WOUNDS. 



grenous bowel perfe<ftly free and iiudiiertiit to the neigh- 

 boiirint; parts. The truth is, that the adhefive inflamma- 

 tion, whicli alfo commences immediately after the operation, 

 fixes the parts near the wound before they can be drawn 

 away by any retraftion of the bowel or mefentery ; and in 

 the courfe of the firft 24 hours the two orifices of the di- 

 vided inteftine are conllantly enveloped in the remains of the 

 hernial fac. In a cafe of this kind, where the mortified 

 bowel was not at all adherent to the neck of the hernial fac, 

 Scarpa introduced a ligature through the mefentery in the 

 ufual way, and on withdrawing it at the end of 24 hours, 

 and pading his finger to the bottom of the wound, he found 

 the circumference of the two orifices of the bowel every 

 where adherent. When a ligature through the mefentery 

 had not been praftifed, and no effufion, he alfo invariably 

 difcovered the bowel adherent to the neck of the hernial 

 fac, in every fubjeft who had died foon after the operation 

 for a ftrangulated hernia, complicated with gangrene, and 

 whom he examined after death. Certainly, he obferves, it 

 muft be allowed that the orifices of the divided inteftine do 

 retraft, and become farther from the ring ; but they do fo 

 very flowly, and always draw along with them the neck of 

 the hernial fac to which they contract early adhefions. 



Our limits oblige us to pafs over many other interefting 

 obfervations relative to the caufes which facilitate or retard 

 the re-eftabli(hment of the continuity of the inteftinal canal, 

 and on the neceflity of the funnel-fhaped membrane as a fub- 

 ftitute for the portion of bowel dellroyed by gangrene. 

 .We fhall next notice the comparifon of the artificial anus, 

 arifing from a mortified hernia, with that which is the refult 

 of a penetrating wound of the abdomen, as made by the in- 

 telligent Scarpa. "Why," he inquires, " is it fo common 

 to fee the continuity of the intellinal canal re-eitabhfiied 

 after a mortified ini^uinal or crural hernia, while the arti- 

 ficial anus is always incurable, when it is formed in confe- 

 quence of a penetrating wound of the abdomen with pro- 

 trufion of the inteftine, whether a part of the canal be de- 

 llroyed by gangrene, as in the inftance related by Mofcati 

 (Mem. de I'Acad. de Chir. t. 8.), or whether it be totally 

 or partially divided by the wounding inilrument, as in the 

 examples recorded by Stalpart- Wander Wiel (Obf. Rar. 

 t. ii. obf. 25.), Cabrole (Oper. Med. obf. 13.), Fabricuis 

 Hildanus (Centur. i. obf. 74.), &c. ?" Scarpa will not 

 even allow as an exception to this remark the cafe recited 

 in the 2d vol. of the Q2uvres Chir. de Default ; becaufe 

 he conceives the details are not fufficiently exphcit. 



In order to refolve this problem, fays he, we have only 

 to compare a wound of the belly complicated with protru- 

 fjon and mortification of the bowel, with a mortified intefti- 

 nal hernia, and draw a paraUel between the circumftances 

 which accompany the two cafes, and conftitute their chief 

 differences, ift. In a hernia, the two extremities of the 

 mortified gut are always enveloped in the remains of the 

 hernial fac, which form in front of the two orifices a kind 

 of funnel-fliaped canal. There is nothing like this at the 

 extremities of a bowel divided either by a cutting inilru- 

 ment which has penetrated the abdomen, or by mortifica- 

 tion, which has comphcated a wound of this defcription. 

 2dly, In thefelaftinftances, the wounded or burft inteftine be- 

 comes adherent to the edges of the external wound ; confe- 

 quently, it cannot retradl into the abdomen, and the feces, 

 which defcend out of the upper portion, being as it were on a 

 level with the fkin, muft necen"arily all efcape out of the exter- 

 nal wound. This is precifely what aAually iiappens, it being 

 known that artificial ani of this kind are always incurable. 

 After a mortified hernia, on the contrary, it is upon the 

 facility with which the bowel becomes fituated farther 



from the wound, drawing along with it the remains of the 

 hernial fac, that the formation of an intermediate cavity be- 

 tween the two orifices of the gut depends, and which is to 

 make the communication between them. What happens 

 after penetrating wounds of the belly, with injury of the 

 bowels, is alfo feen in ventral hernias, which have formed 

 under the cicatrix of a long-cured wound of the abdomen, 

 wh«n fuch herniae are unfortunately attacked by mortifica- 

 tion. Large, old, umbihcal, and ventral hemis, though 

 furnifhed with a hernial fac, generally give rife to incurable 

 artificial ani whenever they flough. Scarpa explains the 

 caufe of this circumftance, by adverting to the very inti- 

 mate adhefion which exifts in fuch hernia between the fac 

 and the aponeurofes and integuments of the abdomen, and 

 which tends to hinder the formation of the funnel-fhaped 

 membranous cavity in front of the orifices of the inteftine, 

 and which alone can eftabhih a communication between 

 them. 



It follows, fays Scarpa, from the foregoing and other 

 fafts, that the retraftion of the neck of the hernial fac, and 

 of the two orifices of the bowel, is effential to the re-efta- 

 blilhment of the continuity of the inteftinal canal, when a 

 breach has been made in it by mortification. Hence, he 

 thinks, that in future every body will confider the plan of 

 pafling a ligature through the mefentery, in order to keep 

 the two ends of the gut near the outer wound, not only as 

 ufelefs, but even as dangerous. The adhefions of the neck of 

 the hernial fac to the inteftine, before the occurrence of 

 gangrene, muft almoft always render the ligature ufelefs. 

 And even when the adhefion does not exift at the period of 

 cutting through the floughs, Scarpa afferts that the ligature 

 is equally unnecefFary. Indeed, fays he, immediately after 

 the operation, while nature is effefting the feparation of the 

 dead from the hving parts, the latter invariably contraft, in 

 a very fhort time, clofe adhefions to the neck of the hernial 

 fac, either on a level with a ring, or a little within it, and 

 there is no danger of the feces being extravafated in the 

 abdomen. If the latter accident has fometimes happened 

 in fubjefts who have died of hernia with gangrene in a few 

 days, it has been becaufe the feces could not make their 

 way outward quick enough, and therefore occafioned a 

 burfting of the bowel in the abdomen, within the ring and 

 beyond the extent of the hernial fac. If, in fome other 

 cafes, the two orifices of the bowel have been found in the 

 dead fubjeft not adherent to the neck of the hernial fac, 

 and the feces extravafated, Scarpa thinks it has happened 

 only after death, when the relaxation of the whole abdomen 

 has let the ends of the bowel quit the neck of the hernial 

 fac, to which it had not yet acquired any adhefions. But 

 he conceives that nothing hke this can ever happen in the 

 hving body, owing to the alternate adlion of the diaphragm 

 and abdominal mufcles, which comprefs all the vifcera, and 

 tend to propel them outward. 



Hippocrates writes, " Si quod inteftinorum gracilium 

 difcinditur, non coalefcit." (Se£l. 4. Aphor. 24.) This 

 aphoriim, fays Scarpa, taken in its true fenfe, is the ex- 

 prcflion of an inconteftible fad. It is very true, that 

 wounds of the inteftinal canal follow in their cicatrization 

 quite a different courfe from fimple wounds of the fldn, 

 mufcles, or any other parts of the body. Their edges are 

 never obferved to become immediately apphed to each 

 other, and therefore, ftriftly fpeaking, they do not re-unite. 

 Their cure is altogether completed through the medium 

 of the furrounding parts ; that is to fay, by the adhefions 

 which the inteftines contradl with the great fac of the peri- 

 toneum lining the parietes of the abdomen, or with the pro- 

 dudioiis of this membrane which compofe the external 



covering 



