A Survey of War Surgery
BMJ (Clinical Research Edition)
The principles of surgery are continually being enriched by new methods which stand the test of time, but in wartime fresh problems are imposed with such insistence as to demand immediate attention, and often hasty improvisation. It has been delightful to see the enthusiastic reception which has greeted the presentation of our difficulties and the genuine desire to get to work on their solution which has been displayed by the profession both in the United States of America and in Canada. At the
... d in Canada. At the outset it may be said that the surgical principles laid down as a result of the last war have stood the test of time, and have remained *the sheet-anchor of present procedures; but before surgery can be established on a satisfactory basis it is necessary to consider some of the points in its organization. Medical Organization The medical organization for this war has been devised on lines different from those of the last. The policy adopted has been the formation of the Emergency Medical Service for the whole country under the Ministry of Health. Hospitals have been decentralized and re-created as sector hospitals in the countryside, and are responsible for the treatment of sick and wounded, both civil and military, although the existing Service hospitals have carried on as usual. Many of these outlying hospitals have been converted into " special hospitals," such as centres for head injuries, chest injuries, plastic surgery, and orthopaedic surgery. Before the war actually started.the medical profession had been voluntarily conscripted. This work was undertaken by the British Medical As,sociation. Every member was card-indexed and his wishes for service consulted, with the result that the Central Medical War Committee is able to satisfy from this pool any demand by the State in the way of personnel in any direction. The staffs of the voluntary and larger city hospitals have been used in manning the outlying sector hospitals. Apart from the inconveniences and the dislocation caused by the migration of large numbers of town folk to the countryside, the health of the population, in spite of rationing an,d overcrowding in shelters, has remained very good, and we have been free from epidemics. One of the anomalies has been that the health of the children who have remained at home has been better than that of those who have been evacuated. Although such a system has its limitations, as a wartime measure which has now become established it is running fairly smoothly and efficiently. War Wounds Early and free surgical excision still remains the basic, and most satisfactory, procedure in the treatment of all war wounds, and although the open Carrel-Dakin method is occasionally employed, the most important change has been the adoption of the closed-plaster method of Winnett Orr and Trueta and the use of drugs of the sulphonamide group for combating infection. The consensus of surgical opinion is that the combination of excision, closed plaster, and sulphonamides has proved a great advance in the treatment of war wounds. Where this method has been used, as at Dunkirk, the wounded have arrived back in good condition and the woun'ds have been clean. It gives the maximum of com-fort and eliminates many of the difficulties of transport. Morale is high, and there is practically none of that distressing condition of " shell-shock " which was so prevalent among the wounded from the trenches during the last war. There is no doubt that the closed-plaster method is a boon to the patient; it gives comfort and rest, and eliminates the dread of the painful daily dressings of the open method. Its greatest objection is the obnoxious smell. However, it requires constant supervision, for on the appearance of a raised pulse or temperature, pain, sleeplessness, loss of appetite, oedema, or coldness of the toes, the plaster should be removed. Where this close observation has not been possible some cases have arrived with spreading infection, sometimes anaerobic, and gangrene beneath the plaster. Under such conditions some surgeons prefer to transport lheir patients with a peeping window ctut in the plaster over the wound, or, if the distances are short, to dispense with it altogether-as in such cases as fractures of the lower limb, in which the Thomas splint with traction has again proved its value. With regard to sulphonamides, these can be employed in two ways-prophylactically, or locally into the wounds: by mouth, starting with 2 grammes followed by 1 gramme fourhourly up to a total of 20 grammes, or by direct insufflation into the wound in doses varying from 5 to 20 grammes.