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The Immediate Closure of Gunshot Wounds.
THE IMMEDIATE CLOSURE OF GUNSHOT WOUNDS.
148
of
all
the
Certain it is that the interdependence subjects of medical study finds no
to
closure
It is now a to state notable advances were what commonplace in our schemes of made on this the of Colonel researches present position by adequate expression training; there has been no dovetailing of subjects. Sir ALMROTH WRIGHT and by ALEXIS CARREL in his An intelligent appreciation of chemistry forms an elaboration of a method of mechanical cleansing essential part of the examination of every patient followed by intermittent flushing, with the result and for the proper understanding of all morbid that most wounds could be secondarily sutured Professor processes, and yet the establishment of a special within a period of five or ten days. chair of chemistry within the Faculty of Medicine RUTHERFORD MoRisoN’s application of bismuth at a particular university is regarded as a novelty, iodoform paste made it possible in some cases to while the chair of physiology at another university carry out such secondary closure at a still earlier has undergone resolution into bio-chemistry and stage. But neither method gave uniformly good The results nor rendered possible the immediate closure we to which experimental pharmacology. pass have come is fairly illustrated by the difficulty of of the gunshot wound on the lines of an aseptic getting teachers who are primarily chemists and operation, with the saving of life, time, and material at the same time graduates in medicine. All these which that would imply. are points deserving of earnest attention. The surgeon has not willingly acquiesced in this Turning now from the Edinburgh discussion to disability, and the impression is steadily gaining its wider application, an example or two may serve ground that the first essential in the treatment of as illustrations. We have just received a handbook, gunshot wounds of any region consists in the prepared by the Health of Munition Workers Com- removal of all dead and infected tissue, after which mittee, the purpose of which is to set forth in the wound can be closed with safety. Such a categorical form the steps necessary to maintain the wound excision to be successful must be both early health and efficiency of the worker. No medical and complete. Early, inasmuch as 12 to 15 hours subject could possibly be of greater interest at this after its infliction pathogenic organisms have or at any other time. The maintenance of the already begun to multiply in the wound and to health of the worker affects a huge proportion of invade the surrounding tissues; sometimes, alas, the total population of the country ; it is obviously even sooner than this. Complete, in the sense the largest single problem confronting medical of a careful dissection of the wound, including the science. In the realm of industrial life medicine paring of the skin edges, the removal of all foreign is just beginning to take its proper place. But is bodies-whether missile, mud, clothing, or bone the medical student as he leaves the hands of his splinters-the excision of injured tissue, such as teachers equipped for such a study ? The handbook muscle or fascia, and careful hæmostasis to avoid will be for him a medical text-book, fascinating, no the subsequent collection of clot within the doubt, but of a new and unfamiliar kind. It is not wound. So much may be said already, but much arranged, like the system of medicine, under topo- still remains to be done before the immediate graphical headings or the various types of bacterial closure of gunshot wounds can become the routine
gymnastics.
by second intention
methods are still on their a solution of common soap applied after excision of damaged tissues. First used by French surgeons, and recommended by Colonel CUTHBERT WALLACE, this has been staleness, irritability, breaks, spells, and pauses. employed with success by Captain R. G. DIXON and These are the subject headings of the new industrial Captain H. T. BATES,1 and more recently by Captain medicine, and to the student who has laid aside J. B. HAYCRAFT.2 M. LE GRAND and other French at an early stage of his studies the subjects of surgeons have attempted by means of a staining chemistry, physics, and physiology, these terms are reaction to delimit the tissues which require to be almost meaningless. The sooner our educational excised. The general principles of wound closure authorities recognise this fact the better it will be for claimed the attention of the Paris Inter-Allied Surgical Conference (see p. 160), and research the status as well as for the efficiency of medicine. work of this kind might well claim the special 0 attention of the whole staff of a casualty clearing if it has not already done so. The Immediate Closure of Gunshot station, But even so, the sphere of useful research has Wounds. not been exhausted. Just as secondary suture has claimed the close cooperation between surgeon and Sir ALFRED KEOGH has more than once
infection. It does not even follow the more primitive arrangement of a text-book of preventive medicine, beginning with the " elements " of air, water, fire, Reference to the index reveals and the like. such items as efficiency, fatigue, nutrition, rhythm,
pointed
out that the well-recognised principles of closing wounds equipped with which the civil surgeons went to the front found little or no application to the types of wound which they found there. This has been, indeed, the great surgical tragedy of the war. The surgeon had to accept the fact that with the trifling exception of a few perforating riflebullet injuries all gunshot wounds suppurated, and their healing consequently demanded the sacrifices of time, material, and vital energy inherent
procedure. Many
new
trial.
simplest is
One of the
so the responsibility for the immediate closure of the wound may well be shared by both. CARREL states that nearly all the cases of which he has seen followed on septicaamia " unseasonablesuture of the wound, and until the general principle of immediate closure is well established it is for the bacteriologist to advise the surgeon of the safety of the proceeding in the
bacteriologist,
1
THE LANCET, 1917, ii., 789. Brit. Med. Jour., 1918, i. 80. Soc. de Chirurg., Dec. 5th, 1917, and THE LANCET, 2
3
1917, ii., 96.
POOR-LAW GUARDIANS AND THEIR FUTURE.
particular case. A streptococcus producing hæmolysis is one of the organisms which may give rise In his study of the bactericidal to difficulty. in the wound, which another part of this issue, Sir ALMROTH WRIGHT describes artificial conditions which he has devised, imitating closely the actual wound conditions with which the surgeon has to deal. To meet present needs bacteriology, like surgery, must be plastic and freed from all hampering prepossessions. In " bio-pyo-culture" the
effects we
of
print
leucocytes
in
is working closely hand-in-hand with the surgeon. More even than this is required ’ if immediate closure of wounds is to become a practical reality. At present it is not considered safe for a surgeon to undertake a primary suture at the front and then to send the case down to the base, inasmuch as jolting on the journey may cause commotion in the wound and hinder the proper course of healing. Wounds, like bones, seem to require splinting for their proper recovery, and facilities of accommodation and of transport are needed unless we are to remain content with the suture primitive retardée at the base. Our Paris Correspondent shows (p. 155) how a group of French surgeons dealt with the situation during an attack. No combined effort can be too great to realise a preventive treatment of gunshot wounds equivalent to the preventive orthopaedics of which we have recently spoken.
bacteriologist
work which they are doing and to compare it in the light of that experience, of traditions, and of their own records with that done by their predecessors. They have also full knowledge of their powers in comparison with those exercised by guardians in the past, and can appreciate expectations of increased opportunities for usefulness. To the question which we have quoted above the reply is in all the examples published an emphatic and uncompromising negative. A second question, relating to the general views of guardians as to the performance of their duties, the chairman of the St. Marylebone board of guardians answers as
follows :-
The great improvement in the administration of the best Poor-law unions of recent years is evidence of the efforts of Poor-law guardians to do their work well and of their The extent of the hard work voluntarily undersuccess. taken and carried through is little known.
This may be taken as summarising the majority of the opinions expressed ; no exception can be taken to it, for allowance may fairly be made for improvement effected when the future of boards of guardians is considered. Stress, too, may reasonably be laid upon advantage willingly taken. of increased powers and of the encouragement received from modern public opinion. The chairman of the West Bromwich union puts the case
thus :
All the best of the recommendations of the Royal ComBoards have effected under mission have been carried out. their extended powers such great improvements that the grounds upon which the Commission made their recom-
mendation for the transfer of the duties of guardians to other authorities have ceased to exist.
The
quid nimis."
POOR-LAW GUARDIANS AND THEIR
modern
development
of
the
Poor-law in-
firmaries, the treatment and nursing provided in them, and all that such development means to
Annotations. " Ne
149
FUTURE.
NINE years ago the Royal Commission on the Poor-law, Majority and Minority Report alike, recommended sweeping changes in the position of boards of guardians, and although these bodies still survive the Reconstruction Committee, to whose report allusion is made in our Parliamentary Correspondence, confirms the need for In the meantime boards of drastic change. guardians have been discussing their own future in a recent number of the Local Government Chronicle in reply to a short series of questions upon the subject of their possible abolition and of the transference of the functions comprised under the term Poor. law administration " to other bodies. Destructive self-criticism could not be expected from persons who have, perhaps frequently, submitted to the ordeal of popular election in order to devote time and trouble to public duties of a more or less onerous character, and naturally few answers, if any, in the affirmative have been returned to the first question put: "Is there any foundation for the suggestion that the abolition of boards of guardians is desirable ?" The replies which have been published are, however, from those who, not returning a mere "Yes’’ or "No," were sufficiently interested, or found the necessary leisure to give their reasons ; and, subject to the suggestion made above that a certain amount of prejudice in their own favour may excusably have coloured their views, they have answered perfectly fairly. And they are persons qualified to speak from experience as to the
those who by their circumstances are compelled to have recourse to them, are dwelt upon with pride in many of the replies given, and here also it cannot be said that the satisfaction expressed is unreasonable. The contrast between the infirmary of to-day and that of a generation or of two generations ago may be, and probably is, more conspicuous than that observable in any other department of Poor-law administration, and the usefulness of such practical progress, as setting an example of humanity, has no doubt made its influence felt rather than recognised. It is a progress which the medical profession may justly ascribe in no small degree to the efforts of its members, and which it may regard as a result of the general development of medical science, and as proof of public acknowledgment and appreciaOn the whole the replies obtained by the tion. Local Government Chronicle constitute an interesting contribution to the accumulating literature on this subject, and it may be added that they do not overlook the all-important question as to how far the public will tolerate the handing over of the expenditure of its money to authorities wholly or in part irresponsible, in the sense of not having to seek election or re-election at its hands. A
NEW
KIND OF SELF-INFLICTED
INJURY.
Professor Ascarelli has recently drawn attention1 to a form of lesion resorted to by recruits in order to evade military service which he thinks has hitherto escaped general observation. It is most frequently met with as a periarticular condition in the knee, ankle, or wrist, and presents the appearance of a uniform or nodulated swelling, 1
II Policlinico, Practical Section, Nov. 25th, 1917.
148
of
all
the
Certain it is that the interdependence subjects of medical study finds no
to
closure
It is now a to state notable advances were what commonplace in our schemes of made on this the of Colonel researches present position by adequate expression training; there has been no dovetailing of subjects. Sir ALMROTH WRIGHT and by ALEXIS CARREL in his An intelligent appreciation of chemistry forms an elaboration of a method of mechanical cleansing essential part of the examination of every patient followed by intermittent flushing, with the result and for the proper understanding of all morbid that most wounds could be secondarily sutured Professor processes, and yet the establishment of a special within a period of five or ten days. chair of chemistry within the Faculty of Medicine RUTHERFORD MoRisoN’s application of bismuth at a particular university is regarded as a novelty, iodoform paste made it possible in some cases to while the chair of physiology at another university carry out such secondary closure at a still earlier has undergone resolution into bio-chemistry and stage. But neither method gave uniformly good The results nor rendered possible the immediate closure we to which experimental pharmacology. pass have come is fairly illustrated by the difficulty of of the gunshot wound on the lines of an aseptic getting teachers who are primarily chemists and operation, with the saving of life, time, and material at the same time graduates in medicine. All these which that would imply. are points deserving of earnest attention. The surgeon has not willingly acquiesced in this Turning now from the Edinburgh discussion to disability, and the impression is steadily gaining its wider application, an example or two may serve ground that the first essential in the treatment of as illustrations. We have just received a handbook, gunshot wounds of any region consists in the prepared by the Health of Munition Workers Com- removal of all dead and infected tissue, after which mittee, the purpose of which is to set forth in the wound can be closed with safety. Such a categorical form the steps necessary to maintain the wound excision to be successful must be both early health and efficiency of the worker. No medical and complete. Early, inasmuch as 12 to 15 hours subject could possibly be of greater interest at this after its infliction pathogenic organisms have or at any other time. The maintenance of the already begun to multiply in the wound and to health of the worker affects a huge proportion of invade the surrounding tissues; sometimes, alas, the total population of the country ; it is obviously even sooner than this. Complete, in the sense the largest single problem confronting medical of a careful dissection of the wound, including the science. In the realm of industrial life medicine paring of the skin edges, the removal of all foreign is just beginning to take its proper place. But is bodies-whether missile, mud, clothing, or bone the medical student as he leaves the hands of his splinters-the excision of injured tissue, such as teachers equipped for such a study ? The handbook muscle or fascia, and careful hæmostasis to avoid will be for him a medical text-book, fascinating, no the subsequent collection of clot within the doubt, but of a new and unfamiliar kind. It is not wound. So much may be said already, but much arranged, like the system of medicine, under topo- still remains to be done before the immediate graphical headings or the various types of bacterial closure of gunshot wounds can become the routine
gymnastics.
by second intention
methods are still on their a solution of common soap applied after excision of damaged tissues. First used by French surgeons, and recommended by Colonel CUTHBERT WALLACE, this has been staleness, irritability, breaks, spells, and pauses. employed with success by Captain R. G. DIXON and These are the subject headings of the new industrial Captain H. T. BATES,1 and more recently by Captain medicine, and to the student who has laid aside J. B. HAYCRAFT.2 M. LE GRAND and other French at an early stage of his studies the subjects of surgeons have attempted by means of a staining chemistry, physics, and physiology, these terms are reaction to delimit the tissues which require to be almost meaningless. The sooner our educational excised. The general principles of wound closure authorities recognise this fact the better it will be for claimed the attention of the Paris Inter-Allied Surgical Conference (see p. 160), and research the status as well as for the efficiency of medicine. work of this kind might well claim the special 0 attention of the whole staff of a casualty clearing if it has not already done so. The Immediate Closure of Gunshot station, But even so, the sphere of useful research has Wounds. not been exhausted. Just as secondary suture has claimed the close cooperation between surgeon and Sir ALFRED KEOGH has more than once
infection. It does not even follow the more primitive arrangement of a text-book of preventive medicine, beginning with the " elements " of air, water, fire, Reference to the index reveals and the like. such items as efficiency, fatigue, nutrition, rhythm,
pointed
out that the well-recognised principles of closing wounds equipped with which the civil surgeons went to the front found little or no application to the types of wound which they found there. This has been, indeed, the great surgical tragedy of the war. The surgeon had to accept the fact that with the trifling exception of a few perforating riflebullet injuries all gunshot wounds suppurated, and their healing consequently demanded the sacrifices of time, material, and vital energy inherent
procedure. Many
new
trial.
simplest is
One of the
so the responsibility for the immediate closure of the wound may well be shared by both. CARREL states that nearly all the cases of which he has seen followed on septicaamia " unseasonablesuture of the wound, and until the general principle of immediate closure is well established it is for the bacteriologist to advise the surgeon of the safety of the proceeding in the
bacteriologist,
1
THE LANCET, 1917, ii., 789. Brit. Med. Jour., 1918, i. 80. Soc. de Chirurg., Dec. 5th, 1917, and THE LANCET, 2
3
1917, ii., 96.
POOR-LAW GUARDIANS AND THEIR FUTURE.
particular case. A streptococcus producing hæmolysis is one of the organisms which may give rise In his study of the bactericidal to difficulty. in the wound, which another part of this issue, Sir ALMROTH WRIGHT describes artificial conditions which he has devised, imitating closely the actual wound conditions with which the surgeon has to deal. To meet present needs bacteriology, like surgery, must be plastic and freed from all hampering prepossessions. In " bio-pyo-culture" the
effects we
of
leucocytes
in
is working closely hand-in-hand with the surgeon. More even than this is required ’ if immediate closure of wounds is to become a practical reality. At present it is not considered safe for a surgeon to undertake a primary suture at the front and then to send the case down to the base, inasmuch as jolting on the journey may cause commotion in the wound and hinder the proper course of healing. Wounds, like bones, seem to require splinting for their proper recovery, and facilities of accommodation and of transport are needed unless we are to remain content with the suture primitive retardée at the base. Our Paris Correspondent shows (p. 155) how a group of French surgeons dealt with the situation during an attack. No combined effort can be too great to realise a preventive treatment of gunshot wounds equivalent to the preventive orthopaedics of which we have recently spoken.
bacteriologist
work which they are doing and to compare it in the light of that experience, of traditions, and of their own records with that done by their predecessors. They have also full knowledge of their powers in comparison with those exercised by guardians in the past, and can appreciate expectations of increased opportunities for usefulness. To the question which we have quoted above the reply is in all the examples published an emphatic and uncompromising negative. A second question, relating to the general views of guardians as to the performance of their duties, the chairman of the St. Marylebone board of guardians answers as
follows :-
The great improvement in the administration of the best Poor-law unions of recent years is evidence of the efforts of Poor-law guardians to do their work well and of their The extent of the hard work voluntarily undersuccess. taken and carried through is little known.
This may be taken as summarising the majority of the opinions expressed ; no exception can be taken to it, for allowance may fairly be made for improvement effected when the future of boards of guardians is considered. Stress, too, may reasonably be laid upon advantage willingly taken. of increased powers and of the encouragement received from modern public opinion. The chairman of the West Bromwich union puts the case
thus :
All the best of the recommendations of the Royal ComBoards have effected under mission have been carried out. their extended powers such great improvements that the grounds upon which the Commission made their recom-
mendation for the transfer of the duties of guardians to other authorities have ceased to exist.
The
quid nimis."
POOR-LAW GUARDIANS AND THEIR
modern
development
of
the
Poor-law in-
firmaries, the treatment and nursing provided in them, and all that such development means to
Annotations. " Ne
149
FUTURE.
NINE years ago the Royal Commission on the Poor-law, Majority and Minority Report alike, recommended sweeping changes in the position of boards of guardians, and although these bodies still survive the Reconstruction Committee, to whose report allusion is made in our Parliamentary Correspondence, confirms the need for In the meantime boards of drastic change. guardians have been discussing their own future in a recent number of the Local Government Chronicle in reply to a short series of questions upon the subject of their possible abolition and of the transference of the functions comprised under the term Poor. law administration " to other bodies. Destructive self-criticism could not be expected from persons who have, perhaps frequently, submitted to the ordeal of popular election in order to devote time and trouble to public duties of a more or less onerous character, and naturally few answers, if any, in the affirmative have been returned to the first question put: "Is there any foundation for the suggestion that the abolition of boards of guardians is desirable ?" The replies which have been published are, however, from those who, not returning a mere "Yes’’ or "No," were sufficiently interested, or found the necessary leisure to give their reasons ; and, subject to the suggestion made above that a certain amount of prejudice in their own favour may excusably have coloured their views, they have answered perfectly fairly. And they are persons qualified to speak from experience as to the
those who by their circumstances are compelled to have recourse to them, are dwelt upon with pride in many of the replies given, and here also it cannot be said that the satisfaction expressed is unreasonable. The contrast between the infirmary of to-day and that of a generation or of two generations ago may be, and probably is, more conspicuous than that observable in any other department of Poor-law administration, and the usefulness of such practical progress, as setting an example of humanity, has no doubt made its influence felt rather than recognised. It is a progress which the medical profession may justly ascribe in no small degree to the efforts of its members, and which it may regard as a result of the general development of medical science, and as proof of public acknowledgment and appreciaOn the whole the replies obtained by the tion. Local Government Chronicle constitute an interesting contribution to the accumulating literature on this subject, and it may be added that they do not overlook the all-important question as to how far the public will tolerate the handing over of the expenditure of its money to authorities wholly or in part irresponsible, in the sense of not having to seek election or re-election at its hands. A
NEW
KIND OF SELF-INFLICTED
INJURY.
Professor Ascarelli has recently drawn attention1 to a form of lesion resorted to by recruits in order to evade military service which he thinks has hitherto escaped general observation. It is most frequently met with as a periarticular condition in the knee, ankle, or wrist, and presents the appearance of a uniform or nodulated swelling, 1
II Policlinico, Practical Section, Nov. 25th, 1917.