in proper position. Bands cut transversely and sewed up longitudinally. Bands about pylorus broken up.

Patient reported by letter on November 24, 1934: "I am still working constantly. My gastro-intestinal tract behaves well."

Case 3. J. S. G., 32 years; male; married. Operation, June 29, 1915. Band from gallbladder which extended across duodenum and caused constriction of pylorus. Duodenum markedly dilated below band and its lower pole hung over true pelvis. Very marked duodenojejunal kink and adhesions around beginning of jejunum, which caused saddle-bag constriction of last portion of duodenum and first portion of jejunum. Transverse colon adherent to stomach and posterior abdominal wall by adhesions in transverse mesocolon; small bowel thrown forward and lay practically anterior, and was strongly adherent to transverse colon, opposite duodenojejunal kink. Ascending colon acutely angulated; bands rotated cecum half-inward and dragged with them peritoneum of right abdominal wall. Accentuation of terminal kink of sigmoid.

Adhesions in right upper abdominal quadrant bisected and kinks ironed out. Adhesions binding transverse colon to abdominal wall, and small intestine to anterior portion of transverse colon separated, leaving large, raw surface, which was covered by gastroenterostomy and by free edge of great omentum. Bands in right lower quadrant bisected, cecum rotated outward and, with great difficulty, sutured in position. It was opinion of operator that there was grave question whether gastroenterostomy with closure of pylorus and relief of bands would be sufficient to enable patient to regain health, but rather that further operative procedure would be necessary.

A few months after operation patient indulged in marked indiscretion in diet, had attack of acute indigestion, and returned for further operation January 14, 1916. Ileum found firmly attached to anterior abdominal wall in three places. Two constrictions over third portion of duodenum and one omental constriction of jejunum. Gastrojejunal opening patulous and without adhesions. Transverse and ascending colon adherent in true pelvis; terminal ileum constricted and adherent in right pelvis.

Adherent gut freed; raw surfaces covered with peritoneum. Terminal ileum obliquely implanted into upper part of rectum by end to side anastomosis.

Following this operation patient gradually improved and was well for about five years, then began to have "weak spells" and discomfort when stomach was empty. Tried medical treatment for a time to no avail.

Third operation performed July 8, 1922. Gallbladder grown across duodenum and attached to transverse colon. Liver adherent to mass of adhesions around pylorus. Gastroenterostomy opening perfectly satisfactory, but for about three inches below adhesions tied small bowel in large mass.

Adhesions cut; organs separated from each other. Pylorus, with one inch of stomach and one inch of duodenum, removed. Rubber tissue drain left in wound.

Pathologist's report of exsected area: "Chronic inflammatory changes following closure of pylorus."

In a letter dated February 2, 1935 patient stated: "I am as well as ever in my life which you will no doubt be glad to know. I eat and sleep well and, in fact, have more endurance than I can ever remember."

Case 4. S. D. K., 51 years; female; married. Operation, January 25, 1917. Stomach and colon adherent to abdominal wall. A Y-shaped band attached to under surface of liver, in center of which was distended gallbladder; no stones. Upper attachment of band consisted of three forks, one to right of gallbladder,

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one to gallbladder, and one to left of it. Distinct duodenojejunal kink. Cecum dilated. Last kink of pelvic colon markedly angulated.

Bands and adhesions relieved; kinks ironed out; cecum plicated; raw surfaces covered.

Last report regarding patient, received November 1934, was that she was in splendid health.

Case 5. G. F. W., 30 years; female; married. Operation, February 12, 1917. Great omentum tightly adherent to right lateral abdominal wall. Two bands under liver and gallbladder, one from about middle of gallbladder over first portion of duodenum just beyond pylorus; the other across duodenum to a condensation band which traveled along transverse colon to edge of gastrocolic omentum, making gallbladder and cystic duct adherent to duodenum. Bands of adhesions which twisted ileocecal junction. Cecum mobile and rotated from within outward. Diverticulum at butt end of cecum and another posterior. Above was tense band fixing longitudinal muscle band to wall of abdomen, making point of obstruction and rotation.

Bands bisected. Cecum plicated and fastened in normal position. Raw surfaces turned in.

Convalescence was complicated by acute dilation of right ventricle of heart twelve hours after operation, and infarct in lower lobe of right lung.

However,

she slowly improved. In March 1935 reported herself in excellent condition.

Case 6. J. C. M., 36 years; male; married. Operation, January 31, 1914. Appendix distended with fecal matter, extended downward to left, twisted at its center. Cecum mobile; adhesions below ileum. Omentum adherent to under surface of liver and pyloric region.

Appendix removed. Adhesions bisected and raw surfaces sutured. Omentum folded on itself to cover its own raw surface. Cecum sutured in position.

Patient improved for a time, but returned for further operation in February 1916 because of complete stoppage of bowel unrelieved by medical measures. Colon greatly dilated; walls attenuated; ascending and transverse colon firmly adherent; cecum fixed in position of internal rotation; terminal 18 inches of ileum fixed in series of loops of varying sizes.

Terminal ileum sectioned 23 inches from valve and ileum anastomosed with most dependent accessible portion of pelvic colon. No drainage.

For three years after this operation patient was in excellent health and considered himself perfectly well. He then had so severe a return of abdominal trouble that further operation was necessary: performed December 9, 1918. Almost complete obstruction of small bowel two feet from ileocecal valve. At one point it was impossible to relieve gut without making small opening into it, which was carefully sutured. Patency of gastro-intestinal tract was restored as well as possible.

Last report received two years ago was that patient was in good condition.

Case 7. A. E. S., 26 years; male; single. Operation, April 23, 1916. Gallbladder adherent to duodenum; at duodenojejunal angle, strong band extended across greatly dilated duodenum to under surface of transverse mesocolon and down almost to brim of pelvis, with jejunum nearly collapsed. Stomach very low. Cecum dilated and prolapsed.

Appendix removed; cecum plicated; bands bisected; parts sutured in proper position.

Patient became well enough to go through the rigorous training of Officers' Training Camp, receive his commission, and go actively into the war. Some years

after his return he was in such condition as to be acceptable to take out a lifeinsurance policy.

Case 8.-N. D., 27 years; male; married. Operation, December 4, 1914. Very mobile cecum which rotated around exceptionally dense ileopelvic band, attaching terminal ileum to brim of pelvis, tightly binding it down and twisting it, making it impossible to lift last loop of ileum out of pelvis, thus causing definite point of obstruction. Appendix lay on under surface of terminal meso of ileum with its tip under band. Terminal ileum so rotated that upper surface of mesentery at its attached margin was almost completely reversed and lay within quarter of an inch of band that held terminal ileum down into pelvis. Hepatic flexure amalgamated with ascending colon and first portion of transverse colon by bands. Adhesions around gallbladder and over first portion of duodenum. Angulation of last kink of pelvic colon extending upward for about four inches.

Appendix removed from bed of adhesions and exsected. Cecum stitched in position. All bands cut and raw surfaces covered. Small rubber tissue drain left in wound for possible colon infection.

Patient reacted very well and in his latest report, February 1934, stated that he was in "perfect condition".

Case 9. L. E., 39 years; male; married; physician. Operation, March 24, 1914. Healed ulcer of duodenum, below which a number of bands extended from behind, across duodenum, indenting it, toward transverse colon and greater curvature of stomach. Transverse colon much collapsed; hepatic flexure hung down almost to umbilicus. Midpoint of appendix represented band extending into pelvis, around which mobile cecum rotated. Ileocecal valve patulous; terminal ileum dilated; ileopelvic band present with mesoappendix attached to it.

Appendix removed; ileopelvic band cut transversely and raw surfaces turned in; caput coli stitched in normal position; adventitious bands of adhesions bisected. This patient was able to take up his practice once again and is now very active as the président of a State Medical Society.

Case 10. R. S., 22 years; female; married. Operation, January 30, 1914. Stomach and gallbladder adherent to anterior abdominal wall. Adhesions from stomach to duodenum, gallbladder, and falciform ligament.

Adhesions separated; pad of fat from left thigh placed between stomach, gallbladder, and duodenum, and sutured. Adhesions about mobile cecum severed. Appendix removed.

Patient became perfectly well; lost track of in the past few years.

The writer wishes to call particular attention to the fact that, in operating on these abdominal cases, it is of the greatest importance for the surgeon to visualize the patient in a sitting and standing posture, in addition to the recumbent state, for it is only thus that the full mechanics of the gastro-intestinal tract can be realized, with the points of stress and strain, rotation, and fixation. The surgeon who, by the eradication of a facial disfigurement, enhances the cosmetic appearance of a patient and so aids his mental outlook, does not stand alone in the field of plastic surgery. While the work of the abdominal surgeon is not permanently visible to the naked eye, the mental and physical resiliency of a patient thus properly treated proves the value of such operative procedure, with its finesse of detail eliminating scars and deformities within the cavity of the abdomen

The suggestions listed below are those that are followed by the author in his abdominal operations:

1. Make incision large enough to perform the necessary work but not so large as to invite hernia.

2. Avoid very strong retraction because of possible trauma to soft tissues.

3. Careful handling so as not to traumatize the field of operation. 4. Operate, if possible, in a fluid field, using normal warm saline solution to lessen the possibility of trauma by handling, even with rubber gloves.

5. Use rubber dam over the surface of the organs which are held back to expose the operative field, the abdominal pads being carefully moistened with warm saline but kept away from the organs by the interposition of the dam. 6. Introduce into the abdomen only warm instruments-heated by placing in warm saline.

7. Careful hemostasis.

8. Careful plastic surgery, covering raw surfaces by use of fine suture material. When there are raw surfaces that can

not be covered or turned in, it may be necessary to utilize fat from the great omentum or the thigh to cover them. 9. Leave warm saline solution in the abdomen whenever possible. 10. In closing the abdominal wall suture any peritoneal layer that has been traumatized by retractors or clamps, so that the traumatized surfaces are turned out and not inside the abdomen to invite adhesions.

11. Sutures should be tied securely-tight enough to hold the parts in approximation, but not so tight as to cut through the tissues and render possible some local infection or subinfection which will result in the formation of adhesions. 12. Interrupted sutures preferred as a rule, for the continuous sutures do not conserve the circulation along the line of approximation as well.

13. Suture so that the knots do not impinge in the line of approximation of the wound or at the point of puncture.

14. To aid in the prevention of adhesions after operation many agents, such as the following, have been employed:

(a) Cargile membrane.

(b) Sterilized paraffin or oil.

(c) Pure oxygen. This tends to prevent adhesions, acts as a tonic, and is a deterrent to bacteriological development.

(d) Blood serum.

(e) Amfetin (sterile, concentrated, purified fraction of amniotic fluid), which has its advocates and which the author is now giving a fair trial.

CONCLUSIONS

1. It is of importance to consider the remote as well as the immediate effects of abdominal trauma.

2. Abdominal traumata received during war are practically similar to those sustained in civil life.

3. Not only may local symptoms arise, but there may be a disturbance of the general physiology of the body.

4. Of the many conditions that may develop years after the infliction of abdominal trauma, such as volvulus, mesenteric rents, necrosis of the intestinal wall, hernia, diverticulosis, the most common and those giving the most general symptoms are adhesions, which cause obstructions, kinks, and displacements.

5. The possibility of the development of neoplastic formation at sites of chronic irritation must always be considered.

6. Plastic operations on the abdominal viscera often are of great importance to assure the proper functioning of the organs.

7. Surgeons should exert every care to guard against secondary trauma, i.e. undue injury to tissues at operation.

Johnson (United States of America)

In his report on "Diaphragmatic Hernia as a Sequel of War Injuries", Captain Lucius W. Johnson, Medical Corps, United States Navy, wrote that great wars stimulate us to study and investigation along many lines which receive little attention during times of peace. Thus, during the World War, we saw a rapid increase in our knowledge of fractures, infected wounds, empyema, and gas gangrene, for example, and great improvements were made in our methods of treating them. Following the war, elaborate studies were published, giving the results of treatment and the lessons learned through observation of large numbers of cases. These form valuable repositories of learning to which we must refer frequently, lest the knowledge gained through war experiences be forgotten.

Traumatic diaphragmatic hernia is another of those topics in which our interest increases during and after great wars but subsides during long periods of peace. One who reviews the literature in this field will be impressed by the fact that the notable studies were made and the best papers published shortly after important wars. In peaceful times of the past it has received scant attention because those types of injury which are likely to produce diaphragmatic hernia are common to military activities but rare in civil enterprises. This trend will be changed in the future by the constantly increasing number of severe injuries in automobile accidents. Already a number of cases have been reported in which a crushing injury by automobile has ruptured the diaphragm and produced herniation through it.

As a post-mortem phenomenon, diaphragmatic hernia has been recognized since early times. Hippocrates wrote of large openings