Paitre (France) Colonel Paitre of France based his communication on the examination of the records of Val-de-Grâce and of the Centre de Réforme of Paris. This long and patient work, still unfinished, does not permit any definite statement on the percentage of sequelae of abdominal wounds. But a first impression stands out: It is the great rarity of such sequelae in comparison with those of wounds of the limbs, head, and thorax. This rarity is attributable to the restricted number of those who have survived abdominal wounds, as well as to the number of operations that were performed in time, and left, so to speak, no chance for a retarded recurrence of infection. Pawlowski (Poland) These abdominal lesions, most often caused by fragments of a bursting shell, are followed, according to Lieutenant Colonel B. Pawlowski of Poland, by thromboses in the veins which follow the path of the projectile in the tissues of the organ. The distance over which these thromboses appear is proportional to the force of the explosion of the projectile, which brutally displaces the cells and occasions modifications in the colloidal equilibrium. Following the contusion of the veins and nerves of the mesentery, sometimes even of the veins and branches of the nerves outside the peritoneum, there is produced a violent spasm of the smaller vessels which causes anemia in the corresponding region or indeed a paralysis of the veins of more important caliber, "arterial stupor". Our personal experience has taught us that abdominal wounds caused by firearms, as well as the succeeding necessary laparotomy, are followed by a general relaxing of the abdominal cavity and by a concomitant weakening of the abdominal wall, and there result ptoses of the organs as well as atonies of the digestive apparatus. We have observed almost always, as a consequence of abdominal wounds from firearms, recurring cases of gastroptosis, hepatoptosis, and enteroptosis. Abdominothoracic wounds which have caused the perforation of the diaphragmatic membrane are followed by prolapsus of the viscera in the pleural cavity. Lesions of the mesenteric veins favor trophic conditions which sometimes end in ulcerations of the intestinal wall. The perforations that result from this, cause purulent intra-intestinal abscesses or, indeed, intestinal fistulas. This is especially observed when the wound is in the neighborhood of the wall of the large intestines. We have had post-traumatic cysts of retarded abscesses of the liver and biliary fistulas following wounds in the hepatic region. Our experience proves that adhesions are more frequent after laparotomies performed for abdominal injuries than after the usual abdominal operation. These adhesions are formed as a result of mechanical irritation of the peritoneum and of inflammation due to difficulties of circulation occasioned by the prolonged eventration of the organs, or, indeed, after operations performed without the necessary precautions when the endothelium of the peritoneum is damaged. The formation of adhesions is favored by the infection due to the wound itself, as well as by the infection that comes from the injury to the digestive tract. The operation, as a secondary traumatism, causes an inflammatory reaction which is more intense when the operation is retarded. Imbedded foreign bodies in the form of splinters of shell, of bullets, or of fragments of shrapnel have a tendency to maintain the inflammatory condition and favor the later development of adhesions due to mechanical irritation. Hernias resulting from abdominal trauma are produced following the suppuration of the wound, due to the drainage of the abdominal cavity and following complications that supervene in the post-operative period, such as: vomiting, coughing, tympanites, adhesions of the organs with the suture of the wound or following operative incisions. In order that operation and treatment of abdominal wounds may be adequate, it is indispensable to provide for a sufficient group of expert surgeon-specialists. It further seems indispensable to create specialized surgical centers for abdominal wounds, installed as close as possible to the front. The wounded who have had such operations ought to be able to remain in such centers for a fortnight before being sent to special establishments where they can have appropriate aftertreatment. In this way one may hope not only to diminish the mortality but also to decrease the number of war invalids. Czechoslovakia As the Czechoslovak Army was not created until after the World War, its medical service has no dependable data with regard to abdominal wounds and their sequelae. The limited and incomplete material that dates from the old Austro-Hungarian Army is not sufficient to draw helpful conclusions. It is, above all, in abdominal wounds that one can prove the worth of the general rule that the greater reduction in time between the moment the wound is received and the administration of perfect surgical care, the more the sequelae are light and benign, for it is only thus that it is possible to insure a complete cure or, at least, the best result. An interesting communication gave the following: A. In the front area: Don't probe the wound. Don't delay evacuation. Don't give morphine unless there is great pain and not then if the nails are cyanosed. Don't give stimulants. Don't move patient more than is absolutely required. Wounds of the stomach and small intestine require no drainage; wounds of the large intestine require drainage. Suture a torn bladder; if the ureters are torn off near the bladder-implant them into the bladder. If the kidney is generally shattered, remove it; if locally wounded, make a local resection and cover the field of suture with a kidney fat. Suture a bleeding liver, using a mattress suture and a round needle. Excise a shattered spleen. Close a rent in the diaphragm and be on the look-out for diaphragmatic hernia. Drain widely a torn pancreas; and if mutton tallow is available, apply it. Abdominal cases must be held in the evacuation hospital until their complete recovery. Gas gangrene of the abdominal wall, of the liver, and of the retroperitoneal area may develop. Visceral perforations may be caused by external injury without penetration. Metcalfe (United States of America) Colonel Raymond F. Metcalfe of the Medical Corps, United States Army, stated that crushing blows on the abdomen often damage the bowel or stomach by pressing them suddenly against the unyielding spine and causing perforation or a clean cut. Sudden blows before a meal may cause an explosive rupture of the gallbladder, and after a full meal rupture of the stomach, laceration of the liver, spleen, or kidney. Gunshot wounds and stab wounds may occur without internal damage; this, however, is the exception, and the conservative watchful treatment is a dangerous procedure. One should not be satisfied after closing one or two intestinal perforations until he has carefully explored the entire length of the intestine, large and small, the stomach, liver, spleen, kidneys, and bladder, and attended to any hemorrhage from mesenteric or omental vessels. Increasing rigidity of the abdominal wall and pain suggest perforation of stomach or bowel. Vomiting of blood suggests stomach injury. Catheterization may give a clue to kidney or bladder damage. Frequently moderate internal hemorrhages are self-limited, as in injured kidneys. Liver or spleen hemorrhages are usually severe and require exploration, especially with increasing dullness at sides of abdomen. The prognosis of gunshot and stab wounds depends largely on the amount of destruction to vital organs. Explosive injuries of the liver are usually fatal. Injuries of the large abdominal vessels rarely reach the operating table. Injuries of the spleen, if operated promptly, usually recover. With severe lacerations a splenectomy should be done. Kidney injuries often recover without operation; however, with continued bleeding into the bladder, increasing shock and lumbar tumor, exposure of kidney, with repair or removal, seems the best treatment. Abdominal distention, rigidity and pain, indicating a stomach or bowel perforation, demand early and careful operation. Those patients operated upon within 6 hours of the injury stand a 75-percent better chance of recovery than those operated upon within 12 hours. Each hour's delay after the first 12 hours increases the hazard to the patient. FOURTH QUESTION: A STUDY OF THE STANDARDIZATION OF METHODS OF ANALYSIS OF FOODSTUFFS FOR MILITARY USE Chile One of the problems of major importance that has preoccupied the Chilean laboratories recently is the standardization of methods of analysis, qualitative and quantitative, especially the latter. In practice it has frequently been seen that the reports of bromatologic examinations coming from different laboratories, have had the immediate result of a confusion of the exact interpretation and of the use that should be made of them. Every kind of foodstuff that is open to suspicion, and especially preserves of every sort, should be subjected to a bromatological examination before being delivered to the troops for consumption, thus avoiding the digestive disturbances and dangers that they may produce. It is certain that in view of the difficulties of diverse character that are involved in making bromatological examinations with precision, it is necessary that each country charge itself with studying and drawing up standardized rules prescribing the methods of examination for foodstuffs, naming a commission of experts for the purpose. Spain According to the communication from Spain, the spirit of an army depends in great part upon proper nourishment, and this primary necessity is ruled by three aspects: maximum economy for the state, maximum benefit for the soldier, and a maximum scientific guaranty. The maximum economy for the state is accomplished: when the foodstuffs are nationally produced; when the foodstuffs are at a minimum in volume and can be packed without loss of space, effecting economies in transport; when the food products accomplish their purpose of repairing the wastes of the body at a reduced cost. The maximum benefit for the soldier is accomplished: when the food products are very digestible or when they achieve some desired purpose in the act of digestion; when these foodstuffs are pleasant to eat; when they repair all body wastes. The maximum scientific guaranty is assured: when the foodstuffs have been carefully studied; when there are simple, practical, and economical methods that permit a conclusion that involves no doubt, whatever, as to the nature of the product and its possible adulteration or alteration; when one knows with certainty that with the quantities of the product eaten by the soldier, he is following a regime that is most desirable as to the calories it represents as well as the vitamins. Pagnielo (Italy) Professor Pagnielo of Italy gave the details of procedure for a rapid analysis of soaps. In the résumé of his address, he said: "Even limiting the analytical examination of soap to the determination of the things of greater interest (water, acid fats, fixed alkalies, free alkalies), with the special technical procedure that I have described, we accomplish a double practical objective: of taking the necessary steps of analysis with notable simplicity and rapidity and of obtaining data sufficiently approximate for arriving at a dependable judgment as to the quality of the product." Parri (Italy) After a statement of the general characteristic of a desirable standardization of systems of analysis, Colonel W. Parri of Italy discussed the fundamental principles that ought to serve as a guide to standardization. He said: "At the present time of rapid evolution of ideas and their application, we are witnessing a continual evolution of official systems of analysis that the laws of the different countries impose also on military laboratories. For Italy, we have only to cite the new laws bearing upon the analysis of alimentary conserves: new definitions for the products of the milling of grain and of the resulting products. "For France, for example, there are the new laws with regard to wines. In such conditions it is impossible to effect a serious stand |