routine secondary closure of the accompanying open wound, an achievement only second to that of Lister in his early treatment of similar injuries. This result attained, the practicability of resort to secondary suture in most wounds was established.
Subsequent advance proved the practicability, under favour- able conditions and environment, of primary closure of the com- pound fracture without the aid of any antiseptic medium. This ideal was reached by a rational extirpation of the infected tissue by mechanical means, followed by a sufficient period of rest to the patient and to the injured part.
The net result, therefore, of a period of strenuous work and argument was to reaffirm the principles with which surgeons were already acquainted at the commencement of the war: (i) that sterilization of living tissue can only be effected by the natural vital process; (2) that no chemical agent is known ca- pable of penetrating the tissues of the body and destroying microorganisms which is not at the same time deleterious to the tissue itself, and that the sole means of procuring abortion in an infected portion of the body is radically to remove the infected tissue. Again, no novelty in principle was introduced by the practice of either the primary or secondary closure of compound fractures, or of wounds in general; the triumph consisted in the translation of these occasionally used methods within the limits of routine practice. It may be added that the method of secondary suture is to be regarded as the more valuable of the two, since it is but rarely that conditions will not allow its adoption, while in military surgery it is generally difficult to ensure the requirements essential to the success of primary suture. Paradoxical as these conclusions may appear, success was only gained after strenuous effort and the development of a technique and degree of judgment equal to those required for the most exacting operations in the entire realm of surgery.
Nature of the Infections. It can hardly be said that any novel form of wound infection was discovered, but knowledge was extended in many directions. The hourly progress of mixed infections was investigated, and the vital tenacity of the different organisms determined, while a still more fruitful series of observations was made in the effort to determine the moment at which a wound with a fouled surface became an actually infected one. The result of the latter investigation allowed a general assumption to be made that during an interval of from four to eight hours the multiplication of organisms in their new environment was slow and penetration of the living tissues by them unlikely. Thus a definite time-limit was assigned, beyond which primary closure should not as a rule be attempted. It was shown that only the staphylococci and strepto- cocci as a rule remained present in the terminal infection, and that of these the streptococcus was the more undesirable occupant of the wound. Further, the power of haemolysis possessed by some forms of streptococcus marked them out as the more dangerous to the progress of the wound and to the life of the patient.
The unusual frequency of anaerobic infections afforded oppor- tunity for an extensive investigation of the microorganisms con- cerned, the special characters of the changes produced by each, also of the importance of symbiosis in these phenomena, thus accen- tuating the importance of suppuration in the development of such diseases as tetanus, or in the causation of gangrenous cellulitis.
Although acute traumatic gangrene was well known in civil prac- tice, yet it seems doubtful whether it has played such a prominent part in any previous war. There is good evidence that it was rare in the American Revolutionary War, and in the S. African War it was certainly but very rarely met with. One very distinct advance was made in the treatment of the condition. It was observed that the spread of the infection tended to be limited by the fascial envelopes of the muscles, particularly in the case of B, perfringens (the organ- ism which specially attacks the muscle fibres), and that, if the vitality of the muscle was lowered by cutting off its blood-supply, the entire muscle rarely escaped destruction. Hence the practice of complete excision of a muscle from within its sheath was introduced, and proved most successful in limiting the spread of the gangrene in the limb, especially when the long muscles were affected.
Little success attended any but the mechanical treatment of anaerobic gangrene, but the treatment of tetanus afforded one of the great triumphs of preventive medicine in fact, the result attained must be placed upon a level with that reached in the preventive treatment of enteric fever. It was recognized at an early date that every breach of surface with which the intensively cultured soil of northern France had come in contact was potentially infected with B. tetanus. Hence it was laid down that in the case of every serious wound the man was to receive an injection of tetanus anti-toxin, and this rule was shortly extended to every wound, and even to chilled feet, especially when vesication had occurred.
Further, since the protection afforded by this measure is known to disappear rapidly, a second injection was given at the end of seven days, and in severe injuries at similar intervals for the suc- ceeding two or three weeks. Again, in view of the known fact that B. tetanus may lie latent in a healed wound for indefinite periods, a prophylactic injection was administered to many of the patients in whom late secondary operations became necessary.
In the curative treatment of tetanus it cannot be claimed that any very important advance was made. The chief variation in method consisted in the administration of greatly increased doses of anti- toxin. While it remains doubtful whether much advantage was gained by this procedure, it was demonstrated that in some instances the dosage had previously been insufficient. In base hospitals in England, as a result of mainly intra-thecal injections, the average mortality of the disease was reduced from 57-7 % to 19 %. In France, where a more acute series of cases had to be dealt with, the reduction only reached equivalents of from 78-2 % to 67-4%.
With regard to the route for the injections, many surgeons con- sidered the spinal intra-thecal the best, but clinical observation does not appear to give strong support to this view, although experimen- tal evidence from animals is adduced in its favour. Intra-muscular injections probably gave the most consistent results, while sub- cutaneous injections proved sufficient for prophylactic purposes.
In connexion with the prophylactic treatment, mention should be made of the fact that, if it failed to prevent, it was still capable of modifying the disease, and local phenomena were much more com- mon than would otherwise have been the case. Except in the splanchnic form, although the local might be only the commence- ment of a general attack, the prognosis was much better.
Shock and Haemorrhage. The circumstances attendant on active warfare, such as anxiety, heated and ill-controlled emotions, fatigue, want of sleep, hunger and thirst, exposure to cold and wet and, lastly, severe injury, often combined with loss of blood and pain, afford every condition with which we are accustomed to associate the occurrence of shock. In spite of the arduous investigations undertaken it can hardly be said that the actual explanation of the phenomena has been unveiled. Observations, however, tended to negative certain theories, such as those of acapnia, acidosis, supra- renal incompetence, exhaustion of the vasomotor centres or cardiac weakness, as a primary factor. Hence we must still be con- tent vaguely to regard the phenomena of shock as nervous in origin. In one particular a definite advance was made in the realization that the fall in blood-pressure, which is so prominent a feature in the condition of shock, is strictly comparable to the fall attendant on haemorrhage, the volume of blood within the arterial system being reduced not by external escape from the open vessels but as a result of stagnation in the capillaries. The older theory of stagnation in the visceral veins of the thorax and abdomen was not only exploded by experimental observation, but its error was also demonstrated by the appearances observed during the performance of numerous operations for visceral injuries during the period in which the state of shock was in some degree persisting.
The condition known as " secondary shock," in which the phe- nomena develop hours or even days after the initial injury, perhaps after primary shock has already been recovered from, had since the Listerian era been regarded as an evidence of toxaemia. The similarity was well illustrated in the cases of acute toxaemia in con- nexion with anaerobic infections, with which the war made every- body familiar. The experimental work of Dale and others on the action of histamine when introduced into the circulation of animals led to an investigation which seems to prove that the phe- nomena of shock may be produced by absorption of the metabolic products resulting from the mechanical destruction of muscle fibre, a common result of gunshot injuries.
The outcome of the observations made was to show that the first principle in combating shock is to attack the most prominent of its phenomena, i.e. lowered blood-pressure. The effect of infusions of normal saline solution for this object was known to be evanescent, and successful attempts to prolong the effect and at the same time to diminish the volume of fluid required were made by adding a colloid constituent to the solution. In order to place the patients under the most favourable conditions possible, a heating-system was added to the ambulances, and special resuscitation wards were equipped, so that the more simple means, such as the application of warmth, the administration of fluids by the mouth or per rectum, and the ensurance of absolute rest, were facilitated. When^ neces- sary, these methods were supplemented by infusion of the " gum- saline " fluid of Bayliss. This solution contained sufficient of the colloid (6 %) to increase its viscosity and endow it with an osmotic pressure comparable to that depending upon the colloid constituent of normal blood. The saline constituent (1-5 to 2 %) of bicarbonate of sodium was introduced to counteract the decreased alkalinity of the blood occurring in shock and to prevent haemolysis.
The same solution was employed in the treatment of the slighter cases of haemorrhage. Serious cases were dealt with by the replace- ment of whole blood. The indication for the latter method was sought for in persistence of a blood-pressure as low as 80 mm. of mercury. In primary haemorrhage estimation of the haemoglobin content of the blood was considered too elaborate a method and unsuitable for use from want of time.
