Gunshot and Bayonnette Wounds of the Stomach [excerpt]

     In some special cases extragastric exploration will be insufficient, in which case gastrotomy is to be resorted to, but before doing this a cushion should be placed under the lumbar region, which may render the examination easier and the endogastric procedure may not be required. However, should this be deemed necessary, the incision in the anterior gastric wall should be horizontal, at least three inches long, and made at equal distance from the curvatures. Introducing the hand behind the stomach, the posterior wall is made to protrude through the gastric incision. The mucosa is wiped with compresses, after which the surface is examined. One may thus discover an ecchy- [594][595] mosis or a perforation which would otherwise have been overlooked.
     This technic, which in gastric ulcer is rather simple, is less so in traumatic perforation, because in the former the gastric cavity is apt to be empty, while very frequently the stomach is full at the time the gunshot injury is received. This being the case, the contents must be removed through the incision, with all due care not to let any of it escape into the peritoneal cavity. Very few surgeons have resorted to endogastric exploration in gunshot wounds, and when it has been done, the incision in the anterior wall has been timidly made, with the result that the posterior perforation has been overlooked. In the case of President McKinley, the anterior perforation was simply enlarged and the gastric cavity explored with the finger, and the posterior perforation was only discovered by a direct examination of the posterior wall.