Anthony Bowlby

THE DEVELOPMENT OF BRITISH SURGERY AT THE FRONT.

THE REGIMENTAL MEDICAL OFFICER. It is unnecessary to write at length on the w-ork of the regimental medical officer, for hlis duties in this war are muclh tlhe same as they have ever been. He shiares tlle dangers common to the combatant officers and men, and stavs with hiis battalion or brigade, as the case may be. His treatment can only be that of first aid, but lie and hiis orderlies lhave saved innumerable lives, botlh by the rescue of woundel comrades from dangerous situations and by careful and rapid transport to the field ambulance sections in the support line.

An Address ON GUNSHOT FRACTURE OF THE FEMUR: Delivered at a Meeting of the American College of Surgeons in New York, October 8th, 1919

else by fragments of higlh explosive slhells, which were often very large, being parts of slhells wlliclh themselves weighed from sixty to two hundred pounds or more. Extensive tearing of tlle muscles was therefore the rule, and in many cases the patient had other wounds in additlion. In the early days of tlle war shrapnel shell was extensively used by the Germans, and it was much used by botlh tlie British and the Frenclh throughout the whole war. The lower velocity of its round bullets caused it to produce much less injury to bone and muscle than tho rifle bullet fired at short range or than the fragments of highi explosive shell. Another very important factor to be considered in estimating tlle danger of fracture of thle femur is tlle lengtlh of time that is often liable to elapse before tlho patient can be adequately treated. If in France a man

A REPORT ON GAS GANGRENE

Certainly it is very gratifying, particularly at this season of the year, that comparatively few cases have occurred. Amonig 2,000 German, English, and Belgian troops who lhave been, or are at present, in the base hospital at Oxford there have only been five cases of typlhoid fever; and tlhis, I believe, to be tlle experience in other large lhospitals tlhroughout the country. It will be a great triunmplh to go tllrough tllis war witlhout a devastating experience of typhoid fever. In the fighting line it is not possiblealways to ask the soldier to carry out sanitary precautions, and in a very infected country, even witlh the best of intentions, lhe cannot avoid exposure. Here we may expect to find tlhe protective value of inoculation, and it is very satisfactory that the value of the nmeasure lhas been so generally recognized by officers and nlen. An immense proportion of those wlho go with tlle Expeditionary Forces will have been protected -for a. period at least. Whlile witlh our present knowvledlge we cannot btut regret that the inoculatioIn lhas not been made comlpulsory, let uIis lhope that a stufficient lnumber lhave taken advantage of the procedure to make impossible a repetition of the enteric catastroplie in Soutll Africa. In tlle midst of tllis great strLuggle we stand aghast at the carnage-at tlle sacrifice of so miiany lives in their primeThe manyv meni so beautiful, And they all dead dlid lie. The bitterness of it comes lhone every mornincg as we iead in tlle Rloll of Honour the names of the mucch loved sons of dear friends. Strange that man wlho so dominates Nature has so departed from Natuire as to be the onily animal to waae relentless wvar on hlis owni species. But there are wars and wars, and let our tlhouglht to-nighit be of the otlher army waging peacef li battles against our tr-e foes. No one has so well contrasted the work of these two armies as the poet laureate of tlle profession, Oliver WVendell Holmes:

An Address ON NINE HUNDRED CASES OF TUBERCULOUS DISEASE OF THE HIP, TREATED AT THE ALEXANDRA HOSPITAL, WITH A MORTALITY OF LESS THAN 4 PER CENT: Delivered to the Nottingham Medical Society

GENTLEMEN,-I propose to speak to you to-day upon my own experience in the treatment of hip disease in children under 12 years of age at the Alexandra Hospital. The Alexandra Hospital was founded in February, 1867, with the object of treating tuberculous disease of the hip without -operation other than the opening of abscesses, that is to say, by rest and by extension, and by good nursing and food, and it was stipulated that the length of time that the children were to remain in the hospital was to be in no way limited. The only ways in which limitations were imposed were in cases of children who were considered to be incurable, or who had had excisions of the hip done or had extensive spinal caries, for all these complications were originally a bar to admission.

Death from Pistol-Shot Wounds: Suicide or Homicide?

enlarged; there may be dropsy of the legs, and some albumen in the urine. In the first case, in spite of the lividity of the skin, the congestion, as seen by its effects on the organs, is not nearly so great as in the second, or cardiac case. I take the case of mitral disease, for in aortic, when the blood is thrown back on the heart, the body is pale and impoverished, and it is not until the mitral valve gives way that the congestive conditions become apparent. Let us see why these differences exist. In the case of bronchitis, the blood is impededl in the pulmonary artery, as is evidenced by the hypertrophy of the right ventricle, and, subsequently, an engorgement takes place in the general venous system. The forces which urge the blood through the lung are in part mechanical and in part chemical. If the air be prevented from entering the trachea from any obstruction, the blood is hinidered in its passage through the alveoli, showing that the chemical process of a6iration is necessary for the natural flow of the blood. In cases of strangulation, therefore, the right side of the heart is distenided, and the whole venous system gorged. If the obstruction be slower or more partial, as in ordinary diseases of the air-passages, the Iight ventricle, after a time, forces the imperfectly aerated blood through the lungs ; and, there being nothing to impede its flow onward in the pulmonary vein or left ventricle,, it takes its course through the system. In this way, the pulmonary circulation is freed, and the lividity of the countenance in bronchitis is therefore not so niuch owing to venous stasis, as to the presence of dark blood circulating in the arteries. This is the only explanation which I can see to accounit for the slight engorgement of the various organs in bronclhial affectionis. Take, now, the case of mitral disease the blood is thrown back on the pulmonary veins, and this arrests the flow coming fi-om the right side of the heart through the pulmonary artery ; consequiently, the whole of the capillary systemii of the lungs is gorged on both sides of the termination of the bronchi. You will see that there is ilo longela question of the possibility of nona6rated blood passilng the alveoli of the lung, since there is a positive mechanical hinidiance to the passage of any fluid. The congestion of the lung in the two cases is, therefore, of a very different kind ; in the bronichitis, it is oIn one side of the alveoli only ; in the lieart-case, it is on both sides ; in the formiier, it is in the pulmonam y aitery ; in the latter, in both pulmonary vein and arteiy commencing in the vein; conseqluently, the efficts are very differeint on the several organs, and onl the body at large. In the case of bronchitis, although the patient is livid, the conigestion does not attain the intensity it does in that of the heart. Here the blood nmay actually stagnate in the vessels, producing, a conlsolidation of the lung, or may burst througlh the tissues, so as to constitute a pulimonary apoplexy. This is know%n (luring life by lhnmoptysis, anid the dulniess and absence of breath-soun(ds on percussion and(auscultatioii. In the samiie way, and for the same reason, the liver becomes altered, as it rarely is in bronchitis, uintil the congestion produces great enlargement and the condition known as nutme-liver; the kidneys, also, from like engorgement, may show albumen in the urine, and the legs become dropsical. After death, the effects of the engorgement are s.een in the indurated lung, spleen, enlarged kidney, and nutmegr-liver. These altered states of organs are so well marked, that their appearance alone would denote death from heart-disease. I have frequently been asked why the same conditions do not obtain in bronchitis. I have now endeavoured to give the explanation. I have brought the subject especially before you in connection with the numerous cases we have in the hospital, on account of the important practical consequences which result from a knowledge of it. Many cases are not so simple as I have described. A patient, for example, may be found sitting up in bed, breathing with difficulty, and with so much rattling in the chest as to preclude the possibility of rightly gauging the state of the heart. If the case be one of primary Oronchitis, this is the disease to treat; if the heart be at fault, that may be the organ to administer to, and the secretion in the tubes be allowved to go on as a salutary process of relief. Suppose, in such a case, the liver be found enlarged, this fact would point to the heart as being the principal cause of the symptoms, and you would prescribe accoidingly. Or we might, as we often dQ, meet with a much more complex case, where, besides the symptoms just named, the urine is albuiminous, andl the patient dropsical. It is much more easy to call such a case one of renal dropsy, as I have often heard doile, than to make out accurately the true causation of the different morbid processes. If, however, oni careful examination, we find the liver enilarged alnd the lung gorged, it is much more likely to be one of heart-disease, and the albuminous urine a seconidary affection. Let the case be treated on this supposition, and we may often see the dropsy disappear, the urine become lhealthy, the liver decrease, the eicrrcreinlent of lhinn, pass off, aii(I the )atient resume his usual condition-one of chronically impaired heart. Such instances are far from common ; for I constantly see cases regarded as primary bronchitis, others as primary liver-disease owinig to its enlargement, others as Brights disease owing to the presence of albumen in the urine, and yet all these conditions are due to congestions arising from heart-disease. This has been overlooked, owingf to the absence of brtits, or their obscuration by pulmonary ,:ounds. It is, therefore, most important to take niote of other facts and considerations on which to found a diagnosis. I could point to numerous cases where digitalis and other appropriate remedies have been given to quiet and strengthen the central organ of the circulation, and all the other ailments have departed. I cannot, therefore, too much impress upon vou the value of a diagnosis in these cases; and consider well all the points to which I have drawn your attention, for upon your due appreciation of them the life of your patient may depend. I have necessarily taken typical cases to dwell upon, and have drawn from a large general experience; at the same time, I should say that there are exceptional cases, which would require further explanation, such as the rarer instances of bronchitis associated with enlargement of the liver and dropsy.