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Gunshot Wounds in the American War

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GUNSHOT WOUNDS IN THE AMERICAN WAR. This paper has been prepared from the record of 1596 cases of gunshot wounds admitted to the First Reserve Hos pital, Manila, Philippine Islands, during the Philippino-Ameri can War, and is supplemented by the personal notes of 462 of these cases occurring during the author's service as operating surgeon. This number is approximately the total of casualties from gunshot wounds up to May 1, i9oo, received by the Eighth Army Corps in the pacification of the islands, and exceeds the total number of gunshot wounds in the whole Spanish-American War.

Until within the past few months, all of the sick and wounded were treated in the Manila hospitals, consequently, the opportunity for studying the effect of the modern high velocity projectile has been unusually great. The statements herein made are from personal observation and actual record of gunshot wounds on the living, and have not been influenced by the opinions of theoretical writers, nor by experimental work on the cadaver. The effort has been made to report facts.

From August I, 1898, to May I, 1900, 22,181 patients were received at the First Reserve Hospital in Manila. Only a little over 7 per cent. of this number had gunshot wounds. The hardy character of the American volunteers is well at tested by the fact that the percentage of sickness among them was less than that of the regular army ; while of the total number of wounded, 59 per cent. were volunteers. It must be borne in mind, however, that the regular army was just recuperating from the severe Cuban campaign, and was scarcely in fit condition to stand trying service in the tropics. The volunteers, by their own wish, were early kept more on the firing-line, leaving the drudgery of patrol and garrison duty to the regular troops. Both were equally brave, and of both the American people may well be proud.

Self-Inflicted Wounds. In this immense army of 65,000 men there were but fifty-nine cases of intentional self-inflicted gunshot wounds. Of this number but twenty-one were among the volunteers and thirty-eight among the regular troops. In our army cowardice is unusual, yet the fear of an approaching engagement was occasionally so intense among raw recruits that this means was taken of attaining disability. As in the Civil War, the first finger was not infrequently shot away, but by far the greater number of such injuries were the so-called " plunging wounds" of the hands and feet. (One soldier, so great was his dread of an approaching battle, de liberately shot himself through the fleshy part of his thigh, thereby injuring the deep femoral artery so severely that he nearly died of secondary haemorrhage.) In almost every in stance these self-inflicted wounds were said to have been re ceived by the accidental discharge of the man's own piece while on outpost duty, alone and at night. Almost invariably the wound was in such a position and from such a direction as to make it impossible except through design. Like suicide, this matter of the self-infliction of wounds threatened to be come almost epidemic at one time. Colonel Woodhull, Chief Surgeon of the Department, made it the subject of a circular letter to regimental officers. Upon his recommendation, a board was appointed to investigate every case of accidental shooting, and to determine whether or not the wound in ques tion was intentionally inflicted. The number of such wounds appreciably diminished after the publication of this order ; yet there were fourteen cases of intentional self-inflicted wounds in the hospital at one time, to such an extent had example pre vailed.

c haracter of Bullet. Of the total number of gunshot wounds received at the Manila hospitals, 223 cases were night in dead or died within twelve hours of admission, having the number treated as 1373. In this number there were but fifty-eight deaths, a mortality of 4.2 per cent. of the cases treated. These cases are classified as follows : High-velocity projectiles, 718 (Mauser, 625 ; Krag, 93).

Low-velocity projectiles, 442 (Remington, 381; revolver, 37; Springfield, i6; shell wound, 8).

Character of missile unknown, 182.

All of these wounds, with the exception of possibly too. were received by our own troops, and at all ranges, from a dis tance so great that the ball was often found lodged in the tissues to those received from the very muzzle of the gun barrel ; but the majority of wounds were received at compara tively close range, ambush being a frequent method of attack, and in a " close country" the distance between the opposing forces was not great.

Explosive Effect. Theoretical writers have stated that there are two places in the trajectory of the modern bullet in which the " explosive effect" on the tissues will be noted. One within 35o yards, when it is said the rotary and unsteady motion of the bullet lacerates and destroys the tissue sur rounding its tract; and the other, in the last portion of the missile's flight, when it again assumes this wabbling, destruc tive character. But in our experience no instance of this destructive effect upon tissue was noted in the wounds received at extreme range, and in the gunshot wounds at close quarters it was comparatively rare. In our personal record of 462 cases of gunshot wounds, mention is made of the " explosive effect" in but twenty-four cases. Practically, all of these were wounds of the long bones and calvarium. In no case was it noted in the muscles alone, and in but two instances in wounds of solid organs. On the contrary, several gunshot wounds of the liver, spleen, and kidneys received from within this " explo sive" zone were entirely without this characteristic. From these facts, we are led to the conclusion that the " explosive effect" of the modern high-velocity projectile depends chiefly on the character of the tissue struck, and less on velocity. In particularly friable, brittle structures this phenomenon will undoubtedly at times occur in wounds received at close range, but its prevalence is by no means as common as recent military literature would lead us to believe.

Comparison of Wounds inflicted by the New and the Old Models of Pro jectiles. The wounds of the Krag and Mauser are indistinguishable, both in appearance and in results. Of Springfield and revolver wounds there were comparatively few. Only eight shell wounds were seen. These occurred among our own men, and beyond severe lacerations presented nothing characteristic. The natives struck by artillery fire were usually killed, or treated in the native hospitals, and so no record of these wounds is at hand. There was a large percentage of Remington wounds. The Remington bullet wound is almost invariably infected, but particularly so when fired by black powder. The insurgents reloaded many of their shells with smokeless powder, so that an opportunity was thus afforded for comparison. Incidentally it may be mentioned that so scarce did powder of any sort become that the natives began to use the heads of matches as an explosive. From a certain Japanese match, in general use in the Philippines, the head was clipped off. Two small boxes thus supplied a smokeless powder for one and one-half shell. Experiments by an artillery officer demonstrated the fact that with this force eight inches more penetration was secured than with the Krag-Jorgensen car tridge. It is needless to add that as soon as the fact became known, matches were made contraband of war, and gunshot wounds from this peculiar explosive ceased. The difference between the wounds of the reloaded shells and those of the old low-velocity charge was not very marked. The destruc tion of tissue was somewhat greater, and infection was more certain in wounds from the high explosive. The character of the bullet itself is a most important factor in the introduc tion of infection. The fact that wounds from the " soft-nosed" or Dumdum Mauser bullet are also very prone to suppurate would tend to support this belief. The ricochetted or spent Mauser bullet from which the metal jacket has been displaced (before or at the time of impact) will almost invariably cause an infected wound.

The aseptic properties, then, of the modern high-velocity projectile, we are led to believe, is brought about, first, by the hard, smooth character of the bullet, which bruises and lacerates the tissue to the minimum extent, and does not carry foreign substances (or minute infection) into the wound. Second, by the velocity of the projectile, whereby in its flight it is rendered sterile. Third, by the early application of an antiseptic dressing on the field.

First Aid. The importance of this method of treatment cannot be overestimated. The remarkable results reported obtained in modern gunshot wounds are due, without doubt, chiefly to the consistent and general application of the prin ciples of antiseptic surgery. Every soldier in the Philippines habitually carries with him a " first-aid package." The men have come to realize the importance of this, and will not be without them. Wrapped in a piece of oiled silk, these little packets of sterile gauze take up no room, and are now as much a part of the soldier's equipment as his canteen.

Flesh Wounds. Wounds of modern high-velocity pro jectiles uncomplicated by visceral lesion are almost invariably aseptic. It not infrequently happens, however, that a slight infection occurs at the wound of exit ; but this is generally very superficial, being confined to the blood-clot and disin tegrated tissue in the centre of the wound, and rarely extends. The wound of entrance is smaller and is attended with but slight destruction of tissue. Infection rarely occurs there, the wound healing under the primary dressing.

Gunshot Wounds of Bone. Gunshot wounds of bone in flicted by Mauser and Krag, in which there is no " explosive effect," can be treated on the same principles as any corn pound comminuted fracture. A very large percentage of them will heal under simple antiseptic treatment and that appro priate to the fracture. In these cases it is better to attempt to get primary skin union of the bullet wound, for the most marked comminution will be often repaired completely. If a small amount of carious bone results, it can be removed later with equal safety, and generally with much less loss of bone tissue. If marked infection occurs, the wound can be laid open, fragments of bone removed, and free drainage provided. Usually such wounds are perforating, but it not infrequently happens that a Mauser bullet lodges in the tissues. Many of these were allowed to remain, and the wound healed primarily. As a general proposition, it is better in these cases to remove the bullet, as the result can never be absolutely secure. If, on the other hand, the wound is from a Remington or revolver, it is always best to at once lay it open, remove all loose frag ments and foreign bodies with the forceps or curette, and drain or pack the cavity. The cases in which infection, gen erally extensive, did not occur were extremely rare. In sixty three cases of high-velocity gunshot wounds of long bones, in which careful personal records were kept, there were but twelve infected and fifty-one aseptic cases, or over 8o per cent. clean wounds ; while out of twenty-seven Remington wounds of the bones of the extremities, twenty-three were infected, only four aseptic, i.e., 14 per cent.

Wounds of Lungs. Probably no better indication of the aseptic character of the modern gunshot wound can be had than a reference to the record of penetrating gunshot wounds of the lungs. There were received at the First Reserve Hospital seventy-eight cases. Of these ten were brought in dead or died within twenty-four hours of admission, thus leaving sixty eight cases treated at this hospital. Of this number forty-four were known to be Mauser or Krag wounds and twenty-four Remington or revolver. Only five of the forty-four high velocity wounds were infected, i.e., 88 per cent. were aseptic. Of the twenty-four low-velocity wounds (Remington and re volver) five were infected and died, and six were infected and later sent to the United States for treatment, and the cases thus lost sight of. Thus it is seen that almost 5o per cent. of the low-velocity gunshot wounds of chest became infected, while only about 12 per cent. of the wounds from the new modern projectile gave serious trouble.

The treatment of these cases consisted simply in an occlu sive antiseptic dressing. Only in those cases in which the haemorrhage was extensive was the pleuia aspirated. An indi vidual report of these cases is not given, as they would only prove a matter of repetition in detailing the wounds of en trance and exit, as it was unnecessary to make any further notes on the cases. They can be referred to by official ;lumber in the records of the First and Second Reserve Hospitals in Manila. One case is, however, of sufficient interest to warrant its publication.

Sergeant-Major, Thirty-sixth U. S. V., In fantry, February II, 19oo.

" Attempted suicide. Gunshot wound, left chest, .45 cal ibre. Wound of entrance one-half inch to left of sternum in third interspace. Badly powder-burned. Wound of exit spine of scapula, one-half inch external to inner border of scapula. Perforating chest, lung, and probably pericardium. Ball must have grazed heart or passed between great vessels at base. Organ in normal position. Shock very great on admission; no pulse. It was thought the man was dying, but under strong stimulation patient finally reacted, so that twelve hours later pulse was io8 strong, temperature 99° F., free haemorrhage from wounds, respiration rapid and labored.

" February 17, 19oo. Continues to improve, but temperature lo3°, pulse 12o, respiration 44. 55o cubic centimetres dark blood removed by aspiration of left pleura.

" February 19. Comfortable ; temperature 98°, pulse 96, respiration 32. ' Feels good.

" February 26. Has been up for several days. Out of dan ger.

" February 28. Wound almost healed. Patient sent to Con valescent Hospital on Corregidor Island." The explanation in this case lies doubtless in the well known property which arteries have in resisting gunshot wounds. In this case the bullet must have either grazed the auricles or passed between the great vessels at the base of the heart. The organ was in its normal position, and no other explanation seems possible.

Injuries to Blood-Vessels. Contrary to the prediction expressed when the modern high-velocity projectile was first introduced, primary haemorrhage from gunshot wound is un common; in fact, no more frequent to-day than it was in the Civil War. Despite the velocity of the modern bullet, blood vessels continue to escape injury in the same remarkable man ner, being pushed aside rather than severed by the rapidly moving bullet. Our records show some remarkable instances. The following case will show this tendency of blood-vessels to escape injury : " Case 2540. Private, Company I, Twenty-fourth Infan try. Wounded at Aryat, P. I., October 12, 1899.

" Gunshot wound, neck, Mauser. Wound of entrance one and one-half inches below mastoid, left side. Wound of exit one and one-half inches below angle inferior maxilla, right side, just grazing bone. Bullet passed between large vessels of neck, push ing them aside without injury. Union primary. Slight tem perature for four or five days. Recovery complete." There were but two cases of severe secondary from gunshot wounds. One in which the brachial artery was completely severed, required amputation.

Aneurism. Three cases of aneurism are recorded from gunshot wounds. Ligation of the main trunk in each case was performed.

" Case 8046. Ligation of femoral in Hunter's canal for pop liteal aneurism with complete establishment of collateral circula tion. ( Robinson.) " Private, Company H, Seventeenth Infantry, in action, Angeles, October i6, 1899. Gunshot wound, Mauser, left thigh. Wound of entrance four inches above knee-joint, posterior exter nal aspect. Ball passed downward and forward, emerging at wound of exit, six inches above left internal malleolus. The note says ' slight' wound, healed by primary union. Three weeks .the peculiar loss of sensation in the limb after ligation. This numb and tingling sensation continued for weeks after circu lation had been re-established. In this case the radial pulse never returned, but circulation was complete.

" Case 9232. Ligation of external iliac artery, for dissect ing aneurism.

" For a gunshot wound causing a large dissecting aneurism of the common femoral, the external iliac was ligated. Collateral circulation was not established, however, and amputation at the hip-joint became necessary. The patient ultimately recovered. (Kendall and Robinson.) " January 6, moo. First Lieutenant, Thirty-sixth U. S. V., Infantry. Gunshot wound, right thigh. Wound of entrance four inches below Poupart's ligament and one-quarter of an inch ex ternal to femoral artery. Wound of exit one and one-half inches external to and one-half inch below tuberosity of ischium. An eurism extended from one inch below wound to above Poupart's ligament, where thrill could be felt by deep pressure. Bruit and thrill marked. Patient could not use the leg at all on account of pain. No sensation in foot and ankle, numbness extended up to knee. Aneurism extended too high up for compression. It was at first decided to place a provisional ligature below Poupart's ligament, but the aneurism was found to have extended two inches or more above this point ; consequently it was necessary to place the ligature higher up. A long incision (four or five inches) was made one inch above Poupart's, extending from near the pubis to the anterior superior spine of the ilium. Upon dissect ing down carefully and stripping back the peritoneum, it was found that the aneurism had extended up between the layers of the artery in a fusiform manner, making it necessary to place the ligature more than two inches above Poupart's ligament. In order to do this successfully and avoid the danger of rupture, the peritoneum was opened. The artery was found just at the brim of the pelvis, and ligated with strong braided silk, the aneurism-needle being passed from within outward. Upon tightening the ligature, pulsation in the aneurism ceased. Wound was closed without drainage. Collateral circulation, however, was not established; gangrene developed, and on the fifth day it became necessary to amputate at hip-joint. Patient ultimately recovered." Gunshot Wounds of Knee-Joint.--Even a better record as far as asepsis is concerned was made in gunshot wounds of the knee-joint. Of eighteen Mauser wounds, only one was in fected. Two Mauser bullets lodged in the joint, and as they produced no symptoms, were allowed to remain. In the medi cal and surgical history of the Civil War it is stated that 60.6 per cent. of gunshot wounds of knee-joint were fatal. With the exception of the one case above mentioned, whose ultimate history is unknown, there is not a single fatality in our records from such an injury, while 51 per cent. of amputations for similar injuries in the Civil War died. How strangely do our opinions change ! In 1865 it was stated that " every knee joint fractured by a ball should be amputated, and the quicker the better," while to-day we amputate only as a last resort. However, the same surgical principle applies to-day as it did then. An infected wound of the knee-joint demands amputa tion at once. Our own record of Remington wounds supports this old opinion of early amputation. Five cases of wounds of this joint resulted in septic poisoning. In three of these cases (two Remington and one Mauser) death would un doubtedly have resulted had amputation not been performed. One compound fracture of the knee-joint, infected, was treated on conservative lines, but, despite the freest drainage and con stant surgical attention, died of septicaemia. Unfortunately, one case of septic Remington wound was transferred to the United States before convalescence was established, and the ultimate history of the case was not known.

" Case 894. November 20, 1899. Corporal, Company E, Fourth Infantry.

"Gunshot wound, Remington, left knee, with longitudinal fracture of patella. Ball passed to inner side, lodging in subcu taneous tissue, two and one-half inches from entrance. Ball extracted on field. Wound infected on admission, November 23, 1899. Temperature, hectic, 99° to to3° F. ; pulse irregular and intermittent. Capsule of joint swollen and full of fetid pus, extending in pockets up flexor muscles of thigh. Imme diate amputation at lower third of thigh ; ether. Circular am putation selected as incurring less haemorrhage and more rapid. Man in septic condition, and one quart of normal salt solution thrown into veins while on the table, besides a pint by hypoder moclysis. Main artery ligated with silk, others with catgut. Re taining sutures of silver wire were placed far back from edge of incision, through the skin and muscular flaps, and the wound thus approximated by fastening the wire to pads of iodoform gauze, after the manner of Wolfler. Skin sutures of silkworm gut, with drainage. Man off the table in good condition, and made a rapid recovery." " Case 7175. Private, Company G, Fourteenth Infantry. November 14, 1899.

"Amputation femur (lower third) for infected compound comminuted fracture into knee-joint, result of gunshot wound; Remington. Wound of entrance two inches below right knee, shattering fibula and tibia into joint. An effort was made to save leg, although wound infected and three inches of bone had been previously removed. But under free drainage and con stant attention, caries extended and no union took place. Ampu tation, ether. Anteroposterior flaps. Femur removed two inches above condyles. Wound closed. Drainage for forty-eight hours, when removed. Flaps united per prima. ' Ideal stump.' " " Case 4365. Private, Company C, Twenty-first Infantry. Amputation middle thigh for gunshot wound of knee-joint. Os teomyelitis and arthritis.

" Note on admission to hospital, July 21, 1899: Gunshot wound left knee-joint ; Mauser, `explosive effect.' Wound of entrance one inch to outer side lower border of patella. Wound of exit, inner side, on level with end of femur ; severe. Action, morning, July 17, 1899. For nearly four months every effort had been made to save the leg.

" November 3o, 1899. An examination revealed an exten sive arthritis and osteomyelitis, and, as the patient was con stantly growing weaker, amputation was decided upon. How ever, an incision was made first for a resection of the knee-joint. The bones and articulating surfaces were found so badly in volved, and two abscess cavities, concealed, were found well up the thigh on the flexor muscles, that amputation in the middle of the thigh was deemed the only means of saving life. Antero posterior flaps were made from without inward. Great difficulty was experienced in tying vessels, as the arterial walls were dis eased, and many had to be repeatedly ligated. It was necessary to tie the main artery and vein three inches higher up on this account. Deep silver-wire sutures, after the manner of Wolfler, were again used, together with drainage. The wound suppurated slightly, but recovery was complete, with a useful stump." The following while not a gunshot wound, was a compound fracture into knee-joint, and hence comes under same category of treatment. The case is reported because it illustrates the necessity of early amputation in cases of infected wounds of the knee-joint. Amputation was not performed, and death resulted. If the operation had been performed early, it is believed the man would have lived.

Compound fracture into ankle and knee joint.

"Native Philippino, about thirty-five years of age; caught in a stone-crusher. Admitted February 19, two. His wounds were treated antiseptically, and the injured ankle healed incident. The knee-joint, however, became infected. However, the patient's condition remained very fair, and it was decided to attempt to save the leg. On three different occasions he was given a general anaesthetic and the joint carefully opened with continuous drainage. The joint surfaces were curetted and an erasion of the articulating surface finally done. The joint was immobilized, nourishing foods and free stimulation were given, but the patient grew continually worse, and died twelve days later of septicaemia." Major Amputations for Gunshot Wounds. As the direct result of gunshot wounds, there were twelve major amputa tions performed. Only three of these were primary, the re maining nine were amputated after every effort had been made to save the limb. One amputation (primary) was done at knee-joint for severe gunshot wound shattering the lower leg, and one at middle of calf for infected gunshot wound of foot. There were four amputations at the shoulder-joint. One was primary for severe laceration and fracture, one for injury to the brachial artery, and two were for severe infections, in which amputation was resorted to as a last resort to save life. Three of these operations were performed by Major Crosby. Inci sion " en racquet" was used in all but the latter in which the head of humerus was not enucleated, a high circular ampu tation being performed. One of these cases died of empyema later, and the other recovered.

Hip-Joint Amputation. There were only three deaths from amputation, and two of these were amputations at hip joint. Three such operations were performed ; one recovered.

Case 9232 was of peculiar interest, as the operation was per formed for gangrene of the leg following ligation of the external iliac artery. The patient, a first lieutenant in the Thirty-sixth U. S. V. Infantry, had been struck in the thigh, high up in Scarpa's triangle, by a Mauser bullet. A large dissecting aneu rism developed, which not only gave great pain, but threatened to rupture. An effort was made to ligate the artery extraperito neally from an incision parallel to Poupart's ligament, but it was found the aneurismal sac had dissected up to such an extent that it was necessary to open the peritoneum in order to place the ligature high enough up about sound tissue. A slight effort seemed to have been made in the upper part of the thigh at col lateral circulation, but on the fifth day gangrene unmistakably developed and the limb was amputated. As in the other opera tions, Wyeth's method of haemostasis was used in this case to control haemorrhage from the branches of the internal iliac and the dilated vessels of the external iliac, in which an effort had been made to establish a return circulation. Patient recovered.

The other two cases died. One was a native, sixty-two years old, and the other an infantry captain about thirty-five years old, whose gunshot wound became infected by gas bacil lus (bacillus aerogenes capsulatus) prior to admission. Opera tion was at once performed, but without avail.

Excision of Elbow-Joint. Two resections of the elbow were done for gunshot wounds with perfect results, and one excision of the hip-joint.

short range, badly shattering left elbow-joint.. Explosive effect. Ball entered tip of olecranon process, exit one and one-half inches anterior to internal condyle. Joint completely destroyed and tissues torn and full of powder and dirt. Ulnar nerve destroyed by bullet for one and one-half inches (nothing remaining but a fibrous cord). The shattered end of humerus and extremi ties of ulna and radius were removed. The ulnar nerve was resected. Primary union. Excision was most successful, as complete power of flexion and extension of forearm resulted." " Case 84t6. Excision of elbow. October 8, 1899. Private, Company L, Ninth Infantry. Was struck by Mauser bullet over olecranon, October 3, 1899, and elbow-joint badly shattered. On admission to First Reserve Hospital, four weeks later, wound infected and much carious bone.

" Operation, ether. Incision along outer aspect of arm, about five inches long. Ulnar nerve displaced and humerus and articu lating surfaces of ulna and radius removed with saw ; carious fragments with curette ; counter-drainage. Internal angular splint for ten days, when simple dressing applied. Primary union, with a useful joint." " Philippino prisoner, about twenty-four years of age.

Excision of head of femur for gunshot wound, Krag.

" Wound of entrance, right buttock, five inches internal to right great trochanter on level with tip of same posterior surface. Wound of exit, right side base of penis, infected. Under ether, adhesions broken up and abscess opened. Man developed all symptoms of hip-joint disease. Pain constant and excessive. Leg semiflexed, adducted, and rotated inward. Another abscess formed in buttock. Patient much emaciated.

" March 8, i9oo. A curvilinear (S-shaped) incision was made just to outer side of great trochanter, capsule of joint opened, teres ligament incised, and head of bone enucleated and removed with chain-saw. The whole articulating surface was much diseased and carious. The ball had passed directly through acetabulum, shattering the innominate bone and displacing frag ments of the joint more than one and one-half inches to the lower side. A large abscess cavity was evacuated. Irrigation was instituted and the wound closed with sutures of silkworm gut. Sand bags with light extension kept the patient quiet. Rapid improvement occurred." Resection of Long Bones. Resection of the shaft of long bones (the humerus, radius, ulna, and fibula) was performed in several instances. Primary wiring can seldom be resorted to, owing to the usual extent of the fracture and the inability to bring the fragments into proper apposition. In these cases the destruction of the soft tissues is also very great and infec tion is prone to occur. This happened in one but complete union resulted. The majority of our cases were those in which the so-called " explosive effect" was noted.

The following cases are reported, as they are types of injuries from gunshot wounds, and represent in kind and ex tent the difficulties that are met and results that are to be attained by the military surgeon.

" Case 1304. S. R. Resection shaft of humerus. Lieu tenant, Twenty-third U. S. Infantry. Gunshot wound left upper arm, Remington, badly shattering humerus. Patient had been treated for five weeks in hospital. Long-continued suppuration, much carious bone removed at an early operation.

" Operation, August 19, 1899, ether. The incision longitudi nally extended along posterior and outer surface from one inch above deltoid tubercle to one and one-half inches below olecra non. The shaft of humerus was found carious for three inches, the lower end of upper fragment soft and necrosed, the upper portion white and hard. No union had taken place, the ends of the bone being simply embedded in a mass of inflammatory tissue. The upper end of the lower fragment was found also necrosed. The fracture had extended into the joint, which had become ankylosed. An inch of the lower fragment and three inches of the upper fragment were removed with the saw, and the necrotic soft parts curetted. As far as possible, an effort was made to save the periosteum, but much of this had already been destroyed by the inflammatory process. Owing to the removal of so much of the shaft of the humerus (four inches), the bones could not be brought together. The wound was approximated, through-and-through drainage was established, and a splint ap plied. Healing occurred without incident. A flail arm' resulted, but this was rather fortunate than otherwise, as the elbow-joint attached to the small lower fragment was ankylosed. The low position of the missing portion of the shaft of the humerus in reality enabled a new joint to be formed just above the elbow joint proper, and by the action of the biceps and triceps muscles very fair flexion and extension were obtained. In fact, a better arm resulted than if the bones had united." " Case 8365. Wiring for gunshot wound of humerus. Hos pital steward, H. C., Seventeenth Infantry. Gunshot wound, upper third humerus. Ball (Remington) entered at deltoid tu bercle and was removed by simple incision from under right scapula. Humerus shattered and musculospiral nerve injured, so that extensor paralysis resulted. Case seen four weeks after receipt of injury; wound not yet healed, carious bone evident to probe, no union. Ends of bone excised and fragments brought together with silver wire. Arm fixed in plaster with fenestration for dressing the wound. Notwithstanding slight suppuration, wound rapidly healed. At end of three weeks silver wire removed. By fifth week bony union was complete." " Case 9687. Resection of radius. Private, Company C, Thirtieth Infantry. Was struck by lead slugs fired from a Rem ington rifle at short range and the forearm badly shattered. Two inches of the radius were completely disintegrated, but ulna es caped. This portion of radius it became necessary to remove. Union occurred between the fragments of the radius to the ulna, but with very little angular deformity. A very useful arm re sulted." Resection of Tarsus. Gunshot wounds of the smaller joints were proportionately as free from infection as those of the knee-joint, with the possible exception of those of the tar sus. Here the chance of primary infection is obviously greater, and the difficulties of maintaining a " clean" wound are ex cessive. In three cases a total or partial excision of the bones of the tarsus was performed. Recovery resulted in each in stance, with a foot that would bear the body weight. How ever, partial bony ankylosis resulted in each instance, and for months the foot was tender and painful. The return of use fulness to the member was long delayed. In fact, it remains a very grave question to-day whether this operation is justifiable. It is always attended with risks, and means weeks or months of suffering, with at the end only a questionable result. Am putation in these cases is attended with much less danger to life than resection, the patient is almost immediately convalescent, and an artificial limb can be worn with equal usefulness and less deformity. This opinion applies particularly to severe gunshot wounds of the tarsus which have become infected. The author does not wish to advocate amputation in all gun shot wounds of this joint, but only in those cases in which the destruction of bone has been sufficient to indicate a resection. In these he affirms amputation is preferable.

Gunshot Wounds of the Face. The gunshot wounds of the head were quite remarkable. There were many cases of wounds of the face and head not involving the calvarium that recovered. In fact, most markedly was it demonstrated to what an extent the lower portion of the head may be injured without serious results. A captain of infantry was struck by a Mauser one and one-half inches internal and below the malar bone, the ball emerged just to the left of the spine of the axis. He was out of the hospital in ten days. With the exception of a slight loss of sensation in the cutaneous nerves of that side of the face, there was no after-effect.

During a moment of temporary insanity, an officer of the Ninth Infantry placed a .38-calibre revolver beneath his chin and fired. The ball passed through the floor of the mouth, the tongue, hard palate, and out at a point one inch above the nasal eminence. With the exception of the opening in the hard palate, which perished, the injury was slight. Numerous simi lar wounds of the face were noted, but in almost every instance they healed primarily, or with but superficial suppuration.

Gunshot Wounds of the Brain. There are three cases on our records of severe penetrating gunshot wounds of the brain which recovered, and two cases lived also for a period suffi ciently remarkable to warrant their publication. They are reported in detail.

above left external angular process of frontal bone, passing transversely and slightly downward through the head. Wound of exit two inches back of and on a line with ' outer angle right eye. Sight totally gone in right eye, three-fourths absent in left. United States for treatment. On admission man was dazed, but sufficiently conscious to answer questions about his sight. Coma soon developed with all symptoms of encephalitis. After living three weeks in a semiconscious condition, his symp toms gradually subsided, and by the fourth week his sight in left eye had almost completely returned, and the man was out of danger. The sight in the right eye was totally destroyed. His only treatment consisted in nourishing foods and stimulation. Locally, the wound had only been cleansed and a simple antisep tic dressing applied. From the position of the wound, it is evident the ball passed directly through the frontal lobes of the brain, severing probably the tract of the right optic nerve." " Case 3807. March 25, 1899. Private, Company F, Second Oregon. Gunshot wound, head, Remington.

" Wound of entrance two and one-half inches above right eye, in centre of frontal eminence. Wound of exit two inches directly posterior, fracturing skull and penetrating brain super ficially. A furrow was made along the brain substance about three-fourths of an inch deep. There was superficial infection of skin wound. Patient made an uneventful recovery, and was transferred to ' Quarters' May 27, 1899. This case also strates the extent the brain may be injured without a fatal result. Unfortunately, complete notes of this case are not at hand." " Case 5379. May 5, 1899. Corporal, Company C, Twen tieth Kansas. Gunshot wound, Mauser. Ball entered head two and one-half inches above and one-half inch to left of left exter nal angular process of frontal bone, passing directly through head from left to right. Exit same measurements on right side. Unfortunately, a detailed report of this case is not at hand. The patient recovered, however, and June 9, 1899, was transferred to hospital ship ' Relief. In this case there was absolutely no men tal impairment from the wound. Upon his return to civil life he resumed his ordinary duties and was attending a business col lege nine months later, when he died from an acute disease." As has been aptly remarked by Clinton Dent, surgeon with the British army in South Africa, " The experience of gunshot wounds of the head in this war (Boer) almost ap pears to render the use of the frontal lobes of the brain ques tionable." The great extent of injury the brain may suffer without an immediately fatal issue is well shown by two cases of gun shot wounds. Nearly a whole lateral hemisphere in each case was completely destroyed, yet each lived exactly twelve days from the receipt of injury.

Spinal Cord. Every case but one of gunshot wounds of the spinal cord died of cerebrospinal meningitis in from three to five days. Our personal records show five cases. The case still living four months after injury had developed complete hemiplegia with trophic bed-sores and marked muscular atrophy. Ultimate death was the only possible result. The wounds in these cases were in every instance apparently aseptic, from an external examination. Unfortunately, no bacterio logical cultures were made from the spinal cord or brain after death, but from the appearance of the wound it is inferred they would have proven negative. Shock was not pronounced. Suddenly, within twelve to twenty-four hours of the receipt of injury, all the symptoms of a severe meningitis developed. Pain was excessive. Hyperwsthesia of the whole body was pronounced. An area of exquisite tenderness and " girdle pain" marked the lower border of sensation, with complete paralysis below the seat of injury. The temperature was re markably high, often remaining so for several hours after death. From an observation of these cases we are led to be lieve that infection had not taken place, but that the simple traumatism effected by the bullet set up a reactionary inflam mation of the cord and brain sufficient to cause death. In volvement of the heat centre early seems to explain the re markable temperature.

Resection of Nerves. Gunshot wounds of nerves were not uncommon. The musculospiral and ulnar were most fre quently injured. Complete paralysis resulted occasionally in cases in which dissection showed the nerve itself had not been severed, but only apparently slightly injured by the passing high-velOcity bullet. The severe local shock inflicted upon ad jacent tissue doubtless explains this condition.

Two cases of resection of nerves for gunshot wounds were performed,—one primary, within twenty-four hours of receipt of injury, and the other secondary, six weeks after the wound was inflicted. In the former No. 10,237, the ulnar nerve had been destroyed for one and one-half inches by the dis charge of a Krag at short range. The injured portion (one and one-half inches) was exsected and the ends brought to gether with fine silk,—one through-and-through suture and three others uniting the nerve sheath. Excision of the elbow joint was performed at the same time. The result was sur prisingly good. At the end of two weeks motion had returned and sensation in all but a small area of the outer side of the little finger. Even here sensation was not completely lost.

The case of secondary suture of the musculospiral nerve, No. 10,289, was not a success two months after operation. At this date the case was lost sight of. The injury was the result of a Mauser wound through the muscles of the upper arm, severing completely the nerve. At operation the scar tissue was removed and the nerve ends brought together with fine silk. The wound closed by primary union. However, but little was hoped for in this as atrophy of the muscles of the forearm was marked before the operation was undertaken.

Gunshot Wounds of Abdomen.Our own military ex perience with the modern high-velocity projectile convinces us conclusively that gunshot wounds of the abdomen should not be operated upon in time of war. In civil life, where the wound is apt to be received after a hearty meal, when the patient can be immediately surrounded by every facility for modern aseptic procedure, his chance is doubtless better with operation. In military practice, however, delay must often supervene before proper surgical surroundings can be secured to warrant safe work. Generally it is from six to twelve hours or more before these cases can be brought to the operating table, and at that time infection, if it is to occur,. has already taken place, or if not, the danger is past. Exhaustion after a long ambulance ride or transfer from the field place the patient in a condition not encouraging, at least, to the suc cessful issue of a prolonged operation. The shock attendant upon such an injury has already reduced his resistance mate rially, and the ethical consideration (by no means a small one) of the greatest good to the greatest number, all tend to con vince the military surgeon that in time of war, at least, abdomi nal section for modern gunshot wounds should rarely, if ever, be performed. Statistics bear out this opinion.

In our records there are forty-five cases of penetrating gunshot wounds of abdomen. Eight of these were brought in dead or died in twenty-four hours, before any operative inter ference was possible. Of the thirty-seven remaining, thirty four were from the Mauser or Krag. Of these, thirty were treated without operation ; twenty recovered and ten died, a percentage of per cent. recovery. These wounds were received at all ranges and in all parts of the abdomen. The liver, kidneys, and bladder were repeatedly punctured, and the cases recovered as if from a simple wound, with the least pos sible inconvenience. Death from haemorrhage usually followed wounds of the spleen. Our record contains but one bullet wound of this organ that recovered. Of the four cases oper ated upon, three died and one recovered. This latter case demonstrates conclusively the point mentioned so frequently by Col. Nicholas Senn, that a Mauser or Krag bullet may pass directly through the abdomen (above the umbilicus) without causing great damage.

In case No. 878o, a private in the Thirty-seventh Infantry was struck by a ricochetted Krag while at target practice. The ball entered two inches above the border of the ribs in the left mammary line, and taking a downward and backward course lodged in the left loin. As the man was received at the hos pital within an hour after the injury, contrary to the usual course, operation was decided upon. Under antiseptic pre cautions, the abdomen was opened in the median line and a large amount of free blood and clots removed. It was found that the ball had passed through the omentum and mesentery, but that the intestines had entirely escaped injury. The bleed ing omental and mesenteric arteries were tied and the abdomen flushed out with normal salt solution. Primary union re sulted.

The fact that men in battle are apt to have their alimentary tract empty when wounded is an important factor in lessening the danger of infection. Often a small punctured wound of an empty intestine will heal primarily or become occluded within twelve hours. Three gunshot wounds of abdomen were from Remington bullets. One of these recovered without opera tion, but developed a double fecal fistula. One died, and one was operated on, but succumbed to shock in twelve hours.

There are two important factors that militate against aseptic surgery in the tropics. (I) The greater tendency here for infection, and (2) the general poor health of the patient, whereby his reactionary powers are lowered. With reference to the first ; the country is hot and moist, the air and the dust of the streets and houses are full of vegetable and animal life. Indeed, to such an extent do these influences prevail that the greatest difficulty is encountered, even in the Manila labora tories, in securing freedom from infection. In fact, it is almost impossible to work out plate cultures, so freely are they con taminated. Surgical material and dressings have to be re peatedly sterilized, much more often than in the United States, to guarantee asepsis. Here truly infection is in the air. Among the natives, as well as the soldiers, the slightest abrasion is prone to suppurate. Persistent ulcers are daily seen, and phagedena is common. If kept aseptic, there is no specific influence in a tropical country to prevent wounds healing. The slowness in this respect is due, apparently, to the relaxed and reduced condition of the patient. Men who have lived for months in a tropical country are below par. All of them have lost weight, many of them are reduced from previous illness or wasting disease. Dengue, dysentery, typhoid and malarial fevers have all exerted their malevolent influence. Resistance is lower and wound repair is consequently less rapid. Often simply the depression incident upon taking an anaesthetic was sufficient to bring on an attack of malaria in one apparently free from the disease. Indeed, this phenomenon was so often noted that quinine was given almost as a routine treatment ; with marked benefit not only to the patient but also to the nerves of the operator. Continuous temperatures were seen after slight injuries. Dengue, dysentery, and phthisis super vened without assignable cause. Pneumonia was not a fre quent complication. Shock was at times pronounced from slight causes, apparently, more severe than in a colder climate. Yet with all this, the results accomplished compared most favorably with those of a temperate climate. The application of the principles of modern surgery was only more difficult in this tropical campaign.

Conclusions.

( I ) The modern gunshot wound is generally aseptic, and should be treated on this supposition.

(2) Asepsis is due chiefly to character of bullet, and early application of first-aid dressing, and in a minor degree to the velocity of the projectile.

(3) Primary haemorrhage from modern gunshot wounds is exceedingly rare, the blood-vessels being displaced rather than cut by the rapidly moving projectile.

(4) The " explosive effect" of the modern bullet is much less common than recent military literature would indicate. This peculiar destructive effect is produced by the character of the tissue struck, as well as by the great velocity of the bullet.

(5) Gunshot wounds of chest are rarely infected. Sim ple antiseptic treatment, with aspiration of pleura in cases of severe haemorrhage, is all that is necessary.

(6) Gunshot wounds of knee-joint are usually aseptic, but if infected, demand immediate amputation to save life.

(7) Excision of elbow is always a justifiable operation in severe shattering or infection of that joint. Resection of bones of other joints is rarely necessary, erasion or amputation being preferable.

(8) Injuries of nerves from gunshot wounds can often be benefited by operative interference or resection.

(9) In modern military surgery, abdominal section for gunshot wound is not justifiable ; the patient's best chance of recovery lies in conservative treatment without operation.

wound, inches, bullet, infected, patient, mauser and joint