WOUNDS. 



adhefions to the inner lips of the wound of the belly, and 

 then we have nothinjT to fear from an extravafation of the 

 intellinal matter in the cavity of the peritoneum. After- 

 wards, in proportion as the feces refume their natural 

 coiirfe, the external wound is to be allowed to dimini(h, and 

 entirely heal up. See Scarpa SuU'ernie Memorie Anato- 

 mico-Chirurgiche, &c. mem. 4. 



In every inftance in which the abdomen has received a 

 penetrating wound, attended with injury and protrufion of 

 a portion of the inteftinal canal, the difplaced part is to be 

 reduced, whether it be ditched or not. This (hould be 

 accomphflied as fpeedily as poiTible, before the bowel has 

 fuffered much from expofure, conftriftion, &c.^ and alfo 

 before any adhefions have formed at the inner orifice of the 

 external wound ; adhefions which would render the reduc- 

 tion of the protruded part imprafticable. Of courfe, if 

 the wound fhould be too fmall to admit of the reduction 

 being effefted without handling and bruiling the bowel im- 

 moderately, it ought to be carefully enlarged with a curved 

 biftoury, guided on a direftor. Indeed, according to 

 Scarpa's principles, one would fuppofe that in every cafe of 

 this kind the wound, if not free, (hould be dilated, as by 

 this means the ifTue externally of whatever efcapes from the 

 breach in the inteftine after its reduftion would be facili- 

 tated. The reft of the treatment confifts in the rigorous 

 adoption of antiphlogiftic meafures, more efpecially a low 

 diet, and copious and repeated venefeftions, with a view of 

 counteratling the danger of peritoneal inflammation. With 

 refpeft to the dreflings, they cannot be too fimple, and 

 they ought always to be hght and fuperficial. A pledget 

 of any common unirritating ointment is all that is requifite, 

 and it muft be renewed as frequently as the quantity of the 

 difcharge, &c. from tlie wound may render neceffary. 



3. Pemtraling Wounds of the Belly, attended ■with Injury 

 of the Bowels, but ivith no Protrufion. — A wound of the 

 inteftines is indicated by the difcharge of blood with the 

 (lools, and fometimes by the efcape of fetid air, or of in- 

 tellinal matter from the external wound. Such an injury, 

 liowever, when the wounded bov/els lie concealed in the 

 belly, does not always admit of being known with certainty 

 immediately after occurrence. In the majority of examples, 

 there is at firft no efcape either of air, or of the contents of 

 the bowels, from the external wound ; the quantity of blood 

 voided per anum may be inconfiderable, and of courfe none 

 at all will generally be difcharged for fome time after the 

 accident. Wounds of the fmaU inteltines, efpecially of the 

 duodenum and jejunum, are indeed ufually followed by great 

 anxiety, palenefs of the countenance, fyncope, cold per- 

 fpirations, a fmall intermitting tremulous pulfe ; but then 

 thefe fymptoms are only equivocal, and furnifh no pofitive 

 information, becaufe feveral of them may happen in nervous 

 fubjefts, from a mere fuperficial unimportant cut or ftab. 

 Our inability, however, to fay alTuredly, in every cafe, 

 whether the bowels are injured or not, is a thing of no 

 praftical importance ; becaufe when the nature of the acci- 

 dent is not clearly manifefted by fome peculiarity or feverity 

 of the fymptoms, the cafe (hould invariably be treated on 

 common, fimple, antiphlogiftic principles ; and alfo, when 

 circumftances leave not the fmalleft doubt of the inteftines 

 being hurt, the fame treatment is the only rational one 

 which can be purfucd. Wounds of the fmall inteftines are 

 reckoned much more dangerous than thofe of the large ; 

 arid the nearer the injury is to the pylorus, the greater, 

 generally fpeaking, is the degree of danger. Such cafes are 

 alfo much more frequently, than injuries of the large intef- 

 tines, the caufe of extravafation. In the latter examples, 

 the fymptoms are commonly milder, and either the pafTage 



7 



of the inteftinal contents outward through the wound more 

 eafy and certain, on account of the bowel being naturally 

 lefs moveable than the other inteftines ; or their pafTage in 

 their natural courfe more ready, by reafon of the greater 

 capacity of that part of the inteftinal tube. 



A wounded inteftine is faid to prefent fome particular 

 appearances, to which the generality of writers have paid 

 no attention. " If a gut be punftured, the elafticity of the 

 peritoneum, and the contraftion of the mufcular fibres, open 

 the wound ; and the villous or mucous coat forms a fort of 

 hernial protrufion, and obliterates the aperture. If an in- 

 cifed wound be made, tlie edges are drawn afunder and 

 reverted, fo that the mucous coat is elevated in the form of 

 a fle(hy lip. If the fe£lion be tranfverfe, the lip is broad 

 and bulbous, and acquires tumefaftion and rednefs from the 

 contraAion of the circular fibres behind it, which produces, 

 relatively to the everted portion, the appearance of a cervix. 

 If the incifion is according to the length of the cylinder, 

 the lip is narrow, and the contraftion of the adjacent longi- 

 tudinal, refifting that of the circular fibres, gives the orifice 

 an oval form. This everfion and contraftion are produced 

 by that ferles of motions, which conftitutes the periftaltic 

 aftion of the inteftines." Travers on Injuries of the Intel- 

 tines, p. 85. 



According to this gentleman, fome of thefe appearances 

 were defcribed by Haller, in Element. Phyfiol. lib. 24. 

 feft. 2. and Opera Minora, tom. i. feft. ij. 



Having witnefTed the facility with which confiderable in- 

 juries of the inteftinal tube were repaired, Mr. Travers was 

 defirous of afcertaining more fully the powers of nature in 

 the procefs of fpontaneous reparation, and of determining 

 under how great a degree of injury it would commence, as 

 well as the mode of its accomph(hment. For thefe pur- 

 pofes, he divided the fmall inteftine of feveral dogs as far as 

 the mefentery. All thefe animals died, in conlequence of 

 the inteftinal matter being extravafated, if they had been 

 lately fed, or if they had been fafting in confequence of in- 

 flammation, attended with a feparation of the ends of the 

 divided bowel, everfion of the mucous coat, and oblitera- 

 tion of the cavity, partly by this everfion, and partly by a 

 plug of coagulated chyle. 



In one particular inftance in which Mr, Travers made a 

 divifion of the bowel half through its diameter, a fort of 

 poucli was formed round the injured inteftine. " A pouch, 

 refembling fomewhat the diverticulum in thefe animals, was 

 formed oppofite to the external wound, on the fide of the 

 parietes, by the lining peritoneum ; on the other fide, by 

 the mefentery of the injured inteftine, that inteftine itfelf, 

 and an adjacent fold, which had contrafted with it a clofe 

 adhefion. The pouch, thus formed and infulated, included 

 the oppofed feftions of the gut, and had received its con- 

 tents, &c. The tube at the orifices was narrowed by the 

 half everfion, but offered no impediment to the pafTage of 

 fluids." (P. 96.) Whether, under thefe circumftances, 

 the funftions of the alimentary canal could have been con- 

 tinued, Mr. Travers profeffes himfelf incapable of deciding. 

 Among the inferences which this gentleman has drawn from 

 the experiments detailed in his publication, the tendency 

 of the two portions of a divided bowel to recede from each 1 

 other, inftead of coalefcing to repair the injury, merits no-f 

 tice, inafmuch as it tends to (hew that the only means of ! 

 fpontaneous reparation confift in the formation of an adven- 

 titious canal, by the encirchng bowels and their appendages. 

 The everted mucous coat, which is the part oppofed to the * 

 furrounding peritoneum, is alfo indifpofed to the adhefive: 

 inflammation. 



When, however, the wound of the inteftine is fmaller, 



the 



