WOUNDS. 



jTi-cne. This inflammation may, no doubt, come on from be thus thrown into the cavity of the peritoneum without 



the fliirhteil fcratch in the peritoneum itfelf ; yet, in general, the utmoft rifk of exciting that fatal kind of inflammation 



it arifes rather from the wound of fome of the vifcera. If which we have already mentioned, as the danger moft to be 



ar inteftine be wounded, it may pour out its feces into the dreaded in all wounds of the abdomen. 



abdomen ; if the liver, fpleen, or kidneys be wounded, thefe 

 pour out blood ; if the bladder, then the urine filters into 

 the cavity of the belly. The extravafated food, feces, urine, 

 ! blood, &c. aft there as irritating extraneous fubltances, 

 , which no aftivity of the abforbents can remove, and which 

 foon caufe a fatal inflammation of every peritoneal furface 

 within the abdomen. See John Bell's Dii^courfes on the 

 Nature and Cure of Wounds, p. 310. edit. 3, 



Apprized by melancholy experience of the vaft difference 



1 which the penetration of the peritoneum makes in the nature 



I of a wound of the abdomen, furgeons have betrayed confi- 



; derable anxiety to be able to afcertain at firft, in every in- 



I ftance, whether the injury partakes of this ferious defcrip- 



tion or not. But although the nature of the cafe is felf- 



evident, when the wound in the parietes of the abdomen is 



large, and attended with protrufion of the vifcera, it is often 



extremely diflicult to judge whether the weapon has gone 



through the peritoneum or not, when the wound is a fimple 



flab, unaccompanied with protrufion of the vifcera, or with 



any effufion of their contents. 



The generality of furgical authors have laid down a va- 

 riety of criteria for determining the queftion, whether the 

 cafe is a penetrating wound ? Some of thefe writers lay 

 much ftrcfs on comparing the direftion of the wound with 

 the natural thickncfs of the parietes of the abdomen at the 

 injured part, and the breadth of the injury with that of the 

 weapon. When the inftrument has afted perpendicularly 

 upon a point, where the parietes arc thin, and the wound, 

 though made with a narrowifh weapon, like a fword, is yet 

 of a certain breadth, there can indeed be little doubt of the 

 cafe being a penetratuig wound. But the impoffibility of 

 knowing in what direftion the thruil has been made, and of 

 procuring the v.rcapon, in order to compare its diameter with 

 that of the wound, generally renders this mode of difcrimi- 

 nation ufelefs in aftual praftice. 



If a probe (fay other writers) will readily enter perpendi- 

 cularly to a certain depth, in a place where the parietes of 

 the abdomen are thin, the circumftance is a proof that the 

 cafe is a penetrating wound. But if the probe cannot be 

 thus introduced, we are by no means juilified in concluding 

 that the wound does not penetrate. As the layers of mufcles 

 do not bear the fame relative pofitiou to each other which 

 they did at the time of the accident, they foon ftop the paf- 

 fage of the probe ; and in whatever pofture we put the 

 patient, it is next to impoffible to put the parts exaftly in 

 the fame pofitioq in which they were at the time of the re- 

 ceipt of the injury. Befides, when the wound is obhque, a 

 probe which is not very flexible cannot eafily be made to 

 follow its track. The employment of this inftrument is alfo 

 not free from objeftions, founded on its creating pain and 

 irritation, or even a renewal of hemorrhage and effufion of 

 blood in the cellular membrane. 



An abfurd propofal has been made to injeft a mucilagin- 

 ous fluid into the wound, the paffage of which into the belly 

 would be a fure indication of the cavity of the abdomen 

 being penetrated. It is obvious, however, that the injefted 

 liquid may not enter, though the cafe be a penetrating 

 wound, owing to the change in the relative pofition of the 

 layers of the abdominal mufcles. The fluid may alfo conti- 

 jiue in the wound in confequence of its paffing into the cel- 

 Jular fubftance ; and tluis it may make the furgeon fuppofe 

 that it enters the abdomen, when in reality it does not pafs 

 dowa even to the peritoneum. Nor can the raildeil inieftion 



The figns then of a penetrating wound of the abdomen are 

 fallacious, and the employment of fuch means as the probe 

 and injeftions, with a view of afcertaining the real nature of 

 the cafe, is not exempt from danger. Many fpafmodic 

 affeftions, which occafionally follow the receipt of a wound 

 of the belly, are only equivocal, as they are fometimes owing 

 entirely to the great fenfibility of the patient. The pro- 

 trufion of the abdominal vifcera, and the difcharge of fluids 

 which they are known to contain, are the only fure figns of 

 a penetrating wound. It is eafily conceivable at the fame 

 time, that a wound may penetrate the cavity of the belly, 

 and yet thefe fymptoms may not occur, either becaufe the 

 external wound is too fmall to allow of the efcape of any of 

 the vifcera or their contents, or becaufe the weapon or 

 ball, after piercing the peritoneum, has aftually touched 

 none of the bowels, or has merely glided over their furface. 

 But penetrating wounds, which are unattended with pro- 

 trufion of the vifcera, or extravafation of any fluid in the 

 cavity of the abdomen, are lefs alarming than feveral compli- 

 cated wounds which do not penetrate. If in fuch cafe, 

 fays Richcrand, the patient or by-ftanders were to inquire 

 about the nature of the injury, we fhould avoid giving a 

 pofitive opinion, informing them of the infufiiciency of the 

 means formerly praftifed, in order to afcertain the precife 

 depth of the wound, and explaining the objeftions to the 

 probe and injeftions. It fhould alfo be mentioned to them 

 that the antiphlogiftic treatment, which is the bell in fimple 

 wounds which do not penetrate, is the only plan which could 

 be adopted, were it certain that the injury had extended into 

 the cavity of the abdomen. Nofographie Chir. torn. iii. 

 P- 327—335- edit. 4. 



In the following defcription of the treatment requifite for 

 the different cafes of penetrating wounds of the belly, we 

 fhall follow the order chofen by M. Richcrand, and con- 

 fider, 



Firfl, the cafes in which the vifcera, though uninjured, 

 protrude at the wound. 



Secondly, the cafes which are complicated both with in- 

 jury and protrufion of the vifcera. 



Thirdly, penetrating wounds unaccompanied with pro- 

 trufion, but yet attended with injury of one or more of 

 the vifcera, as is indicated by particular fymptoms, and efpe- 

 cially by the iffue of certain kinds of matter from the exter- 

 nal wound. 



Andlaftly, we fhall conclude with noticing the fubjeft of 

 extravafations, and fome wounds of particular organs and 

 vifcera. 



I. 0/ Wounds of the Belly, attended tvlth Protrufion of the 

 Vifcera. — When, in confequence of a divifion of the parietes 

 of the abdomen by a cutting inftrument, or their laceration 

 by a buU's-horn, the inteftines protrude between the hps of 

 the wound, the firft indication is to reduce the parts, and then 

 to take meafures for preventing a recurrence of the protru- 

 fion. The reduftion is generally eafy, if care be taken to 

 relax the abdominal mufcles by a judicious pofture. In 

 fome cafes, however, the wound is fo narrow that the 

 thing is more difficult, and here, inftead of punfturing the 

 bowel, in order to diminifli its fize by difcharging the air 

 which it contains, (as advifed by many writers,) we de- 

 cidedly recommend a moderate enlargement of the wound. 

 This ftiould be cautioufly executed with a probe-pointed 

 curved biftoury, introduced along the groove of a direftor ; 

 or, if there be room, under the guidance of the left fore- 

 5 C 2 finger. 



