NA TURE 



5Z7 



THURSDAY, AUGUST 31, 1916. 



1 SURGICAL BOOK FROM THE FRONT. 



Surgery in War. By Major A. J. Hull. Pp. xv + 

 390. (London: J. and A. Churchill, 1916.) 

 ^ Price I05. 6d. net. 



•'T^HIS handbook is described in the introduction 

 Ll by Lieut. -Col. E. M. Pilcher, R.A.M.C., as 

 resume of current practice and experience at the 

 nt; and the fact that Sir Alfred Keogh, the 

 irector-General of the Army Medical Service, has 

 itten a preface to it stamps it as, at any rate, 

 semi-official." It has, therefore, an interest apart 

 -m its strictly surgical aspect, and although, as 

 ir Alfred Keogh remarks, "the views expressed 

 therein may not command assent in every quar- 

 they demand careful and sympathetic con- 

 ration. 

 1 he author has enlisted the service of several 

 :•: his colleagues who have had special experience 

 ertain types of cases and have written the 

 ^^-.ions of the book corresponding to their own 

 particular speciality : Lieut. -Col. Harrison dis- 

 cusses the bacteriology of wounds in war; Dr. 

 Creenfield, the general condition of the wounded 

 — ■ wounds of the abdomen, and he is also respon- 

 for the illustrations; Lieut. Tanner, the treat- 

 ent of wounds by saline solution ; Capt. Snowden, 

 juries to peripheral nerves ; and Lieut. Edwards 

 responsible for the radiographic section of the 

 k. 

 The treatment of a wounded man can be con- 

 red in three stages. The first is to combat 

 k and arrest haemorrhage ; the second is the 

 'reat fight against infection ; while the third is the 

 effort to restore the damaged part to its normal 

 function and the injured man to his normal health. 

 For the first of these stages the author strongly 

 advocates the free use of morphia given in full 

 doses — that is to say, until the patient is well 

 onder its influence and his pain has been materially 

 subdued. This treatment will meet with fairly 

 general approval. It is interesting to note that 

 flie Service affection for initial-letter abbreviations 

 Ids reached even to the morphia bottle : the dose 

 lecommended is I.M.H. gr. \. 



The author is not in favour of stimulants, and 

 it is possible that in this he is regarding shock 

 from an ultra-academic point of view. It is hard 

 to define exactly what is meant by shock, and it is 

 <juite possible that a treatment which is not suit- 

 able for "shock " as defined, for example, by Crile 

 may be quite a good one for a wounded man. It 

 may be easy to draw laboratory distinctions be- 

 tween shock and collapse, but it is not easy to say 

 where one begins and the other ends when con- 

 fronted with what one of our statesmen so aptly 

 calls a "heap of bloody rags." 

 i Injection of saline solution is not recommended 

 "unless thefe has been haemorrhage," as its effects 

 are transitory. This remedy is oif course often 

 ■ disappointing in its results, but it would be a great 

 pity if so simple a method of treatment were 

 discredited. It is not easy to say how much blood 



a man has lost, and unless the saline injection be 

 excessive in amount, it is hard to see what harm 

 is done, especially if the other methods of relieving 

 shock be adopted as well. 



The warning on p. 30 against keeping a 

 patient too long on a restricted diet is very much 

 to the point : this error is probably a survival of 

 the ancient doctrine of "starving a fever." A 

 patient, however, who, in addition to prolonged 

 physical fatigue and mental strain, has to combat 

 a severe suppuration lasting often for weeks or 

 even months requires as generous a diet as he 

 can digest and assimilate. 



The second phase of the surgeon's work is the 

 struggle against infection, and in this connection 

 the^author is a strong supporter of the "strong 

 salt " or " salt-bag " treatment, and equally op- 

 jX)sed to the use of chemical antiseptics. To quote 

 from p. 66 : "I have found the results of treatment 

 by hypertonic solution superior to any antiseptic 

 treatment. . . . The ordinary antiseptics, iodine, 

 boric fomentations, peroxide of hydrc^en, and 

 alcohol dressing, have appeared to me decidedly 

 inferior to the saline treatment. The strong anti- 

 septics — for example, pure carbolic — have not been 

 used in my wards." 



This quotation is an ample explanation of the 

 author's distaste for antiseptics. Iodine is so 

 readily rendered inert by albuminous material as 

 to be practically useless for a discharging wound ; 

 boric acid is a feeble germicide, and its main value 

 is the prevention of secondary infection ; while per- 

 oxide of hydrogen and alcohol must, from then- 

 physical properties, exert a very transient in- 

 fluence. 



In an earlier section the author quotes the 

 results of treating wounds with strong antiseptics 

 early in their course, and sums up strongly against 

 them. The evidence w-hich he quotes of twenty- 

 seven cases treated with pure carbolic acid — be 

 does not say exactly how — is not ver}- satisfying. 



The whole subject of the disinfection of wounds 

 by chemical antiseptics has been argued with an 

 enthusiasm which has at times almost carried with 

 it a sort of "odium theologicum." This is, bow- 

 ever, merely an indication of the sincerity of the 

 protagonists. There are undoubtedly many 

 wounds which it is impossible to disinfect, if for 

 no other reason than that the patient is unable to 

 bear the severe operation whicA would be neces- 

 sary, in order to open up the remote recesses of 

 the wound and apply the antiseptic, until the infec- 

 tive process has gained too firm a hold for it to be 

 stamped out. There are times, too, when the 

 necessary personnel and equipment for such treat- 

 ment are not available, and this must be so ; but 

 there are wounds w:hich can be cleaned surgically, 

 and there are occasions when opportunities for 

 carrying this out are present, even if on rare 

 occasions. 



There is a solution commonly called "Lister's 

 strong lotion," which consists of 5 per cent, car- 

 bolic acid containing i /500th part of perchloride 

 of mercury. This can be applied freely and thor- 

 oughly to wounds, and in some cases is successful 

 in disinfecting them, even when bone has been 



