by Mr. Ellis. A man received a wound about three fourths of an inch long in the abdomen, from which nine inches of intestine protruded; with much difficulty, and after about forty minutes' perseverance, the gut was put out of sight, and in forty-eight hours the man died. On dissection, Mr. Ellis found a considerable portion of the bowel placed between the peritoneum and the abdominal muscles. (Lancet, 1834-5, vol. ii, p. 755.) A similar but not identical misadventure, not noticed by Dr. Gross, consists in pushing the intestine between the abdominal muscles, an example of which occurred in the practice of M. A. Berard. A portion of intestine prolapsed from a wound a little above Poupart's ligament, and was returned with apparent facility, but uniformly presented again externally after having been seemingly reduced. At length the gut remained up, and M. Berard, aware of the possibility of what had actually happened, passed his index-finger into the abdomen in order to assure himself that the intestine had been regularly replaced. On the fourth day after the receipt of the wound the patient died of peritonitis, which evidently commenced at and spread from the site of the wound, and on dissection a portion of intestine was found in a cavity between the external and internal oblique muscles. (Gazette des Hôpitaux de Paris, June 1842.) Those two cases show that such accidents may occur in the practice of surgeons of unquestionable skill and information. Mr. Ellis and M. Berard both ask whether the separation of the tissues into which the bowel was insinuated in their respective cases, was made during the attempts at reduction, or whether it had been in the first instance replaced within the abdomen, and had subsequently gotten into the situation in which it was found, and they both answer that the bowel was placed during the attempts at reduction in the positions above indicated, in which we think they are perfectly right. In both those cases reduction was extremly difficult, and perhaps, therefore, when such difficulty occurs there may be additional reason to suspect the possibility of the existence of a parietal pouch, and to take every possible precaution against passing the intestine into it.

"Penetrating wounds of the abdomen, with protrusion and injury of the intestines." After a judicious section on the therapeutic means to be adopted in those cases, Dr. Gross proceeds to discuss their treatment by different kinds of suture, but it seems more methodical to first consider the methods of treatment without any suture of the wound of the intestine itself. When a wounded intestine protrudes, surgeons are by no means agreed as to what practice should be adopted. Among the older surgeons, Heister, Garengeot, De la Faye, Dionis, Sharp, Palfin and others, inculcated returning the intestine without suture when the wound is small; Le Dran and B. Bell, on the contrary, recommend the smallest orifice through which the contents of the gut could escape to be sewed up. Among modern surgeons, Mr. Travers, though he concludes from experiments that very small wounds may be safely returned, yet recommends the wound, however small, to be secured by suture, though M. Jobert represents him as attributing with Scarpa the most mischievous consequences to sutures, and utterly rejecting them. (Traité des Malad. Chirurg. du Canal Intest., t. i, p. 73.) Mr. Lawrence dispenses with the suture in a mere puncture, but recommends its employment if fæces could possibly escape through the aperture. Boyer considers the suture indispensable in wounds of the intestines exceeding four lines in length; Richerand rejects

it in wounds not more than two or three lines long; Vidal de Cassis recommends its application when the wound is two lines long; and Jobert says we may safely return a wound three lines long, and, à fortiori, a puncture, even though a little fæces exude from it. Callisen, Richter, Marjolin, Begin, and Gibson say that the suture should not be applied in small wounds of the intestines, but none of them specify what extent of wound may be safely left to nature; and Mr. Gibson, as if mistrusting his own precept, during an operation for strangulated hernia, successfully imitated Cooper and Lawrence, by tying a ligature circularly round a small aperture in the intestine. Mr. Syme speaks doubtfully on this matter, but thinks it prudent to make a point of suture when the wound exceeds a mere puncture. Finally, the suture is altogether rejected by some, as, for example, Scarpa, who, however, admits that "a timorous surgeon," afraid "to commit the whole to nature," might "with impunity pass a ligature through the mesentery opposite the seat of the wound of the intestine," a proceeding which others, with J. Bell, more timorous still, replace by stitching the wound of the gut to that of the parietes to the abdomen.

Dr. Gross states that the method of simply returning a wounded intestine without suture was proposed by Scarpa. He considers it to be a plan even "more extraordinary and unaccountable" than that of J. Bell, and states that it, in common with J. Bell's method, is now universally condemned. The fact, however, is that this method is a very old one, was practised long previously to the time of Scarpa, and has frequently succeeded: that it is very easy, moreover, to account for its having been proposed, as the practice is a very legitimate inference from the ideas once generally held respecting the reparation of wounds of the intestine, and that so far from its being universally condemned, many modern surgeons recommend it, and we have some recorded examples of its having been adopted very recently. As to the method having originated with Scarpa, Tulpius (Obs. Med. lib. iii, cap. 20) and Hollerius (Obs. et Cons Curandi, p. 17), who are referred to by Mr. Travers, each record a case in which this mode of treatment succeeded perfectly, the wounds having healed thoroughly after artificial anus had existed for some time: Tulpius's case is the more interesting, as it is, we believe, the first example of a wounded intestine having been dissected long after union; the wound, we are told, was closed by a dense firm cicatrix. Ravaton's practice also was to return a wounded intestine without suture; he condemned the suture as not merely mischievous but murderous, and deemed it to be the essential point not to heal the outer wound till the fæces ceased to pass by it; with which view he sewed the upper portion only of the external wound, and kept a tent in its lower part; and he gives two cases which were thus treated and recovered perfectly. Several modern authors also favour, more or less, the method improperly termed Scarpa's. Delpech, in every case, Richerand, when the wound exceeds three lines in length, and Marjolin (Dict. en vol. 21, t. xvii, pp. 107 et seq.), in extensive transverse wounds and those with loss of substance, recommend that method, with the precaution of passing a thread through the mesentery. We find too, that in addition to the older cases, there are a few of very modern date, in which Scarpa's plan, so called, was adopted. One such case is mentioned in Scarpa's work on Hernia; and we may also refer to the following cases: A female lunatic wounded herself in the abdomen, and cut

away seventeen inches of the small intestine, with a portion of the omentum, weighing one ounce and a quarter. One end of the gut had retracted within the abdomen, the other protruded, presenting an oblique ragged edge. Dr. Buttolph, deeming death inevitable, replaced the protruding portion of gut within the abdomen, and carefully stitched the external wound. No peritonitis supervened. Thirty-three days after the injury there was a scanty discharge of hard fæces, on the following day a copious alvine evacuation occurred, and all then went well. Two years subsequently the woman was in good health. (American Journ. of Med. Sc., by Hayes, 1835.) A man was gored in the abdomen by a bull, a portion of protruding small intestine was perforated by the animal's horn, and its contents issued freely from the wound; Dr. Mayberry returned the intestine into the abdomen without sewing it, and a fæcal fistula resulted, which, four months after the accident, occasionally gave exit to a very little liquid fæces. (Dub. Med. Press, 1842, p. 376.) Reybard also, in a case of wound involving about two thirds of the circumference of the colon, replaced the intestine unsewed, and retained it in the vicinity of the parietal wound by means of a thread in the mesentery; the patient recovered with an artificial anus. (Mém. sur le Trait. des Anus Artif. &c. p. 43.) Velpeau also having in an operation for strangulated hernia returned with impunity a portion of bowel in which three small orifices existed, ventured in another case to replace a wound of the intestine two thirds of an inch long, and the patient recovered. The last case of this kind which we shall mention is that of a man who having been stabbed in the abdomen, a wound six lines long was seen in a protruded portion of small intestine; the surgeons who first saw the patient retained the bowel between the lips of the external wound by a thread in the mesentery; the patient was then carried to La Charité, where M. Roux withdrew the thread, and returned the bowel into the abdomen without sewing it; death occurred on the second day, when fæces were found effused into the abdomen. (Gazette des Hôp. de Paris, 1835, p. 1.) Those cases show that Scarpa's practice is not universally repudiated, and in the two last cited we find it was adopted by surgeons of the highest reputation. We certainly, however, agree with Dr. Gross that it deserves to be rejected, and the last case well illustrates its danger, which might be further shown by several others for example, in Cooper's folio work on Hernia' (pp. 32-34), two cases are given in which, during operations for crural hernia, the gut was either torn or cut in one, and perforated in the other, and in both inadvertently returned, the breach not being perceived at the moment; the patients both died with fæcal effusion into the abdomen.

Among the foregoing cases we have seen one in which a single extremity of a completely divided intestine protruded from the abdomen. The possibility, however, of this event has been doubted, and we do not find it noticed by Dr. Gross. John Bell sneers at B. Bell's recommendation, that in such a case we should search for the other end, and stitch the two together; saying, "as for intestines cut fairly across in all their circle, I believe the thing cannot happen, and that this, like all the rest, is a piece of mere guesswork: for, if I know anything about the way in which the viscera are disposed within the belly, it must happen that a sabre which cuts one piece of intestine fairly across, must have many others torn half through," and then he adds, we may "just as well let the poor man alone."

Roux also says (Nouv. Elémens de Méd. Opérat.) he does not know "that a case of an intestine completely divided by a wound has ever been observed." Such cases are, unquestionably, of very unfrequent occurrence, and are very difficult of explanation, except where, as in Dr. Buttolph's case, a maniac severs the protruded bowel; there are, however, some examples of the intestine having been completely divided by a simple stab. Garengeot gives the case of a soldier who was wounded in the lower part of the right epigastrium; the ileum was completely cut across, and one end of the gut protruded from the wound. The wound was judged mortal, "and the poor man was let alone," but he recovered with an artificial anus. (Traité des Opérations, t. 1.) The following case occurred in the practice of M. Berard. An assassin was carried to the hospital of St. Antoine, after having received in the left inguinal region a sabre wound 3 inches long, from which about two feet of small intestine protruded, the bowel was completely divided, and one of its extremities only depended externally; M. Berard attempted in vain, by methodical traction on the mesentery, to discover the concealed end of the bowel. Matters were then left to themselves, and the man died in a few hours. On dissection the depending end of the gut was found to be the lower end, while the upper extremity lay close to the internal orifice of the wound of the abdominal parietes, and could have been easily reached by dilating the wound a little upwards and following the mesentery. (Gaz. des Hôpit. de Paris, 1832, p. 269.) Despite J. Bell's sarcasms, we cordially concur in the practice recommended by B. Bell in such cases. It may be right to add, that in M. Berard's case just mentioned, J. Bell's speculation was partly borne out, as several coils of the intestine were slightly notched-very slightly so, however; and so far from the bowel being "torn half through" in several situations, its cavity was scarcely laid open, except at the point where it was completely severed.

What is commonly termed John Bell's method, viz. stitching the gut to the external wound, should, Dr. Gross states, rather be termed the method of Palfin, as having originated with that surgeon. This is, however, a mistake. The method in question was, we believe, first proposed by De Blegny, who, having witnessed a wound of the ileum in which the gut adhered to the external wound, and the patient recovered with an artificial anus, instituted experiments on dogs, and finding that they recovered, though with artificial anus, after the intestinal canal had been opened and stitched to the external wound, proposed this mode of treating wounds of the intestine in the human subject. (Acta Eruditorum, 1682, t. i, p. 22.) The date of Palfin's Anat. Chirurg. is 1734 (not 1743, as Dr. Gross states), so that supposing there was any parity between De Blegny's and Palfin's methods, the former anticipated the latter by upwards of sixty years. But dates are here of no importance, for Palfin's method is entirely different from that proposed by De Blegny and adopted by J. Bell, as we shall presently see. Nor was this method forgotten between the days of De Blegny and J. Bell: Amyand, for example, surgeon to St. George's hospital, writing in 1736, says, "the readiest way to obtain a cure of a wounded or bursted gut, is to keep it in contact with the outer wound and the patient on a very low diet." (Phil. Trans. 1736.)

Respecting J. Bell's method (for so we shall term it for convenience sake), Dr. Gross says, "that it might occasionally be attended with suc

cess is not improbable" (p. 106), but that the verdict of the profession is entirely against it. Now the truth is that the method has frequently succeeded; B. Bell, for example, saw two cases of completely divided intestine, in which the extremities of the gut were stitched exactly opposite each other to the lips of the external wound, and recovery ensued without the formation of an artificial anus; and Hennen mentions two cases of oblique wound of the colon, upwards of an inch long, in each of which he secured the gut by a single stitch to the parietes of the abdomen, and both patients recovered in a few days. (Military Surgery, p. 416.) As to the verdict of the profession having been pronounced against this mode of treatment, we really are not quite certain but that the authorities might nearly, if not quite, preponderate in its favour; Dr. Gross himself cites Professors S. Cooper, Gibson, and Syme as giving it their sanction, and Hennen, we have seen, adopted it,-but to this point we shall return. Dr. Gross, while condemning J. Bell's method, resolved to test its value by experiment, though Dr. Smith and Mr. Travers had, he says, already exposed its insufficiency. Mr. Travers, however, has not published any experiment conducted according to J. Bell's method. Dr. Gross refers to his Experiment R (p. 116) as being such, but it is, on the contrary, the very reverse, for in it the lips of the wound of the bowel were brought into contact by a single point of suture inserted opposite the mesentery, the gut was returned, and the external wound sewed. It is right to add that Mr. Travers by no means gives this experiment as a trial of J. Bell's plan; he adduces it to show that the interrupted suture favours fæcal effusion more than no suture at all, as each stitch, he maintains, becomes the extremity of an aperture the area of which is determined by the distance of the stitches. Dr. Smith's experiments, indeed, purport to be trials of J. Bell's method, but they are not; for he distinctly says that the intestinal wound 66 was secured by one stitch, and fastened to the wound of the parietes." Dr. Gross's three experiments, intended to test the value of J. Bell's method, not only have no resemblance to it, but are the very reverse of it; they are simply repetitions of Mr. Travers's experiment just noticed, one stitch having been taken in the wound of the gut and the external wound closed. Consequently, neither Dr. Gross's experiments nor those of Dr. Smith were trials of J. Bell's plan, and Mr. Travers's neither was, nor was intended to be so; yet Dr. Gross says, "thus, in seven experiments, all conducted, there is reason to believe, with the requisite care and skill, not a single one had a favorable termination." (p. 108.) The truth is, J. Bell utterly deprecated any suture of the wound of the intestine; his recommendation was to secure the bowel by a single stitch to the outer wound, which was to remain open to give free exit to the fæces. Dr. Smith's experiments, above noticed, were close imitations of Palfin's plan, the only difference being that Palfin, after making a single stitch in the wound of the gut, simply brought the extremities of the thread through the external wound, instead of fastening the bowel to the external wound. We are not aware of any case in which Palfin's method has been adopted in the human subject.

Dr. Gross, we have seen, considers Palfin's, J. Bell's, and Scarpa's methods as "extraordinary and unaccountable." Palfin, he states, "entertained the singular notion that the divided ends" (of the intestine) "never united with each other, but that the cure was effected solely by