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Hungerford shooting incident
Injury
(1989)
20,
245-246
Printedin Great Britain
245
letters to the Editor
Hunger-ford shooting incident Dear Sir, I am surprised to read that some of the victims of the Hungerford shooting incident had their wounds closed primarily after wound excision (Broome, Butler-Manuel, Budd et al., 1988). The authors claim that “primary closure using large drains.. . proved to be sound”. This technique was not proved to be sound. It is widely considered unsound and unsafe by many authors with a large experience of these injuries. (Dufour et al., 1988, Kirby and Blackbum, 1983, Owen-Smith 1974.) The practice should be strongly discouraged. The most basic principles of war surgery are repeatedly forgotten or ignored in peace time. R. M. Coupland, F.R.C.S., The British Red Cross Society,
The Intematinal Committee of the Red Cross, 9 Grosvenor Crescent, London SWlX 7EJ, UK. Correspondence UK
to: 8 Belvedere Place, Norwich NR4 7PP,
References
I think there are several specific points that are clearly detailed in the article that Mr Coupland may not have appreciated. All wounds were inflicted by missiles of medium or low velocity and the extensive cavitation, tissue necrosis and contamination that occurs with high velocity missile wounds is not apparent in any of our patients. All but one patient was taken to the operating theatre within 8 h of the time of injury and none of the wounds were contaminated in a way that may be found in a battlefield situation. All wounds were subsequently reviewed on a daily basis by the operating surgeon until wound healing had occurred. Finally, and most importantly, I can only say that the method of wound care that we used was successful. Fourteen out of 16 wounds in surviving patients healed primarily without any complication whatsoever. The remaining two wounds required simple delayed excision and secondary closure and then went on to heal uneventfully. In summary, the authors make no pretence of being experienced military surgeons attempting to dictate the modem treatment of gunshot wounds but we are merely reporting a unique series of civilian patients with low and medium velocity gunshot wounds that had been treated quite satisfactorily by the methods that we describe.
Broome G, Butler- Manuel A., Budd J., Carter, P. G. and Warlow, T. A.
G. Broome, F.R.C.S., Orthopaedic
(1988) The Hungerford shooting incident. Injury, 19,313-317. Dufour D., Korman Jensen S., Owen-Smith, M. et al. (1988) Surgery for victims of war. Geneva, The International Committee of the Red Cross. Kirby, N.G., Blackbum, G., (Eds) (1983) Field surgery pocket book. London, HMSO. Owen-Smith M. S. (1978) High velocity missle injuries. In: Hadfield J., Hobsley M. (Eds) Currenf Swrgicul Prucfice, Vol. 2. London, Edward Arnold, 204-209.
Scalp wound closure techniques
Author‘s reply
Dear Sir, Thank you for the opportunity to reply to the letter from Mr R. M. Coupland. I certainly have several comments to make. Firstly, I think it is quite apparent that the Hungerford article is a simple report from the medical aspects of the incident, detailing the patients’ injuries and the treatment they received. We deliberately kept the discussion brief and to the point in order to make it as uncontroversial as possible. We deliberately did not give references to series of military injuries, sustained in very different circumstances and in no way were we attempting to dictate change in the principles of the treatment of gunshot wounds. @ 1989 Butterworth & Co (publishers) Ltd 0020-1383/89/040245-02 $03.00
Registrar, St Bartholomew’s Hospital, West Smithfield, London EClA 7BE, UK.
Dear Sir, I would like to comment on the article concerning an altemative to suture for scalp wounds (Davies, 1988). In his paper Mr Davies gives six conditions that make wounds of the scalp suitable for closure by knitting hair. One is that the aponeurosis of occipito-frontalis is intact and another that there is no fracture of the skull. Does this mean that he is prepared to look inside such wounds without anaesthesia and that the skull should be radiographed in most if not all cases of wounds of the scalp? P. S. London, FRCS, The Ridings,
Singleborough,
Buck-
ingham MK17 ORS, UK
References Davies, M. J. (1988) Scalp wounds. 375.
An alternative
to suture Injq
19,
(1989)
20,
245-246
Printedin Great Britain
245
letters to the Editor
Hunger-ford shooting incident Dear Sir, I am surprised to read that some of the victims of the Hungerford shooting incident had their wounds closed primarily after wound excision (Broome, Butler-Manuel, Budd et al., 1988). The authors claim that “primary closure using large drains.. . proved to be sound”. This technique was not proved to be sound. It is widely considered unsound and unsafe by many authors with a large experience of these injuries. (Dufour et al., 1988, Kirby and Blackbum, 1983, Owen-Smith 1974.) The practice should be strongly discouraged. The most basic principles of war surgery are repeatedly forgotten or ignored in peace time. R. M. Coupland, F.R.C.S., The British Red Cross Society,
The Intematinal Committee of the Red Cross, 9 Grosvenor Crescent, London SWlX 7EJ, UK. Correspondence UK
to: 8 Belvedere Place, Norwich NR4 7PP,
References
I think there are several specific points that are clearly detailed in the article that Mr Coupland may not have appreciated. All wounds were inflicted by missiles of medium or low velocity and the extensive cavitation, tissue necrosis and contamination that occurs with high velocity missile wounds is not apparent in any of our patients. All but one patient was taken to the operating theatre within 8 h of the time of injury and none of the wounds were contaminated in a way that may be found in a battlefield situation. All wounds were subsequently reviewed on a daily basis by the operating surgeon until wound healing had occurred. Finally, and most importantly, I can only say that the method of wound care that we used was successful. Fourteen out of 16 wounds in surviving patients healed primarily without any complication whatsoever. The remaining two wounds required simple delayed excision and secondary closure and then went on to heal uneventfully. In summary, the authors make no pretence of being experienced military surgeons attempting to dictate the modem treatment of gunshot wounds but we are merely reporting a unique series of civilian patients with low and medium velocity gunshot wounds that had been treated quite satisfactorily by the methods that we describe.
Broome G, Butler- Manuel A., Budd J., Carter, P. G. and Warlow, T. A.
G. Broome, F.R.C.S., Orthopaedic
(1988) The Hungerford shooting incident. Injury, 19,313-317. Dufour D., Korman Jensen S., Owen-Smith, M. et al. (1988) Surgery for victims of war. Geneva, The International Committee of the Red Cross. Kirby, N.G., Blackbum, G., (Eds) (1983) Field surgery pocket book. London, HMSO. Owen-Smith M. S. (1978) High velocity missle injuries. In: Hadfield J., Hobsley M. (Eds) Currenf Swrgicul Prucfice, Vol. 2. London, Edward Arnold, 204-209.
Scalp wound closure techniques
Author‘s reply
Dear Sir, Thank you for the opportunity to reply to the letter from Mr R. M. Coupland. I certainly have several comments to make. Firstly, I think it is quite apparent that the Hungerford article is a simple report from the medical aspects of the incident, detailing the patients’ injuries and the treatment they received. We deliberately kept the discussion brief and to the point in order to make it as uncontroversial as possible. We deliberately did not give references to series of military injuries, sustained in very different circumstances and in no way were we attempting to dictate change in the principles of the treatment of gunshot wounds. @ 1989 Butterworth & Co (publishers) Ltd 0020-1383/89/040245-02 $03.00
Registrar, St Bartholomew’s Hospital, West Smithfield, London EClA 7BE, UK.
Dear Sir, I would like to comment on the article concerning an altemative to suture for scalp wounds (Davies, 1988). In his paper Mr Davies gives six conditions that make wounds of the scalp suitable for closure by knitting hair. One is that the aponeurosis of occipito-frontalis is intact and another that there is no fracture of the skull. Does this mean that he is prepared to look inside such wounds without anaesthesia and that the skull should be radiographed in most if not all cases of wounds of the scalp? P. S. London, FRCS, The Ridings,
Singleborough,
Buck-
ingham MK17 ORS, UK
References Davies, M. J. (1988) Scalp wounds. 375.
An alternative
to suture Injq
19,