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. 
President Association of Military Surgeons of the United States; President Association of Military Surgeons 
of Illinois; Surgeon General of the National Guard of Illinois. 
N. SENN, M. D., PH. D,, LL. D., 
Military surgery will always be re- 
garded in the light of a specialty in 
surgery. The principles which govern 
its practice are the same as those which 
guide the civilian surgeon in his work, 
but the art is as widely at variance as 
the circumstances which demand its 
application. The science and art of 
surger}' have undergone such radical 
changes during the last decade that 
nothing short of complete revolutionary 
changes in this special department will 
bring it up to the same enviable degree 
of perfection and usefulness as surgery 
in civil life. The military surgeon must 
keep abreast of the times, in order to 
secure for those placed in his charge 
the blessings to be derived from the 
application of the many important and 
valuable facts brought forward by mod- 
ern investigation and research. Since 
the great war of the Rebellion and the 
more recent Franco-Prussian struggle, 
military surgeons have had only limited 
opportunities to make practical use of 
the great advancements which charac- 
terize modern aggressive surgerjL For 
the good of humanity military surgery 
has been retarded by an epidemic of 
peace. Let us hope that the time is far 
distant when it will receive a new im- 
petus from bloody conflicts on a large 
scale. As military surgeons, however, 
it is our duty to prepare for the future 
so that whenever called upon, we will 
be prepared to meet the emergencies of 
recent warfare. The three great fac- 
tors which will modify the practice of 
surgery 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 in 
the treatment of penetrating wounds of 
the large cavities, a field heretofore 
almost entirely neglected with the con- 
sequence that in a large proportion of 
cases 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 the 
most serious attention of every member 
of the Association, but the scope is 
too extensive to be covered by an ad- 
dress which is necessarily limited as to 
time and which would require better 
opportunities for actual experience than 
have come within my reach for a thor- 
ough elucidation. It is my intention 
on this occasion, our fourth annual 
meeting, to discuss a few of the most 
important points of an entirely new 
departure in the service of the military 
surgeon of the future—viz: Abdominal 
Surgery on the Battlefield. 
is not exhausted and further studies 
must be made to furnish the final posi- 
tive demonstrations. 
During the beginning of our Civil 
War, our infantry was supplied with 
the old Springfield muzzle loader. The 
bullet was conical and had a diameter 
of fifty-eight hundreths of an inch and 
a length of about one inch, and was 
fired at a velocity of about one thousand 
feet a second. The Karg-J-uirensen, 
and similar small calibre gui.s made 
to fire a jacketed bullet about an 
inch and one-third in length, and only 
thirty hundreths of an inch in diameter. 
The modern bullet consists of a jacket 
of thin steel, or of German silver, fill- 
ed with lead and nickel plated. Its 
construction is such that it is but 
little deformed even in striking the 
hardest substances and as the smokeless 
powder imparts to them a velocity dou- 
ble of that of the old bullet, it is less 
liable to deviate from its original course 
and produces much less laceration of 
soft parts and comminution of bone. 
The wounds inflicted resemble more 
closely incised than lacerated wounds. 
The old bullet produced more laceration 
and shock than the new missile. The 
new bullet inflicts wounds which resem- 
ble the injuries caused by the old 
weapons within a distance of 350 yards, 
and as most of the wounds will be pro- 
duced at a greater distance the surgeon 
will have to deal with injuries resembling 
incised or punctured wounds. The 
bullet will also be less liable to carry 
before it infected foreign substances 
and to lodge in the body, consequently 
the 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 the 
efficient treatment of wounds of the 
extremities all are agreed as to the best 
course of treatment to be pursued. 
Rigid antiseptic and aseptic measures 
Since the close of the last great wars 
the inventive genius has been busily 
engaged in devising new weapons and 
other implements of destruction. The 
smokeless powder and the jacketed small 
calibre bullet have revolutionized mod- 
ern warfare. Rapid firing at a greater 
range and certainty of aim will make 
the battles of the future of short dura- 
tion, but the Joss of life and the num- 
ber of disabled and maimed will be 
greater than ever. The wounds that 
will come under treatment on the bat- 
tlefield will present an entirely different 
aspect, and will demand different treat- 
ment than those inflicted by the old 
weapons. The new bullet, by virtue of 
its greater velocity and penetrating 
power, will either produce speedy death 
or the injury which it inflicts will be 
more amenable to successful treatment 
because it produces less contusion of 
the soft tissues and splintering of bone 
than the leaden bullet used in 
the past. Beck, Bruns, Delorme, Tan- 
gier, Roget, Bardeleben, Helferich, 
Kocher, La Garde, Griffith, and others 
have made careful experimental re- 
searches concerning the effect of the 
new projectile upon the different tissues 
at variable distances, but this subject ABDOMINAL SURGERY ON THE BATTLE-FIELD 
3 
will be carried oat at the first dressing 
station and rest will be secured by ex- 
temporized means of immobilization and 
the patients sent to the rear with a 
message informing the hospital surgeons 
whether or not the, first dressing must 
be changed or whether more efficient 
antiseptic measures are required, or 
complications to be treated. Very little 
has been done so far in the way of 
aggressive surgical interference for 
heroes who fell mortally wounded in 
the line of battle in the defense of their 
country, their ruler, their families, their 
homes and their rights. The time has 
to direct means of haemostasis. In 
future wars it should be made the sa- 
cred dot}- of every civilized nation to 
do all that modern surgery can accom- 
plish in the treatment of perforating 
gunshot wounds of the abdomen at the 
first dressing station located as near as 
possible to the fighting line. Every 
soldier who has been in active military 
service can recall instances where com- 
rades dropped in the ranks with a mor- 
tal bullet wound of the abdomen, who 
lived for several hours and died from 
hemorrhage, 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 scenes 
were photographed by Captain Ives and Lieutenant Newgarden at Fort Sheridan.] 
come when in case of war adequate 
provisions should be made on the field 
of battle near the fighting line for the 
prompt treatment of perforating gun- 
shot wounds of the abdomen. It is 
difficult to conceive how many valuable 
lives have been sacrificed on the field of 
battle during the innumerable bloody 
conflicts recorded in the history of the 
world which now could be saved by 
prompt and efficient surgical interfer- 
ence. Thousands of lives have been 
lost from internal hemorrhage alone 
which at the present time could be 
saved by abdominal section and resort 
flict. Justice, patriotism, humanity 
and the present status of abdominal 
surgery demand that in future wars a 
well regulated hospital corps shall ren- 
der efficient first aid, promptly convey 
the severely wounded to the first dress- 
ing station where they can receive fur- 
ther surgical aid, and where, if die they 
must, the last hour of their life shall be 
peaceful, surrounded by those who will 
add to their comfort and administer 
words of consolation as the immortal 
spirit leaves the maimed body for its 
eternal resting place. It is my firm 
conviction that military surgeons will 4 
N. SENN 
follow the precepts and practice of the 
progressive and aggressive civilian sur- 
geons in the treatment of visceral in- 
juries of the abdominal cavity on the 
first opportunity that presents itself. 
To permit a wounded soldier to die 
from hemorrhage of a wound of one of 
the abdominal organs, which otherwise 
would not prove a source of immediate 
or remote danger, is in conflict with 
the duties of the country to its defend- 
ers, and a reproach upon modern surgi- 
cal practice on the battlefield. 
bulance station in some protected lo- 
cality and sufficiently to the rear of 
the fighting line to be out of range of 
the small arm bullets. From here the 
members set out with litters and sup- 
plied with the necessary articles to 
render the first aid. Each member 
should be able to make a quick and 
reliable diagnosis between shock and 
the complexus of symptoms resembling 
shock produced by internal hemorrhage. 
In shock the maximum ap- 
pear immediately after the receipt of 
the injury while in hemorrhage the 
symptoms gradual!} 7 increase in inten- 
sity with the loss of blood. This dis- 
tinction has an important practical 
bearing as the administration of stimu- 
lants increases the danger from hemor- 
rhage while it mitigates the symptoms 
of shock. The treatment of internal 
hemorrhage should receive attention 
on the part of those who first come 
in contact with the wounded. The 
patient must be kept in the recumbent 
position and should be cautioned not 
to make the least muscular exertion. 
The first aid in such cases should con- 
sist of measures best calculated to 
retain within the blood vessels as much 
blood as possible and to place the vis- 
ceral wound in the best possible condi- 
tion for the formation of a thrombus. 
Two leading indications will present 
themselves in the treatment of penetrat- 
ing gunshot wounds of the abdomen. 
(1) Arrest of hemorrhage. (2) Direct 
treatment of visceral wounds. 
The timely treatment of visceral in- 
juries of the abdomen on the battle- 
field will require improved facilities for 
transportation of the wounded and an 
adequate hospital corps force to render 
the first aid and transport the wounded 
to the first dressing station and later to 
the field hospital. In the regular army 
a faithful effort is now made to build 
up an efficient and well-equipped hospi- 
tal corps. The Surgeons of the Na- 
tional Guard should use their influence 
in securing uniform legislation in every 
State of the Union looking toward the 
organization of a similar special mili- 
tary service. So far but little has been 
done in this direction. The hospital 
corps service should be modelled as 
closely as possible after that of the 
regular array. The members of the 
corps should, of course, be non-combat- 
ants and well instructed in their special 
work. The members should at least 
possess a good common school educa- 
tion and sufficiently familiar with minor 
surgery to act as trustworthy assistants 
in emergency operations. During the 
beginning of an engagement the hospi- 
tal corps under the command of the 
officer in charge is stationed at the arn- 
I know of only two indirect means 
to 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 one 
or more extremities sufficiently firm to 
arrest both the arterial and venous 
circulation will preserve the blood con- 
tained in the extremity at the time the 
constrictor is applied and will lighten 
the heart’s action to an extent corres- 
ponding with the amount of blood ex- 
cluded in this manner from the general 
circulation. In this manner a sufficient 
amount of living blood could often be ABDOMINAL SURGERY ON THE BATTLE FIELD 
First Dressing Station. 
retained in the body to carry on the 
functions of life after the cause of 
bleeding has been removed by direct 
hemostatic measures. The wounds of 
entrance and exit are covered with an 
antiseptic pad. The suspenders of the 
wounded soldier, the gun-strap, the 
belt, or strips of his clothing could be 
used to make the adequate number of 
circular constrictions. Direct pressure 
over the wounded organ will diminish 
its vascularity, and bring the tissues of 
the tubular wound in contact, condi- 
tions which will favor spontaneous arrest 
of 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 an 
antiseptic pad a compress composed of 
the canteen, the cartridge box or an 
article of clothing and held in place by 
the belt, the gun-strap, suspender or 
a strip of clothing. After such tem- 
porary aid the patient should be trans- 
ported as quickly as possible from the 
fighting line to the ambulance station 
and from there to the field hospital. 
For obvious reasons the first dressing 
station is not the place for operations 
upon any of the abdominal organs. 
The ever varying position of the line 
of battle, the inadequate supply of in- 
struments and dressing materials as 
well as the exposure more or less to the 
dangers incident to active warfare pro- 
hibit any operations requiring abdomi- 
nal section in such close proximity to 
the danger line. Patients suffering from 
penetrating wounds of the abdomen 
should be transported on the same litter 
in the ambulance from the battle-field 
to the field hospital, as gently and as 
quickly as circumstances will permit. 
The new weapons will make it necessary 
to establish the first dressing station and 
the field hospital at a more distant point 
behind the fighting line than hereto- 
fore. The first dressing station should 
be in some protected place, in a ravine 
or behind a building while the latter 
should be in a place farther in the rear 
entirely out of reach of the infantry 
fire and in a place protected against the 
fire of artillery. While I am extremely 
anxious to impress upon the members 
of this Association the importance and 
justifiability of abdominal section up- 
on the battle-field as a life-saving opera- 
tion I am equally conscious of the 
responsibility which accompanies the 6 
N. SENN. 
teaching and practice of such a new 
departure in military service. The in- 
discriminate adoption of such a prac- 
tice by all military surgeons would in 
all pi obability increase rather than 
diminish the mortalitj' of penetrating 
wounds of the abdomen. Abdominal 
section under such trying circumstances 
i-equires an unusual degree of moral 
courage and special skill. Surgeons to 
whom such a task will be assigned must 
be thoroughly prepared for their work. 
of the medical service men who will be 
competent to perform the most difficult 
operations upon any of the abdominal 
organs at a moment’s notice with the 
simplest instruments, with few assis- 
tants and the most primitive surround- 
ings ; with such a nucleus abdominal 
surgery in military practice will soon 
become a favorite subject for discussion 
and the battlefield of the future will 
bring new laurels upon the many 
achievements of modern surgery. 
The correct diagnosis and proper treat- 
ment of gunshot wounds of the stomach 
and intestines require a degree of skill 
and dexterity which can only be acquired 
by operations on the cadaver and experi- 
ments on the lower animals. 
Operative courses on the cadaver are 
valuable and useful, but they never can 
take the place of experiments on the 
living animal in acquiring a practical 
knowledge of abdominal surgerj'. This 
is more especially true in reference to 
the required manual dexterity in the 
surgical treatment of internal hemor- 
rhage and wounds of the abdominal 
viscera. A certain amount of experi- 
mental experience is absolutely required 
in the preparation of the surgeon for 
this kind of abdominal work which re- 
quires not only courage, good judg- 
ment, and a thorough knowledge of 
every step in diagnosis and treatment, 
but also a certain manual dexterity 
which cannot be acquired in any other 
way. We can hardly hope that every 
military surgeon will acquire the nec- 
essary qualifications for such work. 
Nor is this necessary. Abdominal sur- 
gery on the battlefield will constitute 
only a small part of the work required 
of the surgeons during an engagement. 
Many penetrating wounds of the abdo- 
men will prove speedily fatal. Those 
cases which survive the immediate ef- 
fect of the injury and are in a condition 
to justify abdominal section will be 
comparatively few. The abdominal work 
should be done by surgeons who possess 
special skill and experience. At least 
one surgeon in every brigade should be 
stationed at the field hospital whose 
duty it should be to superintend the 
An accurate knowledge of the anatomy 
and topography of the abdominal organs 
is an essential prerequisite to thestudent 
of abdominal surgery. The necess- 
ary manual dexterity can only be ac- 
quired by actual work and practical 
demonstrations. No amount of reading 
and hearing will bring the necessary 
skill. Even the minutest descriptions 
of the details to be observed and ap- 
plied in the diagnosis and treatment of 
gunshot wounds of the abdomen are 
utterly inadequate to prepare a surgeon 
to interpret correctly the symptoms 
and signs presented by penetrating 
gunshot wounds of the abdomen, or to 
meet the often unexpected emergencies 
in their treatment. The establishment 
of the Army and Naval Medical Schools 
is a source of congratulation not only 
to the respective services of the Govern- 
ment but also to every surgeon of the 
National Guard. To them we shall look 
foremost for the needful advancements 
in military surgery. They should and 
will be the authoritative exponents of 
the much needed improvements of sur- 
gery on the battlefield. I trust they 
will in their curriculum include instruc- 
tion that will prepare in each branch ABDOMINAL SURGERY ON THE BATTLE-FIELD 
preparations and perform the operations 
The most successful laparotomists need 
the fewest assistants and instruments. 
In military practice their example should 
be followed. During an engagement 
on a large scale the surgeons and mem- 
bers of the hospital corps are always 
overtaxed, by urgent demands from all 
directions. Excitement and confusion 
reign everywhere. The deafening roar 
of the artillery, the rattling of the infan- 
try, the commands of the officers, the 
groans of the wounded, the rumbling of 
the ambulances are well calculated to 
corps, a laparotomy for gunshot wound 
of the abdomen can be made quickly 
and successfully provided careful pre- 
parations have been made beforehand. 
Preparations for Operation. 
The field-hospital will be either a 
building used temporarily for hospital 
purposes or a hospital tent. In the 
former case the operating room should 
be cleared of all furniture and drap- 
eries, the floor, walls and ceiling 
sprinkled with a strong solution of 
carbolic acid or corrosive sublimate. 
Ambulance Station. 
excite curiosity and to deviate the no- 
vices from the strict line of duty. It 
is under such circumstances that the 
surgeon who is to perform the most 
difficult operations in surgery must be 
in full possession of all of his mental 
faculties if his work is to save many of 
the lives placed in immediate jeopardy 
from the effects of the enemy’s bullets. 
Ample preparation must be made be- 
forehand otherwise valuable time is lost 
and man}7 lives sacrificed that might be 
saved by prompt action. With two 
skilled assistants, an assistant sur- 
geon, and a member of the hospital 
A portable sheet-iron stove heated by 
coal oil will answer the purpose of 
heating the room and sterilizing the 
instruments and the water used during 
the operation. Two large tin pails, one 
for cold and the other for hot sterilized 
water and three large wash-basins of 
granite ware, and a dipper of the same 
material will answer the purpose of 
handling the antiseptic solutions and 
sterilized water. Sterilized gauze 
should take the place of sea sponges. 
The instrument case that I devised 
some time ago and which I have called 
the emergency pocket operating case, 8 
N. SENN. 
contains all the instruments needed and 
as it contains needles and the neces- 
sary suture material everything in the 
way of instruments, ligatures and su- 
tures can be rendered absolutely sterile 
by placing the case for fifteen minutes 
in boiling water to which has been ad- 
ded one per cent, of carbonate of soda. 
The case is then taken out and after 
pouring out the water it is placed on 
the stove until its contents are dry, 
when they are placed upon an extem- 
porized table covered by an aseptic 
towel. The hands of the operator and 
assistants are in the meantime rendered 
aseptic in the usual manner. During 
the operation the instruments are to be 
cleansed as often as necessary in steri- 
lized water and laid upon the towel 
until needed by the operator. The 
best operating table will be the litter 
operating table. This table is compos- 
ed of the litter upon which the patient 
is brought to the hospital placed upon 
the extension frame. Folding camp- 
stools will answer the purpose of tables 
for the wash-basins and instruments. 
Bricks, stone, sand or earth can be 
heated on the stove and will answer an 
excellent purpose in supplying the ex- 
tremities with artificial heat during and 
after operation. The necessary stimu- 
lants, alcohol, camphor, nitrite of amyl, 
ammonia and strychnine should always 
be on hand to counteract the symptoms 
of shock. One assistant administers 
the anaesthetic while the other hands 
the instruments, handles the gauze 
sponges and otherwise assists the op- 
erator. A number of gauze compresses 
must be kept in readiness. During 
the operation sterilized water is used 
exclusively. If flushing is indicated 
this can be done by pouring warm 
water from a basin. During the opera- 
tion the patient should be placed in 
a slightly inverted position for the 
purpose of increasing the blood supply 
to the vital organs and diminishing 
the tendency to prolapse of the intes- 
stine. 
In the future the differential diag- 
nosis between penetrating and non- 
penetrating wounds of the abdomen 
will be attended by less uncertainty 
than in the past, as in most instances 
the bullet will pass through the body in 
a straight line and the wounds of en- 
trance and exit will indicate whether 
or not the abdominal cavity has been 
invaded. Prolapse of the abdominal 
organs, owing to the smaller size of 
the bullet wound, will be less frequently 
observed. If an operation is decided 
upon and the patient suffers from 
shock, one-twenty-fourth of a grain 
of strychnine should be given subcu- 
taneously before the administration of 
the anaesthetic. No time should be 
lost in removing the patient’s clothing, 
as such a procedure would tend to in- 
crease the Hemorrhage and add to the 
existing shock. The boots or shoes 
should be removed and artificial heat 
applied to the feet, the abdomen laid 
bare, rolling pants and drawers down- 
ward sufficiently far to expose the pubes 
and the remaining clothing upward far 
enough to bring into view the costal 
arches on both sides. After the patient 
is fully under the influence of the 
amesthetic, the abdomen is rapidly 
disinfected by washing with warm 
water and potash soap, shaving, wash- 
ing with a 1:1,000 solution of sublimate 
and finally with alcohol or ether. The 
clothing in the vicinity of the abdomen 
is then covered with dry aseptic towels. 
Unless contraindications exist, the ab- 
domen is opened in the median line as 
this incision affords the most ready 
access to the injured organ. In per- 
forating wounds of the abdomen, pro- 
fuse hemorrhage is more frequently of 
parenchymatous and venous llin ar 
Operation. ABDOMINAL SURGERY ON THE BATTLE-FIELD 
9 
terial origin. Gunshot wounds of the 
liver, spleen, kidneys, and the mesen- 
tery give rise to profuse and often fatal 
hemorrhage. After opening the perito- 
neal cavity it is often very difficult to 
find the bleeding points, as the blood ac- 
cumulates as rapidly as it is sponged 
away, and it becomes necessary to re- 
sort to special means in order to arrest 
temporarily the profuse bleeding suffi- 
ciently to find the source of hemorrhage. 
One of two resources should be em- 
ployed: (1) Digital compression of 
the aorta. (2) Packing of the abdomi- 
nal cavity with a large number of gauze 
compresses. Digital compression of 
the aorta below the diaphragm can be 
readily made by the assistant introduc- 
ing his hand through the incision, 
which in such cases must be larger 
than under ordinary circumstances. 
Compression of the abdominal aorta 
immediately below the diaphragm will 
promptly arrest the hemorrhage from 
any of the abdominal organs for a suffi- 
cient length of time to enable the sur 
geon to find the source of hemorrhage 
and carry out the necessary treatment 
for its permanent arrest. Hemorrhage 
from a perforated lacerated kidney may 
demand a nephrectomy. If an injury 
of this nature is associated with a 
wound of the abdominal cavity the 
organ will probably be removed by 
laparotomy. If this method is employ- 
ed the wound of the parietal peritoneum 
is sutured, and if necessary drainage 
established by a counter opening in the 
lumbar region. A similar wound of the 
liver is cauterized with the actual cau- 
tery, sutured or tamponned with along 
strip of iodoform gauze, one end of 
which is brought out of the external 
wound. 
At the last meeting of the German 
Congress of Surgeons, von Bergmann 
spoke strongly in favor of the suture 
as a haemostatic agent in the treatment 
of wounds of the liver. He asserted 
that Glisson’s capsule offered enough 
resistance to the sutures, while a num- 
ber of other surgeons gave it as their 
opinion that the sutures would tear 
through. A round needle should be 
used invariably in suturing such a vas- 
cular organ as the punctures are less 
liable to bleed than if the ordinary sur- 
gical needle is used. It appears to me 
that on the battlefield the tampon should 
be 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 the 
same time the useful purpose of an effi- 
cient capillary drain. The use of the 
cautery is of course not to be thought 
of in the treatment of tubular wounds, 
and its employment will consequently 
be restricted to wounds of the surface 
of the organ or its lower border. A 
wound of the spleen, if the hemorrhage 
cannot be arrested by the antiseptic 
tampon, necessitates splenectomy as 
the tissues of this organ are too fragile 
for the successful employment of the 
suture as a haemostatic agent. Hemor- 
rhage from the pancreas must be con- 
trolled by antiseptic tamponnade, as 
this organ is not sufficiently accessible 
to permit ligation or suturing without 
too extensive eventration and too great 
a loss of time. Very troublesome hem- 
orrhage is often met with from wounds 
of the mesentery. The mesenteric 
veins are comparatively large in size, 
and the tissues surrounding them are 
not well adapted to effect spontaneous 
arrest of hemorrhage. When multiple 
perforations of the mesentery and vis- 
ceral wounds of the stomach and intes- 
tines are the source of hemorrhage, it 
is a good plan to pack the abdominal 
cavity with a number of large gauze 
compresses, each secured by a strip of 
gauze which should be brought out of 
the wound to facilitate their removal, 
and as a safeguard against losing or 
forgetting them in the abdominal cav- 
ity at the completion of the operation. 
The compresses make sufficient pres- 
sure to arrest parenchymatous oozing as 
well as venous hemorrhage if they are 
placed at different points against the 
mesentery and between the intestinal 
coils. The compresses are removed 
one by one from below upwards and 
the bleeding points secured as fast as 
they are uncovered. The ligation of 
mesenteric vessels, both arteries and 
veins, should be done by applying the 
ligature en masse. Thornton’s curved 
haemostatic forceps, or the ordinary an- 
eurism needle, is the most useful in- 
strument for this purpose. Catgut 
should never be relied upon in tying 
mesenteric or omental vessels, as this 
material for several reasons which it is 
not necessary to mention here, is great- 
ly inferior to fine silk. The omentum 
and mesentery must be tied in fine sec- 
tions, the ligatures firmly drawn, and 
if a part of either of these is excised 
the incision should be made at least 
half an inch from the ligatures to pre- 
vent their slipping. Troublesome hem- 
orrhage from a large visceral wound of 
the stomach and intestines is best con- 
trolled by hemming the margin of the 
wound with fine silk. If hemorrhage 
is profuse from any of the causes which 
have been enumerated, this must be 
attended to before anything is done in 
the way of finding or suturing of the 
visceral wounds. 
, Treatment of Visceral Wounds. 
Clinical experience and experimental 
research have demonstrated beyond all 
doubt that visceral wounds of the stom- 
ach and intestines large enough to give 
rise to extravasation are with but very 
few exceptions mortal injuries. The 
danger arising from such wound is, of 
course, much greater when the organ 
injured is in a condition of active 
physiological function; on the other 
hand, if the organ is in a state of rest 
extravasation is less liable to occur and 
consequently a greater possibility of 
spontaneous healing of the visceral 
wound. For this reason we find numer- 
ous records of recovery from pistol- 
shot wounds of the stomach, this organ 
having been empty at the time the in- 
jury wTas received. More numerous are 
the instances in which patients have 
recovered from perforating wounds of ABDOMINAL SURGERY ON THE BATTLE-FIELD 
11 
the abdomen in which the clinical symp- 
toms did not indicate the existence of 
any visceral injuries. I have been con- 
vinced for years that a bullet passing 
through the abdominal cavity does not 
produce visceral injuries as constantly 
as we have been taught to believe. 1 
made fourteen experiments on the cada- 
ver for the purpose of ascertaining the 
comparative frequency of visceral in- 
juries in perforating wounds of the 
abdomen. In four of these experiments 
the bullet passed through the abdomi- 
nal cavity in an antero-posterior direc- 
would tend to destroy life. In regard 
to the direction of the bullet, it may be 
said 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 have 
escaped injury, while if it has passed 
from side to side or obliquely at a point 
below the umbilicus, it is not only al- 
most certain that it has injured the 
intestines, but it is almost equally cer- 
tain that it has produced from three to 
sixteen perforations. 
The treatment that has been advised 
Laparotomy on the Battle-field. 
tion without producing any visceral 
injury which would require surgical 
interference. In two out of six cases 
of penetrating gunshot wound of the 
abdomen that have come under my own 
observation laparotomy revealed the ab- 
sence of visceral wounds. Laparotomy 
should not be performed simply because a 
bullet has entered the abdominal cavity, 
but its performance should be limited to 
the treatment of intra-abdominal lesions 
which, without operative interference, 
for the arrest of hemorrhage from the 
liver, spleen, pancreas and kidneys is 
about all that can be done for gunshot 
wounds or these organs. A more com- 
plicated and difficult task confronts the 
surgeon in the treatment of visceral 
wounds of the gastro-intestinal canal. 
If the location of the wound of entrance 
and direction of the bullet indicate the 
existence of a wound of the intestinal 
canal below the ileo-caecal valve, a 
speedy and positive diagnosis can be 12 
N. SENN. 
made after the patient is under the 
influence of the anaesthetic, by insuffla- 
tion of air per rectum. If this test 
yields a positive result, median laparo- 
at once, the lowest perforation located 
by rectal insufflation. When this has 
been done the air from the intestinal 
canal 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, the 
wounds located by the same test and 
sutured. In the majority of cases two 
wounds will be found. If the small 
intestines are out of range of the track 
made by the bullet, further search for 
perforations is not only unnecessary, 
but harmful. Careful toilet of the 
peritoneal cavity in the vicinity of the 
intestinal wounds by flushing or mop- 
ping is always necessary in such cases. 
If considerable extravasation has taken 
place, drainage should be provided for 
in addition. If the direction of the 
track of the bullet is such that it is 
probable that the small intestines are 
injured the abdomen should be opened 
removed as far as possible, when the 
insufflation is made from this point in 
an upward direction in search of addi- 
tional perforations. If additional per- 
forations are found, the intervening 
portion 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 by 
this method. Extensive eventration is 
prevented 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 an 
undiscovered wound which has in so 
many instances been the immediate 13 
ABDOMINAL SURGERY ON THE BATTLE-FIELD. 
cause of death after laparotomy for 
gunshot wounds of the abdomen. If 
the wound of entrance and direction of 
the 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 most 
valuable diagnostic measure, and is 
occasionally the only way by which a 
second perforation of this organ can be 
detected, as is the case if it involves 
the smaller curvature or the posterior 
wall. The suturing of the wound is 
done in the quickest possible time and 
in the simplest manner. If bleeding 
has not ceased it is arrested by hemming 
a number of wounds are found in close 
proximity. In such cases extravasa- 
tion during the operation is prevented 
by constricting the bowel on each side 
with a strip of gauze passed through a 
small button hole in the mesentery 
close to the bowel, made with a pair of 
hsemostatic forceps and tied sufficiently 
firm to prevent escape of intestinal 
contents. If any part of the sutured 
bowel presents conditions that might 
endanger the healing process, it should 
be covered by an omental graft. The 
operation must be completed as rapidly 
as 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 continued 
suture of fine silk. 
ternal wound must be completed with 
as little delay as is compatible with the 
safety of the operation. A single row 
of sutures including all of the tissues 
of the abdominal incision, will answer 
the purpose in closing the external in- 
cision. The omentum must invariably 
be drawn down sufficiently far to 
cover the abdominal incision, as this 
procedure is best calculated to pre- 
vent subsequent adhesions of the 
remaining abdominal organs to the 
inner 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 the 
means of preventing death from this 
source. The solution should be pre- 
pared by dissolving in a quart of warm 
sterilized water the requisite quantity 
The closure of the wound is effected 
Lembert stitches, about six to the 
inch, which must include a few fibers 
of the firm sub-mucous coat on each 
side. Trimming of the contused mar- 
gins is superfluous. An ordinal sew- 
ing needle and fine-braided silk should 
be used in suturing the visceral wounds. 
As a rule the line of suturing should be 
made transversely as stenosis is less lia- 
ble to occur and the vascular supply to 
the parts coaptated is less likely to be 
compromised than would be the case if 
the wound is closed in a direction par- 
allel to the long axis of the bowel. 
Enterectomy and circular suturing may 
become necessary if the wound involves 
the mesenteric side of the bowel, or if N. SENN. 
of pure sodic chloride, kept in readiness 
for this purpose. The after-treatment 
must have in view mainly to meet the 
symptoms of shock caused by the in- 
jury and the operation. Rest, external 
dry heat, subcutaneous injections of 
strychnine and alcoholic stimulants will 
meet this indication most satisfactorily. 
Absolute diet for the first three or four 
days with rectal alimentation constitute 
an essential part of the after-treatment. 
modern surgery will be to extend the 
recent achievements of abdominal sur- 
gery to the battlefield. I am painfully 
conscious of the fact that the profess- 
ional military surgeons will regard the 
suggestions that I have made in this 
direction as immature and imperfect, 
but if I have succeeded in awakening 
their interest in this matter the princi- 
pal object in the preparation of this 
address will be realized. 
Author’s Pannier and Dressing-Case. Weight including contents, 70 pounds 
All articles contained in Aluminum cases. 
A saline cathartic should be given as 
soon as tympanites makes its appear- 
ance regardless of the length of time 
that has intervened since the operation. 
I am firmly convinced that abdominal 
surgery has a great future in military 
practice. It is the duty of the proper 
military authorities to make ample pro- 
vision for initiating a well-matured plan 
of procedure calculated to save occas- 
ionally a life upon the battle-field in 
cases heretofore beyond the reach of 
surgery. The nations that spend mil- 
lions of dollars annually in perfecting 
their methods of warfare should not re- 
main unconscious of their full duty to 
the wounded of future conflicts, and 
one of the most urgent demands of 
In conclusion permit me to formulate 
the salient ideas on this subject in the 
following conclusions: 
1. Abdominal surgery will extend its 
life-saving work to the battlefield of 
future wars. 
2. The treatment of dangerous inter- 
nal hemorrhage and visceral wounds of 
the abdominal organs by laparotomy in 
military practice is a justifiable and 
legitimate procedure, which merits the 
earnest consideration of every military 
surgeon and deserving of the most seri- 
ous attention of the proper military 
authorities of all civilized nations. 
3. The first aid to those suffering 
from gunshot wound of the abdomen 
and in which life is threatened by hem- ABDOMINAL SURGERY ON THE BATTLE-FIELD. 
15 
orrhage should consist in compression 
over the injured part and auto-transfu- 
sion by circular constriction at the base 
of one or more extremities. 
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 injured 
4. Operative treatment of gunshot 
wounds of the abdomen should be re- 
sorted to promptly in appropriate cases, 
and for this purpose the wounded should 
be transported from the fighting line to 
the field hospital with great care and 
without delay. 
organ. 
10. Wounds of the stomach and in- 
testines large enough to permit extrava- 
sation with very few exceptions result 
in death, and should therefore be sub- 
jected to direct operative treatment 
before serious complications set in. 
5. The field hospital should be equip- 
ped with the necessary instruments and 
outfit to perform aseptic operations. 
11. Distension of the stomach and 
colon by insufflation of air before 
Author’s Emergency Pocket Operating Case 
6. After opening the peritoneal cavity 
by a median incision temporary haem- 
ostasis can be secured for the purpose 
of arresting dangerous arterial hemor- 
rhage by digital compression of the 
aorta below the diaphragm and venous 
hemorrhage or parenchymatous bleed- 
ing by sponge compression. 
laparotomy and of the small intestines 
through one or more perforations after 
the abdomen has been opened, is a 
valuable diagnostic test. 
12. Wounds of the stomach and in- 
testines can be quickly and safely closed 
by one row of sero-muscular sutures 
including a few fibers of the submu- 
cous fibrous coat. 
7. Permanent haemostasis must be 
secured by ligature or aseptic tarnpon- 
nade. 
18. The after-treatment should con- 
sist of such measures as will most suc- 
cessfully combat the symptoms of shock 
and secure rest for the injured organ. 
8. Visceral wounds of the liver and 
pancreas are amenable to successful