the Dict. des Sc. Méd., and two from Larrey; of those cases two only were fatal. We are aware of but a few additional cases in which this suture has been employed. Guy de Chauliac mentions a successful case in which he sewed an intestine "vulnerata secundem longum et latum, cum sutura pellipariorum." (Ars Chirurgica, 1546, p. 336.) Fallopius, we think, records a similar case, and Garengeot mentions a patient who died the third day after suture of the intestine was practised by Guerin. (Traité des Opérations, t. i. p. 191.) The most remarkable case, however, of the application of the glover's suture on record is one published by M. Reybard. A man, aged twenty-eight, laboured under a carcinomatous tumour of the sigmoid flexure of the colon, and M. Reybard having diagnosed the affection, cut into the abdomen, cut away three inches of the intestine affected with the disease, tied the arteries of the mesocolon, and united the extremities of the divided bowel with the glover's suture, the suture was cut short, the intestine replaced in the abdomen, and the wound of the parietes sewed with three stitches. On the 10th day a copious evacuation was passed per anum, and on the 38th day the patient was pronounced well. After the lapse of six months, symptoms of cancerous disease of the intestine again set in, and the patient died about twelve months after the operation. No examination of the body could be obtained. This case was communicated by M. Reybard to the Academy of Medicine of Paris, and M. Jobert, in a report thereon, stated that M. Reybard had performed experiments, before a committee of the Academy, on seven dogs, but in not a single instance was union of the bowel obtained; fæcal effusion occurred in all, in some diffused through the abdomen, in others circumscribed by adhesions between the intestines. The committee consequently concluded that the glover's suture cannot be relied on in the treatment of wounds of the intestine, and we certainly think that however favorable many experiments may seem to be to it, it is far inferior to suture with inversion of the serous surface of the bowel. (Ann. de la Chirurg. Fr. et Etr. Aug. 1844. p. 493.)

We may pass briefly over Dr. Gross's experiments on the interrupted suture. In fourteen experiments death occurred once only (and that after complete division of the bowel), though in some the stitches were four and five lines apart, and in no instance was the caliber of the intestine diminished. In ten experiments the sutures were cut short, and in all they either passed or were in progress of passing into the cavity of the bowel. We are surprised Dr. Gross fails to remark the great rapidity, as compared to the glover's suture, with which single stitches. are detached. The latest period at which the sutures were found adherent was the 17th day, and in two experiments they were detached by the 7th and 11th days respectively. Dr. Gross concludes this, like the preceding section, by quoting a number of cases in which the interrupted suture was employed in the human subject, which, he observes, "taken in connexion with the experiments just detailed, exhibit an array of success highly favorable to this method of treatment." (p. 82.) Those cases are seven in number, five successful, and two fatal; the two latter are extracted from Cooper's folio work on Hernia; three of the former occurred in America, and two are taken from the Edinburgh Medical Surgical Journal' (vol. xii, p. 27), and the Medico-Chirurgical Review' (vol. xx, p. 182). We may just add that in the latter journal (vol. vi, p. 557) there is another

case mentioned, in which Dr. Washbourn united several small wounds of the intestine by the interrupted suture with success, and in the Journ. der Practisch. Heilkunde, Feb. 1825, is a remarkable case, in which Dr. Fuchsius, having diagnosed the existence of intussusception of the intestine, cut into the abdomen, drew out the invaginated bowel, and, being unable to free it, cut into the gut and disengaged the invaginated portion, which was two feet in length, united the wound by sutures, and the patient recovered in fourteen days.

Dr. Gross next (certainly very unmethodically) introduces a section on the "Method of Ramdohr," the history of which is very accurately given, and Dr. Gross adds to the cases of its application in the human subject that are generally known, one from the American Journal of Medical Science (vol. x, p.42.) In this case the lower extremity of the intestine is supposed to have been passed into the upper extremity, as what seemed to be the lower end was separated from the mesentery by the knife which had inflicted the wound; the invagination was maintained by three points of suture, two other wounds of the small intestine were secured by the continued suture, and a single stitch was taken in a wound of the colon; the patient was well by the 19th day.

The short section on Le Dran's suture requires no comment, and but little need be said respecting that on the "Method of Bertrandi, or la suture à points passés." Dr. Gross says that, excepting Boyer, he knows of no modern advocates of this suture: it is, however, recommended by Sanson, Roux, Patissier, Lombard, Richerand, and others, but by the last writer in long wounds only. Dr. Gross says we have no cases of its application in the human subject, and it is remarkable that we have very few, considering how long this suture was favorably regarded by many continental surgeons. Lombard, however, mentions one case, (Clinique des Plaies Recentes, p. 197): in 1778 an English soldier was landed at Gravelines with a sabre wound in the hypogastric region, through which the ileum protruded, and was wounded to the extent of more than a finger's breadth. Lombard sewed the wound with Bertrandi's suture; all went well till the ninth day, when Lombard lost sight of the case, and did not learn its issue. The following is also an example of the use of Bertrandi's suture, as the mucous surfaces were directly confronted. M. Judrin, operating on a femoral hernia nine days strangulated, found a perforation two lines in diameter in the intestine; finding that two stitches à points passés suffered fæces still to exude, M. Judrin took two other stitches at right angles with the former, the gut was returned, and the patient recovered in a few weeks. (Gazette Méd. de Paris, April, 1840, p. 250.)

Dr. Gross, in his account of the "Method of the Four Masters," only alludes to a single experiment on this method performed by Sir A. Cooper. Louis informs us that Duverger tried the method on dogs previous to his well-known application of it in the human subject. Louis himself tried it on two dogs, and they recovered. (Mém. de l'Acad. Royale de Chirurg. t. iii.) Vogel tells us that Thomas Brayn, a veterinary surgeon, in 1704, opened the abdomen of an ox affected with obstinate constipation, cut away a mortified portion of intestine, and sewed the ends of the bowel over a tube of wood; the cylinder was soon voided per anum and the animal lived several years. (Sandifort, Thesaur. Disputation, etc., vol. ii,

p. 130.) Dr. Watson proposed this method as a new one so lately as 1790, and having excised a portion of the bowel of a large dog, sewed the divided extremities over a cylinder of isinglass. The animal, "recovering perfectly, seemed not to suffer any inconvenience from having had his gut shortened four or five inches." (Medical Communications, vol. ii, p. 111.) But, though successful in those experiments, Duverger's case is, we believe, the only authentic example of its having succeeded in the human subject, or, indeed, rather the solitary instance of its having been so applied, for it seems uncertain whether Jamerius, Roger, Theoderic, William of Salicetus, or the Four Masters, really ever practised this method, or merely recommended it theoretically.

The next section, entitled "Method of Palfin, Bell, and Scarpa," we have already disposed of. The following one is devoted to the "Method of Jobert."

Dr. Gross tried Jobert's method of invagination on two dogs, both died, one on the third, the other on the seventh day; on dissecting the latter animal, he found that the lower extremity of the intestine had been introduced into the upper, "into which it projected (firmly united to its inner surface) in the form of a mammillated protuberance, six inches in length, tapering at its free extremity, and perfectly closed" (p. 118); the intestine, consequently, was completely obstructed, and was distended with gas and fæces to at least five times more than its natural size above the obstruction. Indeed this method has proved very unfortunate in the hands of every experimenter whose account we happen to have met with, excepting always M. Jobert himself. M. Begin tried it on three dogs, they all died, one from fæcal effusion, two from peritonitis. (Recueil des Mém. de Méd. de Chir. et de Pharm. Milit., t. xxii, 1827, pp. 60 et seq.) Reybard, in fifteen experiments on dogs, passed the lower into the upper end of the gut five times, and fæcal effusion uniformly occurred: in the ten others, in which the upper extremity of the bowel was invaginated, fæcal effusion also occurred in two; three of the remaining dogs died within a month, and the five that survived that period remained emaciated, were subject to frequent vomiting, and when killed for examination, it was found that the bowel had contracted almost to obliteration at the seat of invagination, above which, it was greatly dilated, and correspondingly contracted below. (Jour. Complém. des Sc. Méd., t. xxxviii, pp. 337 et seq.) M. Petrequin's experiments with this method were also so unfortunate, that he unreservedly condemns it. Dr. Gross also rejects this plan because of its difficulty, of the violence done to the parts in executing it, and of the uncertainty of its result; and we must entirely concur in this condemnation, were it for no other reason than the impossibility of distinguishing the lower extremity of the intestine with certainty; but that distinction, according to Jobert himself, is so essential to success, that he proposes to adopt Louis' method of discriminating the upper extremity of the intestine, a proceeding which, we trust, needs no refutation. Dr. Gross, after adverting to J. Cloquet's case, in which this method promised to succeed when the case was reported, but the ultimate issue of which we do not know, mentions another, and a fatal case, in which Professor Berard, relying on the alleged sign that the lower orifice of a divided intestine is more contracted than the upper, invaginated the lower extremity of the bowel into the upper one. There is, however, a circumstance of some

interest in this case which Dr. Gross omits to notice; the intestine was furnished with valvulæ conniventes nearly to the cæcum, and it was this circumstance that induced M. Berard to attempt invagination instead of allowing an artificial anus to form ; for as he supposed that the small intestine was divided high up, because of the existence of valvulæ conniventes at the site of the wound, he feared that an artificial anus would have been followed by death from defective nutrition, had the patient survived the immediate consequences of the wound. There are two other cases not mentioned by our author. One is mentioned by M. Jobert. (Archiv. Gén. de Méd. 1824, t. iv, p. 74.) A woman wounded herself in the throat and abdomen; the divided intestine was invaginated, and she died in fifteen hours from the effect of the wound of the throat, but soft filaments of lymph were found interposed between the portions of the bowel. The second occurred in M. Jobert's practice at the Hospital St. Louis. A man, aged 70, cut away a portion of his intestine during the night, and the injury was not discovered till next day, when, in addition to the wound with loss of intestine, it was found that the bowel was completely divided in a second situation; this latter wound was united by an invagination retained by five points of simple suture; the extremities of the portion of the canal which had suffered excision were kept in contact with the abdominal wound, in hopes of establishing an artificial anus. In thirteen hours the patient died, yet adhesion had made such progress that the invaginated serous surfaces remained glued together after the sutures were removed. (Annales de la Chirurg. Fr. et Etrang. Dec. 1842, p. 437.) M. Laborie, who records the foregoing case, adds, that M. Boulen has successfully treated two cases of complete division of the small intestine, by M. Jobert's method of invagination, and that M. Jobert himself had lately performed the same operation with perfect success on a patient of M. Beaumes, in whom the intestine had become gangrened in a crural hernia. No particulars are, however, given respecting the three last cases, and, indeed, the precise mode of invagination practised is not clearly stated as regards the two former either, so that the four last, at all events, of those five cases may be, and we suspect probably are, examples of Lembert's rather than of Jobert's method. Dr. Gross does not appear to have tried experimentally M. Jobert's suture for partial wounds of the intestine; M. Reybard objects to this method, that the kind of valve which results from it would be dangerous in transverse wounds, and that simply collecting and twisting the sutures together and bringing them through the parietal wound, without knotting them, is insufficient to keep the lips of the wound of the intestine inverted and in contact, as he experimentally ascertained in dogs. This objection we find to some extent confirmed by a case published in the 'Annales de la Chirurgie.' (loc. sup. cit.) M. Jobert united a wound in the small intestine three centimetres long, with three sutures inserted according to his method, and instead of knotting the threads, twisted them together, and allowed them to depend from the external wound; the patient died next day from peritonitis and a vast effusion of blood in the pelvis; the wound of the intestine had almost all united, but was patulous at one angle.

Dr. Gross performed twenty-three experiments with Lembert's suture, but he neither deduces any conclusions from them, nor gives any analysis of the results. In nine of the experiments the bowel was completely

divided, and four of those animals died, two with fæcal effusion. The results of the experiments on partial wounds of the bowel with this suture are very favorable, one dog only perished; those experiments also show the rapidity with which single points of suture pass into the bowel; in one experiment they had disappeared on the 12th day, and were never found at a much later date. The caliber of the intestine does not appear to have been in any instance diminished even when the wound was two and a half inches long, nor do the inverted lips of the wound seem to have permanently projected into the bowel; in one dissection, on the 17th day after a wound two and a half inches long had been united by eight points of suture, it is merely stated that "the villous margins of the wound were a good deal more elevated than common, but it was evident that they were everywhere continuous with each other." (p. 140.)*

We pass the "Method of Denans" and its modification by Baudens, nor shall we stop to notice a somewhat analogous, but even more objectionable proceeding proposed by Spillmans, an account of which may be found in the Memoir of M. Begin, which we have already referred to. As regards the "Method of Reybard," we shall only observe that M. Reybard has long since renounced his own method, and strongly pointed out the disadvantages and dangers attendant on it. Dr. Gross says he is not aware that this method has been employed on the human subject; but it has, and with success, by its inventor, who, notwithstanding, we repeat, unreservedly condemns it. The case in which M. Reybard applied his own method, is, we may observe, recorded in M. Reybard's Memoir on Artificial Anus,' &c., a work to which Dr. Gross himself refers.

Dr. Gross finally considers the methods of Amussat, Thomson, Choisy, and Beclard, which are all mere speculative proposals founded on Mr. Traver's celebrated experiment, in which the continuity of the intestine was restored after it had been circularly constricted with a ligature, and severally consist in so constricting the extremities of a divided intestine after they have been invaginated, either simply, as Beclard proposed, or over a tubular apparatus of more or less fanciful construction, as devised by others. On these speculations we need not dwell; but we may here notice the result of the only case we are aware of, in which a human intestine was completely included in a ligature; the case is mentioned by Reybard. (Mém. sur le Trait. des Anus Artif., etc. pp. 86 et seq.) A child, aged between six and seven, was wounded in the abdomen, the colon protruded, but was not wounded, and the surgeon, if such he is to be called, who saw the child, tied a silk ligature round the bowel and replaced it, the result of this strange proceeding was, that symptoms of strangulation came on, and continued until the ligature cut through the coats of the intestine, and an artificial anus resulted. It is well to know that such a proceeding is not necessarily fatal in the human subject.

Of the preceding methods of suture, Dr. Gross prefers the glover's

• Dr. Gross quotes several cases in which Lembert's suture was employed. We are not aware of any other cases besides those quoted by Dr. Gross, and we give the references to them, as so doing may prove convenient to some of our readers. 1. M. Jobert, Recovery (Lawrence, Treatise on Ruptures, p. 306; Veipeau, Médecine Opérat., t. iv, p. 143). 2. Dieffenbach, Complete division of the intestine, recovery from operation, death several weeks after from internal strangulation (Lawrence, ut supra, p. 362; British and Foreign Medical Review, vol. iii, p. 517). 3. Jobert, Recovery (Archiv. Gén. de Méd., March, 1837). 4. Baudens, Recovery (Op. sup. cit., p. 336). 5. Liegard (Velpeau, Méd. Opérat., t. iv, p. 143). 6 and 7. Jobert, Fatal (Lawrence, Op. sup. cit.), 8. Baudens, Fatal (Op. sup. cit.)