Reprint from ST. LOUIS CLINIQUE for June, 181)4

ABDOMINAL

SURGERY

ON THE

BATTLE-FIELD.

N. SENN, M.D., Ph.D., LL.D.,President Association of Military Surgeons of the United States; President Association of Military

Surgeons of Illinois; Surgeon General of the National Guards of Illinois.

Reprint from ST. LOUIS CLINIQUE for June, 1894.

Abdominal Surgery on the Battle-field.

N. SENN, M. D., PH. D,, LL. D.,

President Association of Military Surgeons of the United States; President Association of Military Surgeonsof Illinois; Surgeon General of the National Guard of Illinois.

Military surgery will always be re-garded in the light of a specialty insurgery. The principles which governits practice are the same as those whichguide the civilian surgeon in his work,but the art is as widely at variance as

the circumstances which demand itsapplication. The science and art ofsurger}' have undergone such radicalchanges during the last decade thatnothing short of complete revolutionarychanges in this special department willbring it up to the same enviable degreeof perfection and usefulness as surgeryin civil life. The military surgeon mustkeep abreast of the times, in order tosecure for those placed in his chargethe blessings to be derived from theapplication of the many important andvaluable facts brought forward by mod-ern investigation and research. Sincethe great war of the Rebellion and themore recent Franco-Prussian struggle,military surgeons have had only limited

opportunities to make practical use ofthe great advancements which charac-terize modern aggressive surgerjL Forthe good of humanity military surgeryhas been retarded by an epidemic ofpeace. Let us hope that the time is fardistant when it will receive a new im-petus from bloody conflicts on a largescale. As military surgeons, however,it is our duty to prepare for the futureso that whenever called upon, we willbe prepared to meet the emergencies ofrecent warfare. The three great fac-tors which will modify the practice ofsurgery on future battlefields will be:(1) Prevention of wound infection.(2) Conservative treatment of gun-shot injuries of the extremities. (3)Prompt direct operative interference inthe treatment of penetrating wounds ofthe large cavities, a field heretoforealmost entirely neglected with the con-sequence that in a large proportion ofcases death resulted either from the

2 N. SENN

injury per se or some immediate com-plication. All of these subjects pre-sent sufficient importance to claim themost serious attention of every memberof the Association, but the scope istoo extensive to be covered by an ad-dress which is necessarily limited as totime and which would require betteropportunities for actual experience thanhave come within my reach for a thor-ough elucidation. It is my intentionon this occasion, our fourth annualmeeting, to discuss a few of the mostimportant points of an entirely newdeparture in the service of the militarysurgeon of the future—viz: AbdominalSurgery on the Battlefield.

Since the close of the last great warsthe inventive genius has been busilyengaged in devising new weapons andother implements of destruction. Thesmokeless powder and the jacketed smallcalibre bullet have revolutionized mod-ern warfare. Rapid firing at a greaterrange and certainty of aim will makethe battles of the future of short dura-tion, but the Joss of life and the num-ber of disabled and maimed will begreater than ever. The wounds thatwill come under treatment on the bat-tlefield will present an entirely differentaspect, and will demand different treat-ment than those inflicted by the oldweapons. The new bullet, by virtue ofits greater velocity and penetratingpower, will either produce speedy deathor the injury which it inflicts will bemore amenable to successful treatmentbecause it produces less contusion ofthe soft tissues and splintering of bonethan the leaden bullet used inthe past. Beck, Bruns, Delorme, Tan-gier, Roget, Bardeleben, Helferich,Kocher, La Garde, Griffith, and othershave made careful experimental re-searches concerning the effect of thenew projectile upon the different tissuesat variable distances, but this subject

is not exhausted and further studiesmust be made to furnish the final posi-tive demonstrations.

During the beginning of our CivilWar, our infantry was supplied withthe old Springfield muzzle loader. Thebullet was conical and had a diameterof fifty-eight hundreths of an inch anda length of about one inch, and wasfired at a velocity of about one thousandfeet a second. The Karg-J-uirensen,and similar small calibre gui.s madeto fire a jacketed bullet about aninch and one-third in length, and onlythirty hundreths of an inch in diameter.The modern bullet consists of a jacketof thin steel, or of German silver, fill-ed with lead and nickel plated. Itsconstruction is such that it is butlittle deformed even in striking thehardest substances and as the smokelesspowder imparts to them a velocity dou-ble of that of the old bullet, it is lessliable to deviate from its original courseand produces much less laceration ofsoft parts and comminution of bone.The wounds inflicted resemble more

closely incised than lacerated wounds.The old bullet produced more lacerationand shock than the new missile. Thenew bullet inflicts wounds which resem-ble the injuries caused by the oldweapons within a distance of 350 yards,and as most of the wounds will be pro-duced at a greater distance the surgeonwill have to deal with injuries resemblingincised or punctured wounds. Thebullet will also be less liable to carrybefore it infected foreign substancesand to lodge in the body, consequentlythe wounds will be less liable to prima-ry infection and consequently, better a-dapted for successful conservative treat-ment. In so far as pertains to theefficient treatment of wounds of theextremities all are agreed as to the bestcourse of treatment to be pursued.Rigid antiseptic and aseptic measures

ABDOMINAL SURGERY ON THE BATTLE-FIELD 3

will be carried oat at the first dressingstation and rest will be secured by ex-temporized means of immobilization andthe patients sent to the rear with a

message informing the hospital surgeonswhether or not the, first dressing mustbe changed or whether more efficientantiseptic measures are required, or

complications to be treated. Very littlehas been done so far in the way ofaggressive surgical interference forheroes who fell mortally wounded inthe line of battle in the defense of theircountry, their ruler, their families, theirhomes and their rights. The time has

to direct means of haemostasis. Infuture wars it should be made the sa-

cred dot}- of every civilized nation todo all that modern surgery can accom-plish in the treatment of perforatinggunshot wounds of the abdomen at thefirst dressing station located as near aspossible to the fighting line. Everysoldier who has been in active militaryservice can recall instances where com-rades dropped in the ranks with a mor-

tal bullet wound of the abdomen, wholived for several hours and died fromhemorrhage, often forgotten and un-

eared for in the excitement of the con-

First aiil from behind the line of battle. Looking toward ihe first dressing station. [The field sceneswere photographed by Captain Ives and Lieutenant Newgarden at Fort Sheridan.]

come when in case of war adequateprovisions should be made on the fieldof battle near the fighting line for theprompt treatment of perforating gun-shot wounds of the abdomen. It isdifficult to conceive how many valuablelives have been sacrificed on the field ofbattle during the innumerable bloodyconflicts recorded in the history of theworld which now could be saved byprompt and efficient surgical interfer-ence. Thousands of lives have beenlost from internal hemorrhage alonewhich at the present time could besaved by abdominal section and resort

flict. Justice, patriotism, humanityand the present status of abdominalsurgery demand that in future wars awell regulated hospital corps shall ren-der efficient first aid, promptly conveythe severely wounded to the first dress-ing station where they can receive fur-ther surgical aid, and where, if die theymust, the last hour of their life shall bepeaceful, surrounded by those who willadd to their comfort and administerwords of consolation as the immortalspirit leaves the maimed body for itseternal resting place. It is my firmconviction that military surgeons will

4 N. SENN

follow the precepts and practice of theprogressive and aggressive civilian sur-geons in the treatment of visceral in-juries of the abdominal cavity on thefirst opportunity that presents itself.To permit a wounded soldier to diefrom hemorrhage of a wound of one ofthe abdominal organs, which otherwisewould not prove a source of immediateor remote danger, is in conflict withthe duties of the country to its defend-ers, and a reproach upon modern surgi-cal practice on the battlefield.

Two leading indications will presentthemselves in the treatment of penetrat-ing gunshot wounds of the abdomen.(1) Arrest of hemorrhage. (2) Directtreatment of visceral wounds.

The timely treatment of visceral in-juries of the abdomen on the battle-field will require improved facilities fortransportation of the wounded and an

adequate hospital corps force to renderthe first aid and transport the woundedto the first dressing station and later tothe field hospital. In the regular armya faithful effort is now made to buildup an efficient and well-equipped hospi-tal corps. The Surgeons of the Na-tional Guard should use their influencein securing uniform legislation in everyState of the Union looking toward theorganization of a similar special mili-tary service. So far but little has beendone in this direction. The hospitalcorps service should be modelled asclosely as possible after that of theregular array. The members of thecorps should, of course, be non-combat-ants and well instructed in their specialwork. The members should at leastpossess a good common school educa-tion and sufficiently familiar with minorsurgery to act as trustworthy assistantsin emergency operations. During thebeginning of an engagement the hospi-tal corps under the command of theofficer in charge is stationed at the arn-

bulance station in some protected lo-cality and sufficiently to the rear ofthe fighting line to be out of range ofthe small arm bullets. From here themembers set out with litters and sup-plied with the necessary articles torender the first aid. Each membershould be able to make a quick andreliable diagnosis between shock andthe complexus of symptoms resemblingshock produced by internal hemorrhage.In shock the maximum ap-pear immediately after the receipt ofthe injury while in hemorrhage thesymptoms gradual!} 7 increase in inten-sity with the loss of blood. This dis-tinction has an important practicalbearing as the administration of stimu-lants increases the danger from hemor-rhage while it mitigates the symptomsof shock. The treatment of internalhemorrhage should receive attentionon the part of those who first comein contact with the wounded. Thepatient must be kept in the recumbentposition and should be cautioned notto make the least muscular exertion.The first aid in such cases should con-sist of measures best calculated toretain within the blood vessels as muchblood as possible and to place the vis-ceral wound in the best possible condi-tion for the formation of a thrombus.

I know of only two indirect meansto accomplish these objects, viz.: (1)Constriction at the base of the extremi-ties. (2) Pressure over the seat of in-jury. Constriction at the base of oneor more extremities sufficiently firm toarrest both the arterial and venouscirculation will preserve the blood con-tained in the extremity at the time theconstrictor is applied and will lightenthe heart’s action to an extent corres-ponding with the amount of blood ex-cluded in this manner from the generalcirculation. In this manner a sufficientamount of living blood could often be

ABDOMINAL SURGERY ON THE BATTLE FIELD

First Dressing Station.

retained in the body to carry on thefunctions of life after the cause ofbleeding has been removed by directhemostatic measures. The wounds ofentrance and exit are covered with anantiseptic pad. The suspenders of thewounded soldier, the gun-strap, thebelt, or strips of his clothing could beused to make the adequate number ofcircular constrictions. Direct pressureover the wounded organ will diminishits vascularity, and bring the tissues ofthe tubular wound in contact, condi-tions which will favor spontaneous arrestof hemorrhage by the formation of a

blood-clot. Pressure to meet these in-dications can be made by applying over

the wound of entrance protected by anantiseptic pad a compress composed ofthe canteen, the cartridge box or an

article of clothing and held in place bythe belt, the gun-strap, suspender ora strip of clothing. After such tem-porary aid the patient should be trans-ported as quickly as possible from thefighting line to the ambulance stationand from there to the field hospital.For obvious reasons the first dressingstation is not the place for operationsupon any of the abdominal organs.

The ever varying position of the lineof battle, the inadequate supply of in-struments and dressing materials aswell as the exposure more or less to thedangers incident to active warfare pro-hibit any operations requiring abdomi-nal section in such close proximity tothe danger line. Patients suffering frompenetrating wounds of the abdomenshould be transported on the same litterin the ambulance from the battle-fieldto the field hospital, as gently and asquickly as circumstances will permit.The new weapons will make it necessaryto establish the first dressing station andthe field hospital at a more distant pointbehind the fighting line than hereto-fore. The first dressing station shouldbe in some protected place, in a ravineor behind a building while the lattershould be in a place farther in the rearentirely out of reach of the infantryfire and in a place protected against thefire of artillery. While I am extremelyanxious to impress upon the membersof this Association the importance andjustifiability of abdominal section up-on the battle-field as a life-saving opera-tion I am equally conscious of theresponsibility which accompanies the

6 N. SENN.

teaching and practice of such a newdeparture in military service. The in-discriminate adoption of such a prac-tice by all military surgeons would inall pi obability increase rather thandiminish the mortalitj' of penetratingwounds of the abdomen. Abdominalsection under such trying circumstancesi-equires an unusual degree of moralcourage and special skill. Surgeons towhom such a task will be assigned mustbe thoroughly prepared for their work.

The correct diagnosis and proper treat-ment of gunshot wounds of the stomachand intestines require a degree of skilland dexterity which can only be acquiredby operations on the cadaver and experi-ments on the lower animals.

An accurate knowledge of the anatomyand topography of the abdominal organsis an essential prerequisite to thestudentof abdominal surgery. The necess-ary manual dexterity can only be ac-quired by actual work and practicaldemonstrations. No amount of readingand hearing will bring the necessaryskill. Even the minutest descriptionsof the details to be observed and ap-plied in the diagnosis and treatment ofgunshot wounds of the abdomen are

utterly inadequate to prepare a surgeonto interpret correctly the symptomsand signs presented by penetratinggunshot wounds of the abdomen, or tomeet the often unexpected emergenciesin their treatment. The establishmentof the Army and Naval Medical Schoolsis a source of congratulation not onlyto the respective services of the Govern-ment but also to every surgeon of theNational Guard. To them we shall lookforemost for the needful advancementsin military surgery. They should andwill be the authoritative exponents ofthe much needed improvements of sur-

gery on the battlefield. I trust theywill in their curriculum include instruc-tion that will prepare in each branch

of the medical service men who will becompetent to perform the most difficultoperations upon any of the abdominalorgans at a moment’s notice with thesimplest instruments, with few assis-tants and the most primitive surround-ings ; with such a nucleus abdominalsurgery in military practice will soonbecome a favorite subject for discussionand the battlefield of the future willbring new laurels upon the manyachievements of modern surgery.

Operative courses on the cadaver arevaluable and useful, but they never cantake the place of experiments on theliving animal in acquiring a practicalknowledge of abdominal surgerj'. Thisis more especially true in reference tothe required manual dexterity in thesurgical treatment of internal hemor-rhage and wounds of the abdominalviscera. A certain amount of experi-mental experience is absolutely requiredin the preparation of the surgeon forthis kind of abdominal work which re-quires not only courage, good judg-ment, and a thorough knowledge ofevery step in diagnosis and treatment,but also a certain manual dexteritywhich cannot be acquired in any otherway. We can hardly hope that everymilitary surgeon will acquire the nec-essary qualifications for such work.Nor is this necessary. Abdominal sur-

gery on the battlefield will constituteonly a small part of the work requiredof the surgeons during an engagement.Many penetrating wounds of the abdo-men will prove speedily fatal. Thosecases which survive the immediate ef-fect of the injury and are in a conditionto justify abdominal section will becomparatively few. The abdominal workshould be done by surgeons who possessspecial skill and experience. At leastone surgeon in every brigade should bestationed at the field hospital whoseduty it should be to superintend the

ABDOMINAL SURGERY ON THE BATTLE-FIELD

preparations and perform the operationsThe most successful laparotomists needthe fewest assistants and instruments.In military practice their example shouldbe followed. During an engagementon a large scale the surgeons and mem-bers of the hospital corps are alwaysovertaxed, by urgent demands from alldirections. Excitement and confusionreign everywhere. The deafening roarof the artillery, the rattling of the infan-try, the commands of the officers, thegroans of the wounded, the rumbling ofthe ambulances are well calculated to

corps, a laparotomy for gunshot woundof the abdomen can be made quicklyand successfully provided careful pre-parations have been made beforehand.

Preparations for Operation.

The field-hospital will be either a

building used temporarily for hospitalpurposes or a hospital tent. In theformer case the operating room shouldbe cleared of all furniture and drap-eries, the floor, walls and ceilingsprinkled with a strong solution ofcarbolic acid or corrosive sublimate.

Ambulance Station.

excite curiosity and to deviate the no-vices from the strict line of duty. Itis under such circumstances that thesurgeon who is to perform the mostdifficult operations in surgery must bein full possession of all of his mentalfaculties if his work is to save many ofthe lives placed in immediate jeopardyfrom the effects of the enemy’s bullets.Ample preparation must be made be-forehand otherwise valuable time is lostand man}7 lives sacrificed that might besaved by prompt action. With twoskilled assistants, an assistant sur-

geon, and a member of the hospital

A portable sheet-iron stove heated bycoal oil will answer the purpose ofheating the room and sterilizing theinstruments and the water used duringthe operation. Two large tin pails, onefor cold and the other for hot sterilizedwater and three large wash-basins ofgranite ware , and a dipper of the samematerial will answer the purpose ofhandling the antiseptic solutions andsterilized water. Sterilized gauzeshould take the place of sea sponges.The instrument case that I devisedsome time ago and which I have calledthe emergency pocket operating case,

8 N. SENN.

contains all the instruments needed andas it contains needles and the neces-sary suture material everything in theway of instruments, ligatures and su-tures can be rendered absolutely sterileby placing the case for fifteen minutesin boiling water to which has been ad-ded one per cent, of carbonate of soda.The case is then taken out and afterpouring out the water it is placed onthe stove until its contents are dry,when they are placed upon an extem-porized table covered by an aseptictowel. The hands of the operator andassistants are in the meantime renderedaseptic in the usual manner. Duringthe operation the instruments are to becleansed as often as necessary in steri-lized water and laid upon the toweluntil needed by the operator. Thebest operating table will be the litteroperating table. This table is compos-ed of the litter upon which the patientis brought to the hospital placed uponthe extension frame. Folding camp-stools will answer the purpose of tablesfor the wash-basins and instruments.Bricks, stone, sand or earth can beheated on the stove and will answer anexcellent purpose in supplying the ex-tremities with artificial heat during andafter operation. The necessary stimu-lants, alcohol, camphor, nitrite of amyl,ammonia and strychnine should alwaysbe on hand to counteract the symptomsof shock. One assistant administersthe anaesthetic while the other handsthe instruments, handles the gauzesponges and otherwise assists the op-erator. A number of gauze compressesmust be kept in readiness. Duringthe operation sterilized water is usedexclusively. If flushing is indicatedthis can be done by pouring warmwater from a basin. During the opera-tion the patient should be placed ina slightly inverted position for thepurpose of increasing the blood supply

to the vital organs and diminishingthe tendency to prolapse of the intes-stine.

Operation.

In the future the differential diag-nosis between penetrating and non-

penetrating wounds of the abdomenwill be attended by less uncertaintythan in the past, as in most instancesthe bullet will pass through the body ina straight line and the wounds of en-

trance and exit will indicate whetheror not the abdominal cavity has beeninvaded. Prolapse of the abdominalorgans, owing to the smaller size ofthe bullet wound, will be less frequentlyobserved. If an operation is decidedupon and the patient suffers fromshock, one-twenty-fourth of a grainof strychnine should be given subcu-taneously before the administration ofthe anaesthetic. No time should belost in removing the patient’s clothing,as such a procedure would tend to in-crease the Hemorrhage and add to theexisting shock. The boots or shoesshould be removed and artificial heatapplied to the feet, the abdomen laidbare, rolling pants and drawers down-ward sufficiently far to expose the pubesand the remaining clothing upward farenough to bring into view the costalarches on both sides. After the patientis fully under the influence of theamesthetic, the abdomen is rapidlydisinfected by washing with warmwater and potash soap, shaving, wash-ing with a 1:1,000 solution of sublimateand finally with alcohol or ether. Theclothing in the vicinity of the abdomenis then covered with dry aseptic towels.Unless contraindications exist, the ab-domen is opened in the median line asthis incision affords the most readyaccess to the injured organ. In per-forating wounds of the abdomen, pro-fuse hemorrhage is more frequently ofparenchymatous and venous llin ar

ABDOMINAL SURGERY ON THE BATTLE-FIELD 9

terial origin. Gunshot wounds of theliver, spleen, kidneys, and the mesen-tery give rise to profuse and often fatalhemorrhage. After opening the perito-neal cavity it is often very difficult tofind the bleeding points, as the blood ac-cumulates as rapidly as it is spongedaway, and it becomes necessary to re-sort to special means in order to arresttemporarily the profuse bleeding suffi-ciently to find the source of hemorrhage.One of two resources should be em-

ployed: (1) Digital compression ofthe aorta. (2) Packing of the abdomi-nal cavity with a large number of gauzecompresses. Digital compression ofthe aorta below the diaphragm can bereadily made by the assistant introduc-ing his hand through the incision,which in such cases must be largerthan under ordinary circumstances.Compression of the abdominal aortaimmediately below the diaphragm willpromptly arrest the hemorrhage fromany of the abdominal organs for a suffi-cient length of time to enable the surgeon to find the source of hemorrhageand carry out the necessary treatmentfor its permanent arrest. Hemorrhagefrom a perforated lacerated kidney may

demand a nephrectomy. If an injuryof this nature is associated with a

wound of the abdominal cavity theorgan will probably be removed bylaparotomy. If this method is employ-ed the wound of the parietal peritoneumis sutured, and if necessary drainageestablished by a counter opening in thelumbar region. A similar wound of theliver is cauterized with the actual cau-tery, sutured or tamponned with alongstrip of iodoform gauze, one end ofwhich is brought out of the externalwound.

At the last meeting of the GermanCongress of Surgeons, von Bergmannspoke strongly in favor of the sutureas a haemostatic agent in the treatmentof wounds of the liver. He assertedthat Glisson’s capsule offered enoughresistance to the sutures, while a num-ber of other surgeons gave it as theiropinion that the sutures would tearthrough. A round needle should beused invariably in suturing such a vas-cular organ as the punctures are lessliable to bleed than if the ordinary sur-gical needle is used. It appears to me

that on the battlefield the tampon shouldbe relied upon in arresting hemorrhage

Field Hospital.

10 N. SENN

from wounds of the liver, as its use re-quires less time, and it serves at thesame time the useful purpose of an effi-cient capillary drain. The use of thecautery is of course not to be thoughtof in the treatment of tubular wounds,and its employment will consequentlybe restricted to wounds of the surfaceof the organ or its lower border. Awound of the spleen, if the hemorrhagecannot be arrested by the antiseptictampon, necessitates splenectomy asthe tissues of this organ are too fragilefor the successful employment of thesuture as a haemostatic agent. Hemor-rhage from the pancreas must be con-trolled by antiseptic tamponnade, as

this organ is not sufficiently accessibleto permit ligation or suturing withouttoo extensive eventration and too greata loss of time. Very troublesome hem-orrhage is often met with from woundsof the mesentery. The mesentericveins are comparatively large in size,and the tissues surrounding them arenot well adapted to effect spontaneousarrest of hemorrhage. When multipleperforations of the mesentery and vis-ceral wounds of the stomach and intes-tines are the source of hemorrhage, itis a good plan to pack the abdominalcavity with a number of large gauzecompresses, each secured by a strip ofgauze which should be brought out ofthe wound to facilitate their removal,and as a safeguard against losing orforgetting them in the abdominal cav-ity at the completion of the operation.The compresses make sufficient pres-sure to arrest parenchymatous oozing aswell as venous hemorrhage if they are

placed at different points against themesentery and between the intestinalcoils. The compresses are removedone by one from below upwards andthe bleeding points secured as fast asthey are uncovered. The ligation ofmesenteric vessels, both arteries and

veins, should be done by applying theligature en masse. Thornton’s curvedhaemostatic forceps, or the ordinary an-

eurism needle, is the most useful in-strument for this purpose. Catgutshould never be relied upon in tyingmesenteric or omental vessels, as thismaterial for several reasons which it isnot necessary to mention here, is great-ly inferior to fine silk. The omentumand mesentery must be tied in fine sec-tions, the ligatures firmly drawn, andif a part of either of these is excisedthe incision should be made at leasthalf an inch from the ligatures to pre-vent their slipping. Troublesome hem-orrhage from a large visceral wound ofthe stomach and intestines is best con-trolled by hemming the margin of thewound with fine silk. If hemorrhageis profuse from any of the causes whichhave been enumerated, this must beattended to before anything is done inthe way of finding or suturing of thevisceral wounds.

, Treatment of Visceral Wounds.

Clinical experience and experimentalresearch have demonstrated beyond alldoubt that visceral wounds of the stom-ach and intestines large enough to giverise to extravasation are with but veryfew exceptions mortal injuries. Thedanger arising from such wound is, ofcourse, much greater when the organinjured is in a condition of activephysiological function; on the otherhand, if the organ is in a state of restextravasation is less liable to occur andconsequently a greater possibility ofspontaneous healing of the visceralwound. For this reason we find numer-

ous records of recovery from pistol-shot wounds of the stomach, this organhaving been empty at the time the in-jury wT as received. More numerous arethe instances in which patients haverecovered from perforating wounds of

ABDOMINAL SURGERY ON THE BATTLE-FIELD 11

the abdomen in which the clinical symp-toms did not indicate the existence ofany visceral injuries. I have been con-

vinced for years that a bullet passingthrough the abdominal cavity does notproduce visceral injuries as constantlyas we have been taught to believe. 1made fourteen experiments on the cada-ver for the purpose of ascertaining thecomparative frequency of visceral in-juries in perforating wounds of theabdomen. In four of these experimentsthe bullet passed through the abdomi-nal cavity in an antero-posterior direc-

would tend to destroy life. In regardto the direction of the bullet, it may besaid that if it has crossed the abdomi-nal cavity in an antero-posterior direc-tion at or above the umbilical level,the stomach and intestines may haveescaped injury, while if it has passedfrom side to side or obliquely at a pointbelow the umbilicus, it is not only al-most certain that it has injured theintestines, but it is almost equally cer-tain that it has produced from three tosixteen perforations.

The treatment that has been advised

Laparotomy on the Battle-field.

tion without producing any visceralinjury which would require surgicalinterference. In two out of six casesof penetrating gunshot wound of theabdomen that have come under my ownobservation laparotomy revealed the ab-sence of visceral wounds. Laparotomyshould not be performed simply because abullet has entered the abdominal cavity,but its performance should be limited tothe treatment of intra-abdominal lesionswhich, without operative interference,

for the arrest of hemorrhage from theliver, spleen, pancreas and kidneys isabout all that can be done for gunshotwounds or these organs. A more com-plicated and difficult task confronts thesurgeon in the treatment of visceralwounds of the gastro-intestinal canal.If the location of the wound of entranceand direction of the bullet indicate theexistence of a wound of the intestinalcanal below the ileo-caecal valve, aspeedy and positive diagnosis can be

12 N. SENN.

made after the patient is under theinfluence of the anaesthetic, by insuffla-tion of air per rectum. If this testyields a positive result, median laparo-

at once, the lowest perforation locatedby rectal insufflation. When this hasbeen done the air from the intestinalcanal below the perforation should be

Author’s Litter Operating Table.

Author’s Field Operating Table, Folded.

Operating Table and Litter, Folded.

tomy is to be performed at once, thewounds located by the same test andsutured. In the majority of cases twowounds will be found. If the smallintestines are out of range of the trackmade by the bullet, further search forperforations is not only unnecessary,but harmful. Careful toilet of theperitoneal cavity in the vicinity of theintestinal wounds by flushing or mop-ping is always necessary in such cases.If considerable extravasation has takenplace, drainage should be provided forin addition. If the direction of thetrack of the bullet is such that it isprobable that the small intestines areinjured the abdomen should be opened

removed as far as possible, when theinsufflation is made from this point inan upward direction in search of addi-tional perforations. If additional per-forations are found, the interveningportion of intestine is emptied of air,the first j erforation closed by suturing,and the process repeated until the en-tire intestinal canal has been tested bythis method. Extensive eventration isprevented by reducing the part of in-testine examined and treated as fast as

the exploration is made.By adopting this method the surgeon

guards absolutely against leaving anundiscovered wound which has in somany instances been the immediate

ABDOMINAL SURGERY ON THE BATTLE-FIELD. 13

cause of death after laparotomy forgunshot wounds of the abdomen. Ifthe wound of entrance and direction ofthe bullet point to the probable exist-ence of a wound of the stomach, insuf-flation of the stomach through an elas-tic stomach tube will prove a mostvaluable diagnostic measure, and isoccasionally the only way by which a

second perforation of this organ can bedetected, as is the case if it involvesthe smaller curvature or the posteriorwall. The suturing of the wound isdone in the quickest possible time andin the simplest manner. If bleedinghas not ceased it is arrested by hemming

a number of wounds are found in closeproximity. In such cases extravasa-tion during the operation is preventedby constricting the bowel on each sidewith a strip of gauze passed through a

small button hole in the mesenteryclose to the bowel, made with a pair ofhsemostatic forceps and tied sufficientlyfirm to prevent escape of intestinalcontents. If any part of the suturedbowel presents conditions that mightendanger the healing process, it shouldbe covered by an omental graft. Theoperation must be completed as rapidlyas possible, hence the toilet of the per-itoneal cavity and suturing of the ex-

Author’s Litter. Weight lbs.

Litter, Folded.

the margins of the wound by a continuedsuture of fine silk.

The closure of the wound is effectedLembert stitches, about six to the

inch, which must include a few fibersof the firm sub-mucous coat on eachside. Trimming of the contused mar-

gins is superfluous. An ordinal sew-ing needle and fine-braided silk shouldbe used in suturing the visceral wounds.As a rule the line of suturing should bemade transversely as stenosis is less lia-ble to occur and the vascular supply tothe parts coaptated is less likely to becompromised than would be the case ifthe wound is closed in a direction par-allel to the long axis of the bowel.Enterectomy and circular suturing maybecome necessary if the wound involvesthe mesenteric side of the bowel, or if

ternal wound must be completed withas little delay as is compatible with thesafety of the operation. A single rowof sutures including all of the tissuesof the abdominal incision, will answerthe purpose in closing the external in-cision. The omentum must invariablybe drawn down sufficiently far tocover the abdominal incision, as thisprocedure is best calculated to pre-vent subsequent adhesions of theremaining abdominal organs to theinner surface of the external incis-ion. If the patient has lost a danger-ous amount of blood a saline intra-venous infusion will often prove themeans of preventing death from thissource. The solution should be pre-pared by dissolving in a quart of warm

sterilized water the requisite quantity

N. SENN.

of pure sodic chloride, kept in readinessfor this purpose. The after-treatmentmust have in view mainly to meet thesymptoms of shock caused by the in-jury and the operation. Rest, externaldry heat, subcutaneous injections ofstrychnine and alcoholic stimulants willmeet this indication most satisfactorily.Absolute diet for the first three or fourdays with rectal alimentation constitutean essential part of the after-treatment.

modern surgery will be to extend therecent achievements of abdominal sur-gery to the battlefield. I am painfullyconscious of the fact that the profess-ional military surgeons will regard thesuggestions that I have made in thisdirection as immature and imperfect,but if I have succeeded in awakeningtheir interest in this matter the princi-pal object in the preparation of thisaddress will be realized.

Author’s Pannier and Dressing-Case. Weight including contents, 70 poundsAll articles contained in Aluminum cases.

A saline cathartic should be given assoon as tympanites makes its appear-ance regardless of the length of timethat has intervened since the operation.I am firmly convinced that abdominalsurgery has a great future in militarypractice. It is the duty of the propermilitary authorities to make ample pro-vision for initiating a well-matured planof procedure calculated to save occas-ionally a life upon the battle-field incases heretofore beyond the reach ofsurgery. The nations that spend mil-lions of dollars annually in perfectingtheir methods of warfare should not re-main unconscious of their full duty tothe wounded of future conflicts, andone of the most urgent demands of

In conclusion permit me to formulatethe salient ideas on this subject in thefollowing conclusions:

1. Abdominal surgery will extend itslife-saving work to the battlefield offuture wars.

2. The treatment of dangerous inter-nal hemorrhage and visceral wounds ofthe abdominal organs by laparotomy inmilitary practice is a justifiable andlegitimate procedure, which merits theearnest consideration of every militarysurgeon and deserving of the most seri-ous attention of the proper militaryauthorities of all civilized nations.

3. The first aid to those sufferingfrom gunshot wound of the abdomenand in which life is threatened by hem-

ABDOMINAL SURGERY ON THE BATTLE-FIELD. 15

orrhage should consist in compressionover the injured part and auto-transfu-sion by circular constriction at the baseof one or more extremities.

4. Operative treatment of gunshotwounds of the abdomen should be re-sorted to promptly in appropriate cases,and for this purpose the wounded shouldbe transported from the fighting line tothe field hospital with great care andwithout delay.

5. The field hospital should be equip-ped with the necessary instruments andoutfit to perform aseptic operations.

treatment by suturing, aseptic tampon-nade, or actual cautery.

9. Wounds of the spleen and kidney,if not amenable to the same treatment,may require removal of the injuredorgan.

10. Wounds of the stomach and in-testines large enough to permit extrava-sation with very few exceptions resultin death, and should therefore be sub-jected to direct operative treatmentbefore serious complications set in.

11. Distension of the stomach andcolon by insufflation of air before

Author’s Emergency Pocket Operating Case

6. After opening the peritoneal cavityby a median incision temporary haem-ostasis can be secured for the purposeof arresting dangerous arterial hemor-rhage by digital compression of theaorta below the diaphragm and venoushemorrhage or parenchymatous bleed-ing by sponge compression.

7. Permanent haemostasis must besecured by ligature or aseptic tarnpon-nade.

8. Visceral wounds of the liver andpancreas are amenable to successful

laparotomy and of the small intestinesthrough one or more perforations afterthe abdomen has been opened, is avaluable diagnostic test.

12. Wounds of the stomach and in-testines can be quickly and safely closedby one row of sero-muscular suturesincluding a few fibers of the submu-cous fibrous coat.

18. The after-treatment should con-sist of such measures as will most suc-cessfully combat the symptoms of shockand secure rest for the injured organ.