A Case of Contusion 
and Rupture of the Ileum 
WITH PERITONITIS, WITHOUT EXTERNAL 
WOUND, SUCCESSFULLY TREATED BY 
C(ELIOTOMY AND PRIMARY ENTERECTOMY, 
FOLLOWED BY CIRCULAR ENTERORRHAPHY 
(maunsell's method). 
BY 
FREDERICK HOLME WIGGIN, M.D., 
President of the Society of the A lumni of Bellevue Hospital; 
Visiting Surgeon to the City Hospital (late Charity.); 
Surgeon City Hospital Gynecological Division. 
REPRINTED FROM 
CTfce Neto ¥or& i&etifcal journal 
for January SO, 189^. Reprinted from the New York Medical Journal 
for January 20, 189^. 
A CASE OF 
CONTUSION AND RUPTURE OF THE ILEUM 
WITH PERITONITIS, WITHOUT EXTERNAL WOUND, 
SUCCESSFULLY TREATED BY 
CCELIOTOMY AND PRIMARY ENTERECTOMY, FOLLOWED BY 
CIRCULAR ENTERORRHAPHY (MAUNSELL'S METHOD). 
EXHIBITION OF PATIENT AND SPECIMEN* 
By FREDERICK HOLME WIGGIN, M. D., 
PRESIDENT OP THE SOCIETY OP THE ALUMNI OF BELLEVUE HOSPITAL ; 
VISITING SURGEON TO THE CITY HOSPITAL (LATE CHARITY) ; 
SURGEON CITY HOSPITAL GYNECOLOGICAL DIVISION. 
The case which I desire to call your attention to this 
evening presents several features of interest, and some im- 
portant points for reflection and discussion. The surgeon 
is beginning to invade, and successfully, the field which to 
within a short time the physician has considered entirely 
his own-namely, peritonitis without external evidence of 
injury. Cases of this nature that have been treated by 
coeliotomy and intestinal suture, in which recovery has 
followed, have been few. A careful search of the literature 
discloses only one recorded case of successful primary re- 
* Read before the Society of the Alumni of Bellevue Hospital, No- 
vember 1, 1893. For a report of the discussion, see vol. Iviii, page 700. 
Copyright, 1894, by D. Appleton and Company. 2 
CONTUSION AND RUPTURE OF THE ILEUM. 
section f in this class of injuries, exclusive of the one I am 
about to bring to your notice. 
That injuries of this nature are not of great rarity is 
admitted as soon as the variety of accidents that lead to 
this condition is considered-e. g., kicks, blows, falls, etc.; 
nor are they confined to any locality or any special walk of 
life. That this is true is proved by the fact that in the 
course of my private practice I have had two cases within 
twenty-eight months-one in May, 1891, and the other in 
September of this year. It is a group of cases that will be 
more carefully considered hereafter, and must be of great 
interest to the general practitioner, as from the absence of 
external wround he will be first called to such a case. On 
him, therefore, in the future, will the responsibility largely 
rest for the failure of surgical aid to end in recovery of the 
patient. This my cases exemplify, and the mere statement 
of the facts in each answers the question, Why did one 
patient die while the other recovered ? 
Case I.-Late on the evening of May 28, 1891, I was called 
in consultation to see II. W., fourteen years of age, whose phy- 
sician gave ine the following history: On the afternoon of the 
23d, while feeding a calf, the boy received a kick in the right 
lumbar region. The pain, which was at first severe, soon passed 
away, and he w'ent on with his regular vocation, not even 
mentioning to his family the accident that bad befallen him. 
The following day (the 24th) being Sunday, he attended church 
after doing his chores as usual, and went again in the evening. 
While at this service, he was suddenly seized with violent col- 
icky pains, nausea, and vomiting. On the 25th the family phy- 
sician was sent for. His attention was not at first called to the 
accident, and the patient complaining of constipation with the 
other symptoms, he was given large doses of magnesium sul- 
phate, enemata, and morphine in constantly increasing doses. 
Bran poultices were applied externally. 
As the patient steadily grew worse under this treatment, 
j Croft, Clinical Society, London, March 14, 1890. CONTUSION AND RUPTURE OF THE ILEUM. 
3 
five days after the accident I was sent for. On examination, 
no external marks of violence were found. The abdomen was 
tympanitic; muscular rigidity was marked and increased by 
pressure, and especially at a point two inches to the right of the 
umbilicus. There was slight dullness on percussion at this 
point. The general abdominal pain had disappeared, vomiting 
had ceased, and constipation was absolute. His countenance 
was drawn and anxious; the temperature was 99'5°, pulse 130, 
and respirations 30. 
The diagnosis was intestinal rupture and general suppura- 
tive peritonitis. Although the prognosis was very unfavor- 
able, I advised operation as the patient's only chance. Coeli- 
otomy confirmed the diagnosis. A large amount of pus was 
found in the cavity, shut off at various points by adhesions, 
and a rupture of the ileum, w'hich was closed by Lembert 
sutures. The general cavity was washed out with a weak so- 
lution of hydrogen dioxide, the external wound partially closed, 
and drainage with iodoform gauze employed. 
The anaesthesia was badly borne; the patient stopped 
breathing and was revived with much difficulty during the 
operation. The operation was prolonged by the great intes- 
tinal distention, necessitating several incisions to allow gas and 
faecal matter to escape before they could be returned. The 
patient died six hours after the completion of the operation, 
which occupied two hours. 
The chief points of interest in this case are : (1) The 
absence of shock ; (2) the cessation of pain for twenty- 
four hours after the accident, although the intestine was so 
badly contused that it then became perforated; (3) the en- 
ergetic medical treatment employed for three days and the 
consequent delay before surgical interference was consid- 
ered ; and (4) the length of time required for the operation. 
Case II.-On the evening of September 11, 1893, I was 
called to see A. M., fifteen years of age, a colored boy. He 
gave the following history : On the afternoon of the same day, 
while in a pasture, he had received a kick from a horse on 4 
CONTUSION AND RUPTURE OF THE ILEUM. 
the right lumbar region and right elbow. lie was found 
lying on bis stomach, groaning. In about ten minutes he be- 
gan vomiting, and complained of continuous nausea. At first 
he vomited only food, but later, both before being moved and 
after, be vomited each time about four ounces of dark, clotted 
blood. 
On examination at 8.30 p. m., the patient was found to be suf- 
fering slightly from shock. He lay on his back with his knees 
drawn up, and be complained of great pain, especially at a 
point to the right of the umbilicus. There were no marks of 
external violence on the abdomen. He had an anxious ex- 
pression. Morphine, an eighth of a grain, was administered 
hypodermically, and a drachm of fluid extract of ergot was given 
by mouth. An ice bag was applied locally. At this time his 
temperature was normal and his pulse 80. 
September 12th.-The pain continued all night, at 2 a. m. his 
pulse was 104 and temperature 100 5°, and soon after 3 a. m. 
another haemorrhage through the stomach occurred, about eight 
ounces of dark, clotted blood being ejected. This was repeated 
at 9 a. m., his pulse at this time being 106 and his temperature 
101°. Owing to a misunderstanding, 1 did not see the patient 
again until 7 p. m., when his condition was as follows: Pulse, 
114; respirations, 30; temperature, 102 5° ; he was lying on his 
back with his knees drawn up, and with an anxious countenance. 
The abdomen was tympanitic; there was marked muscular 
rigidity, increased by pressure at the point of greatest tender- 
ness-i. e., to the right of the umbilicus. 
The diagnosis was traumatic peritonitis with contusion and 
perforation of the intestine, and an immediate operation was 
advised. To this the patient consented, and at midnight, with 
the able assistance of Dr. W. S. McLaren, of Litchfield, Conn., 
to whom I wish to acknowledge my indebtedness, the operation 
was performed. Just previous to the administration of the ether 
his temperature was 102'7°, pulse 116, and respirations 33. 
An incision about four inches long, in the median line be- 
tween the umbilicus and pubes, was made and the peritonaeum 
opened The transverse and descending colon were filled with 
hard faecal matter, owing to the fact that the patient had a large CONTUSION AND RUPTURE OF THE ILEUM. 
5 
condyloma which made defecation painful. Beginning at the 
caecum, the small intestine was drawn out of the cavity and 
carefully examined inch by inch. It was more or less dis- 
tended, and there was a fibrinous exudation and also slight ad- 
hesions, especially about the injured knuckle. A knuckle of 
intestine was soon discovered, which was ecchymosed, but only 
near its mesenteric border. It was decided, after careful con- 
sideration, that this portion would recover its circulation and 
tone, and it was passed by. On going higher up, near the jeju 
num, another knuckle of ileum was found, which was so bruised 
and dark in color that, although no perforation could be dis- 
covered prior to removal, it was thought best to excise about 6 
CONTUSION AND RUPTURE OF THE ILEUM. 
six inches. (After removal, a small perforation was found at 
about the center of the specimen, near its mesenteric border.) 
This was done, safety-pins being used for clamps. The vessels 
in the cut mesentery were ligated separately, and the edges of 
the mesentery united by a continuous suture of catgut. The 
healthy ends of the ileum were brought together, invaginated, 
and united by Maunsell's method, except that the sutured ends 
of the bowel and the longitudinal slit in the gut were not paint- 
ed with Woelfler's solution, nor were the raw parts blown over 
with iodoform, as advised by him.* 
While the ileum was being excised the patient came out 
from the influence of the ether, strained and tried to vomit, and 
a quantity of blood and faecal matter escaped into the peritoneal 
cavity. This accident was due to the large size of the safety- 
pins. A liberal quantity of a fifteen-volume solution of hydro- 
gen dioxide was poured into the cavity, and allowed to remain 
while the ends were completely joined, when more hydrogen 
dioxide was poured over them. Some time was allowed to 
elapse before the resulting foam was washed off and the cavity 
flushed with normal sterilized salt solution (0'6 per cent.). Then 
the intestines were returned to the cavity, which was freely 
irrigated and left full of hot sterilized salt solution. The wound 
was closed, no drainage being employed. The operation from 
the time of beginning the anaasthesia occupied an hour and a 
half, and was concluded at 1.30 a. m. 
13th.-At 4 a. m. the patient's pulse had risen to 130, and 
the temperature had fallen to 99'5°. During the night there 
was very little nausea. At 10 a. m. his pulse was 114, tempera- 
ture 102'4°; and at 9 p. m. the pulse was 136 and temperature 
102 2°. Morphine was given in oneeighth-grain doses every 
three hours, beginning at 4 p. m. At 11 p. m. he was comfortable, 
and retained peptonized milk. 
Uth.-At 2 a. m. his pulse was 118 and temperature 100° 
At this time gas escaped from the rectum (twenty-four hours 
and a half after the operation). The patient slept well, retained 
peptonized milk and beef peptonoids during the day, and com- 
plained of no pain. Gas was freely passed from the rectum, 
* Am. Jour, of the Med. Sciences, March, 1892. CONTUSION AND RUPTURE OF THE ILEUM. 
7 
and he had a desire to have a movement. At 8 p. m. his pulse 
was 104 and his temperature 101°. 
There is little of further interest to report. The patient's 
bowels moved without aid on September 15th at 2 p. m. (sixty- 
one hours and a half after the operation). During the ensuing 
twenty-four hours (September 16tb) the patient bad five large 
movements, and the morphine was stopped. On September 17th 
the patient had five movements. He had complained of no pain. 
His pulse was 98 and his temperature 99'5°. After this the 
temperature and pulse became normal and remained so. The 
bowels moved every day or every other day without aid, and 
on September 21st he was allowed ordinary diet. He has re- 
mained in good health, and now awaits your inspection. 
The points of interest in this case, aside from its suc- 
cessful termination, are : (1) The haemorrhages, which in re- 
corded cases, successful and unsuccessful, that I have found, 
occurred only once-in Croft's case, and this was very slight; 
(2) the slight amount of shock when the patient was first 
seen, four hours after the accident, the temperature arid 
pulse being normal; (3) the excision of the contused and 
perforated portion of the ileum, and the end-to-end union 
by Maunsell's method, which is comparatively new, and has 
not been employed many times; (4) the use of hydrogen 
dioxide in full medicinal strength for the purpose of disin- 
fecting the general peritoneal cavity, this being the second 
successful case in which it has been used, the other being 
one of my own a few days previously ; (5) the closing of 
the abdominal wound, leaving the peritoneal cavity full of 
hot, sterilized salt solution, the object of this being to 
lessen shock, to prevent adhesions, to aid in the readjust- 
ment of the intestines and omentum to their proper posi- 
tions, to lessen the danger of septic peritonitis,* and to aid 
by osmosis the action of the bowels; (6) the shorter dura- 
* British Medical Journal, 1892, Max Withard's experiments. 8 
CONTUSION AND RUPTURE OE THE ILEUM. 
tion of the operation; and (7) in the after-treatment the 
early administration of peptonized food. 
In the first case the operation was performed after five 
days' delay, having thereby been rendered more difficult, 
and requiring prolonged amesthesia, which the large doses 
of morphine rendered more dangerous. The patient was 
exhausted from pain, constant nausea, and want of proper 
nourishment, and was septic. In the second, the early 
recognition of the condition, the comparative promptness 
with which the operation followed, its shorter duration, the 
use of hydrogen dioxide in full strength, the filling and 
closing of the peritoneal cavity with hot sterilized salt solu- 
tion, made the difference between failure and success. 
A careful study of all the recorded cases, successful and 
unsuccessful, and my own, shows the causes of failure of 
surgical measures to be (1) delay, which has been responsi- 
ble for by far the greatest number of deaths; (2) haemor- 
rhage ; (3) failure of the suture and septic peritonitis. 
Delay must be obviated by a fuller knowledge of the 
meaning of the symptoms by the general practitioner. The 
important factors in the diagnosis are : The history of in- 
jury, persistent nausea, haemorrhage, prolonged shock, rise 
of temperature, increasing rapidity and weakness of the 
pulse, increased frequency of respiration, rigidity of the 
abdominal muscles, persistent pain, with or without pres- 
sure, and the facial expression. Haemorrhage can be 
avoided after operation by greater care in tying the blood- 
vessels in the mesentery, singly and not en masse ; failure 
of the suture by better technique and the employment of 
Maunsell's method for end-to end union; septic peritonitis 
by the liberal use of hydrogen dioxide where infection is 
known to exist, and leaving the abdominal cavity full of 
sterilized salt solution. 
Finally, it may not be out of place to utter a word of CONTUSION AND RUPTURE OF THE ILEUM. 
9 
caution as to the administration of the anaesthetic. It is 
generally intrusted to the least experienced, and therefore 
the least competent, assistant, and little attention is paid to 
the quantity employed. Operations of the character we 
have been considering must often of necessity be pro- 
longed. It has been my custom when possible, since my 
experience in the first case, to have the anaesthesis in the 
hands of a thoroughly experienced and competent assistant. 
This lessens the mental wear and tear of the operator, and 
allows of more rapid work. By the use of Dawbarn's 
modification of the Clover inhaler, patients have been 
anaesthetized and kept unconscious for an hour with but 
four ounces of ether. They regain consciousness rapidly, 
have little or no nausea, and the danger of nephritis, which 
is getting to be a very frequent cause of death after opera- 
tion, is materially lessened. With closer attention to de- 
tails, quicker recognition by the general practitioner of the 
wisdom, at least, of early surgical advice, and, when doubt 
arises, giving the patient the benefit of it by an explora- 
tory coeliotomy, success will, in these cases, cease to be the 
exception. 
Dr. Charles Phelps said that he could only speak in 
approbation of the paper, for few surgical papers presented 
more of value and novelty than this one. So far as he knew, 
there were only two recorded cases, the one just reported be- 
ing the second one of intestinal resection in which Maunsell's 
method had been adopted in New York or its vicinity. The 
first operation had been done by anothermember of this society, 
Dr. Hartley. The cumbersome and tedious methods hitherto 
employed had rendered the usual operation of intestinal resec- 
tion very uncertain in its results ; hence an operation which 
could be performed with so much rapidity and ease must be re- 
garded as an exceedingly agreeable surgical revelation. Per- 
sonally, he thought that no other device was likely to super- 
Discussion. 10 
CONTUSION AND RUPTURE OF THE ILEUM. 
sede this new operation. With this method at bis disposal, he 
would now be willing to operate on many cases where for- 
merly he would have hesitated or refused to operate. 
The use of peroxide of hydrogen in the peritoneal cavity 
and leaving this cavity filled with hot salt solution he believed 
to be new points in the technique. The knowledge that 
one could successfully use the peroxide of hydrogen in this 
way made the prospect of success much better, and the leaving 
of the hot solution he thought, from theoretical considerations, 
must prove an effectual measure for the treatment of shock. 
Intestinal resection was a much more facile and a much more 
promising operation than it had been heretofore. 
Dr. Frederic S. Dennis said that he had been much in- 
terested in the paper and in the case, which he had seen before 
from time to time. So far as he knew, there had been only one 
case besides the author's in which a diagnosis of rupture of the 
gut had been made, and laparotomy with end-to-end suture of 
the gut after resection performed ; hence Dr. Wiggin should 
be warmly congratulated on the success of so brilliant an oper- 
ation. 
There was another point of interest in the case-namely, 
that the patient had come to this city with a large ulcerating 
tumor at the verge of the anus which had looked very much 
like an epithelioma, but, on examination, had been found to be 
a condyloma. This the speaker had removed by the applica- 
tion of an ordinary elastic band, a procedure described by the 
late Dr. Nathan Smith, of Baltimore. The mass had been, 
without exaggeration, of the size of one's fist, and bleeding, 
ulcerating, and foul. In less than twenty-four hours after 
the application of the elastic ligature around the pedicle of 
this mass it had sloughed off, and had now entirely disap- 
peared, although only five or six days had elapsed since the 
operation. 
Dr. J. W. S. Gouley thought that Dr. Wiggin should be 
congratulated upon the success of this case, which was owing, 
first, to the early surgical interference, and, secondly, to the 
measures adopted in the after-treatment. With respect to the 
first, he would say that there was usually too much delay; even CONTUSION AND RUPTURE OF THE ILEUM. 
11 
in this case the operation might have been performed many 
hours sooner. 
This method of operation, which he had seen Dr. Wiggin 
demonstrate before, impressed him very favorably. It had b^en 
objected that the longitudinal incision of the intestine below 
was an unnecessary complication ; but since such a wound could 
be so easily closed, and since any flatus would be apt to col- 
lect above, the objection did not seem to him to be valid. The 
absolute peritoneal contact secured by this method of suture 
seemed likely to render the end-to-end operation safer than 
even the Murphy button. The latter might become a very dan- 
gerous foreign body in the intestine, although it was a very 
pretty operation, and was even more quickly performed than 
Maunsell's. 
He had been greatly interested in the washing out of the 
peritoneal cavity with peroxide of hydrogen; he was glad to 
know that the peritoneal cavity would tolerate this agent so 
well. It was well borne by connective tissue, and tolerably 
well by the buccal membrane, even when used in its pure state; 
but certain other mucous membranes, such as those of the blad- 
der and urethra, did not tolerate it. Such rapid oxidation was 
produced that the pain was unbearable-worse even than that 
produced by the use of strong solutions of bichloride of mer- 
cury. 
The tilling of the abdominal cavity with warm salt solution 
had been resorted to two years ago in this city by Dr. Baldwin 
in a case of abdominal section for a very large uterine myoma 
-a tumor at least six inches in diameter and almost globular. 
The operation had been difficult and tedious, and the patient 
had been in collapse, so the operator filled the abdominal cavity 
with as much very hot Thiersch's solution as it would hold. 
He had looked upon this as a very important factor in the re- 
covery of bis patient, and he had thought the large volume of 
the fluid, as well as its heat, was important. 
The author of the paper had also introduced another very 
important point which could not be too often repeated, and 
that was that as little time as possible should be lost in the per- 
formance of abdominal operations. It was a potent element of 12 
CONTUSION AND RUPTURE OK THE ILEUM. 
success. Every year, every month, almost every week, did his 
dread of ether increase, especially in connection with the way 
in which it was given in our large hospitals, such as Bellevue. 
In private practice among healthy subjects it was perfectly safe. 
He had had very few deaths from ether, but lie could never 
forget the fust case. It had occurred at the time when Dr. 
Polk was house physician, and, he thought, Dr. Bryant was 
house surgeon-as far back as 1870. The patient had been 
brought to the hospital with luxation of the hip. He was 
a stalwart but drunken fellow. He had first been placed on 
the table and the usual quantity of ether given. Attempts 
had been made by several surgeons to reduce the dislocation of 
the hip, but these had failed. Then some of the medical staff 
had tried, and had also failed. The man had then been put to 
bed for two days, and at the end of this time he had again been 
etherized. The speaker had tried, then the house surgeon had 
tried, and then Dr. Smith and Dr. Sayre, but all had failed. 
There had been almost total suppression of urine following this 
etherization, and two days later the man had died. The au- 
topsy had shown the contracted kidney so commonly found 
among drunkards. Ever since that time he had been afraid of 
ether. In private practice he had given as little as possible, 
sometimes giving chloroform to young subjects, but as far as 
possible using the nitrous oxide. Many years ago Dr. James R. 
Wood bad used it in an amputation of the thigh, but his appa- 
ratus had been cumbersome, and the method bad not been gen- 
erally adopted. In the last few years, in nineteen out of twenty7 
cases, he had used nitrous oxide in preference to ether, on ac- 
count of the evil effects which many had observed from ether. 
Dr. W. R. Townsend said that he had had the pleasure of 
listening recently to a paper on peroxide of hydrogen as a 
haemostatic in cases of epistaxis. The author had found it even 
better than plugging of the nostrils. In the discussion of this 
paper several others had spoken of having had good results 
from it in this direction. In view of this, it might be that 
peroxide of hydrogen would prove especially useful where there 
was troublesome oozing in the abdominal or pelvic cavity. Cer- 
tain experiments which he understood were now being carried CONTUSION AND RUPTURE OF THE ILEUM. 
13 
on by Professor Thompson, of the University, went to show 
that peroxide of hydrogen had a special tendency to produce 
coagulation of the blood, both in the veins and in the arteries. 
Dr. W. Evelyn Porter said that he was inclined to believe 
that if the peroxide of hydrogen had been used with only sim- 
ple water irrigation it would have caused irritation, and even 
adhesions. On this account, in advocating its use, it would be 
wise to recommend in every case that the cavity should subse- 
quently be irrigated with normal salt solution. He believed 
this should be used very generally in abdominal work, not only 
in acute cases, but in the more chronic ones, especially those 
found in women. 
He thought that, in addition to MaunseH's method, the use 
of a single row of sutures, either continuous, or Lembert's in- 
terrupted sutures, around the outer layer, uniting the peritoneal 
surfaces, would be a very great safeguard, as we all knew in 
any case of intestinal suture unless tbeie was very little disten- 
tion there was apt to be leakage of the contents of the bowel. 
He did not like the form of ether inhaler exhibited and recom- 
mended by the author. One modified by Dr. Wyeth, with an 
opening for entrance of air, he considered very much better. 
Dr. R. A. Murray said he thought that the fatal result in 
these cases was due most often to delay in operating, and this 
delay occurred usually because the profession at large believed 
that if there was any septic trouble in the abdomen, there was 
always high temperature, pulse, and respiration. This was a 
very great mistake. We should call the attention of the pro- 
fession generally to the fact that more was to be learned from 
the facial appearance and the condition of shock than from the 
temperature, pulse, and respiration. For instance, two weeks 
before he had had a patient with irreducible crural hernia. Two 
days before he had seen her this time she had complained of 
moderate pain, and as she had been warned about this pain, 
she had immediately applied an ice bag and had sent for him 
the next day. She had vomited once, but the matter ejected 
had not been greenish; the abdomen had been flat; the pulse 
had been 72 and the temperature normal. The next day she 
had vomited once; the abdomen had been flat; there had been 14 
CONTUSION AND RUPTURE OF THE ILEUM. 
no impulse in the tumor, although there had been a slight im- 
pulse on the previous day; the pulse had been 72, and the tem- 
perature had been still normal. The patient had been informed 
that the hernia was strangulated and that an operation was 
necessary. The case had then been transferred to the New 
York Hospital, and that evening there had been still no change 
in the pulse and temperature, but there had been a peculiar 
facial expression and a smallness of the pulse which was sug- 
gestive. There had been some very slight pain. Dr. Bull had 
operated and had found six inches of the gut strangulated and 
almost black, and the sac filled with bloody fluid. He had seen 
puerperal septic peritonitis with almost no rise of temperature, 
yet with a small pulse. He believed that a wiry pulse, even 
though slow, the condition of shock, and the facial expression 
w'ere better guides than the thermometer-in fact, the ther- 
mometer was quite misleading. If we waited for the occur- 
rence of abdominal distention, the result was almost always 
fatal. 
Dr. Syms thought the case reported in the paper should 
be considered as one of the triumphs of modern surgery, 
and he hoped it would lead to very many more cases of this 
kind being recorded. He thought that most surgeons now 
agreed that the existence of peritonitis was an indication for 
operation. About three weeks ago he had made an appoint- 
ment to operate on a case which he had diagnosticated as prob- 
ably tubercular peritonitis. To his surprise, a consultant had 
advised waiting because there had been evidently peritonitis 
present, and he had looked upon this as an indication against 
instead of for an operation. 
Perhaps the most important part of the paper was the call- 
ing attention to the necessity for an early diagnosis of perito- 
nitis in cases where there was injury to the abdomen without 
external marks of violence. Perhaps, as the preceding speaker 
had said, the pulse was the most important sign ; certainly the 
temperature was no guide whatever. In some cases which he 
had seen the advance of the peritonitis had been announced by 
a fall of temperature below the normal. The facial expression 
was fully as important as the pulse-perhaps even more impor- CONTUSION AND RUPTURE OF THE ILEUM. 
15 
tant. The symptom of haemorrhage from the intestinal tract 
which had been present in the author's case would seem to indi- 
cate injury to the intestine, and this should in itself be sufficient 
to indicate the necessity for at least an exploratory operation. 
He had no doubt that Maunsell's method of intestinal suture 
was the method of the present and the future. Intestinal anas- 
tomosis by means of Senn's plates and their various modifi- 
cations had been almost abandoned; it was very difficult, and 
required special apparatus which was not always readily ob- 
tainable. Moreover, the lateral anastomosis was an unnatu- 
ral method of joining divided intestine, and the contraction 
which took place threatened the patient with intestinal ob- 
struction. At post-mortem examination he had seen this con- 
traction so great that a pencil could hardly be passed through 
the aperture left in the intestine. Maunsell's method produced 
such perfect coaptation of the peritonaeum that it seemed hardly 
possible to excel it. The suggestion of Dr. Porter to make an 
overhand Lembert suture after the Maunsell suture had been 
made seemed to him an excellent one. In the first case of 
operation here by Maunsell's method-Hartley's-he believed 
this plan had been adopted. The portion of suture which was 
most difficult to make perfect and where most end-to-end sutures 
had failed was at the intestino-mesenteric junction, and this was 
the portion especially well closed by Maunsell's method. 
About the time of the author's operation he had done the 
same operation for carcinoma. A Kraske operation had been 
attempted for the removal of the carcinoma, but the conditions 
had been such that the tumor could not be reached posteriorly, 
the adhesions being too dense and the tumor too high up. It 
had therefore been considered advisable to perform laparotomy, 
so this resection by Maunsell's method had been done subse- 
quently when the patient had rallied sufficiently from the first 
operation. The man had done very well for a few days, but 
had suddenly developed an extensive slough at the seat of the 
Kraske operation, which had infected the entire posterior 
wound, and he had died of sepsis. There had been much shock 
at the termination of the operation, so the abdomen had been 
filled with hot normal salt solution with very excellent results 16 
CONTUSION AND RUPTURE OF THE ILEUM. 
as to the immediate improvement in his condition. He regarded 
it as nearly equal to infusion. 
The care necessary in the administration of ether was a very 
important element of success in all operations. These abdomi- 
nal operations should be done as speedily as possible. This 
was one of the great advantages of Maunsell's method, for with 
good assistance it could be completed in twenty minutes. 
Dr. Syms exhibited an ether inhaler which he had had made 
and which he considered more convenient than the other in- 
haler shown by Dr. Wiggin. 
Dr. M. D. Field said that some years ago a man had been 
injured on the elevated railroad by a "buffer accident." He 
had made his way from New York city to Brooklyn, walking 
altogether several blocks without assistance. The accident had 
occurred on Sunday afternoon, but nothing serious had been 
observed until Wednesday morning, when he had been taken 
with stercoraceous vomiting. A diagnosis of intussusception 
had been made after a hasty consultation and injection per 
rectum, had been attempted. The speaker had arrived just 
after this had been done, and had found the patient in collapse. 
He had died shortly afterward. The autopsy had shown that 
the man had received a wound across the abdomen, and al- 
though there had never been anything more than a slight dis- 
coloration on the skin, the areolar tissue had been severed. 
On opening the abdomen, it had been found that the mesentery 
had been torn away for nearly half an inch, and that gangrene 
had resulted in nearly two feet of intestine. This evidently 
had accounted for the inaction of the bowels and the stercora- 
ceous vomiting. In addition to this, the intestine had been 
found to have been torn in three places, and every one of those 
wounds had healed, and there was nothing in the abdomen 
which had not been absorbed except a little of the injection 
fluid which was found on one side nearest to the lowest wound 
in the intestine. He would have recovered from the three 
lacerations of the intestine had it not been that they were 
complicated by tearing up of the mesentery, which had caused 
gangrene of the intestine. 
The President said that he agreed fully with Dr. Gouley CONTUSION AND RUPUURE OF THE ILEUM. 
17 
that the operation should have been done earlier; it should have 
been done the first night he saw the patient. When he had first 
seen him he was seven or eight miles from his office, with many 
other engagements which would have made it impossible for 
him to operate for a number of hours. A medical student, who 
was living in the house, had been asked to report the patient's 
condition to him. Receiving word over the telephone subse- 
quently that the patient was "all right," he did not see the boy 
until the following evening. 
He had used the peroxide of hydrogen three times in lapa- 
rotomies where patients had recovered, and there had been no 
sign whatever of intestinal obstruction or of inflammation. 
The first case had been that of an old lady upon whom he had 
operated in September for purulent ovarian cyst. The tumor 
had tilled the pelvis, and had reached half way to the umbili- 
cus. The fluid could not be removed by simple tapping, and 
in breaking up the adhesions with the hand, some of the re- 
maining contents had burst through the sac at a weak point. 
The peroxide of hydrogen had been immediately poured in, 
and allowed to remain for some time. The tumor had then 
been removed and the cavity flooded with hot salt solution. 
The temperature had never risen above 100°. 
About a week after the operation described in the paper 
he had operated on a case of pyosalpinx following abortion. 
The case had been rather septic, the temperature varying be- 
tween 101° and lOSA0 F. In breaking up the adhesions sur- 
rounding the ovary, the sac had been ruptured. Here also the 
peroxide of hydrogen and saline solutions had been used. The 
temperature had reached normal forty hours after the opera- 
tion. There had been no trouble with the movements of the 
bowels in these cases; in fact, he found that the bowels usually 
moved earlier after the saline solution had been used. The use 
of morphine was desirable, and this he thought could be safely 
done when the salt solution had been employed, because this 
counteracted the tendency to constipation. 
He did not think it necessary to use the additional row of 
sutures; he thought there was some danger of strangulating 
the circulation through the intestine. This was the great dan- 18 
CONTUSION AND RUPTURE OF THE ILEUM. 
ger in the first operations of end-to-end suture where a double 
row of sutures was used. In his case an eighth to a quarter of 
a grain of morphine had been given every three hours to pre- 
vent a movement of the bowels, yet they had moved repeatedly 
in the course of the first few days. 
He had been much interested in the remarks of Dr. Murray 
about the misleading character of some of the symptoms. He 
thought that temperature was no guide at all; the pulse and 
facial expression were the real guides to the diagnosis. 
55 West Thirty-sixth Street. The New York Medical Journal. 
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