DIAGNOSIS AND OPERATIVE TREATMENT 
GUNSHOT WOUNDS 
OF 
OF THE 
STOMACH AND INTESTINES. 
SENN. Diagnosis and Operative Treatment of 
Gunshot Wounds of the Stomach. 
and Intestines. 
BY N. SENN, M.D., Ph.D., 
OF MILWAUKEE, WIS. 
Professor Principles of Surgery and Surgical Pathology in Rush 
Medical College, Chicago, 111.; Professor of Surgery iu'the Chi- 
cago Policlinic ; Attending Surgeon to the Milwaukee Hos- 
pital ; Consulting Surgeon to the Milwaukee County 
Hospital and to the Milwaukee County Insane Asy- 
lum ; Honorary Fellow College of Physicians of 
Philadelphia, Pa.; Permanent Member of the 
German Congress of Surgeons; Honora- 
ry Member of La Academie de Medi- 
cina de Mexico, of the D. Hayes 
Agnew Surgical Society in 
Philadelphia, Pa., of the 
Ohio State Medical So- 
ciety, and of the Minne- 
sota State Medical Society ; 
Member of the American Surgical 
Association, of the American Medical 
Association, of the British Medical Asso- 
ciation, of the Wisconsin State Medical Soci- 
ety, and of the Brainard Medical Society, etc. 
Read by invitation in the Surgical Section of the Tenth 
International Medical Congress, August 8, 1890. 
Reprinted from “ The Journal of the American Medical 
tion,” August 30, Sept. 6 and 13, 1890. 
CHICAGO : 
Printed at the Office of the Association. 
1890. DIAGNOSIS AND OPERATIVE TREAT- 
MENT OF GUNSHOT WOUNDS OF THE 
STOMACH AND INTESTINES. 
The existence of a visceral lesion of the stom- 
ach or intestines must be suspected in every case 
where a bullet penetrates the abdominal cavity; 
hence the first step in the diagnosis of gunshot 
injuries of these organs must be directed towards 
establishing the fact that penetration has occurred. 
DIFFERENTIAL DIAGNOSIS BETWEEN NON PEN- 
ETRATING AND PENETRATING GUNSHOT 
WOUNDS OF THE ABDOMEN. 
This part of the diagnosis may be easy or dif- 
ficult, according to circumstances. If the bullet 
has passed through the body, and the wounds of 
entrance and exit occupy such positions that a 
direct line connecting them will necessarily pass 
through the abdominal cavity, there can be but 
little doubt that both abdominal walls have been 
perforated at opposite points, and that the bullet 
has traversed that part of the peritoneal cavity 
interposed between them. In obese persons, the 
exact outlines of the peritoneal cavity cannot be 
located with absolute accuracy, and on this ac- 
count some doubt may remain, in case two bullet 
wounds, made by a single bullet, are found over 
the anterior or lateral aspect of the pendulous ab- 
domen, whether the peritoneal cavity between the 
wounds of entrance and exit falls in the track 
made by the bullet. 
In a case of this kind that recently came under 
my observation, I decided this important question 
by injecting hydrogen gas into the wound of en- 4 
trance. A glass tube corresponding to the size 
of the bullet was connected with the rubber tube 
of a rubber balloon in which the gas was stored, 
and was inserted into the wound of entrance ; by 
gently compressing the balloon the gas was forced 
along the track made by the bullet until it escaped 
at the wound of exit, which demonstrated that 
the wounds communicated with each other, and 
consequently must have been made by the same 
bullet. In order to show conclusively that the 
peritoneal cavity had not been opened at an}" 
point along the track made by the bullet, the 
wound of exit was closed by compression, made 
with self-locking haemostatic forceps, and insuf- 
flation was resumed. After the wound had be- 
come fully distended, the resistance to the escape 
of gas was suddenly increased, which would not 
have been the case had the peritoneal cavity been 
opened, as in that case the gas would have es- 
caped into the peritoneal cavity, makinga free tym- 
panites which could have been easily recognized 
by the usual physical symptoms. Instead of this 
condition, however, a circumscribed area of em- 
physema was caused by a continuation of the in- 
sufflation, which, with the absence of a free tym- 
panites and the escape of gas at the wound of 
exit, I regarded as a positive evidence that pene- 
tration had not occurred. The wounds were not 
drained, but were treated and dressed in accord- 
ance with strict antiseptic precautions, and healed 
by first intention. 
The use of the probe in such cases is of no 
value whatever in determining the existence or 
absence of penetration, and a reliance upon it as 
a diagnostic measure may lead to serious errors, 
both in diagnosis and treatment. Air should 
never be used for insufflating a bullet track for 
diagnostic purposes, as the air injected might be- 
come the direct means of infection. Hydrogen 
gas is a non-toxic, aseptic substance with valualDle 
inhibitory antiseptic properties ; qualities which 5 
render it the most desirable substance to be used 
for inflating tubular wounds for diagnostic pur- 
poses. 
Wounds through the body made with a bullet, 
in parts of the abdomen where, from the direction 
of the track, it is not certain whether or not the 
peritoneal cavity has been opened, call for a most 
careful examination to determine this point. If 
this cannot be done satisfactorily with the hydro- 
gen gas test, the course of the bullet must be fol- 
lowed by a careful dissection from the wound 
nearest the point where we have reason to suspect 
a tear or perforation of the parietal peritoneum. 
If only one wound, the wound of entrance, is 
present, the question of penetration depends upon 
the shape and size of the bullet, the distance from 
which and direction in which the shot was fired, 
the amount and nature of the clothing covering 
the point of impact, the position of the patient 
at the time he received the injury, and the ana- 
tomical character of the parts interposed between 
the wound of entrance and the abdominal cavity. 
i. Shape and Size of the Bullet.—Other things 
being equal, the larger the bullet the greater the 
probability of deep penetration, as in the present 
construction of firearms the amount of powder in 
the cartridge is proportionate to the weight of the 
bullet. A conical bullet penetrates more deeply 
than a round bullet of equal weight. At close 
range, bullets fired from firearms of the smallest 
calibre possess sufficient force to penetrate the 
soft tissues of the thickest abdominal wall. In 
my experiments on dogs with different sized shot, 
I used a double-barreled shotgun, No. 12 gauge; 
the cartridges were charged with the usual amount 
of powder used for duck hunting, and contained 
from four to twelve shots. The dogs were ether- 
ized, strapped on a Pasteur table and placed in an 
erect position, and the shooting was done at a dis- 
tance of twenty feet. The largest shot, calibre 18, 
often passed through the body, if no bone came 6 
iii its way, while even No. 8 shot invariably pen- 
etrated the anterior abdominal wall. 
2. Distance and Direction of the Bullet.—In ref- 
erence to the distance at which the shot is fired, 
the result will be largely influenced by the size 
and shape of the bullet and the quantity of pow- 
der used in the charge. A 38- or 45-calibre con- 
ical bullet propelled by the explosion of sixty to 
seventy grains of powder, fired at a distance of 
two hundred paces, will not only penetrate the 
abdominal cavity, but will pass through the body 
if its course is not impeded by the ribs, spinal 
column, or pelvic bones; while a round bullet of 
22-calibre may fail to pass through the fleshy part 
of the abdominal wall at a distance of ten to 
twenty paces. In my experiments on the cadaver 
I used a 22-calibre Stephenson rifle and conical 
bullets. The cadaver was placed in the erect po- 
sition, and the bullet was fired at a distance of 
twenty feet, directly in front of the subject. In 
every instance the bullet perforated the anterior 
abdominal wall, passed across the peritoneal cav- 
ity, and was found lodged at variable depths in 
the posterior abdominal wall. 
The direction of the bullet plays an important 
part in the differential diagnosis between pene- 
trating and non-penetrating wounds of the abdo- 
men. A bullet fired in a direction which corre- 
sponds with the shortest and most direct route 
from the surface into the peritoneal cavity is most 
likely to cause a penetrating w'ound. Thus, bul- 
lets will enter the abdominal cavity with a mini- 
mum degree of force if in their course the}' pass 
through the thinnest portion of the abdominal 
wall, which corresponds with the linea alba and, 
notably, the umbilicus. A bullet taking a less 
direct route, especially if of small calibre or if 
fired at great distance, may become arrested in 
its course after passing through from two to six 
inches or more of soft tissues before it reaches the 
abdominal cavity. A bullet may reach the ab- 7 
dominal cavity even if the external wound be lo- 
cated a considerable distance from this cavity. In 
one of my cases, a suicide, the bullet entered the 
cavity of the chest on the left side, passed through 
the lower lobe of the left lung, and entered the 
abdominal cavity through the diaphragm, where 
it perforated the stomach from above downwards. 
Perforation of the intestines may also take place 
in the lowest part of the abdominal cavity by the 
passage of a bullet through the pelvic structures, 
the external wound being remote from the perfora- 
tion in the parietal peritoneum and the visceral 
lesions. 
3. Amojcnt and Nature of Clothing at Pomt of 
Impact of Bullet.—Many lives have been saved 
by thick, firm clothing breaking the force of the 
bullet, which then causes an ordinary, innocent 
flesh-wound instead of a penetrating wound, which 
would have been caused had the surface been less 
efficiently protected. In other cases the injury 
was modified by the bullet impinging against a 
button, belt, buckle, note- or pocket-book, which 
not only diminished the force of the missile, but 
changed its course from a direct route into the ab- 
dominal cavity into an oblique direction through 
its wall. The suicide who wants to make sure 
of the deadly intent upon his own life should di- 
vest himself of the clothing covering the heart, 
so as to remove any obstacles which might devi- 
ate or diminish the force of the bullet. 
4. Position of Patient.—In every case of gun- 
shot wound of the abdomen it is important to as- 
certain as nearly as possible the exact position of 
the patient at the instant the shot was fired, as 
information thus obtained will be of great value 
in determining beforehand the probable course of 
the bullet. It is on account of the change of the 
relative position of the parts after the infliction 
of the wound that the track made by the bullet 
cannot usually be followed with a probe, as by 
the change in the position of the muscles, and by 8 
the sliding of fascia and skin, obstructions are 
formed in different parts of the tubular wound. 
Remembering the exact position of the patient 
and his assailant, and imagining the direction of 
the bullet, its course through the tissues can be 
ascertained with at least an approximate degree 
of accuracy'. 
5. Anatomical Character of Parts Interposed Be- 
tween the Wound of Entrance and Abdominal Cav- 
ity.—A conical bullet of large calibre, fired in 
close proximity to the body, will penetrate the 
tissues irrespective of their anatomical character 
and without deflection. Deflection of small bul- 
lets, and of large bullets fired at a considerable 
distance, is occasionally caused when they strike 
a smooth bony surface at an oblique angle, an 
occurrence which abruptly deviates the course of 
the missile. McGraw, of Detroit, has shown ex- 
perimentally that deflection of bullets does not 
take place as often as had been formerly supposed. 
We have no reason to believe that the soft tissues 
of the abdominal wall, under any circumstances, 
offer sufficient resistance to change the course of 
a bullet. A partially spent bullet striking ob- 
liquely against the convex surface of the ribs, or 
against the spinous or lateral processes of the 
vertebrae, or the pelvic bones, may deflect a bul- 
let in its course, and what appears upon first 
sight a penetrating wound may be simply a wound 
of the abdominal wall, with the bullet lodged in 
the tissues at a considerable angle from the line 
of entry. Deflection should therefore be thought 
of as a possible occurrence only when the bullet 
has entered the body and has met with a bony 
resistance in its course towards the peritoneal 
cavity. 
Examination of gunshot wounds of the abdom- 
inal wall must be made with special reference to 
a positive differential diagnosis between penetra- 
ting and non-penetrating wounds. The diag- 
Exploration of Parietal Wound. 9 
nostic aids which I have just enumerated should 
be applied in every case before any attempt is 
made to demonstrate the depth and course of the 
wound by digital or instrumental exploration. 
A positive diagnosis must, however, be withheld 
until the exact course of the bullet has been re- 
vealed by a careful exploration of the wound- 
canal from the point of entrance of the bullet to 
the peritoneal cavity, if the bullet has penetrated, 
or sufficiently far to prove that the abdominal 
cavity has not been invaded. 
Certain precautions should never be neglected 
during the first examination of gunshot wounds 
of the abdomen. In the first place, undue haste 
must be scrupulously avoided. A wound of the 
abdominal wall should never be touched without 
first procuring for the wound of entrance and for 
the surface a considerable distance beyond it, a 
perfectly aseptic condition by thorough disinfec- 
tion. The parts should be scrubbed with warm 
water and potash soap, and then washed with a 
i-iooo solution of corrosive sublimate, or a 5 
per cent, solution of carbolic acid. The sur- 
geon’s and assistants’ hands should be rendered 
aseptic in the same manner, special care being 
taken to disinfect the spaces underneath the fin- 
ger-nails. Digital or instrumental exploration of 
gunshot wounds of the abdomen without the nec- 
essary antiseptic precautions must be regarded, 
in the light of modern surgery, as nothing less 
than criminal negligence, and such recklessness 
may become the direct cause of a fatal wound 
complication in case of injuries which, if treated 
upon strict antiseptic principles, would have re- 
sulted in recovery. The instruments used in ex- 
ploring the wound must be rendered aseptic by 
boiling them for at least five minutes, or by pass- 
ing them through the flame of an alcohol lamp. 
If a large bullet has penetrated the abdominal 
cavity by the shortest possible route through a 
thin portion of the abdominal wall, the fact that 10 
penetration has taken place often becomes evident 
by prolapse of the omentum into the wound-canal. 
In such a case, the surgeon verifies the diagnosis 
by seizing the visible portion of the omentum 
with a pair of dissecting or haemostatic forceps, 
and by making traction, pulls the omentum fur- 
ther into the wound for identification. The ap- 
pearance of the structure, as well as the course 
of the blood-vessels, will enable him to decide 
whether the prolapsed tissue is a part of the 
omentum, or a piece of fat from the subperitoneal 
fat or the panniculus adiposus. If the part under 
examination proves to be the omentum, the ex- 
istence of penetration has been conclusively de- 
monstrated, and the proper treatment for penetra- 
ting wounds is at once to be carried into effect. 
The cases where such a rapid differential diag- 
nosis between non-penetrating and penetrating 
gunshot wounds of the abdomen can be made, 
are comparatively few. In the majority of cases, 
exploration of the wound a careful dissection 
furnishes the only positive and reliable means in 
determining that the bullet has entered the peri- 
toneal cavity. 
Digital exploration of the wound should never 
be relied upon in ascertaining the depth and 
course of the wound, as this procedure is not in- 
fallible in making a correct diagnosis, and as, in 
case the bullet has penetrated the abdominal cav- 
ity, the finger may push before it and into the 
peritoneal cavity infected foreign substances. 
The use of the probe should be discarded in 
the examination of gunshot wounds of the abdo- 
men for diagnostic purposes. The wound-canal 
is often so tortuous from displacement of the tis- 
sues forming its walls that it cannot be followed 
with a probe without fear of making false pas- 
sages, an occurrence which could not fail to lead 
to erroneous conclusions in reference to the extent 
and course of the wound, and in regard to the pres- 11 
ence of visceral complications which might de- 
mand prompt operative treatment. 
In every case of gunshot wound of the abdo- 
men, the track made by the bullet must be fol- 
lowed by enlarging the wound by an incision at 
least two inches in length, which should intersect 
the perforation where its diameter is greatest, and 
in the direction of the principal muscle involved 
by the perforation. Before this is done all the 
preparations for a laparotomy should have been 
completed, everything required in the treatment 
of visceral wounds should be on hand, and the 
consent of the patient and his friends obtained to 
proceed and do what may become necessary in 
case it is found that the bullet has entered the 
abdominal cavity and has caused visceral injuries 
which demand surgical interference. 
It is often not an easy task to follow the track 
of a bullet with the scalpel through a thick ab- 
dominal wall. The best method of procedure is 
to insert a grooved director as far as it will pass 
without resistance, and then divide the tissues 
layer after layer, catching bleeding vessels with 
haemostatic forceps as fast as they are cut, in 
order to keep the field of operation as nearly as 
possible in a bloodless condition. The bullet 
frequently discolors the tissues, and these discol- 
orations are often important landmarks in follow- 
ing the wound. The divided tissues are held out 
of the way with sharp-toothed retractors, in order 
to enable the operator to follow the course of the 
bullet with his eye as well as with his instru- 
ments. When the point of the director is reach- 
ed it becomes necessary to make a close inspec- 
tion, and under no conditions should the knife be 
used until the wound-canal can again be identified 
and followed with the eye or the director. The 
dissection is to be made carefully and slowly until 
the opening in the parietal peritoneum is reached, 
which completes the first part of the diagnosis. 
In non-penetrating wounds the dissection is car- 12 
ried down to the bullet, which is then removed. 
In case this is not practicable on account of the 
location of the wound, the nature of the parts in- 
volved, or the length of the track, it is extended 
sufficiently far to satisfy the operator that the 
abdominal cavity is intact. The operation is 
completed by adopting the usual treatment for 
non-penetrating wounds. By following the meth- 
ods above described in differentiating between a 
non penetrating and penetrating gunshot wound 
of the abdomen, the surgeon is able to make a 
positive anatomical diagnosis, and in either case 
to adopt and carry into effect a rational plan of 
treatment. 
/. Diagnosis of Visceral Wounds of the Stomach and 
Intestines. 
Quite recently the assertion lias been made by 
several good surgeons that laparotomy is a justi- 
fiable procedure in every case of penetrating gun- 
shot wound of the abdomen, and the claim is 
made at the same time that a bullet which enters 
the peritoneal cavity must almost of necessity in- 
flict visceral injuries which require direct surgical 
treatment. The statement must, however, be ac- 
cepted as true, that in the absence of serious vis- 
ceral lesions, penetrating gunshot wounds of the 
abdomen are injuries from which the patients are 
very likely to recover without operative treat- 
ment, and that when such patients are subjected 
to laparotomy, death may occur in consequence ot 
the operation, and not as a result of the injury. 
An injury of this kind is a subcutaneous lesion 
which usually heals without any inflammation or 
suppuration, provided the bullet has not carried 
with it into the abdominal cavity foreign infected 
substances. Iam firmly convinced that in most 
cases of spontaneous recovery after penetrating 
gunshot wounds of the abdomen, the favorable 
termination was due to the fact that the bullet did 
not produce any visceral lesions of the gastro-intes- 
tinal canal. In two of the six cases of gunshot 13 
wound of the abdomen which have come under 
my observation during the last three years—and 
which will be reported further on—the absence 
of perforating wounds of the stomach and intes- 
tines was demonstrated by the hydrogen gas test, 
and both of these recovered. This appears like 
a large percentage, but my own experience so far 
has been in direct contrast with the assertions of 
a number of surgeons that all penetrating wounds 
of the abdomen require treatment by laparotomy. 
Experiments on the Cadaver. 
In order to throw more light on this important 
subject, I made a number of experiments on the 
cadaver to determine the frequency and number 
of visceral wounds of the stomach and intestines 
that may be expected in cases of penetrating gun- 
shot wounds of the abdomen when the course of 
the bullet can be determined beforehand. These 
experiments I will relate very briefly. 
The cadaver was suspended and placed in the 
erect position against a wall. The shooting was 
done at a distance of ten feet with a Stephenson 
rifle, carrying a 22-calibre conical bullet. The 
rifle was held on a level with the wound of en- 
trance, so as to give to the bullet as nearly as 
possible an exact antero-posterior direction ; that 
is, it was intended that the wound in the anterior 
abdominal wall should be on the same level as 
the wound in the posterior wall. As the experi- 
ments were made from one to three days after 
death, the abdomen was in every case somewhat 
distended by accumulation of gas in the intestines. 
Experiment 1Male, fifty-four years, dead twen- 
ty-four hours, emaciated, rigor mortis well mark- 
ed. Bullet entered through the linea alba, 1.8 
cm. below the umbilicus. The abdomen was 
opened at once, and it was ascertained that the 
bullet had passed between the transverse colon 
and small intestine without causing any visceral 
injury, and had lodged in the posterior abdomi- 
nal wall. 14 
Experiment2.—Male, forty-five years, dead thir- 
ty-six hours, very little emaciation. Wound of en- 
trance 4 mm. to the right of the median line and 8.5 
cm. below the umbilicus, producing in its course 
through the abdominal cavity one perforation on 
convex border of loop of small intestine, one per- 
foration of the sigmoid flexure, and a wound in 
the upper portion of the bladder, which was found 
adherent to a loop of the ileum. 
Experiment 3.—Male, thirty years, dead thirty 
hours, fairly well nourished. Entrance of bullet 
4.5 cm. to the left of linea alba and 2 cm. below 
the umbilicus. Result: four perforations of the 
small intestine at mesenteric border, one 011 con- 
vex side, and one through the centre of adjoining 
loop. 
Experiment 4.—Male, sixty years,dead eighteen 
hours, advanced marasmus. Bullet entered 7 cm. 
to the left of middle line and 1.5 cm. below the 
level of the umbilicus, causing three perforations 
in adjoining loops of intestine. 
Experiment 5.—Male, forty-six years, dead 
twenty-four hours, greatly emaciated. Wound 
of entrance 5 mm. to the left of the median line 
and 1 cm. above the umbilicus, producing a dou- 
ble perforation of the transverse colon. 
Experiment 6.—Male, thirty-five years, dead 
eight hours, well nourished, considerable tympa- 
nites. Ball entered 7.5 cm. to the right of the 
middle line and 15 mm. above the umbilicus, 
making in its course through the peritoneal cav- 
ity a marginal wound of the transverse colon. 
Experiment 7. — Male, fifty-six years, dead 
eighteen hours, pronounced emaciation. Entrance 
of bullet 6 cm. to the left of linea alba, and 3 cm. 
above the level of the umbilicus. No visceral in- 
juries could be found on most careful inspection 
of the abdominal cavity, the bullet having passed 
between the transverse colon and the small intes- 
tine. 
Experiment 8.—Male, forty years, dead twen- 15 
ty-four hours, moderate emaciation. Wound of 
entrance 1.2 cm. to the right of median line, and 
2.5 cm. below the umbilicus. Examination of 
the abdominal cavity showed absence of any vis- 
ceral injuries that would require surgical treat- 
ment, the bullet having passed through a trian- 
gular space formed by two adjoining loops of 
small intestine and the transverse colon. 
Experiment 9.—Male, thirty-seven years, dead 
thirty-seven hours; no emaciation. Bullet entered 
9 mm. to the right of the median line and 2.5 
cm. above the umbilicus. Eiver much enlarged, 
and stomach dilated so that the great curvature 
extended below the level of the umbilicus. In 
searching for visceral injuries it was found that 
the bullet had passed through the margin of the 
liver close to the suspensory ligament, above the 
lesser curvature of the stomach, perforating at 
the same time the head of the pancreas. 
Experiment 10.—Male, twenty-five years, dead 
thirty-six hours, well nourished. Wound of en- 
trance 3.9 cm. to the left of the middle line and 
9 mm. above the level of the umbilicus. The in- 
ternal injuries produced consisted of one marginal 
wound and three double perforations of the small 
intestine, with two wounds of the mesentery. 
Experiment 11.—Male, forty-nine years, dead 
thirty-two hours, moderate emaciation. Bullet 
entered 3 cm. to the left of the median line and 
3.3 cm. above the umbilicus, passing in its course 
through both walls of the cardiac extremity of 
the stomach near the great curvature. 
Experime7it 12.—Male, sixty-two years, dead 
seventy-two hours, considerable obesity. Wound 
of entrance 7.5 cm. to the right of the median 
line and 3.1 cm. above the umbilicus, causing a 
wound of the right lobe of the liver and passing 
through the lower segment of the right kidney. 
Experiment ij.—Male, forty-one years, dead 
twenty-three hours, extreme emaciation. Ball 
entered 9 mm. to the right of the median line and 16 
3.6 cm. above the level of the umbilicus. The 
only internal injury found was a small wound at 
the very margin of the left lobe of the liver, the 
bullet having passed between the pyloric extrem- 
ity of the stomach and the transverse colon. 
Experiment 14..—Male, thirty-six years, dead 
twenty-eight hours, moderate emaciation. Wound 
of entrance 4.2 cm. to the right of the median 
line, and 3 mm. above the umbilicus, passing 
through the transverse colon. 
The result of these experiments confirmed me 
in the opinion that I have entertained for years, 
that a bullet passing through the abdominal cav- 
ity does not produce visceral injuries as constantly 
as we have been taught to believe. It will be 
seen from the experiments that in four instances, 
experiments i, 7, 8, and 9, the bullet passed 
through the abdominal cavity in an antero-poste- 
rior direction without causing any visceral injury 
which would require surgical interference. In 
experiment 13, the bullet grazed the margin of 
the liver, producing an insignificant wound which 
could not have given rise to more than trifling haem- 
orrhage, and which would have healed promptly 
without any direct treatment. In the remaining 
experiments where no visceral lesions were pro- 
duced, the only possible indications for laparoto- 
my would have arisen on account of haemorrhage; 
but as a careful examination did not reveal the 
existence of injury of any vessel of sufficient size 
to give rise to this indication, it is only fair to 
assume that patients would recover from such in- 
juries without any special surgical treatment. 
If in two out of six cases, and in four out of 
fourteen experiments, a bullet can traverse the 
abdominal cavity through from wall to wall with- 
out inflicting a mortal visceral injury, it appears 
certainly of the greatest importance, from a prac- 
tical standpoint, to draw a line of distinction in 
the treatment of penetrating gunshot wounds of 17 
the abdomen with and without visceral lesions. 
Laparotomy should not be performed simply be- 
cause a bullet has entered the abdominal cavity, 
but its performance should be limited to the treat- 
ment of intra-abdominal lesions which, without 
operative interference, would tend to destroy life. 
My clinical experience and experimental work 
have satisfied me that the course of the bullet de- 
termines not only the existence, but also the num- 
ber of visceral wounds of the gastro-intestinal 
canal. It may be laid down as a rule, that the 
shorter the route of the bullet through the ab- 
dominal cavity, the greater the possibility that 
the intestines will escape injury, and the fewer 
the number of perforations. A bullet passing 
through the peritoneal cavity in an antero-poste- 
rior direction will meet with fewer intestinal loops 
than one that is fired through the abdomen ob- 
liquely or from side to side. The experiments 
related have demonstrated conclusively that bul- 
lets passing through the abdomen at points above 
the umbilicus are most likely to miss the intes- 
tines and to inflict simple penetrating wounds. 
On the other hand, bullet wounds in the upper 
segment of the abdomen most frequently inflict 
visceral injuries which require treatment by lap- 
arotomy for the arrest of dangerous haemorrhage, 
as a wound of the liver, kidneys, or spleen gives 
rise to alarming and often fatal haemorrhage. My 
experiments on dogs have taught me that the 
largest number of perforations are produced by 
bullets which pass from side to side, or obliquely 
through the abdomen at a point below the level 
of the umbilicus. A bullet passing through the 
abdominal cavity in an antero-posterior direction 
seldom causes more than four perforations, while 
fourteen and sixteen perforations are often found 
if it has passed transversely or obliquely through 
the abdomen at a point below the umbilicus. 
Course of Bullet. 18 
The practical deductions to be drawn from the 
above remarks are that, if in any given case it can 
be shown from reliable information that a bullet 
has crossed the abdominal cavity in an antero- 
posterior direction at or above the umbilical level, 
the gastro-intestinal canal may have escaped in- 
jury, while if it is probable that the bullet has 
passed through the abdomen from side to side or 
obliquely at a point below the umbilicus, it is not 
only almost certain that it has injured the intes- 
tines, but it is almost equally certain that it has 
produced from three to sixteen perforations. 
General Symptoms. 
The general symptoms in cases of gunshot 
wounds of the abdomen, with the exception of 
those due to profuse internal haemorrhage, fur- 
nish absolutely no reliable information in the dif- 
ferentiation between simple penetrating wounds 
and penetrating wounds complicated by visceral 
injuries. 
Severe shock may attend even a non-penetra- 
ting wound, and it may be entirely absent in 
cases of multiple perforations. In one of my 
cases where I found twelve perforations, the pa- 
tient walked a considerable distance immediately 
after he was shot, and was then transported on a 
wagon six miles to the hospital, and on his arri- 
val he did not present a single symptom of shock 
or any other evidence of serious internal injuries. 
Vomiting takes place as frequently in wounds 
of the abdominal wall and simple penetrating 
wounds as when the viscera have been injured. 
Pallor is present in all gunshot wounds of the 
abdomen soon after the receipt of the injury, and 
it is only more pronounced when produced, at 
least in part, by sudden and severe internal haem- 
orrhage. 
Pain is a very unreliable symptom, as it may 
be moderate or almost completely absent soon 19 
after the injury has been inflicted, even when 
subsequently multiple perforations are found. 
The pulse at first is slow and compressible in 
all cases of gunshot wounds of the abdomen, and 
nothing characteristic in its qualities is observed 
even if the stomach or intestines have been injured. 
Haemorrhage caused by wounds of any of the 
large vessels, mesentery, or any of the vascular 
organs, as the spleen, liver or kidneys, gives rise 
to progressive anaemia, small, rapid pulse, cold, 
clammy perspiration, dilated pupils, yawning, 
vomiting, and, in extreme cases, syncope and 
convulsions. 
The local symptoms are of no more value in 
determining the existence of visceral injuries in 
penetrating gunshot wounds of the abdomen than 
are the general symptoms just enumerated. 
1. Hcemorrhage. — External haemorrhage is 
slight or entirely wanting, unless an artery or 
vein in the abdominal wall has been injured. The 
bleeding from visceral wounds gives rise to ac- 
cumulation of blood in the peritoneal cavity; this 
can be recognized by physical signs which denote 
the presence of fluid in the free abdominal cavity 
and by the general symptoms indicating progres- 
sive anaemia; increasing pallor of the face and 
visible mucous membranes, small, feeble pulse 
and dilated pupils. Gunshot wounds of the 
stomach are often followed by haemorrhage into 
this organ and haematemesis. Haemorrhage into 
the bowels from wounds of the intestines is sel- 
dom followed by bloody stools sufficiently early 
to be of any diagnostic value. 
2. Emphysevia.—Circumscribed emphysema in 
the tissues around the track of the bullet has 
been regarded as an important sign of the exist- 
ence of intestinal perforation. This symptom is 
misleading and absolutely devoid of diagnostic 
value, as I have seen quite extensive emphysema 
of the subcutaneous tissues along the track of a 
Local Symptoms. 20 
bullet-wound of the abdominal wall where I was 
able to determine positively that the bullet did 
not penetrate the peritoneal cavity. It is very 
seldom present as the result of escape of gas 
when the stomach or intestines have been perfor- 
ated. 
j. Free Tympanites. —The accumulation of 
any considerable quantity of gas in the peritoneal 
cavity can be easily recognized by the disappear- 
ance of the flormal liver dulness caused by the 
presence of gas between the surface of the liver 
and the chest-wall. This condition has been 
sought for in cases of perforating wounds of the 
abdomen and has been laid down as one of the symp- 
toms which point to the existence of visceral 
wounds of the gastro-intestinal canal. 
In the normal condition the quantity of gas con- 
tained in the intestines is so small that even if 
all of it should escape into the peritoneal cavity 
its presence in this locality could not be recog- 
nized by physical signs. If we remember that 
only a small portion of the gaseous contents of 
the intestinal canal will escape even if a number of 
perforations exist, it is evident that this symp- 
tom should not even be taken into consideration 
in making a diagnosis. In more than a hundred 
experiments on dogs I never found enough gas in 
the peritoneal cavity, after penetrating gunshot 
wounds of the abdomen, to be recognized by 
physical signs, and I am confident that the same 
holds true in gunshot wounds of the abdominal 
cavity in man. 
Escape of Fceces.—Escape of faeces through 
the bullet-wound is of exceedingly rare occur- 
rence, and is only possible when the wound has 
been made with a large bullet and when the vis- 
ceral wound is directly opposite the internal 
opening in the abdominal wall. It is met with 
more frequently in wounds of the large than of 
the small intestine. When this symptom is 
present, it is conclusive proof of the existence of 21 
a visceral wound of the intestines and the char- 
acter of the intestinal contents will furnish some 
indication as to what part of the bowel has been 
injured. 
With the exception of the last mentioned symp- 
tom, there is nothing about the local or general 
symptoms in cases of perforating gunshot wounds 
of the abdomen that would enable the surgeon 
to decide with any degree of positiveness whether 
the bullet had produced any visceral injuries of 
the gastro-intestinal canal, and, consequently, 
whether laparotomy should or should not be per- 
formed. 
I think every modern surgeon will agree with 
me in the assertion that a perforation of any por- 
tion of the gastro-intestinal canal large enough to 
permit the escape of the contents of the stomach 
or intestines into the peritoneal cavity must be 
considered for all practical and medico-legal pur- 
poses a mortal injury, and that its discovery fur- 
nishes a positive indication for laparotomy. In 
exceptional cases, where all the conditions are 
favorable for such a termination, a spontaneous re- 
covery may take place by the wounded intestine 
or stomach forming speedy adhesions with ser- 
ous surfaces, thus protecting the peritoneal cavity 
against infection. One of the most important 
conditions for such a favorable termination to 
take place is that the wounded organ should be 
empty at the time the injury is inflicted and un- 
til the peritoneal cavity has been shut off by 
adhesions. These cases, however, are the ex- 
ception ; extravasation, septic peritonitis, and 
death are the rule. 
If a simple penetrating wound of the abdomen 
is an injury from which a large majority of pa- 
tients recover without exposing them to the addi- 
tional risks of a laparotomy, and since bullet- 
wounds of the gastro-intestinal canal are attend- 
ed by such an enormous mortality without oper- 
ative interference, the practical value and 22 
importance of a correct diagnosis before deciding 
upon a definite plan of treatment becomes appar- 
ent. Hence the necessity of resorting to the use of 
the 
Hydrogen Gas Test in the Diagnosis of Perforating 
Gunshot Wounds of the Abdomen. 
It is .apparent that if some infallible diagnostic 
test could be applied in cases of penetrating gun- 
shot wounds of the abdomen, which would indi- 
cate to the surgeon the presence or absence of 
visceral lesions of the gastro-intestinal canal, the 
indications for aggressive and conservative treat- 
ment would become clear. 
As we can never expect by a study of clinical 
symptoms, or by the ordinary physical examina- 
tion to fill this gap, I was induced three years 
ago to search for some reliable test which in such 
cases should prove that the penetrating bullet 
had injured some portion of the gastro-intestinal 
canal. It occurred to me that a wound in the 
stomach or intestine should be sought for in 
some such way as the plumber locates a leak in 
a gas-pipe. The first object to be accomplished 
was to prove the permeability of the entire gastro- 
intestinal canal to inflation of air; and the next 
step was to find some innocuous gas which when 
inflated would escape from the intestinal wound 
into the peritoneal cavity, and from there through 
the external wound, where its presence could be 
demonstrated by some infallible test. 
Permeability of the Ileo-Ccecal Valve to Rectal Insuffla- 
tion of Air or Gas. 
A great deal has been said and written in refer- 
ence to the permeability of the ileo-csecal valve to 
injections of fluids into the rectum, or to the in- 
sufflation of air or gases. The majority of those who 
have studied this subject clinically or experiment- 
ally make the positive assertion that the ileo- 
caecal valve is perfectly competent and effectually 
guards the ileum against the entrance of both 23 
fluids and gases forced into the rectum; while 
others insist that it is permeable only in excep- 
tional cases, and only a few admit that its 
resistance can be overcome by a moderate and 
safe degree of pressure. I made a number of ex- 
periments on dogs to test the resistance of the 
ileo-csecal valve to rectal injections of fluids, and 
found that the force requisite to overcome it was 
so great that in every experiment where I suc- 
ceeded in injecting fluid into the ileum, I found 
multiple longitudinal lacerations of the peritoneal 
surfaces of the caecum and colon. The experiments 
with insufflation of air and hydrogen gas proved 
uniformly successful, not only in causing incompe- 
tency of the ileo caecal valve under a pressure 
which never resulted in injury to any of the in- 
testinal tunics, but in every instance I could force 
the air or gas from anus to mouth. Of the many 
experiments which I made, I will relate only one 
in illustration of the manner in which the experi- 
ments were made, and the results.1 
Experiment.—“Dog, weight thirteen pounds. 
Animal profoundly etherized, and air forced into 
the rectum through short rectal tube connected 
by rubber tubing with inflated rubber balloon. 
The distended colon could be clearly mapped out 
by percussion before a gurgling sound in the 
region of the ileo caecal valve indicated that the 
air had entered the ileum. As soon as the air 
commenced to distend the ileum the middle of 
the abdomen became prominent and tympanitic. 
It was found that as soon as the ileo-caecal valve 
had been rendered incompetent by the gradual 
elastic dilatation of the caecum, less force was re- 
quired in distending the remaining portion of the 
gastro-intestinal canal. The inflation was carried 
to the extent of distending the stomach, an event 
which was easily recognized by a considerable 
prominence in the epigastric region which was 
1 Journal of the American Medical Association, June 23-30, 
1888. 24 
tympanitic on percussion. At this time an 
elastic tube was inserted into the stomach, and 
its free end immersed under water. Bubbles of 
air escaped freely, and the abdominal distension 
was materially diminished. As the inflation was 
continued the air escaped through the stomach 
tube, showing that a moving current of air ex- 
isted between the rectal and stomach tube.” 
The same experiment was made on the human 
subject with similar results, showing that in the 
human being the ileo-caecal valve can be render- 
ed incompetent rectal insufflation of air or gas 
with the same ease as in the lower animals. 
These experiments demonstrate conclusively that 
in the human subject by a moderate degree of 
force, short of producing any injury of the tunics 
of the intestines, air can be forced along the en- 
tire alimentary tract, and that this procedure 
can be employed with perfect safety for diag- 
nostic and therapeutic purposes in all cases where 
the tissues of the intestinal wall have not suffer- 
ed too much loss of resistance from antecedent 
pathological changes. 
Accurate experiments to determine the force 
required to render the ileo-caecal valve incom- 
petent by insufflation of air or gas had so far not 
been made, and as it was exceedingly important 
to obtain some accurate information on this sub- 
ject, a number of experiments were made on dogs 
and on the human subject. In all experiments 
air or hydrogen gas was used. The inflation 
was made with a rubber balloon. The pressure 
was estimated either with a mercury guage, or 
with a manometer, such as is used by gas-fitters 
and plumbers. The manometer or mercury gauge 
was connected means of rubber tubing with 
the rectal tube on one side, and the rubber bal- 
loon on the other. The rubber balloon in which 
the hydrogen gas was collected held four gallons, 
and numerous experiments showed that when the 
gas was forced through the opening of a stop- 25 
cock, the lumen of which was about the size of 
an ordinary knitting needle, a pressure upon the 
balloon equal to two hundred pounds (ninety kil- 
ograms) would never register more than three 
pounds (1.3 kilograms) of pressure to the square 
inch. The escape of air or gas from the rectum 
was prevented by an assistant pressing the mar- 
gins of the anus against the rectal tube. I will 
give an account of only a few of the experiments 
to illustrate this part of our subject. 
'‘''Experiment 15.— Dog, weight thirty-five 
pounds (16 kilograms). Immediately after death 
the lower portion of the rectum was isolated and 
the rectal tube inserted and fixed in its place by 
tying a string firmly around the rectum. The 
abdomen was opened and the intestines left in 
situ. The ileum was cut six inches 
above the ileo-csecal valve and a glass tube in- 
serted into the distal end, which was also tied in. 
Hydrogen gas was inflated from a rubber balloon. 
Under a pressure of three-quarters of a pound (.3 
kilograms) the caecum dilated, and a moment 
later the gas escaped from the gas tube and was 
ignited. The flame remained steady under a 
pressure of from one-half to three-quarters of a 
pound (.2 to .3 kilograms).” 
“Experiment 25.—Dog, weight eighteen pounds 
(8 kilograms). Rectal insufflation of hydrogen 
gas, the dog being fully under the influence of 
ether. The colon and caecum were only moder- 
ately distended when the gas under one-quarter 
of a pound (. 1 kilogram) of pressure passed the 
ileo-caecal valve with an audible gurgling sound. 
Under one pound (.4 kilogram) of pressure the 
abdomen became uniformly distended and tym- 
panitic, and when an elastic tube was introduced 
into the stomach the escaping gas was ignited 
and burned with a steady flame as long as the 
pressure was continued.” 
“Experiment 18.—Strong, healthy young man. 
The subject was placed flat upon his back and 26 
hydrogen gas was forced into the rectum from a 
rubber balloon; at first the gas was forced in very 
slowly under a pressure of one and a half pounds 
(.6 kilogram) which distended the colon visibly 
as far as the caecum. As the distension appeared to 
remain the same the pressure was increased to two 
pounds (.9 kilogram),when suddenly the indicator 
of the manometer receded to one pound (.4 kilo- 
gram), and the umbilical region became prominent 
and resonant, showing conclusively that the ileo- 
caecal valve had been rendered incompetent and 
that the small intestine was rapidly filling with 
gas. As soon as the whole abdomen had be- 
come distended and tympanitic, the manometer 
again registered one and one-half pounds (.6 kilo- 
gram) of pressure and remained at this figure 
for some time after further inflation was discon- 
tinued by turning the stop-cock.” 
This and other experiments prove that in a 
normal condition the resistance of the ileo-caecal 
valve to rectal insufflation of hydrogen gas in a 
healthy adult person is overcome under a pressure 
of one and one-half to two and one-quarter pounds 
(.6 to 1.1 kilograms). This amount of pressure 
is not sufficient to injure the coats of a healthy 
intestine, and none of the persons experimented 
on suffered much pain or any other immediate or 
remote consequences from the insufflation. 
As the result of numerous observations, I may 
state that when the inflation is made slowly and 
continuously there is less danger of injuring the 
intestines than when it is made rapidly, or with 
interruptions. Slow and gradual distension of 
the caecum is best adapted to overcome the com- 
petency of the ileo-caecal valve, by gradually 
stretching the valve until the margins become 
separated. It is absolutely necessary to relax the 
abdominal muscles completely by placing the pa- 
tient fully under the influence of an anaesthetic. 
A rubber balloon holding from two to four gal- 
lons (10 to 20 litres) recommends itself as the 27 
most efficient and the safest instrument for mak- 
ing rectal insufflation for therapeutic or diag- 
nostic purposes. 
It would be natural to expect that the ali- 
mentary canal could be inflated with more ease 
and with less force by following the direction of 
the normal peristaltic wave. That this is not the 
case was abundantly shown by the experiments 
which I made. These experiments demonstrated 
conclusively that it is more difficult to inflate the 
alimentary canal from above downwards, than 
from below upwards ; as in the living animal I 
succeeded in only one instance in forcing hydro- 
gen gas from mouth to anus, while in others an 
amount of force sufficient to rupture the peri- 
toneal coat of the stomach, only effected disten- 
sion of the stomach and upper portion of the in- 
testinal canal. It is evident that great distension 
of the stomach constitutes an important factor in 
causing or aggravating intestinal obstruction, as 
it results in compression of the intra-abdominal 
organs, which may give rise to impermeability of 
the intestines, or may aggravate conditions aris- 
ing from an existing partial obstruction by pro- 
ducing sharp flexions among the distended coils 
of intestine. 
For diagnostic and surgical purposes the stom- 
ach can be readily inflated to almost any extent 
through a stomach tube, and when it becomes 
necessary to ascertain the presence of a visceral 
wound of the stomach, this method of inflation 
should be invariably practiced. Perforations in 
the posterior wall of the stomach, and in the 
region of the pyloric orifice, are not easily found 
by the ordinary methods of examination, while 
their existence and exact location can be de- 
termined in a few seconds, and with certainty by 
this simple procedure. 
A number of successful operations for gunshot 
Inflation of the Stomach 28 
wounds of the stomach has been reported where 
one bullet produced two perforations ; both per- 
forations were discovered and closed by suturing, 
and the patients recovered. I have knowledge of 
two cases where one perforation was overlooked 
and the patients died of peritonitis, which could 
be traced to the unsutured perforation. In one 
of these cases a bullet passed through the cardiac 
extremity of the stomach in an antero-posterior 
direction. The perforation in the anterior wall 
was readily found and sutured, and as no other 
visceral injuries could be found the operation 
was completed. The patient died of septic peri- 
tonitis on the second day. The necropsy re- 
vealed a second perforation in the posterior wall 
of the stomach, and a septic peritonitis which 
had plainly developed from this source, as the 
large opening had remained patent, establishing 
a free communication between the interior of the 
stomach and the peritoneal cavity. 
The second case is reported by Dr. Ohage, of 
St. Paul, Minn., and is of great interest, as one 
bullet produced three perforations in the stomach. 
The bullet passed transversely through the up- 
per part of the abdominal cavity. Abdominal 
section was made, and two perforations in the 
stomach, one near the cardiac extremity, the 
other near the pylorus, were easily found and 
sutured. The surgeon had every reason to be- 
lieve that he had sutured all of the perforations. 
The patient died of septic peritonitis, which, as 
the post-mortem showed, was caused by an over- 
looked perforation in the small curvature of the 
stomach. In both of these cases it would have 
been easy to discover the undetected perforation, 
had the stomach been inflated after suturing the 
perforations, which were found without this diag- 
nostic test. 
Hydrogen gas being the lightest body known, 
non-toxic, non-irritating, and possessing valuable 
inhibitory antiseptic properties, is the most suitable 29 
substance for ballooning the stomach or intestines 
for diag?iostic purposes. Pure hydrogen gas made 
by using pure zinc and sulphuric acid is non- 
toxic, and when injected into large serous cav- 
ities, as the abdominal and pleural cavities, it 
produces no local irritation, and is absorbed in a 
short time. I made a number of experiments on 
dogs by injecting large quantities of the pure gas 
into the peritoneal and pleural cavities and into 
the subcutaneous cellular tissue, and examination 
of the tissues after the absorption of the gas 
always showed them to be in a normal condition. 
Pure hydrogen gas is not only a harmless aseptic 
substance, but it also possesses at least indirect 
antiseptic properties. The only pathogenic 
microbe which is known to be capable of repro- 
ducing itself upon a proper nutrient medium in 
an atmosphere of hydrogen gas is the bacillus 
tetani; most pathogenic microbes require a cer- 
tain amount of oxygen for their growth and re- 
production besides the nutrient medium. 
Inflation of the peritoneal cavity with hydro- 
gen gas, may prove to be one of the means of pre- 
venting septic peritonitis in cases in which the 
hydrogen gas test is applied in the treatment of 
gunshot wounds of the stomach and intestines. 
There is absolutely no danger of causing an ex- 
plosion in lighting the gas as it escapes from a 
perforation in the abdominal wall or from the end 
of a small glass tube. The smallness of the 
openings in the instances just cited will be a suffi- 
cient safeguard against an explosion. As a matter 
of course, ignition of a large volume of hydrogen 
gas should be carefully avoided, as such an oc- 
currence would cause an explosion. 
Hydrogen Gas Test as Applied in the Diagnosis of 
Perforating Gunshot Wounds of the Abdomen. 
I have up to the present time applied this test 
in over one hundred cases of gunshot wounds of 
the abdomen intentionally produced in dogs, and 30 
in every instance where the stomach or intestine 
was wounded, the visceral complication was pos- 
itively diagnosed before the abdomen was opened; 
hence I have no reason to make any retrac- 
tion from the claim previously made, that the 
test is infallible in making a positive differential 
diagnosis before abdominal section is made, be- 
tween a simple penetrating gunshot wound of 
the abdomen and a penetrating wound compli- 
cated by visceral wounds of the gastro-intestinal 
canal. 
In all these experiments the animal was strap- 
ped on one of Pasteur’s operating tables, the ab- 
domen shaved, and after the animal was fully 
under the influence of an anaesthetic, the shooting 
was done with a 32-calibre revolver. Rectal in- 
flation of hydrogen gas was practiced immediately 
after the shot was fired, and after its diagnostic 
indications were carefully studied and noted, the 
abdomen was opened and its contents examined 
for visceral injuries. In all cases where the 
colon was perforated, inflation could be done 
under slight pressure, as the gas readily 
escaped into the peritoneal cavity and from there 
through the wound of entrance, where it was ig- 
nited as it escaped. If the perforation of the in- 
testine was located above the ileo-caecal valve, 
more pressure was required, as the resistance 
offered by the ileo-caecal valve had to be over- 
come before the small intestine could be inflated. 
I will cite only one of the many experiments. 
“Experiment 65.—Dog, weight twenty-five 
pounds. Under full anaesthesia the animal was 
shot in the abdomen, the bullet passing nearly in 
a transverse direction through the abdominal 
cavity, an inch and a half below the umbilicus, 
the points of entrance and exit being midway be- 
tween the linea alba and spine. Rectal insuffla- 
tion of hydrogen gas made under very low pres- 
sure was followed by rapid distension of the ab- 
domen, an occurrence which furnished strong 31 
evidence that the gas escaped through a perfora- 
tion of the colon into the peritoneal cavity. The 
gas escaped at once from the wound of entrance 
and when ignited burned in a steady blue flame. 
On opening the abdomen, gas-escaped from the 
peritoneal cavity, the small intestine was empty, 
and only a small quantity of gas was found in 
the colon. The following intraperitoneal in- 
juries were found : Four perforations of the duo- 
denum, two of the jejunum, and one of the caecum, 
also a perforation nearly through the center of 
the left kidney, laceration of the receptaculum 
chyli, and a number of perforations in the 
mesentery. The bullet was found between the 
left kidney and the abdominal cavity.” 
In this experiment, as in all others of a similar 
nature, the gas escaped through the lowest per- 
foration and accumulated in the peritoneal 
cavity until the intra-abdominal pressure became 
sufficient to force it through the perforation in 
the abdominal wall. 
In using the hydrogen gas test in the diagnosis 
of perforating gunshot wounds of the abdomen it 
is of the greatest importance to observe carefully 
the effects of the inflation in changing the form 
of the abdomen. If the colon is perforated the 
gas will escape readily through the opening in 
the bowel under low pressure, probably not more 
than quarter to half a pound to the square inch. 
As the gas accumulates in the free peritoneal 
cavity the abdomen is at once uniformly distended 
and the free tympanites can be proved by absence 
of liver dulness. Even if gas should not escape 
through the external wound, its presence in the 
free abdominal cavity would be sufficient proof of 
the existence of intestinal lesions and would con- 
sequently be a convincing argument for the 
necessity of laparotomy. 
If no intestinal complications are present, or if 
the visceral wound is located above the ileo-csecal 
valve, this becomes apparent after insufflation has 32 
progressed sufficiently to distend the entire colon, 
a condition which may be known to be present 
from the increased width of the abdomen and the 
area of tympanitic resonance over the distended 
organ. Auscultation over the ileo-caecal region 
will enable the surgeon to tell when the resist- 
ance of the ileo-csecal valve has been overcome, 
as this will be announced by a distinct and 
audible gurgling or blowing sound as the gas 
rushes from the colon through the opening caused 
by the mechanical separation of the margins of 
the circular valve into the ileum. As the loops 
of small intestine one by one become distended 
from below upwards with the gas, the hypogas- 
tric region first becomes prominent and tympan- 
itic, and if no perforations are present, the abdo- 
men becomes barrel-shaped from the distension 
due to dilated intestines. In this condition the 
liver is lifted upwards by the distended intestines, 
the dulness is not effaced as in free tympanites, 
but the area of dulness is carried higher up. 
If the small intestine is perforated some dis- 
tance from the ileo-caecal region, the limited dis- 
tension and tympanites in the hypogastric region 
caused by the distended intestinal loops below 
the perforation will soon be displaced by the free 
tympanites resulting from the escape of gas into 
the peritoneal cavity. 
If the rules laid down in this paper for the 
treatment of penetrating gunshot wounds of the 
abdomen are followed, free tympanites will never 
occur, as the gas entering the peritoneal cavity 
from an intestinal wound will escape at once 
through the perforation in the parietal peritoneum 
which has previously been exposed by incision 
through the abdominal wall down to this point. 33 
A Clinical Contribution in Testimony of the Value and 
Reliability of the Hydrogen Gas Test hi the Diag- 
nosis of Penetrating Gunshot Wounds of 
the Abdomen. 
The following six cases of penetrating gun- 
shot wounds of the abdomen have come under 
my personal observation since I have demonstrated 
experimentally the value of rectal insufflation of 
hydrogen gas in the diagnosis of traumatic per- 
forations of the gastro-intestinal canal. In the 
treatment of these cases I relied implicitly upon 
the indications derived from the test. 
Case i.“ Gunshot Wound of Chest and Abdo- 
men ; Double Perforatio7i of Stomach; Lapa- 
rotomy; Death from Hcemorrhage and Shock.—C. 
H., a man, seventy-two years of age, was brought 
to the Milwaukee Hospital by the police patrol, 
at 7 A.M., July 9, 1888, for a suicidal, bulldog 
pistol (44-calibre), wound of the chest, inflicted 
about two hours previously. Pistol held in the 
left hand, as ascertained from the patient and 
confirmed subsequently by examination of the 
direction of the bullet. The patient stated that 
he had pointed the pistol toward the heart. 
Examination, 7 a.m.—Wound of entrance sit- 
uated in the sixth left intercostal space, sur- 
rounded by emphysema. Seventh rib fractured 
at junction of cartilage and bone. No wound of 
exit. Patient conscious; complains of severe 
pain in the epigastric region, increased by pres- 
sure. Pulse rapid and weak; vomits and expec- 
torates blood; area of liver dulness diminished. 
Percussion and respiratory sounds normal. No 
evidence of haemo- or pneumothorax. 
9 a.m.—Flexible tube introduced and stomach 
inflated with hydrogen gas from a four gallon 
rubber balloon. Gas escaped and ignited at the 
wound of entrance with an audible sound. Field 
of operation thoroughly disinfected. Patient 
etherized and laparotomy made by incision from the 
2 The Medical News, Aug. 25, 1888. 34 
ensiform cartilage to the umbilicus. The omentum 
and stomach were drawn forward into the wound. 
A large perforation, about one and a half inches 
in length (the large size being due to the oblique 
direction of the bullet), was found in the stomach, 
midway between the pylorus and the cardiac ex- 
tremity, near the greater curvature. Stomach 
partially filled with coagulated blood. With the 
index finger introduced through this perforation, 
another was detected in the posterior wall near the 
lesser curvature. An opening was made in the 
lesser omentum, but on exploration of the pos- 
terior surface of the stomach, the second perfora- 
tion could not be found. The blood-clots were 
removed from the stomach by irrigation through 
the lower wound. 
For the purpose of finding the second wound 
the stomach was again inflated with hydrogen 
gas which wras injected directly through the per- 
foration. The gas escaped through the posterior 
opening in a continuous stream, which made it 
easy to locate the second perforation. The omen- 
tal opening was enlarged by tearing, and the 
perforation was discovered on the posterior sur- 
face near the lesser curvature and close to the 
cardiac orifice. Great difficulty was experienced 
in dragging the stomach sufficiently forward and 
downward into the abdominal incision to enable 
me to suture the perforation, which was two 
inches in length. It was closed by a continued 
sero-muscular suture, the anterior perforation by 
Czerny-Lembert sutures. A large quantity of 
fluid and coagulated blood was found behind the 
stomach, in the region of the pancreas. Copious 
haemorrhage had evidently taken place at both 
perforations as well as in the post-peritoneal 
space. The visceral wounds indicated that the 
bullet had passed from above downward, back- 
ward, and to the right. 
At this stage of the operation the patient col- 
lapsed from the continued effect of shock and 35 
haemorrhage. The foot of the table was elevated, 
external heat applied, and a saline infusion 
to the amount of fifteen ounces was made into 
the left median basilic vein. Brandy was injected 
subcutaneously and the faradic current applied, 
but all these means proved fruitless, and the pa- 
tient died from the combined effects of haemor- 
rhage and shock before the external wound 
could be sutured. 
After death the abdominal incision was closed 
and inflation of hydrogen gas, per rectum, made 
to test the condition of the sutured perforations. 
A stomach tube was introduced and the gas, 
under a pressure of less than a pound to the 
square inch, was forced through the entire gastro- 
intestinal canal and escaped through a small glass 
tube which had been inserted in the distal end of 
the stomach tube, where it was ignited and 
burned in a continuous flame as long as the 
pressure upon the rubber balloon was continued. 
This showed that both visceral wounds had been 
effectually closed and that no other perforations 
existed. 
The necropsy, which was made at once, 
revealed that the bullet had entered the chest 
through the seventh rib near the junction with 
the costal cartilage, causing a comminuted frac- 
ture. The pleural cavity at this point was oblit- 
erated by adhesions. The bullet passed through 
the lower lobe of the left lung, after which it per- 
forated the diaphragm and entered the abdominal 
cavity, passing through the cardiac extremity of 
the stomach from above downwards. Liver and 
spleen intact, upper margin of tail of pancreas 
lacerated. Bullet passed to left of the aorta, 
entered the left crus of the diaphragm, fractured 
the last rib at the neck and perforated the spinal 
column, entering between the last dorsal and first 
lumbar vertebrae, escaping through the body of 
the latter, fracturing at the same time its right 
transverse process. The bullet was found in the 36 
subcutaneous connective tissue in the right lum- 
bar region. The spinal canal was opened by the 
bullet in its passage through the vertebra, 
and loose fragments of bone lay in the canal. 
The membranes were intact and the cord itself 
not injured. 
Remarks.—The location of the wound of en- 
trance in this case did not indicate that the bul- 
let had entered the abdominal cavity, unless the 
revolver was held in the left hand; in that ease, 
if directed toward the heart, the track of the bul- 
let would necessarily be downward, backward 
and from left to right. Taking it for granted 
that the bullet took this direction, it would still 
have been possible for the stomach to escape in- 
jury. The circumscribed emphysema around the 
external wound and the haemoptysis, as well as 
the location of the wound, left no doubt that the 
lobe of the left lung was injured. The absence 
of haemothorax and pneumothorax was explained 
b3" the post-mortem, as the left pleural cavity was 
found completely obliterated by adhesions. 
Under a pressure of not more than half a pound 
to the square inch, the hydrogen gas was forced 
from the stomach through the external wound, 
where it was lighted and burned in a large con- 
tinuous flame until it was extinguished b3r com- 
pression with a large moist sponge, thus demon- 
strating positively the existence of perforations in 
the stomach. 
Although the stomach can be inflated by rectal 
insufflation of hydrogen gas, the more direct 
method by using a stomach tube should have the 
preference in cases of perforating gunshot wounds 
of the abdomen where from the course of the bul- 
let there exists a probability, or even a possibility, 
that this organ has been injured. Dr. Ohage’s 
case serves as a warning to apply the test again 
even after suturing two perforations made by one 
bullet passing transversely through this organ, 37 
for the purpose of detecting a third perforation 
should this exist. 
Case 2. Gunshot Wound of the Abdomen; 
Twelve Perforations; Laparoto7ny; Recovery.3—J. 
J., a young man sixteen years of age, was out 
hunting on Sunday, September 9, 1888, with 
some companions, one of whom accidently dis- 
charged his 22-calibre rifle at a distance of about 
one hundred and fifty feet, the bullet striking the 
patient in the abdomen. The injury caused but 
little pain, and immediately after the accident 
the patient walked about forty yards to a farm- 
house where he was placed in bed. From there 
he was conveyed on a cot, in a farmer’s wagon, 
to the hospital, some six miles distant. The 
accident occurred about noon, and he arrived at 
the hospital at 3 p.m. 
Examination.—Patient complains of consider- 
able pain in the abdomen; pulse 80 and soft; his 
general appearance indicates no serious injury. 
On undressing him, a bullet wound, with omen- 
tum protruding, was found two inches to the 
right of the middle line, and on a level with the 
anterior superior spine of the ilium. Left iliac 
region dull on percussion; and in right a cracked- 
pot sound was elicited 011 percussion. A rectal 
enema was administered, and was followed by a 
free faecal discharge, without admixture of blood. 
(On washing the faeces afterward the bullet was 
found.) 
Operatio?i.—Ether, as an anaesthetic; thorough 
disinfection of abdominal wall; rectal insufflation 
of hydrogen gas, followed by the escape of bub- 
bles of the gas, within a few seconds, at the 
wound of entrance, into which had been placed 
a haemostatic forceps, the blades separated so as 
to render the canal patent. The gas was lighted, 
and after thorough cauterization of the wound by 
the flame it was extinguished by the application 
of a wet sponge. 
3 The Medical News, November io, 1888. 38 
Laparotomy by median incision, eight inches 
in length from pubes upward. About a pint of 
fluid blood in the peritoneal cavity, and haemor- 
rhage continuing from mesenteric veins at two 
points of perforation on the mesenteric side of the 
bowel, and to a less extent from perforations of 
the mesentery ; arrested by ligating en masse. 
Within a distance of four feet, near the middle of 
the ileum, were found ten perforations, two of 
which were at the mesenteric border; also four 
perforations of the mesentery. Another perfora- 
tion of the bowel was found within four inches of 
the ileo-caecal valve on the convex side of the in- 
testine, making so far eleven in all. All were 
closed by Czerny-Lembert sutures. At two 
points the perforations were so close together 
that it was found necessary to invert half the cir- 
cumference of the bowel on the convex side, thus 
producing considerable narrowing of its lumen. 
Two hours had been consumed in arresting the 
haemorrhage and closing the eleven perforations, 
and the patient at this time had become pulse- 
less, and yet it was deemed absolutely necessary 
to determine beyond all doubt if any more per- 
forations existed by repeating the rectal insuffla- 
tion of hydrogen gas. On repeating this test it 
was found that gas escaped freeh' from the pelvic 
cavity, without reaching the ileo-caecal region, 
showing that at least one more perforation was 
below this point. The sigmoid flexure was 
brought into the wound and compressed between 
the index finger and thumb. Insufflation was 
again followed by escape of gas, demonstrating 
that the perforation was below this point. Inch 
by inch the bowel was examined by this method 
in a downward direction, until a perforation 
was found in the anterior portion of the rectum 
at a point where the peritoneum covering its 
anterior wall is reflected upon the bladder. The 
perforation was rendered accessible to direct 
treatment by an assistant making traction on the 39 
colon and by keeping the margins of the wound 
well retracted by means of a pair of Hegar’s 
retractors. It was closed by five Tembert sutures, 
with the greatest difficulty, on account of its deep 
situation and the inadequate light, which was 
furnished by two candles. From the perforations 
in the ileum there escaped pieces of green apples 
and intestinal contents, and from that in the 
rectum fluid faeces. 
The peritoneal cavity was freely irrigated with 
a one-third of i per cent, solution of salicylic acid. 
After completion of the peritoneal toilet, a Keith’s 
glass drain was introduced in such a manner that 
the distal open end was placed opposite the sutured 
rectal wound, and the abdominal incision closed 
in the usual manner. Whiskey was freely ad- 
ministered hypodermatically during the opera- 
tion and after its completion, as the patient 
remained pulseless for half an hour. Time of 
operation two hours and a half. The foot of the 
bed was elevated and dry heat applied to the ex- 
tremities. 
Reaction was established slowly, but although 
the temperature did not rise much above normal, 
the pulse remained between 120 and 144 for two 
days, and during this time the patient was delir- 
ious. After the second day pulse and temperature 
nearly normal. The drainage tube was emptied 
every three or four hours by aspiration with a 
syringe, to the nozzle of which a piece of rubber 
tubing was fastened. Second day normal passage 
from the bowels. On the fourth day a faecal 
fistula formed at the site of drainage, which closed 
ten days later. 
The patient left the hospital completely cured 
six weeks after his admission, and has remained 
in perfect health ever since. 
Remarks.—The subjective symptoms in this 
case four hours after injury, and after transport- 
ing the patient a distance of six miles, furnished 
no indications whatever of the extent of the vis- 40 
ceral injuries which were found and treated dur- 
ing the operation. The rectal insufflation of hy- 
drogen gas at once rendered the diagnosis accurate 
and positive, and pointed out the necessity of ab- 
dominal section. Eleven perforations were found 
and sutured without much difficulty, but the last 
perforation, in the deeper portion of the pelvis, 
could not have been detected by any other means 
of diagnosis short of rectal insufflation. Had 
this perforation been overlooked, death from sep- 
tic peritonitis would have been inevitable, as con- 
siderable faeces had escaped through the perforation 
into the peritoneal cavity. 
Drainage was established in this case, not only 
on account of the fact that faecal extravasation 
had taken place, but also for the reason that, 
owing to the difficulty in gaining access to the 
rectal wound, I feared that the suturing was not 
as perfect as it should be, and by proper drainage 
I wished to guard against possible extravasation 
into the peritoneal cavity. Subsequent events 
proved the necessity of this precaution. 
Case j. Perforating Gunshot Wound of Abdo- 
men; four Perforations; Peritonitis; Laparotomy ; 
Death.—-J. E. (case of Drs. Gudden, Steele, and 
Gordon, of Oshkosh), eighteen years of age, was 
out target-shooting with a companion, who, while 
raising his 22-calibre rifle to his shoulder, acci- 
dentally discharged it; the bullet struck the pa- 
tient in the abdomen. He was about forty feet 
distant, and almost directly facing his companion. 
When first seen by Dr. Gudden, within half an 
hour after the injury was received, he was suffer- 
ing pain in the abdomen, was pale, covered with 
cold, clammy perspiration, and vomited frequent- 
ly. He was placed in a carriage and conveyed to 
his home, a distance of two miles. During the 
journey, the severity of the abdominal pain wras 
so increased by the motions of the carriage as to 
necessitate repeated stops. 
I saw the patient, with the above-named physi- 41 
dans, October 9, 4 a.m., twelve hours after the 
accident. 
Examination.—The wound of entrance was 
found to be at the outer margin of the left rectus 
muscle, about one inch below the level of the 
umbilicus. Abdomen dull on percussion in left 
iliac region, pulse 140, temperature ioo° F. Pen- 
etration of the abdomen was proved by the intro- 
duction of a grooved director, which was left in 
place during the insufflation of the hydrogen gas. 
The patient was placed under the influence of 
chloroform, and during the operation the narcosis 
was maintained with ether. The abdomen was 
thoroughly disinfected, and rectal insufflation of 
hydrogen gas practiced to ascertain if any perfor- 
ation of the intestine existed. Under a pressure 
of about half a pound to the square inch, and 
the use of one-quarter of a gallon of gas, in a 
few minutes the gas escaped along the groove of 
the director, and, on applying a match, ignited 
as it escaped. The flame was now extinguished 
by a moist sponge, and the abdomen opened by 
a median incision, five inches in length, extend- 
ing from the umbilicus to near the pubes. 
On exposing the peritoneum at the lower angle 
of the incision, through this membrane there was 
observed a structure closely resembling an over- 
distended bladder. That this structure was a 
distended bladder was improbable, as the boy had 
urinated before the anaesthetic was administered. 
The peritoneum was carefully incised between two 
forceps and divided upon a grooved director to 
the same extent as the external incision, and it 
was then discovered that what appeared to be an 
over-distended bladder was a coil of small intes- 
tine distended with blood to twice its normal size. 
The whole pelvic cavity was found to be filled 
with fluid blood. On withdrawing the small in- 
testine, five perforations, within a distance of three 
feet, near the junction of the jejunum and ileum, 
wrere found; four occurred in pairs on the lateral 42 
aspect of the bowel, and one at the mesenteric 
attachment. All the perforations were dispropor- 
tionately large to the size of the bullet, and would 
easily admit the tip of the index finger. The in- 
testine, at the point of injury, was covered with 
a thick layer of recent plastic lymph, and the 
parietal peritoneum presented all the evidences of 
a beginning diffuse septic peritonitis. The intes- 
tine, which was over-distended by blood-clots for 
about three feet, was emptied and irrigated with 
a one-third of one per cent, solution of salicylic 
acid, which was used for constant irrigation dur- 
ing the entire time required to suture the perfor- 
ations, which were closed by Czerny-Dembert 
sutures. 
Further examination disclosed four perforations 
of the mesentery, from two of which quite profuse 
venous haemorrhage was still going on. The 
haemorrhage was arrested by ligature en masse, 
by passing a needle, threaded with fine silk, 
through the entire thickness of the mesenterj", on 
either side of the perforations. 
Rectal insufflation of hydrogen gas was repeat- 
ed, so as to ascertain if any other perforations 
existed, and the gas, after it had been gently 
forced beyond the highest perforation, was made 
to traverse the balance of the entire intestinal 
canal by drawing forward loops of the intestine 
and returning them as examined without further 
insufflation. This procedure was found entirely 
satisfactory and practical, as the gas, on account 
of its low specific gravity, readity entered the 
highest point in the prolapsed intestinal loop. 
The abdominal cavity was irrigated with sali- 
cylic acid solution, numerous coagula removed, 
the toilet completed, a glass drain introduced into 
the pelvis, and the abdomen closed. 
Duration of operation two hours. Patient col- 
lapsed, pupils greatly dilated, and almost pulse- 
less in spite of repeated hypodermatic injections 
of brandy, which were administered when signs 43 
of collapse became apparent, throughout the oper- 
ation. Enema of a teacupful of warm water and 
two ounces of brandy. Foot of bed elevated and 
external dry heat applied. 
In an hour and a half he rallied somewhat from 
the operation, but again sank and died at 3 p.m., 
eight hours after the completion of the operation. 
Post-mortem eighteen hours after death (Drs. 
Steele, Gudden, and Gordon). Circumscribed 
peritonitis present at the time of operation, now 
diffuse; very little fluid in abdominal cavity; 
several small blood-clots in vicinity of transverse 
colon. The perforations were all securely closed, 
and the bullet was found in the soft tissues to the 
right of the spinal column, between the fourth 
and fifth lumbar vertebrae, and near the ascend- 
ing colon. The bullet, though only of 22-calibre, 
was oblong, and may thus explain the unusually 
large size of the perforations. 
Remarks.—This case, compared with the fore- 
going, furnishes a strong argument in favor of 
early operative interference in cases of gunshot 
or stab wounds of the abdomen in which the ex- 
istence of visceral lesions can be demonstrated by 
rectal insufflation of hydrogen gas. In the first 
case, although twelve perforations were found and 
sutured, and faecal extravasation had taken place, 
no evidences of peritonitis were found, and the 
patient recovered. In this case twelve hours in- 
tervened between the time the injury was received 
and the treatment by laparotomy, during which 
time a septic peritonitis had developed, the exten- 
sion of which the operation did not arrest, and 
from the effects of which the patient died. 
Case y. Penetrating Gunshot Wound of Abdo- 
men; Hydrogen Gas Test used with Positive Result; 
Laparotomy; Two Perforations of Ascending Colon; 
Deathfrom Peritonitis on fifth Day.—This patient, 
a boy fourteen }Tears of age, was shot in the abdo- 
men by the accidental discharge of a 22-calibre 
rifle in the hands of his playmate, who was stand- 44 
ing a few feet from him. The accident occurred 
September 23, 1889, at 5 o’clock in the afternoon. 
The physician who was first called probed the 
wound and ascertained that the bullet had en- 
tered the peritoneal cavity, and sent the boy at 
once to the Milwaukee Hospital for surgical treat- 
ment. No shock and no evidence of internal 
haemorrhage. 
Two hours later, after the necessar}' prepara- 
tions had been made for laparotomy, the hydro- 
gen gas test was applied, and as this yielded a 
positive result, the abdomen was opened at once. 
The wound of entrance corresponded with the 
umbilical depression, and from the position of the 
patient at the time the accident occurred and from 
the direction in which the bullet was discharged, 
I had reason to believe that the ball passed through 
the peritoneal cavity from the wound of entrance 
in a direction from left to right. 
The abdominal cavity was opened by a median 
incision extending from the wound of entrance to 
near the pubes. A small quantity of hydrogen 
gas was found in the peritoneal cavity. The 
colon was moderately distended, and I had no 
difficulty in detecting a perforation about eight 
centimetres above the ileo-caecal region. The 
visceral wound was on the same level with the 
parietal wound and on the side of the bowel 
towards the umbilicus. I expected to find the 
second perforation at a point opposite and on the 
same level, but the most careful examination 
failed to reveal its existence. I could find no ex- 
travasation or discoloration which would have 
assisted me in locating the second visceral wound, 
of the presence of which I was convinced. 
To locate the second perforation I resorted to 
the following procedure: The colon was com- 
pressed above and below the perforation that I 
had found, and direct insufflation with hydrogen 
gas was made through the visceral wound. The 
gas escaped from behind the bowel, and the con- 45 
tinued escape led me at once to the wound, which 
was located between the serous layers of the meso- 
colon and was completely hidden behind the an- 
terior peritoneal layer. No faecal extravasation 
was found before or after the insufflation. Never- 
theless it was deemed advisable to flush the peri- 
toneal cavity with warm sterilized water. After 
testing the remaining portion of the intestinal 
canal for additional perforations, the visceral 
wounds and the external incision were closed in 
the usual manner. A Keith’s glass tube was in- 
serted to secure drainage. The case progressed 
favorably for thirty-six hours, when evidences of 
diffuse septic peritonitis developed, which rapidly 
increased in intensity until the fatal termination, 
the fifth day after the operation. No post-mortem. 
Remarks.—As the whole length of the gastro- 
intestinal canal was treated for additional perfor- 
ations at the time of the operation, and none were 
found, we must take it for granted that the fatal 
peritonitis was caused by infection through the 
visceral wounds w-hich were sutured, or through 
the operation wound, or possibly, the septic micro- 
organisms were conveyed into the peritoneal cav- 
ity by the bullet. The most interesting feature 
in this case is the procedure which was employed 
to discover the second perforation. The ordinary 
methods of examination proved utterly inade- 
quate to discover the second visceral wound. 
Direct insufflation through the perforation which 
had been found, at once revealed the existence 
and location of the second visceral wound. Be- 
fore the perforations were sutured, the colon below 
the wound was emptied of its gas, and the re- 
maining portion of the gastro-intestinal canal was 
tested for additional perforations by direct insuf- 
flation through the anterior visceral wound. 
This modification of the ordinary method of 
applying rectal insufflation of hydrogen gas in 
the diagnosis of perforations of the gastro-intes- 
tinal canal offers great advantages in that it pre- 46 
vents undue distension of the intestines, and when 
properly used renders it almost impossible to over- 
look a perforation sufficiently large to require di- 
rect surgical treatment. In cases of multiple 
perforations of the intestinal canal the lowest per- 
forations can be readily located by rectal insuffla- 
tion, but the remaining perforations should be 
pointed out by direct insufflation through the 
visceral wounds, taking the precaution to empty 
the sutured portion of the bowel of its gaseous 
contents, and after disinfection, if this becomes 
necessary, to return it into the abdominal cavity, 
thus preventing undue distension and extensive 
eventration. 
Case5. Penetratmg Gunshot Wound of Abdo- 
men; Inflation of Stomach and Colon with Hydro- 
gen Gas; Foreign Body in Peritoneal Cavity; No 
Visceral Injuries Demanding Surgical Treatment. 
Recovery.—W. G., boy six years of age, was shot 
while he was standing on a box behind a saloon 
counter, the umbilicus reaching a little above the 
level of the counter. A bulldog pistol of 38- 
calibre was accidentally discharged at a distance 
of four feet from him. The bullet struck the 
counter to his left and in front, glanced, and pen- 
etrated the abdominal wall half an inch to the 
left of the linea alba and an inch and a half above 
the level of the umbilicus. After the shooting, 
the boy walked into an adjoining room without 
assistance, and the fact of his being seriously in- 
jured was only discovered on removal of his 
clothing. No shock. The patient complained 
of pain in the abdomen and vomited once, an 
hour and a half after the accident. The patient 
had eaten a hearty supper shortly before he was 
shot. No blood in the material vomited. Dr. 
Jurgens, the attending physician, applied a tem- 
porary antiseptic dressing over the wound, and 
administered small doses of morphia and atropia 
hypodermatically. 
The accident occurred at 7 p.m., March 18, 47 
1890, and on my arrival, seven hours later, his 
condition was as follows: Pulse no and full; 
face flushed, and although very quiet, complains 
of pain in the abdomen; liver dulness normal, 
both as regards location and extent. Wound of 
entrance plugged with omentum. The presence 
of omentum in the wound left no doubt that 
the bullet had entered the abdominal cavity, and 
from the location of the wound of entrance, and 
the probable course of the bullet from left to right 
and from below upward, I suspected that either 
the transverse colon or stomach had been perfor- 
ated. Preparations were at once made for a lap- 
arotomy, so that in the event that the hydrogen 
gas test should yield a positive result the neces- 
sary operation should be done at once. 
After the patient was thoroughly under the in- 
fluence of chloroform, rectal insufflation of hy- 
drogen gas was made, but when the colon had 
become fully distended it was discovered that the 
rubber balloon was leaking badly, consequently 
through insufflation could not be made. The in- 
sufflation of the colon, however, showed that this 
portion of the intestinal canal had escaped injury. 
The stomach was now inflated, and as this organ 
was fully distended without any leakage taking 
place, I was satisfied that no perforation existed. 
It still remained to determine whether the upper 
portion of the small intestine was injured, conse- 
quently an incision three inches in length, in the 
line of the wound of entrance, was made for the 
purpose of exploring the upper portion of the ab- 
dominal cavity for visceral injuries which might 
not have been revealed by the insufflations. A 
small shred of underclothing was found between 
the omentum and abdominal wall, near the track 
made by the bullet. After displacing the omen- 
tum upwards and to the left, a number of feet of 
the small intestine from the pylorus downward 
were examined with negative results. After a 
brief search, the bullet was found embedded in 48 
the space between the tenth and eleventh ribs on 
the right side, half way between the costal arch 
and the spine. The bullet was extracted through 
an external incision after pressing it outward with 
the index finger in the abdominal cavity. Only 
a small quantity of blood was found in the ab- 
dominal cavity. One external incision was closed 
in the usual manner, with the exception of a 
space for a small strip of iodoform gauze, which 
was inserted in the track of the bullet as far as 
the peritoneum. Ordinary aseptic dressing, re- 
tained in position by broad strips of adhesive plas- 
ter. The patient recovered promptly from the 
immediate effects of the operation, but soon de- 
developed symptoms of circumscribed peritonitis 
which lasted for a number of days, after which 
he recovered rapidly and completely. The exter- 
nal wound suppurated for a short time. 
Remarks.—This case is of great interest, as it 
was demonstrated at the time of operation that 
the bullet had passed at least six inches obliquely 
through the upper portion of the abdominal cav- 
ity without inflicting any visceral injuries which 
required surgical treatment. The insufflations, 
although imperfect on account of a defective rub- 
ber balloon, proved of great value, as they made 
a direct examination of the stomach and colon 
for perforations unnecessary. The bullet un- 
doubtedly passed between the transverse colon 
and the pyloric extremity of the stomach on its 
way from the point of entrance to the tenth inter- 
costal space. 
It is a comparatively easy task to find the per- 
forations after the abdomen has been opened, if 
they are located in the small intestine, but perfor- 
ations of the stomach and colon are often over- 
looked during an ordinary examination, while 
their existence in these localities is promptly and 
infallibly revealed by insufflating these organs 
with hydrogen gas. 49 
Case 6. Perforating Gunshot Wound of Abdo- 
men; Through Insufflation with Hydrogen Gas 
Showing no Intestinal Perforations; Wound of Left 
Kidney; Expectant Treatment; Recovery.—S. \V. 
A., thirty years of age, railroad conductor, was 
accidentally shot at 8 o’clock on the evening of 
April 3, 1890. The weapon used was a 22-calibre 
revolver. The physicians who were called were 
of the opinion that the bullet had entered the ab- 
dominal cavity, and advised prompt surgical treat- 
ment. An antiseptic compress was applied over 
the wound and morphia given hypodermatically. 
Almost immediately after the injury was inflicted 
the patient complained of a distressing pain in 
the region of the left kidney. No shock, or any 
other symptoms indicative of the existence of 
serious visceral injuries. Patient, accompanied 
by his physician, was transported on a cot by rail 
a distance of twenty-one miles, and arrived at the 
Milwaukee Hospital at 11:30 the same evening. 
At the hospital preparations had been made in 
the meantime for laparotomy. 
Present Condition.—The wound of entrance was 
found near the tip of the cartilage of the seventh 
rib on the left side. The ragged opening, large 
enough to admit the little finger, was surrounded 
by numerous powder marks, showing that the 
shot was fired at very close range. Considerable 
emphysema in the immediate vicinity of the 
wound. Patient complains of pain in the wound 
and in the left lumbar region. Face flushed, 
pulse 90 and full; temperature normal. A small 
dose of atropia was given hypodermatically before 
chloroform was administered. 
The abdomen and external wound were thor- 
oughly disinfected. The track of the bullet was 
followed down to the peritoneal opening by an 
incision about three inches in length, which 
proved that the bullet had entered the peritoneal 
cavity. Under profound narcosis rectal insuffla- 
tion of hydrogen gas was made. The colon 50 
became fully distended before the gas passed 
through the ileo-eaecal valve, showing that no 
perforations existed in this portion of the intes- 
tinal canal. The gas rushed through the ileo-cse- 
cal opening with a distinct gurgling sound, after 
which the hypogastric region became prominent 
and tympanitic. The distension of the abdomen 
gradually ascending as the insufflation advanced, 
proved that the intestines were intact; finally, 
when the stomach became distended, an elastic 
tube was introduced, into the distal end of which 
a small glass tube was tied. As soon as the tube 
reached the stomach, gas escaped and was repeat- 
edly lighted at the end of the glass tube. The 
hydrogen gas test had furnished positive evidence 
of the absence of intestinal perforations, and as 
there appeared to be no danger from internal 
haemorrhage, it was decided to pursue a conserv- 
ative course of treatment. The ragged, discol- 
ored tissues lining the track made by the bullet 
through the abdominal wall were carefully dis- 
sected out, and the wound united with buried and 
superficial sutures, leaving a small space in the 
lower angle for drainage. 
After the completion of the operation a catheter 
was introduced into the bladder, and a consider- 
able quantity of bloody urine escaped. It was 
now evident that the bullet had injured the left 
kidney and that it was probably lodged in the 
tissues behind the organ. As the patient did not 
show any evidence of internal haemorrhage, I 
concluded to await further developments in refer- 
ence to the treatment of the kidney injury. 
The urine contained blood in gradually dimin- 
ishing quantity for two days, after which it re- 
mained normal both in quality and quantity. No 
untoward symptoms appeared, and the patient 
was fully convalescent and left the hospital two 
weeks after admission. He has since followed 
his occupation, and has suffered no inconveni- 51 
ences whatever from the presence of the bullet in 
the lumbar region. 
Remarks.—The hydrogen gas test in this case 
proved a perfect success, as the through insuffla- 
tion demonstrated in a most positive manner the 
absence of intestinal perforations. The bullet 
must have passed between the cardiac extremity 
of the stomach and the splenic flexure of the 
colon on its way through the abdominal cavity to 
the left kidney. Without the hydrogen gas test 
it would have become necessary to make an ab- 
dominal section and examine the whole length of 
the gastro-intestinal canal in order to show that 
no perforations were present, a procedure which 
might in itself have proved a cause of death. 
The belief is almost general that a gunshot 
wound of the kidney should be treated by neph- 
rectomy. In this case I decided to pursue an 
expectant plan on account of the small calibre of 
the bullet, the absence of symptoms indicative of 
serious internal haemorrhage, and the existence 
of only a moderate haematuria. It was my in- 
tention, in case the injury of the kidney should 
result in a suppurative inflammation of this or- 
gan or its surrounding tissues, to make subse- 
quently a lumbar nephrotomy or nephrectomy. 
Like all other departures from the old and time- 
honored methods of diagnosis and treatment, the 
use of the hydrogen gas test in the discovery of 
visceral lesions of the stomach and intestines in 
perforating gunshot wounds of the abdomen will 
have to run the gauntlet of adverse criticism until, 
after a more extended experience in the hands of 
different surgeons, its merits will more generally 
be recognized. The principal objection, and the 
one that has so far been mentioned most frequent- 
ly, is that: 
i. Rectal Insufflation of Hydrogen Gas hi the 
Diagnosis of Perforating Gunshot Wounds of the 
Objections to the Hydrogen Gas Test. 52 
Abdomen Increases the Danger from Fcecal Ex- 
travasation.—The small intestines, even during 
active digestion, contain only a limited quantity 
of chyle, and in the numerous experiments on 
animals I have never observed that the gas forced 
out through the perforations any of the fluid or 
solid intestinal contents. Any one who has ob- 
served the process of inflation ad oculum will un- 
derstand wdiy it does not produce extravasation. 
Hydrogen gas being of much lower specific grav- 
ity than the fluid intestinal contents, lifts the dis- 
tended intestinal loop to the highest possible 
7iiveau compatible with the mesenteric anchorage 
of the bowel; hence wThen the gas reaches a per- 
foration, that portion of the intestine occupies a 
higher plane than the adjacent portions of the 
intestine, and the chyle by its own weight seeks 
a lower level, leaving the perforated part of the 
bowel empty of its normal contents as long as it 
remains distended with the gas. A number of 
experiments were made for the special purpose of 
showing that the fear of faecal extravasation tak- 
ing place on applying the hydrogen gas test in 
the diagnosis of visceral wounds of the gastro- 
intestinal canal is unfounded. This will be shown 
most conclusively by the few experiments which 
I will detail briefly below. 
The dogs used in these experiments had all 
had a full meal from three to four hours previ- 
ously. Immediately after they were killed the 
abdomen was opened, and wounds corresponding 
in size with wound made by a 22-calibre bullet 
were made in different parts of the intestine be- 
fore rectal insufflation was commenced. 
Experiment 1. Duodenum. — Three wounds 
were made in this part of the bowel some distance 
apart, one on the free or convex side, one on the 
mesenteric side, and the third on the side at a 
point half way between the free and mesenteric 
borders. In a few seconds after the insufflation 
was commenced the gas had ascended as far as 53 
the duodenum and escaped from all the openings 
freely without causing a drop of extravasation, 
although this portion of intestine contained a 
considerable quantity of fluid at the time. 
Experiment 2. Jejunum.—Three openings were 
made in this part of the small intestine large 
enough to insert the tip of the little finger. The 
perforations were diminished in size, but not 
closed, by bulging of the mucous membrane. 
The gas reached the perforations after moderate 
distension of the intestine on the distal side, and 
escaped freely from all the perforations without 
causing a trace of extravasation. 
Experiment j. Ileum. —Similar experiment 
with same result. 
Experiment 7. Ccecum. — An opening large 
enough to insert the tip of the little finger was 
made in the anterior wall of the caecum, and 
although this part of the bowel contained liquid 
faeces, the gas did not force out any of the contents. 
Experiment 5. Ascending Colon.—In this ex- 
periment the opening, similar in size, was made 
on the side of the bowel, but the escaping gas 
caused no extravasation. 
Experiment 6. Transverse Colon.—Same ex- 
periment with same result. 
Experiment 7. Sigmoid Flexure. — Lateral 
perforation large enough to correspond with a 
wound made with a 38-calibre bullet through 
which gas was forced by rectal insufflation, but 
no faeces escaped. Faecal extravasation occurred 
when the bowel was compressed above the per- 
foration and the insufflation was continued. 
These experiments only corroborate my obser- 
vations made in over a hundred perforating gun- 
shot wounds of the abdomen in dogs, and my 
clinical experience that the distension of wounded 
intestines with h}rdrogen gas does not increase the 
danger from faecal extravasation. The escape of 
solid faeces through a perforation by insufflation 
of gas is not to be expected, as the gas will pass 54 
between the solid mass and the intestinal wall, 
lifting the perforation away from the intestinal 
contents. 
2. Rectal Insufflation of Hydrogen Gas does not 
Infallibly Demonstrate the Existence of Visceral 
Wounds of the Stomach or Intestines.—I have 
already stated that the hydrogen gas test has 
proved infallible in my hands, both in my experi- 
mental work and in the six cases which I have 
reported in this paper. There are two conditions 
under which hydrogen gas might pass the whole 
length of the gastro intestinal canal without indi- 
cating the existence of a perforation:—(a) Plug- 
ging of the opening by a foreign body; (b]) The 
perforation may be too small for the escape of the 
gas. 
(a) Plugging of Perforation by Foreign Body. 
—Failure of the test from this source could only 
take place in exceptional cases, as when the 
stomach is wounded soon after the ingestion of 
a meal. A case has been reported where the 
stomach contained coarse solid food, in which 
the test resulted negatively. The patient died 
and the post-mortem showed that the perforation 
was closed by grains of rice which the patient 
had eaten shortly before he was shot. It is im- 
possible to say w7hether in this particular case the 
foreign substance was driven into the opening by 
the bullet, or whether it was forced into it by the 
inflation. To prevent the latter occurrence in 
gunshot wounds of the stomach it is absolutely 
necessary to either evacuate the stomach by an 
emetic shortly before the test is applied, or to 
place the patient in such a position during the in- 
flation that the wound in the stomach will occupy 
the highest level, as when this is done the hy- 
drogen will lift the perforation away from 
the solid contents and thus effectually prevent 
plugging of the perforation. If the location of the 
probable wound is not known, the patient should 
be placed alternately in different positions during 55 
the insufflation. If, from the course of the bullet 
it is probable that the stomach has been wounded 
the inflation should not be made per rectum, but 
directly through a stomach tube, as inflation of 
this organ can be made more effectually by this 
direct method. 
There is absolutely no danger that mechanical 
closure of the perforation by the impaction of a 
foreign body will ever interfere with the relia- 
bility of the hydrogen gas test in gunshot wounds 
of the intestines. 
(b) Small Size of Perforation.—In every case 
of gunshot wound of the stomach or intestines, 
the size of the perforation is diminished by ever- 
sion of the mucous membrane which either par- 
tially or completely plugs the opening. The per- 
meability of the perforation will not only depend 
on the size of the opening, but it is also influenced 
by the thickness of the wall of the organ at the 
seat of injury. The wall of the intestinal canal 
diminishes in thickness gradually from the stom- 
ach downward to the ileo-caecal region. A bul- 
let wound of the stomach of the same size as one in 
the lower portion of the ileum wall be more 
securely closed spontaneously by prolapse of 
mucous membrane, and will consequently be less 
likely to be permeable to the escape of gas when 
insufflation is practiced. 
I made an extensive series of experiments on 
dogs with missiles of small calibre, both for the 
purpose of determining the size of perforation 
which makes laparotomy necessary and also to 
ascertain the size of the visceral wound which 
will permit the hydrogen gas to escape into the 
peritoneal cavity when insufflation is made for 
diagnostic purposes. In reference to the first 
point my experiments demonstrated conclusively 
that the size of the missile is absolutely no indi- 
cation of the size of the perforation. I used missiles 
varying in size from a No. 8 shot to a 22 calibre 
bullet. Cartridges containing an ordinary charge 56 
of powder were loaded with from four to twelve 
shot and the shooting was done with an ordinary 
12-gauge single barreled shot-gun at a distance 
of ten feet, with the dog strapped upon a table 
and placed in erect position, and the umbilicus 
for a central mark. Shot of all sizes invariably 
penetrated the abdominal wall and passed through 
the peritoneal cavity. A record was kept of the 
exact location of the wounds of entrance and of 
the number of shots which entered the peritoneal 
cavity in each case. A number of the animals 
died within half an hour to two hours after the 
shooting and the necropsy invariably revealed 
haemorrhage as the immediate cause of death, the 
shot having injured some of the large abdominal 
vessels or vascular organs, as the spleen, liver or 
kidneys. Death from this cause occurred less 
frequently if shot of fine calibre was used, 3'et in 
several instances it was found that No. 8 shot, 
which are not larger than a mustard seed, caused 
death from haemorrhage when the inferior vena 
cava or one of its large branches was injured. 
A number of dogs recovered without treatment 
after having been shot transversely through the 
abdomen with a 22-calibre conical bullet. These 
animals were killed from one to several weeks 
after the shooting, when from one to four healed 
perforations were found. The point of perfora- 
tion always presented the same characteristic ap- 
pearance, a nipple-like elevation on the serous sur- 
face and a corresponding conical depression on the 
mucous surface. What occurred in these cases was 
temporary closure of the perforation by plugging of 
the visceral wound with mucous membrane and 
the formation of a cover of new tissue over the 
apex of the prolapsed mucous membrane. Dogs 
that were wounded with shot finer than No. 4 
seldom died from the effects of the visceral injuries, 
and some of these animals were shot three differ- 
ent times at intervals of one to two weeks, produc- 
ing in this wa}r dozens of minute perforations in 57 
different portions of the gastro-intestinal canal, 
all of which healed without surgical or any other 
treatment. In the animals that died from the 
visceral injuries the necropsy always showed the 
existence of perforations larger than are ordin- 
arily produced by a 22 calibre bullet. These 
large perforations were either caused by two shots 
passing in close proximity through an intestinal 
loop making one common wound, or they were 
the result of a laceration caused by the shot graz- 
ing the convex margin of an intestinal loop. In 
this manner I have seen a No. 2 shot tear an 
opening in the bowel large enough to insert the 
tip of the index finger. 
The next object in this series of experiments 
was to determine the size of the smallest wound 
of the stomach or intestines which could be dis- 
covered by means of the hydrogen gas test with- 
out opening the abdomen. The test was applied 
in perforating wounds of the abdomen inflicted 
with shot varying in size from No. 8 to “B.B.,” 
the latter of which corresponds with an 18-calibre 
bullet. Rectal insufflation was practiced imme- 
diately after the shooting. All animals in which 
the hydrogen gas test gave a positive result died, 
that is, if the gas escaped either through one of 
the perforations in the abdominal wall, or if it 
escaped into the peritoneal cavity in sufficient 
quantity to be recognized by physical symptoms, 
such as free tympanites, as nothing was done in 
the way of treatment in all of these cases. The 
post-mortem invariably showed a perforation or 
laceration of the intestines or stomach too large 
to become temporarily closed with a plug of 
mucous membrane; hence infection of the peri- 
toneal cavity and death from septic peritonitis 
followed in from one to three or four days. 
In the animals in which the test resulted nega- 
tively, and these included some in which shot of 
large calibre were used, peritonitis did not ensue, 
and if haemorrhage did not prove a source of dan- 58 
ger, they recovered without any untoward symp- 
toms. 
This to me proved an object of great interest 
and far-reaching practical value, as it satisfied me 
that the hydrogen gas test can not only be relied 
on when it is necessary to interfere in cases of 
perforating gunshot wounds of the abdomen, but 
that it also furnishes the only safe and positive 
indication for non-interference. 
In all cases where the test resulted negatively, 
the insufflation was continued until the gas 
escaped from the elastic tube which was inserted 
into the stomach, and the presence of the escap- 
ing gas was demonstrated by lighting it at the 
end of the tube. I have frequently had opportu- 
nities to observe that perforations made with a 
18-calibre shot were impermeable to the insuffla- 
tion and that occasionally considerable force had 
to be used to make the gas escape through a 
wound made with a 22-calibre bullet. These are 
the perforations which will heal spontaneously 
and through which infection of the peritoneal 
cavity is not likely to occur, because escape of 
the gaseous and liquid contents of the intestines 
does not occur. 
j. The Hydrogen Gas Test Renders Reductioyi of 
Intestines after Laparotomy more Difficult or Im- 
possible.— This objection can only apply to 
cases of wounds of the stomach or of the upper 
portion of the small intestine. I have already 
insisted that when, from the course of the bullet, 
we have reason to believe that the stomach has 
been injured, this organ should be inflated directly 
through an elastic tube and not by rectal insuffla- 
tion. If the test results positively, the indica- 
tion for a laparotomy has been furnished; if 
otherwise, the nearest hollow organ, the colon, is 
examined for perforations by rectal insufflation. 
In the absence of perforations below the ileo-csecal 
valve, the insufflation is extended as far as the 
stomach, and if the result is positive and the per- 59 
foration is located high lip in the intestinal 
canal, the intestines below the first per- 
foration will be found moderately distended 
upon opening the abdomen. After the last per- 
foration has been found, much of the gas can be 
evacuated through this opening. By resorting 
to Kiimmels’s method of replacing the intestines, 
no difficulty is experienced as a rule in this step 
of the operation. In all of my cases, and in all 
of my experiments I have invariably succeeded in 
replacing the intestines without much loss of 
time and without doing any damage. If high 
insufflation has been made and if after suturing 
all of the perforations, any difficulty should be 
experienced in replacing the intestines, there 
should be absolutely no objection to making a 
small incision into one or more of the most dis- 
tended loops of the inflated intestine and after 
evacuating the gas closing then by one or two 
superficial sutures. 
/. Hydrogen Gas Test is Unnecessary.—It has 
been asserted that the hydrogen gas test is super- 
fluous because every perforating gunshot wound 
of the abdomen is necessarily complicated by vis- 
ceral injuries which require treatment by lapar- 
otomy. This objection to the use of the hydrogen 
gas test has already been disposed of, as I have 
shown experimentally and clinically that in a 
fair percentage of cases of perforating gunshot, 
wounds of the abdomen the bullet inflicts no 
serious visceral injuries, and that such cases will 
recover, as a rule, without laparotomy. 
It has also been stated that the use of the hy- 
drogen gas test is unnecessary in detecting the 
perforations after the abdomen has been opened, 
as it is claimed that the perforations could be 
readily found by examining the intestinal loops 
lying in the course of the bullet. The adoption 
of this advice could not fail to lead to frequent 
errors of diagnosis and disastrous results in treat- 
ment, as the injured part of the bowel changes 60 
its relative position in the abdominal cavity very 
soon after the injury has been inflicted. This is 
especially true of that portion of the small intes- 
tine supplied with a long mesentery. 
In order to show that a perforated intestinal 
loop will in a short time wander away from the 
place it occupied when struck by the bullet, I 
made the following experiments: 
Experiment i.—Medium sized male dog. The 
abdomen was opened by a median incision, ex- 
actly four inches in length; the omentum pushed 
to the left of the median line and sutured to the 
left margin of the abdominal wound. The in- 
testines being disturbed as little as possible, two 
points of intestine corresponding exactly to the 
upper and lower angles of the incision were 
marked by drawing a black thread through the 
serous coat which was loosely tied and cut short. 
The external incision was sutured and the dog 
was killed eighteen hours afterwards. The 
wound was found firmly agglutinated and the 
omentum adherent to the incision. Enlarging 
the incision and leaving the intestines undis- 
turbed, the upper marked loop of the intestine 
was found displaced two inches to the right of 
the median line and one inch and a half down- 
wards and backward, being also covered b)T 
another intestinal loop, and the thread being 
directed toward the spine. The lower marked 
point was found one and one-half inches to the 
left, and one and one-fourth inches downwards, 
behind the bladder with the thread also directed 
towards the spine. 
In the three subsequent experiments, the ab- 
dominal incision was made fully six inches in 
length and the omentum was left undisturbed, 
and in the middle line two loops of the intestine, 
four inches apart, were marked, one with a white, 
and the other with a black thread which wTere 
passed through the serous coat and loosely tied. 
The intestines were exposed by a rent in the 61 
omentum four inches in length. On the margin 
of the abdominal incision a small tranverse cut 
in the skin was made to indicate the exact posi- 
tion occupied by the marked intestinal loops. 
Experiment 2.—Large female dog. Experi- 
ment described as above. Animal killed after 
twelve hours. Abdomen opened by incision from 
sternum to pubes and transversely at level of 
umbilicus. The lower marked loop was found 
displaced upwards three inches, and half an inch 
to the right of the median line. Thread in same 
direction as when introduced. Upper loop dis- 
placed downwards two inches, thread directed 
laterally, covered by another loop of intestine. 
Experiment 3.—Large male dog. Killed six 
hours after marking position of intestinal loops. 
Examination showed that the marked points 
were transposed, upper loop now being the lower, 
displaced four inches downwards and half an 
inch to the left of the median line. Lower loop 
displaced two inches upwards and buried under- 
neath two layers of intestinal coils. 
Experimeiit /.—Large female dog. Killed two 
hours after opening the abdomen. Upper marked 
point displaced an inch and a half downwards 
and an inch to the left of the median line, and 
covered by a loop of intestine; lower loop dis- 
placed one inch downward, and was pushed half 
an inch to the left of the median line. 
These experiments show conclusively that in 
making laparotomy for perforating wounds of the 
abdomen, the wounded intestinal loops are seldom 
found in the position they occupied at the time 
they were hit by the bullet. Even two hours after 
the injury an intestinal loop perforated when it 
occupied a place corresponding with the level of 
the umbilicus may be found in the cavity of the 
pelvis, or several inches above and to the left or 
right of the median line. 
The hydrogen gas test is of the greatest value 
in locating the perforation after the abdomen has 62 
been opened, as without it, one or more perfora- 
tions may be overlooked and become a cause of 
death in cases that might have recovered had the 
perforations been discovered and sutured. From 
the inaccessibility of the duodenum perforations 
of this part of the intestinal canal are very liable 
to be overlooked. Two cases have recently been 
reported where this occurred. Bernays, of St. 
Louis, made a laparotomy for perforating gun- 
shot wound of the abdomen, sutured several per- 
forations, and overlooked, as the post-mortem 
showed, a large perforation of the duodenum. 
The second case is related from the clinic at 
Basle. A man was brought into the hospital 
with a penetrating stab wound of the abdomen. 
The wound was enlarged sufficiently to permit of 
eventration. Inch by inch the small intestine 
was examined, but no perforation was found. 
The man died of septic peritonitis two days later. 
The post-mortem revealed a wound of the 
duodenum over an inch in length which had 
been overlooked, and which was the direct cause 
of the peritonitis and the indirect cause of death. 
It is needless to say, that had the hydrogen gas 
test been applied in these cases before or after the 
abdomen was opened, the perforations would 
have been discovered and sutured, and in all 
probability, both patients would have recovered. 
In all cases of perforating gunshot wounds of 
the abdomen the whole length of the gastro- 
intestinal canal should be tested by ballooning 
the stomach and intestines before the abdomen is 
closed, in order to guard against the possibility 
of leaving an undiscovered perforation. 
2. Treatment of Gunshot Wounds of the Stomach and 
Intestines. 
The propriety of surgical interference in cases 
of gunshot wounds of the stomach and intestines 
will depend on one of two things : 
i. Dangerous internal haemorrhage. 63 
2. Visceral wounds of the stomach or intestines 
large enough to permit of extravasation and the 
escape of hydrogen gas on applying the diagnos- 
tic test. 
Alarming intraperitoneal haemorrhage furnishes 
an urgent indication for treatment by laparotomy 
irrespective of the existence of the visceral lesions 
of the gastro-intestinal canal. In these days of 
aggressive surgery it would indeed be unjustifi- 
able to permit a patient to die slowly but surely 
from haemorrhage from an intra-abdominal wound 
which in itself is amenable to successful treat- 
ment by prompt surgical means. 
The signs and symptoms of profuse internal 
haemorrhage come on soon after the injury has 
been inflicted, and are so plain and significant 
that they can hardly be misinterpreted even upon 
a brief and superficial examination. The pro- 
gressive acute anaemia, the conditions of the 
pupils and pulse, and the complexus of nervous 
symptoms which attend alarming internal haem- 
orrhage present a clinical picture which, when 
once seen, is never forgotten and always recog- 
nized. 
In such cases no time should be lost in looking 
for evidences of the existence of wounds of the 
gastro intestinal canal, or in applying the hydrogen 
gas test, as the prime and most urgent indication 
is to gain access to the bleeding vessels by open- 
ing the abdomen in the median line, and then to 
arrest the haemorrhage at once by compression 
until the bleeding points can be secured by liga- 
tion or the antiseptic tamponnade. After the 
haemorrhage has been arrested, the whole gastro- 
intestinal canal, or such part of it as, from the 
course of the bullet, is known to have been ex- 
posed to injury, is tested by insufflation of hydro- 
gen gas for the purpose of ascertaining in as 
short a time as possible, the existence, location 
and number of perforations. 
In cases in which, on account of the absence of 64 
dangerous haemorrhage, the symptoms are less 
urgent, it is important to determine the necessity 
of treatment by laparotomy by resorting to the 
hydrogen gas test for the purpose of diagnosticat- 
ing the existence and size of perforations of the 
gastro-intestinal canal. If through insufflation 
can be made, it is proof positive that no perfora- 
tions exist, or, if present, that they are too small 
for extravasation to occur, and in the absence of 
other indications for abdominal section it is ad- 
visable to pursue a conservative course of treat- 
ment. Such patients are given an opiate to di- 
minish the peristaltic action of the bowels; an ab- 
solute diet is ordered and rest in bed enforced for 
at least a week, while infection from without is 
prevented by subjecting the external wound to 
rigid antiseptic treatment. 
If the hydrogen gas test, either by rectal in- 
sufflation or direct inflation of the stomach, yields 
a positive result, sufficient and reliable informa- 
tion has been gained to warrant laparotomy, as 
the surgeon has then satisfied himself that he has 
to deal with an injury which, if not properly 
treated, is almost certain to result in the death of 
the patient. 
F Laparotomy for Gunshot Wounds of the Stomach and 
Intestines. 
I have already insisted that in every perforat- 
ing gunshot wound of the abdomen, all necessary 
preparations for laparotomy should be made be- 
fore the existence of visceral wounds of the stom- 
ach or intestines has been demonstrated by the 
application of the hydrogen gas test, as the latter 
procedure necessitates the administration of an 
anaesthetic. The stomach can be inflated with- 
out an anaesthetic and the existence or absence 
of perforations demonstrated before any definite 
plan of treatment is proposed, but rectal insuffla- 
tion of hydrogen gas should never be undertaken 
in the diagnosis of gunshot wounds of the gastro- 
intestinal canal without complete anaesthesia. 65 
Before I was able to demonstrate the existence of 
visceral wounds of the stomach and intestines 
without opening the abdominal cavity, I never 
succeeded in obtaining the consent of the patient 
and friends to make a laparotomy in cases of gun- 
shot wounds of the abdomen ; but since I have 
been able to tell the people that the course to be 
pursued will depend upon the result of the test, 
I have not met with a single refusal. The hy- 
drogen gas flame at the wound of entrance is an 
argument more potent than wTords in convincing 
laymen of the necessity of active surgical inter- 
ference. If the public understands that the ab- 
domen will only be opened after the surgeon has 
satisfied himself and has demonstrated the exist- 
ence of a mortal injury, the patient and his 
friends will be only too anxious to avail them- 
selves of the benefits to be derived from the only 
resource which promises any hope of saving life. 
Medico-Legal Responsibilities in the Performance of 
Laparotomy in the Treatment of Perforating 
Wounds of the Abdomen. 
As in private practice the treatment of pene- 
trating wounds of the abdomen always involves 
great medico-legal responsibilities, it becomes of 
the greatest importance to arrive at positive 
and reliable conclusions in reference to the char- 
acter of the injury before the patient is subjected 
to the additional risks to life incident to an ab- 
dominal section. 
We will suppose a case. In a quarrel a man 
is shot in the abdomen. The assailant is placed 
under arrest. The surgeon who is called estab- 
lishes the fact that the bullet has entered the ab- 
dominal cavity, and from the point of entrance 
and its probable direction he has reason to believe 
that it has wounded some part of the gastro- 
intestinal canal, and he concludes to verify his 
diagnosis by an exploratory laparotomy; the 
operation is performed, the gastro-intestinal 
canal is examined in its whole length, but after 66 
the most careful inspection no visceral wound 
is found. Over an hour is consumed in the ex- 
amination, during which time the peritoneal 
cavity is exposed more or less to infection. The 
wound is closed and the patient dies of shock in 
two or three hours, or of septic peritonitis on the 
third or fourth day. The attorney for the State 
charges the defendant with murder. During the 
trial the defense will very naturally raise the 
questions: “Did the man die from the effects of 
the injury or the operation ?” ‘ ‘Shall the defendant 
be tried for assault and battery or for murder?’’ 
During the trial the attending surgeon is made a 
target for a volley of a medley of scientific and 
unscientific questions “by the cunning attorney 
for the defense in the attempt to save his client 
from the gallows or a sentence of imprisonment 
in the State Prison for life, at the expense of the 
reputation of the surgeon and the respect and 
good name of the profession he represents. 
This picture is not overdrawn. Such cases 
have happened and will happen again. It is en- 
tirely different if the surgeon can, by means of 
the hydrogen gas test, ascertain the existence or 
absence of fatal complications without subject- 
ing the patient to any additional risks to life. If 
the test yields a positive result, the indications for 
an operation are clear, and are understood and 
appreciated by laymen who may serve on the 
jury. 
If a laparotomy, performed in the treatment of 
a mortal injury, is followed by a fatal termina- 
tion, the result must be charged to the person 
who inflicted the injury and not to the surgeon 
who failed in his attempt to save his patient 
from certain death. If the operation proves suc- 
cessful, the surgeon has not only saved a life, but 
he has been at the same time instrumental in 
diminishing the severity of the sentence of the 
one who inflicted the injury. 67 
Preparation of the Patient. 
A patient suffering from a perforating wound 
of the abdomen should be properly prepared be- 
fore he is subjected to examination by the hydro- 
gen gas test, and, if this yields a positive result, 
to laparotomy. If the stomach is filled with 
food, a salt water emetic should be given for the 
purpose of evacuating the stomach. The rectum 
and colon should be emptied by a copious enema 
of lukewarm water to which may be added a 
tablespoonful of common salt. These precau- 
tions greatly facilitate the application of the 
hydrogen gas test, and guard against possible 
sources of error in diagnosis ; at the same time 
they leave the gastro-intestinal canal in a better 
condition for operative treatment and a speedy 
repair of the sutured wounds. A hypodermatic 
injection of one-fourth of a grain of morphia and 
one one-hundredth of a grain of atropia should 
be given shortly before the anaesthetic is admin- 
istered, as these drugs in the doses specified as- 
sist the action of the anaesthetic, secure rest for 
the intestines and sustain the action of the heart. 
If the patient is much prostrated two ounces of 
whisky diluted with four ounces of warm water 
should be given per rectum. The external wound 
and the whole abdomen must be thoroughly dis- 
infected. 
Operating Room. 
The room in which the examination is to be 
made, and possibly laparotomy performed, should 
be cleared of all draperies, pictures and unneces- 
sary furniture, and the temperature should not 
be less than 8o° F. It is a good plan to sprinkle 
the bare floor, walls and ceiling with a strong so- 
lution of corrosive sublimate or carbolic acid. 
An ordinary table covered with blankets and a 
clean sheet will answer for an operating table. 
Wash basins, dishes and pitchers are to be steri- 
lized by heat. Plenty of aseptic sponges, clean 68 
towels, and hot sterilized water must be provided. 
A hypodermic syringe and the necessary stimu- 
lants must never be absent. A sufficient quan- 
tity of hydrogen gas can be generated in from 
five to fifteen minutes. The articles necessary 
for applying the hydrogen gas test are a stomach 
tube and a four gallon rubber balloon in which 
the gas is stored, which is connected by four or 
six feet of rubber tubing with the short rectal 
tube, for which the vaginal tip of an ordinary 
Davidson’s syringe can be used. Wax tapers are 
useful in lighting the escaping gas. 
Great diversity of opinion still prevails in re- 
gard to where the incision should be made. In 
the majority of cases the median incision affords 
advantages which give it the preference. It 
should always be selected in cases of gunshot 
wounds of the stomach, and where the wound of 
entrance is located near the median line, and 
where it is known that the bullet has taken an 
antero-posterior course. A median incision affords 
most ready access in the treatment of wounds of 
the small intestine. 
The result of the hydrogen gas test will prove 
of much value in deciding the location of the in- 
cision. If, in gunshot wounds of the upper por- 
tion of the abdomen, direct inflation of the 
stomach through an elastic tube reveals the ex- 
istence of perforation of this organ, the median 
incision should be selected. If rectal insufflation 
yields a positive result before the gas has passed 
the ileo-caecal valve, the incision should be made 
over the wounded portion of the colon, which is 
usually indicated by the course of the bullet. A 
wound in the transverse colon can be found and 
dealt with most efficiently through a median in- 
cision, while perforation of the caecum or ascend- 
ing colon calls for a lateral incision directly over 
the wounded organ, while a lateral incision on 
Incision. 69 
the left side is indicated if from the direction of 
the bullet it is evident or probable that the colon 
below the splenic flexure is the seat of the vis- 
ceral injury. In the treatment of a gunshot 
wound of the colon through a lateral incision it 
is absolutely necessary to make the incision 
sufficiently long so as not only to facilitate the 
finding and suturing of the perforation, but also 
to enable the surgeon to search for and treat ad- 
ditional injuries. By suturing the external 
wound with several rows of buried sutures there 
is but little danger of a ventral hernia following. 
Daparotomv performed for the arrest of danger- 
ous haemorrhage should always be done by mak- 
ing a long median incision which will afford the 
most direct access to the different sources of 
haemorrhage. Very often it will be advisable to 
make the incision in the line of the wound of 
entrance, more especially in cases where a lateral 
incision is indicated from the location of the 
wound, from the course of the bullet, and from 
the results obtained by application of the hydro- 
gen gas test. 
Arrest of Hcemorrhage. 
In perforating wounds of the abdomen profuse 
haemorrhage is more frequently of parenchy- 
matous and venous than of arterial origin. Gun- 
shot wounds of the liver, spleen, kidneys and the 
mesentery give rise to profuse and often fatal 
haemorrhage. After opening of the peritoneal 
cavity it is often very difficult to find the bleeding 
points, as the blood accumulates as rapidly as it 
is sponged out, and it becomes necessary to re- 
sort to special means in order to arrest the pro- 
fuse bleeding sufficiently to find the source of 
haemorrhage. 
One of two resources should be employed : i. 
Digital compression of the aorta. 2. Packing 
the abdominal cavity with a number of large 
sponges. Digital compression of the aorta below 70 
the diaphragm can be readily made by an as- 
sistant introducing his hand through the abdom- 
inal incision, which in such a case must be larger 
than under ordinary circumstances. Compres- 
sion of the abdominal aorta immediately below 
the diaphragm will promptly arrest the haemor- 
rhage from any of the abdominal organs for a 
sufficient length of time to enable the surgeon to 
find the source of haemorrhage and carry out the 
necessary treatment for its permanent arrest. 
Haemorrhage from a perforated, lacerated kid- 
ney may demand a nephrectomy. A similar 
wound of the liver is cauterized with the actual 
cautery or tamponned with a long strip of iodo- 
form gauze, one end of which is brought out of 
the external wound. A wound of the spleen, if 
the haemorrhage cannot be arrested by the anti- 
septic tampon, necessitates splenectomy. Very 
troublesome haemorrhage is often met with from 
wounds of the mesentery. 
When multiple perforations of the mesentery 
and visceral wounds of the stomach or intestines 
are the source of haemorrhage, it is a good plan 
to pack the abdominal cavity with a number of 
large sponges to each of which a long strip of 
iodoform gauze is securely tied, these strips being 
allowed to hang out of the wound in order that 
none of the sponges may be lost or forgotten in 
the abdominal cavity after the completion of the 
operation. The sponges make sufficient pressure 
to arrest parenchymatous oozing as well as ven- 
ous haemorrhage if they are placed at different 
points against the mesentery and between the in- 
testinal coils. The sponges are removed one by 
one from below upwards and the bleeding points 
secured as fast as they are uncovered. 
The ligation of mesenteric vessels, both arteries 
and veins, should be done by applying the liga- 
ture en masse. Thornton’s curved haemostatic 
forceps is the most useful instrument for this 
purpose. Catgut should never be relied upon in 71 
tying a mesenteric vessel, as this material, for sev- 
eral reasons which it is not necessary to mention 
here, is greatly inferior to fine silk. Trouble- 
some haemorrhage from a large visceral wound 
of the stomach and intestines is best controlled 
by hemming the margin of the wound with fine 
silk. If haemorrhage is profuse this must be at- 
tended to before anything is done in the way of 
finding or suturing of the visceral wounds. 
Search for Perforations. 
If the hydrogen gas test has been employed 
with a positive result before the abdomen was 
opened, there will be no difficulty experienced in 
finding the first opening. If the stomach was 
inflated directly through an elastic tube and the 
test has shown the presence of a perforation, a 
median incision is made from the tip of the ensi- 
form cartilage to the umbilicus and the stomach 
drawn forward into the wound. If no perforation 
is found in the anterior wall, the insufflation is 
repeated, and the escaping gas will direct the sur- 
geon to the perforation. After closing the per- 
foration the stomach is again inflated, and if a 
second perforation exists it is readily detected by 
this test. The possibility of the existence of a 
third perforation should be remembered, conse- 
quently a third inflation becomes necessary. A 
second and a possible third perforation can also 
be detected by inflating the stomach directly 
through the first and second perforations. 
If the wound implicates the abdominal cavity 
below the stomach, the hydrogen gas test is ap- 
plied by insufflation per rectum. If the test has 
yielded a positive result, the lowest perforation is 
readily found by examining the intestine at a 
point where the distended and empty portions 
join, as the leakage of gas through the perfora- 
tion prevents inflation higher up. In one of my 
experiments I carried the inflation so far that the 
intra-abdominal pressure caused by an immense 72 
free tympanites not only prevented the inflation 
of the intestine above the first perforation, but it 
also forced out the gas from the intestine below 
the perforation. If, however, the track of the 
bullet is enlarged down to the peritoneum, as 
should be done in the diagnosis of all perforating 
gunshot wounds of the abdomen before the hy- 
drogen gas test is applied, such an occurrence is 
impossible, as the gas will escape through the 
external wound as fast as it enters the peritoneal 
cavity. 
If the intestine is found distended below the 
first discovered perforation, it is an absolute proof 
that no perforations exist lower down in the intes- 
tinal canal, and hence that it is unnecessary to 
lose any time in looking for perforations in that 
direction. 
As soon as the lowest perforation has been 
found, rectal insufflation should be suspended. If 
possible, the perforated portion of the intestine 
should now be brought forward into the wound, 
and after emptying the intestine below the perfor- 
ation as far as possible of its gas, the bowel is 
compressed below the perforation by an assistant, 
and the intestine higher up is inflated through the 
wound. As a matter of course, a perfectly asep- 
tic glass tube should be inserted into the rubber 
tube instead of the tube used in the rectum. The 
inflation is now carried as far as the second open- 
ing, when the first opening is sutured, and after 
disinfection the intervening portion of the intes- 
tine is replaced in the abdominal cavity. Further 
inflation is now made through the second opening, 
and if a third one is found, the second is su- 
tured, and so on until the entire intestinal canal 
has been thoroughly subjected to the test. By 
following this plan extensive eventration is ren- 
dered superfluous and the overlooking of a per- 
foration is made absolutely impossible. Exten- 
sive eventration in the search for perforations, 
and undiscovered perforations figure largely as 73 
causes of death in gunshot wounds of the abdo- 
men treated by laparotomy, and both of these 
sources of danger are avoided by a thorough and 
systematic employment of the hydrogen gas test. 
Suturing of Wounds of the Stomach and Intestines. 
Trimming the margins of the visceral wounds 
is not only superfluous, but absolutely harmful, 
as it requires a useless expenditure of time and 
may become an additional source of haemorrhage. 
The same can be said of the Czerny-Eembert su- 
ture. All that is required in the treatment of a 
visceral wound of the stomach and intestines is 
to turn the margins of the wound inwards and 
bring into apposition healthy serous surfaces by 
a few points of interrupted sero-muscular sutures. 
Fine aseptic silk should be used for the sutures. 
It is sufficient to use from four to six sutures to 
an inch. Wounds of the stomach should be su- 
tured in a line parallel with the long axis of the 
organ. Wounds of the intestine should be closed 
transversely, with a view of preventing constric- 
tion of the lumen. Defects an inch and a half 
in length on the convex border can be closed safe- 
ly in this manner without fear of causing intesti- 
nal obstruction, while much smaller defects on 
the mesenteric side often necessitate a resection, 
not only because the vascular supply in the cor- 
responding portion of the intestine would be in- 
adequate, but also for the reason that a sufficiently 
sharp flexion might be produced at the seat of 
suturing to become a source of intestinal obstruc- 
tion. 
Enterectomy. 
Enterectomy often becomes necessary in cases 
of double perforation, and in marginal wounds of 
the mesenteric border. If in cases of multiple 
perforations it becomes necessary to make a dou- 
ble enterectomy, and the intervening portion of 
the small intestine is not more than two or three 
feet in length, it is best to resect it at the same 74 
time, as the immediate effect of the operation will 
be less severe than a double resection with a cor- 
responding double enterorrhaphy. The mesentery 
corresponding to the portion of intestine to be re- 
moved should be tied in small sections with fine 
silk before the bowel is excised. 
Restoration of the Continuity of the Intestinal Canal 
after Enterectomy by Lateral Apposition with Decal- 
cified, Perforated, Moist, Bone Plates. 
Cases of gunshot wounds of the intestines re- 
quiring enterectomy are always grave, and any- 
thing which can be done to shorten the operation 
must add to the chances of recovery. Circular 
enterorrhaphy requires a great deal of time and 
is less certain in its results than lateral apposition 
with decalcified bone plates, and for these reasons 
the latter procedure deserves the preference in 
uniting the bowel after resection for gunshot 
wounds of the intestine. For the full technique 
of this part of the operation I must refer the reader 
to my article read in the Surgical Section of the 
American Medical Association at its last meeting, 
and published in The Journal of the Ameri- 
can Medical Association, June 14, 1890. 
If the bowel at the seat of suturing show evi- 
dences of contusion, the line of suturing and the 
damaged portion of the bowel should be covered 
by an omental graft, which is fastened in its place 
on the mesenteric side by passing two catgut su- 
tures in the line of the mesenteric vessels through 
both ends of the graft and the mesentery, and 
tying them loosely. Before the graft is planted, 
the surface of the bowel and the surface of the 
graft which is to be brought in contact with it 
are scarified with the point of an aseptic needle. 
Ome7ital Grafting. 
This is only necessary if faecal extravasation or 
escape of stomach contents has occurred, an acci- 
Irrigation of Abdominal Cavity. 75 
dent which, if it has not occurred before the ab- 
domen has been opened, should be carefully 
avoided during the manipulation of the wounded 
intestines. Flushing the peritoneal cavity with 
warm sterilized water not only clears it of infec- 
tious material, but acts at the same time as a 
stimulant to the flagging circulation. After com- 
pletion of the irrigation the patient is placed on 
his side, and in this manner the fluid contents of 
the abdominal cavity are poured out. The cavity 
is then rapidly dried with large sponges wrung 
out of a weak antiseptic solution. 
Cases wffiich require irrigation also require 
drainage. Other indications for drainage are 
visceral wounds of the liver and wounds of the 
pancreas, spleen, and kidneys, where extirpation 
of the wounded part of the organ, or the whole 
organ is deemed unnecessary, and the existence 
of parenchymatous hsemorrhage which cannot be 
remedied by any of the different haemostatic 
measures. 
Drainage. 
Incisions through the median line are rapidly 
closed by one row of silk sutures which include 
all of the tissues of the margins of the wound. 
Incisions made in any other place are to be closed 
by two or three rows of deep catgut sutures, and 
a superficial row.of silk sutures. 
Closure of External Incision. 
After- Treatment. 
Absolute rest must be strictly enforced. Opi- 
ates must be given in sufficient doses to quiet 
the peristaltic action of the intestines. No food 
should be given by the stomach for at least forty- 
eight hours. During this time brandy and water 
in small doses frequently repeated are agreeable 
to the patient, they quench thirst and exert a 
favorable influence upon the circulation. If 
more active stimulation is required to overcome 76 
shock and the effects of haemorrhage, whiskey, 
ether, musk or camphor can be injected sub- 
cutaneously or per rectum, while the peripheral 
circulation is restored by applying dry heat to 
the extremities and trunk. Should symptoms of 
peritonitis set in, a brisk saline cathartic should 
be given at the end of forty-eight hours, as at 
this time the intestinal wounds will have become 
sufficiently united to resist the violent peristalsis 
provoked by the cathartic, while the removal of 
the intestinal contents and the absorption of 
septic material from the peritoneal cavity are not 
only the most efficient means of cutting short a 
fatal disease, but also of placing the wounds in 
the most favorable condition for rapid repair. 
If the case progresses favorably, liquid food by 
the stomach can be allowed at the end of the 
second day and digestible solid food at the end of 
the first week. Under ordinary circumstances no 
effort is made to move the bowels until the end 
of the fourth or fifth day. If early feeding be- 
comes necessary in marantic or exsanguinated 
patients, this can be done by rectal alimentation. 
Patients should not be allowed to leave the bed 
until the external wound has firmly united 
throughout, as any imprudence in this direction 
is liable to be punished by the formation of a 
ventral hernia. The sutures are removed on the 
eighth day and the patient is directed to wear an 
abdominal supporter for several weeks after he 
has left his bed. 
SUGGESTIONS FOR THE CONSIDERATION OP MILI- 
TARY AUTHORITIES AND MILITARY SURGEONS. 
The object of battle is to kill and disable the 
combatants until the question of victory is 
decided in favor of the army which exceeds in 
numbers, or is superior in courage or more skilled 
in warfare. Very little has been done so far in 
the way of aggressive surgical interference for 
heroes who fell mortally wounded in the line of 77 
battle in the defense of their country, their ruler, 
their families, their homes and their rights. The 
time has come when in case of war adequate pro- 
visions should be made on the field of battle near 
the rear line for the prompt treatment of perfor- 
ating gunshot wounds of the abdomen. It is 
difficult to conceive how many valuable lives 
have been sacrificed on the field of battle during 
the innumerable wars recorded in the history of 
the world which now are within the reach of suc- 
cessful surgical interference. Thousands of lives 
have been lost from internal haemorrhage alone 
which could now be saved by an early lapar- 
otomy. 
In future wars it is the duty of every civilized 
nation to do all that modern surgery can do in 
the treatment of perforating gunshot wounds of 
the abdomen on the battle field. Every soldier 
who has been in active military service can recall 
instances where comrades dropped in the ranks 
with a mortal bullet wound of the abdomen, who 
lived for several hours and died from haemor- 
rhage, often forgotten and uncared for in the ex- 
citement of the conflict. Justice, patriotism, 
humanity and the present status of abdominal 
surgery demand that in future wars enough men 
shall be detailed from each company to convey 
the severely wounded to the rear of the line 
of battle, where they can receive prompt 
and efficient surgical aid, and where, if die they 
must, the last hour of their life shall be peaceful, 
surrounded by those who will add to their com- 
fort and administer words of consolation as the 
immortal spirit leaves the maimed body for the 
future world. 
For the purpose of carrying into effect the 
modern aggressive treatment of perforating gun- 
shot wounds of the abdomen in military practice, 
it will be necessary to erect a large tent for every 
brigade, in a safe place, but sufficiently near the 
line of battle to be within easy reach. This tent 78 
should be heated with gas stoves and provided 
with all the necessary instruments, dressing 
material and medicines required in the operative 
treatment of gunshot wounds of the abdominal 
viscera. One surgeon specially qualified for his 
work should be detailed to superintend the sur- 
gical work, assisted by a sufficient number of 
reliable assistants. This tent should be used ex- 
clusively for the treatment of perforating wounds 
of the abdomen. 
If, as is so often the case in gunshot wounds 
of the abdomen made with bullets of large calibre, 
life is threatened by haemorrhage, the abdomen, 
after rapid but thorough disinfection, should be 
opened at once, and after the bleeding has been 
arrested, visceral injuries of the gastro-intestinal 
canal should be sought for by applying the hy- 
drogen gas test in the manner described above. 
The use of this test will not only shorten the time 
required in the completion of the operation, but 
it will also guard against two grave sources of 
danger—extensive eventration and leaving un- 
discovered and unsntured perforations. Enter- 
eetomy will be more frequently made necessary 
in military than private practice on account of 
the large size of projectiles used in warfare as 
compared with those used in private life. Restor- 
ation of the continuity of the intestinal canal 
after enterectomy for gunshot wounds of the ab- 
domen should be done by a method which saves 
valuable time and secures the best results—advan- 
tages which are gained by the use of decalcified, 
perforated bone plates. Patients who rally from 
the operation should subsequently either receive 
the neccessary after treatment in hospital tents, 
or should be later transported with the greatest 
care to the nearest hospital. 
The Correct Diag?iosis and Proper Treatment of 
Gunshot Wounds of the Stomach and Intestines 
Require a Degree of Skill and Dexterity which can 
only be Acquired by Experiments on the Lower 79 
Animals. Even the minutest descriptions of the 
details to be observed and applied in the diag- 
nosis and treatment of gunshot wounds of the 
abdomen are utterly inadequate to prepare a sur- 
geon to interpret correctly the symptoms and 
signs presented by penetrating gunshot wounds 
of the abdomen, or to meet the often unexpected 
emergencies in their treatment. Operative courses 
on the cadaver are valuable and useful, but they 
never can take the place of experiments on the 
living animal. This is more especially true in 
reference to the use of the hydrogen gas test as a 
diagnostic measure, and the manual dexterity re- 
quired in the surgical treatment of internal haem- 
orrhage and visceral wounds. A certain amount 
of experimental experience is absolutely required 
in the preparation of the surgeon for the kind of 
abdominal work which requires not only courage, 
good judgment, and a thorough knowledge of 
every step in diagnosis and treatment, but also a 
manual dexterity which cannot be acquired in 
any other way. 
conclusions. 
1. In gunshot wounds of the abdomen, in the 
absence of external faecal extravasation and pro- 
lapse of the omentum, it is necessary 
to establish the fact that penetration has or has 
not taken place by enlarging the wound down to 
the peritoneum, if the bullet has entered the peri- 
toneal cavity, or in non-penetrating wounds, 
sufficiently far to show conclusively that the peri- 
toneal cavity has not been invaded. 
2. In a fair percentage of cases a bullet which 
penetrates the abdominal cavity does not produce 
visceral injuries which require treatment by 
laparotomy, and such cases, as a rule, recover 
without surgical interference. 
3. Absence of visceral lesions which require 
treatment by laparotomy is most frequently met 
with in perforating gunshot wounds of the ab- 80 
domen, if the wound of entrance is at or above 
the level of the umbilicus, and if its course is in 
an antero-posterior direction. 
4. In transverse and oblique gunshot wounds 
of the abdomen at a point below the level of the 
umbilicus, multiple perforations of the intestines 
may be confidently expected. 
5. The general and local symptoms, with the 
exception of external faecal extravasation, are of 
absolutely no value in the differential diagnosis 
between simple penetrating gunshot wounds of 
the abdomen and penetrating gunshot wounds of 
the abdomen complicated by serious visceral inju- 
ries which demand prompt surgical interference. 
6. Alarming internal haemorrhage caused by 
perforating gunshot wounds of the abdomen can 
be recognized by the symptoms which character- 
ize progressive acute anaemia, and by the phys- 
ical signs due to the presence of fluid in the free 
peritoneal cavity. 
7. Dangerous internal haemorrhage furnishes a 
positive and urgent indication for treatment by 
laparotomy. The incision in such cases should 
be ample and through the median line. 
8. After opening the peritoneal cavity for the 
treatment of alarming haemorrhage, temporary 
haemostasis should be secured by digital compres- 
sion of the aorta below the diaphragm, or by 
packing the abdominal cavity with a requisite 
number of large sponges until the bleeding points 
can be discovered and the haemorrhage arrested 
by permanent measures. 
9. The existence of wounds of the stomach and 
intestine large enough to permit the escape of the 
contents of these organs can be infallibly demon- 
strated by the application of the hydrogen gas 
test before the abdomen is opened. 
10. Direct insufflation of the stomach through 
an elastic tube is preferable to rectal insufflation 
as a diagnostic test in all cases where, from the 
location of the wound of entrance and the proba- 81 
ble course of the bullet, there is reason to believe 
that this organ is the seat of injury. 
11. The existence and probable location of 
gunshot wounds of the intestines can be ascer- 
tained by rectal insufflation of hydrogen gas. 
12. Through insufflation without evidences 
of free tympanites or escape of gas through the 
external wound demonstrates either the absence 
of perforations, or that if present they are too 
small for leakage to take place ; consequently 
the result of the test is a strong argument in 
favor of non-interference. 
13. The hydrogen gas test should invariably 
be relied upon in searching for the perforations 
after the abdominal cavity has been opened, as 
this method of examination, if properly and care- 
fully conducted, makes extensive eventration un- 
necessary, and never fails in revealing every per- 
foration. 
14. After opening the abdominal cavity for the 
treatment of gunshot wounds of the intestines, 
the lowest perforation is pointed out by rectal in- 
sufflation of hydrogen gas, but in the search for 
additional perforations the inflation should be 
made directly through the perforation last sutured, 
while the portion of the intestines which has been 
tested and the perforation sutured is replaced in 
the abdominal cavity. 
15. The external wound should never be 
closed until the whole length of the gastro- 
intestinal canal has been subjected to the hydro- 
gen gas test, in order to guard against the possi- 
bility of leaving a perforation undiscovered. 
16. The hydrogen gas test under ordinary 
circumstances does not cause faecal extravasation, 
and consequently does not increase the subse- 
quent risks from peritonitis. 
17. Pure hydrogen gas is most suitable for in- 
sufflation of the gastro-intestinal canal for diag- 
nostic purposes, as this substance is non-irritat- 
ing, non-toxic, and possesses valuable inhibitory 82 
antiseptic properties, while its exceedingly low 
specific gravity adds still more to its value when 
used for this purpose. 
18. By following the indications furnished by 
the hydrogen gas test the surgeon relieves him- 
self of all medico-legal responsibilities in the 
operative treatment of penetrating gunshot 
wounds of the abdomen. 
19. A gunshot wound of the gastro-intestinal 
canal sufficiently large to permit escape of the 
contents of the stomach or intestines must, for 
all practical purposes, be regarded as a mortal 
injury, and on this account its treatment by 
laparotomy is urgently indicated. 
20. Daparotomy in the treatment of gunshot 
wounds of the stomach and intestines should be 
performed as soon as possible after the infliction 
of the injury, and always before a septic peri- 
tonitis has had time to develop. 
21. The closure of bullet wounds of the 
stomach and intestines is accomplished most 
speedily, and with a sufficient degree of safety by 
the application of one row of interrupted sero- 
muscular sutures of fine aseptic silk. 
22. If enterectomy becomes an unavoidable 
necessity in the treatment of gunshot wounds of 
the intestines, the continuity of the intestinal 
canal should be restored by making an anastomo- 
sis between the closed ends by lateral apposition 
with decalcified, perforated, moist, bone plates, 
as this procedure requires less time and ac- 
complishes the desired result with a greater de- 
gree of safety than circular enterorrhaphy. 
23. Flushing of the abdominal cavity is to be 
reserved for cases in which the peritoneal cavity 
has become contaminated by escape of the con- 
tents of the stomach or intestines. 
24. Drainage becomes necessary in cases in 
which the peritoneal cavity has become infected, 
also in injuries of the liver, and in wounds of the 
spleen, kidney or pancreas not treated by par- 83 
tial or complete extirpation of the injured organ. 
25. The adoption of adequate provisions for 
the prompt, aggressive treatment of perforating 
gunshot wounds of the abdomen in hospital tents 
in the rear of the line of battle, should receive 
the most serious consideration of military author- 
ities, and military surgeons who will have charge 
of the wounded in the wars of the future. 
26. The necessary diagnostic skill, and requis- 
ite manual dexterity in the operative treatment 
of gunshot wounds of the stomach and intestines, 
can be acquired only by experiments on the 
lower animals.