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SECTION III
NEUROSURGERY
CHAPTER I
ORGANIZATION AND ACTIVITIES OF THE NEUROLOGICAL SERVICE AMERICAN EXPEDITIONARY FORCES a
In June, 1918, upon the reorganization of the professional services of the American Expeditionary Forces, neurological surgery was made a separate subservice of the genaral surgical services, and a senior consultant was appointed thereto.
PROBLEMS OF ORGANIZATION
No precedent covering the activities of such a subdepartment of general surgery existed in either the French or British Armies. Moreover, no figures were available which would serve to give an idea of the probable responsibilities of this service beyond the rough estimate that 25 percent of all surgical casualties presented neurological problems of one sort or another. More or less unofficial figures from British and French sources had given the following percentage of injuries of the nervous system in relation to the wounded: For wounds of the head, including all types, 16 percent; b for wounds of the spine, 2 percent; for wounds of the major peripheral nerves, 20 percent of all serious injuries of the extremities.
The problem, so far as could be seen, divided itself into two main parts:(1) The immediate care in forward hospitals of the more serious cranial cases;(2) the later care at the base hospitals of the residual paralyses of the main peripheral nerves, the neurosurgical aspects of which were not likely to come into prominence until the complete healing of the complicating wounds and fractures.
The results of the early operations for penetrating wounds of the skull, so far as figures rendered them available, had been lamentable, the estimated operative mortality from reports in literature varying from 50 to 65 per cent, and of all spinal cases about 80 percent.
So far as the peripheral nerves were concerned, it was known that they had been accumulating during the four years of war in the French and
a Being the report to the chief surgeon, A. E. F., from the senior consultant in neurological surgery on summary of activities of the department, dated Neufchateau, December 2, 1918. Copy on file, Historical Division, S. G. O.
b The exact figures from two mobile hospitals operating in the Argonne in October and taking only seriously wounded were as follows: Out of a total of 1,202 cases, excluding those marked "multiple G. S. W." there were 135 head cases, giving 11.1 percent. At this time no figures from a field hospital for seriously wounded were at hand and the proportion of head cases to other wounded, owing to the many early fatalities from wounds of this sort, naturally fell off greatly in the hospitals of the intermediate and base zones.
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British hospitals and that great numbers of them were awaiting neurological study and neuroplastic operation or orthopedic procedures to ameliorate deformities.
PLAN OF ORGANIZATION
TEAMS FOR HOSPITALS IN THE ZONE OF THE ADVANCE
Obviously the most urgent need in June, 1918, was to supply the hospitals in the zone of the advance with surgeons who had had some neurological training and experience with penetrating wounds of the skull. As the available number of such officers was small, it became necessary to select and give personal instruction to one surgeon from each evacuation hospital and to supply the proper surgical equipment.
REPRESENTATIVE IN BASE HOSPITALS
In the emergency it was regarded of secondary moment to include in this plan the hospitals at the base, though provision was made so far as possible to have a representative surgeon in each base hospital who, even without much neurological experience, could work in conjunction with the neuropsychiatrist of the unit. Later on, some of the commanding officers of the larger hospital centers cooperated in the secondary routing within the particular center of the majority of the organic lesions of the nervous system to one hospital wherethey could be more satisfactorily supervised.
NEUROLOGICAL CENTERS
It was planned eventually to establish in certain favorable areas centers devoted exclusively to diseases of the nervous system, corresponding to the French neurological centers, where neurological cases might be assembled and where groups of experts, neurologists, neurosurgeons, and orthopedists with neurological interest, could be gathered and thus bring less strain upon a meager personnel. Such a plan, however, could be realized in a very small way only, largely in view of the fact, as is explained below, that relatively little time intervened between the inception of the subservice of neurological surgery in June, 1918, and the signing of the armistice the following November.
ARRANGEMENTS FOR THE CARE OF HEAD WOUNDS
SPECIAL SURGICAL INSTRUMENTS
For success in this work, special surgical instruments not contained in the Army equipment were essential, and only after some delay the necessary perforators, drills, and rongeurs were secured through French manufacturers.
INSTRUCTIONS FOR NEUROLOGICAL SURGEONS
In addition to the practical instruction in craniocerebral surgery given to selected surgeons from the various evacuation hospitals, the following directions were prepared by the senior consultant in neurological surgery, American Expeditionary Forces, and were furnished to members of neurosurgical teams.
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DIRECTIONS TO NEUROSURGICAL TEAMS CONCERNING CRANIOCEREBRAL WOUNDS
It is expected of all neurosturgical teams that they shall primarily be capable of the general surgical work of a forward hospital. This is so, firstly, because multiple wounds are common and a compound fracture of an extremity or any other injury may accompany the head wound; secondly, because neurological cases may not happen to be admitted in sufficient number to occupy the full time of the team, or the situation may be such as to render advisable their early evacuation, untreated, to the nearest base. At best a well-trained team can hardly expect to cover on an average more than 8 or 10 cases of penetrating craniocerebral type in a working day.
It is requested that, on the form shown below, each neurological team send a monthly report of its cases to the senior consultant in neurological surgery, A. P. 0. 731:
CHART
GENERAL REMARKS CONCERNING CRANIOCEREBRAL WOUNDS
Every scalp wound, no matter how trifling, is a potential penetrating wound of the skull. Many penetrating wounds are met with even among the walking wounded. Only after an X-ray, after shaving the head, and possibly only after exploration, can one be assured that there is or is not a cranial fracture with or without dural penetration.
If a case is operated upon and a penetration found, the operation must be completed, with a primary closure following the special debridement applicable to these injuries. In this respect wounds of the nervous system differ from other wounds which in times of rush should not be subjected to primary wound closure. "All or nothing” is a good rule to apply to craniocerebral injuries-in short, evacuate these cases untreated to the nearest base (except for shaving and the application of a wet antiseptic dressing) rather than do incomplete operations. Patients with craniocerebral injuries stand transportation well before operation; badly during the first few days after operation. This is true of all primary wound closures.
Cranial cases in more or less shock need not undergo a period of resuscitation. The operations should be done under local anesthesia combined with morphine. Consequently the patient can be properly warmed and given fluids during the course of the operation through which they will often sleep. Only in exceptional cases, when patients are irrational or uncooperative, is a general anesthetic necessary. Its administration always adds to the difficulty of the operation, and by increasing intracranial pressure causes extrusion of brain and tends to increase the damage already done.
The chief source of the high mortality in cranial wounds is infection-infection of the meninges; direct infection of the brain leading to encephalitis; infection of the ventricles. Wounds in which the dura has been penetrated are supposed to give a mortality of from 50 to 60 percent, due to infection. It, however, has been shown that experienced neurosurgical surgeons can lower this supposedly inevitable mortality to 25 percent if the operations can be done with reasonable promptitude in a forward area and the cases retained for a reasonable time after operation. These figures are capable of still further improvement.
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CLASSIFICATION OF HEAD WOUNDS
On the basis of their severity, gauged by mortality percentage, head wounds may be divided into the following categories:
I. Woulds of the scalp......................................................................................................Mortality circa 5 percent.
II. Cranial fractures without dural penetration................................................................Mortality circa 10 percent.
III. Cranial fractures with depression and dural penetration, but without extrusion of brain....Mortality circa 20 percent.
IV. Wounds usually of gutter type, with brain extruding and indriven bone fragments.........Mortality circa 30 percent.
V. Wounds usually of penetrating type with indriven bone fragments plus metal................Mortality circa 40 percent.
VI. Wounds of Type IV and V with penetration of bone or metal opening ventricles...........Mortality circa 50 percent.
VII. Craniofacial wounds of orbitofrontal or temporopetrosal type in which ethmoid or petrosal sinuses are opened.
Primary closure impossible and risk of secondaryinfection great.........Mortality circa 60 percent.
VIII. Perforating or transversing wounds...............................................................Mortality circa 70 percent.
IX. Extensive bursting fractures. (Fatality very usually due to trauma rather than infection.)
CI.INICAL RECORDS
A preliminary note with (1) a brief history of case, (2) the patient's general condition, (3) the characteristics of wound, and (4) the positive neurological findings, should be made before the patient becomes drowsy from his morphia, which may well be given an hour before the operation and before the act of shaving.
DUPLICATING BOOKS
These are timesaving and desirable, for not only is it essential that the surgeon retain a record of his own cases and keep track of his end results, but it is of great importance that a duplicate record be forwarded in the field envelope with the patient, so that subsequent attendants may know something definite as to the patient's condition and the procedure followed in the forward area.
INFORMATION POST CARDS
Ordinary plain French post cards requesting information as to the outcome of the operating may be inclosed in the field envelope, addressed either to the surgeon himself, or to the senior consultant in neurological surgery, A. P . 0. 731, who will forward the report together with such other information as may be pertinent.
PREPARATION FOR OPERATION
The success of these specialized operations and the celerity with which they may be done depends entirely on attention to detail and development of team play. Don't hesitate to do the first case or two slowly and carefully. Time will be saved on succeeding ones.
As the preliminaries may take almost as long as the operation itself, two tables should be in use, or if not two tables, the patient being prepared should be on a stretcher and trestles alongside the tables on which one operation is being completed.
Morphia is well tolerated. A third of a grain should be given and this repeated if necessary.
After a thorough soaping, with massage to soften the hair matted by blood, the entire head should be shaved, an act which requires no inconsiderable skill and on the perfection of which the successful outcome of the operation depends not a little. A shaving brush is essential to a good lather. The hair should not be clipped as this greatly increases the difficulty of shaving.
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Novocainization of the scalp.- The infiltration should be made in lines of the proposed incisions 15 to 20 minutes before the patient is put on the table for operation. After novo- cainization it will be found that the dirty wound may then be filled with gauze before the final cleaning. This need consist of nothing more than careful wiping of the scalp with alcohol followed by bichloride solution. Avoid the use of iodine, picric acid, etc.
Position of the head.- Ordinary pillows and long sandbags are desirable. In order to get a proper elevation of the head so that it can stand free of the surroundings, one or two loosely filled sandbags, measuring about 8 by 8 by 3 inches, covered with rubber sheeting, will be found convenient.
A secure arrangement of towels to prevent their slipping in the course of a prolonged operation is essential, and it is well to have some sort of makeshift wire rack to keep the towels from settling against the patient's face.
A head-light is desirable, since the lighting system over most operating tables is central with imperfect illumination of the end of the table.
THE OPERATION
Its principles are those of wound débridement in general, consisting in the removal of the contaminated margins of the wound and tract, together with soiled fragments of indriven bone, and, if possible, of the foreign body.
It is unnecessary to remove more than the merest edge of the contused scalp wound. It is found that the making of "tripod incisions," which radiate from the central wound, permits of the reflection of three flaps, which when undermined can subsequently be drawn together with complete wound closure. Sufficient exposure of the cranial lesion is secured by these reflected flaps. Only in the case of large scalp defects is the switching of flaps necessary for closure and it is questionable if this is ever desirable.
The bone defect should be closely encircled by three or four perforations with perforator and burr, and these openings connected by linear cutting forceps (Montenovesi preferable, small De Vilbiss can be used). In this way the bone defect can be excised in toto and in the majority of cases the entire block may be tilted up in one piece. Some bone wax should be at hand. Nibbling with rongelurs across the area of the bone defect after preliminary lateral trephining is undesirable, particularly as this is apt to be a soiled area. Leave as small a bone defect as possible--a quarter of an inch margin beyond the defect suffices.
Do not enlarge the area of dural laceration. Never open an intact dura unless (1) an underlying clot or area of pulped brain is indubitable; (2) the operation is sufficiently early to antedate infection of the internal wound; (3) you have the experience and materials for an accurate reclosure. Except in very skillful hands a dural incision greatly increases the chances of a fatality from infection. In the British Expeditionary Forces there are strict regulations against it under any circumstances whatsoever. Curved French round-pointed needles with fine black silk sutures are essential for proper reclosure of the dura in case it has been opened during the operation.
The débridement of the contused area of the brain and tract can be best carried out with production of the least damage to the brain by gentle suction and irrigation with a soft catheter to which a Carrel syringe with a rubber bulb is attached. The catheter detects indriven bone fragments as well as does the finger, and they can be picked out by delicate esquillectomy forceps. Metallic fragments of small size are surprisingly well tolerated. It is therefore much better to give the patient the chance of carrying the missile, which may not have been contaminated, than the certainty of having existent paralysis increased and perpetuated by too energetic attempts to extract it when deeply placed. When at hand, a magnet will be found useful as a means of extracting shell fragments from the bottom of a tract.
A craniocerebral wound should never be sponged with dry gauze. Pledgets of cotton wrung out of salt solution will clean the wound infinitely better and will be much less likely to start up bleeding. All sponging, whether by operator or assistant, can be done by such pledgets held by the forceps, thus keeping fingers from the wound.
Bleeding points from sinuses or brain should be checked by tissue implantation. "Stamps'" of muscle are most efficacious and can usually be obtained from some other operation or by additional incision from the patient himself.
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ARMAMENTARIUM
In addition to the usual dissecting set with rongeurs, etc., a proper layout of instruments should include:
Perforator and burr.- The burr in the official brain, plastic, and oral surgery set is much too small and is therefore somewhat dangerous. Care must be exercised in making an opening which will be sufficiently large to introduce the cutting forceps.
The cranial cutting forceps in the official sets are of the De Vilbiss pattern with two blades, the smaller of which can, with care, be introduced through the small opening without damage to the dura, and the three or four perforations encircling the bone defect can thus be connected.
The Carrel syringe utilized for suction is of the common type of glass syringe in general use. The catheter should be very soft and should have a large bore with the eye near the end.
Delicate esquillectomy forceps for the removal of bone fragments after they have been detected by the catheter are desirable.
Antiseptics.- In an early operation, in which thorough cleansing of contaminated tissue is possible to the depth of the wound, no antiseptic need be employed. In many cranio-cerebral wounds, however, it is often impossible to be sure when, by thorough suction, the pulped and contaminated brain from the depth of the tract has been completely removed, and there is a temptation to lean, therefore, upon the crutch of an antiseptic. Oily solutions are preferable, and Dakin's dichloramine-T in oils, which has a prolonged antiseptic action, isnot only harmless to the tissues but appears to be the most suitable antiseptic to bury in these cases. Through the catheter, after the tract has been as thoroughly cleansed as possible, a cubic centimeter or so of dichloramine-T may be introduced as the catheter for the last time is withdrawn.
Dressings.- In wounds of the head, particularly if the brain is exposed and the defect can not be closed, gauze should not be placed directly against the wound. The best substance to interpose between the wound and the gauze dressing is gutta-percha tissue which has been practically unobtainable. A fairly good substitute for this is cellulose tissue. This material can be boiled and therefore in the individual cases can be used again for subsequent dressings. It c an also be used most advantageously for drains in case they are needed.
One difficulty which is met with by those inexperienced in cranial operations lies in the application of a dressing which will remain in place. Many of these patients are restless and pick at their bandages, which become easily dislodged. In most hospitals will be found bandages which have been cut on the bias. With practice these bandages can be adjusted to fit the head snugly, and can be brought around under the chin without annoying the patient too greatly. It is usually necessary to place several safety pins in the areas where the turns of the bandage cross. A neat head dressing is usually a good indication of the quality of the operation which it conceals.
APPENDIX
Supplies.- Duplicating books and certain other supplies may be obtained from the senior consultant in neurological surgery, A. P. O. 731.
From Gentile, 49 Rue St. André-des-Arts, Paris, esquillectomy forceps, an excellent perforator and burr, curved French needles, Carrel syringes, and catheters.
From Intermediate Medical Supply Depot No. 3, A. P. 0. 737, by requisition through any commanding officer, Lurken's sterile bone wax, head lamp, cellulose tissue, and dichloramine -T with paraffin and eucalyptus oil. Also Lilly capsules and various novocain preparations. The most convenient are the 1-ounce bottles of powdered novocain of the Saccharin Corporation (Ltd.). To make a 1 percent solution add 0.3 grams of this powder to 30 c. c.of sterile water. To this 30 c. c. of 1 percent solution add 15 drops of adrenalin. This will make the scalp incisions comparatively bloodless. The Lilly No. 1 gelatine capsules which come in boxes of 100, hold just 0.3 grams of this powdered novocain. It is a convenience therefore to secure these capsules, as they can be filled without weighing out each separate portion of 0.3 grams. A Luer syringe and satisfactory needles can also be obtained from the medical stores.
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CARE OF HEAD INJURIES AND INJURIES TO THE SPINE AND PERIPHERAL NERVES IN THE FORWARD HOSPITALS
HEAD INJURIES
The senior consultant in neurological surgery, A. E. F., had learned from personal experience in British casualty clearing stations and general hospitals that the accepted high mortality of the craniocerebral cases could be reduced fully 50 percent if these cases were operated upon in forward areas. A series of about 200 patients operated upon in the fall of 1917 at a casualty clearing station of the British Expeditionary Force, which was given over entirely to wounds of the head, gave 28.3 percent mortality; a similar series operated upon at a later period by members of the same team in an American base hospital attached to the British Expeditionary Force gave a mortality of about 45 per cent.
NEUROSURGICAL TEAMS
Certain difficulties, never entirely overcome, were met with in the organization of the neurosurgical teams. It was obvious that if surgeons were to be assigned to forward hospitals in charge of teams that they should primarily be good general surgeons, for their presence would be an encumbrance if they could only cover their specialty. This had one unfortunate outcome, for during the months of June and July eight of these specially equipped officers were soon put in surgical charge of their hospitals and became triage officers, so that their services as neurosurgical experts were lost. Another difficulty lay in the administration opposition to the performance of operations of a time-consuming and detailed character, particularly during periods of rush. As these operations should be done under local anesthesia, they necessarily consume time, and rarely could more than eight serious head wounds be thoroughly done by one team in a working day. Where there was a large number of wounded, the temptation was strong for hospitals to strive for an operative record, and teams were apt to be rated by the commanding officer according to the number of cases they were able to cover in their individual shift. As a result, in many hospitals the neurosurgical teams were restricted to general operations and the more tedious head cases were either passed on to the base or were distributed without selection among the teams on duty, who did incomplete operations.c
During the early operations in which some of our forces were engaged in the latter part of June, only two teams had been organized, one at Mobile Hospital No. 2 and another at Mobile Hospital No. 1. A subsequent survey of the head cases which had reached the Paris area and the centers of the intermediate zone at Bazoilles and Vittel showed that practically no case of penetrating wound of the head had survived except the 10 or 20 who had gone through the hands of these two teams. By July, 1918, it had become possible to apportion to most of the evacuation and mobile hospitals of the forward area one team which had had more or less personal instruction and which had been equipped with the proper surgical
c To give an idea of the importance of having men for this special work, the operative mortality in a series of 38 cases of dural penetration of one neurosurgical team working at a mobile hospital was 29.4 percent, whereas in 26 cases done by11 different surgeons without equipment or training in the same hospital it was 62 per cent.
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supplies. This was due to the fact that some medical officers who had received some neurological instruction in schools established for this purpose at home had arrived recently in France. Also a number of sets of instruments for brain surgery had been sent out and had become available. Each of the neurological teams was furnished with the instructions quoted above.
Before the St. Mihiel offensive, September, 1918, more time for preparation was given, and each hospital was supplied with one neurosurgical team which had had some experience. Even though this operation was of brief duration, it became apparent that one team in each hospital was not sufficient to screen out the cases, for though the work was covered in some hospitals, in others the neurosurgical team was either off duty or busy doing general surgical work so that most of the head cases were handled by the general surgical teams rather than have them wait. In consequence, more craniocerebral cases had been operated upon, it was found, by inexperienced than by experienced teams and the hospital mortality was very high-considerably over 50 percent, exclusive of the cases which subsequently succumbed in base hospitals.
In view of this experience and in preparation for the Meuse-Argonne operation, the proposal was made to the representative of the chief surgeon, First Army, that at least two neurosurgical teams be supplied to the hospitals which were on the main avenues of evacuation, viz., at Fleury, at Souilly, and at Villers-Daucourt, with the issuance of orders to field hospitals to route cases direct to one of these points. This plan was met with a counterproposal that we should attempt, as the British had done, to have a special hospital somewhat more in the rear to which all head cases could be forwarded. A hospital at Deuxnouds was selected for this purpose by the representative of the chief surgeon, First Army, and several neurological teams were concentrated there. Between September 29 and October 16, when the hospital was in operation 813 cases were secondarily routed there. The situation presented difficulties. Although it seemed an easy matter to have all wounded men wearing head bandages collected at one point, since this point was farther away than the main hospital centers the cases were almost certain to be dropped at these centers, necessitating a delay of from 10 to 12 hours before they could again be sorted and ambulances secured to forward them to the so-called head center. However, this center was placed in a town far from a railhead, so that the hospital became overcrowded and evacuation was difficult. Lastly, the mistake was made which perhaps was unavoidable, of using the personnel and equipment of a mobile hospital unit, which was withdrawn after a 10-days' service, leaving no one to carry on the work in the interval until another mobile hospital unit was similarly and temporarily utilized.
In spite of these difficulties, however, the hospital did creditable work and under different circumstances could have relieved to a greater degree the pressure on the evacuation hospital a few miles farther forward.
In preparation for the later phases of the Meuse-Argonne operation, the earlier proposal to assign neurosurgical teams to the forward hospital was accepted by the general staff, and at Evacuation Hospital No. 7 at Souilly, at Hospital No. 114 at Fleury, at A. R. C. Hospital No. 110 at Villers-Daucourt, a sufficient number of teams to operate continuously on craniocerebral injuries
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were stationed. This implied the setting aside of 50 to 100 beds for the retention of these cases-not a particularly large number of beds, in view of the size of these hospitals.d The work according to this arrangement was very much more satisfactorily accomplished than at any time previously in spite of the fact that with the advancing line an increasingly long interval elapsed between the time of injury and the time of operation.
In summary.- So far as these craniocerebral wounds were concerned, experience may be compared profitably with each of the following plans: (1) Operations on craniocerebral wounds by uninstructed surgeons, unfamiliar with this special kind of work; (2) single neurosurgical teams placed in individual hospitals; (3) a number of teams collected in one special hospital for head wounds, after the principle adopted in the British Army; (4) the placing of two teams in the larger evacuation hospital centers on the main lines of traffic.
Of these four plans undoubtedly the third is suitable for a more or less stationary battle front such as existed in Flanders during 1917. Plan 4 was unquestionably the more desirable under such conditions as existed in our Army during the Meuse-Argonne operation. Supplementary to this arrangement it would have been ideal to have the convalescent cases sent directly to a neurological center in the base.
SPINAL CASES
These did very badly throughout, as was anticipated. Most of them were immediately evacuated to base hospitals and fully 80 percent died in the first few weeks in consequence of infection from bed sores and catheterization. The conditions were such, owing to pressure of work, as to make it almost impossible to give these unfortunate men the care their condition required. No water beds were available, and each case demands the almost undivided attention of a nurse trained in the care of paralytics. Only those cases survived in which the spinal lesion was a partial one.
PERIPHERAL NERVE CASES
It was impossible, owing to the conditions in the forward hospitals and pressure of the work, to do more than emphasize the necessity of some neurological observations being made before any major operation in the nature of a débridement was carried out for wounds of the extremities. Experience had shown that excision of presumed contaminated tissues in the depth of the wound had not infrequently led to accidental nerve division.
It was urged, furthermore, whenever the preliminary examination showed the nerve to be injured, that if possible it should be exposed in the wound, its condition noted, and in case of traumatic division a suture be immediately performed. There can be no question that immediate suture of divided nerves, with primary wound closure, offers the best chance of restored function. However, in view of the regulation against primary wound closure during the active fighting of the summer and fall of 1918, it was practically impossible, except in isolated cases, to attempt the early suture of nerves.
d It may be noted that a sine qua non of these operations is a primary wound closure after thorough wound de bridement, owing to the certainty otherwise of the development of a cerebral fungus. Hence the regulation forbidding primary wound closure in the forward areas was, in cases of this kind, necessarily overridden. It is this fact which made it obligatory that patients thus operated upon should be retained for a period of at least 10 to 14 days.
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CARE OF HEAD INJURIES AND INJURIES OF THE SPINE AND PERIPHERAL NERVES IN BASE HOSPITALS
NEUROLOGICAL CENTERS
Within hospital centers.-The commanding officers of the various hospital groups were requested to sort at the railhead, as far as possible, and to send to a selected hospital in the area as many of the cranial cases as possible, and subsequently to secondarily transfer to this same hospital the peripheral nerve cases. It was the intention to have a nucleus of well-trained neurologists and neurosurgeons for each of the larger hospital centers, and in some areas notably in the Bazoilles group, and at Vittel and Contrexeville, this plan was put in operation. Likewise Military Hospital No. 1 served as aneurological depository for the Paris group.
A special hospital.-Owing to lack of competent personnel and to the difficulties and inconveniences of secondary routing, the project of having one or more actual neurological centers comparable to the French centers, wasnot put into operation, though after the arrival of Base Hospital No. 115 at Vichy a very promising start was made there in this direction.
