The Modern Treatment of Gunshot Wounds

in Military Practice.

BYNicholas Senn,

Lieutenant-Colonel U. S. Volunteers ; Consulting Surgeon with the Army in the Field.

[Reprinted from The Military Surgeon, a Supplement to T National Medical ReviewWashington, D. C., July and A’ S9B.]

The Modern Treatment of Gunshot Woundsin Military Practice.

BYNicholas Senn,

Lieutenant-Colonel U. S. Volunteers; Consulting SttrseaiT \idLliUltC3tfßv4a the Field.

[Reprinted from Thk Military Surgeon,a .Supplement to The National Mkiuoai. RkvikwWashington, D. C., July and August, 1898.]

Two important causes are destined tobring about a radical change in the treat-ment of gunshot wounds as practiced inthe War of the Rebellion and as will betaught and advised in the Spanish-American and future wars: i. Themodifications which the weaponand projectile have undergone sincethat time. 2. The introduction intogeneral practice of aseptic and antisepticsurgery. The diminution in the calibreof the bullet, the metallic jacket, thesubstitution of smokeless for black pow-der, the greater velocity and power ofpenetration of the missile are conditionsand influences which must necessarilymodify the character of the wounds in-flicted with the modern weapon. Vol-umes have been written on this subjectby writers in all countries in which theold weapon has been abandoned and thenew one introduced. Numerous experi-ments have been made on cadavers andanimals for the purpose of studying theeffects of the modern projectile on thetissues with a view to obtaining reliableinformation as to the changes which will

become necessary in the rational treat-ment of gunshot wounds in modern war-fare. Experimental investigation hasdone much in pointing out some of thechanges we may expect to see in thecharacter of gunshot wounds during thepresent and coming wars, but many ofthe conclusions drawn from them willhave to be modified after we have hadan opportunity to study such wounds ona large scale on the battlefield. Therecan be no question but that the livingbody and the cadaver represent two en-tirely different mediums in studying theeffects of the modern bullet. From apractical standpoint there remains nodoubt as to the following facts whichwill be confirmed by future experiencein the treatment of gunshot injuries in-flicted with the small calibre bullet: 1.Few bullets will be found lodged in thebody. 2. Wounds will resemble moreclosely incised than contused wounds.3. Range will have more influence inchanging the character of the wound.4. Diminished risk of infection. 5.Dangerous primary hemorrhage will be

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more, secondary hemorrhage less fre-quent. 6. More difficult extraction ofthe bullet. The relative number ofdead and wounded and the adaptation ofthe jacketed bullet to become encystedare subjects on which we can onlytheorize and conjecture, subjects whichcan„ only be definitely settled by an ex-tensive experience. We are better pre-pared to predict the influence wroughtby the recent discoveries and advance-ments in surgery on the treatment ofgunshot wounds and the fate of thewounded. The antiseptic treatment ofwounds as taught and practiced by theimmortal Eister, and asepsis as devel-oped by the German surgeons, with thedistinguished Volkmann as their leader,are destined to minimize the remote dan-gers of gunshot wounds and other openinjuries inflicted on the battlefield. Wecan safely repeat with the late Professorvon Nussbaum, the most enthusiasticfollower of Eister: “The fate of thewounded rests in the hands of the one whoapplies the first dressing This is themotto every military surgeon must adoptand carry into effect. To this motto Ishould like to add a cast iron rule thatshould never be transgressed, and which,if observed without exception, willguard against one of the most fruitfulsources of infection, and that rule shouldbe ; Never probe a bullet wound on thebatttefield. The experience of the pasthas taught us the wisdom of adoptingsuch a universal rule. As our enemyis armed with the Mauser rifle, the caseswill be few where there is any indicationfor probing wounds, and in those fewwhere the bullet has lodged in the body,exploration should be absolutely pro-hibited until the patient reaches thefield hospital, where the facilities forasepsis are at hand and instruments of

precision in diagnosis can be employedin locating the missile.

First Aid Dressing. —The idea ofsending first aid to the wounded in mod-ern warfare must be abandoned. Alarm-ing hemorrhages from a large vessel ofany of the extremities will, in manyinstances, be arrested by the patienthimself or his nearest comrade, by theuse of some sort of circular constriction,but the legitimate function of the hos-pital corps men will begin after the en-gagement. Desirable as it may appear,attempts at disinfection of the wound orwounds will prove impracticable anduseless on the battlefield. Time alone isan important element in contraindicatingsuch a course. Hundreds and thousandsmay demand attention, to say nothingof the limited facilities for procuring forthe wound and its vicinity an asepticcondition. The wisest and safest courseto pursue under such circumstances isto make an intelligent use of the first aiddressing package which should be foundon the person of every soldier, officersand men. The average first aid pack-age, the one devised by von Esmarchincluded, is too cumbersome. A firstaid package to meet the indications forwhich it is employed should include :

i. An efficient antiseptic powder. 2.A sufficient quantity of a hygroscopicmaterial to absorb the primary woundsecretion and serve as a filter for thewound. 3. A handkerchief or bandagewith which to retain the dressing and incase of necessity to be used in construct-ing a Spanish windlass. 4. Safetypins. A few years ago I devised such apackage. It contains about a teaspoon-ful of a powder composed of four partsof boracic acid and one part of salicylicacid, about one drachm of absorbentcotton, a piece of sterile gauze 40 inchessquare and a number of safety pins.The powder is lodged in the center of

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the cotton compress and is to be applieddirectly to the wound when the pack-age is used. The package, when com-pressed, is small and is wrapped in guttapercha. Every soldier of the Illinoisvolunteers carries such a package and isconversant with the manner in which itshould be employed. The piece ofgauze can be readily transferred into aMayer triangular bandage and serves asan excellent substitute for Esmarch’sbandage, which is heavier and requiresmuch more space. The figures printedon Esmarch’s bandage are useful for in-struction, but absolutely without valueon the battlefield. In rendering firstaid, the injured part should be divestedof clothing with as little disturbance ofthe wound as possible. Instead of re-moving the clothing it is much better tomake free use of scissors and knife ingaining access to the wound. If twowounds are found, both must receive thesame attention and care in protectingthem against infection. I have used theantiseptic powder referred to on a verylarge scale and can speak in positiveterms of its potent antiseptic properties.It resembles in its effects on the tissuesThiersch’s solution, being odorless, non-irritating and non-toxic. It forms withthe cotton and primary wound secretiona crust which effectually seals thewound. In the absence of grave symp-toms, such as hemorrhage, this dressingshould not be disturbed till the patientreaches the field hospital, and in manycases healing of the wound will takeplace without further interference. Theimmobilization of the injured part, par-ticularly in cases of compound fractureof the extremities, constitutes an impor-tant part of the manifold duties of thosewho render first aid to the wounded. Inall large engagements the supply ofmechanical supports carried by the menof the hospital corps will be exhausted

before all the wounded have receivedattention. Splints must be improvised.Rifles, sabres, bayonets, bark, branchesof trees, shrubs, etc.

, the chest in frac-tures of the upper extremity, the oppo-site limb in fractures of the thigh or legwill have to be utilized in procuring restfor the injured limb, in transportingpatients from the line of battle to thefirst dressing station. It is here thatthe surgeons will supplement or improvethe work done by the litter bearers andhospital corps. It is for the purpose ofdoing away with the necessity for usingsplints that a German military surgeonhas recently devised a litter on the planof a double inclined plane for the lowerextremities, a description of which hegave before the Military Section of theInternational Medical Congress held inMoscow last summer.* In the absenceof a litter of such special construction,the same object is attained by securingthe same position for the injured limbby a roll made of a blanket, clothing,knapsack, drum, straw, etc. It is myopinion that the transportation of thewounded, suffering from a fracture ofthe lower extremity, can be done withless pain and with greater security againstadditional injuries, if the fractured limbis placed in a flexed rather than a straightposition. If this statement is found tobe correct by future observations, themanner of dressing such cases mustundergo a material change. The man-ner of handling, carrying and conveyingpatients suffering from fracture of thelower extremity from the field to thehospital is a subject of great importanceto those who have in charge the instruc-tion of the hospital corps and companybearers.

Arrest of Hemorrhage on the Field.—Rife will be placed in jeopardyand deaths

*See National. Medical Review, June, 1898p. 63.—Ed.

4will occur more frequently from in-ternal than from external hemor-rhage ; in the treatment of the formerlittle can be done on the field, and thelatter class will come more frequentlyunder the care of non-professional menthan surgeons, Ligation of arteries inthe field will prove impracticable in mostinstances. The company bearers andhospital corps men should be instructedin the details of the various hemostaticresources applicable in emergency work.Elevation of the injured part, hyperflex-ion, digital compression and antiseptictamponade are some of the measures em-ployed which can be entrusted to intelli-gent and well instructed laymen in ar-

resting hemorrhage. Some form of circu-lar constriction will, however, most fre-quently be relied upon in arresting hem-orrhage complicating gunshot wounds ofthe extremities. Tne advantages anddangers attending this method of arrest-ing hemorrhage must be made a promi-nent feature in giving instructions onfirst aid. The technique of the proce-dure, whether it consists in the use ofthe typical Esmarch elastic constriction,a pair of suspenders, or the Spanishwindlass, must be fully explained anddemonstrated on the living subject. Thefact must be impressed that it is of greatimportance to render the limb that is tobe constricted comparatively bloodless byelevation before the constrictor is applied.The next most important advice to becarried into effect in the use of circularconstriction is to constrict quickly and withsufficientfirmness to interrupt at once andcompletely both the arterial and venous cir-culation. A question of immense and farreaching importance, and one which hasnot yet been definitely answered, is:How long is it safe to continue the con-striction ? There must be, and there is, alimit as to the length of time it is safe toexclude blood from living tissues. Al-

though cases have been reported in whichelastic constriction was continued fromthree to twelve hours without any seri-ous immediate or remote consequences,the present concensus of opinion of sur-geons, I am sure, would be opposed toexcluding the blood supply from anentire limb, the seat of a gunshot injury,for a longer period than 3 to 4 hours.The danger of gangrene is always greaterin constricting an injured than a healthylimb. A number of years ago I made an

extended series of experiments on dogsto determine if possible, the maximumlength of time it would be safe to con-tinue elastic constriction. The limb wasinvariably constricted near its base. Thetime varied from an hour and a half to27 hours. In a number of the cases tem-porary incompetence of Ahe muscles andtemporary paralysis followed when theconstriction was continued beyond fourhours, but the degree of functional dis-turbance was not always proportionateto the length of time. In only one in-stance did gangrene occur, and in thiscase constriction was continued for 17hours, while the maximum time was 27hours. This subject is of special interestto the military surgeon, as, from the verynature of things, if circular constrictionis resorted to as a hemostatic agent onthe battlefield, a considerate length oftime must necessarily intervene beforethe wounded reach the first dressing sta-tion or field hospital, where it is removedand hemorrhage arrested by direct andpermanent hemostatic measures. Ishould consider it dangerous to extendthe time beyond from 3 to 6 hours andshould insist that within this limit oftime the patient be placed in charge ofa surgeon fully equipped to substitutefor it the ligature, aseptic tamponade, orsome other direct hemostatic agent.

Locating, Finding arid ExtractingBullets. —The new weapon will minimize

5the surgeon’s work in locating, findingand removing bullets. In the vast ma-jority of cases requiring surgical treat-ment two wounds will be found, thewound of entrance and of exit markingthe location and direction of the tubularwound made by the bullet. The casesin which the jacketed bullet will befound in the body, indicated by the ex-istence of only one wound, will be•exceptional. During my visit to themilitary hospitals in Greece last summerI found a good many wounds made bythe small calibre projectile, but only intwo cases could I obtain authentic in-formation to the effect that the bulletwas found in the tissues of the body andwas removed b} 7 operative procedure.In the military hospitals in Turkey, Ifound numerous cases in which the old-fashioned large calibre lead bullet usedby the Greeks, had been removed byoperation or remained lodged in thebody. The search for bullets in modernwarfare, if made at all, will be reserveduntil the patient has reached the fieldhospital where the surgeons will have attheir disposal the necessary instrumentsfor making an accurate diagnosis andthe essential facilities for making oper-ations under the strictest aseptic and■antiseptic precautions. Before using thefinger or probe in exploration for a bul-let, the wound and the surface for a con-siderable distance around it should bethoroughly disinfected to guard againstall possibility of infecting the woundduring the examination or attempts atremoval of the bullet should such acourse be deemed advisable after exam-ination. One of the most importantrules to be followed in locating a bulletin the body is to place the patient andthe part injured as nearly as possible inthe same position as that occupied themoment the injury was received. Thetruth of this statement was well exem-

plified in the case of General Hancock.A number of surgeons of good reputehad made repeated attempts to find thebullet by probing, but failed. At lasthe availed himself of the services of Dr.Reade, the present Surgeon-General ofPennsylvania, who placed the Generalin the same position he occupied in thesaddle and the first attempt to locate thebullet proved successful. The metalclad bullet has to a certain extent ren-dered the famous Nelaton probe obso-lete. However, leaden bullets will beused to a greater or less extent by cer-tain branches of the military force, andthe porcelain tip will occasionally proveof service. The great objection toNelaton’s bullet probe is the size of theporcelain tip. The end of the probe shouldcorrespond approximately iri size to thecalibre of the tubular wound. By usingan instrument constructed on this prin-ciple the danger of making false passagesis greatly reduced. I have had a bulletprobe constructed by Truax, Green &

Co., with two porcelain tips, one at eachend, riveted to the end of the silverprobe, one 22 and the other 38 calibre.In parts of the body composed of deepmuscular planes and layers of fascia it isoften found absolutely impossible to fol-low the track of the bullet with anykind of probe. It is in such cases, whenit is deemed prudent, from the symptomspresented and the probable location ofthe bullet, to explore the tract, that thesurgeon will take advantage of the useof the knife in dilating the track, usingthe probe step by step as a guide.The use of the X-ray will prove of thegreatest value in all future attempts tolocate bullets. In order to locate a bulletwith sufficeint accuracy to enable thesurgeon to determine the propriety of anoperation for its removal and to guidehim safely in his work, photographs fromat least two directions will have to be

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taken. Every field and general hospitalshould be supplied with an X-ray appa-ratus, and in all difficult cases this oneof the most recent diagnostic inventionsshould be made use of before undertak-ing an operation and in preference to re-peated recourse to the probe. The fam-ous old-fashioned American bullet for-ceps have lost their distinction in mili-tary surgery through the introduction ofthe metal-clad bullet. The bullet for-ceps which I devised a few years ago, isso constructed that it serves at the sametime as a useful bullet probe. The gripof the instrument on any metallic bullet,regardless of its calibre, is firm, the bul-let once grasped can be extracted withoutdifficulty, as slipping of the instrument isalmost an impossibility. It seems to methat when a small calibre bullet is lodgedin an important anatomical locality diffi-cult of approach and not giving rise toany serious symptoms, it should be al-lowed to remain, with the hope it maybecome encysted wdthout causing anyremote serious consequences. Such aconservative course in well selected caseswill unquestionably give better resultsthan the too routine practice to extractthe bullet at all hazards.

Gunshot Wounds of the Extremities .

—

Besides the ordinary treatment of gun-shot wounds regardless of the anatomicallocation of the injury, bullet wounds ofthe extremities, when complicated byfracture or joint injury, present to thesurgeon special clinical features of greatimportance. Injuries of the soft tissuesnot implicating important vessels andnerves, under modern treatment shouldheal in a short time under the first dress-ing with little or no functional impair-ment. The existence of a gunshot frac-ture, regardless of the extent of bone in-jury, no longer furnishes a legitimateindication for a primary amputation.Such injuries under a satisfactory aseptic

and mechanical treatment are amenable-to repair in the course of time. Theyare the cases that tax the ingenuity ofthe surgeon, in applying and maintain-ing the necessary mechanical support,.,until the fracture heals by a bony con-solidation with the limb in a satisfactory,useful position. In gunshot fractures ofthe femur, extension and immobilization:will now, as it has for a long time, con-stitute the generally accepted treatment.A determined, strong protest must bemade against unnecessary removal of de-tached fragments of bone. If the woundremains aseptic, the loose fragments ofbone will not only retain their vitality,,but will take an important part in therestoration of the continuity of the boneand add materially to the functional re-sult. Debridement more or less exten-sive only becomes necessary and shouldbe performed solely in case the woundbecomes infected. In such an event theloose, infected fragments of bone shouldbe promptly removed, free tubular drain-age established and the wound through-out subjected to thorough disinfection.If the ordinary measures fail, continuedirrigation with a saturated solution ofthe acetate of aluminum will veryoften bring about the desired resultsand obviate the necessity of an am-putation. Fixation and suspension insuch cases will not only procure com-fort for the patient, but will answer anexcellent purpose in securing and main-taining coaptation, and in facilitatingdrainage and irrigation. As soon as thefracture has united with sufficient firm-ness to render extension superfluous,the limb should be immobilized in a cir-cular plaster of Paris splint, extendingfrom base of toes to the groin, and, inhigh fractures, including the pelvis, afterwhich the patient can be permitted towalk about with the aid of crutches. In:gunshot fractures of the leg, early im-

7mobilization in a circular plaster of Parissplint is to be advised and yields the mostgratifying results. Watchful control ofthe patient suffering from such injuriesand treated by the use of the plaster ofParis bandage, is essential in guardingagainst disastrous complications and inobtaining satisfactory functional re-sults. Gunshot injuries of the largejoints are now within the range of suc-cessful conservative treatment. I haveseen in the military hospitals both inGreece and Turkey, soon after the closeof the war, gunshot wounds of the hip,knee, ankle, shoulder, elbow, and wristjoints not only recover without any oper-ative interference whatever, but in manyof the cases, a fair degree of motion andgood use of tue limb rewarded the con-servative treatment. The indications forprimal amputation of a limb or part ofa limb should at present be restricted tocases in which the nutrition is suspendedor seriously threatened by the coexist-ence of vascular lesions incompatiblewith the vitality of the tissues at and be-low the seat of injury. In cases of doubtthe soldier is entitled to the benefit ofthe same, and the conservative treatmentshould be carried to its ultimate limits,until the appearance of complicationsdemonstrates its futility and dictates thepropriety of resorting to a mutilatingoperation. It is always more creditableto the surgeon to save the limb than toremove it, and the soldier is entitled tothe benefits of conservative surgery asmuch as the civilian, and the glory ofthe military surgery of the future shouldand will be to limit more and more theindications for amputation.

Gunshot Wounds of theSkull.—It is myintention to limit my remarks under thisheading to penetrating gunshot woundsof the skull. The few cases of this classof injuries that will come under theobservation of the military surgeon will

invariably require operative interference,provided it holds out any encourage-ment whatever of saving life. In case abullet has passed through the skull andits contents, the entire scalp should bethoroughly shaved and disinfected. Thewound of entrance must be enlarged soas to expose the perforation freely, whichis then enlarged with chisel, DeVilbissor rongeur forceps sufficiently to enablethe surgeon to remove the loose spiculaof bone which are frequently found somedistance in the brain. With a longeyed probe a strip of iodoform gauze,large enough to loosely pack the tubularvisceral wound, should be inserted fromthe wound of entrance to the wound ofexit, and the through gauze drain madeto project a few inches beyond the sur-face of each wound. Through capillarydrainage of this kind will prevent accu-mulation of primary wound secretion inthe interior of the skull, and will be ofvalue in arresting capillary hemorrhage.A large hygroscopic dressing envelopingthe entire scalp and covering bothwounds constitutes the dressing andmust be held in place by a few turns ofplaster of Paris bandage. The drain mustbe allowed to remain till the danger ofinfection is passed, when it is to be re-moved gradually by shortening it everyday or two. In case the bullet shouldbe found lodged in the interior of theskull, the wound of entrance must betreated in the same manner and thebullet located by the careful use ofFluhrer’s aluminum probe. A counteropening may become necessary in re-moving the bullet, if it has reached theopposite side of the skull, or when it hasbecome deflected or arrested in its coursenear the surface of the brain, in case thelocality in which it has become lodgedwarrants operative interference. In alvisceral injuries of the contents of theskull resulting from gunshot wounds.

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capillary or tubular drainage or a com-bination of the two is indicated and shouldbe continued till there is no further dan-ger of infection, hemorrhage or accumu-lation of wound products, when thedrain is to be gradually removed. Thevalue of the X-ray in locating; bullets inthe interior of the cranium has as yetnot been definitely ascertained.

Gunshot Wounds of theChest. —Penetra-ting gunshot wounds of the chest areattended by an enormous mortality ow-ing to the physiological importance ofthe organs which it contains. Visceralwounds of the heart and large bloodvessels usually result in death in a fewmoments from acute anaemia. Hemor-rhage into the pleural cavity and intothe large bronchial tubes interferes me-chanically with the respiratory functionsand frequently proves fatal in a shorttime and if the patient recovers from itsimmediate effects, life is placed in dan-ger by the complic Uions, which toooften occur, caused by the hemothorax.The accumulation of even a large quan-tity of blood in the pleural cavity is notincompatable with a speedy recovery, aswhen the blood is aseptic its removal byabsorption is accomplished in a shorttime. Experience during the War ofthe Rebellion showed that in gunshotwounds of the chest the chances of lifewere much better if the bullet passedthrough the chest than if it remainedlodged in the body. I saw a number ofsoldiers in the Graeco-Turkish war, thathad been shot through the chest, conval-escent and in fair health a few weeksafter the injury was inflicted. We havemade little progress in the treatment ofpenetrating wounds of the chest. Directoperative treatment of visceral woundsof heart and lungs is always attended byimminent risk to life from pulmonarycollapse. This source of danger standsin the way of direct treatment of vis-

ceral wounds of the chest. Hemorrhagefrom wounds of the lung is often arrestedspontaneously by the accumulation ofblood in the cavity of the chest, causingtemporary pulmonary collapse and tam-ponade of the tubular visceral wound bythe formation of a blood-clot. Free in-cision of the chest wall has been stronglyadvocated by several French surgeons incases of pentrating wound of the chestwith a view of arresting hemorrhage byligature, tamponade or the use. of thecautery, but the profession on the whole,for good reasons is opposed to suchheroic treatment. Unless the source ofhemorrhage is one of the intercostal orthe internal mammary artery it is ad-visable to rely on nature’s resourcesin arresting the bleeding. '

Hemorrhage from the intercostal arte-ries can be effectually checked by tampon-ade, using for this purpose an hour glass-shaped tampon of iodoform gauze. Restin the recumbent position, with the chestslightly elevated, is essential in aidingspontaneous arrest of hemorrhage and inthe prevention of complications. A risein the temperature in the first forty-eighthours is no indication of sepsis, as, withfew exceptions, it indicates a febrile dis-turbance caused by the absorption offibrin ferment, the so-called fermentationfever. Should later symptoms set insuggestive of septic infection, aspirationshould be promptly resorted to, and ifnot followed by speedy improvement,time should be lost in subjecting the pa-tient to the same medical treatment as.advised and practised for empyema, thatis,rib-resection, free incisionand drainage.The production of an artificial pneumo-thorax or hydrothorax by the introduc-tion into the pleural cavity on the injuredside of a nontoxic gas or filtered atmos-pheric air or sterilized water or non toxicantiseptic solutions has not proved satis-factory in the treatment of intra-thor

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racic traumatic hemorrhage. From whathas been said it is clear that the besttreatment in penetrating gunshot woundsof the chest consists in hermetically seal-ing the wound of entrance and exit, ifsuch exists, under strict aseptic precau-tions, and in watching for and treatingsubsequent complications as they presentthemselves.

Gunshot Wounds of the Abdomen. —Thegreater part of this paper will be devotedto this subject as recent discoveries andimprovements in surgery have done morefor the succesful treatment of visceralwounds of the abdominal organs than forthe injuries of of the organs con-tained in the remaining large cavities ofthe body. The triumphs that have sig-nalized the practice of civilian surgeonsin the operative treatment of intra-ab-dominal injuries must be repeated on thebattlefield. I look hopefully for manysuccessful results in the operative treat-ment of gunshot wounds in militarypractice. I will in this connection limitmy remarks to penetrating wounds, tak-ing it for granted that when patientssuffering from abdominal wounds arebrought to the field hospitals, the sur-geons in charge will consider it their im-perative duty to make a positive distinc-tion between penetrating and non-pene-trating wounds, before assuming the re-sponsibility of opening the abdomen. Inthe discussion of penetrating wounds ofthe abdomen I shall quote freely from theforthcoming third edition of the Ameri-can Text Book of Surgery, from thechapter which treats of this subject.Sword, bayonet and other stab woundswill diminish in frequency with develop-ment of the modern scientific warfare.The penetrating wounds of the abdomenthat will come under the observation ofthe military surgeon will, with few ex-ceptions, be wounds inflicted with themodern small calibre projectile. The

mural wounds, the wounds of entranceand exit will be small, too small for dig-ital exploration. It is perhaps superflu-ous to make the statement here to the ef-fect that a penetrating wound of the abdo-men should never beprobed either for diag-nostic or therapeutic purposes If anydoubt exists as to whether or not the bul-let has entered the abdominal cavity, itis far better and safer to dilate the trackby the use of the knife, relying on theprobe as a guide, than to work in thedark with the probe and by doing so in-creasing the possibilities of infecting theperitoneal cavity. Quite recently the as-sertion has been made by prominent sur-geons that laparotomy should be per-formed iu all cases when it can be shownthat penetration has occurred. It must,however, be admitted that, in the absenceof serious visceral lesions, penetratingwounds of the abdomen are injuriesfrom which the patients are very likely torecover without operative treatment, andthat when such patients are subjected tolaparotomy, death may occur solely inconsequence of the operation. It is un-doubtedly true that in most cases ofspontaneous recovery after penetratinggunshot wounds of the abdomen, thefavorable termination has been due toabsence of serious visceral lesions, whichsome hold to be universally present insuch cases. A number of years ago Imade a series of experiments on the ca-daver for the purpose of demonstratingthat occasionally a bullet can traversethe abdominal cavity iu certain directionswithout producing visceral wounds thatwould warrant laparotomy.

The cadaver, a marasmic male adult,was placed in the erect position against awall and the shooting was done with a 38calibre rifle at a distance of 30 feet. Thebullet was fired in every instance in anantero-posterior direction and invariablypassed through the body, sixteen shots

were fired and examination of the abdom-inal cavity carefully made by followingthe track of each bullet showed that fourof the bullets traversed the abdominalcavity without injuring the stomach orintestines or any of the large abdominalvessels. In each of these four experi-ments, the bullet entered the abdomen ator a little above the umbilical level. Inall experiments in which the bullet en-tered below the umbilical level, intestinalperforations were found. Absence ofvisceral lesions has also been demonstra-ted during an operation or at the post-mortem. During the Graeco-Turkishwar several cases of gunshot wounds ofthe abdomen recovered under a conserva-tive plan of treatment. In nearly allthese cases the bullet entered the abdo-men above the umbilicus, the most favor-able location for the escape of the intes-tines from the missile, the patient beingin a .standing position. In two out ofsixteen cases of penetrating gunshotwounds of the abdomen, which came un-der the observation of the writer, the ab-sence of visceral injuries of the gastro-intestinal canal was demonstrated by theuse of the hydrogen gas test, and mostof these patients recovered without re-sort to laparotomy. Clinical experienceand the result of experiment show con-clusively that laparotomy should not beperformed simply because a bullet has en-tered the abdominal cavity, but that itsperformance should be limited to thetreatment of intra-abdominal lesionswhich without operative interferencewould tend to destroy life. A bulletwhich passes through the lower part ofthe abdomen from side to side or oblique-ly is almost sure to produce from four tofourteen perforations of the intestines,while absence of dangerous visceral com-plications may be inferred with some de-gree of probability if it crosses the ab-dominal cavity in an antero-posterior di-

rection at or a little above the umbilicallevel.

Symptoms.—The general symptoms incases of penetrating gunshot wounds ofthe abdomen, with the exception of thosedue to profuse hemorrhage, furnish verylittle information in reference to the exis-tence or absence of visceral complica-tions. Severe shock may attend a sim-ple non-penetrating wound, and it maybe wanting or at least slight, in cases ofmultiple perforation of the intestines.It is not an uncommon occurrence for apatient, who has received a penetratingwound of the abdomen, to walk severalblocks, or even a number of miles, with-out a great deal of suffering and withoutshowing any symptoms of shock, andyet for a number of intestinal perfora-tions to be revealed at a subsequent oper-ation or autopsy. Vomiting occurs withequal frequency in parietal wounds and insimple penetrating wounds as when theviscera have been injured. Vomiting ofblood points to the existence of a woundof the stomach. Pallor is present in allpenetrating wounds of the abdomen soonafter the receipt of the injury, and it isonly more pronounced when produced atleast in part, by sudden and severe hem-orrhage. Pain is a very unreliable andoften misleading symptom, as it may bemoderate or almost completely absentsoon after the injury has been inflictedeven when multiple perforations are pres-ent. The pulse at first is slow and com-pressible in all cases and nothing charac-teristic in its qualities has been observedeven if the stomach and intestines havebeen wounded. Hemorrhage caused bywounds of any of the large organs, as thespleen, liver, or kidneys, gives rise toacute progressive anaemia, small rapidpulse, cold clammy perspiration, dilatedpupils, yawning, vomiting, and, in ex-treme cases syncope and convulsions.The local symptoms are of no more value

•in determining the existence of visceralinjuries in penetrating wounds of the•abdomen than are the general symptomswhich have just been enumerated. Ex-ternal hemorrhage is slight or entirelywanting unless an artery or a vein in theabdominal wall has been injured. Thebleeding from visceral wounds gives riseto accumulation of blood in the perito-neal cavity—occult or internal hemorr-hage. This can be recognized by physi-cal signs, which denote the presence offluid in the free abdominal cavity, andby general symptoms, indicating progres-siveanaemia: increasing pallor ofthe faceand of the visible mucous membranes,small, feeble pulse, superficial sighingrespiration and dilated pupils. Woundsof the stomach often cause hemorrhageinto this organ and hematemesis. Bloodin the stools seldom follows hemorrhageinto the bowels sufficiently early, fromintestinal wounds, to be of any diagnos-tic value.

Circumscribed emphysema in the tissuesaround the track has been regarded as animportant sign of the existence of intes-tinal perforation. This symptom is mis-leading and absolutely devoid of diagnos-tic value, as this condition has frequentlybeen observed in non-penetrating woundsof the abdominal wall resulting from theentrance of air into the loose connectivetissue, or later, as gas formation, as oneof the results of putrefactive infection.The accumulation of any considerablequantity of gas in the peritoneal cavitysometimes can be recognized by the dis-appearance of the normal liver dullness,caused by the presence of gas betweenthe surface of the liver and the chestwall. This condition has been soughtfor in cases of perforating wounds of theabdomen as a diagnostic sign, and iffound has been taken as a sure indication•of the existence of visceral wounds of thegastro-intestinal canal. This is not,

however, the case. Adhesionsbetween the surface of the liver andchest wall may have existed before theinjury was received, or the amount of gaspresent may be insufficient to give rise tothis sign. The escape of the contents ofthe woundedstomach orintestines throughthe external wound is a rare occurrenceand is possible only when the externalwound is large and straight and whenit corresponds with the location of thevisceral wound, or in the event of pre-existing adhesions between the abdomi-nal wall and the injured portion of thegastro-intestinal Canal. External extra-vasation occurs more frequently inwoundsof the large than the small intestines.When this symptom is present it is con-clusive proof of the existence of a visce-ral wound of the gastro-intestinal canaland the character of theextravasation willfurnish reliable information as to the an-atomical location of the visceral injury.With the exception of the last mentionedsymptom, and the indications pointing tothe necessity of arresting internal hem-orrhage, there is nothing about the localor general symptoms of penetrating gun-shot wounds of the abdomen that wouldenable the surgeon to decide with anydegree of certainty, soon after the injurywas received, whether or not visceral in-juries existed, and, consequently, wheth-er laparotomy should or should not beperformed.

Diagnosis. —If a gunshotwound has pen-etrated the abdominal cavity and the gen-eral symptoms and local signs lead us tosuspect the existence of dangerous intes-tinal hemorrhage, no timeshould be lost infurther efforts to make an accurate ana-tomical diagnosis, as sufficient evidencehas been obtained to warrant a laparo-tomy for the purpose of preventingdeath from hemorrhage by the directsurgical treatment of the visceral injur-ies. If no such urgent indication pre-

12

sents itself, it is desirable that the ex-istence of visceral lesions demandingsurgical treatment should be ascertainedbefore the patient is subjected to theadditional risks incident to a laparotomy.Since a simple penetrating wound of theabdomen is an injury from which themajority of patients recover withoutoperative treatment, and since visceralwounds of the gastro-intestinal tract areattended by such frightful mortalitywithout surgical interference, the prac-tical value and importance of a correctdiagnosis before deciding upon a definiteplan of treatment become obvious. It isapparent, that if some reliable diagnostictest could be applied in cases of pene-trating wounds of the abdomen whichwould indicate to the surgeon the pres-ence or absence of visceral lesions of thegastro-intestinal canal, the indicationsfor aggressive or conservative treatmentwould become clear. The writer hasshown by his experiments on animals,and later by his clinical experience inthe treatment of a number of gunshotwounds of the abdomen, that rectalinsufflation of hydrogen gas can be re-lied on in demonstrating the existence ofperforations of the gastro-intestinal ca-nal before opening the abdomen. Hehas shown conclusively that, if the ab-dominal muscles are completely relaxedunder the influence of a general anes-thetic, hydrogen gas or filtered air canunder safe pressure be forced from theanus to the mouth if no perforationsexist, and if such are present, the gaswill escape into the peritoneal cavitywhere its presence can be readily de-tected by the physical signs character-istic of a free tympanites or by its escapethrough the external opening. Theo-retical objections have been made againstthis diagnostic test on the ground thatit occasionally fails in demonstrating theexistence of a perforation and that it is

instrumental in causing fecal extrava-sations. In reply to this I must saythat it has never failed in my hands inmaking by its aid a correct diagnosisand the fallacy of the second objection Ihave shown repeatedly by its effect onanimals. Hydrogen gas is a non-toxicsubstance, endowed with valuable inhib-itory antiseptic properties, and is ab-sorbed from all the large serous cavitiesand the connective tissues within a fewhours. Pure zinc and sulphuric acidshould be used in generating the gaswhich is collected in a rubber balloonholding at least four gallons. The rub-ber balloon used for this purpose issquare in shape and is connected withthe rectal tip by means of a rubber tubesix feet in length and supplied with a.stop-cock near its proximal end. Inapplying the test, an assistant presses-the margin of the anus against the rectaltip while another assistant forces the gasalong the intestinal tube by pressing orsitting on the rubber balloon. The-passage of the gas through the ileo-csecal valve takes place under a pressureof two and a half pounds to the squareinch and is announced by a distinct gurg-ling sound which can always be dis-tinctly heard by applying the ear orstethoscope over that region. If therectum or colon have been perforatedthe gas will not reach the small intes-tines as it will escape into the peritonealcavity under less pressure than isquired in rendering the ileo-csecal valveincompetent. As soon as the gas reachesa perforation large enough to permit itsescape, it will enter the peritoneal cavityand escape through the external wound,if this has been freely laid open down tothe peritoneum. If the external woundis in a location which points to an injuryof the stomach, this organ should be in-sufflated through a rubber stomach tube,and if this test proves negative, it is to

13

be followed by rectal insufflation. It isimpossible to inflate the intestines to anyextent from the stomach.

Treatment.—The propriety of surgicalinterference in cases of penetrating gun-shot wounds of the abdomen will dependon one of three things ;

1. General condition of the patient.2. Dangerous internal hemorrhage.3. Wounds of the stomach or intes-

tines large enough to permit of extrava-sations.

If the patient is pulseless and presentsother indications of approaching death,operation is unjustifiable, as it wouldonly hasten the end, bring reproach uponsurgery, and undermine the confidencein the life saving value of operationsamong the troops.

Dangerous internal hemorrhage thatwill come to the notice of military sur-geons in gunshot wounds of the abdo-men, will be the cases in which thevascular organs of the abdomen, theliver or spleen, or some of the largervessels of the mesentery or omentumhave been injured. Delay in such casesis dangerous. The abdomen should beopened promptly and the hemorrhagearrested. The symptoms are apt to beunusnalty severe if the hemorrhage issudden, progressive if the loss of bloodis gradual. In the latter instance itmay be prudent to watch the case forsome time for more pressing indications,as it is well known that spontaneousarrest of hemorrhage may occur andeven large quantities of aseptic blood areremoved from the peritoneal cavity in ashort time. Visceral lesions of the gas-trointestinal canal, large enough to per-mit of extravasation, are with very fewexceptions mortal wounds the existenceof which can leave no doubt in the mindof the surgeon to resort promptly toabdominal section as offering the onlychance to save life.

Preparation of Patient.—A patient suf-fering from a gunshot wound of theabdomen should be properly preparedbefore he is subjected to laparotomy. Ifthe stomach is filled with food a saltwater emetic should be given for thepurpose of emptying its contents, or,better still, this can be done by the useof the stomach siphon tube. The rec-tum and colon must be emptied by a.copious enema of warm water to whicha tablespoonful of salt has been added.The unloading of the gastro-intestinalcanal will not only facilitate the oper-tion but will have a favorable influencein securing rest for the injured part. A.hypodermic injection of gr. of mor-phia and gr. 1-30 of strychnia should begiven shortly before the anesthetic is-administered, as these remedies in thedoses specified assist the action of theanesthetic, secure rest for the intes-tine and sustain the action of theheart. If the patient is much prostrated,,two ounces of whiskey diluted with fourounces of warm water should be givenby the rectum The whole abdomen:should be thoroughly disinfected. Be-fore and during the operation the use ofexternal dry heat will do much in pre-venting shock and in aiding the peri-pheral circulation. Compresses, towelsand several gallons of warm normal,solution of salt must be provided. Theoperator shonld do the work with aslittle assistance and as few instruments-as possible as the danger of infection inemergency work is apt to be propor-tionate with the number of assistantsemployed and number of instrumentsused. Hands, instruments, suturingmaterial, in fact everything that is to bebrought in contact with the wound mustbe sterilized. In military surgery silkwill have the preference over catgut Ahospital tent with a floor will be anadmirable operating room in all semi-

tropical climates. Anesthesia should be'Commenced with chloroform until thepatient is under its full influence when itshould be continued with ether.

Incision. —In the majority of cases themedian incision should be made as it af-fords advantages which give it the pref-erence. It should always be selected incases of gunshot wounds of the stomach,and where the wound of entrance is loca- :ted near the median line. A median in-cision affords most ready access in thetreatment of wounds of the small intes-tine. If the insufflation test is used, itwill prove sometimes of value in decidingupon the location of the incision. If, ingunshot wounds of the upper portion ofthe abdomen, direct inflation of the stom-ach through an elastic tube reveals theexistence of perforation of this organ,the median incision should be selected.If rectal insufflation yields a positive re-sult before the gas has passed the ileo-csecal valve, the incision should be madeover the wounded portion of the colonwhich is usually indicated by the courseof the bullet. A wound in the trans-verse colon can be found and dealt withmost effectually through a high medianincision; perforation of the caecum or ofthe ascending colon calls for a lateral in-cision directly over the wounded orgamwhile a lateral incision on the left side isindicated, if from the direction of thebullet, it is evident or probable that thecolon below the splenic flexure is the seatof the visceral injury. Taparotomy forthe arrest of hemorrhage should alwaysbe done by making a long median incis-ion, which will afford the most directaccess to the different sources of hemorr-hage. Very often it will be advisable tomake the incision in the line of thewound of entrance, more especially in■cases where a lateral incision is indicatedfrom the location of the wound, from thecourse of the butlet, and perhaps from

the results obtained by the insufflationtest.

Arrest ofHemorrhage.—In opening theabdomen in the treatment of internalhemorrhage, the surgeon undertakes atask the gravity of which it is impossibleto foretell. To do the work quickly andwell he must be perfectly familiar withthe anatomy of the abdominal organs,their source of blood supply and musthave full knowledge of all hemostatic re-sources, the indicationsfor their selectionand details of application. Profuse in-tra abdominal hemorrhage resulting frompenetrating gunshot wounds of the ab-domen, is more frequently of parenchy-matous and venous than arterial origin.Wounds of the liver, spleen, kidneys andmesentery give rise to profuse andoften fatal hemorrhage. After openingthe peritoneal cavity it is often very dif-ficult to find the bleeding points as theblood accumulates as rapidly as it issponged out and it becomes necessary toresort to special means in order to arrestprofuse bleeding sufficiently to find thesource of hemorrhage. One of twomeans should be employed:

i. Intra-abdominal digital compres-sion of the aorta.

2. Packing the abdominal cavity wfltha number of large sponges or gauze com-presses. Intra-abdominalcompression ofthe aorta below the diaphragm can bereadily made by an assistant introducinghis hand through the abdominal incisionwhich in such a case must be larger thanunder ordinary circumstances. Compres-sion made in this manner will promptlyarrest the hemorrhage from any of theabdominal organs for a sufficient lengthof time to enable the surgeon to find thesource of hemorrhage and carry out thenecessary treatment for its permanent ar-rest. Hemorrhage from a perforatedkidney may demand a nephrectomy if itdoes not yield to tamponade. If the

tampon is used, an incision in the lumbarregion must be made for theremoval of thetampon, and theparietalperitoneum shouldbe sutured so as to exclude the peritonealcavity from the renal wound. Woundsof the liver are sutured with catgut,cauterized with the actual cautery, ortamponed with a long strip of iodoformgauze or a typical Mikulicz tampon, ineither case the gauze is to be brought outof the wound and utilized as a drain.A wound of the spleen, if the hemorr-hage does not yield to ligature, suturingor tamponade, necessitates splenectomy.Very troublesome hemorrhage is oftenmet with in wounds of the mesentery.When multiple wounds of the mesenteryand visceral wounds of the stomach orintestines are the cause of the hemorr-hage, it is a good plan to pack the ab-dominal cavity with a number of largesponges, napkins, or compresses of gauzeto each of which a long strip of gauze issecurely tied, these strips being allowedto hang out of the wound in order thatnone of the sponges or compresses maybe lost or forgotten in the abdominalcavity after the completion of the opera-tion. The sponges or compresses makesufficient pressure to arrest parenchyma-tous oozing, as well as venous hemorr-hage if they are placed at different pointsagainst the mesentery, and between theintestinal coils. The sponges are re-moved one by one frombelow upward, andthe bleeding points secured as fast asthey are uncovered. The ligation of mes-enteric and omental vessels, both arteriesand. veins, should be done by applyingthe ligature en masse. A round needleor Thornton’s curved hemostatic forcepsare the most useful instruments for thispurpose. Catgut as a rule should not berelied upon in tying a mesenteric vessel,as it is greatly inferior to fine silk. Ifhemorrhage is profuse, this must be at-tended to before anything is done in the

way of finding or suturing the visceral’wounds. Troublesome hemorrhage from;a large visceral wound of the stomach orintestines is best controlled by hemmingthe margin of the wound with catgut orfine silk. In hemorrhage in localitiesnot accessible to ligature and not amena-ble to tamponade, pressure forceps areapplied and allowed to remain twen-ty-four to forty-eight hours. When usedin this manner the instrument must belong enough to be brought out of thewound and is then incorporated in thedressing. For the purpose of finding andfacilitating the removal of the instrumenta strip of gauze is tied to' the handle.

Search for Perforations.—-A numberof cases have been recorded, and I amsure many more have occurred, inwhich laparotomy was performed, one ormore perforations sutured, and the post-mortem showed that a perforation wasoverlooked, death resulting from ex-travasation and diffuse septic peri-tonitis. Such experiences are by nomeans limited to the practice of novi-tiates but have occurred in that of menof large experience and in well equippedfirst class hospitals. The handling ofthe entire length of the gastro-intestinalcanal in the search for perforations re-quires time, adds to the shock of theinjury and operation, and, even if doneby experts and with the utmost care, aperforation may escape the attention ofthe operator and become the sole causeof death. If the surgeon adopts thisplan of detecting perforations the workshould be done systematically. Theileo-csecal juncture is the best landmark for beginning the search. Fromhere the small intestine is traced in anupward direction examining loop afterloop and returning the intestine as soonas examined so as to avoid extensiveeventration which always adds greatlyto the danger of the operation. The

large intestine is traced from the ileo-caecal region downward. In one of mycases perforation of the rectum wasfound low down in the pelvis, which cer-tainly would have been over looked if Ihad not used the inflation test wfliichpromptly revealed not only its existencebut also its exact location. If the air orgas test has been employed with a posi-tive result before the abdomen isopened, there will be no difficulty exper-ienced in finding the first opening. Ifthe stomach was inflated directlythrough an elastic tube, and the test hasshown the presence of a perforation, amedian incision is made from the tip ofthe ensiform cartilage to the umbilicusand the stomach is drawn forward intothe wound.

If no perforation is found in the an-terior wall the insufflation is repeated,and the escaping air or gas will directthe surgeon to the perforation. Throughthis perforation the stomach shouldagain be inflated in search for a secondand possibly a third perforation. Insearching for intestinal wounds by theaid of inflation, further inflations shouldbe suspended as soon as the lowest per-foration has been found. If possible theperforated portion of the intestine shouldnow be brought forward into the wound,and, after emptying the intestine belowthe perforation as far as possible of itscontents including gas or air, the bowelis compressed below the perforation byan assistant and the intestine higher upis inflated through the wound. As amatter of course a perfectly aseptic glasstube should be inserted into the rubber'tube in place of the rectal tip. The in-flation is now carried as far as the sec-ond opening when the first perforation issutured and after disinfection andemptying the intervening portion of itsgas the intestine is replaced in the ab-dominal cavity. Further inflation is

now made through the second openingand if a third wound is found the secondis sutured, and so on until the entireintestinal canal has been thoroughlysubjected to the test. By following thisplan extensive eventration is renderedsuperfluous, and the overlooking of aperforation is made impossible, likewisethe objection to the test that reductionof the intestinesowing to distension withgas or air is overcome if the interveningsections between the perforations areemptied of their contents before suturingthe wound.

Suturing of Perforations. —The mate-rials for suturing are an ordinary sewingneedle and fine aseptic silk. Catgutshould be dispensed with in all intes-tinal work. Trimming the margins ofvisceral wounds is not only superfluousbut absolutely harmful, as it requires auseless expenditure of time and may be-come an additional source of hemorrhage.The same can be said of the Czerny-Lembert suture. All that is required inthe treatment of a visceral wound of thestomach and intestine is to turn the mar-gins of the wound inward and to bringinto opposition healthy serous surfacesby the continuous or interrupted sero-muscular sutures, which should alwaysbe made to include fibres of Halsted’ssubmucosa. From four to six stitchesto an inch will suffice. If possiblewounds of the stomach should be su-tured in the direction of the blood vesselsand transverse suturing of the intestineis necessary for the purpose of prevent-ing constriction of the lumen. Defectsan inch and a half in length can beclosed on the convex side in this mannerwithout fear of causing intestinal ob-struction, while much smaller defects onthe mesenteric side usually necessitate aresection, not only because the vascularsupply in the corresponding portion ofthe intestine would be inadequate, but

•also because a sufficiently sharp flexionmight be produced at the seat of sutur-ing to become the immediate mechanical

■cause of intestinal obstruction.Enterectomy. —Enterectomy is often in-

dicated in cases of double perforation andin marginial wounds in the mesentericborder. If in cases of multiple perfora-tion it should become necessary to makea double enterectomy, and the interven-ing portion of the small intestine is notmore than two or three feet in length, itis best to resect the same, as the imme-diate effect of the single operation willnot be as severe as that of a double re-section with a corresponding double en-terorrhaphy. After resection, the con-tinuity of the intestinal canal should al-ways be restored by a circular enterorr-hapy, using for this purpose the Czerny-Lembert suture. Strips of sterile gauzeare preferable to clamps in preventingextravasation during the operation. Thegauze strip is passed through a smallbutton-hole made with hemostatic for-ceps in the mesentery near the intestineand tied with sufficient firmness to pre-vent escape of intestinal contents.

Irrigation of the Abdominal Cavity. —

This is necessary only if fecal extravasa-tion or escape of stomach contents hastaken place, an accident which if it has notoccurred before the abdomen was open-ed, should be carefully avoided duringthe manipulations of the wounded in-testines. Flushing the peritoneal cavitywith warm sterilized water or normal saltsolution not only clears it of infectiousmaterial, but acts at the same time as a

stimulahit to the flagging circulation. Thecurrent must be sufficiently strong notonly to fill the peritoneal cavity quicklybut to flush it out. After the completion

■of the irrigation the patient is placed onhis side, and in this position the fluid-contents of the abdominal cavity arepoured out. The cavity is then rapidly

dried by large sponges wrung out of aweak sublimate solution (i: 10,000) orThiersch’s solution. Some surgeonshave practically abandoned flushing ofthe abdominal cavity and rely almost ex-clusively on sponging in removing pusand extravasated fecal material. Othersare partial to leaving the physiologicalsolution of salt in the cavity, paying noattention to the peritoneal toilet prac-ticed with conscientious care by all sur-geons only a few years ago.

Drainage. —To drain or not to drain isthe all absorbing topic among surgeonswhose time and attention are largel}r en-gaged in abdominal work. I wish to placemyself on record as being a strong advo-cate of drainage in all cases of abdomi-nal surgery in which we have reason tobelieve that contamination of the perito-neal cavity has taken place by extravasa-tion of contents of the gastro-intestinal ca-nal or pus. In gunshot wounds of theabdomen complicated by visceral injurytheprobability that infection has occurredmust not be lost sight of, and the onlysafe course to pursue under such circum-stances is to drain where you are indoubt. Cases which require irrigationshould always be drained. Other indi-cations for drainage are visceral woundsof the liver and pancreas and the exis-tence of parenchymatous hemorrhagewhich cannot be controlled by any of thedifferent hemostatic measures. A glassdrain reaching to the bottom of the pel-vis loosely packed with a strip of iodo-form gauze answers the purpose. Occa-sionally multiple drains are indicated.The Mikulicz drain is to be dependedupon in arresting troublesome surfaceoozing. Drainage must be suspended atonce, or gradually with the cessation oftheprimary wound secretion.

Suturing of External Incision. —In-cisions in the median line are rapidlyclosed with one row of silk or silkworm-

gut sutures, which are placed close to-gether and include all the tissues of themargins of the wound. Incisions madein any other place are to be closed byburied catgut sutures uniting the peri-toneum and muscular layer separatelyand a superficial row of silkworm gutsutures uniting all the tissues except theperitoneum. A large hygroscopic com-press composed of sterile gauze and cot-ton held in place by broad strips of ad-hesive plaster constitutes the properdressing. The sutures are removed atthe end of the second week and thepatient must not be allowed to leave thebed before the expiration of the fourthweek. Four weeks in bed and the wear-ing of a well fitting abdominal supportfor 3 to 6 months are the most reliableprecautions against the occurrence of a>post operative ventral hernia. Thedrainage opening should be closed withsecondary sutures, inserted at the timeof operation, as soon as the drain is re-moved, otherwise a ventral hernia willbe almost sure to develop in the scar atthe former site of the drainage tube.

After-treatment.—Absolute rest mustbe strictly enforced. Opiates must begiven in sufficient doses to quiet the per-istaltic action of the intestines. Stimu-lants must be used to counteract theeffect of shock and to restore the en-feebled peripheral circulation. Absolutediet must be observed for at least 48hours. During this time a mixture ofbrandy and ice water in small doses fre-quently repeated, or acid champagne, isagreeable to the patient, as it quenchesthirst, relieves nausea and exerts a fav-orable influence on the circulation. Ifmore active stimulation is called for torelieve shock and the effects of hemor-rhage, whisky, strychnine, ether, musk,or camphor can be injected subcutane-ously or by the rectum, while the peri-

pheral circulation is restored by applyingdry heat to the extremities and trunk.The subcutaneous infusion of one to twopints of normal salt solution is an excel-lent restorative of special therapeuticefficiency in cases where the vital forcesare depressed and life is in danger from,the effects of hemorrhage. Shouldsymptoms of peritonitis set in, a brisksaline cathartic should be given at theend of forty-eight hours, as at this timethe intestinal wounds will have becomesufficiently united to resist the peristalsisprovoked by the cathartic, while the re-moval of intestinal contents and theabsorption of septic material from theperitoneal cavity thus attained are notonly the most efficient means of avert-ing a fatal disease, but also placing thewounds in the most favorable conditionfor rapid repair. Reopening the woundand secondary flushing have done littlein arresting or limiting septic peritonitis.If the case progresses favorably, liquidfood by the stomach can be allowed atthe end of the second day, and lightsolid food at the end of the first week.Under ordinary circumstances no effortis made to move the bowels till the end,of the third or fourth day. If earlyfeeding becomes necessary in marasmicor exsanguine patients, this can be doneby rectal alimentation.

From the contents of the paper the fol-lowing conclusions can be formulated :

i. In theory and practice military sur-gery is equivalent in every respect toemergency practice in civil life.

2. The wounded soldier is entitled tothe same degree of immunity against in-fection as persons in civil life sufferingfrom similar injuries.

3. The fate of the wounded rests inthe hands of the one who applies thefirst dressing.

4. The first dressing should be as

19

simple as possible including an anti-septic powder composed of boracic acidfour parts, salicylic acid one part, asmall compress of cotton, safety pins anda piece of gauze 40 inches square.

5. Any attempt to disinfect a woundon the battlefield is impracticable.

6. The first dressing stations and thefield hospitals are the legitimate placeswhere the work of the hospital corps andcompany bearers is to be revised andsupplemented. All formal operationsmust be performed in the field hospitalswhere the wounded can receive the fullbenefits of aseptic and antiseptic pre-cautions.

7. Probing for bullets on the battle-field must be absolutely prohibited.

8. Elastic constriction for the arrestof hemorrhage must not be continuedfor more than 4 to 6 hours for fear ofcausing gangrene.

9. The X-ray will prove a more valu-able diagnostic recourse than the probe

in locating bullets lodged in the body.10. Gunshot wounds of the extremities

must be treated on the most conservativeplan, the indications for primary ampu-tation being limited to cases in whichinjury of the soft parts, vessels andnerves suspend or seriously threaten thenutrition of the limb below the seat ofinjury.

11. Operative interference is indi-cated in all penetrating gunshot woundsof skull.

12. Gunshot wounds of the chestshould be treated by hermetically seal-ing the wound under the strictest asepticprecautions.

13. Laparotomy is indicated in allcases in penetrating gunshot wounds ofthe abdomen where life is threatened byhemorrhage or visceral wounds and thegeneral condition of the patient is suchas to sustain the expectation that hewill survive the immediate effects of theoperation.