Transfusion became common in consequence of the ease with which donors of blood could be secured from amongst the soldiers. The older method of direct transfusion was found inconvenient from an operative point of view, and unsatisfactory from the fact that it is difficult to estimate the amount of blood which has actu- ally passed from donor to recipient. Hence blood was more com- monly collected from the donor into a glass vessel coated with paraffin to prevent coagulation (Kimpton's tube), and thence trans- ferred to the recipient. To meet difficulties resulting from prema- ture coagulation, the blood was sometimes drawn into a vessel con- taining a solution of citrate of sodium, since it had been found that the addition of 0-5 % of this salt to the blood had no deleterious action. In the later stages of the war it was found practicable, in view of the possibility of haying to transfuse a large number of men in an emergency, to substitute a fluid containing preserved red blood-corpuscles suspended in a sufficient volume of a 2-5 % solution of gelatine to bring the total volume into consonance with that of the whole blood originally drawn from the veins of the donor.
To meet the well-known difficulty that individuals fall into definite classes in regard to their capacity to receive the blood of others with safety, a simple classification was arrived at by means of agglutination tests. Thus suitable donors were previously selected and were always available. Four groups were differentiated, of which it was determined that those belonging to the first (8 %) could take blood from either of the remaining three groups. Of the other three, the second group (40%), the third group (12%); and the fourth group (40 %) could receive blood only from individuals be- longing either to their own group or to the fourth group.
Special Surgery. One great principle that in the past has governed the application of a ligature to the great arteries of the limbs received considerable modification. It had always been held that, when a main artery was tied, the conservation of the accompanying vein was of the utmost importance for the preservation of the vitality of the limb affected. Experience gained from observation of a long series of cases, in which both vessels were implicated, demonstrated that not only was the integrity of the vein of no vital importance, but that the immediate results were more favourable when both vessels were occluded simultaneously and a better balance main- tained between the capacity of the modified arterial and venous systems. Experimental investigation supported this clinical experi- ence, since it was shown that the blood-pressure in the affected portion of the limb was maintained at a higher level.
The substitution of local repair of the wounded walls of arteries for complete obliteration of the vessel by ligature made little progress until the general methods of wound treatment allowed such opera- tions to be made without fear of subsequent infection. In the later years of the war steady progress was made in this direction, and it was shown that ideal results might be obtained, and further that even should the local patency of the vessel not be maintained, yet the result was at any rate in no way inferior to that following success- ful ligature of the vessel.
The general treatment of compound fractures has been already alluded to, but beyond improvement in the management of the wound, considerable modification took place in the nature of the means adopted to ensure good position of the bones. The change depended on the general introduction of the metal wire splints of Hugh Owen Thomas. These were found capable of adaptation to the great majority of all fractures of the limbs, and also equally suitable for employment in the front line and in base hospitals. It is of interest to note that one of the main principles of their originator was found capable of modification, as well as variations in construction. Fixed extension did not prove convenient or easy of application in military practice, and the substitution of weight-and-pulley exten- sion, or the employment of the weight of the patient's body as a means of counter-extension, was widely and successfully resorted to. In no department of surgery was more initiative and ingenuity shown than in the numerous devices designed to meet the needs of individ- ual cases or different regions of the body.
Infected wounds involving the articulations maintained the reputation of this form of injury as a source of difficulty and anxiety. One heterodox principle was propounded. Absolute rest to the joint has always been regarded as the surest means of checking the spread of infection, but success attended resort to a method in which active movements of an open articulation were commenced from the out- set. It was claimed, and with some justice, that this method favoured the escape of infective exudation from the cavity of the articulation, and that the formation of adhesions and ultimate restriction of the normal movements were minimized. It is perhaps too early to give a definite opinion on this subject.
As regards injuries to the nervous system, it suffices here to say that the advances made in the more accurate knowledge of localiza- tion of function in the different parts of the brain and the spinal cord, and increased knowledge of the mode and progress of regeneration in wounded peripheral nerves, took a more important place than those in technical treatment of the injuries.
The book of knowledge concerning the possibilities of thoracic surgery (see HEART AND LUNG SURGERY) may be said to have been opened up by the experience of the war. It was proved upon an extensive scale that the mere laying-open of the great serous sacs of the chest was not the dangerous procedure that had been widely
assumed, and that, as Sir W. MacEwen had already demonstrated, no special artificial arrangements are necessary to maintain the normal intra-thoracic pressure during operations. Appreciation of this fundamental fact opened the way to free primary treatment of a large number of thoracic injuries which had formerly proved rapidly fatal not from the hopelessness of the actual injury but from the results of the infection which commonly followed it in consequence of insufficiency in boldness of surgical attack. Thus the way was cleared for dealing with intra-thoracic haemorrhage and its complica- tions, wounds of the lung, retained fragments of infected foreign bodies, and even for dealing on rational lines with wounds of the heart. Of scarcely less consequence than these visceral operations were those rendered possible for removal of foreign bodies from the mediastina, a fruitful source of immediate danger, and of intractable fistula-formation at a later date. It is impossible to estimate how widely this new field of surgery may be exploited in the civil practice of the future.
The technique of the surgery of abdominal injuries had been already so highly developed as to call only for judgment and. initiative to elevate military practice to the same level that had been reached in civil life. The difficulties which required to be surmounted were partly administrative, depending on the all-important element of time and the ensurance of as near an approximation as possible to the golden interval of six hours between injury and operation ; partly dependent upon the severity of the injuries themselves. Both were overcome, and perhaps the most satisfactory feature of the result is seen in the increased tendency to conservancy in the extent of the operations the effort to repair rather than to excise the injured part. The most striking in a series of successes was that attained in the treatment of severe abdomino-thoracic injuries, which had previously been regarded as beyond legitimate surgical intervention.
The experience gained during the war is likely to influence the future of surgical practice mainly in two directions. In the first place, the intimate personal association of workers in the branches of pure science ancillary to the practice of the art of medicine with the practical application of the principles laid down by them demonstrated the fruitfulness of this combination and its capacity to lead to rapid advance in elucidation of the problems constantly confronting the medical practitioner. Secondly, the assemblage of vast numbers of crippled men brought forcibly before the medical profession and the public the waste in national power which results from impairment or defect in physical capacity amongst a whole population, and accentuated the fact that in civil life circumstances had not been favourable for follow- ing up continuously the history and results of many common injuries. Hence surgeons who in the past had busied themselves particularly in the treatment of acquired defects and deformities extended the scope of their activities to preventive effort, and as a consequence greatly increased facilities have been provided for continuous treatment. (G. H. M.)
MEDICINE, INTERNATIONAL. A decision of considerable importance in matters pertaining to international health was taken by the Assembly of the League of Nations at its first meeting held at Geneva in December 1920, when the following resolution was adopted:
" In pursuance of Articles 23 (/), 24 and 25 of the Covenant of the League of Nations, and in order to facilitate the discharge by the League of Nations of the responsibilities which may be placed upon it by provisions of the various Treaties of Peace, the Assembly of the League of Nations resolves as follows :
" That a permanent International Health Organization be established as part of the organization of the League of Nations."
Article 23 (/) of the Covenant of the League of Nations, embodied in the Treaty of Versailles, contains these words:
" Subject to, and in accordance with, the provisions of inter- national conventions at present existing, or hereafter to be agreed upon, the members of the League will endeavour to take steps in matters of international concern for the prevention and control of disease."
Articles 24 and 25 of the Covenant refer to the necessity of arrangements being made for carrying out the above principle in so far as it affects existing international health bureaux and voluntary international Red Cross societies.
The functions of the organization are as follows:
(a) To advise the League of Nations in matters affecting health.
(6) To bring administrative health authorities in different countries into closer relationship with each other.
(c) To organize means of more rapid interchange of information on matters where immediate precautions against disease may be required (e.g. epidemics) and to simplify methods for acting rapidly on such information where it affects more than one country.
