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EXCISION OF WAR WOUNDS
231 to a second operation than an adult. He laid down two axioms for induction in a child: always have the patient sitting up; and do not use restraint of any kind. To be forcibly restrained is objectionable to In Dr. an adult, but is truly terrifying to a child.
Sington’s experience inhalation ansesthesia preceded by paraldehyde is much better suited to children than an injection into a vein or the spinal theca, either of which a child invariably resents, and he recalled the striking lessening of postanaesthetic vomiting that has followed the abolition of preliminary purgation and starvation. The elaborate methods of anaesthesia now in vogue are, he said, ill-suited to children. Nevertheless, it must not be overlooked how vastly the means for conducting anaesthesia in cleft-palate and similar operations in infants have been improved by the endotracheal devices introduced by Magill. In skilled hands these represent a real advance over anything that was possible before. EXCISION OF WAR WOUNDS treatment of wounds in this war will to extent be in the hands of the younger surgeons large who have no first-hand knowledge of what was so hardily learnt in 1914-18. Rouxand Leriche/ who watched the evolution of the methods that finally sucI
THE
early
a
saving lives and limbs, fear that they will not operate with the rigour that by 1918 was considered essential and may put too much faith in chemotherapy. It was the combination of streptococci and anaerobes that proved so fatal, and the one method of attack that proved effective was early and complete removal of all contused, torn and soiled tissues. There is a period of respite before the onset of infection, and if the wound can be operated on within twelve hours there is every chance that it will heal cleanly. Antiseptics play no important part in the regime : the whole aim is to excise before the organisms can " dig themselves in." The question of, primary suture after excision, and whether the wound should be encased in plaster, depends in Leriche’s view on the extent of the damage to muscle. He holds that primary suture and the immediate application of plaster, if performed under the best possible surgical conditions, is justified in many wounds involving bones, whereas a lacerated wound of the calf or thigh should be leftopen until danger of sepsis has passed. The wounded who came over the French border from the Barcelona front of the Spanish war mostly arrived with their wounded limbs encased in plaster, and despite the pus pouring from the wounds were in a surprisingly good condition, with evidence of active healing. But the Spanish surgeons were working under most abnormal conditions; they were treating these wounded and sending them inunediately from their charge, not knowing when they would again receive skilled attention. In such conditions, if the primary excision has been skilfully carried ’out, Leriche agrees that plaster is justified, but he does not agree that it is the ideal method for all wounds of soft parts. All deep wounds of muscle he would leave open; after fifty-four hours inspection may show that the wound is perfectly clean and secondary suture can then be done. Roux describes the stages in which excision should be carried out. Each stage should be distinct and Hsemostasis complete before the next is started. should be perfect, so that no blood-clot is left in the depths of the wound. The best possible operative conditions should be available, and this means rapid ceeded in
.
1. Roux, Pr. méd. 1939, p. 1381. 2. Leriche, R., Ibid, Jan. 3, 1940, p. 1.
evacuation of the wounded to hospitals where strict asepsis can be enforced. Two sets of gloves and instruments should be used, the first set being discarded after the initial process of cleaning up is finished. Liquid soap is used for cleaning; the soap is removed by thorough bathing with sterile water, and ether is then applied to remove grease. Iodine is painted on the skin only. All this is carried out under general anaesthesia, and may be done by an assistant while the surgeon is washing his hands, so long as it is done under his personal supervision. The second stage consists in the excision of the skin edges. The knife must be kept perpendicular to the surface, -1 cm. of skin being removed all round the wound, if possible in one piece, without the knife being allowed to enter the depths of the wound. No subcutaneous dead space must be left; if the skin is undermined, it must either be opened up by branch incision or be counter-drained. Next the aponeurosis is excised with scissors, leaving a smooth, continuous edge. These stages should be completed before deeper excision is attempted and they should give easy access to the depths of the wound. The fourth stage of the operation involves the removal of any foreign bodies and of damaged muscle, and it requires careful judgment. All injured or ischasmic tissue must be removed, but since muscle tissue does not regenerate excessive mutilation should be avoided. The cavity of the wound should never be curetted, and if possible the foreign body, the tissues enclosing it, and those which it has traversed should be removed en bloc. When important structures, such as vessels and nerves, lie in the depths of the wound these must be seen. When the foreign body has passed through leaving an entrance and exit wound, the question arises whether to excise the whole tract. This can be done in the most superficially placed tracts. When the two orifices are far apart, or when the tract goes through an inaccessible part, entrance and exit wounds must be excised and drainage leftfor the deeper part of the tract. Under no circumstances must through drainage be promoted by drawing gauze through on the end of forceps, or by irrigation under force. Leriche says that wounds should never be closed by primary suture if they involve large vessels, if they have gone through the middle of a deeply placed bone, or if they have traversed the substance of a muscle where the surgeon can never be sure of satisfactory excision. Every stage of the operation must be carried out definitely and accurately and under direct vision. THE CANCER CONSTITUTION
WHERE medical examination for life insurance is the rule the data might disclose some distinguishing characteristics of those who are destined to die of a particular disease. Statistical material from this angle relating to people dying of cancer are presented in a recent paper by Mr. Arthur Hunter.1 The analysis comprises 3239 deaths from cancer recorded by the New York Life Insurance Company, and for comparison a randomly selected control group of an equal number of living policy-holders of the same ages and years of issue of policies. The latter were found to have been of normal average weight for their age and sex when their policies were issued, while the cancer death group, both men and women, were slightly above average. On the other hand, neither the average systolic nor diastolic blood-pressures differed materiWith type of comally between the two groups. plexion, hair and eye colour, there is also no striking disparity; the men dying of cancer show a slightly 1. Trans. actuari. Soc. Amer. 1939, 40, 394.
Sington’s experience inhalation ansesthesia preceded by paraldehyde is much better suited to children than an injection into a vein or the spinal theca, either of which a child invariably resents, and he recalled the striking lessening of postanaesthetic vomiting that has followed the abolition of preliminary purgation and starvation. The elaborate methods of anaesthesia now in vogue are, he said, ill-suited to children. Nevertheless, it must not be overlooked how vastly the means for conducting anaesthesia in cleft-palate and similar operations in infants have been improved by the endotracheal devices introduced by Magill. In skilled hands these represent a real advance over anything that was possible before. EXCISION OF WAR WOUNDS treatment of wounds in this war will to extent be in the hands of the younger surgeons large who have no first-hand knowledge of what was so hardily learnt in 1914-18. Rouxand Leriche/ who watched the evolution of the methods that finally sucI
THE
early
a
saving lives and limbs, fear that they will not operate with the rigour that by 1918 was considered essential and may put too much faith in chemotherapy. It was the combination of streptococci and anaerobes that proved so fatal, and the one method of attack that proved effective was early and complete removal of all contused, torn and soiled tissues. There is a period of respite before the onset of infection, and if the wound can be operated on within twelve hours there is every chance that it will heal cleanly. Antiseptics play no important part in the regime : the whole aim is to excise before the organisms can " dig themselves in." The question of, primary suture after excision, and whether the wound should be encased in plaster, depends in Leriche’s view on the extent of the damage to muscle. He holds that primary suture and the immediate application of plaster, if performed under the best possible surgical conditions, is justified in many wounds involving bones, whereas a lacerated wound of the calf or thigh should be leftopen until danger of sepsis has passed. The wounded who came over the French border from the Barcelona front of the Spanish war mostly arrived with their wounded limbs encased in plaster, and despite the pus pouring from the wounds were in a surprisingly good condition, with evidence of active healing. But the Spanish surgeons were working under most abnormal conditions; they were treating these wounded and sending them inunediately from their charge, not knowing when they would again receive skilled attention. In such conditions, if the primary excision has been skilfully carried ’out, Leriche agrees that plaster is justified, but he does not agree that it is the ideal method for all wounds of soft parts. All deep wounds of muscle he would leave open; after fifty-four hours inspection may show that the wound is perfectly clean and secondary suture can then be done. Roux describes the stages in which excision should be carried out. Each stage should be distinct and Hsemostasis complete before the next is started. should be perfect, so that no blood-clot is left in the depths of the wound. The best possible operative conditions should be available, and this means rapid ceeded in
.
1. Roux, Pr. méd. 1939, p. 1381. 2. Leriche, R., Ibid, Jan. 3, 1940, p. 1.
evacuation of the wounded to hospitals where strict asepsis can be enforced. Two sets of gloves and instruments should be used, the first set being discarded after the initial process of cleaning up is finished. Liquid soap is used for cleaning; the soap is removed by thorough bathing with sterile water, and ether is then applied to remove grease. Iodine is painted on the skin only. All this is carried out under general anaesthesia, and may be done by an assistant while the surgeon is washing his hands, so long as it is done under his personal supervision. The second stage consists in the excision of the skin edges. The knife must be kept perpendicular to the surface, -1 cm. of skin being removed all round the wound, if possible in one piece, without the knife being allowed to enter the depths of the wound. No subcutaneous dead space must be left; if the skin is undermined, it must either be opened up by branch incision or be counter-drained. Next the aponeurosis is excised with scissors, leaving a smooth, continuous edge. These stages should be completed before deeper excision is attempted and they should give easy access to the depths of the wound. The fourth stage of the operation involves the removal of any foreign bodies and of damaged muscle, and it requires careful judgment. All injured or ischasmic tissue must be removed, but since muscle tissue does not regenerate excessive mutilation should be avoided. The cavity of the wound should never be curetted, and if possible the foreign body, the tissues enclosing it, and those which it has traversed should be removed en bloc. When important structures, such as vessels and nerves, lie in the depths of the wound these must be seen. When the foreign body has passed through leaving an entrance and exit wound, the question arises whether to excise the whole tract. This can be done in the most superficially placed tracts. When the two orifices are far apart, or when the tract goes through an inaccessible part, entrance and exit wounds must be excised and drainage leftfor the deeper part of the tract. Under no circumstances must through drainage be promoted by drawing gauze through on the end of forceps, or by irrigation under force. Leriche says that wounds should never be closed by primary suture if they involve large vessels, if they have gone through the middle of a deeply placed bone, or if they have traversed the substance of a muscle where the surgeon can never be sure of satisfactory excision. Every stage of the operation must be carried out definitely and accurately and under direct vision. THE CANCER CONSTITUTION
WHERE medical examination for life insurance is the rule the data might disclose some distinguishing characteristics of those who are destined to die of a particular disease. Statistical material from this angle relating to people dying of cancer are presented in a recent paper by Mr. Arthur Hunter.1 The analysis comprises 3239 deaths from cancer recorded by the New York Life Insurance Company, and for comparison a randomly selected control group of an equal number of living policy-holders of the same ages and years of issue of policies. The latter were found to have been of normal average weight for their age and sex when their policies were issued, while the cancer death group, both men and women, were slightly above average. On the other hand, neither the average systolic nor diastolic blood-pressures differed materiWith type of comally between the two groups. plexion, hair and eye colour, there is also no striking disparity; the men dying of cancer show a slightly 1. Trans. actuari. Soc. Amer. 1939, 40, 394.