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one of which was not postoperative, and four others from extreme conditions of

wounds and starvation in which they were reTHE ADAPTATION OF WAR SURGERY

ceived as prisoners from German hospitals. TO CIVILIAN PRACTICE.

('onsequently 18 would correctly represent the FRANK B. WALKER, M.D.

mortality of cases in that hospital or 2.155 per


FRACTURES. Now that the Great War is over there are presented an opportunity and a duty as well

The total number of fractures treated in the for medical officers to adapt the lessons learned

unit was 1405, 199 of them were simple and therein to the welfare of their own patients and

were distributed as follows:

3 of the civilian population at large. From that



Femur viewpoint I shall make some observations on


44 fifteen month's service in France at Base Hos


16 pital No. 36, officially organized as the Detroit


15 College of Medicine and Surgery Unit.


Nasal Bone This paper is not pretended to be exhaustive

Os Calcis but it will serve, I hope, to stimulate discussion

Patella in this meeting and to promote among us the


10 science and art of surgery. In studying this


27 Tibia

39 subject and in drawing conclusions the fact of


13 differences and even of contrasts in the character of injuries and diseases under war and

The 1206 compound fractures involved the peace conditions is understood and due allow


14 ances are made therefor.


39 My observations are founded on those cases


21 that were received at the base referred to, on


63 their conditions and histories brought from .



Hand other base, evacuation or field hospitals and the


56 front, and on such reports as came back after


12 eracuation from the Vittel Center.

Jaw The period of residence varied from one


Radius day to several weeks but averaged about 12 days.


20 There were admitted to Base Hospital No.


4 36 during its active service 15, 097 patients.


58 Of that number 13,564 were American soldiers,


27 1,164 were allied soldiers and sixty-nine were Like many other surgeons who went over French civilians. The surgical cases with an experience in the treatment of fracslightly in excess of the medical.

The mor

tures in civilian practice I had preconceived tality of all was 143.4172 of the surgical pa- opinions, even a prejudice in favor of the opertients were operated on .3879 cases came under ative treatment of many cases and was prepared my more immediate observation and treatment to prosecute that line, but observation and a in Hospital B, an essentially surgical hospital, little experience soon disillusioned our minds of .23 of that number died, two from pneumonia, that idea.





When we went into service French and Eng- . fracture was plated after extension proved unlish medical officers had firmly established the satisfactory. The wound became infected and use of splints for such cases. Since so large the patient died of pneumonia. One metacarpal a proportion of the battle casualties were bone bone was fixed successfully with catgut. All and joint injuries the simplest efficient treat- other fractures were handled along the lines inment and transportability of those cases were dicated and the results were generally satisfaca sine qua non in the war problem.

tory. Seventy-five amputations were done to Accordingly as early as August 20, 1917, save life or to effect more useful members. The General Pershing appointed a Board of Amer- list includes: ican Medical Officers under the Presidency of

9 amputations of arm Colonel W. L. Keller M. C. to investigate the

9 of feet and toes subject and report thereon. That Board recom

4 of forearm mended the use of the three types of wire ring 36 of hands and fingers traction and counter pressure fixation splints, 1 of hip joint Col. Kellar's modified Thomas splint, the Jones 8 of leg and Cock-up” “Crab” wrist splint, the long inter- 8 of thigh. rupted Liston splint with adjustable foot piece,

From my experience I do not discountenance an anterior thigh and leg splint, Hodgen type,

the open operative treatment of selected fracthe Cabot posterior wire splint, the wire ladder

tures but do advise against its promiscuous splint material, light splint wood, and plaster adoption by inexpert surgeons and recommend of Paris bandages and Bradford frames.

strongly the study and use of those methods The Board made it clear that it did not dictate the exact line of treatment to be employed and effective.

which war surgery has demonstrated to be safe in the Base Hospitals but expressed the belief that with such apparatus bone and joint cas

Another element of importance in fracture ualties might be efficiently treated at the front

cases secondary only to a firm union of the

fragments is the utility of the member. I beand if necessary in base hospitals.

lieve that the value and necessity of after Accordingly in order to be prepared a supply treatment of fractures in civilian surgery has of the various splints and frames was obtained

been often underestimated. from the Red Cross organization. It was a

Military surgeons know that their profeswise provision for among our first wounded

sional services are not ended in such cases until were several fractures of the thigh, leg, arm

function of joints and muscles has been fully and fore-arm, which were not only compound

restored or the disability repaired to the highest and comminuted but also infected with viru

degree possible. A wounded soldier must be lent organisms. That was the general charac

made efficient for Class A work or at least for ter of all fracture cases throughout the war.

B or C. Otherwise he becomes a liability of As has been insinuated above I had had no

the government. In civilian practice correshesitaney in recent years to treat difficult frac- ponding results should be obtained and moretures by open operative methods. I had even over in the shortest possible time. platidl • several open and infected fractures of In joint injuries also when bony ankylosis is the long bones successfully when the more con- inevitable the position of ankylosis is imporservative means at hand did not satisfy. The tant for the patient and should be elected after war however produced a different set of con- a careful study of the case. In the army efficdiuions. Consequently our treatment of frac- iency is the standard and the degree obtained tures over there was based almost entirely on marks the result as good or bad. In civil life the use of suitable apparatus, including splints the welfare of the patient is the standard of and frames.

satisfactory or unsatisfactory professional serAll cases of suspected bone injury were ex

vices. amined roentgenologically, manipulated under

SKULL FRACTURES, anesthesia when necessary, rechecked by the

The war brought out some styles of skull X-ray and the open wounds cleaned, drained fractures and brain injuries that are not disand dressed p. r. n.

plaved in civil life. Tangential extra-dural Our socords show only three cases of direct wounds and depressed extra-dural fractures are treatment. One enclosed patellar fracture was common to both.

War surgery has taught or wired and did badly. One tibia with an oblique at any rate impressed upon us the value of

wound closure in head injuries and also the It was found first that antiseptics alone were advantage of sucking or drying of head wounds. of no use and second that nothing short of

The usual treatment of skull and brain debridement or thorough excision of all badly wounds in France consisted of:

damaged tissues and removal of foreign maFirst, the excision of the wound of entrance terial would avail against serious complications. and the removal of bone and splinters, foreign The packing of such wounds tightly with gauze material and devitalized tissue.

was practiced for some time but found vicious Second, the closing of the wound with safety and abandoned. Small perforation wounds drainage. That technique can be adapted to could often be safely closed but the majority civilian surgery in many cases.

of them were lengthened and left open for Contrary to general opinion too it has been ample drainage after debridement had been observed that shock has not been concomitant done and Carrel tubes with light packing inwith head injuries in the same degree as in chest serted, which simplified the post-operative treatinjuries or severe injuries of the extremities. ment. There have been differences in opinions The unconscious condition of patients who have expressed as

as to the efficacy of the Carrelsevere skull injuries seems to obviate that kind Dakin treatment and the use of other antiof shock which has a psychic basis. Advantage septics and methods. I shall not discuss them

. I of that fact may be taken to transport such a in this paper, but will only state my opinion patient to a hospital or other suitable quarters that debridement should not be delayed unnecfor further appropriate treatment and recovery. essarily and that the Carrel-Dakin method has

At Base Hospital No. 36 we had unusual with us proven a valuable adjuvant in many facilities for using and demonstrating the value

bad cases. of fluoroscopy in the removal of foreign bodies If

you asked me why wounds so different have as well in the examinations of all gun-shot been discussed at all I would reply, because wounds and fractures and from our experience of the surgical principles involved and the probthis article would be remiss if it did not contain ability of meeting such cases in later practice. the recommendation for more fluoroscopic work in general surgery.


Wound closure is not new but I venture to WOUNDS OF THE SOFT TISSUE.

state has never been practiced here as much as Recent wounds of the soft tissue in military it was in France. As I have remarked already surgery differ from those in civil practice in small clean wounds were closed immediately their character and in their contamination with with primary suture. If the operator hesitated pathogenic microorganisms.

to make a primary closure a delayed primary As a general rule the gun-shot wounds we closure could be done within the following observed, which were of the average, were char- four or five days if the bacteriological report acterized by comparatively minor injuries to or the surgeon's experience warranted doing so. the skin at the point of entrance and exit of Later on as soon as the open wound under antithe missiles but by great destruction and septic treatment became bacteriologically clean devitalization of all proximal subcutaneous tis- a secondary closure could be made which would sues. In civil practice on the other hand there coapt the muscular, fascial and cutaneous strucare met much contusion and laceration of the tures, avoid more than a linear scar and save skin with less damage beneath.

days or weeks for the patient and hasten his The second striking feature of all wounds return to duty. in France and Belgium was their contamina- Wound closure is a technical procedure which tion and potential infection with not only the is adaptable to many cases in civilian surgery. ordinary pathogenic organisms but also the Convalescence can be markedly shortened, despore-bearing microbes of gas gangrene and formities from large scars avoided and deep tetanus.

burns treated with more satisfaction to both Experience soon led to the rule to “Get the patient and surgeon. wounded man to the casualty clearing station If war surgery has taught anything it is that as soon as possible.” The study of those cases old wounds, and discharging sinuses can be by French and English medical officers and cured scientifically like recent wounds. They notably by Carrel served to explain the de- have been the "bete noir" of every surgeon's velopment of the infection and to indicate sub- practice. They have been neglected and relesequent successful treatment.

gated to the care of internes and orderlies to


the exclusion of so-called major surgery.

We have returned from France with a healthy respect for those cases and with feelings of great satisfaction when we have discharged them cured. They require appropriate surgery and antisepsis to enable them to heal. Major surgeons should no longer contemn them.


That quantity, approximately one ounce, was the average dose and was administered on cotton within a rubber mask which encircled and covered the patient's face. The anesthetic state was produced in two minutes, could be continued from twelve to twenty minutes and the patient awakened in two minutes after the mask was removed. It was useful for debridements, fore gn body removals and other short opera. tions. With us it proved to be an effective and safe anesthetic even in the hands of nurses and operating room orderlies who administered it in several hundred cases. We therefore regarded it as safe and it was unquestionably a great time saver. Patients awakened from it quickly and without nausea and in some instances left the table without the aid of a stretcher.

I feel no hesitancy in recommending it for short operations in civilian surgery.



With the exception of differences in exposure to cold, wet and hunger the same conditions of shock and collapse are found and their causes operate here as they did in France. We met shock frequently. The anemic variety predominated in Pase Hospitals. The psychic form was more prevalent forward. In all there was lack of bodily heat and the power to produce it. Otherwise the treatment trasted. The psychic state demands rest while the anemic condition requires stimulation by warm fluids intravenously, subcutaneously, per rectum or by mouth. We saw several cases of it due to secondary hemorrhage and combated it best with intravenous transfusion of blood. Blood has been found far superior to other Auids since it offers not only volume but also the physiological advantages of serum and corpuscles.

We used the indirect method of administration exclusively, preventing coagulation by the citrate of soda solution in the container. It is recommended for use in civilian practice as a simplified procedure and one by which the amount of blood taken and given can be accurately determined.

Anesthesia was a great boon to the wounded soldier. His confidence in the medical officer was absolute and touching. Anesthesia contributed to that splendid relationship.

In Base Hospital No. 36 novocaine was used considerably in minor and dental surgery. It was used also in head injuries in the field hospitals. Chloroform was seldom used alone. Ether was the sine qua non.

In the summer of 1918 there was developed a rapid induction anesthesia based on the idea of the DePage mixture used in the French clinics. The formula was modified by and used under the supervision of Captain Arthur E. Guedel, who was in charge of anestheties in the Vittel Center. It consisted of:

Ether ..

14 cc
Ethyl Chloride

.512 cc Oil of Orange

1/8 cc


DEAN LEWIS, Fort Sheridan. 111.: I was very much inter ested in Dr. Walker's paper, because I think that there is one t'jug that has been demonstrated in this war and that is, that fractures can be treated by simple methods of continued flexion and Thomas splints and good results obtained. It has also been demonstrated that the Lane plate is a rather dangerous factor in the treatment of fractures. because really I believe there are fewer cases of non-union in war surgery than in the same number of cases treated in civil surgery, and that is due to the fact that no operation has been performed, such as the insertion of a Lane plate. I think the operative treatment of fractures should be reserved for those cases in which reduction cannot be made or maintained in any other way. That limits the operative treatment of fractures. I will speak later of the fractures which we see in the reconstruction period.

The deformities which we see are those in fractures of the femur just below the lesser trochanter and fractures of the femur just above the condvles, a supracondyloid fracture. In treat ing the cases continued traction with splints, such as the Thomas splint, is the best. In these fractures which we see in the construction work the Hodgein splint is the most satis. factory means of treatment that I know of.

DR. G. C. HAFFORD, Albion : I want to say one word about the Thomas splint. I do not see why we have not used it before. It is so simple and covers so many multiple fractures of the thigh and lower limb. It is so simple and more comfortable to the patient and so much easier to apply than plaster-of-Paris. It is hard to obtain, however. I ordered some and waited six weeks before I got them. If you have a little idea of them, you can go into a carpenter shop and make one. In the course of War Surgery which I took at the University of Pennsylvania they put us four days in a factory making splints.

Dr. Walker spoke of transfusion of blood. I want to know if he made the agglutination test. I would also like to know if he had any experience with Dichloramine-T. I believe that Dichloramine-t has the place that is claimed by Carrel-Dakin solution. Carrel-Dakin has a great many disadvantages. Those who attended the Carrel-Dakin place in New York became quite enthusiastic about it. Afterwards when they attended the place where they used Dichloramine-T they lost a great deal of their enthusiasm. Not, that it is not what it is claimed to be, but there is a disadvantage in its use. First, it requires so much constant attention, so much time, and so much care. It has to be used in the proper variety of wounds, as Dr. McLean said yesterday. In wounds near blood vessels it will cause hemorrhage. In

empyema cases where you have an infected process, it is liable to cause trouble. You have to change your Carrel-Dakin solution every hour in order to get the best results. You have the skin outside of the wound wet with the Carrel-Dakin solution. These are some of the things that we cannot handle as well in private practice as

e ceuild in tbe wards of the Army. With Dichlora mine-T

24 Cc



I want


should read

lished in


you only change the dressing every 24 hours. You do not have

periocular tissues, which finally weakens their it slopping over on the bed and you get just as good results.

The paraffin mesh that was spoken of yesterday can be used resistance and encourages the invasion of miwith Dichloramine-T in suppurating wounds and it is wonderful.

crobic life. If uncorrected, the refractive error It comes off easy. I think both of these solutions have their place. I think there is a definite use for each one and when keeps up the congestion, thus preventing the we speak of Carrel-Dakin solution I think we ought not to

cure of the inflammation which under approforget Dichloramine-T and use it. I remember one case where

was shot through the chest, the bullet coming out priate treatment would otherwise subside. through the back and through the pericardium. Now that was A pretty bard case to handle but we determined to do the

Local treatment directed to the microbic best we could. We closed up the wound and used Dichlora

origin will usually check these cases for a time, inine-T and got a good result. In 'wounds of the hands and arms we did not have infection as with the other solution, but, if at all severe, they are bound to recur With a spindle-point syringe we were able to get the Dichlora

and only refraction, done under complete mymine-T down into the wounds pretty well, and in cases of this type we had no serious infection.

driasis, and insistence on the continuous wearDR. H. E. RANDALL, Flint: In this way it seems to me ing of glasses will bring permanent cure. that the war has taught us many things about surgery of the extremities, Heretofore we have paid greater attention to

With the increase in the wearing of glasses abdominal work. In this war the preservation of function of

ere seems to be a corresponding decrease in the soldier has been observed and I think we were taught a great many things; especially in industrial life these lessons the number of severe cases of blepharitis that can be applied.

I see and I can attribute to no other cause. I to recommend to you Jones' little book on "Notes on Military Surgery." think every surgeon

will grant that the most of cases of uncorrected it and know it.

eve strain do not have blepharitis but neither The treatment of fractures in the Army was so simplified and the results were so wonderful that it is surprising to me does every patient with bad tonsils have arin getting back that the splint is not used more in this country.

thritis. The Thomas splint and the Jones splint I am sure you will all be using in a short time. They are so simple that I rather

GLAUCOMA. think in a few years we will find these splints in factories just the same as you now find oxygen tanks. The little book Another disease which I see far less often that was given out by the Red Cross people in France and sent to every officer in the A. E. F., I think should be pub

is glaucoma and I am coming to think that the this country by, say, the Journal of the American

spread of good refraction work with the corMedical Association, and sent to every member of the Isko

responding decrease in ciliary strain is the cause

of its disappearance. SOME PRACTICAL POINTS ABOUT EYE;

Is it not a fair presumption, in the absence EAR AND NOSE WORK.

of any generally accepted cause for glaucoma,

that the constant congestion of the ciliary reCHAS. H. BAKER, M.D.

gion from evestrain gradually develops a low BAY CITY, MICH.

grade of inflammatory action sufficient to block

the canal of Schlemm? In preparing this paper I had in mind the fact that we are all given to doing things in a Oçcurring, as glaucoma does, during and routine way, which, so far as it conserves our after middle life is a natural sequence of a conenergies, is a good thing, except as it tends to tinuous ciliary strain on tissues which are norget us into ruts and make us adhere to pro

mally losing their elasticity. Other factors un. cedures which are not always the best possible. doubtedly contribute their share in causing It is a good rule that a person will do best

glaucoma, just as in the case of blepharitis, but to follow the practice and use the instrument

as the increase of good refracting is the only with which he is familiar until convinced that

change in causes, which were not before in exthere is a better plan or tool.

istence, that applies to practically all persons,

it would seem a fair conclusion to draw. In the hope that the discussion of this paper

Fashion rules in medicine as in clothes and will bring out some helpful suggestions, I am led to group a number of subjects which have

certain drugs get an undeserved popularity no other necessary connection than that they

which finally fails them and they are put in the

discard.. occur in the day's work and we may not always be satisfied with the results we have been get


A case in point I think is the use of argyrol Chalazion, stve and blepharitis marginalis by the men in general practice for almost every are allied diseases of microbic origin, the pre- inflammatory disorder in the eve. disposing cause of which is an uncorrected error I have watched for good effects from its use of refraction, a fact which is often overlooked.

and have about decided that it is just as useful Continued eyestrain from errors of refraction and little more so than any other harmless salt produces chronic congestion of the ocular and when used in an isotonic solution, its value

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