On Gunshot Wounds of the 
Abdomen, with Especial 
Reference to Wounds 
of the Intestines. 
BY 
LEWIS A. STIMSON, M. D., 
SUBGEON TO THE NEW YORK, CHAMBERS STREET, AND 
BELLEVUE HOSPITALS ; PROFESSOR OF SURGERY 
IN THE UNIVERSITY OF THE CITY 
OF NEW YORK. 
REPRINTED FROM 
Etie Nrbi ¥orft fUeUical 
for Oct. 26 and Nov. 2, 1889. Reprinted from the New York Medical Journal. 
ON GUNSHOT WOUNDS OF THE ABDOMEN, 
WITH ESPECIAL REFERENCE TO 
WOUNDS OF THE INTESTINES.* 
By LEWIS A. STIMSOX, M. D., 
SURGEON TO THE NEW YORK, CHAMBERS STREET, AND BELLEVUE HOSPITALS ; 
PROFESSOR OF SURGERY IN THE UNIVERSITY OF THE CITY OF NEW YORK. 
Until within a period relatively short a discussion of the 
subject of gunshot wounds in a society of surgeons in civil life 
would have had an interest almost exclusively academical, 
and, apart from theoretical considerations and analogy, would 
have been based in great part upon experience gained at 
the edge of the battle-field and in the military hospital. But 
the times have changed, and now, to paraphrase a well- 
known quotation, Peace hath her military surgery no less 
renowned than war; and in some varieties of gunshot wounds, 
such as those of the trunk and head, the office of the mili- 
tary surgeon has diminished, while that of his brother in 
civil life shows the budding promise of an important devel- 
opment. The reason is not far to seek. On the one side, 
military fire-arms now discharge their bullets with such ve- 
locity that the wounds they inflict upon the viscera are very 
severe and often beyond hope; while, on the other hand, 
* Read before the New York Academy of Medicine, October 17, 
1889. 2 
GUNSHOT WOUNDS OF THE ABDOMEN. 
the possession of parlor rifles and of pistols of small and 
medium caliber in all classes of the community has become 
very common, and the injuries inflicted by such, either acci- 
dentally or with hostile intent, have correspondingly multi- 
plied. As an indication of this frequency of occurrence of 
such injuries, I may say that 1 can recall, without search of 
the records, twenty cases of serious bullet wounds person- 
ally treated by me during the twelve months last past; of 
these, seven were accidental, three were inflicted with sui- 
cidal, and ten with murderous intent. So long, therefore, 
as pistols are openly sold at prices that place them within 
the reach of almost every half-grown or adult member of 
the community, so long as love, anger and despair, greed 
and want, are strong motives of action, so long as youth is 
heedless, and so long as the idiot who thinks it is not loaded 
goes free in the midst of us-so long will gunshot wounds 
demand our care and attention and deserve our thoughtful 
study. 
All varieties of these injuries have shared in the bene- 
fits conferred by modern improvements in the care of 
wounds and in the stimulus to effort created thereby, but, 
while in wounds of the extremities the gain has been in the 
preservation of limbs that would otherwise have been lost, 
in gunshot wounds of the abdomen the interest is infinitely 
greater, for the issue is of life or death, and it is beyond 
dispute that many lives have been already saved by opera- 
tion during the last five years which would certainly have 
been lost under the methods of treatment which had pre- 
viously prevailed. In a collection made by Dr. W. B. 
Coley, of 124 published and unpublished cases treated by 
laparotomy, which is the largest thus far made, and which 
has been in part published,* there are 37 recoveries, in 
* Dr. W. B. Coley, "Boston Med. and Surg. Journal," Oct. 18, 1888. GUNSHOT WOUNDS OF THE ABDOMEN. 
3 
many of which the nature of the injuries was such as to 
furnish ample ground for the belief that, had the operation 
not been done, the patients would have succumbed. It has, 
therefore, been fully established that formal laparotoxny 
undertaken to discover and repair gunshot wounds of the 
intestines may save lives that are in imminent peril; and 
that, consequently, under certain circumstances, it is a proper 
and justifiable operation. But from this to the position 
that in every gunshot wound of the abdomen that is proba- 
bly perforating, or even in every one that is certainly per- 
forating, a laparotomy should be immediately done, is a 
long step. It is not enough to have shown that some pa- 
tients have survived laparotomy ; it is not enough to have 
shown that those who have died without opera ion could 
have been saved only by one; it is not enough to have 
shown that laparotomy for other morbid conditions is daily 
done with a large measure of success and safety. It must 
also be shown that it saves a larger proportion of wounded 
patients than other methods save, and, even if this is done, 
it must still be ascertained whether we can not discriminate 
between the different injuries, and recognize those in which 
it is proper to operate and those in which it is wiser to ab- 
stain. Experience alone can supply the materials for an 
answer to these questions; for the latter we must study in- 
dividual cases; for the former we must have integral statis- 
tics comprising a sufficient number of cases. Lists made 
up of reported cases contain, as is well known, an undue 
proportion of successful ones, and I have therefore sought 
to obtain a list of all the cases that have been treated by 
laparotomy in the hospitals of New York city. In default 
of a similar list drawn from a larger area, this will best serve 
to determine the percentage of success for comparison with 
the results of other methods. In addition, I shall report 
three new cases, one of which ended in recovery ; and shall 4 
GUNSHOT WOUNDS OF THE ABDOMEN. 
further ask your attention to a consideration in some detail 
of various matters connected with the diagnosis, prognosis, 
and treatment. 
The three new cases are as follows: 
Case I.-C. Z., aged twenty-seven, unmarried, a German, 
shot himself with suicidal intent, at 3 a. m., on December 6, 
1888, with a pist<»l of *32 caliber. On admission to the Cham- 
bers Street Hospital he presented but slight evidences of shock; 
his temperature was normal, pulse good, and respirations regu- 
lar but shallow. He complained of severe pain in the abdomen 
when moved or touched. There was a small blackened wound 
midway between the umbilicus and the ensiform process, half 
an inch to the left of the median line. 
I saw him at 3.15 p. m. He had vomited once, and had 
voided a large quantity of very bloody urine. He was very 
pale, his surface cool, pulse small and quick. His manner was 
apathetic, he answered questions shortly and unwillingly, and 
made no complaint of pain except when the abdomen was 
pressed upon. The abdomen was not distended ; it was reso- 
nant anteriorly and dull in the flanks; liver dullness normal. 
Ether was administered, and the abdomen opened in the 
median line from the ensiform process to the umbilicus, giving 
issue to a considerable quantity of bloody serum and a few 
small blood-clots. On the anterior aspect of the stomach, three 
inches from the pyloius, a circular perforation was found, and 
was at once closed with a row of silk Lembert sutures. 
On raising the omentum and transverse colon, two perfora- 
tions, three fourths of an inch in diameter and half an inch 
apart, were found at the upper end of the jejunum, and were 
closed with a double row of Lembert sutures, the fold being 
longitudinal. Just above arid to the left of the junction of the 
duodenum and jejunum was a large ragged wound in the pari- 
etal peritonaeum, through which blood flowed freely, evidently 
from a wound of the pancreas; it was closed, and the bleeding 
checked by deep sutures. In the mesocolon, two inches above 
the lower end of the duodenum, was a perforation, the bleed- 
ing from which was checked by a suture at its lower angle. GUNSHOT WOUNDS OF THE ABDOMEN. 
5 
Finally, a circular perforation of the posterior wall of the 
stomach was closed with a double row of sutures. A large 
quantity of liquid and clotted blood was removed from the ab- 
dominal cavity. 
The ball had evidently first traversed the stomach, then the 
mesocolon and jejunum, and had then entered the posterior ab- 
dominal wall, wounding the pancreas, and undoubtedly the kid- 
ney also, as shown by the blood in the urine. 
The extent of the injuries and the patient's condition contra- 
indicated further interference. The wound was closed, and he 
died half an hour afterward. At the autopsy the ball was found 
to have traversed the left kidney and to have lodged under the 
skin behind it. No other wounds of the intestine were found. 
Case II.-James D., aged thirty-seven, was brought by the 
ambulance to Chambers Street Hospital at 1.15 a. m. on March 
16, 1889. He had been shot a few minutes previously while 
kneeling upon the ground, his assailant standing over him. The 
weapon was a pistol of-38 caliber. Condition good; no general 
pain; marked tenderness above right inguinal region ; respira- 
tion, 20; pulse, 70; temperature, 98° F. There were two bullet- 
wounds-one about three inches and a half above the free mar- 
gin of the ribs and an inch and a half to the left of the median 
line, the other two inches below the border of the ribs and 
two inches and a half to the right of the median line. At 4 a. m. 
he passed six ounces of clear urine. 
As I was absent from the city, Dr. Charles II. Wilkin, as- 
sistant surgeon of the hospital, was summoned, and he operated 
at 8 a.m., seven hours after the receipt of the injury. 
The wound in the chest was probed and found to pass down- 
ward and outward without perforating. In the abdominal wound 
the probe passed downward in the wall for a distance of three 
inches, and then entered the abdominal cavity. Median incis- 
ion six inches long between the pubes and umbilicus, giving 
issue to considerable bloody serum, containing flakes of lymph 
and some faeces. Six perforations were found at three points in 
the small intestine-the first pair eighteen inches below the 
duodenum, the second pair two feet lower down, the third at 
the lower end of the ileum. The bullet was imbedded in the 6 
GUNSHOT WOUNDS OF THE ABDOMEN. 
mesentery, near the caecum. Each wound was closed with a 
single row of Lembert sutures; two bleeding points in the 
omentum were ligated. The cavity was flushed with hot water, 
and the abdominal incision closed. The patient did well for 
twenty four hours, but when I saw him on the following day 
septicaemia was evidently present. He died at 7.30 a. m. on 
March 18th, forty-eight hours after the operation. The autopsy 
showed general peritonitis and congestion of the left lung. 
In connection with this case it is proper to state that the 
operation was performed rapidly and skillfully, that the 
operator had had a large experience in abdominal surgery, 
and that all antiseptic precautions were rigidly observed. A 
supply of silk and sponges specially prepared for use in 
laparotomies is kept in the hospital, the instruments are 
always boiled before an operation, and the r.ssistants are 
skillful and keenly alive to the possibilities of accidental 
infection and to the need of constant care and watchfulness. 
It is to be remembered that feces had escaped into the 
peritoneal cavity, and that peritonitis had already set in 
before the operation was undertaken. 
Case III.-I). D., aged twenty-eight, a rather fleshv woman, 
was brought to the Chambers Street Hospital in a cab at 9.15 
p. m., April 19, 1889. Six hours previously a man had pressed 
against her abdomen the muzzle of a Flobert pistol, caliber '22, 
thought to be unloaded, and discharged it. She had subsequently 
vomited whenever she had taken anything into the stomach, and 
complained of much distress in the epigastiic region. The hall 
had passed through a wrapper and chemise without causing any 
recognizable loss of substance in them, and had entered the ab- 
dominal wall two inches and a half to the left of the median 
line and an inch and a half below the umbilicus, producing a 
blackened wound a quarter of an inch in diameter with de- 
pressed edges. 
The patient had walked into the hospital and showed but 
little shock; her manner was quiet, she talked freely and natu- 
rally, and complained only of pain in the pit of the stomach, GUNSHOT WOUNDS OF THE ABDOMEN. 
7 
which she attributed to indigestion, and was confident would 
be relieved by a plaster. Her body was covered with a fading 
syphilitic eruption. The abdominal wall was rounded, thickly 
coated with fat, and its muscles contracted sharply when it was 
pressed; in other respects its examination was negative. 
The operation was begun under ether at 12.15 midnight, nine 
hours after the receipt of the wound. The course of the bullet 
was traced by means of a longitudinal incision three inches and 
a half long, having the wound at its center; it passed backward 
through two inches of fat and ended in a small slit in the peri- 
tonaeum, through which blood escaped quite freely from the 
abdominal cavity. 
A second incision, ultimately seven inches long and extend- 
ing downward from a point three inches above the umbilicus, 
was next made in the median line, and the omentum, which was 
firmly adherent to the left ovary and tube, was pushed to the 
left; the small intestine was contracted and of a dull-red color; 
a ragged opening three eighths of an inch in diameter, with 
everted mucous membrane, was found on the surface opposite 
the mesenteric attachment, and closed with a single row of 
three Lembert sutures of fine iron dyed silk; an inch and a 
half from it, longitudinally, was a second smaller opening, 
which was closed with a single Lembert suture. The sigmoid 
flexure, lying in close proximity to the wounded loop of small 
intestine, showed two wounds immediately opposite each 
other which the probe showed to be perforating; one, small 
and round, was at the base of an appendix epiploica in the 
outer longitudinal band of muscular fibers; the other, larger 
and ragged, was in the side of an appendix attached to the inner 
longitudinal muscular bundle; each was closed with a single 
suture. A wounded artery in the mesentery, midway between 
its visceral and parietal attachments, which bled profusely, was 
secured with a catgut ligature. Clotted and liquid blood, esti- 
mated at about one quart in amount, was removed, and the 
peritoneal cavity cleaned with warm sponges. The cavity was 
not washed. The entire length of the small intestine, which 
had been turned out of the abdomen and protected with hot 
towels, was then gone over rapidly in search of other wounds, 8 
GUNSHOT WOUNDS OF THE ABDOMEN. 
and, none having been found, returned into the abdomen. It 
was noted that during the operation they had become distended 
to more than double the size they had when first exposed. The 
omentum had been perforated by the ball, but was not bleed- 
ing; its attachment to the internal genitals made the examina- 
tion and cleansing of the cavity quite difficult. The bullet was 
not found. 
The abdominal wound was then closed by means of stout 
silk sutures, embracing the entire thickness of the wall except 
the peritonaeum, which latter was closed with several successive 
continuous sutures of catgut. The tension of the abdominal 
wall was so great that the peritonaeum could not be closed with 
a single suture, and the method employed was as follows: Silk 
ligature was passed about two inches below the upper angle of 
the wound, and drawn tightly enough to permit the peritoneal 
opening above it to be closed, and two permanent silk sutures 
to be placed in the interval above it; a second temporary silk 
suture was then placed a little lower down, the first one relaxed, 
and the second section of the wound closed in the same manner 
as the first; and this was repeated until the entire wound was 
closed except at the lower angle, where a rubber drainage tube 
was introduced to Douglas's pouch. Between the sutures three 
short drainage-tubes were placed to drain the parietal wound. 
The incision made to explore the track of the bullet through 
the wall was closed with silk sutures and drained. The dress- 
ing was of iodoform and creoline gauze, absorbent cotton, and a 
body bandage. 
During the first thirty-six hours the patient received no 
food or drink except water, a teaspoonful at a time, and was 
kept slightly under the influence of morphine. On the third 
day (April 22d) the drainage-tube was withdrawn from the ab- 
dominal cavity; on the fifth day her menstrual flow appeared 
and a diarrhoea began, which lasted, with intermissions, until 
May 2d. On April 27th most of the sutures were removed, and 
when the wound was again inspected, two days later, the re- 
maining ones were found to have cut out and the sides of the 
wound to be gaping; it was lightly packed with iodoform 
gauze, and the edges approximated with strips of adhesive GUNSHOT WOUNDS OF THE ABDOMEN. 
9 
plaster. On May 3d the regular administration of the protio- 
dide of mercury was begun with the object of preventing any 
harmful influence of the syphilitic virus upon the healing of the 
wound. On June 6th the wound was entirely healed, and the 
patient was allowed to leave the bed; and on June 30th she 
was discharged cured. 
A feature of special interest in this case is that, 
although the bullet was small (caliber -22), it had pro- 
duced a wound of the small intestine three eighths of an 
inch in diameter, evidently by entering the gut obliquely, 
and had so wounded a mesenteric artery as to endanger the 
patient's life by haemorrhage. I would also call attention 
to the absence of shock and of all marked symptoms of 
grave injury. The case was clearly one in which, accord- 
ing to the views held by a number of prominent surgeons, 
an expectant attitude should have been taken, to await the 
possible development of grave symptoms, a course which, 
in my judgment, would have ended fatally by haemorrhage 
or by septicaemia. The preliminary exploration of the tiack 
of the bullet showed perforation of the cavity and the exist- 
ence of an important haemorrhage, and thus, 1 think, made 
the subsequent proceeding imperative. 
The operation of freely opening the abdominal cavity 
to search for and repair gunshot wounds of the intestines is 
not a new one; it does not even belong solely to the period 
of antiseptic surgery, but it was performed, and successfully 
performed, more than fifty years ago. The principles which 
lie at its foundation have, of course, been apparent since 
such wounds were first inflicted; no demonstration was 
needed to show the desirability of closing the wound in the 
intestine or the advantage of a free opening in the abdomi- 
nal wall if sutures were to be applied or if the wound was 
to be sought, but the fear of making such an opening or 
of operating upon the intestines was so great, and indeed 10 
GUNSHOT WOUNDS OF THE ABDOMEN. 
so well founded as surgery was then done, that surgeons, 
with but few exceptions, almost down to the present time, 
practiced and taught abstention, except when the wounded 
loop of intestine protruded through the opening in the ab- 
dominal wall or lay in plain sight beneath it. Under such 
circumstances they sutured the intestine and returned it, or 
they promoted the escape of faeces from within the cavity 
and sought safety in the establishment of a faecal fistula. 
Occasionally the possibility of advantage in a more active 
intervention was more or less hesitatingly suggested, and 
Baudens, in a work published in 1836,* reported a case op- 
erated upon in 1831, which is not only the first instance of 
the operation we are considering, but which was also said 
by the editor of the " Medical and Surgical History of the 
War of the Rebellion" to be, in 1877, "perhaps the only 
instance of completely successful enterorrhaphy for shot- 
wound on record." After having recognized a wound of 
the transverse colon by introducing his finger, he enlarged 
the abdominal wound, drew the bowel toward it, and told 
the patient to cough ; this was immediately followed by the 
protrusion of the wounded bowel and by the escape of in- 
testinal gas from the abdominal cavity. He closed the 
wound with three Lembert sutures, cut their ends short, and 
returned the intestine. The subsequent course of the case 
did not differ from that of an ordinary wound of the ab- 
dominal wall, and the patient recovered. 
He had previously treated a similar case by drawing out 
the intestine through the abdominal wound and suturing 
it; the patient died on the third day, and the autopsy 
showed that a faecal extravasation had taken place from an 
undetected wound in the caecum. It seems not unlikely that 
this experience led him to make the free opening in the 
* Baudens, " Clinique des plaies d'armes & feu," 1836, p. 336. GUNSHOT WOUNDS OF THE ABDOMEN. 
11 
next case and to the expression of opinion (p. 324) : " I do 
not fear to place the knife in the perforation made by the 
projectile in the wall of the abdomen, in order to enlarge 
it, to pursue into that cavity the examination of the course 
it has taken, and to apply to the intestinal lesions a prompt 
and effective remedy." 
It will be instructive and clarifying briefly to trace the 
course of opinion upon this subject during the current cent- 
ury, and then to examine the new material that more 
recent experience has brought to bear upon the questions 
involved. 
It is to be remembered that the earlier experience is 
drawn almost wholly from military surgery, and that the 
bullets were much larger and discharged with a much lower 
initial velocity than at the present time. The wound of 
the abdominal wall appears usually to have been large 
enough at least to permit the introduction of the finger and 
often to permit spontaneous protrusion of a wounded loop 
of intestine. In 1799 Larrey passed a ligature through such 
a protruded loop of the ileum which had been divided by 
a musket-ball, returned it to the abdominal cavity, and fixed 
it by means of the ligature in the parietal opening, so that 
the contents of the bowel could freely escape. The patient 
recovered, and without a permanent faecal fistula. This 
appears to be the maximum of surgical interference ap- 
proved at that time and for many years subsequently. The 
possibility of successfully suturing an incised (not a gun- 
shot) wound of the intestine had been known for over two 
hundred years, and perhaps very much longer,* and in the 
decade between 1820 and 1830 the experiments of Lembert 
and of Jobert not only brought the subject of enterorrhaphy 
very prominently to the attention of the profession, but 
* See " Med. and Surg. Hist, of the War of the Rebellion," Part 
Second, surgical vol., p. 63, note 2, and p. 123, note 5. 12 
GUNSHOT WOUNDS OF THE ABDOMEN. 
also gave us methods of closing wounds or reuniting divided 
ends which are still accepted as the best, with only such 
modifications and additions as the use of absorbable sutures 
has entailed. Aided by these acquisitions, Baudens treated 
his two cases as has been described, and favored the pre- 
liminary enlargement of the parietal wound. His example 
was followed in 1848 by Nelaton,* and in 1849 by Piro- 
goff f; the former overlooked one perforation and lost his 
patient; the latter lost sight of his patient on the fourth day. 
It does not appear in the accounts that either enlarged the 
parietal wound, and both quote their cases to support the 
opinion that it was advisable to resort to enterorrhaphy and 
not to abstain entirely from operative interference. Piro- 
goff says: " I regret that in the cases that came under my 
observation [in the war in the Caucasus] I employed the 
suture only once, and then in a sort of desperation. I gave 
up the other wounded as lost; as enterorrhaphy required 
time and many wounded were awaiting my assistance, I did 
not use the suture. But just this desperate case proved 
that much is to be expected from operative interference." 
Lohraeyer, writing after the Danish War, said that probing 
of the abdominal wound was indicated only when perito- 
nitis had been set up by the escape of the contents of the 
intestine from a concealed wound in it and threatened to 
become fatal, and that then he would follow the example of 
Baudens and suture the bowel rather than try for a fecal 
fistula. Legouest, after the Crimean War, expressed similar 
views, and Demme, after the Italian War of 1859, referred 
to the treatment only to say that most authors condemned 
it, and that, in his opinion, it would prove impracticable in 
the large majority of cases because of the uncertainty of 
* Nelaton, "Path, ext.," vol. iv, p. 153. 
f Pirogoff, quoted in "Med. and Surg. Hist. War of Rebel.," Part 
Second, surgical vol., pp. 125 and 127. GUNSHOT WOUNDS OF THE ABDOMEN. 
13 
diagnosis. In the War of the Rebellion enterorrhaphy was 
done in three cases for shot wound of the small intestine by 
Bentley, Judson, and Gill. In all these cases the wounded 
gut protruded, and all terminated fatally. Kinloch oper- 
ated in 1863 in a case of faecal fistula following a gunshot 
wound received nearly eight months previously. lie laid 
open the peritoneal cavity, excised half an inch of the up- 
per and two inches of the lower portion of the bowel, 
brought the cut edges into direct apposition with silver sut- 
ures, and effected a partial apposition of the serous surfaces 
by a few Lembert sutures. The patient recovered, but 
union failed, and a small faecal fistula persisted.* At the 
close of the war the late Dr. Hamilton f wrote : " Be as- 
sured the patient will have a better chance for life if we 
let him entirely alone; and it surprises me that any good 
surgeon would think otherwise." In 1867, after the Austro- 
Prussian War, Neudorfer says : " What, then, shall the phy- 
sician do with a gunshot wound of the bowel? Nothing at 
all." In the edition of his "Surgery " printed in 1872 the 
late Dr. Gross, who, thirty years previously, had written 
strongly and with great authority in favor of enterorrhaphy 
in incised wounds of the intestine, repeats his approval of 
it, but adds (vol. ii, p. 667): "These remarks are more es- 
pecially applicable to incised wounds. In gunshot wounds 
no benefit, it seems to me, would be likely to accrue from 
such a course of treatment [i. e., to enlarge the abdominal 
orifice, to seek for the wounded tube, and to sew up the 
cut], as the bowel is generally pierced in a number of places, 
* These cases, and most of the historical and bibliographical facts 
here mentioned, have been drawn from the extremely interesting and 
valuable chapter upon this subject in the " Med. and Surg. History of 
the War of the Rebellion," Part Second, surgical volume. 
f " Treatise on Mil. Surg. and Hyg.," p. 354 ; " Med. and Surg. 
Hist.," p. 73, note. 14 
GUNSHOT WOUNDS OF THE ABDOMEN. 
and the case, on this account, must, therefore, generally be 
fatal." 
In the same year, after the Franco-German War, Beck 
argued in favor of a bolder interference, but Erichsen* re- 
jects all operative measures unless the wounded loop pro- 
trudes; and if fteces actually escape into the abdominal cavity, 
he only removes the sutures from the parietal wound and 
gently separates its edge to afford an outlet. Finally, in 
1877, the editor of the "Medical and Surgical History 
of the War of the Rebellion," after an elaborate review of 
the subject, says (p. 128): "Reflection . . . leads un- 
avoidably, in the writer's opinion, to a conviction of the pro- 
priety of incising the abdominal wall when necessary, in 
order to expose and sew up the wounded gut concealed 
within the cavity, whether divided by a cutting instrument 
or by a shot. The obstacles to success are obvious; but it 
is a mortal peril which demands an extreme remedy." He 
adds, in a note, that " over one hundred instances [of en- 
terorrhaphy for incised and gunshot wounds] have already 
been adduced, with such a large percentage of recoveries 
that, with every allowance for the suppression of unfortu- 
nate results, the evidence is very encouraging"; and he 
further supports his opinion (note on p. 12G) by quoting 
similar ones contained in letters sent him by Dr. J. S. Bil- 
lings, Dr. Hunter McGuire, and Dr. N. S. Lincoln. Thus 
Dr. Billings writes : " When there is reason to suspect in- 
testinal injury, it appears to me to be proper to enlarge the 
opening, if necessary, to ascertain the nature aiid amount of 
injury, ... to employ sutures or ligatures where needed, 
and to cut these short and return the injured viscera." 
Professor McGuire says : " If the shock, thermometer, etc., 
indicate wound of the bowel, cut down and sew it up." 
And Professor Lincoln : " In shot wounds of the intestine, 
* Erichsen, " Surgery," vol. i, p. 553. GUNSHOT WOUNDS OF THE ABDOMEN. 
15 
unattended by protrusion, unless the perforation may be in 
the iliac region, with a reasonable likelihood of implicating 
the part of the large intestine uncovered by peritonaeum, 
and therefore avoiding the risk of intraperitoneal extravasa- 
tion, it is the safest course to enlarge the track of the ball 
and to close the intestinal wound by suture." 
These opinions mark the beginning of the change, and 
doubtless were in some degree inspired by growing confi- 
dence in antiseptic surgery. It is noticeable in all that had 
preceded that the discussion always began with the assump- 
tion that a positive diagnosis of wound of the intestine, and 
often of faecal extravasation into the peritoneal cavity, ex- 
isted, and the supporters of active interference had gained, 
even in that class of cases, so few adherents that the in- 
stances could almost be counted upon the fingers, and 
Baudens's enlargement of the parietal wound still remained 
unique. Of the cases which form so laige a proportion of 
those now encountered in civil practice-cases in which there 
is at first no evidence of intestinal wound, and in which 
even the fact of perforation of the abdominal wall is in 
doubt-there is no mention in the discussions. Apparently 
it was the universal practice to give opium and await the re- 
sult. The few cases in which enterorrhaphy had been done 
were of such a character that it is hard to see now how it 
could have been avoided; the wounded intestine lay in plain 
sight at the bottom of a large parietal opening, or was pro- 
truded through it. If anything was to be done, what else 
could it have been? So far as can be judged from reported 
histories, the line of treatment habitually followed was to 
administer opium, for the purpose of relieving pain and check- 
ing peristalsis, to apply ice to the abdomen, or sometimes 
to blister the surface to control inflammation, to keep the 
parietal wound open, and to "maintain the utmost cleanli- 
ness," by which attractive phrase was meant the removal 16 
GUNSHOT WOUNDS OF THE ABDOMEN. 
from the surface of such faecal and inflammatory discharges 
as escaped from the interior of the abdomen. 
Of the results of this treatment we can form, notwith- 
standing the vast number of cases reported, only a general 
idea, because the records probably fail to include a consid- 
erable number of fatal cases abandoned upon the field of 
battle without having received professional care. The Sur- 
geon-General of the United States (loc. cit., p. 202) reports 
3,429 cases of penetrating shot-wounds of the abdomen, 
with visceral injuries, in which the result is known ; of these, 
421 recovered (12-|-per cent.). In addition, there are 19 
cases, with 12 recoveries, of penetration without known in- 
jury to the viscera. Colonel Otis says (p. 204) : " The com- 
paratively small category of cases of recovery after indu- 
bitable shot-penetration of the abdomen may be arranged 
in three divisions. The first and largest group would in- 
clude the cases of perforation of the large intestine in parts 
uncovered by peritonaeum, followed by recovery with or 
without abnormal anus. The second, a group so small that 
the absolutely authenticated examples can be counted on the 
fingers, comprises the instances of wounds of the solid or 
membranous viscera, with extravasation of their contents 
within the peritoneal cavity. In the third division would 
be placed the cases of recovery after undoubted penetration 
or perforation of the peritoneal cavity without visceral in- 
jury, or, as it would be safer to say, with very slight visceral 
injury. On rigorous examination, these also would probably 
be found few in number." A review of the records of the 
cases described as recoveries after wound of the large in- 
testine (Cases 235 to 293 and 295 to 299), which must have 
been included by Colonel Otis in the first of his three divis- 
ions, shows little or no reason in any of them for suppos- 
ing that the intestine was wounded only at a point where 
it was uncovered by peritonaeum, and in a large number GUNSHOT WOUNDS OF THE ABDOMEN. 
17 
of them there seems to be as much reason for supposing 
that the small intestine was wounded as that the large one 
was. Thus, in all the cases except five (295 to 299, in 
which the ball was voided at stool) the ball traversed the 
abdominal cavity, making its entrance or exit, or both, 
through the parietal peritonaeum, and in a large number of 
them the wound of entrance or exit was within a few inches 
of the umbilicus. There is, in my judgment, nothing in 
them to justify the opinion indicated by his classification 
that wounds of the large intestine are so much less fatal 
than those of the small intestine ; and, assuming his opinion 
to be correct, there is nothing in the position of the parietal 
wounds to enable a surgeon in any similar case to recognize 
which part of the intestine was wounded. 1 desire particu- 
larly to emphasize this fact, because Colonel Otis's opinion 
appears to be responsible for the frequently repeated state- 
ment that wounds of the small intestine are necessarily 
fatal, while those of the large intestine are much less dan- 
gerous, and the frequent repetition creates the impression 
that the opinion has been independently formed by many, 
or that it has a solid and unquestionable foundation. Tak- 
ing the figures as they are given, they indicate a mortality 
of gunshot wounds in military practice of about 87 per 
cent.-say seven patients in every eight-and this, though 
somewhat larger, is still in substantial accord with the 
less complete unofficial statistics of individual experience 
in other wars grouped by Colonel Otis in another table 
(loc. cit., p. 203) : 1,146 cases, with 861 deaths (75 per 
cent.). 
But we are considering the question to-day from the 
standpoint of civil practice, and we know that the circum- 
stances of those wounded in battle differ greatly in some 
important respects from those of the wounded received into 
our civil hospitals. I have therefore collected from the 18 
GUNSHOT WOUNDS OF THE ABDOMEN. 
case-books of several of the hospitals of New York the 
cases treated in them during the ten or fifteen years pre- 
ceding 1885-a period during which the so-called "do- 
nothing" plan was habitually followed. The list is as fol- 
lows : 
HOSPITAL. 
Cases. 
Deaths. 
Recoveries. 
Chambers Street, 1876-1884 ... . 
13 
11 
2 
New York, 1884 
4 
2 
2 
Bellevue, 1870-1884 
8 
2 
6 
Roosevelt, 1872-1885 
6 
2 
4 
St. Vincent, 1880-1885 
5 
3 
2 
Presbyterian 
1 
1 
Total 
37 
20 
17 
The question at once arises, In how many of the cases 
tabulated as recoveries was the wound actually perforating? 
and it must be admitted that the question can not be 
categorically answered. But I have included only those 
cases in which the recorded symptoms-pain, vomiting, 
shock, abdominal distension, and tenderness-were such 
as would be held to-day by the supporters of active in- 
terference to justify an explorative laparotomy, and I 
think much weight should be given to the deliberate diag- 
nosis of the attending surgeon. In some the diagnosis is 
absolutely beyond question, as, for example, in one of the 
Roosevelt Hospital cases in which Dr. Sands vainly sought, 
by a long incision of the skin, to trace the course of the bullet; 
two days later faeces escaped through the right inguinal 
canal, and, after this flow had lasted for some time, recovery 
followed. Corroborating evidence of the correctness of the 
diagnosis is, I think, to be found in the fact that, although 
in the last five years twenty-nine laparotomies have been 
done in this city for pistol-shot wounds of the abdomen, I GUNSHOT WOUNDS OF THE ABDOMEN 
19 
have found no record and have not heard of any case in 
which the operation was undertaken and the wound found 
not to be penetrating. It seems highly improbable that, in 
about ten years preceding 1885, there should have been ten 
or fifteen cases in which an erroneous diagnosis of penetra- 
tion was made, and that in the five following years there 
should have been no such mistake. On the other hand, I 
do not believe that the above thirty-seven cases include all 
that have occurred here within the period covered by the 
records, or that the rate of mortality of this table is as high 
as it would be if the record were complete ; but, even if it 
were increased by the addition to the list of an equal num- 
ber of fatal cases, its smallness would still, I think, be a 
surprise to all. Some of our hospital records are well 
known not to be complete, and a large proportion of the 
cases that escape recording are those in which death follows 
promptly after admission to the hospital. The foregoing 
table, therefore, is offered mainly to show that recovery 
after a perforating shot-wound of the abdomen, with prob- 
able injury of the small intestine, under non-operative treat- 
ment, is by no means so great an exception as it is generally 
alleged to be. 
The great majority of these cases are of date subsequent 
to the publication of the opinions in favor of laparotomy 
quoted above. In all of them the treatment consisted al- 
most solely in the administration of opium, and in many 
the parietal wound was washed with some antiseptic solution 
and then covered with carbolic or iodoform gauze. Sur- 
geons possessed, practically, all the knowledge of the pa- 
thology of abdominal shot-wounds, of the various processes 
by which death is caused or repair effected, and of the meth- 
ods of operation upon the intestine which they now have. 
They knew what was necessary or desirable to be done to 
increase the chances of recovery, but their hands were stayed 20 
GUNSHOT WOUNDS OF THE .ABDOMEN. 
by the fear that to do what was necessary or desirable was 
even more dangerous than to leave it undone. The fear 
had heretofore been well founded, and operations in which 
the peritoneal cavity was freely opened deservedly ranked 
among the most serious. But with generalization of the 
antiseptic method came increased security and confidence, 
and came also a revision of former notions of what was prac- 
ticable and permissible, and a great increase in the range of 
operations. The opening of the peritoneal cavity for the 
relief of disease was done not only with greatly increased 
frequency, but also with great success, and it became only a 
question of time and opportunity when it should be ex- 
tended to gunshot injuries. The first operation under the 
new conditions and new ideas was done by Dr. Sevasto- 
poulo. of Constantinople, in October, 1880, but, as it was 
not published until 1887,* it remained without effect upon 
the opinions and practice of the profession. It was a repe- 
tition, and the first repetition if the cases of Nelaton and 
Pirogoff are excluded, under the protection of antiseptics, 
of Baudens's operation in 1831. 
He was called an hour after the accident to a muscular young 
man who had been struck at a point midway between the um- 
bilicus and the anterior inferior spine of the right ilium by a 
small pistol-ball which was thought to have been altered in 
shape by glancing from a neighboring stone. The wound was 
nearly an inch long and at once gave issue to a yellowish liquid 
and blood ; pressure forced out clots and gas having an intestinal 
odor. Although unprovided with instruments or an anaesthetic, 
the surgeon immediately enlarged the wound to a length of six 
inches with a stout pair of scissors; about a quart of clotted 
and liquid blood escaped, followed by the loops of intestine 
soiled with faeces. On the convexity of one loop was a wound 
so large and irregular that he thought it best to resect the part 
* S6vastopoulo, " Bull, de la soc. de chir.," 1887, p. 274. GUNSHOT WOUNDS OF THE ABDOMEN. 
21 
and reunite the ends by invagination (Jobert's method), fastening 
them together by Lembert sutures. The haemorrhage which 
came from the divided epigastric artery was arrested, the abdo- 
men washed out with a hot carbolic solution, and the abdominal 
wound closed with silk sutures, which were removed on the 
eighth day. When seen a year later the patient was again fol- 
lowing his calling of wrestler. 
The case was similar to those that had formed the basis 
of the discussions of the preceding half century in this re- 
spect-that the existence of a wound of the intestine was cer- 
tain, and of an extravasation of faeces probable. It was 
novel in its free incision and in the use of a carbolic solu- 
tion to cleanse the cavity. 
In the following year, 1881, November 1st, Dr. R. A. 
Kinloch,* of Charleston, S. C., operated upon an adult ne- 
gro who had been shot eleven hours previously with a pis- 
tol of '32 caliber; there wa« little shock, considerable ab- 
dominal tenderness, and pain in the sacral region. The finger 
introduced through the anus detected a perforation on the 
posterior wall of the rectum. lie opened the abdomen by 
a median incision between the umbilicus and pubes, closed 
three perforations of the small intestine with Lembert sut- 
ures, and, as he was unable to find the wound in the rectum, 
he inserted a drainage-tube and closed the abdominal incis- 
ion about it. The patient died ten hours later, and at the 
autopsy it was found that a wound of the small intestine 
had also been overlooked, as well as the one in the rectum. 
This was the first case in which the operation was dis- 
tinctly exploratory-that is, in which the abdomen was free- 
ly opened to discover and repair a suspected wound of the 
intestine; for if the wound previously recognized in the rec- 
tum had been the only one intended to be treated, it would 
* Kinloch, " North Car. Med. Journal," July, 1882, p. 1. 22 
GUNSHOT WOUNDS OF THE ABDOMEN. 
hardly have been approached through the anterior abdomi- 
nal wall. To Dr. Kinloch belongs all the credit that at- 
taches to such priority. Moreover, the idea was not a new 
one to him, and the operation was not done simply because 
others had suggested it. I have above referred to the op- 
eration he did in 1863 for the closing of a preternatural 
anus created by a gunshot wound ; in reporting that case, 
he spoke against '' the almost universal practice of aban- 
doning intestinal lesions to nature rather than risk opening 
the peritoneal cavity." Fourteen years previously * he had 
formulated the principle which he applied to this case, and 
he deserves not only the credit which goes with priority in 
practice, but also the much greater one which attaches to 
originality in conception. But-his patient died ; and the 
stamp of success, zsfe stultorum magister, is as necessary to 
the recognition of the merit of an idea as to that of an in- 
dividual. The case passed unnoticed, and this, too, not- 
withstanding the fact that, in a paper read before the New 
York Academy of Medicine in October, 1881, and pub- 
lished in the " British Medical Journal" in the following 
December, the late Dr. Marion Sims had spoken strongly in 
favor of the practice.f 
* His case was reported in "Am. Jour, of the Med. Sei.," July, 
1867. 
f On February 9, 1882, Fitzgerald ("Austral. Med. Jour.," v, 1883, 
33), and on February 26, 1883, Lloyd (" Brit. Med. Jour.," 1883, i, p. 
560), operated unsuccessfully; but neither case belongs fairly in the 
category of those we are considering. In Fitzgerald's the wound in the 
side was large and lacerated and caused by a charge of bird-shot; it 
was enlarged upward and downward, and ten inches of small intestine 
resected. The patient survived five days. In Lloyd's the operation 
was not done until three days after the injury, and, strictly speaking, 
was only to establish drainage in a case of suppurative peritonitis, al- 
though a wounded loop of intestine was drawn up and fastened in the 
abdominal incision. GUNSHOT WOUNDS OF THE ABDOMEN. 
23 
Two years later (September 30, 1883) came the well- 
known successful case of Kocher. It was published in De- 
cember, 1883, and an abstract of the case appeared in the 
"British Medical Journal," July 12, 1884, p. 78, and was 
copied in the "Am. Journal of the Medical Sciences" in 
October, 1884, p. 574, and this was followed the next month 
by Dr. Bull's successful case which was reported to the 
New York Surgical Society, January, 1885, and has done 
so much to spread the practice. How great that spread 
has been is shown by the statistics collected by Dr. W. 
B. Coley, above quoted. They contain 124 operations, 
divided as follows according to years: Previous to 1881, 
3; 1881-'84, 4; 1885, 9; 1886, 22; 1887, 35; 1888, 
32 ; 1889, 19. One hundred and three of the 124 opera- 
tions were done in the United States. The mortality is 70 
per cent. 
The untrustworthiness, in respect of the percentage of 
mortality, of statistics made up largely of published cases is 
well known, and is strikingly shown by Dr. Coley's experi- 
ence and by the results of my own search of the records of 
New York city. Dr. Coley's first collection, published in 
October, 1888, contained seventy-four cases with a mortality 
of about 60 per cent.; his further search has raised the mor- 
tality to about 70 per cent., although very few new cases of 
later date than his publication have been added. His pub- 
lished list contains nine published New York city cases, with 
three recoveries and six deaths. Only three additional op- 
erations-two deaths, one recovery-have since been done 
here. They are those reported this evening, and yet I have 
been able to increase the list by unpublished cases from 
hospital records to a total of twenty-nine cases, with twenty- 
five deaths and four recoveries, a mortality of 86'2 per 
cent. 24 
GUNSHOT WOUNDS OF THE ABDOMEN. 
The details are as'follows: 
HOSPITAL. 
Cases. 
Deaths. 
Recoveries. 
Chambers Street 
12 
9 
3 
New York 
1 
1 
Presbyterian 
1 
1 
Bellevue 
4 
4 
St. Luke's 
1 
1 
Ninetv-ninth Street 
2 
2 
German 
2 
1 
1 
Roosevelt 
3 
3 
St Vincent 
2 
2 
Dr. Jersey 
1 
1 
Total 
29 
25 
4 
Cases treated by Laparotomy in New York City. 
These I believe to be the integral statistics of this 
operation in the city of New York; certainly no success- 
ful cases are likely to have been overlooked. The only 
statistics of non-operative treatment with which I can 
compare them are those given above, the record of the 
War of the Rebellion with a mortality of about 87 per 
cent., and the cases which I collected from hospital records 
in this city. I have given my reasons for doubting the com- 
pleteness of the latter list, and therefore I will select from 
it for comparison the records of a single hospital which 
I believe to be nearly, if not absolutely, exact in both 
classes of cases-those, namely, of the New York Hospital 
and its branch, the Chambers Street Hospital. The rec- 
ords cover the period from the latter part of 1876 to June, 
1889. The cases at Chambers Street were under the care 
of Dr. Bull (1876-'87), myself (1888-'89), and Dr. Wilkin, 
assistant surgeon (1886-'89); those at the New York were 
under the care of Dr. Markoe, Dr. Sands, Dr. Weir, and 
Dr. Bull. GUNSHOT WOUNDS OF THE ABDOMEN. 
25 
HOSPITAL. 
Cases. 
Deaths. 
Recoveries. 
Chambers Street 
13 
11 
2 (Bull.) 
New York 
4 
2 
„ J (Sands, 
( Markoe.) 
Total 
17 
13 
4 
Cases treated without Operation, 1876-1884. 
Mortality, 76'47 per cent. 
Cases treated by Laparotomy, 1884-1889. 
HOSPITAL. 
Cases. 
Deaths. 
Recoveries. 
Chambers Street 
12 
9 
( Bull, 2 ; 
3 4 Stimson, 
New York 
1 
1 (Bull.) 
( 1. 
Total 
13 
10 
3 
In the cases which recovered without operation the diag- 
nosis of penetration was made by Dr. Sands, Dr. Markoe, 
and Dr. Bull, and the recorded symptoms seem fully to jus- 
tify it. If to them should be added the cases treated at the 
Roosevelt H< spital, the records of which are also apparently 
complete-six cases without operation, two deaths; and 
three treated by laparotomy, all fatal-we have these totals : 
Without operation, 23 cases, 15 deaths. Mortality, 65 
per cent. 
With operation, 16 cases, 13 deaths. Mortality, 8D2 
per cent. 
Most of the Roosevelt cases treated without operation 
were under the care of Dr. Sands. 
It is not a brilliant showing for either method of treat- 
ment, and we must still look beyond percentages of results 
to details and principles-ohseruationes perpendendoe non 
Mortality, 76'92 per cent. 26 
GUNSHOT WOUNDS OF THE ABDOMEN. 
numerandoe sunt. Time will not permit me to give even an 
abstractof the histories of the cases; I can only refer to 
some of the more important features. 
In the first place, in some of the cases the injuries were 
such that death, in the light of our present knowledge, must 
be deemed to have been inevitable under any method of 
treatment. Of the thirteen cases treated by laparotomy at 
the Chambers Street and New York Hospitals, four were of 
this character; of the seventeen not operated upon, three 
were of this character, and possibly two others in which 
death followed promptly and there was no autopsy. 
Of the remaining eight that died without operation, two 
survived one day, and one each two, three, four, five, twenty- 
three, and twenty-eight days. Of the four cases that re- 
covered, in one (Sands's) the wound was " in the left hypo- 
chondrium, five inches and a half from the median line"; 
in another (Markoe's) in the "right hypochondrium, on a 
line with the free border of the liver" (•32-caliber ball) ; in 
another (Bull's), two inches to the right of and half an inch 
above the umbilicus, " a probe passed four inches " ; in an- 
other (Bull's) the ball ('22 caliber) entered the right eighth 
intercostal space one inch posterior to the mammary line ; 
a probe passed three inches downward and forward ; there 
was considerable shock and some tympanites at first. 
The patient that survived twenty-eight days died of 
pyaemia; the bullet entered above the right sacro-iliac syn- 
chondrosis and lodged under the skin six inches above the 
right anterior superior spine of the ilium ; at the autopsy 
no wound of the intestine was found, and no peritonitis ; it 
can hardly be doubted that his chances of recovery would 
have been increased by enlargement and drainage of the 
parietal wounds. Possibly the bullet did not fully enter the 
peritoneal cavity, but opened it, if at all, by a slit along the 
side of its track in the lateral abdominal wall. GUNSHOT WOUNDS OF THE ABDOMEN. 
27 
Of the remaining cases, it can only be said that the in- 
juries were such as have been successfully treated in other 
instances by laparotomy. 
Of the ten cases of death after operation, the histories 
of four (including the two reported in this paper) have 
been published. In four, as I have said, the injuries seem 
to have been necessarily fatal; in two of the remaining 
five there is perhaps some ground for thinking that the 
chances of recovery might have been better if the operation 
had not been undertaken; in one of them a small bullet 
(•22 caliber) had lodged in the liver without wounding any 
other organ ; it was removed, and the patient died of peri- 
tonitis ; in the other the bullet had traversed the abdomen 
from the left eleventh intercostal space, three inches from 
the spinal column, and lodged under the skin below the free 
border of the ribs in the left mammary line; it was re- 
moved and the cavity explored with the finger through the 
wound of exit without finding evidence of intestinal injury ; 
three days later the wound of exit was enlarged to three 
inches and a half and the finger again introduced ; this was 
followed by a gush of faeces that had escaped from a ragged 
opening in the transverse colon, and had collected in a 
space that was apparently shut off from the general cavity 
by recent adhesions; the incision was further enlarged by a 
transverse addition extending four inches to the left, the 
cavity cleaned, the edge of the wound in the colon stitched 
to that of the parietal incision, and the cavity lightly packed 
with gauze. The patient died six hours later. Possibly, 
if the interference had been limited to providing free escape 
for the feces, the patient might have recovered with a ster- 
coral fistula, as so many others have done ; but his condi- 
tion previous to the operation was very unpromising. 
Of the remaining four fatal cases, in one the operation 
was done three hours and a half after the receipt of the in- 28 
GUNSHOT WOUNDS OF THE ABDOMEN. 
jury ; five wounds were found in the small intestine and 
were closed ; the patient survived forty-three hours, and at 
the autopsy an additional wound was found in the trans- 
verse colon, from which faeces had escaped into the cavity. 
In another the operation was done four hours after injury, 
and five wounds of the intestine were sutured; the patient 
survived twenty-four hours, and the autopsy showed gen- 
eral peritonitis. In the third (Dr. Wilkin's case, reported 
above) there was an interval of seven hours between the 
injury and the operation; there were six wounds of the in- 
testine, and faecal extravasation had already taken place and 
excited peritonitis. Of the fourth the hospital record gives 
no details. 
The thirteen cases may be fairly summarized, I think, 
as follows: Three recovered; the injuries were multiple 
(six, two, and four perforations of the intestine, and in two 
free haemorrhage from the wounded mesentery), and would 
probably have caused death if not repaired by the opera- 
tion. In four the injuries were necessarily fatal within a 
short time, and at the most the operation hastened an in- 
evitable death. In three in which the injuries were mul- 
tiple (six, six, and five perforations), but limited to the 
intestine, it failed to save; and in these the probability of 
recovery without operation turns entirely upon the trust- 
worthiness of the diagnosis in other cases which appear 
thus to have recovered. In one (wound of the liver alone 
by a small ball) the chance of recovery without operation 
was good; and in another the chance would probablv have 
been better if the first exploration had been cariied far 
enough to detect the wound of the bowels, and if the sec- 
ond had been limited to providing a free escape for the ex- 
travasated faeces. Of the nature of the injuries in the 
remaining case nothing is known. 
Against the three recoveries is to be offset, then, one GUNSHOT WOUNDS OF THE ABDOMEN 
29 
death, probably due to the operation, and the question re- 
mains whether or not the percentage of recovery under non- 
operative treatment justifies the belief that it would have 
furnished two recoveries from among the remaining twelve. 
My conviction is that at least seven of the twelve would 
certainly have died. 
Corroborative evidence of a better prognosis under non- 
operative treatment has been recently supplied by Reclus,* 
in the recovery of three patients treated with opium and 
compression of the abdomen, and by a military surgeon, 
Dr. Nimier,f who has reported the results in 63 cases of 
penetrating wounds received by French soldiers in Tonquin, 
with only 53 deaths, a mortality of 78 per cent. His analy- 
sis has been criticised by Chauvel, who maintains that in 4 
of the 15 cases recovery is not proved, and that in 27 of the 
fatal cases the survival was sufficiently long to justify the 
opinion that they might have been saved by operation. 
Turning now from these details to general considera- 
tions, the facts relating to the pathology of these injuries 
can be briefly stated. When a bullet penetrates the ab- 
dominal cavity it usually causes multiple lesions of the vis- 
cera, the principal exception being when it is a small one 
and first encounters the liver, in which case it may lodge 
within that organ. It has long been a subject of dispute 
whether or not a bullet can traverse the cavity without 
wounding the viscera, but the possibility must now be con- 
ceded on the strength of a very few cases in which an 
autopsy has proved both the fact of penetration and the 
absence of injury to the viscera.J 
* St.-Laurens, " These de Paris," No. 118, 1888. 
f Nimier, "Bull, de la soc. de chir.," 1887, p. 281. 
| I can add to the cases already reported one recently received in 
the German Hospital, New York, in which laparotomy was done by Dr. 
W. Meyer. The ball entered below the apex of the heart, traversed 30 
GUNSHOT WOUNDS OF THE ABDOMEN. 
In several cases a ball has perforated the abdominal wall 
obliquely, cutting the parietal peritonaeum for a greater or 
less distance between its orifices of entrance and exit, but 
not opening the intestine, and it seems probable that most 
of the cases of alleged complete perforation without vis- 
ceral injury or of circuitous passage within the substance 
of the wall between two points separated by a considerable 
interval have been of this character, the apparent deflection 
being due to a change in the attitude of the patient, or to 
the comparatively slow motion of the ball, which permits 
the fasciae to be pushed aside instead of being perforated. 
Certain it is that, even if it is possible for a bullet to trav- 
erse the cavity without wounding the intestines encoun- 
tered in its passage, the occurrence is far too rare to have 
any weight in prognosis or treatment, and we may safely 
assume that any ball that has fairly entered the abdominal 
cavity has also wounded some of the viscera; while, on the 
other hand, the more oblique the track of the ball, the 
greater the probability of the escape of the viscera from 
injury, even if the peritoneal cavity has been opened. It 
sometimes happens that the intestine, if not perforated, is 
so bruised by the bullet that the contused part sloughs and 
an opening is formed, if the patient survives for a sufficient 
length of time. 
The number of openings made in the stomach and in- 
testines by a single ball has varied from 1 to 28 in observed 
cases, the average lying between 2-63 (Colonel Otis) and 5 
(Reclus, in experiments upon animals). The size of the 
openings, while corresponding in a measure with that of the 
bullet, is yet so seriously affected by other circumstances 
the pleural and abdominal cavities, and lodged under the skin of the 
back at the left of the spine, grazing the lesser curvature of the stom- 
ach, but not opening it or wounding any other viscus. GUNSHOT WOUNDS OF THE ABDOMEN. 
31 
that no favorable prognostic influence can be safely drawn 
from the small size of the ball. Thus, in Kocher's case, a 
•22-caliber ball made an opening in the stomach one centi- 
metre and a half in diameter, the increase in size being 
probably due to retraction of the divided muscular fibers; 
in others a small ball, by entering obliquely or by cutting 
along the convexity of a loop of intestine, has made an 
opening an inch or more in length. Sometimes the open- 
ings are even smaller than the ball that made them, the tis- 
sues being pressed apart instead of being punched out by 
it in its passage. In all except the smaller openings there 
is a marked tendency to eversion of the mucosa, and this 
may so fill the opening as greatly to hinder the escape of 
the contents of the bowel into the peritoneal cavity, al- 
though, on the other hand, it carries with it the possibility 
of direct infection by its own soiled surface. The escape 
of faeces into the peritoneal cavity appears generally to be 
slow to occur, except when the opening is large and the 
bowel is distended; and the same is true, so far as known, 
of the intestinal gases, the presence of which in the cavity 
has been rarely recognized except in connection with faeces. 
The direct observation has been made that some fresh small 
openings are impervious to gas even under considerable 
pressure. If an opening is made at a point uncovered by 
peritonaeum, as on the posterior aspect of the duodenum 
or ascending or descending colon, the gas may escape into 
the connective tissue and be recognized under the skin. 
The bullet may lodge in the abdominal parietes or in 
one of the solid viscera and become encysted there without 
having provoked any reaction, or it may come to rest within 
the stomach or intestines, to be subsequently passed with 
the faeces; or even in the bladder, and be voided with the 
urine through the urethra (case of Sands, "Roosevelt Hos- 
pital, New York, Reports," vol. xv, p. 32). 32 
GUNSHOT WOUNDS OE THE ABDOMEN. 
The mesentery or mesocolon is frequently perforated 
by the bullet, and dangerous haemorrhage may ensue. 
Of the solid viscera, the liver is the one most frequently 
wounded; wounds inflicted by small bullets, even when 
they lodge within it and are left there, are capable of spon- 
taneous cure, and, I think, are not to be deemed dan- 
gerous; but large or lacerated ones add greatly to the grav- 
ity of the prognosis, because of the free bleeding and of 
the irritating effects of the bile upon the peritonaeum. As- 
sociated wounds of the pancreas, spleen, and kidney occa- 
sionally occur, and are very dangerous. Wounds of various 
large vessels have been reported-the common iliac and 
renal arteiies, the common iliac, portal, splenic, and renal 
veins. 
The position of the wound on the surface of the ab- 
dominal wall bears little or no fixed relation to that of the 
visceral injuries, but if the direction taken by the bullet 
can be ascertained, some inferences, more or less important, 
may be drawn. A bullet entering at right angles to the 
surface in the epigastrium or the left hypochondrium proba- 
bly wounds the stomach or the transverse colon. The sig- 
moid flexure may be encountered at any point to the left 
of and below the umbilicus. The liver will be wounded by 
a ball entering at any point within the hepatic area, and if 
the ball is small there is considerable probability that it 
may lodge in this organ without wounding any other. Bul- 
lets entering the back between the twelfth rib and the ilium 
are likely to wound the kidney or colon, but small bullets 
entering at this point, within three inches of the spinous 
processes, are likely to lodge in the wall. As the position 
of the loops of intestine appears not to change much within 
a few hours after the receipt of an injury, the search for 
lesions may be safely restricted to the neighborhood of the 
line marking the course of the ball. GUNSHOT WOUNDS OF THE ABDOMEN. 
33 
So far as I know, there has been no demonstration of 
the details of the process by which spontaneous closure of a 
wound of the intestine without stercoral fistula takes place. 
That healing can take place, and without the aid of art, is 
shown by Dr. Lange's case (''Med. News," 1887, p. 630). 
lie closed several perforations with sutures and left one un- 
touched, because it was small and seemed to be impervious. 
The patient recovered. We do know, however, that the irri- 
tation of an injury excites an adhesive peritonitis in the 
neighborhood by which an opposing serous surface may be 
fixed against the opening so as to close it against the escape 
of faeces, and thus effectually to protect the general cavity 
while a permanent cicatrix is forming in the wound. And 
we know, also, that, even where faeces escape into the peri- 
toneal cavity, the contamination may be prevented from be- 
coming general by the agglutination of adjoining loops of 
intestine; and a channel may form between the wound in 
the intestine and that in the abdominal wall along which 
the extravasated faeces will pass to the exterior, and that 
this channel may be permanent or temporary. 
The symptoms may be conveniently grouped in three 
classes-those common to all serious injuries, those indica- 
tive of special visceral injuries, and those later ones belong- 
ing to the pathological processes excited by the injuries. 
Among the first are the symptoms of shock and haemor- 
rhage, often so closely associated that they can not with 
certainty be distinguished from each other. Shock, often 
extreme shock, is present in a large proportion of cases, but 
it is also sometimes very slight or even entirely absent. It 
is at times unquestionably the direct result of the physical 
injury inflicted upon the organism, and varies directly with 
it; but, on the other hand, it is sometimes slight when the 
injury is great, and great when the injury is slight. I am 
convinced that it is often as much affected by extraneous 34 
GUNSHOT WOUNDS OF THE ABDOMEN. 
conditions, notably the circumstances under which the 
wound has been inflicted, as it is by the extent and severity 
of the injuries; that it is as much emotional as physical. 
Thus, in injuries inflicted by accident it is usually much 
less than in those inflicted with homicidal intent, and it is 
noticeably augmented by the patient's fear that the injury 
is a mortal one. Some severely wounded patients have 
walked to the hospital almost unaided, and have shown no 
pallor, no quickening of the pulse, no lowering of the tem- 
perature, while in others the prostration has been extreme 
where the injury has been slight, or even where no injury at 
all has been received. A few weeks ago a man who had 
just been shot in a quarrel, and presented all the symptoms 
of marked shock, was brought to my hospital; on examina- 
tion, the bullet was found to have stopped at his undershirt, 
not even to have broken the skin ; in another, stabbed in 
the abdomen, the pallor, almost imperceptible pulse, and 
semi-unconsciousness pointed to extreme shock or over- 
whelming haemorrhage; yet the weapon had not even pene- 
trated to the abdominal cavity, and, although it had divided 
the circumflex ilii artery, the bleeding had not been profuse. 
External haemorrhage is habitually slight, that from the 
track of the bullet soon ceasing, unless the deep epigastric 
vessels are wounded, and in this latter case the blood flows 
into the cavity much more freely than to the outside. 
Free haemorrhage into the cavity is slow to manifest itself 
externally, unless the parietal wound is large. The consti- 
tutional signs of haemorrhage are the common ones, and, as 
a rule, appear as the prolongation and intensification of 
those of the pre-existing shock. Blood in the urine indi- 
cates a wound of the kidney or bladder; blood voided at 
stool, if present in any considerable amount, is evidence of 
a wound of the intestines, but the symptom has rarely been 
noted, and only as a late one ; vomited blood may come from GUNSHOT WOUNDS OF THE ABDOMEN. 
35 
the wounded stomach or upper part of the intestine, but 
such vomiting may occur when there has been no perfora- 
tion of either stomach or intestine. 
Vomiting immediately after the accident is common, 
and is evidence only of the moral or physical shock; but 
its persistence or return indicates the beginning of a peri- 
toneal reaction, either peritonitis or that form of septicaemia 
described by Verchere, and to which he gave the name 
septicemie intestine peritoneale-an affection distinguishable 
from peritonitis by its slight elevation of temperature and 
slight abdominal tenderness and meteorism, and later by 
the clouding of the intelligence and the facies of a pro- 
found intoxication. 
The signs of perforation of the stomach or the intestine 
are of the utmost importance in the diagnosis and the prog- 
nosis, but, unfortunately, they are rare and inconstant. One 
has been already mentioned-blood in the stools or in the 
vomit. Another is the escape of the liquid or gaseous con- 
tents of the bowel, and their recognition at the parietal 
wound or within the abdominal cavity, if the exploration is 
carried so far. This escape into the cavity is infrequent in 
the early stages, and is practically limited to those cases in 
which the intestinal wound is large, and in which the bowel 
is distended at the time of the accident; and its recogni- 
tion at the cutaneous wound is very rare, being restricted 
to those cases in which the parietes are thin and the open- 
ing in them large. Occasionally the intestinal gases escape 
into the abdominal cavity in sufficient amount for their 
presence to be shown by the resultant loss of the area of 
hepatic dullness; but the cases in which this evidence can 
be obtained are extremely infrequent. On the other hand, 
resonant distension of the abdomen is common after the 
lapse of a few hours, and has long been deemed evidence 
of a probable perforation. Although authors are not agreed 36 
GUNSHOT WOUNDS OF THE ABDOMEN. 
upon its explanation, it certainly is commonly due, not to 
free gas in the abdominal cavity, but, on the contrary, to 
distension by gas of the intestinal loops, and the explanation 
of this rapidly occurring distension is yet to be found. In 
one of my cases it was noted that the intestines, which were 
contracted when the abdomen was opened in the course of 
the operation, promptly became largely distended during the 
search for and the suturing of the wounds-a change which 
I attributed to the irritation of the handling and exposure. 
If this explanation is correct, it suggests a similar cause for 
the distension which follows injury. In two or three re- 
ported cases in which the bowel had been wounded at a 
point where it was uncovered by peritonaeum, the intestinal 
gas escaped into the connective tissue, and was recognized 
by emphysematous crackling under the skin in the loins. 
Erichsen noted this symptom about twenty years ago, 
but, so far as I know, it has since been observed in only 
one additional case. Attention has been called to the pos- 
sible existence of similar emphysematous crackling about 
the parietal wound, produced by the infiltration of intesti- 
nal gas after its escape into the peritoneal cavity, but the 
symptom does not appear to have been clinically noted in 
more than a single case ; and, in view of the fact that it 
may possibly be produced by the entrance of the external 
air through the cutaneous opening, its presence can not, I 
think, be accepted as proof of the existence of a wound of 
the intestine. 
In a few cases a thin liquid has escaped freely through 
the parietal wound, sometimes with a fecal odor or a slight 
recognizable admixture of feces, and sometimes with a color 
suggesting the admixture of bile; it appears to be mainly 
a peritoneal liquid, having its origin either in a pre existing 
dropsy or in a peritonitis excited by the traumatism. 
The course and the prognosis of the injury have been GUNSHOT WOUNDS OF THE ABDOMEN. 
37 
indicated in what has preceded; they may be briefly sum- 
marized as follows : In the great majority of cases the course 
is toward a fatal termination by shock, haemorrhage, perito- 
nitis, and septicaemia. Death by shock and haemorrhage 
follows promptly-usually within a few hours. As between 
peritonitis and septicaemia, death by the latter seems much 
the more common, although there may be some limited 
peritonitis associated with it. It has long been recognized 
that intestinal lesions, with or without recognizable escape 
of the contents of the bowel into the peritoneal cavity, lead 
to death with a train of symptoms which are not those of a 
frank suppurative peritonitis, and have been described under 
various names, such as peritonism, latent peritonitis, or the 
asthenic form of acute peritonitis. It has been described 
in detail quite recently by Verchere,* under the name of 
intestino-pemtoneal septiccemia, and seems to deserve a place 
in our nosological schedule as a pathological entity with 
distinctive characteristics and requiring special treatment. 
Its origin is attributed to the infection of the peritoneal 
cavity by intestinal gases or microbes that have escaped 
either through an opening or by transudation through the 
unbroken intestinal wall, and by this is set up a fermenta- 
tion which produces ptomaines, whose absorption is the im- 
mediate cause of the poisoning. Attempts to isolate these 
ptomaines have not yet been successful. At the autopsy 
there is found but a slight redness of the peritonaeum, or 
possibly at one or more points a distinct inflammation, and 
sometimes a brown foetid effusion ; the intestines are dis- 
tended, and decomposition advances rapidly. The clinical 
features are a prompt and marked meteorism ; painlessness 
of the abdomen, both spontaneous and on pressure, except 
for that which is due to the wound of the parietes when 
present; a normal, subnormal, or but slightly elevated tem- 
* Verchere, "Revue de chirurgie," 1888, p. 559, 38 
GUNSHOT WOUNDS OF THE ABDOMEN. 
perature until shortly before death, when it rises rapidly ; a 
small, rapid pulse; anorexia, thirst, nausea, and even vomit- 
ing of faecal like matter; and a marked alteration of the ex- 
pression. Its course may be marked during the first three or 
four days only by constipation, anorexia, and meteorism ; then 
the severer symptoms appear, and death follows in from five 
to twelve days from the beginning. A well-marked case came 
under my observation at the New York Hospital in Decem- 
ber, 1 888-a stab wound of the abdomen, which I treated 
by laparotomy and suture of four wounds of the intestine; 
the patient survived for a week, and until the last twenty- 
four hours I was hopeful of his recovery ; at the autopsy 
the intestinal wounds were found completely healed, and 
there was slight peritonitis at only two points. I believe 
the best treatment is to be found in drainage of the peri- 
toneal cavity, or possibly in free purgation if that can be 
effected. 
In some of the patients that survive, a stercoral fistula is 
established and persists for a longer or shorter time, perhaps 
indefinitely or until closed by operation; in others, after a 
day or two of anxiety, because of the threatening of perito- 
nitis, the symptoms subside and the patient goes on to a 
complete recovery. Occasionally this progress toward re- 
covery is abruptly interrupted by the intercurrcnce of an 
acute peritonitis, due apparently to the tardy escape of faeces 
through a wound of the bowel, < r through the opening 
created by the sloughing of a contused portion, or to the 
leakage into the peritoneal cavity of pus that has fonned in 
the track of the bullet through the abdominal wall. 
It is not surprising, in view of the facts above stated 
concerning the mortality and the character of the lesions, 
that the opinion should be widely held that a resort to lapa- 
rotomy is imperatively demanded in any case of penetrating 
gunshot wound of the abdomen. Not only has it been gen- GUNSHOT WOUNDS OF THE ABDOMEN. 
39 
erally taught and believed that recovery under non-opera- 
tive treatment is so rare that the fact of recovery is almost 
to be deemed a proof that the intestine has not been wound- 
ed, but also the very existence of a communication between 
the interior of the intestine and the peritoneal cavity creates 
a condition of probable infection which we have learned to 
recognize as a grave danger, and to the prevention of which 
all our efforts are now directed. While the statistics which 
I have collected indicate, to my mind, that the mortality 
under non-operative treatment has been considerably over- 
estimated, yet few, I think, who were cognizant of the facts 
would be willing to take their chances under it if they be- 
lieved that laparotomy held out even an equal prospect of 
success. Unfortunately, the chances of error in the statistics 
at present at ccmmand are so great that the question can 
not be thus determined, and it seems unlikely that the doubt 
cast upon the diagnosis in almost all cases of recovery with- 
out operation will ever be entirely removed; we must there- 
fore still be guided by general considerations. 
The first question in every case-one upon the affirmative 
answer to which all other questions turn-is whether or not 
the bullet has entered the peritoneal cavity. As' has been 
above shown, the cases in which the bullet has entered the 
cavity without wounding the alimentary canal are so few 
that the possibility of its escape from injury in any given 
case of penetration may properly be disregarded. From this 
I would except only those cases in which a small bullet has 
entered at such a point and in such a direction that its 
course must lie for a considerable distance in the substance 
of the liver, and those in which the ball has traversed the 
abdominal wall very obliquely. In view of the fact that 
this opinion is almost universally held, it seems somewhat 
singular that so much attention should have been paid to 
the means of recognizing a wound of the intestines. It is 40 
GUNSHOT WOUNDS OF THE ABDOMEN. 
sufficient as a first step to prove the fact of penetration ; 
and this can be readily done by a measure which not only 
involves no additional risk, but may even be properly deemed 
salutary. I refer to a free incision along the track of the 
bullet. It has occasionally happened that the surgeon has 
not been able thus to follow the course of the ball, but I 
am convinced that in the great majority of cases it can be 
successfully done if the incision is deepened carefully and a 
close watch is kept for the slit-like opening which the bul- 
let usually makes in a strong fascia. If the search fails, I 
see no great objection to a small incision near the wound, 
preferably in the median line, for the purpose either of recog- 
nizing the presence of blood in the abdominal cavity, or of 
introducing the finger to feel for the opening made by the 
bullet in the parietal peritonaeum. I have employed this 
measure several times in stab-wounds, and never with an ill 
result. Such a free incision along the track of the bullet is 
not only valuable as a means of diagnosis, but is also an im- 
portant aid in the proper treatment of the parietal wound, 
for it favors the removal of foreign bodies that may have 
lodged in the track, and, by securing efficient drainage, pro- 
tects the peritoneal cavity from infection by pus that may 
form in the parietal wound. 
I hold the opinion strongly that this exploration should 
be made in every case of doubtful penetration, even if no 
further operative treatment is to be undertaken, for it is 
only by having first clearly established the fact of penetra- 
tion that the non-operative treatment can gain the credit of 
its successes and perhaps show its superiority. 
As soon as the wound in the parietal peritonaeum has 
been thus demonstrated and exposed, the escape through 
it of blood, intestinal gas, or faeces may at once prove the 
existence of an important internal haemorrhage or of a 
wound of the bowel; and if there should be no such escape, GUNSHOT WOUNDS OF THE ABDOMEN. 
41 
the introduction of a sponge upon a holder may furnish the 
evidence. In the absence of positive proof of the existence 
of a wound of the stomach or intestine, the surgeon who 
proposes to close such a wound, if present, has his choice of 
several procedures. He may seek for the wound by direct 
examination of the viscera, eit her through his first incision, 
after having enlarged it, or through another made in the 
median line for the purpose ; or he may seek to demonstrate 
its existence and to be guided to its position by injecting 
gas into the bowel through the anus, as proposed by Senn. 
This insufflation of hydrogen gas or of atmospheric air 
under moderate pressure has been studied experimentally, 
and has been actually employ ed in practice in some eight or 
ten reported cases. It is asserted that its action is prompt, 
efficient, and free from danger, and that by its aid, in at 
least one case, a perforation was found which would cer- 
tainly have been otherwise overlooked. Two main objec- 
tions at once suggest themselves: first, that the resultant 
distension of the bowel may prove a serious obstacle to the 
closing of the parietal incision ; and, second, that the escap- 
ing gas may force out the liquid or gaseous contents of the 
intestine into the peritoneal cavity, and thus cause a danger- 
ous infection. It is maintained that the first objection does 
not arise in practice, and that the gas or air is rapidly ab- 
sorbed by the intestinal mucosa; but in a recent report of 
two cases by Dr. II. C. Dalton, of St. Louis (" Weekly 
Medical Review," Sept. 28, 1889), the distension is said to 
have constituted a very serious trouble, leading to the tear- 
ing out of the intestinal sutures in one case, and greatly in- 
terfering with respiration in the other, in which laparotomy 
was not done. Dr. Dalton further states that Dr. Senn told 
him he had himself experienced the same difficulty, but had 
been able to overcome it by elevating the hips (presumably 
with a tube or cylindrical speculum in the anus) and mak- 42 
GUNSHOT WOUNDS OF THE ABDOMEN. 
ing pressure upon the intestines with "a large funnel-shaped 
towel." In view of this evidence and of Dr. Senn's admis- 
sion, it must be held, I think, that the objection is better 
founded than the statements heretofore published have led 
us to suppose. 
As to the second objection-the danger of infection by 
the contents of the bowel forced out by the gas-it does not 
seem to be capable of direct proof or disproof; that is, if 
faeces were found in the peritoneal cavity after the insuffla- 
tion, it could not be known that they had not previously 
escaped; and the possible causes of infection are so numer- 
ous that if it should ensue it could not be attributed with 
certainty to the insufflation. A comparison of the fre- 
quency of infection in a large number of cases in which the 
test had been employed with that in a similar number in 
which it had not been used might throw some light upon 
the question.* 
Another theoretical objection to the test-that the gas 
might fail to escape through an existing perforation, and 
that consequently its negative evidence was not trustworthy 
-has also been proved by experience to be well founded. In 
Dr. Dalton's second case the test gave no evidence of per- 
foration, but the post-mortem disclosed two large openings 
in the stomach covered by semi-solid food ; and in another 
case, above referred to, it was observed that intestinal gas 
could not be forced out by pressure through a visible per- 
foration. 
Finally, other lesions than perforation of the intestine 
are possible and equally in need of operative treatment, to 
which the test of insufflation gives no clew, notably haemor- 
rhage, and here again its negative evidence would not justi- 
* Insufflation has been done in nine reported cases with eight deaths. 
For brief details of seven cases, see a paper by Burrell in the " Boston 
Med. and Surg. Journal," July 25, 1889. GUNSHOT WOUNDS OF THE ABDOMEN. 
43 
fy abstention. In short, I believe the method, as a pre- 
liminary to operation and as a means of diagnosis, to be 
distinctly inferior to an exploratory incision in facility, effi- 
ciency, and security. 
The penetration having been demonstrated and an op- 
eration determined upon, the surgeon has to choose between 
an incision in the median line and one passing through the 
bullet wound. The preference has usually been given to 
the former, but those who have employed the other do not 
appear to have found any unusual difficulty in completing 
the operation. In one case in which the incision was made 
along the outer border of the rectus, a second incision was 
carried transversely from the upper end of the first along 
the free border of the ribs, giving very free access to the 
abdominal cavity. The patient recovered ; but so large an 
incision is to be deprecated. Two methods of searching for 
wounds of the small intestine have been employed ; in one, 
the bowels are freely exposed or turned out through a rela- 
tively large incision ; in the other, only a small portion is 
drawn out at a time through a small incision and immedi- 
ately returned after examination. I think the former meth- 
od is to be preferred for several reasons : the larger incision 
does not in itself add materially to the danger, less time is 
required, the exposure of the intestines, if they are properly 
protected, is not much increased, and the search can be 
more readily extended to their fixed portions if desirable. 
Moreover, the manipulations needed for the repair of other 
injuries than those of the movable parts of the small intes- 
tine require a fairly large incision. 
There seems to be no reason to doubt that the ball pur- 
sues a straight course through the abdominal cavity, and 
consequently it is not desirable to spend time or enlarge the 
incision in order to examine portions of the viscera or wall 
that lie well outside of that course ; as the coils of the small 44 
GUNSHOT WOUNDS OF THE ABDOMEN. 
intestine may shift their position, the examination should, 
however, cover the entire length of its movable portion in 
every case, and also the sigmoid flexure if the wound is on 
the left side, and the central part of the transverse colon if 
it is near the umbilicus. 
Time will not permit discussion of the various methods 
of closing wounds of the intestine, and 1 shall therefore 
only add that experience has shown that a single row of 
Lembert sutures of fine silk is sufficient in all wounds of 
moderate size. If the wound is large and ragged, and espe- 
cially if two or more such are near each other, it is better to 
excise the corresponding portion, and either reunite the di- 
vided ends or establish a lateral anastomosis. Since Dr. 
Senn reintroduced this method and so greatly improved it 
by his invention of absorbable bone plates, experience has 
shown its efficiency and ease and rapidity of execution. 
Possibly the independent and, perhaps, somewhat earlier 
suggestion of the French surgeons* to use plates of carti- 
lage or catgut rings to reunite the divided intestine end to 
end may prove equally practicable and safe, but at present 
lateral anastomosis is to be deemed preferable. 
In consideration of the fact that death is so frequently 
caused by septicaemia, I think a drainage-tube should al- 
ways be used, in order that the peritoneal effusion may es- 
cape as rapidly as possible, and that thus the chances of 
fatal absorption may be reduced. 
It is greatly to be regretted that the anticipated im- 
provement in results to be obtained by laparotomy under 
antiseptic protection should not yet have been realized, but, 
notwithstanding the unfavorable showing of the statistics at 
present, I believe that the operation will not only make a 
better record in the future by a closer selection of cases in 
which it shall be resorted to, but also that it will show an 
actual gain in the saving of life, as the result of an earlier 
* Michaux, "Gaz. des hopitaux," Aug. 13, 1887, p. 805. GUNSHOT WOUNDS OF THE ABDOMEN. 
45 
and better performance. The tabulation of statistics, ac- 
cording to the length of the interval that has elapsed be- 
tween the receipt of the injury and the performance of the 
operation, has unmistakably shown that the chances of suc- 
cess diminish almost to disappearance as this interval length- 
ens. The cause thereof seems very clear. The patient 
has to recover not only from liis injury and his operation, 
but also usually from an already established peritonitis or 
septicaemia, and experience has clearly proved that the dan- 
gers of the laparotomy itself are vastly increased when it 
is undertaken in the presence of such a complication. The 
simple exposure of the congested and distended intestines 
creates a dangerous shock, and when to this are added the 
greater difficulties and the necessary prolongation of the 
operation and the dangers arising from the already estab- 
lished infection, it is not surprising that the result should 
be so uniformly and so promptly fatal. These are the pa- 
tients who die upon the table or shortly after their removal 
from it, and this is the side, I think, upon which we should 
first restrict the operation. Between the two parties-those 
who would operate in every case and those who would 
operate in none-stands a thi.d : those who would operate 
only after symptoms indicative of dangerous processes have 
appeared ; but I believe this course to be the worst of all, 
and that if it were generally followed it wTould lead to the 
entire abandonment of the operation. We know that an in- 
dividual in fairly good general health can have his abdomen 
opened and explored without very great risk, and one who 
has just received an abdominal wound not necessarily fatal 
ought, at the moment and for a short time thereafter, to be 
able to bear such an exploration almost equally well. Tn 
such a case the risks of the operation, when performed un- 
der proper safeguards, are, I believe, less than those of the 
injury which the bullet has probably inflicted, and it is in 
such cases, notwithstanding the record, that I believe the 46 
GUNSHOT WOUNDS OF THE ABDOMEN. 
operation is capable of furnishing valuable and superior re- 
sults. If, on the other hand, several hours, perhaps a day, 
have passed and the patient is doing well, it may be better 
to accept the indication that the injury is not severe and is 
capable of spontaneous cure, and to abstain from interfer- 
ence. But when several hours have passed and the condi- 
tion of the patient has changed greatly for the worse, and 
especially if the abdomen is largely distended and painful, 
then I believe we should abstain from an attempt to seek 
and close the perforations. It is urged against such absten- 
tion that the case is hopeless without it; it may be so, but 
I believe it is still more certainly hopeless with it, and to 
operate under such circumstances seems to me needlessly to 
compromise our art and to create a harmful prejudice 
against a resort to the operation under more favorable con- 
ditions. Must we then stand idly by and let the patient 
make his struggle for life unaided? Possibly, if the limita- 
tions of our art require it. But between non-interference 
and the full operation there may lie a middle course, by 
which the desperate chances of these unfortunates may be 
somewhat bettered. We have seen that a few such have 
survived without operation, the faeces and the peritoneal pus 
escaping through the parietal wound, and perhaps leading 
to the establishment of a stercoral fistula. Is it not possible 
that this way of escape may be made easier, that an enlarge- 
ment of the bullet-wound and drainage of the peritoneal 
cavity may save some who could not survive a more formal 
operation? Slight as the chance may be, it seems to me 
to be the only one we can offer to such patients. In con- 
clusion, 1 offer the following: 
Summary of the Points to which I have souyht especially 
to call Attention.-The (incomplete) hospital statistics of 
New York city show, for an average period of ten or twelve 
years previous to 1885, 17 cases of recoveiy under non- 
operative treatment after gunshot wound of the abdomen GUNSHOT WOUNDS OF THE ABDOMEN. 
47 
supposed to be perforating. The integral statistics of three 
hospitals-the New York, Chambers Street, and Roosevelt 
-contain 23 cases, with 15 deaths-a mortality of 65 per 
cent. 
The integral statistics of New York city since 1884 give 
29 cases of laparotomy for gunshot wound of the abdomen, 
with 25 deaths-a mortality of 86'2 per cent.; and the 
statistics of the three hospitals above mentioned give 16 
cases, with 13 deaths-a mortality of 81'2 per cent. 
In view of the apparently greater mortality after oper- 
ation, it is highly desirable that any doubt as to the cor- 
rectness of the diagnosis in cases recovering without oper- 
ation should in the future be avoided if possible, and that 
with this object the track of the bullet should be traced to 
the abdominal cavity. 
Preliminary incision along the track of the bullet, or, 
in case of need, in the median line, is the best and safest 
means at our disposal to recognize the presence or absence 
of wounds of the viscera. 
The relations between the number and severity of the 
visceral lesions and the size of the bullet, or the early symp- 
toms, are not, in the majority of cases, sufficiently constant 
to guide us in the choice between operating and not oper- 
ating. 
An improvement in the results of operative treatment 
may be expected if the operations are undertaken earlier 
(before the intercurrence of peritonitis or septicaemia), and 
if their duration is shortened by rapidity of execution and 
by restriction of the search for lesions to the readily acces- 
sible portions of the intestine and to the probable course of 
the ball. While some may die through the overlooking of 
a perforation, fewer, I think, will be killed by the oper- 
ation. 
In cases in which considerable time has elapsed since 
the receipt of the injury and in which the symptoms of 48 
GUNSHOT WOUNDS OF THE ABDOMEN. 
septicaemia or peritonitis are present, with marked disten- 
sion of the abdomen, an attempt to discover and close the 
perforations of the intestine will almost certainly be fatal, 
and operative interference should be restricted to the estab- 
lishment of free drainage of the abdominal cavity through 
the wound. 
In cases seen at an earlier period and in which these 
grave symptoms have not been developed, the probable 
chances of success are sufficient to justify an operation to 
repair the injuries. 
In the present state of our knowledge it can not be said 
that either interference or non-interference should be the 
rule of practice, and the surgeon may be guided by his 
own convictionsand feelings, whether they lead him to seek 
to do as much good or only as little harm as possible. 
Note.-Since the foregoing paper was read I have learned that I 
failed to recognize as a New York case a successful one reported by 
Dr. Manley in the " Medical News " for Septembet 24, 1887. The ad- 
dition raises the list to 30 cases with 25 deaths, a mortality of 83 33 
per cent. Three days after the paper was read, on October 20th, I 
operated in another case which has progressed to the present time, the 
tenth day, without an unfavorable incident, so that the patient may 
fairly be deemed out of danger. He is a man, thirty-two years old, who 
was shot by a policeman with a revolver of '38 caliber, the ball enter- 
ing four inches and a quarter below the umbilicus and one inch and a 
half to the right of the median line. The operation was done five hours 
after the receipt of the injury. There was some escape of feces into 
the abdominal cavity, with beginning peritonitis. Two large ragged 
openings, closely adjoining each other, in the lower part of the ileum 
were closed with a single row of Lembert sutures. It is interesting to 
note that the wounds were separated by a bridge of tissue only an 
eighth of an inch wide, and evidently had been made by the ball pass- 
ing along the side of the intestine in the furrow of a sharp bend, on 
each side of which it cut out a piece without itself entering the lumen 
of the bowel. I purpose to report the case in full in due time. Ac- 
cepting it as successful raises the New York city list to 31 cases with 
25 deaths, a mortality of 80'64 per cent. 
34 East Thirty-third Street, October 29, 1889. REASONS WHY 
Physicians Should 
Subscribe 
FOR 
The New York Medical Journal, 
Edited by FRANK P. FOSTER, M. D., 
Published by D. APPLETON & CO., 1, 3, & 5 Bond St. 
1. BECAUSE : It is the LEADING JOURNAL of America, and 
contains more reading-matter than any other journal of its class. 
2. BECAUSE: It is the exponent of the most advanced scientific 
medical thought. 
3. BECAUSE : Its contributors are among the most learned medical 
men of this country. 
4. BECAUSE: Its "Original Articles" are the results of scientific 
observation and research, and are of infinite practical value to the 
general practitioner. 
5. BECAUSE : The "Reports on the Progress of Medicine," which 
are published from time to time, contain the most recent discov- 
eries in the various departments of medicine, and are written by 
practitioners especially qualified for the purpose. 
6. BECAUSE : The column devoted in each number to "Therapeu- 
tical Notes " contains a resume of the practical application of the 
most recent therapeutic novelties. 
7. BECAUSE : The Society Proceedings, of which each number con- 
tains one or more, are reports of the practical experience of 
prominent physicians who thus give to the profession the results 
of certain modes of treatment in given cases. 
8. BECAUSE : The Editorial Columns are controlled only by the 
desire to promote the welfare, honor, and advancement of the sci- 
ence of medicine, as viewed from a standpoint looking to the best 
interests of the profession. 
9. BECAUSE : Nothing is admitted to its columns that has not some 
bearing on medicine, or is not possessed of some practical value. 
IO. BECAUSE: It is published solely in the interests of medicine, 
and for the upholding of the elevated position occupied by the 
profession of America. 
Subscription Price, tS.OO per Annum. Volumes begin in January 
and July.