The Modern Treatment of Gunshot Wounds 
in Military Practice. 
BY 
Nicholas 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 Review 
Washington, D. C., July and A’ S9B.] The Modern Treatment of Gunshot Wounds 
in Military Practice. 
BY 
Nicholas Senn, 
Lieutenant-Colonel U. S. Volunteers; Consulting SttrseaiT \idLliUltC3tfßv4a the Field. 
[Reprinted from Thk Military Surgeon, a .Supplement to The National Mkiuoai. Rkvikw 
Washington, D. C., July and August, 1898.] 
Two important causes are destined to 
bring about a radical change in the treat- 
ment of gunshot wounds as practiced in 
the War of the Rebellion and as will be 
taught and advised in the Spanish- 
American and future wars: i. The 
modifications which the weapon 
and projectile have undergone since 
that time. 2. The introduction into 
general practice of aseptic and antiseptic 
surgery. The diminution in the calibre 
of the bullet, the metallic jacket, the 
substitution of smokeless for black pow- 
der, the greater velocity and power of 
penetration of the missile are conditions 
and influences which must necessarily 
modify the character of the wounds in- 
flicted with the modern weapon. Vol- 
umes have been written on this subject 
by writers in all countries in which the 
old weapon has been abandoned and the 
new one introduced. Numerous experi- 
ments have been made on cadavers and 
animals for the purpose of studying the 
effects of the modern projectile on the 
tissues with a view to obtaining reliable 
information as to the changes which will 
become necessary in the rational treat- 
ment of gunshot wounds in modern war- 
fare. Experimental investigation has 
done much in pointing out some of the 
changes we may expect to see in the 
character of gunshot wounds during the 
present and coming wars, but many of 
the conclusions drawn from them will 
have to be modified after we have had 
an opportunity to study such wounds on 
a large scale on the battlefield. There 
can be no question but that the living 
body and the cadaver represent two en- 
tirely different mediums in studying the 
effects of the modern bullet. From a 
practical standpoint there remains no 
doubt as to the following facts which 
will be confirmed by future experience 
in the treatment of gunshot injuries in- 
flicted with the small calibre bullet: 1. 
Few bullets will be found lodged in the 
body. 2. Wounds will resemble more 
closely incised than contused wounds. 
3. Range will have more influence in 
changing the character of the wound. 
4. Diminished risk of infection. 5. 
Dangerous primary hemorrhage will be more, secondary hemorrhage less fre- 
quent. 6. More difficult extraction of 
the bullet. The relative number of 
dead and wounded and the adaptation of 
the jacketed bullet to become encysted 
are subjects on which we can only 
theorize and conjecture, subjects which 
can„ only be definitely settled by an ex- 
tensive experience. We are better pre- 
pared to predict the influence wrought 
by the recent discoveries and advance- 
ments in surgery on the treatment of 
gunshot wounds and the fate of the 
wounded. The antiseptic treatment of 
wounds as taught and practiced by the 
immortal Eister, and asepsis as devel- 
oped by the German surgeons, with the 
distinguished Volkmann as their leader, 
are destined to minimize the remote dan- 
gers of gunshot wounds and other open 
injuries inflicted on the battlefield. We 
can safely repeat with the late Professor 
von Nussbaum, the most enthusiastic 
follower of Eister: “ The fate of the 
wounded rests in the hands of the one who 
applies the first dressing This is the 
motto every military surgeon must adopt 
and carry into effect. To this motto I 
should like to add a cast iron rule that 
should never be transgressed, and which, 
if observed without exception, will 
guard against one of the most fruitful 
sources of infection, and that rule should 
be ; Never probe a bullet wound on the 
batttefield. The experience of the past 
has taught us the wisdom of adopting 
such a universal rule. As our enemy 
is armed with the Mauser rifle, the cases 
will be few where there is any indication 
for probing wounds, and in those few 
where the bullet has lodged in the body, 
exploration should be absolutely pro- 
hibited until the patient reaches the 
field hospital, where the facilities for 
asepsis are at hand and instruments of 
2 
precision in diagnosis can be employed 
in locating the missile. 
First Aid Dressing.—The idea of 
sending first aid to the wounded in mod- 
ern warfare must be abandoned. Alarm- 
ing hemorrhages from a large vessel of 
any of the extremities will, in many 
instances, be arrested by the patient 
himself or his nearest comrade, by the 
use 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 or 
wounds will prove impracticable and 
useless on the battlefield. Time alone is 
an important element in contraindicating 
such a course. Hundreds and thousands 
may demand attention, to say nothing 
of the limited facilities for procuring for 
the wound and its vicinity an aseptic 
condition. The wisest and safest course 
to pursue under such circumstances is 
to make an intelligent use of the first aid 
dressing package which should be found 
on the person of every soldier, officers 
and men. The average first aid pack- 
age, the one devised by von Esmarch 
included, is too cumbersome. A first 
aid package to meet the indications for 
which it is employed should include : 
i. An efficient antiseptic powder. 2. 
A sufficient quantity of a hygroscopic 
material to absorb the primary wound 
secretion and serve as a filter for the 
wound. 3. A handkerchief or bandage 
with which to retain the dressing and in 
case of necessity to be used in construct- 
ing a Spanish windlass. 4. Safety 
pins. A few years ago I devised such a 
package. It contains about a teaspoon- 
ful of a powder composed of four parts 
of boracic acid and one part of salicylic 
acid, about one drachm of absorbent 
cotton, a piece of sterile gauze 40 inches 
square and a number of safety pins. 
The powder is lodged in the center of 3 
the cotton compress and is to be applied 
directly to the wound when the pack- 
age is used. The package, when com- 
pressed, is small and is wrapped in gutta 
percha. Every soldier of the Illinois 
volunteers carries such a package and is 
conversant with the manner in which it 
should be employed. The piece of 
gauze can be readily transferred into a 
Mayer triangular bandage and serves as 
an excellent substitute for Esmarch’s 
bandage, which is heavier and requires 
much more space. The figures printed 
on Esmarch’s bandage are useful for in- 
struction, but absolutely without value 
on the battlefield. In rendering first 
aid, the injured part should be divested 
of clothing with as little disturbance of 
the wound as possible. Instead of re- 
moving the clothing it is much better to 
make free use of scissors and knife in 
gaining access to the wound. If two 
wounds are found, both must receive the 
same attention and care in protecting 
them against infection. I have used the 
antiseptic powder referred to on a very 
large scale and can speak in positive 
terms of its potent antiseptic properties. 
It resembles in its effects on the tissues 
Thiersch’s solution, being odorless, non- 
irritating and non-toxic. It forms with 
the cotton and primary wound secretion 
a crust which effectually seals the 
wound. In the absence of grave symp- 
toms, such as hemorrhage, this dressing 
should not be disturbed till the patient 
reaches the field hospital, and in many 
cases healing of the wound will take 
place without further interference. The 
immobilization of the injured part, par- 
ticularly in cases of compound fracture 
of the extremities, constitutes an impor- 
tant part of the manifold duties of those 
who render first aid to the wounded. In 
all large engagements the supply of 
mechanical supports carried by the men 
of the hospital corps will be exhausted 
before all the wounded have received 
attention. Splints must be improvised. 
Rifles, sabres, bayonets, bark, branches 
of trees, shrubs, etc. , the chest in frac- 
tures of the upper extremity, the oppo- 
site limb in fractures of the thigh or leg 
will have to be utilized in procuring rest 
for the injured limb, in transporting 
patients from the line of battle to the 
first dressing station. It is here that 
the surgeons will supplement or improve 
the work done by the litter bearers and 
hospital corps. It is for the purpose of 
doing away with the necessity for using 
splints that a German military surgeon 
has recently devised a litter on the plan 
of a double inclined plane for the lower 
extremities, a description of which he 
gave before the Military Section of the 
International Medical Congress held in 
Moscow last summer.* In the absence 
of a litter of such special construction, 
the same object is attained by securing 
the same position for the injured limb 
by a roll made of a blanket, clothing, 
knapsack, drum, straw, etc. It is my 
opinion that the transportation of the 
wounded, suffering from a fracture of 
the lower extremity, can be done with 
less pain and with greater security against 
additional injuries, if the fractured limb 
is placed in a flexed rather than a straight 
position. If this statement is found to 
be correct by future observations, the 
manner of dressing such cases must 
undergo a material change. The man- 
ner of handling, carrying and conveying 
patients suffering from fracture of the 
lower extremity from the field to the 
hospital is a subject of great importance 
to those who have in charge the instruc- 
tion of the hospital corps and company 
bearers. 
Arrest of Hemorrhage on the Field.— 
Rife will be placed in jeopardy and deaths 
*See National. Medical Review, June, 1898 
p. 63.—Ed. 4 
will occur more frequently from in- 
ternal than from external hemor- 
rhage ; in the treatment of the former 
little can be done on the field, and the 
latter class will come more frequently 
under the care of non-professional men 
than surgeons, Ligation of arteries in 
the field will prove impracticable in most 
instances. The company bearers and 
hospital corps men should be instructed 
in the details of the various hemostatic 
resources applicable in emergency work. 
Elevation of the injured part, hyperflex- 
ion, digital compression and antiseptic 
tamponade 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 of 
the extremities. Tne advantages and 
dangers attending this method of arrest- 
ing hemorrhage must be made a promi- 
nent feature in giving instructions on 
first aid. The technique of the proce- 
dure, whether it consists in the use of 
the typical Esmarch elastic constriction, 
a pair of suspenders, or the Spanish 
windlass, must be fully explained and 
demonstrated on the living subject. The 
fact must be impressed that it is of great 
importance to render the limb that is to 
be constricted comparatively bloodless by 
elevation before the constrictor is applied. 
The next most important advice to be 
carried into effect in the use of circular 
constriction is to constrict quickly and with 
sufficient firmness to interrupt at once and 
completely both the arterial and venous cir- 
culation. A question of immense and far 
reaching importance, and one which has 
not yet been definitely answered, is: 
How long is it safe to continue the con- 
striction ? There must be, and there is, a 
limit as to the length of time it is safe to 
exclude blood from living tissues. Al- 
though cases have been reported in which 
elastic constriction was continued from 
three 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 to 
excluding the blood supply from an 
entire limb, the seat of a gunshot injury, 
for a longer period than 3 to 4 hours. 
The danger of gangrene is always greater 
in constricting an injured than a healthy 
limb. A number of years ago I made an 
extended series of experiments on dogs 
to determine if possible, the maximum 
length of time it would be safe to con- 
tinue elastic constriction. The limb was 
invariably constricted near its base. The 
time varied from an hour and a half to 
27 hours. In a number of the cases tem- 
porary incompetence of Ahe muscles and 
temporary paralysis followed when the 
constriction was continued beyond four 
hours, but the degree of functional dis- 
turbance was not always proportionate 
to the length of time. In only one in- 
stance did gangrene occur, and in this 
case constriction was continued for 17 
hours, while the maximum time was 27 
hours. This subject is of special interest 
to the military surgeon, as, from the very 
nature of things, if circular constriction 
is resorted to as a hemostatic agent on 
the battlefield, a considerate length of 
time must necessarily intervene before 
the wounded reach the first dressing sta- 
tion or field hospital, where it is removed 
and hemorrhage arrested by direct and 
permanent hemostatic measures. I 
should consider it dangerous to extend 
the time beyond from 3 to 6 hours and 
should insist that within this limit of 
time the patient be placed in charge of 
a surgeon fully equipped to substitute 
for it the ligature, aseptic tamponade, or 
some other direct hemostatic agent. 
Locating, Finding arid Extracting 
Bullets.—The new weapon will minimize 5 
the surgeon’s work in locating, finding 
and removing bullets. In the vast ma- 
jority of cases requiring surgical treat- 
ment two wounds will be found, the 
wound of entrance and of exit marking 
the location and direction of the tubular 
wound made by the bullet. The cases 
in which the jacketed bullet will be 
found in the body, indicated by the ex- 
istence of only one wound, will be 
•exceptional. During my visit to the 
military hospitals in Greece last summer 
I found a good many wounds made by 
the small calibre projectile, but only in 
two cases could I obtain authentic in- 
formation to the effect that the bullet 
was found in the tissues of the body and 
was removed b}7 operative procedure. 
In the military hospitals in Turkey, I 
found numerous cases in which the old- 
fashioned large calibre lead bullet used 
by the Greeks, had been removed by 
operation or remained lodged in the 
body. The search for bullets in modern 
warfare, if made at all, will be reserved 
until the patient has reached the field 
hospital where the surgeons will have at 
their disposal the necessary instruments 
for making an accurate diagnosis and 
the essential facilities for making oper- 
ations under the strictest aseptic and 
■antiseptic precautions. Before using the 
finger or probe in exploration for a bul- 
let, the wound and the surface for a con- 
siderable distance around it should be 
thoroughly disinfected to guard against 
all possibility of infecting the wound 
during the examination or attempts at 
removal of the bullet should such a 
course be deemed advisable after exam- 
ination. One of the most important 
rules to be followed in locating a bullet 
in the body is to place the patient and 
the part injured as nearly as possible in 
the same position as that occupied the 
moment the injury was received. The 
truth of this statement was well exem- 
plified in the case of General Hancock. 
A number of surgeons of good repute 
had made repeated attempts to find the 
bullet by probing, but failed. At last 
he availed himself of the services of Dr. 
Reade, the present Surgeon-General of 
Pennsylvania, who placed the General 
in the same position he occupied in the 
saddle and the first attempt to locate the 
bullet proved successful. The metal 
clad bullet has to a certain extent ren- 
dered the famous Nelaton probe obso- 
lete. However, leaden bullets will be 
used to a greater or less extent by cer- 
tain branches of the military force, and 
the porcelain tip will occasionally prove 
of service. The great objection to 
Nelaton’s bullet probe is the size of the 
porcelain tip. The end of the probe should 
correspond approximately iri size to the 
calibre of the tubular wound. By using 
an instrument constructed on this prin- 
ciple the danger of making false passages 
is greatly reduced. I have had a bullet 
probe constructed by Truax, Green & 
Co., with two porcelain tips, one at each 
end, riveted to the end of the silver 
probe, one 22 and the other 38 calibre. 
In parts of the body composed of deep 
muscular planes and layers of fascia it is 
often found absolutely impossible to fol- 
low the track of the bullet with any 
kind of probe. It is in such cases, when 
it is deemed prudent, from the symptoms 
presented and the probable location of 
the bullet, to explore the tract, that the 
surgeon will take advantage of the use 
of the knife in dilating the track, using 
the probe step by step as a guide. 
The use of the X-ray will prove of the 
greatest value in all future attempts to 
locate bullets. In order to locate a bullet 
with sufficeint accuracy to enable the 
surgeon to determine the propriety of an 
operation for its removal and to guide 
him safely in his work, photographs from 
at least two directions will have to be 6 
taken. Every field and general hospital 
should be supplied with an X-ray appa- 
ratus, and in all difficult cases this one 
of the most recent diagnostic inventions 
should 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 of 
the metal-clad bullet. The bullet for- 
ceps which I devised a few years ago, is 
so constructed that it serves at the same 
time as a useful bullet probe. The grip 
of the instrument on any metallic bullet, 
regardless of its calibre, is firm, the bul- 
let once grasped can be extracted without 
difficulty, as slipping of the instrument is 
almost an impossibility. It seems to me 
that when a small calibre bullet is lodged 
in an important anatomical locality diffi- 
cult of approach and not giving rise to 
any serious symptoms, it should be al- 
lowed to remain, with the hope it may 
become encysted wdthout causing any 
remote serious consequences. Such a 
conservative course in well selected cases 
will unquestionably give better results 
than the too routine practice to extract 
the bullet at all hazards. 
and mechanical treatment are amenable- 
to repair in the course of time. They 
are the cases that tax the ingenuity of 
the 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 of 
the femur, extension and immobilization: 
will now, as it has for a long time, con- 
stitute the generally accepted treatment. 
A determined, strong protest must be 
made against unnecessary removal of de- 
tached fragments of bone. If the wound 
remains aseptic, the loose fragments of 
bone will not only retain their vitality,, 
but will take an important part in the 
restoration of the continuity of the bone 
and add materially to the functional re- 
sult. Debridement more or less exten- 
sive only becomes necessary and should 
be performed solely in case the wound 
becomes infected. In such an event the 
loose, infected fragments of bone should 
be promptly removed, free tubular drain- 
age established and the wound through- 
out subjected to thorough disinfection. 
If the ordinary measures fail, continued 
irrigation with a saturated solution of 
the acetate of aluminum will very 
often bring about the desired results 
and obviate the necessity of an am- 
putation. Fixation and suspension in 
such cases will not only procure com- 
fort for the patient, but will answer an 
excellent purpose in securing and main- 
taining coaptation, and in facilitating 
drainage and irrigation. As soon as the 
fracture has united with sufficient firm- 
ness to render extension superfluous, 
the limb should be immobilized in a cir- 
cular plaster of Paris splint, extending 
from base of toes to the groin, and, in 
high fractures, including the pelvis, after 
which the patient can be permitted to 
walk about with the aid of crutches. In: 
gunshot fractures of the leg, early im- 
Gunshot Wounds of the Extremities.— 
Besides the ordinary treatment of gun- 
shot wounds regardless of the anatomical 
location of the injury, bullet wounds of 
the extremities, when complicated by 
fracture or joint injury, present to the 
surgeon special clinical features of great 
importance. Injuries of the soft tissues 
not implicating important vessels and 
nerves, under modern treatment should 
heal 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 legitimate 
indication for a primary amputation. 
Such injuries under a satisfactory aseptic 7 
mobilization in a circular plaster of Paris 
splint is to be advised and yields the most 
gratifying results. Watchful control of 
the patient suffering from such injuries 
and treated by the use of the plaster of 
Paris bandage, is essential in guarding 
against disastrous complications and in 
obtaining satisfactory functional re- 
sults. Gunshot injuries of the large 
joints are now within the range of suc- 
cessful conservative treatment. I have 
seen in the military hospitals both in 
Greece and Turkey, soon after the close 
of the war, gunshot wounds of the hip, 
knee, ankle, shoulder, elbow, and wrist 
joints not only recover without any oper- 
ative interference whatever, but in many 
of the cases, a fair degree of motion and 
good use of tue limb rewarded the con- 
servative treatment. The indications for 
primal amputation of a limb or part of 
a limb should at present be restricted to 
cases in which the nutrition is suspended 
or seriously threatened by the coexist- 
ence of vascular lesions incompatible 
with the vitality of the tissues at and be- 
low the seat of injury. In cases of doubt 
the soldier is entitled to the benefit of 
the same, and the conservative treatment 
should be carried to its ultimate limits, 
until the appearance of complications 
demonstrates its futility and dictates the 
propriety of resorting to a mutilating 
operation. It is always more creditable 
to the surgeon to save the limb than to 
remove it, and the soldier is entitled to 
the benefits of conservative surgery as 
much as the civilian, and the glory of 
the military surgery of the future should 
and will be to limit more and more the 
indications for amputation. 
invariably require operative interference, 
provided it holds out any encourage- 
ment whatever of saving life. In case a 
bullet has passed through the skull and 
its contents, the entire scalp should be 
thoroughly shaved and disinfected. The 
wound of entrance must be enlarged so 
as to expose the perforation freely, which 
is then enlarged with chisel, DeVilbiss 
or rongeur forceps sufficiently to enable 
the surgeon to remove the loose spicula 
of bone which are frequently found some 
distance in the brain. With a long 
eyed probe a strip of iodoform gauze, 
large enough to loosely pack the tubular 
visceral wound, should be inserted from 
the wound of entrance to the wound of 
exit, and the through gauze drain made 
to project a few inches beyond the sur- 
face of each wound. Through capillary 
drainage of this kind will prevent accu- 
mulation of primary wound secretion in 
the interior of the skull, and will be of 
value in arresting capillary hemorrhage. 
A large hygroscopic dressing enveloping 
the entire scalp and covering both 
wounds constitutes the dressing and 
must be held in place by a few turns of 
plaster of Paris bandage. The drain must 
be allowed to remain till the danger of 
infection is passed, when it is to be re- 
moved gradually by shortening it every 
day or two. In case the bullet should 
be found lodged in the interior of the 
skull, the wound of entrance must be 
treated in the same manner and the 
bullet located by the careful use of 
Fluhrer’s aluminum probe. A counter 
opening may become necessary in re- 
moving the bullet, if it has reached the 
opposite side of the skull, or when it has 
become deflected or arrested in its course 
near the surface of the brain, in case the 
locality in which it has become lodged 
warrants operative interference. In al 
visceral injuries of the contents of the 
skull resulting from gunshot wounds. 
Gunshot Wounds of the Skull.—It is my 
intention to limit my remarks under this 
heading to penetrating gunshot wounds 
of the skull. The few cases of this class 
of injuries that will come under the 
observation of the military surgeon will 8 
capillary or tubular drainage or a com- 
bination of the two is indicated and should 
be continued till there is no further dan- 
ger of infection, hemorrhage or accumu- 
lation of wound products, when the 
drain is to be gradually removed. The 
value of the X-ray in locating; bullets in 
the interior of the cranium has as yet 
not been definitely ascertained. 
ceral wounds of the chest. Hemorrhage 
from wounds of the lung is often arrested 
spontaneously by the accumulation of 
blood in the cavity of the chest, causing 
temporary pulmonary collapse and tam- 
ponade of the tubular visceral wound by 
the formation of a blood-clot. Free in- 
cision of the chest wall has been strongly 
advocated by several French surgeons in 
cases of pentrating wound of the chest 
with a view of arresting hemorrhage by 
ligature, tamponade or the use. of the 
cautery, but the profession on the whole, 
for good reasons is opposed to such 
heroic treatment. Unless the source of 
hemorrhage is one of the intercostal or 
the internal mammary artery it is ad- 
visable to rely on nature’s resources 
in arresting the bleeding. ' 
Gunshot Wounds of the Chest.—Penetra- 
ting gunshot wounds of the chest are 
attended by an enormous mortality ow- 
ing to the physiological importance of 
the organs which it contains. Visceral 
wounds of the heart and large blood 
vessels usually result in death in a few 
moments from acute anaemia. Hemor- 
rhage into the pleural cavity and into 
the large bronchial tubes interferes me- 
chanically with the respiratory functions 
and frequently proves fatal in a short 
time and if the patient recovers from its 
immediate effects, life is placed in dan- 
ger by the complic Uions, which too 
often occur, caused by the hemothorax. 
The accumulation of even a large quan- 
tity of blood in the pleural cavity is not 
incompatable with a speedy recovery, as 
when the blood is aseptic its removal by 
absorption is accomplished in a short 
time. Experience during the War of 
the Rebellion showed that in gunshot 
wounds of the chest the chances of life 
were much better if the bullet passed 
through the chest than if it remained 
lodged in the body. I saw a number of 
soldiers in the Graeco-Turkish war, that 
had been shot through the chest, conval- 
escent and in fair health a few weeks 
after the injury was inflicted. We have 
made little progress in the treatment of 
penetrating wounds of the chest. Direct 
operative treatment of visceral wounds 
of heart and lungs is always attended by 
imminent risk to life from pulmonary 
collapse. This source of danger stands 
in the way of direct treatment of vis- 
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. Rest 
in the recumbent position, with the chest 
slightly elevated, is essential in aiding 
spontaneous arrest of hemorrhage and in 
the prevention of complications. A rise 
in the temperature in the first forty-eight 
hours is no indication of sepsis, as, with 
few exceptions, it indicates a febrile dis- 
turbance caused by the absorption of 
fibrin ferment, the so-called fermentation 
fever. Should later symptoms set in 
suggestive of septic infection, aspiration 
should be promptly resorted to, and if 
not followed by speedy improvement, 
time should be lost in subjecting the pa- 
tient to the same medical treatment as. 
advised and practised for empyema, that 
is,rib-resection, free incisionand drainage. 
The production of an artificial pneumo- 
thorax or hydrothorax by the introduc- 
tion into the pleural cavity on the injured 
side of a nontoxic gas or filtered atmos- 
pheric air or sterilized water or non toxic 
antiseptic solutions has not proved satis- 
factory in the treatment of intra-thor 9 
racic traumatic hemorrhage. From what 
has been said it is clear that the best 
treatment in penetrating gunshot wounds 
of the chest consists in hermetically seal- 
ing the wound of entrance and exit, if 
such exists, under strict aseptic precau- 
tions, and in watching for and treating 
subsequent complications as they present 
themselves. 
mural wounds, the wounds of entrance 
and 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 be probed either for diag- 
nostic or therapeutic purposes If any 
doubt exists as to whether or not the bul- 
let has entered the abdominal cavity, it 
is far better and safer to dilate the track 
by the use of the knife, relying on the 
probe as a guide, than to work in the 
dark with the probe and by doing so in- 
creasing the possibilities of infecting the 
peritoneal 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 shown 
that penetration has occurred. It must, 
however, be admitted that, in the absence 
of serious visceral lesions, penetrating 
wounds of the abdomen are injuries 
from which the patients are very likely to 
recover without operative treatment, and 
that when such patients are subjected to 
laparotomy, death may occur solely in 
consequence of the operation. It is un- 
doubtedly true that in most cases of 
spontaneous recovery after penetrating 
gunshot wounds of the abdomen, the 
favorable termination has been due to 
absence of serious visceral lesions, which 
some hold to be universally present in 
such cases. A number of years ago I 
made a series of experiments on the ca- 
daver for the purpose of demonstrating 
that occasionally a bullet can traverse 
the abdominal cavity iu certain directions 
without producing visceral wounds that 
would warrant laparotomy. 
Gunshot Wounds of the Abdomen.—The 
greater part of this paper will be devoted 
to this subject as recent discoveries and 
improvements in surgery have done more 
for the succesful treatment of visceral 
wounds of the abdominal organs than for 
the injuries of of the organs con- 
tained in the remaining large cavities of 
the body. The triumphs that have sig- 
nalized the practice of civilian surgeons 
in the operative treatment of intra-ab- 
dominal injuries must be repeated on the 
battlefield. I look hopefully for many 
successful results in the operative treat- 
ment of gunshot wounds in military 
practice. I will in this connection limit 
my remarks to penetrating wounds, tak- 
ing it for granted that when patients 
suffering from abdominal wounds are 
brought 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. In 
the discussion of penetrating wounds of 
the abdomen I shall quote freely from the 
forthcoming third edition of the Ameri- 
can Text Book of Surgery, from the 
chapter which treats of this subject. 
Sword, bayonet and other stab wounds 
will diminish in frequency with develop- 
ment of the modern scientific warfare. 
The penetrating wounds of the abdomen 
that will come under the observation of 
the military surgeon will, with few ex- 
ceptions, be wounds inflicted with the 
modern small calibre projectile. The 
The cadaver, a marasmic male adult, 
was placed in the erect position against a 
wall and the shooting was done with a 38 
calibre rifle at a distance of 30 feet. The 
bullet was fired in every instance in an 
antero-posterior direction and invariably 
passed through the body, sixteen shots were fired and examination of the abdom- 
inal cavity carefully made by following 
the track of each bullet showed that four 
of the bullets traversed the abdominal 
cavity without injuring the stomach or 
intestines or any of the large abdominal 
vessels. In each of these four experi- 
ments, the bullet entered the abdomen at 
or a little above the umbilical level. In 
all experiments in which the bullet en- 
tered below the umbilical level, intestinal 
perforations were found. Absence of 
visceral lesions has also been demonstra- 
ted during an operation or at the post- 
mortem. During the Graeco-Turkish 
war several cases of gunshot wounds of 
the abdomen recovered under a conserva- 
tive plan of treatment. In nearly all 
these 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 being 
in a .standing position. In two out of 
sixteen cases of penetrating gunshot 
wounds 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 the 
use of the hydrogen gas test, and most 
of these patients recovered without re- 
sort to laparotomy. Clinical experience 
and the result of experiment show con- 
clusively that laparotomy should not be 
performed simply because a bullet has en- 
tered the abdominal cavity, but that its 
performance should be limited to the 
treatment of intra-abdominal lesions 
which without operative interference 
would tend to destroy life. A bullet 
which passes through the lower part of 
the abdomen from side to side or oblique- 
ly is almost sure to produce from four to 
fourteen 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 umbilical 
level. 
Symptoms.—The general symptoms in 
cases of penetrating gunshot wounds of 
the abdomen, with the exception of those 
due to profuse hemorrhage, furnish very 
little 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 may 
be wanting or at least slight, in cases of 
multiple perforation of the intestines. 
It is not an uncommon occurrence for a 
patient, who has received a penetrating 
wound of the abdomen, to walk several 
blocks, or even a number of miles, with- 
out a great deal of suffering and without 
showing any symptoms of shock, and 
yet for a number of intestinal perfora- 
tions to be revealed at a subsequent oper- 
ation or autopsy. Vomiting occurs with 
equal frequency in parietal wounds and in 
simple penetrating wounds as when the 
viscera have been injured. Vomiting of 
blood points to the existence of a wound 
of the stomach. Pallor is present in all 
penetrating wounds of the abdomen soon 
after the receipt of the injury, and it is 
only more pronounced when produced at 
least in part, by sudden and severe hem- 
orrhage. Pain is a very unreliable and 
often misleading symptom, as it may be 
moderate or almost completely absent 
soon after the injury has been inflicted 
even 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 observed 
even if the stomach and intestines have 
been wounded. Hemorrhage caused by 
wounds of any of the large organs, as the 
spleen, liver, or kidneys, gives rise to 
acute progressive anaemia, small rapid 
pulse, cold clammy perspiration, dilated 
pupils, yawning, vomiting, and, in ex- 
treme cases syncope and convulsions. 
The local symptoms are of no more value •in determining the existence of visceral 
injuries in penetrating wounds of the 
•abdomen than are the general symptoms 
which have just been enumerated. Ex- 
ternal hemorrhage is slight or entirely 
wanting unless an artery or a vein in the 
abdominal wall has been injured. The 
bleeding from visceral wounds gives rise 
to 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 of 
fluid in the free abdominal cavity, and 
by general symptoms, indicating progres- 
siveanaemia: increasing pallor of the face 
and of the visible mucous membranes, 
small, feeble pulse, superficial sighing 
respiration and dilated pupils. Wounds 
of the stomach often cause hemorrhage 
into this organ and hematemesis. Blood 
in the stools seldom follows hemorrhage 
into the bowels sufficiently early, from 
intestinal wounds, to be of any diagnos- 
tic value. 
however, the case. Adhesions 
between the surface of the liver and 
chest wall may have existed before the 
injury was received, or the amount of gas 
present may be insufficient to give rise to 
this sign. The escape of the contents of 
the wounded stomach or intestines through 
the external wound is a rare occurrence 
and is possible only when the external 
wound is large and straight and when 
it corresponds with the location of the 
visceral wound, or in the event of pre- 
existing adhesions between the abdomi- 
nal wall and the injured portion of the 
gastro-intestinal Canal. External extra- 
vasation occurs more frequently in wounds 
of 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 canal 
and the character of the extravasation will 
furnish reliable information as to the an- 
atomical location of the visceral injury. 
With the exception of the last mentioned 
symptom, and the indications pointing to 
the necessity of arresting internal hem- 
orrhage, there is nothing about the local 
or general symptoms of penetrating gun- 
shot wounds of the abdomen that would 
enable the surgeon to decide with any 
degree of certainty, soon after the injury 
was received, whether or not visceral in- 
juries existed, and, consequently, wheth- 
er laparotomy should or should not be 
performed. 
Circumscribed emphysema in the tissues 
around the track has been regarded as an 
important sign of the existence of intes- 
tinal perforation. This symptom is mis- 
leading and absolutely devoid of diagnos- 
tic value, as this condition has frequently 
been observed in non-penetrating wounds 
of the abdominal wall resulting from the 
entrance of air into the loose connective 
tissue, or later, as gas formation, as one 
of the results of putrefactive infection. 
The accumulation of any considerable 
quantity of gas in the peritoneal cavity 
sometimes can be recognized by the dis- 
appearance of the normal liver dullness, 
caused by the presence of gas between 
the surface of the liver and the chest 
wall. This condition has been sought 
for in cases of perforating wounds of the 
abdomen as a diagnostic sign, and if 
found has been taken as a sure indication 
•of the existence of visceral wounds of the 
gastro-intestinal canal. This is not, 
Diagnosis.—If a gunshot wound has pen- 
etrated the abdominal cavity and the gen- 
eral symptoms and local signs lead us to 
suspect the existence of dangerous intes- 
tinal hemorrhage, no time should be lost in 
further efforts to make an accurate ana- 
tomical diagnosis, as sufficient evidence 
has been obtained to warrant a laparo- 
tomy for the purpose of preventing 
death from hemorrhage by the direct 
surgical 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 demanding 
surgical treatment should be ascertained 
before the patient is subjected to the 
additional risks incident to a laparotomy. 
Since a simple penetrating wound of the 
abdomen is an injury from which the 
majority of patients recover without 
operative treatment, and since visceral 
wounds of the gastro-intestinal tract are 
attended by such frightful mortality 
without surgical interference, the prac- 
tical value and importance of a correct 
diagnosis before deciding upon a definite 
plan of treatment become obvious. It is 
apparent, that if some reliable diagnostic 
test could be applied in cases of pene- 
trating wounds of the abdomen which 
would indicate to the surgeon the pres- 
ence or absence of visceral lesions of the 
gastro-intestinal canal, the indications 
for aggressive or conservative treatment 
would become clear. The writer has 
shown by his experiments on animals, 
and later by his clinical experience in 
the treatment of a number of gunshot 
wounds of the abdomen, that rectal 
insufflation of hydrogen gas can be re- 
lied on in demonstrating the existence of 
perforations of the gastro-intestinal ca- 
nal before opening the abdomen. He 
has shown conclusively that, if the ab- 
dominal muscles are completely relaxed 
under the influence of a general anes- 
thetic, hydrogen gas or filtered air can 
under safe pressure be forced from the 
anus to the mouth if no perforations 
exist, and if such are present, the gas 
will escape into the peritoneal cavity 
where its presence can be readily de- 
tected by the physical signs character- 
istic of a free tympanites or by its escape 
through the external opening. Theo- 
retical objections have been made against 
this diagnostic test on the ground that 
it occasionally fails in demonstrating the 
existence of a perforation and that it is 
instrumental in causing fecal extrava- 
sations. In reply to this I must say 
that it has never failed in my hands in 
making by its aid a correct diagnosis 
and the fallacy of the second objection I 
have shown repeatedly by its effect on 
animals. Hydrogen gas is a non-toxic 
substance, endowed with valuable inhib- 
itory antiseptic properties, and is ab- 
sorbed from all the large serous cavities 
and the connective tissues within a few 
hours. Pure zinc and sulphuric acid 
should be used in generating the gas 
which is collected in a rubber balloon 
holding at least four gallons. The rub- 
ber balloon used for this purpose is 
square in shape and is connected with 
the rectal tip by means of a rubber tube 
six feet in length and supplied with a. 
stop-cock near its proximal end. In 
applying the test, an assistant presses- 
the margin of the anus against the rectal 
tip while another assistant forces the gas 
along the intestinal tube by pressing or 
sitting on the rubber balloon. The- 
passage of the gas through the ileo- 
csecal valve takes place under a pressure 
of two and a half pounds to the square 
inch and is announced by a distinct gurg- 
ling sound which can always be dis- 
tinctly heard by applying the ear or 
stethoscope over that region. If the 
rectum or colon have been perforated 
the gas will not reach the small intes- 
tines as it will escape into the peritoneal 
cavity under less pressure than is 
quired in rendering the ileo-csecal valve 
incompetent. As soon as the gas reaches 
a perforation large enough to permit its 
escape, it will enter the peritoneal cavity 
and escape through the external wound, 
if this has been freely laid open down to 
the peritoneum. If the external wound 
is in a location which points to an injury 
of 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 is 
impossible to inflate the intestines to any 
extent from the stomach. 
Preparation of Patient.—A patient suf- 
fering from a gunshot wound of the 
abdomen should be properly prepared 
before he is subjected to laparotomy. If 
the stomach is filled with food a salt 
water emetic should be given for the 
purpose of emptying its contents, or, 
better still, this can be done by the use 
of the stomach siphon tube. The rec- 
tum and colon must be emptied by a. 
copious enema of warm water to which 
a tablespoonful of salt has been added. 
The unloading of the gastro-intestinal 
canal will not only facilitate the oper- 
tion but will have a favorable influence 
in securing rest for the injured part. A. 
hypodermic injection of gr. of mor- 
phia and gr. 1-30 of strychnia should be 
given shortly before the anesthetic is- 
administered, as these remedies in the 
doses specified assist the action of the 
anesthetic, secure rest for the intes- 
tine and sustain the action of the 
heart. If the patient is much prostrated,, 
two ounces of whiskey diluted with four 
ounces of warm water should be given 
by the rectum The whole abdomen: 
should be thoroughly disinfected. Be- 
fore and during the operation the use of 
external dry heat will do much in pre- 
venting shock and in aiding the peri- 
pheral circulation. Compresses, towels 
and several gallons of warm normal, 
solution of salt must be provided. The 
operator shonld do the work with as 
little assistance and as few instruments- 
as possible as the danger of infection in 
emergency work is apt to be propor- 
tionate with the number of assistants 
employed and number of instruments 
used. Hands, instruments, suturing 
material, in fact everything that is to be 
brought in contact with the wound must 
be sterilized. In military surgery silk 
will have the preference over catgut A 
hospital tent with a floor will be an 
admirable operating room in all semi- 
Treatment.—The propriety of surgical 
interference in cases of penetrating gun- 
shot wounds of the abdomen will depend 
on 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 presents 
other indications of approaching death, 
operation is unjustifiable, as it would 
only hasten the end, bring reproach upon 
surgery, and undermine the confidence 
in the life saving value of operations 
among the troops. 
Dangerous internal hemorrhage that 
will come to the notice of military sur- 
geons in gunshot wounds of the abdo- 
men, will be the cases in which the 
vascular organs of the abdomen, the 
liver or spleen, or some of the larger 
vessels of the mesentery or omentum 
have been injured. Delay in such cases 
is dangerous. The abdomen should be 
opened promptly and the hemorrhage 
arrested. The symptoms are apt to be 
unusnalty severe if the hemorrhage is 
sudden, progressive if the loss of blood 
is gradual. In the latter instance it 
may be prudent to watch the case for 
some time for more pressing indications, 
as it is well known that spontaneous 
arrest of hemorrhage may occur and 
even large quantities of aseptic blood are 
removed from the peritoneal cavity in a 
short time. Visceral lesions of the gas- 
trointestinal canal, large enough to per- 
mit of extravasation, are with very few 
exceptions mortal wounds the existence 
of which can leave no doubt in the mind 
of the surgeon to resort promptly to 
abdominal section as offering the only 
chance to save life. tropical climates. Anesthesia should be 
'Commenced with chloroform until the 
patient is under its full influence when it 
should be continued with ether. 
the results obtained by the insufflation 
test. 
Arrest of Hemorrhage.—In opening the 
abdomen in the treatment of internal 
hemorrhage, the surgeon undertakes a 
task the gravity of which it is impossible 
to foretell. To do the work quickly and 
well he must be perfectly familiar with 
the anatomy of the abdominal organs, 
their source of blood supply and must 
have full knowledge of all hemostatic re- 
sources, the indications for their selection 
and details of application. Profuse in- 
tra abdominal hemorrhage resulting from 
penetrating gunshot wounds of the ab- 
domen, is more frequently of parenchy- 
matous and venous than arterial origin. 
Wounds of the liver, spleen, kidneys and 
mesentery give rise to profuse and 
often fatal hemorrhage. After opening 
the peritoneal cavity it is often very dif- 
ficult to find the bleeding points as the 
blood accumulates as rapidly as it is 
sponged out and it becomes necessary to 
resort to special means in order to arrest 
profuse bleeding sufficiently to find the 
source of hemorrhage. One of two 
means should be employed: 
Incision.—In the majority of cases the 
median incision should be made as it af- 
fords advantages which give it the pref- 
erence. It should always be selected in 
cases 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 the 
treatment of wounds of the small intes- 
tine. If the insufflation test is used, it 
will prove sometimes of value in deciding 
upon the location of the incision. If, in 
gunshot wounds of the upper portion of 
the abdomen, direct inflation of the stom- 
ach through an elastic tube reveals the 
existence 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 made 
over the wounded portion of the colon 
which is usually indicated by the course 
of the bullet. A wound in the trans- 
verse colon can be found and dealt with 
most effectually through a high median 
incision; perforation of the caecum or of 
the ascending colon calls for a lateral in- 
cision directly over the wounded orgam 
while a lateral incision on the left side is 
indicated, if from the direction of the 
bullet, it is evident or probable that the 
colon below the splenic flexure is the seat 
of the visceral injury. Taparotomy for 
the arrest of hemorrhage should always 
be done by making a long median incis- 
ion, which will afford the most direct 
access to the different sources of hemorr- 
hage. Very often it will be advisable to 
make the incision in the line of the 
wound of entrance, more especially in 
■cases where a lateral incision is indicated 
from the location of the wound, from the 
course of the butlet, and perhaps from 
i. Intra-abdominal digital compres- 
sion of the aorta. 
2. Packing the abdominal cavity wflth 
a number of large sponges or gauze com- 
presses. Intra-abdominal compression of 
the aorta below the diaphragm can be 
readily made by an assistant introducing 
his hand through the abdominal incision 
which in such a case must be larger than 
under ordinary circumstances. Compres- 
sion made in this manner will promptly 
arrest the hemorrhage from any of the 
abdominal organs for a sufficient length 
of time to enable the surgeon to find the 
source of hemorrhage and carry out the 
necessary treatment for its permanent ar- 
rest. Hemorrhage from a perforated 
kidney may demand a nephrectomy if it 
does not yield to tamponade. If the tampon is used, an incision in the lumbar 
region must be made for the removal of the 
tampon, and the parietal peritoneum should 
be sutured so as to exclude the peritoneal 
cavity from the renal wound. Wounds 
of the liver are sutured with catgut, 
cauterized with the actual cautery, or 
tamponed with a long strip of iodoform 
gauze or a typical Mikulicz tampon, in 
either case the gauze is to be brought out 
of the wound and utilized as a drain. 
A wound of the spleen, if the hemorr- 
hage does not yield to ligature, suturing 
or tamponade, necessitates splenectomy. 
Very troublesome hemorrhage is often 
met with in wounds of the mesentery. 
When multiple wounds of the mesentery 
and visceral wounds of the stomach or 
intestines are the cause of the hemorr- 
hage, it is a good plan to pack the ab- 
dominal cavity with a number of large 
sponges, napkins, or compresses of gauze 
to each of which a long strip of gauze is 
securely tied, these strips being allowed 
to hang out of the wound in order that 
none of the sponges or compresses may 
be lost or forgotten in the abdominal 
cavity after the completion of the opera- 
tion. The sponges or compresses make 
sufficient pressure to arrest parenchyma- 
tous oozing, as well as venous hemorr- 
hage if they are placed at different points 
against the mesentery, and between the 
intestinal coils. The sponges are re- 
moved one by one from below upward, and 
the bleeding points secured as fast as 
they are uncovered. The ligation of mes- 
enteric and omental vessels, both arteries 
and. veins, should be done by applying 
the ligature en masse. A round needle 
or Thornton’s curved hemostatic forceps 
are the most useful instruments for this 
purpose. Catgut as a rule should not be 
relied upon in tying a mesenteric vessel, 
as it is greatly inferior to fine silk. If 
hemorrhage 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 or 
intestines is best controlled by hemming 
the margin of the wound with catgut or 
fine silk. In hemorrhage in localities 
not accessible to ligature and not amena- 
ble to tamponade, pressure forceps are 
applied and allowed to remain twen- 
ty-four to forty-eight hours. When used 
in this manner the instrument must be 
long enough to be brought out of the 
wound and is then incorporated in the 
dressing. For the purpose of finding and 
facilitating the removal of the instrument 
a strip of gauze is tied to' the handle. 
Search for Perforations.—-A number 
of cases have been recorded, and I am 
sure many more have occurred, in 
which laparotomy was performed, one or 
more perforations sutured, and the post- 
mortem showed that a perforation was 
overlooked, death resulting from ex- 
travasation and diffuse septic peri- 
tonitis. Such experiences are by no 
means limited to the practice of novi- 
tiates but have occurred in that of men 
of large experience and in well equipped 
first class hospitals. The handling of 
the entire length of the gastro-intestinal 
canal in the search for perforations re- 
quires time, adds to the shock of the 
injury and operation, and, even if done 
by experts and with the utmost care, a 
perforation may escape the attention of 
the operator and become the sole cause 
of death. If the surgeon adopts this 
plan of detecting perforations the work 
should be done systematically. The 
ileo-csecal juncture is the best land 
mark for beginning the search. From 
here the small intestine is traced in an 
upward direction examining loop after 
loop and returning the intestine as soon 
as examined so as to avoid extensive 
eventration which always adds greatly 
to the danger of the operation. The large intestine is traced from the ileo- 
caecal region downward. In one of my 
cases perforation of the rectum was 
found low down in the pelvis, which cer- 
tainly would have been over looked if I 
had not used the inflation test wfliich 
promptly revealed not only its existence 
but also its exact location. If the air or 
gas test has been employed with a posi- 
tive result before the abdomen is 
opened, there will be no difficulty exper- 
ienced in finding the first opening. If 
the stomach was inflated directly 
through an elastic tube, and the test has 
shown the presence of a perforation, a 
median incision is made from the tip of 
the ensiform cartilage to the umbilicus 
and the stomach is drawn forward into 
the wound. 
now made through the second opening 
and if a third wound is found the second 
is sutured, and so on until the entire 
intestinal canal has been thoroughly 
subjected to the test. By following this 
plan extensive eventration is rendered 
superfluous, and the overlooking of a 
perforation is made impossible, likewise 
the objection to the test that reduction 
of the intestinesowing to distension with 
gas or air is overcome if the intervening 
sections between the perforations are 
emptied of their contents before suturing 
the wound. 
Suturing of Perforations.—The mate- 
rials for suturing are an ordinary sewing 
needle and fine aseptic silk. Catgut 
should be dispensed with in all intes- 
tinal work. Trimming the margins of 
visceral wounds is not only superfluous 
but absolutely harmful, as it requires a 
useless 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 in 
the treatment of a visceral wound of the 
stomach and intestine is to turn the mar- 
gins of the wound inward and to bring 
into opposition healthy serous surfaces 
by the continuous or interrupted sero- 
muscular sutures, which should always 
be made to include fibres of Halsted’s 
submucosa. From four to six stitches 
to an inch will suffice. If possible 
wounds of the stomach should be su- 
tured in the direction of the blood vessels 
and transverse suturing of the intestine 
is necessary for the purpose of prevent- 
ing constriction of the lumen. Defects 
an inch and a half in length can be 
closed on the convex side in this manner 
without fear of causing intestinal ob- 
struction, while much smaller defects on 
the mesenteric side usually necessitate a 
resection, not only because the vascular 
supply in the corresponding portion of 
the intestine would be inadequate, but 
If no perforation is found in the an- 
terior wall the insufflation is repeated, 
and the escaping air or gas will direct 
the surgeon to the perforation. Through 
this perforation the stomach should 
again be inflated in search for a second 
and possibly a third perforation. In 
searching for intestinal wounds by the 
aid of inflation, further inflations should 
be suspended as soon as the lowest per- 
foration has been found. If possible the 
perforated portion of the intestine should 
now be brought forward into the wound, 
and, after emptying the intestine below 
the perforation as far as possible of its 
contents including gas or air, the bowel 
is compressed below the perforation by 
an assistant and the intestine higher up 
is inflated through the wound. As a 
matter of course a perfectly aseptic glass 
tube 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 is 
sutured and after disinfection and 
emptying the intervening portion of its 
gas the intestine is replaced in the ab- 
dominal cavity. Further inflation is •also because a sufficiently sharp flexion 
might be produced at the seat of sutur- 
ing to become the immediate mechanical 
■cause of intestinal obstruction. 
dried by large sponges wrung out of a 
weak sublimate solution (i: 10,000) or 
Thiersch’s solution. Some surgeons 
have practically abandoned flushing of 
the abdominal cavity and rely almost ex- 
clusively on sponging in removing pus 
and extravasated fecal material. Others 
are partial to leaving the physiological 
solution of salt in the cavity, paying no 
attention to the peritoneal toilet prac- 
ticed with conscientious care by all sur- 
geons only a few years ago. 
Enterectomy.—Enterectomy is often in- 
dicated in cases of double perforation and 
in marginial wounds in the mesenteric 
border. If in cases of multiple perfora- 
tion it should become necessary to make 
a double enterectomy, and the interven- 
ing portion of the small intestine is not 
more than two or three feet in length, it 
is best to resect the same, as the imme- 
diate effect of the single operation will 
not 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 gauze 
are preferable to clamps in preventing 
extravasation during the operation. The 
gauze strip is passed through a small 
button-hole made with hemostatic for- 
ceps in the mesentery near the intestine 
and tied with sufficient firmness to pre- 
vent escape of intestinal contents. 
Drainage.—To drain or not to drain is 
the all absorbing topic among surgeons 
whose time and attention are largel}r en- 
gaged in abdominal work. I wish to place 
myself on record as being a strong advo- 
cate of drainage in all cases of abdomi- 
nal surgery in which we have reason to 
believe 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 the 
abdomen complicated by visceral injury 
the probability that infection has occurred 
must not be lost sight of, and the only 
safe course to pursue under such circum- 
stances is to drain where you are in 
doubt. Cases which require irrigation 
should always be drained. Other indi- 
cations for drainage are visceral wounds 
of the liver and pancreas and the exis- 
tence of parenchymatous hemorrhage 
which cannot be controlled by any of the 
different hemostatic measures. A glass 
drain 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 depended 
upon in arresting troublesome surface 
oozing. Drainage must be suspended at 
once, or gradually with the cessation of 
the primary wound secretion. 
Irrigation of the Abdominal Cavity.— 
This is necessary only if fecal extravasa- 
tion or escape of stomach contents has 
taken place, an accident which if it has not 
occurred before the abdomen was open- 
ed, should be carefully avoided during 
the manipulations of the wounded in- 
testines. Flushing the peritoneal cavity 
with warm sterilized water or normal salt 
solution not only clears it of infectious 
material, but acts at the same time as a 
stimulahit to the flagging circulation. The 
current must be sufficiently strong not 
only to fill the peritoneal cavity quickly 
but to flush it out. After the completion 
■of the irrigation the patient is placed on 
his side, and in this position the fluid 
-contents of the abdominal cavity are 
poured out. The cavity is then rapidly 
Suturing of External Incision.—In- 
cisions in the median line are rapidly 
closed with one row of silk or silkworm- gut sutures, which are placed close to- 
gether and include all the tissues of the 
margins of the wound. Incisions made 
in any other place are to be closed by 
buried catgut sutures uniting the peri- 
toneum and muscular layer separately 
and a superficial row of silkworm gut 
sutures uniting all the tissues except the 
peritoneum. A large hygroscopic com- 
press composed of sterile gauze and cot- 
ton held in place by broad strips of ad- 
hesive plaster constitutes the proper 
dressing. The sutures are removed at 
the end of the second week and the 
patient must not be allowed to leave the 
bed before the expiration of the fourth 
week. Four weeks in bed and the wear- 
ing of a well fitting abdominal support 
for 3 to 6 months are the most reliable 
precautions against the occurrence of a 
>post operative ventral hernia. The 
drainage opening should be closed with 
secondary sutures, inserted at the time 
of operation, as soon as the drain is re- 
moved, otherwise a ventral hernia will 
be almost sure to develop in the scar at 
the former site of the drainage tube. 
pheral circulation is restored by applying 
dry heat to the extremities and trunk. 
The subcutaneous infusion of one to two 
pints of normal salt solution is an excel- 
lent restorative of special therapeutic 
efficiency in cases where the vital forces 
are depressed and life is in danger from, 
the effects of hemorrhage. Should 
symptoms of peritonitis set in, a brisk 
saline cathartic should be given at the 
end of forty-eight hours, as at this time 
the intestinal wounds will have become 
sufficiently united to resist the peristalsis 
provoked by the cathartic, while the re- 
moval of intestinal contents and the 
absorption of septic material from the 
peritoneal cavity thus attained are not 
only the most efficient means of avert- 
ing a fatal disease, but also placing the 
wounds in the most favorable condition 
for rapid repair. Reopening the wound 
and secondary flushing have done little 
in arresting or limiting septic peritonitis. 
If the case progresses favorably, liquid 
food by the stomach can be allowed at 
the end of the second day, and light 
solid food at the end of the first week. 
Under ordinary circumstances no effort 
is made to move the bowels till the end, 
of the third or fourth day. If early 
feeding becomes necessary in marasmic 
or exsanguine patients, this can be done 
by rectal alimentation. 
After-treatment.—Absolute rest must 
be strictly enforced. Opiates must be 
given in sufficient doses to quiet the per- 
istaltic action of the intestines. Stimu- 
lants must be used to counteract the 
effect of shock and to restore the en- 
feebled peripheral circulation. Absolute 
diet must be observed for at least 48 
hours. During this time a mixture of 
brandy and ice water in small doses fre- 
quently repeated, or acid champagne, is 
agreeable to the patient, as it quenches 
thirst, relieves nausea and exerts a fav- 
orable influence on the circulation. If 
more active stimulation is called for to 
relieve 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- 
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 to 
emergency practice in civil life. 
2. The wounded soldier is entitled to 
the same degree of immunity against in- 
fection as persons in civil life suffering 
from similar injuries. 
3. The fate of the wounded rests in 
the hands of the one who applies the 
first dressing. 
4. The first dressing should be as 19 
simple as possible including an anti- 
septic powder composed of boracic acid 
four parts, salicylic acid one part, a 
small compress of cotton, safety pins and 
a piece of gauze 40 inches square. 
in locating bullets lodged in the body. 
10. Gunshot wounds of the extremities 
must be treated on the most conservative 
plan, the indications for primary ampu- 
tation being limited to cases in which 
injury of the soft parts, vessels and 
nerves suspend or seriously threaten the 
nutrition of the limb below the seat of 
injury. 
5. Any attempt to disinfect a wound 
on the battlefield is impracticable. 
6. The first dressing stations and the 
field hospitals are the legitimate places 
where the work of the hospital corps and 
company bearers is to be revised and 
supplemented. All formal operations 
must be performed in the field hospitals 
where the wounded can receive the full 
benefits of aseptic and antiseptic pre- 
cautions. 
11. Operative interference is indi- 
cated in all penetrating gunshot wounds 
of skull. 
12. Gunshot wounds of the chest 
should be treated by hermetically seal- 
ing the wound under the strictest aseptic 
precautions. 
7. Probing for bullets on the battle- 
field must be absolutely prohibited. 
13. Laparotomy is indicated in all 
cases in penetrating gunshot wounds of 
the abdomen where life is threatened by 
hemorrhage or visceral wounds and the 
general condition of the patient is such 
as to sustain the expectation that he 
will survive the immediate effects of the 
operation. 
8. Elastic constriction for the arrest 
of hemorrhage must not be continued 
for more than 4 to 6 hours for fear of 
causing gangrene. 
9. The X-ray will prove a more valu- 
able diagnostic recourse than the probe