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Medical Societies

ROYAL SOCIETY OF MEDICINE

SECTION OF MEDICINE

AT a meeting of this section held on Nov. 26 the chair (

was taken by the president, Sir MAURICE CASSIDY, and Dr. F. G. CHANDLER opened a discussion on the

Treatment of Traumatic Haemothorax jThoracic surgery, he said, had shown remarkableachievements since the last war, partly owing to theexperience of that war. Few today thought treatmentby abortive drugs of much value. The exploring needlewas essential for diagnosis and treatment, and should beharmless and painless. The physical signs were veryvariable and might be most peculiar, even simulatingpneumothorax with fluid of any kind ; bronchial breath-ing was common. The value of X rays, both in diagnosisand subsequent control, could not be exaggerated. Theproblems of treatment could not be reduced to a simpleone, for the hæmothorax might be simple, or infected, orcomplicated by many features. If the dome of thediaphragm were obscured in a radiogram there wasprobably half a pint of fluid or more and the condition wasapproaching the stage at which active treatment wasessential. If infection was present drainage was

urgent ; there must be no waiting for toxaemia. Thetemperature might be no guide, often being raised inuninfected cases. Complications might include openwound of the thorax ; indriven splinters of bone,missiles or clothing ; damage to lung, with or withoutretained foreign body ; pneumothorax, valvular or

otherwise ; perforation of the diaphragm, and injuries toother parts. These cases were matters for a’ speciallytrained surgeon. The first necessities for the simplenon-infected case were rest ; relief of pain and shock,cough and blood loss; and promotion of sleep. Sulphon-amides would probably be used, but they could notentirely prevent infection, nor would they cure it whenit had started. A small uninfected pneumothoraxneeded nothing more ; for other cases the needle shouldbe used within 24 hours. Every case must be treated onits merits ; aspiration might be needed in a few hours ornot for a few days. The replacement method, preferablyusing air, gave complete safety. If much blood wereleft, the sequelæ might be pleural thickening, inadequateexpansion and calcification. Oxygen had no advantageover air and complicated the technique.The patient should lie comfortably on his back and a

point midway in the axilla should be anaesthetised,remembering that the diaphragm was usually high. Aircould be introduced through the aspiration needle orcannula, or two interspaces higher. The cavity could beleft open to the air, making replacement automatic.To aspirate any quantity of fluid without replacementwas highly dangerous. Watch must be kept for thereaccumulation of fluid, preferably by X rays. Explora-tory puncture must be performed if fluid appeared. Indue time, breathing exercises and restoration of functionwere an essential feature of after-treatment.

Mr. G. A. MASON said that intrathoracic bleeding wasapt to cease spontaneously at an early stage. Too muchreliance should not be placed on a strong slow pulse,which might indicate a damaged autonomic nervoussystem. Rise of temperature might indicate furtherhaemorrhage or infection and called for investigation.A rising leucocyte count, the presence of organisms influid withdrawn, the general clinical picture and badodour of the fluid indicated infection. Massive clottingmight occur and might be absorbed or become calcified.Mr. Mason preferred not to operate for clot unless therewere also infection. If there was no evidence of progres-sive haemorrhage or involvement of the abdominal organs,a major operation should not be undertaken for smallnon-sucking wounds. Radiological examination before-operation should be made carefully, showing antero-posterior and lateral views, upright and recumbent-orlying on back and side. Preparation for operationincluded rest, morphia, transfusion, oxygen and blockageof afferent stimuli. Blood was evacuated by suctionor gentle use of absorbent pads. A Bipp-impregnated

pack could be left in the chest for the control of hmmor-rhage. If the parietes could not be closed because ofdamage to the tissues, tampons must be arranged, carebeing taken to see that they did not press on the greatveins on the right hand side, and to supply syphon drainagebelow them. The principal objectives were to restore thefunction of the chests and to secure complete occlusionof the pleural cavity.

Dr. CLIFFORD HOYLE said that in the last wartraumatic haemothorax had had no mortality after thefirst two days provided it remained sterile. Butinfection occurred in a third of the patients and gave abad prognosis both for death and for invalidism. Thetotal toll was high. The presence of traumatised lungtissue was extremely important. In the simple form thehaemothorax was the chief lesion and cases did well; inthe compound form hsemothorax was merely an incidentand the patients did badly on conservative treatmentand needed operation. Distinction was therefore vitallyimportant. Lateral and anteroposterior radiograms ofgood quality were essential. Treatment in the earlystages-the first few hours-was the same for all types ofcase ; patients should be rested and given morphine forrelief of pain, anxiety and insommia ; morphine did noharm and might facilitate cough. They needed reas-surance badly ; hyoscine and phenobarbitone had theirplace. Transfusion-preferably with blood-was oftenuseful. If there was increased intrapleural pressure theblood should be aspirated and replaced by a lesserquantity of air. A simple haemothorax might produceno symptoms ; a sample of the blood should be obtainedto confirm the diagnosis and exclude infection; bacterio-logical report was necessary for this. Effusions tookweeks or months to absorb, but could be removed surgi-cally in an hour, and the lung could be re-expanded andthe pleural sac replaced at the same time. Re-expansionwas rapid, especially if helped by expiratory breathingexercises. Among the difficulties of air replacement wasdry tap, usually due to trying too low. Villous tagsmight block the cannula. The end of the cannula might,in the posterior position, come into contact with expand-ing lung as the blood was withdrawn ; this was over-come by injecting air. Most failures were due to thechoice of too small a needle or cannula. Otherwisefailure was due to solid haemothorax, which should beevacuated. " Compound " hsemothorax meant compli-cation by damage or foreign body. Injury to the lungwas difficult to estimate, but of great importance.Surgical treatment allowed excision of wounds andtraumatised lung, complete drainage and arrest ofhæmorrhage ; it could only be performed within alimited period, but gave dramatic results. The incidenceof infection ran parallel with the incidence of retainedforeign body. Infection must never be forgotten, itmight occur several weeks after the injury. Often theonly diagnosis was by aspiration, which was also the onlytreatment for the early stages. A tube must not beused too early, or loculation would prejudice recovery.

, The nutrition must be maintained as far as possible;these patients readily developed bedsores.

DISCUSSION

Mr. J. E. H. ROBERTS confined his remarks to thesimple type. He found that if X-ray reports spoke of" a little fluid in the costal angle " he would aspirate, 10-14 oz. He would aspirate on the third or fourth day: unless there were contra-indications. Clotting was by no’ means exceptional ; he believed that aspirated blood, failed to clot because it had already clotted and not

because of any anti-coagulant factor. It could not beL absorbed in a clotted state, and a proteolytic ferment; was not readily forthcoming in a sterile pleura and so the. clot became organised, producing gross dysfunction.; Therefore the blood in a haemothorax should always be- removed. If aspiration with air replacement failed, two, cannulae could be used, breaking up the clot through one1 tube. By the tenth day it was too firm to break up anda- the chest must be opened. After saving life restoration- of function was the next object, and breathing exercises? were very important as soon as the patient was fit fori them. The only criteria of infection were the odour andetests of a removed sample. He did not like repeatedi aspiration, which was intermittent and incompletedrainage ; he preferred to use a self-retaining, catheter

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stretched through a smaller cannula. Practically allcases required a later rib resection. Collapse was alwaysdue to bronchial obstruction, usually by blood clot;that obstruction should early be removed by suctionthrough a bronchoscope, as otherwise a large proportionfailed to re-expand.

Dr. J. L. LIVINGSTONE had found that simple infectedheemothorax was apt to go on to chronic empyema, andadvised aspirations from time to time until, as far aspossible, the pus was at the back and the lung in front.He had found a good deal of difficulty in gas replacementand felt there was a risk of infection if it were done in award. Anaerobic cultures should be used in diagnosinginfection, but immediate smears were valuable.

Mr. TUDOR EDWARDS remarked that traumatic caseswith no penetration of the chest were increasing innumber under bombing. He favoured early removal ofthe contents of the pleura-within a few hours-andair replacement. This would stop bleeding from thelung, but not from the chest wall, and showed up quitesmall foreign bodies on an ordinary X-ray film. Manyinfected effusions yielded no organisms at an early stageif the fluid were drawn from too high up.

Mr. V. C. THOMPSON emphasised the difficulty ofseparating the treatment of haemothorax from that ofchest wounds. No difficulty had been found at theHarefield Chest Centre in aspirating the blood and caseshad cleared up well. In most cases the percentageof haemoglobin in the fluid had been below 20. Therewas often serious loss of blood protein, which should bereplaced by transfusion. The importance of using asyringe with some valvular mechanism was often over-looked. Air should not be allowed to enter the chest inan infected case, as it might make a complete empyemainstead of a small posterior pocket. Air replacement waspurely an emergency procedure to collapse a lung andstop bleeding ; to get re-expansion the air had to beremoved as soon as possible. Breathing exercises gaveremarkable improvements.Mr. C. PRICE THOMAS said clotting might occur with-

out infection and demanded removal. It was verydifficult -to keep an intercostal tube airtight. One com-plication which needed early recognition was theoccurrence of acute dilatation of the stomach.Mr. R. C. BROCK stressed the importance of differen-

tiating between the " simple " and " compound " type.He preferred early aspiration, but patients usuallyneeded 12-18 hours’ rest first. In practice, the presenceof a large hsemothorax often obscured the complication.A fractured rib, damaged costal cartilage or a suckingwound put the case into the " compound " grouprequiring surgery. If blood welled out with respiration,the wound might be called a " leaking " haemothoraxwhich was alarming, but should not preclude bold inter-vention. A large infected clot was most difficult to dealwith, and the correct treatment was prevention.Mr. C. 0. S. Tu]3BS thought that even repeated aspira-

tion sometimes gave misleading results, yielding a sterilefluid in infected cases if there were pus in some loculi andnot in others. Chemotherapy was very valuable prophy-lactically.

SECTION OF ORTHOPaeDICS

A MEETING of this section was held at Hill End Hos-pital, St. Albans, on Nov. 30 with the president, Mr. S. L.HIGGS, in the chair, when Prof. FELix BAUER presenteda paper on the

Functional Treatment of CongenitalDislocation of the Hip

Mr. KENNETH PRIDIE, who read the paper, explainedthat Professor Bauer was orthopsedic physician to theMunicipal Hospital in Vienna, and had gained much ofhis experience in a routine examination of the hip-jointsof Viennese children in a search for the earliest signs ofthis deformity. The condition is much commoner inAustria than in this country. It was his experience ofthe Lorenz method of fixed immobilisation, said Professor

’I Bauer. that had led him to adopt what he termed thefunctional treatment. Fixed plaster methods led to

, stiffness of the joint and lack of development of the bonystructures. The capsular ligaments were shortened, andhis experience was that the late results, some 10-20

years after cessation of treatment, were poor, and thatthe incidence of osteoarthritis of the hip-joint was veryhigh. The time to start treatment in these childrenwas at the second month of life. Examination thenwould show nothing more than a shallow acetabulum,but such a joint was mechanically unsound, and withouttreatment was liable later on to develop osteoarthritis.Possibly these were also the hip-joints most prone todevelop Perthes disease and slipped epiphysis. In aconsiderable number of the children the shallow aceta-bulum was associated with an adductor spasm and theradiogram showed delay in the ossification of the epi-physis. That delay was a danger sign, and these hips,if untreated, became subluxated. Very few hips wereactually dislocated at birth. If seen early enough theyshowed the changes he had described, and by a form oftreatment which combined abduction with function theybecame normal. Professor Bauer’s objection to theLorenz method was that normal function of the hip-jointwas prevented by the fixation, and that therefore therewas a repression of the normal development of bones,ligaments and muscles. In all the younger children,under two years, he reduced the dislocation withoutanaesthesia, using as little violence as possible. Duringthe reduction the child’s knee was in the axilla, and thefemoral head was lifted forward by a rotatory movement.The reduction sometimes took quite a long time. Thefully abducted position was then retained by a brace.In the small babies the brace was a simple affair made ofcotton webbing, which went round the shoulders andchest and held -the knee. At one year old a stouter bracemade of leather was substituted, with an abduction stickrunning between the legs. Abduction to 90 degreeswas usually sufficient at this stage. When the aceta-bulum was well formed, abduction to 45 degrees wasenough and this could be retained by the abduction stickalone. During the whole treatment the children wereallowed as much freedom as possible ; they kickedabout, stood up in their cots, and, later, walked. Hos-pitalisation was reduced to the minimum, they wereeasily nursed and bathed and led natural and healthylives. The bones did not atrophy and the muscles didnot waste. Of 86 hips treated by this method he hadobtained 85 complete cures. In the older children, firstseen when the condition was fully developed, the methodgave good results but not so good. Prevention wasdefinitely better than cure. The index in the radio-gram of complete reduction was that the femoral epi-physis was seen to lie below the epiphysial line of theacetabulum.

Mr. H. A. T. FAIRBANK criticised the photographs andthe films shown by doubting whether abduction wasreally maintained. The early cases, under one year, hesaid were never true dislocations but only subluxa-tions. It was not a fair criticism of the Lorenz methodto say it was not functional. Mr. Fairbank’s own caseshad walked from the start. The plaster was heavier,but that was, as far as he saw, its only disadvantage.He agreed that cases reduced after 18 months to 2 yearsrarely gave a joint so normal that a difference in theX-ray appearance was not detectable to the eye of thetrained observer.

Mr. J. C. ScoTT said he had obtained good results byuse of an abduction frame and gradual reduction. Hecontrolled his results by arthrograms.

Professor BAUER in reply said that he had personallyworked with Lorenz, and treated three hundred cases byhis method. Lorenz specifically stated that the hip mustbe held quite immobile, although he allowed functionof the rest of the limb. The result was that the musclesand ligaments did contract.

Closed Plaster Treatment of WoundsMr. HiGGS began by recalling that ten years ago he

listened with incredulity mixed with horror to WinnettOrr’s exposition of his closed-plaster treatment of osteo-’myelitis before the Royal Society of Medicine. However,Winnett Orr’s results were impressive, and the method wassoon adopted by orthopaedic surgeons, who later expandedits use to the treatment of compound fractures. Thefighting in Spain had given ample proof of the value ofclosed plaster in the treatment of wounds not associatedwith bone injury. With a vivid recollection of thehorrors of wound treatment in the last war, of the

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imperfect immobilisation, the delayed union and non-union, the pain and the toxaemia, one was compelled tothe view that the closed-plaster method was a notableadvance in the surgical treatment of wounds. Hispresent remarks were based on his experience of 44consecutive cases almost all of them wounded men fromFrance. The majority had been admitted five daysafter being wounded, and were still wearing their uniformand their first field dressings, and almost all the woundswere heavily infected. It was too late for wound excision,so the wounds were cleaned, packed with vaseline gauze,and the limbs enclosed in unpadded plaster casts. In

only one case was it necessary to remove the plasterprematurely, and that was on account of haemorrhagefrom the circumflex artery. The advantages of themethod were that it relieved pain and prevented togaemia;that it stimulated the growth of granulation tissue ;that necrosis and sinus formation were exceptional,and bony union rapid ; that nerve suture was possibleat an earlier date ; and that it very much simplifiedthe difficult problem of infected joints. In two caseshe felt sure the adoption of this method had saved legsthat otherwise would have been amputated. Thedisadvantages of the method must be recognised, so thatthey might be overcome. The first was that inexperi-enced application of plaster might lead to gangrene.He had seen three cases, two in the lower limb and onein the upper limb. It was important never to neglectpain when it was complained of, and always to be surethat there was efficient drainage to the skin. There wasalso the difficulty in maintaining extension in lowerlimb fractures ; the smell, worse now in the long black-out hours than it had been in the summer ; the factthat the wounds remained messy till the plaster wasfinally discarded ; the dermatitis of the surroundingskin ; and the poor quality of the skin that covered thewounds when they healed under plaster. Improvementin this last factor might be obtained if skin-grafting wasused as soon as the fracture had united. The variousagents used to combat the smell had been effective onlyfor a week or two. The deodorising bags they hadobtained from Oxford were the best antidote they hadyet tried.

Dr. E. T. C. SPOONER reported the results of hisbacteriological examination of the pus from the woundsenclosed in plaster. The heemolytic streptococcus he hadfound to be the most important infecting organism.There had been no evidence to suggest that the anaerobeswere doing any particular harm in the wounds. Hewarned the -meeting that limb wounds treated in plasterwere not completely protected from outside infection,and that organisms from the wound found their way tothe outside of the plaster and were a potential source ofdanger to other patients in the ward.

Dr. J. TRUETA said he had been interested to find thatMr. Higgs’s experience was the same as his own. Drygangrene occurred under the plaster and not gas-gangrene.There was one type of bomb used in the Spanish War thatdid not seem to have been used in this country yet. Itseffect was to produce small metal fragments of greatpenetrative power that broke bones without shatteringthe muscles. The contractile tone of the muscles waspreserved and the fractures presented a problem morelike closed fractures. Extension was a difficulty andtraction was needed in a few. The closed-plastermethod was capable of giving very good results in civiliancasualties, but it had not been possible to use it in thefront line. To protect the skin from maceration headvised leaving the plaster off for 3-4 days at a time.

Mr. RAiNSPOBD MowLEM described the treatment ofwounds by early skin-grafting. Two days of con-

tinuous local treatment with sulphonamide after granu-lation had restored the level of wound to the skin edges,followed by a split graft, gave rapid epithelialisation inthe cases in which they had tried it. He believed thatin something like 75% of cases the wound was healed atthe next change of plaster.

Colonel RALPH BROOKE said that in France they hadfound that the difficulties of transport precluded the useof plaster. They used the Thomas splint for lowerlimbs and strapped the upper limb to the side. Debride-ment and flavine dressings had given surprisinglygood results. The first dressing was allowed to dry onand only the outer dressings were changed.

Mr. PRIDIE said they had found ultraviolet light to beone of the most potent sterilisers of wounds.

Treatment of Burns

Mr. MowLEM said that a first principle of treatmentmust be to avoid all methods in which the immediateresults were outweighed by future calamities. Hedoubted whether it was possible to distinguish clearlybetween primary and secondary shock, the two conditionsmight be almost coincident. Delayed shock occurredafter 6-8 hours, and the patient was gravely ill, the maincause of the condition being loss of tissue fluid. Hisimpression was that plasma diluted to the normal con-centration gave better results than the concentratedplasma. It was of the greatest importance to check thepatient’s haemoglobin concentration. The figure of115-120 meant that the patient was in extreme danger of .

immediate death. It had been found that a 5% riserequired 250 c.cm. plasma to restore it to normal. If, forexample, the haemoglobin percentage was 110, 500 c.cm.must be run in rapidly, and then a slow plasma dripestablished.The cause of the toxaemia in burns was not clear, but

it was not due to a bacillary septicaemia, for in fatalcases the findings at autopsy were not at all comparable.Three degrees of burns were now recognised. In thefirst and second, the skin recovered, and the first purposeof treatment-to obtain healing-was not difficult torealise. For these burns, in which there was not com-plete destruction of the skin, tannic acid, or the dyes,or any combination of these substances, was probablya good treatment, except for the hands. It greatlydecreased the difficulties of nursing. The trouble oftenwas to be quite sure on first inspection what was thedegree of the burn. Across flexures tannic acid shouldnot be used, because the tan always cracked, and thewound always became septic under it. For third-degreeburns, in which there was complete destruction of theskin, tannic acid was not to be used. The tan dependedfor its separation on epithelial growth beneath it. Thisdid not take place in third-degree burns. The tan hadto be removed with the knife and further mutilation wasinevitable. Tanning had the further disadvantage ofdestroying a proportion of the remaining skin cells, andso delayed healing. The skin that was formed under thetan was of a poor quality and more vascular. He didnot consider the various dyes any real improvementon tannic acid, and advised that all these serious burnsshould be treated by complete immersion-whether ofpatient or of limb-in saline baths. After two immer-sions the treatment was painless. Four hours a dayshould be spent in the bath, and the burnt area shouldthen be covered with gauze soaked in saline always keptmoist. Granulation was promoted, and the patientcould painlessly move the hands through the full rangeof movement. The disadvantage was that the burnswere prone to become rather easily infected, but sulph-anilamide had removed a large part of the fear ofsepsis. Early skin grafting was proving of great value,especially in burns of the hands. As soon as the surfacehad granulated level with the skin, powdered sulphanil-amide was applied for two days. This temporarilystopped the streptococcal infection. A splitgraft wasthen applied, with powdered sulphanilamide beneath it.All burnt hands should be primarily treated by salinebaths, and secondary grafting if skin loss was extensive.Tannic treatment produced first comfort, then a periodof intense pain controlled by morphia, and finally painlessfingers in which the circulation had been strangulated.

Sir Henry Dale, M.D., has been elected president of theRoyal Society in succession to Sir William Bragg. Otherofficers of the society are : treasurer, Prof. T. R. Merton,D.Sc. ; secretaries, Prof. A. V. Hill, Se.D., and Prof. A. C. G.Egerton, F.I.C. ; foreign secretary, Sir Henry Tizard,F.R.Ae.S. ; other members of council, Prof. P. M. S. Blackett,Prof. F. T. Brooks, Mr. C. G. Darwin, Sc.D., Dr. A. N.Drury, Mr. H. J. Gough, D.Sc., Prof. J. B. S. Haldane, Prof.I. M. Heilbron, D.Sc., Prof. 0. T. Jones, D.Se., Prof. R. T.Leiper, M.D., Sir Thomas Middleton, D.Se., Prof. L. J.Mordell, Mr. C. F. A. Pantin, Sc.D., Prof. H. S. Raper, M.B.,Prof. E. K. Rideal, Mr. F. J. W. Roughton, Ph.D. ; and Prof.A. M. Tyndall, D.Sc.