A word must be added as to these difficulties; they are in part purely of an administrative nature, partly surgical. After a great battle the wounded are numerous, and amongst them a very considerable proportion of the wounds and injuries are of such a nature as to do extremely well if promptly dealt with, and each of these makes small demands on the time of the staff. Abdominal operations, on the other hand, are unsatisfactory from a prognostic point of view, and their performance requires much time and the assistance of a considerable number of the men, who are obliged to neglect the treatment of the more promising cases for those of doubtful issue. This difficulty, although not surgical in its nature, is nevertheless a practical one of great importance and appeals strongly to the Principal Medical Officers in charge of the arrangements. It is only to be avoided by an increase of the staff, which is not likely to be made except on very special occasions.
Other difficulties are purely surgical. First, the difficulty of diagnosing with certainty a perforating lesion. In the presence of the fact that many incomplete lesions follow wounds crossing the intestinal area, and that these give rise to modified symptoms, I believe this determination to be impossible without the aid of an exploratory incision. Here we are met with the remaining surgical difficulties—disadvantages such as the absence of sufficient aid to the operating surgeon, difficulties connected with the temperature, wind, and dust, and as to the subsequent treatment of the patient. Again difficulty in obtaining the most important adjunct, suitable water, or indeed any water in a sufficient quantity.
It is of course obvious that conditions may exist in which all these troubles may be avoided. Again, the practical difficulty adverted to above does not come in the way when a single man happens to sustain an abdominal wound on the march. Under such circumstances an exploration may be not only justifiable, but obligatory, and the general rules of surgery must be followed rather than such incomplete indications as are suggested below.
My own experience led me to the following conclusions:
1. A wound in the intestinal area should be watched with care. In the face of the numerous recoveries in such cases, habitual abdominal exploration is not justified, under the conditions usually prevailing in the field.
2. The very large class of patients excluded by this rule from operation leads us to a smaller and less satisfactory number to be divided into two categories:
Patients who die during the first twelve hours. The whole of these are naturally unfit for operation, and their general condition when seen often precludes any thought of it.
Patients with very severe injuries, as evidenced by the escape of fæces, or with wounds from flank to flank or taking an antero-posterior course in the small intestinal area. These patients die, and the majority of them will always die whether operated upon or not. The undertaking of operations upon them is unpleasant to the surgeon, as being unlikely to be attended with any great degree of success, whence the impression may gain ground that patients are killed by the operations. None the less, I think these operations ought to be undertaken when the attendant conditions allow, and it is from this class of case that the real successes will be drawn in the future. The history of such injuries, after all, corresponds exactly with what we were long familiar with in traumatic ruptures in civil practice, and now know may be avoided by a sufficiently early interference. The whole question here is one of time, and this will always be the trouble in military work.
3. The expectant attitude which is obligatory under the above rules in doubtful cases, brings us face to face with a large proportion of patients in the early or late stage of peritoneal septicæmia. These cases run on exactly the same lines as those in which the same condition is secondary to spontaneous perforation of the bowel, in which we consider it our duty to operate, and in which a definite percentage of recoveries is obtained. Hence another unpleasant duty is here imposed upon the surgeon. Two such cases on which I operated are recounted above, and although I cannot say they give much encouragement, I should add that in the only one I left untouched, I regretted my want of courage for the five days during which the patient continued to carry on a miserable existence.
4. The treatment of the cases in which an expectant attitude is followed by the advent of localised suppuration presents no difficulty; simple incision alone is needed, and healing follows.