Reprint from Annxls of Surgery, November, 1887. 
A REVIEW OF SOME FACTS CONNECTED WITH 
GUNSHOT WOUNDS OF THE ABDOMEN, 
AND PRACTICAL DEDUCTIONS 
THEREFROM.1 
By CHARLES T. PARKES, M. D., 
OF CHICAGO. 
PROFESSOR OF ANATOMY IN RUSH MEDICAL COLLEGE. 
THE object of this contribution to the subject of gunshot 
wounds of the abdomen is to pass in review such facts 
as are at our disposal in its consideration, to make such de- 
ductions from these as their limited number will afford, and to 
offer some suggestions based on personal experience. 
Probably no question submitted to the consideration of 
surgeons has ever arrested the attention of the profession more 
promptly than the general question of surgical interference 
in penetrating gunshot wounds of the abdominal cavity, and 
it is at once remarkable, and to the honor of the profession, 
that the obvious deductions have been as promptly applied. 
Up to 1885 the whole number of recorded operations for 
gunshot wounds of the abdomen that I have been able to find 
is six ; by this is meant cases in which the surgeon has de- 
liberately sought out the wounded intestines, and repaired the 
damage inflicted, in accordance with surgical principles. 
Surely, a small number in view of the wars which have gone 
by, contributing and bringing under the surgeon's care, great 
numbers of these injuries under consideration, and the many 
individuals shot through the abdomen in brawls of civil life, 
also placed under medical supervision. 
Up to 1885 the profession had not looked the real question 
square in the face; surgeons held uncertain opinions, with the 
JRead before the Surgical Section of the Ninth International Congress, Septem- 
ber 5, 1887. 2 
CHARLES T. PARKES. 
large majority opposed to any interference whatever, and, as 
might be expected under such complicating conditions, the re- 
sults were not brilliant. Operations previous to three years 
ago were the exception. The magnitude and importance of 
the subject seemed not to be realized. 
Now, I would venture the assertion that there are few mod- 
ern surgeons who, confronted with a bullet wound of the 
abdominal walls and not able to convince themselves that the 
ball had not effected a penetration, but would explore the 
cavity. 
When in the winter of 1884 I reflected on the necessity of 
systematically and experimentally studying this subject, I did 
not anticipate that in so short a time such radical change 
would take place in the method of treating such cases, which, 
previously had been relegated to cure by opium, rest and 
hopes in Providence. 
The results of my observations were published in the Jour- 
nal of the American Medical Association, in 1885 ; they were 
the observations and outgrowing deductions from a series of 
experiments systematically carried out during the previous 
winter for the purpose of throwing light upon the pathology 
and treatment of these injuries, and of recording the clinical 
facets attending shot wounds of these organs. 
Since the publication of my address to the American Medi- 
cal Association in 1885, thirty-six cases of operative inter- 
ference in gunshot wounds of the abdomen have been 
recorded, with nine recoveries following opening the abdomen, 
suturing the wounded intestines and treating other complicat- 
ing injuries. 
Sir William MacCormac in the Annual Oration delivered 
by him May 2, 1887, before the Medical Society of London, 
has collected from all sources thirty cases. To these must 
be added one case reported by Prof. McGraw, of Detroit, of 
double perforation of the ascending colon, exposed by enlarg- 
ing the surface wound, and suturing the intestinal perfora- 
tions; recovery following. Another, by Dr. J. B. Murphy, of 
Chicago, of shot wound of the liver, in which the abdomen 
was opened, blood clots removed, and the wounds sutured; re- 
covery following. Also a death, reported by Dr. J. B. Mur- GUNSHOT WOUNDS OF THE ABDOMEN. 
3 
phy, from post peritoneal hemorrhage; post-mortem showing 
the intestinal wounds to have been safely sutured. One other 
case of recovery is reported by Dr. J. J. Skelly, of Potomac, 
Ill., and two fatal cases coming under my own care, to which 
further reference will be made in this paper; in all thirty-six 
cases, with nine recoveries. 
A reference to the extended reports of these cases, or4to 
the tables of Sir William MacCormac, shows plainly that there 
has been no selection of favorable conditions; that the opera- 
tions have been done under a great diversity of surroundings, 
without special assistants, and in many cases with injuries the 
fatality of which it seemed impossible to overcome. 
These results furnish the greatest encouragement for further 
trials in saving the lives of persons so certainly condemned to 
death, unless relieved by operation, when suffering from the 
wounds under consideration. 
Every case, whether of recovery or death, following opera- 
tion should be published in full, so that our experience may be 
increased, the nature and character of these wounds better 
understood, and definite rules of procedure elucidated. We 
might in this way be able to set aside those cases, which from 
the special character of the wounds will necessarily prove 
fatal. With our present limited knowledge of reliable symp- 
toms, all is uncertain with an unopened abdomen. Gradually 
we may be able to positively recognize these cases which pos- 
sess "a faint hope of relief" to be followed by a good per- 
centage of recoveries after operation. Where to draw the 
line, and what to do, when operation is decided upon, and how 
best to carry out the necessary manipulations, are the ques- 
tions which the future must settle. 
Judging from the valuable papers of Drs. Bull, Dennis and 
Bryant of New York City, Dr. Tremaine of Buffalo, Dr. Nan- 
crede of Philadelphia, Dr. Senn of Milwaukee, Dr. Marcy of 
Boston, Genl. Hamilton of Washington, Sir William MacCor- 
mac and others, and from the expression of opinion, published 
as coming from the surgeons present at the last meeting of the 
American Surgical Association, it is certainly just to claim, 
that the belief that surgical interference in proper cases is the 
accepted course to pursue is rapidly being adopted by the pro- 
fession at large. 4 
CHARLES T. PARKES. 
To me this is a great victory gained. The method of pro- 
cedure has been tried; and notwithstanding the crudest of 
data to build upon-the deficiencies in practical experience 
in man; with propositions already made not thoroughly tested, 
or perhaps only superficially studied, with the dimmest of light 
for a guide, the results have been remarkably good. 
What interferences are justifiable from an external gunshot 
wound of the abdominal walls? 
A single wound of the abdominal walls, in so far as it affords 
any inference at all, from its being single, furnishes a hope 
that no penetration of the peritoneal cavity has taken place, 
but it is merely a hope. 
The resistance of the walls and viscera, though con- 
siderable in every case, varies greatly. Consequently, 
a bullet, although not having momentum enough to 
make an exit, may have force enough to do much 
damage among the viscera. Or its momentum may be so 
slight, and its direction so oblique, as to cause it to remain be- 
tween the planes of the abdominal walls. Even the existence 
of an entrance and exit wound widely separated is not always 
a proof of injury to the viscera. Observations have shown, 
both on man and the lower animals, that a bullet may enter 
the abdominal walls at one point and reappear at another, at a 
considerable distance from the first, and yet not enter the ab- 
dominal cavity. If penetration be present with only a wound 
of entrance, it suggests that the firearm used might have pos- 
sessed moderate penetrating force, that the velocity of the 
bullet may not have been extreme, and that the damage done 
by it is very likely amenable to treatment, with fair prospects 
of relief. 
If there exists a continuous track of tenderness, especially 
if accompanied with slight redness, from the wound of en- 
trance for some distance over the abdominal surface, it is fair 
to infer that the missile has wormed itself between the layers 
of the abdominal walls, and that penetration does not exist. 
This was plainly shown in a case seen in 1886, and reported by 
myself in a paper read in New York that year. 
The peculiar appearance presented by the edges of the 
wound, and its size, when carefully studied, will furnish pretty 
reliable information of the size of the bullet, and its direction GUNSHOT WOUNDS OF 7HE ABDOMEN. 
5 
of impact, both items of considerable importance in estimating 
the; possible damage. 
Bullets from firearms of large calibre are the most destruct- 
ive to the opposing tissues, and have the maximum penetrating 
force. A large bullet hole argues a large bullet, certainty of 
penetration, and large destruction of tissues and organs. 
Powder marks on the clothing or body prove a close body 
shot, and hence greater probability of complete penetration 
of the abdominal cavity, with wounds to the viscera; and this 
is true, no matter what may be the calibre of the firearm used. 
If the edges of the skin perforation are equally stained 
throughout and clean cut, the fact suggests that the bullet 
struck perpendicularly to the surface upon which the wound is 
found. Again, if these edges are unequally stained, if un- 
equally ragged, or if the surrounding surface shows a stain, or 
abrasion, or discoloration leading to some portion of the edge 
of the perforation, all these facts suggest valuable informa- 
tion as to the probable course of the missile in its transit 
through the abdomen, and the conclusion is justifiable that the 
impact was not perpendicular to the surface, and, of course, in 
proportion as the course of impact departs from the perpen- 
dicular, the greater is (the probability that penetration of the 
cavity has not occurred. 
Naturally, one of the most important items of estimation is 
to determine the probable course of the injuring body. To 
this end information as definite as possible must be obtained 
as to the direction in which the shot came, and the distance 
from which it was fired ; both facts having great bearing on the 
organs wounded, and the damage done them. It is no easy 
matter even with very complete data to guide one, to feel cer- 
tain as to the direction of the missile inside the cavity, when 
there is only one wound. A great many cases will furnish no 
corroborative information ; the surgeon will be compelled to 
depend upon the signs belonging to the wound itself. 
If in doubt as to penetration, the wound should be enlarged 
by an incision directly through the skin perforation in some 
chosen direction. By carefully following the track of discol- 
oration left in the tissues by the bullet, not only the fact of 
penetration or non-penetration will be positively determined, 6 
CHARLES T. PARKES. 
but its directness or obliquity through the abdominal walls, 
will furnish positive information as to the course of transit of 
the entering body. With the usual precautions this incision 
will not increase the patient's danger, even if central section 
becomes necessary; It throws valuable light upon subsequent 
requirements, makes clear the fact of penetration, or non-pen- 
etration, and, in some situations, may enable the operator to 
repair all the damage done. 
The presence of a wound of entrance and exit, produced by 
the firearms and missiles of the present day, especially if the 
shot is delivered in close proximity to the body, with scarcely 
an exception possible, indicates injury to all the fixed organs 
lying in the estimated line drawn between the two external 
wounds made by the missile. Moreover, it is highly probable 
that the small intestines are also damaged, although these lat- 
ter wounds may be found some distance away from the line of 
the ball, their changed position being dependent upon the ex- 
treme mobility of the viscera at the time of the receipt of the 
wound, and from the movements of the body subsequent to 
the passage of the bullet or other causes. 
The great majority of double wounds tell positively of com- 
plete and direct perforation and damage, more or less severe, 
to every organ in their path , there seems scarcely any proba- 
bility of deviation from their course, caused by the resistance 
of the soft tissues of the body. 
Whether wounds in organs (as contended by Prof. McGraw), 
found some distance away from the line of transit of a bullet, 
are to be explained by the elasticity and mobility of the tis- 
sues, their constant change of form by inherent contraction, 
enabling them to get in or out of the way, or by subsequent 
change induced by weight of the bullet or movements of the 
body ; or, as contended by myself, are sometimes dependent 
upon an erratic course of the latter, from deviations in its line 
of flight, caused by deflections therefrom, through imping- 
ment on tissues of different powers of resistance or elasticity, 
is a matter that must be settled by an appeal to physical laws 
through experimentation; it will never be settled by assertions 
or assumptions. I am fully convinced that the time does come 
in the "life " of a flying bullet when its velocity and power of GUNSHOT WOUNDS OF THE ABDOMEN. ' 
7 
penetration bear such a relation to the power of resistance of 
the different tissues in the abdominal walls and contents, that 
the softest of these, touched in a certain way, will deflect its 
course. In no other way than through this supposition have I 
been able to explain the character and kind of damage I have 
seen done by a bullet in its transit through the body. 
My conclusions and deductions, on the course of a bullet, 
are based mainly upon the results of experimentation, during 
which the animal was profoundly anesthetized, and conse- 
quently muscular contraction and activity abolished. If the 
ball deviated at all from a straight line, there was nothing else 
to cause the deviations but the soft tissues in its track. 
The situation of the wounds will, of course, call attention to 
the likelihood of damage inflicted upon the organs, in the 
probable course of the bullet. The severity of the injury and 
gravity of prognosis is surely greatly enhanced if the movable 
viscera are wounded. It is much less if only fixed organs are 
hit. In both the absolutely necessary manipulations by the 
surgeon, required for the repair thereof, will be suggested, and 
due preparation to meet all indications can be provided for. 
There is no opportunity to hunt up necessary appliances after 
the operation is begun. 
An antero-posterior shot below the level of the umbilicus 
and well toward the lateral surfaces of the body, will be very 
likely to miss the small intestines entirely and expend its 
damage on the large bowel, as in Prof. McGraw's case. The 
same kind of wound high on the lateral surfaces may pass into 
or through the liver, without injuring the intestines, or the 
spleen alone if the entrance is on the left side. 
If the wound is so situated that the bullet enters the abdo- 
men through the diaphragm, adding injury of abdominal vis- 
cera to that of the contents of the chest, the surgeon's help 
will probably be of little use. 
A wound of entrance and exit, or an entrance wound alone 
showing perforation of the ball from side to side through the 
cavity, means the worst of injuries, and suggests the need of 
the greatest care in staying of hemorrhage, repair of intestines 
and toilet of the contents. 
Antero-posterior perforation, if complete, can only fail to 8 
CHARLES T. PARKES. 
wound the small intestines when situated well on the outskirts 
of the surface of the abdomen ; seemingly, there can be no ex- 
ception to this proposition, save in those extremely rare in- 
stances, in which the perforating body traverses the cavity 
without injuring the contents. 
Penetration through the posterior walls of the cavity, if com- 
plete, with likelihood of laceration of important fixed organs, 
argues an injury of the most severe character, one in which the 
surgeon's art will be of no avail in the majority of instances. 
The exceptions, in which the severity will not prove unsur- 
mountable, will be transit through the space between the lower 
end of the kidney and the crest of the ilium, and in wounds 
occupying the outskirts of the entire posterior surface. If the 
penetration be incomplete, as can, in the majority of instances, 
be determined by enlarging the bullet wound, the injuries are 
by no means necessarily fatal, and do not require any other 
surgical interference than enlargement of the wound and 
proper dressing. Many instances are recorded of recovery 
from posterior penetration of the large and fixed viscera of the 
abdomen, without any surgical operation whatever. 
What collateral evidence influences the formation of a diag- 
nosis ? 
The peculiarities of the individual injured constitute so im- 
portant an element in the development of collateral manifesta- 
tions, that all such testimony should be subjected to the most 
rigorous search, in fact much value cannot be attached to sub- 
jective manifestations. It is not necessary to state to you that 
one person may be prostrated and literally frightened to death 
by the sound of a firearm, or the "swish" of a bullet, while an- 
other will continue his course or perform his usual duties after 
he has been injured, and can only with difficulty be persuaded 
that he has been shot. Between these two extremes all gra- 
dations present themselves. 
There are other phenomena, independent of personal pecu- 
liarities, which contribute to the formation of the surgeon's 
opinion. Among these may be mentioned: tympanitic reson- 
ance, unusual dulness on percussion, the presence of faecal 
matter, or any of the normal secretions or contents of the dif- 
ferent viscera in any of the external blood in the GUNSHOT WOUNDS OF THE ABDOMEN. 
9 
stools or urine, or egesta from the stomach, paralysis of any 
kind, persistent nausea and vomiting, and the general condi- 
tion designated shock. 
Allow me to briefly refer to the probable significance of 
these symptoms when present. 
Unusual and rapidly forming tympanites would suggest the 
escape of the intestinal gases into the peritoneal cavity through 
a perforation, and, if found in a region of normal dulness, as 
in the liver region, it is considered good corroborative testi- 
mony in favor of intestinal rupture, by some authorities. 
Circumscribed dulness on percussion, with localized bulging 
in the abdomen in the neighborhood of the wounds, or in the 
most dependent region of the cavity, argues the possible pres- 
ence of blood accumulation from wound of a large vessel, and 
consequent penetration of the abdomen. 
The rare but possible phenomenon of faecal matter appear- 
ing in the external wounds renders the demonstration of per- 
foration of the alimentary canal absolute. That such extru- 
sion does occur as an early symptom after wounds made by 
large bullets finds illustration in the case to be reported by 
myself in this paper. 
The presence of blood in the urine, in connection with the 
situation of the external opening, demonstrates wound of the 
kidney, ureter or bladder; the two former adding greatly to 
the gravity of the prognosis, and certainly in so far as its pres- 
ence influences opinion at all, such condition would favor the 
necessity for operative procedure. 
Paralysis of any part of the body, below the level of wounds 
in the abdomen, necessarily complicates matters very much, 
rendering it very probable that the ball has not only injured 
the viscera in its course, but has also done irreparable damage 
to the spinal cord or important nerves. 
" Shock " cannot be relied on as a positive indication of the 
presence or absence of perforation of the viscera. Cases with 
many perforations have presented no evidence of shock what- 
ever. Its presence is rather an indication of some special ner- 
vous condition of the patient, of some injury to nervous struc- 
ture, or, perhaps, more often than any other condition, it indi- 
cates the laceration of some large blood vessel with free bleed- 10 
CHARLES T. PARKES. 
ing, the last a condition of itself requiring abdominal section 
for its relief quite as surely as the rupture of the sac of tubal 
pregnancy, and proving quite as fatal if the operation is not 
done. 
It is to me a source of disappointment to be compelled to 
put the presence of " shock " among the doubtful signs of per- 
foration, for I was at one time fully convinced that its presence 
surely meant bowel wound, and I am still of the belief that 
when present, the probability of such injury is very great. 
Absence of pulsation in either of the femoral arteries will 
call attention to injury of the iliac vessels, and as well, when 
present, gives a second point with which to estimate the course 
of the bullet. 
In three cases of penetrating wounds seen by me, all had 
persistent nausea and vomiting present. Other reported cases 
have shown similar symptoms. It is also a common symptom 
with ruptured intestine from other causes: hence I deem it 
proper to claim that its import as a symptom be borne in 
mind. 
What symptoms make it probable that the issue in any case 
will be fatal, whether operated upon or not? 
It seems quite proper to say that the majority of cases of 
through and through perforations of the abdominal cavity, 
with injury to both fixed and movable viscera and blood ves- 
sels, will prove fatal in spite of the best efforts to save them. 
Still, it would not take much time or thought to bring to mind 
instances of individual experience, or cases of record, in which 
the injuries done to abdominal viscera, and the shock inciden- 
tal to a prolonged operation performed in recognized proce- 
dures for the relief of abdominal tumor, has been quite as se- 
vere as could be produced by a bullet in transit through the 
cavity, and yet the patient has survived. So it becomes a dif- 
ficult matter to decide when to decline operative interference. 
Cases of recovery have followed surgical care of the wounds 
when many perforations of the intestines1 were found, and in 
which solid viscera2 have been traversed by the bullet; many 
'Hamilton, Bull. 
2 Murphy. GUNSHOT WOUNDS OF THE ABDOMEN. 
11 
cases have perished in which, after death, examination showed 
the simplest injury to repair, and indicated the probability of 
speedy recovery had the abdomen been opened at once and 
the wounds treated. One is almost tempted to say that all 
cases are entitled to the chance of life offered through opera- 
tive procedure. It is hazardous to predict a fatal issue. How- 
ever, if the abdominal wound is complicated with a severe in- 
jury of the spinal cord, or bad wound of the solid viscera, or so 
great a time has elapsed as to allow of extensive extravasation 
and infiltration, with consequent virulent inflammation, the 
probability is that the issue will be fatal. 
In application I will present the following cases : 
Mr. J. F., shot himself in two places in rapid succession with a 32- 
calibre revolver. I saw him four hours after the injury was produced, 
and found two bullet wounds, four inches to the left of the median line 
on the same line with each other and one and one-half inches apart; 
the lower wound was even with the umbilicus. One bullet had gone 
through the body; its exit posteriorly was just below the last rib and 
close to the outer edge of the erector muscle. There had been and 
still was considerable hemorrhage going on from the posterior wound. 
He had eaten a hearty dinner just previous to the shooting. The pa- 
tient was moderately collapsed, pulse very fast and countenance pale. 
By the time he was anaesthetized and necessary preparations were 
made, darkness had come on, and the operation was done with the 
light from a single gas jet. 
The two bullet wounds were joined by an incision and the fact of 
penetration demonstrated. An opening was then made in the median 
line four inches long through the abdominal walls. Considerable blood 
was found in the peritoneal cavity. This was removed and the 
wounded intestines sought for. These were easily found and the per- 
forations quickly closed with a straight needle, carrying No. 1 silk 
thread. Five perforations were found and secured. On examining 
the posterior peritoneal surface a bullet perforation was found in it 
directly over the body of the left kidney. On passing the finger 
through it the kidney was found to be perforated by the bullet. The 
hemorrhage from the wound was at this time very slight. During this 
period operative procedures had to be discontinued several times to 
prevent the patient from choking during his attempts to evacuate the 
stomach, as he was vomiting large masses of meat and other food- 
The kidney was not removed. The wounds were closed, dressed anti- 12 
CHARLES T. PARKES. 
septically and the patient put to bed. He rallied fairly well in a few 
hours and seemed to progress nicely for twenty-four hours, when he 
began rather suddenly to fail rapidly and died in collapse. There had 
been considerable bleeding from the posterior wound, and the patient 
died from hemorrhage from the wound in the kidney. It is to be re- 
gretted that the organ was not removed. The other wounds were 
comparatively simple in character and easily secured. There was but 
slight extravasation and the cavity was left quite clean. 
P. J., aged 45 years; was shot while walking in the street on the 
night of July 4th. He was seen by me at the Presbyterian Hospital 
sixteen hours alter the injury was inflicted. I found a large-sized bul- 
let wound in the right iliac region, slightly below and two inches inside 
of the right anterior superior spine. The surface had been rendered 
aseptic and the patient anesthetized before I examined him. L'he 
edges of the wound were more ragged and more deeply discolored on 
the outer and upper portion, showing that the missile struck obliquely 
to the surface of the abdomen and that its direction was from the right 
and above. Considerable faecal matter was found in the wound. The 
man held his right thigh semi-flexed even when fairly anaesthetized. 
The right half of the abdomen, the upper portion of the thigh and but- 
tock was fiery red in color, the margin of the erythematous blush being 
well marked. The respiration was entirely thoracic, the abdominal 
walls hard and motionless. An incision was at once made in the mid- 
line after emptying the bladder ol a pint of urine. As soon as the 
peritoneum was opened large quantities of a stinking ichorous serum 
poured out, bringing with it fecal matter and small pieces of potato 
undigested. This material was washed away by a free flow of mild 
boric acid solution. The wounded intestine was then sought, and after 
drawing out about six inches of badly inflamed tube, it was reached. 
It was a large perforation of the small intestine, but was secured by 
the continuous suture, without difficulty. All the folds of the bowel 
in the iliac fossa and pelvis were examined, but no other openings were 
found. A question of perforation of the bladder was raised, but a 
thorough examination with finger failed to find any. To further prove 
the uninjured condition of the bladder, it was distended with warm 
milk, but no leakage was noticed and the milk was allowed to flow 
away through the catheter. The external bullet wound was enlarged 
and its track followed by the finger. The missile barely entered the 
abdominal cavity at the fold between the abdominal walls and iliac 
fossa, and just outside of the femoral vessels, and was then lost in sott 
parts of the thigh on posterior surfaces. It evidently gouged out the 
convexity of the knuckle of intestine lying in its course. GUNSHOT WOUNDS OF THE ABDOMEN. 
13 
After thorough cleansing, the wounds were all closed and drainage 
left in the abdominal cavity. It was now noticed that the patient had 
abdominal respiration and straightened his right leg. The operation 
was done in the presence of Profs. Gunn, Etheridge and Merriman and 
Drs. Talbott, Mellish, Ward and others. All expressed their belief 
that no other incision than that through the midline would have 
enabled the surgeon to as easily and positively repair the injury and 
cleanse the cavity. The man died sixteen hours after the operation. 
With such extensive extravasation and virulent peritonitis as was 
found, no other result could be anticipated. With an early operation 
I believe the recovery would have been prompt in a case with so sim- 
ple a wound and the absence of any complication. The case cer- 
tainly points to the necessity of prompt relief in these injuries. The 
post-mortem confirmed all the facts ascertained during the operation, 
and I have present a section of the bowel showing the wound and the 
condition of the suture used to close it. 
One can fairly believe that the abdominal incision adds but 
little to the patient's danger, and if there be any, it is quite off- 
set by the benefits accruing from a perfect knowledge of the 
wounded person's true condition, as is exemplified in the fol- 
• lowing case : 
Dr. John I. Skelly of Potomac, Ill., reports, in the July num- 
ber of the Annals of Surgery, a case of penetrating shot 
wound of the abdomen. The cavity was opened by median sec- 
tion, no injury to the intestines was found, the bleeding was con- 
trolled, the peritoneal wounds sutured and the patient recov- 
ered. The injury was done by a bullet from a 32 calibre 
revolver. Great shock was present in this case although no 
important viscera were wounded. Dr. Skelly refers especially 
to the great confidence in recovery, expressed by the patient, 
when assured that the intestines were not injured. 
What technical measures are best in the treatment of bullet 
wounds of the intestines, mesentery, stomach, kidney, spleen, 
liver and bladder ? 
It is yet my firm conviction that in the great majority of 
cases the incision in the midline, will allow the most room for 
all the manipulations absolutely necessary on the surgeon's 14 
CHARLES T. PARKES. 
part, and yet be conducive of rapidity of action. It will furnish 
the surest way of following the course of the bullet, and thereby 
enhance the certainty of securing all injured viscera in all cases 
of through and through perforation especially if the course of 
the ball is transvere, oblique or median. It will furnish the 
best way of reaching all parts of the cavity through which to 
insure perfect toilet of the peritoneum. Prof. McGraw's case 
shows there may be exceptions to what it seems should be the 
general rule. Here, as elsewhere, each case has its own indi- 
cations and must be managed according to them. 
It seems proper for me to refer to a few conditions found in 
the wound of the intestine itself dependent upon the character 
of the ball producing it, previous to passing in review the 
means to be adopted for its closure. 
The character of the wound in the bowel depends greatly 
upon the size and shape of the bullet producing it, and much 
also upon the velocity of the missile. Round bullets moving 
rapidly make a clean cut, rather small wound with the mini- 
mum amount of bruising, so that they are comparatively easy 
to close. Rapidly moving conical bullets do much more dam- 
age than the round, still even with these, the great velocity 
makes the injury less severe than might be expected from such 
terribly destructive agents. The extent of bruising is greater, 
the edges of the perforation are more ragged, still if they strike 
the tube fairly in the lateral surface many such wounds can be 
safely managed without resection. The greatest amount of 
damage, in my experience, is done by the rather slowly mov- 
ing missile be it either round or conical; these tear, mash and 
lacerate the tissues instead of making a clean punch, like the 
swift ones. 
However made, the large proportion of perforations in the 
bowel will be well secured, and quite rapidly, by means of the 
continuous stitch, applied so as to invert the edges of the 
wound towards the lumen of the tube, by entering the needle, 
a safe distance, away from the margin of the wound and sew- 
ing over and over until all of it is covered with the opposite 
surfaces of the peritoneum held together by the stitches. 
As the result of experimental research the following state- GUNSHOT WOUNDS OF THE ABDOMEN. 
15 
ment was made by myself in 1885 in an address before the 
American Medical Association, written on this subject, "This 
way (that is the use of the continuous suture) of treating the 
bullet openings in the bowel is susceptible of much wider ap- 
plication than would appear possible at first glance. I am 
quite well satisfied that it will take the place of excision in not 
a few cases of quite severe injury. The torn edges of the wound 
can be turned in, and peritoneal surfaces fastened together, 
even in large wounds, with perfect confidence in the result of 
safe and secure adhesion following." 
This statement has been borne out absolutely in my own 
experience since then in the human being, and I believe it is 
the experience of all other operators. In no instance in any 
of the reported cases submitted to surgical treatment, since 
then, do I remember that the operator has been called upon to 
make a section of the bowel. All seem to have trusted to the 
continuous suture over the inverted wound. The recoveries 
are a positive evidence of its success and none of the fatal 
cases show a failure to secure the bowel wound by its use. It 
apparently makes no difference whether the wound in the 
bowel is closed parallel to the course of the tube, or trans- 
versely or obliquely. The result is the same, provided the 
stitches are securely taken. Of course the most easy and most 
rapid method of procedure is the best to be adopted and of 
this the operator must be the judge. 
With a through and through penetration of the cavity, we 
may expect to find clean perforations and the openings of min- 
imum size in the intestine; with a single entrance wound, argu- 
ing diminished velocity of the bullet, the tube openings will 
be very likely ragged, bruised and difficult to repair without 
sacrifice of intestine. 
If the perforations found in the bowel are situated fairly 
away from the mesenteric surface, little difficulty will be found 
in carrying out the manipulations necessary for their closure. 
Still in cases in which many perforations of the tube are close 
together, the intervening portions between the wounds, have 
their vitality so greatly impaired by contusion, that complete 
••esection of the implicated portion of intestine will be required. 16 
CHARLES T. PARKES. 
When the ball opening is directly at the mesenteric junction 
repeated instances of imperfect union followed by extravasa- 
tion have occurred to me in experimentation. This kind of 
injury requires exceptional care in the application of the su- 
tures, so that they include something more than the peritoneal 
covering, and do not include the larger blood vessels entering 
the coats in this position. 
When the injury is so extensive as to positively require re- 
section of the wounded portion, my experience from experi- 
mental inquiry, was positively in favor of two methods of 
procedure. 1st, cases in which the mesenteric border could 
not be saved, were most successfully treated, by making the 
section in healthy bowel tissue, and removing the injured por- 
tion with a triangular piece of the mesentery, the base of the 
triangle representing the length of intestines, removed. The 
first sutures are best introduced at the mesenteric border of 
the divided ends of the intestines, because this plan furnishes 
more room, in which to make sure of the engagement of suffi- 
cient tissue in the loop of the suture, to make a fast and secure 
hold, than there would be if the other portions of the circum- 
ference were united before reaching this border. Failure to 
get good union, and to avoid extravasation, followed in every 
case in which this plan was not adopted. 
Neither in man nor animal, have I found it necessary to in- 
troduce more than one row of sutures, either in the repair of 
single perforations, or in complete resections, provided the 
hold of the suture included about one-third of an inch of peri- 
toneum with underlying muscular coat, and the sutures were 
placed about one-eighth of an inch apart. 
In no instance, in my experience, except when drawn too 
tightly, have the sutures failed to perfectly close the opening 
so that at the end of twelve hours sufficient plastic adhesion 
had taken place to resist powerful hydrostatic pressure, and, 
that too, in cases in which there were thirteen perforations in 
eighteen inches of intestine. 
That method which safely accomplishes the object of surgi- 
cal interference, in the quickest possible time, and with the 
least possible disturbance of the viscera locally, or in general, 
is the best to adopt; saving of time alone is of vital importance 
to the patient. GUNSHOT WOUNDS OF THE ABDOMEN. 
17 
The edges of the divided mesentery should be sutured and 
all raw surfaces covered with peritoneum by means of stitches, 
with very fine catgut or silk, in order to avoid leaving any 
secreting surfaces free in the peritoneal cavity. 
2d. Cases in which the mesenteric or nutritive border can be 
saved. A plan which I have successfully adopted experimentally 
is as follows : The wounded part is cleanly cut out leaving the 
uninjured mesenteric portion. From this the mucous mem- 
brane is stripped, and the muscular coat with its peritoneal 
covering, drawn downwards in a loop. This loop is closed 
with stitches and the bowel circumference remaining, fastened 
as in complete resection. This method produces no flexure of 
the bowel and does not interfere with the free flow of blood in 
the vessels coming from the mesentery. 
The most reliable and safest clamps, for use in holding the 
bowel, during the manipulations of making a resection, were 
found in experimentation to be the fingers of an assistant, and 
further experience has not changed the result of that observa- 
tion ; they can do the least damage, and produce the least 
amount of shock, and will prove an intelligent aid to the oper- 
ator. 
The wounds of the large intestine can be rapidly, and usually 
easily repaired by means of the continuous stitch on account 
of their large calibre and comparatively thick walls. Here, if 
anywhere, the wounded bowel can be reached through an en- 
largement of the external bullet opening, as has been success- 
fully done in one case by Prof. McGraw, of Detroit, but this is 
only possible, in my opinion, in cases in which the shot is a di- 
rect antero-posterior one, over the course of the large intestines, 
and does not touch any small intestine. It seems impossible 
to me so easily to find the injured parts, or so rapidly repair 
them; or to carry out so successfully proper cleansing of the 
cavity, through any other incision than the median section, in 
oblique or through and through penetration in any transverse 
plane of the abdominal cavity. My belief is based upon 
trials on the cadaver, and living animals, and wounded men. 
No other incision, to my mind, gives such perfect command of 
the entire cavity. 
In one instance an incision extending over the entire length 18 
CHARLES T. PARKES. 
of the lateral surface of the abdomen and fully to the midline 
of Poupart's ligament, failed to enable the operator to find the 
vessel from which the fatal hemorrhage came. The track of 
the bullet could be traced to the opposite side of the cavity, 
but the intestine could not be drawn through this lateral inci- 
sion so as to properly explore the course of the ball. There 
was no wound of exit. It seems very probable that the me- 
dian section, by bisecting the bullet's course, and allowing 
easier access to the cavity would have made this case, as it 
will others, simpler to manage, at least. 
It is a matter of record in surgical experience that the 
wounds confined to the large intestines have often been recov- 
ered from without surgical interference, still, it is certainly 
probable that the number of recoveries will be increased, and 
rapidity of restoration to health more surely provided for, by 
closing the wound in the intestine and cleansing the cavity at 
once, and without adding materially to the patient's danger. 
In animals, and probably likewise in man, a perforation of 
the great omentum is followed, sometimes, by a universal ex- 
travasation of blood throughout the meshes of the mass, pro- 
ducing a condition that requires ablation of the greater por- 
tion, after proper ligation. The end of the stump left after 
separation can be covered by sewing adjoining surfaces of 
peritoneum over it. All slits or openings in the mesentery 
should be carefully closed with the continuous suture so as to 
avoid contaminating secretion into the peritoneal cavity. 
The wound in perforations of the stomach is occasionally 
difficult to find, but when found, no difficulty is met with in 
applying the means of closure. The continuous suture has 
not failed to securely fasten them, and in every instance they 
have been followed by speedy recovery unless they were com- 
plicated by severe injuries to other viscera. 
There are on record quite a number of cases of penetration 
or perforation of the liver alone followed by recovery. If in 
doubt, with a posterior wound of entrance, enlargement 
thereof, with antiseptic care and dressing, would be justifiable. 
With an anterior wound, the course pursued by Dr. Murphy, 
of Chicago, in a case reported by him, was followed by recov- 
ery. Median section was made, the cavity cleaned of blood, GUNSHOT WOUNDS OF THE ABDOMEN. 
19 
and the wounds on the surface of the liver drawn together with 
catgut sutures. In my experience, wounds of the liver were 
managed in the same way and did well if the sutures were 
deeply placed. 
Wounds of the spleen bleed freely and are difficult to man- 
age with sutures on account of the brittle nature of the spleen 
tissue, still sutures rather deeply placed will hold the edges of 
the perforation in apposition. If badly lacerated, the many 
reported cases of recovery, after complete removal of the 
for injury, rather indicate that extirpation is the best means of 
treatment in such injuries. 
Perforation and wounds of the kidney, from the character 
of the organ and the profuse hemorrhage from its torn surface, 
from the danger of urinary infiltration and decomposition, 
seem impossible to manage without extirpation, especially if 
injured by an anterior wound of entrance. In one case of my 
own a complete perforation of the kidney was found. It was 
decided to leave the kidney. The patient did well for about 
twenty-four hours and then succumbed to a profuse hemor- 
rhage from the wounded organ. It seems the chances would 
have been better with it out. 
If the kidney is wounded, with posterior opening only, and 
enlargement thereof shows the injury to be confined to this or- 
gan alone, the cavity of the abdomen is not perforated, and re- 
covery is possible either with or without removal of the organ. 
Perforation or damage done to either the liver, spleen or 
kidneys, accompanying similar injuries to the small intestines, 
greatly increases the gravity of the case, and probably very 
few cases will recover, whatever is done for their relief. 
Sir William MacCormac has positively demonstrated the 
success, following abdominal section in ruptures of the blad- 
der, in order to securely suture the wound. It is proper to in- 
fer that bullet perforation of the viscus can be quite as easily 
secured in the same way. 
The results of the experience of Varick, of New Jersey, and 
Wylie, of New York, should always be borne in mind. They 
have demonstrated that hot water introduced into the perito- 
neal cavity accomplishes three purposes of great moment: relief 
of shock, arrest or abatement of hemorrhage, and cleansing of 
the cavity. 20 
CHARLES T. PARKES. 
I think carbolized silk of fine size is the best material to use 
for the bowel suture, simply because perfectly reliable catgut 
cannot always be obtained, and the risk is too great, if there 
be the least likelihood of any strand giving way. No doubt, 
well prepared catgut may answer every purpose, but the silk 
never fails to do the work required of it satisfactorily. 
If asked what are the points most likely to be neglected or 
slighted in such an undertaking as giving surgical relief to a 
cage of perforating gunshot wound of the abdominal viscera, 
my attention would be drawn to the items leading to failure in 
experimentation, and the conditions mentioned as found in the 
repeated unsuccessful cases in man. Among these would 
come first the paramount necessity of searching out and se- 
curing all bleeding vessels, dependent upon the danger of im- 
mediate or secondary hemorrhage. Hamilton, of Washing- 
ton, tells us that his successful case passed through a period 
of extreme danger, in the last days of his illness, from the for- 
mation of a blood tumor. Murphy, of Chicago, reports a case 
lost from post-peritoneal bleeding. And in this case post 
mortem showed all the intestinal wounds thoroughly closed 
and water-tight. I have reported a case in which the immedi- 
ate cause of death was kidney hemorrhage. 
It is, no doubt, a hazardops ordeal to put a patient through, 
to examine the intestines from one end to the other in order 
to be well satisfied that no perforation has been over-looked, 
yet it is far more hazardous (in fact the result will be surely 
fatal) to leave an opening in the small intestines untreated. 
In some of the reported cases wide open bullet wounds have 
been found with their surrounding faecal extravasations and 
contaminated blood. 
It is to me extremely doubtful if all the wounded parts will 
be found, in an estimated transverse plane drawn through the 
demonstrated track of the bullet, especially if the missile im- 
plicates the ever gliding and moving small intestines. I am 
not prepared to believe that a supposed probability as to the 
seat of injured parts, should take the place of a regular, care- 
fully made and satisfactory search for the wounds, and yet I 
would very carefully avoid practicing, or advising any proce- 
dure that might unnecessarily add to the shock already pres- GUNSHOT WOUNDS OF THE ABDOMEN. 
21 
ent. We do not know all that it is best to do yet, and still we 
do know that failure to close all the wounds means death to 
the patient, and some risk must be taken to avoid so great a 
hazard. 
It needs no argument or demonstration to prove the harm 
resulting from tight suturing. It has been my experience to 
see in animals the edges of several wounds slough away to the 
extent of the bowel tissue included in the sutures, followed by 
extravasation, making a failure out of a case that otherwise 
gave good promise of being a success. The temptation is 
great to be over-sure of good union. In my experience peri- 
toneal surfaces need only be laid in contact with each other 
and kept quiet for a few hours in order that adhesion may oc- 
cur. The paralyzed condition of the bowel at the seat of 
wound from the injury, in itself favors this desirable quiet.