The british and foreign medical review of quaterly journal of practical medicine and surgery

DR. GROSS thinks it necessary to make an apology for the publication
of a work on Wounds of the Intestines, and pleads "that our systematic
treatises on surgery unfortunately contain little, if anything, that is worthy
of reliance; they enter into no details, and some of them do not even
allude to the subject." This is unquestionably to a great extent true; and
it might have been added that there are few subjects in surgery respecting
which both systematic and other writers differ more widely. Dr. Gross
needs to make no apology for the present publication; his attention has
been directed towards a most proper and legitimate field of research, and
his work, therefore, claims an examination which we regret circumstances
have prevented us sooner giving to it.

XLV.-XXIII.

Dr. Gross, with reason, dates the commencement of scientific knowledge respecting wounds of the intestines from the publication of Mr. Travers's excellent work in 1812, stating that he "did not, like his predecessors, limit his inquiries to the human subject, but extended them to the inferior animals;" at the same time Dr. Gross claims priority in this respect to a certain extent for Dr. Thomas Smith. We may just observe that Mr. Travers refers to Dr. Smith's experiments, and that it is not quite accurate to imply that either Mr. Travers or Dr. Smith had no predecessors in this branch of experimental inquiry. Mr. Travers very fully notices the antecedent experiments of Wm. Cowper, Mr. Skipton, Dr. Thomson, and Sir A. Cooper, and alludes to some by Mobius and Louis. De Blegny, also, in 1682, Dr. Wallis in 1695, Vogel in 1704, Brunner in 1722, Schlichting in 1742, Mr. Watson in 1790, and doubtless others of whom we are ignorant, published experiments and facts respecting wounds of the intestines of animals. The value of those experiments, however, taken even in the aggregate, was but trifling. De Blegny, Brunner, Cowper, and Schlichting did not even dissect the animals they experimented on ; and to Mr. Travers unquestionably belongs the merit of having first systematically investigated the subject of wounds of the intestines, and of having put us in possession of any precise and definite knowledge respecting the process whereby such wounds are repaired, whether spontaneously, or with the intervention of art.

Dr. Gross's first chapter, on the "Nature of wounds of the intestines," is divided into four sections, in which he considers the "structure of the alimentary canal," the "nature and extent of the peritoneal cavity," the "symptoms, diagnosis, and prognosis" of wounds of the intestines, and, finally, "their mode of reparation." As regards the three former sections, a few points only require to be adverted to; but the last section demands a more careful examination, which, however, we can most conveniently give to it when considering the chapter on treatment.

Wiseman, La Motte, Garengeot, and, we believe, the older surgeons generally, held that an instrument might traverse the abdomen without injuring its contents, and many modern surgeons are of the same opinion. Dupuytren, for example, states that such an event occurs "very frequently." (Traité des Bless. par Armes de Guerre, t. ii, p. 428.) With this opinion Dr. Gross agrees, while Mr. Travers, as our readers doubtless are aware, strongly maintains the opposite doctrine. Dr. Gross supports his opinion by appealing to the well-known cases recorded by Wiseman, La Motte, Garengeot, Hennen, and others, in which patients recovered rapidly, and without a bad symptom, after the abdomen had been transfixed, and also by adducing, as strikingly illustrative of the manner in which the intestines glide away from the edge of the knife," certain cases of very extensive wounds of the abdominal parietes, in which the intestines protruded without being injured. As to this latter class of cases, they are quite beside the question, and prove nothing in favour of Dr. Gross's position, or against that of Mr. Travers. The former class of cases, however, are more to the purpose, but they are not conclusive. With respect to them, Dr. Gross, in common with Wiseman, &c., infers the absence of wound of the bowel from the absence of symptoms indicating its occurrence; but that such an inference is unwarranted sufficiently appears from

experiments and cases in the human subject, so well known that we shall not occupy space by referring to them. There are, however, some cases on record, which prove that an instrument can pass among the mass of hollow viscera without wounding them. Dr. Gross refers to one inconclu. sive case recorded by La Motte, in which the patient recovered; but he does not refer to two other cases of fatal sword wounds of the abdomen, also recorded by La Motte: in one of which, on dissection, the vena cava, in the other, the vena cava and the aorta, were wounded, but in both the intestines were uninjured. It may be remarked that Mr. Travers refers to those two cases when treating of hemorrhage into the abdomen, and says, "in neither instance had the sword wounded the viscera" (An Inquiry, &c., p. 72); yet he elsewhere denies the fact which he admits in the words just quoted. Those two are, so far as we know, the only conclusive cases in point recorded when Mr. Travers, or even when Dr. Gross, wrote; but some which go to establish the same fact have since been published. Mr. South, in his recent translation of Chelius's Surgery (Part v, p. 458), gives an analogous case, in which an iron spike traversed the abdomen, tore the right common iliac vein and deeply indented the third lumbar vertebra without injuring any of the viscera. In the Experience' (No. 373, Aug. 1844) we find the following remarkable case: a woman, five months pregnant, fell from a tree on a wooden stake, which entered the inner and back part of the left thigh, and could be felt through the soft parts at the external border of the left quadratus lumborum muscle passing up beneath the false ribs. As the stake had broken off deep in the wound, and could not, therefore, be withdrawn from below, M. Scaruffi cut down on it in the lumbar region, opened the peritoneum sufficiently to admit the hand, and extracted a piece of wood 84 inches long; his hand was in contact with the intestines, which certainly do not appear to have been wounded; the woman, we may add, perfectly recovered. The case recorded by Mr. Hennen, in which a ramrod penetrated the abdomen from before backwards, and became firmly impacted in the spine, has been very frequently quoted by writers. We suspect, but cannot be certain, that the following supplies the sequel of that case; but be that as it may, it bears on the point under consideration. Dr. Gilkrest mentioned at the Westminster Medical Society (Lancet, 1832, p. 147) a case, if not the same, precisely similar to that mentioned by Hennen, in which the patient, shortly after his recovery, was drowned, and no injury of any of the viscera could be detected on the most minute examination. If this latter case is excepted to on the grounds that a cicatrix might have been overlooked, which, considering the nature of the projectile (a ramrod), we think quite improbable, the preceding cases sufficiently establish that an instrument can penetrate between the intestinal convolutions without wounding them; and, indeed, we think the fact is proved by one of Mr. Travers's own experiments (Exp. D, p. 54), in which, a month after having pushed a catlin to the shoulder in the abdomen of a dog, he could not detect any sign of the intestine having been wounded; whence, instead of the more obvious inference that the bowel had escaped injury, Mr. Travers concludes that a simple incision in the intestine may unite per se and escape detection.

We have already admitted that the mere fact of absence of symptoms after deeply penetrating wounds of the abdomen affords no evidence that

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