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THE NURSING CRISIS
478
into wounds to proliferate and form toxins are not clearly ‘
understood." Such an hypothesis would not be substantiated by any war surgeon. Clostridia are ubiquitous and no wound in peace or war would be safe from this infection ; the disease would be rampant. The war surgeon has come to realise the truth in the slogan " No dead muscle-no gasgangrene." This was borne out in the war of 1914-18. In the early stages, when wounds were not opened up and
excised, gas-gangrene was most prevalent, but as
soon as
rectified gas-gangrene almost disappeared. Finally, Robb-Smith recommends the injection of antiserum locally around the wound when it has been impossible to remove all necrotic muscle. If the sequestrum is present, clostridia will wallow in it, and I can see no beneficial effects from antiserum injected into its midst. If the sequestrum has been removed, there is no necessity for antiserum, for the remaining clostridia are soon overpowered by the body defences. If Macfarlane and MacLennan’s contention be true-that the systemic symptoms of gas-gangrene are not due to circulating toxins-then antiserum is of no avail. If a muscle sequestrum be present, it must all be removed at operation regardless of disability to follow. If the surgeon does not do this, nature will in her own good time, if the patient is fortunate enough to survive. Dead muscle can never be brought to life again and failure to remove it at operation is only inviting disaster. R. WOOD POWER. Hereford. SiR,-In your issues of Sept. 8 and 15 Majors Macfarlane and MacLennan suggest that the general toxaemia of gas-gangrene produced by Cl. welchii is not due to octoxin but to products derived from disintegrating tissue. They identify in 01. welchii toxic filtrate, an c-nzyme " collagenase," which they state is directly involved in the muscle destruction in gas-gangrene. They further suggest that an antitoxin or toxoid designed to confer a high anticollagenase immunity might be more effective than the present methods which are judged by their a.-antitoxin effect. Cl. welchii A produces a number of
this
was
antigens : (x-toxin, 0-hsemolysin, hyaluronidase, collagenase, and no doubt others not yet identified. The relative importance of the first three of these antigens in experimental gas-gangrene, and of their respective antibodies in the control of the disease, has been the subject of a series of investigations during recent years,! and the results have shown that rt.-toxin plays the most important part in infection and that oc-antitoxin is the significant antibody in the control of the disease. In view of the work of Macfarlane and MacLennan, a similar study has now been made of the protective properties of anticollagenase in experimental gas-gangrene. Two Cl. welchii antisera, kindly supplied and assayed by Dr. C. L. Oakley of the Wellcome Physiological Research Laboratories, were tested for their protective, action against gas-gangrene produced in guineapigs by each of four different strains of 01. welchii A. One of the antisera contained anticollagenase but no rt.-antitoxin, while the other contained oc-antitoxin but no anticollagenase. The serum was administered to the animals 16 hours before infection. Results of the experiments showed that : ( 1 ) Serum containing anticollagenase and no
THE NURSING CRISIS from Sister Bateman (Sept. 22) demands attention as coming from one who by her own experience knows where the shoe pinches. That hospitals are increasingly and admittedly failing to attract entrants to both the nursing and domestic sides shows that there is something fundamentally wrong. An easy reaction is to blame it on " the modern girl "-which certainly saves one the trouble of thinking, but is rather like randfather over again : " In my time ..." The elders of each generation have talked like that. Surely it is time to examine the situation from a new angle and try to find out the causes. Sister Bateman relates some ; others suggest themselves at once to anyone familiar with the way in which hospitals are run. What other industry today attempts to cover a twenty-four-hour day on two shifts ? Why must nursing students be required to live in, and be under some sort of control for twenty-four hours in the day ? Other students are not. And why, as students, must they do so many purely domestic duties, which could be much better done by someone trained or training for such work ? P These, as we all know, keep them from their first duty of attending to the patients. My purpose, however, is not to theorise as to why hospitals cannot attract entrants but to suggest that the Institute of Public Opinion be asked to make an inquiry and find out from the girls themselves why they won’t take up nursing or hospital domestic work. A Gallup poll would, I think, throw light on the question and save To get the history betore us from continued fumbling. attempting diagnosis or treatment is a sound way. The young are not always wrong in what they want, and they are showing that they do not want nursing under present conditions. S. W. SWINDELLS. Grimsby.
SiB,—The letter
SHOULD A BRACHIAL PLEXUS INJURY BE EXPLORED ?
Sin,—The question asked by Mr. Hambly in giving a title to his paper of Sept. 22 is an important one, to which many of us would like to know the answer. As Mr. Hambly says, the general opinion is that exploration of wounds of the brachial plexus is not worth while ; but he evidently thinks as I do that a proper judgment ought to be based on something more substantial than odd impressions. I cannot remember the details of our conversation last October, but I think I suggested to him that the proper approach was to explore all serious open injuries of the brachial plexus to determine how many presented lesions (a) capable of surgical repair, (b) incapable of repair, or (c) not requiring repair. The operative findings and procedures would, of course, be fully documented, and the cases observed subsequently at regular intervals so that in due course we should know whether those in which repair had been carried out showed sufficient recovery to justify what had been done, and whether those in which the damaged parts of the plexus were in continuity, and not sufficiently scarred to warrant resection and suture, had shown the anticipated degree of recovery. Clearly this is a tedious inquiry but one that must be made before we can know what, if anything, we can offer our patients ; and I hoped that a substantial contribution would be made by Mr. Hambly. It is therefore disappointing, when one reads his casereports, to find no mention of the dates of injury, operation, or recovery, and so little neurological information One cannot, however, help susas to be worthless. pecting that in case 8 operation can hardly have been necessary since the rapidity of recovery suggests that
anon -degenerative lesion (neurapraxia) was present, and would have recovered spontaneously anyway. The title of the paper suggests that Mr. Hambly was out to give us some big news. As it is, the only arresting piece of information is that in cases of irreparable brachial plexus paralysis arthrodesis of many joints is preferable to amputation followed by the fitting of an artificial limb. He seems to be fairly certain about this ; but how does he know-may we have the evidence ?P No doubt he will recall the discussion at Oxford last year when Mr. Hendry described his cases (I think there were two) in which he had arthrodesed a number of joints in a paralysed limb and thought the results better than could be obtained by amputation and prosthesis. But I doubt whether Mr.
into wounds to proliferate and form toxins are not clearly ‘
understood." Such an hypothesis would not be substantiated by any war surgeon. Clostridia are ubiquitous and no wound in peace or war would be safe from this infection ; the disease would be rampant. The war surgeon has come to realise the truth in the slogan " No dead muscle-no gasgangrene." This was borne out in the war of 1914-18. In the early stages, when wounds were not opened up and
excised, gas-gangrene was most prevalent, but as
soon as
rectified gas-gangrene almost disappeared. Finally, Robb-Smith recommends the injection of antiserum locally around the wound when it has been impossible to remove all necrotic muscle. If the sequestrum is present, clostridia will wallow in it, and I can see no beneficial effects from antiserum injected into its midst. If the sequestrum has been removed, there is no necessity for antiserum, for the remaining clostridia are soon overpowered by the body defences. If Macfarlane and MacLennan’s contention be true-that the systemic symptoms of gas-gangrene are not due to circulating toxins-then antiserum is of no avail. If a muscle sequestrum be present, it must all be removed at operation regardless of disability to follow. If the surgeon does not do this, nature will in her own good time, if the patient is fortunate enough to survive. Dead muscle can never be brought to life again and failure to remove it at operation is only inviting disaster. R. WOOD POWER. Hereford. SiR,-In your issues of Sept. 8 and 15 Majors Macfarlane and MacLennan suggest that the general toxaemia of gas-gangrene produced by Cl. welchii is not due to octoxin but to products derived from disintegrating tissue. They identify in 01. welchii toxic filtrate, an c-nzyme " collagenase," which they state is directly involved in the muscle destruction in gas-gangrene. They further suggest that an antitoxin or toxoid designed to confer a high anticollagenase immunity might be more effective than the present methods which are judged by their a.-antitoxin effect. Cl. welchii A produces a number of
this
was
antigens : (x-toxin, 0-hsemolysin, hyaluronidase, collagenase, and no doubt others not yet identified. The relative importance of the first three of these antigens in experimental gas-gangrene, and of their respective antibodies in the control of the disease, has been the subject of a series of investigations during recent years,! and the results have shown that rt.-toxin plays the most important part in infection and that oc-antitoxin is the significant antibody in the control of the disease. In view of the work of Macfarlane and MacLennan, a similar study has now been made of the protective properties of anticollagenase in experimental gas-gangrene. Two Cl. welchii antisera, kindly supplied and assayed by Dr. C. L. Oakley of the Wellcome Physiological Research Laboratories, were tested for their protective, action against gas-gangrene produced in guineapigs by each of four different strains of 01. welchii A. One of the antisera contained anticollagenase but no rt.-antitoxin, while the other contained oc-antitoxin but no anticollagenase. The serum was administered to the animals 16 hours before infection. Results of the experiments showed that : ( 1 ) Serum containing anticollagenase and no
THE NURSING CRISIS from Sister Bateman (Sept. 22) demands attention as coming from one who by her own experience knows where the shoe pinches. That hospitals are increasingly and admittedly failing to attract entrants to both the nursing and domestic sides shows that there is something fundamentally wrong. An easy reaction is to blame it on " the modern girl "-which certainly saves one the trouble of thinking, but is rather like randfather over again : " In my time ..." The elders of each generation have talked like that. Surely it is time to examine the situation from a new angle and try to find out the causes. Sister Bateman relates some ; others suggest themselves at once to anyone familiar with the way in which hospitals are run. What other industry today attempts to cover a twenty-four-hour day on two shifts ? Why must nursing students be required to live in, and be under some sort of control for twenty-four hours in the day ? Other students are not. And why, as students, must they do so many purely domestic duties, which could be much better done by someone trained or training for such work ? P These, as we all know, keep them from their first duty of attending to the patients. My purpose, however, is not to theorise as to why hospitals cannot attract entrants but to suggest that the Institute of Public Opinion be asked to make an inquiry and find out from the girls themselves why they won’t take up nursing or hospital domestic work. A Gallup poll would, I think, throw light on the question and save To get the history betore us from continued fumbling. attempting diagnosis or treatment is a sound way. The young are not always wrong in what they want, and they are showing that they do not want nursing under present conditions. S. W. SWINDELLS. Grimsby.
SiB,—The letter
SHOULD A BRACHIAL PLEXUS INJURY BE EXPLORED ?
Sin,—The question asked by Mr. Hambly in giving a title to his paper of Sept. 22 is an important one, to which many of us would like to know the answer. As Mr. Hambly says, the general opinion is that exploration of wounds of the brachial plexus is not worth while ; but he evidently thinks as I do that a proper judgment ought to be based on something more substantial than odd impressions. I cannot remember the details of our conversation last October, but I think I suggested to him that the proper approach was to explore all serious open injuries of the brachial plexus to determine how many presented lesions (a) capable of surgical repair, (b) incapable of repair, or (c) not requiring repair. The operative findings and procedures would, of course, be fully documented, and the cases observed subsequently at regular intervals so that in due course we should know whether those in which repair had been carried out showed sufficient recovery to justify what had been done, and whether those in which the damaged parts of the plexus were in continuity, and not sufficiently scarred to warrant resection and suture, had shown the anticipated degree of recovery. Clearly this is a tedious inquiry but one that must be made before we can know what, if anything, we can offer our patients ; and I hoped that a substantial contribution would be made by Mr. Hambly. It is therefore disappointing, when one reads his casereports, to find no mention of the dates of injury, operation, or recovery, and so little neurological information One cannot, however, help susas to be worthless. pecting that in case 8 operation can hardly have been necessary since the rapidity of recovery suggests that
anon -degenerative lesion (neurapraxia) was present, and would have recovered spontaneously anyway. The title of the paper suggests that Mr. Hambly was out to give us some big news. As it is, the only arresting piece of information is that in cases of irreparable brachial plexus paralysis arthrodesis of many joints is preferable to amputation followed by the fitting of an artificial limb. He seems to be fairly certain about this ; but how does he know-may we have the evidence ?P No doubt he will recall the discussion at Oxford last year when Mr. Hendry described his cases (I think there were two) in which he had arthrodesed a number of joints in a paralysed limb and thought the results better than could be obtained by amputation and prosthesis. But I doubt whether Mr.