The arms producing war wounds are of two kinds: the sidearmsmeaning swords, sabers, and bayonets-and firearms. Considering the fury with which they are used, these sidearms, particularly the bayonets, cause immediate wounds of exceptional gravity, so that the wounded combatant almost always remains upon the field of battle beyond all help. It is easily understood, then, that, in view of the madness of the fight, sequelae following wounds by sidearms are extremely rare.

Wounds by firearms, whether by bullets or by the lightning clash and splintering of an exploding shell, cause the great majority of abdominal wounds and those which leave continuing sequelae.

The rifle bullet, the means of humanitarian strife which caused the greater number of wounds in the battles of the past, has been replaced by the destructive bursting steel shells, characteristic of modern trench warfare.

The lesions produced by bullets shot at a distance of 1,000 to 2,000 meters, which strike the body directly, are less damaging in their effects than those produced by bullets shot from a distance of less than 1,000 meters. The effects of the latter are explosive and serious. The abdominal walls are then traversed by the projectile, which produces at its point of entrance a small and regular orifice and at its point of exit a wound much wider and irregular-when it is a question of a perforating abdominal wound. In exceptional cases, and only when the bullet reaches the end of its trajectory, it may remain in the abdominal wall, acting as an encysted foreign body which may, in time, produce an abscess or a fistula of the wall. The wound produced by a bullet generally heals with a cicatrix of good quality that does not later produce trouble. When the trauma produced is a penetrating one, the projectile may wound the viscera met in its path and remain either in one of them or in the peritoneal cavity.

The organs of the injured cavity, the small or the large intestine, which may have been divided or perforated and upon which the surgeon has operated, either by closing the perforation or, perhaps, by enteric anastomosis after resection, may be the seat of secondary fistulas or cicatricial stenosis with grave intestinal occlusion. Projectiles embedded in the organ may remain for a long time without causing trouble and yet start at a given moment a suppurative process due to a latent microbic cause that had hitherto been unsuspected.

Lesions of the gallbladder or of the biliary tracts, of the pancreatic ducts, and of the urinary bladder, even when sutured, may be the cause of fistulas of these organs.

Bursting shells of moderate size, carrying a great power of destruction, produce actual ravage of the abdominal walls by tearing out and destroying important portions of them. These become the seat of future weaknesses, of hernia and many different kinds of eventrations. When it has proved possible to repair surgically grave lesions of the

hollow organs, tardy complications may still occur, such as: Fistula of the different organs, artificial anus, and all the other complications that may follow a bullet wound, complications due to the separation of sutures, to the suppurative process in the immediate vicinity of the wound, to ulcerations, or to prolonged drainage.

The curative treatment of abdominal sequelae of war wounds is a part of the surgeon's healing work in time of peace, carried on with the same indications and surgical methods specific for each case. The prophylactic treatment of these sequelae is especially important, because if it is applied under the best conditions, early, on the field of battle, it diminishes the gravity of abdominal wounds.

Abdominal surgery ought to be performed, in time of peace, as in time of war, by competent surgeons who have had long practice and experience. Even the assistants in this special branch of surgery ought to be experienced in it. This to insure the maximum of result. The operating equipment ought to be complete, with the most modern apparatus. The operation should be performed at the earliest possible moment, at the latest within six hours from the moment the wound is received. To achieve this desideratum it is necessary that in all great battles, with their agglomeration of wounded, the selection of patients for treatment at the advance post should be rigorously and rapidly made. Those who require immediate surgical attention, that is to say, those with hemorrhages and those with abdominal wounds, should be taken care of first.

After prolonged abdominal operations, it is the custom to pour into the cavity different kinds of antiseptics, which are often harmful on account of their concentration or their composition-harmful for the vitality of the tissues. The use of all such irritating antiseptics should be proscribed, the surgeon limiting himself to a simple washing of the abdominal cavity either by ether or hot normal saline solution.

Drainage of the abdominal cavity, after operation, should be reduced to what is strictly necessary in order to avoid the creation of extensive adhesions between the abdominal organs, or even of fecal fistulas, formidable sequelae produced by drainage, above all in the immediate vicinity of the sutures.

It should be particularly noted that the use of lampwick drains favors the production of fistulas by the unseasonable destruction of adhesions at the moment of the removal of these drains.

The percentage of disability of those who have abdominal sequelae varies not only with the character of the sequelae but with the occupation followed by the individual. Rumanian legislation has fixed the percentage of disability at from 20 to 60 percent for every lesion of the abdominal wall, including lack of power to maintain viscera in place, which, more or less, reduces the working capacity of the man. Those who have fecal fistulas, above all those who have an artificial anus, are true invalids, unable to work, whose infirmity is equally

disagreeable to the sufferer and to those who are around him, because it requires the most minute care in local personal hygiene. A whole gamut of digestive troubles is noted among those who have stenoses of the digestive tract following cicatrices, adhesions, and retractile mesenteries. Among them the percentage of disability will depend upon the degree of the functional troubles.

To help, with a reasonable pension, such invalids, wounded in doing their duty in the fury of battle, is not only a question of equity but an engagement of national honor and an encouraging example for future generations called to shed their blood in eventual war. The state is bound to give them all its solicitude and to spare no sacrifice to aid these national heroes who have not hesitated to risk their lives when their country was menaced. It is the duty of the state to place at the disposal of these war casualties the gratuitous use of hospitals and all necessary treatment.

Pireaux; Beyne (Belgium)

Captain Pireaux and Sublieutenant Beyne of the Belgian Army Medical Service presented Belgium's report on "Sequelae of Abdominal Injuries".

The study of the sequelae of abdominal wounds ought logically to be made by following their evolution from the beginning. But most often all conclusions are reached, a posteriori, by deduction. The wounded treated in the medical formations of the front, are moved just as soon as their transportation toward the rear is thought to be without danger, that is to say, when the serious abdominal symptoms have disappeared and when the intestinal functions are reestablished. The clinical histories compiled by these medical formations at the front most often close their observations on a case in these terms: "Wounded removed-on such or such a day-in good condition." In the days immediately following the wound, the complications which may supervene are numerous:

(1) Early complications of acute intestinal obstruction due to

adhesions.

(2) General peritonitis at the very outset.

(3) General peritonitis, following local peritonitis, by the break-
ing down of the peritoneal defense.

(4) Intestinal perforations following the giving-way of a suture
or in the immediate vicinity of an intestinal cicatrix,
following straining exertion of coughing or defecation.
(5) The appearance of a fecal fistula. Such an early complica-
tion may heal completely or may leave sequelae, more
or less important, that may appear sooner or later.

Some wounds are accompanied at the beginning with lasting complications, true sequelae immediate and persistent, which can only

disappear through appropriate surgical treatment. Others are accompanied by abdominal reactions which cannot be interpreted clinically, which quietly develop, and which open the door to complications only a long while after the original wound was received— a long while after complete healing.

If, most often, a projectile was the first cause, it is not the principal cause of these sequelae. They are the consequences of early complications, themselves occasioned by the wound. Though the wounded may or may not have had an operation, even if the sequence of events in his convalescence has been entirely normal, he is rarely completely cured and he has before him a future full of uncertainties. He should always be considered as not being safe from all danger, even if apparently he is in a state of flourishing health.

(Drs. Pireaux and Beyne give a very comprehensive and helpful summary, chiefly the etiology and pathogeny, of the sequelae of abdominal wounds. Its headings are as follows:)

SEQUELAE OF ABDOMINAL INJURIES

1. Abdominal wounds may result in:

(a) Parietal sequelae (cicatrices, hernia, paralyses, and atrophy of the abdominal wall, fistula)

(b) Peritoneal sequelae (mechanical obstruction, infection)

(c) Visceral sequelae (intestinal tract, liver, kidneys, spleen, bladder, rectum)

(d) Diaphragmatic hernia

(e) Traumatic neurosis

As to the pathogeny of adhesions, we should consider the part played by infection, which is the first in order of time in the greater part of the cases, the part played by peritoneal exudation: A serous reaction may induce the formation of fibrin, then of adhesions after long operations or when the manipulation of the viscera has been necessarily prolonged.

Also must be added the part played by anaphylaxis.

Many authors have, for a long time, maintained that many individuals have a tendency, more than others, toward adhesions and that that is notably the case of those with fibrous tuberculosis and those who are syphilitic. Gratia and Gilson, in a report of the Royal Academy of Medicine of Belgium, of 1934, entitled Le phénomène l'Arthus au catgut, cause insoupçonnée d'accidents post-opératoires, asked themselves if the suture or ligature material of the catgut derived from sheep, acting the part of antigen, is not, as such, responsible for the complications observed, in inducing at the place where it is introduced in a sensitized organism, the reaction of Arthus. It would seem that infection, or the faults of surgical technique, or the serous reaction of the peritoneum cannot explain all the postoperative adhesions.

Reading of the experience of Gratia and Gilson led the writers to believe that there might well be, beyond infection, an anaphylactic pathogeny of adhesions. They produced, experimentally, adhesions in sensitized rabbits-sensitized by sheep serum, or even by other serums-by the intraperitoneal injection of powdered catgut. The introduction of the catgut may produce complications not only in individuals who are sensitized against sheep protein but also in those sensitized to horse serum and other antigens. After some days, a laparotomy shows that the little lumps of powdered catgut are the center of oedematous reactions, congestive and hemorrhagic, and of large visceral adhesions which may create intestinal obstruction.

When, some days after an operation, accidents of occlusion occur, oedematous adhesions may be found on reoperating. They are thick, fragile, and show no infection. If tests are made, proof appears that such individuals are hyperallergic. If their antecedents are examined, it is discovered that they have had some disease that required the use of serum or of some protein—anti-diphtheretic serum, horse serum-or an abdominal operation which required the use of catgut.

If one makes systematic search as to the allergic sensitivity of a certain number of individuals, by an injection beneath the skin of some drops of sheep serum, proof is found that some among them react. Those are the ones who will have adhesions. The phenomena of tardy occlusion are explained in the same way. The local anaphylactic reaction appears; it has caused the formation of adhesions, but there were no complications at the beginning. Adhesive phenomena may manifest themselves only tardily. On operation adhesions are found-slight, nacreous, resistant.

We are justified in asking ourselves in what measure this local anaphylactic cause intervenes in the abdominal pathology of war. It acts, very probably, in the formation of adhesions, but it is not possible to adduce proof of it, for these phenomena have not sufficiently attracted the attention of surgeons.

The septicity of war wounds largely explains the formation of adhesions. But one can understand that infection and anaphylactic reaction may conjoin their action and together produce the formation of adhesions. Besides, what inclines one to admit this anaphylactic pathogeny is the number of cases in which the abdominally wounded, who have had operations and been sutured, have later developed, per primam, as it appeared in examination, either complications of early occlusion, where the operations show no trace of infection, no fluid, and only some adhesions, or else accidents of occlusion, at a more or less long term, without ever having given evidence of any abdominal phenomena whatever.

We have said that the observations from which one might deduce this role played by anaphylaxis are rare. We believe it will be