PERFORATION OF THE SMALL INTESTINE ING FROM THE KICK OF A GUN DR. WILLIAM J. TAYLOR related that on Saturday, July 28, 'goo, a young man of twenty-three was out shooting, using an ordinary double-barrelled shot-gun. This gun was accidentally discharged while he was holding it in front of his body, so that he received a very severe kick from it in the right iliac region. There was intense pain, and he had great difficulty in getting back to his home. Pain and tenderness continued all the next day, and on Monday, the 3oth, he was brought to Philadelphia, arriving here at eight o'clock in the evening, after a journey of five hours. Dr. Taylor saw him immediately on his arrival, and found him to be suffering from general peritonitis, with special pain and tenderness in the right iliac fossa. His temperature was F., his expression anxious, but his pulse fairly good. Within an hour thereafter the abdomen was opened. There was general peritonitis, with masses of lymph here and there over the intes tine. Two coils of small intestine were glued together at one small point. This was separated very easily with the finger, no force at all being used, when immediately there was a gush of liquid faces, and a perforation was seen in the wall of the bowel about the size of a lead-pencil, with ragged, sloughing edges. The lymph from the intestine was carefully wiped off, and there was such gaseous distention that the contents of the gut were milked out of this perforation. The opening in the bowel was invaginated and closed by a double row of silk sutures. A search was now made for the appendix, which was discovered to be post meal and very difficult to find. Its tip was slightly clubbed, and, in view of the possibility of subsequent danger, it was removed. A very careful toilet of the peritoneum was made and a search for further perforations or evidence of ulceration in either the large or small intestine. None, however, could be found, nor any evidence of thickening of the intestinal wall. Drainage was introduced, a wick of gauze wrapped in rubber dam.
He gave a history of not having felt very well for some two or three weeks, and, to eliminate the possibility of his having had a walking typhoid, some of his blood was sent to the city bacteriologist for examination by Widal's method, but a nega tive report was made. He was profoundly poisoned by the septic peritonitis, and, in spite of every effort made to save him, he died seven days after the receipt of his injury.
DR. RICHARD HARTE said that this case emphasized the im portance of dealing surgically with severe contusions of the ab domen. He was convinced that the results would be much better in dealing with these injuries if the abdominal cavity were opened, in properly selected cases. In four cases of abdominal contusions which had been admitted to the Episcopal Hospital within a short time, in two there were ruptures of the liver and in two ruptures of the intestine, one of which was very much of the same char acter as the case cited by Dr. Taylor. A man while attempting to escape from a falling beam fell, and the point of a pair of pliers which he had in his pocket struck the abdomen and made a small puncture, but did not enter the bowel. There was evidence of abdominal contusion. Dr. Deaver opened the abdomen and found a perforation of the bowel, simply by contact with this blunt instrument.
In determining when the abdomen should be opened, he thought that a man's surgical sense had to be relied on to a great extent. There is a class of cases where the element of shock is very noticeable and where the reaction is slow. There is evi dently some disturbance going on which demands surgical inter ference. These cases, if left to themselves, will soon become tympanitic and present all the symptoms of traumatic peritonitis, and will in a short time die ; but if they had been opened imme diately, and if possible before the shock had become too profound, conditions would be found in many of the cases which could have been dealt with surgically. Of course, there are cases where surgical interference will be of no avail, as in case of rupture of the liver or some of the abdominal viscera ; but where there is hxmorrhage, or where the intestine is ruptured, as so often oc curs, with or without extravasations of its contents, most favor able results can be obtained in dealing with these cases by opening the abdomen and seeking systematically for the trouble; and the element of risk involved by this procedure in doubtful cases is slight compared with the old method of dealing with these cases.