GUNSHOT WOUND OF THE INTESTINES, WITH SIXTEEN PERFORATIONS; ENTERORRHAPHY; USE OF THE MURPHY BUTTON; RECOVERY.

1
By GEORGE WOOLSEY, M.D.,
OF NEW YORK,
SURGEON TO BELLEVUE HOSPITAL; PROFESSOR OF ANATOMY AND CLINICAL SURGERY IN THE UNIVERSITY OF THE CITY OF NEW YORK.

T HE following case is of special interest on account of the successful result of the closure of sixteen perforations of the intestine, and on account of the two factors which contributed very largely to this result,-i.e., the very liberal use of hot, sterile, normal salt solution for cleansing, and the fact that the patient had eaten nothing for twenty-four hours previous to being

shot.
The patient, W. McC., age twenty-three, was brought in the ambulance to Bellevue Hospital at 10.30 P.M., on December 21, I895, immediately after being shot twice by a pistol of thirty-two or thirty-eight calibre, in the hands of a man who stood nearly in front of him or a little to his left side. Between this time and 3 A.M. of December 22, when I was called to see him, he had vomited a number of times, not only when stimulants were given by the mouth, but at frequent intervals between. He had had one movement of the bowels, composed mostly of blood. At i i P.M. his temperature was 99.60 F., pulse 94, respiration 28. There was considerable shock, from which he rallied in part after stimulation by hypodermic injections. When I saw him, about 3 A.M., December 22, he complained of great abdominal pain and was vomiting occasionally. He had partly
1 Case presented to the New York Surgical Society, January 22, I896.

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rallied from shock, but his pulse was more rapid and the temperature was higher than when taken four hours before. He presented the appearance of beginning peritonitis. There was one bullet-wound of the left buttock, the bullet having emerged at the inner side of the buttock, and another wound about midway between the anterior superior iliac spine and the umbilicus. A probe introduced into the latter wound passed dorsally inward and downward, but only as far as the muscular abdominal wall. There was no tympanites. His urine was normal. An operation was immediately begun under ether anaesthesia, with the assistance of the house staff. A vertical incision was made a little to the median side of the abdominal bullet-wound and nearly over the left semilunar line. This incision met the track of the bullet as it penetrated the sheath of the rectus muscle near the outer border of the muscle. A blunt probe introduced indicated the course of the bullet to have been more transverse than was at first supposed, so that this incision was carried no farther. A median incision was therefore made from the symphysis pubis to the umbilicus, in order to reach both sides of the abdomen equally well. A moderate quantity of blood, mixed with serum and blood-clots, was found in the peritoneal cavity, and the peritoneum was highly congested. Only a small amount of recognizable fecal matter was found. The small intestine was examined from the ileo-colic valve to the duodenojejunal junction, and sixteen perforations were found in the small intestine and one in the mesentery. Most of these were in the lower ileum, but several were some distance above in the jejunum. The intestines were remarkably empty and collapsed. The perforations were marked as found by artery clamps, and one after another were closed with continuous Lembert sutures of fine silk, applied transversely to avoid stenosing the gut. At one point in the lower ileum four perforations were found in the space of about two inches, where the bullet had apparently traversed a knuckle of intestine. As these could not be closed without causing marked stenosis and kincking of the gut, about three inches of the latter was excised and the ends approximated by a Murphy button, saving thereby considerable time. Large quantities of hot, sterile, normal salt solution were used to clean the surface of the intestines and mesentery and to wash out the cavity, and the intestines were protected throughout with sterilized gauze repeatedly wet in the same solution. The bladder, sigmoid flexure, and cmcum were examined and found intact, and as the

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bullet and its track was not easily found it was not sought for. The wound was closed in the usual way, leaving a glass drainage-tube near its lower end. Through this tube a salt solution was injected and again sucked out until it came away nearly clear. The operation was naturally a long one, lasting over two hours, but at its close the condition of the patient was fairly good. The drainage-tube was exhausted, by means of a sterilized rubber catheter and a syringe, every half-hour for the first few hours, after which no fluid came away. At 9 A.M. on the following day his temperature was IOI.60 F., pulse I40, and respiration 56, and at noon of the same day the temperature reached its highest point, I020 F., after which it continued to fall to 100.20 F. at 3 A.M, on the next morning, the pulse and respiration improving correspondingly. On the day after operation he retained the small amounts of milk and lime-water given, and again some of that given on the following day; but as he vomited more or less from time to time, feeding by the mouth was discontinued, and he was nourished mostly by rectal nutrient enemata for twenty-four hours, after clearing the rectum by a small injection. After giving the stomach a nearly complete rest for twenty-four hours it retained nourishment from the fourth day on, with only occasional vomiting. He was kept on a fluid and soft diet for about two weeks. His bowels moved first on the third day, after an injection which relieved an attack of abdominal pain. After this the bowels were moved every day, or every other day. Vomiting and pain and a rise in temperature on the sixth day were relieved by washing out the stomach and by the movement of the bowels following a large enema. The Murphy button was passed on the ninth day. The tube was removed after four days and the sutures after nine days. The wounds healed per primum, except for small granulating depressed surfaces at the site of the tube and the entrance of the bullet-wound, the edges of which had been much blackened by the nearness of the revolver. Stimulation was discontinued after the third day.

The course of the case was comparatively uneventful after the operation, and this I attribute, apart from the fact that the exposed surfaces and the general peritoneal cavity were thoroughly and repeatedly cleansed with quantities of hot, sterile, normal salt solution, to the fact that the bowels were remarkably empty, owing to the fact that he had eaten nothing for over twenty-four

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hours prior to the accident. This is a most important point, especially in cases where there are many and large perforations, as in this case. Attention has already been called to this point by Matas, of New Orleans, in connection with a case where the number of perforations was even larger,-over twenty. Although this patient did so well, I was not very sanguine as to the result for a number of days, on account of my experience in a case four years ago, in which I sutured eleven perforations. This case did perfectly well until the third day, when he rapidly sank, and died without any peritonitis or other apparent cause, as shown by the autopsy. Death in this case was probably due to auto-septicemia. Usually, owing to partial intestinal paresis, due to the injury or to beginning peritonitis, or from the fear of actively moving the bowels at once, there is constipation for some days, and the intestinal contents have abundant opportunity, by putrefaction or over-digestion, to form ptomaines or leucomaines to be absorbed by the inverted edges of the intestinal wounds. Hence the importance of an empty bowel. The experience in the present case goes to confirm this view, as here there were practically no intestinal contents from which absorption could occur. Thinking that we might to some degree prevent autosepticemia by the employment of some intestinal antiseptic, like salol, betanaphthol-bismuth, or naphthalin, this patient was on the second day put on the regular use of salol, which was discontinued after a week. Whether this had any effect in this case, or would have had if the bowels had been full instead of empty, I am unable to say.