An interesting feature of his present condition, however, is the beginning of a follicular conjunctivitis of the right lower lid.

It is regrettable that the excised masses were lost in the hospital, and that cultures were not made from the exudate. This is partly the fault of the writer who did not at that time recognize the disease as parinaud's conjunctivitis. His treatment was based on general principles only.

REPORT OF CASE OF GUNSHOT WOUND OF AB

DOMEN WITH TWENTY-TWO PERFORATIONS

OPERATION AND RECOVERY.

Geo. T. Horne, M.D. and Guy T. Bernard, M.D., Augusta, Ga.

Gunshot wounds of the abdomen are not of rare occurrence. The surgeon of the south is perhaps more interested in this class of cases now than ever before. Owing to the high mortality these cases have ever been regarded as most serious.

Until a few years ago very little success attended operations of this kind, but a better technique, more fully equipped hospitals, scientific nursing and a more wideexperience all have contributed to make results more satisfactory and to promise even better results in the near future.

We wish to present to your notice a report of a case occurring in our hospital practice that serves to illustrate the possibilities in this line of surgery.

Case of F. R., male, age eighteen years. Occupation, wrapping clerk in department store.

While visiting relatives at Guyton, Ga., near Savannah, this boy was accidentlly shot in the abdomen with a thirty-two calibre revolver, by another boy, his cousin.

The wound of entrance was about one and one-half inches below the umbilicus and about one inch to the left of the median line.

This occurred about 7 a. m., July 15th, 1909.

At time of occurrence medical assistance was summoned, and the physician finding no evidence of hemorrhage concluded that the ball had not penetrated the cavity, but later in the day advised immediate removal of the patient to his home in Augusta, Ga. Accordingly

GEO. T. HORNE AND GUY T. BERNARD

441

he was brought up on the Central train, arriving at 7:55 p. m. On this trip he came in a day coach, sitting in an ordinary car seat the entire distance. On arrival in the city he walked from the train into hospital, a distance of about one hundred and fifty yards.

Upon examination we found abdomen wound as stated above, pulse 80, respiration 24, temperature 101 2-5, with evidence of internal hemorrhage. The abdomen was tense, face pallid and features contracted and pinched.

Immediate operation was decided upon and entered operating room at 8:40 p. m., fifteen hours after the injury.

On opening abdomen the cavity was found to contain a large quantity of blood clots and fecal matter, together with a number of water melon seeds. This was cleaned out and search for damaged tissue was begun. Tracing the intestine twenty-two perforations were found, located as follows:-Sixteen in the ileum, five in the descending colon and one in the rectum. In addition to this the visceral peritoneum was abraded in numerous places.

The perforations were of such size that they were closed without resection being necessary, the largest hole was the one in the rectum, this one being about one and one-half inches in diameter.

The bullet was located in the hollow of the sacrum, behind the posterior peritoneum, from which location it was removed. The cavity was cleansed with saline, and closed with drainage.

On removal to bed he was placed in exagerated Fowler's position and continuous rectal irrigation was begun. At this time there was pulse 134, respiration 30, axilla temperature 99.

The following morning his condition was fairly good, remaining so during the day, but the night succeeding at about one o'clock his condition became suddenly grave, restlessness and delirium setting in followed in a few hours by prostration, temperature 97, pulse 109 and very weak, respiration 36, skin cold and clammy.

The next morning a slight improvement was noticed and which continued. That afternoon his bowels moved freely, discharging constipated fecal matter and watermelon seed. From that time onward his recovery was gradual and uneventful.

He was discharged from the hospital August 4th and about a month later he resumed. his regular occupation. At present, about eight months since operation he is entirely free from any ill effect of his injury, and in fact has changed his occupation from that of wrapping clerk in a department store to apprentice in a large iron works and foundry in this city.

We wish to call attention to one or two rather unusual and interesting features in connection with this case.

First: The lack of any symptoms indicating the amount of damage sustained by the abdominal viscera. In this connection it is fitting to emphasize the importance of a most thorough examination of all wounds which may be penetrating; remembering that though the clinical evidence may be almost nil extensive destruction of abdominal tissue can have taken place.

Secondly: The concensus of opinion in this class of cases is, that the best prognosis is afforded by early operation. It will be noted, however, in this case that there was an interval of about fifteen hours, during which time the patient was subjected to various disadvantages, and among them the hardships of a one hundred mile journey in an ordinary day coach.

Thirdly: In view of the fact that there was a great out-pouring of intestinal contents into the cavity, there was a relatively small amount of toxaemia. We cannot account for this unless it was due to the position he unconsciously assumed while so many hours on the train.

If this be true it is a very practical illustration of the value of Fowler's position in all septic conditions of the abdomen.

CONSTITUTION AND BY-LAWS

OF THE

Medical Association of Georgia

CONSTITUTION.

ARTICLE I.-NAME OF THE ASSOCIATION.

The name and title of this organization shall be the Medical Association of Georgia.

ARTICLE II.-PURPOSES OF THE ASSOCIATION

The purpose of this Association shall be to federate and bring into one compact organization the entire medical profession of the State of Georgia; to extend medical knowledge and advance medical science; to elevate the standard of medical education, and to secure the enactment and enforcement of just medical laws; to promote friendly intercourse among physicians; to guard and foster the material interests of its members and to protect them against imposition; and to enlighten and direct public opinion in regard to the great problems of State medicine, so that the profession shall become more capable and honorable within itself, and more useful to the public, in the prevention and cure of disease, and in prolonging and adding comfort to life.

ARTICLE III.-COMPONENT SOCIETIES.

Component Societies shall consist of those county medical societies which hold charters from this Association.

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