WOUNDS. 



A« wounds of the diaphragm can hardly happen without 

 the fin!)ultaneous injury of feveral other impo'rtant parts, 

 thefe cafes muft neceflarily be attended with confiderablc 

 danger ; and indeed, when the tendinous centre of the dia- 

 phragm is injured, the accident is deemed by feveral writers 

 of modern date as inevitably fatal. ( Laffus, Pathol. Chir. 

 torn. ii. p. 321. Callifen, Syft. Chir. Hodiernae, Pars ii. 

 p. 696. ) The following are faid to be ufual fymptoms of a 

 wound of the diaphragm : — The patient is immediately feized 

 with exceflive anxiety and agitation. He feels acute pain in 

 the hypochondria, and is obhged to keep himfelf bent for- 

 wards ; and he is further afflifted with a cough, hiccough, 

 convulfive fpafms, and great difficulty of breathing. De- 

 lirium enfues, the mufcles of the face are convulfed, the 

 lingultus grows worfe and worfe, and the cafe terminates 

 fatally in the courfe of a few days. 



Dangerous, however, as wounds of the diaphragm muft 

 generally be, on account of their being for the raoft part 

 complicated with injury of fome of the abdominal or thoracic 

 vilcera, there is no doubt that the danger has been exag- 

 gerated. " Wounds of the thorax (fays Dr. Thomfon) 

 are not unfrequently complicated with wounds of the abdo- 

 men. In various inftances of this kind (which this gentle- 

 man faw in the Netherlands after the battle of Waterloo), 

 there exifted undoubted proofs of the faft that wounds of 

 the diaphragm are not neceffarily fatal ; for it muft have been 

 perforated once, if not twice, in feveral of the cafes we faw, 

 in which balls had pafted acrgfs the lower part of the cheft, 

 and the fame thing muft have happened alfo, I conceive, in 

 moft of the cafes in which the liver had been wounded. In 

 one cafe, the ball had entered the right hypochondriac region, 

 under the edge of the falfe ribs, and come out on the right 

 fide of the fpine, on a level with the fuperior edge of the 

 OS ilium. This patient fpit blood for fome days, and voided 

 it alfo by ftool. On the examination after death of a pa- 

 tient who died thirty days after receiving the wound, and in 

 whom a ball had entered the cheft on the lower and outer 

 part of the riglit papilla, and had come out of the abdomen 

 on the left fide of the umbilicus, the right lobe of the lung 

 was found wounded, and the diaphragm and the upper part 

 of the right lobe of the liver perforated. But neither in 

 thefe cafes, nor in feveral others of wounds of the dia- 

 phragm which we faw, did any peculiar fymptoms, fuch as 

 the rifus fardonicus, or convulfive motions of the cueft, pre- 

 fent themfelves to our notice." See Report of Obf. made 

 in the Mil. Hofpitals in Belgium, p. 93. 



In the treatment of wounds of the diaphragm, abftraft- 

 edly confidered, very little can be done ; bleeding and anti- 

 phlogiftic remedies appear the only means which promife any 

 efFeftual good. With thefe, however, we may fometimes 

 iifefuUy conjoin opiates. 



Extenfive wounds and lacerations of the diaphragm occa- 

 sionally give rife to a particular and incurable fpecies of rup- 

 ture, in which fome of the abdominal vifcera form a protru- 

 fion in the cavity of the cheft. This accident is termed a 

 phrenic hernia, and fome account of it will be found in the 

 article Hernia. 



Wounds of the Belly, or Aldomen Wounds of the abdo- 

 men are divided into two principal claffes: in one the folu- 

 tion of continuity is confined to the integuments, mufcles. 

 Sec. exterior to the peritoneum ; in the other this laft mem- 

 brane is penetrated, and frequently fome of the vifcera alfo 

 which are included in it. Wounds affecting the parietes of 

 the abdomen, but not extending through the peritoneum, 

 whether of the punftured, incifed, or contufed kinds, have 

 no effential difference from wounds of other parts, and the 

 obfervations which have been offered on the fubjeft of wounds 



in general are in every refpeft applicable to all fupcrficial 

 wounds of the belly. It is worthy of remark, however 

 that the parietes of the abdomen are always weakened in 

 confequence of wounds, and difpofed to allow the vifcera 

 to form protrufions. Strong as the cicatrix may bt, the 

 point where it is fituated continues fubjeft to a hernia, vvhich 

 feldom fails to occur, unlefs the weakened part be properly 

 fupported with a belt or bandage. This accident may 

 follow a fimple punftured wound ; but it invariably takes 

 place in every inftance where, in confequence of a fevere con- 

 tufion, the parietes of the abdomen have loft their tone, and 

 yield to the impulfe made agninft them by the parts which 

 they contain. It was thus that a cooper's wife, whofe hif- 

 tory is given by Sennertus, after being violently ftruck on 

 the abdomen by a piece of green elaftic wood, which flipped 

 out of her hufband's hands, fuffered fuch a relaxation of the 

 contufed part, that the anterior parietes of the abdomen 

 yielded fo as to form an enormous pouch, containing, during 

 pregnancy, the gravid uterus itfelf. 



After accompliihing the re-union of a fuperficial wound of 

 the belly by means of an eligible pofition, adhefive plafters, 

 and a bandage, we ftiould therefore recommend the patient to 

 wear a belt, or any other means of making preffure on the 

 part which muft be fupported. Should the wound have 

 been confined to the flcin, however, and the mufcles not have 

 been at all divided, there would be no rifle of a hernial pro- 

 trufion afterwards, and of courfe the ufe of a belt, or any 

 fort of bandage, would then be unneceffary. 



If fuperficial wounds of the abdomen are unattended 

 with any particular danger or peculiarity, the fame ob- 

 fervation cannot be made with refpeft to penetrating wounds, 

 or thofe which pafs through the peritoneum. We have feen 

 that penetrating v.ounds of the cheft give rife to a variety of 

 dangers, fometimes depending upon the effufion of blood 

 into the bronchia; and air-cells of the lungs, or into the 

 cavity of the pleura ; fometimes upon the confcquences of 

 that extraordinary complication emphyfema ; but more 

 efpecially upon the great tendency of the pleura and lungs 

 to inflammation. The principal dangers of penetrating 

 wounds of the belly arife alfo partly from internal hemor- 

 rhage within the cavity of the peritoneum ; partly from the 

 irritation which is produced by the occafional extravafation 

 of the contents of the vifcera ; but in a ftill greater degree, 

 from the ftrong difpofltion of the peritoneum to become 

 affefted with violent and extenfive inflammation, in confe- 

 quence of any injury or irritation. There are, fays Mr. 

 John Bell, a thoufand occafions on which this delicacy of 

 the peritoneum may be obferved. The wound of the fmall 

 fword, and the ftab of the ftiletto, explain to us how 

 quickly the peritoneum, and all its contained bowels, inflame 

 from the moft minute wound, although it be almoft too 

 fmall to be vifible on the outfide, and fcarcely within ; for, 

 upon diffeftion, no inteftines are feen wounded, and no feces 

 have efcaped into the abdomen. In thofe who die after 

 hthotomy, we find the cavity of the peritoneum univerfally 

 inflamed. The operation of Caefarean feAion is fatal, 

 not from any lofs of blood, for there is little bleeding, nor 

 from expofure to the air, for they alfo die in whom the 

 womb burfts, and where the air is not allowed to enter ; but 

 merely from that inflammation which fucceeds to wounds of 

 the peritoneum, fmall as well as great, of which we have 

 fometimes a melancholy proof in the operation of hernia, in 

 which the ftitching the wourd, according to the whimfi- 

 cal improvement of fome modern furgeons, or where the 

 mere tying of the fac, as in the praftice of the old rupture- 

 doftors and caftrators, often raifed fuch inflammation as 

 fpread very quickly over the abdomen, and ended in gan- 

 grene. 



