The management of air-raid casualties

PUBLIC HEALTH the functions of gardener and porter was found to be essential. General

Administration

This was placed in the hands of the County or County Borough Council. T h e arrangement had the double advantage of bringing the homes directly under the welfare authority and of utitising the central office machinery for co-ordinating all the homes within each county. The County or County Borough Medical Officer of Health was therefore in administrative charge of the homes in his area. Antenatal care was provided at clinics held in hostels, emergency maternity homes or at local welfare centres. For those mothers billeted some distance from the centre arrangements were made for antenatal care to be carried out by the district midwife. The duration of stay of patients in the maternity homes was not less than fourteen days. So far as could be foreseen only normal cases were admitted to the majority of the emergency maternity homes and the confinements were conducted by midwives. Gas-andair analgesia was provided at homes where midwives with the necessary qualifications were available. Complicated cases were not usually dealt with in the emergency maternity homes, but were admitted either to a hospital or to a central emergency maternity tome especially equipped as a maternity hospital, where the patients could be under the direct care of a resident medical officer and the obstetric consultant. Cases of puerperal sepsis were dealt with under the peacetime arrangements--e.g., at an isolation hospital or a special unit in a general hospital. Each home, in addition, had an isolation room, the details of which are described above, in which cases of puerperal pyrexia could be segregated for observation. A factor helping to reduce the incidence of sepsis was the linking up of the various homes within the Region in order that n o o n e home should at any time be overcrowded.

Antenatal Hostels As billets were often not available near the maternity home, particularly when large numbers of people began to arrive in the reception areas as a result of intensification of bombing, it became necessary to set up antenatal hostels. The hostel had to be near the maternity home to which it was attached, and here local circumstances varied from district to district. In country districts a journey of even a few miles at night might prove a hazardous undertaking. It had also to be borne in mind that such hostels were in general uneconomical if accommodating fewer them ten beds. In most cases a large dwelling house was chosen, since this supplied all the facilities required and needed little adaptation. It was, however, necessary to pay particular attention to fire precautions. Wherever possible a resident midwife was appointed, or, if n o m'dwifc was available, a competent housekeeper, and arrangements were made for a nearby midw;fe to be o n call. The hostels were run on communal line.% the mothers themselves doing light work and daily workers the heavier work. These hostels were under the control and supervision of the welfare authority.

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JULY Postnatal Hostels After confinement every effort was made to retain the mother and her infant in a reception area, either in billets or in a postnatal hostel. The need for these hostets was not felt until the evacuation scheme had been running at full force for some time and the billeting position in the various reception areas had become difficult. In a number of instances these hostels were set up by the local billeting authority and subsequently brought under the control of the welfare authority. The general arrangements made were similar to those at antenatal hostels, and staff experienced in infant care was appointed. Particular attention had to be paid to the provision of adequate washing and drying facilities, and food and milk storage.

Summary

'~

From the outbreak of war to December 81st, 1940, 5,489 mothers were confined in emergency maternity homes set up in reception areas in a civil defence region. An account is given of the arrangements for evacuation of expectant mothers and the procedure followed in the setting up and administration of the emergency maternity homes and associated hostels. Our thanks are due to Miss Nield and Miss Pearce for their help with this paper.

THE MANAGEMENT OF AIR-RAID CASUALTIES* By W. H. GRAHAM JESSOP, M.D., M.CHIR., F.R.C.S. May I begin by saying how much I appreciate the hononr the Society has done me in asking me to deliver this lecture. I must confess to being rather puzzled when I received your Secretary's invitation to find a common topic of interest between surgery and public health. But on reflection the solution of the problem proved fairly easy, since we all may perhaps have a personal interest in the fate of at least one air-raid casualty. So I thought that a discussion of the management of air-raid casualties, mainly from the surgical aspect, must have points of interest for the M.O.H., and I have therefore chosen this title for m y lecture to -night.

Analysis of Cases Since last August I have seen some eighty air-raid casualties admitted to hospital and have detailed notes of some fifty-nine of these. It might be of value to give an analysis of these cases and subsequently to discuss more generally the whole problem of the management of the injuries sustained. The fifty-nine cases may be classified into the following four groups : GRouP 1. Requiring immediate operation .,. 2 cases. GRouP 2 (a). Severe shock; resuscitation; major operations ... 12 cases. GROVP 2 (b). Severe shock; resuscitation; n o operation

. . . . . . . . . . . . . . . . . .

1 case.

GROUP 3. Requiring major operation only ... 4 cases. GROUP 4. Mild shock and injuries requiring n o operation or minor surgery only ... 37 cases, and 3 cases of burns of hands and face. TOTAL 59. * An address to a Branch of the Society of M e d i c a l Officers of Health.

1941

PUBLIC HEALTH GROUP I

responded in due course to morphine, warmth, and, in most instances, transfusion of blood or plasma. Of the two cases in Group I requiring immediate There was one case of severe head injury--a fissured operation the first was a student who sustained a penedepressed fracture of the vault in a boy of about 7 trating wound in the right side of the neck. On years of age. He seemed unlikely to survive on adadmission he was found to be deeply shocked and mission and operation was not at first contemplated. was unconscious. Air and frothy blood were blowing However, the following morning he had recovered very out of the wound in the neck, and it was clear that the well, so the scalp wound was excised and the fissure air passages had been penetrated and opened and that bevelled off. Fortunately the dura had not been peneblood was producing respiratory obstruction. Immedi- trated and he made a complete recovery. There ate operation was undertaken. The wound was exwere two cases of penetrating wounds of the abdomen plored, and it was found that the right thyroid ala sustained during the same raid, both in healthy adult had been shattered and the trachea opened below men who were admitted almost simultaneously. In the this level. The wound was excised, packed with sul- first there was a wound of entry just below the left phapyridine powder, and closed round a tracheotomy costal margin, about 1 in. in diameter, through which tube. The patient never rallied and death occurred a a tongue of omentum protruded. Shock was not few hours later. It was noticed that he developed marked and "laparotomy was undertaken about an hour a distended abdomen with shifting dullness, and it was after admission. Two small perforations were found quite possible that he had a ruptured liver or spleen, in the anterior wall of the stomach ; these were closed in addition to the other injuries. and the wound in the abdominal wall was excised and The second case was that of a young married woman a drain passed through it. Recovery was uneventful who received a perforating wound of the left side of apart from a small incisionat hernia. The second case the thorax. A piece of light metal bomb casing about was very similar, except that the wound in the abdom4 in. by 2 in. entered the thorax below the left angle inal was was more extensive and was closed with of the scapula, passed through the left lung obliquely some difficulty. In this case, too, there was a double upwards and forwards, and came to rest projecting gastric perforation. In neither case was a missile from the front of the chest just below the clavicle. found akhough there was no wound of exit. The wound of entry was somewhat oblique and a A rather bizarre case was that of a well-built young section of one rib was de3troyed. The lung was col- lad of 18 who came in shocked, vomiting, retching lapsed and the pleural cavity partly filled with blood. more than usual, and with some-abdominal rigidity. There was a wound at the posterior surface of the We eventually found a small penetrating wound of the lung about 1 in. by ½ in., through which air blew and scrotum at the bottom of which was a small piece sucked during respiration, rushing in and out through of bomb casing Although it was a comparatively the gap in the chest wall at the same time. The edges trivial injury, the general effects had had all the severity of the anterior wound were " baked " by the hot metal which might have been anticipated from this very for a depth of ½ in. or more. The patient was only unsporting blow. A much more serious injury in moderately shocked and was sent straight to the theatre this region was sustained by a youth who was after sorting. The chest wounds were excised, the rent struck by two fragments, one of which, entering in the lung sutured, and the chest closed without drain- through the scrotum, completely divided the penile age. The general condition rapidly improved after urethra, whilst the second, producing a small wound the first few days; an effusion into the pteural cavity of entry on the buttock, extensively disrupted the cleared up completely in three weeks ; and the patient gluteal region and just failed to penetrate the rectal was able to leave hospital some nine weeks after the mucosa. incident. W i t h the exception of a single severe scalp wound Although these two cases were regarded as requiring with cerebral contusion, the remaining patients in this urgent operation, I think we should have been a little group were all cases of limb injuries. They all had more thorough in the examination of the whole patient extensive laceration of the soft parts, but in two there in the first instance, as the discovery of other lesions was considerable skin loss but no bony injury, and likely to have caused death might have obviated a use- in two others a comparatively small skin defect and less operation. In the second case early closure of the also a fracture. chest wall was very desirable to diminish both cardioOur treatment for all the cases, after resuscitation, vascular and respiratory distress. Had shock been was to carry out thorough wound excision, enlarging severe the usual resuscitation activities could have the skin defect when necessary, to pack the wound been carried on at the same time. with a sulphonamide powder, and to apply an adequate piaster cast. Pre-operative X-ray films were always GROUP 2A asked for, and we found them invaluable for determining the presence of a retained foreign body. The twelve patients in the second group who needed major surgery after resuscitation for severe shock form a GROUP 2B very diverse collection. They were all deeply shocked The single case which I have classified as having on admission, lying very quietly in bed, and showing severe shock necessitating resuscitation but not requiran ashy-grey pallor, a feeble pulse, a clammy skin, and, indeed, the whole classical picture of shock. ing major surgery was that of a heavily built m{ddleOperation could not be undertaken in most of them aged man with an emphysematous chest who was for from two to ten hours after admission, but all found to have a pneumothorax and fractured ribs.

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JULY

PUBLIC HEALTH GROUP 3 Of the four patients for whom major surgery was necessary but who showed little shock, one had a non-penetrating wound of the abdominal wall and another a compound fracture of the tibia. The remaining two cases presented some features of special interest. As I have said we always ask for pre-operative X-ray examination, but during one raid the electric current was interrupted and the plant put out of action for several hours. During this time several patients were operated on, and in nearly every instance a small retained foreign body was missed. One man had a small penetrating wound on the outer side of the calf. In due course a radiograph showed a fracture of the fibular shaft with a piece of bomb casing embedded there. This was removed, but sepsis supervened owing to the delay. In a second ease a small piece of metal was found embedded in the patella. Fortunately in this instance the wound remained clean. A secondary suture after removal of the fragment was successful. GROUP 4 The fourth group, containing the greatest number of cases (forty in all), included mostly examples of mild shock and abrasions, small cuts and lacerations, closed fractures of the more peripheral limb bones, multiple small uncomplicated penetrating wounds, and so forth. There were also three, cases of burns of the hands and face in which ~hock was not severe enough to require special resuscitation. Such, then, are the fifty-nine cases of which I have detailed notes. They represent a fairly random selection of air-raid casualties, although of course the series is too small to be fully representative. It contains, for example, no cases of blast effect or of crushing injuries of the limbs with renal failure. The actual distribution of the injuries is rather instructive. Of the serious cases, there were but two head wounds, one chest wound, and two abdominal wounds; in the remainder the wounds were confined to the limbs. This has, of course, been frequently noted in war surgeD' and is to be expected.

Types o~ Wound The wounds seemed to fall into three main types: (1) There was the extensive lacerated wound due to crushing, probably by falling masonry or possibly by the patient's being flung violently against a rough surface. (2) There was the penetrating wound made by a small high velocity projectile. This was the most interesting and in some ways the most important. The skin defect was usually about ~ in. to 1 in. in diameter, sometimes less, and could easily have been passed over as trivial. The deeper structures, however, were very extensively lacerated, especially in the region of the shoulder or buttock, and were deeply contaminated. Alternatively some unsuspected complication such as a fracture was present (or, in the case of an abdominal wound not included in this series, seven perforations of the small gut). The extensive damage is due to the great energy available, since these particles, although very light, travel very fast and "½m.v. ~'' is correspondingly great. The importance of these injuries lies in the possibility of

184

their seriousness being overlooked by anyone not familiar with them. (3) Lastly, the majority of eases present features similar to those seen in everyday traumatic surgery and require no special comment. The subsequent course of most of the patients has been very satisfactory. Those with limb plasters have been free from pain and in good general health throughout, whilst all have picked up rapidly once the initial shock has been overcome. Sequelae have been few. So far we have had no eases of gas gangrene, which we prefer to attribute to the treatment rather than to the nature of the local dirt. Bone infection has developed in only one ease and the main problem has been to cover the large clean granulating areas which develop under the casts. One patient is, however, worthy of special mention. She was a youn~ girl of good family and above average intelligence who was taking a course to become a physieal training school-mistress. Her first experience of bombing was in a village when a nearby house was demolished. A few weeks later she came into town one evening to see the ballet, and being unable to get back home stayed the night with a girl friend. A single stick of bombs was dropped across the neighbourhood and she was in a badly damaged house. She sustained extensive lacerations of the soft parts of the left arm and forearm with wide skin loss but no fracture. After admission and resuscitation, wound excision was carried out and a east applied. When she had settled down it was found that she had a complete ulnar and a partial median nerve palsy. In a few weeks attacks of severe burning pain in the median distribution with a progressive hyperaesthesia were diagnosed as being causalgia. This is a troublesome complication of partial lesions of the median and sciatic nerves, and was first re eognised in the American Civil War. The symptoms are usually severe enough to demoraiise the patient, and this occurred to some extent here. Matters were not helped by a further "incident" which took place whilst she was in the hospital. Some bombs were dropped close by and the windows of the ward were blown in. However, we got her safely away to the country for a couple of months (and incidentally remained raid-free here). She was brought back with the eausalgia very much less severe --and a shower of incendiaries were dropped in the grounds of the hospital the following night. The interesting surgical point is that the causalgia should have undergone a further striking spontaneous remission when the patient herself got a little peace and quiet. The great majority of patients cease to attend the out-patient department soon after discharge, and only half-a-dozen or so persist in coming up for their compensation papers to be signed. Certainly the compensation neurosis has not yet developed as freely as in civil practice, I think.

Principles of Casualty Service Such then is the general nature and course of the cases we have had in hospital. I should like to turn now to the broader questions of the management of air-raid casualties in general and review some of them in the light of these findings. I can claim no practical experience of these aspects and merely put them forward rather tentatively for your comments,

1941 I think we may take it that the general principles of treatment for each individual must be to save life, to preserve function, and to ensure the most rapid and painless return to a normal existence. It is desirable that every casualty should therefore have the best possible treatment right through from the moment of injury to the end. The problems which are involved as I see them are therefore fourfold: the management at the site of the incident; the transport to hospital; the procedure in hospital; and the after treatment. The management at the site of the incident may be conveniently discussed first. There has been some controversy as to how much sorting should be done at this point, as to what is essential and what superfluous in the first-aid, and as to whether a doctor should be present at each incident site. As regards the question of sorting, it seems desirable to me that all patients should go to hospital, at all events on the scale of casualties we have so far experienced. If any are sent home or detained at a first-aid post, then a certain number will be wrongly disposed--mainly cases of wounds with small high velocity fragments, leaving small apertures in the skin but with serious damage in the depths; and cases of small lacerations, especially of the scalp, where an underlying fracture of the vault may have been easily overlooked. No doubt the risk would be minimised if an "incident doctor" were present, but I do not see how it could be overcome under the conditions likely to prevail at the site of an incident. I have already given two examples of apparently trivial wounds with underlying complications. Here is a third. The stoker of a tug boat had just come up on deck for a " breather" when a bomb struck the water close by. He felt an apparent blow in the chest and was dazed for a moment, but soon recovered and was apparently all right. However, he was brought to hospital and we found a tiny skin wound over the lower part of the back of the chest on the right side. A radiograph showed a small bomb fragment in the right lower lung and a rather extensive opacity in this lobe. The latter eventually cleared up and was probably due to haemorrhage, but was rather an unexpected finding in view of the apparently trivial nature of the injury. The amount of first-aid treatment necessary in most cases is small; warmth and rest and the relief of pain are desirable for all. The arrest of haemorrhage, preferably by a pad and bandage, the covering of wounds and of burns by a sterile dressing, and the application of splints to the limbs, more or less exhaust the list. In our own series the laryngeal wound required a similar dressing to that advised for cut throats in the first-aid manuals. For the sucking pneumothorax a firm pad and bandage had to be applied over the wound, and the same was necessary for the abdominal and scrotal cases. The limbs required simple dressings and orthodox splinting. Nothing elaborate is practicable or should be attempted, and I must say I have been very favourably impressed by the efficiency, of the first-aid on those cases which I have seen come m. As regards burns, my own view is that an ordinary sterile dressing is the best thing for cases that are sent to hospital, since cleansing and the application of coagulants will in any event have to be carried through from

PUBLIC HEALTH the beginning again there. The question arises whether anything more elaborate should ever be undertaken at the site of an incident. It would seem that the necessity could arise only in special circumstances, as, for example, where people are trapped and partially accessible, so that morphine, dressings, and even transfusions, are desirable. But such instances must be rare. Certainly the best thing is to get all cases needing wound surgery to hospital as rapidly as possible so that shock may be treated and wound excision performed within six hours of the incident. This brings me to the question of the procedure in hospital. This is, I think, pretty generally standardised now. Admission should always be to a large, well-lit, and well-warmed sorting room, where somebody who knows the work--i.e., a fairly senior surgeon and/or physician with plenty of assistants--can go round and decide on the disposal of each case. This has been done at the hospital by the R.S.O. or someone of similar standing. The patients are given A.T.S. as a routine and morphine and A.G.S. where indicated. Casualties have been divided into the dead; the dying; those requiring urgent operation; those requiring resuscitation to be followed by major surgery or not; those requiring major surgery; and those mainly requiring rest and warmth with or without minor surgery when things get quieter. Apart from the first two categories, about a third of the patients needed major surger~r or half major and minor surgery. The average time taken by the wound excisions and laparotomies, exclusive of the application of casts, was about fifty minutes, so that seven cases represents the limiting number which can be dealt with by one surgeon within the optimum period, and also about the limit of personal endurance. The saturation point for the hospital is thus about fourteen to twenty cases per table and team, if half or one-third of the casualties need operative treatment. The number can be raised by about 25 per cent. if the plaster work is done by plaster nurses away from the operating table, each case being transferred for this purpose to a plaster room after wound excision has been completed. If the number of cases exceeds this quota the value of sending further mobile surgical teams may be considered. My only personal experience of this procedure was to go away once as a member of a surgical team. We had a rather lengthy and uncomfortable journey and arrived to find the local staff exhausted, as was to be expected. We took no equipment and found that available rather inadequate and, of course, unfamiliar. We did not know their theatre routine or arrangements, nor the position of the wards. We also made the mistake of not seeing our patients before they came to the theatre, which I now regard as an imperative duty on the part of a surgeon. So we treated about six cases rather inadequately, and I do not think our trip was of much value. No doubt we should have done better to take equipment and also sufficient dressers to act as porters and plasterers to relieve the local staff of all responsibility. But the alternative of moving patients to surgeons seems worthy of serious consideration. Lastly, a word may be said about after treatment

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HEALTH

and disposal. Most bombed patients are rather jumpy in subsequent alerts, and the early evacuation of as many as possible to peripheral hospitals appears to be good policy, both for the individual and the organisation of the initial hospital in the target area. The great majority are fit to travel in twenty-four to fortyeight hours or so, and only a few of the serious cases need to be left in the initial hospital under the direct care of the operating surgeon for a longer period.

Summary l. Fifty-nine air-raid casualties seen personally have been analysed into four groups: (1) Requiring immediate operation (two cases); (2a) Severe shock requiring resuscitation followed by major operation (twelve cases); (2b) Severe shock requiring resuscitation but no operation (one case) ; (8) Requiring major operation only (four cases) ; (4) Mild shock and minor injuries (forty cases). 2. An account of these cases is given. Wound excision within six hours, a sulphonamide pack, and for limb cases a plaster cast, have given uniformly favourable results. 3. It is suggested from this experience that ideally all cases from an incident should go to hospital. Firstaid treatment is confined to treatment of shock, wound dressing, and adequate splintage. The possible seriousness of small skin wounds due to high velocity fragments is emphasised. 4. Saturation point at hospital is fourteen to twenty cases per team. Beyond this limit it would be preferable to switch cases rather than to send out mobile surgical teams. My thanks are due to my chief for permission to refer to cases under his care.

PRECAUTIONS TAKEN TO PROTECT LONDON'S WATER SUPPLY* By LIEt~T.-CoLONELE. F. W. MACKENZIE,M.B., D.P.H.,

Director of Water Examinatiotl, Metropolitan Water Board The water supply of London is derived from the Thames, the Lea, and from wells. The well waters are, generally speaking, easily purified, and the only additional war measure which has been taken has been the application of chlorine treatment to all well supplies. It is most unlikely that gross pollution will gain access to a well unless the pumping machinery is put out of action.

Pollution of River Water Supply The river waters are heavily polluted, and the main lines of defence against pollution before the war were : (a) Storage in reservoirs; (b) Filtration through slow sand filters ; and (c) Terminal chlorination. It was anticipated that the effects of aerial bombardment upon these processes might be : - (1) Damage to reservoirs or to machinery which pumps the water up to them, or to aqueducts which carry the stored water to the slow sand filters, any of which might result in the loss of * Abstract of an address delivered to the Metropolitan Branch of the Society of Medical Officers of Health, 186

JULY the important safeguard effected by storage. (2) Damage to filter beds or to conduits which might permit unfiltered water or subsoil water to gain access to filtered water channels. (8) Pollution in mains or service reservoirs from simultaneous damage to drains or sewers. (4) The deliberate pollution of water supplies by chemical poisons or bacterial cultures introduced by enemy agents or dropped from aeroplanes.

Pre-Chlorination Pollution by loss of storage or by damage to filter beds has been guarded against by chlorinating the water before it passes on to the filters. By this means it has been possible to bring the water supplied to the works to a stare'of high bacteriological purity before filtration. The high degree of protection which this procedure gives has already been amply demonstrated. This " pre-chlorination," as it has been termed, has also provided a safeguard against interconnection between raw water and filtered water channels, but it does not protect against the infiltration of ground water into broken filtered water channels. This has, however, been satisfactorily covered by increasing the terminal dose of chlorine which is administered to the water before it is passed into supply. The increase in the residual chlorine passed into supply, which may at times be objected to on account of the taste which has been inseparable from this procedure, also provides a considerable degree of protection against the deliberate introduction of bacterial pollution by enemy agents directly into the mains or into service reservoirs, and against any failure to effect complete sterilisation of broken mains before they are put back into supply as a result either of physical difficulties, which often exist, or of failure on the part of the human element.

Protection of Works and Reservoirs The introducEon of chcm'cal po',~on~ into the water has been countered by a system of guards at works and reservoirs, and by arrangements which have been made for immediate testing at the works for poisons should there be any suspicion that the water may have been tampered with. The results of these tests would be confirmed as rapidly as possible by samples analysed in the laboratories, where a staff of sample collectors and chemists are on duty day and night. In addition to this, a daily examination for poisons in the water is made on samples representative of the contents of every pipe passing water into supply from the filtration works. In order to minimise the possibility of the breakdown of chlorinating apparatus at the works the chlorination houses have been strongly protected against damage by blast, and in many cases new and specially designed chlorination houses have been constructed. Duplicate chlorinating points have also been provided by means of which it is possible to reestablish chlorination with the least possible delay should instruments in use be damaged. The most serious danger is that which results from the fracture of mains in close proximity to sewers. Protection against this has been provided by laying down that no main shall be put back into supply after