WOUNDS. 



vf the abdomen, atteniied ivilh injury of the iniejl'ine, -whether 

 the canal be opened long':ludinally or tranfverfely, a future is 

 altvays an operation not merely ufelefs, but even dangerous and 

 fatal. In whatever manner it is praftifed, one cannot avoid 

 the evils which muft originate from the punftures, however 

 few, and from the pafTage of the ligatures through the coats 

 of the inteftine; a part endued with exquifite fenfibility, and 

 whofe external tunic is much difpofed to inflame, and 

 rapidly to communicate the inflammation to all the other 

 abdominal vifcera. It has been unfortunately proved, by the 

 experience of feveral ages, that in moil of t!;e cafes in which 

 the inteftine has been ftitclied in penetrating wounds of the 

 belly, the patients have died in the greateft agony. If a 

 few have efcaped the dangers of this operation, it has been 

 becaufe in them the ftitches foon cut their way out, and 

 were voided with the feces which continued to efcape from 

 the wound until it was entirely healed. 



All furgeons of experience, and particularly thofe of 

 large hofpitals, have often feen wounds of the right or left 

 iliac region accompanied with injury of the great inteftine. 

 They may alfo have noticed, in thefe examples, that after 

 the fubfidence of the local and general inflammatory fymp- 

 toms, the wound ftill continues to difcharge the feces for a 

 certain time ; but that afterwards it contrafts, and the ex- 

 crement refumes its ufual courfe. Thefe wounds almoft 

 always heal completely : firft, becaufe the adhefion of the 

 large inteftine to the parietes of the abdomen prevents the 

 feces from being extravafated in the cavity of the peri- 

 toneum ; and fecondly, becaufe the ample capacity of the 

 fame bowel always prefents a ready paflage for the feces, 

 notwithftanding the progreflive and fometimes quick clofure 

 of the external opening. 



If, in the inftance of a penetrating wound of the belly 

 attended with a wound of the fmall inteftines, it were in the 

 furgeon's power (as indeed it is) to return the bowel into 

 the abdomen, fo that the opening in it may exaftly corre- 

 fpond with the wound in the abdominal parietes, there could 

 not be a doubt of its quickly acquiring adhefions to the 

 I peritoneum, which lines the part around the internal orifice 

 ; of the external wound : hence the feces would readily 

 ' efcape through the outer wound, and at length it would 

 ' happen, after a certain time, as in wounds of the large in- 

 teftines, that the artificial anus would gradually clofe up, 

 I and the feces refume their natural track. The narrow dia- 

 I meter of the fmall inteftines would not make an infurmount- 

 able obftacle to the paifage of the feces, provided they be, 

 ' as they ufually are in this portion of the inteftinal canal, 

 i fufficiently fluid ; and befides (fays Scarpa) is it not proved 

 : by experience, that they relume their natural courfe, after 

 ; the cure of an artificial anus, even when a confiderable 

 ' noofe of the fmall inteftines has been deftroyed by gangrene, 

 \ and when the two ends form by their re-union a very acute 

 angle ? In all cafes, the patient's hfe would be faved, and 

 I the worft that could happen would be his being afflifted the 

 ; reft of his days with a fiftula difcharging feces. 



Encouraged by thefe principles, which are the natural 

 I deduftions of a comparifon of wounds of the large intef- 

 : tines with thofe of the fmall ones, Scarpa feels no hefitation 

 in admitting the pofllbility of curing the latter, without 

 .having recourfe to a future. He obferves, that it would 

 1 not be difficult for him to quote examples of fuch cures. 

 I Amongft others, he has lately feen one which deferves to be 

 ! mentioned here. A portion of fmall inteftine, protruded 

 j through a penetrating wound of the abdomen, happened to 

 be punctured with a bodkin by a country furgeon, in his 

 j mdeavours to return the part into the belly. The feces, 

 ' however, were not extravp.fated iu the cavity of the peri- 

 ' Vol. XXXVIJI. 



toneum, but were for a long while difcharged through the 

 wound. The opening in the bowel always correfponded 

 exaaiy to that in the parietes of the abdomen, although no 

 future was praftifed, nor any ligature put through the me- 

 fentcry in order to keep it in this fituation. The feces 

 afterwards gradually refumed their natural courfe, the wound 

 at the fame time became fmaller, and in the end healed up. 

 The young man, the fubjeft of this cafe, now enjoys very 

 good health, and fufFers no inconvenience which can juftify 

 a fufpicion of any obftruAion in the paifage of the feces. 



The inceilant prefTure made by the abdominal mufcles 

 and diaphragm upon all the vifcera, is a caufe why the 

 wounded inteftine, inftead of quitting the external wound, 

 enters it, and contrails adhefions to its lips. If, however, a 

 too timorous furgeon were afraid of entirely trufting, on 

 this point, to the wife providence of nature, he might 

 (Scarpa thinks) without inconvenience pafs a ligature 

 through the mefentery, behind the portion of wounded 

 bowel, as is ufually and quite unneceflarily done in cafes of 

 mortified hernia. Forty-eight hours, or thereabouts, would 

 be time enough for the inteftine to contract adhefions, 

 through the medium of the peritoneum, to the inner edges 

 of the wound. After this period, the ligature would be 

 completely ufelefs, and it ought to be withdrawn, as there 

 would now be no chance of extravafation of the feces in 

 the belly. At the fame time one fhould negledl no remedies, 

 internal as well as external, which may be of ufe in mode- 

 rating the patient's fufferings, diminifliing the energy of the 

 circulation, and bringing the inflammation down to the de- 

 gree requifite for the formation of adhefions. One ought 

 alfo to keep open the external wound with the fame precau- 

 tions, and according to the fame indications which are to be 

 attended to in the treatment of an artificial anus. The 

 principal objedl of thefe precautions is, to let the treatment 

 be fuch that the wound may only diminifti in proportion as 

 the evacuation from the lower part of the inteftinal canal 

 increafes. 



Here it may be a propos to obferve, that the conduft of 

 a furgeon in the treatment of penetrating wounds of the 

 abdomen, attended with injury of the fmall inteftines, is 

 exaftly the reverfe of what it ought to be in the treatment 

 of penetrating wounds of the cheft, accompanied with injury 

 of the lungs. 



In the latter, fays Scarpa, phyfiology, agreeing with ex- 

 perience, teaches us that no means ftiould be omitted for 

 efFefting the immediate union of the wound, (as it is termed, 

 by thejirfl intention, ) care being taken to check the force of 

 the circulation by repeated bleedings and every antiphlo- 

 giftic remedy, in order to prevent or diminifti, as much as 

 poffible, internal hemorrhage. If, notwithftanding all thefe 

 means, blood fhould be extravafated between the pleura 

 and lungs, it prefles equally upon every point of thefe vif- 

 cera, refifts their motion, and thereby contributes to flop 

 the bleeding. If, after the wound in the lungs is healed, 

 the extravafated blood be not in too large quantity, it will 

 be gradually removed by the abforbeiitsi. In the contrary 

 cafe, it will form a fwelling beneath the external cicatrix, 

 and prefent itfelf externally (fee Difcours fur les Principales 

 Maladies obfervees a I'Hotel Dieu de Lyon, &c. par M. 

 Petit, p. 299.) ; orelfe a counter opening muft be praftifed 

 at the inferior part of the cheft. See Empyema. 



We are to aft quite differently in the treatment of a pene- 

 trating wound of the belly, with protrufion and injury of 

 the inteftine ; for in this cafe, the chief indication, that on 

 which the patient's fafety mainly depends, confifts in keep- 

 ing the external wound open, in order that the feces may 

 find a ready outlet. The wounded bowel foon contraAs 

 J D adhtftons 



