Timely Suggestions

     THE official report of the autopsy and the real cause of the death of our much lamented President, Wm. McKinley, reads as follows: “Gangrene of both walls of the stomach and pancreas following gunshot wound.”
     Autopsies scientifically conducted are of great value, not only to the medical profession, but they are also of great benefit to the human family at large. A post mortem examination will not only reveal the real cause of death; it will either confirm, or it will correct our diagnosis at the sick bed, but it will also enlighten the surgeon and the medical man of possible errors and omissions in the treatment of the case, to be avoided in the future in other similar cases.
     Despite the great strides and advances of the medical science in all its branches, especially during the latter part of the nineteenth century, we have to acknowledge that medicine, and to some extent also surgery, is not as yet an exact science; is more or less empirical. Long years of experience in practice will therefore greatly assist the practitioner to operate with greater skill, and more successfully combat and cure a disease. The writer, a humble general practitioner, has not the remotest intention to criticise the most able talent and the attendants to our late President, he merely calls your kind attention to his suggestions in gunshot wounds in the stomach and in the intestines, whereby he hopes to have the mortality rate considerably lowered. His first idea in form of suggestion in treating stab wounds, and especially gunshot wounds in any cavity of the human body, and particularly into the chest and [87][88] abdomen, is the time-honored expectant plan and conservatism. There are numerous cases on record, where stab and gunshot wounds in the stomach left to nature, ended in perfect closure of the orifice and healed up, id est, by forming a circumscribed peritonitis and exudation, which walls in the wound and seals it up hermetically. We call that process vis medicatrix naturæ, which the surgeon ought to imitate.
     The term “gangrene” is applied to the death of living tissues, and the immediate cause of the local death is deprivation of an adequate supply of nutritive material. We experience gangrene, that most dreadful sequel, mostly after amputation, despite all antiseptic precautions, when either not all necrosed and laceated [sic] tissues have been removed, or when the stitches in the stump are applied too tightly, and the more so in wounds of the stomach, on account of its anatomical and histological condition. The walls of the stomach, when deprived of sufficient blood supply, will necessarily become necrotic and gangrenous, on account of formation of stasis and thrombosis in its blood vessels.
     Pepper, in his System of Medicine, defines gangrene as “a pathological condition consequent upon interference with either the inflow or outflow of blood in the wounded part, or below it, and such interference with the circulation by plugging or ligation of blood vessels, or occasionally by the constriction of badly applied sutures and dressings, in consequence of which stasis occurs in the vessels of the affected area on account of the pressure exerted by the effusion and exudation upon the arteries and veins of the adjacent parts, thereby causing gangrene or mortification.” The writer is therefore of the opinion that surgical interference in gunshot wounds in the stomach is only indicated where there is strong suspicion or evidence of considerable hemorrhage in the cavity of the abdomen, or of laceration of some intestinal coils or collapse. Here laparotomy with prompt resection of the lacerated coils, or in wounds in the walls of the stomach through excision of the contused and necrotic edges, before applying stitches, is then the very best and safest procedure. Sutures, however carefully placed in contused or necrotic tissues, will only cause additional injury by infecting the surrounding healthy tissues, [88][89] and will only lead to septicemia or gangrene. Small bleeding in the abdominal cavity does not require laparotomy. The great absorbent capacity of the peritoneum, reinforced by the large army of phagocytes, will in most cases dispose of the blood or extraneous matter, and even if the blood should be present there in some larger quantity, we know that in a great many instances blood will eventually become encysted and thereby comparatively rendered harmless.
     In his address some months ago before the British Medical Association on “Some Surgical Lessons from the Campaigns in Cuba, South Africa and the Philippines,” Sir Wm. Thomson discoursed on the subject of gunshot wounds in the abdomen, and proved that the conservative treatment in these cases resulted in more recoveries than does the immediate opening of the abdomen and search for injuries of the intestines. He recorded that cases where undoubtedly the stomach and other intestines were perforated, recovered without laparotomy; except in cases where great internal hemorrhage, etc., was suspected, it was wise to pursue the conservative course. He also expressed himself as opposed to the search for the lodged bullets, unless such give rise to trouble. The outcome was in most cases favorable, and absence of such infectious diseases as tetanus, pyemia and gangrene was noted.
     The late Prof. Nussbaum, surgeon-general of the German army in the Franco-German war, 1870 to 1873, stated in one of his lectures to his class at the University of Munich, “The fate of the wounded rests in the hands of the one who applies the first dressing.”
     Dr. G. W. Penn, of Humboldt, Tenn., in a communication to the Phila. Med. Journal, October 12th, 1901, relates a similar case of gunshot wound, which healed by the expectant plan of treatment. He concludes as follows: “As one of the lessons of the President’s case, would it not be well in such wounds to first excise the necessarily contused and possibly infected edges elliptically, much as an ulcer might be excised, before uniting by sutures? Would gangrene of the stomach have been so likely had this been done?”
     Another: “Chicago, Oct. 4, 1901. A man suffering from the same kind of wounds as were those of McKinley, is at [89][90] the St. Elizabeth’s Hospital. Peter Arp attempted suicide and shot himself through the stomach. Instead of closing the wound by sutures, as was done with the President, it was left open to prevent gangrene. No solid food was given him for some weeks, and the man recovered!”
     In connection with the expectant plan, we must also take into consideration the effect of shock on the nervous system, on the heart and on the blood vessels, primarily produced by the assaulting weapon, knife or bullet. As much as we know of shock, we define it as a paralytic condition of the vasomotor system, and especially of a paresis of the nervus vagus, due to a general exhaustion of the nervous centers consequent upon an extremely violent impulse, which is followed by more or less thickening of the blood, according to the severity of the lesion.
     We have also to take into consideration idiosyncrasy, or susceptibility of some individuals to the bearing and the effect of an injury, shock, hemorrhage, anesthesia and surgical operations. As a rule women will stand and survive all these ordeals better than men, elderly men in particular. It is a well-known fact that general anesthesia in persons with a weak or diseased myocardium is not only badly borne, but the effect of the anesthesia will even some days after its administration prove fatal.
     Surgical interference, as laparotomy, closely following the primary injury, will most necessarily give rise to additional shock, which will greatly interfere with the natural healing process and will even eventually menace the life of the patient. Surgical interference in shot and stab wounds in the abdominal cavity shall therefore only take place upon strong evidence of internal hemorrhage or of laceration of intestinal coils.
     The fourth of these suggestions is more an appeal to you, to the medical profession at large and to the men in the laboratory, to find out any material substance or compound, preferably of an absorbent nature, which substance applied on a wound of the peritoneal surface of the stomach, large or small intestines, to the gall bladder or to the peritoneal portion of the genito-urinary organs, shall have the effect of hermetically [90][91] closing up such wounds and to dispense with the harmful stitches, leaving it then to nature to heal such wounds.
     We are all acquainted with the healing properties of collodion with or without iodoform in superficial wounds.
     A zinc oxide antiseptic plaster will replace sutures in most of the minor surgical wounds; it has even been found effective to bring union after minor surgical operations.
     You all know the value of the Murphy button—in fact the beneficial action of the Murphy button has now passed the experimental stage, and it is gratifying that since a few months the button is improved now by an absorbent material.
     During the last two years experiments have been conducted at the Vienna, Austria, surgical clinic under Prof. Gersuny. There it was found and practiced since with unfailing success, that paraffin (white vaselin) injections into cavities of organs in the body caused either on account of natural defects, holes or depressed scars, promptly replaced the original bones and tissues in functional and cosmetic way; for instance the gap in cleft palate, also filling out the space after resection of bones, or after enucleation of the testis, and in a score of other defects. It is to be hoped, therefore, that in no distant time a material will also be found, which applied on the surface of any peritoneal wound, will close that wound properly and will thereby replace the suture and its evil effects.
     To sum up, the writer suggests:
     1. To use as much as possible the conservative plan in stab and gunshot wounds in cavities of the body, particularly in the abdomen.
     2. To relieve and to minimize the baleful effect of the shock with all the means at our command.
     3. If laparotomy is strongly indicated, then not to omit to resect or to excise the lacerated and contused parts and edges of the wound.
     4. Finally, an appeal to find out any material or substance which will promptly replace sutures to the intestines.
     How many valuable lives could annually be saved, if such a substance could be found to replace the sutures.
     How many thousands stricken down with stab or gunshot wounds in the abdominal cavity, also cases of perforating [91][92] ulcus ventriculi or perforating ulcers, in consequence upon typhoid, typhus abdominalis, dysentery, and perforating ulcers due to tuberculosis of the intestines, could then be rescued from an early death.