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same method is by far safer than excision. There are a number of other operations, but these are the principal ones.
Prolapse of the third degree begins at a point more or less removed from the anus, and is limited in extent or descent only by the length of the colon, or may be the small intestines, the prolapse or invagination protruding from the anal orifice. This condition may come on gradually, but usually is sudden in its descent, caused by straining or the like thereof. When the protrusion first presents at the anal orifice it points straight downward, but with further descent it is drawn first backward by its meso-rectal attachment, and later is twisted or drawn forward and laterally by the meso-sigmoid and meso-colon attachments. The anus and lower part of rectum are normal. The finger may be inserted at the side of the prolapsus and the sulcus thus followed to the starting point if in reach of finger, if not, a soft catheter may be used in this inanner, and will usually meet no obstruction until the height of the sulcus is reached; in this way only can the extent of the prolapse be ascertained. The protruding bowel often becomes highly inflamed, ulcerated, or strangulation with gangrene, which is nature's effort to effect a cure by a slough. The treatment is surgical. The application of fuming nitric acid to the whole surface is advised by Allingham, followed by reduction and absolute rest in bed until all evidence of disease disappears. Cold irrigation or douching may be employed in the interim, and after patient is allowed to be up the bowels should be moved in the recumbent posture for some weeks. The cautery may be substituted for the acid with excellent results, the danger of stricture not being nearly so great.
If this method fail to cure, abdominal fixation of the meso-sigmoid or meso-colon is the best operation for radical cure. If the rectum or lower part of the prolapsed bowel be severely ulcerated colotomy should be done with the view of re-establishing the normal channel after healing the ulceration. If the fixation is done, two inches of the mesenteric attachment should be sutured to the abdominal wall in a manner that will not cause or leave a volvulus. Care should be taken to avoid suturing near the blood supply. This operation has only a few advocates, but seems to me to be an ideal operation.
The fourth and last degree may very properly be termed an intussusception or invagination, as the upper part of the rectum, the sigmoid, or the colon becomes prolapsed into the ampulla of the rectum without any external evidence, the anus and lower part of rectum appearing
perfectly normal. This condition is not as uncoinion as is generally believed, although its discovery is of comparatively recent date, and I think was first brought into print by Cripps. Tuttle, of New York, reports over fifty cases. I have seen two cases only.
The cause remains unknown, but must be due to a giving away of the superior support of the bowel or, as has been said, a slight stricture at the mouth of the sigmoid.
The symptoms are common, but when taken collectively are said to be unmistakable, a feeling of incompleted defecation at stool, constipation, periodical discharge of mucus, weight and aching in sacral region, pain and heaviness in lower abdomen, aching in perineum, indigestion and fullness of stomach, the physical signs being an enormously distended ampulla. An effort should be made to reduce the mass, which may best be done with patient in knee-chest position and the introduction of a Wales bougie, with a small stream of water playing upon the parts; absolute rest in bed, and, if no permanent relief be obtained from astringents and cold water-irrigation of colon, the operation of fixation before mentioned should be advised. The colon should face inward from the sutured area. The incision should be treated as any abdominal wound. The bowels should be moved only by enema in recumbent posture for three weeks, and patient kept in bed.
GUNSHOT WOUNDS OF FUTURE WARS,
BY THOMAS PAGE GRANT, M. D. Member Association of Military Surgeons of the U. S., The Mississippi l'alley Medical Association, etc.
From time to time there has appeared in the press of the country absurd statements about the "humane” modern small-bore rifle, of the advance that mankind was making in using a rifle that would put the enemy hors du combat without killing him or inflicting any permanent injury. To-day, with a war staring us in the face, the subject of the character of wounds made by modern arms, which are so essentially and radically different from gunshot wounds of civil life, as well as those of all previous wars, becomes a subject of interest to the public as well as the surgeon, and should be carefully considered, that adequate surgical and hospital provisions may be made before hostilities begin. This is the day of small projectiles shot with greatly increased
force, for at this time every nation has equipped its army with guns with a caliber of less than three eighths of an inch, firing a bullet having a steel or other hard metal jacket. The army of the United States is armed with the Krag-Jorgenson rifle, which shoots a ball .30 of an inch, while our navy has the Lee rifle, shooting a bullet .236 of an inch, which is the smallest bore of any military rifle now in use. The muzzle velocity of the army rifle is twenty-one hundred feet per second, while that of the navy gun is twenty-four hundred feet per second. Contrast these guns with those used during the Revolution, when the American army used a musket six feet long and firing a ball one inch in diameter.
In addition to the opportunity for observing the effects of the modern equipment afforded by the war between Japan and China, and the uprising in India, there have been a great many experiments made, both in this country and Europe, by medical as well as line officers to test the penetration of the modern small-bore gun.
Lieut.-Col. J. D. Griffith, Medical Director, in a paper read before the Association of Military Surgeons, speaking of the new army rifle, says: “At a distance of ten yards from the muzzle of the rifle its bullet perforated twenty-four inches of well-seasoned white oak; at two hundred yards it went through forty-five poplar planks, each an inch thick and one inch apart; at two thousand yards it perforated a horse's body at the shoulders, and at the same distance passed through three human bodies; at twenty-eight hundred yards it perforated four inches of deal plank, and at two miles yet retained velocity to penetrate the human body."
These experiments were made to determine the character of the wounds that may be looked for in future wars with modern methods of warfare, and were made on cadavers and live animals, notably horses. Of course it is impossible to give at this time even a summary of these experiments, but I will mention briefly a few characteristic ones. At seventy-five yards a wound in the leg showed that while the tibia was mutilated for about six inches it was not so badly shattered as in a wound in the saine location made at fifteen hundred yards. In the latter case the bone was mutilated for more than eight inches, and very much worse than at the shorter range. Under five hundred yards the wounds of entrance and exit were generally but little larger than the bullet, and did not produce the extensive mutilation of those made at longer range. A shot in the elbow at five hundred yards made only a small
wound, not fracturing the bones very badly, while a shot in the elbow at one thousand yards tore away almost the entire joint. (See cut.)
But in wounds of the cavities of the body the laceration is fearful; to quote Dr. Griffith, “At one thousand yards-wound in the chest under the left nipple, skin entrance size of bullet-passed through heart making frightful wounds of entrance and exit (in the heart), large (torn) wound in left lung, passing through the lower part of the scapula, shattering this bone and leaving the wound at exit almost the same as entrance."
In wounds of the abdomen the injuries were simply fearful, the explosive action of the bullet in this cavity was terrific, tearing frightful holes in the viscera in almost every case.
Although the German Commission reported “that the large vessels were rarely hit in its experiments, and the small ones torn,” the majority of the investigators, in this country at least, have found that the large vessels are frequently wounded, and that the wound is clean cut, punched out as it were, and that hemorrhage will be an important factor in the mortality of future wars.
In the course of these experiments it was found that bullets fired into old earth-works penetrated in some instances to the depth of thirtysix inches, and were dug out almost perfect, while those shot into new earth-works did not go deeper than sixteen inches, and were twisted and battered out of all shape, thus showing that a man can with his bayonet in a few moments throw up the best protection that is to be had in the field against the modern rifle.
Surgeon Captain Melville, of the East India Service, is one of the few authorities who claim that in the future wars there will be no increase in the duties of the medical department, for "he classifies wounds of the future into, first, slight and demanding little attention, or, second, severe and probably fatal. He contends that the proportion of killed to wounded will be greater, and thus materially lessen the labors of the surgeon.” One can not fail to be impressed by the grim humor of Surgeon Lieutenant Evans who, while serving with the Chitral expedition, wrote, “All uncomplicated wounds healed readily, but that there were no severe bone injuries under treatment was due to the fact that all men who suffered from fractures of the long bones were dead.”
That the casualties for the future wars will be great there can be no question. Fisher (Oesterreichische Militarische Zeitschrift) estimates the casualties at from twenty-two to thirty per cent of the force
engaged, while other writers make even higher estimates; of course the losses will depend largely on the courage of the troops engaged. The probabilities are that in naval battles these estimates will fall short of the actual losses. This statement is based on the reports of naval battles in the past, when guns had not reached the present state of development, then the loss sometimes reached fifty per cent, and in the late war between Japan and China the loss on the Chinese ship “Chen-Yuen” at Yalu was three hundred and fifty out of a crew of four hundred and sixty, or seventy-six per cent.
According to S. Suzuki, surgeon Japanese Navy, in London Lancet: There were ten Japanese sailors killed “by the vibration of air caused by the firing of their own guns," at the battle of Yalu. In the same engagement the Japanese loss was two hundred and ninety-eight killed and wounded, of this number 21.15 per cent were head injuries, after which came, in order, wounds of the body, the upper limbs, lower limbs, and the neck which suffered least. In land fights, however, the greatest number of wounds were in the lower extremities, those of the head and upper extremities next, then the body, and here again the neck wounds were the fewest. The number of wounds in land and naval battles were about the same.
While not germane, I can but mention the practice of the Japanese of photographing every wounded man, as well every case of serious illness. This was done to facilitate claims for pensions and to prevent frauds in obtaining them.
Of wounds produced by shrapnel and shells fired from machine and rapid-fire guns or cannons there is but little change in their character, but with the improvement in accuracy there will be a larger per cent of such injuries, which will be severe, lacerated, septic wounds; for it has been demonstrated that the heat of firing does not sterilize the projectile.
But to summarize the effects of the small-bore rifle, for it is evident that the future battles will not be fought at artillery range, but largely by troops armed with this gun, and the majority of the wounds that will come to the surgeon will be made by it.
There will probably be more wounds of the large blood-vessels, and these will require prompt aid and often amputations to save life. Wounds of the cancellous bones—as the ilium-will be punctured with but little or no explosive or lateral effect, the wounds of entrance and exit being practically the saine size, that of the ball. Wounds in bones