WOUNDS. 



teftine receding far from the wound ; and if the ends of the 

 ligature are then of no ufe in keeping the bowel in this 

 pofition, they muft be objedionable as extraneous fubftances. 

 Dift. of Praft. Surgery, edit. 3. art. Wounch. 



The following is the procefs by which, according to Mr. 

 Travers, a divided inteftine is healed, when futures are em- 

 ployed : " It commences with the agglutination of the 

 contiguous mucous furfaces, probably by the exudation of 

 a fluid, fimilar to that which glues together the fides of a 

 recent flefh wound, when fupported in contact. The ad- 

 hefive inflammation fupervenes, and binds down the everted 

 edges of the peritoneal coat, from the whole circumference 

 of which a layer of coagulable lymph is effufed, fo as to 

 envelope the wounded bowel. The aftion of the longitudinal 

 fibres being oppofed to the artificial conneftion, the fedions 

 mutually recede, as the futures loolen by the procefs of 

 ulcerative abforption. During this time, the lymph de- 

 pofited becomes organized, by which further retraftion is 

 prevented, and the original cylinder, with the threads at- 

 tached to it, is encompafled by the new tunic. 



" The gut ulcerates at the points of the ligatures, and 

 thefe fall into its canal. The fiffures left by the ligatures 

 are gradually healed up ; but the oppofed villous furfaces, 

 fo far as my obfervation goes, neither adhere nor become 

 confolidated by granulation, fo that the interftice, making 

 the divifion internally, is probably never obliterated." Tra- 

 vers on Injuries of the Inteftine, &c. p. 128. 



The celebrated Scarpa pubhfhed, a few years ago, fome 

 highly interefting remarks on the procefs employed by 

 nature in repairing folutions of continuity in the inteftinal 

 canal, efpecially in cafes of hernia with gangrene ; and the 

 refults of his inveftigations are alfo both curious and in- 

 llruftive, in relation to what happens, and what ought to be 

 done, in wounds of the abdomen. ( SuU'ernie Memorie 

 Anatomico-Chirurgiche, &c. Milano, 1809.) He obferves, 

 that the leaft fatal confequence of a mortification of the 

 bowel is the efcape of the excrement through the wound, 

 or artificial anus ; an afRifting and difgufting infirmity, but 

 one which does not preclude all hope of a radical cure, 

 even though a confiderable portion of the inteftinal canal 

 may have been deftroyed by fphacelus. The recorded 

 examples of fuch cures are abundant, and yet, fays Scarpa, 

 nothing has yet been written which will ferve to convey an 

 exaft idea of the fimple and admirable means which nature 

 employs in accompli(hing them. Surgeons generally fup- 

 pofe, that after the detachment of the dead parts, the two 

 orifices of the bowel remain gaping, and acquire adhefions 

 to the margins of the external wound ; that afterwards, in 

 proportion as this contrafts, they come gradually nearer 

 together, and in the end touch each other fo accurately, 

 that the feces are capable of palling direftly from the fupe- 

 rior into the inferior portion of the gut. But this theory 

 cannot fatisfy thofe who have attentively examined, in fome 

 cafes of mortified hernia, the refpeftive fituation of the two 

 orifices of the inteftine, and their relation to the external 

 wound. In faft, the two ends of the bowel are conftantly 

 found lying in a parallel manner by the fide of each other : 

 the upper with its orifice open, and direfted towards the 

 external wound by the feces which iffue from it ; the lower, 

 on the contrary, as it gives paftage to nothing, always has 

 a tendency to become lefs capacious, and retrafted into the 

 cavity of the abdomen. The contraction of the external 

 . v/ound cannot have the leaft efFeft in changing the direftion 

 of thefe two orifices, nor confequently in applying them 

 to each other. Even fuppofing there were fome natural 

 tendency to this approximation, the upper orifice, being 

 wider than in the natural ftate, and direfted outwards, 



could never accurately coalefce with the lower one, which is 

 flirunk, and retrafted within the belly. The feces then 

 could never pafs from one into the other without the eff'u- 

 fion of a large part of them outwardly, and an incurable 

 filtula, difcharging the inteftinal contents, would in every 

 inftance be the confequence. 



Scarpa had an opportunity of examining the body of a 

 young man, who, in confequence of eating a large quan- 

 tity of indigeftible food, died about ten months after having 

 been operated upon for a congenital hernia, attended with 

 mortification of the protruded bowels, at a period when he 

 had recovered, with the exception of an occafional dif- 

 charge of a very fmall quantity of feces from an incon- 

 fiderable fiftulous opening. He alfo dilTefted two other 

 cafes. From all thefe it appears, that the breach in the 

 inteftinal canal is not repaired by the orifices of the uppec 

 and lower portions of the bowel re-uniting, coalefcing, and 

 running as it were into each other ; nay, that they meet at 

 a very acute angle, the axis of one not correfponding with 

 that of the other, and they never lie laterally together. On 

 the contrary, Scarpa's inveftigations fatisfaftorily prove, 

 that a funnel-ftiaped membranous canal (what he terms thi 

 Imbuto inembranofo), compofed of the remains of the hernial 

 fac, conftitutes the medium of communication between the 

 upper and lower orifices of the bowel, which, in an early ftage 

 of the cafe, becomes adherent to the peritoneum about the 

 neck of the hernial fac. The bafeof the funnel-ftiapcd m.em-' 

 branous cavity conefponds to the bowel, and its apex tends 

 towards the wound or fiftula. It farther appears, that the 

 feces, in order to get from the upper into the lower part of 

 the bowel, have to pafs through the funnel-ftiaped cavity in 

 quite a femicircular track, and that between the orifices of 

 the bowel, direftly oppofite to the aperture between the 

 cavity of the inteftine and that of the funnel-ftiaped mem- 

 brane, a confiderable projeftion or jutting angle is formed, 

 which makes a material additional obftacle to the direft 

 paflage of the feces, from the upper into the lower portion 

 of the inteftinal tube. 



Scarpa thus explains the formation of the funnel-ftiaped 

 membranous cavity, that conftitutes the channel of com- 

 munication betwixt one part of the bowel and the other : 

 " The hernial fac, as every furgeon knows, does not always 

 partake of gangrene with the vifcera contained in a hernia : 

 and even when it does Hough, fince the feparation of the 

 dead parts happens on the outfide of the abdominal ring, 

 there almoft always remains in this fituation a portion of the 

 neck of the hernial fac perfectly found. We may fay, 

 therefore, that in all cafes immediately after the detach- 

 ment of the mortified inteftine, whether it happen within or 

 on the outfide of the ring, the two orifices of the gut are 

 enveloped in the neck of the hernial fac, which foon be- 

 coming adherent to them by the effeft of inflammation, 

 ferves for a certain time to direft the feces towards the ex- 

 ternal wound, and to prevent their eff"ufion in the abdomen 

 In proportion as the outer wound diminifties, the external 

 portion of the neck of the hernial fac alfo contrafts ; but 

 that part which embraces the orifices of the inteftine gra- 

 dually becomes larger, and at length forms a kind of mem- 

 branous funnel or intermediate cavity, which makes the 

 communication between the two parts of the bowel. This 

 adhefion of the neck of the hernial fac round the two ori- 

 fices of the gut does not hinder the latter from gradually 

 quitting the ring, and becoming more and more deeply 

 placed in the cavity of the abdomen." Scarpa then cau- 

 tions furgeons not to fancy from this account, that there is 

 any occafion to pafs a ligature through the mefenterj' for 

 the purpofe of fixing it near the ring, even were the gan- 

 grenous 



'i 



