SURGEKY. 720 SURGERY. all former methods of treatment as to lead to the now thoroughly established maxim formulated by Senn in the recent war between the United States and Spain, "The fate of the wounded rests in the hands of the one who applies the first dressing." The lesson has only recently been learned that bullet woimds must never be touched on the field — much less explored by probing or otherwise — before the first aid (antiseptic) dressing is applied. Operative interference is justifiable on the battlefield only in cases of ex- treme urgcnc_y, where extensive hemorrhage ex- ists, or where the -wound is in the region of the throat and suffocation is inuninent. As a rule gunshot wounds are bloodless. Primary hemor- rhage, unless resulting from the very rare acci- dent of cutting some lai'ge vessel, is usually ab- sent altogether, or can readily be controlled by a compress or first aid bandage. Especially in ■n'ounds of the abdomen the law of non-interfer- ence applies with double force. In the Spanish- American War 50 per cent, of all the cases of abdominal wounds unoperated upon recovered, while all operated upon died. In the Russo-Tur- kish War, that great apostle of conservatism in military surgery, Von Bergman, by the use of occlusive dressings, immobilization of the limb, and antiseptic precautions, saved thirteen out of fourteen cases of severe gunshot womids of the knee-joint complicated with extensive comminu- tion of the bone, while of similar cases treated by the old method of exploration without anti- septic precaution 95 per cent. died. Observations during the recent Spanish-Ameri- can War and the Boer War have led to the following deductions: (1) Small-calibre bullet wounds are usually aseptic and heal promptly. (2) Jagged and extensive wounds, poisoned by such missiles, are due to the detachment of the jacket, the introduction into the bullet of for- eign particles (such as cloth, buttons, etc.), lat- eral impingement of the bullet, or ricochet. (3) Owing to the small diameter of the bullet and its great velocity, the orifices at entrance and exit are minute, and it is almost impossible to dis- tinguish one from the other. (4) The cardinal principle has been established that manipulation of such wounds an<l probing on the field (except in the rarest instances) is surgical malpractice. To Esmarch is really due the latest conception of the axiom 'laissez aller,' and his first aid pack- age is a memorial to his practical grasp of the principles of wound infection. The first aid package has been modified by Senn. of Chicago, who emphasizes his conclusions as follows: (1) First aid packages are indispensable on the bat- tlefield in modern warfare. (2) The first aid dressing must be sufficiently compact and light to be carried in the skirt of the uniform, or on the inner surface of the cartridge or sword belt, to be of no inconvenience to the soldier or in con- flict with military regulations. (3) The Esmarch triangular bandage is of great value in the school of instruction, but as a component part of the first aid package it is inferior to the gauze band- age. (4) The first aid package nrast contain in a waxed aseptic envelope an antiseptic powder, such as borosalicylie powder; two strips of aseptic lintine. each 2if; X 4 inches; a triangu- lar piece of gauze, the diagonal half of a square yard; sterilized pins wrapped in tin foil, and be- tween this package and the outside impermeable cover, two strips of adhesive plaster an inch wide and eight inches long. (5) The first aid dressing must be applied as soon as possible after the re- ceipt of the injury, a part of the field service which can be safely intrusted to competent hospi- tal corps men. (6) The first aid dressing, if em- ployed on the firing line, should be applied with- out removal of the clothing over the injured part, and fastened to the surface of the skin w-ith strips of rubber adhesive plaster, the bandage being ap- plied over and not under the clothing. (7) The first aid dressing must be dry and should remain so by dispensing with an impermeable cover of any kind over it, so as not to interfere w-ith free evaporation of the wound secretion. (8) The first aid dressing should not be disturbed un- necessarily, but any defects should be corrected at the first dressing station. Suppurating wounds from small-calibre bullets, having high velocity, heal with comparative promptness. Wounds from such bullets are necessarily more humane and less painful than those from the older missiles; but the relative percentage of deaths to wounded is but slightly reduced. Unless unusual complications call for immediate surgical interference, the injured should be removed as rapidly as possible to a well-equipped base or general hospital for treat- ment. Penetrating abdominal and thoracic wounds give a vastly larger percentage of recov- eries where non-interference has been observed. Laparotomy, except under the most favorable conditions, such as hold in well-equipped hospi- tals, is attended with great peril. The Rontgen ray has been of utility in indicating where surgi- cal interference is justified and in many cases has averted infection which would result from probing or similar surgical procedures. It has also thrown light on the pathology of wounds in- volving the solid structures, and shown that the severest lesions of bones will progress toward recovery, provided the wound is sterile. It proved an invaluable aid in the Spanish-Ameri- can War, in the Boer War, and in the Philip- pines, where it was used in general hospitals at the base of operations and on hospital ships ; but it is not a practical apparatus near the firing line, where its use in the detection of bullets could only prove an incentive to premature opera- tions. The modern jacketed bullet is practically aseptic ; there is never urgency for its removal except where aseptic technique is possible, other- wise infection of the wound is an inevitable con- sequence. The Rontgen ray was also of especial scientific value in gunshot fractures by showing the character of the bone lesions, the form of the fracture, and the amount of bone coiiuiiinution by small-calibre bullets, fragments of shells or other missiles, conditions that could not have been otherwise determined in the living body, thus also proving an important factor in developing the principle of conservatism in surgery of war. It is to Pasteur and Lister that military sur- gery owes its greatest debt. They have simplified its labors and taught the great lesson of non- interference. The soldier who falls on the battle- field from the effect of a ball passing through any but a vital part of his anatomy and who has a 'first-aid' dressing promptly applied and is then transported to a general hospital where the Rontgen ray and the principles of asepsis and antisepsis can be utilized, has a far greater chance of recovery than when his wounds are treated on the field. By following these conserva-
