THE MEDICAL DEPARTMENT OF THE UNITED STATES ARMY IN THE WORLD WAR
VOLUME XI
S U R G E RY
PART ONE
GENERAL SURGERY
ORTHOPEDIC SURGERY
NEUROSURGERY
PREPARED UNDER THE DIRECTION OF
MAJ. GEN. M. W. IRELAND
The Surgeon General
WACHINGTON : : GOVERNMENT PRINTING OFFICE : : 1927
LETTER OF TRANSMISSION
I have the honor to submit herewith a portion of the history of THE MEDICAL DEPARTMENT OF THE UNITED STATES ARMY IN THE WORLD WAR. The portion submitted is Part One of Volume XI, on the subject of SURGERY, and includes General Surgery, Orthopedic Surgery, and Neurosurgery.
M. W. IRELAND,
Major General, the Surgeon General.
The SECRETARY OF WAR.
Lieut. Col. FRANK W. WEED, M. C., Editor in Chief
Loy MCAFEE, A. M., M. D.. Assistant Editor in Chief
EDITORIAL BOARD a
Col. BAILEY K. ASHFORD, M. C.
Col. FRANK BILLINGS, M. C.
Col. THOMAS R. BOGGS, M. C.
Col. GEORGE E. BREWER, M. C.
Col. W. P. CHAMBERLAIN, M. C.
Col C. F. CRAIG, M. C.
Col. HAVEN EMERSON, M. C.
Brig. Gen. JOHN M. T. FINNEY, M. D.
Col. JOSEPH H. FORD, M. C.
Lieut. Col. FIELDING H. GARRISON, M. C.
Col. H. L. GILCHRIST, M. C.
Brig. Gen. JEFFERSON R. KEAN, M. D.
Lieut. Col. A. G. LOVE, M. C.
Col. CHARLES LYNCH, M. C.
Col. JAMES F. MCKERNON, M. C.
Col. R. T. OLIVER, D. C.
Col. CHARLES R. REYNOLDS, M. C.
Col. THOMAS W. SALMON, M. C.
Lieut. Col. G. E. DE SCHWEINITZ, M. C.
Col. J. F. SILER, M. C.
Brig. Gen. W. S. THAYER, M. D.
Col. A. D. TUTTLE, M. C.
Col. WILLIAM H. WELCH, M. C.
Col. E. P. WOLFE, M. C.
Lieut. Col. CASEY A. WOOD, M. C.
Col. HANS ZINSSER, M. C.
a The highest rank held during the World War has been used in the case of each offlcer.
PREFACE a
This part of Volume XI, Surgery, comprises three sections, devoted to general surgery, orthopedic surgery, and neurosurgery. This grouping of subjects is inevitable, since some changes in the original plan (which was to narrate in separate volumes general surgical activities and the surgical activities relating to injuries of the brain, spinal cord, and peripheral nerves) were necessitated by the fact that the anticipated quantity of manuscript on these subjects didnot prove adequate for more than one book (part of a volume). Furthermore, though it was intended to have the subject of roentgenology in a separate volume, a chapter only has been given to it, and this appears in the section on general surgery herein. The statistical data in the section on general surgery, particularly those concerning the incidence of various kinds of battle injuries, are essentially general kin character; that is to say, they are studies, made in the home territory and after the war, of records received from all sources. Though these data serve a very useful purpose, a far better purpose would have been served had studies been made along this line on special types of injuries in the theater of operations and by trained observers. Such a course of procedure was impracticable, however, in view of the fact that our available personnel was relatively very limited at the time when we were receiving in our hospitals in France the major portion of our wounded. Furthermore, it must be borne in mind that most of our battle casualties resulted from two military operations-the St.Mihiel operation and the Meuse-Argonne operation. The former began on September 12, 1918, and the latter ended on November 11, 1918. Thus itwill be seen that relatively little time was available for other than the reception and care of the wounded.
Much of the material of some of the chapters of the general surgery section was obtained from published sources and used as a basis for the chapters as they now stand. For the use of this material grateful acknowledgment is now made to Oxford University Press, American Branch, for permission to use such text and illustrations as were found to be desirable in the chapters on "Localization and extraction of foreign bodies under X-ray control"; "Wounds of the soft parts and wounds of the joints "; " Wounds of the chest"; "Wounds of the abdomen." Acknowledgment is also made to Paul B. Hoeber (Inc.),for permission to use certain parts of the United States Army X-ray Manual for the chapter on "Localization and extraction of foreign bodies under X-ray control."
Grateful acknowledgment is made to the Bureau of Medicine and Surgery, Navy Department, for certain plates of the Report on the Medico-Military
a For the purpose of the History of the Medical Department of the United States Army in the World War, the period of war activities extends from April 6, 1917, to December 31, 1919. In the professional volumes, however, in which are recorded the medical and surgical aspects of the conflict as applied to the actual care of the sick and wounded, this period is extended, in some instances, to the time of the completion of the history of the given service. In this way only can theresults be followed to their logical conclusion.
VI
Aspects of the European War, by Surg. A. M. Fauntleroy, United States Navy, 1915, which are used partly to illustrate Chapter II of the first section of this volume.
The section on orthopedic surgery is so arranged as to show, first the character of treatment it was possible to give to the injured assigned to the care of orthopedic surgeons in the American Expeditionary Forces, and, second, the after care of such cases in the home territory. The section was compiled from the contributions of various officers of the orthopedic division whose names are as follows: Col. Elliott G. Brackett, M. C.; Col. Joel E. Goldthwait, M. C.; Col. Nathaniel Allison, M. C.; Lieut. Col. Clarence B. Francisco, M. C.; Lieut. Col. George W. Hawley, M. C.; Lieut. Col. Hiram W. Orr, M. C.: Lieut. Col. Robert B. Osgood, M. C.; Lieut. Col. James T. Rugh, M. C.; Lieut. Col. David Silver, M. C.; Maj. Zabdiel B. Adams, M. C.; Maj. Wallace Cole, M. C.; Maj. Murray S. Danforth, M. C.; Maj. Norman T. Kirk, M. C.; Maj. John L. Porter, M. C.; Maj. Edward A. Rich, M. C.; Maj. Philip O. Wilson, M. C.; Maj. Carl C. Yount, M. C.; Capt. Horace Morison, San. C.; Capt. John H. Morse, San. C.
Col. Elliott G. Brackett, M. C., who edited the section on orthopedic surgery, was chief of the division of orthopedic surgery, Surgeon General's Office, during the war.
The section on neurosurgery was edited by Lieut. Col. Charles H. Frazier, M. C. Shortly after the war began, Colonel Frazier was placed in charge of the Army neurosurgical school of instruction, which was established in Philadelphia at that time. When General Hospital No. 11, Cape May, N. J., was instituted, Colonel Frazier became its chief of neurosurgical service. Here he remained for the greater part of the war period. General Hospital No. 11 was one of the special hospitals designated to receive from overseas, cases of peripheral nerve injuries, and wounds or injuries of the skull or brain and spinal cord. Subsequent to his service at this general hospital, Colonel Frazier was on duty in the subdivision of surgery of the head, Surgeon General's Office, and became a member of the peripheral nerve commission, appointed by the Surgeon General on January 29, 1919.
It was upon the advice of the peripheral nerve commission that the peripheral nerve register was distributed with the view of recording thereon the results of the examination of every peripheral nerve case. Since duplicate peripheral nerve registers of the cases examined were furnished the Surgeon General's Office, the hope was entertained that uniform data of a large number of cases of peripheral nerve injuries might lead to a determination of the end results of such cases. However, with the wide dispersion of these cases throughout the country, following their discharge from military hospitals, it would have been necessary, in the subsequent reexamination of them, to rely upon medical men inexpert in neurological examinations. In consequence, efforts to determine the end results necessarily were abandoned.
TABLE OF CONTENTS
Preface
Introduction
SECTION I. -GENERAL SURGERY
CHAPTER I. Helmets and body armor-The medical viewpoint. By Maj. Bashford Dean, O. D
II. Firearms and projectiles; their bearing on wound production. By Col Louis B. Wilson, M. C
III. Statistics. By Lieut. Col. Albert G. Love, M. C.
IV. Surgery at the front. By Col. George De Tarnowsky, M. C
V. Collective surgical experiences at the front and at the base
VI. Anesthesia. By Col. George Crile, M. C
VII. Wound shock. By Lieut. Col. Walter B. Cannon, M. C
VIII. Localization and extraction of foreign bodies under X-ray control. By Lieut. Col. James T. Case, M. C
IX. Gas gangrene. By Maj. Ellsworth Eliot, jr., M. C
X. Tetanus. By Lieut. Col. Frank W. Weed, M. C
XI. Trench foot. By Lieut. Col. Frank W. Weed, M. C
XII. Wounds of soft parts. By Lieut. Col. Eugene H. Pool, M. C
XIII. Wounds of joints. By Lieut. Col. Eugene H. Pool, M. C
XIV. Wounds of the chest. By Lieut. Col. John L. Yates, M. C
XV. Wounds of the abdomen. By Lieut. Col. Burton J. Lee, M. C
XVI. Wounds of the genitourinary tract. By Col. Hugh H. Young, M. C
XVII. End results, fractures of long bones. By Col. John B. Walker, M. C
LIST OF TABLES
1. Some German guns and howitzers
2. German trench mortars
3. Shrapnel shell used in light field guns
4. Characteristics of the principal rifles used in the World War
5. Automatic pistols and their cartridges
6. Various dissected rifle cartridges and their ballistic data
7. Various dissected pistol cartridges and their ballistic data
8. Battle injuries, admissions, officers and enlisted men, United States Army, 1917-18
9. Battle injuries, deaths from injuries, officers and enlisted men, United States Army, 1917-18
10. Battle injuries, discharge for disability, officers and enlisted men, United States Army, 1917-18
11. Battle injuries, days lost in hospital, officers and enlisted men, United States Army, 1917-18
12. Battle injuries, duration of treatment (fatal cases excepted), classification by cases under 29 and over 29 days, officers and enlisted men, 1917-18
13. Battle injuries by diagnosis, deaths in hospital, showing the day of treatment on which death occurred, officers and enlisted men, United States Army, 1917-18
14. Battle injuries by diagnosis, wounded returned to the United States for further treatment, officers and enlisted men, United States Army, 1917-18
15. Battle injuries by military destructive agents, admissions, officers and enlisted men, United States Army, 1917-18
16. Battle injuries by military destructive agents-deaths from injuries, officers and enlisted men, United States Army, 1917-18
17. Battle injuries by military destructive agents, discharges for disability, officers and enlisted men, 1917-18
18. Battle injuries by military destructive agents, days lost in hospital, officers and enlisted men, United States Army, 1917-18
19. Battle injuries by missiles, admissions, deaths, and case fatality, officers and enlisted men, United States Army, 1917-18
20. Battle injuries by anatomical part and by military agent, admissions, deaths, and case fatalities, single and multiple wounds, officers and enlisted men, 1917-18
[table continued]
[table continued]
[table continued]
[table continued]
21. Fractures (all), battle and nonbattle, of long bones, officers and enlisted men, 1917-1919. Case fatality and average days lost. Percentage rates
22. Battle fractures of the long bones, admissions, dealth, recoveries and case fatality, annual admissions, deaths and noneffective. Rates per 1,000
23. Summary of definite physical disabilities which resulted from battle injuries, officers and enlisted men, 1917-18
[table continued]
24. Associated physical disabilities (fatal cases excepted), resulting from battle injuries, in 19,768 officers and enlisted men, 1917-18
[table continued]
[table continued]
[table continued]
[table continued]
[table continued]
[table continued]
25. Physical disabilities, resulting from wounds (excepting fatal cases), by military agents, officers, and enlisted men, 1917-18; absolute numbers and percentage of each disability to the total number of cases wounded by the military agents
[table continued]
[table continued]
[table continued]
[table continued]
[table continued]
26. Measurements for use in connection with Hirtz compass
27. Depth of anatomical landmarks
[table continued]
28. Battle fractures, including single and associated fractures
29. Battle fractures, long bones, showing both single fractures and those in association, and deaths
30. Non-battle fractures
31. Battle and nonbattle fractures of long bones, showing immediate result
32. Fractures of long bones of United States veterans of the World War, by type of fracture, showing bone or bones involved, and deaths, as of January 1, 1926
[table continued]
33. Fractures of long bones of United States veterans of the World War, by age group and bone or bones involved, and deaths, as of January 1, 1926
34. Fractures of long bones of United States veterans of the World War, by condition on first examination, by location of fractures, and deaths, as of January 1, 1926
35. Fractures of long bones of United States veterans of the World War, by character and degree of disability, bone or bones involved, and deaths, as of January 1, 1926
[table continued]
[table continued]
36. Fractures of long bones of United States veterans of the World War, by bone and joints involved, showing condition on first examination, as of January 1, 1926
37. Fractures of long bones of United States veterans of the World War, showing bone involved, location and character of the fracture, and amputation and deaths, January 1, 1926
38. Amputations as a result of fractures of long bones of United States veterans of the World War, by bone or bones involved, amputation levels and interval elapsing between injury and amputation, and deaths, January 1, 1926
39. Amputations as a result of fractures of long bones of United States veterans of the World War, by character and degree of disability, bone or bones involved, amputation levels, and deaths, January 1, 1926
40. Fracture femur, United States veterans of the World War, rated less than 10 percent on first examination; showing interval elapsing between injury and last rating, and degree of disability on last rating, as of January 1. 1926
41. Fracture femur, United States veterans of the World War, rated 10-29 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating as of January 1, 1926
42. Fractured femur, United States veterans of the World War, rated 30-49 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
43. Fractured femur, United States veterans of the World War, rated 50-79 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
44. Fractured femur, United States veterans of the World War, rated 80-99 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of Januray 1, 1926
45. Fractured femur, United States veterans of the World War, rated 100 percent disabled on first examination; showing interval clasping between injury and last rating and degree of disability on last rating, as of January 1, 1926
46. Fractured tibia, United States veterans of the World War, rated 100 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
47. Fractured tibia, United States veterans of the World War, rated 10-29 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as ofJanuary 1, 1926
48. Fractured tibia, United States veterans of the World War, rated 30-49 percent disabled on first rating examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
49. Fractured tibia, United States veterans of the World War, rated 100 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as ofJanuary 1, 1926
50. Fractured fibula, United States veterans of the World War, rated less than 10 percent on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
51. Fractured fibula, United States veterans of the World War, rated 10-29 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
52. Fractured tibia and fibula among United States veterans of the World War, rated less than 10 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, January 1, 1926
53. Fractured tibia fibula, United States veterans of the World War, rated 10-29 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
54. Fractured tibia and fibula, United States veterans of the World War, rated 30-49 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
55. Fractured tibia and fibula, United States veterans of the World War, rated 50-79 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
56. Fractured tibia and figula, United States veterans of the World War, rated 100 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, January 1, 1926
57. Fractured humerus, United States veterans of the World War, rated less than 10 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
58. Fractured humerus, United States veterans of the World War, rated 10-79 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
59. Fractured humerus, United States veterans of the World War, rated 30-49 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
60. Fractured humerus, United States veterans of the World War, rated 50-79 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on lst rating, as of January 1, 1926
61. Fractured humerus, United States veterans of the World War, rated 80-99 percent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
62. Fractured humerus, United States veterans of the World War, rated 100 percent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
63. Fractured ulna, United States veterans of the World War, rated 10-29 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
64. Fractured ulna, United States veterans of the World War, rated 30-49 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
65. Fractured radius, United States veterans of the World War, rated less than 10 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
66. Fractured radius, United States veterans of the World War, rated 10-29 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
67. Fractured radius, United States veterans of the World War, rated 30-49per cent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
68. Fractured radius, United States veterans of the World War, rated 100 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
69. Fractured radius and ulna, United States veterans of the World War, rated less than 10 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
70. Fractured radius and ulna, United States veterans of the World War, rated 10-29 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
71. Fractured radius and ulna, United States veterans of the World War, rated 30-49 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating as of January 1, 1926
72. Fractured radius and ulna, United States veterans of the World War, rated 50-79 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
73. Fractured radius and ulna, United States veterans of the World War, rated 100 percent disabled on first examination; showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926
74. Fractures of the long bones, United States veterans of the World War, showing the number and percentage of cases which reached their stationary level after periods of 2, 3, 4, 5, or more years, as of January 1,1926
75. Fractures of the long bones, United States veterans of the World War, showing the change in per cent of impairment on first examination by the United States Veterans' Bureau, and on the last examination prior to January 1, 1926
[table continued]
76. A study of 4,647 single femur fractures among the World War veterans, showing the change in ratings by 6-month intervals from the Veterans' Bureau's first examination after injury, as of January 1, 1926
LIST OF CHARTS
I. The effect of intravenous ether on the pulse and blood pressure
II. Comparative effects of ether and nitrous oxide in thigh amputations, as indicated by the pulse and blood pressure
III. Effect of special anesthesia on pulse and blood pressure
IV. Comparative effects of ether and of nitrous oxide in operations for the repair of extensive abdominal wounds
V. Comparative effects of ether and of nitrous oxide in thigh amputations as indicated by the pulse and blood pressure
VI. Incidence of cases of tetanus. Ratio of cases per thousand wounded, by months
LIST OF PLATES
I. Multiple high explosive wound. Marked comminution of cortical sections of tibia, showing mixed and pure infection
II. High explosive shell wound; gas gangrene
III. Gunshot wound; gas gangrene
IV. Experimental splenization in a dog's lung
V. Lacerated wound of lower lobe of lung
LIST OF FIGURES
1. Mushrooming of bullets upon impact with
2. Diagram showing larger degree of protection of American helmet, Model 2A, contrasted with standard British model
3. Diagram showing areas of danger
4. Diagram showing anterior portion of chest
5. Diagram indicating by small dots entry wounds in chest and abdomen as recorded in about 1,000 cases (163 thoracic, 834 abdominal)
6. United States 14-inch railway artillery
7. United States 12-inch rifle on sliding-type railway mount
8. British 9.2-inch howitzer, model 1917
9. United States 240-mm. howitzer, model 1918
10. United States 155-mm. howitzer, model 1918 (Schneider)
11. United States 7-inch Navy rifle mounted on a pedestal on a railway car
12. United States 4.7-inch gun and carriage, model 1906
13. United States 75-mm. field gun, model 1917 (British)
14. French 75-mm. field gun
15. Types of shrapnel in modern use
16. A type of high-explosive shrapnel
17. French 75-mm. high-explosive, nose-fuse shell
18. Fragmentation of 10-inch common steel shell weighing 221 pounds
19. Smaller fragments of high-explosive shell
20. Fragment of high-explosive shell removed from lower jaw
21. Shrapnel and rifle bullets removed from wounds
22. Shell fragments removed from wounds
23. Portion of casing of 210-mm. high-explosive shell, with pieces of olive-drab cloth still adherent, removed from wound
24. Piece of shell (above) and two pieces of cloth (below) removed from a shell wound of the back, having some fibers of cloth still clinging to piece of shell
25. Trench mortar, 240-mm. (9.45-inch)
26. Stokes 4-inch trench mortar, and ammunition
27. Trench mortar, shell, 240-mm
28. Regulation French bracelet type of hand grenade and a number of extemporized types, such as the "racquet" and "jam-tin"
29. German combination grenade for hand or rifle use
30. English combination grenade used in the rifle
31. English combination grenade
32. Longitudinal section of an English grenade
33. United States hand grenades
34. Demolition bomb, 25-pound, carrying 125 pounds of explosive and having heavy cast-steel nose and pressed sheet-steel rear body, for airplane use
35. Fragmentation bomb, 25-pound, carrying 3 pounds of explosive, designed for use by airplanes against troops
36. Incendiary bomb, 40-pound, of the intensive type with steel nose and fusible zinc rear casing for airplane use
37. Italian Mannlicher rifle, model 1891
38. Austrian straight-pull Mannlicher rifle, model 1895
39. German Mauser rifle, model 1898
40. German short rifle, model 1898
41. English short Lee-Enfield rifle, model 1907
42. Canadian Ross magazine rifle, Mark III, model 1916
43. French Lebel rifle, model 1886-93
44. French Lebel rifle, model 1907-15
45. French automatic rifle, model 1917
46. American Springfield rifle, model 1903
47. American Enfield, model 1917
48. Japanese Arisaka rifle, model 1907, officially known as the "Thirty-eighth year model "
49. Russian Mouzin rifle, model 1901, officially known as the "3-line Nagant"
50. Belgian Mauser rifle, model 1889
51. Browning automatic rifle, model 1918, caliber .30
52. Chauchat machine rifle, model 1915, caliber 8 mm
53. Maxim machine gun and tripod (American), model 1904, caliber .30
54. German Maxim machine gun on mount
55. Fiat (Italian) machine gun and tripod
56. Browning heavy machine gun, model 1917
57. Hotchkiss machine gun, model 1914, 8 mm
58. Vickers' machine gun, model 1915, caliber .30
59. Vickers' aircraft machine gun, model 1918, caliber .30
60. Lewis machine gun, model 1917, caliber .30, ground type
61. Lewis aircraft machine gun, model 1917, caliber .30
62. Marlin tank machine gun
63. Marlin aircraft machine gun, type 8 M. G.
64. German 08/15 (Spandau) machine gun
65. Colt .45 automatic pistol
66. Colt double action revolver, model 1917, caliber .45
67. Smith and Wesson double action revolver, model 1917, caliber .45
68. German Luger automatic pistol, caliber 7.65 mm
69. German Mauser automatic pistol, caliber 7.63 mm
70. Photographs of various dissected rifle cartridges
71. German antitank rifle cartridge, compared with the United States Springfield model 1906 cartridge. Full size
72. Photographs of sundry dissected automatic pistol cartridges
73. Various deformed rifle bullets removed from wounds
74. Sundry bayonets
75. United States trench knives, models 1917 and 1918
76. German coup stick or trench club
77. French steel darts which were dropped in showers from airplanes
78. Front line packages Nos. 1, 2, and 3
79. First-aid outfit, complete
80. First-aid bandage, with hooks and tape
81. Immobilization of upper extremity against patient's side
82. Thomas leg splint applied over clothing; traction made on shoe
83. First aid in trench warfare
84. Administering a hot drink to a shock case
85. Regimental aid station, 321st Infantry, October 3, 1918
86. Dressing station. Croix de Charemont, August 17, 1918
87. Ambulance company dressing station, open warfare
88. Dressing station, Lahayville
89. Unloading severely wounded at Field Hospital No. 28, Varennes, Meuse, October 2, 1918
90. Slightly wounded, awaiting readjustment of dressings, Field Hospital No.28, October 2, 1918
91. Sorting wounded
92. Wounded awaiting admission to hospital
93. Admission office of an evacuation hospital
94. Recovery ward of an evacuation hospital
95. Heating chamber for shock cases
96. Fracture ward of an evacuation hospital
97. The splint room of an evacuation hospital
98. Nitrous oxide manufacturing plant
99. Storage building, office and laboratory of nitrous oxide manufacturing plant
100. Motors of 25 horsepower, used to drive compressors
101. Detail of compressors
102. Partial view of retort room
103. Drip bottles and wash bottles which were connected with the retorts shown in Figure 102
104. Military balloon, used to store gas
105. Method of folding three blankets to provide four layers beneath and four above the patient
106. Transfusion apparatus
107. Transfusion apparatus
108. Graphic illustration of macroscopic agglutination test
109. Palpator made from a small wooden rod, with a screw and a screw-eye
110. Showing the positions of shadow of plumb bob on fluorescent screen when X-ray tube is properly centered, and when off center
111. Screen appearance of a tumbler with the tube properly centered and not properly centered
112. Screen appearance of an intracranial foreign body
113. Screen appearance which might lead to an erroneous diagnosis of intracranial foreign body
114. Method of rotation of the part (Nogier)
115. Method of rotation of the part
116. Diagrammatic representation of the parallax method
117. Screen appearance during different steps of the parallax method
118. Schematic drawing of parallax localizer
119. Apparatus shown in Figure 118
120. Orthodiagraphic method of localization
121. Measurement in two directions (right-angled planes)
122. Screen appearance of, and method of using, the ring localizer
123. Malleable band, and the six-point survey methods
124. Classical single-shift, triangulation method
125. Wall meter, or indicator, for tube-shift method, also showing method of using adjustable double-slider caliper
126. Apparatus shown in Figure 125
127. Method of similar triangles (double-shift, fixed-angle method)
128. Screen appearance at different steps in the double-shift, fixed-angle method
129. Screen appearance after notching the diaphragm leaves for the Roussel method
130. Hirtz compass guidance during a surgical operation
131. Hirtz compass
132. Schematic drawing of Hirtz compass with legs adjusted at zero points and resting on a plane
133. Arms and indicator of Hirtz compass
134. Schematic drawing of Hirtz compass set up on skin of patient
135. Reason for shift of leg of compass from zero point by the amount stated
136. Accessory apparatus for flouroscopic work with Hirtz compass
137. Method of showing fluoroscopic adapter with Hirtz compass 2
138. Setting arms and legs of Hirtz compass directly from the auxiliary compass
139. Detail of holder for direct setting of Hirtz compass
140. Direct setting of Hirtz compass
141. Centering of tube above plate holder on cassette with small cross wires, photographic method, Hirtz compass
142. Skin markers, plate holder and tube holder in position for photographic method,Hirtz compass
143. Schematic representation of plate, cross wire marker and tube focus positions for radiographic use of Hirtz compass
144. Construction for finding one of the foot points from the shadows of a corresponding marker as shown at Ml and M2, and the shadow of the cross marker
145. Complete chart for setting feet of Hirtz compass
146. Equipment supplied for use with Hirtz compass
147. Head rest for use with the eye localizer
148. Sweet eye localizer
149. Position for first exposure in localization of projectiles in the eye
150. Specimen plate of projectile in the eye illustrating the method of measurement
151. Second exposure for localization of projectiles in the eye
152. Schematic drawing of localizing chart illustrating the method of obtaining measurements
153. Chart used in eye localization
154. Extraction of a foreign body under flouroscopic control. The open screen method in darkened room
155. This illustration represents the radiological step of the procedure of localizing foreign bodies under fluoroscopic control
156. Arrangement of the tube and table for the Bonnet method
157. Gas gangrene of arm before operation
158. Gas gangrene of arm, colored man, after amputation
159. Débridement. Excision of the external wound
160. Débridement. Excision of the aponeurotic layer
161. Débridement. Excision of injured muscle
162. Change of position of wound tract from changed position of limb
163. Wound by shell fragment two weeks after debridement and primary suture
164. Perforating shell wound, left thigh, the same missile penetrating right thigh and fracturing right femur
165. Multiple, penetrating wounds of back, soft parts, closed by primary suture
166. Long perforating wound of thigh, with opening of knee joint, closed by primary suture
167. This and Figure 168 show perforating wounds of forearm with fracture, two
168. 1 weeks after debridement and primary suture
169. Outline of X ray, Figure 167
170. Large penetrating shell wound, internal aspect of leg, closed by retarded primary suture
171. Large perforating wound of thigh, closed by primary suture
172. Wound, posterior aspect, right thigh; compound comminuted fracture of femur. Two weeks after debridement
173. Same wound as that shown in Figure 172, two weeks after secondary suture
174. Gunshot wound of knee
175. Gunshot wound of knee
176. A convenient method of recording the range of motion
177. The same method as that shown in Figure 176, of recording motion in the elbow
178. Gunshot wound of the knee
179. Gunshot wound of the knee
180. Dunham's original model of the air cell capillary gear
181. Sheep's lung five weeks after ligation of the artery supplying the left tipper lobe
182. Sheep's lung five months after ligation of the artery supplying the left lower lobe, showing adhesions produced by simple thoracotomy
183. Patient in position for operation. Line of incision for a thoracotomy of election
184. Method of exposing a rib for resection
185. Simple type of rib shears. Bone biting forceps for chest surgery
186. Tuffier's rib spreader. Thin bladed clamp used to secure hemostasis, and as a tractor
187. Thoracotomy of election
188. Cow horn rib stripper. Tuffier's lung forceps. Periosteal elevator
189. Incision for exposure of the phrenic nerve
190. Exposure of the phrenic nerve
191. Thoracotomy of election
192. Methods of reducing the number of stitches used in repair after a resection
193. Closure of the visceral pleura with an exaggerated Cushing stitch
194. Inner aspect of the chest wall, obtained after death from purulent pleurisy without open pyothorax
195. Closure of the chest wall after thoracotomy
196. Closure of the chest wall after thoracotomy
197. Closure of the chest wall after thoracotomy
198. Closure of the chest wall after thoracotomy
199. Closure of the chest wall after thoracotomy
200. Closure of the chest wall after thoracotomy
201. Trocar, cannula, and catheter for intercostal drainage. Flap valve used to secure automatic one-way drainage
202. Form of trap to be attached to a catheter drain
SECTION II. ORTHOPEDIC SURGERY
I. Organization
II. The foot and its relation to military service
III. Fractures caused by projectiles
IV. Orthopedic surgery in embarkation hospitals, American Expeditionary Forces
V. Autogenous bone grafts for nonunion in atrophic long bones and in chronic suppurative osteitis (osteomyelitis) following war wounds
VI. Amputation service, American Expeditionary Forces
VII. Care of the amputated in the United States
LIST OF FIGURES
1. The Poliquen hitch. This and Figures 2 and 3 illustrate three practical methods of applying traction to a fractured lower extremity over the shoe
2. The Collins hitch
3. Special adjustable traction strap for saddle-girth hitch
4. Adhesive plaster traction
5. Stocking traction
6. Sinclair skate
7. Mechanical drawing of Thomas traction arm splint
8. Thomas traction arm splint applied for bed treatment
9. Thomas traction arm splint applied with rods in vertical place and arm slung from upper rod
10. Thomas traction arm splint applied to obtain traction on the lower fragment and at the same time to allow flexion of elbow
11. Treatment without splints due to extensive wounds
12. Mechanical drawing of hinged traction arm splint
13. Hinged traction arm splint
14. Mechanical drawing of Jones humerus traction splint
15. Jones humerus traction splint in use for fracture of the humerus at or below the middle of the shaft in which flexion of the elbow is desired
16. Jones "cock-up" or "crab" wrist splint and application
17. Mechanical drawing of hinged half-ring thigh and leg splint
18. Method of applying traction to fractured lower extremity in the field
19. Method of applying traction to fractured lower extremity in the field
20. Mechanical drawing of long Liston splint with interrupting bridge of iron wire
21. Long Liston splint with interrupting bridge, applied for stretcher transport only
22. Long Liston splint with interrupting bridge, applied for stretcher transport only
23. Mechanical drawing of Thomas traction leg splint
24. Thomas traction leg splint with traction attached to end of splint and splint slung from cradle
25. Thomas traction leg splint applied with suspension to the Balkan frame
26. Use of Ransohoff "ice tongs" in conjunction with the Thomas traction leg splint, to secure skeletal traction
27. Position for fracture of neck of femur or fracture into the trochanter
28. Mechanical drawing of anterior thigh and leg splint. Hodgen type
29. Wooden bed frame, for traction by weight and pulley and overhead counterweight suspension
30. Mechanical drawing of Cabot posterior wire leg splint, to be used with or without side splints
31. Cabot posterior wire splint applied with supination of the foot
32. Mechanical drawing of ladder splint material
33. Mechanical drawing of snowshoe litter
34. Maddox unit clamps, iron pipe and bed frame clamp
35. Special use of Thomas traction leg splint
36. Hand and wrist splint
37. Mechanical drawing of abduction arm splint
38. Tomahawk wedge, the standard shoe alteration for ankle valgus, to shift weight-bearing to the outer side of the foot
39. The tomahawk wedge in place
40. Anterior heel in position
41. Position of rocker shank on the outer sole
42. Destruction of the head of the humerus, outer portion of the clavicle, head of the scapula, and comminuted fracture of the upper portion of the shaft of the humerus, by rifle missile
43. X-ray picture showing fractured clavicle and lodged missile in the outer end of the clavicle
44. Fissure fracture of the greater tuberosity of the humerus by shell fragment, which is shown lodged
45. Comminuted fracture of the upper portion of the diaphysis of humerus, with moderate dispersion of bone fragment
46. Fracture of upper end of diaphysis of humerus by rifle missile, with much loss of bone
47. Wound of the upper portion of the shaft of the humerus
48. Fracture of middle of shaft of humerus by shell fragment; moderate separation of bone fragments
49. Wound of diaphysis of humerus by rifle missile, with wide separation of bone fragments
50. Compound comminuted fracture, lower end of humerus, result of deformed rifle missile
51. Rifle missile injury of shafts of ulna and radius and indirect fracture of lower end of shaft of humerus
52. Fracture of upper ends of ulna and radius by rifle missile
53. Fracture of shaft of femur, juncture of middle and lower thirds, by rifle missile
54. Same as Figure 53, taken three months after receipt of injury, showing progress of repair
55. Fracture of shaft of femur by shell fragment, shown lodged
56. Rifle bullet wound, lower extremity, femur
57. Same as Figure 56, viewed from front
58. Compound comminuted fracture, lower extremity of femur, with marked dispersion of fragments
59. Pistol-ball wound, head of tibia
60. Same as Figure 59, viewed from inner side
61. Penetration of upper extremity of tibia by rifle missile, with slight detachment of fragment of shaft
62. Same as Figure 61, viewed from front
63. Perforating wounds of upper portion of shaft of tibia by rifle missile
64. Same as Figure 63, viewed from the back
65. Compound, comminuted fracture of shaft of tibia, showing typical "butterfly"arrangement of fragments
66. Fracture or middle of diaphysis of tibia, caused by shell fragment
67. Extensive destruction of shaft of tibia caused by shell fragment
68. Perforating wound of lower end of diaphysis of tibia
69. Cloth gaiter, applied over shoe for extension
70. Fracture ward, Base Hospital No. 41, St. Denis, Paris
71. Treatment of fractured humerus
72. Compound, comminuted fracture involving shoulder joint
73. Compound, comminuted fracture involving shoulder joint
74. Method of treatment of fracture of both bones of forearm
75. Compound, comminuted fracture, carpal and metacarpal bones
76. Application of finger splint, showing extension applied
77. Balkan frame, showing suspension apparatus. Thomas splint
78. Fracture of femur, showing double extension. Inverted Hodgen splint
79. Pelvic lifter
80. Method of using pelvic lifter
81. Bridge transportation splint for fracture of tibia
82. Delbet plaster splint for fracture of tibia
83. Plaster splint for fracture of tibia, permitting mobilization of ankle
84. Bridge plaster splint for fracture of tarsal bones
85. Case 1. Loss of bone substance, and bone atrophy
86. Case 1. Roentgenogram three and one-half months after graft
87. Case 1. August 1, 1922. Roentgenogram showing excellent bony union
88. Case 1. Roentgenogram, May, 1924, showing hypertrophy of graft in tibia
89. Case 2. Marked deformity and eburnation of bone ends where the pseudarthrosis had occurred
90. Case 2. After resection of bone ends and removal of plate. Deformity corrected
91. Case 2. March 23, 1921. Excellent bony union and hypertrophy of radius
92. Case 3. Roentgenogram, December 10, 1921, showing bone being thrown across between graft and old eburnated bone
93. Case 3. Roentgenogram, July 28, 1922, 14 months after operation. There is excellent bony union
94. Case 4. Condition before operation
95. Case 4. Solid bony union January 17, 1922, five months after graft
96. Case 5. Anteriorposterior view of both tibiae before bone graft
97. Case 5. Right tibia four months after graft
98. Case 5. Left tibia four months after graft
99. Case 6. Roentgenogram showing loss of bone substance before operation
100. Case 6. Good bony union six months after arthrodesis
101. Case 6. Photograph showing function
102. Case 7. Roentgenogram before operation showing loss of substance
103. Case 7. Union five months after operation
104. Case 7. Photograph showing function
105. Case 7. Another view showing function
106. Case 8. Loss of substance and atrophy present in humerus before graft
107. Case S. Excellent bony union at end of six months
108. Case 8. Another view showing excellent bony union at end of six months
109. Case 9. Lateral view showing comminuted fracture of patella and separation of fragments
110. Case 9. Union present January, 1924
111. Case 10. Roentgenogram showing loss of substance and deformity
112. Case 10. Two months after graft-deformity corrected, with bony union
113. Case 10. Showing function on completion
114. Case 10. Another view showing function on completion
115. Case 11. Roentgenogram showing loss of substance
116. Case 11. Roentgenogram three months after graft, showing excellent condition of bone
117. Case 12. Roentgenogram showing loss of substance
118. Case 12. Roentgenogram three months aftergraft
119. Case 12. Linear fracture ninth month
120. Case 12. Note absorption two months later
121. Case 12. Solid bony union, 19 months after fracture
122. Case 13. Roentgenogram November 17, 1921, fracture of first graft during fourth month and loss of substance bridged by graft
123. Case 13. Excellent union in old fracture in original graft and in new graft
124. Case 14. Roentgenogram of graft six weeks after operation
125. Case 14. One year after Figure 124, or 13½ months after operation, showing poliferation which had occurred in graft which bridged loss of substance
126. Case 15. No attempt at union in old fracture. Note proximity to ankle joint
127. Case 15. Lateral roentgenogram three months after graft
128. Case 15. Roentgenogram 11 months after graft. Outline of graft can barely be distinguished. Note union in fibula
129. Use of Thomas splint in application of fixed extension to an amputation stump to overcome soft part retraction
130. Use of a spreader in sliding extension applied to an amputation stump to overcome soft part retraction
131. Amputation of the thigh by the flapless method in various stages of healing under the influence of continuous extension
132. Amputation of the thigh by the flapless method in various stages of healing under the influence of continuous extension
133. Amputation of the thigh by the flapless method in various stages of healing under the influence of continuous extension
134. Amputation of the thigh by the flapless method with oblique section in order to save the maximum amount of soft tissue
135. Short amputation of the thigh
136. Short amputation of the thigh with marked retraction of the soft parts and protrusion of the end of the bone covered by granulation tissue
137. Plastic closure of an open amputation stump with marked retraction of the soft parts
138. Plastic closure of an open amputation stump with marked retraction of the soft parts
139. Double amputation of both legs
140. Short amputation of the lower leg with marked flexion contracture of the knee
141. Provisional appliance used in the American Expeditionary Forces for above-the-knee amputation
142. Provisional appliance used in the American Expeditionary Forces for above-the-knee amputation
143. Type of temporary appliance used for hip joint amputations
144. Patients with above-the-knee amputation fitted with the temporary peg leg with plaster socket
145. Mechanical drawing of the provisional appliance for below-the-knee amputation used in the American Expeditionary Forces
146. Application of the provisional appliance for below-the-leg amputation
147. Application of the provisional appliance for below-the-leg amputation
148. Application of the provisional appliance for below-the-leg amputation
149. Application of the provisional appliance for below-the-leg amputation
150. Application of the provisional appliance for below-the-leg amputation
151. The temporary leg completed, ready to apply
152. Group of soldiers fitted with temporary peg legs
153. Average sagittal stumps from four to eight months after trauma
154. Average sagittal stumps from four to eight months after trauma
155. Average sagittal stumps from four to eight months after trauma
156. Average sagittal stumps from four to eight months after trauma
157. Average sagittal stumps from four to eight months after trauma
158. Same as in Figure 157, after reamputation and healing
159. Stump showing terminal edema and other evidences of latent infection
160. Typical ring sequestrum
161. Complete ring sequestrum surrounded by new bone formation
162. Excessive terminal bone production, "mushrooming"
163. Bony spur in below-knee amputation
164. Interosseous bony union in below-knee stump
165. Long thigh stump requiring secondary plastic operation
166. A typical sagittal Chopart stump
167. Transcondylar reamputation
168. Temporary appliance-plaster socket; stock metal bars; wooden foot
169. Original models of stock provisional appliances
170. Original models of stock provisional appliances
171. Provisional appliance used at Letterman General Hospital
172. Letterman General Hospital leg; assembled and unassembled
173. The final model of provisional leg with a plaster-of-Paris inset
174. Type of provisional arm used, and various attachments for work and play
175. Type of provisional arm used, and various attachments for work and play
176. Type of provisional arm used, and various attachments for work and play
SECTION III. NEUROSURGERY
CHAPTER I. Organization and activities of the Neurological Service, A. E. F. By Col. Harvey Cushing, M. C.
II. Activities of the American First Army Hospital at Deuxnouds. By Maj. Samuel C. Harvey, M. C.
III. Management of gunshot wounds of the head and spine in forward hospitals, A. E. F. By First Lieut. Adolph M. Hanson, M. C.
IV. Neurological aspects of the effects of gunshot wounds of the head. By Lieut. Col. Charles H. Frazier, M. C., and Capt. Samuel D. Ingham, M. C.
V. Late treatment of gunshot wounds of the head. By Maj. Claude C. Coleman, M. C.
VI. A statistical analysis of gunshot wounds of the head. By Lieut. Col. Harry H. Kerr, M. C.
VII. Experimental study of problems of infection of the central nervous system and the treatment therefor. By Capt. Lewis H. Weed, M. C.
VIII. Motor disturbances in peripheral nerve lesions. By Maj. Lewis J. Pollock, M. C.
IX. Sensory disturbances in peripheral nerve lesions. By Maj. Lewis J. Pollock, M. C.
X. Electrical examinations in the diagnosis of peripheral nerve injuries. By First Lieut. Samuel Silbert, M. C.
XI. Technique of nerve surgery. By Maj. K. Winfield Ney, M. C.
XII. Results of peripheral nerve surgery. By Lieut. Col. Charles Frazier, M. C.
XIII. Experimental observations on peripheral nerve repair. By Contract Surgeon G. Carl Huber, United States Army
LIST OF TABLES
1. Classification of gunshot wounds of the head, according to depth of injury, or its severity
2. Symptoms
3. Primary operations performed
4. Secondary operations performed
5. Complications of head injuries
6. Disposition of head injuries
7. Persisting symptoms
[table continued]
8. Causes of death
9. Data concerning time of operation in a series of 400 cases of peripheral nerve injury
10. Certain operated cases, observed in the peripheral nerve centers
11. Proportion of neurorrhaphies to neurolyses
12. The percentage of good, mediocre, and negative results after neurolyses. Indirect observation
13. The percentage of good, mediocre, and negative results in motor function after neurorrhaphy. Indirect observation
14. The percentage of good, mediocre, and negative results in motor function in the total series of operated cases, including neurorrhaphy and neurolysis. Indirect observation
15. Percentage of end results of 497 operations, including 132 neurolyses, 350 neurorrhaphies and 14 transplants
16. Percentage representing Tables 14 and 15 combined
LIST OF FIGURES
1. This and Figures 2 to 4, inclusive, illustrate the technique of the osteoplastic method with the wound near the center of the flap
[Figure 2]
[Figure 3]
[Figure 4]
5. Sketch illustrating the method of suction of the tract of a penetrating wound while searching for foregin bodies
6. Grade II. Wounds producing local fractures of variable types, with the dura intact. Type A, without depression of external table. Type B, with depression of external table
7. Grade III. Local depressed fractures of various types, with the dura punctured
8. Grade IV. Wounds, usually of gutter type, with detached bone fragments driven into brain
9. Grade V. Wounds of penetrating type, with lodgement both of projectile and bone fragments
10. Grade VI. Wounds with ventricles penetrated or traversed (A) by bone fragments (B) by projectile
11. Grade VII. Wounds of craniocerebral type involving (A) orbitonasal (B) auri-petrosal region
12. Grade VIII. Wounds with craniocerebral perforation
13. Grade IX. Craniocerebral injuries with massive fracture of skull
14. The indriven fragments of inner table (natural size)
15. From a sketch at autopsy after removing calvarium
16. Section through the contused area, showing position of bone fragments
17. Trepanation block showing behaviour of thick skull to tangential wound
18. Bone block specimen on left shows interparietal suture and fissures radiating from gutter; on the right, a few fragments of internal table attached
19. Example of lodged shell fragment, lodged in an oblique gutter wound
20. Small gutter fracture in thin skull; complete dislodgement of fragments
21. Tripod incision for small irregular wound of vault. Dotted lines indicate area of reflection of flaps. (Cushing)
22. Three-legged (Isle of Man) incision for larger wound of cranial vault. (Cushing)
23. Quadrangular trepanation
24. Diagram to show the insertion of a soft rubber catheter in the tract of a penetrating missile to locate foreign bodies
25. Split shell fragments with separate tracts and fragments at varying depths. (Cushing)
26. Split shell fragments in temporal lobe (Cushing)
27. Method of opening dura
28. Exposing cord for removal of embedded shell fragment
29. Exposing cord for removal of embedded shell fragment; using nerve root as tractor
30. Conspicuous craniofacial defect with dense scar
31. Large right parietal defect
32. Characteristic defect in the parietal region
33. Characteristic defect in the frontal region
34. Skiagraph of an irregular defect in the parietal region
35. Skiagraph of a characteristic oval defect in the frontal region
36. Skiagraph of a rectangular defect, in the parietooccipital region, resulting from removal en bloc of area of skull in debridement
37. Large parietal defect. Roentgenogram before cranioplasty
38. Roentgenogram of head shown in Figure 37, after repairs
39. Posterior parietal defect. Roentgenogram before cranioplasty
40. Roentgenogram of head shown in Figure 39 after autogenous cranial transplant
41. Consecutive stages of operation
42. Bagley's hinged-flap method
43. Bagley's hinged-flap method
44. Cranioplasty by transplant from tibia
45. Cranial defect in right parietooccipital region following loss of osteoplastic flap
46. Roentgenogram showing osteomyelitis of osteoplastic flap and outline of bony defect
47. Cranial abscess
48. Section of wall from b in Figure 47
49. Pedunculated dural abscess
50. Section at x of wall of abscess shown in Figure 49
51. Higher magnification of a section from c in Figure 50
52. A higher magnification of d in Figure 50 showing neuroglia fibrils
53. Section at y of wall of abscess shown in Figure 49
54. Higher magnification of section at e in Figure 53
55. Frontal section of a brain with left temporal lobe abscess
56. A section from c in wall of abscess shown in Figure 55
57. A section from b in wall of abscess shown in Figure 55
58. Section from an abscess wall similar in type to that shown in Figure 56
59. Frontal view of brain with large abscess in right frontal lobe
60. A section from the wall of the abscess shown in Figure 59
61. A higher magnification of wall of abscess seen in Figure 60
62. Section of the innermost portion of abscess wall in Figure 60
63. Upper surface of cerebellum, with abscess in left hemisphere
64. Cross section of cerebellum seen in Figure 63
65. Section from c in Figure 64
66. Section from d in Figure 64
67. A transverse section through occipital pole of brain
68. Transverse section through the occipital pole of the brain shown in Figure 55
69. Section of the abscess wall at d in Figure 68
70. Patient with hernia at the site of the frontal defect
71. Brain shown (a) enlargement of left hemisphere and hernia cerebri at site of cerebral defect; (b) horn of dilated ventricle in relation with tubular abscess, cavity filled with inspissated pus; (c) bullet just beneath the cortex
72. Abscess from penetrating gunshot wound of left parietal and occipital lobes
73. Fungus following exploration from multiple right frontal abscess
74. Fungus complicating the drainage of a large abscess of the right frontal lobe
75. Case 1. a, Point of entrance; b, machine-gun bullet in right cerebellar hemisphere
76. A "shower" of metallic fragments partly intracerebral and partly extracerebral
77. Large single metallic fragment, intrahemispheric
78. Three metallic fragments at a distance from the defect; two bone fragments within the margin of the defect
79. One minute bone fragment, and three silver clips applied at operation overseas for control of hemorrhage
80. Lead tape and tracings
81. Spring scales dynamometer
82. Measuring pronation by spring scales
83. Ulnar nerve lesions
84. Tonometer
85. Can with spout for measuring volume of extremity by water displacement
86. Imprint in a case of ulnar nerve lesion
87. Imprint in a case of median nerve lesion
88. Imprint in a case of radial nerve lesion
89. Imprint in combined lesions of ulnar and median nerves
90. Musculospiral palsy
91. Attempted flexion of fingers in musculospiral palsy
92. Extension of wrist by supplementary movement of flexion of fingers
93. Extension of wrist by supplementary movement of contraction of pronator radii teres
94. Extension of the distal phalanx of the thumb in musculospiral palsy
95. Partial lesion of musculospiral nerve
96. Sign of complete recovery of musculospiral nerve
97. Median nerve palsy
98. Inability to completely close the fist in median palsy
99. Imperfect clasping of fingers in median nerve palsy
100. Imperfect opposition of thumb in median nerve palsy
101. Opposition of the thumb by the adductor pollicis and flexor brevis pollicis in median nerve palsy
102. Closure of fist in recovered median palsy
103. Recovery of median nerve
104. Causalgie in median nerve lesion combined with ulnar lesion
105. Ulnar nerve lesion
106. Ulnar "paper sign"
107. Extension of the distal phalanges of the index and middle fingers in ulnar palsy
108. Adduction of the thumb by the extensor longus pollicis in ulnar palsy
109. Adduction of fingers by forced extension
110. Adduction of index finger by extensor indicis with hand in ulnar deviation
111. Pitres test for recovery from ulnar palsy
112. Ulnar and median nerve lesion
113. Flexion of the wrist by the extensor ossei metacarpi pollicis
114. Musculocutaneousparalysis
115. Circumflex nerve palsy. Greatest adduction
116. Complete adduction of arm by supplementary movement in circumflex nerve palsy
117. Erb's form of brachial plexus plasy analgesia (black) of fifth and sixth cervical segments
118. Brachial plexus lesion affecting common trunk of ulnar and median nerves
119. Partial lesion of whole brachial plexus affecting chiefly posterior and outer cords
120. Sciatic nerve palsy
121. External popliteal nerve palsy
122. Anterior crural palsy
123. Facial palsy
124. Paralysis of trapezius
125. Hypoglossal nerve palsy
126. Syndrome of the posterior retroparotid space
127. Sensory changes in ulnar nerve lesions
128. Smallest composite area of analgesia in ulnar nerve lesions
129. Sensory changes in median nerve lesions
130. Smallest composite area of analgesia in median nerve lesions
131. Sensory changes in radial nerve lesions
132. Sensory changes in external popliteal lesions
133. Smallest composite area of analgesia in external popliteal lesions
134. Sensory changes in sciatic nerve lesions
135. Smallest composite area of analgesia in sciatic nerve lesions
136. Sensory changes in combined lesions of the ulnar, median, and internal cutaneous nerves
137. Sensory changes in combined lesions of the ulnar, radial, and median nerve, a, b, c, and of the median and radial d, e, f, g
138. Sensory changes in combined lesions of internal and external popliteal portions of sciatic nerve
139. Sensory changes before and after resection and suture of the ulnar, median and ulnar, and median nerves
140. Sensory changes before and after resection of external popliteal and sciatic nerves
141. Sensory changes in lesions of median, internal cutaneous, combined median and radial nerve, b, g, m, from which the residual sensibility of the ulnar nerve was obtained; and of the ulnar and internal cutaneous, radial, combined radial and median nerves, h, j, m, from which the residual sensibility of the median nerve was obtained
142. Residual sensibility to prick pain of the ulnar nerve
143. Residual sensibility to prick pain of the median nerve
144. Residual sensibility to prick pain of the musculospiral nerve
145. Residual sensibility to prick pain of the musculocutaneous nerve
146. Sensory changes of combined lesions of internal saphenous and internal nerves, f; mall sciatic, external popliteal, popliteal, and internal saphenous and sciatic nerve lesions from which the residual sensibility of the external and internal popliteal nerves was obtained
147. Residual sensibility to prick pain of external popliteal nerve, b; sensory changes in an uncertified case of complete interruption of the internal popliteal, a
148. Residual sensibility to prick pain of the internal popliteal nerve
149. Residual sensibility to prick pain of internal saphenous nerve
150. Bundle or "cable" graft, using an autosensory nerve for repair of the defect
151. Diagram showing the necessity of determining the intraneural location of a given branch
152. Electroanatomic method of topographical identification
153. Application of forceps to an immobilized nerve during section
154. Sectioning of nerve ends for removal of neuroma and scar tissue. Method of preserving sections in order of removal
155. A, Technique of end-to-end suture, showing the placing of identification sutures before a nerve is removed from scar tissue. B, Exposed nerve before resection of neuroma and scar from its ends. C, Nerve resected, identification forceps applied, and three quadrant sutures placed
156. A, Rotation of the nerve for the purpose of placing the posterior quadrant suture. B, Intermediate sutures placed and all sheath sutures held in position to prevent rotation in placing a tension suture
157. A, Approximation by tension suture. B, Order in which sheath sutures are tied after nerve is approximated by the tension suture. C, End-to-end suture completed
158. The V section of a small distal segment used for the same purpose as the diagonal section in Figure 159
159. Diagonal section of distal segment where it is smaller than proximal segment, for the purpose of securing accurate sheath approximation
160. A, Partial lesion of a nerve trunk. B, Isolation of the interrupted portion from the physiological normal portion. Quadrant sutures placed for approximation. C, Approximation in partial suture such as a partial division of the sciatic nerve, showing relaxed undivided portion of the nerve
161. A, Partial lesion of a nerve trunk, where gross anatomic isolation of functionally intact portion of a nerve can not be made, as in Figure 160. B, Opening of the nerve sheath, showing involvement of bundle. C, V-shaped incision of sheath by which approximation of the bundle is made possible
162. A, Approximation of the divided bundle accomplished by relieving tension in the approximation of the resected sheath. B, The thickened sheath is not entirely closed for fear of strangulation; the defect is covered by a fat transplant
163. A, Physiologic interruption of a nerve; nerves with this appearance are occasionally considered as having an "internal neuroma." B, Showing the enlargement to be due to a greatly thickened nerve sheath, producing compression or strangulation. C, Perifunicular adhesions following the prolonged use of a tourniquet
164. Plastic procedures and alcoholic injection to prevent the formation of amputation neuroma
165. Infraclavicular exposure of brachial plexus
166. Infraclavicular exposure of brachial plexus
167. Infraclavicular exposure of brachial plexus
168. Exposure of medial portion of musculospiral nerve in the axilla and upper portion of the arm
169. Exposure of medial portion and internal part of posterior portion of musculospiral trunk through medial incision
170. Showing course of musculospiral nerve and relation of branches to triceps, as it passes behind humerus in musculospiral groove
171. Landmarks for exposure of musculospiral nerve in its latero-ventral aspect
172. Musculospiral nerve, latero-ventral aspect
173. Musculospiral nerve, postero-ventral aspect
174. Musculospiral nerve at elbow
175. A, Supinator brevis exposed by separating extensor carpi radialis brevior and extensor longus digitorum. B, Intrasupinator portion of posterior interosseous nerve exposed by dividing superficial fibers of supinator brevis
176. Exposure of median nerve in lower arm and upper forearm
177. Exposure of median nerve in the antecubital fossa; bicipital fascia divided, pronator teres mobilized from its attachment to flexor carpi radialis. B, Humeral head of pronator teres divided and retracted, exposing branches of the median nerve in this region
178. Intraneural dissection of median branches in the forearm
179. Median nerve lesion in middle third of forearm
180. Transposition of median nerve to a plane superficial to superficial head of pronator radii teres
181. Median nerve transposed to overcome median defect and sutured
182. Branches of median nerve in hand
183. Ulnar nerve, showing scar tissue as found at operation
184. Ulnar nerve exposed above medial humeral condyle preparatory for transposition anterior to the condyle
185. Ulnar nerve transposed; defect overcome by transposition and flexion relaxation of elbow; branches preserved through mobilization
186. Branches of ulnar nerve in hand
187. Tendon transplant for restoring opponens position and function to the thumb in intrinsic hand muscle paralysis; exposure of palmaris longus tendon
188. Tendon transplant for restoring opponens position and function to the thumb in intrinsic hand muscle paralysis
189. Tendon transplant for restoring opponens position and function to the thumb in intrinsic hand muscle paralysis
190. Tendon transplant for restoring opponens position and function to the thumb in intrinsic hand muscle paralysis
191. Diagrammatic explanation of viable neuroplastic transplant for filling of median defect in irreparatble lesion of both median and ulnar nerves
192. Exposure of sciatic trunk and branches to the hamstrings in gluteal region
193. Exposure of the sciatic in the middle and lower thirds of the thigh by lateral retraction of the short head of the biceps
194. Diagrammatic cross section of sciatic trunk, showing its tibial and peroneal components
195. Method of alignment in physiologic approximation of the sciatic trunk, the intraneural septum between the peroneal and tibial portions of the trunk serving as a guide to alignment
196. Exposure of the external and internal popliteal nerves in the politeal space
197. Exposure of external popliteal and its terminal divisions, as it swings around the neck of the fibula, the insertion of the peroneus longus having been divided to expose the terminal branches
198. Viable neuroplastic transplant for repair of tibial portion of sciatic trunk in irreparable lesions of both divisions
199. Viable neuroplastic transplant for repair of tibial portion of sciatic trunk in irreparable lesions of both divisions
200. Dissection of temporal bone, showing course of facial canal in its vertical and tympanic portion-wire directed through canal
201. Primary incision and exposure of the mastoid tip, suprameatal ridge, superior, posterior, and inferior bony meatal walls
202. Auditory portion of the tympanic bone partially removed
203. Bridge formed by the posterior meatal wall broken down over antrum, exposing the eminence of the lateral semicircular canal; suprameatal ridge not sufficicently broken down
204. Facial nerve uncovered through a portion of its vertical and tympanic course, showing method of breaking down the wall with a fine, sharp chisel
205. The sheath of the facial nerve is firmly attached to the periosteum of its canal; its attachment is severed with a cataract knife while the nerve is gently lifted from its bed
206. The nerve removed from the facial canal throughout its vertical and tympanic course
207. Decompression of the facial nerve by opening its sheath
208. Plastic procedure to protect the nerve from subsequent compression by turning down a flap of temporal fascia which is passed under the nerve, separating it from immediate contact with the bone; method of anchoring the flap
209. The portion of the temporal muscle denuded of its fascia, turned over the nerve
210. Incision closed; points of drainage indicated. External auditory meatus lightly packed with iodoform gauze
211. Diagrammatic cross section of the spinal cord showing on the right side the nerve roots and type nerve fibers
212. Microphotograph of a pyridine-silver preparation from a longitudinal section of the distal end of the central stump of the sciatic of a dog
213. From longitudinal section of a regenerating distal segment of a severed nerve several weeks after operation
214. Taken from the distal half of a neuroma, 21 days after severance of the sciatic nerve of a dog; pyridine-silver preparation
215. From a longitudinal section of the proximal zone of a neuroma on the sciatic of a dog, 31 days after section; pyridine-silver preparation
216. From a longitudinal section of a neuroma on the sciatic of a dog, 31 days after nerve section; pyridine-silver preparation
217. From a longitudinal section of a neuroma, removed three weeks after section of the sciatic of a dog; pyridine-silver preparation
218. A longitudinal section of a typical neuroma removed from the sciatic of a dog 31 days after section; pyridine-silver preparation
219. Longitudinal section of an atypical neuroma from the sciatic of a dog, 18 days after section; pyridine-silver preparation
220. Spiral formations of neuraxes from neuroma shown in Figure 219
221. Cross section through the middle of a cable-auto-nerve transplant, Experiment No. 74, 11 days after operation; pyridine-silver preparation
222. Cross section through the middle of a cable-auto-nerve transplant, Experiment No. 75, 26 days after the operation; pyridine-silver preparation
223. Longitudinal section through the central wound region, cable-auto-nerve transplant, Experiment No. 75, 26 days after operation; pyridine-silver preparation
224. From a longitudinal section of the central wound region in cable-auto-nerve transplant, Experiment No. 75, 26 days after operation; pyridine-silver preparation
225. From a cross section of a cable-auto-nerve transplant, Experiment No. 75, 26 days after operation; pyridine-psilver preparation
226. From a longitudinal section of the central third of a cable-auto-nerve transplant, Experiment No. 75, 26 days after operation
227. Cross section of cable-auto-nerve transplant, Experiment No. 77, 152 days after operation; pyridine-silver preparation
228. Cross section of homo-nerve transplant, stored in liquid petrolatum, at 3º C., 8 days before use as transplant, Experiment No. 171, 12 days after operation; pyridine-silver preparation
229. Cross section of homo-nerve-transplant, stored in liquid petrolatum at 3º C. for 39 days before use, Experiment No. 174, removed 23 days after operation; pyridine-silver preparation
230. Cross section of homo-nerve-transplant, stored in liquid petrolatum 39 days at 3º C. before use; Experiment No. 174. Experiment terminated at 23 days after operation. Higher magnification of portion of the larger funiculus shown in Figure 229
231. From a longitudinal section of homo-nerve transplant, stored in 50 percent alcohol for 10 days before use as transplant; Experiment No. 206. Nerve removed 62 days after operation
232. From a cross section of homo-nerve transplant, stored in 50 percent alcohol for 10 days before use as transplant; Experiment No. 206. Nerve removed 62 days after operation
233. Cross section of auto-nerve transplant, wrapped with two layers of alcoholized Cargile membrane; Experiment No. 234; 44 days after operation
234. Cross section of auto-nerve transplant, wrapped in alcoholized Cargile membrane; Experiment No. 236; terminated 272 days after the operation; pyridine-silver preparation
235. Cross section of an auto-nerve transplant, wrapped in an auto-fascial sheath; Experiment No. 240; terminated 14 days after operation
236. Cross section of auto-nerve transplant wrapped in auto-fascial sheath; Experiment No. 241; terminated 15 days after operation
237. Cross section of auto-transplant wrapped in auto-fascial sheath; Experiment No. 250; terminated 268 days after the operation
