WOUNDS. 



the blood does not infinuate itfelf among the vifcera till the 

 moment when the abdomen is opened, and the mafs pre- 

 viouflf lies in a kind of pouch. This pouch is frequently 

 circumfcribed, and bounded by thick membranes, efpecially 

 when the extravafation has been of fome ftanding. Saba- 

 tier, MSdecine Operatoire, torn. i. p. 28 — 30. 



It is of the higheft confequence to a pradical furgeon to 

 remember well that all the parts contained in the abdomen are 

 clofely in contaft with each other, and with the inner fur- 

 face of the peritoneum. This is one grand reafon why ex- 

 travafations are feldom fo extenfively diffufed as one might 

 imagine, but commonly He in one mafs, as Petit, Sabatier, 

 and all the bed moderns, have noticed. The preffure of the 

 elaftic bowels, of the diaphragm, and abdominal mufcles, not 

 only frequently prefents an obftacle to the diffufion of ex- 

 travafated matter, but often fervcs to propel it towards the 

 mouth of the wound. The records of furgery make men- 

 tion of numerous inftances in which perfons have been 

 ftabbed through the body without any fatal confequences, 

 and fometimes without the fymptoms being even feverc. In 

 Mr. Travers's publication many cafes exemplifying this ob- 

 fervation are quoted from a variety of fources. Fab. 

 Hildan. Obf. Chirurg. cent. v. obf. 74. (Euvres de Pare, 

 liv. X. chap. 35. Wifeman's Surgery, p. 371. LaMotte's 

 Traite Complet de Chirurgie, &c. &c. In fuch cafes, the 

 bowels have been fuppofed to have eluded the point of the 

 weapon, and this may, perhaps in a few inftances, have been 

 aftually the faft ; but in almoft all fuch examples there can 

 be no doubt that the bowels have been punftured, and an 

 extravafation of inteftinal matter has been prevented by the 

 oppofite preflure of the adjacent vifcera. Such refiftance 

 and preflure may alfo have occafionally obliged intef- 

 tinal matter, or blood aftually extravafated, to pals through 

 the wound of the bowel into its cavity, and thus be fpeedily 

 removed. Certain it is, fuch copious evacuations of blood 

 per anum have followed ftabs of the abdomen as could hardly 

 proceed from the arteries of the inteftines. This way of 

 getting rid of an extravafation muft be rare, however, com- 

 pared with that by abforption. 



The pouch or cyft including extravafated blood or 

 matter, as mentioned by Sabatier, is formed by the fame 

 procefs which circumfcribes the matter of abfccifes. ( See 

 Suppuration.) It is in (hort the adhefive infiammation. 

 All thefe furfaces in contaft with each other, and furround- 

 ing the extravafation and track of the wound, generally 

 foon become fo intimately connefted together by the adhe- 

 five inflammation, that the place in which the extravafation 

 is lodged is a cavity entirely deititute of all communication 

 with the cavity of the peritoneum. The track of the 

 wound leads to the feat of the efFufed fluid, but has no dif- 

 tmft opening into the general cavity of the abdomen. The 

 rapidity with wliich the above adhefions form is often very 

 great, almoft incredible. 



Urir.e and bile are more frequently difperfed to a great 

 extent among the abdominal vifcera than blood. The latter 

 fluid, indeed, muft often coagulate ; a circumftance that 

 muft both tend to ftop further hemorrhage, and confine the 

 extravafation in one mafs. 



Symptoms and Triatmcnt of Extravafations in the Abdomen. 

 — I. Blood. — Wounds of the fpleen, and of fuch veins and 

 arteries as are above a certain fize, almoft always prove 

 fatal from internal hemorrhage. The blood generally makes 

 its way downwards, and accumulates at the inferior part of 

 the abdomen, unlefs the exiftence of adhefions happen to 

 oppofe the defcent of the fluid to the moft depending fitua- 

 tion. The belly fwells, and the fludluation of a fluid is per- 



ceptible through the anterior part of the abdominal pariete*. 

 The patient grows pale, lofes his ftrength, is affefted with 

 fyncope, and his pulfe becomes weaker and weaker. la 

 (hort, the fymptoms ufually attendant on hemorrhage are 

 obfervable. The vifcera and veflels in the abdomen being 

 continually compreffed on all fides by the furrounding parts, 

 the blood cannot be efTufed without overcoming a certain 

 degree of refiftance ; and unlefs a veflel of the firft magni- 

 tude, like the aorta, the vena cava, or one of their princi- 

 pal branches, has been wounded, the blood efcapes from the 

 veflel flowly, and feveral days elapfe before any confiderable 

 quantity has accumulated in the lefler cavity of the pelvis. 



In thefe cafes of extravafated blood, the fymptoms, 

 which perhaps had difappeared under the employment oF 

 bleeding and anodyne medicines, now come on again. A 

 foft fluftuating tumour may be felt at the lower part 

 of the abdomen, fometimes on the right fide, fometimes 

 on the left, occafionally on both fides. The preflure 

 made by the eff"ufed blood on the urinary bladder ex- 

 cites dillreffing inchnations to make water ; while the 

 preflure which the figmoid flexure of the colon fufiers is 

 the caufe of obftinate conftipation. In the mean time, the 

 quantity of extravafated blood increafing, irritation and in- 

 flammation of the peritoneum are induced. The pulfe 

 grows weaker, debiUty enfues, the countenance is moiftened 

 with cold pcrfpirations ; and, unlefs inftigated by all the an- 

 tecedent circumftances, the furgeon pradifes anincifion for 

 the difcharge of the fluid, the patient falls a viftim to the 

 accident. 



In the year 1733, Vacher, principal furgeon of the mih- 

 tary hofpital at Befan5on, fuccefsfully adopted this mode of 

 treatment. Petit (the fon) afterwards tried the fame plan, 

 though it did not anfwer, (as is alleged,) in confequence of 

 the inflammation having advanced too far before the operation 

 was performed. Long before the time of Vacher and Petit, 

 a fuccefsful inftance of fimilar practice had been recorded by 

 Cabrolc. 



Indeed, when the fymptoms leave no doubt of there being 

 a large quantity of blood extravafated in the abdomen ; when 

 the patient's complaints are of a very ferious nature, and are 

 evidently owing to the irritation and preflure of the blood 

 on the furrounding vifcera ; and when a local fwelling de- 

 notes the feat- of the extravafation, there cannot be two 

 opinions about the propriety of making an incifion for its 

 evacuation. 



Surgeons, however, ftiould recolleft, that a fmall extrava- 

 fation of blood may cxift without producing any confi- 

 derable irritation, provided no opening be made into the 

 cyft with which it becomes furrounded. On the contrary, 

 when fuch cyft is opened, the air then having free accefs to 

 the blood contained there, that part of the fluid which 

 cannot be difcharged is apt to putrefy, and become fo irri- 

 tating, as to excite inflammation of the furrounding parts. — 

 Even though there may be an evident extravafation of blood, 

 the bad fymptoms are alfo fometimes entirely owing to the 

 injury done to the parts within the abdomen, and neither to 

 the prefl'ure nor the irritation of the eff"ufed blood. 



But fometimes, as we have already noticed, the accumu- 

 lated blood at firft neither irritates the adjacent parts by its 

 quantity nor quality. An infiammation, however, of the 

 parts furrounding the extravafation at length takes place. 

 The tenfion, irritation, and pain, which in the firft inftance 

 arofe from the wound itfelf, and fubfided, feem now to be 

 renewed. When the extravafation is at the lower and ante- 

 rior part of the abdomen, the patient experiences pain about 

 the hypogaftric region. He is alfo conftipated, and as he 



fuffers 



