·No text on this page.

·OXFORD WAR MANUALS
THE
EARLY TREATMENT
OT
WAR WOUNDS
BY
WILLIAM ANDERSON
OBE (ML), MB C# B, TRCS
Surgeon and Lecturer in Surgery
Aberdeen Roval Infirmary
Surgeon to Bunicipal Hospitals Aberdeen
Surgical Daredor Emergency Medical Service
Aorthern and North-eastern Districta
General Editor
THE RT HON LORD HORDER
асvo
OXFORD UNIVERSITY PRESS
LONDON HUMPHREY MILFORD
1941

·OSFORD UNIVERSITY PRESS
AWEN HOUSE, E C 4
London Edinburgh Glasgow New York
Toronto Melbourne Capetowa Bombay
Calcutta Vadrag
IVXPIREY MILFORD
PUBLISHER TO THE UNIVERSITY
PRINTED IN ORRAT BRITAIN

·FOREWORD DUEIG the War of 1914-18 the OXFORD WAR PRRIERS, a series of small treatises covering a wide range of practical topics achieved a high degree of well deserved popularity among the medical profession Although certain of the more fundamental members of the series may still be found useful in their respective spheres the advances in military, no less than medical, science have been so great that an up to date series has been called for Hence the 188ue of the OXFORD WAR MANUALS of 1941, which, like their prototypes, proceed from the same University Press The first group of Manuals is already planned, and three members of it are in course of production These deal with the Early Treatment of Wounds, the Treatment of Bums, and certain aspects of Wartıme Psychiatry Others, designed to meet a variety of special requirements, will follow This war, to a far greater extent than that of 1914-18, involves as potential casualties a crosssection of the whole community in medical as well as surgical emergencies Moreover, the number and variety of medical personnel engaged much exceeds that available a quarter of a century ago The present series of Oxford War Manuals is visely planned to cover this mider field If any good is to emerge from the evil which confronts us to day, it will be salvaged in the form of medical progress accelerated through

·FOREWORD
of experience Tital to the future stability of this
hoped for gain is the adequate documentation of
that hardly won experience which the Oxford series
aims to encourage
HORDER
General Editor

·PREFACE
The change from crilian to war conditions causes
a terrible uphearal in the uſe of the individual
While the doctor 13 fortunate in that he can still
follow his calling as a medical man the chango of
perspective is so great that, even though we have
been well warned, it 19 difficult to accept it in ito
entirety It 13 with the hope that the experiences
of the last war (1914-18) may make this chango
easier for my junior colleagues, and that a record
of the failures and mucoases in the treatment of tho
wounded will act as a starting point for the great
advances which I am confident will be achieved
1---L- *- ln hint T I.-..
Lyle Dak wrILIA II Iviv •y lay Gall, the late
Mi-1-1 -- 1;-- Vinni
res
co
machine of war Accustomed as his hing been to
- Il16 !.!

·2
PREFACE
houses, &c, and why should be inspect men's
quarters, dinners, and so forth? It takes some httle
time for one to realize that all those duties are
essential of the unit us to run smoothly and well in
times of stress and that even the application of
a Thomas s splint by numbers 13, when training
orderles and stretcher bearers the only efficient
and fool proof method Again it is galling to realize
claims as doctors may be brushed aside in farour
of more important considerations At the same
time, as Hr Henry Wade says Julitary discipline
must not sterilize personal initiative' The adminis
trative and the professional points of view must
be blended and harmonized to the adrantage of the
Founded man who so thoroughly deserves better
than the present best What at first sight may seem
to be impossible can by a policy of give and talo'
and mutual understanding be made not only pos
gible but practicable Let there be criticism, but
let it be balanced and constructure
WILLIAM ANDERSON
ABERDEES
April 1941

·1
31
CONTESTS
I SCP.GICAL TP.E.TWENT 4T DI ASCED
TITS
IL TOPE AT THE CAST ALTI CLIATIV,
STATION
IIL PRECIPLES OF TPEAT' T OF
WORDS AT TILF CLS LTI ('LISI
LG STATION
I WOCYD) OF THE Lr 13
AD Its
COVEPONG
V PEVETP 4TING I OL DO TI AI
DOVES
VI. PENETRATING
WOLD
THE
THOP AY
VII WOCNDS OF JOI'T
VIII. OTHEP SPECIAL 1531 15
IXDET
24
81
9)

·No text on this page.

·00 splint} 16 LIST OF ILLUSTRATIONS 1 Stretcher ready to recente patient ? Bethod of blanketing patient 8 3 Sagittal section of blanketing 9 4 Stove for liot air bath 10 5 (a) Depage modified humerus splint (6) Splint applied 6 (a) Jones s humerus splint (6) Splint applied 7 (a) Small Thomas s splint for arm 16 (6) Small Thomas s splint with hinge) 8 (a) Foot piece (6) Stretcher suspension bar) 17 9 Thomas s knee splint applied 20 10 Plastic operation for closure of scalp wound show mg lines for teachment of flaps 46 11 Operation concluded 46 12 Diagram of plastic operation for triangular defect 47 plint 06

·No text on this page.

·CHAPTER I SURGICAL TREATMENT AT ADVANCED UNITS The treatment of war wounds is in the rast majority of cases, operative, and therefore it must be the aim of all attached to advanced units to transport the wounded man as quickly and as comfortably as possible to the unit where surgical treatment and nursing can be carried out The reason for speed is that infection in the wound track may spread so rapidly and so exten- 1 L. + esten rendering the patient quite unfit to stand surgica! treatment, and may even turn the scales between life and death These axioms being granted, it 19 quite unnecessary to stress the great importance of the work which is carried out by the regimental moll of non ho the hosror in i fiala .ml c visualize the adverso couWtions under which he mli be called upon to discharge his duties during a big whiclming Now 13 the opportunity to deplas B ·2 SURGICAL TREATVENT AT ADVANCED UNITS qualities of coolness, common sense and adapta. bility, for only by so doing can order be restored, at any rate, to a workable degree The principles of surgery are the same in all situations but circumstances may call for such alterations and changes that no two methods of handling the situation can be similar This is sometimes forgotten when criticism of adranced unit work is offered by those farther down the line Let everyone aim at the ideal realizing that seldom can it be reached The importance of preventive work The influence of efficient early treatment cannot bo over estimated Tho fate of a life or a limb is often determined during the first hour long before the wounded man arrives at the casualty clearing station It is only by the closest liaison and inter communication between the front and back areas that efficiency can be attained The three enemics' to be overcome are Shock Haemorrhage and Sopsis Shock The problems of the causation patho stages were carried out In spite of all that has been done and written the pathology of shock is still imperfectly understood Shock may be defined as a depression of all the vital functions of the body It is characterized by a rapidly progressing fall of blood pressure due in part at least to a reduction of tho blood volume The most obvious causo of this 19 hacmorrhage but the loss of blood in somo cases is not commensurate with the degree of shock Whero external haemorrhage is slight or absent, tho ·at other times symptoms may be delayed for some time and develop insidiously These conditions nervous influences and profuse haemorrhage are the causative agents while in the secondary variety cyanosis of the lobes of the ears and of the finger tips and nail beds Beads of perspiration appear on the forehead The pulse is soft, rapid and, later, irregular Respirations are slow, sighing, and, as the condition advances become urregular The eur face temperature as felt by the hand will be found to be lowered, especially at the peripheryears so characteristic of the condition, can only be accu rately estimated by the aid of a sphygmomano meter, but under battle conditions this examination SURGICAL TREATMENT AT ADVANCED YITS, reduction of blood volume is due to status of blood in the capillaries the patient haarla at vessels perfect m acidosis The clinical features of shock may appear within a few minutes and become rapidly profound, while have been named primary and secondary shock. The pathological processes are probably similar but the aetiology is different In primary shock exposure to cold oozing of blood are the initiating factors und Lioses nils byes the lace is pale with some hands, and feet The rapid fall of blood trauma fatigue, or persistent pressure can seldom be carried out ·4 SURGICAL TREATVEYT AT ADVANCED UNITS Treatment The treatment which can be carried out at an advanced post may be briefly summarized thus (1) lower the receptivity to painful stimuli, (2) arrest the escape of blood, (3) avoid loss of heat and any added trauma Relief of pain The degree of pain suffered by the wounded man does not bear any relationship to the degree or to the extent of the wound Appre ciation of this point is important otherwise an erroneous estimate of the condition may be made and a proper look out for signs of shock in a lightly wounded man may not be kept Unfortunately, pain is a purely subjective sign but it is none the less important Morphia or better still omnopon if available must be our standby for this purpose Dorphia is known to depress the vital centres and 19 also said to depress metabolism It is difficult, or impossible to estimate clinically to what extent the drug augments the depression brought about by the wound and its complications and we must be influenced by the inaccurate method of clinical impression Sy feeling is that the depressing action of morphia has been os er emphasized and that the relief of pain and anxiety which it gives more than compensates for any deleterious effects This was borne out by the Crile treatment of penetrating abdominal wounds when large and frequently re peated doses of morphia were given for a week or more without obvious depressing effects Omnopon 19 lesg depressing but must be gren in larger doses two thirds of a grain being equal to one quarter or one third grain of morphia It is well to remember that much of the benefit of a scda tro 13 lost of the patient 13 at once sent off on his journey down the line An interval of at least ·SURGICAL TREATMENT AT ADVANCED UNITS G fifteen minutes should be allowed for the drug to take effect Effectire splinting of the injured part also re- Leves pain and prerents shock The universally recognized benefit obtained by the application of Thomas's splint in front line units for cases of fractured femur, introduced by Su Henry Gry in 1917, bears testimony to the importance of this procedure The use of a general anaesthetic (chloroform or ether) 13 to be avoided except under exceptional circumstances Apart from delay in elimination, general anaesthesia predisposes to shoch and to a rapid loss of body heat Instances occur where tho calls of humanity demand its use, but one must be certain that the advantages outweigh the many disadvantages Treatment of the wound. It has for so long attempt to carry out an elaborate cleansing or *disinfecting' of the wound Apart from tho re. moval of gross fragments of clothing, mud, and missiles, nothing more than the application of a dry dressing, supported and kept in place by an cven, firm bandage, should be done I realizo that this 1 ·8 SURGICAL TREATMENT AT ADVANCED UNITS Arrest of haemorrhage Loss of blood 13 & frequent cause of shock and continued loss argra Fates the shoch already present The arrest of haemorrhage at the earliest possible moment 13 therefore of prime importance An obmous small spurting ressel should be choght bran arters forceps and the vessel ligatured by linen thread the ends of which should be left long It is not essential to sterilize the thrend before use but if a spool which has been previously boiled 13 aroulable the doctor wll be happier In somo cases it will be necessary to Jerre the forceps on and this should be done even at the rich of a strife for the locs of instruments When the large vessel of a limb has been injured the only hope of saving lifo is by the use of n tourniquet Vuch has been written regarding its dangers such as rupture of the resol and death of the fimb dastalls but our first consideration must be the life of the patient Ise as wide a tourniquet as possible apply it as clove to the upper limit of the wound as possible and loosen it after fifteen minutes to see if the bleeding has been arrested Decision on this point may be difficult While it is true that the brief meat bleeding it all recur as the cspecialls if he Ivecomes restless' As the case must paes rapidly out of the doctor s control it may be a wiser policy to reappls the tourniquet and zal injury to the tissues rather than another haemorrhage which mir proro rapidly fatal Harmth of the many lessons learned in the last war nono was more striking and more life Baring thin the realization of the terrible mpidity

·SURGICAL TREITVET AT ADI INCID UNITS 7
with which a wounded and shocked patient Inung
body heat and how essential it is that means to
present this should be instituted at the carliest
possible moment The regimental medical Officer
should therefore impress on his regimental stretcher.
bearers how important it is to presenc bal heat
Blankets. The chief protection against the long
of heat lies in the liberal use of blanketa In tinca
of great stress the ideal of three blankets to each
stretcher case may be impossible of attainment, but
'by
tho
practice may be universal and that the maximum
advantage may be obtained from the blankets tho
following routine should be adopted and adhered
to
T.
and
the
clean and prepared stretcher Two blankets are
nomlin 1 - 1
LION occupied by the pillow Blanket beneath tho
rillow 10 wnta 1
C
1
+
www mau xul wounded man by this arrangement

·8 SURGICAL TREATMENT AT ADVANCED UNITS
has four thicknesses of blanket beneath him
and two on top If his jacket has been removed,
or if ho has an overcoat, it is laid as an extra
covering over his feet. In rainy weather a mackin.
Fold of
Fold of
lower blanket
Upper blanket
Pillow
Fro. 1. Stretcher ready to receis o patient.
Longitudinally
folded blanket
Fig 2 Method of blankoting patient
tosh sheet is added to protect him from further wet.
On arrnal at the advanced dressing station, or
beforo leaving tho ard post, if the supply permits,
a third blanket is added The portions of the
blanket wrapped round him are undono and the
third blanket, folded along its length, is placed over
hım (sco Fig ?) The lower extremity of this is
tuched well in beneath the man's feet and the two
corners brought round and secured above the lege
by a cafety-pin After the addition of the third
11
1

·SURGICAL TREATJIFXT AT ADYAXCED UNITS 9 This method of using blankets has three adian. tages (1) By haring a routine procedure, to bo employed in every case, there is less likelihood of men being eracuated insufficiently protected Longitudinally folded blanket Lowest blanket Stretcher FIQ 3 Sagittal section of blanketing. against cold (2) The maximum benefit is obtained by using blankets in this manner. (3) Blankets Bo adjusted do not work out of position in the way they do when other methods are employed. An adequate supply of dry, clean blankets in tho reception-room of the casualty clearing station must be in readiness to replace those brought in from advance units When the supply of blankets was well organized, the improvement in the con. dition of the men admitted to a casualty clearing station in cold, wet weather had to be seen to bo appreciated The use of hot water bottles would also be ad. vantageous but can rarely be carried out owing to the limited supply of hot water. At the first suit. 11. nonnapplication the resus. This need lan is two ·10 SURGICAL TREATMENT AT ADVANCED UNITS trestles on which the stretcher is laid, underneath which an oil stove or primus stove, burning slowly, is placed The sides-from the stretcher to the floor -are draped by blankets so that there is a heated chamber under the patient and he is warmed from below To minimize the danger of setting fire to the over hang OIL ing blankets the store should DRUM be placed in an oil drum in the side of which a hole has been cut to allow of the free ingress of air (see Fig 4) The application of heat under a cradle placed over the patient is not so efficient as when its source is under PRIMUS him It is essential that a FIC 4 Stove for lot air careful watch be kept as bath over hcating which may occur rapidly and insidi ously may lead to loss of fluid by sweating and rapid spreach of infection in the wound Administration of fluids In this connexion it is to be remembered that the giving of fluds freely to a patient suffering from cold may bring on vomiting which may be difficult to control The administration of fluids except in very small quan titres should not be commenced until after the patient has been warmed Tea with plenty of sugar is the most acceptable and most easily prepared of all araulable fluids and is less likely than cocoa or meat extract to give rise to vomiting In certain cases where vomiting 19 a prominent

·and well equipped advanced dressing stations
SURGICAL TREATMENT AT ADVANCED UNITS 11
symptom, or where the patient's condition page
cludes the administration of fluids by mouth, after.
natire methods must be found The three arailalie
rout s are rectal subcutaneous, and intrarenous,
and the fluid is given in the form of 0 9 per cent
sodium chloride solution, or 5 per cent glucose in
saline solution
Rectal salınes These hare the adsantage over
the other methods in that they can be administered
without the risk of accidents from Jack of aseptic
precautions If the rectum is loaded, or if the
patient is restless and semi conscious, fluids will not
be retained It also tales some time for the fluid
to be absorbed so that the field of application of
this form of treatment is limited
nating
thigh muscles, 1 to be recommended
TL
AL

·12 SURGICAL TREATVENT AT ADVANCED UNITS minutes being taken to introduce a pint The tem. perature of the fluid is of little importance of the administration is carried out slowly To avoid un. toward reactions it is essential that the flud used be prepared under well controlled conditions and forwarded to advanced units in properly secured bottles ready for use Transfusion of blood at advanced dressing stations During the last war blood transfusion was successfully carried out in field ambulances, but only to a very limited extent With the newer methods for storing and transporting blood a much wider use of this method of treatment will be made The giving of blood does not require any very special knowledge or technique but a proper selec tion of cases must be made in order to prevent wastage The recently introduced administration of stored serum or plasma promises greatly to sim plify the treatment of shock, especially in advanced units Stimulants These are mentioned only to be condemned Of the drugs used as stimulants in civil work strychnine digitalın camphor, adrenalin were all tried and found wanting In fact, they r cannot be too strongly made as the temptation 'to do something is difficult to resist Application of splints Perhaps the most fre quent cause of delayed' or secondary shock is the presence of an inadequately supported fracture Repeated painful stimulı from the grating of the fractured ends absorption of toxins from the dam aged soft tissues and the risk of fat embolism, ·SURGICAL TREATVEST AT ADVAACED UNITS 13 miltate strongly against eren the most robust constitutions It is therefore of supremne importance that adequate fixation of a fractured bone bo carried out at the earliest possible moment During the tedious days of training the budding regimental medical officer mas fail to realize how vital is the training of the regimental stretcher bearers Thes, less than he can appreciate the importance of their work, but in action so much depends on the effi ciency of the team and so much trust is placed in them by their fighting comrades, that time and trouble spent in practice and re practice cannot be considered wasted Patience and confidence on the part of the regimental medical officer will surely have its reward on the battle field MT moment aujuslinelli wilu lue least po Sole uisturbance to the patient It should be remembered that the

·14 SURGICAL TREATVENT AT ADVANCED UNITS
'setting' of the fracture does not require elaborate
technique nor profound knowledge It consists of
restoring the alınement of the limb by steady, firme
1 L
patient during transport the following three pomis
must be attended to (1) adequate fixed extension,
(2) adequate support for the wounded part, and
(3) prevention of rotation
The minimum amount of bandaging must be
done so that readjustment of the splint 18 readily
possible The use of tapes with buckles or straps
of adhesive plaster will be found efficient Care
must be taken that these things do not constrict
the soft parts and act as inefficient tourniquets
Whenever possible the splint should be applied, and
as a sling, and a many tailed or triangular bandage
to fix the arm to the chest Fractures of the shaft
are difficult to control especially if comminuted
Depage 8 humerus splint (see Fig 5) and Jones's
extension humerus splint (sce Fig 6) will be found
to give a moderate extension and are most com
fortable of the patient can walk The Thomas's
splint for arm, with or without hingo (seo l'ug 7),
gives better extension by a clove hitch round the
wrist, but care must be taken not to apply tho
extension too tightly, otherwise the ring will com.
pass the axıllary vessels and cause extreme vascular

·SURGICAL TREATVEYT AT ADVANCED UYITS 15
A
B
F10 - (a) Depage mo ! rod humerus splint
(6) Spint appl ed
I
B
A
FIG 6 (a) Joncs umerus spl nt
(5) Splint applied
interfercnco when the arm is brought down by the
side as is necessary when the patient is loaded on
to an ambulance

·16 SURGICAL TREATMENT AT ADVANCED UNITS
Fractures in the region of the elbow joint Frac
tures involving the elbow joint are best supported
by an internal angular splint The arm and forearm
pieces should be guttered connected by two iron
pieces and the joint controlled by a thumb screw
so that it can be adjusted rapidly to fit either the
O
A
a
8
Fia 7 (a) Small Ti omas s splint for arm (6) Small
Thomas a splent with hinge
right or the left arm As extension is not necessary,
it is better to apply the splint after the wounds
have been dressed
Fractures of forearm urist and hand Unless the
displacement is gross splints are not required and
iternal angu
in fractures
Olyn a short
anterior splint extending to just above the hand
and a longer posterior splint extending from the
elbow to the knuckles may be used if the splints
are made of wood and are flat they should be wider
than the diameter of the forearm otherwise con
striction of the soft parts will occur
Fradures of the femur The only efficient splint

·SURGICAL TREATJIEYT AT ADI ANCED UXITS 17
for controlling these fractures is Thomas's enco
splint The outfit consists of
1 Thomas's knee splint
2 A posterior supporting splint (Gooch's splint.
ing 26 X5 in, & wooden 'Ham' splint, or
Jones's metal gutter splint)
B
JA
A
Fio 8 (a) Foot piece (6) Stretcher suspension bar
3 A short anterior splint for the thigh
4 A strong wire foot pieco
5 Two stretcher suspension bars) (Tio 8)
6 l in adhesive strapping and bandages 4 and
6 in
7 Heel clips
The splint should be applied without removing the
trousers or boots
1 Prepare a fresh stretcher for the reception of
the patient
2 No l assistant stands at the foot of the
atentchanfon nathanat autanlanant a

·18 SURGICAL TREATMENT AT ADVANCED UNITS i. -- 11 - Ar- 1 effort, for the time required for the rest of the manqurte No 2 assistant supports the injured Imb above and below the fracture 3 Application of the extension A steel clip fixed into the heel of the boot, if available, is the most comfortable form of extension but efficient exten sion by means of a clove hitch may be attained This is slipped over the boot, assistant No 1 re applying it nust on no The clore hatch must encircle the ankle of the boot very loosel Both ends of the clove hitch are placed over the external malleolus but the longer end must be resting next the boot This long end is then carried under the instep and through the loop at the internal malleolus This produces an extension band on each side of the ankle The clore bitch now passes obliquely over the dorsum and behind the heel of the boot 4 The operator threads the ring of the Thomas's splint over the foot No 1 assistant relaxing his ir D -- Ilalmh the notch at the end of the splint, one passing from above and the other from below Traction is made and the ends tied 5 Clothing is then cut away from the site of injury and the sound is dressed

·SURGICAL TREATMENT AT ADIANCED UNITS 19
6 The posterior spunt 19 held in position by
assistant No 2, and slings applied to heep it against
the limb These slings are made of flannel or folded
triangular bandages passed round the inner lir,
the foot in the sturtup a narrow bandago is passed
under the heel and the ends coming up inside the
extension bands are crossed and carried round the
stutup and tied opposite one of its vertical barg.
8 A piece of wood or nail is used as a Spanish
prepared stretcher
10 Suspension bars These are fixed to the
stretcher and to them is Blung the splint by four
bandages (see Fig 9) The upper suspension
bar prevents slipping of the ring over the tuber
ischu and provides greater comfort in travelling
The splint should be allowed to swing freely Apart
Operating table
When the patient is picked up on the field a

·18 SURGICAL TREATMENT AT ADVANCED UNITS effort, for the time required for the rest of the manæuvre No 2 assistant supports the injured limb above and below the fracture 3 Application of the extension A steel clip fixed into the heel of the boot, if available, is the most comfortable form of extension but efficient exten sion by means of a clove hitch may be attained This is slipped over the boot assistant No 1 re laxing first his hold by the left hand, reapplying it and then relaxing his right hand He must on no account relax his control of the fracture The clove hitch must encircle the ankle of the boot very loosely Both ends of the clove hitch are placed over the external malleolus but the longer end must be resting next the boot This long end 19 then carried under the instep and through the loop at the internal malleolus This produces an extension band on each side of the ankle The clove hitch now passes obliquely over the dorsum and behind the heel of the boot 4 The 'n splint or ו י * MAS hand gr slightly until it 'fork' lhe extension bands are then passed round the notch at the end of the splint, one passing from above and the other from below Traction is made and the ends tied 6 Clothing is then cut away from the site of injury and the wound is dressed ·SURGICAL TREATJIEYT AT ADVANCED UNITS 21 the bleeding point will control the haemorrhage Hair should be cut short It is a taste of time to persist in attempts at shaving the scalp of a semi. conscious and restless patient This can be much more efficiently done when he has reached the operating theatre, and is under an anaesthetic If lacerated brain is escaping, the only thing to bo done 19 to apply a moist dressing To prevent lateral movements during transport sand bagy or extra pillows should be placed on each side of the head Wounds of the chest Many of theso cascs aro rapidly fatal due to masgive haemorrhage into the pleural or precardial spaces Through and through 'sucking' wounds of the chest suffer severely from shock owing to the mediastinal shift towards tho wounded side These wounds call for immediato temporary closure by suture or 'corking' the wound with gauze fixed by strips of broad adhesive plaster The relef of symptoms is almost immediato Tho question of evacuation of chest injuries 19 some. times difficult If there are facilities, the retention of such cases for even an hour or two, especially when shock is present, will greatly enhance tho patient's chances of recovery Abdominal wounds. These cases should bo eracuated as soon as possible It must not be for gotten that wounds of the lower chest, buttock, back, and upper thigh are often associated with intra abdominal injuries, and signs of this complica. tion must be looked for It should be remembered also that rigidity and absence of free movement

·22 SURGICAL TREATMENT AT ADVANCED UNITS
are important signs, and that tenderness is moro
conclusive evidence than pain dſorphia should not
be withheld from these cases, but a note of the time
every case of abdominal injury to travel-ıt may,
giving of morphia
Fluids should be given sparingly, and if the
reason for this is explained to the patient he will,
in most instances co operate

·CHIPTER II WORK AT THE CASUALTY CLEARING ST.ITION The most important lesson of the war of 1914-18 was the necessity for treatment of a war wound at the earliest possible moment, and as a result the casualty clearing station erolved and expanded to its present important position As in more ad vanced units so also in casualty clearing stations professional desires cannot always be satisfied as one would wish owing to many considerations connected with the military situation The congregating of three or more casualty that an ever increasing number of wounds were dealt with before massive infection had obtained a stranglehold The supply of essential aids to diagnosis and +-antment lingly undertaken by those in charge of administra tion The planning of the hospital to allow of rapid emptying and re equipping of ambulances with fresh blankets, stretchers, and splints added greatly to tbe numbers which were efficiently treated Once into hospital the patient mored by stages from the reception room towards the evacuation

·24 WORK AT THE CASUALTY CLEARING STATION
siding whether through the pre operative, resus
citation, or operating tent, or, if he were moro
fortunate, to the tent for immediate evacuation
By such organization and whole hearted co opera
ܝܙܬ 3 ܕ
Their duty was to save life, limb, and function
the range of ordinary shell fire Apart from the
danger of injury, the mental effect on the helpless
wounded man of shells or bombs bursting in the
neighbourhood cannot be disregarded The site
must be chosen where roads from the front, passablo
for ambulances, converge, where there is a good
water supply and where there is easy evacuation
by ambulance train The ideal site may quite well
be impossible for other military considerations The
sites for the sarious groups should be so chosen
that one group can take over the work of another
to allow it to move as the position of the front lino
changes
The importance of varmth to a wounded man
has already been emphasized The casualty clear
ing station is looked upon by the wounded man as
the first haven of rest, and that haven must be
Warm The temperature of the reception room,
evacuation room, and other wurds is little less im.
portant than that of the operating theatre
Grouping of casualty cleanng stations Groups of
two to four were placed in one sito They admitted

·ame
a group may be detailed to admit a certain typ
Organization within the casualty clearing
Reception room Ambulance cars dniso
Special care should be taken that the
WORK AT THE CASUALTY CLFARNG STATIONS
mhor anar angle
batch came along Tro sitting cases were looki
upon as equivalent to one lyzng cave On Occasion
of injury, eg abdominal, head, or walking casing
Vi vuv uinu
station
switch
blankets have been thoroughly dried, and for this
purpose wooden frames on which blankets can be
hung, and stoves to provide heat, are very efficient
1
operating theatre.
tant than man
1
E

·26 WORK AT THE CASUALTY CLEARING STATION are the most important in the casualty clearing station and should be men of sound judgement and experienced in base as well as in casualty clearing work One medical officer can supervise four to eight tables provided that one good nurse or nursing orderly is detailed for each table It is preferable to deal with talking wounded in a been The mber coming in by the time of departure of the next ambulance train and by its likely time of arrival at the base Severely shocked cases will not be handled at this stage unless there are signs of external haemor rhage nor should fractured limbs be interfered with Having made his decision the medical officer sees that the cases are re dressed and if necessary re splinted that anti tetanic serum has been given as evidenced by the Field Medical Card and that a suitably marked or coloured label is attached to the mans tunic to indicate hus disposal Cases may be classified as follows (a) Evacuate sitting (6) Evacuate lying (c) Pre operation ward (d) Resuscitation ward (e) X ray and pre operation ward (a) and (b) are transferred to a ward near the railway siding Their clothes are not removed unless they are wet food and drink are supplied and the waiting period made as comfortable as pos sible The experienced sister in charge of the ward immediately informs the medical officers if a caso ·TORK AT THE CASUALTY CLEARING STATIOV 27 derelops any unforeseen complication, but a per. sonal visit should be made to the yard beforo evacuation takes place (c) Pre operation ward Here the patient is un dressed, washed and put in warm appropriate clothing Wounds should not be interfered with and splints should not be removed Cases requiring immediate operation should be specially marked by the admitting officer eg tourniquet case', 'abdo. minal case' The officer in charge, or at times the sister, will arrange for the patient to be taken to the theatre as quickly as possible (d) Resuscitation uard The evolution of this ward 13 shown by the fact that in the early days of the war it was called the 'moribund' ward It was found that with careful nursing a fair number of the manuanil honplann an con mand an important part of the unit A team consisting of medical officer and assis. tants, together with a sister and nurses, should be specially selected for this life saving work Tho equipment must be adequate Warmth, absoluto rest sedatives, and transfusions of various kinds are tho remedies on which reliance must be placed. Emphasis has already been placed on the impor. tance of fluids I would plead for sound and dig. criminating judgement in the administration of fluids intravenously Some cases will recover with. out this and, while others are so seriously all tha little or no hope can be entertained for their re COFCry "To do something' may be not only taste ful but harmful Of the various fluids recommended ·28 WORK AT THE CASUALTY CLEARING STATION the first consideration should be given to normal saline solution or 5 per cent glucose These may be given either by the subcutaneous or intravenous routes The former is not recommended except under exceptional circumstances It way be pain ful absorption in a badly wounded man is too slow and there is a very real danger of the devitalized tissues becoming the site of infection-streptococ cal or by gas gangrene The intravenous method is more reliable less painful and can be carried out with easo in a casualty clearing station Tho fluid should be run in by the drip method at first fifty to sixty drops per minute and after the first pint has been introduced the rate is reduced to thirty or forty drops per minute Intravenous injection of 6 per cent gum acacia solution Although this means of replace ment of fluid has received authoritative support I believe that any ads antage it may have in the prolongation of the time in which the blood volume is maintained is more than countermanded by the dangers of danger of kidneys D in whom the variants are so numerous both as regards the patient s resistance and the extent and severity of the injuries it 18 ita possible to assess accurately or scientifically the merits or demerits of any form of treatment From clinical observa tion for what it is worth I heartily agree with Surgeon Rear Admiral G Gordon Taylor in hus condemnation of this method of treatment Blood transfusion To ever extending use of this form of treatment in the war of 1914 18 was dramatic but even by the end perfection was not ·TORK AT THE CASUALTI CLFARING STATION attained We now hnow that the universal donor' was a myth and I hare no doubt that much harm and even the acceleration of death resulted from our well meaning efforts Direct cross typing under war conditions is impossible and it still remains to be seen how far the introduction of blood banks will help to solve the problem It is receiving the attention of many well equipped scientific workers, and I have every confidence that a reliable work able method of replacing the lost blood will lo available very soon An Annexe for the preparation of fluids and their storage will add greatly to the ease of working and the efficiency of the unit Operating theatres Large huts capable of accommodating four to six teams with two tables each will be found to be the most convenient and economical from the heating and lighting points of view Space for free movement of stretcher bearers should be provided and easy communication with the X ray department is essential An Annexe for dressings and towels sterilizers, Sterilization of rubber gloves The usual methods of boiling or dry sterilization have been found unreliable of contamination by spore bearing organisms has taken place The most reliable 11. - wh am bhn with Roan and ma l math 1 used gloves are clean and intact Sterilization by ·30 WORK AT THE CASUALTY CLEARING STATIOY boiling, and the using of one pair of gloves for several cases, with scrubbing in some strong dısın fectant between cases, will be found to be the most effectual and workable method written on the Field Medical Card A coloured card indicating whether the patient is to be detained or evacuated by the first arailablo hospital train should be attached by the clerk to the patient's clothing as this guides the bearers to the proper ward The clerk must also see that the bag con taining the patients personal belongings leaves the theatre with him Wards The worh and responsibility of the team in charge of the post operative wards 13 colossal, and post operatire sichness, the relief of pain and must be reapplied and a continuous watchi kept for the development of gas gangrene Before evacuation every patient should be seen It is almost unbelievable how rapidis (within a few hours) a patient who 13 apparently doing very well, will pass into a most critical condition due to the de- Telopment of gis gingrene As often as is possible the operating surgeon should visit the words and see for himself how his patients are faring

·CHAPTER III
PRINCIPLES OF TREATJIEYT OF WOUNDS
AT THE CASUALTY CLEARING STATION
At the beginning of the war of 1914-18 most surgeons
were strongly imbued with the faith that antiseptics
provided all that was essential for successful treat.
mant
virulent this new sepsis was, and how impotent
were standard antiseptics to stay its course
Tho
cl 1 elchu, together with streptococci of different
strains, were found to be the causative organism.
As in every other war it was found that the old
it en.
new
and
renamed Gradually a treatment way evolved
which had as its basis an attack on the dead and
lacerated tissues These, acting as inaccessible
- t
spread of the invading organism The "dug out'
must be destroyed, and only in one way is this
possible-by excision with a sharp scalpel In
retrospect it seems rather sad that such oby

·3? PRECIPLES OF TREATIENT OF TOUNDS reasoning should have been so long delayed, and we can only plead conservatism, and an intense desire to avoid adding to the terrible mutilation which confronted us The treatment by ercision of war wounds came slowly and universally as an erolution affecting each individual surgeon as the solution acting on the osmotic pressure principle Organisms were washed out of the tissues by the flow of lymph and this idea was elaborated by Sir Henry Gray br the salt pack Later liquid paraffin was substituted for the salt but to satisfy the gods of our forefathers acriflavine (1 1,000), brilliant green ( 1500) 1odoform (1 100) were added Various pastes such as BIP were smeared on the wound surfaces although their antiseptic powers have been seriously questioned All garo improved results beciuse the two essentials of wound treat. ment were observed 12 removal of dead or dying tissue and rest Apart from the tissue surrounding the track which has been killed by the missile, death results from arrest of the blood supply caused by division or contusion of the nutrient arteries, or from their occlusion by pressure This pressure may come from within the limb, eg haemorrhage, in. flammatory oedema or distension by gas, or from without--too tightly applied bandages, badly ap plıcd splints and of course à tourniquet An insidious ciuse of external pressure is a roll of gauze inner 1 r be inks ·AT THE CASUALTY CLE RING STATION causing constnction of the enveloped limb Unless this danger is appreciated, extensive and irreparable damage will be done One has only to deal with a few cases of multiple small injuries of the limbs to realize how great is the temptation to use a roll of gauze in the manner described, and yet we must remember to resist it The wound of the skin is not a danger and therefore only the obviously dead edges should be excised Soon after the introduction of this method of treatment, a wide excision of shin was practised and this involved quite unnecessary sacrifice of covering tissue The deep fascia should be freely excised, as its blood supply is poor, and sloughing is likely to follow, especially of tension due to haemorrhage is not relieved The disability due to future herniation of the muscle should not deter the surgeon from freely incising the deep fascia upwards and downwards in order that the underlying muscle should be thoroughly inspected In dealing with muscle while every attempt should be made to remove dead muscle, excision of Living muscle should be avoided In wounds seen soon after infliction the absence of haemorrhage, when the muscle is cut, and also the absence of contrac tion when it is cut or pinched by forceps, is evidence that the muscle 13 dead Within a few hours after 1 ample of this is seen in the case of a wound in the upper thigh involving the upper part of the sar. torious muscle The blood supply being cut off, the F ·34 PRINCIPLES OF TREATMENT OF WOUNDS wholc muscle, to its insertion into the tibia, will die If gas gangrene is to be avoided the whole of the affected muscle must be removed The situa tion may be summed up by stating that gas gan grene will not develop in tissues in which there 19 a vigorous circulation of healthy blood In carrying out tho excision operation another important point must be kept in mind If the excision is made at the distal parts first blood vessels supplying the tissues left behind may be cut across in removing the proximal parts of the wound The organisms left in the wound may find a suitable nidus in the devitalized custal tissues and later give rise to gas gangrene The infecting bacılh will also develop in blood clot although much less readily and it is therefore necessary that it also should be removed from all rocesses of the wounds of the soft parts It is not always possible to carry out the ideal of complete wound cxcisions The track of the wound may be such that in order to give the necessary exposure important structures such as main blood vessels nerves &c would have to be divided. Under suls circumst inces one should capitulato and endeavour to make as thorough a removal of the lacernter musclo and fascia as 19 possible Whero compound fractures are encountered, conservatism must also be practised The presence of dead bone although it leids to delayed healing, does not lead to the derelopment of the deadly spreading infection ag does the presence of dead muscle tissue Only completely detached bono fragmenty should be remoi ed and doubtful frag. ments left in position Removal of foreign bodies It 19 a counsel of perfection to say that all foreign bodies should bo ·35 AT THE CASUALTY CLEARING STATION remored as soon as possible As a matter of fact, whether they should be removed at all, and the necessity for their early remoral, depends on their size, shape, and character, and also on the mobility of the part in which they are lodged and their probable effect on function The amount of damage done to the tissues depends on the shapo and roughness of the missile An undistorted rifle. bullet 19 much less likely to cause trouble than shrapnel balls or, more particularly, fragments of shell casing It may quite often be observed that an undistorted rifle bullet lodged in the condyle of the femur will cause no trouble, while a small shell fragment lodged in the belly of a muscle will almost certainly cause sepsis If the foreign body is lodged pear a pulsating vessel the danger of a secondary haemorrhage is very real From what has been said it is evident how essential 13 the necessity for guidance by X ray in this important problem The prolonged searching for a foreign body or bodies in a recently wounded man is to be depre. cated and more courage is shown in giving up the hunt' than in persisting When the 'toilet' of the wound has been com. pleted, the decision as to whether it should be butured or left open his to be made Early expert. ence of the results of immediato closure of wounds in the last war were so uniformly bid-due to incomplete operation that it became a rulo that no sutures should be inserted The Younds were plain--and some days later removing the pach and suturing the found In some cases, eg amputations ·36 PRINCIPLES OF TREATMENT OF WOUNDS primary suture of the wound was practised with satisfactory results One must not sacrifice use. ful length of stump to satisfy the ambition to obtain primary union The experiences of Trueta and others have shown us that excision and primiry Buture of war trounds 13 not only possible but desırable if the case is scen early and if the proper technique can be carried out Only experience in the present war will show how far this is possible Much depends on the nature of the fighting, the facıhties for rapid transport and the number of wounded to be dealt with by the available teams Until further experience is gained it will be safer to aim at delay rd primary suture Splinting The importance of adequato fixntion of the wounded part (innot be too strongly emphasized During the last war, plaster of Paris casing was not user extensively in fact, there was n very strong feeling agunut its uso Since then, however the works of Winnett Orr and Trueta have demonstrates beyond doubt how useful a this trentment can play in maintaining position and IN ensuring a muih more comfortable means of transport for the wounded man It is recommended that a shin tight plaster be applied and that it should immobilize the joints above and below the wounded area The case must however bo closely watched experially if the ercision of the wound has part 1 since such and .

·AT THE CASUALTI CLEARING STATIOX 37 an increased watery discharge from the wound, will occur unnoticed and one must rely on the general toxic symptoms—an increasing pulse rate, pale anxious expression sweating, &e The patient often falls into a deceptive sleep, and when wakened shows signs of mild delirium If the surgeon 13 in doubt, he should refrain from enclosing the wounded limb in plaster and use instead a plaster of Paris slab splint or one of the splints already described under forward area treatment Anti-tetanic serum No matter how insigni ficant the wound, every patient must receive a pro phylactic dose of anti tetanic serum If doubt exists as to whether this has already been done, another should be given In the case of a man wounded for the second or third time it is safer to give it in fractional doses, noting any local reaction In all seriously infected wounds the administration should be repeated every seventh day until the wounds are clean It is only very rarely that tetanus will be seen in the forward arcas, except when at develops in a case where the wound has been 80 slight that the patient has failed to report its occur rence In such a case large doses, 60-100 thousand units, should be given intravenously and repeated the following day Careful nursing to maintain nutrition and to procure rest, helped by the ad ministration of large doses of hypnotics, such as potasgium bromide and chloral hydrate or, in more resistant cases, avertin, 13 of the greatest importance, Anti-gas-gangrene serum. How far the use 11 ·38 PRINCIPLES OF TREATJENT OF WOUNDS Drugs of the sufphonamide group We hope for very great help from this recently introduced form of therapy, and without doubt we shall not be disappointed Time alone will show how far the surgical procedures recommended will be modified by their use It is doubtful however if their mar vellous curatire powers against organisms inbabit ing living tissues can be expected to act against organisms in dead tissue The treatment of late cases It is impossible to lay down a fixed time in hours to mark the pas sage from an early to n lite case Some men hare succumbed to acute gas gangrene within twelvo hours of the reception of a sound while in others, after two to three dis of completo inattention, Lttle or no sin of infection mar bo present The surgeon must therefore he guided by the appear. ance of the sound and by the general condition of the prtient Where it 19 felt that sepeis has obtained a hold the aim (f the surgeon is still to remove deadl tante to relieve tension and to establish adequate Irunage There in be no question of suture either primary or secondary and the en closing of the limb in a plaster caso will be fraught with dinger Gas gangrene la mu be gathered from what las already been written La9 gingrene was a now and terrible (yrke nue in the last war It had to be seen anley need life its insidious onsct, its rapid d un it and its deadly consequences could be a't isted It w is at first a strange unknown and all sorts of thcorice such as copper flating intected projectiles &c, scro hinted at It » is some little time before we appre ciated that the infection was the result of the

·AT THE CASUALTI CLEAROG STATIOV 39
excellent husbandry of the French peasant and
that all clothing and equipment became infected
by the ci Welchu This inaerobe can only grow
in tissues deprived of their blood supply resulting
from the injury or from the action of other organ
isms such as the streptococcus
Symptoms The wound shows signs of acuto in
flammation It 13 red tender and there is slight
1.
On palpation the characteristic crackling of the
-lo falt autonino mlolv from
and this state 19 followed by coma and death
Treatment The treatment 19 surgical and must
be undertaken as soon as possible wide opening
up of the wound track with removal of all muscle
tissue which shows signs of discoloration or which
does not contract when cut Relief of tension by
incision of the deep fascia in the part of the limb
which shows the presence of gas should be carried
out but incision into healthy muscles must be
avoided If the main blood supply is interfered
with and all the muscles below the site of injury
are dead then amputation sbould be carried out at
once The extent of the spread of gas does not
influence the site of amputation Tor example in
a case of yound of the leg with division of the
r
1

·40 PRINCIPLES OF TRE 4TVENT OF WOUNDS knee joint, cartie gen anaesthesia, hopeless case T packed with gauze, and only one or two sutures inserted into the skin to retain the dressing There is another case of fulminating infection which is not so common as gas gangreno In it the limb becomes swollen and tense but no gas can be palpated The patient also shows signs of acute toraemia When the wound 19 opened up the whole of the tissues and especially the subcutaneous fat, aro oedematous The intcting organism is tho streptococcus fiecalis Amputation above the oedematous area must be carried out at once Amputations The young surgeon, full of his trainın, in conservative methods, will be dis appointed and shocked by the number of cases wluch in spite of all his care in tho carly treatment of the wounds will show signs of spreading infec. tion within twenty tour to forty eight hours, and at which time the question of amputation will havo to be decided the responsibility of deciding Le. tween an attempt to save a limb especially a hand and arm and the 114k of losing a life is indeed grave Experx nit will help but we hnow how fall utous it can be and no hard and fast rules can be gwen The following considerations may proro helpful Limb (1) Prothes for the lower limb are much more satistictory thin ire those for the upper limb (2) The state of the circulation distal to the wound (3) The general condition of the patient Patients who have been bulls shocked even though they hare apparentis recovered well are less likely to resist infection than those who have not been bo ·AT THE CASUALTY CLEARING STATION 41 affected (4) Is the found single or multiple? If there are wounds of any severity elsewhere, am putation of the doubtful limb should be more seriously considered (5) Age Other things being equal it is justifiable to attempt conservative treatment for a little longer in the young man than it is in the old Type of amputation In order to ensure drainage and to shorten the time of operation the guillotino amputation was popular in the early years of the war The exposed raw surfaces caused so much pain, and took so long to heal, that this type of amputation was largely given up in favour of flaps The length of the flaps as indicated in operativo surgery books are too long, and nothing is to be gained by having a mass of redundant skin the edges of which are likely to die In advanced units, amputation through the site of fracture will often be possible and will be found to be satisfactory. The flaps, shaped as the available skin will allow, should not contain muscle The end of the bone 15 trimmed and vessels ligatured There seems to be difference of opinion regarding the treatment of the main nerve trunks Apparently high division does not prevent the development of painful neuromata The wound should be packed with gauze and one profusc oozing To prerent thus it is well to cover the raw surfaces of the stump with thin artificial silk, if such can be procured, and place the gauze superficially to this The silk presents adhesion of tbo gruze and does not interfere with the escape of serum or of pus. Gauze impregnated with vase.

·42 TRINCIPLES OF TREATMENT OF WOUNDS line or liquid paraffin also makes a comfortablo dressing, but oozing from small vessels is apt to persist. A firm, well padded dressing is then appled and the stump firmly bandaged It is sometimes necessary, especially in amputation through the upper part of a limb, to fix the bandage and for this purpose adhesive strapping or elastoplast may bo necessary Fixation of the stump by splints 19 ideal, but frequently, ay in the case of the thigh, cannot be carried out ofhctently Commencing at once and during cont descence a watch must bo hept to prevent the son deformity at the joint abovo the nmputation 'The placing of the limb on a pillow although comfortable must not be main. tained continues otherwise flexion deformity very quickly develops Drainay n kind of drun Discusgion has rageu, and still rike ta the type of drain which permatot the ot wound discharges in the wound bis lint itself to 81019factory surge el ning the user ton of a drainage tube, whithur mode of rubber kl.4 (s perforated zinc, 14 Uni (11) bure however an abacess has been opened the surgeons bound to preservo an of* ning to the hunt future shischarges Jaconct, rubler (111) 12.Xullo giun do not do 80 8$ 14 euch mordlys the tithi when they are removed a guxh of Mund te los proves that they havo acted as stark septes the rubber tulo as the method ostir um in impyema thoracie, and hence it 4 - conubile tund 1140 that whero A cauty * tl druge N nereiry a rubber tubo will anewer the purpose more efficiently than any other material On muust weigh the disad. vantages against the advantages Tlc rubber tubo 14 PM

·AT THE CASUALTY CLEARING STATIOV
is a foreign body and causes irritation and even
necrosis of the structures with which it comes in
contact It should not therefore be placed in close
proximity to important structures such as arteries,
veins, the synovial membrane of a joint, brain
tissue, &c Even in less vulnerable tissue its poten
tialty for danger must be recognized and its use
dispensed with as soon as possible The presence
of a drain does not prevent the development of a
haematoma as the blood quickly clots, filling the
wound and the tube

·42 PRINCIPLES OF TREATDIENT OR WOUNDS line or liquid paraffin also makes a comfortable dressing, but oozing from small vessels 18 apt to persist A firm, well padded dressing is then applied and the stump firmly bandaged It is sometimes necessary, especially in amputation through the upper part of a limb, to fix the bandage, and for this purpose adhesive strapping or elastoplast may be necessary Fixation of the stump by splints 19 ideal, but frequently, as in the caso of the thigh, cannot be carried out efficiently Commencing at once and during cony elevcence a watch must bo hept to prevent flexion deformity at the joint above the amputation The placing of the limb on a pillow though confortable must not be main. tained continuous otherwise flexion deformity 1er quels descope Drainu anlhind of train Discussion has raged, and till rik Is to the type of drain which permit if the ancip" of wound discharges is the w bien dent itself to satisfactory surgwalche inng the insertion of a drainage tube, wht 1814 r n ut of rubber g/144 or perforated zinc, 14 und CESAR Where however an abscess has been on the site on fe bound to preserve an opening forth 144 of future discharges Jaconet, rublis luminex nuils pauze do not do so as 19 evlene i by ti ti t shit when they are removed A guxh Bund! ! o proves that they have acted as i suth (1) puutes the rubber tubo as the method of Iruntha in empiema thoracis, ond hence it wmns 2 en alle to adx190 that whero & cavitsai ar unite is necessary a rubler tube will answer the purpow more efficiently than any other material On must weigh the disad. vantages agarizst the advantages Thic rubber tubo

·AT THE CASUALTY CLEARAG STATION 43
is a foreign body and causes irritation and even
necrosis of the structures with which it comes in
contact It should not therefore be placed in close
proximity to important structures such as arteries,
veins, the synosial membrane of a joint, brain
tissue, &c Even in less vulnerable tissue its poten.
trality for danger must be recognized and its use
dispensed with as soon as possible The presence
of a drain does not prevent the development of a
haematoma as the blood quickly clots, filling the
wound and the tube

·CHAPTER IV WOUNDS OF THE BRAIN AND ITS COVERING IF the wounds of the brain are left untreated until inflammation has obtained a hold the results to life and function are disastrous It is thereforo of the utmost importance that these wounds should bo treated efficiently at the earliest possible moment It was, however found that ifter operation 'brain' cases travel indlind their eiri evacuation is often imposibl The (suits clearing stations which are to deal with such asce must thercforo be equipped for the retention of a largo proportion of them for not class ind even two to three wechs The prinsiple underlying the treatment of brain caves do not differ from thone alre uds stated Sepais I bout presented his airls and complete operation Foreign mata presjettles and displaced bone shoukl ut pathleen removed as should dead brain 14116 Halt esion of shin edges is not necer but the sound should be enl urged to giro goxxl exposun Some base and ocated tho turnung down of a wall he ne flip for this purpose, but in the majority o* l careful en irgement of tho sound in the hull i trong mbbling forcepe will be found to the authakent The r moval of bono should be caru at ut the nubbling of small bites, rather than by them here and shock prodlucing method of cuttine sufflurke fragments by a strong Lone cutting force 1 14 well to remember that caro must le fnken tutto further injure the already torn dura while this is being carried out Hasing ·WOUNDS OF THE BRAIN AND ITS COVERING 45 made an opening in the skull the size of a five. !!! :-),I,,..1!. :. list' IT'!. I': . - galine solution through the catheter also helps to wash out the lacerated brain It must be done carefully and systematically and requires time and patience Rough searching for metal bodies or looso bone in the depth must be avoided A probe or ventricular needle, and very occasionally the gloved operating finger, may be used for this purpose When satisfied with the 'toilet' of the wound, the surgeon should endeavour to close the scalp over the exposed brain, inserting a small drain at the most dependent part This drain should penetrate the scalp only and must not lie in the substanco of the brain Closure can almost always be obtained by enlarging the incision so as to form a slıdıng flap with a broad base (see Figs 10, 11, and 12) It 19 important to suture the galea as well as the skin, and for this purpose linen or silk thread (not catgut) should be used in times of stress one is tempted to dispense with the time consumed in the Buturo of the galea, but this procedure controls haemorrhage, gives an even tension in a wound which has to be closed with considerable difficulty, and may Prerent a hernia cerebri during con. valescence 7

·46 WOUNDS OF THE BRAIY AND ITS COVERING
CHA
714
2
olun
111 iro of scalp wound,
Stlap BV Aap
*
th
AR
ܢܢ
Fia 11
tatto con luda!

·WOUNDS OF THE BRAIN AND ITS COVERING 47
symptoms The Found may be gutter shaped or
the entrance and exit wounds
теrу
close
If the patient gives the history of having been
stunned at the time of injury it is wise to presume
may be
Fia 12 Diagram of plastic operation for triangular
defect
that a serious intracranial lesion has occurred and
therefore operation should be undertaken Some
cases will be encountered where, on ercision of
the scalp wound, only a slight bruising of the
periosteum will be seen It has been found very
frequently that in this type of caso an extensivo
comminution of the inner table has occurred In
some cases a good shiagram will show the presenco
of a fracture of the inner table, but in others
evidence will be lacking, or the tahing of an X ray
plate has not been considered necessary
doubt the surgeon should make a small trephine
or burr opening through the outer table and the
condition of the inner table be ascertained If a
If in

·48 WOUNDS OF THE BRAIN AND ITS COVERING of the dura mater After removal of the fractured bono the dura 13 inspected If it is normal in appearance and tho brain pulsates well, the opera. tion is ended by closure of the scalp wound If, howerer, tho dura looks muddy', if there is loss of pulsation and circumscribed loss of elasticity, it should bo incised This is done by a small crucial incision which may be enlarged of extensive blood. clot or lacerated brain is found (c) Derply reated foreign bodies It goes without saying that it would be the ideal treatment at a primary operation for a penetrating wound of the foreign bords could always be remored Otherwise the operation must be regarded as incompleto with afir greiter lihtlthod of gubsequent absceas forma. tion than if remos al of the missile has been accom. plistica It is equally true thnt foreign body extration 110 matter how desirable, as a means of asoiling these puble complicitions should norer bo forces to the point of inerensing the damage to the nervou4 tit* 4 Elready done by tho penetra. tion Some Menu301 infection at any cost', others better a fatults from infection than tho certainty of perpetuting part 14 Between these to schools one must be cock in the individual caso-- always attract a trein bxxly if it can bo accom plished without une ressing the damago already donc Thuis de 11-17 n applies solely to deeply im plantal mizuiley tir all agree that superficial and casily accessible on * should of course, bo remore! Extraction with a mi net is the only justifiable method applicable to sleep seated bodies and can ·WOUNDS OF THE BRAIN AND ITS COVERING 49 often be accomplished after suction of the track in the usual method by gently sliding into it, to the proper depth, a French wire nail with rounded point Contact with the proximal end of the nail is then made with a portable electromagnet which need not be a weight greater than can be easily handled, and if the foreign body 18 magnetizable and proper contact secured it will be withdrawal along its own track of entry In not a few cases the missile and bone fragments have been driven through into the ventricle and in the process of suction the cerebrospinal fluid spaces have been suched completely dry Many cases with opened ventricle when treated in this way have made perfect recoveries 1J T. to cortical irritation and not to interference with the blood flow in the sinus Operation in such cases may be difficult on 11111 an inexperienced operator A trephine or burr opening should be made just beyond the fracture, and, with a Montınovesi or de Velbis forceps the frac- 4 1 ·48 TSOUNDS OF THE BRAIN AND ITS COVERING the dura mater After removal of the fractured bono the dura is inspected If it is normal in appearance and the brain pulsates well, the operation is cnded by closuro of the scalp wound if, however, the dura looks 'muddy', if thero is lows of pulsation and circumscribed loss of ciasticity, it should be incised This is done by a small crucial incision which may be enlırged if extensive blood. clot or lacerated brain 14 found (c) Deeply seated forsign bodies It goes without saying that it woull be the ideal treatment at a primir operation for a penetrating wound if the foreign bexts could alu is be removed Otherwise the opx rition must be regarded as incomplete with a fur greater the laboul of subsequent abscess forma. tion than it remos al of the missile has been accomplished It is equally true thnt foreign-body extraction no matter how desirable, as a means of awowin these posible complications, should never bo forced to the point of in reasing the damago to the rous they alreads done by tho penetratron some 11 ore infection at any cost'; others Ixtter a fatalits from infection than tho certainty of perpetutin paralı 14 Between the two schools ont munt of red in the individual case als 159 estrutoreign body if it can bo accomplished ssthout ane te esing the dimago already done Thy I upon applied solely to deply im plantei mitles for all agree that surperficni and 01911y necessibles should of course, be removed. Extraction with a mignet is the only justifiable method applicable to deep seated bodies and can ·WOUNDS OF THE BRAIN AND ITS COVERING 61 cose-solution gives rise to a temporary fall in cerebrospinal pressure, but is quchis followed by a rise above the previous level In most cases of hernia cerebri careful and frequent dressing of the wound to prevent secondary infection is all that is called for. As the reactionary oedema subsides the hernia will slowly regress On no account should the protruding brain tissue be 'shaved off' Lumbar puncture. This 13 seldom called for in brain injuries, either from the diagnostic or from the post operative points of view The knowledge that there are blood cells in the cerebrospinal fluid or that there is an increase in pressure will not carry us any farther in the diagnosis and treatment than what is already known by the history and physical signs, and, unless it is established that further knowledge is likely to help, ono 19 not justified in carrying out a procedure which is not without some rek Such sonbus cases should be admitted to the resuscitation wards for observation, as occasionally an apparently moribund case will improve to such an extent that operation may be carried out later From this point of view also the apparently trivial head wounds ought to be care. reduce conralescence by months Anaesthesia. In cascs of head injury, local anaesthesia has many advantages The addition of adrenalin (4-5 drops to the oz) controls haemor- J ·62 WOUNDS OF THE BRAIN AND ITS COVERINO proposed incision Cutting the bono does not causo pain, but pressure on the dura mater, or the catching of vessels in the dura, causes discomfort Tho mental condition of the patient and also of tho Burgeon are important considerations in coming to a decision If general anaesthesia 19 called for, tho intratrachenl method, which gives a free air way and therefore diminishes congestion, 19 to Lo prc. ferred Preparation of the scalp. In the reception. room a soup soah should be applied and the sharing of tho scalp carried out on the operation table Previous cutting of the hair by sorssors or clippers carries no ads intagns of a well sharpened 'cutthroat razor drawn with the lic of the hair 19 skilfulls used trained orderly can carry out the preparation on the spire table while tho surgeon 19 closing the sound of the previous cisc În dis. orientated patients the shaving should be dono after the patient 19 under tho anaesthetic Tho astra time taken wall more than compensato for tho shock which follows valint but misguided attempts to remove Jinir caked with blood and mud from tho scalp of a non cu operative apprehensive patient.

·CHAPTER V PENETRATING WOUNDS OF THE ABDOJEN In the war of 1914-18 two or three per cent of the cases handled at the casualty clearing station were penetrating wounds of the abdomen, but this represents only a small proportion of the total number, as many died on the field or on the way back With increasing aerial activity, the surgeon is likely to get a large proportion of the wounded much sooner, and therefore the number of penetrating abdominal injuries is likely to increase The two lethal factors in this type of injury are (a) Haemorrhage which cannot be controlled by non operative measures, and (b) Infection of the peritoneal cavity or retro peritoneal tissue following the perforation of hollow viscera To combat these with reasonable hope of success, operation at the earliest possible moment 19 essential Apart from internal injuries, the wound of the abdominal wall is also a source of danger, 1 3 An anywhere in the trunk where excessive external haemorrhage has not occurred must give rise to the fear that either intra thoracic or intra abdominal lesions have occurred Unless this is remembered, ·64 PENETRATING WOUNDS OF THE ABDOMEN cases of this type will be missed in the carly stages and treatment delayed with regrettable results The surgeon, accustomed to the diagnosis of civil abdomini disasters, will be misled by tho absenco of signs, which he regarded as pathognomonic, of perforation of a hollow viscus As the small intes. rigidity of the abdominal muscles and even tender: ness aro not present ercept in the region of tho wound Within a varnıble time depending on the rato of haemorrhage a peritoneal reaction docs occur this is characterized by a spreading tenderness and a prisitive rebound phenomenon Al. though there may be como increased muscular resretin e mun ular riadits docs not appear until much later It the stomach is distended at the timo of wounds in the type of injury allows tho (unpe of its contents HILLS almilar to thoso caused is a part rated ul or will be present Perforations of the con dont as a rule' glo riso to signs of early peritone il reation The presence or abaenco of liver duties het no value in the dignosis, nor 19 the crimin if the alxdomen for the presenco of free tlux! Ithals to lx of any help In cases shoun an entry and exit wound somo help in the diagnosis in stenderl by trying to visualizo the track whith the manyle has made Too niuch reliance on this meth wł of diagnosis should not bo made becau- the cute taken by the migilo is not always a straight line and also becius of tbo varging positions we uprte? by tbo normal hollow 119cera Tho aid of an atl14 of sectional anatomy will ret, acidom bn of saluc ·PENETRATING WOUNDS OF THE ABDOJEV 55 Radiography. Where there is no erit wound, and where the entrance found indicates that the missile 13 of considerable size, it is important to obtain such assistance as one can from X ray in Testigation The removal of such a foreign body from the retroperitoneal space may be imperative to present a fatal ending from infection, and a knowledge of its site permits of its surer and more rapid removal In cases where the missile 13 small, Xray etamination can well be omitted It is time consuming and the transport and manupulation will only aggrarate the already present shock From what has been said it will be seen that fre quently the diagnosis can only be provisional and an untra abdominal lesion suspected This, however, is enough to warn the surgeon of what lies ahead and not only to warrant but to demand surgical investigation Treatment Pre operatie Shock being, in many cases, a well marked symptom, treatment by the methods already described must be instituted It must always be remembered, however, that whatever method or methods are used, haemor- 1 must rest on the judgement and experience of the surgeon On the whole, it will be found better to undertahe operation early, and to rely on restora, 1 in the condition of the patient Blood transfusion is much more beneficial and more lasting in its ·56 PENETRATIXG WOUNDS OF TAC ABDOVEX effect if performed after operation If this attitudo 19 adopted, more cases will be operated upon, and the operatire mortality rate will rise, but the chances of recovery to tho indu idual will be in creased When the patient is seen in the resuscitation ward his general condition may appear to lo such as to warrant operation Merely transporting him from the ward to the operating theatro may 11 upon to deal with war wounds of the abdomen Both will be mvarels ind frequently tested Anaesthesia The judgement shall, and sym. pathetic o oprition of the anaesthetist aro of immese value to the surgeon under warfaro connu Forest hominal injury suffering from phone in ud onogen is undoubtedly the annesthetica che la but for its successful ad. ministratine hill and experienco are neces. NITS The UIRED dealing with a progresne uncontrolled line Tebibe of unknown location, and much mumpulation with as little increze in shoch. Able is Dry The increase] respirators rute ta training during induction mni increase the rate of hue morrhage, and a light Anacathesia during the brandkng of the loops of intestin mas la prenotive of still greater Bloch In the list war of the folloysing n rapid induc. tion with ethulihend or nitrous oxide, was tho most uniservilly implu nuesthosin, and it grie, on the whole the lat results Spinni annesthesia was not employed to any extent and the fall of blood pressure, which frequently accompanies thus ·PENETRATING toyds or DIY TY TNI" method of angretheua wall wipilt in alt risk of operation It x doulful tren, introduced barbiturate will in front !!! the same reason for premeraterm rm : *** omnopon with atropune *7] In findinis tirpiut reliable Operation Speel is the animali ang but must not le sehrred ar thin magazynol gormek bandung or bruine of the proje 117 ** in entrance or exst woux} }* 358frymnis loin, buttock or even thigh 12 mnt 13 ww! before the abdominal incision is mulr 7 #rx seems to contradict Round rurpiral tew! : "", ty that a 'dirty wound 1 dialt with In your * } Found is made but the great fall of liwg**11* wbich ensues of the patirit is turi afy szereya tomy makes its obowmanit trgutaute in won cases it is also neccesan to explore the source length oputing of the actug mus ir plinul in avoided as the muscle filrt Winnn tl - In1,199 and the milline are thereby cut off from their blood and nerse supplıry and marlily brother prey to C! Tech The incision may lraunmental by transverse or oblique incision of it in Detmonry tn rna L - 13 tis lne gmall intestine and it mesentery are the parts damaged in the majonty of cases, thus portion of the lowel must ·58 PENETRATING WOUNDS OF THE ABDOMICN systematically either at the ileo caecal val the site of the wounds in some cases Besides the bowel itself, its mesentery must be carefully ex amined for bleeding points The omentum must be inspected as must also the stomach and the colon through its whole length A retroperitoneal hae matoma in the region of the duodenum or colon peritoneum 19 difficult vious that hacmorrhage is coming from the liver or spleen In this case a largo pack of gauze should be used to arrest the bleeding while the rest of the examinatron is carried out 19 wounds of tho viscera aro frequently multiple it is better to control the injured segment by a lightly applied bowel clamp and to proceed with the examination rather than to repair the wounds as they are discovered Having completed the < ramination there must be no re examinition Handling causes shock and must be reduced to the necesary mimmum Small intestine Herniation of the small bowel through the sound in the abdominal wall, although usually accompanied by severe shock, docg not mean a hopele 4 prognosis and it is often well worth wlule tas hling such cases as it is unlikely that estensne infection of the peritoneal cavity has occurred In the war of 1914 18 frequent discussions took place regarding the relatie merits of suture and resection By 1918 the general opinion was that simple suture of the perforation as to be preferred in suitablo cases If suture is decided upon, a single ·PEXETRATAG ROUNDS OF THE ABDOMEN 59 layer of linen or silk thread is all that is necessary, inserted as a continuous suture and invaginating the pouting mucous membrane Considerable narrowing of the bowel should not cause dismay Special care must be taken then the wound of the gut is closed at the mesenteric attachment The presence of a haematoma into the mesentery mahes tzualization difficult, and it is frequently necessary to ligature the divided vessels and clear the bowel edge so as to make sure that a perforation, if pre sent, is securely closed Although simple suture 18 the ideal method of treatment many cases will be encountered where this procedure would be disas trous on account of interference with the blood Bupply If bowel is separated from its mesentery for more than three quarters of an inch resection 13 sa fer than simple suture Multiple wounds within a short segment of gut may make efficient suture impossible Very numerous and extensive wounds may make suture more time consuming than resec tion Extensive infarct of the mesentery may demand resection on account of interference with blood supply It is therefore a mistako to make hard and fast rules The decision must depend on the judgement of the surgeon Anastomosis. An end to end anastomosis in the small bowel will usually be found to be the most rapidly carried out and the most efficient method The escape of intestinal contents should be controlled by clamps and the crushing forceps should be removed before suturing is commenced -AL 'inen teric the suus ellu viing in long waen luo uut mesuliterio T.

·GO PENETRATING WOUNDS OF TIIE ABDOVEN called dangerous mesenteric angle need cause no anxiety of this technique is adopted One or two e Wounds of the Je regarded with urse, due to the ents and also to the fact that the retroperitoneal tissue 19 frequently infiltrated by haemorrhage and bowel contents Infection of the retroperitone al t199ue spreads with alarmning rapidity ind little can be done by drainago to present this fatul completion Tho thinness of the bowel will makes suture difficult and often insecure It is quite eart in the presenco of a retro peritoneal hiemituma to overlooh a small perfora. tion of the colon while bruising of the wall and interference with the blood supply may lead to lato perforation For these various re 19ons prognosis in a ca tho aby reveal some cases suture of the wound will be succcesful. but, if the legion is extensive if there is any doubt concerning the ability of the segnient or if Buturo 15 doubtfully succesful the involved segment should be exteriorized through a separate incalon add & temporary culo-tomy performed In other cases it will be necessari to treat tho insolved seg. ment by resection and this can be more safely and .

·PENETRATIXG WOUNDS OF THE ABDOVEX 61 more quickly performed by the two stage Paul- Mikuliez method The writer agrees with Surgeon Rear-Admiral G Gordon Taylor that resection in all but the simplest cascs is the method of choice His pioneer and apparently daring vorh in the surgery of gun shot wounds of the abdomen in the last war was more than justified by the outstanding results which he obtained In the rush of work at found safer than the one stage end to end anastomosis method It will also shorten the time spent at the operation which is important in patients already suffering from shock “As has been said, Bepsis, especially infection of the retroperitoneal space, 19 a constant dread, and therefore every available method of treatment to combat this must be instituted at once This will include drainage, sera, and drugs of the sulphanılamide group Wounds of the stomach and duodenum. Wounds of the stomach vary in size and in site, being frequently multiple The extent of peritoneal soiling depends on whether the stomach was empty or full at the time of wounding They can almost always be closed by suture Professor Wilson Hey has shown experimentally that it is almost impos- Bible so to deprive the stomach of blood supply as to causo gangrene or sloughing of its valls, and even very considerable deformity caused by suture is unlikely to interfere with function Wounds of the duode its fix preser ·62 PENETRATING WOUNDS OF THE ABDOJIEN calls for careful search for a retroperitoneal perfora- 121. 11 Inar in many cases of intraperitoneal injury the icsion will be discovered during exploratory laparotomy The bladder should be sutured whenever the con dition of the patient and the accessibility of the wound permit Where this is impossible a self retaining suprapubic tube should be introduced, and the vicinity of the extraperitoneal bladder wound drained Wounds of the liver The type of wound found in the liver may vary from 1 small perforation to almost complete disruption of the whole organ In some cnges ihe wound 19 40 extensive that it would be impossible to prevent infection by surgical measures If the track of the missile indicates that only the liver is injured and if the signs of haemor. rhnge are not pronounced expectant treatment shoukl be instituteri Sir Cuthbert Wallace and the late i 1744+ ate have conclusively shonn that Burgical al stention in most of these wounds is ad 191ble When the women has been opened and a bleeding wound of the liver is discovered, attempts should be made mittrexy suture to control it This honeser kurften difhcult both on account of the friability of the liver and also on account of the difficulty of cong In such cases it may be neces sary to pach the wound with gruze If the bleeding 19 an ooze it 1* butter to do nothing as frequently this will stop when the abdomen is closed å slight jaundice soon after injury 13 of no importance, whilo ·PENETRATING WOUNDS OF THE ABDOMEN 63 an icterus, developing later in the case, is of grave significance and indicates sepsis Gun-shot sounds of the kidney. All grades Armadonntinn ld 1e hilum 19 injured or there is extensive laceration of the body of the hidney should nephrectomy be undertaken Usually it is enough to excise the parietal wound, expose the kidney for examination, and control haemorrhage by pack or suture Very frequently the kidney injury is accompanied by lesions of a hollow viscus, the treatment of which is much more urgent Retroperitoneal haematoma In quite a num. ber of cases, after the abdomen has been opened and explored, the only lesion found will be a retroperitoneal haematoma Attention has already been drawn to the importance of looking for a hidden perforation of a hollow viscus in these cases, and the surgeon must not rest until he has excluded such a lesion If none is found, no attempt to deal with the haematoma should be made Theoretitissues, and any attempt to do so prolongs the a phool Tha chance e, . 10 st id may be dealt with at a later date Abdomino-thoracic wounds. Shock 29 an early and prominent symptom in Founds of ++ ·64 PENETRATING WOUNDS OF TIIE ABDOJEV class, and the mortality 13 high Increasing experi counts for many of the late deaths in those who survive the initial loss of blood and shock Vhen whether the abdominal cauty has been perforated or not The rigidits due to a chest injury is not 80 constantly mutuned as is the rigidity of peri tonenl irritation During the abdominal examination of the hind us hept moderately firmly applied to the ab lomunal wall a distinct lessening of the muscular rigility will be appreciated This is not maintuned for long but is enough in some cases, to establi-4 the dignes If doubt still exists, exploration must be infried out Treatment 4* a rule the approach should lo in the thoraco rather than the abdominal route The parut i wound ist keised and enlarged along the course of the ruly downwards and forwards The pleural carits 18 opened up and fluid blood removed by nurtun The ragged sound of the diaphragm 1 IHI and enlarged and a very satisfacturi minal ser tho injuries 1 the diaplıragm is al ser} using small curred round bodied needley in the fine interrupted linen sutures The plural runty 19 then dealt with in the manner discussed in the following chapter, 11 ·CHAPTER VI PENETRATING WOUNDS OF THE THORAX EXPERIENCES in the last war in base hospitals and casualty clearing stations led to the erroneous opinion that a 'chest' wound was the most favour able of all the rarious types in that a large number recovered with no greater risk than an empyema Further experience at adranced dressing stations or regimental and posts cast considerable doubt on this opinion, but the true mortality of thoracic Founds can be gauged only by examination of the dead on the battle field Nr K M Walker quotes Sauerbruch who found that out of three hundred dead examined on the battle field 37 per cent showed chest wounds The obvious conclusion 18 that a large number of chest wounds are immedi ately fatal, nor us this to be wondered at when one considers the large and vulnerable organs and ves. sels contained within the thoracic cavity Under the cond. some of long eno under the observation of the surgeon In spite of the advances made in recent years in civilian thora cic surgery, and the hope that these would prove successful in many cases of chest injuries due to Warfare, we must realize that the derangement of function of heart and lungs following the formation of a large opening into the pleural carty is fatal, due to mediastinal swing The only treatment possible in such cases is to pack the wound with dry gauze, using skin sutures to maintain its positio K ·66 PENETRATING WOUNDS OF THE THORAX and to apply antı shock treatment The patient is usually distressed, and to combat this, morpha or omnopon should be freely giren Continuous ory. gen administration by the BLB Mash, under supervision, also promises to be of very great help in this type of case Less severely wounded cases If the patient has survived the initial haemorrhage and slioch sepsis, as in wounds of other parts of the body, is an ever present danger and in order to combat its development certain measures must be instituted. It was found that most patients with punctato entrance and exit wounds whether duo to bullet or small shell fragments recovered without operativo measures but one and all must be carefully watched There may be little or no haemorrhage If the haemothor ar does not reich higher than tho nipplo line and does not how signs of increasing, no anxiety on the score of haemorrhage need bo main. tained if however the temperature and pulse do not subside or tend to increase if there is increase in respiratory testress or if the patient abows an anxious expression then sep-19 must be suspected and by the use of the exploring syringo, flud removed for bı teriolok al examination A crimsonpurple colour of the truth in the barrel of the syringo and a foul olur it the fluid aro sufficient proof of anaerobie mittion i negative finding 13 by 10 mcang infallible for use rp 19 may develop in islands or areas of the clot or fluid hich are not tapped by the needle Increase in pneumothorax or development of resonance in prosously dull Areas should make one suspicious of gas infection, ond af, in such rise other symptoms pointing to infection are sufficiently prominent, operation ·PENETRATING TOUNDS OF THE THORAX 67 should be undertaken without waiting for bacteriological confirmation In no part of the body does toxaemia of grs gangrene develop so rapidly and so fatally as in an infected haemothorar In cases of limited non infected haemothorax, trentment by aspiration 19 unnecessary as the fluid is tisually fairly rapidly absorbed If the haemothorax 19 large, aspiration may be required to reliero symp toms of distressed respiration, even though no in fection is present Fresh bleeding very rarely, or Berous effusion, may cause increased intrapleural pressure which will call for treatment Aspiration should be done slowly and no more fluid removed than is necessary to make the patient comfortable If urgent symptoms recur it is probably best to operate at once Make a large opening in the chest wall, clear out the pleural cavity, control the source nfl ment by air Between the two types of cases de scribed there exists a fairly large number in which decision as to treatment is fraught with great diffi culty and anxiety Operation The late Professor John Anderson, DSO, classified cases requiring operation as follows 1 Wounds causcd by large irregular fragments of high explosive shell which have lodged in the thorax These are almost always asso ciated with (a) open 'sucking' wounds of the chest wall, and (b) infected fragments of clothing carried in with the missile 2 Tangential wounds of the thoras enfilading ·68 PENETRATING WOUNDS OF THE THORAX 11.-L.-12. L. 3. exit sounds are esplosiçe in character Discussion of the extraordinary variation of tho lesions which occur in the thoracic viscera 19 not necessary hero Suffice it to say that they may bo extraordinarily simple and eney to deal with or they may demand great skill and dexterity combined with amplo courige on the part of the surgeon Immediate fatul hemorrhage as the result of removal of a laige plece of shell from the root of tho lung need not deter the surgeon keen to accept his responsibilitar a from tichling the next apparently similar case the heart as well as the lung, has shown itmelt to be tolerint of manipulation Foreign bodies in the wall or cut of the heart have been Tooned with wederful time and success ras plates tih n both in the antero posterior and larri de Supplemented where thought ad. visible by terron op ves are cssential beforo opratintor de lazatan foreign bodies, and to ned ite the 'Itent it bons damage Choke of anaesthetics Many cases can bo done well in the bus infiltration at the este o in un lly the blocking of several inter. costal niti se te dross the site of entry If n general ant sth is rated it should be giren by the intrih i mother! In no branch of sur. gery 13 the lynti perition between Aurgeon and annesthetists twntnl On one, just as much ag on the other the succes of tho operation depend Tho uel no quit induction, absenco of truma to the uj]*Tur pasages, control of tho ·PENETRATING WOUNDS OF THE THORAX 69 Atha the surgeon must do all in his power to avoid unnecessary trauma and must inform the anacs thetist in adrance regarding the stages of the opera tion With the help of an erpert anaesthetist exploration of the chest causes the surgeon no more anxiety than does evploration of the abdomen Technique of operation The incision will fre quently be decided by the site of the wound This will be treated according to general principles by excision of shin edges lacerated muscles, and com minuted ribs Access must be adequate and this may be attained by intercostal incision without removal of lengths of normal ribs The use of an efficient rib spreading retractor is essential If the missile wound is situated over the scapula, or 19 high up in front of the chest a separate incision through the sixth or seventh space will be required to give efficient access Blood in the pleural cavity should be removed by suction if available, as this method causes less trauma and 19 more rapid than embedded in the spine is removed, and the bed cleaned by gauze or spoon The wound in the chest wall 13 now completely closed by approximating the separated ribs, holding them in position by interrupted sutures of strong catgut passed through the intercostal spices abore and below the wound, and tied after all havo bocn inserted It is not necessary to stitch the pleura, but the overlying muscles and ·70 PENETRATING WOUNDS OF THE THORAX skin must bo accurately approximated to ensure an air tight wound Fluid which accumulates in the pleural cavity during the first day or two should be removed, either by an air tight drainage tube inserted through a sepirate wound with rescction of ono inch of rib at the lowest prrt of the pleural cavity and led under flud into a bottlo by the bed. side, or by repented aspiration during the first days of convalescenco As sepsis is a danger the former method 19 preferable The tube should enter the plcural cavity only for short distanco so as not to interfere with expansion of the lung It is impos Biblo to state how long the drunnge tubo should remain in situ Vuch depenils on the amount and nature of the discharge and on the rato of expan sion of the lunk which in only be estimated by repeater lumination Ittempts to crpand the lung I run the intratracheal pressuro at the ani nf the prition should not bo attempted Immediately after parutun origen therapy in the mo at suitable it ulable form should be instituted, anal illni transfusion (ven when the general Uncat the patient 14 kood will bo found to accelerate antil enre The following report by the late Tarın en n show how successful this treatment in a hunts four c19eq treated by him at a csalt le rune station in France from 2 April 1915 to! line is Hloun 14 | twaint pening pleura nro not includint 1 Cases Total nun ti stint with penetrating wound it I the occurred in pro operation * 1 Causeall all Caused bs ]] bomb &c 57 17 ·chest cavity PENETRATING HOUYDS ON TIIF THORAX 71 Operative procedure in 55 Aumber of these cases with multiple wounds 34 Cases with sounds of thorax and abilomen, involving and requiring suture of dia phragma 20 Cases with foreign body lodged in lung or 17 Foreign body removed The majority of cases were operated on between eight and twenty hours after wound ing Pesulls Cases evacuated to Base apparently well Died at Base (sub phrenic abscess and shock) 1 Requured secondary drainage of empyema at base and recovered 1 Under treatment (one with secondary drainage for Cl Helci 11 and strep infec tion) Died at casualty clearing station after operation 9 Anal jsis of Deaths Chest and abdomen 5 Peritonitis 3 Septic lung 2 Infection of haemothorax caused by haemo lyzing streptococcus multiple, E and E bullet (No other case of strep I found) 2 Pure chest, shock and E bullet, involv ing lung and root of nech Both chest cavities and cervical spine One German prisoner went to basc with open thorax, local Remarks Thero was an unusually largo proportion of shell wounds and of chest abdominal injuries Most of open thorax cases arrived with temporary 2 1 1 ·72 PENETRATING WOUNDS OF TIIE THORAX outure and travelled well to casualty clearing station, when compared with purely abdominal cases, who travelled badly Nearly every caso required aspira. tion, some six or set en tirang Prevailing infection, Cl 15 elchu All except two cases remained closed and required no secondary operation exept aspiration Septic haemothorax When septıc infection of n hacmothorax occurs operation becomes imperative If the general condition of the patient is good, operation on the lines above described should bo carried out In sonu cu deterioration 19 so rapid that any extensive operation is likely to end fatally, and under these cridatic14 resection of one or two inches of the aghth or ninth rib in the posterior axıllar line with acuation of fud and the in. stitution of closed cir uniga should bo performed under kil intitution and thesia It is to bo remembered that we metimes thu duphragm will be found to it up in high posstion in this typo of injury and it is very to enter the abdominal, insta id of this than 01 (Ants Should this unfor tunately caur the diaphragm is immediately closed by suuri olan ikin of the rib abore and moro xori risoned Irrigation of the pleural cavity. This should not be care le ut at the time of operation, but it 19 of value valescence 1114 becomo estal- Iished It shallx instituted cautiously owing to the possible present a brong ho pleural fistula Decision as t si bf the various methods of carrying out the lion will be influenced by the cxperience of the individual surgeon in charge of the case Breathing exercises The introduction of this

·AL
PENETRATIXG WOUNDS OF THF THORAX 73
form of treatment, under skilled supervision, has
done much to hasten convalescence in cmp3cms
nd is applicablo
wounds They
patient can bo
persuaded to co operate
Surgical emphysema Some degree of surgical
emphysema occurs in most cases of penetrating
wounds of the lung As a rule it remains localized
and is of no significance In a few cases, however,
at spreads orer the whole body and may prore fatal
In such cases it is advisable to open the pleural
cavity and to separate the injured adherent lung
from the chest wall
L

·CHAPTER VII WOUNDS OF JOINTS In the early days of the last war wounds of joints, particularly the knee joint gare most disheartening results The smo sad story of scpsis amputation, and frequently death had to be recorded in almost overy case, and only occasionally after a long and stormy convalescence was the patient left with an ankylosed joint The late Sir Henry Gray im mediately became interested in the problem and with his usual energy and ingenuity began to derisa mctbody to improve the results In 1915 he lard down a line of the itment which materially changed the unfaveur ible prognosis and saved many useful Joint Woundsofthe knee joint are more frequent, and linble to be a re dimrous in their consequences, than these fans «ther joint Their treatment therefore receive first attention but the principles can be idapted to other joints The great improve. ment in the results was due to thorough treatment during the premtumitors stage and to careful fixation de transport The cul effects of trans. port are minute 1 1 greater degree in wounds of tho hnce ) int il 11) in most (ther types of wound Types of injury (ammon types of injury may be summaru 1 1 || - I Casce otetfus it without lodgement of the projcctile in ti Jant (a) in which it 19 uncertain whether the į mnt Wits has been trarersed or whether the syr al my inbrane hing becn merely bruised, (6) in whi h the xx novial cavity has been ·WOUNDS OF JOLYTS 75 traversed by a rifle bullet without injury to the bones In connexion with injuries of this class the frequent association of effusion into an intact hnee joint with fracture of the shaft of the femur must also be kept in mind Treatment Cases in this class should be treated expectantly by complete rest with moderate exten bion If suspicion of infection arises the joint should be tapped and the effusion examined bac teriologically If the infection seems to be mud, repeated tapping with the administration of sul phonamides may be tried under close supervision but usually it is better to open up the joint freely, wash out thoroughly with a saline solution, and to close the wound carefully again 2 Retained missiles (a) Missile wthin the syno vial cavity (6) Dissile retained in the articular ends of the bones Treatment (a) If the retained body 13 a rifle bullet and the superficial wound is small it may be left for a few days the joint being meantime im mobilized but the better plan is to arrange for its removal as soon as possible Fragments of shells or bombs must be promptly removed (6) 1/1ssiles embedded in the bones Rifle bullets 80 situated as not to interfere with the movements of the joint need not be interfered with at an early stage They may do no harm and have frequently ro 13 body must be removed by the shortest and safest route This may bo by the original wound althou sometimes tho skiagrams may indicate a sh route but as tho bed of tho missila @ nert ·76 HOUNDS OF JOINTS infected, no advantage ercept that of direct access 18 gained by a special incision As the estruction im 1. LILLIY TILL Irri 3 Open rounds of the joint (ases in which tho synovial cavity has been more or less widely opened without, or with only very slimht damage of the articular surfacea On adinusion the limb should be fixed in a stable aplint and the patient sont for ray eramın ition in order to locate any foreign body and to cart in to what extent if any, tho bones have been injureri Un transference to tho operating the tre the splint should not be removed until the tunt has been inaesthetized fiind The prinary object must lo to viure then I the sureat and quuchest any to obt un this tor 19 the sound completely, if posible en mi 1 with a scalpel vihen this 1174 by imple helt used instruments, towels, and loves w ut due li ir led and a fresh outfit cmple wat Ill I will should be remored from the joint (suit il! r tus purpo4c o Higginson's BVTILC presse dels at rilizeni bi boiling and hot siline are the Its pafshrapnel in the joint must be rouillir un mors making a second incision for its Frans (ffort to close tho synovial membrumado os on this depends tlio future funiti the joint This is not alway! possible, but if tt a futella pouch 19 loosenel from its upper and interior connexions and pulle! downwaris, cnout tune will frequently be found to accomplish the Iraining of the external wound ·WOUNDS OF JOINTS for twenty four to forty eight hours down to but not into, the synovial cants may be emplosal if there is doubt regarding sepsis On the completion of the operation the limb should be fixed in a Thomas & splint slightly flexed and should be kept under the supervision of the surgeon for a few days 4 Cases shou ing extensile injury to the bones Tho majority of cases showing extensive comminution of the bones or a T shaped fracture of the lower end of femur or upper end of tibia can rarely bo saved and primary amputation is frequently ad visable The severe constitutional symptoms which follow septic absorption from the injured spongy bone make this type of wound particularly danger ous When a comminuted fracture of the patella has occurred the fragments should be removed en masse with the wounded soft tissues It 19 not advisable to leave a part of the patella even though ats blood supply seems intact through its attach, mont AL encouraging late results reported on excision of fractured patella in civil practice the operation can be undertaken with increased confidence In some cases of injury to the lower end of femur or upper end of tibia it may be possible to perform resection As little bone as possible should be removed-only what is boiled and badly comminuted At the same time frec drainage must be obtained At the end of the operation the joint should be packed lightly with sterile dry gauze to control oozing and the skin wound closed by a few interrupted sutures Two or three days later the pack 18 removed, and ·78 WOUNDS OF JOINTS if conditions aro satisfactory, the wound 13 sutured without drainage Treatment at advanced units. I'rom what has been said the necessity for complete fixation of the joint, even if injury is only suspected, will be appro. ciated by all who have to handlo such cascs The regimental and field ambulance medical officers will contributo in no small measure to the ultimato fato of tho joint by ensuring adequate and comfortablo aplıntage, and br expediting the transferenco of tho patient to the operating centre as soon as possible As the patient ieri frequently suffers a grcat deal of pain morphu should be freely given Treatment of case where suppuration has already occurred Where treatment has been delave i for a few dals on account of impossibility of evacuation or where in spite of surgical treat ment captar arthritis desclopu the surgeon must realize that th for shlem 14 Heriots nnd the prognosis krave Attempts at crainage by the insertion of rubler tube in the joint will nlmost certainly fail Irhequate or unite his this method, cren if followed by frequent flushings of the joint cruity wth noto simple ou ing to the scserni compartments from the contour of the bones, crucial los mente innowalſnngey Long inci Bions on the fthe puutella into the joint cavity should be drains or picks should lo inserted the sun is ng covered by a simplo dry dressing and the patient encouraged to more tho joint voluntaris tan win after operation as possible Pasirc moset Ota must not be undertaken Thy treatment was mmended by Ilillems and good results nerc olt! If in spite of this treatment, toxic symptom-Tant a transicrso or flap incision ·HOUNDS OF JOINTS 70 should be made followed by resection or after free division of the lateral and cruciate ligaments by packing and fixing the joint in nearly full flexion in a specially made splint In some cases the ques tion of amputation wall hare to be considered and we must be careful not to postpone this decision until too late The surgeon must always remember that his first duty is to save life and that the skill of the prosthesis manufacturer has deprived amputa tron of much of its dread and disability Wounds of other joints Shoulder joint If the articular surfaces are shattered limited excision with free drainage preferably posterior should be carried out The arm is fixed in 60° abduction and 15° in front of the coronal plane by abduction framo or by a plaster of Paris spica In cases showing less extensive injury to bone treatment of the flesh wounds followed by adequate fixation will give good results even though the joint cavity has bee opened and the escape of synovial fluid noted Hip joint Owing to the extensive injury to sur rounding soft tissues the shock accompanying injury to the hip joint was very frequently pro found and the mortality rate was high Operation consists of the excision of the wound track and roma Irir om toll ond of the fomir Thia moderate abduction either in plaster or in an abduc tion frame Il rist and elboul joints Limited excision is ad visable in all severe cases where the bones have been shattered but where the main vessels and

·80
JOUNDS OF JOINTS
nertes are intact In the hope of a firm ankylosis
as little bone as possible should be remored, but
eren a 'fail' joint is better than an amputation Tho
joint should be immobilized in tho position of choico
-dorsi fletion in the case of wist joint, and at a
right anglo in the case of the elbow.
Anlle joint and larsal joints Wounds of tho foot
and ankle joints frequently do badly on account of
the difficulty in obtaining free drainage In somo
checs a modified resection of the injured bono may
bo successful, but if the injury is extensive it 18
better to perform amputation through tho lover
third of tho les

·CHALTER VIII OTHER SPECIAL EXJURIES 1. THE VERTEBRAL COLUMN DIPLE fracture or fracture dislocation of the rerte bral column, which may occur as the result of enemy action, will not be discussed at length apart from stressing the importance of care in handling and transport I there 18 a suspicion of vertebral column injury estensive examination should not be carried out The patient should be transferred to stretcher with the least possible disturbance taking care to support the shoulders buttochs, and lower limbs If the cervical spine is involved the patient is to be placed on bis back with a small pillar or roll of clothing placed under the neck and shoulders to maintain extension In thoracic or Dumbar unjunes the patient is placed face down wards, the upper part of the body being salsed slightly on a pillow Gun-shot wounds of the spinal column, accompanied by paralysis give rise to such an over potrering sense of hopelessness on the part of the surgeon that he may well be pardoned for tackling such a case in a half hearted manner He must remember, however, that the paralysis may be due to concussion and that complete recovery mar erentually take place There aro no sure sirds to distingish between paraly s13 due to concussion, and that due to irreparable damage of the cond, and therefore aven a remote chance of the restoration of function must continually stimulate him + further endeavour Clean through and ·82 OTHER SPECIAL INJURIES bullet trounds aliould bo treated on the samo lines as simplo fractures Good antero-posterior and Iron vigu. 1 out by an expert neurologist Operation on the vertebral column should be un. dertaken (1) if X-rays slow displaced fragments of bono or the presence of a piece of metal in or near the spinal canal, (2) when simptoms of paralysis haso developed a short time after the infliction of the injury, indicating that this may be due to pressure from blooxl.clot (vi mptoms of cord involvement coming on at a later ditt and due to inflammatory changes will not be relieved by operation). (3) when pain due to pre tire on perie roots, 28 excessive. In < 1W* suttering from laceratc shell wounds it 19 Tout un tos e xove the truth in order to ascertain the prove the or otherwise of a cord lesion, even though meally it 4 superted if possible, tho operation and berrieri out under local infiltra. In nathrall This allows the patient to lio prono clean its respirators difficulties, and marhalls leven hat morrhage A act laminectomy should is one the laminao can usually bo nibbled away and all obstruction to the enay re. moval of fragments should be removed bcforo any attempt is made to lift them out if this principlo Is not followe! ftirties injury to dura and cord will result. If the durs frau fren openei, attempts should be made to dost it but this is scry often impossible Dending on the extent of tho injury and tho efficients of the operation, the surgeon will decido whether it will be safe to suture tho muscles ·OTHER SPECIAL INJURIES 83 aala nad har ontifin at Aller-case The pursing duu a tanu patients suffering from spinal injuries present pecu har difficulties, and these are aggravated in the presence of paralysis The greatest care must be taken to guard against two complications, namely, (!) pressure sores, and (2) cystitis 1 Pressure sores In spite of incessant care on the part of the most capable nursing sisters, pres sure sores wall develop in many cases The surgeon must see that the splint or plaster does not cause Undue pressure at any one point, and he must be prepared to modify or even abandon this method of treatment of cores threaten to develop 2 Cystitis In epite of every care inflammatory changes in the bladder will take place in cases of spinal cord lesion as the result of the upset of bladder function It is the duty of the surgeon to try to control the infection and to prevent its spread to the kidneys The muscle of the bladder wall passes through various changes subsequent to the paralysis For the first few weeks it 18 flaccid and incapable of contraction Later there is some degree of muscular tone and reduction of bladder capacity, and finally there develops the stage of automatic and, of course, unconscious, evacuation, 2 by catheterization which should be repeated at in-

·No text on this page.

·No text on this page.

·84 OTHER SPECIAL INJURIES the last war, the fact that various methods of treat ment were recommended at different times shows how unsatisfactory each was found to be I Regular catheterı-ation This is impossible during heavy fighting or at other times during transport Strict aseptic technique must be main tained, but in spite of this the repeated and unaroidable irritation of the urethral mucous mem brane ultimately leads to a urethritis and cystitis 2 Continuous catheterisation This is carried out by an indwelling catheter which should not be placed in a urinal but connected to a bottle con taining a weak antiseptic at the bedside by means of long rubber tubing Urinals are difficult to cleanse and disinfect and the danger of infection through the citheter is considerable The catheter should be changed every third or fourth day and the bladder washe l out daily with weak antiseptic lotion Urethritis 18 an inevitable sequel sz, rapubic c/stotomy A de Pezzer catheter ܐܝܘܩ ܕ ܢ legable quein 1 is undue distension of the Diaguel cannot take jlue (Istitis is inevitable, but can be controlled lv lavage through the catheter and the use of sul; hapridine 4. Janual o mires ion of the distended bladder 15 mentioned only to be condemned It is uncertain and dangerous II INJURI TO PERIPHERAL NERVES The surgeon will be impressed by the number of cases in which, although the nerve is in the wound ·OTHER SILCI IL IL RITS 8 track its continuity has not been interrupted Fre quently it will be bruised and it is impossible to assess the degree of injury to the axis cylinders Inside the sheath In sucli cases the nerve should not be touched learing to future development the decision as to whether resection will be necessary or not When the it will often together ar three fine luen or silk futures passed through the sheath Ao attempt at elaborate suture should be made the aim of the operation being to facilitate the finding of the nerve ends at the operation of Derve suture undertaken later when the wound has healed Reports from the Base indicated that in & fer cases this simple procedure resulted in a restoration of function without further operation III INJURY TO THE MAIN ARTERIES In war surgery the main blood vessels assume & more important role than they do in civil surgery Apart from the danger of immediate death from bleeding there are the most important questions of the vitality of the muscles tho development of massive gangrene the spread of infection part: cularly of tho gas gangrene type and the risk of Becondary haemorrhage It is therefore essential that early in the treatment the possibility of injury to a big artery should be looked for In some cases it will be obvious from the position of the wound and from the history of excessive bleeding that injury to an important Llood vessel has taken place In other cases bleeding will bure stopped and the diagnos19 is more diffeult Absenco of the pulse distal to the injury will often make one susticia ·86 OTHER SPECIAL INJURIES but in the lower limb this test is not always con clusive Excessive cramp like pain and board like injury, loss of heat and a stocking' anaesthesia will frequently be found In other cases the vas cular lesion will be found only when the track is explored Tho arteries which cruse difficulty are (a) the popliteal artery When ligature of this vessel 15 called for the collateral circulation is so poor that, in the majority of cases gangrene develops within two or three days In cases where this does not occur, the ischaemic fibrosis of the leg muscles and the trophic changes in the foot are so extensive that the limb remains functionless and, later, amputation has to be carried out (o) Posterior tibral artery Similar although less extensive changes such as those which result from injury to the popliteal artery follow occlusion of this vessel Owing * the accompanying comitantly injured field is obscured making higation difficult and tedious (c) The gluteal artery is frequently injured in penetrating wounds of the buttock Emerging from the pelvis above the pyriformis muscle, it im mediately divides into a superficial branch which supplies the gluteus maximus and a deep branch which lies under the gluteus medius and again divides into two terminal branches It will be readıly understood how difficult may be the control of haemorrhage in injury to this yessel, and, further.

·OTHER SPECIAL INJURIES
87
more, the danger of death of the large muscles
supplied by it, with accompanying gas gangrene,
explains the apprehension with which the surgeon
approached these cases, particularly in the early
months of the last war
(d) The femoral artery Injury to the femoral
artery may prove fatal within a few minutes from
loss of blood, but if the haemorrhage 13 arrested,
or, if the vessel 19 only partially divided the loss
of blood may not be excessive After ligature of
the femoral artery the collateral circulation is estab
lished fairly rapidly and efficiently so that if the
the profunda branch may take place apart from
these vessels does not present great difficulty, and
the collateral circulation is good
(1) Brachial artery Injury to this artery is fre
quently accompanied by injury to the median and
ulnar nerves The collateral circulation, established
after ligation depends on the extent of injury to
the surrounding parts but is often poor and the
danger of gangrene 13 considerable
Treatment. Treatment consists of ligature of
-411
far the
were made to re estabusu lie couliliuity vi luu
divided vessel Silver tubes (Tuffier) and circular
suturc, when the divided ends could be brought

·88 OTHER SPECIAL INJURIES given for the establishment of a good collateral circulation Ligation of the accompanying vein in order to prevent the development of gangrene was advocated by many including the late Sir George Makins, whose great interest in and wide experience of the diagnosis and treatment of blood vessel injuries, and his widely recognized sound judgement compel the greatest respect and consideration The experience of one individual is 80 limited that an expression of opinion is unjustifiable, and only impressions can be recorded The writer did not feel that ligature of the accompanying vein was an important factor in the prevention of gangrene or of the spread of sepse but in discussions on this point he was generally in a minority Contusion of arteries When the track of a missile passes Jose to a vessel the wall may be bruised but not divided in those cases careful examination for pulation distal to the bruised area should be made at operation as frequently the tunica intima and media will be found to be rup tured and intravascular clotting will have taken place The risk of secondary haemorrhage is very great, and resection of the affected segment should be undertaken at the primary operation If it is felt that the lumen is not completely occluded, it is better to leave the sessel intact so as to allow of the formation of a collateral circulation, and to inspect the vesse) carefully at the first dressing, on the second or third day mth a view to resection if the previous diagnosis is confirmed ·OTHER SPECIAL INJURIES 89 Secondary haemorrhage. This usually occurs a week or more after injury, but 19 an ever. present danger so long as the wound is unhealed and sepsis is present It may occur as a sudden massive bleeding or a warning may be given by one or more small haemorrhages In either case treatment must be prompt and should consist of double Ligature of the vessel at the site of injury This, in the presence of oedematous granulations, may be difficult, but should be done whenever possible Linen thread and silk are more reliable ligature appointing results, as haemorrhage is likely to recur as soon as the collateral circulation has become established In some cases, however, it may be the only means of stopping bleeding and therefore in these it must be carried out N ·INDEX Abdominal wounds (pene trating), 53 Anaesthesia in, 56 haemorrhage, arrestof, 57 mortalty from, 53 operation, 57 physical signs in, 54 radiography m, 55 symptoms of, 53 treatment of, 55 Abdominal thoracic wounds, 63 shock in, 63 treatment 6+ Adrenalin uso with local anaesthetice 51 Advanced Units 1 abdominal wounds at, 21 blanket adjustment at 79 blood transfusion at 12 chest wounds at 21 dressings at 5 drug administration at 4 Alud administration at 10 11 fractures at 12 fractures of elbow joint at, 16 fractures of femur at 16 17, 18 19 fractures of forearm wrist, and hands at 16 fractures of humerus at 14, 15 fractures of leg bones at, 20 haemorrhage at 6 hend wounds at 20 heat, loss of, 6 hot air batha at, 9, 10 joint wounds, 76 pain, relief of, 4 shock at, 2 splints, application of, 12 splints (Thomas 8), ep plication of, 16-20 stimulants at, 12 warmth at, 6-7 wound treatment at, 5. Amputations, 40 drossings for, 41 gas gangrene 39 guillotine, 41 in injuries to anklo joint and tarsal joints, 80, in injuries to lower end of fernur and upper end of tibra, 77 Anaesthetics adrenalin in local, 51 in abdomual wounds, 56 in brain wounds, 61 in shock casos, 5 in spinal cord injuries, 89 in thoracic sounds, 68 Anastomos18, intestinal, 69 Ankle joint injuri09, 80 Antiges gangrene serum, 37 Antiseptics, 32 Antı tetanic serum, 37 Arm splints, 14 methods of application, 16 Arteries, contusion of. 88 injury to, 85 Aspiration, of chest wounds, 07 of knee joint, 75 ·91 INDEX Bandaging, fixation and exploration of, 45 support by, 5 exposure in, method of Beverages, 10 covering. 45 Bladder, paralysed, treat foreign bodies in, 48 ment of 83 fracture, without external wounds of 62 sigris, 45, without Blankets, method of folding, laceration of dura 7 mater, 48 supply at casualty clear hernia cerebri 50 ing station, 25 lumbar puncture in, 57 Blood clot, removal from preparation of scalp in. joint cavity, 76 52 Blood pressure fall of, due treatment, excision and to shock, Buture, 45, opening of how raised, 11 dure in, technique, 15, Blood supply, factor in use of catheter in, 45 success of operative Breathing exercises, in cases measures, 33 of empyema thoracis, 73 in splinting, 36 Blood transfusion, at ad Casualty clearing stations, vanced dressing sta 23 tions, 12 arrangement and equip in abdomino thoracic ment of, 23 wounds, 63 grouping of, 24 in hip joint injury, 79 operating theatres in, 29 post operative, 55 organization of, 25 Blood vesel injuries, 85 pre oporation ward in, Body fluds, 10 27 Bone fragments, in the reception ward in, 25 brain, 44. resuscitation ward in, 27. Bones, foreign bodies burred site of, 24 in, 75 transfusion in, 27–1 injury to, 77 Chest, sce Thorar long fracturos of, treat Circulation, in splınting, 14 ment, 14 Clothing, vet, removal of, Brain wounds, 44 26 anaesthesis in, 51 Cold, protection against, by blood einus injury accom blankets, 7 panying, 49 Colon, injuries of, 54 bone fragments in, ro Colostomy, 61 moval of, 44 Crepitation, sign of gas cerebral oedema, control gangrene, 39 of, 50 Cushing, Dr H, 45 drainago in, 45 stite, prevention of, { ·92 INDEX Dopage humerus splint, 14, Evacuation, at casualty 15 clearing stations, 23–7 Diaphragm, wound of, excı Excision of wounds, of Bion and suture, 69 joints, 76 foreign body in, 69 use of scalpel in, 76 injuries of abdominal vis Exit wounds of abdomen, cera accompanying, 64 54 Drainage, by de Pezzer | Extension, 18 catheter, 84 splint tapes, 14 by indwelling catheter, 84 Fascia, sloughing of, 33 in amputations, 42, 77 Femur fractures, 16 in wounds of joints, 76–7 amputation in, 40 of bladdor in spinal cases, prevention of gagging of 83 soft parts, 12, 14 of pleural cavity, 70 Thomas's splint in, 17, 18, Drossing rooms, at casualty 19, 20 clearing stations, 20 Flud administration, Dressing stations, see Ad shoch, 10 vanced units intravenous method, 11. Dressings, application of, 5 rectal salines, 11. for amputation stumps, subcutaneous injections, 41 Drinks, for recently wound vomiting complicating. ed 10 10 Duodenum, wounds of, 61 root, wounds of, 80 Dura, complicated by Foreign bodies, degree of foreign bodies and sep sepsis in relation to, 35 Bis, treatment, 44 in chest wounds, 69 docply seated foreign in knco joint, 76. bodies in, 48 in the brain, 48 drainage, 45 indications for non te exploration of, 45 moval of, 75 fracture with depression, radiography, 65 but without laceration removal of, 31 of, 48 sepsis, due to, 35 fracturo, depressed, with Fractures, 14 out definite external carly amputations for gas Bigns of injury to, 45 gangrene, 39 fracture with injury to s splanting, 12, general to blood sinua, 49 marke on, 13 Elbow joint injuries, 79 Gas gangrene, 38. Emphysema, surgical, 73. amputation for, 39 ·67 21 INDEX 93 Gas gangrene (cont) Hernia cerebri 50 antigas gangrene scrum Hip joint injuries 79 37 Hot water bottles 9 haemothorax infected by Humerus fractures splints appled for (illustrations) symptoms of 39 15 16 treatment of 39 treatment of late cases Infection see Sopsie 38 Infective material removal Gauze pack 42 before suture 35 Gloves sterilization of 29 Intestine colostomy in 61 Glucose 11 penetrating wounds of drip method 28 large 60 in fud administrat on penetrating wounds of 11 small 58 intravenous administra Intrapleural haemorrhage ton of (hernia cerebri) 50 Intravenous injection of Gooch splinting 17 gum solution 28 Gum intravenous injection Intravenous saline injec of 28 tion, 11 Gutter wounds of the skull 47 Jount wounds 74 treatment 75 Haemorrhage appl cation types of injury 74 of tourniquet 6 Jones s extension humerus control of in abdominal splint appl cation of 14 injuries 57 in brain cases 45 Kidney injuries of 63 pleural 21 Knee joint wounds com secondary 89 minuted fracture of 77 Haemothorax 66 removal of foreign bodies aspiration in 67 in 76 diagnosis 66 removal of patella in 77 peptic haemothorax 79 sepsis compl cating treat technique of operation in ment of 78 69 splinting in 77 79 Ham splint 17 Head wounds (see Brain) Lacerated wounds Jain nectomy-rarely indi Heat blankets use of 7 cated 82 hot air baths 9 Leg bones fractures of "o Heel cl ps in leg spl nting Ligatures in treatment of 18 early haemorrhage 6 ·INDEX Liver, injuries to, 62. Pain, relief of, 4 Local anaesthesia, in chest Paraplegia, spinal cascs cases, 68 showing, 81 in head injuries, 61 Patella fractures, excision in spinal injuries, 82 and suture in, 77 Lumbar puncture, 51 treatment where suppurat Lung see Thorar tion has already oc curred 78 Diagnet, extraction of Plaster of Paris, 36 foreign bodies from brain Plastic operations, of the by, 48 scalp, 46, 47 Mask, B LB, 66 Pleura destruction in cheat 212581les, see Foreign bodies wound3, 65 Morphia, administration of Pleural cavity, irrigation of, st advanced units 4 72 depressing effect of 6 Pulsating vessels, foreign in cases of wounds of the bodies in neighbourhood abdomen 21 of, 35 Multiple wounds associated Pulse rate, in gaa gangreno, with sovere shock, 53 39 characteristics 53 54 in relation of shock, 3 Muscle dead and living indications for removal and non removal of 33 Reception rooms atcasualty clearing stations, 25 Rectal salınes, 11 Nervos injurica to 84 Nitrous oxide and oxygen Regiinental and poste, treat anaesthesia, in chest ment at (see Adianced units), 1 ca902, 68 in wound, of the abdo Respiratory distress due to men, 56 chest wounds, 66 Rest for the wounded, 24 Resuscitation warda at Omonopon, in relief of pain casualty clearing stations. 27 in antı shock treatment Retroperitoneal haema 10 injuries of the thorax toma, 63 66 Ribs fragment penetrating Operating theatres chest, 68 casualty clearing sta rcsection of, 70 tions, 20 uso of rb spreading ro. pro operatro ward 27 tractor, 69 resuscitation Ward, 27 Rotation prosention Oxygen administration, 06 fractures of femur, 19 at in ·45 in, 4 INDEX 95 Sagging of soft parts, pre Shock, application of vention of, 14 warmth during, 6 Salines, administration in blood pressure in, 2 shock haemorrhage, 28 blood transfusion in, 12 hot salıne solution, uso of, fud administration in, 10 rectal and subcutaneous haemorrhage in, 6. administration, 11 hot air baths in, 9 Salt pack treatment, 32 mental condition of Scalp wounds, closure of, patient in, 3 morphia administration (illustration, 46) enlargement for procur operatio treatment, ing adequate access, 44 anaesthetics in, 5, at excision and suture of, 45, casualty clearing sta. trons, 26, salunes an. See also Brain 11 Scalpels, for excision, 31, 76 pain in relation to, 4. Scapula, wound over, 69 primary, on the field, 2. Sedatives, use of, 4 secondary and early Sepsis, antiseptics, in pre symptoms, 3, inade. vention of, 31, 32 quately supported fracbullet and shell frag turo in, 12. ments, causing, 75, 76 Shock haemorrhage, 6 complicating brain administratronoffudsin, wounds, 50 10 complicating chest factors, influencing de wounds, 66 velopment of, 35. complicating knee joint Shoulder joint injuries, wounde, 78 characteristics and treat. drugs of the sulphonil Inent, 79 amido group, 61. Shrapnel, excision of favourable media for wounds due to, 76 growth of, 34 removal from tisgues, 34. following dramage, 43 Sepsis, due to, 35 foreign body, in relation Skull-cutting forceps, uso to, 35 of, 44 prevention of, 61, Skull wounds, see Brain, rapid development of, on Sphygmomanometer, 3. what dependent, 66. Spinal anaesthesia, 82 Berum, antı gas gangrene, Spinal cord injuries, administration of, 37. Vertebral column. anti tetanic, administra Splinting, 12 tion of, 37. general remarks on, 13.

·06 INDEX Stimulants, see Fluid ad. closed sounds of, 66, ministration. pas gangrene in, 67. Stomach, wounds of, 61. mortality from, 65. Stretcher-bearing, applica. operation for, 69 tion of warmth, 6. treatment of, 67 u90 of blankets during. 7. Tibia, comınıuted fracture Subcutaneous injection of of, 77. salines, technique, II. Tourniquet, application of, Sulphonamides, 38, 75 6 Superior longitudinal ginus, Transfusion, see Blood injury to, 49. transfusion. Support, in fracture of Transport, splinting, uso in, femur, 19 36 Surgical teams at casualty suspension bars in, 19 clearing stations, 23. Trephining, techniquo, 47. Suspension bars, 19 Trueta, 36 Suturo, delayed primary, 35 of galea, 45 Vertebral column, injurics (illustrations, 46) to, 81 of perforation of small cystitis in, 83. intestino, 58 treatment of, 82 Synovial cavit109, treatment) Vomiting, prevention of, 10. of, 75 Warmth, at Advanced units, Tarsal joint injurio9, 80 6 Tetanus, dovelopment and blankets, method of fold. treatment, 37 ing, 7 Thigli splints, application Wet clothing, removal of of, 17 26 Thomas s splint in fractures Winnett Orr, 36 of tho Arm (illustra Wrist joint injuries, treat. tron), 16 ment, 79. in fractures of fernur, 17 (illustration) X-rays, at casualty clearing Thorax, penetration wounds stations, 23. of, 65 for assistanco in the loca. anacsthesia in, 69 tion of foreign boulice, aspiration in, 66 35, 55, 82. PAINTED IT GELAT BRITANT AT TÜZ YITORSITT TIBI OIT r BT JOLLY JONYSOY, PANTIR TO TIL CTITIRITT

·No text on this page.