UPPER EXTREMITY WRINGER INJURY JERRY L. FRANZ, M.D.,
AND
H. DAVID ROOT, M.D.
&dquo;Wringer arm&dquo; was initially used by MacCollum in 19381 to describe the complex traction-compression injury to skin, subcutaneous tissue, and muscles of the arm(s) that results from compression by the rollers of the clothes wringer of non-automatic washing machines. Strict guidelines for treatment have evolved from many clinical reports emphasizing the severity of’ complications that may occur.2-6 Current recommended management includes hospital admission, surgical preparation of the skin, compression dressing-elevation, and observation until the swelling has resolved. Complex tissue avulsion, fractures, and associated vascular injuries are treated immediately as indicated. This report is a clinical survey of 92 upper extremity wringer injuries in 90 patients treated at the Bexar County Hospital over the last four years. Attention is directed toward our immediate management and our delayed management of complex injuries. CLINICAL SURVEY
The medical records of all upper extremity wringer injuries treated at Bexar over the past four years were reviewed retrospectively. Records were reviewed for age, sex, admitting service, duration of hospitalization, radiographic findings, injury sustained, treatment regimen, and result of management. There were 92 extremities injured in 90 patients. Table 1 records the age distribution of’ the patients. Seventy-six percent of the patients were less than 10 years old. Orthopaedic surgery managed 57% of the patients, general surgery the remainder. Females accounted for 61% of the injured patients. Each extremity was equally involved. Table 2 lists the level of injury to the extremity. The hand or portions of the hand only were involved in 22% of the injuries. The injury extended to the elbow in 37%, and 72% of the injuries occurred below the elbow. The entire extremity was involved in 11%. Both extremities were injured in two patients. In one case, injury occurred to mid-forearm in one extremity, and to the wrist in the other. In the second case, injury extended to the elbow and the hand. No recurrent injuries were recorded. Table 3 records the manifestations of the sustained injury. Soft tissue swelling and pain were recorded for 96% of the involved extremities. Skin violation occurred in 79%. Major tissue avulsion was present in 8% while lacerations involved 15%. Table 4 lists six complex injuries that occurred.
County Hospital
From the University of Texas Health Science Center at San Antonio, Department of Surgery, 7703 Floyd Curl Drive, San Antonio, Texas 78284. Presented at the Twenty-First Annual Meeting, American College of Angiology, February 24-28, 1975, San Juan, Puerto Rico. 302
Downloaded from ves.sagepub.com at Bibliothekssystem der Universitaet Giessen on May 14, 2015
303 Table 1 AGE DISTRIBUTION
Table 2 LEVEL OF INJURY
Treatment for 87% consisted of admission to the hospital, a 10-minute surgical preparation with surgical scrub, compression dressing, elevation, and frequent observation. Thirteen lacerations were closed. No vascular insufficiency developed and no fasciotomies were required. Antibiotics were not routinely used. No enzyme preparations were utilized. The complex injuries were treated immediately as indicated in Table 4. Injury one was treated with debridement and closure. The extremity in Case 2 was debrided and loosely closed with K-wire fixation of the fracture. The hand in Case 3 was converted to a 3-finger hand. The tendon injuries of patients 4 and 6 were repaired and soft tissue defects debrided and closed. A Wolfe graft was utilized to replace the finger pulp in Case 5.
Downloaded from ves.sagepub.com at Bibliothekssystem der Universitaet Giessen on May 14, 2015
304 Table 3
INJURY MANIFESTATIONS
Full thickness skin slough occurred in 16 of 92 extremities. Twelve occurred 24 hours after injury. Five split thickness skin grafts were performed, all in the late group. It is of interest that two patients presented late, one at 3 days and the other at 3 weeks post-injury and each required grafting. Duration of hospitalization is shown in Table 5. Thirty-nine percent were hospitalized for two days or less, while 81% were confined for five days or less. Six patients did not return for followup examination. Five patients have some degree of impaired function of the extremity and are confined to the complex injury group as described in Table 4. DISCUSSION
The forces of injury from the washing machine wringer rollers are friction, avulsion and compression. Friction causes abrasion to skin as well as contusion and may be responsible for full or partial skin 10ss.3, 7. Avulsion forces are responsible for skin separation from its blood supply and subcutaneous hematoma formation and fat necrosis. 3, Compression causes contusion of the soft tissues with subsequent edema formation and fractures. The expanding edema in closed tissue compartments is thought to result in venous and lymphatic obstruction and later possible arterial insufficiency accompanied by ischemia of muscle, nerve and skin. ~, ’-9 Adams and Fowler9 describe the pathophysiology in immature rats. Hemorrhage, edema, venous dilatation, polymorphonuclear cell infiltrate, and muscle necrosis occur. Gross changes were initially evident at 3-5 hours and were maximal by 16-24 hours. Functional impairment occurred at 7-23 hours depending on the severity of injury. The loss of muscle function is possibly due to the muscle ischemia resulting from compression by expanding fluid in closed compartments.~7
Downloaded from ves.sagepub.com at Bibliothekssystem der Universitaet Giessen on May 14, 2015
305
Our clinical survey corresponds with most other series reported.’-’, 8-11, 18 Data indicates that there are fortunately few fractures and few complex injuries requiring extensive reconstructive procedures. Our data also shows no vascular injury and only small vessel problems of hematoma and edema formation. Surgical cleansing of the extremity is supported by most authors. 3-6, a-11, 18 In MacCollum’sl series and the early segment of Hausmann and Everett’sl0 series, local infections occurred. MacCollum actually had 6 cases of streptococcal septicemia. An antibiotic impregnated gauze is used to cover abrasions. MacCollum in 1938, used immobilization and ice packs followed by alternating hot and cold packs to reduce edema. Schultz 11 in 1946, suggested Table 4 ’
COMPLEX INJURIES
Downloaded from ves.sagepub.com at Bibliothekssystem der Universitaet Giessen on May 14, 2015
306 Table 5 DURATION OF HOSPITALIZATION
the use of pressure to prevent swelling. Comparison data by Hausmann and Everett 10 showed a decrease from 71°7o to 18% of patients requiring skin grafts. Initial treatment was hot compresses, multiple incisions, and Dakin’s solution. The later regimen consisted of surgical cleansing, debridement, sterile dressing, and antibiotics. Golden, et al.,12 point out that this comparison must be scrutinized closely because their initial group appeared to have more severe injury. Several authors3-6. 8-&dquo;, 18 confirm the value of compression dressing. Golden, et al.,12 and Chamberlain and Soltes 13 have found no difference between groups of patients treated with or without compression dressings. Elevation is routinely used, however. Authors agree that close observation is necessary. Golden, et aI.,12 and Lindsay, et al., treat some patients without hospitalization, but see tie patient daily. At Bexar County Hospital, our best mechanism for observation is admission because we have no daily clinic to follow patients. If close followup is available and patient return is assured, we agree with out-patient management in selected cases. The treatment regimen at Bexar County Hospital is standardized. All patients are admitted to the General Surgery Service for soft tissue injury or the Orthopaedic Surgery Service if fractures are present or hand surgery is required. All extremities are examined by a surgery resident for extent of injury and neurovascular status. Radiographic studies are obtained on all patients because children are frequently difficult to examine. All extremities are subjected to a 10-minute surgical scrub, except for complex injuries that are to be handled in the operating room. Antibiotic impregnated gauze is applied to abrasions and areas of skin loss that are not considered for grafting. The lacerations are sutured. A compression dressing is applied and the extremity is elevated. Frequent checks of the extremity by examination of the fingers are made by the nursing staff and resident staff. The patients are discharged after swelling has resolved and soft tissue injuries are progressively healing. Debridement and skin grafting are carried out as needed. If parents or family are reliable and the injury is considered to be
Downloaded from ves.sagepub.com at Bibliothekssystem der Universitaet Giessen on May 14, 2015
307 may be allowed to go home and be followed in the emergency procedure has only been followed one or two times. Oral and parenteral enzymes have been advocated to minimize edema and to hasten its resolution.14 Golden, et al.,12 have found these of little value.
&dquo;minor,&dquo; the patient room.
Bennett, value and
This
al.,15 have shown experimentally that only hyaluronidase is of only when injected early into the site of injury. Steroids have been
et
advocates 16 and condemned.&dquo; Additionally, parents are counseled with regards to prevention of recurrent injury or injury to siblings. Location of machine and the need to keep it unplugged are stressed. SUMMARY
A clinical survey of 92 upper extremity wringer injuries over the past four years at the Bexar County Hospital are presented. Our treatment regimen and results are outlined. Complex injuries occurred infrequently (7%). No vascular insufficiency developed and no fasciotomies were required. We are of the opinion that hospitalization is necessary in all but a small number of selected cases. Close observation is necessary to prevent edema progression and further tissue loss.
Ninety-two
upper
extremity compression injuries secondary
to
washing
machine wringers were reviewed. Seventy-six percent of the injuries occurred in persons under 10 years of age. Extremity distribution was equal. Injury occurred below the elbow in 72% of the extremities. Soft tissue injury was manifested by swelling and tenderness in 96%. Twenty-one percent had no violation of the skin. Major avulsion, such as third degree skin loss, crush injury, dislocation, and tendon avulsion, occurred in 8%. The treatment regimen consisted of surgical preparation with Betadine, compressing dressing, and elevation. Observation of the involved extremity is made every hour for development of vascular insufficiency. Fractures and other major injuries were treated as indicated. No fasciotomy was required. No vascular insufficiency developed. Skin slough was present in 16 of 92 extremities and skin graft was required in 5 of the 16. Results of treatment reveal 87% with no functional impairment of the involved extremity. Varying degrees of impairment are present in 6% of the injured extremities with all localized to the major avulsion group of injuries. . Franz D . ,M Jerry L The University of Texas Health Science Center at San Antonio
Department of Surgery 7703 Floyd Curl Drive San Antonio , Texas 78284 REFERENCES 1. 2.
MacCollum, D. W.: Wringer Adams, J. P., and Fowler,
Pathological
Arm. New Eng. J. Med., 218 : 549, 1938. F. D.: Wringer Injury of the Upper Extremity: A Clinical, and Experimental Study. South. Med. J., 52: 798, 1959.
Downloaded from ves.sagepub.com at Bibliothekssystem der Universitaet Giessen on May 14, 2015
308 3.
Allen, J. E., Beck, A. R., and Jewett, T. C.: Wringer Injuries in Children. Arch. Surg., 97 : 194,
4. 5.
: 500, 1960. Lynn, H. B., and Reed, R. C.: Wringer Injuries. J.A.M.A., 174 MacCollum, D. W., Bernhard, W. F., and Banner, R. L.: The Treatment of Wringer Arm New J. Injuries. Eng. Med., 247: 750, 1952. Mosely, T., and Hardman, W. W.: Treatment of Wringer Injuries in Children. South. Med. J.,
1968.
6.
: 58
7. 8. 9.
1372, 1965.
: 57, 1969. Strahan, J., and Crockett, D. J.: Wringer Injury. Injury 1 : Lindsay, W. R., Thompson, H. S., and Farmer, A. W.: The Wringer Injury. Can. J. Surg., 1 189, 1958. : Adams, J. P., and Fowler, F. D.: Observations in Wringer Injuries. J. Bone Joint Surg., 43
1179, 1961. 10. 11. 12.
Hausmann, P., and Everett, H. H.: Wringer Injury. Surgery, 28: 71, 1950. Schultz, I.: Wringer Injury. Surgery, 20: 301, 1946. Golden, G. T., Fisher, J. C., and Edgerton, M. T.: "Wringer Arm" Re-evaluated: A Surgery of Current Surgical Management of Upper Extremity Compression Injuries. Ann. Surg., 177 :
362, 1973. : 46, 1961. Chamberlain, J. W., and Soltes, M.: Wringer Injuries. Pediatrics, 28 Entin, M. A.: Roller and Wringer Injuries: Clinical and Experimental Studies. Plas. Reconstr. : 290, 1955. Surg., 15 15. Bennett, J. E., Zook, E. G., Ashbell, T. S., and Hugo, N. E.: The Spreading Enzymes and Localized Edema: A Study of Wringer Crush Injury in the Rabbit. J. Trauma, 10 : 240, 1970. 16. Medl, W. T.: ACTH in Crush Injuries of the Hand. Surg. Clin. North Amer., 34: 363, 1954. 17. Harrison, S. H.: Crush Injury of the Hand Treated by Cortisone. Br. J. Plast. Surg., 5: 181, 13. 14.
1952. 18.
: 1101, Allen, H. S.: Wringer Injury of the Upper Extremity. Ann. Surg., 113
Downloaded from ves.sagepub.com at Bibliothekssystem der Universitaet Giessen on May 14, 2015
1941.
AND
H. DAVID ROOT, M.D.
&dquo;Wringer arm&dquo; was initially used by MacCollum in 19381 to describe the complex traction-compression injury to skin, subcutaneous tissue, and muscles of the arm(s) that results from compression by the rollers of the clothes wringer of non-automatic washing machines. Strict guidelines for treatment have evolved from many clinical reports emphasizing the severity of’ complications that may occur.2-6 Current recommended management includes hospital admission, surgical preparation of the skin, compression dressing-elevation, and observation until the swelling has resolved. Complex tissue avulsion, fractures, and associated vascular injuries are treated immediately as indicated. This report is a clinical survey of 92 upper extremity wringer injuries in 90 patients treated at the Bexar County Hospital over the last four years. Attention is directed toward our immediate management and our delayed management of complex injuries. CLINICAL SURVEY
The medical records of all upper extremity wringer injuries treated at Bexar over the past four years were reviewed retrospectively. Records were reviewed for age, sex, admitting service, duration of hospitalization, radiographic findings, injury sustained, treatment regimen, and result of management. There were 92 extremities injured in 90 patients. Table 1 records the age distribution of’ the patients. Seventy-six percent of the patients were less than 10 years old. Orthopaedic surgery managed 57% of the patients, general surgery the remainder. Females accounted for 61% of the injured patients. Each extremity was equally involved. Table 2 lists the level of injury to the extremity. The hand or portions of the hand only were involved in 22% of the injuries. The injury extended to the elbow in 37%, and 72% of the injuries occurred below the elbow. The entire extremity was involved in 11%. Both extremities were injured in two patients. In one case, injury occurred to mid-forearm in one extremity, and to the wrist in the other. In the second case, injury extended to the elbow and the hand. No recurrent injuries were recorded. Table 3 records the manifestations of the sustained injury. Soft tissue swelling and pain were recorded for 96% of the involved extremities. Skin violation occurred in 79%. Major tissue avulsion was present in 8% while lacerations involved 15%. Table 4 lists six complex injuries that occurred.
County Hospital
From the University of Texas Health Science Center at San Antonio, Department of Surgery, 7703 Floyd Curl Drive, San Antonio, Texas 78284. Presented at the Twenty-First Annual Meeting, American College of Angiology, February 24-28, 1975, San Juan, Puerto Rico. 302
Downloaded from ves.sagepub.com at Bibliothekssystem der Universitaet Giessen on May 14, 2015
303 Table 1 AGE DISTRIBUTION
Table 2 LEVEL OF INJURY
Treatment for 87% consisted of admission to the hospital, a 10-minute surgical preparation with surgical scrub, compression dressing, elevation, and frequent observation. Thirteen lacerations were closed. No vascular insufficiency developed and no fasciotomies were required. Antibiotics were not routinely used. No enzyme preparations were utilized. The complex injuries were treated immediately as indicated in Table 4. Injury one was treated with debridement and closure. The extremity in Case 2 was debrided and loosely closed with K-wire fixation of the fracture. The hand in Case 3 was converted to a 3-finger hand. The tendon injuries of patients 4 and 6 were repaired and soft tissue defects debrided and closed. A Wolfe graft was utilized to replace the finger pulp in Case 5.
Downloaded from ves.sagepub.com at Bibliothekssystem der Universitaet Giessen on May 14, 2015
304 Table 3
INJURY MANIFESTATIONS
Full thickness skin slough occurred in 16 of 92 extremities. Twelve occurred 24 hours after injury. Five split thickness skin grafts were performed, all in the late group. It is of interest that two patients presented late, one at 3 days and the other at 3 weeks post-injury and each required grafting. Duration of hospitalization is shown in Table 5. Thirty-nine percent were hospitalized for two days or less, while 81% were confined for five days or less. Six patients did not return for followup examination. Five patients have some degree of impaired function of the extremity and are confined to the complex injury group as described in Table 4. DISCUSSION
The forces of injury from the washing machine wringer rollers are friction, avulsion and compression. Friction causes abrasion to skin as well as contusion and may be responsible for full or partial skin 10ss.3, 7. Avulsion forces are responsible for skin separation from its blood supply and subcutaneous hematoma formation and fat necrosis. 3, Compression causes contusion of the soft tissues with subsequent edema formation and fractures. The expanding edema in closed tissue compartments is thought to result in venous and lymphatic obstruction and later possible arterial insufficiency accompanied by ischemia of muscle, nerve and skin. ~, ’-9 Adams and Fowler9 describe the pathophysiology in immature rats. Hemorrhage, edema, venous dilatation, polymorphonuclear cell infiltrate, and muscle necrosis occur. Gross changes were initially evident at 3-5 hours and were maximal by 16-24 hours. Functional impairment occurred at 7-23 hours depending on the severity of injury. The loss of muscle function is possibly due to the muscle ischemia resulting from compression by expanding fluid in closed compartments.~7
Downloaded from ves.sagepub.com at Bibliothekssystem der Universitaet Giessen on May 14, 2015
305
Our clinical survey corresponds with most other series reported.’-’, 8-11, 18 Data indicates that there are fortunately few fractures and few complex injuries requiring extensive reconstructive procedures. Our data also shows no vascular injury and only small vessel problems of hematoma and edema formation. Surgical cleansing of the extremity is supported by most authors. 3-6, a-11, 18 In MacCollum’sl series and the early segment of Hausmann and Everett’sl0 series, local infections occurred. MacCollum actually had 6 cases of streptococcal septicemia. An antibiotic impregnated gauze is used to cover abrasions. MacCollum in 1938, used immobilization and ice packs followed by alternating hot and cold packs to reduce edema. Schultz 11 in 1946, suggested Table 4 ’
COMPLEX INJURIES
Downloaded from ves.sagepub.com at Bibliothekssystem der Universitaet Giessen on May 14, 2015
306 Table 5 DURATION OF HOSPITALIZATION
the use of pressure to prevent swelling. Comparison data by Hausmann and Everett 10 showed a decrease from 71°7o to 18% of patients requiring skin grafts. Initial treatment was hot compresses, multiple incisions, and Dakin’s solution. The later regimen consisted of surgical cleansing, debridement, sterile dressing, and antibiotics. Golden, et al.,12 point out that this comparison must be scrutinized closely because their initial group appeared to have more severe injury. Several authors3-6. 8-&dquo;, 18 confirm the value of compression dressing. Golden, et al.,12 and Chamberlain and Soltes 13 have found no difference between groups of patients treated with or without compression dressings. Elevation is routinely used, however. Authors agree that close observation is necessary. Golden, et aI.,12 and Lindsay, et al., treat some patients without hospitalization, but see tie patient daily. At Bexar County Hospital, our best mechanism for observation is admission because we have no daily clinic to follow patients. If close followup is available and patient return is assured, we agree with out-patient management in selected cases. The treatment regimen at Bexar County Hospital is standardized. All patients are admitted to the General Surgery Service for soft tissue injury or the Orthopaedic Surgery Service if fractures are present or hand surgery is required. All extremities are examined by a surgery resident for extent of injury and neurovascular status. Radiographic studies are obtained on all patients because children are frequently difficult to examine. All extremities are subjected to a 10-minute surgical scrub, except for complex injuries that are to be handled in the operating room. Antibiotic impregnated gauze is applied to abrasions and areas of skin loss that are not considered for grafting. The lacerations are sutured. A compression dressing is applied and the extremity is elevated. Frequent checks of the extremity by examination of the fingers are made by the nursing staff and resident staff. The patients are discharged after swelling has resolved and soft tissue injuries are progressively healing. Debridement and skin grafting are carried out as needed. If parents or family are reliable and the injury is considered to be
Downloaded from ves.sagepub.com at Bibliothekssystem der Universitaet Giessen on May 14, 2015
307 may be allowed to go home and be followed in the emergency procedure has only been followed one or two times. Oral and parenteral enzymes have been advocated to minimize edema and to hasten its resolution.14 Golden, et al.,12 have found these of little value.
&dquo;minor,&dquo; the patient room.
Bennett, value and
This
al.,15 have shown experimentally that only hyaluronidase is of only when injected early into the site of injury. Steroids have been
et
advocates 16 and condemned.&dquo; Additionally, parents are counseled with regards to prevention of recurrent injury or injury to siblings. Location of machine and the need to keep it unplugged are stressed. SUMMARY
A clinical survey of 92 upper extremity wringer injuries over the past four years at the Bexar County Hospital are presented. Our treatment regimen and results are outlined. Complex injuries occurred infrequently (7%). No vascular insufficiency developed and no fasciotomies were required. We are of the opinion that hospitalization is necessary in all but a small number of selected cases. Close observation is necessary to prevent edema progression and further tissue loss.
Ninety-two
upper
extremity compression injuries secondary
to
washing
machine wringers were reviewed. Seventy-six percent of the injuries occurred in persons under 10 years of age. Extremity distribution was equal. Injury occurred below the elbow in 72% of the extremities. Soft tissue injury was manifested by swelling and tenderness in 96%. Twenty-one percent had no violation of the skin. Major avulsion, such as third degree skin loss, crush injury, dislocation, and tendon avulsion, occurred in 8%. The treatment regimen consisted of surgical preparation with Betadine, compressing dressing, and elevation. Observation of the involved extremity is made every hour for development of vascular insufficiency. Fractures and other major injuries were treated as indicated. No fasciotomy was required. No vascular insufficiency developed. Skin slough was present in 16 of 92 extremities and skin graft was required in 5 of the 16. Results of treatment reveal 87% with no functional impairment of the involved extremity. Varying degrees of impairment are present in 6% of the injured extremities with all localized to the major avulsion group of injuries. . Franz D . ,M Jerry L The University of Texas Health Science Center at San Antonio
Department of Surgery 7703 Floyd Curl Drive San Antonio , Texas 78284 REFERENCES 1. 2.
MacCollum, D. W.: Wringer Adams, J. P., and Fowler,
Pathological
Arm. New Eng. J. Med., 218 : 549, 1938. F. D.: Wringer Injury of the Upper Extremity: A Clinical, and Experimental Study. South. Med. J., 52: 798, 1959.
Downloaded from ves.sagepub.com at Bibliothekssystem der Universitaet Giessen on May 14, 2015
308 3.
Allen, J. E., Beck, A. R., and Jewett, T. C.: Wringer Injuries in Children. Arch. Surg., 97 : 194,
4. 5.
: 500, 1960. Lynn, H. B., and Reed, R. C.: Wringer Injuries. J.A.M.A., 174 MacCollum, D. W., Bernhard, W. F., and Banner, R. L.: The Treatment of Wringer Arm New J. Injuries. Eng. Med., 247: 750, 1952. Mosely, T., and Hardman, W. W.: Treatment of Wringer Injuries in Children. South. Med. J.,
1968.
6.
: 58
7. 8. 9.
1372, 1965.
: 57, 1969. Strahan, J., and Crockett, D. J.: Wringer Injury. Injury 1 : Lindsay, W. R., Thompson, H. S., and Farmer, A. W.: The Wringer Injury. Can. J. Surg., 1 189, 1958. : Adams, J. P., and Fowler, F. D.: Observations in Wringer Injuries. J. Bone Joint Surg., 43
1179, 1961. 10. 11. 12.
Hausmann, P., and Everett, H. H.: Wringer Injury. Surgery, 28: 71, 1950. Schultz, I.: Wringer Injury. Surgery, 20: 301, 1946. Golden, G. T., Fisher, J. C., and Edgerton, M. T.: "Wringer Arm" Re-evaluated: A Surgery of Current Surgical Management of Upper Extremity Compression Injuries. Ann. Surg., 177 :
362, 1973. : 46, 1961. Chamberlain, J. W., and Soltes, M.: Wringer Injuries. Pediatrics, 28 Entin, M. A.: Roller and Wringer Injuries: Clinical and Experimental Studies. Plas. Reconstr. : 290, 1955. Surg., 15 15. Bennett, J. E., Zook, E. G., Ashbell, T. S., and Hugo, N. E.: The Spreading Enzymes and Localized Edema: A Study of Wringer Crush Injury in the Rabbit. J. Trauma, 10 : 240, 1970. 16. Medl, W. T.: ACTH in Crush Injuries of the Hand. Surg. Clin. North Amer., 34: 363, 1954. 17. Harrison, S. H.: Crush Injury of the Hand Treated by Cortisone. Br. J. Plast. Surg., 5: 181, 13. 14.
1952. 18.
: 1101, Allen, H. S.: Wringer Injury of the Upper Extremity. Ann. Surg., 113
Downloaded from ves.sagepub.com at Bibliothekssystem der Universitaet Giessen on May 14, 2015
1941.
