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A NOTE ON THE TREATMENT OF GUNSHOT WOUNDS OF THE FEMUR.
323
A NOTE ON THE TREATMENT OF GUNSHOT WOUNDS OF THE FEMUR. BY
CUTHBERT
WALLACE,
M.B.,
B.S.LOND.,
F.R.C.S. ENG., SURGEON TO ST.
THOMAS’S HOSPITAL, LONDON,
BRITISH RED CROSS
AND MAJOR, R.A.M.C., HOSPITAL, NETLEY.
A LITTLE time ago Mr. B. C. Maybury and myself devised a modification of Thomas’s knee splint with the idea of producing powerful extension of the leg during the process of plating fractures of the femur When the Red Cross Hospital at Netley or tibia. was opened the difficulty of adequately treating compound fractures of the femur was soon apparent. The chief difficulty was in maintaining extension and at the same time providing for efficient dressing and (possibly more important) the comfort of the patient. It was determined to try this modified Thomas’s splint. The result more than came up to expectations, and cases which arrived with bad wounds and suffering great pain during the process of dressing were soon put at their ease and improved rapidly. In addition to this, some cases which were admitted six weeks after the injury with 3 inches of shortening were soon restored to their normal, or nearly normal, length, and union in a good position resulted. A short description of the splint (Fig. 1) may be of service to those in charge of other hospitals. The splint as maae consists of the original
Thomas’s crotch ring with a lateral diameter of 9t inches. The two side pieces are made of mild steel, are parallel, and 8 inches apart. Sliding on these parallel side pieces are two transThe upper verse bars. one is fitted with an
ordinary
footpiece.
The lower one is perforated to accommodate a large machinecut screw. The top of the screw runs in a collar in the transverse
The splint applied to a fracture in the lower third of the femur. The splint is slung to the roof of the hut by a Note the small pillow under the outer side of chain. the ring. The man’s face is expressive of his comfort.
this means the patient is free to move about in bed within reasonable limits, and the dressing of a posterior wound can be effected without discomfort to the patient by either raising the splint or turning him on one side, the constant steady pull of the screw preventing any undue shifting of the limb and consequent pain to the patient. If the limb tends to sag when the patient is turned on his side it can be prevented by loops of bandage fastened to the uppermost bar. (Fig. 4.) In those cases in which it is impossible to apply the stirrup extension, either because of the state of the skin or from the presence of wounds in the leg, a pin can be driven through the lower end of the femur and the extension applied by a chain or thick picture wire, which runs from one end of the
footpiece.
The process of application is as follows. The ring is slipped the over foot and adjusted in the ordinary way, care being taken that the inner and back part of the
The splint applied to
a
fracture in the middle of the femur.
pin his
been driven through the bottom of the shaft of the bone and extension produced by a chain. The man’s foot had been injured by a bullet, so that a strapping extension could not be applied. A
pin down to the transverse footpiece over two pulleys let into this, and up again to the opposite end of the pin. The use of the pulleys is to allow
324 the strain on either side of the limb to be equal, which it is difficult to ensure if the ends of the pin are fastened to the corresponding ends of the transverse footpiece. (Figs. 1 and 3.) The distance between the parallel bars ensures the easy application of the dressing, and also enables an operation to be performed while the limb lies stretched in the splint. If relaxation is required this can be obtained by reversing the foot screw, and then when extension is required to get the ends in position the screw can again be tightened. The essential part of the splint is the screw, and no other method which has been tried produces a like amount of extension with so little discomfort to the patient. This splint has been made by Messrs. Allen and Hanbury, of Wigmore-street, London, W. The cost is somewhat heavy, but I do not think it is out of proportion when the results obtained by the splint are considered. In addition, the expenditure is a capital one, and when a number of splints are in hand they can be passed from one FIG. 4.
TYPHOID AND PARATYPHOID INFECTION IN RELATION TO ANTITYPHOID
INOCULATION, TOGETHER WITH REMARKS ON THE IMPORTANCE OF THE USE OF PROPHYLACTIC PARATYPHOID INOCULATION.1
BY GEORGES DREYER, M.A.
OXON., M.D. COPENHAGEN,
PROFESSOR OF PATHOLOGY IN THE UNIVERSITY OF OXFORD, HONORARY CONSULTING PATHOLOGIST TO THE THIRD SOUTHERN GENERAL
HOSPITAL ;
E. W. AINLEY WALKER,
M.A., M.D. OXON.,
LECTURER IN PATHOLOGY IN THE UNIVERSITY OF OXFORD, HONORARY ASSISTANT CONSULTING PATHOLOGIST TO THE THIRD SOUTHERN GENERAL
HOSPITAL ; AND
ALEX. G.
GIBSON, M.D. OXON., F.R.C.P. LOND.,
LECTURER IN MORBID ANATOMY IN THE UNIVERSITY OF OXFORD, CAPTAIN R.A.M.C. (T.), PATHOLOGIST TO THE THIRD SOUTHERN GENERAL HOSPITAL.
present time when the prophylactic value antityphoid inoculation has been fully recognised by the authorities, but is still vehemently opposed in certain quarters, it may prove not only of interest, but perhaps also of considerable value, to record briefly the results of observations made on patients in the Base Hospital at Oxford. In the light of these observations we wish to emphasise, firstly, the extreme importance of classifying all cases returned as cases of " enteric AT the
of
"
fever in accordance with the results of detailed
bacteriological examination, particularly
on his side for dressing a posterior wound (represented by a black piece of paper). Note the small cushion under the junction of the side bar and crotch ring. The limb is kept from sagging by means of loops of bandage passing round _the limb and fastened to the upper side bar. They cannot be seen as they are hidden by the slings.
Shows the patient turned
sent across the water to in their transit to this in this A man once splint can be moved country. with very little discomfort, and constant extension of the limb is maintained in spite of the inevitable movement from bed to stretcher which the wounded have to undertake in the process of removal to the base. If one type of splint is to be used for all cases, which can well be done, it is necessary to have the side bars 54 inches long in order to take the limb of a 75-inch man. A 66-inch man wants side bars 43 inches long. There is no disadvantage in having the long splint except that it sticks over the end of the bed. I am, however, having some splints made so that side bars of different lengths can be screwed into the crotch ring. This arrangement has the advantage that the splint can be packed flat. It would also be possible to have one traction-screw attachment for many splints if the transverse foot bar was provided with fastening thumb-screws. A number of these splints have been provided by the British Red Cross Society and are now in use at this hospital. The British Red Cross Hospital, Netley. to another, and accommodate other
case
even
people
as
regards
the precise and careful differentiation between B. typhosus and B. paratyphosus. For if this be not done a large number of cases of paratyphoid " fever are likely to be returned as cases of enteric." The consequence will be that the statistics regarding the protective value of antityphoid inoculation will become seriously vitiated. Secondly, we wish to urge again the importance of making prophylactic inoculations against certain other bacterial infections, some of which have already appeared during the war. And on the present occasion we refer particularly to paratyphoid infections, which seem to be occurring with considerable frequency, both in inoculated (antityphoid) and uninoculated individuals. The prophylactic paratyphoid inoculation suggested can readily be effected simultaneously with the antityphoid inoculation by using a mixed vaccine, and, so far as the evidence goes, this procedure does not lead to any notable increase in the severity of the reaction produced. The Diagnosis. The agglutination test is the quickest method of diagnosis. Blood cultures and cultures from the urine and faeces will usually enable the observer to isolate the micro-organism where opportunity exists for carrying out repeated examinations. But under war conditions the agglutination method is the Accurate one on which reliance must be placed. differential diagnosis, however, can only be obtained by routine testing of the serum of the patient against the three micro-organisms, B. typhosus and B. paratyphosus (A) and (B), in parallel series of observations, and by always determining the maximum dilution of the serum in which agglutination takes place. Individuals who have been inoculated with antityphoid vaccine within a period of some months or even years will give a high agglutination titre against expenses of this work have been defrayed out of received from the National Medical Research Committee.
1 The
a
grant
A NOTE ON THE TREATMENT OF GUNSHOT WOUNDS OF THE FEMUR. BY
CUTHBERT
WALLACE,
M.B.,
B.S.LOND.,
F.R.C.S. ENG., SURGEON TO ST.
THOMAS’S HOSPITAL, LONDON,
BRITISH RED CROSS
AND MAJOR, R.A.M.C., HOSPITAL, NETLEY.
A LITTLE time ago Mr. B. C. Maybury and myself devised a modification of Thomas’s knee splint with the idea of producing powerful extension of the leg during the process of plating fractures of the femur When the Red Cross Hospital at Netley or tibia. was opened the difficulty of adequately treating compound fractures of the femur was soon apparent. The chief difficulty was in maintaining extension and at the same time providing for efficient dressing and (possibly more important) the comfort of the patient. It was determined to try this modified Thomas’s splint. The result more than came up to expectations, and cases which arrived with bad wounds and suffering great pain during the process of dressing were soon put at their ease and improved rapidly. In addition to this, some cases which were admitted six weeks after the injury with 3 inches of shortening were soon restored to their normal, or nearly normal, length, and union in a good position resulted. A short description of the splint (Fig. 1) may be of service to those in charge of other hospitals. The splint as maae consists of the original
Thomas’s crotch ring with a lateral diameter of 9t inches. The two side pieces are made of mild steel, are parallel, and 8 inches apart. Sliding on these parallel side pieces are two transThe upper verse bars. one is fitted with an
ordinary
footpiece.
The lower one is perforated to accommodate a large machinecut screw. The top of the screw runs in a collar in the transverse
The splint applied to a fracture in the lower third of the femur. The splint is slung to the roof of the hut by a Note the small pillow under the outer side of chain. the ring. The man’s face is expressive of his comfort.
this means the patient is free to move about in bed within reasonable limits, and the dressing of a posterior wound can be effected without discomfort to the patient by either raising the splint or turning him on one side, the constant steady pull of the screw preventing any undue shifting of the limb and consequent pain to the patient. If the limb tends to sag when the patient is turned on his side it can be prevented by loops of bandage fastened to the uppermost bar. (Fig. 4.) In those cases in which it is impossible to apply the stirrup extension, either because of the state of the skin or from the presence of wounds in the leg, a pin can be driven through the lower end of the femur and the extension applied by a chain or thick picture wire, which runs from one end of the
footpiece.
The process of application is as follows. The ring is slipped the over foot and adjusted in the ordinary way, care being taken that the inner and back part of the
The splint applied to
a
fracture in the middle of the femur.
pin his
been driven through the bottom of the shaft of the bone and extension produced by a chain. The man’s foot had been injured by a bullet, so that a strapping extension could not be applied. A
pin down to the transverse footpiece over two pulleys let into this, and up again to the opposite end of the pin. The use of the pulleys is to allow
324 the strain on either side of the limb to be equal, which it is difficult to ensure if the ends of the pin are fastened to the corresponding ends of the transverse footpiece. (Figs. 1 and 3.) The distance between the parallel bars ensures the easy application of the dressing, and also enables an operation to be performed while the limb lies stretched in the splint. If relaxation is required this can be obtained by reversing the foot screw, and then when extension is required to get the ends in position the screw can again be tightened. The essential part of the splint is the screw, and no other method which has been tried produces a like amount of extension with so little discomfort to the patient. This splint has been made by Messrs. Allen and Hanbury, of Wigmore-street, London, W. The cost is somewhat heavy, but I do not think it is out of proportion when the results obtained by the splint are considered. In addition, the expenditure is a capital one, and when a number of splints are in hand they can be passed from one FIG. 4.
TYPHOID AND PARATYPHOID INFECTION IN RELATION TO ANTITYPHOID
INOCULATION, TOGETHER WITH REMARKS ON THE IMPORTANCE OF THE USE OF PROPHYLACTIC PARATYPHOID INOCULATION.1
BY GEORGES DREYER, M.A.
OXON., M.D. COPENHAGEN,
PROFESSOR OF PATHOLOGY IN THE UNIVERSITY OF OXFORD, HONORARY CONSULTING PATHOLOGIST TO THE THIRD SOUTHERN GENERAL
HOSPITAL ;
E. W. AINLEY WALKER,
M.A., M.D. OXON.,
LECTURER IN PATHOLOGY IN THE UNIVERSITY OF OXFORD, HONORARY ASSISTANT CONSULTING PATHOLOGIST TO THE THIRD SOUTHERN GENERAL
HOSPITAL ; AND
ALEX. G.
GIBSON, M.D. OXON., F.R.C.P. LOND.,
LECTURER IN MORBID ANATOMY IN THE UNIVERSITY OF OXFORD, CAPTAIN R.A.M.C. (T.), PATHOLOGIST TO THE THIRD SOUTHERN GENERAL HOSPITAL.
present time when the prophylactic value antityphoid inoculation has been fully recognised by the authorities, but is still vehemently opposed in certain quarters, it may prove not only of interest, but perhaps also of considerable value, to record briefly the results of observations made on patients in the Base Hospital at Oxford. In the light of these observations we wish to emphasise, firstly, the extreme importance of classifying all cases returned as cases of " enteric AT the
of
"
fever in accordance with the results of detailed
bacteriological examination, particularly
on his side for dressing a posterior wound (represented by a black piece of paper). Note the small cushion under the junction of the side bar and crotch ring. The limb is kept from sagging by means of loops of bandage passing round _the limb and fastened to the upper side bar. They cannot be seen as they are hidden by the slings.
Shows the patient turned
sent across the water to in their transit to this in this A man once splint can be moved country. with very little discomfort, and constant extension of the limb is maintained in spite of the inevitable movement from bed to stretcher which the wounded have to undertake in the process of removal to the base. If one type of splint is to be used for all cases, which can well be done, it is necessary to have the side bars 54 inches long in order to take the limb of a 75-inch man. A 66-inch man wants side bars 43 inches long. There is no disadvantage in having the long splint except that it sticks over the end of the bed. I am, however, having some splints made so that side bars of different lengths can be screwed into the crotch ring. This arrangement has the advantage that the splint can be packed flat. It would also be possible to have one traction-screw attachment for many splints if the transverse foot bar was provided with fastening thumb-screws. A number of these splints have been provided by the British Red Cross Society and are now in use at this hospital. The British Red Cross Hospital, Netley. to another, and accommodate other
case
even
people
as
regards
the precise and careful differentiation between B. typhosus and B. paratyphosus. For if this be not done a large number of cases of paratyphoid " fever are likely to be returned as cases of enteric." The consequence will be that the statistics regarding the protective value of antityphoid inoculation will become seriously vitiated. Secondly, we wish to urge again the importance of making prophylactic inoculations against certain other bacterial infections, some of which have already appeared during the war. And on the present occasion we refer particularly to paratyphoid infections, which seem to be occurring with considerable frequency, both in inoculated (antityphoid) and uninoculated individuals. The prophylactic paratyphoid inoculation suggested can readily be effected simultaneously with the antityphoid inoculation by using a mixed vaccine, and, so far as the evidence goes, this procedure does not lead to any notable increase in the severity of the reaction produced. The Diagnosis. The agglutination test is the quickest method of diagnosis. Blood cultures and cultures from the urine and faeces will usually enable the observer to isolate the micro-organism where opportunity exists for carrying out repeated examinations. But under war conditions the agglutination method is the Accurate one on which reliance must be placed. differential diagnosis, however, can only be obtained by routine testing of the serum of the patient against the three micro-organisms, B. typhosus and B. paratyphosus (A) and (B), in parallel series of observations, and by always determining the maximum dilution of the serum in which agglutination takes place. Individuals who have been inoculated with antityphoid vaccine within a period of some months or even years will give a high agglutination titre against expenses of this work have been defrayed out of received from the National Medical Research Committee.
1 The
a
grant