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THX BRITISH JOURNAL O F SURGERY
REVIEWS
AND
NOTICES
O F BOO/<..’;.
War Surgery of the Abdomen. I-ly CcriinEnT ~VALLACI:,
C.M.G., I:.R.C.s. 1’:ng.. M.B., U.S.
1,ond. Surgeon, St. Thomas’s Ilospital ; Lecturer on Surqery in the Medical School ; Consulting Surgeon, nritish Armies in France. Pp. 152 ; 26 illustrations. 1918. London :
J . it A. Churrhill. 10s. Gd. net.
S o chapter of war surgery has been more dramatic than that dealing with abdominal wounds ;
the complete reversal of the practice of prcvious rampaigns, the equipment of units for the
performance of operations calling for the highest surgical skill within the battle zone, and the
saving of nearly 50 per cent of those so wounded, were all accomplished within a year of the
commencement of the war. This, perhaps one of the most difficult problems of the many t h a t
presented themselves to the surgeon, was one of the first to be settled. Before even the pathological
processes underlying the evolution of an ordinary wound of the soft parts were understood, or
fractures received more than casual attention, results were being attained in the treatment of
penetrating wounds of the abdomen t h a t have been but little improved since.
This rapid surcess must be attributed t o the high state of evolution of abdominal surgery in
the years immediately preceding the war, to the facilities for rapid transport by motor ambulance,
and t o the stationary warfare that became established after the first few months.
JVallace’s hook is chieHy based on cases operated on during the period July, 1915, t o December,
1916 ; i t embraces the work of many surgeons carried out a t different hospitals on a wide sector
of the front, and includes both quiet periods and times of heavy fighting. The many statistical
tables built up froni a large number of cases under such varying conditions form a valuable
historical record, and afford a standard by which t o judge the results of future work.
The operative mortality (all cases) is remarkably uniform throughout successive periods from
July, 1915, t o September, 1917, varying from 53.9 per cent t o 51.3 per cent. It is interesting t o
observe, however, t h a t whilst only 60 per cent of cases (310 out of 511) were operated on in the
first six months, 76 per cent (640 out of 889) were so treated in the last nine months; this,
together with the general speeding up of evacuation, which has resulted in more cases reaching
the surgeon alive, means a very real improvement in results which the tables hardly bring out.
The rapid evacuation of these rases from the firing line, early operation. and retention in thc
unit in which they are operated on for some days after operation, are the three essentials for
success. They are purely administrative problems, and any or all of them m a y be rendered
impossible by the exigencies of the military situation. Speaking broadly, the arrangements of
our French and Belgian Allies have been much the Pame as our own in dealing with these cases.
AIorc and more the attempt has been made t o bring the surgeon t o the wounded rather than carry
the wounded t o the surgeon. Perhaps this has bern overdone; certainly, with the onset of
more open warfare and the increased use of long-range artillery, there has been a reaction since
1916. The author is opposed on the whole t o the advanced operating centre a s the most suitable
unit with dealing with these cases, especially during periods of heavy fighting, and prefers direct
cvacuation t o a casualty clearing station in spite of the longer journey entailed : the smaller unit
is liable t o be swamped, because cases accumulate, a r d thus defeat the attempt t o secure early
operation. Certainly, with the diversion of heavy and lightly wounded cases t o different casualty
clearing stations and the pushing up of clearing stations nearer t o the front line than was a t one
time the case, the advanced operating centre has t o a large extent outlived its usefulness ; nevertheless it played an important part in the evolution of abdominal war surgery.
From a clinical point of view these cases present many difficult problems even to the surgeon
skilled in abdominal work in civil life. Wounds of the hollow viscera, wounds of the solid organs,
penetrating wounds without visceral injury, and parietal wounds, may present a similarity of
symptoms that makes an exact diagnosis at times almost a matter of guess-work. Under these
circumstances an exploratory incision is frequently the wisest and safest course to take, and one
rarely has cause to regret it. Haemorrhage is the chief cause of the high mortality, and its
persistence demands that intervention be carried out as early as possible. Pre-operative measures
t o combat shock are of the greatest importance, and only experience can enable a surgeon t o select
the proper moment t o operate on a patient who is reacting t o this treatment ; in the same manner,
when casualties are heavy, the greatest skill and experience are necessary to select those cases
most likely to benefit by operative interference.
The author is to he congratulated on having produced a book, not only of interest from the
point of view of what has been achieved, but also of considerable assistance t o those who are
at present. engaged on the problems with which it deals.