In the latter half of the nineteenth century, there was growing interest in the operation of the nervous system in health and disease. University professors studied different aspects of neurological form and function. On the clinical side, several new hospitals devoted to the nervous system were established in the British capital (see ), and an insane asylum in the north of England became a leading center for research into mental and neurological disorders. In Paris, the large Salpêtrière Hospital was converted from a hospice for destitute, chronically ill, or supposedly immoral women to a hospital with a primary focus on neurological disease. Patients were examined, symptoms and signs were analyzed, distinct diseases were identified, and treatable disorders were managed appropriately. Patients were also photographed, and some were studied by electrical techniques and even by muscle biopsy. Neurology was emerging as a distinct discipline of medicine. Important centers for neurological and psychiatric diseases were established at many other Parisian institutions including the famous Pitié, Bicȇtre, and Sainte Anne hospitals.

In 1914, Europe blundered into war. Horsley regarded it as “an insane folly” and hoped that it would lead the peoples of Central Europe to rise up and remove their rulers from power, that democracy and universal suffrage would follow. He did not foresee that an uprising against the government would occur in Russia, one of the allies but a country that he detested because of its autocratic barbarism.

Horsley should have had charge of a center for head injuries in Western Europe or Alexandria, where his skills as a neurological surgeon could have been used to best advantage. Instead, the authorities foolishly allowed him to go to Mesopotamia, then a seeming outpost of the war, believing he would be a less visible nuisance, and there he died, pushing hard to improve the care of the needy. His death was something that he himself had considered. Even as he was leaving Egypt for Mesopotamia, he had said to Eldred: “I don’t matter, I can’t live forever, it’s the young that matter.”1 Surprisingly, an administrative error resulted in a failure of the war office to notify his family that he had died, and Eldred only learned of it when she received a letter of sympathy from a friend.2

Extensive blunt soft tissue trauma may occur after traffic accidents, falls from significant heights, and crush injuries. It is a common problem after major earthquakes or collapsed buildings (see Chapter 15, Disaster Medicine). Injuries can be closed, open, or both.

Disasters often occur without any warning and may result in mass casualties that can overwhelm the capacity of local and regional healthcare systems. The etiology of disasters can be man-made or natural, can be localized or effect a large geographic area, and can result in minimal harm to the population or mass casualties. The most lethal natural disasters include earthquakes, hurricanes, floods, tsunamis, snowstorms, and fires. Man-made disasters include wars, building collapses, mine cave-ins, chemical and biological exposures, nuclear accidents, and civil unrest.

Traditionally, a tube thoracostomy is placed using the open technique; however, percutaneous techniques, and those using serial dilation, are also acceptable. Care should be taken with trocar techniques due to the high incidence of iatrogenic injuries.

The pregnant patient represents a double resuscitation, as there are two patients to simultaneously consider. Fetal resuscitation is dependent upon adequate maternal resuscitation and stability and ongoing monitoring of both patients is essential for optimal outcomes. The pregnant trauma patient poses additional challenges because the anatomy and physiology are different from the nonpregnant patient, and this affects the physical exam, the clinical presentation, and the management of the patient.

Place the tourniquet around the limb and weave the strap through the buckle. Alternatively, in tourniquets that come preassembled, they can be slipped over the limb. If possible, clothing should be removed prior to placement. If this is not possible, avoid placing tourniquet over bulky clothing or pockets.

Chest trauma is estimated to be the primary cause of death in 25% of traumatic mortalities and a contributing factor in another 25% of deaths. Good understanding of the pathophysiology of chest trauma and timely selection of the appropriate investigations and treatment are all critical components for optimal outcome.

In the US, approximately 10,000 spinal cord injuries yearly result in permanent disability. Most spinal cord injuries are caused by motor vehicle collisions (40%), violence (30%), falls (20%), and sporting accidents (6%). Although spinal fractures can occur in any age group, the peak incidence is in males from ages 18 to 25. Certain conditions predispose to spinal fracture, spinal cord injury, or dislocation: old age, rheumatoid arthritis, osteoporosis, and spinal stenosis.

Ultrasound offers a quick, repeatable, and moderately sensitive assessment for an important subset of traumatic injuries. The Focused Assessment with Sonography for Trauma (FAST) exam is performed at the bedside without the need to transport a potentially unstable patient away from a monitored setting. The investigation is now incorporated into ATLS guidelines.

Neck injuries, particularly those due to penetrating trauma, are difficult to evaluate and manage due to the dense concentration of vital structures in a small anatomical space that can be surgically challenging to access. Only 15–20% of patients with penetrating trauma and very few with blunt mechanism require operative intervention. Meticulous clinical examination and well-selected diagnostic investigations are paramount to safely selecting those patients who require an operation and those that can be observed.

Diagnostic peritoneal aspiration (DPA) involves the insertion of a needle or a catheter in the peritoneal cavity and aspiration of any blood or other fluid. Diagnostic peritoneal lavage (DPL) includes infusion of normal saline, lavage of the cavity, and macroscopic and microscopic evaluation of the returned fluid.