign of paralysis or con- tracture. In injuries with much destruction of tissue, this method of treatment is much superior to the older conservative method. TREATMENT OF GUNSHOT FRACTURES OF THE EX- TREMITIES IN WAR.— G. von Saar. Beitr. z. klin. Chir., 1914, xci, p. 351. Von Saar reports one month's service in the reserve hospital in Belgrade. He says that injuries of the extremities comprise between one-half and three-fourths of all injuries, while gun- shot fractures comprise about one-fifth of all injuries. Among 518 injuries of the extremities von Saar observed 84 fractures, 40 of the upper, 44 of the lower extremity. He holds that roentgen examination, while very interesting from a scientific point of view, may be dispensed with for fracture treatment even in stationary hospitals. He lays the greatest emphasis on improvised methods with simple means. High fractures of the humerus should be treated with Christen 's double right-angled splints and double extension traction. Fractures of the forearm are also treated by extension to avoid a fracture callus, and by a simple right-angled splint similar to Borchgrevink's. The results of the extension treatment are good. In fractures of the lower extremities von Saar points out that not only the first dressing but also the further treatment is of great importance. In treating fractures of the femur Florsehutz's method is used, which combines semiflexion suspen- sion, and extension. As a transportation dressing for fractures of the femur he recommends von Hacker's, which consists of a long strip of wood as broad as two fingers, provided above with a notch and below with a nail. It is applied to the side, reaching from the umbilicus down to the foot, and provides for simple extension. This is practically the same as the old Esmarch's transport dressing for fractures of the femur. Mention is made of Weissenstein 's adaptation of the military stretcher for the transportation of fractures of the lower ex- ABSTRACTS OP WAR SURGERY 327 tremity, in which the stretcher rods are used as external splints. In fractures of the leg he recommends for the infected cases fenestrated plaster casts; for the noninfected, the splint extension with traction on the upper part of the shoe, especially in fractures of the lower third. In general, he recommends plaster casts only when infection renders frequent changing of the dressings necessary. He discusses the "Introduction to Military Surgery on the Battle-Field, " issued to the Austrian army, in which he thinks too much importance is attached to plaster and papier mache dressings. TEN RULES FOR AMPUTATIONS OF THE LOWER LIMBS. — -R. Ritschl. Med. Klin., 1915, xi, p. 1270. Ritschl gives the following ten rules for amputations of the lower limbs : 1. It is of great importance that the stump should be capable of bearing the weight of the body; this keeps it strong as well as avoiding artificial supporting surfaces, which are of less value. 2. A circular incision seldom gives a weight-bearing stump, because it makes the scar pass across the end of the bone. 3. "Whenever possible flap methods should be used, care being taken to make as small a scar as possible on the lateral surface of the stump. 4. By removing the periosteum and bone-marrow for 1 to 2 cm. the stump can be made painless. 5. As soon as the wound is healed the stump should be hardened with baths, alcohol rubs, massage, and using it on crutches. 6. The muscles of the rest of the limb should be strengthened by active gymnastics, and the joints should be kept active by passive movements. 7. As soon as possible the patient should be provided with an artificial limb. 8. If the amputation was above the knee the artificial leg should be provided with a knee-joint. 9. The uninjured limb must be kept from atrophy by gymnastic exercise while the patient is in bed, as greater demands than usual will be made on it later. 10. For the same reason any decreased functional capacity of the uninjured limb should be given especial attention and treat- ment, such as active gymnastics and orthopedic treatment for actual or threatened flat-foot. BURNS PARAFFIN TREATMENT OF BURNS.— Maj. Geo. de Tarnow- sky. (In a report to the Surgeon-General.) "Parowax" (a trade name applied to paraffin marketed by the Standard Oil Company, of Indiana) ; "Paraffin 120-122, F," (put up by the same company), and formula No. 21 {Jour. Am. Med. Assn., May 19, 1917, p. 1499), consisting of: Paraffin, 120-122 F 97.5 gms. Olive Oil 1.5 gms. Asphalt 4 drops all fulfil the above requirements. The addition of two per cent eucalyptus oil, or of some other pleasant deodorant, is very grate- ful to most patients. Technic. — 1. Place the paraffin cake in a sterile metal container and heat over a flame. A quick and practical way of estimating the proper temperature is to thoroughly melt the entire cake, stirring occa- sionally with a sterile glass rod or sterile metal instrument. By waiting until the paraffin begins to show a solidifying film upon the surface, one obviates the danger of overheating. 2. With a soft cotton mop (a piece of absorbent cotton grasped in the bite of forceps answers very well) sop — do not rub the entire surface of the burn. 3. Place a thin layer (i/ 8 inch) of absorbent cotton, cut the same size as the area of the burn, over the wound after the first layer of paraffin has been applied. 4. Cover the cotton with a second layer of paraffin. This may be more rapidly painted on by means of a broad soft camel-hair brush. 5. Apply a thick layer of cotton and a light bandage. 6. Immobilize the area whenever possible. Formula for white wax type (Tarnowsky) : White precipitate of mercury 5 per cent Zinc oxide ointment 70 per cent White wax 25 per cent 328 ABSTRACTS OF WAR SURGERY 329 The melting point is approximately that of the paraffin mix- tures, and its application the same. Stock dressings may also be prepared with the same formula and kept on hand, ready for instant use. Preparation of Stock Dressings. — 1. Sterilize by boiling a sufficient quantity of the above formula. 2. Cut strips of gauze of varying width and length. 3. Pick up each strip of gauze with forceps, allowing it to un- roll its full length ; dip same in the boiling liquid ; allow the excess to drain back into the vessel and drop the impregnated gauze into a sterile jar. 4. Do not pack the jar tightly. Close and seal jar as soon as full. When required, pick up a piece of impregnated gauze by means of a sterile forceps and lay it lightly over the previously prepared burnt area. When the second dressing is made, either in the Field or Evacua- tion Hospital, the degree and extent of the burn and the probable additional treatment required, should be estimated. Burns of the first degree and all burns of the second degree not requiring graft- ing should be kept in the zone of the advance or zone of the line of communications. Burns requiring grafting, burns of the third degree, and those complicated by severe wounds (deep lacera- tions, compound fractures, etc.) belong to the Base Hospitals. Skin-grafting will be required in second and third degree burns of: (1) Face, neck; (2) Hands; (3) Immediate vicinity of joints. When should grafting be resorted to? — As soon as sloughing of burnt tissues has ceased. The presence of slight amounts of pus is not a contraindication. Types of Graft. — (a) Thiersch or Eeverdin (superficial defects) ; (b) Skin-flap (deep defects). A. Thiersch or Reverdin. — 1. The sooner the grafts are applied, the greater the percentage of "takes." 2. Grafts applied late, over granulating surfaces seldom "take"; if they do they are apt to die subsequently as the granulations under them contract and shut off their blood supply. 3. Protect the grafts by applying thin strips of gutta-percha tissue over them ' ' criss-cross ' ' ; over this lay gauze impregnated with paraffin or wax-mixture. 330 ABSTRACTS OF WAR SURGERY 4. Do not disturb the dressing for several days. 5. A wire netting cage protecting the burnt area obviates the necessity of a dressing and gives the best results. It is not always possible to devise such a cage. B. Skin Flap.- — (1) One-step method (transplantation) ; (2) Two-step method. 1. The entire thickness of the skin, including adipose tissue, should be used. It is only successful if done early, and if the vas- cularity of the burn is good and hyperemia can be maintained. 2. The two-step or flap method is always reliable and should be selected whenever the location of the burn makes it possible. An interval of ten to fourteen days should elapse between the two steps and immobilization of the flap should be absolute. The margin of the burn should be trimmed vertically (at right-angle to skin sur- face) the flap sutured at its free margin and laterally, the sutures should be interrupted without tension, and the wound covered with impregnated gauze which is usually not changed until the second step is completed. Be sure to allow for retraction of the flap. (25 per cent margin is a safe one to go by) . Prevention of Contractures and Disfiguring Scars. — 1. By early and complete grafting. 2. By means of casts or splints. (a) Immobilize in flexion, burns of: 1. Posterior surface of elbows. 2. Dorsal surface of wrist, hand or fingers. 3. Anterior patellar region. (b) Immobilize in extension, burns of: 1. Antero-lateral aspect of neck. 2. Anterior surface of elbow. 3. Palmar aspect of wrist, hand and fingers. 4. Popliteal space. (c) Immobilize in abduction, burns of: 1. The axilla. 2. The crotch. Summary. — 1. Do not scrub off the epidermal cells with soap, water and brush. 2. Leave burns of the first degree to nature as far as possible. 3. If grafting be necessary, resort to it as early as possible, even in the presence of a slight amount of pus. 4. The open-air treatment of burns of all degrees gives the best results. ABSTRACTS OF WAR SURGERY 331 5. If the open-air treatment is not practicable, always use a bland nonadherent type of dressing and change the dressings as seldom as possible. 6. Beware of contractures and disfiguring scars. Proper splinting will always, proper grafting will often obviate this calamity. PARAFFIN IN THE TREATMENT OF WOUNDS AND BURNS. OBSERVATIONS ON VARIOUS PREPARA- TIONS.— J. B. Beiter. Jour. Am. Med. Assn., lxviii, p. 1801. The successes claimed for "Ambrine" in the treatment of burns promised a large field in industrial accidents and therefore prompted extensive trials. Owing to my inability to obtain ''Ambrine," various paraffin compounds were used — formulas containing eucalyptus, resorcin, betanaphthol, resin, cora flava, olive oil, and scarlet red, in ordinary paraffin. My series of cases represents over 4,000 wax dressings on every conceivable burn, and many lacerated wounds. Prior to the employment of the wax treatment of burns we had employed the usual methods — various ointments, various aqueous solutions, the bath treatment, exposure to the air, and picric acid. Our technic in the use of waxes was as follows : All burns were carefully cleaned at our emergency hospital by well trained men, any blebs were opened, and all the skin that could be taken off with ease was removed. The burned area was dried either by ex- posure to air or by gently wiping the surface with cotton pledgets dipped in ether. Over the involved area a thin film of the wax was painted. (The wax is kept constantly in a water bath, so that it is at all times ready for instant use.) Over the wax film a thin layer of cotton or a split piece of sheet wadding was placed and a second film of wax was painted, sealing it to the skin at the edges of the cotton dressing. Over this a heavier cotton dressing was applied and then the bandage. We found that if the injured sur- face was wet or damp the first paraffin film would not adhere. We began with the various paraffin mixtures enumerated above ; but we failed to see any differences, except some disagreeable fea- tures with the resin mixtures. For example, the undissolved resin sank to the bottom of our warming receptacle and injured the brush with which the wax was applied, making the application to the in- 332 ABSTRACTS OF WAR SURGERY jured surface painful. We therefore discarded all drugs in our wax and used the commercial ' ' Parowax, ' ' applied as above. This was sometimes tinted pink with scarlet red simply for cos- metic reasons. The question of melting point was at first an important one, be- cause to apply a hot solution to a large area of denuded nerve endings usually brought a prompt and energetic reaction, and to wait until the wax cooled to the extent that a film formed over it meant that it would cool below the liquid state before it could be applied. However, the water bath or household double boiler holds the melting point very well. A suggestion made to me by Dr. Terald Sollamann has elimi- nated the importance of melting point temperature entirely and greatly simplified the dressing as well as adding to the comfort of the patient at the time of the dressing, and in no way changing the results. His suggestion was that the wounds be painted with liquid petrolatum, further treatment proceeding as with the wax. In this method a layer of liquid petrolatum and then the cotton or sheet wadding are placed over the injured area before the warm paraffin is painted on the dressing. This method has been followed in all of our recent cases and is greatly appreciated by the patients who are the court of last appeal. It is essential that the dressing adhere at least to the skin about the edges of the dressing ; other- wise the secretions are pouring out over the intact skin and excor- iating it, soiling the dressings and making a disagreeable odor. Advantages of the Wax Treatment of Burns. — 1. It is an inex- pensive dressing ; a pound of wax and a pint of liquid petrolatum together costing about 65 cents, will dress many burns. It replaces the gauze which at this time is quite expensive. 2. It is a comfortable dressing because it is firm and smooth, and the granulating surface does not grow through it as with the gauze. The paraffin is hard enough to make the dressing somewhat rigid and acts as a splint. 3. It is a cleaner dressing than any I have used because the wound discharge is not permitted to soak through the impermeable wax covering, soiling all the linen that comes in contact with the patient. As the secretions are sealed up, there is no noticeable odor about the patient, which was a disagreeable factor with for- mer methods of treating these injuries. 4. Superficial burns heal more readily under the wax treatment than with any other method with which I am familiar. This is due to but one fact: Under former methods of application of ABSTRACTS OF WAR SURGERY 333 solutions and oily substances, no matter what their kind, the granu- lations penetrated the meshes of the dressing in contact with the wound and on removal at redressings, these granulations were de- stroyed, regardless of the care with which the dressing was done or the method employed in the removal of the dressings in contact with the wound. The paraffin film method does not adhere to the in- jured area, and therefore does not injure the granulation tissue and the epithelium that is attempting to cover the denuded area. Early in the course of the burn, if it is an extensive one, the entire sealed surface of the dressing will be filled with fluid so that it is merely lifted off. Later, as the wound heals the secretion dimin- ishes, and the granulations begin to grow, the epithelial islands ap- pear as white points at the side of hair follicles, and from these islands the epithelization takes place rapidly because the epithe- lium is not injured in the dressings and redressings. 5. Deep burns do not repair any more rapidly under this method than any other method. There is no difference in the scars of burns treated by the wax method and any other method. If the true skin is destroyed, the end-result is scar tissue or an ulcer. If scar tissue replaces the destroyed tissue, it performs as does scar tissue that develops under any and all forms of treatment, and as scar tissue has performed since the beginning of time. We have tried treat- ing two sides of a body burned to about the same degree, with the wax method, the solution method, and various other methods, and have been unable to detect any difference in the end-result, as to scar. 6. The wax method is much more comfortable at dressing time than any other method with which I am familiar, for the purely mechanical reason that the granulations do not grow through it, and it is lifted off painlessly. To those who have to do with burned men this means a great deal. The pain endured by the patient as the dressings were removed under previous methods of treating burns left an unpleasant impression to carry with one on the day's rounds. 7. We think there are fewer furuncles on our burned patients since the wax has been used, but nephritis is quite as common. Disadvantages. — 1. Some patients refused to be treated with the wax when we were applying the warm wax directly to the injured area, because of the pain. These complaints are no longer heard since the liquid petrolatum has been used for the first coat. 2. Owing to the fact that this method has received so much 334 ABSTRACTS OF WAR SURGERY favorable comment in the lay press, as to negligible sears, perfect comfort on application, and other extravagant statements, the man who uses it for the first time will probably be disappointed. 3. This method is a time consumer; it requires more care and patience than do the dressings by other methods. ANESTHESIA IN WARFARE ANESTHESIA IN WARFARE. —Report to the Surgeon General by Paluel J. Flagg, M. D., Lecturer on Anesthesia, Rockefeller Institute, War Demonstration Hospital. Henri Vignes, in a paper read before the Societe de Pathologie Comparee, insists that "It is very important to have specialists in anesthesia at the front," that "anesthesia must not be made an easy berth for the physician who is sent by chance to a military surgical ambulance. Each surgeon should have his own anesthetist, who should be an expert in his specialty and should be conversant with the most recent advances." It is interesting to note that after three and a half years of war the British Army Medical authorities have finally established a large training school for anesthetists. This school is located at Buxton, England. Only medical officers are trained in this special work. Communications from the front demonstrate a wide divergence in anesthetic agents and methods employed by the Allied forces and suggest deductions and conclusions which may be found profit- able in this emergency. Anesthetic Agents, Methods Employed and Difficulties to Be Overcome. — Ether is universally used, it is employed as a terminal anesthetic in about 80 per cent of all cases. It is argued that the ether manufactured in Europe is irritating, nonvolatile and ineffi- cient. These characteristics are emphasized when used with an open mask. "It is not much better than our wash ether at home," writes Guedel. "It is difficult, indeed, to put a patient to sleep with it, to say nothing of securing a quiet state of anesthesia. From the coughing and the great quantities of mucus secreted, it would seem to contain more sulphuric acid and formalin than anything else. Also it is about as volatile as alcohol. You never get any frosting on the mask. Usually a patient will walk right out from under anesthesia with this ether in spite of continuous administration, and a clean mask becomes soggy and useless after about ten minutes. Whether or not this ether is the usual European ether I am not certain, but from many inquiries that I have made I am inclined to believe that it is. ' ' 335 336 ABSTRACTS OF WAR SURGERY When a closed method is used, however, these difficulties become less apparent. The Shipway apparatus is quite popular with the British. It has proved especially useful in head and neck work. Chloroform-ether anesthesia has been extensively employed by McCardie, of London. After numerous experiments it was found E P that the proportion ' ■ gave the greatest satisfaction. Ib.l Bilhaut, of the Hospital International de Paris, finds chloroform easier to administer than ether and less likely than ether to cause chilling of the respiratory tract such as may produce pneumonia or pulmonary congestions. In 812 important operations performed by Bilhaut there were no unhappy results from the use of chloro- form. The reaction on the liver has been found negligible. Geudel states : "I have come to the point that with all my anti- chloroform prejudices I am using chloroform in all cases when I can not get American ether." "From my point of view," writes Corfield, "patients were di- vided into two classes, those necessitating a short anesthesia, up to ten or twelve minutes, who were given nitrous oxide, and those requiring a longer period, who were given chloroform and ether. The first class comprised wounds to be cut out and dressed, foreign bodies removed and guillotine amputations, and for such cases nitrous oxide was used. The advantages were a saving of both time and labor. Time was saved because the period of induction and returning consciousness were a matter of seconds rather than minutes, and labor was saved because most of these patients could walk back to their own wards, either by themselves or by the help of one orderly, whereas chloroform or ether would have meant that every case would be a stretcher case. For prolonging nitrous oxide anesthesia one had to use a gas and air mixture. My method was to get them deeply under and then push back the air valve for a quarter to a third of an inch so that the patient would get suffi- cient oxygen to keep him from asphyxiation. Patients varied in the amounts they required. It was, one might say, a compromise between color and consciousness; with too much air they became sensitive to pain, and with too little air they became cyanotic. ' ' The importance of substituting oxygen for the air which is em- ployed in nitrous oxide air anesthesia is rapidly being appreciated by European anesthetists. The resulting gas oxygen anesthesia is gradually finding its proper place as an invaluable anesthetic agent in military surgery. The delay in this movement may be explained by the fact that the majority of those who gave an- ABSTRACTS OF WAR SURGERY 337 esthetics at the beginning of the war were not all-around experi- enced anesthetists. Had they been so the great value of gas-oxygen anesthesia in selected cases would have been well known to them and would have been employed at the start. The English were the first to introduce the use of gas-oxygen in the military surgery of this war. The simplest methods were used with success. The Clover inhaler and other closed devices were employed, the gases being fed intermittently and rebreathing being practiced. The advent of America was followed by a marked impetus in gas-oxygen anesthesia. Most of the apparatus sent from America to France and Eng- land for the administration of gas and oxygen is complicated in structure, designed for constant flow methods and intended to be as nearly as possible automatic in action. These machines are for the most part accurately and painstakingly made. It has been attempted in the construction to do away, if possible, with the need of an experienced physician anesthetist. In view of the shortage of anesthetists, such an attempt is certainly justifiable if the perfect delivery of gases were the solution of the problem. M. Boureau recommends ethyl chloride for the Divisional Am- bulances and Field Hospitals as well as for operations in the Base Hospitals. Induction is speedy and recovery rapid and complete. The patients are shocked, more or less tired mentally and physic- ally from continual tension. They often suffer from hemorrhage and are generally depressed. ' ' The most courageous does not wish to suffer further pain. One should not hesitate, therefore, to put him to sleep whenever necessary. ' ' Ethyl chloride is recommended as the anesthetic of choice. It is well borne and chosen by the patient, where ether or chloroform have been previously used. Boureau has made use of ethyl chloride as many as fifteen times on the same case for the application of painful dressings. The recovery from the anesthetic is proportional to the size of the dose. If administered less than ten minutes the recovery is rapid. If more than ten minutes the period of recovery may extend to ten or fifteen minutes. There may or may not be slight vomiting after the recovery. It appears to be especially useful in pulmonary cases. • B. Desplas, in an article entitled, Anesthesia a la Stovaine en Chirurgie de Guerre, extols spinal anesthesia as easy to administer, rapid, economical, may be repeated, good in emergency work, and does not demand the presence of a specialist. 338 ABSTRACTS OF WAR SURGERY He employs stovaine in doses of 5 cgm. (ampoules de Billon), injected between the fourth and fifth lumbar vertebrae. Instead of entertaining his patient by conversation or by al- lowing him to smoke or view the operation, he recommends abso- lute silence, has the patient blindfolded, and cotton placed in his ears. If slight pallor or nausea appears the patient is instructed to breathe deeply and is given something warm to drink. Intravenous ether anesthesia, regional intravenous anesthesia, local anesthesia and hypnotism have all been used in the military surgery of the present war. In war conditions Podiapolsky has found that the men responded with exceptional facility to hypnosis ; he found only about 2 per cent quite refractory. He has found it useful in the wounded of all the nationalities that he has encoun- tered. This treatment is rather for the sensory crisis of psychic origin than for anesthesia for major operations. Henri Vignes points out in an interesting manner the indica- tions for general anesthesia as opposed to local anesthesia. He believes that general anesthesia should be used: In bleeding vas- cular regions, where dissections are difficult, where important or- gans are involved, where tendons and aponeuroses cross the opera- tive field, when a retractor is necessary, involvement of the crural or popliteal space, in wounds of the leg excluding the bulge of the calf, in wounds of the bend of the elbow, lower arm, wrist and especially the palm of the hand, in deep wounds of the neck, in- juries of large blood vessels and periosteal involvements, for pro- ducing local anesthesia he employs novocaine, stovaine and cocaine. The literature which is at our disposal brings out rather vividly the essential difference between civil and military anesthesia. These differences or rather difficulties, which must be met, are as follows : the lack of preliminary preparation ; the unusual and urgent need of a speedy induction and a rapid recovery; the bulk of the work to be disposed of; the problem of securing the safest and most efficient anesthesia with the available anesthetic agents and ap- paratus. Lack of Preliminary Preparation. — It is a more or less generally recognized fact that unless a patient is properly prepared for operation by preliminary catharsis and fasting the course of his anesthesia will not run smoothly. We fail to appreciate this fact in our routine work and its significance is only apparent when an "immediate" operation is undertaken. When practically all operations are immediates, as is the case in the Zone of the Advance and in many instances in the Inter- ABSTRACTS OP WAR SURGERY 339 mediate Zone, we are constantly confronted by this situation. "Not only the bowels but the condition of the bladder requires atten- tion. So many patients voided their urine while under nitrous oxide gas, a bottle was given them as a matter of routine immedi- ately before." As might be expected where nitrous oxide alone is the anesthetic, vomiting is infrequent. "I never had any vomiting after this anesthetic (N 2 0) and I dare say most of the patients had a stomach fairly full of food," (Corfield). On the other hand, the same author states, "It is a curious thing that in many patients who have had a meal just before they were wounded, the process of digestion, or at any rate the stomach movement, is totally ar- rested and they will often vomit food ten or twelve hours after they have taken it. I remember one patient who in the first stage of anesthesia, started to vomit violently and brought up three bowl- fuls of bully beef and biscuits. By the time he had finished he was fully conscious again, and I found out from him that he had had this meal twenty-eight hours before and that he had been wounded two hours after it. " The wounded approaches anesthesia in a very different frame of mind from the ordinary civil patient. He has been for hours on intimate terms with death. He has seen his friend of yesterday spill his life's blood on the common dust, or in his mind's eye he still beholds the savage bayonet poised above his breast. To such a one the tinkle of instruments implies ultimate recovery and the anesthetic an immediate relief from urgent pain. Such a patient is prone to yield cheerfully to his anesthetic and to suffer the minimum of excitement. The routine use of morphine in the Dressing Stations and the Field Hospitals if occurring shortly before operation is a valuable aid towards securing a smooth induction. Soldiers exposed to all sorts of weather under the most trying conditions become victims of bronchial affections which render them particularly irritable to ether vapor. Continuous smoking increases this irritability, which preliminary morphine allays but does not always completely remove. The injury which the patient has experienced, coupled with the subsequent exposure and loss of blood, tends to make the wounded an easy patient to anesthetize. The accidental and peculiar circumstances which preceded an- esthesia administered at the Field Hospitals and ambulances, as well as those at the Casualty Clearing Stations, are such as to 340 ABSTRACTS OF WAR SURGERY counteract the need of the usual fast and catharsis, reducing or completely eliminating the period of excitement, shortening the period of rigidity and hastening the onset of complete relaxation. Anesthesia administered at the Base Hospitals and elsewhere in the Zone of the Interior closely resembles the anesthesia ordinarily seen in civil life. Preliminary preparation may be painstaking and deliberate as most of the operations done here are planned in advance. The Unusual and Urgent Need of a Speedy Induction and Rapid Recovery. — Where hundreds and thousands of wounded are to be briefly treated and passed on for further observations, it is es- sential that each patient be rendered unconscious and recover con- sciousness again as soon as possible. A slow induction takes time which should be used for operating, otherwise it takes longer to induce the anesthesia than it does to do the operation. A slow recovery requires the presence of a nurse or an attendant who might be useful elsewhere; it also prevents rapid evacuation to the Zone of the Interior. In order to meet these conditions various agents and methods have been employed and found satisfactory. Ethyl chloride, nitrous oxide, nitrous oxide and oxygen, chloroform, chloroform-ether mix- tures and ether alone have been used for general anesthesia; novo- caine, cocaine, stovaine for local and spinal methods. For general anesthesia gas oxygen is certainly the anesthetic of choice. Its limited use has been due to the employment of com- plicated apparatus designed for constant flow methods instead of simple devices for use with an intermittent flow. Marshall ( Am. Jour. Surg., i, 18) makes this clear when he says: "The ideal anesthetic is one with which induction is rapid, and recovery com- plete in a few minutes after operation, so that the patient is in a fit condition for early evacuation by the ambulance train. Ap- paratus is subjected to much wear and tear, so it should not be complicated or delicate. Of the anesthetics I have used gas and oxygen meets these requirements best. Its only drawbacks are that the apparatus is somewhat cumbersome and the materials costly." Apparatus for the administration of gas oxygen anes- thesia by the method of intermittent flow, is not cumbersome and the volume of gas consumed is so small that the method is not costly. Ethyl chloride resembles gas-oxygen in its speed of induction and its rapid recovery. It appears fairly safe in experienced hands. M. Boureau (Presse medical, 21, May 17) recommends it ABSTRACTS OP WAR SURGERY 341 for its nontoxic qualities, its rapid elimination and the ease with which it is accepted by the patient. It is especially useful as a first-aid anesthetic ; i. e., ligation of blood vessels, removal of large superficial foreign bodies, etc. Nothing could be more simple than the paraphernalia required, for a handkerchief is all that is neces- sary. The Bulk of the Work to Be Disposed of. — Operative activity in the Zone of Advance and in the Intermediate Zone depends directly upon military activity in the particular zone under consideration. The surgery which is done in the Base Hospitals in the Zone of the Interior, drawing as it does its wounded from a wide territory, is of a more leisurely, more constant, and less acute nature. Major Kellog Speed describes the methods in the average Casualty Clearing Station as follows : "In addition to administrative offi- cers, etc., there are assigned to each Casualty Clearing Station surgical teams composed of picked men of surgical ability, each supplied with his own anesthetist, operating nurse and orderly. These teams divide the major and the minor surgical patients in rotation as fast as they are able to finish each operation. Team work is divided thus, each team works for eight hours a day except during rush times, when they are expected to do sixteen hours' duty. Three teams are on duty from 9 :00 a. m. to 5 :00 p. m. in the major theater, using five or six operating tables; two teams work from 5 :00 p. m. to 1 :00 a. m., and one team from 1 :00 a. m. to 9 :00 a. m., under ordinary conditions. The work is continuous as long as the hospital is taking in. Teams cease to take on patients one-half hour before the expiration of their time so that their table may be cleaned up and prepared for the next group. "The major operating theater is centrally located. The minor theater is near the dressing tent. All are electrically lighted. The arrangement of five or six tables in the major theater permits the anesthetist to move from patient to patient in advance of the operator while dressings and splints are being applied or the opera- tion is being finished. The operating nurse assists the surgeon, the orderly brings in the supplies, helps with the dressings and cleans up the table. There is complete independence for each team. ' ' The necessarily large amount of work to be done in a short time calls for skilful and speedy anesthesia. Gwathmey writes as fol- lows: "Nitrous oxide-oxygen and ether is the only anesthetic for this kind of work, as speed is the only desideratum. I have given 342 ABSTRACTS OF WAR SURGERY as many as thirty-four anesthetics in one day — something which would be impossible with chloroform or ether. ' ' The Problem of Securing the Safest and Most Efficient Anes- thesia With the Available Anesthetic Agents and Apparatus. — This problem is one of the great difficulties of military anesthesia. Spe- cial supplies soon become exhausted and are difficult, if not im- possible, to replace. Intricate apparatus often can not be re- paired on the spot and becomes worse than useless. The ability to improvise apparatus is essential. Improvised apparatus can be safely used only by an experienced administrator, for experience must supply the elements of safety which the apparatus lacks. The Field Hospital, the Divisional Ambulance and the Casualty Clearing Station is no place to begin one's experience as an anes- thetist. The anesthesia administered here must be expert from every point of view. Unless this is so an attempt to make speed will result in a stormy induction, and uneven maintenance under poor control and a delayed recovery. One must know by ex- perience the limits of safety which the patient will tolerate. The experienced man will not be carried away by the allurements of a new agent or technic which is brought before his attention, as he will already have experienced fads and seen their early demise. The experienced man will be conservative, and for this reason safe. On the other hand, he will be so familiar Math the various phe- nomena which normally appear with the unconsciousness of an- esthesia that the question of apparatus to bring about this state will be of secondary consideration. He will appreciate the value of preliminary medication and he will be in a position to diagnose preliminary medication which has not been reported and which influences the course of the anesthesia. The military anesthetist should not only know the best methods which are available for in- sufflation anesthesia, but he should be able to improvise inhalation methods to take their place. He should be prepared to give good gas oxygen anesthesia without the use of percentage devices de- pendent upon complicated reducing valves and heating attach- ments. The difficulty, then, of accomplishing satisfactory anesthesia with limited apparatus implies the need of a trained anesthetist. As there is little likelihood of a sufficient number of trained anesthe- tists being found in the enlisted personnel to supply the demands of the army and navy the government is confronted with the problem of training anesthetists for the various branches of its service. ABSTRACTS OF WAR SURGERY 343 Deductions and Conclusions. — The most striking fact brought out by the increasing number of articles dealing with "the anes- thesia at the front" is the complete diversity of views as to the best anesthetic agent and technic of administration to be used as a routine under given conditions. Straight ether by the open and semiopen method, chloroform, ether mixtures, ethyl chloride, nitrous oxide-oxygen, spinal anesthesia, and even hypnotism, as we have seen, each has its earnest advocate, who uses his method largely to the exclusion of others. One might conclude from this condition of affairs that one agent and method is about as good as another, that the apparent success of all methods is due to a keen specialization of the par- ticular method in question, or that the agent and the method em- ployed is merely the result of accident, nothing else having been available. The first consideration, that one anesthetic agent and method is as good as another will find credence only with those who are un- acquainted with the subject. For the ability to choose the anes- thetic and its method of administration is the mark which dis- tinguishes the physician anesthetist from the mere lay technician or so-called nurse anesthetist. The second consideration, that the apparent success of all meth- ods is due to specialization of the method in question, is certainly true to a considerable degree. Practice makes perfect here as in any other division of labor. By constant application anyone of ordinary manual dexterity can give an entirely satisfactory anes- thesia with ether, chloroform, ethyl chloride, or even with gas and oxygen. If this were the end of the matter no harm would be done; the difficulty lies in these administrators heralding their work as a discovery and inviting the uninitiated to follow in their steps. The worth of any anesthetic agent can be determined only by the aggregate experience of many workers. It is only in this fashion that we may anticipate and guard against fatalities in the work of the average anesthetist. It is, therefore, not fair to con- clude that specialization in the use of a single agent will control the safety of that particular drug, that experience alone is all that is essential to make a drug safe. The third consideration, that the agent and the method em- ployed is merely the result of accident, nothing else having been available, may be true where there is a constantly shifting per- sonnel, as is likely to occur in the Field Hospital and the Casualty 344 ABSTRACTS OF WAR SURGERY Clearing Station. In the Base Hospitals, on the contrary, the personnel is more or less fixed and the selection of the anesthetic may be painstaking and deliberate. The literature which has appeared has been of such a character as to emphasize the fact that the worker at the Base Hospital has had not only the time but the inclination to work out the problem of anesthesia in his particular case. The diversity of opinion, then, which shows itself in the litera- ture is quite natural and interesting. Surgical methods and tech- nic changes with war conditions. Anesthesia, when accommodated to the difficulties mentioned in the first part of this article, namely, the need of a rapid induc- tion and recovery in a large number of poorly-prepared patients, often with improvised apparatus, remains essentially the same as it was before the war. The underlying principles for inducing and maintaining anesthesia are the same, and the accepted methods of securing rapid and complete recovery are identical. The need of anesthesia in wounded cases, as pointed out by M. H. Vignes (Presse medical, Dec. 4, 1916), is even greater than in times of peace. "It is absolutely necessary to protect patients from pain. Anesthesia alone places the patient in the best condition and al- lows the performance of good surgery, and, of even greater im- portance, it prevents shock incidental to surgical manipulation, which has been added to that of trauma. One can die of pain. It is essential to be as economical in the loss of nervous energy as in the loss of blood. The ambulances should, therefore, have trained anesthetists, and perfected appliances should be carried to the front." In the light of the facts which have been considered, it would seem just to assume the following conclusions : 1. That in the Zone of Advance and in the Intermediate Zone the anesthetic indicated for incomplete anesthesia is gas and oxygen, administered in the simplest manner; namely, by the method of intermittent flow with rebreathing. Complete anesthesia to be brought about and maintained by ether given with a closed method, recovery to be ushered in and completed by a return to gas and oxygen. When gas and oxygen is not available a chloroform, ether, ethyl chloride or chloroform anesthesia, may be employed for incomplete anesthesia, which may be made complete and maintained by ether given by a semiopen or closed method. 2. That spinal, intravenous, regional or morphine hyocine anes- ABSTRACTS OF WAR SURGERY 345 thesia, per se, be reserved as methods of expediency to be used by an experienced administrator. 3. That in the Zone of Advance and in the Intermediate Zone inhalation methods be the methods of choice. Intrapharyngeal and intratracheal inhalation anesthesia for head and neck work by the tin-can method, to be used in preference to complicated insufflation methods. On the other hand, in the Zone of the Interior, the Base Hos- pitals should have the best and most complete equipment. Gas- oxygen by constant flow methods may here be used if desired. Insufflation anesthesia by the Connell Anesthetometer should be the method of choice. At the Base Hospital arrangements should be made to instruct as well as to anesthetize. The most complete ante- and post- operative treatment may here be carried out, with every assurance of success. ANESTHETICS AT A CASUALTY CLEARING STATION.— G. Marshall. Proc. Boy. Med. and Ghir. Soc, London, 1917, x, Sect. Anesth., p. 17. Gas and oxygen anesthesia meets the requirements best in slightly injured cases. Its only drawbacks are that the apparatus is some- what cumbersome and the materials costly. Local anesthesia can be employed only in a small number of cases on account of the multi- plicity of wounds and their lacerated and soiled condition. Ether remains the most generally used anesthetic. The great majority of slight cases are anesthetized by Shipway's warm vapor method. For induction the mixed vapors of ether and chloroform are used ; the patient is free from struggling so that it is seldom necessary for an assistant to stand by the patient. It is rapid ; in a hundred cases which were timed, induction was invariably complete in five minutes. Anesthesia is maintained with ether alone. There is an absence of secretion, and atropine is not given unless the patient has signs of bronchitis. Consciousness is regained quickly and vomiting has occurred in only 26 per cent of all cases, including abdominal cases. Since the warm vapor method was introduced, the drop bottle has passed out of use. Compared with the open method there is a saving of at least 60 per cent of ether. There is much less diffusion of the anesthetic into the atmosphere of the theater. This is important to those working in it at times of sus- tained pressure. It has been urged that spinal anesthesia would be of great value 346 ABSTRACTS OF WAR SURGERY in military surgery. For men wounded in the lower extremities, it is a convenient and satisfactory method at a base hospital; cases of profound collapse do not occur. The same good results were obtained at a clearing station in all patients who had been wounded not less that forty hours before operation. It is to the man whose wounds are less than forty hours old and who has lost blood that spinal anesthesia is dangerous. Of the recently wounded patients all do not collapse under spinal anesthesia. It is impor- tant that one should be able to recognize beforehand which cases will tolerate this procedure. Is there any physical sign which will prove a reliable guide ? The appearance of the patient is of little assistance, the pulse-rate and blood-pressure do not help at all. A valuable indication is obtained by determining the concentra- tion of the blood. The method the author employs is to estimate the percentage of hemoglobin in the patient's blood by means of a Galdane hemoglobinometer. If a recently wounded man has a hemoglobin percentage of over 100, it is safe to administer stovaine intrathecally. If the reading is below 100 per cent, he will al- most certainly show a serious fall of blood pressure and symptoms of collapse. Subcutaneous injection of strychnine appears to be without value, both as a preliminary measure to prevent collapse and sub- sequently in its treatment. Intramuscular injection of pituitrin proved useless in combating the fall of blood-pressure. Intraven- ous saline caused temporary improvement in the one case in which it was tried but the blood-pressure fell again after one and a half hours and the patient died. This last case was a man with a pene- trating wound of the abdomen. The author's experience with spinal anesthesia for these cases has been limited and unfortunate. Three men with penetrating wounds of the abdomen were each given 0.67 gm. of stovaine. In each case the injection was fol- lowed by a great fall of blood pressure and death within a few hours. Spinal anesthesia is contraindicated in shock. Incomparably good results are obtained with gas and oxygen and no ether anes- thetic should be used for this type of case. The anesthesia may be so light that the patient will move when nerves are resected. The opinion is now general that chloroform is a bad anesthetic for head cases. Operation may be performed under local anesthe- sia; all tissues of the scalp are infiltrated in a circle widely sur- rounding the site of incision A 0.2 per cent solution of novocaine with adrenalin is generally used. The forcible cutting of bone is ABSTRACTS OF WAR SURGERY 347 disturbing to the patient, so that where mentality is unimpaired general anesthesia is preferable. Warm ether vapor is exceedingly satisfactory. It is in the group of cases with abdominal wounds that the warm vapor method has shown to the full its striking advantages. The quiet induction may save much loss of blood from wounded ves- sels in the peritoneal cavity. The easy breathing and diminished heat loss leave the patient in a remarkably good condition at the end of a long operation. "With open ether 34 per cent of the ab- dominal cases had bronchitis after operation. With warm ether vapor the percentage has dropped to 14.7. Apart from copious hemorrhage, there is one other procedure which causes a rapid fall of blood pressure during abdominal operations. This is turning the patient on his side. The effect is produced only if the patient has been under the anesthetic for a considerable time before being turned. For abdominal cases oxygen with the ether vapor is given. No atropine is administered before operation as there is no ad- vantage in giving it. Ether gives better results than chloroform in these cases. With chloroform the blood pressure falls steadily and, if operation be prolonged, the patient may die before the ab- domen is closed, or shortly after. Hypertonic saline given intravenously raises the blood pressure, slows the pulse-rate and dilutes the blood for a longer period than does the normal solution. TRENCH-FOOT TRENCH-FOOT.— H. M. Frost. Boston Med. and Surg. Jour., 1917, clxxvi, p. 301. The author gives a very interesting and complete account of trench-foot. The factors which tend to produce it are: (1) cold — not enough to freeze of itself but enough to reduce the resistance of the tissues through chilling; (2) wet — accentuating the chilling effects of the cold and interfering with the circulation by causing shoes and puttees to shrink; (3) inactivity — often in cramped po- sitions, conducive to a sluggish circulation, not only from lack of exercise but from constriction of vessels in the popliteal space. Officers are much less affected with trench-foot than privates. Trench-foot occurs during the winter months, roughly December to March. During the winter months in 1914-15 trench-foot oc- curred in 17 per cent of the admissions at the American "Women's "War Hospital at Paignton. The winter of 1915-16 showed, how- ever, that this number had decreased to nearly one-third. The symptoms occur after the soldiers have been on duty in the trenches for from a few hours to several days soaked with cold water up to the knees or hips. First comes numbness and cold, followed by pain and tenderness which makes walking difficult. Pain may be burning or tingling and is most marked at the points of greatest pressure, the heel and the ball of the foot; often it is rheumatic, involving the toes and ankles and extending up to the knee and thigh muscles. Clinically in the simplest type there is a discoloration, varying from a hyperemia to a dark red or a purple hue, usually confined to areas where greatest pressure is exerted by the shoe. Anesthesia to the touch and pin-point confined to the areas of discoloration is common in the toes. Hyperesthesia generally occurs in a small zone just outside the anesthetic area. More severe cases may be pale and the hyperesthesia more marked with severe pain on ex- posure to heat or motion of the joints. Still severer cases are ac- companied by edema and bleb formation and great pain with both anesthesia and hyperesthesia. In these cases gangrene at times supervenes at those areas where the pressure has been most marked. 348 ABSTRACTS OF WAR SURGERY 349 Treatment consists of elevation of feet, protection from heat, massage with oil, and sedatives. The greater part of the edema subsides in two to three days. The simplest cases recover in about two weeks, the average in three weeks, and the most severe in from five to seven weeks. Where gangrene has occurred amputa- tion of varying degrees is necessary, and this means being in- valided out of service. Prevention is a matter of great importance. The measure of greatest benefit seems to be a shorter period of duty in the trenches with more frequent relief. Such a thing as keeping the trenches dry is practically impossible in the first line, in the winter time. Long waterproof boots which impede the activity of the soldier are objectionable; frequent application of oil helps somewhat, but the best method is to have sufficient reserve to permit frequent relief from trench duty. TRENCH-FOOT.— Rev. of War Surg, and Med., September, 1918, ii, No. 7. 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 anesthesia; (2) edema; (3) phlyctenules; (4) sloughing. Three clinical forms may be described — (a) slight (85 to 90 per cent of the cases), characterized by painful anesthesia, edema, and redness; (b) moderate (13 to 14 per cent), characterized by phlyctenules and limited sloughs; (c) severe (1 per cent on an average), characterized by extension of sloughing and the appear- ance 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 tetanous or gas gangrene, and relapses and recurrences may take place. Trench foot occurs almost ex- clusively in 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 immobility, and to a bad attitude (stooping), compression of the leg and inter- ference with the venous circulation, particularly by puttees, and 350 ABSTRACTS OF WAR SURGERY 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 frost-bite and with chilbains. True frost-bite is characterized by sudden massive mor- tification of a part of a limb (the front of the foot, the whole foot, etc.) ; trench foot, on the contrary, is characterized by lim- ited destruction (gangrenous patches on the dorsum of the foot, the sole or the toes) and by progressive invasion of the tissues of the foot. Frost-bite is met with in severe dry cold, especially in mountainous regions. Trench foot occurs only in damp weather and at low altitudes (valleys, plains) ; it disappears in frost. Chil- blains are characterized — at any rate in their early stage — 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 ad- mitted, however, that sometimes the diagnosis between ulcerated chilblains and the ulcerated phlyctenules 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 followed by the disappearance of cases of trench-foot, or may at least render them very rare. The treatment includes (a) collective measures — hygiene and draining of the trenches, gratings, trench boots, dry warmed shelters, with, if necessary, frequent reliefs; and (b) individual preventive precautions taken daily (drying, cleansing and massage of the feet, change of socks in the shelters, supervision of the puttees and of everything that can cause com- pression 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 measures: (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. (b) Severe cases; when phlyc- tenules 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 be removed with the knife; they should only be scarified, without causing bleeding, so that the drugs used may act on the subjacent tissues. Spontaneous sep- aration must be awaited, and complications carefully watched ABSTRACTS OF WAR SURGERY 351 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 defective 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 anti-tetanic treat- ment should be used (injection of antitetanic serum repeated every week until the wound is cicatrized). SHOCK SHOCK AS SEEN AT THE FRONT.— E. Archibald, and J. W. Maclean. — Tr. Am. Surg. Assn., Boston, 1917, June. An analysis is given of 40 cases of shock due chiefly to wounds of the abdomen and high explosive wounds of the extremities as seen at a casualty clearing station, situated five to seven miles behind the trenches. Attention is called particularly to the subnormal temperature found in bad cases of shock, in which the ordinary clinical ther- mometer was often found to be insufficient, that is, that the patient's temperature was obviously below 92°. This suggests the desirabil- ity of a new form of clinical thermometer with a register running from 80° F. up. Attention was called to the observations of Gor- don Holmes, who found in cases of injury of the cord at the sixth to eighth cervical segments a temperature of 80°, which was com- patable with life for several days. An analysis of the author's cases shows the profound effect of fatigue, cold, and exposure to wet, in the production and aggrava- tion of shock. From numerous blood pressure observations, the general rule might be deduced that in the presence of a pressure of below 75 mm. recovery was the exception. Of seventeen cases with a blood pressure of below 75 mm. only three rallied from shock, and they died in two to three days from gas gangrene. While hemorrhage, even of moderate degree, is apt to aggravate shock, in the authors' opinion there is a fundamental difference between the two ; and the recent view of Mann, Gatch, and others, that the two were essentially of like nature, was combated. In severe shock there is apathy and cyanosis, as opposed to restless- ness and blanching in hemorrhage ; another striking difference lay in the effect of intravenous salt, or of blood transfusion helpful in hemorrhage, useless in shock. In treatment, Hogan's gelatine solution restored blood pressure and held it up longer than did intervenous saline; and both were of some benefit in the milder cases of shock combined with hemor- 352 ABSTRACTS OF WAR SURGERY 353 rhage. In bad cases, neither was of permanent benefit. Trans- fusion was disappointing. It had no more permanent effect than the gelatine solution. Pituitrin was of some value in moderate shock, but not in serious shock. Amyl nitrate was of no value. In blood-pressure readings, the systolic pressure is not so im- portant as the diastolic. Systolic may occasionally be up near 100, and diastolic 20 to 40 ; this spells shock. If the intravenous saline raises a low systolic, but fails to raise the diastolic, shock is still present and unrelieved and the patient will die. If the sharp click of the systolic is weak or distant throughout, there is danger. If the systolic sound is first heard only during expiration, and becomes continuous only some 10 to 20 mm. lower, such cases are always in shock and blood pressure is low. These cases frequently die. A man with the ordinary symptoms of shock, whose systolic is 65 or below, rarely recovers. One whose blood pressure is low from hemorrhage alone, will frequently recover with salt infusions. Or- dinary hemorrhage unaccompanied by fatigue or cold, does not reduce the blood pressure materially. The author discusses briefly the origin of shock in the light of clinical observations and recent physiological work. By exclusion it would appear that the trouble begins, in the vast capillary sys- tem, and is characterized chiefly by a loss of blood-plasma into the tissues, and very possibly into the tissue cells, rather than into the lymph-spaces. This, however, is not equivalent to plain hemor- rhage inasmuch as the process is apparently progressive, so that transfused blood is soon lost out of the blood vessels just as is salt solution. Attention is called to the recent English work con- cerning these points. The ultimate cause of shock still remains undetermined. SURGICAL SHOCK.— Rev. of War Surg, and Med., May, 1917, i, No. 3. More than three decades ago the elder Gross defined shock as " a rude unhinging of the machinery of life. ' ' Notwithstanding all the painstaking investigations of latter-day surgery, no equally satis- factory definition has been furnished. One after another, clinicians and laboratory men have failed to link the cause of shock with the breakdown of any one organ or set of organs. Up to the outbreak of the war no doctrine satisfactorily explained the symptom com- plex of shock. 354 Abstracts of war surgery When in August, 1917, the Medical Research Committee of Great Britain appointed a special investigating committee to undertake the correlation of laboratory and clinical observations concerning shock, it was natural to hope that the tremendous number of unfor- tunate war victims would furnish material upon which to base at least a working hypothesis. Unhappily, this hope has not been realized. The report of the special committee 1 develops much that is both interesting and valuable, but nothing that is fundamen- tally creative. Frazer and Cowell, who devoted themselves to the clinical study of blood pressure in wound conditions, reported for the committee as follows: In Wounds of the Head. — 1. Scalp wounds show no appreciable alteration in blood pressure. 2. Cases of compound fracture of the skull, with dura intact, show a relatively high blood pressure, averaging above 140 mm. 3. Penetrating wounds of the skull with free drainage are gen- erally associated with a low blood pressure — from 60 to 112 mm. 4. In perforating wounds the blood pressure would appear to vary according to the anatomic distribution of the wound. If the pressure has involved the ventricles, the blood pressure is high, varying from 130 to 170 mm. ; if the wound is more superficial and has not involved the ventricles, the blood pressure is low. 5. The blood pressure subsequent to wounds of the head is apt to be unstable. If operation is performed under general anesthesia, before the blood pressure has become stable, disaster is liable to ensue. The possibilities of such an ill result can be diminished by delaying operation until the blood pressure can be diminished or by performing the operation under local anesthesia. In Abdominal Wounds. — 1. In patients seen on arrival at a casualty clearing station within six hours of being wounded, if there is an intraperitoneal injury of a hollow viscus, the blood pressure is low. 2. When a period of from 6 to 10 hours has elapsed the pressure will probably have risen, for the primary wound shock is now be- ginning to pass off — the rest on the stretchers, the warmth and the sedative action of morphin are beginning to have effect. 3. At a period later than 10 hours the pressure begins to fall iTkis report was published in six papers in the issues of Feb. 23 and Mar. 2, 1918, of the Jour, of Amer. Med. Assn. ABSTRACTS OF WAR SURGERY 355 and a shockless condition becomes evidenced; the change is due to sepsis and to loss of blood (secondary wound shock). 4. Perforating wounds of solid viscera of moderate severity appear to be associated with a relatively high blood pressure ; wounds of the liver and kidney often exhibit a systolic reading of from 130 to 140 mm., and this even in cases in which the hemor- rhage is considerable. 5. Perforating wounds of the viscera which do not open into the peritoneal cavity are associated with a practically normal blood pressure. 6. Large wounds of the parietes are generally associated with a lower blood pressure than small wounds, even though the former may have produced much less visceral destruction than the latter. This is probably explained by the fact that in the former instance peritoneal blood readily escapes, while in the latter the hemorrhage continues to be retained. Observations regarding the effect on the blood pressure of open- ing the peritoneal cavity showed that if the abdominal cavity con- tained a large amount of blood there was a very rapid fall of pressure as soon as the peritoneal cavity was opened and the blood allowed to escape. If, on the other hand, the abdominal cavity did not contain much blood, the opening of the abdomen was followed by a temporary rise in blood pressure by as much as 20 mm. After 10 minutes the blood pressure fell to slightly below the figure that it registered before operation. In Wounds of the Chest. — 1. Large open wounds of the chest with free entrance and exit of air are accompanied by a profound fall of blood pressure. 2. Patients with uncomplicated closed wounds of the chest who arrive at the casualty clearing station well cared for show normal pressure. 3. When severe internal hemorrhage has occurred and the patient has been exposed to the cold for some hours, or when infection has become established, hypotension is present and progressive. 4. Patients whose chest wounds are complicated by perforation or laceration of the diaphragm behave in the same way as class 2 or 3. In Multiple Wounds and Wounds of the Extremities. — 1. Com- pound fracture of the lower extremity, seen in the casualty clearing station, was generally associated with a considerable fall in blood 356 ABSTRACTS OF WAR SURGERY pressure, more marked when the fracture affected the region of the knee-joint. 2. Compound arm fractures generally registered comparatively low pressure. The remarks that are made as regards hemorrhage in wounds of the lower extremity equally apply in this connection. 3. In face wounds there is not much alteration of the blood pres- sure, unless there is an associated compound fracture of the face bones, when the pressure is generally lowered. 4. Multiple wounds of the body and extremities were accom- panied by a considerable fall in blood pressure. As Regards Treatment. — 1. In cases of profound shock accom- panied by loss of blood, excellent results are obtained from direct blood transfusion. 2. Injection of the calcium hypertonic gum acacia solution will produce an immediate rise of pressure in hemorrhage cases or cases of hypotension, complicated by toxemia. This rise may tide the patient through an operation. If the source of the infection is removed, the tension will remain sup- ported. 3. In milder cases of shock and hemorrhage, infusion with hyper- tonic saline is useful. 4. Results obtained after infusion with physiologic sodium chlorid solution have been unsatisfactory. Probably the most baffling phenomenon of shock is the altered blood distribution leading, according to the belief of many, to en- gorgement of the splanchnic area. When the cause of this maldis- tribution of blood is thoroughly understood, we shall be on the road to understand shock. It is interesting to note, in the report to the committee, made by Cannon, Frazer and Hooper, that in their investigation of the problem of "Alterations in Distribution and Character of Blood in Shock, ' ' they point out that : In cases of shock as seen at a casualty clearing station in conditions of war- fare, the red count of blood, taken from various capillaries, is higher than that of blood taken from a vein. The discrepancy is greater the more profound the shock, and not infrequently is as much as 2,000,000 corpuscles per cubic millimeter. Since the venous count is approximately normal, the condition is due to a stagnation of corpuscles in the capillaries. Cannon, working alone, showed that patients in shock were also in a condition of acidosis, his studies leading him to conclude that cases of low blood pressure due to shock, hemorrhage or in- ABSTRACTS OF WAR SURGERY 357 fection with the gas bacillus have a diminished supply of available alkali in the blood, that is, an acidosis. As a general rule, the lower the pressure the more marked the acidosis. The pulse is rapid in these cases, but does not vary with the degree of acidosis. The res- piratory rate becomes more rapid as the acidosis increases until, shortly before death, a true ' ' air hunger ' ' may prevail. Blood sugar is usually somewhat increased above the normal in cases of shock and hemorrhage. The acidosis in these cases, there- fore, is not due to lack of circulating carbohydrate. Operation on men suffering from shock and acidosis results in serious and rapid sinking of arterial pressure when it is already low, and in marked and sudden decrease of the alkali reserve in the blood when that reserve likewise is already low. This change may not occur if nitrous oxid-oxygen anesthesia, instead of ether, is employed, but that anesthetic affords no guarantee against the ominous decline. Shocked men suffering after operation from extreme acidosis with "air hunger" can be quickly relieved of their distress by in- travenous injection of a solution of sodium bicarbonate, and their blood pressure restored to normal. Cannon further amplifies his argument in favor of acidosis as the prominent factor in shock in his report on "The Nature of Wound Shock. ' ' In this report he analyzes some of the more im- portant theories of shock, showing them all to be inadequate. After this he attempts to show that the blood in shock is, as it were, redis- tributed, with stagnation in the capillaries. The facts derived from various studies, in Cannon's opinion, warrant the conclusion that the capillary capacity is sufficient to contain the lost blood in shock, and that the chances of its doing so are greater the more concentrated the lost blood. Alterations in the viscosity of the blood are thought to be favorable to capillary stagnation of the cor- puscles. Concentration of corpuscles, lowered temperature, and increase of H-ions are conditions tending to increase the viscosity of the blood. The state of acidosis which Cannon makes responsible for the capillary congestion, and blood concentration, has also other im- portant effects : ( 1 ) There is evidence that acid or change in the blood in the direction of acidity may have depressive effects on the blood pressure; (2) Increase of carbonic acid of the blood affects cardiac contraction; (3) Increase of carbonic acid increases the viscosity of the blood; (4) The size of corpuscles is increased by the action of carbonic and other acids. 358 ABSTRACTS OF WAR SURGERY Cannon presents the following concept of the development of shock or exemia ("drained of blood") in a correlation of the facts developed in the course of the investigations into the nature and treatment of wound shock and allied conditions. The facts are listed as follows : There are primary wound shock with rapid lowering of arterial pressure, and secondary wound shock with toxemia and hemorrhage, and later lowering of the pressure. Sweating occurs, leading to loss of fluid and loss of heat from the body. The blood becomes stag- nant and concentrated in the capillaries, and as the blood pressure falls there is loss of the alkali reserve of the blood (acidosis) roughly corresponding to the drop in pressure. Primary wound shock — dusky pallor; rapid, thready, low ten- sion pulse, hypotension; sweating; thirst, and restlessness — may come on as soon after the injury as to be accounted for only as the result of nervous action. The organization of the individual (for example, a "high strung" temperament), fear and fatigue probably provide favorable conditions for the nervous response. Cowell's observation of fainting after slight wounds may perhaps be re- garded as a transient state which in true shock is more persistent. Sweating and exposure lead to rapid loss of heat from the body; previous sweating, wetness of the clothing, and low external temper- ature favor the process. Inactivity of the wounded man and ab- sence of shivering lessen heat protection. Thus the body becomes cold, especially the surface and extremities. In consequence of the low blood pressure, aided by chilled tissues, there is a stagnation of corpuscles in the capillaries. The onward flow here checked under- goes concentration, so that the capillary red count is high. Pro- longed lack of fluid and sweating may favor the stagnation and further concentration of the blood. The low arterial pressure can continue a flow through easy channels, but is insufficient to main- tain the normal flow where resistance is high. Thus cooled regions receive less heat from the interior of the body and tend to become cooler, and thus in turn more blood accumulates. By accumulation in capillaries the return of blood to the heart is lessened until a persistent low blood pressure becomes established. The blood lost from currency produces a state equivalent to hemorrhage. Any true hemorrhage therefore exaggerates the existent shock (exemia). When a wound has not caused a primary fall of blood pres- sure, but has rendered the control of the circulation unstable, unfavorable conditions, such as cold, hemorrhage, and toxemia, ABSTRACTS OF WAR SURGERY 359 will bring about the same sequence of events that is seen in primary shock. As the low blood pressure continues, the alkali reserve of the blood is reduced (acidosis). Previous starvation and fatigue would favor the development of acidosis. This state, by locally re- laxing vessels which are not under nervous control, by weakening cardiac contraction, and by increasing the viscosity of the blood, tends to make worse the dangerous condition which has been es- tablished. And, as pointed out in an earlier paper, the individual with acidosis is sensitized so that operation, because still further increasing the acidosis and still further lowering blood pressure, becomes hazardous. This conception of the events that take place in a wounded man who passes into shock gives a reasonable account of the primary effect of wounds, the influence of cold in continuing the low blood pressure or inducing it when the circulatory apparatus is unsta- ble, the influence of warmth in restoring him in part to a fit condi- tion, and the slowness of a full recovery. It leaves unsettled the occasion for the primary fall of pressure, though the suggestion is offered that it may be of reflex character, similar to fainting. The conception offers a hopeful outlook for the care of the shocked man, because two of the most potent factors making his chances unfav- orable — cold and acidosis — can be controlled. In a final paper the research committee deals with the problem of the "preventive treatment of wound shock." In this paper nothing is added to the comparatively well-known principles of civil surgery — warmth, quiet, rest, and posture — although admir- able ingenuity is displayed in adapting these principles to the exi- gencies of warfare. The one new phase of treatment recommended by the committee is the injection of a 4 per cent solution of sodium bicarbonate or of 4 per cent bicarbonate in 6 per cent acacia solution. They lay stress on the fact that the solution must be sterilized and emphasize that sodium bicarbonate solution can not be boiled. The salt itself must be sterilized, but since the salt is also broken up by heat it is un- fortunate that the committee does not state that it can be effectively autoclaved in a sealed ampoule (the carbon dioxide that is driven off during sterilization is later taken up by the sodium carbonate, converting it back to bicarbonate). It will be noted that there is nothing in these various papers that may be construed as fundamentally new. They do, in admirable 360 ABSTRACTS OF WAR SURGERY fashion, restate the shock problem, analyze clinical phenomena, and emphasize the role of acidosis as causative factor and of sodium bicarbonate as a rational therapeutic agent. Unfortunately, the usual element of lack of confirmation fogs the issue, as it always has fogged the shock problem. As early as 1913 Seelig, Tierney, and Rodenbaugh (Am. Jour. Med. Sc, August, 1913, p. 195) studied Sodium Bicarbonate and Other Allied Salts in Shock, reach- ing conclusions somewhat at variance with the idea of acidosis as a primary causative agency in shock. Very recently McElroy (Jour. Am. Med. Assn., March 23, 1918, p. 846), working on the shock problem from the experimental point of view, reached the conclu- sion that acidosis is not an important primary causative factor in shock, but was rather to be construed as one of the many associated secondary changes. Still more recently one of the American Medi- cal Reserve Corps officers now serving with a base hospital abroad expressed himself as follows, in a letter : "The treatment of shock is about where it always has been with the added ray of hope that some good men are at work upon it. It is difficult to conceive of shock as due to acidosis. A little thought tends to confuse one, because the most severe acidosis encountered clinically, namely in diabetes, never produces symptoms of surgical shock. That acidosis is present is almost to be expected, because the failure of the circulation results in a failure on the part of the lung to properly oxygenate the blood, a necessary and natural increase of the CO 2 content and, therefore, again naturally and logically, a diminution of the alkali reserve; and also the sodium bicarbonate infusions do no more good in practice than anything else. I should say that, as always, common sense and trust in God still remain the best treatment of shock. ' ' Among the men referred to in the above paragraphs as being at work is Prof. W. T. Porter, of the Harvard Medical School. Prof. Porter has kindly summarized his later views on the shock problem, for presentation in this issue, as follows : "An understanding of the critical level of the blood pressure is of the first importance in the study and treatment of shock. If the blood pressure just touches the critical level, a difference of 10 millimeters of mercury may be the difference between life and death. A few millimeters above this level, recovery will usually occur spontaneously; a few millimeters below, death will follow unless skilled aid be at hand. It follows from this vital fact (1) that procedures which at ordinary blood pressures are not harmful. ABSTRACTS OF WAR SURGERY 361 or are but slightly harmful, may kill the patient at the critical level ; (2) remedies that raise the blood pressure but 10 or 15 milli- meters will save the patient when this rise carries the blood pres- sure from just below to just above the critical level. ' ' The critical level of the diastolic blood pressure in shock is not far from 60 mm. ' ' The critical level varies with the condition of the nerve cells and other tissues. A blood pressure raised by the surgeon to a point above the usual critical level may shortly sink again. Hence the importance of frequent readings of the blood pressure until shock patients are clearly out of all danger. Treatment not based on repeated readings of the blood pressure is not intelligent and may be harmful. "The diastolic blood pressure should be employed in shock. In this condition, the heart beats feebly. The systolic pressure falls more than the diastolic pressure falls. Conversely, when remedies are used, they often raise the systolic pressure more than they raise the diastolic pressure. Conclusions drawn from the systolic pres- sure may easily err 15 mm. or more. But in shock the blood pres- sure is at a critical level ; a change of even 15 mm. may be a matter of life or death. The error in using the systolic instead of the diastolic pressure may therefore do much harm. "In the summer of 1916, during my service in the fighting line in France, I learned that in this war shock occurs chiefly after shell fractures of the femur and after multiple wounds through the subcutaneous fat. In 1,000 casualties, observed by me at the Massif de Moronvillers, these were the only injuries producing shock, except certain abdominal wounds in which the shell frag- ments undoubtedly disturbed the vasomotor apparatus of the larg- est vascular area in the body. It has long been known that fat em- bolism takes place after fractures of the thigh and after multiple wounds through the subcutaneous fat. "In February, 1917, I proved that the injection of a small quan- tity of neutral olive oil in the jugular vein was followed by a falling blood pressure and other symptoms of traumatic shock. The re- sulting publication was the first clear statement that shock as seen on the battlefield is frequently, perhaps usually, caused by fat embolism. "Shortly thereafter I developed a remedy for the treatment of shock. It has long been known that the pumping action of the diaphragm is an important aid in the movement of blood from the abdomen into the chest. At the height of a strong inspiration 362 ABSTRACTS OF WAR SURGERY the venous pressure in the chest may be 40 mm. lower than the venous pressure in the abdomen. I produced strong respiratory- movements of the diaphragm by allowing the animal to breathe an atmosphere rich in carbon dioxide. The diastolic arterial pres- sure was thereby increased 15 and even 30 mm. "In June, 1917, at the Chemin des Dames, I successfully applied this method to the treatment of wounded soldiers. In cases almost pulseless, cases in which all other means of raising the blood pres- sure had failed, the carbon dioxide respiration strengthened the pulse and raised the diastolic blood pressure 10 mm. This rise is of great value when the pressure is at the critical level. ' ' The general treatment employed by me at the Chemin des Dames was as follows: A shock room was made next the operating room. The patient was carried to the shock room directly from the am- bulance. He was not washed. He was at once placed on an operating table, inclined so that the feet were 30 cm. higher than the head. An electric heater was put between the blankets and the body. The diastolic pressure was taken every 15 minutes. Where indicated, injections of warm normal saline solution were made into a vein. If his state was grave, adrenalin was added to the saline solution. When his condition justified operation, the clothing was cut away about the wound and the area disin- fected. Neighboring regions were covered with sterile cloths. He was then moved, still in the inclined positon and still on his hot table, to the operating room. The operation was done under local anesthesia whenever possible. At its close the patient was wheeled back to the shock room, still on the same inclined hot table. I did not leave him until he was out of danger or dead. Repeated readings of the pressure were taken. The remedies were directed to raising the diastolic pressure to a point about 15 mm. above the critical level — more is not necessary. Carbon dioxide respiration was frequently employed with benefit. One case was operated on during the carbon dioxide breathing, with apparent advantage. "Under these methods four-fifths of the patients recovered. "A word as to details may be of interest. "Normal saline solution should be injected at 39° C, measured by a thermometer in the vertical limb of a T tube placed next the cannula. If the pressure has not remained too long below the critical level, it will be raised by the normal saline; other- wise not, because the permeability of the vessel walls is increased by prolonged low pressures. Prof. Bayliss states that the addi- ABSTRACTS OF WAR SURGERY 363 tion of 5 per cent of gum arabic to the saline solution will pre- vent leakage and thus raise the pressure under all circumstances. This suggestion was made after my leaving France and I have had no personal experience of its value. "Adrenalin is of temporary advantage, but even this fleeting rise of blood pressure may save life. In the laboratory, the blood pressure of animals may be raised for considerable periods by allowing the well diluted adrenalin to flow into the vein drop by drop from a burette. I have not tried this on men. "Dr. Meltzer very recently stated that the pressor action of epinephrin is much prolonged when the drug is injected into the vertebral canal. "The carbon dioxide respiration should not be stopped too abruptly. ' ' FLUID SUBSTITUTES FOR TRANSFUSION IN SHOCK AND HEMORRHAGE.— Rev. of War Surg, and Med., May, 1918, i, No. 3. Closely allied with shock is the problem of blood substitutes. In both hemorrhage and shock, intravenous therapy has always occupied a prominent place. The object in one instance is to supply bulk (hemorrhage), and in the other, to overcome the dis- turbance in blood distribution (shock). Eous and Wilson (Jour. Am. Med. Assn., Jan. 26, 1918, p. 219), discussing the question of fluid substitutes to combat hemorrhage, say that since severe acute hemorrhage, even to apparent ex- sanguination, does not entail permanent damage to the organ- ism, as is shown by the rapid and complete recovery that usually follows transfusion, the question arises whether such recovery may be expected to follow when another fluid than blood is used, or whether this is essentially dependent on the new supply of corpuscles and plasma. The important role of the plasma in the rapid and complete recovery that usually follows transfusion has been investigated by Abel, Rowntree, and Turner (Jour. Pharmac. and Exper. Therap., 1914, v., p. 625), who demonstrated that the healthy body will withstand and quickly repair great losses of the fluid. The first point taken up by Rous and Wilson had reference to the ability of the healthy body to withstand similar losses of red cells only, or, more properly speaking, of functioning hemoglobin — a point not previously investigated. From their experiments with rabbits, in which they were able 364 ABSTRACTS OF WAR SURGERY to make a reduction of from 17 to 18 per cent, they consider the view justifiable that, however desirable it may be, it is not es- sential to supply blood corpuscles in ordinary cases of acute hemorrhage. Even in the worst examples, the body retains at least twice the minimum functioning hemoglobin, which, if other factors are favorable, will support life. The limits of substitution for plasma are directly dependent on the time taken for the plasma's removal and that allowed for recovery. When both are generous, the possibilities as regards plasma withdrawal and substitution are practically unlimited. Unfortunately, in cases of hemorrhage the depletion is extremely rapid and involves both cells and plasma. New fluid is required, not merely to replace the plasma, but also to make up the total blood bulk. The ability of plasma to replace whole blood was studied. When more than half the total calculated blood volume had been taken, and the carotid pressure had fallen to a physiologic zero (from 10 to 20 mm. of mercury), it was instantly and permanently restored to the normal by the injection of an equivalent quantity of plasma. This was the case, too, when horse serum was used. A saline solution (Ringer's fluid), on the other hand, brought about only a slight transient recovery of the pressure. Some- times, nevertheless, the animal survived for the half hour or more necessary for the successful utilization of its own fluid resources. In studying the relative merits of blood substitutes Rous and Wilson tested several fluids made with gelatins which answered to Hogan's (Jour. Am. Med. Assn., Feb. 17, 1915, p. 721) require- ments for purity and ability to "gel." While these solutions un- doubtedly restored blood pressure better than did salt solution, their effect was soon lost. Hogan used 2.5 per cent gelatin; Bayliss 6 per cent, Rous and Wilson found that larger concentrations of gelatin up to 6 per cent act proportionately better than Hogan's solution. In their ex- perience, in some instances, 4 per cent gelatin restores blood pres- sure permanently, but in others it does not, whereas 6 per cent gelatin was always effective. Eight per cent dextrin in salt solu- tion, and 5.4 per cent glucose in Ringer's solution— a fluid with twice the tonicity of blood — were found to exert only a slight tran- sient effect to raise the blood pressure in bled rabbits. Bayliss has recently (Arch. Med. beige, 1917, lxx, p. 793) ad- vocated 7 per cent gum acacia as a blood substitute. It can be sterilized by boiling, whereas the autoclaving of gelatin is neces- ABSTRACTS OF WAB SUBGERY 365 sary in order to kill tetanus spores. It. is more uniform, in con- stitution than commercial gelatin, and, being protein free, it does not induce anaphylaxis or severe reactions that often fol- low the latter. Rous and Wilson were able to confirm the state- ment of Bayliss that 7 per cent gum acacia will permanently restore blood pressure to normal. Bayliss studied ox serum, 2 per cent wheat starch, 1.7 per cent amylopectin, 7 per cent acacia with calcium and also with sodium, and 6 per cent gelatin. He reached the following con- clusions : When the arterial pressure is low from the loss of blood, it can not be brought back, except to a certain degree, by the injection of saline solution in volume equal to that of the blood lost. But if the viscosity of such solutions is raised to that of the blood, a return to normal height is possible. The effect, of saline injections is also much less lasting than that of solutions containing gum or gelatin. The difference in this case is due to the osmotic pressure of the colloids, by which loss of water by the kidneys and to the tissues is prevented. Solutions containing gum do not produce edema in artificial perfusion of organs. When the fall of blood pressure is due to peripheral vasodila- tation, gum or gelatin solutions, although more effective than pure saline, produce a much less permanent rise than in cases of loss of blood. No signs of heart failure could be detected and the cause of the fall of the raised pressure to its original height is still obscure. At the British front, according to Rous and Wilson, where acacia solutions are now used, the higher percentages have been abandoned in favor of a 2 per cent fluid; the results have been encouraging but not convincing. A 2 per cent acacia solu- tion at first raises the pressure to normal, but it drops off with- in a few minutes to the danger point. Four per cent is more satisfactory, as the secondary drop in pressure, being slow, is better compensated. But neither the 4 per cent nor the 5 per cent solution recommended by Hurwitz {Jour. Am. Med. Assn., Mar. 3, 1917, p. 699) is effective in all cases. Six or seven per cent is required if one is to bring back the normal pressure in an organism depleted of its fluid reserves. The indications are that horse serum would be an effective blood substitute, except for the risk of inducing sensitization or causing anaphylactic shock. 366 ABSTRACTS OF WAR SURGERY Their investigations and conclusions are summarized by Rous and Wilson as follows : "The animal organism will withstand an abrupt reduction in hemoglobin to almost, if not quite, the low percentage that is tolerated in chronic anemia. Roughly speaking, three-quar- ters of the total hemoglobin may be safely removed, provided the blood bulk is maintained. If four-fifths is suddenly with- drawn, the animal becomes apathetic, shows symptoms of air hunger, and dies in a few hours. The amount of hemoglobin which remains after fatal acute hemorrhage is far above the minimum requirement of the body. As Abel and his coworkers have shown, great losses of plasma are soon repaired by the organism, if only the blood bulk is maintained. Taking all facts together, Rous and Wilson believe the conclusion warrant- able that however desirable transfusion may be (especially to furnish the elements needed in clotting, to lessen acidosis, to improve oxygenation, etc.) it is not essential to recovery from even the severest acute hemorrhage, if only the blood bulk can be re- stored in other ways. "Of the several fluid substitutes for transfusion which have recently been suggested, all are preferable to salt solution. Bayliss' 7 per cent gum acacia solution is up to the pres- ent time the best, and its use should save life in many instances. In less urgent cases, from 2 to 3 per cent acacia solution, or Hogan's 2.5 per cent gelatin solution, are to be preferred to salt solution. But these fluids leave the circulation relatively soon, and when the organism has been drained of its fluid re- sources their injection restores the blood pressure to the nor- mal level for only a few minutes. Permanent betterment can not be expected in cases of severe hemorrhage with solutions containing less than from 5 to 7 per cent gum acacia. It is not essential that a blood substitute should possess the viscos- ity of whole blood." As regards shock, in its relationship to blood substitutes, the problem is somewhat different from that of hemorrhage. The general tendency is to distrust more and more the various salt solutions and to pin more and more faith to the colloidal solu- tions. Of these, the acacia solution ranks in popularity next to actual blood. The recent work of Erlanger and Woodyat {Jour. Am. Med. Assn., Oct. 27, 1917, p. 1410) lends a rational hope for the use of glucose solution in shock. These authors report that: ABSTRACTS OF WAR SURGERY 367 Glucose injected intravenously at rates varying between 0.57 and 4 gm. per kilogram per hour for from 20 to 60 minutes into anesthetized dogs reduced to a state of "shock" (by partial temporary occlusions of the inferior cava or aorta) has been observed uniformly to increase the mean arterial pressure. The injections have uniformly produced a marked increase in the pulse amplitude, indicating a condition of plethora. The increase in pulse amplitude has usually been more strik- ing than the increase in arterial pressure. In one case the increase in pressure determined by the infec- tion of glucose continued after the cessation of the injection until the pressure was approximating the normal. A subtolerant dose has raised the arterial pressure and in- creased the pulse amplitude as effectively as many of the injec- tions made at more rapid rates. With the more rapid injections, a marked hemorrhagic tend- ency may develop in animals in this condition. No other palpable deleterious effects were observed. The conclusion is drawn that, on theoretical and experimental grounds, supported by some clinical evidence, it would appear that intravenous injections of glucose at appropriate rates are of distinct benefit in certain phases of shock. No discussion of transfusion (whether blood or blood substi- tutes be used) is complete without a word of caution regarding the potential harm that is essentially resident in this procedure. Well intentioned therapy may, by actual disturbance of blood chemistry, by anaphylactic reaction, or by embarrassment of an enfeebled right heart, result in the sacrifice of a patient who might have been saved by the conservation of his own forces, through the judicious use of warmth, posture, rest, and morphine. FOREIGN BODIES SIMPLE METHOD OF LOCALIZATION OF FOREIGN BODIES. — J. S. Young. Arch. Radiol, and Electrotherap., 1917, xxii, p. 40. The method employed by the author, as described by him- self, consists simply in the use of a small apparatus, with an aluminum base, which rests underneath the part which con- tains the foreign body, and an upright standard which rests upon the broad end of the aluminum base. This standard has two adjustable cuffs, an upper and a lower, through each of which a rod passes. The upper rod has a loop on its end, while the lower has a small metallic ball. These rods are both ad- justable in two directions, and are secured by two set-screws. The patient is placed upon the aluminum base (tube of course underneath table), the foreign body is located by the central rays, and the loop is pressed directly over the same. After hav- ing pressed the loop on the upper rod close to the skin so that there will be no motion, the diaphragm is then opened and the tube moved up and down and the ball then adjusted so that it moves in the same plane with the foreign body. The foreign body is thus located in two directions, the ball locating it at the base line, and the loop locating it in the perpendicular plane. The method is perfectly simple and is absolutely correct, if the operator is careful first in posing his patient, and second in observing that the foreign body and ball move in the same plane. Otherwise he will find there is a variation of from half an inch to two inches in the lower plane of his localization. THE LOCALIZATION OF FOREIGN BODIES.— W. A. Wil- kins. Am. Jour. Roent., 1917, iv, p. 343. The author dismisses the two-plane and stereoscopic methods of localization by brief mention as having only a small field of usefulness. The method of choice which he has found entirely efficient under conditions of active service is a modification of a method described by Hampson some years ago depending upon a triangulation calculation. Two exposures are made upon the same plate with the foreign body as nearly as possible 368 ABSTRACTS OF WAR SURGERY 369 perpendicularly above the center of the plate. During the first exposure the center of the target is a known distance vertically above the center of the plate. This center is indicated by cross- wires stretched on an overlying board and these when inked leave their impress on the overlying skin. The second exposure is made with the tube shifted a known distance horizontally in the direction of either cross-wire. To ascertain the location of the foreign body in relation to the center of the cross-wire, di- rect measurement is made after the true position of that body has been obtained by certain intersecting lines. The depth of the foreign body is found by constructing right-angled triangles whose bases are represented respectively by the distances be- tween the foreign body shadow and the shift of the target. The perpendiculars can be ascertained algebraically as the total is a known quantity, being the distance from the target to the plate. With the ink-marks of the cross-wires as guides, a final mark is made on the skin to represent the spot beneath which the foreign body lies at the determined depth. A number of cases to demonstrate the method are illustrated and described. The author recommends it for its simplicity and practicability, having tried it under many and varied circum- stances to the satisfaction of all concerned. THE SUTTON METHOD OF FOREIGN BODY LOCALIZA- TION.— E. H. Skinner. Amer. Jour. Roent., 1917, iv, p. 350. The method is best described in the originator's own words quoted from Binnie's "Operative Surgery." "Having located the shadow of the foreign body by means of the axial ray upon a large screen, firmly supported about six inches above the surface of the part examined, the surface is painted with iodine, cocainized, and a small skin incision made in the center of the shadow. The special cannula bearing the blunt or sharp trocar, as circumstances may indicate, and held by a strong clamp at right angles, is then entered through the skin incision. The room is then darkened and under the guid- ance of the x-ray the instrument is driven through the tissues. As long as the point is advancing straight toward the anode, and hence toward the foreign body, the shadow of the point will be hidden by the shadow of the upper portion of the in- strument. "When the trocar strikes the foreign body, the patient in- variably complains of a sharp pain. Contact is then verified 370 ABSTRACTS OF WAR SURGERY by slight waving movements of the point of the trocar which can be made to cause the foreign body shadow to describe a circular excursion on the screen. "The current is now cut off, the screen removed, and the room lighted while the operator continues to hold the trocar immovable. Next the trocar is withdrawn from the cannula and one of the small hooked piano-wire indicators inserted in its place. Holding the hook of the latter against the foreign body, the cannula is withdrawn and the wire snipped off one- fourth inch above the skin. Over this a fairly thick dressing is applied. If other foreign bodies are present, each may be localized in the same way. On the operating table each indi- cator may be readily followed to the corresponding foreign body. The particular advantages of this method are : "1. Operations may almost always be done under local anesthesia. "2. Changes in the position of limbs or body do not vitiate the result. "3. There are no calculations to introduce a possible mathe- matical error. "4. The localization may be carried out aseptically without sterilizing the hands." This method has simplicity, ease and rapidity of application, and absolute accuracy to recommend it and practically none of the sources of error or difficulties of application incurred with the various triangulation or other methods in use. OPERATIVE REMOVAL OF BULLETS AND FRAGMENTS OF GRENADES, WITH SPECIAL REFERENCE TO THE USE OF THE ELECTROMAGNET.— von Hofmeister. Beitr. z. klin. Chir., 1915, xcvi, p. 166. (Abstr. by Surg., Gynec. and Obst.) The opinion still prevails among the laity that the most im- portant thing to be done in case of gunshot injury is to re- move the bullet. Von Hofmeister points out that a metallic foreign body, as a rule, is perfectly harmless and the wound heals without reaction. The mere presence of a bullet is not an indication for operation, nor is the desire of the patient. If phlegmons or abscesses arise, the projectile generally plays only a secondary part in their formation. The object of operation in these cases is not primarily to remove the bullet, but to pro- cure free egress for the secretion. The projectile may be re- ABSTRACTS OF WAR SURGERY 371 moved if it lies in the abscess, so that its removal is easy, but the surrounding tissue should not be probed for it, as removal of the bullet or fragment is only indicated when it is in a loca- tion where it may do further injury, as in the eye, the bladder, the trachea, etc., where it exercises pressure on nerves or ves- sels or where it interferes with the motion of joints, tendons or muscles. It has been claimed that lead bullets may produce toxic ef- fects due to lead poisoning, but, though this may be true to a certain extent, von Hofmeister believes that the danger of lead poison is less than that of operative interference. There are two procedures which tempt surgeons to remove foreign bodies unnecessarily: (1) roentgen photography and (2) the use of the electromagnet. The roentgen picture shows the position of the foreign body so plainly it seems the simplest thing in the world to remove it. Von Hofmeister thinks that it is not justifiable to extend the use of the electromagnet from ophthalmology to general surgery. The magnet easily removes the body from the fluid media, of the eye, but not through solid muscle or cicatricial tissues. Surgeons should be impressed with the fact that the indica- tions for the removal of a foreign body should be as definite as for any other surgical procedure, and no physician need be ashamed to refer a patient to a surgeon for this purpose. PERIPHERAL NERVE INJURIES INJURY TO PERIPHERAL NERVES —Sir Berkeley Moynihan. Surg., Gynec. and Ohst., Dec, 1917. The lesion of nerve trunks as the result of wounds inflicted in war may be of diverse forms. 1. In the majority of cases the nerve trunk has not sustained a primary injury. It may be exposed in greater or less degree in a wound of the soft parts, with or without fracture. If such wounds are gravely infected and suppuration occurs with, per- haps, necrosis of one or of many fragments of bone, the pro- cess of healing may be long delayed, and the cicatricial tissue which results will be of exceeding density. The nerve trunk is strangled, bereft of its due supply of blood, and becomes in consequence functionless. It is impossible before operation to decide in the severer cases whether such a nerve has or has not been completely divided. 2. The nerve fibers may not have been directly, or they ma- have been only very trivially implicated, but the projectile may have passed so near the nerve trunk as to have opened its sheath. The nerve then becomes adherent to the track of the missile, and a mass of fibrous tissue is found firmly welded on to its lateral aspect. Or, the projectile, in this case a rifle or machine gun bullet, may, at that period of its flight when it has become steady, have cleaved through the trunk of a nerve separating the fibers and severing few or none. Hemorrhage within the sheath occurs, and a fibrous mass develops in the center of the nerve, causing it to assume a fusiform appearance. There is then a central neuroma. 3. The nerve may have been partly severed, say in half its diameter, by a projectile, or a fragment of bone. The gap in the nerve is soon filled up by fibrous tissue which extends widely upward and downward and away from the side of the nerve, so that a hard fibrous lateral neuroma is found. 4. The nerve may be completely severed. In such a case a gap of greater or less length is found between the divided ends. Bridging this interval there may be a connecting strand of fibrous tissue, or a blurred mass of scar material in which both cut ends are lost. In some cases the nerve may appear hard 372 ABSTRACTS OF WAR SURGERY 373 and swollen, and as though its fibers were continuous ; but careful dissection Avill show that there is complete division. When the nerve has been cut completely across, the upper divided end is soon found to present a characteristic bulbous appearance. On. section this is seen to consist partly of fibrous tissue and partly of nerve tissue. From the upper end of any divided nerve, the axis cylinders grow downward tirelessly, each one searching out diligently but blindly the lower end to which it seeks to unite. When the quest fails in one direction and an uncongenial tissue is met, the axis cylinder turns in another direction, searching there fruitlessly again, and so twists itself in ceaseless contortion until a tumor, a terminal neuroma, is formed. The relative frequency of affected nerves has in Moynihan's experience been as follows : Nerve Per Cent Musculospiral 25 Ulnar 24 Median 14 Sciatic 12 External popliteal 12 Internal popliteal 1 Upper portion of the brachial plexus 4 Lower portion of the brachial plexus (cords) 7 Anterior crural 1 This corresponds fairly accurately with the experience re- corded by Gosset and by Tinel. Diagnosis. — The following points in the clinical histories are investigated: date of injury; nature of projectile; position of patient at moment of injury; immediate effects; after history (including history of operations performed). Physical examination consists in — A. Inspection of the limb to note (1) attitude, contractures (claw hands, etc.) ; (2) position of wounds and scars. B. Testing of the efferent impulses: (1) Motor weakness for paralysis, each muscle and each muscle group being tested separately. (2) Trophic and vasomotor disturbances. Non- shedding of epidermis, "glossy skin," ulcers, changes in nails, etc. (3) Changes in deep tissues, e. g., muscular atrophy, fib- rillation, bone decalcification, etc. C. Testing of the afferent impulses: (1) Pain, its character, dis- tribution, relation to hot and cold applications of weather. (2) Loss of cutaneous sensibility, tested by standardized 374 ABSTRACTS OF WAR SURGERY stimuli of special instruments so that the results are strictly comparable. Light touch. Localization of spot touched. Tac- tile discrimination (pressure, texture, etc.). Stereognostic sense (size and shape of three dimensions) ; appreciation of compass points applied simultaneously. Thermal stimuli (hot and cold test tubes). Painful stimuli (pinprick controlled by standardized spring). Eoughness (Graham Brown esthesiom- eter). (3) Deep sensibility — pressure, pain, vibration sense in bones, joint and muscle sense, etc. D. In the electrodiagnosis, the reactions to the interrupted cur- rent are tested by shocks from an induction coil, the electrode being placed upon the "motor point" of each muscle in turn. The current from a secondary coil is always used. A positive reaction to faradism is regarded as a contraindica- tion to operation, but failure to respond gives no definite in- formation, for voluntary movement may return, after nerve in- jury, before the faradic response. The muscles are next investigated by a constant current. "Polar changes" have been found to be of minor value; they may vary with the local circulatory changes following massage, etc. The character of the contraction is of much more im- portance. A brisk twitch indicates the probable presence of some conduction nerve fibers in the muscle tested, while a slow, "vermicular" response is usually associated with a complete interruption of nerve fibers. The nerve muscle is next examined by means of a condenser discharge. The method depends upon the fact that a condenser discharge, through a constant resistance, gives a current which varies in duration according to the capacity of the condenser used. The more severe the damage to the nerve the greater will be the capacity of the condenser required to excite it; or, in other words, the longer the duration of the current the more chance is there of obtaining a response in such a nerve muscle. The whole advantage of the condenser method is that a definite measurement of current, or condenser used, may be noted and future progress may be accurately followed. The condenser method is chiefly used in cases where opera- tion is deferred because some function is found to be present in a given injured nerve. (The work done recently by E. D. Adrain and others shows that the condenser is disappointing in practice; nevertheless, it gives useful information in recording progress.) ABSTRACTS OF WAR SURGERY 375 Complete absence both of faradic and galvanic response is an indication for early operation. The cases which require care- ful and repeated examinations are those where there is pres- sure on the nerve trunk by a contracting scar. In some nerve trunks there is little damage to some of the fibers with total loss in others. Operation must not be deferred too long in these cases, because the fibers with complete reaction of degenera- tion may never recover on account of a dense scar-tissue forma- tion at the site of injury. In other words, the presence of a degree of voluntary power in some individual muscles of a group supplied by a damaged nerve is no sure criterion that the paralyzed muscles will recover without operation. It is most important that nerve injuries should be reexamined at frequent intervals and carefully detailed records of motor power, sensory changes, and electrical reactions kept. In this way treatment may be modified according to progress. In operations upon nerves where a diagnosis of total loss in some fibers only has been made, it is Moynihan's practice to test the exposed nerve both above and below the site of injury at the time of operation. For this examination special steriliz- able electrodes and long connecting cords which can be boiled, are used. The nerve is gently lifted upon two small glass hooks and a very weak faradic current employed. The most accurate anatomical arrangement of fibers may be noted by this means and the knowledge used to secure perfect adaptation in nerve suture. The diagnosis is often completed during a period in which massage, baths, and electrical treat- ment are employed to improve the local circulation, and splint treatment adopted to relax affected muscle groups and to over- come contractures. The distinction between anatomical and physiological division is not made before operation. Operation is decided upon in the following circumstances : (1) in cases of complete division; (2) in cases of incomplete division, where progress is arrested; (3) where there is severe neuralgic pain, "causalgia. " Operation is deferred (1) for one month after the closure of the wound where soft parts only are injured; (2) for two or three months after complete closure of the wound where bone has been involved; and (3) definitely so long as progressive signs of recovery in nerve functions continue. The suture of the nerve may have to be delayed until un- satisfactory joint conditions are improved. Contractures of the knee for example, should be corrected before the sciatic nerve 376 ABSTRACTS OF WAR SURGERY is sutured, otherwise the nerve would be in danger of rupture if the deformity were subsequently rectified. In other cases the nerve may be sutured, and the joint dealt with at the same period, and subsequently. It is of the first importance to start active measures to prevent or remove stiffness and deformity in the parts supplied by a wounded nerve. This can often be done for many weeks before it is possible to repair the nerve. It is not sufficiently realized that a nerve to be of use after suture must act upon live and supple tissues. Joints and muscles must be kept ready for the nerve impulses which some day will come to them again. When the diagnosis of a nerve lesion requiring operation has been made, the earliest prudent occasion must be chosen for operation. In both the French and British armies nowadays the suture of a divided nerve is performed in those most ad- vanced operating centers where the first deliberate toilet of the wound is possible. In many cases an injury to bone may have been inflicted at the same moment as the division of the nerve ; this is, of course, frequently the case when the musculospiral nerve is implicated. Many loose pieces of bone may remain as sequestra in the wound and may need removal or may escape spontaneously from time to time. In all such cases, operation upon the nerve must be deferred until the wound has been soundly healed for some weeks; no rule is more binding upon the surgeon than that. During this period, which may be protracted, the most diligent attention must be given to the limb, especially to those parts, muscles and joints, distal to the injury. Special and unremitting attention is given to the joints, which must always be kept supple. Every day, many times a day, all the paralyzed parts must be freely moved to their full range, and the patient must be instructed to attend to this matter un- ceasingly. When the operation actually takes place it is important to observe certain essentials to success. There must be the most perfect and scrupulous asepsis and the most gentle handling. The finger should never be placed in the wound. All dissection should be carried out deftly and neatly; the most diligent care must be taken never to bruise the nerve by seizing it, however gently, in forceps. The nerve must never be twisted, or torn or stretched, or unduly separated from its bed. Other struc- tures must be dissected from the nerve; the nerve must not be dissected from them. The nerve must not be stripped bare for ABSTRACTS OF WAR SURGERY 377 too long a distance, otherwise it will be devascularized, and recuperative processes will be slow or absent. The wound as a whole, and the nerve in particular must not be allowed to dry or to be chilled. The most dainty and precise movements are necessary throughout and every bleeding point must be thor- oughly secured. There are, of course, the observances that go to make up the ritual of every well-trained surgeon; their strict acceptance is more necessary here than in almost any other operation, if the most rapid and the most flawless re- covery is to be made certain. As a rule a tourniquet is undesirable. The incision is de- signed to fall on the skin at some distance from the original wound if possible ; very often a flap will occur from the mak- ing of a curved incision. The planning of the incision gives scope for one's knowledge of anatomy; it is so arranged that no small nerves are wounded. The nerve trunk is sought above and below the point of severance, and is traced downward and upward to the gap. It is his business to know before he begins these operations ex- actly where the nerve lies, and he should always be able to cut directly down on it. When the injured nerve is exposed, it is usual to find a bridge of fibrous tissue between the ends; the proximal end being very often turgid and bulbous. If the gap between the refreshed ends of the nerve is likely to be wide, now is the time for stretching the nerve, so as to lessen the interval as much as possible. This is done with infinite gentle- ness and care by seizing the fibrous band between the ends, and drawing steadily upward and downward, always remembering to make the pull in the line of the nerve trunk and to avoid twisting. The fibrous band is now split longitudinally, and then its ends are divided, above in one direction, below in the other, so that to each cut end of nerve a fibrous tag is attached by means of which the nerve ends can be drawn together. Prog- ressive transverse cuts are now made into the nerve ends until on the cross-section nothing but nerve fibers are seen. Every tiniest particle of fibrous tissue must be removed or the opera- tion will fail. The axis cylinders coming from above must have free entry into the nerve below; otherwise in their downward development they will lose their way, and restoration of the nerve function will not take place. When the nerve ends are duly prepared they are brought into apposition with the greatest care. A series of very fine catgut sutures holding only the nerve sheath are inserted at intervals round the circum- 378 ABSTRACTS OF WAR SURGERY ference of the nerve. A suture is never passed through the substance of the nerve itself. In uniting the nerve ends, it is of the first importance to avoid axial rotation. We know now that there is a differentiation of function within each nerve and it is, therefore strictly necessary to unite corresponding bundles of fibers. A nerve does not act as a whole, but consists of a multitude of strands each with its proper and restricted func- tion. Unless nerve bundles which were originally continuous are brought accurately together by suture, the nerve is com- pelled to rearrange the functions of its several parts. This it can, and no doubt frequently has to, do. An examination of many cases shows, however, that a perfect and flawless recovery after a nerve suture is unusual, and it is at least a tenable be- lief that this inadequacy or delay in recovery is due to want of recognition by the surgeon of all that is needed in the technical part of the operation. My colleagues on the staff of the Second Northern Hospital in Leeds are obtaining results which in rapidity and completeness would have been thought impossible before the war. There is rarely any difficulty in obtaining accuracy of ap- position without tension. If, however, the nerve ends can not readily be brought together, various procedures may be adopted to shorten the course of the nerve. The nerve may be dis- located from its bed and laid in a new and shorter line. The ulnar nerve, for example, may be brought to the front of the inner condyle. Or flexion of the limb may be enough to allow of easy approximation. In the case of the median nerve divided low in the forearm, flexion of the wrist will give an inch or more additional reach. In other cases the limb may be short- ened by removing an inch or two of bone. It is desirable to avoid a subcutaneous course in all transferences to new posi- tions. The nerve after suture should be brought to lie in a bed of healthy tissue. It must be placed between muscles, and away from all contact with new connective tissue, which will adhere to it, and hinder its union, or cripple its subsequent action. It has been the fashion with many surgeons to surround the sutured nerve with some material supposed to have protective virtues. A piece of a vein, the saphenous for example, is threaded over the upper cut end of the nerve before suture, and after these ends are approximated the vein is drawn downward and made to surround the line of suture. In other cases, a piece of fat dissected from near the wound, or from another ABSTRACTS OF WAR SURGERY 37'J part, is wrapped round the nerve: fat being supposed to be capable of insulating the nerve in its new position: or a layer of fascia may be used, or a piece of Cargile membrane. The value of all such methods is open to serious question; it is certain that they are sometimes harmful, it is doubtful if they ever help. They prevent access of blood to the nerve by new channels, they cause adhesions and compression of the nerve and at times they are discharged from the wound almost un- altered. It is better to avoid such membranes, and to be con- tent with insuring that the nerve is laid along a path of unin- jured tissues. Where end-to-end suture is impossible a variety of other procedures may be attempted. A nerve graft, taken from a neighboring cutaneous nerve, from the radial, the inter- nal cutaneous of the thigh, or an intercostal nerve may be used. Nerve-anastomosis has been tried in a number of cases. The divided ends of a nerve are implanted into the side of a near- lying nerve; the ulnar into the median for example. This has been done both with, and without, section of the nerve fibers of the intact nerve. All such procedures are worthless and can not be too strongly condemned. Happily the resources of surgery are not at an end in all cases where union of divided nerves is impossible. Tendon transplantation, especially in the case of the musculospiral nerve, and the posterior interosseous, gives results which in point of function are almost as good as those which come from nerve suture, and in point of time are much quicker. In those cases where the nerve is partly divided, strands of intact fibers still remaining, the severed fibers are united in the same careful way, and the normal strand of the nerve bent upon itself so as to allow easy approximation of the cut por- tions of the nerve. In perhaps the majority of operations upon nerves, there is no division of fibers, but a length of the nerve is embedded in dense fibrous tissue. These cases give most excellent results. The fibrous tissue which so intimately sur- rounds the nerve is dissected away little by little. The nerve when first freed is seen to be white and shrunken; but within a few minutes it expands and takes on its normal color. After-treatment. — (1) Postural. — In those cases where flexion of a joint has been necessary to allow approximation of the cut ends of nerves the position is maintained for a period of six weeks. By this time union of the severed ends is probably well advanced. Extension by slow and most cautious degrees is then begun. If the knee has been flexed to allow the sciatic 380 ABSTRACTS OF WAR SURGERY nerve to be united, the patient can walk with a boot and leg irons, keeping the position unaltered for say two months. Wherever possible a splint is applied which produces a "relaxa- tion position." In the case of the median and the ulnar this is difficult, but is best secured by molding a "ball splint" to the hand of the patient. Every such splint must be made for the individual. In the case of the musculospiral, it is very simple. The "cock-up" splint designed by Colonel Sir Robert Jones is excellent, if the lesion of the nerve is below the branch to the supinator. It maintains hyperextension of the wrist, and reaching only to the heads of the metacarpal bone it allows a forward bend of the metacarpophalangeal articulations. The thumb lies forward and a little inward, so that the position of the whole hand is very much that assumed when a bottle is grasped. If the lesion is above the nerve to the supinator brevis, it is essential that this muscle also should be relaxed. For this purpose Cuthbert Morton has devised a splint which retains the forearm and hand in supination while the wrist is fully ex- tended, the fingers being at the same time kept in the bottle- grasping position. 2. Massage and Electrical Treatment. — These measures are re- started about two weeks after operation with all due precau- tions and safeguards. If a splint has been applied to secure the "relaxation position" it must not be removed. Indeed, not for one moment at any time must paralyzed muscles be stretched. An overstretching of a few minutes may call for diligent treat- ment of many weeks before the harm is undone. Results. — Our records are as yet necessarily incomplete. Re- covery in the case of the musculospiral has begun within 9 weeks; in the case of the ulnar within 3y 2 months; in the case of the median in 4 to 5 months. In one case of division of the inner cord of the brachial plexus, recovery in all anesthetic areas, and a degree of recovery in all muscles, occurred within 5 months. Recovery in the case of the sciatic nerve is slower. Something depends, it is sometimes said, upon the length of time elapsing between division of the nerve and its suture. My colleague, Captain Richardson, has, however, united the ends of an ulnar nerve cut across 15 years before and signs of re- turning function were seen in about four months. The dura- tion of the disability is, therefore, no bar to successful nerve repair. The functions return usually in the following order : (1) trophic and vasomotor function, (2) deep sensibility, (3) tactile dis- ABSTRACTS OF WAR SURGERY 381 crimination and localization, (4) motor power, (5) cotton wool sensation. Perfect restoration of function has been most nearly ap- proached in the case of the musculospiral nerve. In other nerves with more complex distribution, perfect recovery will depend upon a recognition of the functional localization within the nerve trunk, in addition to the most scrupulous observance of all those technical details without which there will always be something less than perfection. In the diagnosis and treatment of an organic lesion of a nerve, it should never be forgotten that there may be super- added a functional disability. It is advisable at every stage to get rid of the functional in order to properly appreciate the organic. This is particularly important when the organic lesion is well on the way to recovery. Thus, in a recovering lesion of the inner cord of the brachial plexus, it may be pos- sible for the fingers to be flexed until reeducation has trained the laggard muscles into obeying orders from headquarters. THE TREATMENT OF PERIPHERAL NERVE INJURIES.— Rev. of War Surg, and Med., May, 1918, i, No. 3. Of all the surgical specialties, none have had graver prob- lems in diagnosis and therapy than those which have fallen to the lot of neurological surgeons during this war. It is unhap- pily true that most of the moot points, vital as they are, will have to wait till time deferred before certain judgment may be practiced. It is none the less necessary, however, to take inventories now and then, in order to estimate, if not actually to measure, progress. The following report to the Surgeon General enables the reader to trace the problem of the treat- ment of peripheral nerve injur y from the beginning of the war down to date : Preliminary Treatment. — Every wound or injury of peripher- al nerves should be recognized at the earliest possible time. Areas of anesthesia, hypotonia, loss of reflexes, trophic changes, atrophy, and characteristic attitudes serve as evidence of nerve lesion. In all cases treatment should begin at once. Lyle has emphasized this in the statement : " It is imperative, whether nerve is divided or not, that the paralyzed muscles be relaxed and protected from strain by a suitable apparatus. Under no circumstances must this be deferred as an after-treatment." The postural prophylaxis begins with receipt of wound and con- 382 ABSTRACTS OF WAR SURGERY timies after operation until voluntary movement is resumed. Frequent examples of violation of this principle are too com- mon. On the one hand support of paralyzed muscles is neg- lected; the limb drops and this results in stretching of the paralyzed muscles and tendon and an almost hopeless condi- tion. On the other hand, splints continually applied holding in a fixed position both paralyzed muscles and those not par- alyzed result in extensive joint and tendon lesions. In this way fascial, tendon, and joint fixation occur. Not only should no overstretching of paralyzed muscles be permitted, but per- manent fixation of tendon and joints should be prevented by early massage. Von Lorentz urges early postural treatment and gives as an additional argument the statement that overstretching, in the case of nerve section, causes the end of the nerve to separate to so great a degree that they can not be gotten together at operation. The massage of inflamed tissues must be avoided. With the disappearance of inflammation active movement and massage is suitable. Borchardt emphasized early movement, massage, and elec- trical treatment. Even in seemingly hopeless cases massage seems to be of use, and sometimes the final result is good. Tinel urges massage, even in painful cases. Some of these contrac- tures are caused by infection. "With extensive infection dam- age is done that can not easily be corrected, and early massage is impossible. Every surgeon should know the nerve supply of the various groups of muscles, so as to be able intelligently to apply post- ural splints. Without such knowledge any explanation is difficult; with such knowledge it is superfluous. Lyle's teachings are of the utmost value and make possible a successful outcome to surgical procedure. Many of the numer- ous contributors to literature have passed lightly over, or neg- lected entirely, the question of postural treatment and mas- sage. Jones, Tubby, and Lyle are noted exceptions to this. In the light of the Canadian returned soldiers this phase of the question would seem to be of fundamental importance. As an after-treatment, massage is mentioned by Nonne and Thoele. Indications for Operation. — Clinical manifestations of nerve disturbances have as a basis, functional causes, physiological interruption, and anatomic interruption. Separation into these three classes gives a basis for surgical interference, but diag- nosis is by no means easy. Operation is applicable to anatomic ABSTRACTS OF WAR SURGERY 383 interruptions and to physiological interruptions when due to pressure of scar. In many cases distinction is made clear only by observation and time. In functional cases no pathology can be described. Func- tional cases give normal electrical reactions and are distinct from physiological interruption, although in cases of the latter definite pathology may escape observation or may have disap- peared at the time of the observation. Tubby terms physiolog- ical interruptions "concussions of the nerve." It is damage done to a nerve trunk without actual destruction of axis cylin- ders, and the damage may consist of an effusion of blood be- tween the fibers following compression of nerve against bone, caused by rapid passage of foreign body in the immediate neighborhood of the nerve. In other cases the actual lesion may not amount to hemorrhage but to a temporary anemia. Heile and Hezel state that if the nerve is grazed by a bullet, an inflammatory exudate may occur in the nerve, changing its contour. "The diameter of the swollen nerve in extreme cases may be three times that of the normal nerve." In time this exudate is absorbed, leaving behind more or less scar tissue and ad- hesions to the nerve sheath. The amount of connective tissue determines whether the interruption is physiological or anatom- ical. In addition it is recalled that rapid recovery usually fol- lows the liberation of nerves slightly bound by extraneural scar tissue (Monsaigeon). Tinel explains this on the ground of physiological interference of conductivity without occur- rence of Wallerian degeneration. These lesions can not be dis- tinguished clinically from those of anatomic interruptions. Ex- cept in cases definitely strangled with scar tissue, spontaneous recovery may follow massage and other nonoperative remedies. A full description of the pathology of anatomical separation will be deferred to that part of the report devoted to "suture." Anatomical interruption includes lesions of intraneural scar tissue as well as actual solution of continuity of nerve. Fright may cause complete or partial interruption. Unfortunately, the reaction of degeneration is common to both physiological and anatomical interruptions. However, this is usually partial and incomplete in former conditions. In addition, muscular tone in physiological interruptions is not usually lost, according to Tinel. In case of doubt as to neurological findings an expect- ant treatment would seem to be best. Tinel found that 60 per cent of nerve lesions recover spontaneously with proper post- ural, mechanical, and electrical treatment. He states the in- 384 ABSTRACTS OP WAR SURGERY dications for operation as follows: (1) Absence of regenera- tion; (2) defective, difficult, or partial regeneration; (3) com- plete interruption. Tinel states further: "Because a nerve fiber is incapable of excitement we can not conclude that it is not in spontaneous regeneration." Electrical excitability is a late phenomenon. The sensibility of nerve to pressure, formica- tion, and return of tone and paresthesia are important signs. Tinel's syndromes are important to remember: (1) Interrup- tion, (2) compression, (3) irritation, (4) regeneration. Cassirer found only 60 operative cases among 240 nerve in- juries and in only 15 was the nerve found severed. In litera- ture there seems to be a great diversity of opinion as to the advisability of early operation. Wilms makes exploratory operation to find out the condition of the nerve without wait- ing at all. He urges that it is best to operate before scar-tis- sue changes have occurred. One fails to see why scar tissue developing after operation is not as bad as or worse than might develop before. Infection is the main source of scar tis- sue. Thoele and Auerbach also advise early operation. Thoele waits six to eight weeks after healing where there is partial reaction of degeneration. If reaction of degeneration is com- plete Auerbach urges early operation if a history of infection does not prevent. In healed, formerly infected wounds he waits three months. Borchardt advocates early operation. He considers severe sensory disturbances, trophic changes, and complete reactions of degeneration as indications. Relying on neurological examinations he has operated 56 times and found pathological conditions in all but two cases. Carrel, in connection with Carrel-Dakin treatment, advised immediate suture of nerves in fresh injuries, as nerves resist infection well, and excessive retraction of the nerves is by this procedure prevented, so that subsequent operation is easy. Nonne, in presence of reaction of degeneration and anesthesia, does not urge immediate operation, but waits six or eight weeks. Ferrand says operations should never be undertaken within the first two months and sometimes urges waiting even longer. He advises operation in cases of compression or interruption, but not in partial lesions. Hoffman insists on waiting for com- plete healing of the wound. He emphasizes the persistence of bacteria in the tissues after healing, especially in fracture cases, and therefore urges a delay of from six to nine months. The persistence of bacteria in apparently healed wounds is re- markable. Gallie encountered a small abscess with living bac- ABSTRACTS OF WAR SURGERY 385 teria in a wound that was apparently healed over four months. Bone has been known to harbor infection for a longer time. The tendency of old wounds to suppurate after long quiescence and apparent healing is but another manifestation of this. Stop- ford considers cases surgical if there is no improvement after four to eight months. He also operates when improvement is checked or there are retrograde symptoms. Moynihan oper- ates in complete division of the nerve in cases of incomplete divisions or arrested improvement, and in causalgia. He waits three months after healing in bone cases and one month in other cases. He urges the correction of joint ankylosis before operating on nerves — "Do not operate until healing is complete, else infection will flare up." As an additional argument for delay, it may be stated that cases treated with massage give their first signs of regeneration in from two to four months, and in one case in nine months. Preparation of Field. — The operative field must be prepared according to approved aseptic rules, and then the limb must be draped so that at any stage of the operation it may be moved into any desired position. Use of Tourniquet. — The tourniquet gives a dry field. When it is used the tissues rapidly dry out from exposure to the air and unless prevented from doing so will suffer damage. Anemia of a limb lasting over two hours is hazardous. The pressure of the tourniquet on the nerve for a period of time greater than two hours may cause paralysis. Intraneural bleeding might be masked by a tourniquet and overlooked. In addition hemor- rhage and hematoma are complications that sometimes occur after artificial anemia. Shiffbauer, Thoele, Grosse, Lorentz, and Moynihan condemn the tourniquet. On the other hand opera- tion in a bloodless field gives an opportunity to recognize anato- my and avoids the escape of blood into the tissues. Diffuse blood in the tissues interferes. with healing. Borchardt, Gibson, and Hoffman favor the use of the tourniquet. Operative Procedures. — There are two distinct types of opera- tive procedure: (1) Neurolysis, or freeing of nerves bound by extraneural scar tissue (the so-called simple compression of Tinel). (2) Repair of complete anatomical division. The operation of neurolysis is a simple procedure consisting of free- ing nerves from extraneous scar tissue. With operation in aseptic field, with proper control of hemorrhage and suitable after-treatments, the adhesions have the likelihood of not re- turning; or their return is benign. Liberation is ineffective in 386 ABSTRACTS OF WAR SURGERY intraneural nerve scar, "keloid" or severe lesion of nerve sheath involving the nerve itself. Tinel states that in such cases, either suture or noninterference is indicated. In addi- tion to simple neurolysis, Grosse, Auerbach, Schiffbauer, and Ferrand transplanted liberated nerves to new muscle bed. Hoff- man criticises this procedure and urges in its place the invest- ment of the suture with grafts of fascia. These must be large and loose. Stoffel, in his "Review of Neurolysis" says, "Re- sults are bad after simple nerve liberation when no wrapping has been done." He urges the use of calves' veins and peri- toneum. Bittorf states that fat sheaths become adherent. He uses formalized calves' arteries and celluloid tubes. Borchardt, after two years, still clings to his fascial graft. Tuffier and Dumas, at the beginning of the war, used investments of fascia. Heile and Hezel use rubber tubes. Steinhall condemns these tubes and shows cases where they have failed. Thoele believes sheaths contract and strangulate the nerves. He advocates covering the nerves with normal attached fat and keeping the suture lines from crushing the bare nerves. Tinel condemns investing material of any kind. Moynihan does not approve of any form of material about the suture line. Nerve Suture. — Complete anatomical division may be due to section and absolute separation of the ends of nerve or it may be due to intraneural connective tissue, either combined with extraneural tissue or not combined. This condi- tion calls for cutting through the nerve and reunion by suture. Following gunshot injuries the nerves may be found either con- tinuous or divided, but completely fused in a great mass of general scar tissue. The scar may be extraneural, it may in- volve the sheath, it may appear as an intraneural diffuse or massed scar tissue. As much as 4 inches of this type of de- struction may be present. If there is complete separation, usually a neuroma occurs on either segment. To allow access to such damaged areas very wide dissection must be practiced, start being made in normal regions to either side of damaged area. Intimate anatomical knowledge is necessary. In mak- ing these dissections the nerve should not be handled. Tissues are best retracted away from the nerve. When necessary to retract the nerve this should be done with tape (Thoele) or by a rubber band (Jones). Usually the proximal portion of the nerve will be found to terminate in a large ball of scar tis- sue. This sometimes is an inch in diameter and may be more or less connected with surrounding structures. Such a mass ABSTRACTS OF WAR SURGERY 387 differs in no way from the ordinary amputation neuroma. The distal segment may also present a similar clubbed end. These masses are usually composed either entirely or to a great de- gree of connective tissue. Sometimes the connective tissue ap- pears as a tumorlike mass. At other times the axis cylinders try to penetrate the scar tissue, but are overwhelmed. When the nerve is freed examination is made to see how much is functional and how much is scar tissue. The condition of the nerve may be ascertained by incising the sheath and examin- ing for fasciculi. These have an anglewormlike appearance. It is customary to make repeated transverse sections of the neuroma until the cross section presents a normal appearance, both in the distal and proximal portions. The normal nerve presents fasciculi close together with good blood supply. De- lorme repeatedly resects until he gets good nerve. Borchardt also resects. He sometimes sutures the nerve without remov- ing all of the scar-bearing tissue if it is necessary to do this to get approximation. Dumas attempted to bridge defects in nerve with scar tissue and had 100 per cent failures. Wilms ap- proximates normal nerves but uses scar as a splint. Blood Supply of the Nerves. — The blood supply of the nerves is important both from a question of viability and the question of hemostasis. This has been emphasized by Grosse. Dumas raised the scar in proximity to the nerve as the best way to maintain the blood supply. Nerves have rather abundant blood supply and will frequently bleed on section. This vascularity is largely longitudinal, but repeated reinforcement from the periphery is received. Fifteen inches of the nerve can be stripped loose and yet retain enough circulation to give capil- lary oozing when cut. Whether this is sufficient to maintain life or not experiments will have to prove. Moynihan cautions against devascularizing the nerves. The control of intraneural hemorrhage is important. This has been emphasized by Bor- chardt, Schiffbauer, Edinger, and Lewis. Hemorrhage some- times has to be controlled by the use of mosquito forceps and very fine ligatures. This is especially difficult to do without injury to the nerve fasciculi as the minute vessels tend to re- tract into the nerve. Squeezing the nerve gently with the fingers makes the blood vessel stand out like a comedo. The use of adrenalin is not permissible. Approximation. — All operators agree that the ends of the nerve, after being freed from scar tissue, had best be approxi- 388 ABSTRACTS OF WAR SURGERY mated. Tinel says this is the only way. This may be brought about by bending the joint, as indicated by Delorme. A nerve gap of 2 inches may be overcome by moving the limb. Bor- chardt emphasized the importance of flexion. Heile and Hezel state that gaps up to 6 centimeters may be closed by flexion and liberation of the nerve. Sharp states that posture can supply only 4 centimeters of gap. The effect on the nerve by bending joints is increased by mobilizing the nerve, especially in case of the ulnar. This may mean complete dissection for 15 inches, a questionable procedure, because important motor branches have to be severed and circulation is jeopardized. Such mobili- zation might correct a gap of 4 inches. Fascicular Orientation. — The bringing together of a nerve without twisting or altering its anatomical relationship is im- portant. Stoffel has mapped out a topographical arrangement of the fasciculi. These are separated into groups with specific functions. In making suture the topography must be con- sidered. Tinel and Thoele indorse this principle. Heile and Hezel rather minimize the importance of such orientation. They use for argument the good results obtained when nerves, in former times, were united haphazard. Borchardt says cor- responding nerve tracts must be brought into apposition. Suture Material. — In small nerves Sherren advocated one through-and-through suture of chromic catgut. This does not seem to be applicable to the suture of the larger nerves. Gibson, following Thoele, uses four sutures of plain catgut through nerve sheath only. Moynihan advocates nerve sheath suture. Bonnet compares neurilemma to peritoneum in regard to suture. Heile and Hezel at first used silk, but changed later to catgut. Inter- position of blood clot in suture line will deflect axis cylinders ac- cording to Edinger. The least crushing at the point of suture will cause fasciculi to turn out. The use of silk advocated in Schiff- bauer seems unnecessary, for healing in nerve is rapid. Union of cut nerves, according to Dustin, is fairly well advanced in four days. Tension must be avoided in suture, as the very slightest traction on suture line renders proper coaptation impossible. Suture Line. — The junction is important. Thoele has urged preserving the fasciculi intact, when damage does not extend through entire section of nerve. Gibson is utilizing this principle with remarkably good results on partial lesions. He cuts diagon- ally through the damaged nerve, leaving a bridge of normal nerve so that the suture line crosses the nerve at oblique angle. From the good results obtained in this case Gibson was led to ABSTRACTS OF WAR SURGERY 389 cut all his nerves on the bevel so as to bring about a large area. Heile and Hezel speak of slitting the nerve sheath after suture to prevent an accumulation of exudate and avoid damage that might result from pressure. Bridging Gaps in a Nerve. — When, by flexing the limb, it is impossible to secure coaptation of the cut ends of the nerve, some other device must be resorted to. Even shortening of the bone has been suggested. The more logical remedies seem to be free grafts of nerve or use of hollow tubes intended for the down- growth of axis cylinders. Fascial Tubes. — The use of the fascial tube about the nerve lying in scar tissue is a question concerning which authorities differ. This has already been discussed. Lewis suggested the use of hollow tubes of fatty fascia connecting the ends of the nerve when they could not be approximated. This procedure works admirably in experimental work. Its place in surgery, according to Lewis, is not definitely established. The author of this report saw one case of beginning motor function where this had been done. Col. Starr states that isolated cases done with fatty fascial graft were successful but that there were many failures. He cited two instances where grafts were found to be mere cords of tissue on subsequent operations. Tubes of various kinds have been suggested. Edinger says human fibers grow best when the two united ends of the nerve are inserted into an agar filled artery. Cases operated upon in this way have shown reduced areas of anesthesia or return of reflexes within a very short time. Heile and Hezel use rubber tubes employing nonvul- canized pure rubber tubes. This is condemned by Steinhall, but the same idea has been suggested by St. Martin. Nerve Grafting. — The oldest type of nerve grafting to fill in a gap is that of Letievant. This author operated successfully on no case in that manner. Gratzel still used this method, calling attention to the importance of using the distal portion of the nerve for the graft and covering the entire graft with a tube of fascia. Thoele speaks of this procedure as "Peripheral Grafts." Keene and Loebker, independently, advocated a free graft of the radial in wide defects of musculospiral nerve. This method has been brought to our attention and given an experimental foundation by the work of Ingebrigtsen, who has contributed a number of articles on this subject. In one of the early ones he shows that when the bits of nerve are cultivated in vitro, the axis cylinders do not grow, but growth does occur in the syncytial 390 ABSTRACTS OF WAR SURGERY cells of Schwann. Axis cylinders will grow in vitro from nerve cells, but have no independent power of growth. In a subse- quent paper he shows that autogenous grafts undergo Wallerian degeneration and serve as a scaffolding for new axis cylinders. In this connection one recalls Murphy's neurotropism. Inge- brigtsen believes that free grafts are feasible and supports his contention by a series of animal experiments and review of the literature of nerve grafts. He recommends the use of intercostal nerves for free grafts. Sicard says where impossible to do end- to-end suture to use nerve grafts. Moynihan does not approve of free grafts. Lorentz, Nonne, and Thoele mention nerve graft- ing as possible. Gratyl states that 66 per cent of his successful cases were done by this method, while Heinemann gives 70 per cent as his figure. Tinel describes nerve grafting as the only legitimate operation for bridging gaps when done as recorded by Dejerine and Mouzon. One objection to nerve grafting seems to be the disparity in size between the nerves to be used as grafts, and the nerves that are to be grafted. Only small nerves can be sacrificed and these serve only as slender threads between the cut ends of the large motor nerves. The supply of material is practically limited to the radial or intercostal nerves. Treatment of Painful Cases. — Kaiser, in cases of neuralgia and neuritis, urges use of hot air, hot bath, massage, electrical and postural treatment so as to relieve tension of the nerves. Sicard mentions section and suture of nerve. In the localized lesion he states this is of value, but is useless in true neuritis. To relieve pain, injections of 60 per cent alcohol have been recommended by the same author. Two cubic centimeters are used. Ionization with salicylate also has been suggested. After-treatment. — In case distance has to be regained from loss of nerve substance, this is usually overcome by flexing the limb. When so flexed the limb must be immobilized for six weeks, and then gradually extended. This immobilization is mentioned by Lorentz, but is generally discarded, although on absolutely necessary procedure. Where grafts are used and there is no tension on the nerve, mobilization is used to a much less degree. Postural, mechanical, and electrical treatment should be car- ried out on every operative nerve lesion. It is remarkable to see how contractures to tendons and joints are made to lessen by gentle massage and gentle mechanical manipulation, hydrothera- peutic treatment, ionization, and electricity. The straightening of bent limbs may be done by plaster casts and wedges. Forcible ABSTRACTS OF WAR SURGERY 391 tearing up of scar tissue in tendons or joints should be avoided. Elastic traction with a variety of splints is sometimes used. With the return of voluntary movement gymnastic and reeducational exercises are employed. THE AFTER-CARE OF NERVE INJURIES.— Rev. of War Surg, and Med., May, 1918, i, No. 3. The preceding report has emphasized the absolute necessity of instituting intelligent after-care in all instances of nerve injury. The following report to the Surgeon General elaborates this topic : The after-care of nerve injuries involves two problems : first, the care of freshly wounded and postoperative cases; second, the care of late neglected cases where muscular contraction has taken place and deformity has already resulted. In one case treatment is preventive, in the other corrective. Many neglected cases may re- quire secondary operative procedures. This paper is concerned with the first class of cases and those of the second class which are capable of correction by mechanical means alone. Types of Injury. — Nerves may be completely or partially cut or torn across ; so seriously bruised that function is interrupted tem- porarily or permanently ; strangulated by pressure from contracted scar tissue. Greater or less degrees of paralysis are present ac- cording to the type of injury. The ends of severed nerves may be separated by considerable distances and operation is often a neces- sary preliminary. Postoperative treatment does not differ from that required in cases which do not call for operation, and both classes may be grouped in considering after-care. Upon the interruption of nerve function, the following effects on muscles are observed: (a) Tone and contractibility are lost. (b) Atrophy sets in, due to — 1. Lack of voluntary action. 2. Alteration in nutrition. (c) Deformity due to — 1. Stretching of the paralyzed muscle. 2. Contraction of healthy muscle. (a) Muscle tone is a condition of normal elasticity inherent in muscle fiber. Kept on the stretch for a considerable period this elasticity is lost in a manner analogous to the loss of elasticity in an overstretched band of rubber. Voluntary contraction is dependent on nerve impulse, and ceases on interruption of that stimulus. 392 ABSTRACTS OF WAR SURGERY (b) Atrophy from disuse does not differ from the wasting seen in any prolonged period of inactivity. There is in addition an atro- phy due directly to nutritive changes from loss of innervation. This affects muscle, bone, and skin and is apparent in the glossy and often cyanotic appearance of the latter. (c) Deformity occurs first as a result of naccidity of paralyzed muscle groups and may be passively corrected. The habitual posi- tion is that produced by strong or extreme contraction of the un- paralyzed groups. If this condition is allowed to continue without treatment, contractures occur in the active muscles which prevent correction of the deformity. At the same time the paralyzed mus- cles lose their tone and elasticity. If proper treatment is neglected during convalescence the nerve may recover but leave a function- ally useless limb because of the development of a permanent de- formity which interferes with effective muscular activity. It is very necessary to emphasize the fact that degeneration be- gins immediately after injury. Treatment, therefore, should be in- augurated at once and should be continuous. The objects to be achieved are — A. In recent cases — 1. Prevention of deformity. 2. Restoration of function. B. In old, untreated cases — 1. Correction of deformity. 2. Development of any remaining function. At the outset the fact must be faced that treatment is nearly al- ways prolonged and often discouraging. The repair of sutured nerves requires, roughly, a year or longer, and the surgeon 's hard- est task is to maintain his own and his patient's enthusiasm during the long convalescence. Continuity of treatment is of the utmost importance. Relaxation for a week may undo many weeks' con- structive work. The methods of treatment employed are splinting and physical theraphy of various kinds. Preventive Splinting. — Rest in splints which hold the part in an overcorrected position is essential to prevent deformity in re- cently paralyzed muscles. The required position is one of maximum overcorrection with the paralyzed muscles completely relaxed and the active muscles held on the stretch to overcome their tendency toward contracture. The types of splints supplied by the Army will be found sufficient for many cases. Where preferable, plaster of Paris splints may be ABSTRACTS OF WAR SURGERY 31>3 made and are often more adaptable to individual cases. Splints should be light in weight, clean, durable, easy to apply, and easily removed for the frequent treatments usually required. The simpler splints without mechanical adjustments are far more desirable where they yield nothing in efficiency. Adjustable splints are some- times necessary, however, but their care is more exacting, and in a busy ward there is danger of failure from their use through lack of sufficient attention. A rigid retaining splint padded with felt, as necessary for further correction, will be found to be most generally useful. Many of the cases are ambulatory, and this fact must be remembered in adapting a suitable appliance. Application of Splints. — Each case will present its individual problem and calls for special modification in the use of splints, but the following principles of treatment may be of service in ap- proaching the more frequent types of paralysis : Circumflex Nerve. — Injury to the circumflex nerve results in del- toid paralysis. The shoulder sags under the weight of the arm and power of abduction is lost. The arm should be maintained in a position of abduction at right angles to the body. To accomplish this, a splint molded to the trunk is necessary, and it should take its bearing from the crest of the ilium on the affected side, otherwise it will slide downward when the patient is in the upright position and lose its efficiency. From the body portion of the splint a right- angled armpiece runs outward at the axilla in a plane a little an- terior to the coronal plane of the body and on this rests the arm. The splint supplied for the Army — Jones Abduction Arm Splint — is well adapted to this purpose, though plaster with wire armpiece is perhaps more commonly employed and is both comfortable and efficient. Median Nerve. — Ulnar Nerve. — These nerves supply the flexor muscles of the forearm. When paralyzed the tendency will be to- ward hyperextension of the hand on the wrist and the fingers on the hand. To offset this a splint should be worn to maintain the hand and fingers in flexion. A reversal short cock-up splint with a ball or a roller bandage held in the palm of the hand will serve. A plaster splint is more convenient and is easily removed and replaced when necessary. Moderate pronation should also be provided on account of the loss of the pronator teres. Musculospiral Nerve. — Loss of the musculospiral nerve results in paralysis of the extensors of the arm, forearm, and hand. The typi- cal sign is wrist-drop and loss of supination. The cock-up splint is serviceable and the arm should be extended to relax the triceps and 394 ABSTRACTS OF WAR SURGERY held in supination. Plaster splints will again be found efficient, especially in maintaining outward rotation of the forearm. Anterior Crural Nerve. — Paralysis of the anterior crural gives loss of power in the anterior muscles of the thigh and the iliacus and pectineus which act as thigh flexors. Kicking power is absent and contraction of the flexors of the knee is to be expected. The leg should be held extended on the thigh by means of a straight pos- terior splint of wood or plaster of Paris or by means of a Thomas knee splint, which is light, easy to apply, and comfortable to wear. Sciatic Nerve. — The sciatic supplies the muscles of the back of the leg. Paralysis causes hyper extension of the knee, best guarded against by a Thomas splint. At the same time there is complete paralysis of the muscles moving the foot, and retention at right angles is necessary by means of a metal or plaster foot piece. The Internal Popliteal Nerve. — As the tibial and posterior tibial nerve, this supplies the plantar flexors of the foot. Its paralysis re- sults in the deformity of calcaneus. The foot must be held in ex- treme plantar flexion, and plaster of Paris is the most effective splinting material. The External Popliteal Nerve. — Paralysis of the anterior tibial branch, supplying the dorsal flexors, allows foot-drop and eversion. This must be met by hyperextension and inversion which may be accomplished by bending upward the foot piece of the Jones short or long leg splint, but is more commonly effected by means of plas- ter. Musculocutaneous nerve paralysis produces inversion through loss of the peroneal muscles and a position of the foot approximat- ing clubfoot. Overcorrecting clubfoot braces are useful, though here again plaster is more often employed. The splints should be comfortable and worn constantly, save when treatment is being given. During the late stages of con- valescence they should be gradually removed, at first for short periods during the day when the patient is allowed active exercise. They should be worn at night for a prolonged period after re- covery is well advanced. This extends into many weeks or months, and it is very important to keep the patient under observation dur- ing this period of splint removal, as contractures may occur long after recovery of muscle power and tone is apparently complete. Corrective Splinting. — In an old deformity resulting from paralysis of nerve there are three tissues entering into the con- tracture, ligament, tendon, and muscle. Ligaments are nonelastic; muscle possesses elasticity. Care must be taken that nonelastic tis- sue is not unnecessarily torn by efforts at forcible correction. On ABSTRACTS OF WAR SURGERY 395 account of nutritional changes, affected structures atrophy and become less resistant to trauma. There is danger of rupture of liga- ments and even avulsion of bone at the point of ligamentous at- tachment. For this reason, nonoperative correction of deformity- is always preferable in cases where it can be accomplished by this method. It is a slow and often tedious process, but eliminates the danger of injury to atrophic muscles, ligament, and bone, which may occur from rough handling under ether. Many patients have been through several operations and would themselves prefer a slower convalescence to further operative interference. If proper patience is exercised, successful correction of very ex- tensive deformity may be accomplished by gradual stretching of contractures with splints. The initial selection and fitting of the splint is of great importance, and accepted principles of splint ap- plication must be kept constantly in mind. Corrective pressure is borne on soft tissues, and the amount that can be applied is limited. Constant watchfulness is required to avoid skin or tissue necrosis. The splint should be removed at frequent intervals and regular physical treatment given both for the purpose of forestalling pres- sure injury and to increase pliability and local circulation. Skin sensation may be absent or lessened, and many patients are quite uncomplaining. The vigilance of the attending surgeon should be constant to assure as rapid correction as the skin resistance will permit. Adjustments left to the control of the patient are unwise, and the judgment of nurses and orderlies must not be trusted too implicitly. It is of great importance to gain the cooperation of the patient himself by explaining the purpose of the splint and the necessity for continuous treatment, otherwise he may loosen splints at night and retard his own recovery. Physiotherapy. — Pathology of Nerve Repair. — A severed nerve begins active efforts of repair immediately in a clean wound; as soon as infection is checked in a septic wound. The nerve ten- drils grow in loose granulation tissue and are very delicate and easily injured. During this stage vigorous treatment of the in- jured part does only harm to the new forming tissues. Gentleness is the first caution in beginning routine treatment necessary during repair of injured nerves. Position to prevent tearing of the delicate tendrils must be maintained constantly. For two or three weeks after injury or operation the splint should not be removed for treatments. As soon as opportunity has been allowed for the wound to solidify, further treatment should begin. The splint must be 896 ABSTRACTS OF WAR SURGERY removed every day or several times a day and proper physical treatment started. Treatment. — The order of application of the usual remedial measures will vary with the individual case. In general, hydro- therapy presents an early method of great value. Hot packs are useful as a preliminary to massage. Contrast baths with varia- tions from 50 to 120 degrees of temperature are of service in in- creasing nutritional repair. The whirling and bubbling baths and hose baths under heavy pressure are valuable. Electrotherapy. — Electricity in addition to its diagnostic value is of pronounced assistance as a mechanical means of stimulation to muscle. The latest type of coil, known as the Bristow coil, has become the recognized method for the application of faradism on account of its simplicity and the fact that its construction al- lows of its use without discomfort to the patient. It may not be out of place to explain the purpose of electricity. Too often the lay impression that electricity possesses some miraculous force which it can transmit to nerves prevails among our profession. The action of electricity in the recovery after nerve injury is upon the muscles alone and not the nerves. Its first effect on muscle tissue is to maintain tone and aid nutrition by direct stim- ulation of muscle fiber. Secondly, it produces contraction of muscle in the early stages of reinnervation during convalescence and thus exercises the feebly contracting muscles and hastens the return of power. Thermotherapy. — Heat may be applied by means of hot baths or baking chambers. "While kerosene or gas may be used, an elec- tric cabinet will prove more convenient and is usually available. Extraordinary temperatures may be borne by the perspiring skin and nutritional improvement follows their use. Both hydro- and thermotherapy are most useful as preliminaries to massage. Massage. — This is the most useful and generally applicable method of physical treatment in these cases. Many inventions have sought to supersede the human hand as instruments of mas- sage but without success. Attention should first be paid to main- taining the nutrition of paralyzed muscles. The overlying skin, often atrophic, benefits equally from the treatment. As ex- plained in discussing the pathology of nerve repair great gentle- ness should guide the masseur during the early stages of work with recent injuries. Effleurage and wholly passive treatment with the part retained by a proper splint is followed gradually by more vigorous methods during temporary removal of the splint. Work should be done with the paralyzed muscle relaxed ABSTRACTS OF WAR SURGERY 397 and the deformity overcorrected and the patient's position while being massaged must be wisely planned. For example, in wrist- drop have the hand in supination and the reverse in paralysis of the median and ulnar nerves. In circumflex involvement, the patient should be lying on his back and the arm raised beyond a right angle in abduction. Likewise in foot-drop a prone position with foot hanging over the edge of the table will lessen the tend- ency toward plantar flexion, or the patient may be made to sup- port the foot at right angles by holding the ends of a bandage looped about the toes. The selection of efficient operators is a matter for careful con- sideration. Not only should we insist on well trained and experi- enced masseuses but they should not be expected to undertake too many cases in a day. It has been found in English hospitals that one operator can care for about 15 cases. If more than 20 cases are assigned to one masseuse the quality of her work de- teriorates noticeably. Corrective exercises should follow the gentler forms of mas- sage necessary in freshly wounded cases, and are begun at once in older cases with deformity already developed. Force should be wisely graded, as it is in this type of work that much damage may be done through the use of too vigorous methods. Resistive and assistive exercises are of great benefit in the development of muscular strength and the reeducation of the patient in the use and control of muscle. Finally it is the duty of the masseuse to follow up the patient even after he has recovered sufficiently to begin active exercise and training in the curative workshop. Supplementary massage and direction is often of great assistance at this time in hasten- ing the wounded man along the road toward the complete restora- tion of voluntary function. JAWS AND FACE EARLY CARE OP GUNSHOT WOUNDS OF THE JAWS AND SURROUNDING SOFT PARTS. (Submitted by Subsec- tion of Plastic and Oral Surgery of the Surgeon General's office as a basis for lectures to be given in Medical Officers' Training Camps.) Of not uncommon occurrence in the present war are those distressing wounds of the face and jaw bones which have at- tracted particular attention not only on account of the disfigure- ment which they cause, but even more so from the difficulty that was at first encountered in dealing with them. This difficulty is the logical outcome of an attitude that regarded dentistry and surgery as two distinct and separate professions. As long as this theory was allowed to dominate practice, a man who had an exten- sive injury of the face and jaw bones had about as much chance for an ideal result as had the man with an open fracture of a limb in the days when the physician and the bone setter could find no common ground upon which to meet. The bone setter and the physician who refused to recognize the surgeon, are of the past, but the surgeon and the dentist in their relation of each other only too frequently perpetuate the agnosticism of those older prac- titioners. It is now accepted as axiomatic that in dealing with an open frac- ture of the thigh, the fixation of the bones and the treatment of exposed tissues should be concurrent, and that early treatment is one of the most important factors. It is not universally recognized that these same principles hold in the treatment of a wound in- volving the jaw bone and the soft tissues, whether it be the result of an industrial accident, a removal of a tumor, or a war injury. The surgeon has expended much study upon making himself master of the various means of splinting the injured limb, but proper fixation of a fractured jaw can only be done by the use of dental splints. These he can not apply himself, and he has not al- ways sought the help that the dentist could so easily lend. The late von Langenbeck, after the war of '70-71, said, "I would not care to go through another campaign without the help of skilled technicians to aid in the care of these jaw injuries." 398 ABSTRACTS OF WAR SURGERY 399 The surgeon is not technically trained to splint these cases, yet early proper fixation is one of the most important points of the treat- ment. The dentist as such is not trained to care for the wounded tissues beyond fixation of the bones, yet repair of the soft tissues and proper drainage may be equally important. A few have bridged this "no man's land" between surgery and dentistry, re- cently a much larger number have learned cooperation, but today I believe that the majority are pursuing their separate ways, that a patient with a jaw injury will be treated either by a surgeon or a dentist, neither of whom is master of all of the problems, and that either the fixation or the care of the tissues will suffer ac- cordingly. Of the two, the dentist is the one more likely to recog- nize his need of help. It is or has been the custom to transport these cases back to special centers where qualified men are stationed. In the meantime the patients receive what might, for want of a better term, be called general treatment. We have recently been told by Crile that the most important step in the preparation for the care of our wounded is to plan to give them the proper operative treatment within the first twelve hours, and if this is done, that primary union may be obtained in 90 per cent and that gas gangrene, etc., may by this means be eliminated. This may be too much to expect literally of mouth injuries, but I feel absolutely certain that in over 90 per cent of these cases earlier treatment would accomplish even better results than late treatment where reconstruction must overshadow conservation, and that Kazan jian, Morestin, and the others, could accomplish even better results in the individual cases with less effort and less distress to the patient, if they could have their plan of treatment started in the earlier hours after the injury, than later when the wound is complicated by infection muscular spasm, infil- tration of the tissue or scar contraction. In the light of our past clinical observation and of what we have learned from workers abroad it is our hope to place in every evacuation, base and recovery hospital, men who are familiar with the problems and technic of dealing with these face and jaw in- juries so that from the very first each of these patients will re- ceive the best that surgery has to offer. Early Wounds. — Under this heading would be included wounds of twelve hours or less, but about the face where the blood sup- ply is excellent, wounds of twenty-four hours' duration or even longer might under certain circumstances fall into this class. 400 ABSTRACTS OF WAR SURGERY Three objects are to be attained in the treatment of any wound : (1) control of hemorrhage, (2) control of infection and (3) ana- tomic restoration. The means of accomplishment of each one of these is closely allied to that used to attain either of the other two. Control of Hemorrhage. — The simplest procedure is the sutur- ing of the separated tissues, larger bleeders when seen may be caught and tied, while bleeding from depth may require packing or ligation of an artery in continuity. Ligation of a lingual artery, when indicated, is as a rule a very satisfactory operation, because it is almost terminal in its distri- bution. Ligation of the trunk of the external carotid is very much less satisfactory except for wounds of its primary divisions, be- cause the anastomoses are so free that the bleeding may scarcely be influenced. A serious objection to ligation of the external carotid is that of sepsis and secondary hemorrhage occurring at the site of the ligation, necessitating ligation of the common carotid. A good rule is to ligate all branches of the external carotid as far as possible from the parent trunk, and not to tie the ligature sufficiently tight to crush the wall of the vessel. Approximation of the intima is all that is needed. The common carotid should be tied only when absolutely neces- sary. The risk to life and brain function is very great. Hemorrhage from the posterior part of the tongue may require ligation of a lingual artery; bleeding from further forward is usually controlled by one or two deep sutures, possibly tied over a piece of gauze. Hemorrhage from the pharynx may strongly suggest the ligation of an external carotid but it is important to determine which one is involved. By alternate compression of the common vessel against the carotid tubercle on each side with careful sponging, a valuable hint may be given as to which is to be attacked. Bleeding from the cavities of the face, natural or artificial, is as a rule best treated by packing with mildly antiseptic gauze. Iodoform with balsam of Peru or even other noncorrosive antiseptics may be used, but these packs should not remain in place, without being changed for more than 24 hours and should in almost every instance be put in from the mucous surface. Even the pharynx may be packed tightly after a tracheotomy. In the neck and submaxillary region, the wound should be enlarged and the bleeding point ligated. ABSTRACTS OF WAR SURGERY 401 Prevention of Sepsis. — This is to be accomplished by (a) the removal of foreign bodies and damaged tissue, (b) control of hemorrhage, (c) early accurate approximation of the tissues without undue tension, (d) rest of the parts, (e) drainage of all actual or potential pockets. In the bony part of the face, bone fragments or projectiles may be lodged and require special procedures for their detec- tion, but if seen early, careful palpation will reveal even very small bodies lodged in the pharyngeal wall, the tongue, cheeks, or floor of the mouth. In a patient with a muscular neck external palpation is much less satisfactory. All absolutely dead soft tissue should be removed and when not too extensive it is better to cleanly excise all badly contused tissue that borders wounds. All absolutely free bone spicules should be removed, but no fragment that has any attachment should be disturbed. Control of hemorrhage has already been considered. Approxi- mation of the tissues and drainage will be taken up later. Rest of the bones will be considered under splinting. Physio- logic rest is as important as in any case of injury. Nothing will interfere with the rest more than lack of proper breathing space. Immediate Fixation of Fractures. — Partly from want of early treatment, cases of gunshot fracture of the jaws are often received in base hospitals with marked deformity, the wounds septic and inflamed. If the injury is in the region of the symphysis, with part of the chin carried away, the two halves of the mandible are apt to fall together toward the median line, narrowing the arch. In lateral fractures, the larger fragment is drawn over toward the affected side. The longer these displacements are allowed to con- tinue, the greater the difficulty experienced in reduction. In the treatment of gunshot fractures of the jaws and associated wounds of the soft parts, practically all workers in the war zone are agreed that the chief aim should be the reestablishment as soon as possible of the normal occlusion of the remaining teeth of the two jaws together with early closure or approximation of the soft parts with provision for adequate drainage. The principle should be in- augurated at the front where the treatment given should be part of a general plan to be followed throughout. Several methods of temporary fixation of the fracture are available, according to the needs of individual cases, as follows: (a) If the upper jaw is intact, a roll of softened dental model- ing composition is placed between the teeth, and the upper and 402 ABSTRACTS OF WAR SURGERY lower teeth brought into as nearly correct occlusion as possible, the composition being then allowed to harden in position. Addi- tional stability is afforded by a chin cup of modeling composition, held in place by an elastic head band. This method has the dis- advantage that no breathing space is afforded between the teeth, and no provision is made for accommodation of swelling of soft parts within the mouth. (b) A stock splint of suitable size made on the Gunning idea, of aluminum, may be used to hold the parts temporarily in approxi- mate position. It is applied by filling an upper and lower groove that receives each dental arch with softened modeling composition and forcing the teeth deep into the composition with the fragments of the fractured arch in relatively good position. The chin is then supported by a chin cup and elastic head bandage. A splint of this type fixes the mouth with the jaws partly open, thus providing breathing and feeding space, and room for the tongue to swell. (c) Pickerill's modification of the Kingsley splint has the ad- vantage that the mouth may be opened. It consists of a tray of light metal, with arms made of stout wire soldered to the body, and made in several sizes. The splint is first tried in the mouth over the teeth, and if too deep at any point is trimmed with scissors and otherwise adapted with pliers. Modeling composition softened in hot water is placed in the splint and the latter is then pressed down into position over the teeth and the jaw, care being taken that the fragments are in normal position. A bandage is passed under the mandible up between each arm of the splint and the cheek, over the arm and down under the mandible, where it is tied firmly. (d) Intermaxillary fixation by direct application of wire liga- tures to the teeth of the upper and lower jaws is often of value either as a temporary or a permanent measure. For this purpose flexible iron or brass wire, 24 or 26 gauge, may be used. The wire, cut into a 13-inch length, is bent in the middle, and by means of forceps is passed from the lingual surface through the interdental space on each side of the tooth to be ligated. An assistant holds the loop of the wire well down on the lingual side of the neck of the tooth, while the operator, having obtained a firm grasp on each end, makes a twist of two full turns. This is the most im- portant part of the application of the wire ligature. It should grasp the neck of the tooth so firmly as to preclude any motion. The ligature can be tightened with hemostatic forceps, but it is better to get the tension while the first twist is being made. The ABSTRACTS OF WAR SURGERY 403 serrations on the jaws of the forceps weaken the wire wherever they grasp it. If possible, ligatures are applied to two adjacent teeth on either side of the fracture and to two corresponding teeth of the upper jaw. The upper wires are then twisted with the lower, the wire around the more posterior of the two lower teeth being twisted with the wire around the more anterior of the teeth above and vice versa so that the wires are crossed. While the upper wires are being twisted with the lower, the teeth should be held in occlusion by pressure from below the chin. It is extremely important that the teeth be held in proper occlusion while the wires are being tightened. Wire ligatures put on by this method will not slip or become untwisted, but the incisor teeth offer poor anchorage, and, owing to the slight constriction at its neck, the ca- nine is a difficult tooth to wire. In fractures of the upper jaw, to prevent displacement, the metal Gunning splint may be applied with a bandage under the chin. Where there has been extensive comminution of the bones of the nose and upper jaw regions, the bandage should not make pressure over these parts. Closure of Soft Parts and Drainage. — Wounds of the soft parts, if seen early before infection has occurred may frequently be im- mediately repaired by suture. The wound is cleansed of all blood clots, hemorrhage is controlled and foreign bodies are removed; with the latter are included totally detached bone fragments. Above the lower border of the body of the mandible, local and gen- eral conditions permitting, immediate closure of the wound should be made, but all shredded and pulpefied tissue is removed by clean excision, no attached fragments of bone being removed. If the defect is too large for simple suture, then, local and general con- ditions permitting, undermining of the borders may be done with provision for drainage of these pockets, or the wound is closed by flap operation. If the parotid duct is severed, provision for drain- age into the mouth is made. In the neck there are two especially notable danger zones in reference to subsequent infection: (1) The lower parts of the subfascial spaces that lead directly into the mediastina and (2) the immediate wound area about the ligated carotid or carotid primary branches. In the first instance the dan- ger is that of mediastinitis, whereas in the second it is the possi- bility of secondary fatal hemorrhage. The blood supply, and there- fore the resistance to sepsis, is not as good in the neck as on the face. Recent wounds, after proper preparation, are sutured with ample provision for drainage. If the deep subfascial spaces are 404 ABSTRACTS OF WAR SURGERY opened, in the deepest part of the lower end of each invaded space a small strip of gauze packing is placed. If one of the primary branches of the external carotid artery is divided, this part of the wound is packed, because sepsis here predisposes to fatal secondary hemorrhage. A wound in the trachea or larnyx may be sutured, the more superficial part being packed to furnish drainage away from the tracheal lumen. A wound of the pharynx or esophagus is sutured and the line of union reinforced by some superimposed tissue, but the mediastinum is guarded by a light packing at the lowest part of the wound. These packs are not al- lowed to remain when fouled. A complete wound through the floor of the mouth, as Billroth long ago pointed out, should never be primarily sutured on account of the danger of indurating in- fection and secondary hemorrhage. If the bones are involved then the remaining portions should be splintered in their proper posi- tions and no attached fragment removed. Every pocket, every open bone cavity including the maxillary sinus, and the lower end of every fracture line should have efficient dependent drainage. If this is done early, it is surprising to note the conservation and regeneration that may result. After the bony fixation and drain- age have been provided for, then the soft parts may be repaired as outlined above. The necessity for late repairs will largely be in in- verse ratio to the early care that the case has received. The swelling of the tongue and other soft tissues as well as nasal obstruction often renders breathing difficult in cases of gunshot injury of the face and jaws. Owing to the high mortal- ity following it, tracheotomy should be avoided if it be possible to ensure a sufficient amount of air by any other means. Draw- ing the tongue forward and maintaining it in this position by a thread attached to the chin with adhesive plaster, or the inser- tion of rubber tubing through the mouth and passed well back into the pharynx will in many cases allow of adequate respiration. ' Control of Sepsis. — Early localized sepsis in a wound may at times be controlled by excision of the walls. This refers particu- larly to gas bacillus infection. Diffuse indurations are best treated by hot packs or ice, with incision of softened areas, the wound itself being treated by accepted antiseptic methods. As a rule, little is accomplished by early incisions in rapidly extending indurations except the type known as Ludwig's angina. (See Blair's "Surgery and Diseases of the Mouth and Jaws," 3rd ed.) Every softened or brawny area should be incised and given de- ABSTRACTS OF WAR SURGERY 405 pendent drainage. If cavities are opened within the mouth, especially where they lie close to the bones, careful repeated pack- ing of these cavities should usually be practiced. Careful atten- tion to this will do away with the odors that frequently render these cases so objectionable. Frequent irrigation of these cavities with peroxide of hydrogen is not as satisfactory as repeated packing where it can be practiced. Secondary Hemorrhage. — Secondary hemorrhage is the result of sepsis, by which the temporarily occluded artery is again opened. This usually occurs six to eighteen days after the in- jury. The first consideration is the control of the bleeding, but the presence of the sepsis should not be forgotten. Measures that stop the hemorrhage but further the sepsis are as a rule to be condemned. Where it can be practiced, the wound should be cleaned out and the bleeding controlled by simple or antiseptic packing but no corrosive antiseptic should be used. "Where such is packed, the packing should be changed sufficiently often to encourage control of sepsis regardless of the recurrence of the bleeding. Rest of the parts is important. For many cases liga- tion of the contributing artery only in its course is indicated. In ligating the branches of the external carotid this could be done as far from their origin as possible, and great care should be exercised not to transfer the infection to the site of ligation. Secondary hemorrhage from the external carotid itself is only to be controlled by ligation of the common carotid, which is fol- lowed by a high mortality rate. Our observation has not led us to believe that this mortality is to any great extent lessened by gradual occlusion of the common carotid. Secondary Repair of Defects. — The operations for the repair of defects that have not been closed immediately after the in- fliction of the wound, may be undertaken as soon as sepsis is con- trolled, clean healthy granulations have been established, and all dead bone thrown off. Before closure of a defect is undertaken, all binding scars should be removed. In making these repairs the neighboring tissues may be drawn into the defect to a certain ex- tent, but it is better to use pedicled flaps from neighboring areas or the arm than to simply draw the tissues together over large defects. Feeding During the Treatment of a Fracture of the Jaw. — Food and fresh air are important factors in the treatment of any frac- ture. With a fracture of the jaw, especially if the jaws are wired together, especial attention must be paid to the feeding. With an interdental splint, ordinary soft foods and chopped meat can be 406 ABSTRACTS OP WAR SURGERY taken from the first. When the jaws are wired together, the diet must often be restricted entirely to fluids. Diet. — A consideration of the methods of administration and the character and variety of food in individual cases is of the ut- most importance when a patient has to be on a liquid or semisolid diet for weeks. As much variety as possible is essential in order to provide sufficient nourishment. The patient on liquid diet loses weight at first, but after a time with proper selection and variation he begins to regain it. Not all patients thrive on a purely albumi- nous diet, and it is well to mix it with liquid potatoes, gruels, and fruit juices. Especially in older people highly albuminous diet is apt to cause diarrhea. The method of administering liquid food to be resorted to ac- cording to the exigencies of the case are: 1. Sucking through a porcelain goose-necked feeder. 2. Funnel with tube to pharynx through mouth. 3. Tube to the stomach. 4. Tube through the nose. It is surprising what can be administered through a half-inch tube introduced into the back of the mouth, even in the way of mashed potatoes, minced meat, etc. Semisolid Dietary for Convalescent Patients. — Same as above in 4 hourly feeds. In addition: Baked custard Strained fruit juice or stewed fruit Jelly Benger's food Bread and milk Porridge (Per diem) Convalescent Semisolid. — Breakfast: 7:45 A. M. Porridge, 1 pt., milk, 1 pt., sugar. Tea, thin bread and butter. Alternative, bread and milk or gruel. Luncheon: 11:00 A. M. Bread and milk, or beef tea, with bread. Dinner: 1:00 P. M.. Minced meat, mashed potatoes, greens. Milk pudding. Tea: 4:00 P. M. Tea, or bread and milk; 2 eggs lightly boiled, poached, fried or scrambled. Bread and butter. ABSTRACTS OF WAR SURGERY 407 Supper: 7:00 P. M. Cocoa, 1 pt., or bread and milk. A No. 18 French gum catheter introduced low in the esophagus through the nostril and anchored to the lip with adhesive plaster is usually well tolerated for weeks, and through this, liquids may be given through a funnel or semisolids may be forced from a syringe. If the catheter is placed too deep in the esophagus, fluids may re- gurgitate through the tube and a slip on the tube may be necessary. If the tube is not sufficiently far down, food may regurgitate around the catheter. For convenience, the following summary of dietary, taken from Kazanjian, comprising the range of liquids, serniliquids, and semi- solid diet, is given here. Summary of Dietary in Acute Injury of Jaw. — Liquid through esophageal tube or mouth tube. Every 2 hours during day. Every 4 hours during night. Milk 1 pt., egg 1, or strong soup, or Benger's food with egg; or Bovril made with milk, or thin arrowroot. with Valentine's meat juice; or boiled custard with addition of stimulants — brandy or port wine as ordered. Basis of dietary 24 hours: Milk, 4 pts.; eggs, 4; soup, 2 pints. Five hundred grams of perfectly fresh chopped lean beef with an equal quantity of water, soaked for six hours at an ice-cold temperature, will when the fluid is pressed out, yield 500 cubic centimeters of rich beef juice which may be taken raw or put into soups. The juice expressed from boiled or baked meats is much more palatable, but not so economical. Of course, no dependence should be placed upon beef tea or clear soups. Definitive Methods of Fixation of Jaw Fractures. — Definitive immobilization of the bones can usually be carried out within a few days at a time when the fractured parts can still be moved freely. The former occlusion of the lower teeth with the upper should al- ways be the guide in fixation of the fragments, even though this entails considerable separation between the fractured ends. The form of fixation to be applied depends on the location of the fracture, the amount of substance lost, the amount of displace- ment, the number, condition, and position of teeth present. Below is given a rational classification of gunshot fractures of the jaws, with an indication of the form of apparatus best adapted to each type. 408 ABSTRACTS OF WAR SURGERY The selection and adoption of the best method of fixation for individual cases must be left to the ingenuity of the surgeon and his assistants. In a general way, any method of fixation that is effec- tive and allows the mouth to be open, is better than one in which the jaws must be kept closed. The latter interferes with mastica- tion, predisposes to ankylosis, and hinders drainage. A. Recent Fractures.' — 1. Fracture of the body of the mandible anterior to the last existing tooth without loss of substance. Fractures of this type frequently occur from concussion, where the projectile does not strike the jaw itself, or if so has largely spent its force. They may be treated by methods of fixation em- ployed in civil practice, among the best of which are the vulcanite or metal jacket splint made to fit over several teeth on each side of the fracture, i. e., Gilmer's lingual band splint (see Blair's Sur- gery and Diseases of the Mouth and Jaws, 3rd ed., p. 116) may also be found useful. 2. Fractures of the body of the mandible anterior to the last ex- isting tooth, with few teeth, considerable displacement, or loss of substance. In this class are found the majority of gunshot fractures. "When there is loss of substance at the symphysis, the fragments tend to be drawn together in front with the occlusal surfaces of the teeth facing inwards toward each other. In the lateral portion of the bone, the loss of substance causes the fragment on the sound side to be drawn over to the affected side. The best method of main- taining separation and fixing the fragments in their normal posi- tions in relation to the upper teeth in these cases is by the metal band and wire splint, either made in one solid piece or applied in sections afterwards fastened together. In the making of this splint, several teeth on each fragment are fitted with ready made thin copper bands of suitable size, trimmed and bent so as to leave the occlusal surfaces free. With the bands in place, an impression is taken, a cast made, cut at the line of fracture, and reassembled with the lower teeth occluding properly with the upper. The bands of each segment are then soldered to form one piece, and the two sides united by soldering a heavy wire or metal band which passes across the seat of fracture. The piece is then cemented to the teeth in the mouth. In difficult cases, this splint may be made in two sections applied separately, and afterwards fastened together with liga- ture wire. In cases with considerable loss of substance, where there is a ABSTRACTS OF WAR SURGERY 409 tendency for the lower jaw to swing over to one side, the outer sur- face of the splint on the opposite side may be provided with a metal- lic flange to engage the teeth of the upper jaw, thus acting as an inclined plane to bring the teeth into proper occlusion when the jaws are closed. 3. Fracture of the mandible behind the last existing tooth. The form of apparatus is selected to best suit the individual case. These cases comprise fractures of the body of the bone, ramus, or condyle, with or without loss of substance. Where there is no ten- dency to displacement and no loss of substance, the simplest form of treatment is by fixation of the lower jaw to the upper by means of ligature wires directly applied to the teeth or through the inter- vention of bands and arches around the teeth. In fracture of the angle and ramus with loss of substance, if the ramus stays in good position this form of wiring may be sufficient, but if the ramus displaces forward or laterally, after fixing the an- terior fragment by wiring the teeth to those of the upper jaw, the ramus may be steadied in position by drawing it back with a hook passed around it through the cheek, or a lion- jaw forceps catching it through the skin, and then placing modeling composition be- tween the ramus and the last molars above and extending down behind the molars below. Fractures in this region may also be treated through the medium of upper and lower swaged metal jackets applied separately and then fastened together by means of ligature wire attached to the hooks provided. Occasionally also, in cases where there is tendency for displacement of the jaw to one side, the hooks on the splint afford attachment for intermaxillary elastics, this force being used to overcome the deviation. Where it is desirable to dress the jaw with the mouth open, and prevent forward displacement of the ramus, the splint de- scribed by Herpin is applicable. This consists of metal bridge with a vulcanite extension backward which embraces the anterior edge of the ramus of the jaw, preventing its forward displacement. If necessary, the vulcanite piece may be made removable, and can be provided with a jackscrew extension apparatus so that the ramus can be gradually forced backward if forward dislocation has oc- curred. Gunshot Fractures of the Upper Jaw. — (a) Partial fractures as a rule are easily maintained in position by some form of appliances such as a band and wire splint, or a swaged metal jacket attached 4.10 ABSTEACTS OF WAR SURGERY to the upper teeth. In unilateral fractures ligation of the teeth of the sound side to those of the lower jaw is often efficient. (b) In transverse fracture of the entire maxilla, the reversed Kingsley bar splint combined with a head cap as described by Mar- shall (Blair, p. 90) is suitable. It consists of a swaged metal or vulcanite piece on the upper teeth with heavy iron wire bars pro- jecting from the angles of the mouth to provide attachment to the head cap. The head cap may be made of woven material, netting, metal bands, celluloid, plaster of Paris, etc. (c) In comminuted fractures, or those associated with much loss of bone, the modification of the Kingsley splint is not applicable, for the upward pull of the bands will tend to displace the palate and alveolar parts upward. In such cases a swaged metal splint is cemented to the upper teeth and attached to a fixed head cap by metal rods that "will hold the dental arch in its proper relation to the lower and maintain its proper distance from the base of the skull. B. Old Fractures of the Mandible with Partial or Nonunion, and the Fragments in Bad Position. — By carrying out the principles of early treatment outlined above, it is hoped that the number of fractures in this classification will be much reduced. For these cases, two general methods of treat- ment are available: 1. Operative Treatment. — The method of choice in these cases is, under local or general anesthesia, to divide adhesions, fibrous bands or callus bringing the fragments into their correct re- lations, and fixing them there by means of any of the appliances described in the previous section suitable for the given case in hand. Considerable gaps in the bone, even amounting to several centimeters in width, produced by the readjustment of the frag- ments, may be in time solidly filled with new bone. If nonunion persists after several months' trial, the case may be considered suit- able for replacement of the lost tissue by bone or cartilage graft- ing. It is in these late cases especially that the inclined planes made by flanges of suitable shape to engage the teeth of the op- posite jaw, are of especial value in overcoming the tendency to re- turn of the fragments to their old incorrect position. In operat- ing on these cases, after dividing cicatrices, the separated tissues may be kept apart by means of softened modeling composition pressed into the wound. 2. Orthopedic Splints. — In cases of displacement of lesser degree, ABSTRACTS OF WAR SURGERY 411 or where for some reason operative measures are not to be con- sidered, orthopedic splints for the gradual restoration of the frag- ments to their normal position may be employed. Great ingenuity is manifested in the adaption of these principles to individual cases. The forms of apparatus most commonly used for this purpose are : the sectional band and wire splint, the jackscrew, and lugs and in- clined planes. Bandaging 1 . — Bandaging in connection with fractures is of im- portance. The most useful bandage is modification of the Barton, which avoids the disadvantage of the latter in making backward pressure on the chin. An elastic bandage, preferably a piece of rubber dam 3 inches wide, if not put on too tightly, is more com- fortable and more effective than a nonelastic bandage. SURGICAL AND PROSTHETIC TREATMENT OF FRAC- TURES OF THE JAWS BY WAR PROJECTILES, IN AN EVACUATION CENTER.— Frison, Dufourmentel, Bonnet- Roy, and Brunet. Paris Med., 1917, vii, p. 202. The privileged situation of the writers in a very important evacuation center in the immediate neighborhood of the front, giving them care of the wounded within a few hours, has per- mitted them to gather some valuable personal experiences on the constant and intimate collaboration of the surgeon and the prosthetist. Immediate Surgical Treatment. — A certain number of simple fractures by shock, falling or even by projectile, has been ob- served, but the great majority of mandibular fractures pre- sent themselves with the usual characters of war fractures, i. e., they are comminuted and infected. The course to be immediately followed, however, will differ in the two cases. If it is universally admitted now that as perfect toilet and aseptization as possible of a region of frac- ture of the limbs is the absolute rule, in mandibular fractures, according to their experience, this can be followed only to a limited extent. Infection is constant and inevitable, since saliva, food, nasopharyngeal secretion maintain it. No opera- tive measure will prevent an open fracture of the jaw from being infected and reinfected incessantly. On the other hand, if infection is constant, it is never grave, so to speak, and puru- lent collections which can occur secondarily in the neighbor- hood of the wounds are of little importance. The grave infec- 412 ABSTRACTS OF WAR SURGERY tions common to fractures of the limbs are never to be feared, and gaseous gangrene in particular is unknown in this region. This is because the seats of fracture are drained normally both externally and by the mouth, the salivary flow sweeps them in- cessantly, moderating the infection as well as maintaining it, and there is no doubt that these peribuccal regions have better defenses than the majority of others. The floor of the mouth itself, considered as a frequent seat of grave phlegmons, is never the source of serious menace. The writers have only observed one case of local infection with rapid progress and disquieting symptoms in a wounded man who carried a shell splinter which had penetrated by the mouth and had left around it no drainage opening. There was also no mandibular fracture. A submental incision quickly cleared up the case. However, the toilet of the wound should be made for the purpose of relieving it of all kinds of debris (broken teeth, fragments deprived of periosteum, shreds of soft tissue), and above all to forestall secondary hemorrhage. The latter, in fact, results most often from the presence of traumatizing splinters, and it is generally the lingual artery that is torn by them in the floor of the mouth. But to practice this toilet no sort of anesthesia, no bistoury, no curette is needed. The fingers and a pair of forceps nearly always suffice. The free splinters are lifted out, in places a still adherent shred of periosteum is detached, to be left in the wound; sometimes a cut with scissors is necessary to free a poorly detached shred ; sometimes again the pointed end of a utilizable fragment is taken off with a rongeur. All this is only slightly painful, slightly bloody, and rapid, and possesses the double advantage of avoiding anesthesia, which augments the predisposition of these wounded men to pulmonary accidents, and incisions more disfiguring than before. Finally, and above all, if the remain- ing splinters of bone should be cast off eventually, they do not carry with them their periosteum, which will constitute valu- able centers of osteogenesis in the loss of substance. The enormous serosanguineous infiltration of the floor of the mouth which is frequently observed, disappears of its own accord in a few days, and does not contraindicate this conserva- tive treatment. The role of the surgeon is not limited to this. He must also safeguard respiration and alimentation. For the first, it suf- fices to assist the lack of support of the tongue by application ABSTRACTS OF WAR SURGERY 413 of a traction thread attached to the dressing. If the patient is not put to sleep, tracheotomy is always avoided when the traumatism is anterior to the pharynx. For feeding, almost always possible spontaneously, the application of an esophageal catheter will suffice in all cases. WAR INJURIES OF THE JAW.— N. G. Bennett. Practitioner, London, 1917, xcix, p. 201. Early treatment consists in control of hemorrhage, support of fractured portions of the mandible, and abatement of sepsis. Support with a four-tailed bandage should be condemned, as it compresses the fragments and results in a contracted bone. For the sepsis, almost constant irrigation with Wright's saline solution, or nonirritant antiseptics, such as hydrogen dioxide, boracic acid, hypochlorous acid, or permanganate of potash, is employed. The use of the compressed air spray and local ap- plication of 2 per cent tincture of iodine is advised. Extraction of Teeth and Roots. — As soon as possible all loose teeth, broken teeth, and septic roots should be removed, as well as the teeth in the immediate vicinity of the fracture. There are exceptions to this rule, and judgment is required. The suc- cess of subsequent treatment for the correction of displacement may depend very much upon the opportunity of fixing splints to the teeth, and even a loose or broken tooth may be of great value temporarily even though it is extracted later. As regards the teeth adjacent to the fracture, removal promotes union, but, on the other hand, their presence often served, for the time being, to prevent dropping together of the fragments into false positions, their extraction, therefore, should usually be deferred until a splint has been fixed, or at least is ready for fixing. The objects ultimately to be attained are : (a) Firm union of the fractured portions of bone. (b) Restoration of the jaws as nearly as possible to their nor- mal form and function, with normal occlusion of the teeth. (c) Replacement of lost portions by prosthetic appliance. (d) Union of the soft tissues, with as little contraction and scarring as possible, by immediate suturing or gradual healing by granulation, or with the aid of subsequent plastic opera- tions. The amount of bone destroyed determines to some extent the ultimate result to be attempted, and therefore the methods to be employed. If new growth of bone can reasonably be ex- 414 ABSTRACTS OP WAR SURGERY pected to fill the gap, correct treatment consists in reducing the parts to their normal positions, and holding them there firmly by means of an intraoral or other splint. If this can not be expected, then the question arises whether the normal mandibular contour and dental occlusion should not be sacri- ficed to some extent, in order to approximate the fragments and obtain firm bony union rather than an unsatisfactory fibrous union. "With loss of bone up to half an inch in length, bony union may be expected with some confidence. "With a loss up to three-quarters of an inch, or even more, it is not impossible under favorable conditions, without the aid of a bone graft. Beyond that length, replacement by natural growth can not be expected, and the initial course of treatment is to some extent determined by the intention to make use of a bone graft ulti- mately. Larger losses involving most of one side of the hori- zontal ramus are probably beyond the aid of a bone graft. When the case comes under treatment reasonably early, two courses present themselves, namely, to correct the displacement by immediate methods, fixing the parts firmly by means of a splint ; or to employ appliances that will gradually reduce the displacement, and then to fix as before. Bennett's experience leads him to believe that with a small amount of destruction of bone, say up to half an inch, in cases seen soon after the injury, immediate methods may be adopted, but that with a larger amount of destruction, or in old cases, or after division for false union, gradual methods are prefer- able. It is probable that by allowing callus to form with the ends of the bone approximating and then stretching the callus during bone formation, bony union is more likely to be induced across a considerable gap than if the two ends be immediately separated. The cases in which bony union can not be hoped for without the aid of a bone graft demand much consideration. Even in these cases, the fragments should be reduced to normal posi- tions. If a bone graft is ultimately successful, well and good; if not, a fibrous union must be accepted, and will probably re- sult in a more satisfactory mandible than if the parts had been allowed to contract with the object of getting bony union. It is obvious that, in such cases, the contraction would have to be so considerable that the dental occlusion would be destroyed and the jaw would be so small as to be nearly useless. In Ben- nett's opinion the cases in which it is desirable to sacrifice con- ABSTRACTS OF WAR SURGERY 415 tour and occlusion in order to obtain bony union are compara- tively few, and almost limited to a particular class. It may fairly be said that when normal position has been sacrificed to only a slight extent, bony union could usually have been ob- tained without such sacrifice ; and that where by such means bony union is obtained that would otherwise have been unob- tainable, then the contraction is so great that the jaw is less useful than would be obtained by firm fibrous union in good position. In cases of unilateral fracture in the region of the angle, however, the approximation of the fractured ends, by allowing the posterior fragment to swing forward, even where there is considerable loss of substance, often materially assists bony union and does not cause loss of occlusion of any moment. Ex- ternally, there is little visible defect beyond a diminution of prominence of the angle of the jaw. It may be desirable to ex- tract an upper molar to permit of this movement. In frac- tures anterior to the first molar, this method of treatment in- volves a shortening of the alveolar arch on the affected side, and it is questionable how far the forward movement should be permitted. SUGGESTIONS TOWARD A SYSTEMATIC OPERATIVE TREATMENT OF GUNSHOT WOUNDS OF THE MANDI- BLE.— W. Trotter, Brit. Med. Jour., Jan. 12, 1918. The very success of the dental specialist in securing, by in- geniously contrived apparatus, fixation of the fragments in the most unpromising cases tends to overshadow the difficulties still remaining in dealing with sepsis and the plastic reconstruc- tion of the jaw. Surgical problems met with in serious wounds involving the lower jaw : 1. Complications following soon after the wound: Hemorrhage. — Especially of the soft tissues of the floor of the mouth and tongue. May be seriously persistent or recurrent, and is notoriously difficult to control. Acute Sepsis. — Cellulitis and sloughing. These infections bear some direct relation to the amount of oral sepsis. Secondary Hemorrhage. — Peculiarly liable to appear from about the seventh to the tenth day. 2. Complications during healing: Chronic suppuration, re- 416 ABSTRACTS OF WAR SURGERY current abscesses, necrosis of the jaw. These complications are apt to drag out the cases for an indefinite period. 3. Difficulties of plastic reconstitution of the jaw. Kelapses of sepsis after bone grafting. These may be due to the im- possibility of exposing the bone on either side of the gap with- out opening the buccal cavity, or to the implantation of the graft in the septic scar which has resulted from prolonged sup- puration. Such septic scars, as is well known, are particularly prone to cause failure of bone grafting operations. Attention hitherto has perhaps tended too exclusively to be concentrated on the fixation of the fractured ends of bone. It is clear that when there has been a large loss of bone substance, no amount of fixation can lead to reconstitution of the bone, and that it is toward the latter purpose that all treatment must be di- rected. If, by fixation, displacement of the fragments can be pre- vented until reconstitution can be undertaken so much the better, but reconstitution must be regarded as the essential purpose, and nothing be allowed to prejudice it. The prevention of displacement is certainly less important than the attainment of sound union of the reformed jaw, and there can be no doubt that if there is any clash of interests between the two subjects, a strong and solid bone, even if somewhat deformed, is worth a good deal more than an insecurely united but shapely one. For considerations of treatment, cases may conveniently be divided into three classes: (1) Fractures without considerable loss of substance, actual or probable; (2) fractures with con- siderable loss of substance, either actual from immediate de- struction or probable from necrosis, but with the superficial soft parts more or less intact; (3) fractures with considerable de- struction of bone and of the overlying soft parts — cases where the bone and lower part of the face are "blown away." The second class is the commonest following gunshot injury and is of chief interest to us, lending itself as it does most readily to a radical and systematic treatment. In a ease of this class, with, for example, considerable destruction of the bone in the incisor or premolar region, and extensive wounding of the floor of the mouth and tongue, while the lower lip and cheek remain intact, one of the outstanding features of the early treatment is the extreme inaccessibility of the wounded soft parts. Should serious hemorrhage occur, the ordinary methods of control are almost helpless, and the surgeon may even be tempted to the desperate and valueless expedient of ABSTRACTS OF WAR SURGERY 417 distant ligature. The same inaccessibility is apt to interfere with radical treatment in the prevention or cure of sepsis. Free access to the whole wound by uncompromising division of the underlying soft parts, as in the case of malignant tumor, in order to allow of such excision of the wound surfaces as seems necessary and subsequent suture is the first suggestion. Primary Operation. — A preliminary puncture laryngotomy should be done, or intratracheal anesthesia be given. The frac- ture should be exposed either by free incision over it or by turning back the soft parts in a flap from the middle line, thus avoiding paralysis of the lower lip, loose fragments of bone should be removed, the wound in the soft parts excised, a clean surface being given to the fractured ends of bone by a saw cut, and the alveolar border cut back at an angle. The cheek and floor of the mouth and side of the tongue should then be brought together with numerous large mattress sutures so as to com- pletely obliterate any cavity between the ends of the bones. A large opening should be left for drainage beneath the jaw. If intrabuccal fixation of the fragments is possible, now, it should of course be used, and will doubtless favor healing and the comfort of the patient. If such treatment were successfully carried out and healing were reasonably rapid, the necessary plastic operation should be possible within a few weeks. Plastic Operation. — Aseptic union in bone grafting operations on the jaw is always difficult to attain, and therefore special efforts should be made to maintain the vitality of the trans- plant. To attain this object an obvious method is the use of the pedunculated graft. The part best adapted to such a pur- pose is the attachment of the sterno-mastoid to the inner end of the clavicle. The bone here closely resembles the mandible in texture, the upper half of it, with the broad attachment of the muscle itself, lends itself to detachment and to displacement without undue difficulty into the gap of the jaw. Grafts may also be taken from unaffected portions of the jaw itself. The primary and immediate operation giving full access to the fracture with the purpose of limiting hemorrhage, sepsis, and necrosis, and attaining a limited and relatively aseptic scar, is an indispensable preliminary to a systematic application of bone surgery to large destructive lesions of the mandible. If the surgeon keeps clearly in mind the principle that protection of raw surfaces in order to secure rapid union must be the first consideration, the minor procedures that facilitate this will suggest themselves readily. 418 ABSTRACTS OF WAR SURGERY RECONSTRUCTION OF THE JAWS AFTER WAR WOUNDS. — E. Matti, Correspondenzbl. /. schweiz. Aerzte, 1917, xlvii, p. 1361. The present war has brought about a great transformation in the treatment of jaw injuries. The treatment of interned soldiers in Switzerland with jaw injuries was organized in such a way that in Zurich, Geneva, and Berne, jaw centers were constituted, in each of which the joint services of a surgeon and a dentist skilled in orthopedic technic were made use of. The Berne jaw center, which con- tained 20 beds, was located at the Spital Salem. The dental prosthetic treatment was undertaken by Dr. Egger, the surg- ical care by the writer. The modern management of jaw fractures in general con- sists of the following : The fresh jaw fracture is splinted in correct position by the dentist; the wound treatment is under control of the surgeon. There are two principal groups of old jaw injuries : 1. Solidly healed jaw fractures with bad dental articulation following bony defect or displacement of fragments. 2. Pseudarthrosis of the lower jaw with more or less exten- sive loss of substance. Technic of Bone Transplantation. — The author uses nerve blocking combined with infiltration anesthesia. He generally employs the crest of the ilium, which is better than clavicle, rib, or tibia. In the experience of the writer the importance of the periosteum in free transplantation in general is overestimated. Of greater importance than a painstaking periosteal plastic, according to the observation of the writer, is the accurate me- chanical placing of the transplant, and restoration of func- tion of the jaw from the beginning. He therefore does not fix the lower jaw against the upper, but allows the patient to move the lower jaw at will immediately after the operation. This movement in the first two weeks will not be very extensive owing to fear of producing pain. High-grade atrophy of the jaw fragments can be very much aggravated by a solid me- chanical fixation between implant and fragment. Infection does not necessarily imperil the success of the transplantation. In 21 bone transplantations 16 healed without reaction. In 5 cases suppuration occurred, in spite of which, in 3 of these ABSTRACTS OF WAR SURGERY 419 complete consolidation took place; 2 cases are still under ob- servation. A further group of jaw injuries occurs with the picture of jaw closure requiring treatment : 1. Injuries of the mandibular joint with bony ankylosis. These cases are to be treated by resection of the joint. 2. Wounds of the region of the coronoid process and tem- poral muscle; bony union between coronoid process and zygoma or base of skull (operative treatment). 3. Chronic inflammatory alterations with considerable shrink- age in the region of the masseter or of the pterygoid muscles as a result of long-standing suppuration. Slight cases treated by stretching under anesthetic and long- continued after-treatment with screw gags. Operative treatment for severe cases. 4. Pertinacious and high-grade contraction of the muscles of mastication, caused by chronic irritation, arising from a punc- tured wound of the region. CASES OF GUNSHOT INJURY OF THE FACE AND JAW, WITH SPECIAL REFERENCE TO TREATMENT.— F. N. Doubleday. Proc. Roy. Soc. Med., London, 1917, x. Sect. Odontology, p. 51. Doubleday mentions the Dowsing heat treatment for soften- ing scars about the face before carrying out operative proced- ures. The heat is applied for 15 minutes daily, a 50 candle- power lamp being placed about 6 inches from the patient's face, and the rays interrupted by the hand of the nurse being passed to and fro between the lamp and the patient's face. This treatment has been employed in several cases where excision of the scar was for various reasons undesirable, and always with most satisfactory results. VINCENT'S DISEASE OF THE MOUTH AND PHARYNX.— W. H. McKinistry. Practitioner, London, 1917, xcix, p. 507. The author finds that so-called "trench mouth" is identical with Vincent's agina of the gums. A thorough scaling of the teeth and gums is desirable if the condition of the patient permits. Sometimes this can not be carried out thoroughly at first owing to extreme tenderness present. The frequent use of a mouth wash, especially after meals, is 420 ABSTRACTS OF WAR SURGERY advised, together with the use of a soft toothbrush. The pa- tient is cautioned of the danger of spreading the contagion to others. Several local applications have been tried, but none seem so efficient as an alkaline salvarsan solution double the strength ordinarily used for intravenous injections. Before swabbing, the gums are carefully dried with cotton, and all extraneous matter picked out from between the teeth. This treatment is continued daily or twice daily until smears from the gums show no fusiform bacilli, and every niche and corner of the gums, after careful examination, show no bleeding points. In no case has it been found necessary to extract teeth to clear up the condition. TREATMENT OF FACIAL PARALYSIS DUE TO GUNSHOT INJURY BY MUSCULAR ANASTOMOSIS.— H. Morestin. Bull, et mem. Soc. de chir. de Paris, 1916, p. 370. The patient was wounded by a rifle bullet which entered the upper part of the neck a little below the mastoid process on the right side, crossed the parotid region from behind forward and from without inward, sectioning the trunk of the facial nerve at its exit from the petrous bone, passed inside the as- cending ramus of the inferior maxilla, perforated the buccal mucosa in front of the anterior pillar of the causes, crossed the palatine vault obliquely, then perforated the latter, passed through the palatal process of the left superior maxilla and the corresponding maxillary sinus, with wound of exit in the in- fraorbital region of the left side. When seen five months later the patient was found to have a total paralysis of the right side of the face. The right lingual nerve had also been cut as evidenced by complete anesthesia and abolition of taste sensation of the right half of the tongue in its anterior part. There was besides, complete anesthesia of the infraorbital distribution of the left side, owing to sever- ing of this nerve at its emergence from the maxillary sinus. The facial paralysis was attended with great visible deform- ity and had shown no improvement in the five months follow- ing receipt of the injury. The laxity of the cheek interfered with speech and mastication. Epiphora was present, and the globe of the right eye showed marked conjunctival injection in its lower segment. Two operations were performed under local anesthesia. At the first operation, a slightly curved incision was made follow- ABSTRACTS OF WAR SURGERY 421 ing the anterior boundary of the temporal fossa, descending on to the malar bone, about 7 cm. in length. A bundle of fibers was detached from the anterior part of the temporal muscle, left continuous below with the main portion. The fibers of the orbicularis palpebrarum were then sought beneath the skin of the lower eyelid and the bundle of muscle fibers from the tem- poral was inserted beneath them, being fixed with a few buried sutures of fine catgut. Before placing and tying the threads, the most favorable points for correcting the vicious attitude of the eyelid were selected by making traction with forceps and the result quoted. The cutaneous wound was closed without •drainage. At the second operation, an incision 5 cm. long was made under the angle of the jaw, the anterior border and part of the external surface of the masseter being exposed. The buc- cinator was then sought and drawn back and fixed by a series of buried sutures to the anterior border, to the aponeurosis, and to the superficial fibers of the masseter, the points of sut- ure being guided by the effects of traction at certain points. These operations, while far from bringing about restoration of function, at the same time caused to a large extent the dis- appearance of the asymmetry of the face when the muscles are at rest; when the muscles are in action, the asymmetry increases, but is not nearly so marked as previously. The patient can not completely close the right eye, but, by comparison with the previous condition, a great improvement is seen, the eye- ball being better protected, the lacrymation having ceased, and the conjunctival irritation having disappeared. This method, particularly in cases of gunshot wound where the search for ends of the nerve would be fruitless, can there- fore render valuable service as a palliative. SALIVARY FISTULAE.— Rev. of War Surg, and Med., June, 1918, i, No. 4. Within the past few months several important papers have appeared in the French literature dealing with the treatment of salivary fistulas resulting from war wounds. These fistulas practically always are connected with the parotid gland and its duct, injuries in the submaxillary region rarely .being followed by salivary fistulas. All the writers divide these fistulas into two forms: 1. Glandular fistula. 2. Fistula of Steno's duct. 4.22 ABSTRACTS OF WAR SURGERY An idea of the relative frequency of these two forms may be gained by noting Morestin's figures (Bull, et mem. Soc. de chil. de Paris, 1917, xliii, p. 835). Since the beginning of 1915, this sur- geon has treated 62 salivary fistulas, 30 being glandular and 32 involving Steno's duct. Parotid Glandular Fistulae. — According to Dieulafe (Res- tauration Maxillo-faciale, Paris, 1917, p. 197), clean incised wounds involving the parotid gland usually heal spontaneously. The destructive wounds caused by modern war projectiles, always complicated by infection which involves the individual lobules and acini of the gland, frequently lead to fistula. The fact that a fistula exists may be hidden for some time, being masked by the inflammatory phenomena which give rise to suppuration. In these cases the fistulas are preceded by a slowly progressive salivary tumor, varying in volume from day to day. After recession of the inflammatory phenomena, there is observed at a place on the surface of the masseter or in the sternomaxillary space a small reddish point, flattened or acumi- nated, at the site of which is established a flow of thin clear liquid, limited to a few drops when the jaws are at rest, be- coming abundant and at times excessive during the movements of mastication. The diagnosis can be in doubt only in cases where a very small fistula exists or where suppuration of the parotid wound is still very marked. In these cases, if observa- tion of the production of secretion is not sufficient to establish the diagnosis, the functioning of the gland is provoked by touching the lingual mucosa with a drop of vinegar or by mak- ing the patient masticate a small piece of hard bread; a clear thin fluid will then be seen streaming abundantly, in veritable jets, from the fistulous point. The patient himself may make the diagnosis by noticing a marked increase in the flow of liquid at meal times, and may be literally inundated by the saliva which runs down his cheek onto his clothing. The fistu- lous openings may be multiple, but those generally observed are single. The site of the lesion varies, all of the region occupied by the parotid being subject to traumatism or suppurative com- plications by extension from the original wound. Spontane- ous closure of glandular fistulas sometimes occurs, but not so frequently after war injuries as after those seen in civil prac- tice. According to Pietri (Restauration Maxillo-faciale, 1917, p. 105) the location and direction of the wound in relation to the in- ABSTRACTS OF WAR SURGERY 423 traglandular ducts have an important bearing on the gravity of the case. The principal intraparotid collecting duct emerges from the anterior border of the gland at the junction of its upper and middle thirds. Anatomical considerations show that a wound situated farther from the median collecting duct will involve a rather large number of collateral branches, whilst a wound of the upper or lower portion of the gland will involve, especially if superficial, only small, unimportant branches. Spontaneous healing often occurs in these latter cases. If the wound is parallel to the principal parotid duct and situated very close to it, the lesion will involve, near to their point of junction with the main collecting channel, all the collateral branches coming from the portion of gland above or below the lesion, resulting in an obstinate salivary fistula. In a vertical wound of the parotid the median duct may or may not be in- volved. If the median duct is spared the collateral branches involved will often be unimportant and in any case will be few in number, so that the external flow of saliva will be relatively slight and the healing of the wound easily accomplished. If, on the contrary, the vertical lesion involves the central duct of the gland, the flow of saliva from the wound may be very abundant. All of the saliva carried by the collateral branches mesial to the section will flow out by the wound. Furthermore, since the presence of valves regulating the flow of saliva in the excretory canal has not been demonstrated, a portion of the saliva emptying by collateral branches distal to the section may be discharged through the wound instead of into the mouth. Surgical intervention in a case of this kind, in order to have some chance of success must aim not only to direct into the mouth the flow of saliva discharged into the duct behind the solution of continuity, but also to prevent, at the same time, the discharge through the wound of saliva entering the anterior portion of the canal. The second part of this problem seems easily achieved, but the first, on the other hand, may appear impossible, owing to continuous secretion from the posterior part of the gland interfering with the cicatrization of the wound. Treatment of Glandular Fistulae. — The multiplicity of pro- cedures proposed proves that no one of them can be used ex- clusively for all cases. Dieulafe discusses most of the methods of treatment that have been employed, such as compression, excision of the fistulous region followed by suture, oily injections, etc. He briefly dis- 424 ABSTRACTS OF WAR SURGERY misses immobilization of the jaws as a method of treatment per se with the remark that many cases will heal spontaneously when the jaw is free and mobile, and that persistence of the fistula is found just as often among patients who have had the mouth closed during a long period as among those who have all the time preserved their masticatory movements. Pietri, on the other hand, believes that the simple procedure of immobiliza- tion of the jaws should be tried first in all cases before resort- ing to operation, claiming that it is logical to favor healing by diminishing the production of saliva through the suppression of the function of mastication. He uses a skull cap of woven material, which prevents the mouth from being opened. In certain cases it is advisable to combine this with intermaxil- lary ligation or splinting of the teeth. The patient is given liquid diet for several weeks and abstinence from speech as far as possible is enjoined. As the fistula is seen to close, in the return to normal, the diet is increased by gradual stages. It is not known what becomes of the parotid gland in the course of this treatment, but it probably enters simply into a state of rest, and then, with mastication, if the excretory duct is permeable, it takes up again its normal function. It can not be claimed that this method of immobilization of the jaws is infallible; however, it is so simple, and the results obtained are so encouraging, that it is always worthy of trial. Pietri 's observations are based on 38 cured cases. Dieulafe recommends cauterization with silver nitrate for small fistulas draining slightly and limited to small groups of acini. Cauterization with a fine thermocautery point has also given him good results. The accessible portions of the paren- chyma are reached directly through the fistulous tract by ap- plication of the cautery two or three times at three or four days' interval. This may be insufficient and at the same time the lesions may be too insignificant to justify an operation. In these cases Dieulafe makes an incision above and below the fistula (always in the direction of the fibers of the facial nerve) and through this little opening he touches with the cautery all of the exposed surface; he then curettes or excises the cutane- ous tract and reunites the skin with horsehair or silk threads. One of the foregoing methods is indicated particularly for small fistulas following intraglandular suppuration. In cases of fistula involving portions of the parotid paren- chyma which is spread over the surface of the masseter and near the anterior border of this muscle, Dieulafe imitates the ABSTRACTS OF WAR SURGERY 425 procedure which he applied to fistulas of Steno's duct when this duct is injured at its posterior extremity or when it is grasped very tightly in scar tissue. A tunneled sound with blunt end is introduced into the cutaneous orifice and thrust gently through the tract. The skin is sectioned in a linear direction anteriorly and posteriorly to the sound, and the end of the sound must not be displaced and must always remain in contact with the bottom of the fistula, this being the point where the junction of the abnormally open acini or canaliculi occurs and serving as the landmark for transfixion. Without losing contact, the sound is directed obliquely forward toward the mucous membrane of the cheek and perforates through the injured parenchyma; with a narrow bistoury and guided by the sound, all the tissues are opened which separate the gland from the buccal cavity, the incision passing over the anterior border of the masseter, for if this muscle were transfixed the new tract would be quickly closed by muscular contractions. A very oblique tract is thus made through the gland, the aponeuro- sis of the cheek, the fatty pad of Bichat, and the mucous mem- brane. The tissues in front of the masseter are drawn forward in order to avoid cutting the facial vessels. A rubber drain is introduced into the tract, 6 or 8 mm. long, by means of a forceps passed from the mouth through the orifice made in the mucous membrane; the forceps are pushed as far as the cutane- ous opening, the drain grasped and drawn toward the mouth, and secured by a thread attached to the neck of a tooth. On the skin side the drain is cut even with the parenchyma of the gland, and the cutaneous incision sutured over it after excision of the fistulous tract. The drain is left in place as long as possible — 10, 12, or 15 days — in order to insure the production of a well-formed false duct. Deupes (Restauration Maxillo-faciale, 1917, p. 189) and Dieu- lafe each call attention to the rationality of diminishing the secretory function in fistula of the parotid gland by resection of the auriculotemporal nerve. Claude Bernard first demon- strated the secretory role of this nerve. Later experiments have shown that the secretory fibers carried by the auriculo- temporal come neither from the inferior maxillary nor from the facial, but from the glossopharyngeal through the nerve of Jacobson which supplies the small deep petrosal nerve to the otic ganglion. Dieulaf e believes that the cervical sympathetic and facial nerves also play a secretory role. Deupes thus describes the 426 ABSTRACTS OF WAR SURGERY course of the auriculotemporal nerve: It arises from the posterior branch of the inferior maxillary by roots arranged in the form of a buttonhole through which passes the middle meningeal artery, progresses toward the neck of the condyle, passes around this, penetrates the parotid gland, and runs to- ward the zygomatic arch in a vertical direction as far as its final distribution in the temporal region. Maigrot likened the course of the nerve to the shape of a Deschamps pedicle needle, whose concavity corresponds to the posterior border of the condyle; he divides it into three segments, the first from its origin to its entrance into the parotid, the second within the parotid, and the third the temporal portion. It is the second segment of the nerve which gives off the parotid fibers, behind the condyle; and this is the portion which must be attacked in order to suppress the secretion of the parotid gland. Deupes thus summarizes the technic of resection of the auriculotem- poral nerve in fistulas of the parotid gland : 1. Local anesthesia with novocain-adrenalin. 2. Vertical incision of about 3 cm. in length, half above and half below the zygomatic arch. 3. Search for the nerve. The pulsation of the temporal art- ery may be suppressed by the vasoconstrictor action of the local anesthetic solution, and therefore this landmark may not be available. The nerve trunk is behind the vessels, and it may be necessary to seek under the upper part of the incision a peripheral filament, and follow it down to the trunk. 4. Dissection of the nerve in the parotid sheath down to the lower part of the incision, i. e., to the glandular tissue. 5. Gentle traction on the nerve, according to the Thiersch method, with hemostatic forceps in such a way as to obtain the greatest length possible before rupture. This stage is al- ways rather painful. 6. Reunion of the skin edges with Michel clamps. Deupes has performed this operation on two patients wounded by grenade splinters, in whom the injuries were almost iden- tical. The projectiles had been exfoliated with some tooth fragments, and there was no other damage than that of the tissues of the cheek and of the parotid gland; a rather severe trismus and the fistulous tract were the only functional dis- turbances. The fistulous orifice was situated about 10 or 12 mm. in front of and a little below the lobe of the right ear. During feeding, saliva appeared and flowed abundantly down ABSTRACTS OF WAR SURGERY 427 the cheek. In both cases the salivary secretion ceased imme- diately after the operation. Dieulafe also recommends the performance of a very exten- sive resection of the nerve. He reserves local anesthesia for cases with no inflammation of the scar tissue of the region, while he prefers general anesthesia in cases with inflammation. In front of the tragus an incision 4 cm. in length is made, as- cending a little in front of the ear and descending as far as the posterior border of the jawbone a little below the neck of the condyle; beneath the skin in front of the ear the tem- poral artery is carefully sought by its pulsation. Behind the vessels the nerve is found, isolated, seized in a flat-beaked for- ceps, and its peripheral end sectioned; descending through the gland the nerve is isolated. In some cases the anastomosing branch from the facial may be seen and cut separately. When the nerve has been isolated from the depths of the gland, a twisting motion is given to the forceps, the nerve being wrapped about the beaks as it stretches, the deepest portions are detached and it breaks solely by the mechanism of avul- sion. In operating in a cicatricial field, the search for the nerve is difficult, and it may be necessary to ascend into healthy tissue, find a peripheral branch and trace this down to the main trunk. The operation is useless if all of the glandular portion of the nerve be not resected, taking in all of the secre- tory fibers and the anastomosing branch from the facial. Dieulafe finds that the secretion of saliva always persists for a few days after the operation, but gradually disappears. He has successfully performed the operation in five cases, in two of which it was necessary to complete the cure by cauteriza- tion, which had previously failed alone. Fistulae of Steno's Duct. — Dieulafe finds that the war has greatly enriched surgical practice in regard to fistulas of Steno's duct. He has met with three forms: (1) Very limited traumatism of the cheek by shell fragments, involving directly the duct of Steno and creating the fistula by a lateral section of the canal; (2) great destruction of the cheek by shell frag- ments followed by contractile scars occluding the duct, obliter- ating its normal orifice and leaving open the skin wound which involves it; (3) destructive traumatism by shell fragments, in- volving the bone and soft parts and giving rise to inflammatory phenomena which open (abscess) and cause fistula of the duct of Steno. The second form is by far the most common. Tak- 4.28 ABSTRACTS OF WAR SURGERY ing into consideration the frequency of facial wounds in the present war and the extensive injuries which they produce, salivary fistula must be regarded as an uncommon complica- tion. In the healing of wounds of this region the contraction of the scar tissue frequently acts as a spontaneous ligature of the canal followed by secondary arrest of the secretory func- tion and glandular atrophy. In performing secondary cos- metic plastic operations in this region it is frequently noted that no trace of the duct can be found in the mass of scar tis- sue. In view of this spontaneous tendency toward cure, fistulas should be regarded as permanent only after persistence of sali- vary flow through an abnormal opening some time after the original wound has healed. Generally there is a point of granulation situated in the re- gion of the masseter or of the buccinator, through which clear- fluid is seen emerging. This flow becomes very abundant dur- ing mastication, and is more marked than in cases of paren- chymatous fistulas, because all of the parotid saliva is dis- charged through the opening. The quantity of saliva dis- charged is variable ; a patient of Duphoenix lost 70 gm. in one- quarter of an hour; a patient of Jobert lost several cupfuls in 24 hours. Mischerlich has observed a fistula which gave only 60-95 gm. in 24 hours ; Beaunis notes that the average amount of the secretion is between 80 and 100 gm. per day; while Hirschfeld has collected one-fourth liter at a single meal. The quantity, of course, varies according to whether the fistula is partial or complete. At times the saliva accompanies purulent secretions arising from the inflammatory site with which the history of the fistula is bound up; at other times the salivary flow is the only symptom. The loss of a large quantity of a fluid which normally acts as a useful secretion and which con- tains mineral salts, especially chlorides and phosphates, leads at length to a weakening of the organism; besides, the abund- ance of the flow itself constitutes a true infirmity. In these cases a more or less visible orifice leads down to Steno's duct. There exists at times a sort of cystic pouch at the site of the fistula, which empties itself easily by pressure. This pocket is caused by the accumulation of fluid between the wound in the canal and the cutaneous orifice. Its existence, when interven- tion is to be made, is a valuable landmark in the formation of a new duct. Treatment of Duct Fistulae. — After reviewing all of the vari- ous procedures that have been suggested for the cure of fistulas ABSTRACTS OF WAR SURGERY 42£ of Steno's duct, Dieulafe considers that the creation of an arti- ficial passageway by transfusion through the cheek is most appli- cable to the majority of cases occurring in the wounded, in which, as a rule, the situation of the fistula and the scar tis- sue present do not permit a dissection of the posterior end of the duct. The technic followed is the same as that previously described under fistulas of the parenchyma overlying the mas- seter muscle. Dieulafe has performed this operation four times, always successfully. Transplantation of Steno's duct is advised by Dieulafe when one can find an appreciable segment of the posterior end which can be fixed to healthy oral mucous membrane. He has per- formed this twice successfully. He hesitates to advise resec- tion of the auriculotemporal nerve for fistula of Steno's duct, which should usually be susceptible to cure either by trans- plantation or transfixion. Certain authors have obtained suppression of the parotid secretion by imitating a process that nature has put in prac- tice in numerous face mutilations. In a large number of cases Steno 's duct has been the seat of a destructive wound and later occluded by a cicatricial progress causing cessation of all secre- tion and secondary atrophy of the corresponding parotid gland. Morestin is led to artificial obliteration of the duct by several considerations, as he has found in the patients treated, that re- implantation of the duct after elimination of the fistualized por- tion was impossible, and internal drainage pure and simple rarely utilizable. His procedure, then is to extirpate Steno's- duct, ligature its stump at its origin, and obtain reunion with- out drainage. Obliteration of the duct brings about rapid physiological death of the parotid gland, but Morestin says that this has no perceptible effect on the organism. This com- plete radical operation has been done in 13 cases with excellent results and Morestin now employs the method exclusively. In performing this operation it is important to remove all of the fibrous scar tissue through which the fistulous tract passed, so that only supple and healthy tissues are left. Summary. — From the experience of the four authors quoted, the most suitable treatment for the various forms of parotid fistula may be summed up as follows : Glandular Fistulae. — 1. For slight or moderate discharges — im- mobilization of the jaws, with or without cauterization. 430 ABSTRACTS OF WAR SURGERY 2. For moderate or more obstinate cases — cauterization, or creation of an artificial opening into the mouth by transfixion of the cheek. 3. For persistent cases that do not respond to other treat- ment — resection of the auriculotemporal nerve. Fistulae of Steno's Duct. — 1. For cases in which an appreciable segment of the posterior end of the duct can be freed — trans- plantation of the duct into the buccal mucous membrane. 2. For cases in which the situation of the fistula and the scar tissue do not permit freeing of a sufficient segment of the posterior end of the duct — creation of an artificial opening into the mouth by transfixion of the cheek. 3. Where internal drainage of the parotid can not be brought about — permanent occlusion of the duct by ligature. INDEX Abdomen, 165-206 drainage of after operation, 174 gunshot wounds, 177-185 stab and gunshot injuries, 177 Abdominal injuries, 79 in a casualty clearing station, 188 laparotomy in, 179 prognosis and treatment, 165, 183 signs, 168 treatment at Front, 179 Abdominal wounds, 30 necessity of operation, 186 operative measures, 169 surgical treatment, 199 treatment, 32, 33, 34 wounds and the surgical ambu- lance, 188 wounds treated in automobile sur- gical ambulance No. 2, 182 wounds and a series of 500 cases of emergency operations, 165 Advanced operating centers, 24 surgical post, 110 Alimentary canal, gunshot injuries of, 190 Ambulance, the working of a clear- ing, 111 field, 17 motor, 18 motor and hospital trains, 48 surgical and abdominal wounds 188 Amputations, functional value of the stump after, 319 primary, 27 reduction of number of, at Front, » 312 resection of knee to avoid amputa- tion of thigh in fractures of knee, 296 ten rules for amputations of lower limbs, 327 thigh, 319 Anesthesia in warfare, 335-347 Anesthetics, 24 at a casualty clearing station, 345 Aneurisms in war, 273 Antitetanus serum, endoneural in- jection of, 124 Antiseptic methods, 25 Antitoxin, tetanus, comparison of subcutaneous with intravenous administration, 131 content of antitoxin in serum of tetanus patients, 122 endoneural injection, 124 intraneural injection, 127 intraspinal administration, 123 intrathecal route, 131 Arthritis, purulent, immediate re- sults of surgical intervention, 304 suppurative, following gunshot fractures, 324 traumatic, of knee, 301 Arthrotomy in treatment of wounds of knee-joint, 306 Articular wounds of the knee, pri- mary resection, 319 Baeteriologv, septic wounds, 113 Bladder, 173 (See also Wounds of Special Organs) foreign bodies resulting from gun- shot wounds, 195 intraperitoneal rupture, 189 intraperitoneal wounds, 197 treatment of gunshot wounds, 196 treatment of simultaneous lesions of the bladder and rectum, 198 Blood vessels, wounds, 37 injuries, 59 Bone transplantation, technic of, 418 Bones, infection, gunshot injuries, 314 British surgery, development at the Front, 17 development in hospitals on lines of communication in France, 47 Burns, 328-334 paraffin in treatment of, 328-331 C Cardiovascular surgery, 245-275 Casualty clearing station, 20 abdominal injuries, 188 anesthetics, 345 dressing and distribution of the wounded, 21 table of operations performed, 22 treatment of wounds in, 21 431 432 INDEX Chest, 207-244 treatment of penetrating gunshot wounds of, 216 thoracotomy indicated in treat- ment of wounds to arrest hem- orrhage, 217 Chloramine-T, for sterilization of wounds, 116, 117 Cicatrization of wounds, 116 D Diaphragm, suture for gunshot wound with hernia of omen- tum and transverse colon, 181 E Electro-magnet, operative removal of bullets and fragments of grenade, with special refer- ence to the use of, 370 Electro-therapy in treatment of peripheral nerve injuries, 396 Excision, of joints for gunshot in- jury, 70 wound, 97 Experiences of a consulting surgeon, 109 Extremities, treatment of gunshot injuries of, 325 F Face, jaws and, {See Jaws and Face) Facial paralysis due to gunshot wounds, 420 Femur, treatment of shell fractures of, 311 Field, ambulance, 17 Fistulae : parotid glandular, 422 salivary, 421 Steno's duct, 427 Foreign bodies, 368-371 extraction under the screen, 220 in the pleural cavity, 220 localization, 368, 369 technic of extraction in the mediastinum, 221 Fractures, 44, 63, 311-327 diagnosis of suppurative arthritis following gunshot fractures, 324 earty treatment of compond frac- ture of long bones of extremi- ties, 321 important point in treatment of gunshot fractures, 315 jaw, 406 plating of gunshot fractures, 315 primary resection in treatment of articular gunshot wounds with fracture, 299 Fractures — Cont 'd primary transformation of open gunshot thigh fractures into- closed fractures, 313 resection of knee to avoid amputa- tion of thigh in fractures of the knee, 296 secondary suture of wound in cases~ of open fracture, 323 treatment of gunshot fractures,. 311 treatment of complicated gunshot fractures of humeral di- aphysis, 320 treatment of shell fractures of femur, 311 G Gangrene, gas {See Gas Gangrene)- Gas gangrene, 138-163 bacterial factors, 149 bacterial flora of, 143 bibliography of, 162 classic, 148 clinical considerations, 147 mechanical factors in, 148 mixed, 148 part played by the gas, 152 toxic, 148 toxins produced by bacteria, 151 treatment, 157, 158, 160 Gas phlegmon in the field, 163 Gunshot wounds and their treatment,. 83 {See also Injuries) H Head injuries, 41, 72 Heart, injury by bursting of gren- ade, 245 conservative or operative treat- ment, 245 wounds, 37 Hemorrhage, 209 secondary, 54 transfusion in, 363 Hemothorax, 209 infection of, by gas-producing bacilli, 218 Hospitals, special, at Front, 24 Humerus, treatment of complicated gunshot fractures of humeral diaphy- sis, 320 Infections, wound, 28, 43, 103 treatment of infected suppurating- war wounds, 106 Injuries, abdominal, 79 extremities, 325 great vessels, 44 head, 41, 72 INDEX 433 Injuries — Cont 'd jaw, 413 joints, 39 spinal cord, 77 vascular, 246, 274 war injuries, consideration of, 120 Interallied Surgical Commission on treatment of wounds, 112 Intestine, operative treatment of gunshot injuries, 187 Jaw, early care of gunshot wounds and surrounding soft parts, 398 feeding during treatment of frac ture of, 405 Jaws and face, 398-430 reconstruction of, after wounds, 418 surgical treatment of fractures of, 411 Joint, excision, for gunshot injury, 70 injuries of joints, 39 primary resection in articular wounds of knee, 319 resection of shoulder in war sur- gery, 298 results of operative treatment in purulent arthritides, 304 _ treatment of wounded knee joint, 309 treatment of traumatic arthritis of knee, 301 wounds of joints, 67 Joints, 277-310 K .Knee, arthrotomy followed by im- mediate closure of the articu- lation in treatment of cer- tain wounds of the, 305 resection to avoid amputation of thigh in fractures of, 296 results obtained in wounds of the knee-joint, 72 treatment of wounded knee-joint, 309 treatment of gunshot wounds, 297, 306 treatment of traumatic arthritis, 301 Larynx, gunshot wounds of larynx and trachea, 226 war wounds of larynx and trachea ; 223 Lung, gunshot injury, 227 {See also Chest: Foreign Bodies) gunshot wound of lung and pleura, 207 gunshot wounds of lungs and tu- berculosis, 244 mortality of war wounds, 230 war wounds of, 227 M Mandible, gunshot wounds of, 415 Massage in treatment of peripheral nerve injuries, 396 Mediastinum, technic of extraction of foreign bodies in the, 221 Missiles, retained, 76 Motor, ambulances, 18 ambulances and hospital trains, 48 Mouth, and pharynx, "Vincent's disease of, 419 N Nerve injuries, aftercare of, 391 nerve suture, 386 nerves, injuries to peripheral nerves and their treatment, 372, 381 O Operating, advanced operating cen- ters, 24 theaters, 20 Paraffin treatment of wounds and burns, 328, 331 Parotid glandular fistulae, 422 Peripheral nerve injuries, 372-397 Physiotherapy, in treatment of peripheral nerve injuries, 395 Plating, gunshot fractures, 315 Pleura, gunshot wounds of lungs and, 207 Pleural cavity, projectiles in, 220 Projectiles, extraction of intratho- racic, 220, 223 {See also For- eign Bodies in Pleural Cavity, 220) E Eectum and bladder, treatment of simultaneous lesions of, 198 Eegimental Medical Officer, duties of, 17 Eetained missiles, 76 S Salivary fistulae, 421 Secondary suture of the wound in cases of open fracture, 323 434 INDEX Septicemia, 5S Serum of tetanus patients, antitoxin content of. 122 serum of Leclainche and Vallee, 1G0 Shock. 352-367 and the condition of wounded men, 27 as seen at the front, 352 fluid substitutes for transfusion in, 363 surgical, 353 Shoulder, resection in war surgery, 298 Special hospitals, 24 Special organs, wounds of, 35 Spinal cord, injuries to, 77 Spleen, 171, 182 Splints, 277, 279 Sterilization of war wounds, 116, 117, 120 Stump after amputation, functional value of the, 319 Surgery, British, 17, 47 Surgical ambulance and abdominal wounds, 188 Sutton method of foreign body lo- calization, 369 T Tetanus, 56, 122, 123, 132-137 a report of twenty-five cases of, 129 clinical and therapeutical experi- ences with, 125 comparison of subcutaneous with intravenous and intrathecal administration of tetanus an- titoxin in experimental teta- nus, 131 antitoxin content of the serum of tetanus patients, 122 endoneural injection of antiteta- nus serum, 124 intrathecal route for the adminis- tration of tetanus antitoxin, 131 intraneural injection of tetanus antitoxin in local tetanus, 125 intraspinal administration of anti- toxin in tetanus, 123 late tetanus, 125 local tetanus, 128 statistics, 127 treatment of, 122, 123, 124 Thermotherapy in treatment of peripheral nerve injuries, 396 Thigh, amputations in war surgery, 319 primary transformation of open gunshot fractures into closed fractures, 313 Thoracotomy in chest wounds, 217 Thorax, extraction of intrathoracic projectiles, 220, 223 extraction of intrapulmonary pro- jectiles under the screen, 220 open, emergency operations for, 239 penetrating wounds of the, 225 Trachea, gunshot wounds of the lar- ynx and, 226 war wounds of the larynx and, 223 Traction, in joint injuries, 282 Trains, motor ambulances and hos- pital, 48 Trench-foot, 348-351 Tuberculosis, gunshot wounds of the lungs and, 224 Vascular injuries, 246, 274 Vincent 's disease of mouth and phar- ynx, 419 Viscera, wounds of, 171 W War injuries, consideration of some, 120 Wound excision, 97 infection and treatment, 83-121 infections, 28, 58 treatment, 49 Wounds, abdominal, 30 {See also In- juries) articular {See Joints) bacteriology of septic, 113 bladder, 173 blood vessel, 37 chest, thoracotomy in, 160 cicatrization of, 116, 117 gunshot and their treatment, 83 heart, 37, 245 infected, 106, 107 Interallied, Surgical Commission on, 112 intestines, 172 joints, 67, 285, 295 kidney 171 knee joint, 298 larynx, 223, 226, 306 liver, 171 lung, 227 septic, 113 special organs, 35 spleen, 171, 182 suture of, 102 thorax, 225 trachea, 223, 226 viscera, upper, 171 X-rays, 24 COLUMBIA UNIVERSITY LIBRARY This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE #* ; r^*% ■. ! C28(239)M100 Un3 -general's office. Abstracts of war surgery. RD151 U. S. Surgeon U^% COLUMBIA UNIVERSITY LIBRARIES (hsl.stx) RD 151 Un3 C.1 Abstracts of war surqerv; 2002159228