Part 2

In their monograph on The Abnormal Forms of Tetanus, MM. Courtois-Suffit and Giroux treat of those varieties of the disease in which the spasm is confined to a limited group of muscles, e. g. those of the head, or one or more limbs, or of the abdomino-thoracic muscles. The constitutional symptoms are less severe than in the generalised form of the disease, and the prognosis is more favourable.

The volume by Dr. G. Thilbierge on Syphilis in the Army is intended as a vade-mecum for medical officers in the army.

Turning now to works of neurological interest we have two volumes dealing with lesions of the peripheral nerves by Mme. Atanassio Benisty, who has been for several years assistant to Professor Pierre Marie at La Salpêtrière. The first volume contains an account of the anatomy and physiology of the peripheral nerves, together with the symptomatology of their lesions. The second volume is devoted to the prognosis and treatment of nerve lesions.

The monograph of MM. Babinski and Froment on Hysteria or Pithiatism and Nervous Disorders of a Reflex Character next claims attention. In the first part the old conception of hysteria, especially as it was built up by Charcot, is set forth, and is followed by a description of the modern conception of hysteria due to Babinski, who has suggested the substitution of the term "Pithiatism," i. e. a state curable by persuasion, for the old name hysteria. The second part deals with nervous disorders of a reflex character, consisting of contractures or paralysis following traumatism, which are frequently found in the neurology of war, and a variety of minor symptoms, such as muscular atrophy, exaggeration of the tendon reflexes, vasomotor, thermal and secretory changes, etc. An important section discusses the future of such men, especially as regards their disposal by medical boards.

An instructive companion volume to the above is to be found in the monograph of MM. Roussy and Lhermitte, which embodies a description of the psychoneuroses met with in war, starting with elementary motor disorders and concluding with the most complex represented by pure psychoses.

SURGICAL SERIES

When the present war began, surgeons, under the influence of the immortal work of Lister, had for more than a quarter of a century concerned themselves almost exclusively with elaborations of technique designed to shorten the time occupied in or to improve the results obtained by the many complex operations that the genius of Lister had rendered possible. The good behaviour of the wound was taken for granted whenever it was made, as it nearly always was, through unbroken skin, and hence the study of the treatment of wounds had become largely restricted to the study of the aseptic variety. Septic wounds were rarely seen, and antiseptic surgery had been almost forgotten. Very few of those who were called upon to treat the wounded in the early autumn of 1914 were familiar with the treatment of grossly septic compound fractures and wounded joints, and none had any wide experience. To these men the conditions of the wounds came as a sinister and disheartening revelation. They were suddenly confronted with a state of affairs, as far as the physical conditions in the wounds were concerned, for which it was necessary to go back a hundred years or more to find a parallel.

Hence the early period of the war was one of earnest search after the correct principles that should be applied to the removal of the unusual difficulties with which surgeons and physicians were faced. It was necessary to discover where and why the treatment that sufficed for affections among the civil population failed when it was applied to military casualties, and then to originate adequate measures for the relief of the latter. For many reasons this was a slow and laborious process, in spite of the multitude of workers and the wealth of scientific resources at their disposal. The ruthlessness of war must necessarily hamper the work of the medical scientist in almost every direction except in that of providing him with an abundance of material upon which to work. It limits the opportunity for deliberate critical observation and comparison that is so essential to the formation of an accurate estimation of values; it often compels work to be done under such high pressure and such unfavourable conditions that it becomes of little value for educative purposes. In all the armies, and on all the fronts, the pressure caused by the unprecedented number of casualties has necessitated rapid evacuation from the front along lines of communication, often of enormous length, and this means the transfer of cases through many hands, with its consequent division of responsibility, loss of continuity of treatment, and absence of prolonged observation by any one individual.

In addition to all this, it must be remembered that in this war the early conditions at the front were so uncertain that it was impossible to establish there the completely equipped scientific institutions for the treatment of the wounded that are now available under more assured circumstances, and that progress was thereby much hampered until definitive treatment could be undertaken at the early stage that is now possible.

But order has been steadily evolved out of chaos and many things are now being done at the front that would have been deemed impossible not many months ago. As general principles of treatment are established it is found practicable to give effect to them to their full logical extent, and though there are still many obscure points to be elucidated and many methods in use that still call for improvements, it is now safe to say that the position of the art of military medicine and surgery stands upon a sound foundation, and that its future may be regarded with confidence and sanguine expectation.

The views of great authorities who derive their knowledge from extensive first-hand practical experience gained in the field, cannot fail to serve as a most valuable asset to the less experienced, and must do much to enable them to derive the utmost value from the experience which will, in time, be theirs. The series covers the whole field of war surgery and medicine, and its predominating note is the exhaustive, practical and up-to-date manner in which it is handled. It is marked throughout not only by a wealth of detail, but by clearness of view and logical sequence of thought. Its study will convince the reader that, great as have been the advances in all departments in the services during this war, the progress made in the medical branch may fairly challenge comparison with that in any other, and that not the least among the services rendered by our great Ally, France, to the common cause is this brilliant contribution to our professional knowledge.

A glance at the list of surgical works in the series will show how completely the ground has been covered. Appropriately enough, the series opens with the volume on The Treatment of Infected Wounds, by A. Carrel and G. Dehelly. This is a direct product of the war which, in the opinion of many, bids fair to become epoch-making in the treatment of septic wounds. It is peculiar to the war and derived directly from it, and the work upon which it is based is as fine an example of correlated work on the part of the chemist, the bacteriologist and the clinician as could well be wished for. This volume will show many for the first time what a precise and scientific method the "Carrel treatment" really is.

The two volumes by Prof. Leriche on Fractures contain the practical application of the views of the great Lyons school of surgeons with regard to the treatment of injuries of bones and joints. Supported as they are by an appeal to an abundant clinical experience, they cannot fail to interest English surgeons, and to prove of the greatest value. It is only necessary to say the Wounds of the Abdomen are dealt with by Dr. Abadie, Wounds of the Vessels by Prof. Sencert, Wounds of the Skull and Brain by MM. Chatelin and De Martel, and Localisation and Extraction of Projectiles by Prof. Ombredanné and R. Ledoux-Lebard, to prove that the subjects have been allotted to very able and experienced exponents.

ALFRED KEOGH.

PREFACE

No attempt is made in this little book to describe all the artificial limbs and appliances that have been invented. Before the war these were very numerous, since then their number has become countless, and not a day passes without the appearance of some new model of greater or less ingenuity.

But all these special inventions, the utility of which we should not think of denying, are only of real practical value if the makers have followed out certain general principles in their manufacture. In the following pages we have attempted to indicate what these principles are.

Our experience has been gained in connection with the Fédération des Mutilés, where hundreds of disabled men have been examined and fitted, and where we have always tried to give to each that appliance which is best suited to his work.

For this indeed is the vital principle, and great disappointments will result if, for æsthetic reasons, every patient is given the same appliance, whether it be the leg known as the American leg or an elaborate artificial arm. More often than might be believed accurate imitation of the external form of the natural limb is incompatible with good functional use. This is particularly so in the upper limb.

Perhaps the readers of these pages will gain a clear understanding of these principles; and we shall have attained our object if by enabling them to understand certain typical appliances we make it possible for them to devise others which are at the same time strong, shapely and practical.

Throughout the volume it will be found that we express a preference for the construction of artificial limbs for the lower limb out of wood, the method adopted by the Americans. This procedure, because strength and durability are so necessary, seems to us to constitute a very real advance; these considerations are, however, of much less importance in the case of the upper limb. It is a matter for regret that the French official instructions have not compelled our manufacturers to adopt this technique, too often the latter are inclined to keep to their old routine, but they can be induced to alter it, as we have proved by our success at the Fédération des Mutilés.

There is nothing revolutionary in such a suggestion. It has been adopted by the Belgian Government in the fitting centres which they have established; this is also the case with the English authorities, who, we understand, have even attracted from America special fitters for this work. We should have thought that we, in France, might have developed our national supply of artificial limbs in the same direction.

INTRODUCTION TO THE ENGLISH EDITION

The details of the manufacture of artificial limbs naturally differ greatly in different countries. So much so that at first sight it might appear useless to introduce into England and America the account given in this work of the methods adopted in France. But, as the authors state in their preface, the principles remain the same whatever the details of the methods used. In the lower limb the essentials to be studied are the points upon which weight can be taken, the "Bearing Points," the proper method of fitting the stump, the principles of securing stability and the mechanism of the knee and ankle joints. These remain unalterable whatever be the material used and whatever be the details of manufacture.

In England it has for a long time been understood that every sailor or soldier who has lost a limb has the right to expect that he will be supplied with a good artificial substitute. And, further, it has been taken for granted that this will, in the case of the lower limb, be a full artificial leg and not a peg leg. Therefore the standard pattern has in England been a full limb, and the peg has only been supplied as a temporary appliance, and as an alternative appliance to be used when the other limb requires alteration or repair. For this reason the possibilities of the peg leg, except in its simplest form, have perhaps been neglected in this country, and a study of the French methods of making these peg legs, particularly the convertible peg leg, is well worth while.

The introduction of American artificial legs into this country has not been so revolutionary in its results as it is apparently in France, for we have been accustomed for many years to make the bucket out of a single piece of willow. The alterations in our methods introduced recently from America are essentially the following--

1. The use of a sling which passing over the shoulders is attached to the leg below the knee in such a way as to act as a mechanism for extending the knee.

2. The manufacture of the leg portion out of a single piece of wood.