Brigade Marocaine Ambulance n° 1 M et Prenons Ahmed bin Itforlani Numéro matricule 6902 Infection de serum antitetanique" faite le 22/1 1915Morphine - Cafecue. Diagnostic Blessé le 22/1/15 Pansé le 10) Place pénétrante de poitrine Pas d'orifice de sortie To Place du pied droit. Orifice d'entrée : & constrictes au dessous de la malliole interue. Orifice de sortie: Au milieu de la plause du pied. FIG. 2. FIG. 3. American ambulances receiving wounded at Compiègne. meet an automobile, save occasionally some military car or motor-cycle, tearing along at forty, fifty, or even sixty miles an hour. Nothing impresses one as much as the complete absence of motors and of men of military age. If you see one in citizen's clothes you always look twice to see what he is and why he is there. leaves the town in which he holds his permis de sejour. At Juilly a great number of cur cases were bullet fractures and severe wounds, not involving the body cavities. The peritoneal wounds, etc., stayed further front, while the minor injuries went further to the rear. Naturally, however, we had a few of both the more severe and the lighter type of wounded. A short time before I left Juilly I had in my ward of 50 beds, 25 bullet fractures, 1 brain abscess, 2 penetrating wounds of the abdomen, 4 penetrating wounds of the chest, and 1 septic knee joint, as well as several flesh wounds, closed fractures and severe sprains. Most of the wounds were caused by shell or shrapnel, with about 15% from rifle balls and a few by hand grenades. I saw only one bayonet wound and no sabre cuts. Shell fragments and shrapnel almost always become septic, usually from the presence of clothing carried in by the missile, and the removal of the dirty, sodden mass of wool is probably more important than that of the missile itself. We found that it was of the greatest importance to examine the clothing wherever possible, in order to find out just how much we had to search for. Every case was x-rayed at enOne rarely sees soldiers, except a certain num- trance and if it was deemed advisable the missile ber ploughing or lounging about the villages. was often localized later under the fluoroscope or There are no great camps, as the men are all bil- by triangulation with two plates taken at different leted on the villages or housed in barns, store- angles. Taken altogether, it seems to me these houses and the like, and this, I am told, is true cases were chiefly of interest, not from an operall through France. Later I did see a few ative point of view, but as a constantly changing camps back of the English lines, but nothing problem in immobilization and sepsis, although to what I had expected. Along all the railroads the nerve injuries were only slightly less in imand on every bridge were guards, usually older portance. Nearly all the shell and shrapnel men of the reserves, clothed in blue coats, but- cases were septic, and a moderate number toned back and the red trousers which have been immortalized by Detaille in his battle pictures of the Franco-Prussian war. It always seems to me that these old men, who do nothing but guard duty from one month's end to the next, have about the most miserable existence possible for a soldier. They are always keenly on the job, how ever, and you know when you see one step out to the middle of the road ahead of you and raise his rifle horizontally above his head at arm's length, that it is time to stop and have passes examined, or give the mot. As this happens every few miles it is easy to see that the passless motor will not get far. showed clinically the presence of gas bacillus. It seems to me that this infection as a rule was less virulent in France than the few cases it has been my lot to see here at home, free incision almost invariably giving good result. It has been said, and I believe correctly, that the gas bacillus varies tremendously in virulence, and that if carefully sought for, can be found in 90% of all shell and shrapnel cases. Clinically the case of gas infection is unmistakable.-a dirty gray wound discharging rather thin brownish gray pus, mixed with bubbles of gas, skin around the wound showing a pinkish brown discoloration, later turning to purple or Naturally passes are not given out freely, and chocolate, often, but not always, with fine crepto get one it is necessary to go to the headquar- itus beneath. There is always a peculiar, unters of the army in whose zone you wish to pleasant odor to the pus and moderate elevation travel, state your business and then, perhaps, of temperature. At the suggestion of Dr. Allan you will get the necessary document. Passes for ambulances on a fixed route or in a definite area are given out for two weeks and specify the military number of the car, name and number of the driver, and name or occupation of the passenger (doctor, litter bearer, etc.). No passes given by the headquarters of one army are good in the territory of any other. Travel of all sorts is dis- The immobilization of these fractures, which couraged, and passes issued by the civil or mili- are usually complicated with one or two distary authorities are required whenever one charging wounds, forms a difficult problem, and Hervey, who had put in a good deal of time in Switzerland, we exposed a considerable number of septic wounds of various sorts, including the gas infection, to graded doses of direct sunlight, beginning with 10 minutes a day, with very gratifying results, as I do not remember a single case that did not improve under this treatment. Septic fracture of both bones of forearm. we found that plaster, either in the form of a bivalve or else with large bows of plaster built over wire netting, was usually the best. In a certain number of cases, particularly badly comminuted fractures of the femur, a Steinman pin is most useful and is less painful than any other form of traction dressing, while Dr. Joseph Blake's modification of the Thomas splint is also extremely valuable. We did no bone plating, as we did not deem it advisable to open new tissue and traumatize uninjured bone in the presence of severe sepsis, and it should always be remembered that to immobilize successfully in the presence of extreme comminution it is necessary to use a very long plate, thus opening up a very large area for new infection. Fig. 5. Comminuted fracture of elbow with gas bacillus infection. of shell and shrapnel ball, which did not involve the body cavities on account of the great danger of sepsis, and I feel, as these operations are usually slight after the missile has been care. fully localized, that such a procedure is justifiable. I do feel very strongly, however, that prolonged search with opening up of much uninfected tissue is far more dangerous than a retained ball. Wounds of the knee joint are not uncommon, and are among the most trying which one has to treat. In the Spanish-American war, and in the Russo-Japanese war, the results in these cases were much better than in the earlier wars, owing to the use of small calibre bullets and antiseptic surgery, but in the fighting in France conditions have changed again, and owing to shrapnel and Our usual procedure in a fracture case was to shell fragments, the old conditions are more put on traction and do nothing to the wound, nearly approached. This is true more or less in not even remove the bullet, unless the patient regard to all wounds, and it may be said that the developed sepsis, when the abscess was opened, war surgeon now has the problems of those old and bullet, clothing and unattached bone days. A septic knee joint is a terrible injury, cleaned out as far as possible without opening and almost always leads to permanent disability up any new area. Loose bone fragments at- or even death. We found that light traction tached by periosteum we always left in situ, as helped greatly to alleviate the pain, particularly such fragments make a good trellis for the formation of the callus. when the wounds were dressed, and I believe that suction drainage, which was suggested by Fractures of the long bones by rifle bullets, al- Dr. Carrel is of benefit, although my experience though often very extensive, usually remained is too limited to speak confidently. I remember clean, and we found it was necessary simply to very distinctly the suffering of one Moroccan paint the wounds of entrance and exit with Tr. whose patella had been shattered by a large Iodi and treat them as closed fractures. Of shrapnel ball. I sutured his patella and removed course, in a certain number of cases where frag- the ball and hoped vainly for a clean result. ments of bone had been driven out through the Low lateral drainage finally resulted in a cure skin it was necessary to remove some of the loose of the septic process and the patella held. When pieces. Retained rifle bullets were rare, and I left he could flex his knee about 15 degrees and usually could be left without danger to the pa- had far better function than if the quadriceps tient. If the bullet had "upset" and small frag- had been lost. ments were lying beneath the skin, we made a practice of removing them, but as a rule these did not become infected. In some of the recent articles I have noticed that the writers advised leaving all retained fragments, both bullet, shrapnel and shell, unless they cause abscess formation. We usually removed large fragments was uniformly good. As I have said before, the French policy is to keep the most severe type of cases near the front, and the fact that we had only three deaths at Juilly during the time I was there tends to show that the judgment of the French surgeons at the front, both as regards diagnosis and prognosis, It was my good fortune after leaving Juilly to spend three weeks in a first line hospital, and during this period to get a little glimpse of the French soldier, and the life immediately behind the firing line. Mr. and Mrs. C. M. Depew have given their chateau, which lies only three miles back of the first line trenches, as a hospital under the auspices of the British Red Cross. Nothing has been omitted which can add to the comfort or well being of the wounded, and yet, as is proper in a first line hospital, expensive and unnecessary equipment has been reduced to a minimum. One wing has been given over to hospital purposes, and the family, doctors, etc., live in the rest of the house. noeuvres. On my way home I was able to spend a day at Boulogne and so to compare the French and the English. Boulogne is now a city of hospitals, It seems very unreal to live a quiet, peaceful, and everywhere you turn you see hurrying amcountry house existence, with the trenches so bulances, men in khaki, and Red Cross flags. In close that rifle and machine gun fire is distinctly the town itself are many hospitals (I think fifteen audible, and where one can, by going to the end in all) including the Casino and all the largest of the park, watch the French shells bursting on hotels, while all through the surrounding counthe German gun positions if the artillery is fir- try are others, some under canvas, while others ing. To me, perhaps, the most interesting part are in hotels, factories, etc. The work in the of this experience was the more intimate relation English hospitals seemed to be of a very high into which I was thrown with things military grade and in most respects similar to the French. and the French officers. There were few days Two differences struck me, however, one that the when we did not see scouting areoplanes under seriously wounded were being sent back from fire, either French or German, and we soon the first line more rapidly than among the learned to recognize the German shrapnel bursts French, the other that there was more specializaby the slight violet tinge to the white smoke. An tion, one man doing all cranial work, and so on. aeroplane at two thousand yards elevation makes It was impossible for me to go to La Panne to but a small mark, and though the gunners seldom see Dr. Depage and his work, owing to lack of bring one down, the continuous firing keeps the time. Dr. Depage and his wife, who met her plane so high in the air that accurate observa- death so tragically on the Lusitania, meant a tion is difficult in the extreme. I have seldom great deal to us here in Boston, and my inability seen a more striking picture than one of the to see him was one of my bitterest disappointgraceful German Tauben silhouetted against a clear blue sky with around and behind it thirty or forty round fleecy puffs of smoke left by a bursting shrapnel. The cases seen were not unlike those we had at Juilly, except for the larger percentage of severe cases, some of which were moribund when ments. endeavoring to summarize in my own mind the In looking back on the past four months and surgical impressions I received, I think they fall as follows: 1. Gun shot wounds do best if let alone as brought to the hospital. It gives a greater sense much as possible, unless there is some direct inof reality to see these poor fellows brought in dication for interference. 2. All war wounds except those caused by bullets which do not "upset" will almost certainly go septic. 4. Military surgery is so different from civil surgery that those of us who would expect to serve, were this country to find itself at war, 3. Gun shot fractures, even if septic, show should have some definite training to fit us for remarkable powers of repair. our duties. THE COMMON SHOULDER INJURIES. BY EDW. H. RISLEY, M.D., F.A.C.S., BOSTON, Assistant Surgeon to Out-Patients, Massachusetts General Hospital. [From the Out-Patient Clinic of the Massachusetts General Hospital.] It seems advisable from time to time that certain regions of the body should have their pathology and the end results of treatment studied or reviewed in order that our knowledge of the subject be brought up to date and certain obscure lesions further studied and have attention directed to them. For the past two years it has been the author's privilege to have seen practically all of the cases of shoulder injury or disability treated in all of the rooms of the out-patient department of the Massachusetts General Hospital. These cases have been seen either directly in the two surgical rooms or by courtesy or consultation in the nerve, orthopedic or other departments of the out-patient service. In all some 450 cases have been seen and treated. A review of these cases is here presented with the especial desire to direct attention to the socalled trivial injuries to the bones of the shoulder joint and to emphasize the fact that often seemingly trivial or slight bone injury may be productive of very painful incapacity of long duration. The author also wishes to emphasize the importance of early diagnosis and the payment of due respect, as trouble-makers, to such lesions as are ordinarily regarded as of minor importance, particularly such as injuries to the acromion and the greater tuberosity of the humerus and lesions of the acromio-clavicular articulation, all of which have formerly received scant attention. The majority of shoulder disabilities are, of course of traumatic origin. This paper will not deal with arthritis except of traumatic origin, nor with diseased conditions, such as tuberculosis, but only with disability due directly or indirectly to trauma. One very noticeable fact in this review is the great rarity of injuries to the brachial plexus. I think it can safely be said that nerve involvement in shoulder injuries is noticeably rare. Brachial plexus injuries occur only after great violence and rather more often in connection with dislocation than with fracture about the shoulder joint. The shoulder joint, with its ample protection by large muscles, the laxity of its capsule, not allowing of extreme tension by effusion into the joint, and because of the influence of the weight of the upper extremity in the usual hanging po |