WOUNDS. 



finger. In this manner, and with due care, the wound may 

 always be fufficiently dilated without the protruded parts 

 being cut. Authors alfo recommend the iiicifion for this 

 purpofe to be direfted upwards ; for (fay they) the further 

 the cut is from the lower part of the belly, the lefs liable 

 will the patient afterwards be to hernia. The inteftines 

 (hould invariably be returned without delay, in every in- 

 ftance in which they are free from wound or gangrene. 

 Should they even be (lightly wounded or inflamed, no time 

 Jhould be loft in abfurdly applying fomentations, &c, to 

 them in their protruded ftate. The natural warmth and 

 moifture of the cavity, into which they are to be replaced, 

 will be far more congenial than any topical remedies. 

 Should the parts, however, have any dirt or fand upon them, 

 the moft which ought to be done before their reduction is to 

 •warti them vnth warm milk and water. 



The reduftion having been effefted, the patient is to lie 

 upon his back, with the thighs bent upon the peUis, and he 

 muft ttriftly avoid making any exertion, left it bring on an- 

 other protrufion. The wound is to be clofed with adhelive 

 plafter, and the uniting bandage ; but if the wound fhould 

 be large, and thefe means ineffeftual, it would alfo be pro- 

 per to employ futures. The ftitches, however, fhould always 

 be as few as poiEble. This method of fewing up wounds 

 of the belly made a long fubjeft in all the old works on fur- 

 gery, under the appellation of Gajlroraphe (fee that article) ; 

 but at the prefent day, futures are comparatively fpeaking 

 almoft rejefted from praftice, or are only employed when 

 the oppofite furfaces of wounds cannot be kept in contaft 

 without them. Nor are they then ever ufed, except the 

 chance of union by the firft intention ftill forms a temptation 

 for the trial of the plan ; for when a wound muft heal by 

 the granulating procefs, ftitches can never be of the leaft 

 utility. 



When the omentum protrudes through a penetrating 

 wound, and is ftrangulated by the narrownefs of the open- 

 ing, it foon contrafts adhefions. Richerand recommends us 

 to cut off all this membrane which exceeds the level of the 

 integuments, and to leave in the wound the reft, which, he 

 aflerts, will aft hke a ftopper, and hinder future herniae. 

 Were the wound, however, quite recent, fo that adhefions 

 could not yet have formed, the propriety of dilating the 

 opening, and reducing the piece of omentum, would be un- 

 queftionable. Whenever, alfo, the omentum is found, and 

 free from conftriftion, it (hould be reduced. In cafes where 

 a portion of this membrane is not only protruded, but gan- 

 grenous, writers authorize the excifion of the dead part, and 

 reducing the reft after the cut vcffels have been tied (ingly 

 with fmall filk ligatures. We apprehend, however, that in 

 general, whenever the omentum has been out fo long as 

 to (lough, adhefions within the wound have had time to 

 form ; an event which would embarrafs the operator, and 

 even render the fafety and propriety of the attempt to reduce 

 the living portion of the piotruded membrane very quef- 

 tionable. Should the omentum, or inteftine, however, be 

 not adherent to the neck of the hernial fac, though gangre- 

 nous, (as occurred in an inftance cited by Scarpa, Traite 

 des Hernies, p. 268.) the propriety of trying to reduce it 

 would be undeniable. 



2. Wounds of the Belly, 'with Injury and Protrufion of the 

 Vifcera. — Penetrating wounds of the abdomen, attended 

 with protrufion of the inteftines, are always to be regarded 

 as dangerous cafes ; but the danger is much more ferious, if, 

 befides being protruded, the bowels are alfo wounded. 

 Under fuch circumftances, we have the authority of nu- 

 merous writers on furgery, as a fanftion of the praftice of 

 fewing togethtr the edges of the divifion in the protruded 



inteftine ; a praftice, however, which, as we (hall hereafter 

 explain, does not meet with the approbation of that excel- 

 lent modern furgcon, profeffor Scarpa, of Pavia. Every 

 one, however, allows, that the attempt would be highly im- 

 proper and ra(h, were the bowel only wounded, without 

 forming a protrufion. It is this laft occurrence which creates 

 a material difference in eftimating the polTibihty of the plan, 

 the queftion of its necelTity being at prefent excluded from 

 confideration. When the parts are protruded, no enlarge- 

 ment of the external wound is neceffary to render the applica- 

 tion of a future prafticable ; the plan creates no difturbance 

 and irritation of the peritoneum and contiguous vifcera ; 

 there is no doubt concerning the aftual exiftence of the 

 injury, no difficulty in injmediately finding out its precife 

 fituation. 



But though many authors are fo generally agreed about 

 the propriety of ufing a future in the cafe of a wounded and 

 protruded bowel, they differ exceedingly, both as to the 

 right objeft of the method, and the moft advantageous mode 

 of making the ftitches. Some, having little apprehenfion of 

 extravafation after the reduftion of the gut, advife only one 

 ftitch to be made, (frequently only through the mefentery,) 

 and they employ the ligature chiefly with a view of confining 

 the injured bowel near the external wound, fo that whatever 

 part of it« contents may be effufed, there will be a ready 

 pafTage for the matter outward. Other writers wifh to re- 

 move the poflSbility of extravafation, by applying numerous 

 ftitches, and attach little importance to the plan of ufing the 

 ligature, principally for the purpofe of keeping the inteftine 

 near the external wound. 



When the wound of a bowel is fo fmall that it is clofed 

 by the protrufion of the villous coat, the application of a 

 future muft evidently be altogether needlefs ; and fince the 

 ligature could not fail to caufe irritation, as an extraneous 

 fubftance, the employment of it ought unqueftionably to be 

 difpenfed with. 



Suppofing, however, the breach in the inteftine to be 

 fmall, but yet fufficient to let the feces efcape, what method 

 ought to be adopted ? The following praftice has been 

 tried. As Mr. A. Cooper was performing the operation 

 for a ftrangulated hernia, at Guy's hofpital, an aperture, 

 giving iflue to the inteftinal contents, was difcovered in a 

 portion of the found bowel, juft when the part was about 

 to be reduced. The operator, including the aperture in his 

 forceps, caufed a fine filk ligature to be carried beneath the 

 point of the inftrument, firmly tied upon the gut, and the 

 ends cut off clofe to the inteftine. The part was then re- 

 placed, and the patient did well. Mr. Travers, who has 

 related this faft, approves of the plan of cutting away the 

 extremities of the ligat;ire, inftead of leaving them hanging 

 . out of the external wound. It appears that when the firft 

 praftice is followed, the remnant always finds its way into 

 the inteftine, and is difcharged with the ftools, without any 

 inconvenience. But when the long ends are drawn through 

 the outer wound, and left in it, they materially retard the 

 procefs of healing. See Travers's Inquiry into the Procefs 

 of Nature in repairing Injuries of the Inteftines, &c. 

 p. 112, 113. 



Let us now inquire what ought to be the conduft of a 

 furgeon, were he called to a patient, whofe bowel is divided 

 through its whole diameter, and protruded at the external 

 wound ? Various have been the fchemes and propofals for 

 the treatment of this fort of accident ; and fince experience 

 has furnifhed few praftitioners with an opportunity of feeing 

 fuch a cafe in the human fubjeft, a variety of experiments 

 have been made on animals, in order to determine what 

 treatment would be the moft fuceefsful. Ramdohr, indeed. 



