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BACK FROM THE FRONT
761
BACK FROM THE FRONT
THE LANCET
-
LON.DON: ST 171DY, JUNE 10, 1944
BACK FROM THE FRONT In training, equipment and leadership our army of invasion is perhaps the best force this country has ever put into the field : and its medical services are in keeping with the rest. Many of the medical units have long experience of previous campaigns ; others carry a number of battle-trained veterans on their muster. Their work, the primary treatment of casualties, will be well done. We of the medical services at home, who for the first time have been given our place in the battle order, must see to it that our work is also good. The casualties of open warfare, which many surgeons will be treating for the first time, differ from those of air bombardment in three main ways :1. Their wounds
injuries is far tissue
caused
are mostly penetrating or perforating by high-speed projectiles. Haemorrhage
Laceration and devitalisation of found to a greater extent and to a greater depth. Contamination by dirt, and the lodgment of foreign matter, bits of clothing and metal fragments, must be expected. Pathogenic organisms, particularly the spore-bearing anaerobes, are usually present. Shock in the wounded soldier is usually the result of haemorrhage ; loss of plasma, and nervous and toxic factors are less important. 2. The time-lag between wounding and surgical treatment is inevitably greater. In air-raids the injured may reach the operating-table within two hours ; but in mobile war they seldom reach a surgical group in less than twelve hours, and when the sea separates the fighting line from the main medical centres those who are not treated by the surgical units of the field force must face a longer journey before they come under the care of a surgeon in England. Air transport cannot play a large part in evacuation till a broad belt of territory has been captured and cleared. 3. The patients come, not as sojourners, but as migrants. When a hospital acts as casualty-clearing station, all but those who cannot be moved without grave danger-perhaps 10%-must be evacuated within 48 hours of their arrival. more common.
are
In these circumstances surgeons have not the choice of alternatives or the freedom of action that is theirs in civil practice. For the period of the emergency they become part of a national mechanism for dealing with batches of injured fellow-countrymen. The territory of each operation is already marked out by the wound ; its scope is limited by the or probability of infection ; and its aim is the simple one of ensuring the greatest safety of the patient, since postoperative care will fall to the hands of others. Safety lies in wide opening along anatomical planes with minimal excision of skin (or none), in the removal of dead tissues and foreign bodies, in drainage, in immobilisation, and in the use of sulphonamides. Immobilisation must take account of the coming journey and the change of hospital ; hip or shoulder spicas and unpadded plaster casts have no place at this stage. Sulphonamide administration, in the case of British patients, will be directed by the sulphonamide label (buff with red borders and lettering), and the course of five 0-5 g. tablets twice daily which it indicates should be continued’till the patient reaches a home base.
presence’
The fate of the wounded depends on the distribution of the work to the surgeons no less than on the adequacy of their surgery. Rather than spend 24 hours in a preoperative ward, waiting his turn for the attention of a first-class surgeon, the patient would probably fare better if he travelled for another 4 hours to be operated on at once by a less experienced At times of stress when wounded are arriving man. in large batches, the wise sorting of each group assumes the greatest importance. It is essential that those who need immediate operation should be picked out ; but equally it is essential that those who do not need it should not be picked out. The number of " immediate operations that can be done immediately by the largest group of teams that any hospital can accommodate is small, and there is real risk that centres nearest to the ports of disembarkation may be overwhelmed with cases of this type, many of which would stand a better chance if they were sent further afield. In particular, special groups of cases must be got to those with special skill or special facilities before infection or the beginnings of repair can prevent attainment of the best possible result. Most urgent for transfer are the neurosurgical cases, next the fractures, burns and maxillofacial injuries, and then the chests. Next to sorting, the most necessary task is that of preoperative care and resuscitation. The plan of making one man responsible for the care of the seriously wounded at all stages-for resuscitation, for sending cases to the theatre, and for caring for them when they return-has amply proved its worth. The surgeon, once he has started operating, cannot turn aside for detailed clinical examinations, and can do no more than discuss priorities with the resuscitation officer. The latter, in treating shock, must also investigate the injuries that have caused it and decide what is the best time for operation. He must assess the need for X rays ; for at such times radio-, graphy cannot be used for routine purposes like the recording of obvious fractures, and must be reserved for investigating specific problems-such as the direction of a track-whose answer the operating surgeon must know. The postoperative treatment, on which survival often depends, is better superintended by the man who studied the patient’s wounds and corrected his shock before operation than by someone who now sees him for the first time. Segregation of cases, when they leave the theatre, into two groups -those for evacuation and those for retention-helps both the clinical and administrative staffs ; it allows sisters and surgeons to concentrate on the more serious cases, and the clerks to prepare lists for evacuation without further selection. Documentation, which becomes a burden at rush times, then assumes its greatest importance. When a casualty hands in passes through many rapid succession before his final the information of his reaching hospital, his the and correctness of his treatment, unit, family his recovery, and ultimately his pension, may depend on the accuracy with which his papers have been filled in by the units on the way. At every stage of the work before us, we shall do well to say : Here is a wounded soldier. Where do his best interests lie ?1 He has given all he has. I in my turn must not fail him." "
762
REGENERATION AFTER NERVE INJURIES
MORE ABOUT INFLUENZA VACCINES
Should we, at this moment, be aiming to have available influenza vaccines on a large scale ?1 We have just been through an influenza A outbreak,fortunately a mild one. According to the rules, we should not be afflicted by virus A next winter ; but can we trust the virus to obey the rules ?1 Ought we to be vaccinating against a possible influenza B epidemic ?1 It is true that no really serious B outbreak is known to have occurred over here, but there was a big one in the USA in 1936. The evidence indicates that the immunity following vaccination, at least against A, is fleeting. Widespread use of precious vaccine this autumn on the off-chance of an epidemic seems therefpre inadvisable. Much more reasonable would be the.provision of vaccine on a large scale, ready to be used immediately the red light showed. Such a policy would imply that epidemiological and laboratory workers must collaborate to watch for an outbreak and identify the causative agent promptly. Finally, is there any likelihood that vaccine would, if we wanted it, be available ?1 One could notjustify its manufacture over here at the expense of the public’s meagre quota of shell-eggs. Eggs exist, we believe, across the seas, but is any country likely to be able to make more vaccine than it can easily use itself ?1 It is clear that many difficult problems arise ; of that," as the Grand Inquisitor remarked, ’’ there is no possible doubt whatever."
NEWS has come in from time to time during the last few years of trials of influenza virus vaccines on man. The general conclusion from the tests has been that some protection can be achieved, but this has not yet been sufficiently encouraging to justify the use -of vaccines on a large scale. Now things are looking up. While reportspublished in 1941 held out hopes of, at best, halving the incidence by inoculation, recent trials offer prospects of a three- or four-fold reduction. An influenza A epidemic occurred in the USA during the last quarter of 1943, at about the time of the outbreak over - here. In nine communities under six groups of observers2 vaccination studies had been planned, and 6263 persons were injected subcutaneously with inactivated virus (A and B), 6211 others serving as uninoculated controls. Several previous trials of vaccine, both here and in the USA, have miscarried because influenza has failed to appear within a reasonable time. But on this occasion the luck was in : the wave of influenza broke at the optimum time, in most groups 2 or 3 weeks after the vaccinations. The incidence of clinical influenza in the vaccinated people of the whole series was 2-22%, in the controls 7’11%, a ratio of 1 to 3,2. Only one group of the nine failed to show a substantial difference between the treated and untreated groups ; this was in California, where, among other factors, there was a rather longer interval between vaccination and the REGENERATION AFTER NERVE INJURIES onset of the outbreak. Exclusion of this group would THE alignment of surgical treatment with pathobring the ratio to 1 : 3’6 in favour of the vaccinees. is nowhere more important than in It is of great practical importance to determine the logical histology the of peripheral nerves. In the war of One factor may well have injuries reason for this good result. 1914-18 a good knowledge was acquired of the been the great stroke of luck that the epidemic folchanges that follow complete division of nerves, lowed the vaccinations so promptly. A rather brief and both clinical and experimental work in this duration of the increased immunity after vaccination field have been considerably extended in the past few is suggested by trials3 carried out in America in Less is known both of those " lesions in 1942-43 when groups of volunteers vaccinated against years. which in wallerian degeneration occurs influenza A were subsequently exposed to active continuity," the injury does not entail anatomical virus by inhalation ; the results were assessed by the although severance of the nerve, and the condition known as of febrile response. Against virus A, vaccinadegree "transient block," in which recovery is rapid and Hon 2 weeks before exposure reduced the incidence of and is unaccompanied by wallerian degenerafever (over 100° F.) from 50% to 14-3%. Of a group complete tion of the peripheral portion of the nerve. In a vaccinated 4t months before exposure, 32% had by SEDDON, based on 650 cases, these three fever-no significant reduction from the control figure. study of disturbance are analysed and defined from types Against virus B, however, vaccination reduced the the practical standpoint of the surgeon who has to incidence of fever from 41 % to about 10% irrespective treat them. of whether the inoculations had been made 4tmonths To the first in which there is complete or 2 weeks previously. There have been earlier severance of the group, nervous elements, the name neurosuggestions that virus B is a better antigen than A. ’tmesisis given. This injury most often accompanies A second possible factor may have been the nature of wounds. The subsequent phases of degenerathe vaccine used. A formalin-inactivated vaccine open tion and regeneration have been worked out with made from the allantoic fluid of infected chick- considerable by J. Z. YourrG and his Oxford embryos was used, two strains of virus A and one of B collaborators.precision Spontaneous regeneration is rare and being represented. The virus had been concentrated always imperfect ; hence operative intervention ten-fold by adsorption on, and subsequent elution is The term axonotmesis is applied to the necessary. from; embryonic chicken red-cells by the method of second in which the nerve lesion is in continuity. FRANcis and SALK.4 We badly need to know whether Blunt group is the The nervecommonest cause. injury the use of more concentrated vaccine was indeed the fibres are sufficiently damaged to entail wallerian determining factor, for a ten-times concentrated of the peripheral portion of the nerve, vaccine means that only a tenth as much vaccine degeneration but the supporting structures are intact. Recovery can be made from a given number of eggs. here is spontaneous, satisfactory and fairly rapid ; 1. Horsfall, F. L. jun., Lennette, E. H., Rickard, E. R. and Hirst, it may be presumed that the regenerating fibres grow G. K. Publ. Hlth Rep. Wash. 1941, 56, 1863. 2. US Commission on Influenza, J. Amer. med. Ass. 1944, 124, 982. along the old paths and reach their appropriate "
3. Francis, T. jun., Salk, J. E., Pearson, H. E. and Brown, P. N. Proc. Soc. exp. Biol., N.Y. 1944 55, 104. Salk, J. E., Pearson, H. E., Brown, P. N. and Francis, T. jun. Ibid, p. 106. 4. Francis, T. jun. and Salk, J. E. Science, 1942, 96, 499.
1. Seddon, H. J. Brain, 1944, 66, 238. 2. The names adopted for the three types
Henry Cohen.
were
suggested by Prof.
BACK FROM THE FRONT
THE LANCET
-
LON.DON: ST 171DY, JUNE 10, 1944
BACK FROM THE FRONT In training, equipment and leadership our army of invasion is perhaps the best force this country has ever put into the field : and its medical services are in keeping with the rest. Many of the medical units have long experience of previous campaigns ; others carry a number of battle-trained veterans on their muster. Their work, the primary treatment of casualties, will be well done. We of the medical services at home, who for the first time have been given our place in the battle order, must see to it that our work is also good. The casualties of open warfare, which many surgeons will be treating for the first time, differ from those of air bombardment in three main ways :1. Their wounds
injuries is far tissue
caused
are mostly penetrating or perforating by high-speed projectiles. Haemorrhage
Laceration and devitalisation of found to a greater extent and to a greater depth. Contamination by dirt, and the lodgment of foreign matter, bits of clothing and metal fragments, must be expected. Pathogenic organisms, particularly the spore-bearing anaerobes, are usually present. Shock in the wounded soldier is usually the result of haemorrhage ; loss of plasma, and nervous and toxic factors are less important. 2. The time-lag between wounding and surgical treatment is inevitably greater. In air-raids the injured may reach the operating-table within two hours ; but in mobile war they seldom reach a surgical group in less than twelve hours, and when the sea separates the fighting line from the main medical centres those who are not treated by the surgical units of the field force must face a longer journey before they come under the care of a surgeon in England. Air transport cannot play a large part in evacuation till a broad belt of territory has been captured and cleared. 3. The patients come, not as sojourners, but as migrants. When a hospital acts as casualty-clearing station, all but those who cannot be moved without grave danger-perhaps 10%-must be evacuated within 48 hours of their arrival. more common.
are
In these circumstances surgeons have not the choice of alternatives or the freedom of action that is theirs in civil practice. For the period of the emergency they become part of a national mechanism for dealing with batches of injured fellow-countrymen. The territory of each operation is already marked out by the wound ; its scope is limited by the or probability of infection ; and its aim is the simple one of ensuring the greatest safety of the patient, since postoperative care will fall to the hands of others. Safety lies in wide opening along anatomical planes with minimal excision of skin (or none), in the removal of dead tissues and foreign bodies, in drainage, in immobilisation, and in the use of sulphonamides. Immobilisation must take account of the coming journey and the change of hospital ; hip or shoulder spicas and unpadded plaster casts have no place at this stage. Sulphonamide administration, in the case of British patients, will be directed by the sulphonamide label (buff with red borders and lettering), and the course of five 0-5 g. tablets twice daily which it indicates should be continued’till the patient reaches a home base.
presence’
The fate of the wounded depends on the distribution of the work to the surgeons no less than on the adequacy of their surgery. Rather than spend 24 hours in a preoperative ward, waiting his turn for the attention of a first-class surgeon, the patient would probably fare better if he travelled for another 4 hours to be operated on at once by a less experienced At times of stress when wounded are arriving man. in large batches, the wise sorting of each group assumes the greatest importance. It is essential that those who need immediate operation should be picked out ; but equally it is essential that those who do not need it should not be picked out. The number of " immediate operations that can be done immediately by the largest group of teams that any hospital can accommodate is small, and there is real risk that centres nearest to the ports of disembarkation may be overwhelmed with cases of this type, many of which would stand a better chance if they were sent further afield. In particular, special groups of cases must be got to those with special skill or special facilities before infection or the beginnings of repair can prevent attainment of the best possible result. Most urgent for transfer are the neurosurgical cases, next the fractures, burns and maxillofacial injuries, and then the chests. Next to sorting, the most necessary task is that of preoperative care and resuscitation. The plan of making one man responsible for the care of the seriously wounded at all stages-for resuscitation, for sending cases to the theatre, and for caring for them when they return-has amply proved its worth. The surgeon, once he has started operating, cannot turn aside for detailed clinical examinations, and can do no more than discuss priorities with the resuscitation officer. The latter, in treating shock, must also investigate the injuries that have caused it and decide what is the best time for operation. He must assess the need for X rays ; for at such times radio-, graphy cannot be used for routine purposes like the recording of obvious fractures, and must be reserved for investigating specific problems-such as the direction of a track-whose answer the operating surgeon must know. The postoperative treatment, on which survival often depends, is better superintended by the man who studied the patient’s wounds and corrected his shock before operation than by someone who now sees him for the first time. Segregation of cases, when they leave the theatre, into two groups -those for evacuation and those for retention-helps both the clinical and administrative staffs ; it allows sisters and surgeons to concentrate on the more serious cases, and the clerks to prepare lists for evacuation without further selection. Documentation, which becomes a burden at rush times, then assumes its greatest importance. When a casualty hands in passes through many rapid succession before his final the information of his reaching hospital, his the and correctness of his treatment, unit, family his recovery, and ultimately his pension, may depend on the accuracy with which his papers have been filled in by the units on the way. At every stage of the work before us, we shall do well to say : Here is a wounded soldier. Where do his best interests lie ?1 He has given all he has. I in my turn must not fail him." "
762
REGENERATION AFTER NERVE INJURIES
MORE ABOUT INFLUENZA VACCINES
Should we, at this moment, be aiming to have available influenza vaccines on a large scale ?1 We have just been through an influenza A outbreak,fortunately a mild one. According to the rules, we should not be afflicted by virus A next winter ; but can we trust the virus to obey the rules ?1 Ought we to be vaccinating against a possible influenza B epidemic ?1 It is true that no really serious B outbreak is known to have occurred over here, but there was a big one in the USA in 1936. The evidence indicates that the immunity following vaccination, at least against A, is fleeting. Widespread use of precious vaccine this autumn on the off-chance of an epidemic seems therefpre inadvisable. Much more reasonable would be the.provision of vaccine on a large scale, ready to be used immediately the red light showed. Such a policy would imply that epidemiological and laboratory workers must collaborate to watch for an outbreak and identify the causative agent promptly. Finally, is there any likelihood that vaccine would, if we wanted it, be available ?1 One could notjustify its manufacture over here at the expense of the public’s meagre quota of shell-eggs. Eggs exist, we believe, across the seas, but is any country likely to be able to make more vaccine than it can easily use itself ?1 It is clear that many difficult problems arise ; of that," as the Grand Inquisitor remarked, ’’ there is no possible doubt whatever."
NEWS has come in from time to time during the last few years of trials of influenza virus vaccines on man. The general conclusion from the tests has been that some protection can be achieved, but this has not yet been sufficiently encouraging to justify the use -of vaccines on a large scale. Now things are looking up. While reportspublished in 1941 held out hopes of, at best, halving the incidence by inoculation, recent trials offer prospects of a three- or four-fold reduction. An influenza A epidemic occurred in the USA during the last quarter of 1943, at about the time of the outbreak over - here. In nine communities under six groups of observers2 vaccination studies had been planned, and 6263 persons were injected subcutaneously with inactivated virus (A and B), 6211 others serving as uninoculated controls. Several previous trials of vaccine, both here and in the USA, have miscarried because influenza has failed to appear within a reasonable time. But on this occasion the luck was in : the wave of influenza broke at the optimum time, in most groups 2 or 3 weeks after the vaccinations. The incidence of clinical influenza in the vaccinated people of the whole series was 2-22%, in the controls 7’11%, a ratio of 1 to 3,2. Only one group of the nine failed to show a substantial difference between the treated and untreated groups ; this was in California, where, among other factors, there was a rather longer interval between vaccination and the REGENERATION AFTER NERVE INJURIES onset of the outbreak. Exclusion of this group would THE alignment of surgical treatment with pathobring the ratio to 1 : 3’6 in favour of the vaccinees. is nowhere more important than in It is of great practical importance to determine the logical histology the of peripheral nerves. In the war of One factor may well have injuries reason for this good result. 1914-18 a good knowledge was acquired of the been the great stroke of luck that the epidemic folchanges that follow complete division of nerves, lowed the vaccinations so promptly. A rather brief and both clinical and experimental work in this duration of the increased immunity after vaccination field have been considerably extended in the past few is suggested by trials3 carried out in America in Less is known both of those " lesions in 1942-43 when groups of volunteers vaccinated against years. which in wallerian degeneration occurs influenza A were subsequently exposed to active continuity," the injury does not entail anatomical virus by inhalation ; the results were assessed by the although severance of the nerve, and the condition known as of febrile response. Against virus A, vaccinadegree "transient block," in which recovery is rapid and Hon 2 weeks before exposure reduced the incidence of and is unaccompanied by wallerian degenerafever (over 100° F.) from 50% to 14-3%. Of a group complete tion of the peripheral portion of the nerve. In a vaccinated 4t months before exposure, 32% had by SEDDON, based on 650 cases, these three fever-no significant reduction from the control figure. study of disturbance are analysed and defined from types Against virus B, however, vaccination reduced the the practical standpoint of the surgeon who has to incidence of fever from 41 % to about 10% irrespective treat them. of whether the inoculations had been made 4tmonths To the first in which there is complete or 2 weeks previously. There have been earlier severance of the group, nervous elements, the name neurosuggestions that virus B is a better antigen than A. ’tmesisis given. This injury most often accompanies A second possible factor may have been the nature of wounds. The subsequent phases of degenerathe vaccine used. A formalin-inactivated vaccine open tion and regeneration have been worked out with made from the allantoic fluid of infected chick- considerable by J. Z. YourrG and his Oxford embryos was used, two strains of virus A and one of B collaborators.precision Spontaneous regeneration is rare and being represented. The virus had been concentrated always imperfect ; hence operative intervention ten-fold by adsorption on, and subsequent elution is The term axonotmesis is applied to the necessary. from; embryonic chicken red-cells by the method of second in which the nerve lesion is in continuity. FRANcis and SALK.4 We badly need to know whether Blunt group is the The nervecommonest cause. injury the use of more concentrated vaccine was indeed the fibres are sufficiently damaged to entail wallerian determining factor, for a ten-times concentrated of the peripheral portion of the nerve, vaccine means that only a tenth as much vaccine degeneration but the supporting structures are intact. Recovery can be made from a given number of eggs. here is spontaneous, satisfactory and fairly rapid ; 1. Horsfall, F. L. jun., Lennette, E. H., Rickard, E. R. and Hirst, it may be presumed that the regenerating fibres grow G. K. Publ. Hlth Rep. Wash. 1941, 56, 1863. 2. US Commission on Influenza, J. Amer. med. Ass. 1944, 124, 982. along the old paths and reach their appropriate "
3. Francis, T. jun., Salk, J. E., Pearson, H. E. and Brown, P. N. Proc. Soc. exp. Biol., N.Y. 1944 55, 104. Salk, J. E., Pearson, H. E., Brown, P. N. and Francis, T. jun. Ibid, p. 106. 4. Francis, T. jun. and Salk, J. E. Science, 1942, 96, 499.
1. Seddon, H. J. Brain, 1944, 66, 238. 2. The names adopted for the three types
Henry Cohen.
were
suggested by Prof.