TWO CASES 
OF 
GUNSHOT WOUND OF THE ABDOMEN 
ILLUSTRATING THE USE OF 
RECTAL INSUFFLATION WITH HYDROGEN GAS 
AS A DIAGNOSTIC MEASURE. 
BY 
N. SENN, M.D., Ph. D., 
OF MILWAUKEE, WISCONSIN ; 
ATTENDING SURGEON TO THE MILWAUKEE HOSPITAL ; PROFESSOR OF 
PRINCIPLES OF SURGERY AND SURGICAL PATHOLOGY IN THE 
RUSH MEDICAL COLLEGE, CHICAGO. 
FROM 
THE MEDICAL NEWS, 
November io, 1888. [Reprinted from The Medical News, November 10, 1888.] 
TWO CASES OF GUNSHOT WOUND OF THE 
ABDOMEN, ILLUSTRATING THE USE OF 
RECTAL INSUFFLAT ION WITH HY- 
DROGEN GAS AS A DIAGNOSTIC 
MEASURE. 
By N. SENN, M.D., Ph.D., 
OF MILWAUKEE, WISCONSIN ; 
ATTENDING SURGEON TO THE MILWAUKEE HOSPITAL ; PROFESSOR OF 
PRINCIPLES OF SURGERY AND SURGICAL PATHOLOGY IN THE 
RUSH MEDICAL COLLEGE, CHICAGO. 
Case I.—J. J., sixteen years of age, was out hunt- 
ing with some companions on Sunday, September 
9, 1888, one of whom accidentally discharged his 
22-calibre rifle at a distance of about one hundred 
and fifty feet, the bullet striking the patient in the 
abdomen. The injury caused but little pain, and 
immediately after the accident the patient walked 
about forty yards to a farm-house, where he was 
placed in bed. From there he was conveyed on a 
cot, in a farmer’s wagon, to the Milwaukee Hospital, 
some six miles distant. The accident occurred 
about noon, and he arrived at the hospital at 3 p.m. 
Examination.—Boy complains of considerable 
pain in the abdomen; pulse 80 and soft; his gen- 
eral appearance indicates no serious injury. On 2 
SENN, 
undressing him, a bullet wound, with omentum 
protruding, was found two inches to the right of the 
middle line, and on a level with the anterior supe- 
rior spine of the ileum. Left iliac region dull on 
percussion; and in right, a cracked-pot sound was 
elicited on percussion. A rectal enema was admin- 
istered, and was followed by a free fecal discharge, 
without admixture of blood. (On washing the feces 
afterward the bullet was found.) 
Operation.—Ether, as an anaesthetic; thorough 
disinfection of abdominal wall; rectal insufflation of 
hydrogen gas, followed by the escape of bubbles of 
the gas, within a few seconds, at the wound of en- 
trance, into which had been placed a haemostatic 
forceps, the blades separated so as to render the 
canal patent. The gas was lighted, and after thor- 
ough cauterization of the wound by the flame, the 
flame was extinguished by the application of a wet 
sponge. 
Laparotomy by median incision, eight inches in 
length, from pubes upward. About a pint of fluid 
blood in the peritoneal cavity, and hemorrhage 
continuing from the mesenteric veins at two points 
of perforation on the mesenteric side of the bowel, 
and to a less extent from perforations of the mesen- 
tery; arrested by ligating en masse. Within a dis- 
tance of four feet, near the middle of the ileum, 
were found ten perforations, two of which were at 
the mesenteric border ; also four perforations of the 
mesentery. Another perforation of the bowel was 
found within four inches of the ileo-csecal valve on 
the convex side of the intestine, making so far eleven 
in all. All were closed by Czerny-Lembert sutures. 
At two points the perforations were so close together 
that it was found necessary to invert half the circum- GUNSHOT WOUND OF THE ABDOMEN. 
3 
ference of the bowel on the convex side, thus pro- 
ducing considerable narrowing of its lumen. 
Two hours had been consumed in arresting the 
hemorrhage and closing the eleven perforations, and 
the patient at this time had become pulseless, and 
yet it was deemed absolutely necessary to determine 
beyond all doubt if any more perforations existed 
by repeating the rectal insufflation of hydrogen gas. 
On repeating this test it was found that gas escaped 
freely from the pelvic cavity, without reaching the 
ileo-caecal region, showing that at least one more 
perforation was below this point. The sigmoid 
flexure was brought into the wound and compressed 
between the index finger and thumb. Insufflation 
was again followed by escape of gas, demonstrating 
that the perforation was below this point. Inch by 
inch the bowel was examined by this method in a 
downward direction, until a perforation was found 
in the anterior portion of the rectum at a point 
where the peritoneum covering its anterior wall is 
reflected upon the bladder. This perforation was 
rendered accessible to direct treatment by an as- 
sistant making traction on the colon and by keeping 
the margins of the wound well retracted by means 
of a pair of Hegar’s retractors. It was closed by 
five Lembert sutures, with the greatest difficulty, on 
account of its deep situation and inadequate light, 
which was furnished by two candles. 
From the perforations in the ileum there escaped 
pieces of green apples and intestinal contents, and 
from that in the rectum fluid feces. 
The peritoneal cavity was freely irrigated with a 
one-third per cent, solution of salicylic acid. After 
completion of peritoneal toilet, a glass drain was in- 
troduced in such a manner that the distal open end 4 
SENN, 
was placed opposite the sutured rectal wound, and 
the abdominal incision closed in the usual manner. 
Whiskey was freely administered hypodermatically 
during the operation and after its completion, as the 
patient remained pulseless for half an hour. 
Time of operation two and a half hours. 
The foot of the bed was elevated and dry heat 
applied to the extremities. 
io p. m. Temp. 99.50 F.; pulse rapid and weak. 
About one ounce of bloody serum withdrawn from 
glass drain. 
Sept, io, 8 a. m. Temp. 990 F.; pulse 126. Clear 
serum only in the drain; about one drachm with- 
drawn every three hours. During the day the pa- 
tient was slightly delirious, and in the absence of 
the nurse he got out of bed and walked across the 
ward to another bed. 
8 p. M. Temp. 99.8° F.; pulse 144. Some tym- 
panites. Ordered one drachm of turpentine in half 
a pint of warm water, as an enema, which was fol- 
lowed by free discharge of feces and flatus. 
nth. Temp, normal; pulse 104. Natural passage 
from bowels; delirium continues. 
12th. Temp, normal; pulse 96; delirium disap- 
peared. Allowed liquid food in small quantities. 
ijth. Pulse 72. The contents of the glass drain 
have a suspicious fecal odor. Glass replaced by 
rubber drain. Slight diarrhoea, which relieved the 
tympanites. 
14th. A fecal fistula has formed along the track 
of the drainage-tube. Large rubber tube intro- 
duced through the anus, and left in rectum to allow 
free escape of fluid feces. Fluid injected into fis- 
tula does not flow through the rectal tube. Rectum 
disinfected every four hours with saturated salicylic 
acid solution. GUNSHOT WOUND OF THE ABDOMEN. 
5 
9 a.m. Temp. ioi° F.; pulse 126. 
17th. Temp, normal; pulse 108. Free discharge 
of fluid feces from rectal tube and fistula. 
18th. Sutures removed from the abdominal inci- 
sion ; only deep parts united, granulating surfaces 
approximated by strips of adhesive plaster over an 
antiseptic compress. 
igth. Fluid flows freely from fistula through the 
rectal tube. No feces have escaped through fistula 
for twelve hours. 
20th. Rectal tube withdrawn, followed by return 
of fecal discharge through fistula. 
Oct. 1. The discharge of feces through the fistula 
has been gradually diminishing, and has now ceased. 
igth. Fistulous track completely closed. Ab- 
dominal incision all healed, except a small granu- 
lating surface at lower angle. 
Patient discharged cured, November 3d. 
Remarks.—The subjective symptoms in this case 
four hours after injury, and after transporting the 
patient a distance of six miles, furnished no indica- 
tions whatever of the extent of visceral injury which 
was found on exploring the abdominal cavity. The 
rectal insufflation of hydrogen gas at once rendered 
the diagnosis positive, and pointed out the necessity 
of treatment by abdominal section. Eleven perfora- 
tions were found and sutured without much difficulty, 
but the last perforation in the deepest portion of 
the pelvis could not have been found by any other 
means of diagnosis short of rectal insufflation. Had 
this perforation been overlooked death from septic 
peritonitis would have been inevitable. Drainage 
was resorted to in this case, not only from the fact 6 
SENN, 
that fecal extravasation had taken place, but also for 
the reason that owing to the difficulty in gaining 
access to the rectal wound I feared that the suturing 
was not as perfect as it should be, and by proper 
drainage I wished to prevent possible extravasation 
into the peritoneal cavity from this cause. Subse- 
quent events showed the propriety of this pre- 
caution. 
Case II.—J. E. (case of Drs. Gudden, Steele, 
and Gordon, of Oshkosh), eighteen years of age, 
was out target-shooting with a companion, who, 
while raising his 22-calibre rifle to his shoulder, acci- 
dentally discharged it; the bullet struck the patient 
in the abdomen. He was about forty feet distant, 
and almost directly facing his companion. When 
first seen by Dr. Gudden, within half an hour after 
the injury was received, he was suffering severe pain 
in the abdomen, was pale, covered with cold, 
clammy perspiration, and vomited frequently. He 
was placed in a carriage and conveyed to his home, 
a distance of two miles. During the journey, the 
severity of the abdominal pain was so increased by 
the motions of the carriage as to necessitate re- 
peated stops. 
I saw the patient, with the above-named physi- 
cians, October 9th, 4 a.m., twelve hours after the 
accident. 
Examination.—The wound of entrance was found 
to be at the outer margin of the left rectus about 
one inch below the level of the umbilicus. Abdo- 
men dull on percussion in left iliac region, pulse 
140, temperature ioo° F. Penetration of the ab- 
domen was proved by the introduction of a grooved 
director, which was left in place during the insuffla- 
tion of the hydrogen gas. GUNSHOT WOUND OF THE ABDOMEN. 
The patient was placed under the influence of 
chloroform, and during the operation the narcosis 
was maintained with ether. The abdomen was 
thoroughly disinfected, and rectal insufflation of 
hydrogen gas practised to ascertain if any perfora- 
tion of the intestine existed. Under a pressure of 
about a half a pound to the square inch, and the use 
of one-quarter of a gallon of gas, in a few minutes 
the gas escaped along the groove of the director, 
and, on applying a match, lighted as it escaped. 
The flame was now extinguished by a moist sponge, 
and the abdomen opened by a median incision, five 
inches in length, extending from the umbilicus to 
near the pubes. 
On exposing the peritoneum at the lower angle of 
the incision, through this membrane there was ob- 
served a structure closely resembling an over dis- 
tended bladder. That this structure was a distended 
bladder was improbable as the boy had urinated be- 
fore the anaesthetic was administered. The perito- 
neum was carefully incised between two forceps and 
divided upon a grooved director to the same extent 
as the external incision, and it was then discovered 
that what appeared to be an over-distended bladder 
was a coil of small intestine distended with blood to 
twice its normal size. The whole pelvic cavity was 
found filled with fluid blood. On withdrawing the 
small intestine, five perforations near the junction 
of jejunum and ileum, and within a distance of three 
feet, were found; four occurred in pairs on the 
lateral aspect of the bowel, and one at the mesen- 
teric attachment. All the perforations were dispro- 
portionately large to the size of the bullet and would 
easily admit the tip of the index-finger. The intes- 
tine, at the point of injury, was covered with a thick 
layer of recent plastic lymph, and the parietal peri- 8 
S E N N, 
toneum presented all the evidences of a beginning 
diffuse septic peritonitis. The intestine, which was 
over-distended by blood-clots for about three feet, 
was emptied and irrigated with a one-third per 
cent, solution of salicylic acid, which was used 
for constant irrigation during the entire time re- 
quired in suturing the perforations, which were 
closed by Czerny-Lembert sutures. 
Further examination disclosed four perforations of 
the mesentery, from two of which quite profuse 
venous hemorrhage was still going on. The hemor- 
rhage was arrested by ligature en masse, by passing 
a needle, threaded with fine silk, through the entire 
thickness of the mesentery, on either side of the 
perforations. 
Rectal insufflation of hydrogen gas was repeated 
so as to ascertain if any other perforations existed, 
and the gas after it had been gently forced beyond 
the highest perforation was made to traverse the 
balance of the entire intestinal canal by drawing 
forward loops of the intestine and returning them 
as examined without further insufflation. This pro- 
cedure was found entirely satisfactory and practical, 
as the gas on account of its low specific gravity 
readily entered the highest point in the prolapsed 
intestinal loop. 
The abdominal cavity was irrigated with salicylic 
acid solution, numerous coagula removed, the toilet 
completed, a glass drain introduced into the pelvis, 
and the abdomen closed. 
Duration of operation two hours. Patient col- 
lapsed, pupils greatly dilated, and almost pulseless 
in spite of repeated hypodermatic injections of 
brandy, which were administered when signs of col- 
lapse became apparent, throughout the operation. 
Enema of a teacupful of warm water and two GUNSHOT WOUND OF THE ABDOMEN. 
9 
ounces of brandy. Foot of bed elevated and ex- 
ternal dry heat applied. 
In an hour and a half he rallied somewhat from 
the operation, but again sank and died at 3 p.m., 
eight hours after the completion of the operation. 
Post-mortem eighteen hours after death (Drs. 
Steele, Gudden, Gordon). Circumscribed peri- 
tonitis present at time of operating, now diffuse; 
very little fluid in abdominal cavity; several small 
blood-clots in vicinity of transverse colon. The per- 
forations were all securely closed, and the bullet was 
found in the soft tissues to the right of the spinal 
column, between the fourth and fifth lumbar verte- 
brae, and near the ascending colon. The bullet 
though only of 22-calibre was oblong and may thus 
explain the unusually large size of the perforations. 
Remarks.—This case compared with the forego- 
ing furnishes a strong argument in favor of early- 
operative interference in cases of gunshot or stab 
wounds of the abdomen in which the existence of 
visceral lesions can be demonstrated by rectal in- 
sufflation of hydrogen gas. In the first case, al- 
though twelve perforations were found and sutured, 
and fecal extravasation had taken place, no evi- 
dences of peritonitis were found, and the patient 
recovered. In this case twelve hours intervened 
between the time the injury was received and the 
treatment by laparotomy, during which time a 
septic peritonitis had developed, the extension of 
which the operation did not arrest, and from the 
effects of which the patient died. THE MEDICAL NEWS. 
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