by a smooth and easy path, neither were the full fruits rapidly gathered. Experience indeed was but a repetition of that gained in all previous campaigns. In Aug. 1914 time had been allowed for collation and digestion of the observations made in the more recent wars, while in civil life progress in surgery had been continuous and considerable. Hence the military surgeon entered upon his duties with confidence in the methods at his disposal and with fair hope of eliminating more or less completely many of the mischances from which his predecessors had suffered. These anticipations were not promptly realized; in spite of the perfected technique which was considered to have been acquired in the general treatment of wounds, and the accurate knowledge which had accumulated as to the characters of the injuries inflicted by modern rifle bullets, it soon became evident that this war, like all its predecessors, would have to teach its own lessons. This experience depended chiefly upon two factors: (i) bullet wounds did not form the preponderating element, but were less frequent than those produced by fragments of shells and bombs, which latter were of a severity and extent scarcely conceived beforehand; (2) the forms of infection met with were more varied and virulent than those commonly dealt with.
Thus in the earlier stages of the war the entire field of surgery was necessarily dominated by the elementary but fundamental question of appropriate treatment of the mere wound, to an extent which materially prejudiced advance in the management of individual injuries. The actual starting-point of real advance was relegated almost to the pre-Listerian period, and a vast amount of past experience required to be repeated and controlled before a firm foundation for progress was established.
When definite principles had been laid down to guide the routine treatment of infected wounds, a second great question still demanded settlement: At what stage in relation to the fighting-line should the definite treatment of gunshot injuries be undertaken? The result of all previous experience had been to the effect that field hospitals were unsuitable for any but temporary measures except in the case of great urgency. The casualty clearing-stations, a recent introduction into the British establishment, were originally intended to act mainly as sorting and distributing centres, and it was laid down that the great bulk of the wounded men should be transferred to the stationary and general hospitals on the lines of communication.
A short time sufficed to prove this arrangement to be defective, since, in spite of the efficient means of transport which had been rapidly developed, it became evident that the primary treatment of the wound needed to be more radical than had been antici- pated; when only provisional measures were adopted the patients were in little better condition for the procedure on their arrival at the stationary and general hospitals than if treatment had been entirely omitted. The progress of the infections, in fact, was far more rapid than any means of transport, and such preliminary steps as had been taken required to be repeated upon wounds already increased in extent, with very definite disadvantage to the patient. At this stage the settling-down of the form of warfare to a stationary character allowed for the development of the casualty clearing-station into a potential stationary hospital, while in addition it was found practicable to establish small advanced operating units still nearer to the front to deal with injuries to the abdomen, head, etc. To this development, and in great measure as a result of the bravery and efficiency of the bearers who brought in the wounded men, the whole of the advance in the primary treatment of gunshot injuries is referable. Such conditions may not often recur, but one result of the work done must remain and exert a permanent influence on military surgery. The efforts and firm convictions of a band of enthusiastic and capable surgeons demonstrated for all time that results of equal excellence can be obtained by the military as by the civil surgeon if only sufficient initiative, care and resolution be maintained. The bugbear of " the exigencies of warfare " has been in fact displaced from the commanding position which it has held heretofore.
The Treatment of Wounds. At the outbreak of war it was generally held that the treatment of gunshot wounds should
approximate itself in procedure to the methods in use in civil practice, purely aseptic measures being supplemented by the addition of some antiseptic medium in the case of open wounds fouled by contact with the clothing, the missile or the soil. It was believed that this addition should suffice at the primary dressing to check the progress of the initial infection. This view was founded upon experience gained in recent wars, in which the great majority of the injuries were inflicted by bullets of small calibre. It had been observed that many of these healed well even in the absence of any surgical aid, while the great majority closed without any serious accidents when protected by an occlusive dressing adjusted either by a bandage or some sort of adhesive such as collodion or mastisol. Too little attention indeed was given to the further observation that the compara- tively rare shell wounds always suppurated even under the favourable conditions which attended the S. African War of 1899-1902. In the early days it was assumed that the ravages induced by infection were to be explained by the conditions then existing, such as the long distances the patients had to travel, the impossibility of sufficiently frequent changes of dressing, and the want of proper rest. The pernicious influence of these conditions is obvious, but it was rapidly grasped that they should not be held to be an insurmountable element of failure. An attempt was at once made to combat the primary infection more efficiently by mechanical procedures, consisting of free excision of bruised, soiled or devitalized tissue by the knife or the scissors, followed by drainage of all recesses of the wound by india-rub- ber tubes and a completely " open " method of treatment.
At this period two principles concerning the management of an open infected wound were freely debated. By Almroth Wright and his school it was maintained that the extinction of infection was most rapidly effected by attempting to increase the activity of the normal factors in the process of healing. The method adopted was called the " physiological or phylacogogic," and an endeavour to accomplish the desired aim was made by flooding the wound with a saline solution of a higher specific gravity than that of the fluids permeating the body tissues and thus to " draw " an abundant flow of lymph towards the free surface. By this means also the tissues were "lavaged" by a stream of lymph, the current of which flowed in a direction opposed to the spread of infection inwards. Later the " hyper- tonic " solution, while accomplishing this end, was found to check the migration of leucocytes to which Wright eventually ascribed the chief place in subduing the infection; hence at a certain stage in the course of healing an isotonic was substituted for the hypertonic solution.
The second school, influenced by the early work of Lister, retained allegiance to the use of antiseptic media of varying kinds. By many the hope was cherished that an agent might be dis- covered that would not only cleanse and disinfect the exposed surface of the wound, but would also penetrate the underlying infected tissue and thus hasten the natural process. This dream, emanating from an imperfect appreciation of the " preventive " nature of Lister's work, was not fulfilled. Nevertheless, the supporters of the antiseptic theory played a highly important part during the period of argument and uncertainty both as to principle and practice. The most important of the media em- ployed consisted in perfected solutions of the hypochlorites, and certain anilin dyes, particularly flavine and brilliant green. It may fairly be stated that the application of an antiseptic to the wound, or in the dressing, in itself played a minor part, the real advance which followed depending not upon the antiseptic which was employed but upon the development of an efficient system. In the Carrel-Dakin system, although great importance was attributed to the hypochlorite solution, yet the success, which it attained was really due to exact observation of the nature and course of the infection concerned, careful initial preparation of the wound, meticulous precaution against stagnation of infective material in recesses in the cavity, and the prevention of rein- fection of the surface. It was the experience gained from the practice of this method in the treatment of compound fractures of the bones that clearly demonstrated the possibility of the
