1888 Journal of the American Medical Association  
Recognizing that whatever illustrates any new method in surgery is of advantage to the profes¬ sion, I take pleasure in reporting the following case : August 13, 8 p.m., I was called to see J. Wil¬ liams, a strong man aet. 49 years, and City Mar¬ shal, who had been shot about two hours before. Dr. Shaw had previously reached the case and administered a full dose of morphine. Found the countenance anxious, breathing slightly acceler¬ ated and pulse 80, temperature not taken, but about normal,
more » ... ut about normal, pain and jactitation'considerable. The ball, from a 42-calibre pistol, struck the ab¬ dominal wall on a level with and 4 inches to the left of the umbilicus. There was considerable haemorrhage but no escape of gas from the wound. The finger would not enter it, but the probe fol¬ lowed it for about 3 inches toward the umbil¬ icus when, in the position the body occupied, it refused to go any further. While there was no special evidence of the bowels having been in¬ jured, we decided to insufflate with hydrogen gas. The urine drawn with the catheter gave no evidence of injury to the urinary organs. The bow¬ els not having been moved for two days, large and repeated enemata of soap and water were admin¬ istered, but with little result, no peristaltic action being excited and voluntary effort causing unen¬ durable pain. Before we could complete our ar¬ rangement for the insufflation midnight came. The general condition of the patient seeming good, we decided rest for the remainder of the night would be better for him than an operation by lamplight. Administering yi grain of sulph. morph. and T^0 gr. of sulph. atrop. hypodermically and leaving morphine to be given pro re nata, we adjourned until 9 a.m. August 14, 9 a.m. The patient had had a quiet sleep and, though the countenance was anxious, the face pallid, the breathing hurried and the pulse 120 and quite compressible, he was cheerful and courageous. In a few moments we were ready to insufflate and, if need be, to operate-Dr. J. M. Heller to administer chloroform, H. C. Galliher, chemist, to attend to the gas, and Dr. Schenck, assisted by Dr. Shaw, to use the knife. At this juncture, alas ! the man of the law came upon the scene to prepare for a post-mortem by an ante-mortem examination. Encouraging the patient with the thought that the operation might prove fatal, he proceeded to take his testimony. We waited im¬ patiently until 10:30, when, with greatly increased exhaustion, after a full dose of brandy, the patient went kindly under the influence of chloroform and ether aa, and the hydrogen gas was soon travers¬ ing the rectum, descending, transverse and ascend¬ ing colon. At the ileo-caecal valve there was a slight gurgling sound followed by a tremulous movement, which was very soon transferred to the track of the ball through the abdominal wall, and in a moment the diagnostic flame told the tale of a perforated bowel. The bladder was emptied, the abdomen shaved and washed with an antisep¬ tic solution, and at n o'clock an opening made from a little above the pubic bone to 2 inches above the umbilicus, and very soon an opening was found in the ileum 3 feet from its caecal ter¬ minus. The edges of the opening were trimmed and it was closed with Gely's suture. Six inches nearer the ileo-caecal valve the ball passed through the gut, its exit making a wound / inch in lengh. The edges of these wounds were trimmed and closed with a continuous suture. Four inches further up the bowel there was a solution of con¬ tinuity in its'peritoneal and muscular coats. These were brought together with a few stitches and, there being no other wounds near except a perfor¬ ation through the mesentery, the gas was again injected, when other openings were quickly dem¬ onstrated. Twenty inches further up the bowel was a hole in the bowel near its mesenteric attach¬ ment. This being closed, it was found that a lit¬ tle further on the ball had again passed through the bowel, one opening being an inch in length, and the space between the openings very narrow. This was closed by folding in the peritoneal coat and making the cuff suture with a continuous stitch, trusting to adhesion of the serous surfaces and the sloughing away of the intervening portion. The last perforations were double ragged wounds extending to within % inch of the caecum. An¬ other injection of the gas proved all the open¬ ings, nine in number, closed. The bullet passed thence behind the caecum, bruising it as it passed, and entered the crest of the ileum }i inch be¬ neath its superior border. Either the twisted po¬ sition of the body when the shot was received had lifted up the colon, or it was congenitally higher than is supposed to be normal. During the operation the bowels were kept cov¬ ered with a warm solution of boracic acid, and the cavity was well sponged and washed with so¬ lutions of the acid and of bichloride of mercury. The external opening was closed, with a drainagetube at its lower angle, the suture dusted with iodoform, covered with a pad of absorbent cotton saturated with a 5 per cent, solution of boracic acid and kept in place by a broad flannel bandage.
doi:10.1001/jama.1888.02400670017001e fatcat:54zvemwa6bhsnfbabrhaw7dfwy