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THE AIR-RAID
171
THE AIR-RAID A series of articles on medical organisation and surgical practice in air attack by P. H. MITCHINER, C.B.E., T.D., F.R.C.S., and E. M. COWELL, D.S.O., T.D., F.R.C.S. III—GENERAL PRINCIPLES OF WOUND SURGERY AND ANÆSTHETICS THE general principles of war-wound surgery differ considerably from those of ordinary civil
practice, although they are somewhat comparable by the severe injuries met with
to those necessitated
in motor-car and industrial accidents. This difference in principles is due mainly to infection of the wound caused both by the carrying in of shreds of clothing and surrounding dirt with the projectile and by the considerable disruption of tissue round the wound track. Micro-organisms are thus introduced into the damaged tissue, often isolated from the surrounding air, in conditions which favour their rapid growth. The principle therefore to be observed in all warwound surgery is the prompt and thorough excision of the entire wound track, together with the damaged surrounding tissue, and the primary suture of the resultant wound, or delayed (secondary) suture if primary cannot be carried out without tension. Delay in transport caused by enemy action is likely to result in the wounds of many patients being already extensively infected before they come under the care of the surgeon, and the extent of the wound and the involvement or close proximity of important anatomical structures often render impossible complete excision of the wound track. As a general rule excision, to be satisfactory, must be performed within twelve hours of the infliction of the wound, and earlier than this if possible. After this period the chances of obtaining primary union after excision are extremely small, but in the case of superficial wounds it may be justifiable to perform this operation up to twentyfour hours, roughly approximating the surface of the resultant wound, when this can be done without tension and no obvious infection is present, and draining the incision for twenty-four hours. In cases seen after twenty-four hours, and in any case seen at an earlier period in which total excision is impossible, debridement of the wound must be undertaken. This consists in free excision of crushed and damaged tissue and the provision of adequate drainage from the most dependent part of the wound. Dibridement should always be carried out in the case of all extensive lacerated wounds in which coaptation of the surfaces after excision must of necessity entail tension and therefore should not be attempted. Compound fractures should be examined, obviously loose and necrotic pieces of bone removed, and the limb put up on a skeleton splint with extension. The delays so often seen in previous wars will probably not occur in the evacuation of most ,of the casualties in air-raids in cities, but there are bound to be delays owing to the blockage of streets by fallen buildings and to the necessity of rescuing the wounded from beneath the debris. TYPES OF WOUNDS
The following types of injury are to be expected from the action of high-explosive and incendiary bombs ; further, gas may be used by enemy aircraft, and the surgeon at any clearing station may therefore have to contend with decontamination of injured persons before operating upon them, or in certain circumstances he must operate in a gas mask (this should be practised in peace-time, for it is both exhausting and difficult).
a result of the blast of high-explosive bombs crush many injuries and fractures, due mainly to falling masonry, are bound to be met with, and in many cases these will be immediately fatal or the victims will be past surgical aid by the time they have been rescued from under the fallen debris. In the remaining cases severe mangling of limbs and compound and simple fractures will be the chief
(1) As
injuries. (2) Many
wounds will be due to the explosion of bombs and the falling fragments of shrapnel and shell casing from anti-aircraft guns. These fall into three main types :-
(a) Lacerated wounds due either to bomb casing, in which event whole limbs are often avulsed and the patient eviscerated, so that they come very seldom under the care of the surgeon, or, more commonly, to fragments of shell cases and shrapnel, in which event they are usually of moderate severity. (b) Penetrating wounds usually due to high-velocity bullets fired from low-flying aircraft, a type of wound not likely to be much met with in London, where air defence against this form of aircraft is well organised and efficient. (c) Contusions due to small fragments of falling masonry and by patients injuring themselves in their haste to enter air-raid shelters.
(3) Burns due to incendiary bombs and the resulting fires, and to chemicals, such as mustard gas or cordite. Certain types of wounds deserve special consideration. Chest wounds are usually caused by bomb fragments ; hence extensive laceration of the chest wall combined with damage to the underlying viscera ensures a high mortality. When the case is not immediately fatal, the wound and pleural cavity should be rapidly cleansed and the complete thickness of the parietes promptly closed, so as to allow the lungs to expand. This operation, to be successful, will probably have to be performed at a dressing station. If, after suture, the patient has a little dyspnoea, or cyanosis, he is best left quiet in any position comfortable to him, and no attempt should be made to interfere with the wound for at least after which it may be explored, if necessary, under intratracheal anaesthesia, and any fragments of shell may be removed after being localised by X rays. When there is haemorrhage from the great vessels, heart, or lungs, prompt operation to secure haemostasis is essential, and the same procedure must be carried out in ingravescent pneumothorax to crush and ligate any patent bronchi. Abdominal wounds.-All wounds of the abdominal parietes must be explored and, if there is any doubt about penetration of the abdominal cavity, laparotomy performed. The common complications are internal haemorrhage and perforation (often multiple) of the intestines. Internal haemorrhage must be arrested by ligation of the blood-vessels and by suture, excision, or plugging of damaged solid viscera and a systematic search made of the entire intestinal tract from the stomach to the colon in cases of suspected perforation. Such search must be con-’ ducted foot by foot, the intestine being returned immediately after examination, while a lower portion is withdrawn through the laparotomy wound. Small perforations can be invaginated, but extensive ones need excision and suture of the gut.
twenty-four hours,
172 Wounds
of the head fall clinically into two types : ferred to another hospital, it may be known what a thin rapid pulse and extensive treatment has been given. It cannot be too strongly impressed upon the young damage to the brain (here an early fatal result is to be expected) ; and (2) those with a slow full surgeon that every wound, however trivial, must be pulse which have a fair chance’of recovery if operation completely and thoroughly explored, for the vagaries is performed. It is important whenever possible of bullet tracks are many, and until such exploration to radiograph these cases before operating, so as to has been carried out it is impossible to tell the exact locate the missile and remove it at the operation with course of the projectile, or what damage has been as little disturbance as possible to the brain tissue. inflicted to subjacent viscera. Hence in the case of minute wounds of the abdominal parietes laparotomy Should pre-operative radiography be impossible, the surgeon should content himself with excising is often necessary and must always be performed if the edges of the wound, removing the damaged or any doubt exists about penetration of the abdominal depressed fragments of bone and any obviously cavity. In the case of lacerated wounds care must be necrotic brain tissue, but forbearing to search for the exercised in the débridement lest important anatomical missile unless it comes readily to hand in the wound. structures be damaged, and when such damage Wounds of the spine should be treated by the is found it must be repaired as far as possible by operator much on the lines of those of the brain. suture of nerves, ligation of vessels, and reduction of fractures, efficient drainage being Owing to damage of the spinal cord the subsequent and splinting in mortality is considerable. In all cases with retention provided every case. of urine a suprapubic cystotomy should be performed, RADIOGRAPHY for it has been proved that patients who have If time and circumstances permit, radiography not been catheterised do not develop ascending should be carried out as a routine in all cases of kidney infection. Wounds of the peripheral nerves wounds by projectiles, to ascertain if fragments have should be sutured, provided this can be done without been left behind and to locate their position. For tension when the wound is excised or cleaned, and this purpose there should be one or two X-ray units the limb splinted to rest any muscles paralysed at each clearing hospital. It will seldom be possible as a result of the nerve injury. Wounds of the face or advisable to carry out these X-ray examinations and jaw should be cleaned and passed as soon as before performing the routine wound toilet, but every possible to a plastic surgeon accustomed to dealing effort should be made to radiograph head wounds with this type of injury. Injured blood-vessels should, before operation. When small fragments are deeply as a general rule, be divided and ligated above and embedded in the tissues and cause no apparent below the site of injury and no attempt made to trouble, it is advisable to leave them in situ rather reconstruct their lumen. Such attempts are dangerous than to undertake extensive operation, the successful and likely to be followed by severe secondary results of which are and usually problematical, haemorrhage, should the wound become infected, and negligible compared with the damage done to the the ultimate results are unsatisfactory. body tissues. All cases of both simple and open fractures should be radiographed after they have been ROUTINE TREATMENT IN CLEARING HOSPITAL splinted, and all cases of dubious fractures must be The treatment of war wounds involves care of the radiographed to establish a diagnosis, though this patient from the time of infliction of the wound until procedure may be impossible during rush periods the end-results have been attained, but in this article or when it may only be possible to adjust splints, if it is intended to deal mainly with the treatment which necessary, before transferring these patients elsewhere. such cases should receive at the first hospital to which A proportion of X-ray units should be mobile. they are admitted, and from which they will probably ANTISEPTICS have to be removed in a few days or earlier to make The application of antiseptics to the two ends room for succeeding casualties from further airof a penetrating wound cannot affect the track of raids. the wound, and this is on the whole a good thing, It should be the aim to keep patients for 3-8 days for in our experience the use of antiseptics in sufficient at the clearing hospital, but this may be impossible strength to destroy micro-organisms has a most owing to the number of casualties or the exigencies deleterious effect on the already damaged tissues. As of transport, and the medical officer should select a general rule, therefore, antiseptics are strongly the cases to be evacuated prematurely, should such contra-indicated in wound surgery, for experience conditions arise. These clearing hospitals will preshows that antiseptic dressings cause more damage sumably be established in existing hospitals in the to the tissue cells than to the micro-organisms metropolis and will be organised with a number of and thus encourage the spread of infection. The use surgical teams on the lines suggested in the first article of coloured antiseptics may be justifiable in following of this series. All cases admitted must be treated through the track of a projectile and can be used as when necessary for shock-briefly, this consists of giva first-aid dressing when efficient cleansing is out of ing fluids by mouth, or intravenously in severe cases, the question, but in such cases only a mild antiseptic in which continuous blood-transfusion is of great should be used, such as a 1 per cent. aqueous solution value. All wounded patients must receive a prophyof gentian violet or a 1 in 1000 solution of acriflavine or lactic injection of tetanus and gas-gangrene antibrilliant green, which are painless and non-irritant. The toxic serum. A combined injection is obtainable, use of that popular and painful antiseptic 2-5 per cent. and for the average case an injection containing iodine in spirit is mentioned only to be condemned. 500 units of tetanus antitoxin, 400 units of ANESTHESIA B. perfringens antitoxin, and 400 units of vibrion Anaesthesia will be necessary in the thorough septique antitoxin should be administered. When wounds are obviously fouled with road dirt or manure, excision and cleansing of all wounds, and for any four times this dose should be administered hypopatient suffering from loss of blood, shock, and low dermically, and this treatment and any other given blood-pressure some form of stimulant anaesthetic must be recorded on the patient’s medical card at is necessary. For this purpose a hypodermic injection the time of administration, so that, when he is transof morphine gr.$-4, together with atropine sulphate (1) those with
173 is a valuable premedication and allows the to be conducted under gas-and-oxygen ansesthesia. Should deeper anaesthesia be required, as in laparotomy or thoracotomy, ether can be administered. In no circumstances should spinal anaesthesia be used in such cases, for the resultant fall of blood-pressure is very hard to combat and often fatal in already feeble patients. Local anaesthesia is inadvisable, for the oedema consequent on the local infiltration in the area of the wound favours the growth of micro-organisms and retards healing. Nerve-block may be possible, but it is difficult to foretell the exact area of operation, and the patients’ mental condition is usually such that it is preferable that they should be unconscious of what is going on round them. Chloroform (except in hot climates) must not be used to anaesthetise such patients if it can be avoided, for the risk of cardiac failure is very great. Asa general rule most of the wounded patients undergo anaesthesia extremely well and cause but little anxiety to the anaesthetist, provided he administers only gas and oxygen, supplemented if necessary with ether. The apparatus must be compact and simple, and portable if possible, such as the apparatus of Shipway,
1/100, operation gr.
Boyle, or McKesson, or some modification of these. A large reserve of cylinders of gas and of oxygen must be kept handy, but these should be stored outside the theatre and in such a place that they are unlikely to be exploded by a bomb falling in the vicinity. A cylinder of oxygen and carbon dioxide should also be available and a few inhalations from this given to every patient as a routine at the termination of anaesthesia to reduce the incidence of lung complications and, by inducing deep breathing, to promote a more rapid recovery from the anaesthesia. The anaesthetist’s equipment must include gag and tongue clips, intratracheal catheters and Hewett’s airways, as well as a ready sterilised hypodermic syringe and needles and ampoules of such restoratives as Coramine and strychnine. It is a wise precaution to place a drop of castor oil in each eye before the patient leaves the theatre, lor this greatly diminishes any risk of post-anaesthetic conjunctivitis. In many cases the patient will be returned to the ward to be nursed by V.A.D.’s or orderlies, and it will be necessary to instruct these in turning the patient’s head to one side and keeping the jaw forward so that the pharynx may be kept clear when the patient vomits.
J
GRAINS
AND
SCRUPLES
Under this heading appear week by week the unfettered thoughts of doctors in various occupations. Each contributor is responsible for the section for a month ; his name can be seen later in the half-yearly index
FROM A PHYSIOLOGIST IN AMERICA III Nov. 23-Getting colder :s severe frosts at night, but a fortnight ago sat outside in the garden reading all day-and they complain of the weather. The days are generally sunshiny and bracing, the cloudy days muggy and warm. Last week it snowed. Dr. S-- insisted on my accepting two tickets for Saturday’s ’Yale v. Harvard football match, so B-- and I caught the early train to Boston. He is another Englishman and we passed the journey comparing notes and seemed to arrive quickly at our destination. Boston station, like most I have seen, is magnificent and spotlessly clean. It is important in this country to differentiate between the " station " and the " track." We had a cup of coffee, and descended into the subway where we were packed tight and trundled off to the Stadium. We arrived a little late, but found our seats without difficultytwo numbers painted on a plank. They certainly don’t pander to the comfort of the spectators ; it was the same at Yale. Unlike the Yale Bowl, which is quite open all over, this horse-shoe-shaped structure is topped by a roof, covering the upper half-dozen It or so rows of seats, and supported by pillars. is there only for architectural effect and certainly does look rather fine. We were miles away from the pitch, but could see perfectly. Yale never had a look-in, and suffered their first defeat of the season. Rather bad luck, as it was the last and most important game. Football stops now, probably owing to the imminence of winter, or perhaps because all the players get used up just about now. A snowstorm came on and lasted all through the second half. We buttoned up our coat collars and stuck it like Spartans; many of our companions drank whisky as well and became steadily more partisan. (Even girls take their spirits "straight.") The game, unlike the previous one, was quite interesting, and included a lot of open play. The Harvard team were
magnificent, making their
10 yards time after time, and their two scores were beautifully clean. Yale relied too much on brute force, and came off very much second best. They were lucky to escape with their 13-6 beating. The significance of university football is rather difficult for us to understand. The seats are quite expensive, and the game may be played before anything up to 80,000 spectators-very much like our professional games. Whether the money goes to the university, or the football club, or into some special fund I don’t know, but I gather vaguely that it is almost essential for a university to have a first-class team and that some people think it is not all for the best. *
It is
*
*
coincidence that on the same day as writing up good football match I have also to report a proper tea. We went to H--’s this afternoon, where " pouring out " was done in the good oldfashioned way. All the departmental wives were there, the husbands dropping in by ones and twos. We sat round the apartment and yelled at each other until it was time to leave, happy but exhausted. Marjorie was quite one of us, and solemnly produced a little basket she had made at school and passed round pea-nuts ! As a matter of fact, I find that tea is not quite so unknown here as I thought. Two or three people make it in their labs, and in a tremendous lounge in the medical school there is a daily function, presided over by wives of prominent members of the teaching staff, at which tea is dispensed from silver urns and" cookies " distributed. The only unEnglish features about this are first, that it is free, and secondly that it is free to all-staff, students, and nurses. I believe it is unique, and not a national a
a
custom. *
Nov. 29-Last
cleaning
out
*
I spent all morning in the afternoon we and cages,
Wednesday
mouse
*
THE AIR-RAID A series of articles on medical organisation and surgical practice in air attack by P. H. MITCHINER, C.B.E., T.D., F.R.C.S., and E. M. COWELL, D.S.O., T.D., F.R.C.S. III—GENERAL PRINCIPLES OF WOUND SURGERY AND ANÆSTHETICS THE general principles of war-wound surgery differ considerably from those of ordinary civil
practice, although they are somewhat comparable by the severe injuries met with
to those necessitated
in motor-car and industrial accidents. This difference in principles is due mainly to infection of the wound caused both by the carrying in of shreds of clothing and surrounding dirt with the projectile and by the considerable disruption of tissue round the wound track. Micro-organisms are thus introduced into the damaged tissue, often isolated from the surrounding air, in conditions which favour their rapid growth. The principle therefore to be observed in all warwound surgery is the prompt and thorough excision of the entire wound track, together with the damaged surrounding tissue, and the primary suture of the resultant wound, or delayed (secondary) suture if primary cannot be carried out without tension. Delay in transport caused by enemy action is likely to result in the wounds of many patients being already extensively infected before they come under the care of the surgeon, and the extent of the wound and the involvement or close proximity of important anatomical structures often render impossible complete excision of the wound track. As a general rule excision, to be satisfactory, must be performed within twelve hours of the infliction of the wound, and earlier than this if possible. After this period the chances of obtaining primary union after excision are extremely small, but in the case of superficial wounds it may be justifiable to perform this operation up to twentyfour hours, roughly approximating the surface of the resultant wound, when this can be done without tension and no obvious infection is present, and draining the incision for twenty-four hours. In cases seen after twenty-four hours, and in any case seen at an earlier period in which total excision is impossible, debridement of the wound must be undertaken. This consists in free excision of crushed and damaged tissue and the provision of adequate drainage from the most dependent part of the wound. Dibridement should always be carried out in the case of all extensive lacerated wounds in which coaptation of the surfaces after excision must of necessity entail tension and therefore should not be attempted. Compound fractures should be examined, obviously loose and necrotic pieces of bone removed, and the limb put up on a skeleton splint with extension. The delays so often seen in previous wars will probably not occur in the evacuation of most ,of the casualties in air-raids in cities, but there are bound to be delays owing to the blockage of streets by fallen buildings and to the necessity of rescuing the wounded from beneath the debris. TYPES OF WOUNDS
The following types of injury are to be expected from the action of high-explosive and incendiary bombs ; further, gas may be used by enemy aircraft, and the surgeon at any clearing station may therefore have to contend with decontamination of injured persons before operating upon them, or in certain circumstances he must operate in a gas mask (this should be practised in peace-time, for it is both exhausting and difficult).
a result of the blast of high-explosive bombs crush many injuries and fractures, due mainly to falling masonry, are bound to be met with, and in many cases these will be immediately fatal or the victims will be past surgical aid by the time they have been rescued from under the fallen debris. In the remaining cases severe mangling of limbs and compound and simple fractures will be the chief
(1) As
injuries. (2) Many
wounds will be due to the explosion of bombs and the falling fragments of shrapnel and shell casing from anti-aircraft guns. These fall into three main types :-
(a) Lacerated wounds due either to bomb casing, in which event whole limbs are often avulsed and the patient eviscerated, so that they come very seldom under the care of the surgeon, or, more commonly, to fragments of shell cases and shrapnel, in which event they are usually of moderate severity. (b) Penetrating wounds usually due to high-velocity bullets fired from low-flying aircraft, a type of wound not likely to be much met with in London, where air defence against this form of aircraft is well organised and efficient. (c) Contusions due to small fragments of falling masonry and by patients injuring themselves in their haste to enter air-raid shelters.
(3) Burns due to incendiary bombs and the resulting fires, and to chemicals, such as mustard gas or cordite. Certain types of wounds deserve special consideration. Chest wounds are usually caused by bomb fragments ; hence extensive laceration of the chest wall combined with damage to the underlying viscera ensures a high mortality. When the case is not immediately fatal, the wound and pleural cavity should be rapidly cleansed and the complete thickness of the parietes promptly closed, so as to allow the lungs to expand. This operation, to be successful, will probably have to be performed at a dressing station. If, after suture, the patient has a little dyspnoea, or cyanosis, he is best left quiet in any position comfortable to him, and no attempt should be made to interfere with the wound for at least after which it may be explored, if necessary, under intratracheal anaesthesia, and any fragments of shell may be removed after being localised by X rays. When there is haemorrhage from the great vessels, heart, or lungs, prompt operation to secure haemostasis is essential, and the same procedure must be carried out in ingravescent pneumothorax to crush and ligate any patent bronchi. Abdominal wounds.-All wounds of the abdominal parietes must be explored and, if there is any doubt about penetration of the abdominal cavity, laparotomy performed. The common complications are internal haemorrhage and perforation (often multiple) of the intestines. Internal haemorrhage must be arrested by ligation of the blood-vessels and by suture, excision, or plugging of damaged solid viscera and a systematic search made of the entire intestinal tract from the stomach to the colon in cases of suspected perforation. Such search must be con-’ ducted foot by foot, the intestine being returned immediately after examination, while a lower portion is withdrawn through the laparotomy wound. Small perforations can be invaginated, but extensive ones need excision and suture of the gut.
twenty-four hours,
172 Wounds
of the head fall clinically into two types : ferred to another hospital, it may be known what a thin rapid pulse and extensive treatment has been given. It cannot be too strongly impressed upon the young damage to the brain (here an early fatal result is to be expected) ; and (2) those with a slow full surgeon that every wound, however trivial, must be pulse which have a fair chance’of recovery if operation completely and thoroughly explored, for the vagaries is performed. It is important whenever possible of bullet tracks are many, and until such exploration to radiograph these cases before operating, so as to has been carried out it is impossible to tell the exact locate the missile and remove it at the operation with course of the projectile, or what damage has been as little disturbance as possible to the brain tissue. inflicted to subjacent viscera. Hence in the case of minute wounds of the abdominal parietes laparotomy Should pre-operative radiography be impossible, the surgeon should content himself with excising is often necessary and must always be performed if the edges of the wound, removing the damaged or any doubt exists about penetration of the abdominal depressed fragments of bone and any obviously cavity. In the case of lacerated wounds care must be necrotic brain tissue, but forbearing to search for the exercised in the débridement lest important anatomical missile unless it comes readily to hand in the wound. structures be damaged, and when such damage Wounds of the spine should be treated by the is found it must be repaired as far as possible by operator much on the lines of those of the brain. suture of nerves, ligation of vessels, and reduction of fractures, efficient drainage being Owing to damage of the spinal cord the subsequent and splinting in mortality is considerable. In all cases with retention provided every case. of urine a suprapubic cystotomy should be performed, RADIOGRAPHY for it has been proved that patients who have If time and circumstances permit, radiography not been catheterised do not develop ascending should be carried out as a routine in all cases of kidney infection. Wounds of the peripheral nerves wounds by projectiles, to ascertain if fragments have should be sutured, provided this can be done without been left behind and to locate their position. For tension when the wound is excised or cleaned, and this purpose there should be one or two X-ray units the limb splinted to rest any muscles paralysed at each clearing hospital. It will seldom be possible as a result of the nerve injury. Wounds of the face or advisable to carry out these X-ray examinations and jaw should be cleaned and passed as soon as before performing the routine wound toilet, but every possible to a plastic surgeon accustomed to dealing effort should be made to radiograph head wounds with this type of injury. Injured blood-vessels should, before operation. When small fragments are deeply as a general rule, be divided and ligated above and embedded in the tissues and cause no apparent below the site of injury and no attempt made to trouble, it is advisable to leave them in situ rather reconstruct their lumen. Such attempts are dangerous than to undertake extensive operation, the successful and likely to be followed by severe secondary results of which are and usually problematical, haemorrhage, should the wound become infected, and negligible compared with the damage done to the the ultimate results are unsatisfactory. body tissues. All cases of both simple and open fractures should be radiographed after they have been ROUTINE TREATMENT IN CLEARING HOSPITAL splinted, and all cases of dubious fractures must be The treatment of war wounds involves care of the radiographed to establish a diagnosis, though this patient from the time of infliction of the wound until procedure may be impossible during rush periods the end-results have been attained, but in this article or when it may only be possible to adjust splints, if it is intended to deal mainly with the treatment which necessary, before transferring these patients elsewhere. such cases should receive at the first hospital to which A proportion of X-ray units should be mobile. they are admitted, and from which they will probably ANTISEPTICS have to be removed in a few days or earlier to make The application of antiseptics to the two ends room for succeeding casualties from further airof a penetrating wound cannot affect the track of raids. the wound, and this is on the whole a good thing, It should be the aim to keep patients for 3-8 days for in our experience the use of antiseptics in sufficient at the clearing hospital, but this may be impossible strength to destroy micro-organisms has a most owing to the number of casualties or the exigencies deleterious effect on the already damaged tissues. As of transport, and the medical officer should select a general rule, therefore, antiseptics are strongly the cases to be evacuated prematurely, should such contra-indicated in wound surgery, for experience conditions arise. These clearing hospitals will preshows that antiseptic dressings cause more damage sumably be established in existing hospitals in the to the tissue cells than to the micro-organisms metropolis and will be organised with a number of and thus encourage the spread of infection. The use surgical teams on the lines suggested in the first article of coloured antiseptics may be justifiable in following of this series. All cases admitted must be treated through the track of a projectile and can be used as when necessary for shock-briefly, this consists of giva first-aid dressing when efficient cleansing is out of ing fluids by mouth, or intravenously in severe cases, the question, but in such cases only a mild antiseptic in which continuous blood-transfusion is of great should be used, such as a 1 per cent. aqueous solution value. All wounded patients must receive a prophyof gentian violet or a 1 in 1000 solution of acriflavine or lactic injection of tetanus and gas-gangrene antibrilliant green, which are painless and non-irritant. The toxic serum. A combined injection is obtainable, use of that popular and painful antiseptic 2-5 per cent. and for the average case an injection containing iodine in spirit is mentioned only to be condemned. 500 units of tetanus antitoxin, 400 units of ANESTHESIA B. perfringens antitoxin, and 400 units of vibrion Anaesthesia will be necessary in the thorough septique antitoxin should be administered. When wounds are obviously fouled with road dirt or manure, excision and cleansing of all wounds, and for any four times this dose should be administered hypopatient suffering from loss of blood, shock, and low dermically, and this treatment and any other given blood-pressure some form of stimulant anaesthetic must be recorded on the patient’s medical card at is necessary. For this purpose a hypodermic injection the time of administration, so that, when he is transof morphine gr.$-4, together with atropine sulphate (1) those with
173 is a valuable premedication and allows the to be conducted under gas-and-oxygen ansesthesia. Should deeper anaesthesia be required, as in laparotomy or thoracotomy, ether can be administered. In no circumstances should spinal anaesthesia be used in such cases, for the resultant fall of blood-pressure is very hard to combat and often fatal in already feeble patients. Local anaesthesia is inadvisable, for the oedema consequent on the local infiltration in the area of the wound favours the growth of micro-organisms and retards healing. Nerve-block may be possible, but it is difficult to foretell the exact area of operation, and the patients’ mental condition is usually such that it is preferable that they should be unconscious of what is going on round them. Chloroform (except in hot climates) must not be used to anaesthetise such patients if it can be avoided, for the risk of cardiac failure is very great. Asa general rule most of the wounded patients undergo anaesthesia extremely well and cause but little anxiety to the anaesthetist, provided he administers only gas and oxygen, supplemented if necessary with ether. The apparatus must be compact and simple, and portable if possible, such as the apparatus of Shipway,
1/100, operation gr.
Boyle, or McKesson, or some modification of these. A large reserve of cylinders of gas and of oxygen must be kept handy, but these should be stored outside the theatre and in such a place that they are unlikely to be exploded by a bomb falling in the vicinity. A cylinder of oxygen and carbon dioxide should also be available and a few inhalations from this given to every patient as a routine at the termination of anaesthesia to reduce the incidence of lung complications and, by inducing deep breathing, to promote a more rapid recovery from the anaesthesia. The anaesthetist’s equipment must include gag and tongue clips, intratracheal catheters and Hewett’s airways, as well as a ready sterilised hypodermic syringe and needles and ampoules of such restoratives as Coramine and strychnine. It is a wise precaution to place a drop of castor oil in each eye before the patient leaves the theatre, lor this greatly diminishes any risk of post-anaesthetic conjunctivitis. In many cases the patient will be returned to the ward to be nursed by V.A.D.’s or orderlies, and it will be necessary to instruct these in turning the patient’s head to one side and keeping the jaw forward so that the pharynx may be kept clear when the patient vomits.
J
GRAINS
AND
SCRUPLES
Under this heading appear week by week the unfettered thoughts of doctors in various occupations. Each contributor is responsible for the section for a month ; his name can be seen later in the half-yearly index
FROM A PHYSIOLOGIST IN AMERICA III Nov. 23-Getting colder :s severe frosts at night, but a fortnight ago sat outside in the garden reading all day-and they complain of the weather. The days are generally sunshiny and bracing, the cloudy days muggy and warm. Last week it snowed. Dr. S-- insisted on my accepting two tickets for Saturday’s ’Yale v. Harvard football match, so B-- and I caught the early train to Boston. He is another Englishman and we passed the journey comparing notes and seemed to arrive quickly at our destination. Boston station, like most I have seen, is magnificent and spotlessly clean. It is important in this country to differentiate between the " station " and the " track." We had a cup of coffee, and descended into the subway where we were packed tight and trundled off to the Stadium. We arrived a little late, but found our seats without difficultytwo numbers painted on a plank. They certainly don’t pander to the comfort of the spectators ; it was the same at Yale. Unlike the Yale Bowl, which is quite open all over, this horse-shoe-shaped structure is topped by a roof, covering the upper half-dozen It or so rows of seats, and supported by pillars. is there only for architectural effect and certainly does look rather fine. We were miles away from the pitch, but could see perfectly. Yale never had a look-in, and suffered their first defeat of the season. Rather bad luck, as it was the last and most important game. Football stops now, probably owing to the imminence of winter, or perhaps because all the players get used up just about now. A snowstorm came on and lasted all through the second half. We buttoned up our coat collars and stuck it like Spartans; many of our companions drank whisky as well and became steadily more partisan. (Even girls take their spirits "straight.") The game, unlike the previous one, was quite interesting, and included a lot of open play. The Harvard team were
magnificent, making their
10 yards time after time, and their two scores were beautifully clean. Yale relied too much on brute force, and came off very much second best. They were lucky to escape with their 13-6 beating. The significance of university football is rather difficult for us to understand. The seats are quite expensive, and the game may be played before anything up to 80,000 spectators-very much like our professional games. Whether the money goes to the university, or the football club, or into some special fund I don’t know, but I gather vaguely that it is almost essential for a university to have a first-class team and that some people think it is not all for the best. *
It is
*
*
coincidence that on the same day as writing up good football match I have also to report a proper tea. We went to H--’s this afternoon, where " pouring out " was done in the good oldfashioned way. All the departmental wives were there, the husbands dropping in by ones and twos. We sat round the apartment and yelled at each other until it was time to leave, happy but exhausted. Marjorie was quite one of us, and solemnly produced a little basket she had made at school and passed round pea-nuts ! As a matter of fact, I find that tea is not quite so unknown here as I thought. Two or three people make it in their labs, and in a tremendous lounge in the medical school there is a daily function, presided over by wives of prominent members of the teaching staff, at which tea is dispensed from silver urns and" cookies " distributed. The only unEnglish features about this are first, that it is free, and secondly that it is free to all-staff, students, and nurses. I believe it is unique, and not a national a
a
custom. *
Nov. 29-Last
cleaning
out
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I spent all morning in the afternoon we and cages,
Wednesday
mouse
*