WOUNDS. 



fufi'crs great irritation of the bladder, he feels frequent pro- 

 penfities to make water, but cannot relieve himfelf. Atlatt 

 a tumour makes its appearance, attended with a fluftuation 

 more or lefs diftinft. 



In this inftance, it feems proper to give vent to the accu- 

 mulated blood. If this fluid fhould be found coagulated, 

 injeftions of warm water would facilitate its difcharge. Sa- 

 balier, Medecine Operatoire, torn. i. 



2. Chyle and Feces. — Thefe are not fo eafily extravafated 

 in the abdomen as blood, becaufe they do not require fo 

 much refiftance on the outfide of the ftomach and inteftines, 

 to make them continue their natural route through the ali- 

 mentary canal, as blood requires to keep it in the vefTels. 

 Extravafations of this kind, however, fometimes happen 

 when the wound is large and the bowel diftended at the mo- 

 ment of the injury, or when, as Mr. Travers has likewife 

 explained, air is extravafated, or bloed elFufed in the abdo- 

 men ; thefe fluids being incapable of making effedlual re- 

 fiftance to the efcape of the inteftinal matter. (See an 

 Inquiry into the Procefs of Nature in repairing Injuries of 

 the Inteftines, &c. p. 26. ) Nothing is a better proof of the 

 difhculty with which chyle and feces are extravafated than 

 the operation of an emetic, when the ftomach is wounded 

 and full of aliment. In this inftance, if the refiftance to 

 the extravafation of the contents of the ftomach were not 

 confiderable, they would beeff^ufed in the abdomen, inftead 

 of being vomited up. A peculiarity in wounds of the fto- 

 mach and inteftines is, that the opening which allows their 

 contents to efcape may alfo allow them to return into the 

 wounded vifcus. 



Extravafation of inteftinal matter in the abdomen is attend- 

 ed with a fevere train of febrile fymptoms ; drynefs of the 

 mouth, tongue, and fauces ; confiderable pain and fwelling 

 of the belly ; convuliive ftartings ; and hiccough and vo- 

 miting, with which the patients are generally attacked on 

 the day after that on which the wound was received. Sa- 

 batier de la Medecine Operatoire, torn. i. p. 34. 



In thefe cafes, general means are the only ones which can 

 be employed ; venefeftion, fomentations, low diet, perfedl 

 reft, anodynes, &c. All folid food muil be moft ilriftly 

 prohibited. The clofe ftate of the vifcera may alfo be in- 

 creafed by applying a bandage round the body. 



If the fymptoms are not fpeedily afluaged, the abdominal 

 vifcera become afFefted with general inflammation and gan- 

 grene, and the patients die in the courfe of a few days. 



3. Bile — Bile, on account of its great fluidity, is more 

 eafily extravafated extenfively in the abdomen than either 

 blood or the contents of the ftomach and inteftines. Be- 

 fides, the gall-bladder has the power of contrafting itfelf 

 fo completely as to expel the whole of its contents. Not- 

 withttanding thefe circumftances, however, extravafations 

 of this kind are exceedingly uncommon, doubtlefs on ac- 

 count of the fmall fize of the gall-bladder, and its deep- 

 guarded fituation, between the concave furface of the liver 

 and upper part of the tranfverfe arch of the colon. 



Sabatier informs us, that he has only been able to find one 

 example on record. This cafe, after having been commu- 

 nicated to the Royal Society of London by Dr. Steward 

 {N°4I4, p. 341. Abridgm. torn. vii. p. 571, 572.), was 

 inferted as an extraft in the third volume of the Edinburgh 

 Effays, and alfo in the third volume of Van Swieten's Com- 

 mentaries on the Aphorifms of Boerhaave. (Tranfl. p. 65. 

 edit. 1754.) An ofBcer received a wound, penetrating the 

 cavity of the abdomen, and entering the fundus of the gall- 

 bladder, without doing any material injury to the adjacent 

 parts. The abdomen was immediately diilended, as if the 

 patient had been afBifted with an afcites, or tympanitis ; 



nor did the fwelling cither increafe or diminiih til! th« 

 patient's death, which happened a week after the ir-fliaio 

 of the wound. 



There was no rumbling noife in the abdomen, though it 

 was exceedingly tenfe. There were no ftools, and very 

 Lttle urine was difcharged, notwithftanding purgatives and 

 glyfters, and a good deal of liquid nouriftiment, were given. 

 The patient never had one inftant of found deep, but was 

 always reftlefs, though anodynes were exhibited. There 

 was no appearance of fever, and the pulfe was always natu- 

 ral till the laft day of the patient's life, when it became iir- 

 termittent. The inteftines were found, after death, very 

 much diftended, the gall-bladder quite empty, and a large 

 quantity of bile extravafated in the abdomen. 



Sabatier met with an opportunity of obfervingthe fymp- 

 toms of an extravafation of bile, in confcquence of a wound 

 of the gall-bladder. The patient's abdomen fwelled very 

 quickly ; his refpiration became difficult, and he foon after- 

 wards complained of tenfion, and pain in the right hypo- 

 chondrium. His pulfe was fmall, frequent, and contrafted ; 

 his extremities were cold, and his countenance very pale. 

 The bleedings which were praftifed the firft day gave him a 

 little relief ; but the tenfion of the abdomen, and the diffi- 

 culty of breathing, ftill continued. A third bleeding threw 

 the patient into the loweft ftate of v^eaknefs, and he vomited 

 up a greenifti matter. On the third day, the lower part of 

 the belly was obferved to be more prominent, and there was 

 no doubt of an extravafation. M. Sabatier introduced a 

 trocar, and gave vent to a green blackifti fluid, which had 

 no fmell, and was pure bile, that had efcaped from the 

 wound of the gall-bladder. After the operation, the patient 

 grew weaker and weaker, and died in a few hours. On 

 opening the body, a large quantity of yellow bile was found 

 between the peritoneum and inteftines ; but it had not in- 

 finuated itfelf among the convolutions of the vifcera. A 

 thick gluten connefted the bowels together, and they were 

 prodigioufly diftended. The gall-bladder was ftirivelled, and 

 almoft empty. Towards its fundus, there was a wound 

 about a line and a half long, correfponding to a fimilar 

 wound in the peritoneum. The wound which had occurred 

 at the middle and lower part of the right hypochondrium, 

 between the third and fourth falfe ribs, had glided from be- 

 hind forward, and from above downward, between the car- 

 tilages of the ribs, until it reached the fundus of the gall- 

 bladder. 



Sabatier takes notice, that the fymptoms of the two 

 cafes which have juft now been related were very fimilar. 

 Both the patients were affefted with an exceedingly tenfe 

 fwelling of the belly, unattended with pain or borboryg- 

 mus, and they were both obftinately conftipated. Their 

 pulfe was extremely weak the latter days of their indifpo- 

 fition, and they were afflifted with hiccough, naufea, and 

 vomiting. 



M. Sabatier feems to think one thing certain, viz. that 

 wounds of the gall-bladder, attended with effufion of bile, 

 are abfolutely mortal, and that no operation can be of any 

 avail. Medecine Operatoire, torn. i. p. 34 — 37. 



We are, however, to infer the contrary from the extraor- 

 dinary cafe lately pubhftied by Mr. Fryer of Stamford. 

 A boy, about thirteen years old, received a violent blow 

 from one of the fliafts of a cart, on the region of ^the liver. 

 The injury was fucceeded by pain, frequent voniiting of 

 bihous matter, great finking, coldnefa of the extremities, 

 and a weak, fmall, fluttering pulfe. The belly was fo- 

 mented, and purging clyfters thrown up. On the third 

 day, fymptoms of inflammation began, attended with con- 

 fiderable pain about the liver, great tenfion and forenefs of 



the 



