chance for improvement in many directions, and one such chance is that of prophylaxis, symptomatic treatment, the grappling with conditions which arise before they amalgamate and develop into something serious. Furthermore, while we direct treatment to such conditions, it behooves us to be scrupulous in our selection of means, and employ such remedies as will do the desired work without producing, collaterally, any harm. This we can accomplish by the use of active principles, rather than "whole-drug” preparations. We wish to produce certain effects, and if we can do so "cito, tuto et jucunde,” so much the better.

Confidence is a great desideratum in the practice of therapeutics, and this quality is begotten of a thorough knowledge of the means which we adopt and the results which they produce, rather than a hope that certain results will be attained. Further than this, the practice of therapeutics is impossible without power to diagnosticate correctly.

To sum up, then, the lesson to which we would call attention, we will adopt for our watchword: "To recognize the indications, to fufill them, and, in doing so, adopt those means which experience has proved to be the very best."

R. L. P.

GENERAL SURGERY.

IN CHARGE OF

H. T. BAHNSON, M. D,

R. L. GIBBON, M. D.,

J. HOWELL WAY, M. D.

"RECENT EXPERIENCES IN MILITARY SURGERY AFTER THE BATTLE OF SANTIAGO."-Under the above title Professor Nicholas Senn, now Lieutenant-Colonel of the United States Volunteer Service, and chief of operating staff with the Army in the field, contributes a most interesting article to the Medical Record, from which we extract the following: "Wound Infection.-The military surgeon of today has the advantage over his colleague in civil practice, in knowing that the smallcalibre bullet inflicts wounds which per se are more often aseptic than septic. The small, jacketed bullet seldom carries with it into the tissues clothing or other infected substances. Most of the wounds of the soft tissues, uncomplicated by visceral lesions which in themselves would furnish a source of infection, healed by primary intention in a remarkably short time. If infection followed, it usually did so in the superficial portion of the wound in connection with the skin, and, what is more than suggestive, the wound of exit was more frequently affected than the wound of entrance. This can be readily explained from the larger size of the wound and more extensive laceration of the tissues. The deep tissues were seldom implicated, when, owing to a subsequent superficial suppuration of the wound, ideal healing did not occur. I

have reason to belive that some of the compound fractures which are now suppurating had such a source of infection; that is, the extension of a superficial infection to the seat of fracture.

The many failures in protecting the more serious wounds against infection are attributable to three principal causes:

1. Inadequate supply of first dressings.

2. Faulty application of first dressing. 3. Unnecessary change of dressing.

Proper dressing material was lacking at the front. Most of the dressings were too small, and not sufficiently secured to keep them in place during the transportation from the front to the field hospital. Not enough attention was paid to the immobilization of the injured part an important element in securing rest for the wound, and in guarding against the displacement of dressings. It is a source of regret that plaster of paris dressings were not more frequently employed in the treatment of gunshot fractures of the extremities.

Patients brought from the first dressing station to the field hospital usually were subjected to a change of dressing, and when a few days later they reached the general hospital at Sibony, they had to undergo the same ordeal, and often not only once, but whenever they came into the hands of another surgeon. Patients thus treated, were dissatisfied, as the laymen are still laboring under the erroneous impression that the oftener a wound is dressed, the quicker it will heal.

In all cases in which the first examination does not reveal the existence of complications which require subsequent operative treatment, the diagnosis tag should convey this important instruction: "Dressing not to be touched unless symptoms demand it." I am satisfied more than ever of the necessity of including in the first-aid-dressing-package an antiseptic powder. For years I have used for this purpose a combination of boric and salicylic acid, 1 to 4, with the most satisfactory results. A teaspoonful of the powder dusted on the wound forms with the blood that escapes and the overlying cotton a firm crust which seals the wound hermetically. Should the primary dressing become saturated with blood, the same powder should be dusted over the wet dressings and an additional compress of cotton be added to the dressing. Much can be done in the after treatment in the way of readjusting the bandage and in immobilizing the injured part, but the first dressing must remain unless local or general symptoms set in which warrant its removal. I wish to repeat again and in the most forcible manner the language of the late Professor vonNussbaum: "The fate of the wounded rests in the hands of the one who applies the first dressing." If this be true in civil practice, its meaning cannot be misinterpreted in military surgery."

The Effects of Bullets On the Soft Tissues.-According to Dr. Senn's description, the effects of the Mauser bullets on the soft tissues differ slightly if at all, from those of the small-caliber lead bullets, and he

has no further doubt that the new bullet will become encapsulated and remain harmless as readily or more so, than the old-fashioned leaden bullet.

THE X-RAY IN MILITARY PRACTICE.—The probe as a diagnostic instrument in locating bullets has in modern military service been almost entirely superseded by dissection and the employment of the X-ray. If from the nature of the injury and the symptoms presented, the bullet is located in a part of the body readily and safely accessible, and it is deemed expedient to remove it, this can often be done more expeditiously and with a greater degree of certainty by enlarging the track of the bullet, than by relying on the probe in finding and on the forceps in extracting the bullet. If the whereabouts of the bullet is not known, its exact location can by the X-ray be determined without pain or risk to the patient. The X-ray apparatus also showed the presence or absence of fractures, their relation to joints, the displacement of fragments in fractures of the long bones and enabled the surgeons to resort to timely measures to prevent vicious union. In the light of our recent experience the X-ray has become an indispensable diagnostic resource to the military surgeon in active practice, and the suggestion that ever army corps should be supplied with a portable apparatus and an expert to use it must be considered a timely and urgent one.

COURSE OF THE BULLET-Deflection of the bullet in the body is exceptional; as a rule the wound canal was in a perfectly straight line from the entrance to the exit. By following the track of the bullet it is not difficult to determine the organ or organs implicated in the injury. GUN-SHOT WOUNDS OF THE HEAD.-A number of sufferers from gun-shot wounds of the head who survived long enough to be transported to the general hospital died within twelve days after the receipt of the injury. In all these cases intracranial infection was the immediate cause of death. Encephalitis and leptomeningitis constituted the fatal complications. The beginning of the intracranial inflammation was always announced by cerebral hernia, which in size was proportionate to the extent and intensity of the inflammatory process. The surgical treatment resorted to in most cases proved powerless in limiting the infection.

GUN-SHOT WOUNDS OF THE SPINE.-All who received gun-shot wounds of the spine, in which the cord was seriously dainaged have died or will die in the near future. The immediate cause of death in such cases is either septic or leptomeningitis, or sepsis and exhaustion from the first-named cause takes place early, as the result of infection of the wound, and extension of the inflammation at the seat of the injury along the meninges and surface of the spinal cord. Wounds of the spine without injury to the cord frequently gave rise to temporary paralysis varying greatly in degree and duration.

GUN-SHOT WOUNDS OF THE CHEST.-It is well known that during our civil war, men had a better chance for life when the bullet passed through the

134

sur

chest, than when the chest was opened and the bullet remained inside. The same remains true, now, although not to the same extent, since the smallcalibre bullet is less likely to carry with it into the chest clothing or other infectious material. The number of those with chest wounds who lived long enough to reach the hospital on the coast is astonishing, and still more prising is the fact that unless the hemorrhage was severe the symptoms were mild, some of these patients being confined to bed only for a few days. All of these cases were treated on the expectant plan-that is, by dressing the external wound or wounds; in no instance was the pleural cavity opened for the purpose of arresting the hemorrhage. No further doubt remains in regard to the difference in the mortality of wounds inflicted with the large and the small-calibre bullets. The danger incident to gun-shot wounds of the chest made by small projectiles, consists in complicating injuries involving the heart and large blood vessels, and in the absence of such injuries the prognosis is favorable. It seems that empyema is a rare remote result of such wounds. Rib resection and free incision and drainage of the chest must be reserved for cases in which a positive diagnosis of empyema can be made. The safest and best treatment for hæmothorax requiring operative interference, is tapping and evacuation by syphonage.

GUN-SHOT WOUNDS OF THE ABDOMEN.-Our recent experience has confirmed my convictions that not unfrequently cases of penetrating gun-shot wounds of the abdomen will recover without active surgical interference. A bullet may pass through the abdomen on a level with and above the umbilicus in an antero-posterior direction without producing visceral injuries demanding operative intervention. If the bullet traverse the small intestine area it is more than probable that from one to fourteen perforations will be found. Four laparotomies for perforating gun-shot wounds of the abdomen were perfomed. All of the patients died. This unfavorable experience should not deter surgeons from performing the operation in the future in cases, in which from the course taken it is reasonable to assume that the bullet has made visceral injuries which would be sure to destroy life without surgical interference. Abdominal section is always justifiable in cases of internal hemorrhage sufficient in amount to threaten life. A number of gunshot wounds of the abdomen have occurred in connection with gun-shot injuries of the neck and chest in which the cavities of the chest and abdomen and their contents were implicated at the same time, and which are now on the way to recovery without laparotomy having been performed. A number of perforating wounds of the abdomen were on a fair way to recovery without operation, before they were sent home on transports. In most of these cases the bullet wounds were either in the umbilical region or in one of the iliac fossæ.

GUN-SHOT WOUNDS OF THE EXTREMITIES.—It is a source of gratification to know that few primary amputations were made for gun-shot injury of the extremities. Amputations were limited to cases, in which the condition of the soft tissue precluded any other course. A number of secondary amputations became necessary to save life in cases of infected compound fractures, complicated with injury and infection of the adjacent joint. A num

ber of gun-shot fractures of the thigh and leg have become infected, and are now being treated by establishing free tubular drainage and resorting to frequent or continuous irrigation. Owing to the want of reliable plaster of paris, we had to resort to various kinds of splints, simple and double inclined plane, in effecting immobilization. The sheath of the leaf of the cocoa palm has served as an excellent material for this purpose. There is every prospect that most of these cases will ultimately recover with useful limbs. H. T. B、

Therapeutic bints.

INTESTINAL ANTISEPTIC FOR CHILDREN. --Tompkins speaks highly of the following as an intestinal antiseptic in children: Calomel gr. ij;

Ꭱ

Sulphocarbolate of Zinc gr. iij;
Subnitrate of Bismuth dr. ij;
Pepsin dr. ss

Sufficient for twelve powders.

year old.

Three per diem in a child one
-Monthly Cyclopædia.

GASTRALGIA.

Ꭱ

M. Sig. -To Rev. of Rev.

Codeine Phosphatis gr. 4;

Bismuthi Subnitratis gr. v;

Sacchari Lactis, gr. iij.

be taken every two hours. -Ewald-Med.

ANTI-RHEUMATIC MIXTURE (Dujardin-Beaumetz)

B Sodii Salicylatis dr. iij;

Aquæ Laurocerasi oz. j;

Spt. Vini Rect. oz. ss.
Syrupi Simp. oz. j.

Aquæ q. s. ad oz. vj.

M. Sig-A tablespoonful twice to five times a day.

CHILD.

A NEW METHOD TO RESTORE AN ASPHYXIATED Stringer (Vir. Med. Semi monthly, May 13, 1898) calls attention to the fact that the asphyxiation of an infant after a difficult labor, being due to lack of oxygen, may be overcome if the blood is kept oxygenated, until the sensitiveness of the child is sufficiently restored to permit normal breathing to begin. He