another worker, the Franco-American surgeon Alexis Carrel, had introduced with Prof. H. D. Dakin an antiseptic not formerly much employed. This was a hypochlorite solution which had been christened " ensol " or " Dakin's solution." The technique employed was more important than the antiseptic, and to some extent justified the views of Wright. It was a continuous drain- age secured by the use of cans and rubber tubes. The wound was thus kept flushed and all its discharges were washed away. This system found many supporters but was attacked by Wright. Finally a third school dealt with the problem and brought to its solution the methods of the great German biochemist Paul Ehrlich. Ehrlich's idea was that a drug possessing a specific effect on specific forms of protoplasm might be found in connexion with any bacterium. He proved his case with his own discovery " salvarsan " or " 606," which possesses a special destructive power where the spirochaetes of syphilis are concerned. In the case of the bacterial poisons of wounds another sub- stance, flavine, was brought forward. This preparation belonged to the same group as salvarsan; it was used in the first instance by Prof. C. H. Browning. Very good reports of its efficacy were received. But again Wright and his followers attacked it on the ground that it failed of its object, the destruction of bacteria, and interfered with the physiological processes of nature. It canno't be said that any permanent settlement of this dis- pute has as yet been reached, but it does seem clear that the foundations of Wright's work physiological study will be hard to shake. Indeed he has here an advantage over all his critics, the nature of which they did not seem at first to realize. Vaccine Methods. To Wright indeed belongs the credit of having brought the laboratory to the bedside. He saw that no method can succeed unless it is based on practice. Practice in this sense means physiological principle. It was recognition of this fact which inspired his antiseptic studies. Further, though this has not been sufficiently appreciated, it was recognition of it which enabled him and those who worked with him to bring the anti-typhoid vaccination to the high pitch of perfection it had reached when war broke out. Typhoid. Of the single facts of medical history during the war period the success of this anti-typhoid vaccination is certainly the most conspicuous. Such a success was indeed undreamed of, for of all the enemies of the soldier typhoid fever ranked first. A study of earlier campaigns reveals the fact that this scourge usually swept away large proportions of the armies engaged in European warfare, and in some cases the casualties by bacilli chiefly typhoid stood to the casualties by bullets in the pro- portion of 80 to 20. Thanks largely to the preventive inoculation against typhoid this condition of affairs was reversed in the World War, the proportion being gun-shot wounds (including all forms made by all manner of missiles) 80 and disease 20. The credit for this result is due largely to Sir Almroth Wright and Sir Wm. Leishman, who devoted endless trouble to the work of perfecting this brilliant application of bacteriological and physiological principles to preventive medicine. Tetanus. Not less striking, though less dramatic, was the success achieved in the prevention of tetanus or lockjaw. This dreaded disease began to manifest itself almost at the beginning of the campaign. Before the battle of the Marne was fought it was relatively prevalent and was causing great consternation, for it was recognized that the intensively cultivated soil of Europe was impregnated with tetanus bacilli, and that thus every wound was dangerous. Moreover, up till this time the treatment of tetanus had proved singularly ineffective, so much so indeed that the patient was regarded as doomed. As the tetanus bacillus presents many features in common with the diphtheria bacillus, and as the antidiphtheria serum had proved a very great success, it was thought that a serum prepared in the same manner might solve the tetanus problem. This hope had not been realized in practice at the time of the outbreak of war. Nevertheless, there was some reason to think that, though the serum failed when given after the disease had declared itself, it might not fail if administered at the time of actual wounding. Tetanus, as is well known, takes several days to incubate. In consequence, there is available a period in which measures for its suppression can be carried out. This fact was the basis of the antitetanus inoculation which was begun experimentally in 1914. From the outset the experiment succeeded beyond the expectation of those who had planned it. Tetanus became a rare disease, thanks to the fact that every wound, no matter how trivial, was regarded as a possible source of danger. It was an order that as soon as a soldier got even a scratch of the skin he must report to his medical officer. A prophylactic dose of serum was then administered. At a late period the War Office set up a Tetanus Committee under the chairmanship of Sir David Bruce. This committee investigated cases of so-called " delayed " tetanus, and also those cases in which tetanus made its appearance at long periods after the initial wounding when surgical measures had been car- ried out on the wound. The view which was formed was that the bacilli in such cases were walled in and rendered innocuous; but manipulations of the wound were apt to break down the walls and so release the toxins. Shell Shock. Meanwhile the circumstances of war were directing attention to a series of new disease conditions which the peace-time physician had not encountered in so severe a form. Chief perhaps among these was the nervous disturbance caused by high explosive shells. At first a number of wild statements were made and believed, but presently, and thanks in no small measure to the common sense of Sir Frederick Mott and other distinguished neurologists, some light on the darkness was ob- tained. Mott pointed out that among the large group of cases classed as shell-shock patients there were a number who had suffered actual physical injury of the brain as a result of ex- plosives. If these people died, punctiform haemorrhages were found in the brain substance. These cases were not psychopathic, they were organic lesions cases of injury. After elimination of this group there remained a large group of individuals, considerable numbers of whom had not received any injury. These cases were often very severe, but they differed in no material respect from the neurasthenics and victims of functional neuroses well known in civil life. The ques- tion was asked why these patients should break down whereas other men could be severely wounded and yet show no sign of nervous disturbance. Various answers were given to this question, and probably all of them contained a germ of truth. Thus it was pointed out that hereditary influences played a part in some of the cases. The men came from mentally unstable families; they themselves had only just managed to support the conditions of ordinary life. The conditions of life in the trenches broke them down. Again, many of these patients were clearly the victims of chronic in- fections such as rheumatism, which exercise an irritant effect on the nervous system. Thus the men were more easily stimu- lated than in normal cases, and so more easily fell victim to the excessive stimulation of war. Thus new recognition was given to relationship existing be- tween disease and temperament, between the nervous system and the functional activity of the body. It was seen with a clearness not before achieved that the mental case may be the case of disease, slight, unrecognized, yet perpetually active. The treatment of these cases occupied a large number of distinguished workers. Little by little a process was evolved whereby disease elements were eliminated so far as possible before mental con- ditions as such were pronounced upon. Thus the patient's general health was made the subject of careful study, while at the same time his mind was being dealt with. Psycho-analysis. The purely mental aspect of the subject forms one of the fascinating chapters of modern medicine. Never before was so vast a material presented to scientific work- ers. This material, too, came at an hour when a great upheaval in mental medicine was in process. The writings of Sigmund Freud of Vienna had just begun to find adherents among British psy- chiatrists. They were the subject of hot dispute; but the first wave of incredulity was spending its force. Thus Freud's methods
Page:EB1922 - Volume 31.djvu/950
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MEDICINE AND SURGERY