l Volume OCTOBER II 1918 Number 3 WAR MEDICINE Biological * Medi Wia Published Monthly by theAmerican Red Cross Society in France for the Medical Officers of THE AMERICAN EXPEDITIONARY FORCES ditorial Offices : 2, place de Rivoli, Paris, Rooms 422-425 CONTENTS RESEARCH SOCIETY REPORTS — SURGERY. SUMMARIZED REPORT OF THE CONFERENCF ON SUR- ACGUETREYRIENSPBIARTATTLOERYARIENFAESC,TILOeaNdSe.r,—Lt.-Colonel G. w! Crile CONSIDERATIONS IN THE PREVENTION OF RESPIR- ACAUTTOERYREASFPFIERCATTIOORNYS,INCoFlEonCeTlIWO.NSW.AOM.OBNeGverTiHdgFe COLOr'- 3oo REESDPITRRAOTOOPRSY IINNFTEHCETIFONRSENICNHTAHREMY,AMMEaRloIrCABNoreEXPFD- 3o6 IITONARY FORCES, Major Haven Emerson ADICSUCTUESSRIEOSNPIRATORY INFECTIONS, Major H.Zinsser.' ' " ' 31(; Col. P. B. Soltau, Col. Cummins, Major Borel' Ihaver, Col. Beveridg—e, MajorEmerson, and General BurtciheCloll*. FIELD SANITATION. METHODS OF FECES DISPOSAL AND FLY PREVENTION INN TTHHEE FBRRIETNICSHH AARRMMYY,, MMeadjeocrinF-.MaP.joJrosOccetlayvnee.Monqd ' 3\-'4S IN A DIVISION, Colonel J. W. Gres.^inger . IN A BASE SECTION, . . . D^UCuAIMINS MaJ°r Z'NSSELRt.'-CGoalp.t-IIM. °CS.S'CoCbouLrnS.,LE'.R> ^aJ"r ^,ST> 3V, NOTES FROM THE FIELD SERVICE SCHOOL - CONVALESCENT CAMPS, Colonel Bailey K. Ashford — ABSTRACTS Surgery. Surgical Shock andSome Related Problems,J. E. Sweet p BloodGroupingAppliedtoSkin Grafting,Capt.H.K. Siiaww. p." Alkali and Hypochlorite Solution in the Treatment of War Wounds, Noel Fiessinger and Rene Clogne. Treatment of Gangrene Infection, L. Ombredan.ne. p. CSaurrrgyeirnygooffthWeoHuenadde,dCiunartlheesTrAe.ncFhreasz,icLri.eut. B. Graves, ppP 3 Gunshot Wounds of the Chest, Lt-Col. J. F. Dodson p Cases of Injjry to the Chest, Seen at the Base, C. Dean. p. 3 CcnUnls 1 ^»»piyet C^ibralrea de l'Academle de Mcdecln, g Q Pliri. JUN 25 # ]3t>t ^V^ry to***^ of 111 CONTENTS (Concluded.) ABSTRACTS PartialResection of theLung for Abscess, R. Gregoire. p. 3~o Extraction of Intrapulmonary Projectiles, G. Marion. p. 3j2 Extraction of Projectiles Lodged in the Hilum of the Lungs, Petit de la Villeon. p. 3j2 Operations on the Heart, H. Constantine and M. Vigot. p. 874 Wounds of the Knee-Joint, Major Richard Charles. p. 374 — Orthopedics. Kineplastic Amputation, V. Putti. p. 3j6 Kineplastic Amputation, Dr. Vincent Gaudeans. p. 3j8 The Careful Treatmentof Stumps, P. Desfosses. p. 379 The Treatment of Diaphysealfractures, J. Delmas. p. 38 Madderized Bone for Bone Grafts, M. Thurlow, and C. C. Macklin. P- 38 Small Bone Transplants in Bridging, F. W. Bancroft. p. 3?2 — Medicine. Report of a Base Laboratory in Mesopotamia for 1916, T. K. Boney, L. G. Crossman, and C. L. Boulenger. p. 382 — Neurology and Psychiatry. "Paralysis"of"Voluntary" Movement,BrownandStewart, p. 388 Exhaustion Pseudo-Paresis, J. Ramsay Hunt. p. 390 Jacksonian Epilepsy, H. Meige and A. Benisty. p. 39 Note on Tremors, H. Meige and A. Benisty. p. 39?. — Pathology and Bacteriology. A Time-governed Slide Method, W. Broughton-Alcock. p. 3g3 — Urology and Dermatology. Dermatology in a British General Hospital, F. C. Knowles. p. 3(j6 — Roentgenology. Simplification of Radiographic Technic, Dr. Fornario. p. 398 — Ophthalmology and Oto-Laryngology. Effects of Mustard Gas on the Eyes, George S. Derby, p. 399 — Editorial Comments. Surgery in Battle Areas. Antiseptic Versus Asepsis. Acute Respiratory Infections. Feces Disposal and FlyPrevention. Papers by Medical Officers. Shock Following Extensive Muscle Injury. Notes from the Field Service School. Convalescent Camp. The British Medical Supplement. Increased Rank for Medical Officers. p. 402 — Circulars, Bulletins, and Reports from the C. S. O. — Circulars : Papers for publication. TreatmentinOrthopedic Condition—s. Collection of Museum Material. p. 425 Bulletins : Orders Regarding Drinking Water. The Duties of a Battalion Medical Officer. Sanitary Details. Prevention of Respiratory Diseases. Meningococcus Serum. Factsabout Trench Fever. Dysentery and Typhoid. Bacteriological Diagnosis. Dysentery in Germany. Cultures from Enteric Cases. Food Topics. Messing Conditions. The Company Cook. Waste in the Messes. Pigs and Garbage. Unsound Meat. Gas Poisoning. Arsenic Gases. New Clinical Picture. Tuberculosis Again. Motor Oil in Sanitation. p. 435 Vol. II. \ Paris October 1918 WAR MEDICINE Published by the American Red Cross Society in France for the Medical Officers of the American Expeditionary Forces RESEARCH SOCIETY REPORTS The Tenth Session of the Research Society of the American Red Cross Society in France September 6 and 7. 1918. at the Hotel Continental, Paris. The ;:rst meeting of tin- Session. September 6 at 2 : 00 P.M., was devoted to a Conference on Surgery in Battle Areas, led by Lieuten- ant-Colonel Cri/e. It was followed by a demonstration of••splint adjustment by Lieutenant-ColonelJoel Goldthwait. M. R. C. The second meeting. September j at 9 : 50 A.M., wa*rdevoted to a discussion ofAcute Respiratory Infections Papers were read by . Colonel P \Y. O. Beveridge, A. D. M. S. Sanitation. B. E. F., . Medecin-Major13oreloftheServicede Sante, MajorHaven Emerson , M. R. C. and Major H. Zinsser. M. R. C. . The third meeting. September 7 at 2 : 00 P.M., was devoted to a discussion of Field Sanitation. Papers were read by Medecin- Major Octave Monod. Major F. P. Josceline.CA. D. M. S. Sanita- tion, B. E. FC., Colonel Henry A. Shaw,\M. and Colonel Gres- singer. M. SUMMARIZED REPORT OF THE CONFERENCE ON SURGERY IN BATTLE AREAS Leader, Lieutenant-Colonel G. W. Crile. M.R.C. Friday, September 0. 1918. Introduction. Thegreat value of theConference was owing to the fullest parti- cipation with American officers of certain military surgeons of the — widest experience including the clinical chiefs for both France T. II. RESEARCH SOCIETY REPORTS. 294 and England. These distinguished officers gave to our cause their counsel and advice as freely and as enthusiastically as if it were for their own armies. Among these were Professor Tuffier, Gen- eral Sir Anthony Bowlby, Colonel Gask, Colonel Richards, Col- onel Soltau, Major Lockwood. Captain Betz and Captain Dehelh . The conclusions of this Conference were slightly modified in a later Conference with a Committee appointed by the Chief Con- sultant, A. E. F. The following is the final conclusion. I. Problems Relating to Organ*ration. i. What should be the personnel of a standard surgical team? — A. (a) Surgeon. (b) Assistant surgeon. (c) Nurse assistant. (d) Anesthetist (Nurse or M. O.). [c) Two theater orderlies. (/") One striker. Comment : (a) and (b) Surgeon and Assistant surgeon : Every surgeon should have an assistant surgeon for two reasons : first, to train the younger men to become competent surgeons; and second, to facili- tate work. The assistant surgeon of today is the surgeon oftomor- row. The relation between the surgeon and his assistant should be that of pupil and teacher. A nurse or an orderly may be trained to be as useful a technical assistant as an officer. When there is a sufficient number of trained surgeons, the nurse assistants or orderly assistants may be used to replace the medical assistants. ^c) Nurse Assistant: Were itnotfor the necessity of training new- surgeons, the nurse assistant answers every purpose. (d) Anesthetist: Preferably a nurse, for i. Each nurse anesthetist adds an officer to the medical corpse 2. The nurse anesthetist has proven satisfactory to the surgeon. The nurse anesthetists should be trained just as surgeons are 3. — trained by acting as pupils to skilled anesthetists. Skilled anes- thetists should have pupils until there are a sufficient number of Women trained anesthetists for the army. physicians, trained in administering anesthetics, may be employed. The degree of M. D. does not confer qualification togiveanesthetics. Everyanesthetist, medical or non-medical, should receive adequate training at the expense of the teacher, not at the expense of the patient. RESEARCH SOCIETY REPORTS. 295 c) Orderlies: Each team shouldhavetwo theaterorderlies, and, it there is shortage- of personnel in the forward area, four nursing- orderlies and two bearers maybe added to a team to reinforce the personnel of the forward unit. Surgeons are of little use if pa- tients cannot be carried. An organization may break at the point of enlisted personnel, as well as at the point of surgical personnel. The quality of work and the quantity of work are dependent on a well-balanced personnel. (f) Striker: The striker is an accessory, but the surgeon's time can be better occupied than in taking care of his own quarters. Disorderly quarters, mess-room and premises adversely affect the work of an organization. 1 How many tables shall beallotted to each team? . — A. In ordinary cases, two: in lightly wounded, three or even more. In rush periods, patients need not be removed from the stretcher; they may be operated on the stretcher resting on the — table. But few metal tables are required anything that will support a stretcher will answer. In periods of rush, the time and labor of orderlies must be conserved as well as the time and labor of the surgeon. 3. What is the best arrangement of hours for a considerable pull? — A. When the fight opens and the wounded begin to come in. all surgeons go on duty for the first 4 to 6 hours; then they begin to go off in relays ofeight-hour and twelve-houroperating periods. The following plan has worked out satisfactorily in a longer pull : four hours on and four hours off, excepting the night team, which works straight from midnight to 8:00 a.m. By having two breakfasts, two lunches and two dinners, an hour apart, and at the same hours for surgeons, nurses, and orderlies of the same team. the operating tables may then run continuously. First Team. Second Team. Third Team. On. Off. On. Off. On. Off. 8a.111.-12N. i:N.-4pm. 12N.-4p.n1. 4p.m.-8p.m. 12M.-8a.rn. 8a.rn.-12N. 4p.m.-8p.m. 8p.m.-8a.m. 8p.m.-12M. 12M.-12N. 4. —What is the best means of transport of teams? A. Ambulance. Shall teams furnish any instrument or apparatus? 5. A. Teams should be self-contained as regards the commonly used instruments, unless the hospital to be reinf< reed has an ade- quate excess of instruments. RESEARCH SOCIETY REPORTS. 296 6. What shall be the proportion of X-ray operators? — .\ . For each three teams; an operator for the day and an oper- ator for the night would seem to provide sufficient X-ray service. 7. What shall be the proportion of nurses, not attached to teams, in the operating: room? — A. Two nurses to supervise the theater in the day and two in •the night, for each six teams. 8. Shall each surgeon be responsible for the after-care of his cases? — A. Yes, as far as possible. Shall there be a day and night chief of surgical service? 9. — A. Yes, the chief of surgical service by day, and the second surgeon by night. 10.—Under whose direction shall the resuscitation team work? A. The resuscitation team will work under the general direc- tion of, and in close co-operation with, the operating surgeons. It shall consist of two medical men, two nurses, and two orderlies. 1 1. —Shall abundant reserves of teams be in readiness? A. There must be kept as many teams in reserve as possible — teams trained to work together. The teams should be promptly exchanged between the front area and the base according to need. 12. What is the most available type of mobile unit for emer- gency reinforcements? — — A. As far as possible mobile hospitals mobile operating units. When advancing, have reserve mobile units ready, and leap-frog these past the units in operation. Operate, evacuate and leap-frog again. If these mobile units are not available in suf- ficient number, then make use of the field hospital. As a policy, except in emergencies, the field hospital should not function as an operating center. The mobile unit must be flexible', must remain mobile, must be expansible in its operating capacity. Its primary job is to afford great facility for operating. Evacuate every operated case as early as possible. As a rule early evacuation after operation is better than in the third or fourth day, which are the critical days for infection. It is the great virtue ofgas and oxygen that evacuations are hastened. 13. In periods of great activity what cases can be evacuated unoperated from the evacuation hospitals? — V. During periods of great activity, when it is impossible to make complete operations at the evacuation hospitals within a safe period of time, the following types should be promptly sent by pro-operation train to the nearest base : . RESEARCH SOCIETY REPORTS. 297 Perforating wounds with punctiform orifices. (1) (2) Superficial wounds, and those deeper wounds not extensively involving the musculature of the calf, thigh, buttock, and shoulder areas. 3N Wounds of the face, hands, and feet, not involving tarsus and deep plantar fascia. (4) Fractures of bones caused by rifle and machine-gun bullets with through and through wounds, and without extensive commin- ution, marked displacements, or marked swelling. W II. Problems Relating to ah Wounds. 1. In cases suitable for primary closure, it has heretofore been agreed that patients should remain under the care of the operating surgeon until there is sound healing. Are there any new facts suggesting a modification of this principle? — A. Wounds should not be closed unless they can be contin- uously under the care of the operating surgeon until the wound is healed. There are these exceptions : heads, joints, sucking wounds of the chest, abdomens in chest and joints it may be well to leave skin unsuturedj. These should be closed, and if they cannot be held until healed, they should be sent on at once rather than evacuated in the third or fourth day when infection is apt to be spreading. If a sutured wound is to be moved at all it should be moved promptly. 2. If a suturable case must be evacuated, and if there is opportunity for making debridement before evacuation, shall the surgeon introduce stitches, leaving them untied, or shall the wound be left wide open without stitches placed? — A. Put in no stitches unless they are to be tied at once. Untied stitches in a well debrided wound may become infected: infected stitches delay subsequent closure. Inserted, untied stitches are a handicap, not a help, for a delayed primary woun—d should have its first dressing under—anesthesia in the theatre preferably gas and oxygen anesthesia and the entire field cleansed under anesthesia, as if for performing an aseptic operation; then and only then should the gauze dressing be removed and the wound immediately closed. Redressing such wounds in the wards usually leads to infection. 5. Shall debrided wounds be protected by sterile gauze during evacuation? Or shall an aseptic dressing be applied? If so,—what antiseptic? A. Dry sterile gauze: paraffined gauze: and, if there is a prob- RESEARCH SOCIETY REPORTS. 298 ability of two or more days* delay, the peculiar property of fiavine which inhibits bacterial growth is an advantage; hence, in such cases, gauze wet with 1/3000 fiavine is good. Studies are being- undertaken with other methods which may modify the foregoing. Shall wounds be packed with gauze? 4. — A. Loosely dressed with gauze, yes; packed with gauze, never.. Drygauze should be placed in contact with every part of the raw surface, for it absorbs toxins, bacteria and wound secre- tions, hence aids the wound in its defense against infection. Shall splints be placed on limbs having wounds of the soft 5. parts only? — A. In extensive wounds, yes, not only because they provide comfort and physiologic rest, but also, if nerves or tendons have been severed, they are less displaced. 6. Is a bacteriologic examination of the wound required in making primary suture during the period of contamination, which usually lasts from 10 to 12 hours? — A. No. Clinical judgment is sufficient in primary suture. 7. If, owing to rush, no surgical treatment of a wound can be given before evacuation, shall the wound be covered with dry sterile gauze only? Shall any antiseptic be used? If the latter, what antiseptic? — A. Make no instrumental, no digital examination of the wound. Place no drain tubes, no gauze, no foreign body in the wound. Apply dry sterile gauze dressing. It may be worth while to apply alcohol, picric acid, or iodin on the skin only. 8. If there is a larger number of wounded than the surgeon can give a complete debridement, shall he complete as many as he can, leaving the remainder of the wounded unoperated, or should he perform an incomplete operation on every wounded man? — A. The adage that " Anything worth doing at all is worth doing well " applies here. Underthese circumstances, thesurgeon should give his time to those patients on whom operation is likely to result in recovery; and those who, if unoperated, are not safe for evacuation. In stress, the surgeon should do only work with greatest net profit. It has been shown that wounds of the soft parts, including com- pound fractures, may be remarkably well reclaimed up to and into the third day. The reclamation is mad—e through complete revi- sion, just as in the wounds at the front just as acute appendicitis is reclaimed up to the period of new tissue formation and abscess. Do well as much as possible; evacuate the rest.