are good reasons for this. The stomach receives, as a rule, only accidental shots. A shot fired with intent to kill, as in murder or suicide, is never fired purposely at the stomach. For this purpose the head or chest in the region of the heart are selected. Of course, it is much more frequent in military practice, but I have had no experience in that, and my paper is written entirely from the standpoint of civil practice. I have had a varied and fairly busy practice for the past twenty-five years, and yet I have had but two cases of gunshot wound of the stomach. Both were fatal. As I look over the literature of the subject, I am surprised to find so little written on gunshot wound of the stomach. Many works on surgery, exhaustive on other subjects, devote onehalf or one-third of a page, or possibly only a few lines to this important subject. Dr. Ochsner, in his late and most excellent "Clinical Surgery," devotes twenty-five pages to surgery of the stomach, but does not mention gunshot wound of that organ at all. Dr. Senn, in his late work on "Practical Surgery" (1902), devotes twelve pages to gunshot wounds of the abdomen, but dismisses gunshot wounds of the stomach with but few words. However, principles are fixed and eternal, and the principles of gunshot wounds of any one of the hollow abdominal viscera apply with equal force to all others, whether they be bladder, stomach, or intestines.

Diagnosis: Assuming that the surgeon has a patient who has a gunshot wound in the region of the stomach, the first question he asks himself is, Has the stomach been perforated? It is not always easy to determine whether this be true or not; but usually the patient vomits and vomits blood. When this symptom is present we can

feel almost certain that the bullet has passed into or through the stomach. Shock is of some value, but often misleading. A valuable diagnostic aid is the use of hydrogen gas, as recommended by Dr. Senn, but this can rarely be with the sand and have found how utilized to advantage in gunshot wounds of the stomach, and as my paper does not contemplate intestinal perforations, I will dismiss the subject of gas by the mere mention of it.

Treatment: Having made the diagnosis, the surgeon must decide a question of vital importance, one upon which mightily hinges the life of the patient. Shall the treatment be operative, or palliative and expectant? If the projectile is large, and the firearm is in close range and the patient has recently. taken food into the stomach, then there can be no question. The treatment should be operative, and immediately operative. I think all of these conditions were present in the case of the late lamented President McKinley. If the projectile is small, the range far, and the patient has an empty stomach, the line of treatment is not as plain. Dr. Senn says that gunshot wounds of the stomach inflicted by a small caliber bullet frequently heal without operative interference. The same writer says "Clinical experience and the results of experiment show conclusively that laparotomy should not be performed simply because a bullet has entered the stomach." Dr. Warren, of Boston, equally good authority, says "safer to make an exploratory operation than to wait for evidences of perforation. A possibility cannot be counted upon as a probability."

Army records show many recoveries from gunshot wounds of the stomach. without operation, but the wounds are inflicted with a small bullet at long

range. Not so in civil practice, in this the wounds usually are inflicted by large bullets at short range. Since men in the profession with an international reputation do not agree as to an immediate operation, I prefer to accept that which seems less conservative, namely, an immediate operation in all cases where it is reasonably certain. that the stomach has been perforated. The operation may only be exploratory, but I believe that an exploratory incision is fraught with less danger to the patient than to risk later developments which speedily prove fatal. Exploratory operation enables the surgeon to secure bleeding vessels, if there be any; to remove clots of blood, and (in importance second only to securing bleeding vessels) to remove from the peritoneal cavity stomach contents, if there

be any.

If none of these conditions exist, the patient's life has been but little jeopardized by the operation, and the surgeon is relieved of much anxiety. Hence, I repeat: In gunshot wound of the stomach in civil practice, when the evidence is reasonably positive that the missile has perforated the stomach, operate as soon as the patient can be prepared.

How to operate. Some good sur geons recommend recommend washing out the stomach before commencing the operation. This is a very questionable procedure, for it is very possible that some of the stomach contents will in this way be washed into the peritoneal cavity. The stomach can best be reached and manipulated through an incision three or four inches in length in the median line above the umbilicus. Upon entering the abdomen the surgeon's attention should first be directed to controlling the hemorrhage. Second, to removing from the peritoneal cavity blood clots, and stomach contents, where these are found. Third, to finding and

closing wounds in the stomach. Any method of closing these wounds, or any form of stitch which will bring peritoneal surfaces well together, and turn pouting tissue inward will suffice. Wounds of the stomach, if clean, heal very readily. If deemed wise, the omentum may be utilized in closing the wounds in the stomach. This is especially true where the perforations are large. Enderlen's recent experiments have shown how omental tissue thus utilized will undergo change, and take on the structure of the stomach tissue. I quote from the "Year Book of Surgery." Enderlen has experimented extensively to obtain repair of wounds of the stomach by means of transplanted portions of the omentum. He gives the results of his experiments on cats and dogs, and shows that after excising portions of the stomach and closing the openings by means of the omentum it (omental tissue) not only effectually closes the wound, but gradually assumes the character of gastric mucous membrane. He found that well devel

I

oped gastric glands developed in transplanted portions of the omentum. have had no experience with the pursestring suture, so beautifully described by Dr. Senn, but theoretically this is a good suture to use and one easily applied. Certainly, the Lembert interrupted suture, made with fine, strong. sterile silk, is a good one and cannot well be improved upon.

Hemorrhage having been arrested, blood clots and stomach contents hav

ing been removed, and the wounds in the stomach having been closed, the toilet of the peritoneum engages the attention of the surgeon before closing the abdominal wound. This may be done by flushing or mopping. I have had some sad experience with flushing the peritoneal cavity in other laparotomies. The septic material is carried to remote

parts of the cavity and new foci of infection implanted. It is now my universal practice to mop out well the soiled portions of the peritoneal cavity with soft sponge cloths, wrung out of warm normal saline solution. The abdominal wound may be closed in the ordinary way with silkworm gut.

Prognosis: The prognosis in gunshot wounds of the stomach is always grave. A very large percentage of these cases in civil practice die. They die either from hemorrhage or septic peritonitis. Even in military practice these are very fatal wounds. In the War of the Great Rebellion, 87, 72 per cent of gunshot wounds of the stomach proved fatal. Military surgery furnishes very few cases of recovery from gunshot wounds of the stomach. More than 90 per cent of the cases attacked with septic-peritonitis following gunshot wound of the stomach die within fortyeight hours. Perforations of the gastrointestinal canal, sufficiently large to permit extravasation of its contents are with few exceptions mortal wounds.

It is reported that some of the patients operated upon by Dr. Lorenz have paralysis, but it is hoped and expected they will recover in time. Some paralysis must be anticipated in an operation that does violence to muscles, blood vessels, and nerves, and it would seem to be a fair question to ask, if some process of unrolling a club-foot, or the replacing of a dislocated limb with moderate force, giving more time for the muscles, blood vessels and nerves to accommodate themselves to the new situation, might not be adopted with benefit and less danger to the patient than the rapid and immediate one used?

The English surgeons, it is said, did not look with favor upon the opera

tions of Dr. Lorenz, but were rather suspicious of the results.

Formalin.

On the same morning, last Christmas day, that Mrs. Wm. A. Clark, Jr., of Montana, was dying, Dr. Barrows, of ew York. saved, apparently from death, a woman by the injection of formalin directly into the veins of the patient. Both were suffering from the same disease, blood-poisoning, and both from the same cause, child-birth. Since the successful result of Dr. Barrows experiment, several others have been reported with good effects, and tests are being made on animals of various kinds. It was tried in the case of Gonzales, the wounded editor of South Carolina, but he died, probably from other causes than septicism. This may prove one of the greatest of modern medical discoveries.

Damages for Deaths From Impure Antitoxins.

A St. Louis jury has awarded a complainant $1,000 damages against the former city bacteriologist for the death of the man's daughter, who died from tetanus after having been inoculated with diphtheria antitoxin provided by the city. Nine other cases are pending, in which damages are demanded aggregating $72.000. The jury held that the bacteriologist of the Health Board alone was responsible for the death of the child. -Medical Record.

Lord Lister Again Honored.

The Copley medal has been awarded this year to Lord Lister. This medal is regarded as the "blue ribbon" of science. It was founded in 1709, by Sir Godfrey Copley, for distribution to the living authors of such philosophical research, either published or communicated to the Society, as might appear to the Council to be deserving of that honor.-Philadelphia Med. Journal. Cancer Research in Germany.

The committee headed by Drs. von Leyden, Kirchner and Wutzdorf, is collecting further statistics in those regions of Germany in which cancer appears to be exceedingly frequent. It is expected that physicians will be sent into these districts in order to make special studies of the cases of cancer occurring there. The German Committee claims priority in cancer research, believing that the formation of such committees in other countries followed its example.-Philadelphia Med. Journal.

School Hygiene and Sanitation.

Statistics show that there are over fifteen million children enrolled in the common schools of the United States. Important as its existence is, nevertheless it was not until forty years ago that modern school hygiene and sanitation had its birth. Since then there has been considerable attention paid to the environments which are a part of school life. School buildings are built with regard to sanitary laws. Cleanliness is more rigidly observed. Sewage drainage is more thorough. Drinking water facilities are much improved, and altogether the general conditions are more favorable to hygiene living.

Not wishing to underestimate the great importance which should be attached to those conditions which underlie and to which are due many nervous and chronic affections, it is, nevertheless, to infectious diseases that we owe our most concern.

When it is considered that children up to the age of six or seven years are allowed to run and play and are subject to no restraints, and at this time with out a period of transition they are plunged into a life with new environments, being obliged to remain in a sometimes unsanitary school room, it is not to be wondered at that there exists these so-called school diseases.

Statistics show that there is a decided increase in infectious diseases during

the school year. This is due, unquestionably, to the mingling together of children from many localities, thus establishing many routes and possibilities for infection. In the school room there is a continual interchange of slates. pencils and books. In kindergartens their caresses bring them in close contact with each other. In both instances these habits invite infection. Children are more susceptible to infectious diseases than adults, and these habits are sufficient to prepare a means of communication.

For fourteen months, ending in January, 1896, 16,790 children were examined in the schools of Boston. Of this number, 6,053 were found to be not well, 10,000 ill, and 2,041 sick enough to be sent home. Of the number examined, 453 had contagious diseases; that number were sitting alongside of well ones. thus exposing them. When a number of sick children are allowed to remain in school it is obvious that the number of exposures will be very great. In 1899, in the same city, there were 468 specific infectious disease cases; oral and respiratory, 2.738; ear, 144; eye. 434: skin, 3.252, and miscellaneous, 10.413. making a total of 17.499. Most of these were in a condition to communicate the disease.

From a consideration of this subject and the facts which are involved, it becomes plain that there is a need of an

The part which a campaign of education is destined to play in the prevention of tuberculosis in the next quarter of a century can hardly be realized. All hands recognize the benefits which would result from the proper instruction of the public regarding the nature of the disease and those conditions which tend towards its dissemination. Societies are being organized for the education of the masses by means of the distribution of literature, setting forth the factors in this question. The Charity Organization of the City of New York is an example of such

progress.

The work of this society includes research into the social aspect of tuberculosis, i. e., the relation between the disease and over-crowding, unhygienic tenements and unhealthy occupation; also the influence of nutritious food and wholesome surroundings upon recovery; the relief of consumptives by means of provision of desirable food, fresh air, medicine and even transportation when it is deemed essential. The society publishes pamphlets pertaining to the disease, arranges for lectures and promulgates the idea in every manner possible that tuberculosis is a preventable and communicatable disease and gives results of treatment at home

and in Sanitariums. It further strengthens and encourages movements for the establishment of suitable public and private Sanitoriums, both for advanced and incipient cases. The popularity of this method is fast obtaining a strong hold among the profession. The idea that this disease in its early stages is curable cannot be disputed. The advisability of curing as many cases as possible before the infectious stage is reached is obvious. It is, however, an open question as to how much can be done by means of sanitoria as a retrogressive measure in tuberculosis, as it would require a large number of such institutions to secure appreciable results.

In conclusion, when the history of this disease is considered and the recent date of the discovery of its cause taken into consideration, we may feel. a certain satisfaction in the promising beginnings which have been made in combating tuberculosis. Among signs of better times are the establishment of consumptive hospitals in England, the legal regulations in many countries, efficient sanitary organizations in a number of American cities, the movement to institute state and private sanitoria and the gradual awakening of the general public that tuberculosis is a disease that can be eradicated by diligent attention to modern sanitary

measures.

Smallpox.

The persistency with which smallpox clings to this country is a vivid illustration of the fact that the application of the principles of Preventive. Medicine is far inferior to what Scientific Medicine warrants. There is no excuse for the manner in which smallpox has prevailed in these late years. Statistics show conclusively that in the pre-vaccination days smallpox was one