Wounds of the abdomen. These may, or may not, injure the contents of the cavi ty; but the mere circumstance of their penetrating it constitutes a source of great danger, from the peritoneal inflam mation which is likely to ensue. We may not be able to discover whether the cavity is exposed or no ; but this is of no consequence. A small, feeble, and con tracted pulse ; pallid countenance ; cold. ness of the extremities ; great and sud den debility ; hiccough ; vomiting ; and tension of the abdomen ; show that some important parts are injured. A bloody state of the urine ; discharge of blood by vomiting and stool ; escape of urine, feces, or chyle, by the wound ; indicate to us what particular parts are included in the injury. A protrusion of the viscera is a frequent attendant on these cases. The subsequent occurrence of the symp toms described as belonging to perito nitis (see Mamma) is the natural con sequence of the injury, and brings the greatest danger to the patient.
The treatment divides itself into two parts as regarding the wound, and the constitution in general. An over anxiety to discover the extent of the wound, and the parts injured, is useless and repre hensible ; if these facts cannot be made out with facility, the surgeon must be contented to remain ignorant of them. Protruded parts must be immediately re stored in the most gentle way, and the wound may probably require dilatation for this purpose ; which the surgeon may accomplish with the probe-pointed cur ved knife, guided by his finger or a di rector. Fomentation of such parts is perfectly useless. A discoloured state of intestine is no reason why it should not be replaced; if it looks very suspicious, it may be retained near the wound by a suture through the mesentery. If the gut be wounded, three simple stitches may be made at three different parts of the circumference, and the part retained near the wound. To attempt to unite the edges by making them touch at every point, would be obviously nugatory. The ensuing inflammation agglutinates the gut to the surrounding parts, and thus the breach becomes gradually closed, while the extravasated matter readily escapes through the wound, behind which the injured part is confined. If the wounded portion of the gut be with in the cavity, we must trust to the powers of nature, observing only to facilitate the discharge of the intestinal contents. Sometimes in such a case a perfect cure is obtained ; sometimes thp feces are discharged for ever after through the wound, and sometimes a fistulous open ing remains. Should the return of a large piece of omentum be very difficult, it may be cut off, and any bleeding vessels secured. The wound should then be ac curately and firmly closed by means of sticking plaster, aided by an attention to position, which is much better than using sutures. The introduction of tents is a part of the old practice, contrary to all principle, and therefore universally ex ploded. The general treatment of the
patient requires a strict observance of the antiphlogistic plan ; perfect quiet, ab stinence from animal food and fermented liquors, and mild purgatives, should be employed in every case ; and where symp toms of inflammation exist, even although the pulse should be small, copious bleed ing from a large orifice is absolutely ne cessary. Cupping, or leeches to the ab domen, followed by fomentations and blisters, will also be necessary.
Gunshot wound* of the abdomen are very seldom attended with protrusion of the intestines. The treatment is here limit ed to the employment of general means, which have sometimes the happiest ef fect under very unpromising circumstan ces.
Wounds of the abdominal viscera are often attended with extravasation of va rious substances into the cavity ; these may consist of intestinal contents, bile, urine, or blood. Besides the swelling which they cause, their presence irri tates the surrounding parts, producing inflammation, constitutional disturbance, and sometimes even suppuration and a manifest fluctuation. If bile or urine be effused, the symptoms come out very rapidly, and are extremely urgent ; but in other cases the symptoms are not so pressing. The resistance arising from the pressure of the respiratory muscles occasions the effused matters to be col lected into one mass, and prevents them from becoming generally diffused over the cavity. When swelling, attended with local pain, fluctuation, &c. and the other symptoms which will attend the case, clearly indicate a collection of this kind, it may be opened by the sur geon.
Paves abscess, is a collection of matter behind the peritoneum, in the cellular substance surrounding the 'psoas muscle. It forms in a very gradual manner, ge nerally without inflammatory or febrile symptoms. There is a dull pain in the loins, and a slight weakness of the af fected thigh. After some time, the mat ter, descending by its own weight, passes Poupart's ligament, and forms a swell ing in the groin : or it may be present in the back just under the last rib. At this period the motions of the thigh are considerably impaired, particularly those in which the psoas muscle is concern ed. There is an impulse in the tumour when the patient coughs, and the swell ing is larger in the erect position. Sometimes disease of the vertebra ac companies this affection. When the abscess bursts, the whole cyst falls into a state of inflammation ; violent irritative fever ensues ; and there is a copious sup puration, under which the patient gra dually sinks. The most successful plan hitherto adopted is, that of opening the abscess as soon as it has presented fairly, by a pretty free incision with the abscess lancet; bringing the wound together, without allowing the introduction of any air, and closing it accurately with sticking plaster.