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debridement was complete. Radiography throughthe plaster is always advisable, to indicate the kind offracture that has to be dealt with, and to show whetherthere are any metallic fragments still to be removed ;for it has been shown that foreign bodies near thefracture site are incompatible with smooth healing ofa sutured- wound. The blood-picture is investigated,and the patient is transfused with whole blood if hishaemoglobin is below 80%. Any but life-savingoperations on the travel-weary should be avoided, andthe 24 hours’ rest which this assessment enforces isgood in every way. In the operating-theatre theplaster is removed and the wound inspected with fullsurgical ritual. Bacteriological cultures -are taken,but the decision to. close is made on the appearanceof the wound. It has been shown repeatedly that ifthe primary treatment has been thorough, and ifthe wound on exposure has clean bleeding surfaces,suture may be safely undertaken. Danger signs arethe presence of gas or of pus in deep pockets, andoedema, of the skin or surrounding parts.The operation of closure is conducted on-- the sim-

plest lines. Projecting tags of muscle or tendonthat do not appear to be viable may be trimmed offwith scissors, but as far as possible the wound surfaceis left alone. The skin edges may be freed from theirbed with a blunt instrument, but are not undercutif this can be avoided. They are brought together bya series of vertical mattress stitches of some unabsorb-able suture material. No buried sutures are used, butdeep parts of the wound may be approximated byinserting a few figure-of-eight stitches among thosethat close the skin. There is usually a certain amountof tension in a wound thus sutured at the end of aweek, even though little skin is missing. Wheretension is due to traumatic cadema of the underlyingmuscles it will subside rapidly with closure andimmobilisation, and the wound three or four days laterwill have lost its stretched appearance. Experiencehas shown that quite considerable tension, as long asthe skin is not blanched, will do no harm except inwounds of the leg. Where the skin cannot be approxi-mated by any means, or where closure leads to"

9 tentage "-a roof of skin stretched over an under-lying space--two-stage closure or skin flaps may beemployed. The wound may be closed except for afew inches where the tension is greatest, and the sitemarked on the plaster case, so that it can be exposedafter a week by cutting a window over it; if the re-

maining gap cannot then be closed by suture, which itusually can, it may be covered by a graft. Two-stageclosure is applicable to wounds where the greatestskin defect does not overlie the bone. If such a stepwould leave the fracture side exposed, it is preferableto provide cover by the simplest available method ofskin transference, as by releasing incisions which areimmediately grafted, or by swinging a flap from oneside. The last device is particularly applicable tofractures of subcutaneous bones. After closure, thefracture is treated secundum artem, usually by plaster-of-paris or skeletal traction. British surgeons in Italyand Canadian surgeons in the European theatre arefreely using internal fixation for the fracture site.Their late results will be awaited with interest. Theuse of screws, wires, or plates, if it proves to be harm-less, will undoubtedly make it easier to obtain anato-mical alignment and to secure early joint movement;

but the more conservative may wonder whether theaddition of a foreign body to the difficulties with whichlacerated and contaminated tissues have to deal is notasking too much of the natural powers of resistance.FURLONG’S ngures for Italy, in which the femurs ofthe penicillin series, many of which were plated,showed a higher incidence of chronic sinuses than thenon-penicillin series, none of which were plated, lendsome support to this cautious attitude.The results quoted by MAcFARLANE from the wards

of a group of Canadian hospitals in Britain are typicalof those now being reported by many groups usingsimilar but not- identical methods and relying on peni-cillin as a safeguard against systemic infection.In the Canadian series of 200 compound fractures,80% were successful; success implying either completehealing, or healing of the soft parts with a small skindefect, at the end of 8 weeks. As might be expected,the proportion of successful sutures varies with thebone : it is highest in the arm and forearm, inter-mediate in the femur where 72% were successful, andlowest in the leg. The leg has always been thesurgeon’s bugbear. Its skin has little subcutaneous

fat and fits too tightly to allow any slack ; for surgicalpurposes its fascia is dense and unyielding ; its circula-tion has all the disadvantages of being at the peri-phery ; its soft parts in the lower third are almostunrelieved tendon ; and its main bone is subcutaneousthroughout. That the Canadian surgeons are able toreport 68% success in 44 sutured fractures of. thebories of the leg is therefore all the more striking.

An Industrial Health ServicePROFESSION and public are wakening to the import-

ance of industrial medicine, and many organisationsand individuals are engaged in planning the industrialhealth services of the future. The latest plan comesfrom a committee of the Royal College of Physicians.aIts remark that these services should be planned " in abold manner without much regard for traditionalarrangements

" will evoke wry comment from someof the people who have been working on the subjectfor many years without much encouragement: theymay say that the traditions of industrial medicine,like those of royal colleges, are by no means alwaysdisadvantageous. But the committee’s plan, if not thelast word, is certainly a valuable basis for discussion.An industrial health service, it believes, should be

planned as part of the national health service, andclosely associated with it at all levels-central,regional, and local. It should be national in its scopeand apply to every variety of employment. Itshould be staffed by medical inspectors, consultantsin industrial medicine, and whole-time and part-timemedical officers, together with the non-medical person-nel, all of whom should be trained for their particularwork. In administration the service must be linkednot only with the national health service but withuniversity departments of industrial health, where suchexist. Perhaps the most important recommendationis that clinical facilities, including hospital beds,1. Furlong, R., Clark, J. M. P. Brit. J. Surg. 1944, 32, 147.2. Second interim report of the Social and Preventive Medicine

Committee of the Royal College of Physicians of London.The members are Dr. A. A. Moncrieff (chairman), Lord Moran,Prof. M. Greenwood, FRS, Prof. A. W. M. Ellis, Dr. H. E. A.Boldero, Dr. J. A. Charles, Dr. P. M. D’Arcy Hart, Dr. AubreyLewis, Dr. Janet Vaughan, Sir Allen Daley, Dr. J. E. Gordon,and Prof. J. M. Mackintosh.

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should be provided for- the consultants and research-,workers in industrial medicine. The aims of theservice should include the establishment and nÚ1Ínten-ance of the best possible environment for work ; the

prevention of disease and accidents in industry ; thereabling of the injured worker ; and the education ofthe workers in health. Finally encouragement shouldbe given to research, both by the service and by theindustries themselves.The committee presupposes that the national health

service,’with which the industrial health services areto be coordinated, will be built on central, regional,and local organisations. It suggests that ultimate re-sponsibility for the industrial service should be vestedin the Minister of Health, and that the chief medicalofficer of the Ministry,of Health should also be chiefmedical officer of the industrial health service.

Surprisingly, it adds that administration should bedelegated mainly to the Ministry of Labour andNational Service, but for special purposes might still becarried out within the geheral framework of the service-by such bodies as the Ministry of Fuel and Power, theMinistry of War Transport, and the General, PostOffice. On the face of it, this arrangement seemslikely to lead to interdepartmental strife and to defeatthe aim of coordination of the national health services ; ;,it would surely be much more satisfactory to place allthe civilian health services in the country under asingle Ministry. No doubt contact would be facili-tated if the Ministries of Labour and Health had thesame chief medical officer, and the suggestion is interest-ing ; but the sharing of CMO by the Ministries ofHealth and Education is not completely comparable,and it is by no means customary for officials of oneMinistry to be controlled by those of another.In considering the best arrangements, the question

arises whether practitioners of what one may calllocal-authority public health are the proper people tocontrol industrial public health, which needs a differ-ent approach. Industrial health, which involves

inspection of individual factories, is all the better forbeing divorced from local politics and influence ; anda tenable objection to control by the Ministry ofHealth, ne’e’Local Government Board, is that this

Ministry is built on a local-authority basis. It is ofcourse true that the local-authority public healthservices have been more developed than the industrialhealth services. COLLIS 3 in his Milroy lectures of ’

1915, after describing the brilliant investigations in the1860’s of GREENHOW into the effect of occupationaldusts on the lungs, says : ,

" Why work so well started was then allowed to liedormant for so long, while other aspects of publichealth were being strenuously developed by medicalofficers of health with inspectors of nuisances appointedfor every town and district, reinforced now by a batta-lion of tuberculosis officers, is astonishing."

Much could be written about the reasons for thisunequal growth of the two branches of preventivemedicine, and probably the term " vested interests "would find a place in the discussion. But the indus-trial health services have been slowly but surelydeveloping since the appointment of Sir THOMASLEGGE as the first medical inspector of factories in1898. At the Home Office LEGGE laid the founda-tions soundly and well, and the structure he - builtcannot be lightly demolished. Especially as regards

3. Collis, E. L. Public Health, 1919.

administration, the Royal College of Physicianscommittee has tackled a difficult problem, and its

report might have taken a different turn if more of itsmembers had been industrial doctors and more thanone of the interested Ministries had been represented.One of its purposes, however, will be served if criticswill now state their alternative solutions.

Hæmothorax. BLOOD in the pleural cavity is due of the common-

places of war-tinie surgery. The amount lost in thisway can be considerable, and a bigger internal hmmor-rhage can be concealed in the pleura than in any otherpart of the human frame without necessarily causingdeath. In the treatment of haemothorax there is onepiece of good fortune that simplifies surgical treat-ment-the fact that it remains largely fluid, andtherefore can be removed through a needle withoutgreat difficulty for the surgeon or great inconvenienceto the patient. The reason for the fluidity of theblood has long been a subject for speculation. It is now

. being suggested that it does not arise from failureof the blood to clot when it is poured out into aserous-lined cavity, but rather that coagulation takesplace normally and the-rapid .movements of heart andlung defibrinate the blood. SELLORS points out in thisissue that haemothorax blood a few hours after injurycontains virtually no fibrinogen, and that its haemo-globin content is 30-40% lower than that of thecirculating blood. The inference is that defibrinationoccurs rapidly and completely, and that there isan early reactionary ’effusion. The precipitatedfibrin is ultimately organised or absorbed into thewalls of the haemothorax cavity.

In most cases well-controlled needle aspiration canbe used to evacuate a haemothorax completely, leavingonly a little local pleural thickening which clears upadequately with expansion breathing exercise. Shredsof clot and fibrin which block the aspirating needle canbe removed through a thoracoscopy cannula, but.in some cases a more massive basal shadow on radio-graphy suggests the presence of a clot which has tobe evacuated through a small thoracotomy incisionEffective treatment of a more or less uncomplicatedhsemothorax on these lines,will produce an admirablefunctional recovery, as BARRETT emphasised in thesecolumns last week. ’ ’

’

There are, however, cases in which, through delayedtreatment or added complications, an obvious massive-clot is found in the pleural cavity. This group de-mands adequate recognition. There are several pos--sible reasons for the unusual behaviour of the extrudedblood. If blood is slowly poured out into the pleuralcavity the movements of the thoracic viscera may - be-so little disturbed that defibrination does not takeplace. This is particularly likely when extensivepleural adhesions resulting from some previous diseaseor injury mechanically limit the size of the haemor-rhage. The resulting haematoma may then resemblean encysted haematoma in other parts of the body.This is the one true form of " clotted haemothorax."The more usually designated clotted hemothorax,recognised in the later stages, is strictly a clottedfibrinohaemothorax.1 Here the irritative effect of bloodon the pleural surfaces produces a serous effusion,1. Lush, R. W., Stevenson, C. R., Nicholson, J. C., Nicholson,

W. F. Lancet, 1944, ii, 467.