TO-DAY I have been asked to talk about what one would do in the event of an air raid, where one would be meeting all sorts of casualties, and I do not quite know how to tackle it, because you will have the ordinary injuries to deal with and, in addition, there will be a large fear-element, and it is going to be very difficult to give you anything more than an outline of what you may be up against and how you are going to tackle it. As far as I can see the only way one could approach the subject would be to imagine an air raid–go to the movies and see what it is like–and then try and picture what sort of injuries it would produce; or find out from the Spanish medical men what sort of injuries they met with, and see what sort of drugs you would require to use for them. But it is going to be very sketchy and theoretical, and I do not know whether it will be of much value.
The other thing people are very much exercised in their minds about is what they are going to do for gas cases should they have to deal with them.
Well, as regards the ordinary injuries, it depends very largely on the type of bombs that are used. If they are using the small bombs, such as they used mainly in Spain, we shall get any amount of small puncture wounds with a great deal of destruction of the soft tissues underneath. The splinters from the small bombs are very small, they are just like little pieces of tin really, they make quite a small hole in the skin but lacerate the soft tissues underneath to an enormous extent. They are the kind of case which is the ideal breeding ground for gas gangrene.
And for a case of that sort, an injury of that sort, there are two drugs which you will have to consider; and it will be very difficult until we see the cases to know which drug is going to be the most useful. It is exactly the picture one is accustomed to associate with Arnica.
But I am not sure that from the point of view of considering the danger of gas gangrene, we would not be much better using Ledum for these cases rather than Arnica. Ledum has a definite prophylactic effect on gas gangrene ; but where gas gangrene has actually developed you get much more effect from one of the drugs like Crotalus horridus, which has much more the appearance of a gas gangrene wound with its typical horrible black look and the complete liquifaction of the tissues.
So once you have got a gas gangrene I think you will want Crotalus rather than Ledum ; but as a prophylactic I think Ledum will be more helpful. If, as one hopes. Arnica will greatly minimize the effusion of blood from the area underneath, then it will also minimize the nidus for your gas gangrene to grow in, and it is quite possible that Arnica will be a most useful prophylactic; but personally I think Ledum will be more hopeful; and if gas gangrene develops, one of the snake poisons will be most useful of all.
Then again, these small, irregular fragments do set up a frightfully painful wound, which makes one wonder if Hypericum is not going to come into the picture too, because it produces the horribly septic, spreading type of infection and much more acutely, violently, painful injuries than either Ledum and Arnica. Ledum and Arnica, have much more the dull pain, and Hypericum the flaring, stabbing pains which you are likely to get from these rough, small fragments. And Hypericum, again, is a powerful prophylactic in the way of sepsis developing in a small wound.
So these are the three drugs on which I think you will have to ring the changes in the immediate stage.
Then, as far as the other types of injuries are concerned, where you have got definite dislocations or fractures. Here I think the simplest way is to take the question up in degrees of severity.
If the patient has merely been knocked over and bruised, perhaps with a dislocated shoulder or wrist, then in the first instance you should consider whether the nervous alarm–the fear element–or the actual physical injury is the more important. If you decide that the shock and terror is of greater importance, I think in the first instance you would be very much wiser giving them a dose of Aconite, just for the sudden, terrifying experience they have gone through. Aconite will often steady the nerves, and then you will have to treat the actual traumatic condition.
If the injury is a simple sprain, you come down to the old trinity of Arnica, Rhus tox. and Ruta. The Arnica patient, of course, will want to keep as still as possible, and there will be effusion and a lot of swelling of the injured part. The Rhus patient will have less swelling of the injured part, the affected joint will feel horribly stiff, and the patient will always be wanting to move the injured part just to ease it, it stiffen up so abominably if kept still.
And anatomically Ruta has rather more affinity for a piece of periosteum torn away from bone, or a ligament torn from its attachment, rather than fro the ordinary strain in which a few fibres are split in the course of a tendon. It is when the injury is at the junction of fibrous ligament and bone that Ruta particularly helps you.
Then when you are dealing with a fracture, it depends to a very large extent whether you have got a simple fracture or a compound fracture. I think most simple fractures get their greatest relief from Arnica in the first instance, I mean as the immediate treatment of them.
In the compound fractures I think you mostly have much more nerve injury as well, owing to the fact that the ends of the bone come in contact with the cutaneous nerves, and you get much more stabbing pain as well as the bruised condition. And you very often find you want a dose of Hypericum, rather than Arnica, in the first instance, until the fracture has been set, and then you want some Arnica to follow it up with.
Then there is the question of dressings for wounds. Here it is going to be very difficult, because all these people are automatically going to hospital, and there will be definite instructions issued by the authorities as to what dressings are to be applied, and these instructions will more or less have to be followed. On the other hand, were one free to treat these cases as one wished, personally I would have no hesitation in going away from the ordinary, automatic painting of everything with Iodine, and would apply Calendula dressings to all these wounds without exception. I think they do much better.
If you have a devitalized tissue and apply strong antiseptic dressings you still further devitalize it, and your ultimate result is bad. Whereas if you use a part-antiseptic, part-stimulant like Calendula, you get a very much better result you do no get bad septic wounds if you treat them with Calendula. Supposing you have a shattered stump, and you put in into a Calendula clean wound you get, instead of the septic, sloughing wound you have been accustomed to see. And as regards changing dressings.
If I were dealing with a large, lacerated area I would change the dressing every four hours. If it was quite a simple wound I would change the dressing every twelve hours. But I am afraid we shall not be allowed to treat wounds as we like, and it is not as if we would be able to see the patents through from start to finish, for if there is much air activity we shall not be allowed to keep the patients but will have to clear them all out of this hospital at the end of twenty-four hours.
As regards the question of Anti-tetanus and Anti-gas serums. Again we shall almost certainly be told what we have to do, and as the essence of all these treatments is early administration, and as the case will be going out of homoeopathic hands, I think the only fair thing to do for the patients is to initiate the treatment as soon as possible and give Anti-tetanus. or Anti-gas serum as the case may be. But, even, with the administration of these, I should feel inclined to give the homoeopathic drug as well.
The reason being that where we were dealing with diphtheria cases, which we had to send on to the fever hospital, we found that the administration of the homoeopathic drug plus their serum materially speeded up their recovery and minimized the severity of the attack as compared with treating them by serum alone. So in these casualties I should treat them on homoeopathic lines plus whatever the authorities ordered. I do not think the administration of the serum will interfere with the homoeopathic drug.
Then there is one other useful thing to remember, namely that where you are dealing with a scalp wound Calendula in potency has a peculiar affinity for scalp wounds. You can diminish the probability of sepsis in scalp wounds by giving Calendula in potency as well as applying a local Calendula dressing.
I am perfectly certain you would be astonished at the way these scalp wounds do not go septic after the administration of Calendula, This is the case even when you would normally expect the wounds to go septic–and you know how beastly they are if they go septic, and you get a horrible mess tracking under the tense fascia, so if you can avoid that it is well worth while. So to any casualties with a scalp wound I would certainly give Calendula in potency automatically–three or four doses about an hour apart– and I should expect definitely to minimize the scalp sepsis.
Fortunately, in a Casualty Clearing Station like this we shall not see the later cases, the people who have gone badly septic. There you may require any of the acutely septic drugs, such as the Snake Poisons, Hepar, Silica, Pyrogen; any of these may be required in the later stages. But as we shall not have to deal with them here I shall not attempt to give you the indications.
Then, to take up the question of pure nervous trauma, the terrified patients. I think you have to concentrate on the fact that the nervous element is fear, and you will have to give our terrified drugs. In the immediate onset the drug that is going to stand you in greatest stead is Aconite. There has been a tendency in considering these cases to advocate the administration of Ignatia. The patients come in weeping, terrified, and shaking giving quite an Ignatia picture, but I am perfectly certain that Ignatia will not work.
Ignatia patients are shocked patients, but they are not shocked from the same cause, they have not been terrified out of their wits; and Ignatia will let you down in most of these cases. Whereas, if you get patients coming in jittering as some of them will do, unable to keep still, simply terrified out of their wits, jumping at every sound, that is the typical Aconite picture; and Aconite is going to quieten them down more quickly than anything else, and with far less harm to them and a far more speedy recovery than by putting them on to sedatives.
We are advised by the consulting neurologist than any badly shocked case should be put on to two to four drachms of Paraldehyde right away, in order to induce from four to eight hours sleep, and that at the end of that time the patient will be perfectly all right. But I am quite sure you will get much better results by giving Aconite, and the patients will get up feeling much better than they would after Paraldehyde. I would give a 200 every fifteen minutes.
Then as regards the treatment of the worst cases of shock, where the patients go on to loss of speech, twitching and convulsions. They are a little more difficult to cover, and the two drugs that I think you will find most useful are Hyoscyamus and Stramonium. Certain of these cases are definitely violent, and in these more violent cases you will want Stramonium. It is an absolute picture of the condition which you will meet, and it has the fear element as marked as in Aconite, and Stramonium will help you out with these violent cases.
But where the patients suffer from loss of memory, not knowing where they are, unable to remember their names, general hebetude, Hyoscyamus is going to help more than any other drug in the Materia Medica. It, again, has the fear element in it, and again, the peculiar dissociation that we meet with in the case of shell shock patients. It is rather interesting to notice that the orthodox do recommend giving Hyoscyamus rather than Paraldehyde in some of these cases; they say they get better results.
In cases of pure scare, as from an air raid warning, Aconite will often quieten the patients. Very often they are suffering from anticipation, not fear, and then they will run to Ignatia, Phosphoric acid, Argentum nit., or Gelsemium. And, incidentally, Gels. is one of our great standbys for the patient who is alternately hot and cold, shivering, trembling, and in a constant state of anticipation. Argentum nit. gets an acute sick feeling, with a sensation of “tummy turning” or with diarrhoea. Your Ignatia is just shaky, trembling, weepy, wanting to be comforted and told they are all right.
Then the other type of casualty we may have to deal with in these air raids is the gas casualty. And it is very difficult to say exactly what is going to be our greatest help in these gas cases. I think the most helpful way to look at the problem is to take the two types of gas with which we are most likely to meet. I think we are almost certain to be up against Mustard Gas or a gas of that type, but we may also have some of the lachrymatory gases to cope with. Mustard Gas is the deadly type. And with Mustard Gas the problem differs to the tissue attacked.
The actual danger to the eyes will have been tackled to a large extend by the mechanical measures taken to wash them out, so when you see them after they have been decontaminated you will get very little indication on which to prescribe. We have a potency of Mustard Gas made, and failing, any other indication, personally I should give every one of these cases whose eyes had been attacked by Mustard Gas a dose of potentized Mustard Gas, purely as a prophylactic measure.
You may get no immediate eye symptoms at all, or very slight ones which may subside after the eyes have been cleaned out and yet at anytime up to twenty-five years afterwards to least you may get a degenerative condition of the epithelial covering of the cornea, which simply dies. It is a very insidious thing; it may develop at any time even years after; and if we can get a prophylactic to stop it, it is worth trying. I cannot tell you that potentized Mustard Gas works, as we hadnt it in the last war, but I think it will work, and it certainly ought to be tried as a prophylactic. There are still cases of corneal ulceration developing, due to exposure to gas in the last war twenty-five years ago.
So far as the acuter stages are concerned, we have to rely mainly on mechanical measures of washing out the irritant. As regards treating any remaining acute conjunctivitis, it is very difficult to know what will be our most useful medicine. There are dozens of drugs which have acute inflammatory conditions of the eyes and one cannot know in advance which is going to be most useful.
Another effect produced by Mustard Gas is an intense burning irritation of the skin, which is a slowly developing, acute dermatitis. Clinically, the outstanding characteristic is the fact that the irritation develops long before there is any sign of acute inflammation in the skin. The first thing the soldier used to complain about in the last war was the irritation; he could not see anything, but it got steadily worse. The drug in the Materia Medica which behaves like that is Mezereum, which starts as an acute irritation in the skin, blowing up into an acute dermatitis; and it is quite possible that Mezereum may be helpful in these skin conditions.
I think the probability is that we shall have to use other drugs as well, and the kind of drugs and I would expect to be indicated are those drugs and produce an acute dermatitis from a surface irritation, such as Poison ivy, Croton oil, and so on; possibly Petroleum, which, again produces a slowly developing, very acute dermatitis, but more probably Anacardium, Clematis, Croton tig, Rhus tox, Ranunculus, that group of drugs. They all produce a somewhat similar kind of dermatitis, but of the lot Mezereum produces the irritation most marked before the dermatitis develops.
Once vesication of the skin has developed, I think Croton tig. is going to help you more than anything, but Nitric acid and Carbolic acid, which both have the horrible, corrosive irritation, may also be useful, and possible Apis.
The most serious lesion produced by this Mustard Gas is acute pulmonary oedema; and that was the deadly factor during the last war. The men used to come in with their lungs simply bubbling from top to bottom, coughing incessantly, and spitting up a little blood-stained, watery fluid, the lungs rapidly became completely waterlogged, and they simply died like flies.
Well, there are certain drugs which have a very definite similarity to the picture that one sees in these cases. In the last war the least severe cases presented a picture which is almost identical with Ipecac. They were hot, and miserable, and felt deadly ill, they were very often sick with the attempt to cough, and they had a very rapid pulse. They were covered with a hot, clammy sweat, and, of course they were cyanosed. And that picture does respond to Ipecac.
In the next stage, a little beyond the Ipecac picture, they were rather more cyanosed, there was rather more blood in the sputum, it was rather darker in colour, and there was rather more blood in the sputum, it was rather darker in colour, and there was more definite evidence of heart failure, and they went on to Laurocerasus.
There was another stage, very similar to the last, with rather less coughing, possibly less fluid in the chest, with the feeling that their chests were absolutely bursting, rather more definite cyanosis, more obvious heart failure, and extreme air hunger; and they responded to Lachesis.
There were others, again who were very hot, very sweaty, very offensive with very offensive mouth, and who were coughing up a somewhat purulent, bloody, frothy sputum. They were horribly restless, shaky, tremulous, and either burning hot or sweaty and cold. And they responded to Mercury.
And then, lastly, there was another type; the patients were paler, completely thirstless, with more bubbles in their chests, though less able to get up any sputum at all, getting rather cold, beginning to collapse. And they ran either to antimony tart. or to Arsenic.
These acute gas cases are the most horrifying sight you can imagine; they simply die off in no time at all. They have complete destruction of the alveolar lining of their lungs, the whole chest just full of watery blood.
For the bronchitis which comes afterwards, or which may be induced by a mild dose of gas, one may require any of the bronchitis drugs, and there is nothing peculiar about them, One still meets men who had a very mild dose of gas, perhaps just a little day after day, never enough to knock them out, but whose lungs have never been sound since.
Well, that is the picture of gas cases a I remember them, and these are the drugs that I think you will want to use. A lot of this is fitting the Materia Medica to the pictures I remember, and I do not like doing this; in this class I like to tell you the things I have done, the things I can speak of fro experience, and although these gas cases responded to the different drugs, they were evacuated from the Field ambulance as soon as possible, and one had no chance of seeing them through to a finish.
Fortunately we have not yet had a experience, and I hope we shall not get it, but if we have an idea of the kind of things to look for it may be a help. I can tell you the one side, and I can tell you the other side, but I have not had an opportunity of combing the two. I have seen the gas, and I do know my Materia Medica, but I have not had an opportunity of combining the two and treating the cases to a conclusion and I hope I shall never have to do so. But that is what I shall look if I do see these cases.